Commentary

Traditionally, as the ides of August descend upon us we expect to be bombarded with advertisements encouraging parents and students to finish up their back-to-school shopping. But, this year the question on every parent and school administrator’s mind is not which color back pack will be the most popular this year but whether a mask should be a required part of the back-to-school ensemble.

The American Academy of Pediatrics has recommended that “All students older than 2 years and all school staff should wear a mask at school” (“American Academy of Pediatrics Updates Recommendations for Opening Schools in Fall 2021.” 2021 Jul 19). The academy’s statement includes a generous list of common sense caveats but it does not include a statement that masks have been shown to be protective for children in school environments. The Centers for Disease Control and Prevention “recommends” universal indoor masking along with keeping a 3-foot separation but again fails to include any references to support the effectiveness of masks (“Guidance for COVID-19 Prevention in K-12 Schools.” 2021 Aug 5).

Not surprisingly, into this void have stepped two pairs of experts – one group purporting to have evidence that masking is effective in school environments and the other warning that masks may not only be ineffective but that they also carry some significant downsides. And, where can you find these opposing positions? Not in The Lancet. Not in the New England Journal of Medicine. We don’t have time for any of that peer-reviewed monkey business. No, this is pandemic-era science where we have an abundance of opinions and paucity of facts. You will find these opposing articles on the op-ed pages of two of this country’s major newspapers.

In the Aug. 10, 2021, edition of the New York Times you will find an article (“We Studied One Million Students. This Is What We Learned About Masking”) by two pediatricians, Kanecia Zimmerman, MD, and Danny Benjamin Jr., MD, who have “studied” a million students in North Carolina school systems and tell us universal masking is “one of the most effective and efficient strategies for preventing SARS-CoV-2 transmission in schools. These investigators write that they “believe” the low rate of in school transmission they observed in North Carolina was “because of the mask-on-mask school environment.”

However, in the next paragraph the authors admit, “Because North Carolina had a mask mandate for all K-12 schools, we could not compare masked schools with unmasked schools.” They lean instead on studies from three other states with mask mandates that also had low transmission rates and a single report of an outbreak in Israel that employed neither masking nor safe distancing.

On the other side of the divide is an article in the Wall Street Journal titled “The Case Against Masks for Children” by Marty Makary, MD, and H. Cody Meissner, MD, (2021 Aug 9). The authors, one a pediatric infectious disease specialist, argue that there is “no science behind mask mandates for children.” And, observe that, of the $46 billion spent on research grants by the National Institutes of Health, “not a single grant was dedicated to studying masking in children.”

Dr. Makary and Dr. Meissner present a variety of concerns about the effects of masking including those on the development and communication skills of young children. None of their theoretical concerns of course are supported by controlled studies. They also observe that in previous studies children seem to be less likely to transmit COVID-19 than adults. Although we all know the landscape is changing with the emergence of the delta strain. In their strongest statement the authors claim, “It is abusive to force kids who struggle with them [masks] to sacrifice for the sake of unvaccinated adults.”

So there you have it. It is a situation we have come to expect over the last 2 years – plenty of opinions and too few facts supported by controlled studies. Both pairs of authors, however, agree on two things: Vaccination should continue to be considered our primary tool in prevention and control of COVID-19. and children need to be in school. Based on nothing more than a hunch and 7 decades of hunching, I tend to side with Dr. Makary and Dr. Meissner. Depending on the situation, I suggest masking but wouldn’t mandate it for children in school.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Traditionally, as the ides of August descend upon us we expect to be bombarded with advertisements encouraging parents and students to finish up their back-to-school shopping. But, this year the question on every parent and school administrator’s mind is not which color back pack will be the most popular this year but whether a mask should be a required part of the back-to-school ensemble.

The American Academy of Pediatrics has recommended that “All students older than 2 years and all school staff should wear a mask at school” (“American Academy of Pediatrics Updates Recommendations for Opening Schools in Fall 2021.” 2021 Jul 19). The academy’s statement includes a generous list of common sense caveats but it does not include a statement that masks have been shown to be protective for children in school environments. The Centers for Disease Control and Prevention “recommends” universal indoor masking along with keeping a 3-foot separation but again fails to include any references to support the effectiveness of masks (“Guidance for COVID-19 Prevention in K-12 Schools.” 2021 Aug 5).

Not surprisingly, into this void have stepped two pairs of experts – one group purporting to have evidence that masking is effective in school environments and the other warning that masks may not only be ineffective but that they also carry some significant downsides. And, where can you find these opposing positions? Not in The Lancet. Not in the New England Journal of Medicine. We don’t have time for any of that peer-reviewed monkey business. No, this is pandemic-era science where we have an abundance of opinions and paucity of facts. You will find these opposing articles on the op-ed pages of two of this country’s major newspapers.

In the Aug. 10, 2021, edition of the New York Times you will find an article (“We Studied One Million Students. This Is What We Learned About Masking”) by two pediatricians, Kanecia Zimmerman, MD, and Danny Benjamin Jr., MD, who have “studied” a million students in North Carolina school systems and tell us universal masking is “one of the most effective and efficient strategies for preventing SARS-CoV-2 transmission in schools. These investigators write that they “believe” the low rate of in school transmission they observed in North Carolina was “because of the mask-on-mask school environment.”

However, in the next paragraph the authors admit, “Because North Carolina had a mask mandate for all K-12 schools, we could not compare masked schools with unmasked schools.” They lean instead on studies from three other states with mask mandates that also had low transmission rates and a single report of an outbreak in Israel that employed neither masking nor safe distancing.

On the other side of the divide is an article in the Wall Street Journal titled “The Case Against Masks for Children” by Marty Makary, MD, and H. Cody Meissner, MD, (2021 Aug 9). The authors, one a pediatric infectious disease specialist, argue that there is “no science behind mask mandates for children.” And, observe that, of the $46 billion spent on research grants by the National Institutes of Health, “not a single grant was dedicated to studying masking in children.”

Dr. Makary and Dr. Meissner present a variety of concerns about the effects of masking including those on the development and communication skills of young children. None of their theoretical concerns of course are supported by controlled studies. They also observe that in previous studies children seem to be less likely to transmit COVID-19 than adults. Although we all know the landscape is changing with the emergence of the delta strain. In their strongest statement the authors claim, “It is abusive to force kids who struggle with them [masks] to sacrifice for the sake of unvaccinated adults.”

So there you have it. It is a situation we have come to expect over the last 2 years – plenty of opinions and too few facts supported by controlled studies. Both pairs of authors, however, agree on two things: Vaccination should continue to be considered our primary tool in prevention and control of COVID-19. and children need to be in school. Based on nothing more than a hunch and 7 decades of hunching, I tend to side with Dr. Makary and Dr. Meissner. Depending on the situation, I suggest masking but wouldn’t mandate it for children in school.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Traditionally, as the ides of August descend upon us we expect to be bombarded with advertisements encouraging parents and students to finish up their back-to-school shopping. But, this year the question on every parent and school administrator’s mind is not which color back pack will be the most popular this year but whether a mask should be a required part of the back-to-school ensemble.

The American Academy of Pediatrics has recommended that “All students older than 2 years and all school staff should wear a mask at school” (“American Academy of Pediatrics Updates Recommendations for Opening Schools in Fall 2021.” 2021 Jul 19). The academy’s statement includes a generous list of common sense caveats but it does not include a statement that masks have been shown to be protective for children in school environments. The Centers for Disease Control and Prevention “recommends” universal indoor masking along with keeping a 3-foot separation but again fails to include any references to support the effectiveness of masks (“Guidance for COVID-19 Prevention in K-12 Schools.” 2021 Aug 5).

Not surprisingly, into this void have stepped two pairs of experts – one group purporting to have evidence that masking is effective in school environments and the other warning that masks may not only be ineffective but that they also carry some significant downsides. And, where can you find these opposing positions? Not in The Lancet. Not in the New England Journal of Medicine. We don’t have time for any of that peer-reviewed monkey business. No, this is pandemic-era science where we have an abundance of opinions and paucity of facts. You will find these opposing articles on the op-ed pages of two of this country’s major newspapers.

In the Aug. 10, 2021, edition of the New York Times you will find an article (“We Studied One Million Students. This Is What We Learned About Masking”) by two pediatricians, Kanecia Zimmerman, MD, and Danny Benjamin Jr., MD, who have “studied” a million students in North Carolina school systems and tell us universal masking is “one of the most effective and efficient strategies for preventing SARS-CoV-2 transmission in schools. These investigators write that they “believe” the low rate of in school transmission they observed in North Carolina was “because of the mask-on-mask school environment.”

However, in the next paragraph the authors admit, “Because North Carolina had a mask mandate for all K-12 schools, we could not compare masked schools with unmasked schools.” They lean instead on studies from three other states with mask mandates that also had low transmission rates and a single report of an outbreak in Israel that employed neither masking nor safe distancing.

On the other side of the divide is an article in the Wall Street Journal titled “The Case Against Masks for Children” by Marty Makary, MD, and H. Cody Meissner, MD, (2021 Aug 9). The authors, one a pediatric infectious disease specialist, argue that there is “no science behind mask mandates for children.” And, observe that, of the $46 billion spent on research grants by the National Institutes of Health, “not a single grant was dedicated to studying masking in children.”

Dr. Makary and Dr. Meissner present a variety of concerns about the effects of masking including those on the development and communication skills of young children. None of their theoretical concerns of course are supported by controlled studies. They also observe that in previous studies children seem to be less likely to transmit COVID-19 than adults. Although we all know the landscape is changing with the emergence of the delta strain. In their strongest statement the authors claim, “It is abusive to force kids who struggle with them [masks] to sacrifice for the sake of unvaccinated adults.”

So there you have it. It is a situation we have come to expect over the last 2 years – plenty of opinions and too few facts supported by controlled studies. Both pairs of authors, however, agree on two things: Vaccination should continue to be considered our primary tool in prevention and control of COVID-19. and children need to be in school. Based on nothing more than a hunch and 7 decades of hunching, I tend to side with Dr. Makary and Dr. Meissner. Depending on the situation, I suggest masking but wouldn’t mandate it for children in school.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

The current pandemic is forcing changes throughout the health care industry. Telehealth is witnessing a surge. Hospitals are struggling without elective care, and remarkably, physicians are being laid off during a time of crisis. While some states have a surplus work force, other states go begging, and they lock the system up with delays in the processing of applications.

Considering the prevalence of noncompete clauses and a schism in state-to-state processing of complaints, patients are suffering and dying under an antiquated system. The Federation of State Medical Boards doesn’t seem to add to the solution, but instead confounds the problem with new directives. The time is nigh for the federal government to eliminate state medical licensure and replace it with a national medical license for all physicians and health care professionals.

Because physicians’ training requirements don’t vary from state to state, it makes sense. We must take national standardized exams to qualify. Locum tenens physicians must maintain licensure in as many states as they practice; this creates an unnecessary burden and expense, when there is a better alternative. Some states have arranged reciprocity licensure with other states. This is commendable but doesn’t go far enough to manage national shortages in rural areas.

Under a national licensing system, physicians and other health care professionals would not only be free to travel anywhere in the United States to practice, they can count on consistent and equal management of their license. The federal government can track regional overages and shortages and redirect physicians and other medical professionals with incentives to areas in need.

The FSMB claims that there is interstate continuity among state medical boards, but the data don’t support this.

Why is this the case? Each medical board fails to manage their charges equally. Often, action taken by one state board when reported to another state board can cause a review and readjudication. This occasionally results in the overturning of a reprimand or suspension because of differences in legislation.

Yet the physician or health care professional must bear the burden of the notification against their license. Once again, the FSMB claims there is interstate continuity in disciplinary actions, but the data do not support this.

Once someone brings a complaint against a health professional, which in this health care climate is inevitable, the medical board must institute an investigation. Even if it has no merit, the process must go forward. Under a national system, a consistent approach to dismiss and investigate issues and complaints might expedite the process. This eliminates inefficiency and delays in clearance of charges.

A report in 2006 identified fragmentation and discontinuities in the way each state medical board manages a physician or other health care personnel’s complaints. The number of hands involved in the process varies and is often onerous and redundant. Several sources may request the same information, tying it up as it moves through an inefficient and uncooperative system. With the increase in internal politics since then, this only compounds rather than improves the problem.

Yet the benefit of national licensure is not just for the health care personnel but also for insurance companies that must register and screen physicians as they move from region to region. In each state, the physician must repeat the accreditation process, delaying reimbursements and denying care. Hospitals also must repeat the credentialing task as well. This, although the physician or health care worker has a clean record with the same company or the same hospital system in their original state.

Perhaps data from one insurance group or hospital in another state get lost or altered in transfer, but under national licensing, this would not be possible. Furthermore, the current system limits the individual professional’s input. By nationalizing, record corrections would go through a federal database rather than state data banks that don’t sync.

This already partially exists with the National Practitioner Identifier. But we can take it one step further. Through nationalization, we could institute a fairer system of reporting where both the professional’s and the complainant’s summary is included. One might argue the National Physician Data Bank performs this function, but in fact, it merely reflects state assessments – which again vary.

The infrastructure is already in place to transition from a state to national system with facilities and records kept in each state’s medical board. It would simply be a matter of replacing state personnel with federal employees who all work from the same script. A national medical license simply makes sense for all parties. It reduces discontinuity and increases efficiency. A national medical license empowers the individual rather than institutions, yet benefits both.

The time is nigh to nationally certify and set physicians free, reduce paperwork and needless fees, and eliminate state supremacy.  


Dr. Raymond is an emergency physician based in Hickory, N.C., and Muckendorf an der Donau, Austria.

A version of this article first appeared on Medscape.com.

The current pandemic is forcing changes throughout the health care industry. Telehealth is witnessing a surge. Hospitals are struggling without elective care, and remarkably, physicians are being laid off during a time of crisis. While some states have a surplus work force, other states go begging, and they lock the system up with delays in the processing of applications.

Considering the prevalence of noncompete clauses and a schism in state-to-state processing of complaints, patients are suffering and dying under an antiquated system. The Federation of State Medical Boards doesn’t seem to add to the solution, but instead confounds the problem with new directives. The time is nigh for the federal government to eliminate state medical licensure and replace it with a national medical license for all physicians and health care professionals.

Because physicians’ training requirements don’t vary from state to state, it makes sense. We must take national standardized exams to qualify. Locum tenens physicians must maintain licensure in as many states as they practice; this creates an unnecessary burden and expense, when there is a better alternative. Some states have arranged reciprocity licensure with other states. This is commendable but doesn’t go far enough to manage national shortages in rural areas.

Under a national licensing system, physicians and other health care professionals would not only be free to travel anywhere in the United States to practice, they can count on consistent and equal management of their license. The federal government can track regional overages and shortages and redirect physicians and other medical professionals with incentives to areas in need.

The FSMB claims that there is interstate continuity among state medical boards, but the data don’t support this.

Why is this the case? Each medical board fails to manage their charges equally. Often, action taken by one state board when reported to another state board can cause a review and readjudication. This occasionally results in the overturning of a reprimand or suspension because of differences in legislation.

Yet the physician or health care professional must bear the burden of the notification against their license. Once again, the FSMB claims there is interstate continuity in disciplinary actions, but the data do not support this.

Once someone brings a complaint against a health professional, which in this health care climate is inevitable, the medical board must institute an investigation. Even if it has no merit, the process must go forward. Under a national system, a consistent approach to dismiss and investigate issues and complaints might expedite the process. This eliminates inefficiency and delays in clearance of charges.

A report in 2006 identified fragmentation and discontinuities in the way each state medical board manages a physician or other health care personnel’s complaints. The number of hands involved in the process varies and is often onerous and redundant. Several sources may request the same information, tying it up as it moves through an inefficient and uncooperative system. With the increase in internal politics since then, this only compounds rather than improves the problem.

Yet the benefit of national licensure is not just for the health care personnel but also for insurance companies that must register and screen physicians as they move from region to region. In each state, the physician must repeat the accreditation process, delaying reimbursements and denying care. Hospitals also must repeat the credentialing task as well. This, although the physician or health care worker has a clean record with the same company or the same hospital system in their original state.

Perhaps data from one insurance group or hospital in another state get lost or altered in transfer, but under national licensing, this would not be possible. Furthermore, the current system limits the individual professional’s input. By nationalizing, record corrections would go through a federal database rather than state data banks that don’t sync.

This already partially exists with the National Practitioner Identifier. But we can take it one step further. Through nationalization, we could institute a fairer system of reporting where both the professional’s and the complainant’s summary is included. One might argue the National Physician Data Bank performs this function, but in fact, it merely reflects state assessments – which again vary.

The infrastructure is already in place to transition from a state to national system with facilities and records kept in each state’s medical board. It would simply be a matter of replacing state personnel with federal employees who all work from the same script. A national medical license simply makes sense for all parties. It reduces discontinuity and increases efficiency. A national medical license empowers the individual rather than institutions, yet benefits both.

The time is nigh to nationally certify and set physicians free, reduce paperwork and needless fees, and eliminate state supremacy.  


Dr. Raymond is an emergency physician based in Hickory, N.C., and Muckendorf an der Donau, Austria.

A version of this article first appeared on Medscape.com.

The current pandemic is forcing changes throughout the health care industry. Telehealth is witnessing a surge. Hospitals are struggling without elective care, and remarkably, physicians are being laid off during a time of crisis. While some states have a surplus work force, other states go begging, and they lock the system up with delays in the processing of applications.

Considering the prevalence of noncompete clauses and a schism in state-to-state processing of complaints, patients are suffering and dying under an antiquated system. The Federation of State Medical Boards doesn’t seem to add to the solution, but instead confounds the problem with new directives. The time is nigh for the federal government to eliminate state medical licensure and replace it with a national medical license for all physicians and health care professionals.

Because physicians’ training requirements don’t vary from state to state, it makes sense. We must take national standardized exams to qualify. Locum tenens physicians must maintain licensure in as many states as they practice; this creates an unnecessary burden and expense, when there is a better alternative. Some states have arranged reciprocity licensure with other states. This is commendable but doesn’t go far enough to manage national shortages in rural areas.

Under a national licensing system, physicians and other health care professionals would not only be free to travel anywhere in the United States to practice, they can count on consistent and equal management of their license. The federal government can track regional overages and shortages and redirect physicians and other medical professionals with incentives to areas in need.

The FSMB claims that there is interstate continuity among state medical boards, but the data don’t support this.

Why is this the case? Each medical board fails to manage their charges equally. Often, action taken by one state board when reported to another state board can cause a review and readjudication. This occasionally results in the overturning of a reprimand or suspension because of differences in legislation.

Yet the physician or health care professional must bear the burden of the notification against their license. Once again, the FSMB claims there is interstate continuity in disciplinary actions, but the data do not support this.

Once someone brings a complaint against a health professional, which in this health care climate is inevitable, the medical board must institute an investigation. Even if it has no merit, the process must go forward. Under a national system, a consistent approach to dismiss and investigate issues and complaints might expedite the process. This eliminates inefficiency and delays in clearance of charges.

A report in 2006 identified fragmentation and discontinuities in the way each state medical board manages a physician or other health care personnel’s complaints. The number of hands involved in the process varies and is often onerous and redundant. Several sources may request the same information, tying it up as it moves through an inefficient and uncooperative system. With the increase in internal politics since then, this only compounds rather than improves the problem.

Yet the benefit of national licensure is not just for the health care personnel but also for insurance companies that must register and screen physicians as they move from region to region. In each state, the physician must repeat the accreditation process, delaying reimbursements and denying care. Hospitals also must repeat the credentialing task as well. This, although the physician or health care worker has a clean record with the same company or the same hospital system in their original state.

Perhaps data from one insurance group or hospital in another state get lost or altered in transfer, but under national licensing, this would not be possible. Furthermore, the current system limits the individual professional’s input. By nationalizing, record corrections would go through a federal database rather than state data banks that don’t sync.

This already partially exists with the National Practitioner Identifier. But we can take it one step further. Through nationalization, we could institute a fairer system of reporting where both the professional’s and the complainant’s summary is included. One might argue the National Physician Data Bank performs this function, but in fact, it merely reflects state assessments – which again vary.

The infrastructure is already in place to transition from a state to national system with facilities and records kept in each state’s medical board. It would simply be a matter of replacing state personnel with federal employees who all work from the same script. A national medical license simply makes sense for all parties. It reduces discontinuity and increases efficiency. A national medical license empowers the individual rather than institutions, yet benefits both.

The time is nigh to nationally certify and set physicians free, reduce paperwork and needless fees, and eliminate state supremacy.  


Dr. Raymond is an emergency physician based in Hickory, N.C., and Muckendorf an der Donau, Austria.

A version of this article first appeared on Medscape.com.

With the need to adapt to the given challenges associated with COVID-19, artificial intelligence (AI) serves as a potential tool in providing access to medical-based diagnosis in a novel way. Artificial intelligence is defined as intelligence harnessed by machines that have the ability to perform what is called cognitive thinking and to mimic the problem-solving abilities of the human mind. Virtual AI in dermatology entails neural network–based guidance that includes developing algorithms to detect skin pathology through photographs.¹ To use AI in dermatology, recognition of visual patterns must be established to give diagnoses. These neural networks have been used to classify skin diseases, including cancer, actinic keratosis, and warts.²

AI for Skin Cancer

The use of AI to classify melanoma and nonmelanoma skin cancer has been studied extensively, including the following 2 research projects.

Convolutional Neural Network
In 2017, Stanford University published a study in which a deep-learning algorithm known as a convolutional neural network was used to classify skin lesions.³ The network was trained using a dataset of 129,450 clinical images of 2032 diseases. Its performance was compared to that of 21 board-certified dermatologists on biopsy-proven clinical images with 2 classifications of cases: (1) keratinocyte carcinoma as opposed to benign seborrheic keratosis and (2) malignant melanoma as opposed to benign nevi—the first representing the most common skin cancers, and the second, the deadliest skin cancers. The study showed that the machine could accurately identify and classify skin cancers compared to the work of board-certified dermatologists. The study did not include demographic information, which limits its external validity.³

Dermoscopic Image Classification
A 2019 study by Brinker and colleagues⁴ showed the superiority of automated dermoscopic melanoma image classifications compared to the work of board-certified dermatologists. For the study, 804 biopsy-proven images of melanoma and nevi (1:1 ratio) were randomly presented to dermatologists for their evaluation and recommended treatment (yielding 19,296 recommendations). The dermatologists classified the lesions with a sensitivity of 67.2% and specificity of 62.2%; the trained convolutional neural network attained both higher sensitivity (82.3%) and higher specificity (77.9%).⁴

Smartphone Diagnosis of Melanoma

An application of AI has been to use smartphone apps for the diagnosis of melanoma. The most utilized and novel algorithm-based smartphone app that assesses skin lesions for malignancy characteristics is SkinVision. With a simple download from Apple’s App Store, this technology allows a person to check their skin spots by taking a photograph and receiving algorithmic risk-assessment feedback. This inexpensive software ($51.78 a year) also allows a patient’s physician to assess the photograph and then validate their assessment by comparing it with the algorithmic analysis that the program provides.⁵

A review of SkinVision conducted by Thissen and colleagues⁶ found that, in a hypothetical population of 1000 adults of whom 3% actually had melanoma, 4 of those 30 people would not have been flagged as at “high risk” by SkinVision. There also was a high false-positive rate with the app, with more than 200 people flagged as at high risk. The analysis pegged SkinVision as having a sensitivity of 88% and specificity of 79%.⁶

In summary, systematic review of diagnostic accuracy has shown that, although there is accuracy in AI analyses, it should be used only as a guide for health care advice due to variability in algorithm performance.⁷

Utility of AI in Telehealth

Artificial intelligence algorithms could be created to ensure telehealth image accuracy, stratify risk, and track patient progress. With teledermatology visits on the rise during the COVID-19 pandemic, AI algorithms could ensure that photographs of appropriate quality are taken. Also, patients could be organized by risk factors with such algorithms, allowing physicians to save time on triage and stratification. Algorithms also could be used to track a telehealth patient’s treatment and progress.⁸

Furthermore, there is a need for an algorithm that has the ability to detect, quantify, and monitor changes in dermatologic conditions using images that patients have uploaded. This capability will lead to creation of a standardized quantification scale that will allow physicians to virtually track the progression of visible skin pathologies.

Hazards of Racial Bias in AI

Artificial intelligence is limited by racial disparity bias seen in computerized medicine. For years, the majority of dermatology research, especially in skin cancer, has been conducted on fairer-skinned populations. This bias has existed at the expense of darker-skinned patients, whose skin conditions and symptoms present differently,⁹ and reflects directly in available data sets that can be used to develop AI algorithms. Because these data are inadequate to the task, AI might misdiagnose skin cancer in people of color or miss an existing condition entirely.¹⁰ Consequently, the higher rate of skin cancer mortality that is reported in people of color is likely to persist with the rise of AI in dermatology.¹¹ A more representative database of imaged skin lesions needs to be utilized to create a diversely representative and applicable data set for AI algorithms.¹²

Benefits of Conversational Agents

Another method by which AI could be incorporated into dermatology is through what is known as a conversational agent (CA)—AI software that engages in a dialogue with users by interpreting their voice and replying to them through text, image, or voice.¹³ Conversational agents facilitate remote patient management, allow clinicians to focus on other functions, and aid in data collection.¹⁴ A 2014 study showed that patients were significantly more likely to disclose history and emotions when informed they were interacting with a CA than with a human clinician (P=.007).¹⁵ Such benefits could be invaluable in dermatology, where emotions and patient perceptions of skin conditions play into the treatment process.

However, some evidence showed that CAs cannot respond to patients’ statements in all circumstances.¹⁶ It also is unclear how well CAs recognize nuanced statements that might signal potential harm. This fits into the greater theme of a major problem with AI: the lack of a reliable response in all circumstances.¹³

Final Thoughts

The practical implementations of AI in dermatology are still being explored. Given the uncertainty surrounding the COVID-19 pandemic and the future of patient care, AI might serve as an important asset in assisting with the diagnosis and treatment of dermatologic conditions, physician productivity, and patient monitoring.

With the need to adapt to the given challenges associated with COVID-19, artificial intelligence (AI) serves as a potential tool in providing access to medical-based diagnosis in a novel way. Artificial intelligence is defined as intelligence harnessed by machines that have the ability to perform what is called cognitive thinking and to mimic the problem-solving abilities of the human mind. Virtual AI in dermatology entails neural network–based guidance that includes developing algorithms to detect skin pathology through photographs.¹ To use AI in dermatology, recognition of visual patterns must be established to give diagnoses. These neural networks have been used to classify skin diseases, including cancer, actinic keratosis, and warts.²

AI for Skin Cancer

The use of AI to classify melanoma and nonmelanoma skin cancer has been studied extensively, including the following 2 research projects.

Convolutional Neural Network
In 2017, Stanford University published a study in which a deep-learning algorithm known as a convolutional neural network was used to classify skin lesions.³ The network was trained using a dataset of 129,450 clinical images of 2032 diseases. Its performance was compared to that of 21 board-certified dermatologists on biopsy-proven clinical images with 2 classifications of cases: (1) keratinocyte carcinoma as opposed to benign seborrheic keratosis and (2) malignant melanoma as opposed to benign nevi—the first representing the most common skin cancers, and the second, the deadliest skin cancers. The study showed that the machine could accurately identify and classify skin cancers compared to the work of board-certified dermatologists. The study did not include demographic information, which limits its external validity.³

Dermoscopic Image Classification
A 2019 study by Brinker and colleagues⁴ showed the superiority of automated dermoscopic melanoma image classifications compared to the work of board-certified dermatologists. For the study, 804 biopsy-proven images of melanoma and nevi (1:1 ratio) were randomly presented to dermatologists for their evaluation and recommended treatment (yielding 19,296 recommendations). The dermatologists classified the lesions with a sensitivity of 67.2% and specificity of 62.2%; the trained convolutional neural network attained both higher sensitivity (82.3%) and higher specificity (77.9%).⁴

Smartphone Diagnosis of Melanoma

An application of AI has been to use smartphone apps for the diagnosis of melanoma. The most utilized and novel algorithm-based smartphone app that assesses skin lesions for malignancy characteristics is SkinVision. With a simple download from Apple’s App Store, this technology allows a person to check their skin spots by taking a photograph and receiving algorithmic risk-assessment feedback. This inexpensive software ($51.78 a year) also allows a patient’s physician to assess the photograph and then validate their assessment by comparing it with the algorithmic analysis that the program provides.⁵

A review of SkinVision conducted by Thissen and colleagues⁶ found that, in a hypothetical population of 1000 adults of whom 3% actually had melanoma, 4 of those 30 people would not have been flagged as at “high risk” by SkinVision. There also was a high false-positive rate with the app, with more than 200 people flagged as at high risk. The analysis pegged SkinVision as having a sensitivity of 88% and specificity of 79%.⁶

In summary, systematic review of diagnostic accuracy has shown that, although there is accuracy in AI analyses, it should be used only as a guide for health care advice due to variability in algorithm performance.⁷

Utility of AI in Telehealth

Artificial intelligence algorithms could be created to ensure telehealth image accuracy, stratify risk, and track patient progress. With teledermatology visits on the rise during the COVID-19 pandemic, AI algorithms could ensure that photographs of appropriate quality are taken. Also, patients could be organized by risk factors with such algorithms, allowing physicians to save time on triage and stratification. Algorithms also could be used to track a telehealth patient’s treatment and progress.⁸

Furthermore, there is a need for an algorithm that has the ability to detect, quantify, and monitor changes in dermatologic conditions using images that patients have uploaded. This capability will lead to creation of a standardized quantification scale that will allow physicians to virtually track the progression of visible skin pathologies.

Hazards of Racial Bias in AI

Artificial intelligence is limited by racial disparity bias seen in computerized medicine. For years, the majority of dermatology research, especially in skin cancer, has been conducted on fairer-skinned populations. This bias has existed at the expense of darker-skinned patients, whose skin conditions and symptoms present differently,⁹ and reflects directly in available data sets that can be used to develop AI algorithms. Because these data are inadequate to the task, AI might misdiagnose skin cancer in people of color or miss an existing condition entirely.¹⁰ Consequently, the higher rate of skin cancer mortality that is reported in people of color is likely to persist with the rise of AI in dermatology.¹¹ A more representative database of imaged skin lesions needs to be utilized to create a diversely representative and applicable data set for AI algorithms.¹²

Benefits of Conversational Agents

Another method by which AI could be incorporated into dermatology is through what is known as a conversational agent (CA)—AI software that engages in a dialogue with users by interpreting their voice and replying to them through text, image, or voice.¹³ Conversational agents facilitate remote patient management, allow clinicians to focus on other functions, and aid in data collection.¹⁴ A 2014 study showed that patients were significantly more likely to disclose history and emotions when informed they were interacting with a CA than with a human clinician (P=.007).¹⁵ Such benefits could be invaluable in dermatology, where emotions and patient perceptions of skin conditions play into the treatment process.

However, some evidence showed that CAs cannot respond to patients’ statements in all circumstances.¹⁶ It also is unclear how well CAs recognize nuanced statements that might signal potential harm. This fits into the greater theme of a major problem with AI: the lack of a reliable response in all circumstances.¹³

Final Thoughts

The practical implementations of AI in dermatology are still being explored. Given the uncertainty surrounding the COVID-19 pandemic and the future of patient care, AI might serve as an important asset in assisting with the diagnosis and treatment of dermatologic conditions, physician productivity, and patient monitoring.

With the need to adapt to the given challenges associated with COVID-19, artificial intelligence (AI) serves as a potential tool in providing access to medical-based diagnosis in a novel way. Artificial intelligence is defined as intelligence harnessed by machines that have the ability to perform what is called cognitive thinking and to mimic the problem-solving abilities of the human mind. Virtual AI in dermatology entails neural network–based guidance that includes developing algorithms to detect skin pathology through photographs.¹ To use AI in dermatology, recognition of visual patterns must be established to give diagnoses. These neural networks have been used to classify skin diseases, including cancer, actinic keratosis, and warts.²

AI for Skin Cancer

The use of AI to classify melanoma and nonmelanoma skin cancer has been studied extensively, including the following 2 research projects.

Convolutional Neural Network
In 2017, Stanford University published a study in which a deep-learning algorithm known as a convolutional neural network was used to classify skin lesions.³ The network was trained using a dataset of 129,450 clinical images of 2032 diseases. Its performance was compared to that of 21 board-certified dermatologists on biopsy-proven clinical images with 2 classifications of cases: (1) keratinocyte carcinoma as opposed to benign seborrheic keratosis and (2) malignant melanoma as opposed to benign nevi—the first representing the most common skin cancers, and the second, the deadliest skin cancers. The study showed that the machine could accurately identify and classify skin cancers compared to the work of board-certified dermatologists. The study did not include demographic information, which limits its external validity.³

Dermoscopic Image Classification
A 2019 study by Brinker and colleagues⁴ showed the superiority of automated dermoscopic melanoma image classifications compared to the work of board-certified dermatologists. For the study, 804 biopsy-proven images of melanoma and nevi (1:1 ratio) were randomly presented to dermatologists for their evaluation and recommended treatment (yielding 19,296 recommendations). The dermatologists classified the lesions with a sensitivity of 67.2% and specificity of 62.2%; the trained convolutional neural network attained both higher sensitivity (82.3%) and higher specificity (77.9%).⁴

Smartphone Diagnosis of Melanoma

An application of AI has been to use smartphone apps for the diagnosis of melanoma. The most utilized and novel algorithm-based smartphone app that assesses skin lesions for malignancy characteristics is SkinVision. With a simple download from Apple’s App Store, this technology allows a person to check their skin spots by taking a photograph and receiving algorithmic risk-assessment feedback. This inexpensive software ($51.78 a year) also allows a patient’s physician to assess the photograph and then validate their assessment by comparing it with the algorithmic analysis that the program provides.⁵

A review of SkinVision conducted by Thissen and colleagues⁶ found that, in a hypothetical population of 1000 adults of whom 3% actually had melanoma, 4 of those 30 people would not have been flagged as at “high risk” by SkinVision. There also was a high false-positive rate with the app, with more than 200 people flagged as at high risk. The analysis pegged SkinVision as having a sensitivity of 88% and specificity of 79%.⁶

In summary, systematic review of diagnostic accuracy has shown that, although there is accuracy in AI analyses, it should be used only as a guide for health care advice due to variability in algorithm performance.⁷

Utility of AI in Telehealth

Artificial intelligence algorithms could be created to ensure telehealth image accuracy, stratify risk, and track patient progress. With teledermatology visits on the rise during the COVID-19 pandemic, AI algorithms could ensure that photographs of appropriate quality are taken. Also, patients could be organized by risk factors with such algorithms, allowing physicians to save time on triage and stratification. Algorithms also could be used to track a telehealth patient’s treatment and progress.⁸

Furthermore, there is a need for an algorithm that has the ability to detect, quantify, and monitor changes in dermatologic conditions using images that patients have uploaded. This capability will lead to creation of a standardized quantification scale that will allow physicians to virtually track the progression of visible skin pathologies.

Hazards of Racial Bias in AI

Artificial intelligence is limited by racial disparity bias seen in computerized medicine. For years, the majority of dermatology research, especially in skin cancer, has been conducted on fairer-skinned populations. This bias has existed at the expense of darker-skinned patients, whose skin conditions and symptoms present differently,⁹ and reflects directly in available data sets that can be used to develop AI algorithms. Because these data are inadequate to the task, AI might misdiagnose skin cancer in people of color or miss an existing condition entirely.¹⁰ Consequently, the higher rate of skin cancer mortality that is reported in people of color is likely to persist with the rise of AI in dermatology.¹¹ A more representative database of imaged skin lesions needs to be utilized to create a diversely representative and applicable data set for AI algorithms.¹²

Benefits of Conversational Agents

Another method by which AI could be incorporated into dermatology is through what is known as a conversational agent (CA)—AI software that engages in a dialogue with users by interpreting their voice and replying to them through text, image, or voice.¹³ Conversational agents facilitate remote patient management, allow clinicians to focus on other functions, and aid in data collection.¹⁴ A 2014 study showed that patients were significantly more likely to disclose history and emotions when informed they were interacting with a CA than with a human clinician (P=.007).¹⁵ Such benefits could be invaluable in dermatology, where emotions and patient perceptions of skin conditions play into the treatment process.

However, some evidence showed that CAs cannot respond to patients’ statements in all circumstances.¹⁶ It also is unclear how well CAs recognize nuanced statements that might signal potential harm. This fits into the greater theme of a major problem with AI: the lack of a reliable response in all circumstances.¹³

Final Thoughts

The practical implementations of AI in dermatology are still being explored. Given the uncertainty surrounding the COVID-19 pandemic and the future of patient care, AI might serve as an important asset in assisting with the diagnosis and treatment of dermatologic conditions, physician productivity, and patient monitoring.

The United States of America is home to a rapidly growing population of more than 3.5 million Muslims. The American Muslim population is a microcosm of global Islamic culture and religious practice, with heterogeneity across age, sex, ethnic origin, immigration status, socioeconomic background, and religiosity. Muslims in America face stressors, including challenges with migration, language barriers, and acculturation.

Some Muslim subgroups (for example, Black Muslims) face additional, intersectional struggles, such as racial discrimination and multigenerational trauma. These challenges may lead to the onset or exacerbation of psychopathology. Nevertheless, the mental health needs of this segment of the American population remain unmet.

Among mental health problems, suicide is inadequately researched among American Muslims. Global studies from both Muslim majority and non-Muslim majority countries consistently indicate that Muslims have among the lowest rates of suicide in comparison with other religious and nonreligious groups. Overall, this body of literature alludes to suicide resiliency in Muslim populations.

However, these studies may not depict the reality for American Muslims. A new research letter, published by two of us (R.A. and B.Z.) and other colleagues at Stanford (Calif.) University’s Muslim Mental Health and Islamic Psychology Lab, highlights the possibility of risk rather than resilience among American Muslims.

In a widely sampled population-based poll, we found that across religious groups in America, Muslims were up to twice as likely to endorse a lifetime history of suicide attempt than other religious or nonreligious groups.

Because of the paucity of suicide research, further inquiry is needed to explain American Muslim evident suicide risk. Nevertheless, our research shows that discrimination and marginalization, both religious and racial, are prominent suicide risk factors in the American Muslim narrative. From 2016 to 2020, almost two-thirds of American Muslims reported facing religious discrimination every year. In 2020, Muslim children in public K-12 systems were twice as likely to face bullying, a third of whom indicated that their bully was a school staff member. While the suicide literature has yet to explore Islamophobia in depth, marginalization and discrimination are demonstrably linked to suicide.

Here are a few clinical pearls that we think will help clinicians meet the needs of these patients:

1. Emphasize the basics. Muslims may be hesitant to engage with mental health practitioners and are often unfamiliar with confidentiality standards. Some may have experience with paternalistic health care cultures where patient privacy is violated. Consequently, some Muslim patients may have concerns that medical professionals can share personal medical history with family members or allied health professionals without obtaining consent. They may worry that private matters will be spread in their community, resulting in stigmatization or discrimination.

Providers should clearly communicate the terms of confidentiality and emphasize patient autonomy over information disclosed outside of the therapeutic partnership.

2. Develop a therapeutic alliance with cultural humility. Since Muslim patients have likely witnessed discrimination, either directly or indirectly, clinicians must adopt a nonjudgmental stance when discussing cultural, religious, or moral values different from their own. Muslim patients may find defending their faith and cultural norms stigmatizing, when faced with clinicians’ assumptions.

Providers should be transparent about their knowledge limitations, ask humbly for a partnership of shared learning, and allow the patient to lead where appropriate. Clinicians should develop a working understanding of Islamic values and cultural norms. See below for Muslim Mental Health resources.

3. Assess suicide risk and ask follow-up questions. Some clinicians may not deem suicide assessments valuable for Muslim patients, believing that strong religious values may preclude them from suicide risk. New findings that suicide risk is prominent among American Muslims highlights the necessity for assessment.

Practitioners should conduct thorough suicide risk assessments, including: past and present ideation, plan, intent, means, relevant risk, and resilience factors. Muslims may be culturally inclined to deny ideation, especially when accompanied by family members. Providers should be on alert for incongruent cues in patient affect and behavior.

4. Accommodate inpatient religious practice. Muslims navigate daily religious choices, from prayers at prescribed times to observing Islamic dietary guidelines. During psychiatric admissions, many of these norms are suspended temporarily. Treatments that do not include the flexibility to address these concerns may mirror patients’ experiences with Islamophobia. For example, being asked to remove the hijab, even with good cause (that is, self-harm precautions), may trigger familiar discriminatory threats to safety and belonging.

Religious accommodations should be addressed in rounds so that all interacting staff maintain collective accountability for religious needs. Accommodations may require adaptive solutions, such as one-piece pull-on–style hijabs as safer alternatives to rectangular wraps. To prevent pathologizing religious observance, providers should consider meeting with Muslim chaplains and patient advocates, including family members or religious care providers, where appropriate.

Addressing the mental health needs of Muslim patients not only requires cultural humility but knowledge about unique challenges facing this diverse community.

To help further advance understanding of these issues, consider taking the American Psychiatric Association’s Muslim Mental Health CME course, which will be taught by Dr. Awaad. In addition, we have included a list of resources below.
 

Further reading

Moffic S et al. Islamophobia and Psychiatry: Recognition, Prevention and Treatment. New York: Springer, 2019.

Keshavarzi H et al. Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy. New York: Routledge, 2020.

Ahmed S and MM Amer. Counseling Muslims: Handbook of Mental Health Issues and Interventions. New York: Routledge/Taylor & Francis Group, 2012.

American Psychiatric Association. Stress & Trauma Toolkit for Treating Muslims in a Changing Political and Social Environment, 2019.

American Psychiatric Association. Mental Health Disparities: Muslim Americans, 2019.

Awaad R et al. JAMA Psychiatry. 2021 Jul 21. doi: 10.1001/jamapsychiatry.2021.1813.

Baca-Garcia E et al. J Affect Disord. 2011;134(1-3):327-32.

Institute for Muslim Mental Health: https://muslimmentalhealth.com/

Institute for Social Policy and Understanding. “Religious Discrimination in Multiple Forms Impacts Muslims of All Ages: American Muslim Poll, 2020.

Silverman JJ et al. Am J Psychiatry. 2015 Aug 1;172(8):798-802.

Resources

Stanford Muslim Mental Health and Islamic Psychology Lab: http://med.stanford.edu/psychiatry/research/MuslimMHLab.html

Maristan: https://maristan.org/

Naseeha mental health hotline: https://naseeha.org/

Dr. Awaad is a clinical associate professor in the department of psychiatry and behavioral sciences at Stanford University. She also serves as associate division chief of public mental health and population sciences, and diversity section chief in the psychiatry department. In addition, Dr. Awaad is executive director of Maristan, an organization focused on using authentic traditions to meet the mental health needs of the Islamic community, and is affiliated with the department of psychiatry and behavioral sciences at Stanford. Dr. Awaad is coeditor of “Islamophobia and Psychiatry: Recognition, Prevention and Treatment” (New York: Springer, 2019), and “Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy” (New York: Routledge/Taylor & Francis Group, 2020).

Dr. Husain completed her medical degree from St. George’s University in True Blue, Grenada; she is currently a graduate student in the department of public health concentrating on mental health parity in the United States. She also works as a researcher at the Stanford Muslim Mental Health & Islamic Psychology Lab and as an organizer for Team Liyna, a national effort aimed at diversifying the stem cell registry responsible for more than 10,000 new registrants since 2019.

Mr. Zia, who has been affiliated with the department of psychiatry and behavioral sciences at Stanford, is a PhD candidate and Canada-Vanier scholar in the department of clinical psychology at the University of Manitoba, Winnipeg. Mr. Zia is also a psychological associate at the New Leaf Psychology Centre in Milton, Ont. He has no relevant financial relationships.


 

The United States of America is home to a rapidly growing population of more than 3.5 million Muslims. The American Muslim population is a microcosm of global Islamic culture and religious practice, with heterogeneity across age, sex, ethnic origin, immigration status, socioeconomic background, and religiosity. Muslims in America face stressors, including challenges with migration, language barriers, and acculturation.

Some Muslim subgroups (for example, Black Muslims) face additional, intersectional struggles, such as racial discrimination and multigenerational trauma. These challenges may lead to the onset or exacerbation of psychopathology. Nevertheless, the mental health needs of this segment of the American population remain unmet.

Among mental health problems, suicide is inadequately researched among American Muslims. Global studies from both Muslim majority and non-Muslim majority countries consistently indicate that Muslims have among the lowest rates of suicide in comparison with other religious and nonreligious groups. Overall, this body of literature alludes to suicide resiliency in Muslim populations.

However, these studies may not depict the reality for American Muslims. A new research letter, published by two of us (R.A. and B.Z.) and other colleagues at Stanford (Calif.) University’s Muslim Mental Health and Islamic Psychology Lab, highlights the possibility of risk rather than resilience among American Muslims.

In a widely sampled population-based poll, we found that across religious groups in America, Muslims were up to twice as likely to endorse a lifetime history of suicide attempt than other religious or nonreligious groups.

Because of the paucity of suicide research, further inquiry is needed to explain American Muslim evident suicide risk. Nevertheless, our research shows that discrimination and marginalization, both religious and racial, are prominent suicide risk factors in the American Muslim narrative. From 2016 to 2020, almost two-thirds of American Muslims reported facing religious discrimination every year. In 2020, Muslim children in public K-12 systems were twice as likely to face bullying, a third of whom indicated that their bully was a school staff member. While the suicide literature has yet to explore Islamophobia in depth, marginalization and discrimination are demonstrably linked to suicide.

Here are a few clinical pearls that we think will help clinicians meet the needs of these patients:

1. Emphasize the basics. Muslims may be hesitant to engage with mental health practitioners and are often unfamiliar with confidentiality standards. Some may have experience with paternalistic health care cultures where patient privacy is violated. Consequently, some Muslim patients may have concerns that medical professionals can share personal medical history with family members or allied health professionals without obtaining consent. They may worry that private matters will be spread in their community, resulting in stigmatization or discrimination.

Providers should clearly communicate the terms of confidentiality and emphasize patient autonomy over information disclosed outside of the therapeutic partnership.

2. Develop a therapeutic alliance with cultural humility. Since Muslim patients have likely witnessed discrimination, either directly or indirectly, clinicians must adopt a nonjudgmental stance when discussing cultural, religious, or moral values different from their own. Muslim patients may find defending their faith and cultural norms stigmatizing, when faced with clinicians’ assumptions.

Providers should be transparent about their knowledge limitations, ask humbly for a partnership of shared learning, and allow the patient to lead where appropriate. Clinicians should develop a working understanding of Islamic values and cultural norms. See below for Muslim Mental Health resources.

3. Assess suicide risk and ask follow-up questions. Some clinicians may not deem suicide assessments valuable for Muslim patients, believing that strong religious values may preclude them from suicide risk. New findings that suicide risk is prominent among American Muslims highlights the necessity for assessment.

Practitioners should conduct thorough suicide risk assessments, including: past and present ideation, plan, intent, means, relevant risk, and resilience factors. Muslims may be culturally inclined to deny ideation, especially when accompanied by family members. Providers should be on alert for incongruent cues in patient affect and behavior.

4. Accommodate inpatient religious practice. Muslims navigate daily religious choices, from prayers at prescribed times to observing Islamic dietary guidelines. During psychiatric admissions, many of these norms are suspended temporarily. Treatments that do not include the flexibility to address these concerns may mirror patients’ experiences with Islamophobia. For example, being asked to remove the hijab, even with good cause (that is, self-harm precautions), may trigger familiar discriminatory threats to safety and belonging.

Religious accommodations should be addressed in rounds so that all interacting staff maintain collective accountability for religious needs. Accommodations may require adaptive solutions, such as one-piece pull-on–style hijabs as safer alternatives to rectangular wraps. To prevent pathologizing religious observance, providers should consider meeting with Muslim chaplains and patient advocates, including family members or religious care providers, where appropriate.

Addressing the mental health needs of Muslim patients not only requires cultural humility but knowledge about unique challenges facing this diverse community.

To help further advance understanding of these issues, consider taking the American Psychiatric Association’s Muslim Mental Health CME course, which will be taught by Dr. Awaad. In addition, we have included a list of resources below.
 

Further reading

Moffic S et al. Islamophobia and Psychiatry: Recognition, Prevention and Treatment. New York: Springer, 2019.

Keshavarzi H et al. Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy. New York: Routledge, 2020.

Ahmed S and MM Amer. Counseling Muslims: Handbook of Mental Health Issues and Interventions. New York: Routledge/Taylor & Francis Group, 2012.

American Psychiatric Association. Stress & Trauma Toolkit for Treating Muslims in a Changing Political and Social Environment, 2019.

American Psychiatric Association. Mental Health Disparities: Muslim Americans, 2019.

Awaad R et al. JAMA Psychiatry. 2021 Jul 21. doi: 10.1001/jamapsychiatry.2021.1813.

Baca-Garcia E et al. J Affect Disord. 2011;134(1-3):327-32.

Institute for Muslim Mental Health: https://muslimmentalhealth.com/

Institute for Social Policy and Understanding. “Religious Discrimination in Multiple Forms Impacts Muslims of All Ages: American Muslim Poll, 2020.

Silverman JJ et al. Am J Psychiatry. 2015 Aug 1;172(8):798-802.

Resources

Stanford Muslim Mental Health and Islamic Psychology Lab: http://med.stanford.edu/psychiatry/research/MuslimMHLab.html

Maristan: https://maristan.org/

Naseeha mental health hotline: https://naseeha.org/

Dr. Awaad is a clinical associate professor in the department of psychiatry and behavioral sciences at Stanford University. She also serves as associate division chief of public mental health and population sciences, and diversity section chief in the psychiatry department. In addition, Dr. Awaad is executive director of Maristan, an organization focused on using authentic traditions to meet the mental health needs of the Islamic community, and is affiliated with the department of psychiatry and behavioral sciences at Stanford. Dr. Awaad is coeditor of “Islamophobia and Psychiatry: Recognition, Prevention and Treatment” (New York: Springer, 2019), and “Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy” (New York: Routledge/Taylor & Francis Group, 2020).

Dr. Husain completed her medical degree from St. George’s University in True Blue, Grenada; she is currently a graduate student in the department of public health concentrating on mental health parity in the United States. She also works as a researcher at the Stanford Muslim Mental Health & Islamic Psychology Lab and as an organizer for Team Liyna, a national effort aimed at diversifying the stem cell registry responsible for more than 10,000 new registrants since 2019.

Mr. Zia, who has been affiliated with the department of psychiatry and behavioral sciences at Stanford, is a PhD candidate and Canada-Vanier scholar in the department of clinical psychology at the University of Manitoba, Winnipeg. Mr. Zia is also a psychological associate at the New Leaf Psychology Centre in Milton, Ont. He has no relevant financial relationships.


 

The United States of America is home to a rapidly growing population of more than 3.5 million Muslims. The American Muslim population is a microcosm of global Islamic culture and religious practice, with heterogeneity across age, sex, ethnic origin, immigration status, socioeconomic background, and religiosity. Muslims in America face stressors, including challenges with migration, language barriers, and acculturation.

Some Muslim subgroups (for example, Black Muslims) face additional, intersectional struggles, such as racial discrimination and multigenerational trauma. These challenges may lead to the onset or exacerbation of psychopathology. Nevertheless, the mental health needs of this segment of the American population remain unmet.

Among mental health problems, suicide is inadequately researched among American Muslims. Global studies from both Muslim majority and non-Muslim majority countries consistently indicate that Muslims have among the lowest rates of suicide in comparison with other religious and nonreligious groups. Overall, this body of literature alludes to suicide resiliency in Muslim populations.

However, these studies may not depict the reality for American Muslims. A new research letter, published by two of us (R.A. and B.Z.) and other colleagues at Stanford (Calif.) University’s Muslim Mental Health and Islamic Psychology Lab, highlights the possibility of risk rather than resilience among American Muslims.

In a widely sampled population-based poll, we found that across religious groups in America, Muslims were up to twice as likely to endorse a lifetime history of suicide attempt than other religious or nonreligious groups.

Because of the paucity of suicide research, further inquiry is needed to explain American Muslim evident suicide risk. Nevertheless, our research shows that discrimination and marginalization, both religious and racial, are prominent suicide risk factors in the American Muslim narrative. From 2016 to 2020, almost two-thirds of American Muslims reported facing religious discrimination every year. In 2020, Muslim children in public K-12 systems were twice as likely to face bullying, a third of whom indicated that their bully was a school staff member. While the suicide literature has yet to explore Islamophobia in depth, marginalization and discrimination are demonstrably linked to suicide.

Here are a few clinical pearls that we think will help clinicians meet the needs of these patients:

1. Emphasize the basics. Muslims may be hesitant to engage with mental health practitioners and are often unfamiliar with confidentiality standards. Some may have experience with paternalistic health care cultures where patient privacy is violated. Consequently, some Muslim patients may have concerns that medical professionals can share personal medical history with family members or allied health professionals without obtaining consent. They may worry that private matters will be spread in their community, resulting in stigmatization or discrimination.

Providers should clearly communicate the terms of confidentiality and emphasize patient autonomy over information disclosed outside of the therapeutic partnership.

2. Develop a therapeutic alliance with cultural humility. Since Muslim patients have likely witnessed discrimination, either directly or indirectly, clinicians must adopt a nonjudgmental stance when discussing cultural, religious, or moral values different from their own. Muslim patients may find defending their faith and cultural norms stigmatizing, when faced with clinicians’ assumptions.

Providers should be transparent about their knowledge limitations, ask humbly for a partnership of shared learning, and allow the patient to lead where appropriate. Clinicians should develop a working understanding of Islamic values and cultural norms. See below for Muslim Mental Health resources.

3. Assess suicide risk and ask follow-up questions. Some clinicians may not deem suicide assessments valuable for Muslim patients, believing that strong religious values may preclude them from suicide risk. New findings that suicide risk is prominent among American Muslims highlights the necessity for assessment.

Practitioners should conduct thorough suicide risk assessments, including: past and present ideation, plan, intent, means, relevant risk, and resilience factors. Muslims may be culturally inclined to deny ideation, especially when accompanied by family members. Providers should be on alert for incongruent cues in patient affect and behavior.

4. Accommodate inpatient religious practice. Muslims navigate daily religious choices, from prayers at prescribed times to observing Islamic dietary guidelines. During psychiatric admissions, many of these norms are suspended temporarily. Treatments that do not include the flexibility to address these concerns may mirror patients’ experiences with Islamophobia. For example, being asked to remove the hijab, even with good cause (that is, self-harm precautions), may trigger familiar discriminatory threats to safety and belonging.

Religious accommodations should be addressed in rounds so that all interacting staff maintain collective accountability for religious needs. Accommodations may require adaptive solutions, such as one-piece pull-on–style hijabs as safer alternatives to rectangular wraps. To prevent pathologizing religious observance, providers should consider meeting with Muslim chaplains and patient advocates, including family members or religious care providers, where appropriate.

Addressing the mental health needs of Muslim patients not only requires cultural humility but knowledge about unique challenges facing this diverse community.

To help further advance understanding of these issues, consider taking the American Psychiatric Association’s Muslim Mental Health CME course, which will be taught by Dr. Awaad. In addition, we have included a list of resources below.
 

Further reading

Moffic S et al. Islamophobia and Psychiatry: Recognition, Prevention and Treatment. New York: Springer, 2019.

Keshavarzi H et al. Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy. New York: Routledge, 2020.

Ahmed S and MM Amer. Counseling Muslims: Handbook of Mental Health Issues and Interventions. New York: Routledge/Taylor & Francis Group, 2012.

American Psychiatric Association. Stress & Trauma Toolkit for Treating Muslims in a Changing Political and Social Environment, 2019.

American Psychiatric Association. Mental Health Disparities: Muslim Americans, 2019.

Awaad R et al. JAMA Psychiatry. 2021 Jul 21. doi: 10.1001/jamapsychiatry.2021.1813.

Baca-Garcia E et al. J Affect Disord. 2011;134(1-3):327-32.

Institute for Muslim Mental Health: https://muslimmentalhealth.com/

Institute for Social Policy and Understanding. “Religious Discrimination in Multiple Forms Impacts Muslims of All Ages: American Muslim Poll, 2020.

Silverman JJ et al. Am J Psychiatry. 2015 Aug 1;172(8):798-802.

Resources

Stanford Muslim Mental Health and Islamic Psychology Lab: http://med.stanford.edu/psychiatry/research/MuslimMHLab.html

Maristan: https://maristan.org/

Naseeha mental health hotline: https://naseeha.org/

Dr. Awaad is a clinical associate professor in the department of psychiatry and behavioral sciences at Stanford University. She also serves as associate division chief of public mental health and population sciences, and diversity section chief in the psychiatry department. In addition, Dr. Awaad is executive director of Maristan, an organization focused on using authentic traditions to meet the mental health needs of the Islamic community, and is affiliated with the department of psychiatry and behavioral sciences at Stanford. Dr. Awaad is coeditor of “Islamophobia and Psychiatry: Recognition, Prevention and Treatment” (New York: Springer, 2019), and “Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy” (New York: Routledge/Taylor & Francis Group, 2020).

Dr. Husain completed her medical degree from St. George’s University in True Blue, Grenada; she is currently a graduate student in the department of public health concentrating on mental health parity in the United States. She also works as a researcher at the Stanford Muslim Mental Health & Islamic Psychology Lab and as an organizer for Team Liyna, a national effort aimed at diversifying the stem cell registry responsible for more than 10,000 new registrants since 2019.

Mr. Zia, who has been affiliated with the department of psychiatry and behavioral sciences at Stanford, is a PhD candidate and Canada-Vanier scholar in the department of clinical psychology at the University of Manitoba, Winnipeg. Mr. Zia is also a psychological associate at the New Leaf Psychology Centre in Milton, Ont. He has no relevant financial relationships.


 

As working mothers with babies in tow when the COVID-19 crisis struck, countless uncertainties threatened our already precarious work-life balance. We suddenly had many questions:

“If my daycare closes, what will I do for childcare?”

“How do I navigate diaper changes, feedings, and naps with my hectic remote work schedule?”

“If I’m constantly interrupted during the day, should I skip sleep to catch up on work and not let my colleagues down?”

As professionals who work closely with medical trainees, we knew our parenting dilemmas were being experienced even more acutely by our frontline worker colleagues.

Medical training is an increasingly common time to start a family. In a recent study, 34% of trainees in Harvard-affiliated residency programs became parents during training, and another 52% planned to do so. Trainees have higher breastfeeding initiation rates but lower continuation rates than the general population. Early nursing cessation among trainees is well documented nationally and is most often attributed to work-related barriers. These barriers range from insufficient time and limited access to facilities to a lack of support and discrimination by supervisors and peers.

This trend does not discriminate by specialty. Even among training programs known to be “family friendly,” the average duration of nursing is just 4.5 months. Residents of color are disproportionately affected by inadequate support. Studies show that Black parents breastfeed at lower rates than White parents. This has been largely attributed to structural racism and implicit bias, such as Black parents receiving less assistance initiating nursing after delivery. Adequate lactation support and inclusivity are also lacking for transgender parents who choose to breastfeed or chestfeed.

The very nature of residency training, which includes shifts that can span more than 24 hours, conflicts with many health-promoting behaviors like sleeping and eating well. However, its interference with lactation is correlated with gender. Women are disproportionately affected by the negative outcomes of unmet lactation goals. These include work-life imbalance, career dissatisfaction, and negative emotions. In a study of pediatric residents, one in four did not achieve their breastfeeding goals. Respondents reported feeling “sad, devastated, defeated, disappointed, guilty, embarrassed, frustrated, angry, like a failure, and inadequate.” Among physician mothers more broadly, discrimination related to pregnancy, parental leave, and nursing is associated with higher self-reported burnout.

Navigating nursing during residency training has more than just emotional and psychological consequences – it also has professional ones. Pursuing personal lactation goals can delay residency program completion and board certification, influence specialty selection, negatively impact research productivity, impede career advancement, and lead to misgivings about career choice.

Trainees and their families are not the only ones harmed by inadequate support in residency programs. Patients and their families are affected, too. Research suggests that physicians’ personal breastfeeding practices affect the advice they give to patients. Those who receive lactation support are more likely to help patients meet their own goals. In the previously mentioned study of pediatric residents, more than 90% of the 400 respondents said their own or their partner’s nursing experience affected their interaction with lactating patients in their clinic or hospital.

Increased lactation support is a straightforward, low-cost, high-impact intervention. It benefits trainee well-being, satisfaction, workflow, and future patient care. The Accreditation Council for Graduate Medical Education mandated in July 2019 that all residency programs provide adequate lactation facilities – including refrigeration capabilities and proximity for safe patient care. However, to our knowledge, rates of compliance with this new policy and citation for noncompliance have yet to be seen. Regardless, facilities alone are not enough. Residency programs should develop and enforce formal lactation policies.

Several institutions have successfully piloted such policies in recent years. One in particular from the University of Michigan’s surgery residency program inspired the development of a lactation policy within the internal medicine residency at our institution. These policies designate appropriate spaces at each clinical rotation site, clarify that residents are encouraged to take pumping breaks as needed – in coordination with clinical teams so as not to compromise patient care – and communicate support from supervisors.

Our program also established an informal peer mentoring program. Residents with experience pumping at work pair up with newer trainees. The policy benefits residents who wish to chestfeed or breastfeed, normalizes lactation, and empowers trainees by diminishing the need to ask for individual accommodations. It also costs the program nothing.

As more women enter medicine and more trainees become parents during residency, the need for support in this area will only continue to grow. The widespread lack of such resources, and the fact that clean and private facilities are only now being mandated, is symbolic. If even this basic need is rarely acknowledged or met, what other resident needs are being neglected?

A version of this article first appeared on Medscape.com.

As working mothers with babies in tow when the COVID-19 crisis struck, countless uncertainties threatened our already precarious work-life balance. We suddenly had many questions:

“If my daycare closes, what will I do for childcare?”

“How do I navigate diaper changes, feedings, and naps with my hectic remote work schedule?”

“If I’m constantly interrupted during the day, should I skip sleep to catch up on work and not let my colleagues down?”

As professionals who work closely with medical trainees, we knew our parenting dilemmas were being experienced even more acutely by our frontline worker colleagues.

Medical training is an increasingly common time to start a family. In a recent study, 34% of trainees in Harvard-affiliated residency programs became parents during training, and another 52% planned to do so. Trainees have higher breastfeeding initiation rates but lower continuation rates than the general population. Early nursing cessation among trainees is well documented nationally and is most often attributed to work-related barriers. These barriers range from insufficient time and limited access to facilities to a lack of support and discrimination by supervisors and peers.

This trend does not discriminate by specialty. Even among training programs known to be “family friendly,” the average duration of nursing is just 4.5 months. Residents of color are disproportionately affected by inadequate support. Studies show that Black parents breastfeed at lower rates than White parents. This has been largely attributed to structural racism and implicit bias, such as Black parents receiving less assistance initiating nursing after delivery. Adequate lactation support and inclusivity are also lacking for transgender parents who choose to breastfeed or chestfeed.

The very nature of residency training, which includes shifts that can span more than 24 hours, conflicts with many health-promoting behaviors like sleeping and eating well. However, its interference with lactation is correlated with gender. Women are disproportionately affected by the negative outcomes of unmet lactation goals. These include work-life imbalance, career dissatisfaction, and negative emotions. In a study of pediatric residents, one in four did not achieve their breastfeeding goals. Respondents reported feeling “sad, devastated, defeated, disappointed, guilty, embarrassed, frustrated, angry, like a failure, and inadequate.” Among physician mothers more broadly, discrimination related to pregnancy, parental leave, and nursing is associated with higher self-reported burnout.

Navigating nursing during residency training has more than just emotional and psychological consequences – it also has professional ones. Pursuing personal lactation goals can delay residency program completion and board certification, influence specialty selection, negatively impact research productivity, impede career advancement, and lead to misgivings about career choice.

Trainees and their families are not the only ones harmed by inadequate support in residency programs. Patients and their families are affected, too. Research suggests that physicians’ personal breastfeeding practices affect the advice they give to patients. Those who receive lactation support are more likely to help patients meet their own goals. In the previously mentioned study of pediatric residents, more than 90% of the 400 respondents said their own or their partner’s nursing experience affected their interaction with lactating patients in their clinic or hospital.

Increased lactation support is a straightforward, low-cost, high-impact intervention. It benefits trainee well-being, satisfaction, workflow, and future patient care. The Accreditation Council for Graduate Medical Education mandated in July 2019 that all residency programs provide adequate lactation facilities – including refrigeration capabilities and proximity for safe patient care. However, to our knowledge, rates of compliance with this new policy and citation for noncompliance have yet to be seen. Regardless, facilities alone are not enough. Residency programs should develop and enforce formal lactation policies.

Several institutions have successfully piloted such policies in recent years. One in particular from the University of Michigan’s surgery residency program inspired the development of a lactation policy within the internal medicine residency at our institution. These policies designate appropriate spaces at each clinical rotation site, clarify that residents are encouraged to take pumping breaks as needed – in coordination with clinical teams so as not to compromise patient care – and communicate support from supervisors.

Our program also established an informal peer mentoring program. Residents with experience pumping at work pair up with newer trainees. The policy benefits residents who wish to chestfeed or breastfeed, normalizes lactation, and empowers trainees by diminishing the need to ask for individual accommodations. It also costs the program nothing.

As more women enter medicine and more trainees become parents during residency, the need for support in this area will only continue to grow. The widespread lack of such resources, and the fact that clean and private facilities are only now being mandated, is symbolic. If even this basic need is rarely acknowledged or met, what other resident needs are being neglected?

A version of this article first appeared on Medscape.com.

As working mothers with babies in tow when the COVID-19 crisis struck, countless uncertainties threatened our already precarious work-life balance. We suddenly had many questions:

“If my daycare closes, what will I do for childcare?”

“How do I navigate diaper changes, feedings, and naps with my hectic remote work schedule?”

“If I’m constantly interrupted during the day, should I skip sleep to catch up on work and not let my colleagues down?”

As professionals who work closely with medical trainees, we knew our parenting dilemmas were being experienced even more acutely by our frontline worker colleagues.

Medical training is an increasingly common time to start a family. In a recent study, 34% of trainees in Harvard-affiliated residency programs became parents during training, and another 52% planned to do so. Trainees have higher breastfeeding initiation rates but lower continuation rates than the general population. Early nursing cessation among trainees is well documented nationally and is most often attributed to work-related barriers. These barriers range from insufficient time and limited access to facilities to a lack of support and discrimination by supervisors and peers.

This trend does not discriminate by specialty. Even among training programs known to be “family friendly,” the average duration of nursing is just 4.5 months. Residents of color are disproportionately affected by inadequate support. Studies show that Black parents breastfeed at lower rates than White parents. This has been largely attributed to structural racism and implicit bias, such as Black parents receiving less assistance initiating nursing after delivery. Adequate lactation support and inclusivity are also lacking for transgender parents who choose to breastfeed or chestfeed.

The very nature of residency training, which includes shifts that can span more than 24 hours, conflicts with many health-promoting behaviors like sleeping and eating well. However, its interference with lactation is correlated with gender. Women are disproportionately affected by the negative outcomes of unmet lactation goals. These include work-life imbalance, career dissatisfaction, and negative emotions. In a study of pediatric residents, one in four did not achieve their breastfeeding goals. Respondents reported feeling “sad, devastated, defeated, disappointed, guilty, embarrassed, frustrated, angry, like a failure, and inadequate.” Among physician mothers more broadly, discrimination related to pregnancy, parental leave, and nursing is associated with higher self-reported burnout.

Navigating nursing during residency training has more than just emotional and psychological consequences – it also has professional ones. Pursuing personal lactation goals can delay residency program completion and board certification, influence specialty selection, negatively impact research productivity, impede career advancement, and lead to misgivings about career choice.

Trainees and their families are not the only ones harmed by inadequate support in residency programs. Patients and their families are affected, too. Research suggests that physicians’ personal breastfeeding practices affect the advice they give to patients. Those who receive lactation support are more likely to help patients meet their own goals. In the previously mentioned study of pediatric residents, more than 90% of the 400 respondents said their own or their partner’s nursing experience affected their interaction with lactating patients in their clinic or hospital.

Increased lactation support is a straightforward, low-cost, high-impact intervention. It benefits trainee well-being, satisfaction, workflow, and future patient care. The Accreditation Council for Graduate Medical Education mandated in July 2019 that all residency programs provide adequate lactation facilities – including refrigeration capabilities and proximity for safe patient care. However, to our knowledge, rates of compliance with this new policy and citation for noncompliance have yet to be seen. Regardless, facilities alone are not enough. Residency programs should develop and enforce formal lactation policies.

Several institutions have successfully piloted such policies in recent years. One in particular from the University of Michigan’s surgery residency program inspired the development of a lactation policy within the internal medicine residency at our institution. These policies designate appropriate spaces at each clinical rotation site, clarify that residents are encouraged to take pumping breaks as needed – in coordination with clinical teams so as not to compromise patient care – and communicate support from supervisors.

Our program also established an informal peer mentoring program. Residents with experience pumping at work pair up with newer trainees. The policy benefits residents who wish to chestfeed or breastfeed, normalizes lactation, and empowers trainees by diminishing the need to ask for individual accommodations. It also costs the program nothing.

As more women enter medicine and more trainees become parents during residency, the need for support in this area will only continue to grow. The widespread lack of such resources, and the fact that clean and private facilities are only now being mandated, is symbolic. If even this basic need is rarely acknowledged or met, what other resident needs are being neglected?

A version of this article first appeared on Medscape.com.

The 47th Annual Scientific Meeting of the Society of Gynecologic Surgeons (SGS), like so many things in our modern world, endured many changes and had to stay nimble and evolve to changing times. In the end, however, SGS was able to adapt and succeed, just like a skilled gynecologic surgeon in the operating room, to deliver a fresh new type of meeting.

When we chose the meeting theme, “Working together: How collaboration enables us to better help our patients,” we anticipated a meeting discussing medical colleagues and consultants. In our forever-changed world, we knew we needed to reinterpret this to a broader social context. Our special lectures and panel discussions sought to open attendees’ eyes to disparities in health care for people of color and women.

While we highlighted the realities faced by colleagues in medicine, the topics addressed also were designed to grow awareness about struggles our patients encounter as well. Social disparities are sobering, long-standing, and sometimes require creative collaborations to achieve successful outcomes for all patients. The faculty of one of our postgraduate courses reviews in this special 2-part section to OBG Management strategies on dismantling racism, and Christine Heisler, MD, MS, and Sarah M. Temkin, MD, summarize their recent research and special lecture on gender equity in gynecologic surgery (see part 2 of this series in next month’s issue of OBG Management).

The meeting also kicked off with a postgraduate course on fibroid management, with workshops on harnessing the power of social media and lessons on leadership from a female Fortune 500 CEO, Lori Ryerkerk, offered as well. As the scientific program launched, we were once again treated to strong science on gynecologic surgery, with only a small dip in abstract submissions, despite the challenges of research during a pandemic. Mark Walters, MD, gave the inaugural lecture in his name on the crucial topic of surgical education and teaching. We also heard a special report from the SGS SOCOVID research group, led by Dr. Rosanne Kho, on gynecologic surgery during the pandemic. We also convened a virtual panel for our hybrid attendees on the benefits to patients of a multidisciplinary approach to gynecologic surgery, presented here by Cecile Ferrando, MD.

As our practices continue to grow and evolve, the introduction of innovative technologies can pose a new challenge, as Miles Murphy, MD, and members of the panel on novel gynecologic office procedures will present in this series next month.

The TeLinde keynote speaker was Janet Dombrowski, who works as a coach for many surgeons in various disciplines across the country. She spoke to the resilience gained through community and collaboration.

While our meeting theme dated to the “before” pandemic era, those who were able to be in attendance in person can attest to the value we can all place now on community and personal interactions. With experience strengthened by science, I hope this meeting summary serves to highlight the many ways in which we can collaborate to improve outcomes for ourselves in medicine and for patients. 

The 47th Annual Scientific Meeting of the Society of Gynecologic Surgeons (SGS), like so many things in our modern world, endured many changes and had to stay nimble and evolve to changing times. In the end, however, SGS was able to adapt and succeed, just like a skilled gynecologic surgeon in the operating room, to deliver a fresh new type of meeting.

When we chose the meeting theme, “Working together: How collaboration enables us to better help our patients,” we anticipated a meeting discussing medical colleagues and consultants. In our forever-changed world, we knew we needed to reinterpret this to a broader social context. Our special lectures and panel discussions sought to open attendees’ eyes to disparities in health care for people of color and women.

While we highlighted the realities faced by colleagues in medicine, the topics addressed also were designed to grow awareness about struggles our patients encounter as well. Social disparities are sobering, long-standing, and sometimes require creative collaborations to achieve successful outcomes for all patients. The faculty of one of our postgraduate courses reviews in this special 2-part section to OBG Management strategies on dismantling racism, and Christine Heisler, MD, MS, and Sarah M. Temkin, MD, summarize their recent research and special lecture on gender equity in gynecologic surgery (see part 2 of this series in next month’s issue of OBG Management).

The meeting also kicked off with a postgraduate course on fibroid management, with workshops on harnessing the power of social media and lessons on leadership from a female Fortune 500 CEO, Lori Ryerkerk, offered as well. As the scientific program launched, we were once again treated to strong science on gynecologic surgery, with only a small dip in abstract submissions, despite the challenges of research during a pandemic. Mark Walters, MD, gave the inaugural lecture in his name on the crucial topic of surgical education and teaching. We also heard a special report from the SGS SOCOVID research group, led by Dr. Rosanne Kho, on gynecologic surgery during the pandemic. We also convened a virtual panel for our hybrid attendees on the benefits to patients of a multidisciplinary approach to gynecologic surgery, presented here by Cecile Ferrando, MD.

As our practices continue to grow and evolve, the introduction of innovative technologies can pose a new challenge, as Miles Murphy, MD, and members of the panel on novel gynecologic office procedures will present in this series next month.

The TeLinde keynote speaker was Janet Dombrowski, who works as a coach for many surgeons in various disciplines across the country. She spoke to the resilience gained through community and collaboration.

While our meeting theme dated to the “before” pandemic era, those who were able to be in attendance in person can attest to the value we can all place now on community and personal interactions. With experience strengthened by science, I hope this meeting summary serves to highlight the many ways in which we can collaborate to improve outcomes for ourselves in medicine and for patients. 

The 47th Annual Scientific Meeting of the Society of Gynecologic Surgeons (SGS), like so many things in our modern world, endured many changes and had to stay nimble and evolve to changing times. In the end, however, SGS was able to adapt and succeed, just like a skilled gynecologic surgeon in the operating room, to deliver a fresh new type of meeting.

When we chose the meeting theme, “Working together: How collaboration enables us to better help our patients,” we anticipated a meeting discussing medical colleagues and consultants. In our forever-changed world, we knew we needed to reinterpret this to a broader social context. Our special lectures and panel discussions sought to open attendees’ eyes to disparities in health care for people of color and women.

While we highlighted the realities faced by colleagues in medicine, the topics addressed also were designed to grow awareness about struggles our patients encounter as well. Social disparities are sobering, long-standing, and sometimes require creative collaborations to achieve successful outcomes for all patients. The faculty of one of our postgraduate courses reviews in this special 2-part section to OBG Management strategies on dismantling racism, and Christine Heisler, MD, MS, and Sarah M. Temkin, MD, summarize their recent research and special lecture on gender equity in gynecologic surgery (see part 2 of this series in next month’s issue of OBG Management).

The meeting also kicked off with a postgraduate course on fibroid management, with workshops on harnessing the power of social media and lessons on leadership from a female Fortune 500 CEO, Lori Ryerkerk, offered as well. As the scientific program launched, we were once again treated to strong science on gynecologic surgery, with only a small dip in abstract submissions, despite the challenges of research during a pandemic. Mark Walters, MD, gave the inaugural lecture in his name on the crucial topic of surgical education and teaching. We also heard a special report from the SGS SOCOVID research group, led by Dr. Rosanne Kho, on gynecologic surgery during the pandemic. We also convened a virtual panel for our hybrid attendees on the benefits to patients of a multidisciplinary approach to gynecologic surgery, presented here by Cecile Ferrando, MD.

As our practices continue to grow and evolve, the introduction of innovative technologies can pose a new challenge, as Miles Murphy, MD, and members of the panel on novel gynecologic office procedures will present in this series next month.

The TeLinde keynote speaker was Janet Dombrowski, who works as a coach for many surgeons in various disciplines across the country. She spoke to the resilience gained through community and collaboration.

While our meeting theme dated to the “before” pandemic era, those who were able to be in attendance in person can attest to the value we can all place now on community and personal interactions. With experience strengthened by science, I hope this meeting summary serves to highlight the many ways in which we can collaborate to improve outcomes for ourselves in medicine and for patients. 

Rashes that develop during pregnancy often result in considerable anxiety or concern for patients and their families. Recognizing these pregnancy-specific dermatoses is important in identifying fetal risks as well as providing appropriate management and expert guidance for patients regarding future pregnancies. Managing cutaneous manifestations of pregnancy-related disorders is challenging and requires knowledge of potential side effects of therapy for both the mother and fetus. It also is important to appreciate the physiologic cutaneous changes of pregnancy along with their clinical significance and management.

In 2006, Ambrose-Rudolph et al¹ proposed reclassification of pregnancy-specific dermatoses, which has since been widely accepted by the academic dermatology community. The 4 most prominent disorders include intrahepatic cholestasis of pregnancy (ICP); pemphigoid gestationis (PG); polymorphic eruption of pregnancy (PEP), also known as pruritic urticarial papules and plaques of pregnancy; and atopic eruption of pregnancy.² It is important to recognize these pregnancy-specific disorders and to understand their clinical significance. The morphology of the eruption as well as the location and timing of the onset of the rash are important clues in making an accurate diagnosis.³

Clinical Presentation

Intrahepatic cholestasis of pregnancy presents with severe generalized pruritus, usually with involvement of the palms and soles, in the late second or third trimester. Pemphigoid gestationis presents with urticarial papules and/or bullae, often in the second or third trimester or postpartum. An important diagnostic clue for PG is involvement near the umbilicus. Polymorphic eruption of pregnancy presents with urticarial papules and plaques; onset occurs in the third trimester or postpartum and initially involves the striae while sparing the umbilicus, unlike in PG. Atopic eruption of pregnancy has an earlier onset than the other pregnancy-specific dermatoses, often in the first or second trimester, and presents with widespread eczematous lesions.³

Diagnosis

The pregnancy dermatoses with the greatest potential for fetal risks are ICP and PG; therefore, it is critical for health care providers to diagnose these dermatoses in a timely manner and initiate appropriate management. Intrahepatic cholestasis of pregnancy is confirmed by elevated serum bile acids (ie, >10 µmol/L), often during the third trimester. The risk of fetal morbidity is high in ICP with increased bile acids crossing the placenta causing placental anoxia and impaired cardiomyocyte function.⁴ Fetal risks, including preterm delivery, meconium-stained amniotic fluid, and stillbirth, correlate with the level of bile acids in the serum.⁵ Maternal prognosis is favorable, but there is an increased association with hepatitis C and hepatobiliary disease.⁶

Diagnosis of PG is confirmed by classic biopsy results and direct immunofluorescence revealing C3 with or without IgG in a linear band along the basement membrane zone. Additionally, complement indirect immunofluorescence reveals circulating IgG anti–basement membrane zone antibodies. Pemphigoid gestationis is associated with increased fetal risks of preterm labor and intrauterine growth retardation.⁷ Clinical findings of PG may present in the fetus upon delivery due to transmission of autoantibodies across the placenta. The symptoms usually are mild.⁸ An increased risk of Graves disease has been reported in mothers with PG.

In most cases, diagnosis of PEP is based on history and morphology, but if the presentation is not classic, skin biopsy must be used to differentiate it from PG as well as more common dermatologic conditions such as contact dermatitis, drug and viral eruptions, and urticaria.

Atopic eruption of pregnancy manifests as widespread eczematous excoriated papules and plaques. Lesions of prurigo nodularis are common.

Comorbidities

It is important to be aware of specific clinical associations related to pregnancy-specific dermatoses. Pemphigoid gestationis has been associated with gestational trophoblastic tumors including hydatiform mole and choriocarcinoma.⁴ An increased risk for Graves disease has been reported in patients with PG.⁹ Patients who develop ICP have a higher incidence of hepatitis C, postpartum cholecystitis, gallstones, and nonalcoholic cirrhosis.⁸ Polymorphic eruption of pregnancy is associated with a notably higher incidence in multiple gestation pregnancies.²

Treatment and Management

Management of ICP requires an accurate and timely diagnosis, and advanced neonatal-obstetric management is critical.³ Ursodeoxycholic acid is the treatment of choice and reduces pruritus, prolongs pregnancy, and reduces fetal risk.⁴ Most stillbirths cluster at the 38th week of pregnancy, and patients with ICP and highly elevated serum bile acids (>40 µmol/L) should be considered for delivery at 37 weeks or earlier.⁵

Management of the other cutaneous disorders of pregnancy can be challenging for health care providers based on safety concerns for the fetus. Although it is important to minimize risks to the fetus, it also is important to adequately treat the mother’s cutaneous disease, which requires a solid knowledge of drug safety during pregnancy. The former US Food and Drug Administration classification system using A, B, C, D, and X pregnancy categories was replaced by the Pregnancy Lactation Label Final Rule, which provides counseling on medication safety during pregnancy.¹⁰ In 2014, Murase et al¹¹ published a review of dermatologic medication safety during pregnancy, which serves as an excellent guide.

Before instituting treatment, the therapeutic plan should be discussed with the physician managing the patient’s pregnancy. In general, topical steroids are considered safe during pregnancy, and low-potency to moderate-potency topical steroids are preferred. If possible, use of topical steroids should be limited to less than 300 g for the duration of the pregnancy. Fluticasone propionate should be avoided during pregnancy because it is not metabolized by the placenta. When systemic steroids are considered appropriate for management during pregnancy, nonhalogenated corticosteroids such as prednisone and prednisolone are preferred because they are enzymatically inactivated by the placenta, which results in a favorable maternal-fetal gradient.¹² There has been concern expressed in the medical literature that systemic steroids during the first trimester may increase the risk of cleft lip and cleft palate.^3,12 When managing pregnancy dermatoses, consideration should be given to keep prednisone exposure below 20 mg/d, and try to limit prolonged use to 7.5 mg/d. However, this may not be possible in PG.³ Vitamin D and calcium supplementation may be appropriate when patients are on prolonged systemic steroids to control disease.

Antihistamines can be used to control pruritus complicating pregnancy-associated dermatoses. First-generation antihistamines such as chlorpheniramine and diphenhydramine are preferred due to long-term safety data.^3,11,12 Loratadine is the first choice and cetirizine is the second choice if a second-generation antihistamine is preferred.³ Loratadine is preferred during breastfeeding due to less sedation.¹² High-dose antihistamines prior to delivery may cause concerns for potential side effects in the newborn, including tremulousness, irritability, and poor feeding.

Recurrence

Women with pregnancy dermatoses often are concerned about recurrence with future pregnancies. Pemphigoid gestationis may flare with subsequent pregnancies, subsequent menses, or with oral contraceptive use.³ Recurrence of PEP in subsequent pregnancies is rare and usually is less severe than the primary eruption.⁸ Often, the rare recurrent eruption of PEP is associated with multigestational pregnancies.² Mothers can anticipate a recurrence of ICP in up to 60% to 70% of future pregnancies. Patients with AEP have an underlying atopic diathesis, and recurrence in future pregnancies is not uncommon.⁸

Final Thoughts

In summary, it is important for health care providers to recognize the specific cutaneous disorders of pregnancy and their potential fetal complications. The anatomical location of onset of the dermatosis and timing of onset during pregnancy can give important clues. Appropriate management, especially with ICP, can minimize fetal complications. A fundamental knowledge of medication safety and management during pregnancy is essential. Rashes during pregnancy can cause anxiety in the mother and family and require support, comfort, and guidance.

Rashes that develop during pregnancy often result in considerable anxiety or concern for patients and their families. Recognizing these pregnancy-specific dermatoses is important in identifying fetal risks as well as providing appropriate management and expert guidance for patients regarding future pregnancies. Managing cutaneous manifestations of pregnancy-related disorders is challenging and requires knowledge of potential side effects of therapy for both the mother and fetus. It also is important to appreciate the physiologic cutaneous changes of pregnancy along with their clinical significance and management.

In 2006, Ambrose-Rudolph et al¹ proposed reclassification of pregnancy-specific dermatoses, which has since been widely accepted by the academic dermatology community. The 4 most prominent disorders include intrahepatic cholestasis of pregnancy (ICP); pemphigoid gestationis (PG); polymorphic eruption of pregnancy (PEP), also known as pruritic urticarial papules and plaques of pregnancy; and atopic eruption of pregnancy.² It is important to recognize these pregnancy-specific disorders and to understand their clinical significance. The morphology of the eruption as well as the location and timing of the onset of the rash are important clues in making an accurate diagnosis.³

Clinical Presentation

Intrahepatic cholestasis of pregnancy presents with severe generalized pruritus, usually with involvement of the palms and soles, in the late second or third trimester. Pemphigoid gestationis presents with urticarial papules and/or bullae, often in the second or third trimester or postpartum. An important diagnostic clue for PG is involvement near the umbilicus. Polymorphic eruption of pregnancy presents with urticarial papules and plaques; onset occurs in the third trimester or postpartum and initially involves the striae while sparing the umbilicus, unlike in PG. Atopic eruption of pregnancy has an earlier onset than the other pregnancy-specific dermatoses, often in the first or second trimester, and presents with widespread eczematous lesions.³

Diagnosis

The pregnancy dermatoses with the greatest potential for fetal risks are ICP and PG; therefore, it is critical for health care providers to diagnose these dermatoses in a timely manner and initiate appropriate management. Intrahepatic cholestasis of pregnancy is confirmed by elevated serum bile acids (ie, >10 µmol/L), often during the third trimester. The risk of fetal morbidity is high in ICP with increased bile acids crossing the placenta causing placental anoxia and impaired cardiomyocyte function.⁴ Fetal risks, including preterm delivery, meconium-stained amniotic fluid, and stillbirth, correlate with the level of bile acids in the serum.⁵ Maternal prognosis is favorable, but there is an increased association with hepatitis C and hepatobiliary disease.⁶

Diagnosis of PG is confirmed by classic biopsy results and direct immunofluorescence revealing C3 with or without IgG in a linear band along the basement membrane zone. Additionally, complement indirect immunofluorescence reveals circulating IgG anti–basement membrane zone antibodies. Pemphigoid gestationis is associated with increased fetal risks of preterm labor and intrauterine growth retardation.⁷ Clinical findings of PG may present in the fetus upon delivery due to transmission of autoantibodies across the placenta. The symptoms usually are mild.⁸ An increased risk of Graves disease has been reported in mothers with PG.

In most cases, diagnosis of PEP is based on history and morphology, but if the presentation is not classic, skin biopsy must be used to differentiate it from PG as well as more common dermatologic conditions such as contact dermatitis, drug and viral eruptions, and urticaria.

Atopic eruption of pregnancy manifests as widespread eczematous excoriated papules and plaques. Lesions of prurigo nodularis are common.

Comorbidities

It is important to be aware of specific clinical associations related to pregnancy-specific dermatoses. Pemphigoid gestationis has been associated with gestational trophoblastic tumors including hydatiform mole and choriocarcinoma.⁴ An increased risk for Graves disease has been reported in patients with PG.⁹ Patients who develop ICP have a higher incidence of hepatitis C, postpartum cholecystitis, gallstones, and nonalcoholic cirrhosis.⁸ Polymorphic eruption of pregnancy is associated with a notably higher incidence in multiple gestation pregnancies.²

Treatment and Management

Management of ICP requires an accurate and timely diagnosis, and advanced neonatal-obstetric management is critical.³ Ursodeoxycholic acid is the treatment of choice and reduces pruritus, prolongs pregnancy, and reduces fetal risk.⁴ Most stillbirths cluster at the 38th week of pregnancy, and patients with ICP and highly elevated serum bile acids (>40 µmol/L) should be considered for delivery at 37 weeks or earlier.⁵

Management of the other cutaneous disorders of pregnancy can be challenging for health care providers based on safety concerns for the fetus. Although it is important to minimize risks to the fetus, it also is important to adequately treat the mother’s cutaneous disease, which requires a solid knowledge of drug safety during pregnancy. The former US Food and Drug Administration classification system using A, B, C, D, and X pregnancy categories was replaced by the Pregnancy Lactation Label Final Rule, which provides counseling on medication safety during pregnancy.¹⁰ In 2014, Murase et al¹¹ published a review of dermatologic medication safety during pregnancy, which serves as an excellent guide.

Before instituting treatment, the therapeutic plan should be discussed with the physician managing the patient’s pregnancy. In general, topical steroids are considered safe during pregnancy, and low-potency to moderate-potency topical steroids are preferred. If possible, use of topical steroids should be limited to less than 300 g for the duration of the pregnancy. Fluticasone propionate should be avoided during pregnancy because it is not metabolized by the placenta. When systemic steroids are considered appropriate for management during pregnancy, nonhalogenated corticosteroids such as prednisone and prednisolone are preferred because they are enzymatically inactivated by the placenta, which results in a favorable maternal-fetal gradient.¹² There has been concern expressed in the medical literature that systemic steroids during the first trimester may increase the risk of cleft lip and cleft palate.^3,12 When managing pregnancy dermatoses, consideration should be given to keep prednisone exposure below 20 mg/d, and try to limit prolonged use to 7.5 mg/d. However, this may not be possible in PG.³ Vitamin D and calcium supplementation may be appropriate when patients are on prolonged systemic steroids to control disease.

Antihistamines can be used to control pruritus complicating pregnancy-associated dermatoses. First-generation antihistamines such as chlorpheniramine and diphenhydramine are preferred due to long-term safety data.^3,11,12 Loratadine is the first choice and cetirizine is the second choice if a second-generation antihistamine is preferred.³ Loratadine is preferred during breastfeeding due to less sedation.¹² High-dose antihistamines prior to delivery may cause concerns for potential side effects in the newborn, including tremulousness, irritability, and poor feeding.

Recurrence

Women with pregnancy dermatoses often are concerned about recurrence with future pregnancies. Pemphigoid gestationis may flare with subsequent pregnancies, subsequent menses, or with oral contraceptive use.³ Recurrence of PEP in subsequent pregnancies is rare and usually is less severe than the primary eruption.⁸ Often, the rare recurrent eruption of PEP is associated with multigestational pregnancies.² Mothers can anticipate a recurrence of ICP in up to 60% to 70% of future pregnancies. Patients with AEP have an underlying atopic diathesis, and recurrence in future pregnancies is not uncommon.⁸

Final Thoughts

In summary, it is important for health care providers to recognize the specific cutaneous disorders of pregnancy and their potential fetal complications. The anatomical location of onset of the dermatosis and timing of onset during pregnancy can give important clues. Appropriate management, especially with ICP, can minimize fetal complications. A fundamental knowledge of medication safety and management during pregnancy is essential. Rashes during pregnancy can cause anxiety in the mother and family and require support, comfort, and guidance.

Rashes that develop during pregnancy often result in considerable anxiety or concern for patients and their families. Recognizing these pregnancy-specific dermatoses is important in identifying fetal risks as well as providing appropriate management and expert guidance for patients regarding future pregnancies. Managing cutaneous manifestations of pregnancy-related disorders is challenging and requires knowledge of potential side effects of therapy for both the mother and fetus. It also is important to appreciate the physiologic cutaneous changes of pregnancy along with their clinical significance and management.

In 2006, Ambrose-Rudolph et al¹ proposed reclassification of pregnancy-specific dermatoses, which has since been widely accepted by the academic dermatology community. The 4 most prominent disorders include intrahepatic cholestasis of pregnancy (ICP); pemphigoid gestationis (PG); polymorphic eruption of pregnancy (PEP), also known as pruritic urticarial papules and plaques of pregnancy; and atopic eruption of pregnancy.² It is important to recognize these pregnancy-specific disorders and to understand their clinical significance. The morphology of the eruption as well as the location and timing of the onset of the rash are important clues in making an accurate diagnosis.³

Clinical Presentation

Intrahepatic cholestasis of pregnancy presents with severe generalized pruritus, usually with involvement of the palms and soles, in the late second or third trimester. Pemphigoid gestationis presents with urticarial papules and/or bullae, often in the second or third trimester or postpartum. An important diagnostic clue for PG is involvement near the umbilicus. Polymorphic eruption of pregnancy presents with urticarial papules and plaques; onset occurs in the third trimester or postpartum and initially involves the striae while sparing the umbilicus, unlike in PG. Atopic eruption of pregnancy has an earlier onset than the other pregnancy-specific dermatoses, often in the first or second trimester, and presents with widespread eczematous lesions.³

Diagnosis

The pregnancy dermatoses with the greatest potential for fetal risks are ICP and PG; therefore, it is critical for health care providers to diagnose these dermatoses in a timely manner and initiate appropriate management. Intrahepatic cholestasis of pregnancy is confirmed by elevated serum bile acids (ie, >10 µmol/L), often during the third trimester. The risk of fetal morbidity is high in ICP with increased bile acids crossing the placenta causing placental anoxia and impaired cardiomyocyte function.⁴ Fetal risks, including preterm delivery, meconium-stained amniotic fluid, and stillbirth, correlate with the level of bile acids in the serum.⁵ Maternal prognosis is favorable, but there is an increased association with hepatitis C and hepatobiliary disease.⁶

Diagnosis of PG is confirmed by classic biopsy results and direct immunofluorescence revealing C3 with or without IgG in a linear band along the basement membrane zone. Additionally, complement indirect immunofluorescence reveals circulating IgG anti–basement membrane zone antibodies. Pemphigoid gestationis is associated with increased fetal risks of preterm labor and intrauterine growth retardation.⁷ Clinical findings of PG may present in the fetus upon delivery due to transmission of autoantibodies across the placenta. The symptoms usually are mild.⁸ An increased risk of Graves disease has been reported in mothers with PG.

In most cases, diagnosis of PEP is based on history and morphology, but if the presentation is not classic, skin biopsy must be used to differentiate it from PG as well as more common dermatologic conditions such as contact dermatitis, drug and viral eruptions, and urticaria.

Atopic eruption of pregnancy manifests as widespread eczematous excoriated papules and plaques. Lesions of prurigo nodularis are common.

Comorbidities

It is important to be aware of specific clinical associations related to pregnancy-specific dermatoses. Pemphigoid gestationis has been associated with gestational trophoblastic tumors including hydatiform mole and choriocarcinoma.⁴ An increased risk for Graves disease has been reported in patients with PG.⁹ Patients who develop ICP have a higher incidence of hepatitis C, postpartum cholecystitis, gallstones, and nonalcoholic cirrhosis.⁸ Polymorphic eruption of pregnancy is associated with a notably higher incidence in multiple gestation pregnancies.²

Treatment and Management

Management of ICP requires an accurate and timely diagnosis, and advanced neonatal-obstetric management is critical.³ Ursodeoxycholic acid is the treatment of choice and reduces pruritus, prolongs pregnancy, and reduces fetal risk.⁴ Most stillbirths cluster at the 38th week of pregnancy, and patients with ICP and highly elevated serum bile acids (>40 µmol/L) should be considered for delivery at 37 weeks or earlier.⁵

Management of the other cutaneous disorders of pregnancy can be challenging for health care providers based on safety concerns for the fetus. Although it is important to minimize risks to the fetus, it also is important to adequately treat the mother’s cutaneous disease, which requires a solid knowledge of drug safety during pregnancy. The former US Food and Drug Administration classification system using A, B, C, D, and X pregnancy categories was replaced by the Pregnancy Lactation Label Final Rule, which provides counseling on medication safety during pregnancy.¹⁰ In 2014, Murase et al¹¹ published a review of dermatologic medication safety during pregnancy, which serves as an excellent guide.

Before instituting treatment, the therapeutic plan should be discussed with the physician managing the patient’s pregnancy. In general, topical steroids are considered safe during pregnancy, and low-potency to moderate-potency topical steroids are preferred. If possible, use of topical steroids should be limited to less than 300 g for the duration of the pregnancy. Fluticasone propionate should be avoided during pregnancy because it is not metabolized by the placenta. When systemic steroids are considered appropriate for management during pregnancy, nonhalogenated corticosteroids such as prednisone and prednisolone are preferred because they are enzymatically inactivated by the placenta, which results in a favorable maternal-fetal gradient.¹² There has been concern expressed in the medical literature that systemic steroids during the first trimester may increase the risk of cleft lip and cleft palate.^3,12 When managing pregnancy dermatoses, consideration should be given to keep prednisone exposure below 20 mg/d, and try to limit prolonged use to 7.5 mg/d. However, this may not be possible in PG.³ Vitamin D and calcium supplementation may be appropriate when patients are on prolonged systemic steroids to control disease.

Antihistamines can be used to control pruritus complicating pregnancy-associated dermatoses. First-generation antihistamines such as chlorpheniramine and diphenhydramine are preferred due to long-term safety data.^3,11,12 Loratadine is the first choice and cetirizine is the second choice if a second-generation antihistamine is preferred.³ Loratadine is preferred during breastfeeding due to less sedation.¹² High-dose antihistamines prior to delivery may cause concerns for potential side effects in the newborn, including tremulousness, irritability, and poor feeding.

Recurrence

Women with pregnancy dermatoses often are concerned about recurrence with future pregnancies. Pemphigoid gestationis may flare with subsequent pregnancies, subsequent menses, or with oral contraceptive use.³ Recurrence of PEP in subsequent pregnancies is rare and usually is less severe than the primary eruption.⁸ Often, the rare recurrent eruption of PEP is associated with multigestational pregnancies.² Mothers can anticipate a recurrence of ICP in up to 60% to 70% of future pregnancies. Patients with AEP have an underlying atopic diathesis, and recurrence in future pregnancies is not uncommon.⁸

Final Thoughts

In summary, it is important for health care providers to recognize the specific cutaneous disorders of pregnancy and their potential fetal complications. The anatomical location of onset of the dermatosis and timing of onset during pregnancy can give important clues. Appropriate management, especially with ICP, can minimize fetal complications. A fundamental knowledge of medication safety and management during pregnancy is essential. Rashes during pregnancy can cause anxiety in the mother and family and require support, comfort, and guidance.

Amid the parades and speeches that commemorate Pride Month across the United States, a remarkable event occurred in Florida at the Orlando Veterans Affairs Healthcare System. At the 11th annual celebration of Pride on June 21, US Department of Veterans Affairs (VA) Secretary Denis R. McDonough made a historic announcement, “We are taking the first necessary steps to expand VA’s care to include gender-confirmation surgery, thus allowing transgender vets to go through the full gender-confirmation process with VA by their side.”²

The proclamation reflected the results of a review of VA transgender policies that McDonough had ordered in February 2021 to coordinate VA policies with those of the US Department of Defense (DoD) and to actualize President Biden’s January 2021 executive order that prohibited discrimination on the basis of sexual orientation or gender identity.^3,4 In an interview with NPR shortly after the Orlando commemoration, Secretary McDonough reported that the governing body overseeing VA health care services unanimously endorsed the proposal.⁵ The National Center for Transgender Equity estimates there are 134,000 transgender veterans.⁶ VA authorities believe 4000 transgender veterans may be interested in obtaining the new gender-affirming benefit when it is available, and Secretary McDonough indicated that about 543 veterans a year soon might be eligible.^5,7

Transgender veterans and their supporters along with many of the VA practitioners who care for them had long waited and hoped for this announcement. The Secretary ended a too-long period in which transgender veterans encountered enormous practical, financial, and personal obstacles, causing frustration and despair on their journey to becoming who they knew they are. Although VA previously did not provide gender-affirmation surgery, it did deliver other forms of transgender care to veterans, such as hormone therapy and other transition-related services. Yet it was painful for transgender veterans and their health care professionals (HCPs) to see that under the VA medical benefits package prior to Secretary McDonough’s historic announcement, gender-affirmation surgery was not deemed care “to promote, preserve, or restore the health of the individual.”⁸

Similarly, the decision is the beginning of the end of an ethical dilemma with which many VA clinicians struggled: They had the competence to perform gender-affirming surgery, but VA policy prohibited them from providing it to their patients.^9,10 The 2013 directive issued under the Obama administration made the ethics of gender-confirmation surgery even more complex. A VA surgeon could perform “medically-indicated procedures” or treat “other medical conditions” even if it simultaneously furthered gender transition. What the surgeon could not perform was a procedure solely for the purpose of gender transition. Because transgender veterans seeking gender-affirmation surgery were forced to go outside the VA system and use their resources to pay for the surgery, VA did permit practitioners to perform preoperative and postoperative treatment, including treating surgical complications of an outside gender-affirmation surgery. VA HCPs were placed in a catch-22 situation that pitted their duty to care in accordance with the preferences and interests of the veteran against their obligation to practice and adhere to VA policy and federal regulation.⁸ With his Pride-month speech, Secretary McDonough resolved this conflict for VA HCPs and made a strong public declaration VA should and will provide gender-affirming surgery that can promote, preserve, and restore the health of transgender veterans.

Secretary McDonough called the move to formally change the rule regarding gender-affirming surgery “the right thing to do” and emphasized that it was “life-saving.”⁷ This last remark was in recognition of the strong evidence demonstrating the adverse psychological impact on transgender veterans of the previous position.²

Denial of gender-confirmation surgery was not the only health care inequity identified among transgender veterans. Research inside and outside VA has found significant health disparities between transgender and nontransgender veterans, including higher rates of depression, suicidality, serious mental illness, posttraumatic stress disorder, military sexual trauma, and homelessness.¹¹ The provision of gender-affirming surgery to transgender veterans whether through VA hospitals or through partnerships with academic affiliates and the community is a major step to remedy these disparities. A 2019 systematic review found that gender-affirming surgery is far from cosmetic: It leads to marked improvement in many of the mental health problems transgender persons experience.¹²

Anyone who has experienced the snail’s pace of change in the behemoth VA bureaucracy knows that this initial movement is only the beginning of the laborious federal process of changing the regulation that currently prohibits VA from offering and paying for gender-confirmation surgery under the VA medical benefits package. Once the regulation is changed, then VA will be empowered to establish policy that in Secretary McDonough’s words, “will ensure the equitable treatment and safety of transgender veterans.”² The decision to eventually provide gender-confirmation surgery as part of VA care was an important aspect of the agency’s overall attempt to make VA more welcome to lesbian, gay, bisexual, transgender, and queer (LGBTQ) veterans. During the Orlando speech, Secretary McDonough also announced that VA was changing the name of its LGBT program to LGBTQ+ to clearly communicate that all veterans are included in VA care.²

The announcement sends a powerful message of hope, which was a central theme of slain San Francisco supervisor, Harvey Milk, an early and influential LGBTQ activist and advocate.¹ But as always in our polarized country, there was immediate opposition to the proposal arguing that the surgery would place transgender veterans at greater risk of depression and suicide, was not compatible with the VA mission and diverts VA funding from meeting more legitimate care needs in a timely manner.¹¹ It is a sad irony that transgender veterans defended the freedom of their opponents to express their opinion and had to fight this long and hard for their liberty to live as they choose.

Amid the parades and speeches that commemorate Pride Month across the United States, a remarkable event occurred in Florida at the Orlando Veterans Affairs Healthcare System. At the 11th annual celebration of Pride on June 21, US Department of Veterans Affairs (VA) Secretary Denis R. McDonough made a historic announcement, “We are taking the first necessary steps to expand VA’s care to include gender-confirmation surgery, thus allowing transgender vets to go through the full gender-confirmation process with VA by their side.”²

The proclamation reflected the results of a review of VA transgender policies that McDonough had ordered in February 2021 to coordinate VA policies with those of the US Department of Defense (DoD) and to actualize President Biden’s January 2021 executive order that prohibited discrimination on the basis of sexual orientation or gender identity.^3,4 In an interview with NPR shortly after the Orlando commemoration, Secretary McDonough reported that the governing body overseeing VA health care services unanimously endorsed the proposal.⁵ The National Center for Transgender Equity estimates there are 134,000 transgender veterans.⁶ VA authorities believe 4000 transgender veterans may be interested in obtaining the new gender-affirming benefit when it is available, and Secretary McDonough indicated that about 543 veterans a year soon might be eligible.^5,7

Transgender veterans and their supporters along with many of the VA practitioners who care for them had long waited and hoped for this announcement. The Secretary ended a too-long period in which transgender veterans encountered enormous practical, financial, and personal obstacles, causing frustration and despair on their journey to becoming who they knew they are. Although VA previously did not provide gender-affirmation surgery, it did deliver other forms of transgender care to veterans, such as hormone therapy and other transition-related services. Yet it was painful for transgender veterans and their health care professionals (HCPs) to see that under the VA medical benefits package prior to Secretary McDonough’s historic announcement, gender-affirmation surgery was not deemed care “to promote, preserve, or restore the health of the individual.”⁸

Similarly, the decision is the beginning of the end of an ethical dilemma with which many VA clinicians struggled: They had the competence to perform gender-affirming surgery, but VA policy prohibited them from providing it to their patients.^9,10 The 2013 directive issued under the Obama administration made the ethics of gender-confirmation surgery even more complex. A VA surgeon could perform “medically-indicated procedures” or treat “other medical conditions” even if it simultaneously furthered gender transition. What the surgeon could not perform was a procedure solely for the purpose of gender transition. Because transgender veterans seeking gender-affirmation surgery were forced to go outside the VA system and use their resources to pay for the surgery, VA did permit practitioners to perform preoperative and postoperative treatment, including treating surgical complications of an outside gender-affirmation surgery. VA HCPs were placed in a catch-22 situation that pitted their duty to care in accordance with the preferences and interests of the veteran against their obligation to practice and adhere to VA policy and federal regulation.⁸ With his Pride-month speech, Secretary McDonough resolved this conflict for VA HCPs and made a strong public declaration VA should and will provide gender-affirming surgery that can promote, preserve, and restore the health of transgender veterans.

Secretary McDonough called the move to formally change the rule regarding gender-affirming surgery “the right thing to do” and emphasized that it was “life-saving.”⁷ This last remark was in recognition of the strong evidence demonstrating the adverse psychological impact on transgender veterans of the previous position.²

Denial of gender-confirmation surgery was not the only health care inequity identified among transgender veterans. Research inside and outside VA has found significant health disparities between transgender and nontransgender veterans, including higher rates of depression, suicidality, serious mental illness, posttraumatic stress disorder, military sexual trauma, and homelessness.¹¹ The provision of gender-affirming surgery to transgender veterans whether through VA hospitals or through partnerships with academic affiliates and the community is a major step to remedy these disparities. A 2019 systematic review found that gender-affirming surgery is far from cosmetic: It leads to marked improvement in many of the mental health problems transgender persons experience.¹²

Anyone who has experienced the snail’s pace of change in the behemoth VA bureaucracy knows that this initial movement is only the beginning of the laborious federal process of changing the regulation that currently prohibits VA from offering and paying for gender-confirmation surgery under the VA medical benefits package. Once the regulation is changed, then VA will be empowered to establish policy that in Secretary McDonough’s words, “will ensure the equitable treatment and safety of transgender veterans.”² The decision to eventually provide gender-confirmation surgery as part of VA care was an important aspect of the agency’s overall attempt to make VA more welcome to lesbian, gay, bisexual, transgender, and queer (LGBTQ) veterans. During the Orlando speech, Secretary McDonough also announced that VA was changing the name of its LGBT program to LGBTQ+ to clearly communicate that all veterans are included in VA care.²

The announcement sends a powerful message of hope, which was a central theme of slain San Francisco supervisor, Harvey Milk, an early and influential LGBTQ activist and advocate.¹ But as always in our polarized country, there was immediate opposition to the proposal arguing that the surgery would place transgender veterans at greater risk of depression and suicide, was not compatible with the VA mission and diverts VA funding from meeting more legitimate care needs in a timely manner.¹¹ It is a sad irony that transgender veterans defended the freedom of their opponents to express their opinion and had to fight this long and hard for their liberty to live as they choose.

Amid the parades and speeches that commemorate Pride Month across the United States, a remarkable event occurred in Florida at the Orlando Veterans Affairs Healthcare System. At the 11th annual celebration of Pride on June 21, US Department of Veterans Affairs (VA) Secretary Denis R. McDonough made a historic announcement, “We are taking the first necessary steps to expand VA’s care to include gender-confirmation surgery, thus allowing transgender vets to go through the full gender-confirmation process with VA by their side.”²

The proclamation reflected the results of a review of VA transgender policies that McDonough had ordered in February 2021 to coordinate VA policies with those of the US Department of Defense (DoD) and to actualize President Biden’s January 2021 executive order that prohibited discrimination on the basis of sexual orientation or gender identity.^3,4 In an interview with NPR shortly after the Orlando commemoration, Secretary McDonough reported that the governing body overseeing VA health care services unanimously endorsed the proposal.⁵ The National Center for Transgender Equity estimates there are 134,000 transgender veterans.⁶ VA authorities believe 4000 transgender veterans may be interested in obtaining the new gender-affirming benefit when it is available, and Secretary McDonough indicated that about 543 veterans a year soon might be eligible.^5,7

Transgender veterans and their supporters along with many of the VA practitioners who care for them had long waited and hoped for this announcement. The Secretary ended a too-long period in which transgender veterans encountered enormous practical, financial, and personal obstacles, causing frustration and despair on their journey to becoming who they knew they are. Although VA previously did not provide gender-affirmation surgery, it did deliver other forms of transgender care to veterans, such as hormone therapy and other transition-related services. Yet it was painful for transgender veterans and their health care professionals (HCPs) to see that under the VA medical benefits package prior to Secretary McDonough’s historic announcement, gender-affirmation surgery was not deemed care “to promote, preserve, or restore the health of the individual.”⁸

Similarly, the decision is the beginning of the end of an ethical dilemma with which many VA clinicians struggled: They had the competence to perform gender-affirming surgery, but VA policy prohibited them from providing it to their patients.^9,10 The 2013 directive issued under the Obama administration made the ethics of gender-confirmation surgery even more complex. A VA surgeon could perform “medically-indicated procedures” or treat “other medical conditions” even if it simultaneously furthered gender transition. What the surgeon could not perform was a procedure solely for the purpose of gender transition. Because transgender veterans seeking gender-affirmation surgery were forced to go outside the VA system and use their resources to pay for the surgery, VA did permit practitioners to perform preoperative and postoperative treatment, including treating surgical complications of an outside gender-affirmation surgery. VA HCPs were placed in a catch-22 situation that pitted their duty to care in accordance with the preferences and interests of the veteran against their obligation to practice and adhere to VA policy and federal regulation.⁸ With his Pride-month speech, Secretary McDonough resolved this conflict for VA HCPs and made a strong public declaration VA should and will provide gender-affirming surgery that can promote, preserve, and restore the health of transgender veterans.

Secretary McDonough called the move to formally change the rule regarding gender-affirming surgery “the right thing to do” and emphasized that it was “life-saving.”⁷ This last remark was in recognition of the strong evidence demonstrating the adverse psychological impact on transgender veterans of the previous position.²

Denial of gender-confirmation surgery was not the only health care inequity identified among transgender veterans. Research inside and outside VA has found significant health disparities between transgender and nontransgender veterans, including higher rates of depression, suicidality, serious mental illness, posttraumatic stress disorder, military sexual trauma, and homelessness.¹¹ The provision of gender-affirming surgery to transgender veterans whether through VA hospitals or through partnerships with academic affiliates and the community is a major step to remedy these disparities. A 2019 systematic review found that gender-affirming surgery is far from cosmetic: It leads to marked improvement in many of the mental health problems transgender persons experience.¹²

Anyone who has experienced the snail’s pace of change in the behemoth VA bureaucracy knows that this initial movement is only the beginning of the laborious federal process of changing the regulation that currently prohibits VA from offering and paying for gender-confirmation surgery under the VA medical benefits package. Once the regulation is changed, then VA will be empowered to establish policy that in Secretary McDonough’s words, “will ensure the equitable treatment and safety of transgender veterans.”² The decision to eventually provide gender-confirmation surgery as part of VA care was an important aspect of the agency’s overall attempt to make VA more welcome to lesbian, gay, bisexual, transgender, and queer (LGBTQ) veterans. During the Orlando speech, Secretary McDonough also announced that VA was changing the name of its LGBT program to LGBTQ+ to clearly communicate that all veterans are included in VA care.²

The announcement sends a powerful message of hope, which was a central theme of slain San Francisco supervisor, Harvey Milk, an early and influential LGBTQ activist and advocate.¹ But as always in our polarized country, there was immediate opposition to the proposal arguing that the surgery would place transgender veterans at greater risk of depression and suicide, was not compatible with the VA mission and diverts VA funding from meeting more legitimate care needs in a timely manner.¹¹ It is a sad irony that transgender veterans defended the freedom of their opponents to express their opinion and had to fight this long and hard for their liberty to live as they choose.

What do you want to be when you grow up? What kind of doctor do you want to be? These are common conversation starters that we probably have all heard at some point in our lives.

But perhaps these are not the most thought-provoking or insightful questions to ask or be asked.

Instead, “What is your passion?” or “What inspires/motivates you?” or “What makes you want to get out of bed in the morning?” or “What creates flow for you?” may be more thoughtful questions that encourage greater self-reflection.

There is a Japanese concept called ikigai that loosely translates to “a reason for being.” This framework suggests that one should attempt to find the intersection of four things:

• One’s interests.
• One’s abilities/talents.
• What the world needs.
• What one can be paid for.

When any two of these intersect, you will have the following:

A passion: something that interests you and you excel at.

A profession: something that you excel at and are paid for.

A vocation: something that the world needs and that you’re paid for.

A mission: something that interests you and that the world needs.

Finding that “sweet spot” that intersects all four is the ideal prescribed by ikigai.

Ultimately, ikigai challenges us to find purpose, and finding this alignment of purpose can subsequently help us plan our professional and personal lives.

Of note, several of the world’s communities that are known for longevity/higher proportion of centenarians are linked by the common concept of ikigai. While there isn’t strong evidence that this phenomenon is correlated with or predictive of longevity, I believe we can all agree that finding purpose can lead to increased satisfaction, happiness, and perhaps less stress.

Achieving this sweet spot that satisfies all conditions above is undoubtedly easier said than done when placed in the context of real life, as there are often competing interests. Your purpose may align with a job that doesn’t pay the bills, or the job that provides financial stability may be uninteresting work to you. The path there may be winding, but eventually, with enough trial and error, I think we can all carve out a version of ikigai for ourselves.

I’ve had conversations with more senior physicians who have made a great impact in their fields and could certainly retire yesterday if they desired. When asked why they keep showing up, it is usually some version of “this is what I’m meant to do” or “this is my purpose” or “this is my joy.” In some ways, if you find true joy in what you do, it becomes part of your identity (in a positive way).

Though our health care system and culture are certainly far from perfect, many of us went to medical school because this was/is our “calling” – vocational, if you will. For me personally, it was a unique intersection of being able to serve others, use my abilities in math/science, and make a living.

In some ways, being a physician or health care worker puts us in a unique position to serve and provide services that the world needs. But with burnout rampant within the physician community, it is even more important to understand ourselves, work out our own version of ikigai, and make sure that we are living it daily.

Dr Thachil is a noninvasive cardiologist and assistant professor of medicine at the Albert Einstein College of Medicine, New York. She is a graduate of Jefferson Medical College and completed cardiology training at Mount Sinai Hospital. She is a fellow of the American College of Cardiology.

A version of this article first appeared on Medscape.com.

What do you want to be when you grow up? What kind of doctor do you want to be? These are common conversation starters that we probably have all heard at some point in our lives.

But perhaps these are not the most thought-provoking or insightful questions to ask or be asked.

Instead, “What is your passion?” or “What inspires/motivates you?” or “What makes you want to get out of bed in the morning?” or “What creates flow for you?” may be more thoughtful questions that encourage greater self-reflection.

There is a Japanese concept called ikigai that loosely translates to “a reason for being.” This framework suggests that one should attempt to find the intersection of four things:

• One’s interests.
• One’s abilities/talents.
• What the world needs.
• What one can be paid for.

When any two of these intersect, you will have the following:

A passion: something that interests you and you excel at.

A profession: something that you excel at and are paid for.

A vocation: something that the world needs and that you’re paid for.

A mission: something that interests you and that the world needs.

Finding that “sweet spot” that intersects all four is the ideal prescribed by ikigai.

Ultimately, ikigai challenges us to find purpose, and finding this alignment of purpose can subsequently help us plan our professional and personal lives.

Of note, several of the world’s communities that are known for longevity/higher proportion of centenarians are linked by the common concept of ikigai. While there isn’t strong evidence that this phenomenon is correlated with or predictive of longevity, I believe we can all agree that finding purpose can lead to increased satisfaction, happiness, and perhaps less stress.

Achieving this sweet spot that satisfies all conditions above is undoubtedly easier said than done when placed in the context of real life, as there are often competing interests. Your purpose may align with a job that doesn’t pay the bills, or the job that provides financial stability may be uninteresting work to you. The path there may be winding, but eventually, with enough trial and error, I think we can all carve out a version of ikigai for ourselves.

I’ve had conversations with more senior physicians who have made a great impact in their fields and could certainly retire yesterday if they desired. When asked why they keep showing up, it is usually some version of “this is what I’m meant to do” or “this is my purpose” or “this is my joy.” In some ways, if you find true joy in what you do, it becomes part of your identity (in a positive way).

Though our health care system and culture are certainly far from perfect, many of us went to medical school because this was/is our “calling” – vocational, if you will. For me personally, it was a unique intersection of being able to serve others, use my abilities in math/science, and make a living.

In some ways, being a physician or health care worker puts us in a unique position to serve and provide services that the world needs. But with burnout rampant within the physician community, it is even more important to understand ourselves, work out our own version of ikigai, and make sure that we are living it daily.

Dr Thachil is a noninvasive cardiologist and assistant professor of medicine at the Albert Einstein College of Medicine, New York. She is a graduate of Jefferson Medical College and completed cardiology training at Mount Sinai Hospital. She is a fellow of the American College of Cardiology.

A version of this article first appeared on Medscape.com.

What do you want to be when you grow up? What kind of doctor do you want to be? These are common conversation starters that we probably have all heard at some point in our lives.

But perhaps these are not the most thought-provoking or insightful questions to ask or be asked.

Instead, “What is your passion?” or “What inspires/motivates you?” or “What makes you want to get out of bed in the morning?” or “What creates flow for you?” may be more thoughtful questions that encourage greater self-reflection.

There is a Japanese concept called ikigai that loosely translates to “a reason for being.” This framework suggests that one should attempt to find the intersection of four things:

• One’s interests.
• One’s abilities/talents.
• What the world needs.
• What one can be paid for.

When any two of these intersect, you will have the following:

A passion: something that interests you and you excel at.

A profession: something that you excel at and are paid for.

A vocation: something that the world needs and that you’re paid for.

A mission: something that interests you and that the world needs.

Finding that “sweet spot” that intersects all four is the ideal prescribed by ikigai.

Ultimately, ikigai challenges us to find purpose, and finding this alignment of purpose can subsequently help us plan our professional and personal lives.

Of note, several of the world’s communities that are known for longevity/higher proportion of centenarians are linked by the common concept of ikigai. While there isn’t strong evidence that this phenomenon is correlated with or predictive of longevity, I believe we can all agree that finding purpose can lead to increased satisfaction, happiness, and perhaps less stress.

Achieving this sweet spot that satisfies all conditions above is undoubtedly easier said than done when placed in the context of real life, as there are often competing interests. Your purpose may align with a job that doesn’t pay the bills, or the job that provides financial stability may be uninteresting work to you. The path there may be winding, but eventually, with enough trial and error, I think we can all carve out a version of ikigai for ourselves.

I’ve had conversations with more senior physicians who have made a great impact in their fields and could certainly retire yesterday if they desired. When asked why they keep showing up, it is usually some version of “this is what I’m meant to do” or “this is my purpose” or “this is my joy.” In some ways, if you find true joy in what you do, it becomes part of your identity (in a positive way).

Though our health care system and culture are certainly far from perfect, many of us went to medical school because this was/is our “calling” – vocational, if you will. For me personally, it was a unique intersection of being able to serve others, use my abilities in math/science, and make a living.

In some ways, being a physician or health care worker puts us in a unique position to serve and provide services that the world needs. But with burnout rampant within the physician community, it is even more important to understand ourselves, work out our own version of ikigai, and make sure that we are living it daily.

Dr Thachil is a noninvasive cardiologist and assistant professor of medicine at the Albert Einstein College of Medicine, New York. She is a graduate of Jefferson Medical College and completed cardiology training at Mount Sinai Hospital. She is a fellow of the American College of Cardiology.

A version of this article first appeared on Medscape.com.

Over the 10 years we’ve been writing this column, we have often found inspiration for topics while traveling – especially while flying. This is not just because of the idle time spent in the air, but instead because of the many ways that air travel and health care experiences are similar. Both industries focus heavily on safety, are tightly regulated, and employ highly trained individuals.

Consumers may recognize the similarities as well – health care and air travel are both well-known for long waits, uncertainty, and implicit risk. Both sectors are also notorious drivers of innovation, constantly leveraging new technologies in pursuit of better outcomes and experiences. Occasionally, however, advancements in technology can present unforeseen challenges and even compromise safety, with the potential to produce unexpected consequences.

A familiar reminder of this potential was provided to us at the commencement of a recent flight, when we were instructed to turn off our personal electronic devices or flip them into “airplane mode.” This same admonishment is often given to patients and visitors in health care settings – everywhere from clinic waiting rooms to intensive care units – though the reason for this is typically left vague. This got us thinking. We wondered, what is the real risk of smart phones in medicine , or aviation, for that matter. More importantly, what other emerging technologies have the potential to create issues we may not have anticipated?

Mayo Clinic findings on radio communication used by mobile phones

Once our flight landed, we did some research to answer our initial question about personal communication technology and its ability to interfere with sensitive electronic devices. Specifically, we wanted to know whether radio communication used by mobile phones could affect the operation of medical equipment, potentially leading to dire consequences for patients. Spoiler alert: There is very little evidence that this can occur. In fact, a well-documented study performed by the Mayo Clinic in 2007 found interference in 0 out of 300 tests performed. To quote the authors, “the incidence of clinically important interference was 0%.”

We could find no other studies since 2007 that strongly contradict Mayo’s findings, except for several anecdotal reports and articles that postulate the theoretical possibility.

This is confirmed by the American Heart Association, who maintains a list of devices that may interfere with ICDs and pacemakers on their website. According to the AHA, “wireless transmissions from the antennae of phones available in the United States are a very small risk to ICDs and even less of a risk for pacemakers.” And in case you’re wondering, the story is quite similar for airplanes as well.

The latest publication from NASA’s Aviation Safety Reporting System (ASRS) documents incidents related to personal electronic devices during air travel. Most involve smoke production – or even small fires – caused by malfunctioning phone batteries during charging. Only a few entries reference wireless interference, and these were all minor and unconfirmed events. As with health care environments, airplanes don’t appear to face significant risks from radio interference. But that doesn’t mean personal electronics are completely harmless to patients.

Smartphones’ risks to patient with cardiac devices

On May 13 of 2021, the FDA issued a warning to cardiac patients about their smart phones and smart watches. Many current personal electronic devices and accessories are equipped with strong magnets, such as those contained in the “MagSafe” connector on the iPhone 12, that can deactivate pacemakers and implanted cardiac defibrillators. These medical devices are designed to be manipulated by magnets for diagnostic and therapeutic purposes, but strong magnetic fields can disable them unintentionally, leading to catastrophic results.

Apple and other manufacturers have acknowledged this risk and recommend that smartphones and other devices be kept at least 6 inches from cardiac devices. Given the ubiquity of offending products, it is also imperative that we warn our patients about this risk to their physical wellbeing.

Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece.

Over the 10 years we’ve been writing this column, we have often found inspiration for topics while traveling – especially while flying. This is not just because of the idle time spent in the air, but instead because of the many ways that air travel and health care experiences are similar. Both industries focus heavily on safety, are tightly regulated, and employ highly trained individuals.

Consumers may recognize the similarities as well – health care and air travel are both well-known for long waits, uncertainty, and implicit risk. Both sectors are also notorious drivers of innovation, constantly leveraging new technologies in pursuit of better outcomes and experiences. Occasionally, however, advancements in technology can present unforeseen challenges and even compromise safety, with the potential to produce unexpected consequences.

A familiar reminder of this potential was provided to us at the commencement of a recent flight, when we were instructed to turn off our personal electronic devices or flip them into “airplane mode.” This same admonishment is often given to patients and visitors in health care settings – everywhere from clinic waiting rooms to intensive care units – though the reason for this is typically left vague. This got us thinking. We wondered, what is the real risk of smart phones in medicine , or aviation, for that matter. More importantly, what other emerging technologies have the potential to create issues we may not have anticipated?

Mayo Clinic findings on radio communication used by mobile phones

Once our flight landed, we did some research to answer our initial question about personal communication technology and its ability to interfere with sensitive electronic devices. Specifically, we wanted to know whether radio communication used by mobile phones could affect the operation of medical equipment, potentially leading to dire consequences for patients. Spoiler alert: There is very little evidence that this can occur. In fact, a well-documented study performed by the Mayo Clinic in 2007 found interference in 0 out of 300 tests performed. To quote the authors, “the incidence of clinically important interference was 0%.”

We could find no other studies since 2007 that strongly contradict Mayo’s findings, except for several anecdotal reports and articles that postulate the theoretical possibility.

This is confirmed by the American Heart Association, who maintains a list of devices that may interfere with ICDs and pacemakers on their website. According to the AHA, “wireless transmissions from the antennae of phones available in the United States are a very small risk to ICDs and even less of a risk for pacemakers.” And in case you’re wondering, the story is quite similar for airplanes as well.

The latest publication from NASA’s Aviation Safety Reporting System (ASRS) documents incidents related to personal electronic devices during air travel. Most involve smoke production – or even small fires – caused by malfunctioning phone batteries during charging. Only a few entries reference wireless interference, and these were all minor and unconfirmed events. As with health care environments, airplanes don’t appear to face significant risks from radio interference. But that doesn’t mean personal electronics are completely harmless to patients.

Smartphones’ risks to patient with cardiac devices

On May 13 of 2021, the FDA issued a warning to cardiac patients about their smart phones and smart watches. Many current personal electronic devices and accessories are equipped with strong magnets, such as those contained in the “MagSafe” connector on the iPhone 12, that can deactivate pacemakers and implanted cardiac defibrillators. These medical devices are designed to be manipulated by magnets for diagnostic and therapeutic purposes, but strong magnetic fields can disable them unintentionally, leading to catastrophic results.

Apple and other manufacturers have acknowledged this risk and recommend that smartphones and other devices be kept at least 6 inches from cardiac devices. Given the ubiquity of offending products, it is also imperative that we warn our patients about this risk to their physical wellbeing.

Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece.

Over the 10 years we’ve been writing this column, we have often found inspiration for topics while traveling – especially while flying. This is not just because of the idle time spent in the air, but instead because of the many ways that air travel and health care experiences are similar. Both industries focus heavily on safety, are tightly regulated, and employ highly trained individuals.

Consumers may recognize the similarities as well – health care and air travel are both well-known for long waits, uncertainty, and implicit risk. Both sectors are also notorious drivers of innovation, constantly leveraging new technologies in pursuit of better outcomes and experiences. Occasionally, however, advancements in technology can present unforeseen challenges and even compromise safety, with the potential to produce unexpected consequences.

A familiar reminder of this potential was provided to us at the commencement of a recent flight, when we were instructed to turn off our personal electronic devices or flip them into “airplane mode.” This same admonishment is often given to patients and visitors in health care settings – everywhere from clinic waiting rooms to intensive care units – though the reason for this is typically left vague. This got us thinking. We wondered, what is the real risk of smart phones in medicine , or aviation, for that matter. More importantly, what other emerging technologies have the potential to create issues we may not have anticipated?

Mayo Clinic findings on radio communication used by mobile phones

Once our flight landed, we did some research to answer our initial question about personal communication technology and its ability to interfere with sensitive electronic devices. Specifically, we wanted to know whether radio communication used by mobile phones could affect the operation of medical equipment, potentially leading to dire consequences for patients. Spoiler alert: There is very little evidence that this can occur. In fact, a well-documented study performed by the Mayo Clinic in 2007 found interference in 0 out of 300 tests performed. To quote the authors, “the incidence of clinically important interference was 0%.”

We could find no other studies since 2007 that strongly contradict Mayo’s findings, except for several anecdotal reports and articles that postulate the theoretical possibility.

This is confirmed by the American Heart Association, who maintains a list of devices that may interfere with ICDs and pacemakers on their website. According to the AHA, “wireless transmissions from the antennae of phones available in the United States are a very small risk to ICDs and even less of a risk for pacemakers.” And in case you’re wondering, the story is quite similar for airplanes as well.

The latest publication from NASA’s Aviation Safety Reporting System (ASRS) documents incidents related to personal electronic devices during air travel. Most involve smoke production – or even small fires – caused by malfunctioning phone batteries during charging. Only a few entries reference wireless interference, and these were all minor and unconfirmed events. As with health care environments, airplanes don’t appear to face significant risks from radio interference. But that doesn’t mean personal electronics are completely harmless to patients.

Smartphones’ risks to patient with cardiac devices

On May 13 of 2021, the FDA issued a warning to cardiac patients about their smart phones and smart watches. Many current personal electronic devices and accessories are equipped with strong magnets, such as those contained in the “MagSafe” connector on the iPhone 12, that can deactivate pacemakers and implanted cardiac defibrillators. These medical devices are designed to be manipulated by magnets for diagnostic and therapeutic purposes, but strong magnetic fields can disable them unintentionally, leading to catastrophic results.

Apple and other manufacturers have acknowledged this risk and recommend that smartphones and other devices be kept at least 6 inches from cardiac devices. Given the ubiquity of offending products, it is also imperative that we warn our patients about this risk to their physical wellbeing.

Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece.