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More than half of psychiatrists have net worth under $1 million
Most psychiatrists live at or below their means, and more than half have a net worth of less than $1 million, according to the Medscape Psychiatrist Debt and Net Worth Report 2020.
An important caveat, however, is that the data for this year’s report were collected as part of the Medscape Physician Compensation Report 2020, prior to Feb. 11, 2020 – and before COVID-19 was declared a pandemic.
Although it will be some time before medical practices become accustomed to a new version of normal,
Among the lowest earners
According to the Medscape Psychiatrist Compensation Report 2020, psychiatrists are among the lowest earners of all physicians, earning $268,000 on average this year. However, that’s up somewhat from last year’s earnings of $260,000.
Among psychiatrists, 57% report a net worth (total assets minus total liabilities) of less than $1 million; 38% have a net worth between $1 million and $5 million, and 5% top $5 million in net worth.
Among specialists, orthopedists are most likely (at 19%) to top the $5 million level, followed by plastic surgeons and gastroenterologists (both at 16%), according to the overall Medscape Physician Debt and Net Worth Report 2020. The report is based on more than 17,000 physicians and spans 30 specialties.
By gender, more female than male psychiatrists have a net worth of less than $1 million (61% vs. 53%). The percentages are closer between female and male psychiatrists who have a net worth between $1 million and $5 million, at 36% and 41%, respectively. In addition, more male than female psychiatrists have a net worth above $5 million (6% vs. 3%).
As expected, the older the physician, the more money they have as earnings increase and early-career debt decreases. This is the case for psychiatrists, whose net worth over $1 million increased with age.
However, psychiatrists are among the most likely of all physicians to have a net worth of less than $500,000 (at 37%), which is on par with public health and preventive medicine physicians (also at 37%) and just below family medicine physicians (at 46%), pediatricians (44%), neurologists (41%), and internal medicine physicians (40%).
For nearly two-thirds of psychiatrists (63%), mortgage payments on their primary residence are the major expense; 39% of psychiatrists have a mortgage of $300,000 or less, and 12% have a mortgage topping $500,000; 31% have no mortgage at all. Six in 10 psychiatrists live in a house that is 3,000 sq ft or smaller.
Mortgage aside, other top ongoing expenses for psychiatrists are car payments (38%), school loan payments (28%), credit card debt (26%), and medical expenses for self or loved one (20%). At 28%, psychiatrists are toward the top of the list of all physicians when it comes to those still paying off loans for education.
Spending vs. saving
The average American has four credit cards, according to the credit reporting agency Experian. More than half of psychiatrists said they have four or fewer credit cards (35% have three or four credit cards, 20% have one or two cards, and 1% have none). A quarter of psychiatrists (25%) have five or six credit cards, and 19% have seven or more at their disposal.
Only a small percentage of psychiatrists (7%) say they live above their means; 53% live at their means, and 39% live below their means.
Most psychiatrists (62%) contribute $1,000 or more to a tax-deferred retirement or college savings account each month; 13% do not do this on a regular basis. Nearly two-thirds (65%) of psychiatrists contribute to a taxable savings account, a tool many use when tax-deferred contributions have reached their limit.
Nearly half of psychiatrists (47%) rely on a mental budget for personal expenses; 16% rely on a written budget or use software or an app for budgeting; and 37% don’t have a budget for personal expenses.
Three-quarters of psychiatrists did not experience a financial loss in 2019. Of those who did have a loss, the main causes were bad investments (6%) and practice-related problems (6%). Other factors were job loss (self or spouse/partner), real estate loss (4%), legal fees (3%), and divorce (3%).
Among psychiatrists who have joint finances with a spouse or partner, 51% pool their income to pay household expenses. For 14%, the person who earns more pays more of the bills and/or expenses. Only a small percentage divide bills and expenses equally, regardless of how much each makes (5%).
About 43% of psychiatrists currently work with a financial planner or have done so in the past, 40% never did, and 17% met with a financial planner but did not pursue working with that person.
A version of this article originally appeared on Medscape.com.
Most psychiatrists live at or below their means, and more than half have a net worth of less than $1 million, according to the Medscape Psychiatrist Debt and Net Worth Report 2020.
An important caveat, however, is that the data for this year’s report were collected as part of the Medscape Physician Compensation Report 2020, prior to Feb. 11, 2020 – and before COVID-19 was declared a pandemic.
Although it will be some time before medical practices become accustomed to a new version of normal,
Among the lowest earners
According to the Medscape Psychiatrist Compensation Report 2020, psychiatrists are among the lowest earners of all physicians, earning $268,000 on average this year. However, that’s up somewhat from last year’s earnings of $260,000.
Among psychiatrists, 57% report a net worth (total assets minus total liabilities) of less than $1 million; 38% have a net worth between $1 million and $5 million, and 5% top $5 million in net worth.
Among specialists, orthopedists are most likely (at 19%) to top the $5 million level, followed by plastic surgeons and gastroenterologists (both at 16%), according to the overall Medscape Physician Debt and Net Worth Report 2020. The report is based on more than 17,000 physicians and spans 30 specialties.
By gender, more female than male psychiatrists have a net worth of less than $1 million (61% vs. 53%). The percentages are closer between female and male psychiatrists who have a net worth between $1 million and $5 million, at 36% and 41%, respectively. In addition, more male than female psychiatrists have a net worth above $5 million (6% vs. 3%).
As expected, the older the physician, the more money they have as earnings increase and early-career debt decreases. This is the case for psychiatrists, whose net worth over $1 million increased with age.
However, psychiatrists are among the most likely of all physicians to have a net worth of less than $500,000 (at 37%), which is on par with public health and preventive medicine physicians (also at 37%) and just below family medicine physicians (at 46%), pediatricians (44%), neurologists (41%), and internal medicine physicians (40%).
For nearly two-thirds of psychiatrists (63%), mortgage payments on their primary residence are the major expense; 39% of psychiatrists have a mortgage of $300,000 or less, and 12% have a mortgage topping $500,000; 31% have no mortgage at all. Six in 10 psychiatrists live in a house that is 3,000 sq ft or smaller.
Mortgage aside, other top ongoing expenses for psychiatrists are car payments (38%), school loan payments (28%), credit card debt (26%), and medical expenses for self or loved one (20%). At 28%, psychiatrists are toward the top of the list of all physicians when it comes to those still paying off loans for education.
Spending vs. saving
The average American has four credit cards, according to the credit reporting agency Experian. More than half of psychiatrists said they have four or fewer credit cards (35% have three or four credit cards, 20% have one or two cards, and 1% have none). A quarter of psychiatrists (25%) have five or six credit cards, and 19% have seven or more at their disposal.
Only a small percentage of psychiatrists (7%) say they live above their means; 53% live at their means, and 39% live below their means.
Most psychiatrists (62%) contribute $1,000 or more to a tax-deferred retirement or college savings account each month; 13% do not do this on a regular basis. Nearly two-thirds (65%) of psychiatrists contribute to a taxable savings account, a tool many use when tax-deferred contributions have reached their limit.
Nearly half of psychiatrists (47%) rely on a mental budget for personal expenses; 16% rely on a written budget or use software or an app for budgeting; and 37% don’t have a budget for personal expenses.
Three-quarters of psychiatrists did not experience a financial loss in 2019. Of those who did have a loss, the main causes were bad investments (6%) and practice-related problems (6%). Other factors were job loss (self or spouse/partner), real estate loss (4%), legal fees (3%), and divorce (3%).
Among psychiatrists who have joint finances with a spouse or partner, 51% pool their income to pay household expenses. For 14%, the person who earns more pays more of the bills and/or expenses. Only a small percentage divide bills and expenses equally, regardless of how much each makes (5%).
About 43% of psychiatrists currently work with a financial planner or have done so in the past, 40% never did, and 17% met with a financial planner but did not pursue working with that person.
A version of this article originally appeared on Medscape.com.
Most psychiatrists live at or below their means, and more than half have a net worth of less than $1 million, according to the Medscape Psychiatrist Debt and Net Worth Report 2020.
An important caveat, however, is that the data for this year’s report were collected as part of the Medscape Physician Compensation Report 2020, prior to Feb. 11, 2020 – and before COVID-19 was declared a pandemic.
Although it will be some time before medical practices become accustomed to a new version of normal,
Among the lowest earners
According to the Medscape Psychiatrist Compensation Report 2020, psychiatrists are among the lowest earners of all physicians, earning $268,000 on average this year. However, that’s up somewhat from last year’s earnings of $260,000.
Among psychiatrists, 57% report a net worth (total assets minus total liabilities) of less than $1 million; 38% have a net worth between $1 million and $5 million, and 5% top $5 million in net worth.
Among specialists, orthopedists are most likely (at 19%) to top the $5 million level, followed by plastic surgeons and gastroenterologists (both at 16%), according to the overall Medscape Physician Debt and Net Worth Report 2020. The report is based on more than 17,000 physicians and spans 30 specialties.
By gender, more female than male psychiatrists have a net worth of less than $1 million (61% vs. 53%). The percentages are closer between female and male psychiatrists who have a net worth between $1 million and $5 million, at 36% and 41%, respectively. In addition, more male than female psychiatrists have a net worth above $5 million (6% vs. 3%).
As expected, the older the physician, the more money they have as earnings increase and early-career debt decreases. This is the case for psychiatrists, whose net worth over $1 million increased with age.
However, psychiatrists are among the most likely of all physicians to have a net worth of less than $500,000 (at 37%), which is on par with public health and preventive medicine physicians (also at 37%) and just below family medicine physicians (at 46%), pediatricians (44%), neurologists (41%), and internal medicine physicians (40%).
For nearly two-thirds of psychiatrists (63%), mortgage payments on their primary residence are the major expense; 39% of psychiatrists have a mortgage of $300,000 or less, and 12% have a mortgage topping $500,000; 31% have no mortgage at all. Six in 10 psychiatrists live in a house that is 3,000 sq ft or smaller.
Mortgage aside, other top ongoing expenses for psychiatrists are car payments (38%), school loan payments (28%), credit card debt (26%), and medical expenses for self or loved one (20%). At 28%, psychiatrists are toward the top of the list of all physicians when it comes to those still paying off loans for education.
Spending vs. saving
The average American has four credit cards, according to the credit reporting agency Experian. More than half of psychiatrists said they have four or fewer credit cards (35% have three or four credit cards, 20% have one or two cards, and 1% have none). A quarter of psychiatrists (25%) have five or six credit cards, and 19% have seven or more at their disposal.
Only a small percentage of psychiatrists (7%) say they live above their means; 53% live at their means, and 39% live below their means.
Most psychiatrists (62%) contribute $1,000 or more to a tax-deferred retirement or college savings account each month; 13% do not do this on a regular basis. Nearly two-thirds (65%) of psychiatrists contribute to a taxable savings account, a tool many use when tax-deferred contributions have reached their limit.
Nearly half of psychiatrists (47%) rely on a mental budget for personal expenses; 16% rely on a written budget or use software or an app for budgeting; and 37% don’t have a budget for personal expenses.
Three-quarters of psychiatrists did not experience a financial loss in 2019. Of those who did have a loss, the main causes were bad investments (6%) and practice-related problems (6%). Other factors were job loss (self or spouse/partner), real estate loss (4%), legal fees (3%), and divorce (3%).
Among psychiatrists who have joint finances with a spouse or partner, 51% pool their income to pay household expenses. For 14%, the person who earns more pays more of the bills and/or expenses. Only a small percentage divide bills and expenses equally, regardless of how much each makes (5%).
About 43% of psychiatrists currently work with a financial planner or have done so in the past, 40% never did, and 17% met with a financial planner but did not pursue working with that person.
A version of this article originally appeared on Medscape.com.
No-suicide contracts: Can they work?
An elderly, retired, married African American man sought psychiatric treatment for depression and suicidal thoughts. He had a detailed, lethal suicide plan, but he had not taken any steps to carry it out.
He met DSM-5 criteria for a major depressive episode, and he described a lifelong history of recurrent depressions as well as hypomanic episodes. He was diagnosed with bipolar II disorder, and he began weekly therapy, as well as medication. Despite several static and dynamic suicide risk factors, the psychiatrist also noted that he was help seeking and future oriented. He seemed transparent during his initial appointments. He did not have access to lethal means and welcomed the psychiatrist to communicate openly with his spouse.
The patient had never attempted suicide, there was no family history of suicide, and there was no psychosis or substance use disorder present. He was able to commit to reaching out to the psychiatrist, his spouse, or emergency personnel in the case of worsening suicidal thoughts or imminent suicidal action. He remained in the outpatient setting. His suicidal ideation faded and depression receded as psychotherapy and pharmacotherapy continued.
Discussion
Depression and suicidal ideation are ubiquitous in the practice of psychiatry. Psychiatrists draw from an array of assessment and management tools when this common clinical challenge arises. Among these tools is the no-suicide contract (NSC). The NSC goes by many names, including the no-harm contract and suicide prevention contract.1 It is a promise, verbal or written, from the patient to not attempt suicide and to tell a loved one or psychiatric provider instead.2 The verbal exchange between the patient and therapist described in the case fits the widely accepted clinical definition of an NSC. The contents and implementation of NSCs vary greatly; no standard approach is taught in psychiatric training.3 The American Psychiatric Association has warned against over-reliance on them, emphasizing that they have not been proven effective. It advises that NSCs should not be used independently of other tools or outside well-established patient-provider relationships.4 A 2007 review of the literature on NSCs concluded that there were no data to support their effectiveness and some data that they might even cause harm.5
The origin of the NSC
The NSC is fairly young and its foundation arguably weak. Its evolution has been traced back to a study published in 1973 by Robert C. Drye, MD, and associates on the effectiveness of a questionnaire for the assessment of suicide risk.6 The questionnaire centered on the patient’s reaction to the statement, “No matter what happens, I will not kill myself, accidently or on purpose, at any time.” The authors placed special emphasis on the words “I will,” which they felt to be a stronger indicator of commitment to safety than “I promise.” The authors thought the latter statement sounded like a child’s empty reply to a demanding parent. The authors reported a 100% success rate with “approximately 600 patients” across geographic regions and clinical settings.7 The study group is not further described, and that the authors contend that the intervention had “complete effectiveness in evaluating suicide risk” should give pause to anyone aiming to practice evidence-based psychiatry.
The theoretical basis of the NSC has been presumed by others to be based, in part, on the principles of transactional analysis. Specifically, the suicidal patient is seen as occupying the child ego state, and the NSC is seen as a means of moving the patient into the less problematic adult ego state. It has been argued, however, that an NSC can achieve exactly the opposite. The contract can pit the patient against the clinician, entrenching the patient deeper into the child ego and, therefore, suicidal state.8
Michael Craig Miller, MD, and associates proposed other psychological reasons why NSCs may be counterproductive. They write, “Psychological pitfalls abound, and any of them may contribute to a contract being thoughtless, unrealistic, irrelevant, cynical, punitive, or coercive.”9 They postulated that the NSC grew out of and assumes the same shared decision-making inherent in any therapeutic contract – and they argue that this assumption is flawed given the legal power clinicians have over suicidal patients. While acknowledging this problematic power differential, the authors go on to urge clinicians to aim for shared decision-making and a shared burden of risk when discussing treatment with suicidal patients.
Possible NSC common factors
Psychiatry, like the rest of medicine, is increasingly practiced in an evidence-based manner. The NSC should not be excluded from this movement. To this end, a recently published, randomized study of 97 active duty Army personnel seeking emergency behavioral health evaluation compared the effectiveness of NSCs and with an alternative intervention, the crisis response plan (CRP). The CRP was chosen because it had been suggested by the Joint Commision as an alternative to the NSC, although it also has little evidence supporting its use.10
The NSC and CRP interventions of the Army study were very similar. Both included suicide risk assessment, supportive listening, provision of crisis resources, and referral to treatment. In addition, the NSC intervention included asking whether the patients could keep themselves safe at home. The CRP intervention included collaboration with the patient to identify warning signs of crisis, self-management skills, and support persons. A seemingly small but interesting difference between the two interventions was which member of the dyad, patient or clinician, created a written record of the discussion. In the NSC group, the assessor did the writing, while in the CRP group, the patient controlled the pen.
The results of the study were intriguing. Suicidal ideation declined faster in the CRP arm. and lost statistical significance when controlling for baseline severity of suicidal ideation. Despite those promising data, the only completed suicide was in the CRP arm.
The authors compared the makeup of the CRP intervention with key components of dialectical behavior therapy (DBT). They pointed to a 2015 study by Marsha Linehan, PhD, and associates that sought to identify the active ingredients of DBT. The Linehan study indicated that attending to warning signs and using self-management tools and social supports contributed more to the success of DBT than the individual therapy component. Interestingly, these were the same features that set the CRP intervention apart from the NSC in the Army study. Perhaps these are the common factors of effective counseling of suicidal patients.
Indeed, these factors seem to harken back to the NSC as originally envisioned by the late Dr. Drye – a patient-driven collaboration. Dr. Drye and associates wrote: “This approach developed out of our belief that the only therapeutic contracts likely to lead to change are those developed by the patient himself, for which he will assume responsibility.” While the data presented by Dr. Drye and associates were weak, the theory behind their NSC – patient commitment – seems solid. Commitment strategies, which grew out of social psychology, are effective and heavily used in DBT, including to decrease suicidal behaviors.11
Conclusion
Suicidologist Shawn Christopher Shea, MD, argues that the answer to whether or not NSCs can work is conditional on the unique combination of patient, clinician, and therapeutic relationship at play. He considers the limited data available and has warned against resolutely assuming either a pro- or anti-NSC stance. He postulates that NSCs might have the best chance at saving a life in the context of ongoing therapy with a patient with mature defenses, while in other contexts, such as with a patient with borderline personality disorder, it might prove counterproductive. Importantly, he wrote, “there is not a shred of empirical evidence that safety contracting has not been a deterrent with specific clients in the hands of specific clinicians.”
Dr. Shea describes various ways of maximizing the utility of the NSC. First, he describes that NSCs may be more effective as safety assessment tools (paying attention to both verbal and nonverbal cues) than tools to directly deter attempts. Second, NSCs may have increased utility when repeated across time to provide an understanding for how the patient typically engages in contracting. Soliciting a patient’s reasons for living also can enhance a contract’s usefulness because patients with suicidal ideation weigh reasons for living against reasons for dying in their decision-making. Finally, the sound documentation of the process of contracting not only protects against subsequent legal action but also improves the quality of the clinical care, in part by entraining the psychiatrist to incorporate key elements into the contracting process.
Returning to the clinical case, the strengths and weakness of that NSC can now be evaluated. Looking at the NSC through the eyes of Dr. Shea, the young therapeutic relationship diminishes the value of the NSC, while the relationship’s ongoing basis and the patient’s mature defenses bolster it. Dr. Shea would encourage the psychiatrist to use the NSC as an assessment tool, including assessment of ambivalence. In this case, the patient’s ambivalence about suicide comes through, but it could have been explored and expanded through explicit discussion of reasons for living. Applying the lens of Dr. Linehan, the contract is strengthened by the attention paid to social supports, while it would have been improved by specific discussion about warning signs and self-management tools.
In line with Dr. Drye’s original vision of the NSC, the degree to which the patient owns the NSC seems to be particularly crucial. In this case, the patient’s ownership of the no-suicide decision was suggested by his transparency during interview and full engagement in contracting, including identification of crisis resources. Still, the patient could have been encouraged to take additional responsibility for the NSC. One means of transferring responsibility to the patient could have been giving the patient a pen to create a written record of the contract, mobilizing and symbolizing the patient’s greater control of the process and outcome. Finally, and of utmost importance, it should be reiterated that the NSC should be only part of the assessment and planning that a psychiatrist does with a suicidal patient. While there are circumstances and strategies that augment its utility, it should not be overly relied on.
References
1. Weiss A. Am J Psychother. 2001;55(3):414-9.
2. Kroll J. Am J Psychiatry. 2000;157(10):1684-6.
3. Shea SC. The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors. Hoboken, N.J.: John Wiley & Sons, 2011.
4. Jacobs DG et al. Practice guideline for the assessment and treatment of patients with suicidal behavior. American Psychiatric Association, 2003 Nov.
5. Lewis LM. Suicide Life Threat Behav. 2007;37(1):50-7.
6. Goin M. Psychiatr News. 2003 Jul 18;38(14):3-38.
7. Drye RC et al. Am J Psychiatry. 1973;130(2):171-4.
8. Farrow TL. J Psychiatr Ment Health Nurs. 2003 Apr;10(2):199-202.
9. Miller MC et al. Harv Rev Psychiatry. 1998;6(2):78-87.
10. Bryan CJ et al. J Affect Disord. 2017 Apr;212:64-72.
11. Pederson LD. Dialectical Behavior Therapy: A Contemporary Guide for Practitioners. Hoboken, N.J.: John Wiley & Sons, 2015.
Dr. Roberts is a board-certified psychiatrist in Northern Virginia, working in both the partial hospital and outpatient settings. She has a special interest in working with patients with serious mental illness and believes in the recovery model of care, in which each patient’s life goals become the focal point of their treatment. Dr. Roberts completed her psychiatry residency at George Washington University, in Washington, where she also served as the 2018-2019 chief outpatient resident. She is a native of Minnesota and earned her medical degree from the University of Minnesota, Minneapolis, in 2015. Dr. Roberts has no disclosures.
An elderly, retired, married African American man sought psychiatric treatment for depression and suicidal thoughts. He had a detailed, lethal suicide plan, but he had not taken any steps to carry it out.
He met DSM-5 criteria for a major depressive episode, and he described a lifelong history of recurrent depressions as well as hypomanic episodes. He was diagnosed with bipolar II disorder, and he began weekly therapy, as well as medication. Despite several static and dynamic suicide risk factors, the psychiatrist also noted that he was help seeking and future oriented. He seemed transparent during his initial appointments. He did not have access to lethal means and welcomed the psychiatrist to communicate openly with his spouse.
The patient had never attempted suicide, there was no family history of suicide, and there was no psychosis or substance use disorder present. He was able to commit to reaching out to the psychiatrist, his spouse, or emergency personnel in the case of worsening suicidal thoughts or imminent suicidal action. He remained in the outpatient setting. His suicidal ideation faded and depression receded as psychotherapy and pharmacotherapy continued.
Discussion
Depression and suicidal ideation are ubiquitous in the practice of psychiatry. Psychiatrists draw from an array of assessment and management tools when this common clinical challenge arises. Among these tools is the no-suicide contract (NSC). The NSC goes by many names, including the no-harm contract and suicide prevention contract.1 It is a promise, verbal or written, from the patient to not attempt suicide and to tell a loved one or psychiatric provider instead.2 The verbal exchange between the patient and therapist described in the case fits the widely accepted clinical definition of an NSC. The contents and implementation of NSCs vary greatly; no standard approach is taught in psychiatric training.3 The American Psychiatric Association has warned against over-reliance on them, emphasizing that they have not been proven effective. It advises that NSCs should not be used independently of other tools or outside well-established patient-provider relationships.4 A 2007 review of the literature on NSCs concluded that there were no data to support their effectiveness and some data that they might even cause harm.5
The origin of the NSC
The NSC is fairly young and its foundation arguably weak. Its evolution has been traced back to a study published in 1973 by Robert C. Drye, MD, and associates on the effectiveness of a questionnaire for the assessment of suicide risk.6 The questionnaire centered on the patient’s reaction to the statement, “No matter what happens, I will not kill myself, accidently or on purpose, at any time.” The authors placed special emphasis on the words “I will,” which they felt to be a stronger indicator of commitment to safety than “I promise.” The authors thought the latter statement sounded like a child’s empty reply to a demanding parent. The authors reported a 100% success rate with “approximately 600 patients” across geographic regions and clinical settings.7 The study group is not further described, and that the authors contend that the intervention had “complete effectiveness in evaluating suicide risk” should give pause to anyone aiming to practice evidence-based psychiatry.
The theoretical basis of the NSC has been presumed by others to be based, in part, on the principles of transactional analysis. Specifically, the suicidal patient is seen as occupying the child ego state, and the NSC is seen as a means of moving the patient into the less problematic adult ego state. It has been argued, however, that an NSC can achieve exactly the opposite. The contract can pit the patient against the clinician, entrenching the patient deeper into the child ego and, therefore, suicidal state.8
Michael Craig Miller, MD, and associates proposed other psychological reasons why NSCs may be counterproductive. They write, “Psychological pitfalls abound, and any of them may contribute to a contract being thoughtless, unrealistic, irrelevant, cynical, punitive, or coercive.”9 They postulated that the NSC grew out of and assumes the same shared decision-making inherent in any therapeutic contract – and they argue that this assumption is flawed given the legal power clinicians have over suicidal patients. While acknowledging this problematic power differential, the authors go on to urge clinicians to aim for shared decision-making and a shared burden of risk when discussing treatment with suicidal patients.
Possible NSC common factors
Psychiatry, like the rest of medicine, is increasingly practiced in an evidence-based manner. The NSC should not be excluded from this movement. To this end, a recently published, randomized study of 97 active duty Army personnel seeking emergency behavioral health evaluation compared the effectiveness of NSCs and with an alternative intervention, the crisis response plan (CRP). The CRP was chosen because it had been suggested by the Joint Commision as an alternative to the NSC, although it also has little evidence supporting its use.10
The NSC and CRP interventions of the Army study were very similar. Both included suicide risk assessment, supportive listening, provision of crisis resources, and referral to treatment. In addition, the NSC intervention included asking whether the patients could keep themselves safe at home. The CRP intervention included collaboration with the patient to identify warning signs of crisis, self-management skills, and support persons. A seemingly small but interesting difference between the two interventions was which member of the dyad, patient or clinician, created a written record of the discussion. In the NSC group, the assessor did the writing, while in the CRP group, the patient controlled the pen.
The results of the study were intriguing. Suicidal ideation declined faster in the CRP arm. and lost statistical significance when controlling for baseline severity of suicidal ideation. Despite those promising data, the only completed suicide was in the CRP arm.
The authors compared the makeup of the CRP intervention with key components of dialectical behavior therapy (DBT). They pointed to a 2015 study by Marsha Linehan, PhD, and associates that sought to identify the active ingredients of DBT. The Linehan study indicated that attending to warning signs and using self-management tools and social supports contributed more to the success of DBT than the individual therapy component. Interestingly, these were the same features that set the CRP intervention apart from the NSC in the Army study. Perhaps these are the common factors of effective counseling of suicidal patients.
Indeed, these factors seem to harken back to the NSC as originally envisioned by the late Dr. Drye – a patient-driven collaboration. Dr. Drye and associates wrote: “This approach developed out of our belief that the only therapeutic contracts likely to lead to change are those developed by the patient himself, for which he will assume responsibility.” While the data presented by Dr. Drye and associates were weak, the theory behind their NSC – patient commitment – seems solid. Commitment strategies, which grew out of social psychology, are effective and heavily used in DBT, including to decrease suicidal behaviors.11
Conclusion
Suicidologist Shawn Christopher Shea, MD, argues that the answer to whether or not NSCs can work is conditional on the unique combination of patient, clinician, and therapeutic relationship at play. He considers the limited data available and has warned against resolutely assuming either a pro- or anti-NSC stance. He postulates that NSCs might have the best chance at saving a life in the context of ongoing therapy with a patient with mature defenses, while in other contexts, such as with a patient with borderline personality disorder, it might prove counterproductive. Importantly, he wrote, “there is not a shred of empirical evidence that safety contracting has not been a deterrent with specific clients in the hands of specific clinicians.”
Dr. Shea describes various ways of maximizing the utility of the NSC. First, he describes that NSCs may be more effective as safety assessment tools (paying attention to both verbal and nonverbal cues) than tools to directly deter attempts. Second, NSCs may have increased utility when repeated across time to provide an understanding for how the patient typically engages in contracting. Soliciting a patient’s reasons for living also can enhance a contract’s usefulness because patients with suicidal ideation weigh reasons for living against reasons for dying in their decision-making. Finally, the sound documentation of the process of contracting not only protects against subsequent legal action but also improves the quality of the clinical care, in part by entraining the psychiatrist to incorporate key elements into the contracting process.
Returning to the clinical case, the strengths and weakness of that NSC can now be evaluated. Looking at the NSC through the eyes of Dr. Shea, the young therapeutic relationship diminishes the value of the NSC, while the relationship’s ongoing basis and the patient’s mature defenses bolster it. Dr. Shea would encourage the psychiatrist to use the NSC as an assessment tool, including assessment of ambivalence. In this case, the patient’s ambivalence about suicide comes through, but it could have been explored and expanded through explicit discussion of reasons for living. Applying the lens of Dr. Linehan, the contract is strengthened by the attention paid to social supports, while it would have been improved by specific discussion about warning signs and self-management tools.
In line with Dr. Drye’s original vision of the NSC, the degree to which the patient owns the NSC seems to be particularly crucial. In this case, the patient’s ownership of the no-suicide decision was suggested by his transparency during interview and full engagement in contracting, including identification of crisis resources. Still, the patient could have been encouraged to take additional responsibility for the NSC. One means of transferring responsibility to the patient could have been giving the patient a pen to create a written record of the contract, mobilizing and symbolizing the patient’s greater control of the process and outcome. Finally, and of utmost importance, it should be reiterated that the NSC should be only part of the assessment and planning that a psychiatrist does with a suicidal patient. While there are circumstances and strategies that augment its utility, it should not be overly relied on.
References
1. Weiss A. Am J Psychother. 2001;55(3):414-9.
2. Kroll J. Am J Psychiatry. 2000;157(10):1684-6.
3. Shea SC. The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors. Hoboken, N.J.: John Wiley & Sons, 2011.
4. Jacobs DG et al. Practice guideline for the assessment and treatment of patients with suicidal behavior. American Psychiatric Association, 2003 Nov.
5. Lewis LM. Suicide Life Threat Behav. 2007;37(1):50-7.
6. Goin M. Psychiatr News. 2003 Jul 18;38(14):3-38.
7. Drye RC et al. Am J Psychiatry. 1973;130(2):171-4.
8. Farrow TL. J Psychiatr Ment Health Nurs. 2003 Apr;10(2):199-202.
9. Miller MC et al. Harv Rev Psychiatry. 1998;6(2):78-87.
10. Bryan CJ et al. J Affect Disord. 2017 Apr;212:64-72.
11. Pederson LD. Dialectical Behavior Therapy: A Contemporary Guide for Practitioners. Hoboken, N.J.: John Wiley & Sons, 2015.
Dr. Roberts is a board-certified psychiatrist in Northern Virginia, working in both the partial hospital and outpatient settings. She has a special interest in working with patients with serious mental illness and believes in the recovery model of care, in which each patient’s life goals become the focal point of their treatment. Dr. Roberts completed her psychiatry residency at George Washington University, in Washington, where she also served as the 2018-2019 chief outpatient resident. She is a native of Minnesota and earned her medical degree from the University of Minnesota, Minneapolis, in 2015. Dr. Roberts has no disclosures.
An elderly, retired, married African American man sought psychiatric treatment for depression and suicidal thoughts. He had a detailed, lethal suicide plan, but he had not taken any steps to carry it out.
He met DSM-5 criteria for a major depressive episode, and he described a lifelong history of recurrent depressions as well as hypomanic episodes. He was diagnosed with bipolar II disorder, and he began weekly therapy, as well as medication. Despite several static and dynamic suicide risk factors, the psychiatrist also noted that he was help seeking and future oriented. He seemed transparent during his initial appointments. He did not have access to lethal means and welcomed the psychiatrist to communicate openly with his spouse.
The patient had never attempted suicide, there was no family history of suicide, and there was no psychosis or substance use disorder present. He was able to commit to reaching out to the psychiatrist, his spouse, or emergency personnel in the case of worsening suicidal thoughts or imminent suicidal action. He remained in the outpatient setting. His suicidal ideation faded and depression receded as psychotherapy and pharmacotherapy continued.
Discussion
Depression and suicidal ideation are ubiquitous in the practice of psychiatry. Psychiatrists draw from an array of assessment and management tools when this common clinical challenge arises. Among these tools is the no-suicide contract (NSC). The NSC goes by many names, including the no-harm contract and suicide prevention contract.1 It is a promise, verbal or written, from the patient to not attempt suicide and to tell a loved one or psychiatric provider instead.2 The verbal exchange between the patient and therapist described in the case fits the widely accepted clinical definition of an NSC. The contents and implementation of NSCs vary greatly; no standard approach is taught in psychiatric training.3 The American Psychiatric Association has warned against over-reliance on them, emphasizing that they have not been proven effective. It advises that NSCs should not be used independently of other tools or outside well-established patient-provider relationships.4 A 2007 review of the literature on NSCs concluded that there were no data to support their effectiveness and some data that they might even cause harm.5
The origin of the NSC
The NSC is fairly young and its foundation arguably weak. Its evolution has been traced back to a study published in 1973 by Robert C. Drye, MD, and associates on the effectiveness of a questionnaire for the assessment of suicide risk.6 The questionnaire centered on the patient’s reaction to the statement, “No matter what happens, I will not kill myself, accidently or on purpose, at any time.” The authors placed special emphasis on the words “I will,” which they felt to be a stronger indicator of commitment to safety than “I promise.” The authors thought the latter statement sounded like a child’s empty reply to a demanding parent. The authors reported a 100% success rate with “approximately 600 patients” across geographic regions and clinical settings.7 The study group is not further described, and that the authors contend that the intervention had “complete effectiveness in evaluating suicide risk” should give pause to anyone aiming to practice evidence-based psychiatry.
The theoretical basis of the NSC has been presumed by others to be based, in part, on the principles of transactional analysis. Specifically, the suicidal patient is seen as occupying the child ego state, and the NSC is seen as a means of moving the patient into the less problematic adult ego state. It has been argued, however, that an NSC can achieve exactly the opposite. The contract can pit the patient against the clinician, entrenching the patient deeper into the child ego and, therefore, suicidal state.8
Michael Craig Miller, MD, and associates proposed other psychological reasons why NSCs may be counterproductive. They write, “Psychological pitfalls abound, and any of them may contribute to a contract being thoughtless, unrealistic, irrelevant, cynical, punitive, or coercive.”9 They postulated that the NSC grew out of and assumes the same shared decision-making inherent in any therapeutic contract – and they argue that this assumption is flawed given the legal power clinicians have over suicidal patients. While acknowledging this problematic power differential, the authors go on to urge clinicians to aim for shared decision-making and a shared burden of risk when discussing treatment with suicidal patients.
Possible NSC common factors
Psychiatry, like the rest of medicine, is increasingly practiced in an evidence-based manner. The NSC should not be excluded from this movement. To this end, a recently published, randomized study of 97 active duty Army personnel seeking emergency behavioral health evaluation compared the effectiveness of NSCs and with an alternative intervention, the crisis response plan (CRP). The CRP was chosen because it had been suggested by the Joint Commision as an alternative to the NSC, although it also has little evidence supporting its use.10
The NSC and CRP interventions of the Army study were very similar. Both included suicide risk assessment, supportive listening, provision of crisis resources, and referral to treatment. In addition, the NSC intervention included asking whether the patients could keep themselves safe at home. The CRP intervention included collaboration with the patient to identify warning signs of crisis, self-management skills, and support persons. A seemingly small but interesting difference between the two interventions was which member of the dyad, patient or clinician, created a written record of the discussion. In the NSC group, the assessor did the writing, while in the CRP group, the patient controlled the pen.
The results of the study were intriguing. Suicidal ideation declined faster in the CRP arm. and lost statistical significance when controlling for baseline severity of suicidal ideation. Despite those promising data, the only completed suicide was in the CRP arm.
The authors compared the makeup of the CRP intervention with key components of dialectical behavior therapy (DBT). They pointed to a 2015 study by Marsha Linehan, PhD, and associates that sought to identify the active ingredients of DBT. The Linehan study indicated that attending to warning signs and using self-management tools and social supports contributed more to the success of DBT than the individual therapy component. Interestingly, these were the same features that set the CRP intervention apart from the NSC in the Army study. Perhaps these are the common factors of effective counseling of suicidal patients.
Indeed, these factors seem to harken back to the NSC as originally envisioned by the late Dr. Drye – a patient-driven collaboration. Dr. Drye and associates wrote: “This approach developed out of our belief that the only therapeutic contracts likely to lead to change are those developed by the patient himself, for which he will assume responsibility.” While the data presented by Dr. Drye and associates were weak, the theory behind their NSC – patient commitment – seems solid. Commitment strategies, which grew out of social psychology, are effective and heavily used in DBT, including to decrease suicidal behaviors.11
Conclusion
Suicidologist Shawn Christopher Shea, MD, argues that the answer to whether or not NSCs can work is conditional on the unique combination of patient, clinician, and therapeutic relationship at play. He considers the limited data available and has warned against resolutely assuming either a pro- or anti-NSC stance. He postulates that NSCs might have the best chance at saving a life in the context of ongoing therapy with a patient with mature defenses, while in other contexts, such as with a patient with borderline personality disorder, it might prove counterproductive. Importantly, he wrote, “there is not a shred of empirical evidence that safety contracting has not been a deterrent with specific clients in the hands of specific clinicians.”
Dr. Shea describes various ways of maximizing the utility of the NSC. First, he describes that NSCs may be more effective as safety assessment tools (paying attention to both verbal and nonverbal cues) than tools to directly deter attempts. Second, NSCs may have increased utility when repeated across time to provide an understanding for how the patient typically engages in contracting. Soliciting a patient’s reasons for living also can enhance a contract’s usefulness because patients with suicidal ideation weigh reasons for living against reasons for dying in their decision-making. Finally, the sound documentation of the process of contracting not only protects against subsequent legal action but also improves the quality of the clinical care, in part by entraining the psychiatrist to incorporate key elements into the contracting process.
Returning to the clinical case, the strengths and weakness of that NSC can now be evaluated. Looking at the NSC through the eyes of Dr. Shea, the young therapeutic relationship diminishes the value of the NSC, while the relationship’s ongoing basis and the patient’s mature defenses bolster it. Dr. Shea would encourage the psychiatrist to use the NSC as an assessment tool, including assessment of ambivalence. In this case, the patient’s ambivalence about suicide comes through, but it could have been explored and expanded through explicit discussion of reasons for living. Applying the lens of Dr. Linehan, the contract is strengthened by the attention paid to social supports, while it would have been improved by specific discussion about warning signs and self-management tools.
In line with Dr. Drye’s original vision of the NSC, the degree to which the patient owns the NSC seems to be particularly crucial. In this case, the patient’s ownership of the no-suicide decision was suggested by his transparency during interview and full engagement in contracting, including identification of crisis resources. Still, the patient could have been encouraged to take additional responsibility for the NSC. One means of transferring responsibility to the patient could have been giving the patient a pen to create a written record of the contract, mobilizing and symbolizing the patient’s greater control of the process and outcome. Finally, and of utmost importance, it should be reiterated that the NSC should be only part of the assessment and planning that a psychiatrist does with a suicidal patient. While there are circumstances and strategies that augment its utility, it should not be overly relied on.
References
1. Weiss A. Am J Psychother. 2001;55(3):414-9.
2. Kroll J. Am J Psychiatry. 2000;157(10):1684-6.
3. Shea SC. The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors. Hoboken, N.J.: John Wiley & Sons, 2011.
4. Jacobs DG et al. Practice guideline for the assessment and treatment of patients with suicidal behavior. American Psychiatric Association, 2003 Nov.
5. Lewis LM. Suicide Life Threat Behav. 2007;37(1):50-7.
6. Goin M. Psychiatr News. 2003 Jul 18;38(14):3-38.
7. Drye RC et al. Am J Psychiatry. 1973;130(2):171-4.
8. Farrow TL. J Psychiatr Ment Health Nurs. 2003 Apr;10(2):199-202.
9. Miller MC et al. Harv Rev Psychiatry. 1998;6(2):78-87.
10. Bryan CJ et al. J Affect Disord. 2017 Apr;212:64-72.
11. Pederson LD. Dialectical Behavior Therapy: A Contemporary Guide for Practitioners. Hoboken, N.J.: John Wiley & Sons, 2015.
Dr. Roberts is a board-certified psychiatrist in Northern Virginia, working in both the partial hospital and outpatient settings. She has a special interest in working with patients with serious mental illness and believes in the recovery model of care, in which each patient’s life goals become the focal point of their treatment. Dr. Roberts completed her psychiatry residency at George Washington University, in Washington, where she also served as the 2018-2019 chief outpatient resident. She is a native of Minnesota and earned her medical degree from the University of Minnesota, Minneapolis, in 2015. Dr. Roberts has no disclosures.
FDA allows qualified claims for UTI risk reduction with cranberry products
The Food and Drug Administration will not object to qualified health claims that consumption of certain cranberry juice products and cranberry supplement products may reduce the risk of recurrent urinary tract infections in otherwise healthy women.
In a letter of enforcement discretion issued on July 21, the FDA responded to a health claim petition submitted by Ocean Spray Cranberries. “A health claim characterizes the relationship between a substance and a disease or health-related condition,” according to the FDA. Ocean Spray Cranberries asked the FDA for an authorized health claim regarding the relationship between the consumption of cranberry beverages and supplements and a reduction in the risk of recurrent urinary tract infections (UTIs) in healthy women.
After reviewing the evidence, the FDA determined that the existing science did not support an authorized health claim, but did allow for a qualified health claim for certain cranberry juice beverages and supplements. A qualified health claim does not constitute an FDA approval; the FDA instead issues a Letter of Enforcement Discretion that includes language reflecting the level of scientific evidence for the claim.
The currently available scientific evidence for a relationship between cranberry and recurrent UTIs includes five intervention studies, according to the FDA letter. Two of these were high-quality, randomized, controlled trials in which daily consumption of a cranberry juice beverage was significantly associated with a reduced risk of recurrent UTIs. Another randomized, controlled trial yielded mixed results, and two other intervention studies that were moderate-quality, randomized, controlled trials showed no effect of cranberry juice consumption on UTI risk reduction.
The FDA’s letter of enforcement discretion states that, with regard to cranberry juice beverages, “Limited and inconsistent scientific evidence shows that by consuming one serving (8 oz) each day of a cranberry juice beverage, healthy women who have had a urinary tract infection may reduce their risk of recurrent UTI.”
Similarly, for cranberry dietary supplements, the FDA states that “Limited scientific evidence shows that, by consuming 500 mg each day of cranberry dietary supplement, healthy women who have had a urinary tract infection may reduce their risk of recurrent UTI.”
The qualified health claims apply specifically to cranberry juice beverages that contain at least 27% cranberry juice, and cranberry dietary supplements containing at least 500 mg of cranberry fruit powder. “The claims do not include other conventional foods or food products made from or containing cranberries, such as dried cranberries or cranberry sauce,” according to the FDA statement.
“With recurrent UTI, a major concern is the frequent use of antibiotics,” Constance Bohon, MD, an ob.gyn. in private practice in Washington and an assistant clinical professor at George Washington University, Washington, said in an interview.
“The challenge is to identify habits and/or nonantibiotic treatment to prevent recurrent UTI and decrease the need for antibiotics,” she said. “The regular use of cranberry can decrease the frequency of UTI in some, but not all, people.
“It does not appear to mask the symptoms of a UTI, so if it is not effective to prevent the infection, the presumptive diagnosis can be made based on the common symptoms,” she explained.
Dr. Bohon said that she has recommended the use of cranberry to some of her patients who have recurrent UTIs and has had success with many of them.
“I think it is important to make it clear that cranberry can be beneficial for some patients to decrease the frequency of UTI. It will not be effective for everyone who has frequent UTI, but for those who use it and have fewer UTIs, there will be less frequent exposure to antibiotics,” she emphasized. “What we need to know is who benefits the most from cranberry to prevent recurrent UTIs; whether age, race, coexisting health problems [such as diabetes], and use of hormonal contraception or menopause impact on its success.”
Dr. Bohon had no relevant financial conflicts to disclose.
The Food and Drug Administration will not object to qualified health claims that consumption of certain cranberry juice products and cranberry supplement products may reduce the risk of recurrent urinary tract infections in otherwise healthy women.
In a letter of enforcement discretion issued on July 21, the FDA responded to a health claim petition submitted by Ocean Spray Cranberries. “A health claim characterizes the relationship between a substance and a disease or health-related condition,” according to the FDA. Ocean Spray Cranberries asked the FDA for an authorized health claim regarding the relationship between the consumption of cranberry beverages and supplements and a reduction in the risk of recurrent urinary tract infections (UTIs) in healthy women.
After reviewing the evidence, the FDA determined that the existing science did not support an authorized health claim, but did allow for a qualified health claim for certain cranberry juice beverages and supplements. A qualified health claim does not constitute an FDA approval; the FDA instead issues a Letter of Enforcement Discretion that includes language reflecting the level of scientific evidence for the claim.
The currently available scientific evidence for a relationship between cranberry and recurrent UTIs includes five intervention studies, according to the FDA letter. Two of these were high-quality, randomized, controlled trials in which daily consumption of a cranberry juice beverage was significantly associated with a reduced risk of recurrent UTIs. Another randomized, controlled trial yielded mixed results, and two other intervention studies that were moderate-quality, randomized, controlled trials showed no effect of cranberry juice consumption on UTI risk reduction.
The FDA’s letter of enforcement discretion states that, with regard to cranberry juice beverages, “Limited and inconsistent scientific evidence shows that by consuming one serving (8 oz) each day of a cranberry juice beverage, healthy women who have had a urinary tract infection may reduce their risk of recurrent UTI.”
Similarly, for cranberry dietary supplements, the FDA states that “Limited scientific evidence shows that, by consuming 500 mg each day of cranberry dietary supplement, healthy women who have had a urinary tract infection may reduce their risk of recurrent UTI.”
The qualified health claims apply specifically to cranberry juice beverages that contain at least 27% cranberry juice, and cranberry dietary supplements containing at least 500 mg of cranberry fruit powder. “The claims do not include other conventional foods or food products made from or containing cranberries, such as dried cranberries or cranberry sauce,” according to the FDA statement.
“With recurrent UTI, a major concern is the frequent use of antibiotics,” Constance Bohon, MD, an ob.gyn. in private practice in Washington and an assistant clinical professor at George Washington University, Washington, said in an interview.
“The challenge is to identify habits and/or nonantibiotic treatment to prevent recurrent UTI and decrease the need for antibiotics,” she said. “The regular use of cranberry can decrease the frequency of UTI in some, but not all, people.
“It does not appear to mask the symptoms of a UTI, so if it is not effective to prevent the infection, the presumptive diagnosis can be made based on the common symptoms,” she explained.
Dr. Bohon said that she has recommended the use of cranberry to some of her patients who have recurrent UTIs and has had success with many of them.
“I think it is important to make it clear that cranberry can be beneficial for some patients to decrease the frequency of UTI. It will not be effective for everyone who has frequent UTI, but for those who use it and have fewer UTIs, there will be less frequent exposure to antibiotics,” she emphasized. “What we need to know is who benefits the most from cranberry to prevent recurrent UTIs; whether age, race, coexisting health problems [such as diabetes], and use of hormonal contraception or menopause impact on its success.”
Dr. Bohon had no relevant financial conflicts to disclose.
The Food and Drug Administration will not object to qualified health claims that consumption of certain cranberry juice products and cranberry supplement products may reduce the risk of recurrent urinary tract infections in otherwise healthy women.
In a letter of enforcement discretion issued on July 21, the FDA responded to a health claim petition submitted by Ocean Spray Cranberries. “A health claim characterizes the relationship between a substance and a disease or health-related condition,” according to the FDA. Ocean Spray Cranberries asked the FDA for an authorized health claim regarding the relationship between the consumption of cranberry beverages and supplements and a reduction in the risk of recurrent urinary tract infections (UTIs) in healthy women.
After reviewing the evidence, the FDA determined that the existing science did not support an authorized health claim, but did allow for a qualified health claim for certain cranberry juice beverages and supplements. A qualified health claim does not constitute an FDA approval; the FDA instead issues a Letter of Enforcement Discretion that includes language reflecting the level of scientific evidence for the claim.
The currently available scientific evidence for a relationship between cranberry and recurrent UTIs includes five intervention studies, according to the FDA letter. Two of these were high-quality, randomized, controlled trials in which daily consumption of a cranberry juice beverage was significantly associated with a reduced risk of recurrent UTIs. Another randomized, controlled trial yielded mixed results, and two other intervention studies that were moderate-quality, randomized, controlled trials showed no effect of cranberry juice consumption on UTI risk reduction.
The FDA’s letter of enforcement discretion states that, with regard to cranberry juice beverages, “Limited and inconsistent scientific evidence shows that by consuming one serving (8 oz) each day of a cranberry juice beverage, healthy women who have had a urinary tract infection may reduce their risk of recurrent UTI.”
Similarly, for cranberry dietary supplements, the FDA states that “Limited scientific evidence shows that, by consuming 500 mg each day of cranberry dietary supplement, healthy women who have had a urinary tract infection may reduce their risk of recurrent UTI.”
The qualified health claims apply specifically to cranberry juice beverages that contain at least 27% cranberry juice, and cranberry dietary supplements containing at least 500 mg of cranberry fruit powder. “The claims do not include other conventional foods or food products made from or containing cranberries, such as dried cranberries or cranberry sauce,” according to the FDA statement.
“With recurrent UTI, a major concern is the frequent use of antibiotics,” Constance Bohon, MD, an ob.gyn. in private practice in Washington and an assistant clinical professor at George Washington University, Washington, said in an interview.
“The challenge is to identify habits and/or nonantibiotic treatment to prevent recurrent UTI and decrease the need for antibiotics,” she said. “The regular use of cranberry can decrease the frequency of UTI in some, but not all, people.
“It does not appear to mask the symptoms of a UTI, so if it is not effective to prevent the infection, the presumptive diagnosis can be made based on the common symptoms,” she explained.
Dr. Bohon said that she has recommended the use of cranberry to some of her patients who have recurrent UTIs and has had success with many of them.
“I think it is important to make it clear that cranberry can be beneficial for some patients to decrease the frequency of UTI. It will not be effective for everyone who has frequent UTI, but for those who use it and have fewer UTIs, there will be less frequent exposure to antibiotics,” she emphasized. “What we need to know is who benefits the most from cranberry to prevent recurrent UTIs; whether age, race, coexisting health problems [such as diabetes], and use of hormonal contraception or menopause impact on its success.”
Dr. Bohon had no relevant financial conflicts to disclose.
New osteoporosis recommendations from AACE help therapy selection
Recommendations on use of the new dual-action anabolic agent romosozumab (Evenity, Amgen) and how to safely transition between osteoporosis agents are two of the issues addressed in the latest clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis from the American Association of Clinical Endocrinologists and American College of Endocrinology.
“This guideline is a practical tool for endocrinologists, physicians in general, regulatory bodies, health-related organizations, and interested laypersons regarding the diagnosis, evaluation, and treatment of postmenopausal osteoporosis,” the authors wrote.
The guidelines focus on 12 key clinical questions related to postmenopausal osteoporosis, with 52 specific recommendations, each graded according to the level of evidence.
They also include a treatment algorithm to help guide choice of therapy.
Reiterating role of FRAX in the diagnosis of patients with osteopenia
Among key updates is an emphasis on the role of the Fracture Risk Assessment Tool (FRAX) in the diagnosis of osteoporosis in patients with osteopenia.
While patients have traditionally been diagnosed with osteoporosis based on the presence of low bone mineral density (BMD) in the absence of fracture, the updated guidelines indicate that osteoporosis may be diagnosed in patients with osteopenia and an increased fracture risk using FRAX.
“The use of FRAX and osteopenia to diagnosis osteoporosis was first proposed by the National Bone Health Alliance years ago, and in the 2016 guideline, we agreed with it,” Pauline M. Camacho, MD, cochair of the guidelines task force, said in an interview.
“We reiterate in the 2020 guideline that we feel this is a valid diagnostic criteria,” said Dr. Camacho, professor of medicine and director of the Osteoporosis and Metabolic Bone Disease Center at Loyola University Chicago, Maywood, Ill. “It makes sense because when the thresholds are met by FRAX in patients with osteopenia, treatment is recommended. Therefore, why would they not fulfill treatment criteria for diagnosing osteoporosis?”
An increased risk of fracture based on a FRAX score may also be used to determine pharmacologic therapy, as can other traditional factors such as a low T score or a fragility fracture, the guidelines stated.
High risk vs. very high risk guides choice of first therapy
Another key update is the clarification of the risk stratification of patients who are high risk versus very high risk, which is key in determining the initial choice of agents and duration of therapy.
Specifically, patients should be considered at a very high fracture risk if they have the following criteria: a recent fracture (e.g., within the past 12 months), fractures while on approved osteoporosis therapy, multiple fractures, fractures while on drugs causing skeletal harm (e.g., long-term glucocorticoids), very low T score (e.g., less than −3.0), a high risk for falls or history of injurious falls, and a very high fracture probability by FRAX (e.g., major osteoporosis fracture >30%, hip fracture >4.5%) or other validated fracture risk algorithm.
Meanwhile, patients should be considered at high risk if they have been diagnosed with osteoporosis but do not meet the criteria for very high fracture risk.
Romosozumab brought into the mix
Another important update provides information on the role of one of the newest osteoporosis agents on the market, the anabolic drug romosozumab, a monoclonal antibody directed against sclerostin.
The drug’s approval by the Food and Drug Administration in 2019 for postmenopausal women at high risk of fracture was based on two large trials that showed dramatic increases in bone density through modeling as well as remodeling.
Those studies specifically showed significant reductions in radiographic vertebral fractures with romosozumab, compared with placebo and alendronate.
Dr. Camacho noted that romosozumab “will likely be for the very high risk group and those who have maxed out on teriparatide or abaloparatide.”
Romosozumab can safely be used in patients with prior radiation exposure, the guidelines noted.
Importantly, because of reports of a higher risk of serious cardiovascular events with romosozumab, compared with alendronate, romosozumab comes with a black-box warning that it should not be used in patients at high risk for cardiovascular events or who have had a recent myocardial infarction or stroke.
“Unfortunately, the very high risk group is often the older patients,” Dr. Camacho noted.
“The drug should not be given if there is a history of myocardial infarction or stroke in the past year,” she emphasized. “Clinical judgment is needed to decide who is at risk for cardiovascular complications.”
Notably, teriparatide and abaloparatide have black box warnings of their own regarding risk for osteosarcoma.
Switching therapies
Reflecting the evolving data on osteoporosis drug holidays, the guidelines also addressed the issue and the clinical challenges of switching therapies.
“In 2016, we said drug holidays are not recommended, and the treatment can be continued indefinitely, [however] in 2020, we felt that if some patients are no longer high risk, they can be transitioned off the drug,” Dr. Camacho said.
For teriparatide and abaloparatide, the FDA recommends treatment be limited to no more than 2 years, and for romosozumab, 1 year.
The updated guidelines recommend that upon discontinuation of an anabolic agent (e.g., abaloparatide, romosozumab, or teriparatide), a switch to therapy with an antiresorptive agent, such as denosumab or bisphosphonates, should be implemented to prevent loss of BMD and fracture efficacy.
Discontinuation of denosumab, however, can have notably negative effects. Clinical trials show rapid decreases in BMD when denosumab treatment is stopped after 2 or 8 years, as well as rapid loss of protection from vertebral fractures.
Therefore, if denosumab is going to be discontinued, there should be a proper transition to an antiresorptive agent for a limited time, such as one infusion of the bisphosphonate zoledronate.
Communicate the risks with and without treatment to patients
The authors underscored that, in addition to communicating the potential risk and expected benefits of osteoporosis treatments, clinicians should make sure patients fully appreciate the risk of fractures and their consequences, such as pain, disability, loss of independence, and death, when no treatment is given.
“It is incumbent on the clinician to provide this information to each patient in a manner that is fully understood, and it is equally important to learn from the patient about cultural beliefs, previous treatment experiences, fears, and concerns,” they wrote.
And in estimating patients’ fracture risk, T score must be combined with clinical risk factors, particularly advanced age and previous fracture, and clinicians should recognize that the absolute fracture risk is more useful than a risk ratio in developing treatment plans.
“Treatment recommendations may be quite different; an early postmenopausal woman with a T score of −2.5 has osteoporosis, although fracture risk is much lower than an 80-year-old woman with the same T score,” the authors explained.
Dr. Camacho reported financial relationships with Amgen and Shire. Disclosures for other task force members are detailed in the guidelines.
A version of this article originally appeared on Medscape.com.
Recommendations on use of the new dual-action anabolic agent romosozumab (Evenity, Amgen) and how to safely transition between osteoporosis agents are two of the issues addressed in the latest clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis from the American Association of Clinical Endocrinologists and American College of Endocrinology.
“This guideline is a practical tool for endocrinologists, physicians in general, regulatory bodies, health-related organizations, and interested laypersons regarding the diagnosis, evaluation, and treatment of postmenopausal osteoporosis,” the authors wrote.
The guidelines focus on 12 key clinical questions related to postmenopausal osteoporosis, with 52 specific recommendations, each graded according to the level of evidence.
They also include a treatment algorithm to help guide choice of therapy.
Reiterating role of FRAX in the diagnosis of patients with osteopenia
Among key updates is an emphasis on the role of the Fracture Risk Assessment Tool (FRAX) in the diagnosis of osteoporosis in patients with osteopenia.
While patients have traditionally been diagnosed with osteoporosis based on the presence of low bone mineral density (BMD) in the absence of fracture, the updated guidelines indicate that osteoporosis may be diagnosed in patients with osteopenia and an increased fracture risk using FRAX.
“The use of FRAX and osteopenia to diagnosis osteoporosis was first proposed by the National Bone Health Alliance years ago, and in the 2016 guideline, we agreed with it,” Pauline M. Camacho, MD, cochair of the guidelines task force, said in an interview.
“We reiterate in the 2020 guideline that we feel this is a valid diagnostic criteria,” said Dr. Camacho, professor of medicine and director of the Osteoporosis and Metabolic Bone Disease Center at Loyola University Chicago, Maywood, Ill. “It makes sense because when the thresholds are met by FRAX in patients with osteopenia, treatment is recommended. Therefore, why would they not fulfill treatment criteria for diagnosing osteoporosis?”
An increased risk of fracture based on a FRAX score may also be used to determine pharmacologic therapy, as can other traditional factors such as a low T score or a fragility fracture, the guidelines stated.
High risk vs. very high risk guides choice of first therapy
Another key update is the clarification of the risk stratification of patients who are high risk versus very high risk, which is key in determining the initial choice of agents and duration of therapy.
Specifically, patients should be considered at a very high fracture risk if they have the following criteria: a recent fracture (e.g., within the past 12 months), fractures while on approved osteoporosis therapy, multiple fractures, fractures while on drugs causing skeletal harm (e.g., long-term glucocorticoids), very low T score (e.g., less than −3.0), a high risk for falls or history of injurious falls, and a very high fracture probability by FRAX (e.g., major osteoporosis fracture >30%, hip fracture >4.5%) or other validated fracture risk algorithm.
Meanwhile, patients should be considered at high risk if they have been diagnosed with osteoporosis but do not meet the criteria for very high fracture risk.
Romosozumab brought into the mix
Another important update provides information on the role of one of the newest osteoporosis agents on the market, the anabolic drug romosozumab, a monoclonal antibody directed against sclerostin.
The drug’s approval by the Food and Drug Administration in 2019 for postmenopausal women at high risk of fracture was based on two large trials that showed dramatic increases in bone density through modeling as well as remodeling.
Those studies specifically showed significant reductions in radiographic vertebral fractures with romosozumab, compared with placebo and alendronate.
Dr. Camacho noted that romosozumab “will likely be for the very high risk group and those who have maxed out on teriparatide or abaloparatide.”
Romosozumab can safely be used in patients with prior radiation exposure, the guidelines noted.
Importantly, because of reports of a higher risk of serious cardiovascular events with romosozumab, compared with alendronate, romosozumab comes with a black-box warning that it should not be used in patients at high risk for cardiovascular events or who have had a recent myocardial infarction or stroke.
“Unfortunately, the very high risk group is often the older patients,” Dr. Camacho noted.
“The drug should not be given if there is a history of myocardial infarction or stroke in the past year,” she emphasized. “Clinical judgment is needed to decide who is at risk for cardiovascular complications.”
Notably, teriparatide and abaloparatide have black box warnings of their own regarding risk for osteosarcoma.
Switching therapies
Reflecting the evolving data on osteoporosis drug holidays, the guidelines also addressed the issue and the clinical challenges of switching therapies.
“In 2016, we said drug holidays are not recommended, and the treatment can be continued indefinitely, [however] in 2020, we felt that if some patients are no longer high risk, they can be transitioned off the drug,” Dr. Camacho said.
For teriparatide and abaloparatide, the FDA recommends treatment be limited to no more than 2 years, and for romosozumab, 1 year.
The updated guidelines recommend that upon discontinuation of an anabolic agent (e.g., abaloparatide, romosozumab, or teriparatide), a switch to therapy with an antiresorptive agent, such as denosumab or bisphosphonates, should be implemented to prevent loss of BMD and fracture efficacy.
Discontinuation of denosumab, however, can have notably negative effects. Clinical trials show rapid decreases in BMD when denosumab treatment is stopped after 2 or 8 years, as well as rapid loss of protection from vertebral fractures.
Therefore, if denosumab is going to be discontinued, there should be a proper transition to an antiresorptive agent for a limited time, such as one infusion of the bisphosphonate zoledronate.
Communicate the risks with and without treatment to patients
The authors underscored that, in addition to communicating the potential risk and expected benefits of osteoporosis treatments, clinicians should make sure patients fully appreciate the risk of fractures and their consequences, such as pain, disability, loss of independence, and death, when no treatment is given.
“It is incumbent on the clinician to provide this information to each patient in a manner that is fully understood, and it is equally important to learn from the patient about cultural beliefs, previous treatment experiences, fears, and concerns,” they wrote.
And in estimating patients’ fracture risk, T score must be combined with clinical risk factors, particularly advanced age and previous fracture, and clinicians should recognize that the absolute fracture risk is more useful than a risk ratio in developing treatment plans.
“Treatment recommendations may be quite different; an early postmenopausal woman with a T score of −2.5 has osteoporosis, although fracture risk is much lower than an 80-year-old woman with the same T score,” the authors explained.
Dr. Camacho reported financial relationships with Amgen and Shire. Disclosures for other task force members are detailed in the guidelines.
A version of this article originally appeared on Medscape.com.
Recommendations on use of the new dual-action anabolic agent romosozumab (Evenity, Amgen) and how to safely transition between osteoporosis agents are two of the issues addressed in the latest clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis from the American Association of Clinical Endocrinologists and American College of Endocrinology.
“This guideline is a practical tool for endocrinologists, physicians in general, regulatory bodies, health-related organizations, and interested laypersons regarding the diagnosis, evaluation, and treatment of postmenopausal osteoporosis,” the authors wrote.
The guidelines focus on 12 key clinical questions related to postmenopausal osteoporosis, with 52 specific recommendations, each graded according to the level of evidence.
They also include a treatment algorithm to help guide choice of therapy.
Reiterating role of FRAX in the diagnosis of patients with osteopenia
Among key updates is an emphasis on the role of the Fracture Risk Assessment Tool (FRAX) in the diagnosis of osteoporosis in patients with osteopenia.
While patients have traditionally been diagnosed with osteoporosis based on the presence of low bone mineral density (BMD) in the absence of fracture, the updated guidelines indicate that osteoporosis may be diagnosed in patients with osteopenia and an increased fracture risk using FRAX.
“The use of FRAX and osteopenia to diagnosis osteoporosis was first proposed by the National Bone Health Alliance years ago, and in the 2016 guideline, we agreed with it,” Pauline M. Camacho, MD, cochair of the guidelines task force, said in an interview.
“We reiterate in the 2020 guideline that we feel this is a valid diagnostic criteria,” said Dr. Camacho, professor of medicine and director of the Osteoporosis and Metabolic Bone Disease Center at Loyola University Chicago, Maywood, Ill. “It makes sense because when the thresholds are met by FRAX in patients with osteopenia, treatment is recommended. Therefore, why would they not fulfill treatment criteria for diagnosing osteoporosis?”
An increased risk of fracture based on a FRAX score may also be used to determine pharmacologic therapy, as can other traditional factors such as a low T score or a fragility fracture, the guidelines stated.
High risk vs. very high risk guides choice of first therapy
Another key update is the clarification of the risk stratification of patients who are high risk versus very high risk, which is key in determining the initial choice of agents and duration of therapy.
Specifically, patients should be considered at a very high fracture risk if they have the following criteria: a recent fracture (e.g., within the past 12 months), fractures while on approved osteoporosis therapy, multiple fractures, fractures while on drugs causing skeletal harm (e.g., long-term glucocorticoids), very low T score (e.g., less than −3.0), a high risk for falls or history of injurious falls, and a very high fracture probability by FRAX (e.g., major osteoporosis fracture >30%, hip fracture >4.5%) or other validated fracture risk algorithm.
Meanwhile, patients should be considered at high risk if they have been diagnosed with osteoporosis but do not meet the criteria for very high fracture risk.
Romosozumab brought into the mix
Another important update provides information on the role of one of the newest osteoporosis agents on the market, the anabolic drug romosozumab, a monoclonal antibody directed against sclerostin.
The drug’s approval by the Food and Drug Administration in 2019 for postmenopausal women at high risk of fracture was based on two large trials that showed dramatic increases in bone density through modeling as well as remodeling.
Those studies specifically showed significant reductions in radiographic vertebral fractures with romosozumab, compared with placebo and alendronate.
Dr. Camacho noted that romosozumab “will likely be for the very high risk group and those who have maxed out on teriparatide or abaloparatide.”
Romosozumab can safely be used in patients with prior radiation exposure, the guidelines noted.
Importantly, because of reports of a higher risk of serious cardiovascular events with romosozumab, compared with alendronate, romosozumab comes with a black-box warning that it should not be used in patients at high risk for cardiovascular events or who have had a recent myocardial infarction or stroke.
“Unfortunately, the very high risk group is often the older patients,” Dr. Camacho noted.
“The drug should not be given if there is a history of myocardial infarction or stroke in the past year,” she emphasized. “Clinical judgment is needed to decide who is at risk for cardiovascular complications.”
Notably, teriparatide and abaloparatide have black box warnings of their own regarding risk for osteosarcoma.
Switching therapies
Reflecting the evolving data on osteoporosis drug holidays, the guidelines also addressed the issue and the clinical challenges of switching therapies.
“In 2016, we said drug holidays are not recommended, and the treatment can be continued indefinitely, [however] in 2020, we felt that if some patients are no longer high risk, they can be transitioned off the drug,” Dr. Camacho said.
For teriparatide and abaloparatide, the FDA recommends treatment be limited to no more than 2 years, and for romosozumab, 1 year.
The updated guidelines recommend that upon discontinuation of an anabolic agent (e.g., abaloparatide, romosozumab, or teriparatide), a switch to therapy with an antiresorptive agent, such as denosumab or bisphosphonates, should be implemented to prevent loss of BMD and fracture efficacy.
Discontinuation of denosumab, however, can have notably negative effects. Clinical trials show rapid decreases in BMD when denosumab treatment is stopped after 2 or 8 years, as well as rapid loss of protection from vertebral fractures.
Therefore, if denosumab is going to be discontinued, there should be a proper transition to an antiresorptive agent for a limited time, such as one infusion of the bisphosphonate zoledronate.
Communicate the risks with and without treatment to patients
The authors underscored that, in addition to communicating the potential risk and expected benefits of osteoporosis treatments, clinicians should make sure patients fully appreciate the risk of fractures and their consequences, such as pain, disability, loss of independence, and death, when no treatment is given.
“It is incumbent on the clinician to provide this information to each patient in a manner that is fully understood, and it is equally important to learn from the patient about cultural beliefs, previous treatment experiences, fears, and concerns,” they wrote.
And in estimating patients’ fracture risk, T score must be combined with clinical risk factors, particularly advanced age and previous fracture, and clinicians should recognize that the absolute fracture risk is more useful than a risk ratio in developing treatment plans.
“Treatment recommendations may be quite different; an early postmenopausal woman with a T score of −2.5 has osteoporosis, although fracture risk is much lower than an 80-year-old woman with the same T score,” the authors explained.
Dr. Camacho reported financial relationships with Amgen and Shire. Disclosures for other task force members are detailed in the guidelines.
A version of this article originally appeared on Medscape.com.
Internists still low for earnings and net worth, report finds
according to the Medscape Internist Debt and Net Worth Report 2020.
The results are from a larger survey that tracked physicians’ efforts to reduce or eliminate debt, save, invest, purchase property, and prepare for retirement. The annual survey was completed just as the COVID-19 pandemic was taking hold, and the findings provide a baseline against which to view the effects of the pandemic, which turned the lives of many physicians upside down.
Conducted from Oct. 4, 2019, until Feb. 10, 2020, the survey represents 17,461 physicians from 29 areas of medicine, including family practice, internal medicine, pediatrics, and obstetrics and gynecology.
Earnings and net worth
Internists earned on average $251,000 annually, sixth from the bottom of the list and approximately half the amount of the most lucrative specialty, orthopedics. The annual salary increased from $243,000 in 2019.
The average annual salary for internists represents a 2.5% increase, compared with the 1.5% increase for specialists, whose annual income rose from $341,000 in 2019 to $346,000 in 2020.
The low earnings for internists are echoed in the findings for net worth: 58% of internists have a net worth of less than $1 million, 37% have between $1 million and $5 million, and 5% have more than $5 million. For comparison, half of all physicians have a net worth of less than $1 million, 42% have between $1 million and $5 million, and 8% have over $5 million.
About 40% of internists indicated that their net worth was less than $500,000, which is the fourth highest of the 29 medical fields surveyed. About 44% of pediatricians, 46% of family practitioners, and 30% of ob.gyns. also reported their net worth at less than $500,000, so the primary care providers share low net worth compared with their colleagues. About 41% of neurologists reported a net worth of less than $500,000.
Only 5% of internists reported a net worth of more than $5 million. The specialties with the most physicians with net worth exceeding $5 million are orthopedists, at 19%, and plastic surgeons and gastroenterologists, each at 16%.
Gender disparity in net worth appears to be lower among internists than in other fields. Among all physicians, 56% of men and 39% of women reported a net worth in excess of $1 million, but among internists, 46% of men and 36% of women did so. About 64% of the internists who took the survey are men, and 34% are women.
Higher net worth tracks clearly with age group, as expected in light of diminishing debt over time and an accumulation of wealth.
Expenses
The top three expenses that internists face are mortgage on primary residence (60%), car loans (36%), and credit card debt (26%); 12% of respondents reported no debt or expenses. Among all physicians, the breakdown of expenses by category is very similar to that for internists.
Paying off school loans affects 24% of internists, which was in the middle of the 29 physician groups. The percentage ranges from physical medicine and rehabilitation at 34% to rheumatology at 15%.
About 42% of internists have a mortgage of less than $300,000, and 30% have no mortgage at all. Figures are similar for all physicians.
Internists are apparently savers and not spenders. Only 8% reported living above their means; 39% indicated that they live below their means. These figures are similar for all physicians who responded to the survey.
About 60% of internists put more than $1,000 a month into tax-deferred accounts. Most internists also contribute to taxable savings accounts, which might reflect the fact that they had contributed the maximum amount to tax-deferred accounts.
Two-fifths of the internists reported having worked with a financial planner. Of the nearly three fourths of responding internists who share finances with a spouse or partner, a few more than half pool resources.
In the world before COVID-19, 31% of internists reported significant financial losses over the previous year, most because of bad investments or problems relating to their practice. Financial losses since that time obviously have another predominant cause – the direct and ripple effects of the pandemic.
As of July 22, primary care providers reported a 55% decrease in revenue and a 20%-30% decrease in patient volume, according to Travis Singleton, senior vice president of Merritt Hawkins, a physician placement and recruiting company. Some practitioners have closed their physical offices because patient demand has plummeted and nonessential office procedures and exams have been postponed or canceled. The use of telemedicine has soared.
Medscape’s Internist Debt and Net Worth Report 2020, and the larger report from which it was derived, may come to serve as a marker between two very different financial worlds for clinical medicine.
A version of this article originally appeared on Medscape.com.
according to the Medscape Internist Debt and Net Worth Report 2020.
The results are from a larger survey that tracked physicians’ efforts to reduce or eliminate debt, save, invest, purchase property, and prepare for retirement. The annual survey was completed just as the COVID-19 pandemic was taking hold, and the findings provide a baseline against which to view the effects of the pandemic, which turned the lives of many physicians upside down.
Conducted from Oct. 4, 2019, until Feb. 10, 2020, the survey represents 17,461 physicians from 29 areas of medicine, including family practice, internal medicine, pediatrics, and obstetrics and gynecology.
Earnings and net worth
Internists earned on average $251,000 annually, sixth from the bottom of the list and approximately half the amount of the most lucrative specialty, orthopedics. The annual salary increased from $243,000 in 2019.
The average annual salary for internists represents a 2.5% increase, compared with the 1.5% increase for specialists, whose annual income rose from $341,000 in 2019 to $346,000 in 2020.
The low earnings for internists are echoed in the findings for net worth: 58% of internists have a net worth of less than $1 million, 37% have between $1 million and $5 million, and 5% have more than $5 million. For comparison, half of all physicians have a net worth of less than $1 million, 42% have between $1 million and $5 million, and 8% have over $5 million.
About 40% of internists indicated that their net worth was less than $500,000, which is the fourth highest of the 29 medical fields surveyed. About 44% of pediatricians, 46% of family practitioners, and 30% of ob.gyns. also reported their net worth at less than $500,000, so the primary care providers share low net worth compared with their colleagues. About 41% of neurologists reported a net worth of less than $500,000.
Only 5% of internists reported a net worth of more than $5 million. The specialties with the most physicians with net worth exceeding $5 million are orthopedists, at 19%, and plastic surgeons and gastroenterologists, each at 16%.
Gender disparity in net worth appears to be lower among internists than in other fields. Among all physicians, 56% of men and 39% of women reported a net worth in excess of $1 million, but among internists, 46% of men and 36% of women did so. About 64% of the internists who took the survey are men, and 34% are women.
Higher net worth tracks clearly with age group, as expected in light of diminishing debt over time and an accumulation of wealth.
Expenses
The top three expenses that internists face are mortgage on primary residence (60%), car loans (36%), and credit card debt (26%); 12% of respondents reported no debt or expenses. Among all physicians, the breakdown of expenses by category is very similar to that for internists.
Paying off school loans affects 24% of internists, which was in the middle of the 29 physician groups. The percentage ranges from physical medicine and rehabilitation at 34% to rheumatology at 15%.
About 42% of internists have a mortgage of less than $300,000, and 30% have no mortgage at all. Figures are similar for all physicians.
Internists are apparently savers and not spenders. Only 8% reported living above their means; 39% indicated that they live below their means. These figures are similar for all physicians who responded to the survey.
About 60% of internists put more than $1,000 a month into tax-deferred accounts. Most internists also contribute to taxable savings accounts, which might reflect the fact that they had contributed the maximum amount to tax-deferred accounts.
Two-fifths of the internists reported having worked with a financial planner. Of the nearly three fourths of responding internists who share finances with a spouse or partner, a few more than half pool resources.
In the world before COVID-19, 31% of internists reported significant financial losses over the previous year, most because of bad investments or problems relating to their practice. Financial losses since that time obviously have another predominant cause – the direct and ripple effects of the pandemic.
As of July 22, primary care providers reported a 55% decrease in revenue and a 20%-30% decrease in patient volume, according to Travis Singleton, senior vice president of Merritt Hawkins, a physician placement and recruiting company. Some practitioners have closed their physical offices because patient demand has plummeted and nonessential office procedures and exams have been postponed or canceled. The use of telemedicine has soared.
Medscape’s Internist Debt and Net Worth Report 2020, and the larger report from which it was derived, may come to serve as a marker between two very different financial worlds for clinical medicine.
A version of this article originally appeared on Medscape.com.
according to the Medscape Internist Debt and Net Worth Report 2020.
The results are from a larger survey that tracked physicians’ efforts to reduce or eliminate debt, save, invest, purchase property, and prepare for retirement. The annual survey was completed just as the COVID-19 pandemic was taking hold, and the findings provide a baseline against which to view the effects of the pandemic, which turned the lives of many physicians upside down.
Conducted from Oct. 4, 2019, until Feb. 10, 2020, the survey represents 17,461 physicians from 29 areas of medicine, including family practice, internal medicine, pediatrics, and obstetrics and gynecology.
Earnings and net worth
Internists earned on average $251,000 annually, sixth from the bottom of the list and approximately half the amount of the most lucrative specialty, orthopedics. The annual salary increased from $243,000 in 2019.
The average annual salary for internists represents a 2.5% increase, compared with the 1.5% increase for specialists, whose annual income rose from $341,000 in 2019 to $346,000 in 2020.
The low earnings for internists are echoed in the findings for net worth: 58% of internists have a net worth of less than $1 million, 37% have between $1 million and $5 million, and 5% have more than $5 million. For comparison, half of all physicians have a net worth of less than $1 million, 42% have between $1 million and $5 million, and 8% have over $5 million.
About 40% of internists indicated that their net worth was less than $500,000, which is the fourth highest of the 29 medical fields surveyed. About 44% of pediatricians, 46% of family practitioners, and 30% of ob.gyns. also reported their net worth at less than $500,000, so the primary care providers share low net worth compared with their colleagues. About 41% of neurologists reported a net worth of less than $500,000.
Only 5% of internists reported a net worth of more than $5 million. The specialties with the most physicians with net worth exceeding $5 million are orthopedists, at 19%, and plastic surgeons and gastroenterologists, each at 16%.
Gender disparity in net worth appears to be lower among internists than in other fields. Among all physicians, 56% of men and 39% of women reported a net worth in excess of $1 million, but among internists, 46% of men and 36% of women did so. About 64% of the internists who took the survey are men, and 34% are women.
Higher net worth tracks clearly with age group, as expected in light of diminishing debt over time and an accumulation of wealth.
Expenses
The top three expenses that internists face are mortgage on primary residence (60%), car loans (36%), and credit card debt (26%); 12% of respondents reported no debt or expenses. Among all physicians, the breakdown of expenses by category is very similar to that for internists.
Paying off school loans affects 24% of internists, which was in the middle of the 29 physician groups. The percentage ranges from physical medicine and rehabilitation at 34% to rheumatology at 15%.
About 42% of internists have a mortgage of less than $300,000, and 30% have no mortgage at all. Figures are similar for all physicians.
Internists are apparently savers and not spenders. Only 8% reported living above their means; 39% indicated that they live below their means. These figures are similar for all physicians who responded to the survey.
About 60% of internists put more than $1,000 a month into tax-deferred accounts. Most internists also contribute to taxable savings accounts, which might reflect the fact that they had contributed the maximum amount to tax-deferred accounts.
Two-fifths of the internists reported having worked with a financial planner. Of the nearly three fourths of responding internists who share finances with a spouse or partner, a few more than half pool resources.
In the world before COVID-19, 31% of internists reported significant financial losses over the previous year, most because of bad investments or problems relating to their practice. Financial losses since that time obviously have another predominant cause – the direct and ripple effects of the pandemic.
As of July 22, primary care providers reported a 55% decrease in revenue and a 20%-30% decrease in patient volume, according to Travis Singleton, senior vice president of Merritt Hawkins, a physician placement and recruiting company. Some practitioners have closed their physical offices because patient demand has plummeted and nonessential office procedures and exams have been postponed or canceled. The use of telemedicine has soared.
Medscape’s Internist Debt and Net Worth Report 2020, and the larger report from which it was derived, may come to serve as a marker between two very different financial worlds for clinical medicine.
A version of this article originally appeared on Medscape.com.
‘Defending Jacob’ and defending psychiatry
The 2012 crime fiction novel, “Defending Jacob,” by William Landay was dramatized into a miniseries created by Mark Bomback that premiered on April 24, 2020, on Apple TV+ (and for those resisting a subscription, “The Morning Show” and “Defending Jacob” are both worth it). Both the “Defending Jacob” novel and the miniseries have themes that are of interest to psychiatry, especially to child and forensic psychiatrists, and both the literary and TV versions are excellent, albeit disturbing, diversions from the current pandemic.
(Spoiler alert!) The story is set in the affluent town of Newton, Mass., where crime is generally low and homicides extremely infrequent. Protagonist Andy Barber, a 51-year-old Jewish assistant district attorney, is played by a younger Chris Evans in the miniseries. His wife, Laurie Gold Barber, a 51-year-old Jewish former schoolteacher and stay-at-home mom, is played by a younger Michelle Dockery of Downton Abbey fame. In the miniseries, her character is actively working as a teacher and social activist for children. Other differences between the novel and the miniseries will be pointed out when relevant, but the overall narrative is similar. Both stories are cleverly told through Andy Barber speaking in retrospect as he is being questioned in front of a grand jury for a potential indictment.
When 14-year-old Ben Rifkin is found stabbed to death in Cold Spring Park before school one morning, Andy Barber initially takes the case despite his boss’s reservations that there may be a conflict because Andy’s son Jacob is a student in Ben’s class at school. As the title suggests, it soon becomes clear that Jacob may have had something to do with the murder. At that point, Andy is taken off the case and it is given to a junior colleague, Neal Logiudice, who demonstrates both admiration and contempt for his former mentor, perhaps because of underlying jealousy and insecurity. Neal Logiudice becomes the DA questioning Andy Barber.
Prior to Jacob’s formal accusation of murder, the Barbers appear to be fiercely loyal and unable to fully see and understand their son. The difficulty with objectivity and the reasons why family member physicians should never treat family members – and why family member attorneys should never represent loved ones – is abundantly clear in this story. When Andy receives an anonymous tip that Jacob’s childhood best friend, Derek Yoo, posted on Facebook, “Jake, everyone knows you did it. You have a knife. I’ve seen it,’ ” Andy then looks through Jacob’s drawers and finds a folding knife in one of his T-shirts. In the chapter aptly titled “Denial,” Andy, an experienced prosecutor, does not turn the knife over as evidence, but instead disposes of it – believing Jacob that he did not take the knife to school the day his classmate was stabbed.
After Jacob is indicted, Andy Barber confesses to his wife, Laurie, that his estranged father who left when he was 6 is actually in prison convicted of murdering and raping a woman. In the novel, his grandfather and great-grandfather are also convicted felons. Laurie reveals this family history to Jacob’s attorney, and the attorney subsequently refers the family to a forensic psychologist. In the novel, she is a large Jewish woman; in the miniseries she is played by a very thin Poorna Jagannathan (who incidentally has portrayed a therapist in the television series “Sorry for your Loss,” and a doctor in “The Act,” “Better Call Saul,” “NCIS: Los Angeles,” “House of Cards,” “The Game,” “Law and Order: Criminal Intent,” “Rescue Me,” “Jonny Zero,” “An Actor Prepares,” “The Circle,” “Thanks for Sharing,” and “Montclair.”) Although the goal of the defense was a finding of “not guilty,” a psychiatric defense was going to be used as a last resort if necessary.
Laurie had already googled and learned of “the murder gene,” which was further explained by the forensic psychologist as a mutation called:
“MAOA Knockout. It has been argued in court as a trigger for violence before, but the argument was too simplistic, and it was rejected. Our understanding of the gene-environment interplay has improved since then – the science is getting better and very quickly – and we may have better testimony now. The second mutation is located in what’s called the serotonin transporter gene. The official name for the gene is SLC6A4. It’s located on chromosome 17. It encodes a protein that facilitates the activity of the serotonin transporter system, which is what enables the reuptake of serotonin from the synapse back into the neuron.”1
She further explains that there have been many studies on the “nurture” side of the nature/nurture question and that, with new developments in DNA studies, it is now becoming possible to study the “nature” side.
“Defending Jacob” explores the nature/nurture issue, as well as issues with forensic testimony in court and the criminal justice system in general. The issue of repressing feelings and hiding secrets and then having to confront both in a brutal manner is another theme addressed in the story. Andy tried to hide and forget that his father was in prison and the criminal history in his family, but he was forced to face this and his feelings about it when confronted with his own son being accused of murder. Of note, he does not seek help from a therapist despite these life-altering events. (Humongous spoiler alert:) The story that began with a murder of an unrelated child may end with a family murder, one that would be well described and could be understood by psychiatrists using the categories of motives initially described by Phillip Resnick, MD.2
Once again, and unfortunately, as we have pointed out in other media reviews, the portrayal of psychiatric/psychological themes is problematic. Using a psychologist to explain the science of DNA and not a psychiatrist is an interesting choice. Diagnosing a 14-year-old with personality disorders also contributes to misunderstanding and stigma. In addition, no timely attempt is made to refer the accused Jacob for mental health treatment. The stigmatization of psychiatry in the media was addressed by the World Psychiatric Association task force guidance on how to combat stigmatization of psychiatry and psychiatrists,3 including breaking down negative views of psychiatrists and psychiatry in the general public, among medical students, other health professionals, and patients and relatives. The task force made recommendations for national psychiatric societies and for individual practitioners to help reduce stigma of the profession of psychiatry. We would argue that speaking to the media, including fiction authors, to help educate about mental health is an important role for psychiatrists. It would lead to more realistic portrayals in film and books.
Overall, “Defending Jacob” is a compelling story in both the novel and the miniseries. Despite some problems with how it depicts mental health issues, both are engaging and contain thoughtful, extremely well-written themes of interest to many clinical and forensic psychiatrists.
References
1. Landay W. Defending Jacob, a novel. New York: Delacorte Press, 2012.
2. Friedman SH. Family Murder: Pathologies of Love and Hate. Washington: American Psychiatric Association Publishing, 2019.
3. Sartorius N et al. World Psychiatry. 2010 Oct;9(3):131-44.
Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill Cornell Medical Center. Dr. Hatters Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington: American Psychiatric Association Publishing, 2019), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law and was awarded the 2020 Manfred Gutmacher Award by the American Psychiatric Association.
The 2012 crime fiction novel, “Defending Jacob,” by William Landay was dramatized into a miniseries created by Mark Bomback that premiered on April 24, 2020, on Apple TV+ (and for those resisting a subscription, “The Morning Show” and “Defending Jacob” are both worth it). Both the “Defending Jacob” novel and the miniseries have themes that are of interest to psychiatry, especially to child and forensic psychiatrists, and both the literary and TV versions are excellent, albeit disturbing, diversions from the current pandemic.
(Spoiler alert!) The story is set in the affluent town of Newton, Mass., where crime is generally low and homicides extremely infrequent. Protagonist Andy Barber, a 51-year-old Jewish assistant district attorney, is played by a younger Chris Evans in the miniseries. His wife, Laurie Gold Barber, a 51-year-old Jewish former schoolteacher and stay-at-home mom, is played by a younger Michelle Dockery of Downton Abbey fame. In the miniseries, her character is actively working as a teacher and social activist for children. Other differences between the novel and the miniseries will be pointed out when relevant, but the overall narrative is similar. Both stories are cleverly told through Andy Barber speaking in retrospect as he is being questioned in front of a grand jury for a potential indictment.
When 14-year-old Ben Rifkin is found stabbed to death in Cold Spring Park before school one morning, Andy Barber initially takes the case despite his boss’s reservations that there may be a conflict because Andy’s son Jacob is a student in Ben’s class at school. As the title suggests, it soon becomes clear that Jacob may have had something to do with the murder. At that point, Andy is taken off the case and it is given to a junior colleague, Neal Logiudice, who demonstrates both admiration and contempt for his former mentor, perhaps because of underlying jealousy and insecurity. Neal Logiudice becomes the DA questioning Andy Barber.
Prior to Jacob’s formal accusation of murder, the Barbers appear to be fiercely loyal and unable to fully see and understand their son. The difficulty with objectivity and the reasons why family member physicians should never treat family members – and why family member attorneys should never represent loved ones – is abundantly clear in this story. When Andy receives an anonymous tip that Jacob’s childhood best friend, Derek Yoo, posted on Facebook, “Jake, everyone knows you did it. You have a knife. I’ve seen it,’ ” Andy then looks through Jacob’s drawers and finds a folding knife in one of his T-shirts. In the chapter aptly titled “Denial,” Andy, an experienced prosecutor, does not turn the knife over as evidence, but instead disposes of it – believing Jacob that he did not take the knife to school the day his classmate was stabbed.
After Jacob is indicted, Andy Barber confesses to his wife, Laurie, that his estranged father who left when he was 6 is actually in prison convicted of murdering and raping a woman. In the novel, his grandfather and great-grandfather are also convicted felons. Laurie reveals this family history to Jacob’s attorney, and the attorney subsequently refers the family to a forensic psychologist. In the novel, she is a large Jewish woman; in the miniseries she is played by a very thin Poorna Jagannathan (who incidentally has portrayed a therapist in the television series “Sorry for your Loss,” and a doctor in “The Act,” “Better Call Saul,” “NCIS: Los Angeles,” “House of Cards,” “The Game,” “Law and Order: Criminal Intent,” “Rescue Me,” “Jonny Zero,” “An Actor Prepares,” “The Circle,” “Thanks for Sharing,” and “Montclair.”) Although the goal of the defense was a finding of “not guilty,” a psychiatric defense was going to be used as a last resort if necessary.
Laurie had already googled and learned of “the murder gene,” which was further explained by the forensic psychologist as a mutation called:
“MAOA Knockout. It has been argued in court as a trigger for violence before, but the argument was too simplistic, and it was rejected. Our understanding of the gene-environment interplay has improved since then – the science is getting better and very quickly – and we may have better testimony now. The second mutation is located in what’s called the serotonin transporter gene. The official name for the gene is SLC6A4. It’s located on chromosome 17. It encodes a protein that facilitates the activity of the serotonin transporter system, which is what enables the reuptake of serotonin from the synapse back into the neuron.”1
She further explains that there have been many studies on the “nurture” side of the nature/nurture question and that, with new developments in DNA studies, it is now becoming possible to study the “nature” side.
“Defending Jacob” explores the nature/nurture issue, as well as issues with forensic testimony in court and the criminal justice system in general. The issue of repressing feelings and hiding secrets and then having to confront both in a brutal manner is another theme addressed in the story. Andy tried to hide and forget that his father was in prison and the criminal history in his family, but he was forced to face this and his feelings about it when confronted with his own son being accused of murder. Of note, he does not seek help from a therapist despite these life-altering events. (Humongous spoiler alert:) The story that began with a murder of an unrelated child may end with a family murder, one that would be well described and could be understood by psychiatrists using the categories of motives initially described by Phillip Resnick, MD.2
Once again, and unfortunately, as we have pointed out in other media reviews, the portrayal of psychiatric/psychological themes is problematic. Using a psychologist to explain the science of DNA and not a psychiatrist is an interesting choice. Diagnosing a 14-year-old with personality disorders also contributes to misunderstanding and stigma. In addition, no timely attempt is made to refer the accused Jacob for mental health treatment. The stigmatization of psychiatry in the media was addressed by the World Psychiatric Association task force guidance on how to combat stigmatization of psychiatry and psychiatrists,3 including breaking down negative views of psychiatrists and psychiatry in the general public, among medical students, other health professionals, and patients and relatives. The task force made recommendations for national psychiatric societies and for individual practitioners to help reduce stigma of the profession of psychiatry. We would argue that speaking to the media, including fiction authors, to help educate about mental health is an important role for psychiatrists. It would lead to more realistic portrayals in film and books.
Overall, “Defending Jacob” is a compelling story in both the novel and the miniseries. Despite some problems with how it depicts mental health issues, both are engaging and contain thoughtful, extremely well-written themes of interest to many clinical and forensic psychiatrists.
References
1. Landay W. Defending Jacob, a novel. New York: Delacorte Press, 2012.
2. Friedman SH. Family Murder: Pathologies of Love and Hate. Washington: American Psychiatric Association Publishing, 2019.
3. Sartorius N et al. World Psychiatry. 2010 Oct;9(3):131-44.
Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill Cornell Medical Center. Dr. Hatters Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington: American Psychiatric Association Publishing, 2019), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law and was awarded the 2020 Manfred Gutmacher Award by the American Psychiatric Association.
The 2012 crime fiction novel, “Defending Jacob,” by William Landay was dramatized into a miniseries created by Mark Bomback that premiered on April 24, 2020, on Apple TV+ (and for those resisting a subscription, “The Morning Show” and “Defending Jacob” are both worth it). Both the “Defending Jacob” novel and the miniseries have themes that are of interest to psychiatry, especially to child and forensic psychiatrists, and both the literary and TV versions are excellent, albeit disturbing, diversions from the current pandemic.
(Spoiler alert!) The story is set in the affluent town of Newton, Mass., where crime is generally low and homicides extremely infrequent. Protagonist Andy Barber, a 51-year-old Jewish assistant district attorney, is played by a younger Chris Evans in the miniseries. His wife, Laurie Gold Barber, a 51-year-old Jewish former schoolteacher and stay-at-home mom, is played by a younger Michelle Dockery of Downton Abbey fame. In the miniseries, her character is actively working as a teacher and social activist for children. Other differences between the novel and the miniseries will be pointed out when relevant, but the overall narrative is similar. Both stories are cleverly told through Andy Barber speaking in retrospect as he is being questioned in front of a grand jury for a potential indictment.
When 14-year-old Ben Rifkin is found stabbed to death in Cold Spring Park before school one morning, Andy Barber initially takes the case despite his boss’s reservations that there may be a conflict because Andy’s son Jacob is a student in Ben’s class at school. As the title suggests, it soon becomes clear that Jacob may have had something to do with the murder. At that point, Andy is taken off the case and it is given to a junior colleague, Neal Logiudice, who demonstrates both admiration and contempt for his former mentor, perhaps because of underlying jealousy and insecurity. Neal Logiudice becomes the DA questioning Andy Barber.
Prior to Jacob’s formal accusation of murder, the Barbers appear to be fiercely loyal and unable to fully see and understand their son. The difficulty with objectivity and the reasons why family member physicians should never treat family members – and why family member attorneys should never represent loved ones – is abundantly clear in this story. When Andy receives an anonymous tip that Jacob’s childhood best friend, Derek Yoo, posted on Facebook, “Jake, everyone knows you did it. You have a knife. I’ve seen it,’ ” Andy then looks through Jacob’s drawers and finds a folding knife in one of his T-shirts. In the chapter aptly titled “Denial,” Andy, an experienced prosecutor, does not turn the knife over as evidence, but instead disposes of it – believing Jacob that he did not take the knife to school the day his classmate was stabbed.
After Jacob is indicted, Andy Barber confesses to his wife, Laurie, that his estranged father who left when he was 6 is actually in prison convicted of murdering and raping a woman. In the novel, his grandfather and great-grandfather are also convicted felons. Laurie reveals this family history to Jacob’s attorney, and the attorney subsequently refers the family to a forensic psychologist. In the novel, she is a large Jewish woman; in the miniseries she is played by a very thin Poorna Jagannathan (who incidentally has portrayed a therapist in the television series “Sorry for your Loss,” and a doctor in “The Act,” “Better Call Saul,” “NCIS: Los Angeles,” “House of Cards,” “The Game,” “Law and Order: Criminal Intent,” “Rescue Me,” “Jonny Zero,” “An Actor Prepares,” “The Circle,” “Thanks for Sharing,” and “Montclair.”) Although the goal of the defense was a finding of “not guilty,” a psychiatric defense was going to be used as a last resort if necessary.
Laurie had already googled and learned of “the murder gene,” which was further explained by the forensic psychologist as a mutation called:
“MAOA Knockout. It has been argued in court as a trigger for violence before, but the argument was too simplistic, and it was rejected. Our understanding of the gene-environment interplay has improved since then – the science is getting better and very quickly – and we may have better testimony now. The second mutation is located in what’s called the serotonin transporter gene. The official name for the gene is SLC6A4. It’s located on chromosome 17. It encodes a protein that facilitates the activity of the serotonin transporter system, which is what enables the reuptake of serotonin from the synapse back into the neuron.”1
She further explains that there have been many studies on the “nurture” side of the nature/nurture question and that, with new developments in DNA studies, it is now becoming possible to study the “nature” side.
“Defending Jacob” explores the nature/nurture issue, as well as issues with forensic testimony in court and the criminal justice system in general. The issue of repressing feelings and hiding secrets and then having to confront both in a brutal manner is another theme addressed in the story. Andy tried to hide and forget that his father was in prison and the criminal history in his family, but he was forced to face this and his feelings about it when confronted with his own son being accused of murder. Of note, he does not seek help from a therapist despite these life-altering events. (Humongous spoiler alert:) The story that began with a murder of an unrelated child may end with a family murder, one that would be well described and could be understood by psychiatrists using the categories of motives initially described by Phillip Resnick, MD.2
Once again, and unfortunately, as we have pointed out in other media reviews, the portrayal of psychiatric/psychological themes is problematic. Using a psychologist to explain the science of DNA and not a psychiatrist is an interesting choice. Diagnosing a 14-year-old with personality disorders also contributes to misunderstanding and stigma. In addition, no timely attempt is made to refer the accused Jacob for mental health treatment. The stigmatization of psychiatry in the media was addressed by the World Psychiatric Association task force guidance on how to combat stigmatization of psychiatry and psychiatrists,3 including breaking down negative views of psychiatrists and psychiatry in the general public, among medical students, other health professionals, and patients and relatives. The task force made recommendations for national psychiatric societies and for individual practitioners to help reduce stigma of the profession of psychiatry. We would argue that speaking to the media, including fiction authors, to help educate about mental health is an important role for psychiatrists. It would lead to more realistic portrayals in film and books.
Overall, “Defending Jacob” is a compelling story in both the novel and the miniseries. Despite some problems with how it depicts mental health issues, both are engaging and contain thoughtful, extremely well-written themes of interest to many clinical and forensic psychiatrists.
References
1. Landay W. Defending Jacob, a novel. New York: Delacorte Press, 2012.
2. Friedman SH. Family Murder: Pathologies of Love and Hate. Washington: American Psychiatric Association Publishing, 2019.
3. Sartorius N et al. World Psychiatry. 2010 Oct;9(3):131-44.
Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill Cornell Medical Center. Dr. Hatters Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington: American Psychiatric Association Publishing, 2019), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law and was awarded the 2020 Manfred Gutmacher Award by the American Psychiatric Association.
Novel drug may lower agitation, aggression in multiple psychiatric disorders
The novel lysine-specific demethylase 1 inhibitor vafidemstat (ORY-2001, Oryzon Genomics) is effective for treating agitation and aggression across a number of psychiatric disorders, new research suggests.
The REIMAGINE trial included 30 patients with autism spectrum disorder (ASD), ADHD, or borderline personality disorder (BPD). Results showed significant improvements after 8 weeks in general functioning and agitation-aggression scores for all three disorders.
The study “supports vafidemstat as an emerging therapeutic option to treat aggression-agitation, as well as the nonaggression features of psychiatric diseases with high unmet medical need,” lead researcher Roger Bullock, MD, Oryzon Genomics, Corneliá De Llobregat, Spain, told Medscape Medical News.
Bullock added.
However, another expert urged prudence when interpreting the findings.
“The study results must be viewed with caution, given the inherent limitations of an open-label trial, small sample size, and weak rationale for the sample selection,” said Nathan Kolla, MD, PhD, a psychiatrist at the University of Toronto, Canada, who was not involved with the research.
The findings were presented at the European Psychiatric Association (EPA) 2020 Congress, which was held online this year because of the COVID-19 pandemic.
Little evidence available
“Epigenetic mechanisms have been proposed in many psychiatric conditions, but so far, little clinical evidence is available,” Bullock said during his presentation.
In preclinical models, vafidemstat has been associated with a reduction in aggressive behavior “and the normal response to stress of immediate early genes in the prefrontal cortex” via the modification of gene transcription, noted Bullock.
“This new approach makes it a good candidate to look at aggression in multiple psychiatric and CNS conditions,” he added.
REIMAGINE was a phase 2a open-label trial that included 30 patients (53% women; mean age, 33.5 years; 87% White) with psychiatric disorders who had significant or persistent agitation or aggression that was disruptive of the patients› daily life.
Among the participants, 12 had BPD, 11 had ADHD, and seven had ASD. All were treated with vafidemstat 1.2 mg for 8 weeks.
In all, 23 patients completed all 8 weeks of treatment, including nine patients with BPD, eight with ADHD, and six with ASD.
Results showed that the study drug was well tolerated, with no serious adverse events reported and no patients withdrawing because of safety-related events.
The most common adverse events were headache (20%) and insomnia (10%), which resolved without intervention or treatment modification.
Significantly improved scores
Across the whole cohort, the drug was associated with significant reductions in scores over baseline on the Clinical Global Impression–Severity (CGI-S) and CGI-Improvement (CGI-I) scales. There were also significant improvements for Neuropsychiatric Inventory (NPI) total scores and agitation-aggression scores (P < .001 for comparisons).
Similar results were observed with respect to individual diagnoses, albeit at varying degrees of significance for each scale.
Patients with BPD experienced significant reductions in scores on the Borderline Personality Disorder Checklist (BPDCL) (P < .01). Patients with ADHD experienced reductions on the ADHD Rating Scale (P < .05).
Patients with BPD also experienced reductions in suicidal ideation, as measured with the Columbia Suicide Severity Rating Scale (P < .01). That is “the only cohort where this trait is relevant,” the researchers note.
In addition, significant correlations were shown between NPI total scores and scores on the BPDCL after treatment with vafidemstat (P = .015), as well as between NPI agitation-aggression scores and both CGI-I (P = .008) and CGI-S scores (P = .0001).
“This convergence of signals in scales of different nature and scope support the pharmacological role of vafidemstat in controlling aggression-agitation in different psychiatric conditions,” the investigators note.
Bullock added that further randomized placebo-controlled clinical trials “to confirm vafidemstat’s potential to treat aggression-agitation in psychiatric disorders are now planned.”
First up will be PORTICO, which is planned to start over the coming months in Spain and will include patients with BPD.
Several limitations
Commenting on the study for Medscape Medical News, Kolla, who is also a researcher at the Center for Addiction and Mental Health, noted that REIMAGINE was originally designed to test vafidemstat for the treatment of agitation and aggression in patients with Alzheimer’s disease (AD).
“It seems peculiar that the study investigators would choose to examine three additional psychiatric disorders that bear little resemblance to AD in terms of phenomenology. Additionally, the etiological underpinnings of the three disorders likely differ markedly from AD,” said Kolla, who was not involved with the research.
In addition, the “very small” sample size in each group makes it difficult to interpret the investigators’ conclusions, he noted.
There are also “many more sophisticated scales” to assess agitation and aggression than what were used in the study, he added.
Kolla also questioned the notion that a drug such as vafidemstat satisfies an unmet clinical need for the treatment of aggression and agitation.
Trials that “purport to reduce aggression in these populations often provide some level of global improvement in functioning that may appear as if they directly treat agitation or aggression,” he said. “However, no drug has ever been developed that directly reduces aggression and agitation.”
That means that, for now, there is insufficient evidence to “conclude that vafidemstat overcomes the unmet medical need of treating aggression/agitation,” he said.
For Kolla, the concept of a psychiatric drug that works by effecting epigenetic changes to the genome is also questionable, although such mechanisms may “play a role in the salubrious effects of certain mood stabilizers or antipsychotics for which better-defined mechanisms of action have been established.”
The study was funded by Oryzon Genomics. Bullock and the other investigators are employees of Oryzon Genomics.
This article first appeared on Medscape.com.
The novel lysine-specific demethylase 1 inhibitor vafidemstat (ORY-2001, Oryzon Genomics) is effective for treating agitation and aggression across a number of psychiatric disorders, new research suggests.
The REIMAGINE trial included 30 patients with autism spectrum disorder (ASD), ADHD, or borderline personality disorder (BPD). Results showed significant improvements after 8 weeks in general functioning and agitation-aggression scores for all three disorders.
The study “supports vafidemstat as an emerging therapeutic option to treat aggression-agitation, as well as the nonaggression features of psychiatric diseases with high unmet medical need,” lead researcher Roger Bullock, MD, Oryzon Genomics, Corneliá De Llobregat, Spain, told Medscape Medical News.
Bullock added.
However, another expert urged prudence when interpreting the findings.
“The study results must be viewed with caution, given the inherent limitations of an open-label trial, small sample size, and weak rationale for the sample selection,” said Nathan Kolla, MD, PhD, a psychiatrist at the University of Toronto, Canada, who was not involved with the research.
The findings were presented at the European Psychiatric Association (EPA) 2020 Congress, which was held online this year because of the COVID-19 pandemic.
Little evidence available
“Epigenetic mechanisms have been proposed in many psychiatric conditions, but so far, little clinical evidence is available,” Bullock said during his presentation.
In preclinical models, vafidemstat has been associated with a reduction in aggressive behavior “and the normal response to stress of immediate early genes in the prefrontal cortex” via the modification of gene transcription, noted Bullock.
“This new approach makes it a good candidate to look at aggression in multiple psychiatric and CNS conditions,” he added.
REIMAGINE was a phase 2a open-label trial that included 30 patients (53% women; mean age, 33.5 years; 87% White) with psychiatric disorders who had significant or persistent agitation or aggression that was disruptive of the patients› daily life.
Among the participants, 12 had BPD, 11 had ADHD, and seven had ASD. All were treated with vafidemstat 1.2 mg for 8 weeks.
In all, 23 patients completed all 8 weeks of treatment, including nine patients with BPD, eight with ADHD, and six with ASD.
Results showed that the study drug was well tolerated, with no serious adverse events reported and no patients withdrawing because of safety-related events.
The most common adverse events were headache (20%) and insomnia (10%), which resolved without intervention or treatment modification.
Significantly improved scores
Across the whole cohort, the drug was associated with significant reductions in scores over baseline on the Clinical Global Impression–Severity (CGI-S) and CGI-Improvement (CGI-I) scales. There were also significant improvements for Neuropsychiatric Inventory (NPI) total scores and agitation-aggression scores (P < .001 for comparisons).
Similar results were observed with respect to individual diagnoses, albeit at varying degrees of significance for each scale.
Patients with BPD experienced significant reductions in scores on the Borderline Personality Disorder Checklist (BPDCL) (P < .01). Patients with ADHD experienced reductions on the ADHD Rating Scale (P < .05).
Patients with BPD also experienced reductions in suicidal ideation, as measured with the Columbia Suicide Severity Rating Scale (P < .01). That is “the only cohort where this trait is relevant,” the researchers note.
In addition, significant correlations were shown between NPI total scores and scores on the BPDCL after treatment with vafidemstat (P = .015), as well as between NPI agitation-aggression scores and both CGI-I (P = .008) and CGI-S scores (P = .0001).
“This convergence of signals in scales of different nature and scope support the pharmacological role of vafidemstat in controlling aggression-agitation in different psychiatric conditions,” the investigators note.
Bullock added that further randomized placebo-controlled clinical trials “to confirm vafidemstat’s potential to treat aggression-agitation in psychiatric disorders are now planned.”
First up will be PORTICO, which is planned to start over the coming months in Spain and will include patients with BPD.
Several limitations
Commenting on the study for Medscape Medical News, Kolla, who is also a researcher at the Center for Addiction and Mental Health, noted that REIMAGINE was originally designed to test vafidemstat for the treatment of agitation and aggression in patients with Alzheimer’s disease (AD).
“It seems peculiar that the study investigators would choose to examine three additional psychiatric disorders that bear little resemblance to AD in terms of phenomenology. Additionally, the etiological underpinnings of the three disorders likely differ markedly from AD,” said Kolla, who was not involved with the research.
In addition, the “very small” sample size in each group makes it difficult to interpret the investigators’ conclusions, he noted.
There are also “many more sophisticated scales” to assess agitation and aggression than what were used in the study, he added.
Kolla also questioned the notion that a drug such as vafidemstat satisfies an unmet clinical need for the treatment of aggression and agitation.
Trials that “purport to reduce aggression in these populations often provide some level of global improvement in functioning that may appear as if they directly treat agitation or aggression,” he said. “However, no drug has ever been developed that directly reduces aggression and agitation.”
That means that, for now, there is insufficient evidence to “conclude that vafidemstat overcomes the unmet medical need of treating aggression/agitation,” he said.
For Kolla, the concept of a psychiatric drug that works by effecting epigenetic changes to the genome is also questionable, although such mechanisms may “play a role in the salubrious effects of certain mood stabilizers or antipsychotics for which better-defined mechanisms of action have been established.”
The study was funded by Oryzon Genomics. Bullock and the other investigators are employees of Oryzon Genomics.
This article first appeared on Medscape.com.
The novel lysine-specific demethylase 1 inhibitor vafidemstat (ORY-2001, Oryzon Genomics) is effective for treating agitation and aggression across a number of psychiatric disorders, new research suggests.
The REIMAGINE trial included 30 patients with autism spectrum disorder (ASD), ADHD, or borderline personality disorder (BPD). Results showed significant improvements after 8 weeks in general functioning and agitation-aggression scores for all three disorders.
The study “supports vafidemstat as an emerging therapeutic option to treat aggression-agitation, as well as the nonaggression features of psychiatric diseases with high unmet medical need,” lead researcher Roger Bullock, MD, Oryzon Genomics, Corneliá De Llobregat, Spain, told Medscape Medical News.
Bullock added.
However, another expert urged prudence when interpreting the findings.
“The study results must be viewed with caution, given the inherent limitations of an open-label trial, small sample size, and weak rationale for the sample selection,” said Nathan Kolla, MD, PhD, a psychiatrist at the University of Toronto, Canada, who was not involved with the research.
The findings were presented at the European Psychiatric Association (EPA) 2020 Congress, which was held online this year because of the COVID-19 pandemic.
Little evidence available
“Epigenetic mechanisms have been proposed in many psychiatric conditions, but so far, little clinical evidence is available,” Bullock said during his presentation.
In preclinical models, vafidemstat has been associated with a reduction in aggressive behavior “and the normal response to stress of immediate early genes in the prefrontal cortex” via the modification of gene transcription, noted Bullock.
“This new approach makes it a good candidate to look at aggression in multiple psychiatric and CNS conditions,” he added.
REIMAGINE was a phase 2a open-label trial that included 30 patients (53% women; mean age, 33.5 years; 87% White) with psychiatric disorders who had significant or persistent agitation or aggression that was disruptive of the patients› daily life.
Among the participants, 12 had BPD, 11 had ADHD, and seven had ASD. All were treated with vafidemstat 1.2 mg for 8 weeks.
In all, 23 patients completed all 8 weeks of treatment, including nine patients with BPD, eight with ADHD, and six with ASD.
Results showed that the study drug was well tolerated, with no serious adverse events reported and no patients withdrawing because of safety-related events.
The most common adverse events were headache (20%) and insomnia (10%), which resolved without intervention or treatment modification.
Significantly improved scores
Across the whole cohort, the drug was associated with significant reductions in scores over baseline on the Clinical Global Impression–Severity (CGI-S) and CGI-Improvement (CGI-I) scales. There were also significant improvements for Neuropsychiatric Inventory (NPI) total scores and agitation-aggression scores (P < .001 for comparisons).
Similar results were observed with respect to individual diagnoses, albeit at varying degrees of significance for each scale.
Patients with BPD experienced significant reductions in scores on the Borderline Personality Disorder Checklist (BPDCL) (P < .01). Patients with ADHD experienced reductions on the ADHD Rating Scale (P < .05).
Patients with BPD also experienced reductions in suicidal ideation, as measured with the Columbia Suicide Severity Rating Scale (P < .01). That is “the only cohort where this trait is relevant,” the researchers note.
In addition, significant correlations were shown between NPI total scores and scores on the BPDCL after treatment with vafidemstat (P = .015), as well as between NPI agitation-aggression scores and both CGI-I (P = .008) and CGI-S scores (P = .0001).
“This convergence of signals in scales of different nature and scope support the pharmacological role of vafidemstat in controlling aggression-agitation in different psychiatric conditions,” the investigators note.
Bullock added that further randomized placebo-controlled clinical trials “to confirm vafidemstat’s potential to treat aggression-agitation in psychiatric disorders are now planned.”
First up will be PORTICO, which is planned to start over the coming months in Spain and will include patients with BPD.
Several limitations
Commenting on the study for Medscape Medical News, Kolla, who is also a researcher at the Center for Addiction and Mental Health, noted that REIMAGINE was originally designed to test vafidemstat for the treatment of agitation and aggression in patients with Alzheimer’s disease (AD).
“It seems peculiar that the study investigators would choose to examine three additional psychiatric disorders that bear little resemblance to AD in terms of phenomenology. Additionally, the etiological underpinnings of the three disorders likely differ markedly from AD,” said Kolla, who was not involved with the research.
In addition, the “very small” sample size in each group makes it difficult to interpret the investigators’ conclusions, he noted.
There are also “many more sophisticated scales” to assess agitation and aggression than what were used in the study, he added.
Kolla also questioned the notion that a drug such as vafidemstat satisfies an unmet clinical need for the treatment of aggression and agitation.
Trials that “purport to reduce aggression in these populations often provide some level of global improvement in functioning that may appear as if they directly treat agitation or aggression,” he said. “However, no drug has ever been developed that directly reduces aggression and agitation.”
That means that, for now, there is insufficient evidence to “conclude that vafidemstat overcomes the unmet medical need of treating aggression/agitation,” he said.
For Kolla, the concept of a psychiatric drug that works by effecting epigenetic changes to the genome is also questionable, although such mechanisms may “play a role in the salubrious effects of certain mood stabilizers or antipsychotics for which better-defined mechanisms of action have been established.”
The study was funded by Oryzon Genomics. Bullock and the other investigators are employees of Oryzon Genomics.
This article first appeared on Medscape.com.
Survey: U.S. oncologists have high net worth, live within their means
The average annual income for oncologists surveyed was $377,000, which was 5% higher than the $359,000 reported for 2018. This put oncologists in eleventh place among 29 specialties.
However, this information was obtained prior to February 11, 2020, before the COVID-19 pandemic took hold in the United States, and the financial situation has changed for many physicians.
For example, primary care physicians have reported a 55% decrease in revenue along with a 20% to 30% reduction in patient volume. The decline has even led some to shutter their physical offices, according to the larger survey of all physicians, the Medscape Physician Debt and Net Worth Report 2020. This full survey included 17, 461 physicians and represented 30 specialties.
Physicians in specialty practices may be facing even greater reductions. “Specialists are currently having more troubles than PCPs because they’re largely dependent on elective cases, which can’t be directly addressed by telemedicine,” commented Joel Greenwald, MD, CEO of Greenwald Wealth Management, St. Louis Park, Minnesota, in the survey.
Community oncology clinics and practices have reported a substantial decline in office visits and new patients because of the COVID-19 pandemic. Even before the pandemic, clinics had been closing in recent years as a result of being acquired, merging, or because of financial struggles, although that trend has been plateauing, according to the latest report from the Community Oncology Alliance.
Oncologists’ net worth
With regard to net worth, 42% of the oncologists surveyed reported having assets totaling from $1 million to $5 million, which is about the same for physicians in general. Only 15% reported a net worth of $5 million or higher; a quarter reported a net worth of less than $500,000.
Wealth is more evenly divided when it comes to gender in comparison with other specialties. For all physicians, 56% of men and 39% of women reported a net worth of more than $1 million. For oncologists, that ratio is 59% of men and 54% of women.
Not surprisingly, net worth also increased by age. Only about a quarter (27%) of oncologists younger than age 45 reported a net worth of $1 million to $5 million, compared to 48% aged 45-54 and 56% of physicians aged 55-64. This makes sense, inasmuch as earnings generally increase over time and early-career debt is paid down. However, net worth does appear to decline somewhat after the age of 65, presumably because of a decrease in income on retirement.
Debts and expenses
For debts and expenses that are currently being paid off, mortgage on a primary residence (59%) topped the list. More than half of oncologists reported living in a home that is 3,000 sq ft or larger, and nearly half (49%) have a mortgage of $300,000 or higher. About a third of the oncologists surveyed have no mortgage or one that has been paid off.
Car loan payments (35%) and college education/medical school loans (25%) were the second and third most common sources of debt. As compared with other specialties, oncologists land right in the middle of those still paying off school loans. Only 15% reported that they had no debts or expenses to be paid off.
Savings and living within one’s means
The average American has four credit cards. About half of oncologists surveyed reported having four or fewer, although about a fifth (22%) have seven or more. But the vast majority reported living within their means (49%) or below their means (46%). Only 6% reported living above their means.
Surveyed oncologists also reported putting money aside in a tax-deferred retirement account or college savings account. Almost half (48%) are putting aside more than $2000 every month, and 28% save from $1000 to $2000. A small percentage (8%) reported not doing this on a regular basis.
A smaller percentage (40%) responded that they put more than $2000 a month into a taxable retirement or college savings account; 18% reported not doing this on a regular basis. More than two thirds also reported either having a written budget or a mental one for their personal expenses.
In 2019, most oncologists (77%) did not experience a financial loss. For those who did, bad investments on the stock market (14%) were the main cause. A smaller number reported real estate losses, problems with their practice, or job loss.
Nearly half (49%) reported that they currently work with a financial planner or have done so in the past.
This article first appeared on Medscape.com.
The average annual income for oncologists surveyed was $377,000, which was 5% higher than the $359,000 reported for 2018. This put oncologists in eleventh place among 29 specialties.
However, this information was obtained prior to February 11, 2020, before the COVID-19 pandemic took hold in the United States, and the financial situation has changed for many physicians.
For example, primary care physicians have reported a 55% decrease in revenue along with a 20% to 30% reduction in patient volume. The decline has even led some to shutter their physical offices, according to the larger survey of all physicians, the Medscape Physician Debt and Net Worth Report 2020. This full survey included 17, 461 physicians and represented 30 specialties.
Physicians in specialty practices may be facing even greater reductions. “Specialists are currently having more troubles than PCPs because they’re largely dependent on elective cases, which can’t be directly addressed by telemedicine,” commented Joel Greenwald, MD, CEO of Greenwald Wealth Management, St. Louis Park, Minnesota, in the survey.
Community oncology clinics and practices have reported a substantial decline in office visits and new patients because of the COVID-19 pandemic. Even before the pandemic, clinics had been closing in recent years as a result of being acquired, merging, or because of financial struggles, although that trend has been plateauing, according to the latest report from the Community Oncology Alliance.
Oncologists’ net worth
With regard to net worth, 42% of the oncologists surveyed reported having assets totaling from $1 million to $5 million, which is about the same for physicians in general. Only 15% reported a net worth of $5 million or higher; a quarter reported a net worth of less than $500,000.
Wealth is more evenly divided when it comes to gender in comparison with other specialties. For all physicians, 56% of men and 39% of women reported a net worth of more than $1 million. For oncologists, that ratio is 59% of men and 54% of women.
Not surprisingly, net worth also increased by age. Only about a quarter (27%) of oncologists younger than age 45 reported a net worth of $1 million to $5 million, compared to 48% aged 45-54 and 56% of physicians aged 55-64. This makes sense, inasmuch as earnings generally increase over time and early-career debt is paid down. However, net worth does appear to decline somewhat after the age of 65, presumably because of a decrease in income on retirement.
Debts and expenses
For debts and expenses that are currently being paid off, mortgage on a primary residence (59%) topped the list. More than half of oncologists reported living in a home that is 3,000 sq ft or larger, and nearly half (49%) have a mortgage of $300,000 or higher. About a third of the oncologists surveyed have no mortgage or one that has been paid off.
Car loan payments (35%) and college education/medical school loans (25%) were the second and third most common sources of debt. As compared with other specialties, oncologists land right in the middle of those still paying off school loans. Only 15% reported that they had no debts or expenses to be paid off.
Savings and living within one’s means
The average American has four credit cards. About half of oncologists surveyed reported having four or fewer, although about a fifth (22%) have seven or more. But the vast majority reported living within their means (49%) or below their means (46%). Only 6% reported living above their means.
Surveyed oncologists also reported putting money aside in a tax-deferred retirement account or college savings account. Almost half (48%) are putting aside more than $2000 every month, and 28% save from $1000 to $2000. A small percentage (8%) reported not doing this on a regular basis.
A smaller percentage (40%) responded that they put more than $2000 a month into a taxable retirement or college savings account; 18% reported not doing this on a regular basis. More than two thirds also reported either having a written budget or a mental one for their personal expenses.
In 2019, most oncologists (77%) did not experience a financial loss. For those who did, bad investments on the stock market (14%) were the main cause. A smaller number reported real estate losses, problems with their practice, or job loss.
Nearly half (49%) reported that they currently work with a financial planner or have done so in the past.
This article first appeared on Medscape.com.
The average annual income for oncologists surveyed was $377,000, which was 5% higher than the $359,000 reported for 2018. This put oncologists in eleventh place among 29 specialties.
However, this information was obtained prior to February 11, 2020, before the COVID-19 pandemic took hold in the United States, and the financial situation has changed for many physicians.
For example, primary care physicians have reported a 55% decrease in revenue along with a 20% to 30% reduction in patient volume. The decline has even led some to shutter their physical offices, according to the larger survey of all physicians, the Medscape Physician Debt and Net Worth Report 2020. This full survey included 17, 461 physicians and represented 30 specialties.
Physicians in specialty practices may be facing even greater reductions. “Specialists are currently having more troubles than PCPs because they’re largely dependent on elective cases, which can’t be directly addressed by telemedicine,” commented Joel Greenwald, MD, CEO of Greenwald Wealth Management, St. Louis Park, Minnesota, in the survey.
Community oncology clinics and practices have reported a substantial decline in office visits and new patients because of the COVID-19 pandemic. Even before the pandemic, clinics had been closing in recent years as a result of being acquired, merging, or because of financial struggles, although that trend has been plateauing, according to the latest report from the Community Oncology Alliance.
Oncologists’ net worth
With regard to net worth, 42% of the oncologists surveyed reported having assets totaling from $1 million to $5 million, which is about the same for physicians in general. Only 15% reported a net worth of $5 million or higher; a quarter reported a net worth of less than $500,000.
Wealth is more evenly divided when it comes to gender in comparison with other specialties. For all physicians, 56% of men and 39% of women reported a net worth of more than $1 million. For oncologists, that ratio is 59% of men and 54% of women.
Not surprisingly, net worth also increased by age. Only about a quarter (27%) of oncologists younger than age 45 reported a net worth of $1 million to $5 million, compared to 48% aged 45-54 and 56% of physicians aged 55-64. This makes sense, inasmuch as earnings generally increase over time and early-career debt is paid down. However, net worth does appear to decline somewhat after the age of 65, presumably because of a decrease in income on retirement.
Debts and expenses
For debts and expenses that are currently being paid off, mortgage on a primary residence (59%) topped the list. More than half of oncologists reported living in a home that is 3,000 sq ft or larger, and nearly half (49%) have a mortgage of $300,000 or higher. About a third of the oncologists surveyed have no mortgage or one that has been paid off.
Car loan payments (35%) and college education/medical school loans (25%) were the second and third most common sources of debt. As compared with other specialties, oncologists land right in the middle of those still paying off school loans. Only 15% reported that they had no debts or expenses to be paid off.
Savings and living within one’s means
The average American has four credit cards. About half of oncologists surveyed reported having four or fewer, although about a fifth (22%) have seven or more. But the vast majority reported living within their means (49%) or below their means (46%). Only 6% reported living above their means.
Surveyed oncologists also reported putting money aside in a tax-deferred retirement account or college savings account. Almost half (48%) are putting aside more than $2000 every month, and 28% save from $1000 to $2000. A small percentage (8%) reported not doing this on a regular basis.
A smaller percentage (40%) responded that they put more than $2000 a month into a taxable retirement or college savings account; 18% reported not doing this on a regular basis. More than two thirds also reported either having a written budget or a mental one for their personal expenses.
In 2019, most oncologists (77%) did not experience a financial loss. For those who did, bad investments on the stock market (14%) were the main cause. A smaller number reported real estate losses, problems with their practice, or job loss.
Nearly half (49%) reported that they currently work with a financial planner or have done so in the past.
This article first appeared on Medscape.com.
New CDC guidance for health care personnel exposed to HCV
The new guidance was developed in part as a result of an increase in the incidence of acute HCV infection in the United States, which increases the risk for occupational exposure among HCP. “[I]n certain health care settings, HCP might be exposed to source patients with early HCV infection before those patients develop serologic evidence of infection or symptoms indicative of viral hepatitis,” wrote the authors of the report, published online July 24 in the CDC’s Morbidity and Mortality Weekly Report.
The guidelines, which no longer recommend waiting for spontaneous resolution upon initial diagnosis, include recommendations and algorithms for baseline and follow-up testing, appropriate test type, and recommendations for clinical management. The recommendations were developed on the basis of a current literature review, expert opinion from subject matter experts, and recent guidance from the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America.
Baseline testing ASAP
Baseline testing of the source patient and the HCP should be performed as soon as possible, preferably within 48 hours of exposure. The source patient should be tested for HCV RNA using a nucleic acid test. Alternatively, screening anti-HCV serology can be performed in patients at low risk for HCV and a nucleic acid test performed if serology is positive.
Baseline testing for the HCP should include anti-HCV testing and, if positive, HCV RNA testing is recommended. HCPs who test positive for HCV RNA at baseline are considered to have a preexisting HCV infection and should be referred for treatment.
Follow-up testing
For HCPs with exposure to blood or body fluids from a patient who is anti-HCV positive but HCV RNA negative, follow-up testing is not required.
If the source patient is HCV RNA positive, or if status of the source patient is unknown, the authors recommend that exposed HCPs have HCV RNA follow-up testing at 3-6 weeks post exposure, in addition to baseline testing. A final anti-HCV test is recommended at 4-6 months post exposure as there can be potential periods of aviremia during acute HCV infection.
Exposed HCPs who develop signs of illness indicative of HCV infection at any time should be tested for HCV RNA.
HCPs with positive HCV RNA test results should be referred for care and curative antiviral therapy.
Postexposure prophylaxis is not recommended
Recent data have shown that the risk for HCV infection from percutaneous exposure is 0.2% and from mucocutaneous exposure is 0%. On the basis of this information, the CDC guidelines no longer recommend routine postexposure prophylaxis for HCPs with occupational exposure to HCV. Rather, curative antiviral regimens should be reserved for instances of documented HCV transmission.
The authors disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
The new guidance was developed in part as a result of an increase in the incidence of acute HCV infection in the United States, which increases the risk for occupational exposure among HCP. “[I]n certain health care settings, HCP might be exposed to source patients with early HCV infection before those patients develop serologic evidence of infection or symptoms indicative of viral hepatitis,” wrote the authors of the report, published online July 24 in the CDC’s Morbidity and Mortality Weekly Report.
The guidelines, which no longer recommend waiting for spontaneous resolution upon initial diagnosis, include recommendations and algorithms for baseline and follow-up testing, appropriate test type, and recommendations for clinical management. The recommendations were developed on the basis of a current literature review, expert opinion from subject matter experts, and recent guidance from the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America.
Baseline testing ASAP
Baseline testing of the source patient and the HCP should be performed as soon as possible, preferably within 48 hours of exposure. The source patient should be tested for HCV RNA using a nucleic acid test. Alternatively, screening anti-HCV serology can be performed in patients at low risk for HCV and a nucleic acid test performed if serology is positive.
Baseline testing for the HCP should include anti-HCV testing and, if positive, HCV RNA testing is recommended. HCPs who test positive for HCV RNA at baseline are considered to have a preexisting HCV infection and should be referred for treatment.
Follow-up testing
For HCPs with exposure to blood or body fluids from a patient who is anti-HCV positive but HCV RNA negative, follow-up testing is not required.
If the source patient is HCV RNA positive, or if status of the source patient is unknown, the authors recommend that exposed HCPs have HCV RNA follow-up testing at 3-6 weeks post exposure, in addition to baseline testing. A final anti-HCV test is recommended at 4-6 months post exposure as there can be potential periods of aviremia during acute HCV infection.
Exposed HCPs who develop signs of illness indicative of HCV infection at any time should be tested for HCV RNA.
HCPs with positive HCV RNA test results should be referred for care and curative antiviral therapy.
Postexposure prophylaxis is not recommended
Recent data have shown that the risk for HCV infection from percutaneous exposure is 0.2% and from mucocutaneous exposure is 0%. On the basis of this information, the CDC guidelines no longer recommend routine postexposure prophylaxis for HCPs with occupational exposure to HCV. Rather, curative antiviral regimens should be reserved for instances of documented HCV transmission.
The authors disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
The new guidance was developed in part as a result of an increase in the incidence of acute HCV infection in the United States, which increases the risk for occupational exposure among HCP. “[I]n certain health care settings, HCP might be exposed to source patients with early HCV infection before those patients develop serologic evidence of infection or symptoms indicative of viral hepatitis,” wrote the authors of the report, published online July 24 in the CDC’s Morbidity and Mortality Weekly Report.
The guidelines, which no longer recommend waiting for spontaneous resolution upon initial diagnosis, include recommendations and algorithms for baseline and follow-up testing, appropriate test type, and recommendations for clinical management. The recommendations were developed on the basis of a current literature review, expert opinion from subject matter experts, and recent guidance from the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America.
Baseline testing ASAP
Baseline testing of the source patient and the HCP should be performed as soon as possible, preferably within 48 hours of exposure. The source patient should be tested for HCV RNA using a nucleic acid test. Alternatively, screening anti-HCV serology can be performed in patients at low risk for HCV and a nucleic acid test performed if serology is positive.
Baseline testing for the HCP should include anti-HCV testing and, if positive, HCV RNA testing is recommended. HCPs who test positive for HCV RNA at baseline are considered to have a preexisting HCV infection and should be referred for treatment.
Follow-up testing
For HCPs with exposure to blood or body fluids from a patient who is anti-HCV positive but HCV RNA negative, follow-up testing is not required.
If the source patient is HCV RNA positive, or if status of the source patient is unknown, the authors recommend that exposed HCPs have HCV RNA follow-up testing at 3-6 weeks post exposure, in addition to baseline testing. A final anti-HCV test is recommended at 4-6 months post exposure as there can be potential periods of aviremia during acute HCV infection.
Exposed HCPs who develop signs of illness indicative of HCV infection at any time should be tested for HCV RNA.
HCPs with positive HCV RNA test results should be referred for care and curative antiviral therapy.
Postexposure prophylaxis is not recommended
Recent data have shown that the risk for HCV infection from percutaneous exposure is 0.2% and from mucocutaneous exposure is 0%. On the basis of this information, the CDC guidelines no longer recommend routine postexposure prophylaxis for HCPs with occupational exposure to HCV. Rather, curative antiviral regimens should be reserved for instances of documented HCV transmission.
The authors disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
Lenalidomide may be an answer for refractory cutaneous lupus
Cutaneous lupus erythematosus (CLE) is present in 25% of patients with systemic lupus at the time of diagnosis, but it can also occur in up to 85% of cases at some point in their disease course, Eveline Y. Wu, MD, said during the virtual annual meeting of the Society for Pediatric Dermatology.
“CLE can also occur without any systemic disease,” said Dr. Wu, associate professor of pediatrics at the University of North Carolina at Chapel Hill. “It’s been shown that the risk of developing systemic lupus differs according to the type of skin involvement, meaning that cutaneous lupus can be classified into acute, subacute, chronic, and intermittent forms.”
Malar rash is the prototypical acute cutaneous lesion and is associated with active systemic lupus erythematosus (SLE) and anti–double stranded DNA antibody positivity, while discoid lupus erythematosus is the most common chronic lesion. “A small percentage of patients with discoid lupus can develop systemic lupus, particularly when the lesions are more disseminated,” said Dr. Wu, who specializes in pediatric rheumatology as well as allergy and immunology.
In the American College of Rheumatology’s 1997 classification system, mucocutaneous manifestations constitute 4 out of the 11 criteria that clinicians use to make a diagnosis of SLE: malar rash, discoid-lupus rash, photosensitivity, and oral or nasal mucocutaneous ulcerations. Dr. Wu recommends performing an oral exam on suspect cases, “because the oral ulcers that we see in systemic lupus tend to be painless, so oftentimes patients don’t realize they have them.”
Five other organ-specific manifestations of SLE include nonerosive arthritis, nephritis, encephalopathy, pleuritis or pericarditis, and cytopenia. The two other criteria are positive immunoserology and a positive antinuclear antibody test. “If you have any individuals present with one of these [mucocutaneous manifestations criteria], you want to think about getting a CBC to look for cytopenia or a urinalysis to look for evidence of nephritis, and potentially some additional blood studies, depending on your level of suspicion for systemic lupus,” Dr. Wu said.
Other rarer CLE manifestations include lupus pernio or chilblains, lupus panniculitis, livedo reticularis, bullous LE, urticarial vasculitis, neutrophilic dermatoses, and alopecia.
Common treatments for cutaneous manifestations associated pediatric SLE include hydroxychloroquine, low dose corticosteroids, topical steroids, methotrexate, and leflunomide. Other options for increasing severity of systemic disease include lenalidomide/thalidomide, azathioprine, calcineurin inhibitors, belimumab (Benlysta), high-dose corticosteroids, mycophenolate mofetil (CellCept), rituximab (Rituxan), and cyclophosphamide. Cutaneous manifestations of pediatric SLE can often be refractory to treatments.
In 2017, Dr. Wu and associates published a retrospective chart review of 10 adolescents who received lenalidomide for refractory CLE. One of the subjects was a 21-year-old male with a significant malar rash despite being on hydroxychloroquine, azathioprine, and prednisone 40 mg daily. “One month after being on lenalidomide he had a pretty impressive response,” Dr. Wu said. “It’s not quite clear how lenalidomide works in cutaneous lupus. Currently it’s only approved for use in myelodysplastic syndromes, multiple myeloma, as well as certain lymphomas. It’s thought to modulate different parts of the immune system, which collectively result in the cytotoxicity against tumor cells.”
Lenalidomide is supplied in capsule sizes ranging from 2.5 mg to 25 mg and is given once daily. “For a smaller child, I would think about starting 5 mg once a day,” Dr. Wu said. “For an adult-sized adolescent, you could start at 10 mg once a day and then titrate up based on response. Side effects that you need to worry about are cytopenia and GI symptoms. The venous and arterial thromboembolism risk has been seen in patients with multiple myeloma, and it is unclear if this risk is applicable to all indications.” Use of the medication requires enrollment into a safety monitoring program.
She reported having no financial disclosures.
Cutaneous lupus erythematosus (CLE) is present in 25% of patients with systemic lupus at the time of diagnosis, but it can also occur in up to 85% of cases at some point in their disease course, Eveline Y. Wu, MD, said during the virtual annual meeting of the Society for Pediatric Dermatology.
“CLE can also occur without any systemic disease,” said Dr. Wu, associate professor of pediatrics at the University of North Carolina at Chapel Hill. “It’s been shown that the risk of developing systemic lupus differs according to the type of skin involvement, meaning that cutaneous lupus can be classified into acute, subacute, chronic, and intermittent forms.”
Malar rash is the prototypical acute cutaneous lesion and is associated with active systemic lupus erythematosus (SLE) and anti–double stranded DNA antibody positivity, while discoid lupus erythematosus is the most common chronic lesion. “A small percentage of patients with discoid lupus can develop systemic lupus, particularly when the lesions are more disseminated,” said Dr. Wu, who specializes in pediatric rheumatology as well as allergy and immunology.
In the American College of Rheumatology’s 1997 classification system, mucocutaneous manifestations constitute 4 out of the 11 criteria that clinicians use to make a diagnosis of SLE: malar rash, discoid-lupus rash, photosensitivity, and oral or nasal mucocutaneous ulcerations. Dr. Wu recommends performing an oral exam on suspect cases, “because the oral ulcers that we see in systemic lupus tend to be painless, so oftentimes patients don’t realize they have them.”
Five other organ-specific manifestations of SLE include nonerosive arthritis, nephritis, encephalopathy, pleuritis or pericarditis, and cytopenia. The two other criteria are positive immunoserology and a positive antinuclear antibody test. “If you have any individuals present with one of these [mucocutaneous manifestations criteria], you want to think about getting a CBC to look for cytopenia or a urinalysis to look for evidence of nephritis, and potentially some additional blood studies, depending on your level of suspicion for systemic lupus,” Dr. Wu said.
Other rarer CLE manifestations include lupus pernio or chilblains, lupus panniculitis, livedo reticularis, bullous LE, urticarial vasculitis, neutrophilic dermatoses, and alopecia.
Common treatments for cutaneous manifestations associated pediatric SLE include hydroxychloroquine, low dose corticosteroids, topical steroids, methotrexate, and leflunomide. Other options for increasing severity of systemic disease include lenalidomide/thalidomide, azathioprine, calcineurin inhibitors, belimumab (Benlysta), high-dose corticosteroids, mycophenolate mofetil (CellCept), rituximab (Rituxan), and cyclophosphamide. Cutaneous manifestations of pediatric SLE can often be refractory to treatments.
In 2017, Dr. Wu and associates published a retrospective chart review of 10 adolescents who received lenalidomide for refractory CLE. One of the subjects was a 21-year-old male with a significant malar rash despite being on hydroxychloroquine, azathioprine, and prednisone 40 mg daily. “One month after being on lenalidomide he had a pretty impressive response,” Dr. Wu said. “It’s not quite clear how lenalidomide works in cutaneous lupus. Currently it’s only approved for use in myelodysplastic syndromes, multiple myeloma, as well as certain lymphomas. It’s thought to modulate different parts of the immune system, which collectively result in the cytotoxicity against tumor cells.”
Lenalidomide is supplied in capsule sizes ranging from 2.5 mg to 25 mg and is given once daily. “For a smaller child, I would think about starting 5 mg once a day,” Dr. Wu said. “For an adult-sized adolescent, you could start at 10 mg once a day and then titrate up based on response. Side effects that you need to worry about are cytopenia and GI symptoms. The venous and arterial thromboembolism risk has been seen in patients with multiple myeloma, and it is unclear if this risk is applicable to all indications.” Use of the medication requires enrollment into a safety monitoring program.
She reported having no financial disclosures.
Cutaneous lupus erythematosus (CLE) is present in 25% of patients with systemic lupus at the time of diagnosis, but it can also occur in up to 85% of cases at some point in their disease course, Eveline Y. Wu, MD, said during the virtual annual meeting of the Society for Pediatric Dermatology.
“CLE can also occur without any systemic disease,” said Dr. Wu, associate professor of pediatrics at the University of North Carolina at Chapel Hill. “It’s been shown that the risk of developing systemic lupus differs according to the type of skin involvement, meaning that cutaneous lupus can be classified into acute, subacute, chronic, and intermittent forms.”
Malar rash is the prototypical acute cutaneous lesion and is associated with active systemic lupus erythematosus (SLE) and anti–double stranded DNA antibody positivity, while discoid lupus erythematosus is the most common chronic lesion. “A small percentage of patients with discoid lupus can develop systemic lupus, particularly when the lesions are more disseminated,” said Dr. Wu, who specializes in pediatric rheumatology as well as allergy and immunology.
In the American College of Rheumatology’s 1997 classification system, mucocutaneous manifestations constitute 4 out of the 11 criteria that clinicians use to make a diagnosis of SLE: malar rash, discoid-lupus rash, photosensitivity, and oral or nasal mucocutaneous ulcerations. Dr. Wu recommends performing an oral exam on suspect cases, “because the oral ulcers that we see in systemic lupus tend to be painless, so oftentimes patients don’t realize they have them.”
Five other organ-specific manifestations of SLE include nonerosive arthritis, nephritis, encephalopathy, pleuritis or pericarditis, and cytopenia. The two other criteria are positive immunoserology and a positive antinuclear antibody test. “If you have any individuals present with one of these [mucocutaneous manifestations criteria], you want to think about getting a CBC to look for cytopenia or a urinalysis to look for evidence of nephritis, and potentially some additional blood studies, depending on your level of suspicion for systemic lupus,” Dr. Wu said.
Other rarer CLE manifestations include lupus pernio or chilblains, lupus panniculitis, livedo reticularis, bullous LE, urticarial vasculitis, neutrophilic dermatoses, and alopecia.
Common treatments for cutaneous manifestations associated pediatric SLE include hydroxychloroquine, low dose corticosteroids, topical steroids, methotrexate, and leflunomide. Other options for increasing severity of systemic disease include lenalidomide/thalidomide, azathioprine, calcineurin inhibitors, belimumab (Benlysta), high-dose corticosteroids, mycophenolate mofetil (CellCept), rituximab (Rituxan), and cyclophosphamide. Cutaneous manifestations of pediatric SLE can often be refractory to treatments.
In 2017, Dr. Wu and associates published a retrospective chart review of 10 adolescents who received lenalidomide for refractory CLE. One of the subjects was a 21-year-old male with a significant malar rash despite being on hydroxychloroquine, azathioprine, and prednisone 40 mg daily. “One month after being on lenalidomide he had a pretty impressive response,” Dr. Wu said. “It’s not quite clear how lenalidomide works in cutaneous lupus. Currently it’s only approved for use in myelodysplastic syndromes, multiple myeloma, as well as certain lymphomas. It’s thought to modulate different parts of the immune system, which collectively result in the cytotoxicity against tumor cells.”
Lenalidomide is supplied in capsule sizes ranging from 2.5 mg to 25 mg and is given once daily. “For a smaller child, I would think about starting 5 mg once a day,” Dr. Wu said. “For an adult-sized adolescent, you could start at 10 mg once a day and then titrate up based on response. Side effects that you need to worry about are cytopenia and GI symptoms. The venous and arterial thromboembolism risk has been seen in patients with multiple myeloma, and it is unclear if this risk is applicable to all indications.” Use of the medication requires enrollment into a safety monitoring program.
She reported having no financial disclosures.
FROM SPD 2020