Feature

More and more physicians are being wooed by private equity firms that want to buy their practices. The total value of private equity deals in health care in 2019 is estimated at about $120 billion, and it’s expected to grow over the coming years.

While the potential profit may seem alluring, physicians have mixed feelings as to whether this will be a boon or a disappointment.

Angelo Falcone, MD, a former emergency physician in Rockville, Md., found that a private equity investment transformed his career path.

For 19 years, Dr. Falcone was CEO of an emergency medicine group with 35 partners that staffed 10 emergency departments, mostly in Maryland. “We were a pretty small operation looking to get bigger, but to do that would require a substantial investment,” he said.

In 2015, after checking out all their options, the partners decided to sell to US Acute Care Solutions (USACS), a new private equity company founded by Welsh, Carson, Anderson & Stowe, an investment firm in New York. Private equity can be used to expand practices and pay for new equipment. Dr. Falcone, serving as a USACS board member and its operational president, helped spur the company’s astounding growth. Today, USACS has about 5,000 physicians and other clinicians operating in 30 states.

In 2019, Dr. Falcone stepped down from his management post at USACS, took training in integrative medicine, and 2 years later opened a solo integrative medicine practice in Rockville. The new practice, which operates on a concierge model, is not connected with USACS, but Dr, Falcone still sits on the USACS board.

“I had a great experience at USACS. I believe in the power of private equity to support our patients and physicians,” Dr. Falcone said. “Now, at age 58, I have a second career in integrative medicine.”
 

Private equity is still controversial

David Fleeger, MD, has a different opinion of private equity. “I get offers from private equity firms fairly often, but I’m not seriously interested,” said Dr. Fleeger, a surgeon with Central Texas Colon and Rectal Surgeons in Austin.

“We don’t want to sell to anybody; we want to control our destiny,” he said. “We don’t have to borrow money or repay loans, and we don’t expect to get a windfall for the practice. The profits in medicine are too narrow for that to be realistic. There is no free lunch.”

Some of the doctors who sign up for private equity deals become dissatisfied and want to end the arrangement, according to John Pinto, an ophthalmic practice management consultant in San Diego.

“I get calls about once a month from doctors who want to get out of a private equity deal or revise the terms,” he said. “Some complaints are that the PE firm was too tight with the budget, wouldn’t hire needed staff, mismanaged operations, or otherwise mishandled their investment in the practice.”

It’s difficult for disgruntled physicians to exit a private equity deal, Mr. Pinto said. They commonly have to give up part of the payment they had received for their practice if they leave prematurely, and depending on the jurisdiction, stiff noncompete clauses in their contract won’t allow them to practice nearby.

Disillusioned physicians – and even many physicians who had good experiences with private equity – usually don’t want to air their complaints in public. One reason most of these doctors keep silent is that they have signed nondisclosure and nondisparagement agreements that are part of most private equity deals.
 

The private equity proposition

Private equity firms typically pay a great deal more for practices than hospitals or even many large private practices, according to James D. Wall, an attorney in Winston-Salem, N.C., who has handled many private equity deals. Mr. Wall said private equity often organizes physicians around one specialty. One advantage these physicians have over hospital-employed physicians is that they aren’t under pressure to refer within a network.

Private equity companies set values for practices on the basis of their earnings before interest, taxes, depreciation, and amortization (EBITDA), said Howard Bogard, an attorney with Burr & Forman in Raleigh, N.C., who has handled many deals. Mr. Bogard said the amount physicians are paid is usually between 4 and 12 times’ EBITDA, so if your practice is earning $1 million a year in EBITDA, you would get $4 million to $12 million for it.

Of the total price tag, “Doctors get a hefty immediate payment when they sell,” Mr. Bogard said. “It might be 70% of the purchase price up front, and the 30% left over is equity in the buyer. The private equity firm then sells the practice 5-7 years later, and at that time, the physician’s equity is converted to cash and equity in the new buyer, often at the same 70/30 ratio. The idea is to keep the doctor interested in staying.”

Private equity firms expand practices to receive more favorable reimbursements and achieve economies of scale, according to Jane Zhu, MD, an assistant professor of medicine at Oregon Health & Science University, Portland, who has studied the phenomenon. Dr. Zhu said these firms may enhance profits by contracting with Medicare Advantage plans, joining accountable care organizations (ACOs), having their physicians work longer hours, and using advanced-practice clinicians instead of physicians.

“They want to make a large return in the order of 20% per year over several years, but they don’t want to strip the practice of value, because they’ll need to sell it to a new investor,” Dr. Zhu said.

When doctors sell to a private equity firm, they become employees and often have to take a pay cut, but their pay may rise again as new efficiencies are instituted. This occurred for partners in Minnesota Eye Consultants (MEC), an 11-member ophthalmology practice in Bloomington, Minn., that helped found Unifeye Vision Partners (UVP), a private equity company financed by Chicago-based Waud Capital Partners.

“When we sold the practice in 2017, we expected to see a 30% cut in the partners’ personal income,” said Richard L. Lindstrom, MD, who headed MEC until he retired last year. “Now, coming into the 6th year, all of the former partners who are still working are earning 10% above presale levels, except for one doctor who wanted to work fewer hours.” These doctors aren’t working longer hours but rather are benefiting from efficiencies, such as adding scribes and improving scheduling, he said.

Private equity brought discipline to the practice, said Dr. Lindstrom, who still sits on the Unifeye board. “In an independent practice, the partners may decide on a new piece of equipment because it would be fun to have, not because they’ve done a financial analysis,” he said. “We don’t wing it anymore.”

On the other hand, according to Dr. Zhu, some private equity firms may use draconian methods to improve efficiency. “Doctors may be expected to order or perform more services or work faster or longer to reach a certain threshold,” she said.
 

Can private equity uphold your interests?

To win over doctors, a private equity firm may agree to finance projects that the doctors want. For example, Dr. Lindstrom said after his group joined Unifeye, Waud Capital agreed to finance the doctors’ plan to open a new $6 million office. Before the deal, the partners would have had to take out a $6 million loan and personally guarantee it, he said.

A private equity firm may even agree to support the selling doctors’ practice philosophy, such as serving low-income patients – as long as it has a revenue stream. Luis Benavides, MD, is part of a seven-physician family medicine practice that treats many low-income patients in Laredo, Tex. “There is a lot of poverty here,” he said. This March, the group sold to a large private equity company, whose name Dr. Benavides preferred not to reveal.
One reason they made the new arrangement, Dr. Benavides said, was to qualify for ACO REACH, a new Medicare payment program that is mostly used in underserved areas and that allows more distribution of shared savings payments. “Our goal has always been better care,” he said. “We want to know how we can best serve our community.”

Dr. Benavides acknowledges that he has less independence in the new arrangement, but “I already lost my independence when I went from solo practice to a group,” he said. “The upside of a larger organization is that other people may have better ideas than you have.”

Private equity firms often set up governance structures to give physicians some measure of control. Dr. Lindstrom said the governing board of his former practice is solely made up of physicians and deals with local issues such as what office doctors will work in and how many patients they will see. Waud Capital has control of the Unifeye board of directors, but it mainly deals with larger issues, such as acquisition of more practices, he said.

In rare instances, private equity gives doctors control. Dr. Falcone said that from the start of USACS, doctors owned 65% of the company, and in 2020, the physician partners bought out Welsh Carson. “Then we engaged the private equity firm Apollo Global Management, which lent us money for the buyout and became our capital partner, with the doctors now owning 98% of the company,” he said.

On the other hand, some private equity arrangements reportedly have little regard for doctors’ well-being, especially if they are new doctors who didn’t participate in the deal and don’t have equity in it. Dr. Zhu recalled that a new physician was recruited by a practice and was promised a partnership track, but she wasn’t told that the partners were negotiating a private equity deal. “She didn’t find out until the practice was sold months later,” Dr. Zhu said. “The chances of her getting any equity now are unclear.”

Making sure that you pick a company that has your interests at heart requires a lot of digging. Dr. Lindstrom said he and his partners took 3 years to make a decision. They hired a broker to pick the 10 best private equity firms. Then they met with those companies and hired a law firm and an accounting firm to assess them. As the partners inched toward a deal, they voted on each of five critical steps in the decision-making process, he said. He noted that each vote was unanimous.
 

Impact of private equity

“Private equity deals are changing the health care landscape,” Mr. Wall said. “They are creating large, independent practices that help physicians remain independent from hospital systems and potentially have the clout to get more favorable reimbursements.”

“There is a lot of misunderstanding and mistrust among physicians about private equity,” Dr. Benavides said. “I imagine it will take a while for it to be accepted.”

Until the COVID pandemic, the annual number of private equity deals for doctors had been rising. Will it recover that pace? Mr. Pinto said rising interest rates may dampen activity in the near future.

“The private equity firm often performs a leveraged buyout using borrowed money,” he explained. “This works better when interest rates are low, but interest rates are trending higher. Private equity firms aren’t going away, but they may have to be less generous as the cost of money rises.”

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

More and more physicians are being wooed by private equity firms that want to buy their practices. The total value of private equity deals in health care in 2019 is estimated at about $120 billion, and it’s expected to grow over the coming years.

While the potential profit may seem alluring, physicians have mixed feelings as to whether this will be a boon or a disappointment.

Angelo Falcone, MD, a former emergency physician in Rockville, Md., found that a private equity investment transformed his career path.

For 19 years, Dr. Falcone was CEO of an emergency medicine group with 35 partners that staffed 10 emergency departments, mostly in Maryland. “We were a pretty small operation looking to get bigger, but to do that would require a substantial investment,” he said.

In 2015, after checking out all their options, the partners decided to sell to US Acute Care Solutions (USACS), a new private equity company founded by Welsh, Carson, Anderson & Stowe, an investment firm in New York. Private equity can be used to expand practices and pay for new equipment. Dr. Falcone, serving as a USACS board member and its operational president, helped spur the company’s astounding growth. Today, USACS has about 5,000 physicians and other clinicians operating in 30 states.

In 2019, Dr. Falcone stepped down from his management post at USACS, took training in integrative medicine, and 2 years later opened a solo integrative medicine practice in Rockville. The new practice, which operates on a concierge model, is not connected with USACS, but Dr, Falcone still sits on the USACS board.

“I had a great experience at USACS. I believe in the power of private equity to support our patients and physicians,” Dr. Falcone said. “Now, at age 58, I have a second career in integrative medicine.”
 

Private equity is still controversial

David Fleeger, MD, has a different opinion of private equity. “I get offers from private equity firms fairly often, but I’m not seriously interested,” said Dr. Fleeger, a surgeon with Central Texas Colon and Rectal Surgeons in Austin.

“We don’t want to sell to anybody; we want to control our destiny,” he said. “We don’t have to borrow money or repay loans, and we don’t expect to get a windfall for the practice. The profits in medicine are too narrow for that to be realistic. There is no free lunch.”

Some of the doctors who sign up for private equity deals become dissatisfied and want to end the arrangement, according to John Pinto, an ophthalmic practice management consultant in San Diego.

“I get calls about once a month from doctors who want to get out of a private equity deal or revise the terms,” he said. “Some complaints are that the PE firm was too tight with the budget, wouldn’t hire needed staff, mismanaged operations, or otherwise mishandled their investment in the practice.”

It’s difficult for disgruntled physicians to exit a private equity deal, Mr. Pinto said. They commonly have to give up part of the payment they had received for their practice if they leave prematurely, and depending on the jurisdiction, stiff noncompete clauses in their contract won’t allow them to practice nearby.

Disillusioned physicians – and even many physicians who had good experiences with private equity – usually don’t want to air their complaints in public. One reason most of these doctors keep silent is that they have signed nondisclosure and nondisparagement agreements that are part of most private equity deals.
 

The private equity proposition

Private equity firms typically pay a great deal more for practices than hospitals or even many large private practices, according to James D. Wall, an attorney in Winston-Salem, N.C., who has handled many private equity deals. Mr. Wall said private equity often organizes physicians around one specialty. One advantage these physicians have over hospital-employed physicians is that they aren’t under pressure to refer within a network.

Private equity companies set values for practices on the basis of their earnings before interest, taxes, depreciation, and amortization (EBITDA), said Howard Bogard, an attorney with Burr & Forman in Raleigh, N.C., who has handled many deals. Mr. Bogard said the amount physicians are paid is usually between 4 and 12 times’ EBITDA, so if your practice is earning $1 million a year in EBITDA, you would get $4 million to $12 million for it.

Of the total price tag, “Doctors get a hefty immediate payment when they sell,” Mr. Bogard said. “It might be 70% of the purchase price up front, and the 30% left over is equity in the buyer. The private equity firm then sells the practice 5-7 years later, and at that time, the physician’s equity is converted to cash and equity in the new buyer, often at the same 70/30 ratio. The idea is to keep the doctor interested in staying.”

Private equity firms expand practices to receive more favorable reimbursements and achieve economies of scale, according to Jane Zhu, MD, an assistant professor of medicine at Oregon Health & Science University, Portland, who has studied the phenomenon. Dr. Zhu said these firms may enhance profits by contracting with Medicare Advantage plans, joining accountable care organizations (ACOs), having their physicians work longer hours, and using advanced-practice clinicians instead of physicians.

“They want to make a large return in the order of 20% per year over several years, but they don’t want to strip the practice of value, because they’ll need to sell it to a new investor,” Dr. Zhu said.

When doctors sell to a private equity firm, they become employees and often have to take a pay cut, but their pay may rise again as new efficiencies are instituted. This occurred for partners in Minnesota Eye Consultants (MEC), an 11-member ophthalmology practice in Bloomington, Minn., that helped found Unifeye Vision Partners (UVP), a private equity company financed by Chicago-based Waud Capital Partners.

“When we sold the practice in 2017, we expected to see a 30% cut in the partners’ personal income,” said Richard L. Lindstrom, MD, who headed MEC until he retired last year. “Now, coming into the 6th year, all of the former partners who are still working are earning 10% above presale levels, except for one doctor who wanted to work fewer hours.” These doctors aren’t working longer hours but rather are benefiting from efficiencies, such as adding scribes and improving scheduling, he said.

Private equity brought discipline to the practice, said Dr. Lindstrom, who still sits on the Unifeye board. “In an independent practice, the partners may decide on a new piece of equipment because it would be fun to have, not because they’ve done a financial analysis,” he said. “We don’t wing it anymore.”

On the other hand, according to Dr. Zhu, some private equity firms may use draconian methods to improve efficiency. “Doctors may be expected to order or perform more services or work faster or longer to reach a certain threshold,” she said.
 

Can private equity uphold your interests?

To win over doctors, a private equity firm may agree to finance projects that the doctors want. For example, Dr. Lindstrom said after his group joined Unifeye, Waud Capital agreed to finance the doctors’ plan to open a new $6 million office. Before the deal, the partners would have had to take out a $6 million loan and personally guarantee it, he said.

A private equity firm may even agree to support the selling doctors’ practice philosophy, such as serving low-income patients – as long as it has a revenue stream. Luis Benavides, MD, is part of a seven-physician family medicine practice that treats many low-income patients in Laredo, Tex. “There is a lot of poverty here,” he said. This March, the group sold to a large private equity company, whose name Dr. Benavides preferred not to reveal.
One reason they made the new arrangement, Dr. Benavides said, was to qualify for ACO REACH, a new Medicare payment program that is mostly used in underserved areas and that allows more distribution of shared savings payments. “Our goal has always been better care,” he said. “We want to know how we can best serve our community.”

Dr. Benavides acknowledges that he has less independence in the new arrangement, but “I already lost my independence when I went from solo practice to a group,” he said. “The upside of a larger organization is that other people may have better ideas than you have.”

Private equity firms often set up governance structures to give physicians some measure of control. Dr. Lindstrom said the governing board of his former practice is solely made up of physicians and deals with local issues such as what office doctors will work in and how many patients they will see. Waud Capital has control of the Unifeye board of directors, but it mainly deals with larger issues, such as acquisition of more practices, he said.

In rare instances, private equity gives doctors control. Dr. Falcone said that from the start of USACS, doctors owned 65% of the company, and in 2020, the physician partners bought out Welsh Carson. “Then we engaged the private equity firm Apollo Global Management, which lent us money for the buyout and became our capital partner, with the doctors now owning 98% of the company,” he said.

On the other hand, some private equity arrangements reportedly have little regard for doctors’ well-being, especially if they are new doctors who didn’t participate in the deal and don’t have equity in it. Dr. Zhu recalled that a new physician was recruited by a practice and was promised a partnership track, but she wasn’t told that the partners were negotiating a private equity deal. “She didn’t find out until the practice was sold months later,” Dr. Zhu said. “The chances of her getting any equity now are unclear.”

Making sure that you pick a company that has your interests at heart requires a lot of digging. Dr. Lindstrom said he and his partners took 3 years to make a decision. They hired a broker to pick the 10 best private equity firms. Then they met with those companies and hired a law firm and an accounting firm to assess them. As the partners inched toward a deal, they voted on each of five critical steps in the decision-making process, he said. He noted that each vote was unanimous.
 

Impact of private equity

“Private equity deals are changing the health care landscape,” Mr. Wall said. “They are creating large, independent practices that help physicians remain independent from hospital systems and potentially have the clout to get more favorable reimbursements.”

“There is a lot of misunderstanding and mistrust among physicians about private equity,” Dr. Benavides said. “I imagine it will take a while for it to be accepted.”

Until the COVID pandemic, the annual number of private equity deals for doctors had been rising. Will it recover that pace? Mr. Pinto said rising interest rates may dampen activity in the near future.

“The private equity firm often performs a leveraged buyout using borrowed money,” he explained. “This works better when interest rates are low, but interest rates are trending higher. Private equity firms aren’t going away, but they may have to be less generous as the cost of money rises.”

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

More and more physicians are being wooed by private equity firms that want to buy their practices. The total value of private equity deals in health care in 2019 is estimated at about $120 billion, and it’s expected to grow over the coming years.

While the potential profit may seem alluring, physicians have mixed feelings as to whether this will be a boon or a disappointment.

Angelo Falcone, MD, a former emergency physician in Rockville, Md., found that a private equity investment transformed his career path.

For 19 years, Dr. Falcone was CEO of an emergency medicine group with 35 partners that staffed 10 emergency departments, mostly in Maryland. “We were a pretty small operation looking to get bigger, but to do that would require a substantial investment,” he said.

In 2015, after checking out all their options, the partners decided to sell to US Acute Care Solutions (USACS), a new private equity company founded by Welsh, Carson, Anderson & Stowe, an investment firm in New York. Private equity can be used to expand practices and pay for new equipment. Dr. Falcone, serving as a USACS board member and its operational president, helped spur the company’s astounding growth. Today, USACS has about 5,000 physicians and other clinicians operating in 30 states.

In 2019, Dr. Falcone stepped down from his management post at USACS, took training in integrative medicine, and 2 years later opened a solo integrative medicine practice in Rockville. The new practice, which operates on a concierge model, is not connected with USACS, but Dr, Falcone still sits on the USACS board.

“I had a great experience at USACS. I believe in the power of private equity to support our patients and physicians,” Dr. Falcone said. “Now, at age 58, I have a second career in integrative medicine.”
 

Private equity is still controversial

David Fleeger, MD, has a different opinion of private equity. “I get offers from private equity firms fairly often, but I’m not seriously interested,” said Dr. Fleeger, a surgeon with Central Texas Colon and Rectal Surgeons in Austin.

“We don’t want to sell to anybody; we want to control our destiny,” he said. “We don’t have to borrow money or repay loans, and we don’t expect to get a windfall for the practice. The profits in medicine are too narrow for that to be realistic. There is no free lunch.”

Some of the doctors who sign up for private equity deals become dissatisfied and want to end the arrangement, according to John Pinto, an ophthalmic practice management consultant in San Diego.

“I get calls about once a month from doctors who want to get out of a private equity deal or revise the terms,” he said. “Some complaints are that the PE firm was too tight with the budget, wouldn’t hire needed staff, mismanaged operations, or otherwise mishandled their investment in the practice.”

It’s difficult for disgruntled physicians to exit a private equity deal, Mr. Pinto said. They commonly have to give up part of the payment they had received for their practice if they leave prematurely, and depending on the jurisdiction, stiff noncompete clauses in their contract won’t allow them to practice nearby.

Disillusioned physicians – and even many physicians who had good experiences with private equity – usually don’t want to air their complaints in public. One reason most of these doctors keep silent is that they have signed nondisclosure and nondisparagement agreements that are part of most private equity deals.
 

The private equity proposition

Private equity firms typically pay a great deal more for practices than hospitals or even many large private practices, according to James D. Wall, an attorney in Winston-Salem, N.C., who has handled many private equity deals. Mr. Wall said private equity often organizes physicians around one specialty. One advantage these physicians have over hospital-employed physicians is that they aren’t under pressure to refer within a network.

Private equity companies set values for practices on the basis of their earnings before interest, taxes, depreciation, and amortization (EBITDA), said Howard Bogard, an attorney with Burr & Forman in Raleigh, N.C., who has handled many deals. Mr. Bogard said the amount physicians are paid is usually between 4 and 12 times’ EBITDA, so if your practice is earning $1 million a year in EBITDA, you would get $4 million to $12 million for it.

Of the total price tag, “Doctors get a hefty immediate payment when they sell,” Mr. Bogard said. “It might be 70% of the purchase price up front, and the 30% left over is equity in the buyer. The private equity firm then sells the practice 5-7 years later, and at that time, the physician’s equity is converted to cash and equity in the new buyer, often at the same 70/30 ratio. The idea is to keep the doctor interested in staying.”

Private equity firms expand practices to receive more favorable reimbursements and achieve economies of scale, according to Jane Zhu, MD, an assistant professor of medicine at Oregon Health & Science University, Portland, who has studied the phenomenon. Dr. Zhu said these firms may enhance profits by contracting with Medicare Advantage plans, joining accountable care organizations (ACOs), having their physicians work longer hours, and using advanced-practice clinicians instead of physicians.

“They want to make a large return in the order of 20% per year over several years, but they don’t want to strip the practice of value, because they’ll need to sell it to a new investor,” Dr. Zhu said.

When doctors sell to a private equity firm, they become employees and often have to take a pay cut, but their pay may rise again as new efficiencies are instituted. This occurred for partners in Minnesota Eye Consultants (MEC), an 11-member ophthalmology practice in Bloomington, Minn., that helped found Unifeye Vision Partners (UVP), a private equity company financed by Chicago-based Waud Capital Partners.

“When we sold the practice in 2017, we expected to see a 30% cut in the partners’ personal income,” said Richard L. Lindstrom, MD, who headed MEC until he retired last year. “Now, coming into the 6th year, all of the former partners who are still working are earning 10% above presale levels, except for one doctor who wanted to work fewer hours.” These doctors aren’t working longer hours but rather are benefiting from efficiencies, such as adding scribes and improving scheduling, he said.

Private equity brought discipline to the practice, said Dr. Lindstrom, who still sits on the Unifeye board. “In an independent practice, the partners may decide on a new piece of equipment because it would be fun to have, not because they’ve done a financial analysis,” he said. “We don’t wing it anymore.”

On the other hand, according to Dr. Zhu, some private equity firms may use draconian methods to improve efficiency. “Doctors may be expected to order or perform more services or work faster or longer to reach a certain threshold,” she said.
 

Can private equity uphold your interests?

To win over doctors, a private equity firm may agree to finance projects that the doctors want. For example, Dr. Lindstrom said after his group joined Unifeye, Waud Capital agreed to finance the doctors’ plan to open a new $6 million office. Before the deal, the partners would have had to take out a $6 million loan and personally guarantee it, he said.

A private equity firm may even agree to support the selling doctors’ practice philosophy, such as serving low-income patients – as long as it has a revenue stream. Luis Benavides, MD, is part of a seven-physician family medicine practice that treats many low-income patients in Laredo, Tex. “There is a lot of poverty here,” he said. This March, the group sold to a large private equity company, whose name Dr. Benavides preferred not to reveal.
One reason they made the new arrangement, Dr. Benavides said, was to qualify for ACO REACH, a new Medicare payment program that is mostly used in underserved areas and that allows more distribution of shared savings payments. “Our goal has always been better care,” he said. “We want to know how we can best serve our community.”

Dr. Benavides acknowledges that he has less independence in the new arrangement, but “I already lost my independence when I went from solo practice to a group,” he said. “The upside of a larger organization is that other people may have better ideas than you have.”

Private equity firms often set up governance structures to give physicians some measure of control. Dr. Lindstrom said the governing board of his former practice is solely made up of physicians and deals with local issues such as what office doctors will work in and how many patients they will see. Waud Capital has control of the Unifeye board of directors, but it mainly deals with larger issues, such as acquisition of more practices, he said.

In rare instances, private equity gives doctors control. Dr. Falcone said that from the start of USACS, doctors owned 65% of the company, and in 2020, the physician partners bought out Welsh Carson. “Then we engaged the private equity firm Apollo Global Management, which lent us money for the buyout and became our capital partner, with the doctors now owning 98% of the company,” he said.

On the other hand, some private equity arrangements reportedly have little regard for doctors’ well-being, especially if they are new doctors who didn’t participate in the deal and don’t have equity in it. Dr. Zhu recalled that a new physician was recruited by a practice and was promised a partnership track, but she wasn’t told that the partners were negotiating a private equity deal. “She didn’t find out until the practice was sold months later,” Dr. Zhu said. “The chances of her getting any equity now are unclear.”

Making sure that you pick a company that has your interests at heart requires a lot of digging. Dr. Lindstrom said he and his partners took 3 years to make a decision. They hired a broker to pick the 10 best private equity firms. Then they met with those companies and hired a law firm and an accounting firm to assess them. As the partners inched toward a deal, they voted on each of five critical steps in the decision-making process, he said. He noted that each vote was unanimous.
 

Impact of private equity

“Private equity deals are changing the health care landscape,” Mr. Wall said. “They are creating large, independent practices that help physicians remain independent from hospital systems and potentially have the clout to get more favorable reimbursements.”

“There is a lot of misunderstanding and mistrust among physicians about private equity,” Dr. Benavides said. “I imagine it will take a while for it to be accepted.”

Until the COVID pandemic, the annual number of private equity deals for doctors had been rising. Will it recover that pace? Mr. Pinto said rising interest rates may dampen activity in the near future.

“The private equity firm often performs a leveraged buyout using borrowed money,” he explained. “This works better when interest rates are low, but interest rates are trending higher. Private equity firms aren’t going away, but they may have to be less generous as the cost of money rises.”

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

The glucagon-like peptide-1 (GLP-1) agonist semaglutide formulated for treating obesity (Wegovy) had a roaring takeoff a little more than a year ago, with surging patient demand after the U.S. Food and Drug Administration approved it in June 2021. But starting doses of the Wegovy form of semaglutide went missing in action starting late 2021 and continue to date, frustrating patients and their health care providers. 

The arrival of Wegovy last year was hailed by obesity medicine specialists and others as a “game changer” for treating people with obesity because of semaglutide’s proven safety and efficacy at the subcutaneous dose of 2.4 mg delivered once a week to produce at least 15% weight loss in half the people who received it, as documented last year in results from one of the drug’s pivotal clinical trials.

But during the months following semaglutide’s approval for treating obesity (it also received an FDA marketing nod in late 2017 as Ozempic for treating type 2 diabetes), a worldwide shortage of Wegovy, including in the United States, emerged.

A manufacturing glitch shut down the primary location for production of U.S.-bound Wegovy injector pens for several months starting in late 2021, according to a December report from Novo Nordisk, the company that makes and markets the agent. (The Wegovy production issue appears to have had a very modest impact, especially in U.S. pharmacies, on the supply of semaglutide formulated as Ozempic, also marketed by Novo Nordisk, although Wegovy supply and demand have dramatically limited Ozempic availability in Australia.)
 

‘Unprecedented demand’ for Wegovy derailed when plant went offline

The supply side for Wegovy became so hopelessly broken that just months after U.S. sales began and immediately skyrocketed, Novo Nordisk made the remarkable decision to pull starting doses of Wegovy from the market to make it much harder to initiate patients (semaglutide and other GLP-1 agonists require gradual dose ramp-up to avoid gastrointestinal side effects), and the company publicly implored clinicians to not start new patients on the agent, which is where the status remains as of early August 2022.

Novo Nordisk’s financial report for the second quarter of 2022, released on Aug. 3, said the company “expects to make all Wegovy dose strengths available in the United States towards the end of 2022.”

A Dear Health Care Provider letter that Novo Nordisk posted on its U.S. Wegovy website last spring cited “unprecedented demand” that exceeded every prior product launch in the company’s history. It forced Novo Nordisk to pull the plug on all U.S. promotion of Wegovy and compelled the company to ask U.S. clinicians to halt new patient starts.

“I stopped offering Wegovy to new patients” since about the beginning of 2022, says Lauren D. Oshman, MD, a family and obesity medicine specialist at the University of Michigan, Ann Arbor. “It’s very frustrating to not have patients [with obesity] receive the optimal treatment available.” Although she adds that she tries to match obesity treatments to each patient’s clinical needs, and a GLP-1 agonist is not the first choice for every person with obesity.

“It was a disastrous rollout,” says Catherine W. Varney, DO, a family and obesity medicine specialist at the University of Virginia, Charlottesville. “It’s frustrating to know that the treatment is there but not being able to use it,” she said in an interview.

“I had about 800 patients on Wegovy” when the supply dropped earlier this year, and “I couldn’t handle the volume of messages that I got from patients,” recalls Angela Fitch, MD, associate director of the Massachusetts General Hospital Weight Center, Boston. “It was painful,” she said in an interview.

“Frustrating and chaotic,” is the description from Ivania M. Rizo, MD, director of obesity medicine at Boston Medical Center.
 

The liraglutide/Saxenda workaround

The upshot is that people with obesity and their health care providers have been busy devising workarounds to try to meet the intense demand for this drug-assisted approach to appetite control and weight loss. Their tactics run a wide gamut based on the crazy-quilt diversity of health insurance coverage across America.

Because the bottleneck for starting Wegovy resulted from unavailable starting doses (dosing starts at 0.25 mg delivered subcutaneously once a week, eventually ramping up to a maximum of 2.4 mg weekly), one option was to start patients on a different GLP-1 agonist, such as liraglutide (Saxenda, approved for obesity).

Starting a patient on liraglutide involves the same sort of up-titration and acclimation to a GLP-1 agonist that semaglutide requires, and transition between these agents seems feasible for at least some. It also means daily injections of liraglutide rather than the weekly schedule for semaglutide, although some patients prefer maintaining a daily dosing schedule. Another limitation of liraglutide is that evidence shows it is not nearly as effective for weight loss as semaglutide.

Results from the head-to-head STEP 8 trial, published in JAMA, showed an average weight loss from baseline of about 16% with semaglutide and about 6% with liraglutide (and about 2% with placebo).
 

A ‘reasonable’ evidence base, but more work

Changing from Saxenda to Wegovy, or from Wegovy to Saxenda, “would be reasonably evidence-based medicine,” said Dr. Oshman in an interview. She has managed a Wegovy-to-Saxenda switch for a “handful” of patients to deal with Wegovy shortages, but she has not yet moved anyone to Wegovy after a Saxenda initiation.

“No prospective study has looked at this transition,” but dose equivalence tables exist based on expert opinion, noted Dr. Oshman, as in this 2020 report.

Dr. Varney has several patients on the Saxenda-to-Wegovy track. She up-titrates patients on Saxenda to the maximum daily dose of 3.0 mg and then switches them to the 1.7 mg weekly dose of Wegovy, one of the “destination” Wegovy doses that has remained generally available during the shortage. But Dr. Varney’s experience is that only half of her patients made the changeover smoothly, with the others having “severe gastrointestinal distress,” including vomiting, she notes.

Dr. Fitch has also successfully used this Saxenda-to-Wegovy approach for some of her patients, but it hasn’t been easy.

“It’s more work and more prior authorizations. It’s harder and adds a layer of stress,” but, Dr. Fitch adds, “people are willing to work on it because the weight loss is worth it.”

The liraglutide to semaglutide shuffle is “doable,” says Dr. Rizo, “but I’m looking forward to not having to do it and being able to just start Wegovy.”
 

The tirzepatide coupon program works ‘off label’ for obesity

Another workaround depends on the FDA approval in May for tirzepatide (Mounjaro) for type 2 diabetes. Tirzepatide is a related GLP-1 agonist that also adds a second incretin-like agonist activity that mimics the glucose-dependent insulinotropic polypeptide.

Soon after approval, Lilly, the company that markets tirzepatide, started a U.S. coupon program geared exclusively to people with commercial insurance. Within certain refill and dollar limits, the program lets patients buy tirzepatide at pharmacies at an out-of-pocket cost of $25 for a 4-week supply (tirzepatide is also dosed by weekly subcutaneous injections). The program will extend into 2023.

Novo Nordisk offered U.S. patients with commercial insurance a similar discount when Wegovy first hit the U.S. market in 2021, but the program closed down once the supply shortage began.

Despite tirzepatide’s current approval only for type 2 diabetes, Dr. Varney has been successfully prescribing it to patients without diabetes off-label for weight loss.

“The coupons still work even when tirzepatide is used off-label,” she notes. And while the drug’s rollout is still only a couple of months old, so far, it’s gone “beautifully” with no hints of supply issues, she says.

But a major drawback to relying on an introductory coupon program that makes these agents affordable to patients is their ability to maintain treatment once the discounts inevitably end.

“We try to only prescribe agents that patients can continue to access,” says Dr. Fitch, who has had some patients with commercial insurance start on Wegovy with coupon discounts only to later lose access.

Many commercial U.S. insurers do not cover obesity treatments, a decision often driven by the employers who sponsor the coverage, she notes.

Study results have documented that when people with obesity stop taking a GLP-1 agonist their lost weight rebounds, as in a study that tracked people who stopped taking semaglutide.

Dr. Fitch has had success prescribing tirzepatide to patients with obesity but without diabetes who have certain types of Medicare drug coverage policies, which often do not deny off-label drug coverage. That approach works until patients reach the “donut hole” in their drug coverage and are faced with a certain level of out-of-pocket costs that can balloon to several thousand dollars.
 

Even more workarounds

Other approaches patients have used to acquire Wegovy include purchasing it in other countries, such as Canada or Brazil, says Dr. Fitch. But prices outside the United States, while substantially lower, can still be a barrier for many patients, notes Dr. Oshman.

Semaglutide in Canada goes for about $300 for a 4-week supply, roughly a quarter the U.S. price, she says, but is “still too high for many of my patients.”

Intense patient demand sometimes bordering on desperation has prompted some to seek semaglutide from private compounding pharmacies, a step clinicians regard as downright dangerous.

“Semaglutide from compounding pharmacies is not known to be safe. We feel strongly that it’s not something that people should do,” says Dr. Fitch.

“Compounding pharmacies have no FDA regulation. People don’t know what they’re getting. It’s dangerous,” agrees Dr. Varney. Physicians who refer people for privately compounded semaglutide “are taking advantage of desperate people,” she adds.

Although it seems likely that Novo Nordisk will soon sort out the supply problems and Wegovy will once again become more widely available, some of the issues patients have had with access to the weight loss medication stem from more systemic issues in the United States health insurance landscape: an unwillingness by payers to cover the costs of weight loss medications, a shortcoming that also exists for Medicare and Medicaid.

“We need to make obesity treatment a standard benefit, and not something that can be carved out,” says Dr. Fitch. People with obesity “deserve access to effective treatments for their disease,” she declares.

Dr. Oshman, Dr. Varney, and Dr. Rizo have reported no relevant financial relationships. Dr. Fitch has reported being an advisor to Jenny Craig.

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

The glucagon-like peptide-1 (GLP-1) agonist semaglutide formulated for treating obesity (Wegovy) had a roaring takeoff a little more than a year ago, with surging patient demand after the U.S. Food and Drug Administration approved it in June 2021. But starting doses of the Wegovy form of semaglutide went missing in action starting late 2021 and continue to date, frustrating patients and their health care providers. 

The arrival of Wegovy last year was hailed by obesity medicine specialists and others as a “game changer” for treating people with obesity because of semaglutide’s proven safety and efficacy at the subcutaneous dose of 2.4 mg delivered once a week to produce at least 15% weight loss in half the people who received it, as documented last year in results from one of the drug’s pivotal clinical trials.

But during the months following semaglutide’s approval for treating obesity (it also received an FDA marketing nod in late 2017 as Ozempic for treating type 2 diabetes), a worldwide shortage of Wegovy, including in the United States, emerged.

A manufacturing glitch shut down the primary location for production of U.S.-bound Wegovy injector pens for several months starting in late 2021, according to a December report from Novo Nordisk, the company that makes and markets the agent. (The Wegovy production issue appears to have had a very modest impact, especially in U.S. pharmacies, on the supply of semaglutide formulated as Ozempic, also marketed by Novo Nordisk, although Wegovy supply and demand have dramatically limited Ozempic availability in Australia.)
 

‘Unprecedented demand’ for Wegovy derailed when plant went offline

The supply side for Wegovy became so hopelessly broken that just months after U.S. sales began and immediately skyrocketed, Novo Nordisk made the remarkable decision to pull starting doses of Wegovy from the market to make it much harder to initiate patients (semaglutide and other GLP-1 agonists require gradual dose ramp-up to avoid gastrointestinal side effects), and the company publicly implored clinicians to not start new patients on the agent, which is where the status remains as of early August 2022.

Novo Nordisk’s financial report for the second quarter of 2022, released on Aug. 3, said the company “expects to make all Wegovy dose strengths available in the United States towards the end of 2022.”

A Dear Health Care Provider letter that Novo Nordisk posted on its U.S. Wegovy website last spring cited “unprecedented demand” that exceeded every prior product launch in the company’s history. It forced Novo Nordisk to pull the plug on all U.S. promotion of Wegovy and compelled the company to ask U.S. clinicians to halt new patient starts.

“I stopped offering Wegovy to new patients” since about the beginning of 2022, says Lauren D. Oshman, MD, a family and obesity medicine specialist at the University of Michigan, Ann Arbor. “It’s very frustrating to not have patients [with obesity] receive the optimal treatment available.” Although she adds that she tries to match obesity treatments to each patient’s clinical needs, and a GLP-1 agonist is not the first choice for every person with obesity.

“It was a disastrous rollout,” says Catherine W. Varney, DO, a family and obesity medicine specialist at the University of Virginia, Charlottesville. “It’s frustrating to know that the treatment is there but not being able to use it,” she said in an interview.

“I had about 800 patients on Wegovy” when the supply dropped earlier this year, and “I couldn’t handle the volume of messages that I got from patients,” recalls Angela Fitch, MD, associate director of the Massachusetts General Hospital Weight Center, Boston. “It was painful,” she said in an interview.

“Frustrating and chaotic,” is the description from Ivania M. Rizo, MD, director of obesity medicine at Boston Medical Center.
 

The liraglutide/Saxenda workaround

The upshot is that people with obesity and their health care providers have been busy devising workarounds to try to meet the intense demand for this drug-assisted approach to appetite control and weight loss. Their tactics run a wide gamut based on the crazy-quilt diversity of health insurance coverage across America.

Because the bottleneck for starting Wegovy resulted from unavailable starting doses (dosing starts at 0.25 mg delivered subcutaneously once a week, eventually ramping up to a maximum of 2.4 mg weekly), one option was to start patients on a different GLP-1 agonist, such as liraglutide (Saxenda, approved for obesity).

Starting a patient on liraglutide involves the same sort of up-titration and acclimation to a GLP-1 agonist that semaglutide requires, and transition between these agents seems feasible for at least some. It also means daily injections of liraglutide rather than the weekly schedule for semaglutide, although some patients prefer maintaining a daily dosing schedule. Another limitation of liraglutide is that evidence shows it is not nearly as effective for weight loss as semaglutide.

Results from the head-to-head STEP 8 trial, published in JAMA, showed an average weight loss from baseline of about 16% with semaglutide and about 6% with liraglutide (and about 2% with placebo).
 

A ‘reasonable’ evidence base, but more work

Changing from Saxenda to Wegovy, or from Wegovy to Saxenda, “would be reasonably evidence-based medicine,” said Dr. Oshman in an interview. She has managed a Wegovy-to-Saxenda switch for a “handful” of patients to deal with Wegovy shortages, but she has not yet moved anyone to Wegovy after a Saxenda initiation.

“No prospective study has looked at this transition,” but dose equivalence tables exist based on expert opinion, noted Dr. Oshman, as in this 2020 report.

Dr. Varney has several patients on the Saxenda-to-Wegovy track. She up-titrates patients on Saxenda to the maximum daily dose of 3.0 mg and then switches them to the 1.7 mg weekly dose of Wegovy, one of the “destination” Wegovy doses that has remained generally available during the shortage. But Dr. Varney’s experience is that only half of her patients made the changeover smoothly, with the others having “severe gastrointestinal distress,” including vomiting, she notes.

Dr. Fitch has also successfully used this Saxenda-to-Wegovy approach for some of her patients, but it hasn’t been easy.

“It’s more work and more prior authorizations. It’s harder and adds a layer of stress,” but, Dr. Fitch adds, “people are willing to work on it because the weight loss is worth it.”

The liraglutide to semaglutide shuffle is “doable,” says Dr. Rizo, “but I’m looking forward to not having to do it and being able to just start Wegovy.”
 

The tirzepatide coupon program works ‘off label’ for obesity

Another workaround depends on the FDA approval in May for tirzepatide (Mounjaro) for type 2 diabetes. Tirzepatide is a related GLP-1 agonist that also adds a second incretin-like agonist activity that mimics the glucose-dependent insulinotropic polypeptide.

Soon after approval, Lilly, the company that markets tirzepatide, started a U.S. coupon program geared exclusively to people with commercial insurance. Within certain refill and dollar limits, the program lets patients buy tirzepatide at pharmacies at an out-of-pocket cost of $25 for a 4-week supply (tirzepatide is also dosed by weekly subcutaneous injections). The program will extend into 2023.

Novo Nordisk offered U.S. patients with commercial insurance a similar discount when Wegovy first hit the U.S. market in 2021, but the program closed down once the supply shortage began.

Despite tirzepatide’s current approval only for type 2 diabetes, Dr. Varney has been successfully prescribing it to patients without diabetes off-label for weight loss.

“The coupons still work even when tirzepatide is used off-label,” she notes. And while the drug’s rollout is still only a couple of months old, so far, it’s gone “beautifully” with no hints of supply issues, she says.

But a major drawback to relying on an introductory coupon program that makes these agents affordable to patients is their ability to maintain treatment once the discounts inevitably end.

“We try to only prescribe agents that patients can continue to access,” says Dr. Fitch, who has had some patients with commercial insurance start on Wegovy with coupon discounts only to later lose access.

Many commercial U.S. insurers do not cover obesity treatments, a decision often driven by the employers who sponsor the coverage, she notes.

Study results have documented that when people with obesity stop taking a GLP-1 agonist their lost weight rebounds, as in a study that tracked people who stopped taking semaglutide.

Dr. Fitch has had success prescribing tirzepatide to patients with obesity but without diabetes who have certain types of Medicare drug coverage policies, which often do not deny off-label drug coverage. That approach works until patients reach the “donut hole” in their drug coverage and are faced with a certain level of out-of-pocket costs that can balloon to several thousand dollars.
 

Even more workarounds

Other approaches patients have used to acquire Wegovy include purchasing it in other countries, such as Canada or Brazil, says Dr. Fitch. But prices outside the United States, while substantially lower, can still be a barrier for many patients, notes Dr. Oshman.

Semaglutide in Canada goes for about $300 for a 4-week supply, roughly a quarter the U.S. price, she says, but is “still too high for many of my patients.”

Intense patient demand sometimes bordering on desperation has prompted some to seek semaglutide from private compounding pharmacies, a step clinicians regard as downright dangerous.

“Semaglutide from compounding pharmacies is not known to be safe. We feel strongly that it’s not something that people should do,” says Dr. Fitch.

“Compounding pharmacies have no FDA regulation. People don’t know what they’re getting. It’s dangerous,” agrees Dr. Varney. Physicians who refer people for privately compounded semaglutide “are taking advantage of desperate people,” she adds.

Although it seems likely that Novo Nordisk will soon sort out the supply problems and Wegovy will once again become more widely available, some of the issues patients have had with access to the weight loss medication stem from more systemic issues in the United States health insurance landscape: an unwillingness by payers to cover the costs of weight loss medications, a shortcoming that also exists for Medicare and Medicaid.

“We need to make obesity treatment a standard benefit, and not something that can be carved out,” says Dr. Fitch. People with obesity “deserve access to effective treatments for their disease,” she declares.

Dr. Oshman, Dr. Varney, and Dr. Rizo have reported no relevant financial relationships. Dr. Fitch has reported being an advisor to Jenny Craig.

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

The glucagon-like peptide-1 (GLP-1) agonist semaglutide formulated for treating obesity (Wegovy) had a roaring takeoff a little more than a year ago, with surging patient demand after the U.S. Food and Drug Administration approved it in June 2021. But starting doses of the Wegovy form of semaglutide went missing in action starting late 2021 and continue to date, frustrating patients and their health care providers. 

The arrival of Wegovy last year was hailed by obesity medicine specialists and others as a “game changer” for treating people with obesity because of semaglutide’s proven safety and efficacy at the subcutaneous dose of 2.4 mg delivered once a week to produce at least 15% weight loss in half the people who received it, as documented last year in results from one of the drug’s pivotal clinical trials.

But during the months following semaglutide’s approval for treating obesity (it also received an FDA marketing nod in late 2017 as Ozempic for treating type 2 diabetes), a worldwide shortage of Wegovy, including in the United States, emerged.

A manufacturing glitch shut down the primary location for production of U.S.-bound Wegovy injector pens for several months starting in late 2021, according to a December report from Novo Nordisk, the company that makes and markets the agent. (The Wegovy production issue appears to have had a very modest impact, especially in U.S. pharmacies, on the supply of semaglutide formulated as Ozempic, also marketed by Novo Nordisk, although Wegovy supply and demand have dramatically limited Ozempic availability in Australia.)
 

‘Unprecedented demand’ for Wegovy derailed when plant went offline

The supply side for Wegovy became so hopelessly broken that just months after U.S. sales began and immediately skyrocketed, Novo Nordisk made the remarkable decision to pull starting doses of Wegovy from the market to make it much harder to initiate patients (semaglutide and other GLP-1 agonists require gradual dose ramp-up to avoid gastrointestinal side effects), and the company publicly implored clinicians to not start new patients on the agent, which is where the status remains as of early August 2022.

Novo Nordisk’s financial report for the second quarter of 2022, released on Aug. 3, said the company “expects to make all Wegovy dose strengths available in the United States towards the end of 2022.”

A Dear Health Care Provider letter that Novo Nordisk posted on its U.S. Wegovy website last spring cited “unprecedented demand” that exceeded every prior product launch in the company’s history. It forced Novo Nordisk to pull the plug on all U.S. promotion of Wegovy and compelled the company to ask U.S. clinicians to halt new patient starts.

“I stopped offering Wegovy to new patients” since about the beginning of 2022, says Lauren D. Oshman, MD, a family and obesity medicine specialist at the University of Michigan, Ann Arbor. “It’s very frustrating to not have patients [with obesity] receive the optimal treatment available.” Although she adds that she tries to match obesity treatments to each patient’s clinical needs, and a GLP-1 agonist is not the first choice for every person with obesity.

“It was a disastrous rollout,” says Catherine W. Varney, DO, a family and obesity medicine specialist at the University of Virginia, Charlottesville. “It’s frustrating to know that the treatment is there but not being able to use it,” she said in an interview.

“I had about 800 patients on Wegovy” when the supply dropped earlier this year, and “I couldn’t handle the volume of messages that I got from patients,” recalls Angela Fitch, MD, associate director of the Massachusetts General Hospital Weight Center, Boston. “It was painful,” she said in an interview.

“Frustrating and chaotic,” is the description from Ivania M. Rizo, MD, director of obesity medicine at Boston Medical Center.
 

The liraglutide/Saxenda workaround

The upshot is that people with obesity and their health care providers have been busy devising workarounds to try to meet the intense demand for this drug-assisted approach to appetite control and weight loss. Their tactics run a wide gamut based on the crazy-quilt diversity of health insurance coverage across America.

Because the bottleneck for starting Wegovy resulted from unavailable starting doses (dosing starts at 0.25 mg delivered subcutaneously once a week, eventually ramping up to a maximum of 2.4 mg weekly), one option was to start patients on a different GLP-1 agonist, such as liraglutide (Saxenda, approved for obesity).

Starting a patient on liraglutide involves the same sort of up-titration and acclimation to a GLP-1 agonist that semaglutide requires, and transition between these agents seems feasible for at least some. It also means daily injections of liraglutide rather than the weekly schedule for semaglutide, although some patients prefer maintaining a daily dosing schedule. Another limitation of liraglutide is that evidence shows it is not nearly as effective for weight loss as semaglutide.

Results from the head-to-head STEP 8 trial, published in JAMA, showed an average weight loss from baseline of about 16% with semaglutide and about 6% with liraglutide (and about 2% with placebo).
 

A ‘reasonable’ evidence base, but more work

Changing from Saxenda to Wegovy, or from Wegovy to Saxenda, “would be reasonably evidence-based medicine,” said Dr. Oshman in an interview. She has managed a Wegovy-to-Saxenda switch for a “handful” of patients to deal with Wegovy shortages, but she has not yet moved anyone to Wegovy after a Saxenda initiation.

“No prospective study has looked at this transition,” but dose equivalence tables exist based on expert opinion, noted Dr. Oshman, as in this 2020 report.

Dr. Varney has several patients on the Saxenda-to-Wegovy track. She up-titrates patients on Saxenda to the maximum daily dose of 3.0 mg and then switches them to the 1.7 mg weekly dose of Wegovy, one of the “destination” Wegovy doses that has remained generally available during the shortage. But Dr. Varney’s experience is that only half of her patients made the changeover smoothly, with the others having “severe gastrointestinal distress,” including vomiting, she notes.

Dr. Fitch has also successfully used this Saxenda-to-Wegovy approach for some of her patients, but it hasn’t been easy.

“It’s more work and more prior authorizations. It’s harder and adds a layer of stress,” but, Dr. Fitch adds, “people are willing to work on it because the weight loss is worth it.”

The liraglutide to semaglutide shuffle is “doable,” says Dr. Rizo, “but I’m looking forward to not having to do it and being able to just start Wegovy.”
 

The tirzepatide coupon program works ‘off label’ for obesity

Another workaround depends on the FDA approval in May for tirzepatide (Mounjaro) for type 2 diabetes. Tirzepatide is a related GLP-1 agonist that also adds a second incretin-like agonist activity that mimics the glucose-dependent insulinotropic polypeptide.

Soon after approval, Lilly, the company that markets tirzepatide, started a U.S. coupon program geared exclusively to people with commercial insurance. Within certain refill and dollar limits, the program lets patients buy tirzepatide at pharmacies at an out-of-pocket cost of $25 for a 4-week supply (tirzepatide is also dosed by weekly subcutaneous injections). The program will extend into 2023.

Novo Nordisk offered U.S. patients with commercial insurance a similar discount when Wegovy first hit the U.S. market in 2021, but the program closed down once the supply shortage began.

Despite tirzepatide’s current approval only for type 2 diabetes, Dr. Varney has been successfully prescribing it to patients without diabetes off-label for weight loss.

“The coupons still work even when tirzepatide is used off-label,” she notes. And while the drug’s rollout is still only a couple of months old, so far, it’s gone “beautifully” with no hints of supply issues, she says.

But a major drawback to relying on an introductory coupon program that makes these agents affordable to patients is their ability to maintain treatment once the discounts inevitably end.

“We try to only prescribe agents that patients can continue to access,” says Dr. Fitch, who has had some patients with commercial insurance start on Wegovy with coupon discounts only to later lose access.

Many commercial U.S. insurers do not cover obesity treatments, a decision often driven by the employers who sponsor the coverage, she notes.

Study results have documented that when people with obesity stop taking a GLP-1 agonist their lost weight rebounds, as in a study that tracked people who stopped taking semaglutide.

Dr. Fitch has had success prescribing tirzepatide to patients with obesity but without diabetes who have certain types of Medicare drug coverage policies, which often do not deny off-label drug coverage. That approach works until patients reach the “donut hole” in their drug coverage and are faced with a certain level of out-of-pocket costs that can balloon to several thousand dollars.
 

Even more workarounds

Other approaches patients have used to acquire Wegovy include purchasing it in other countries, such as Canada or Brazil, says Dr. Fitch. But prices outside the United States, while substantially lower, can still be a barrier for many patients, notes Dr. Oshman.

Semaglutide in Canada goes for about $300 for a 4-week supply, roughly a quarter the U.S. price, she says, but is “still too high for many of my patients.”

Intense patient demand sometimes bordering on desperation has prompted some to seek semaglutide from private compounding pharmacies, a step clinicians regard as downright dangerous.

“Semaglutide from compounding pharmacies is not known to be safe. We feel strongly that it’s not something that people should do,” says Dr. Fitch.

“Compounding pharmacies have no FDA regulation. People don’t know what they’re getting. It’s dangerous,” agrees Dr. Varney. Physicians who refer people for privately compounded semaglutide “are taking advantage of desperate people,” she adds.

Although it seems likely that Novo Nordisk will soon sort out the supply problems and Wegovy will once again become more widely available, some of the issues patients have had with access to the weight loss medication stem from more systemic issues in the United States health insurance landscape: an unwillingness by payers to cover the costs of weight loss medications, a shortcoming that also exists for Medicare and Medicaid.

“We need to make obesity treatment a standard benefit, and not something that can be carved out,” says Dr. Fitch. People with obesity “deserve access to effective treatments for their disease,” she declares.

Dr. Oshman, Dr. Varney, and Dr. Rizo have reported no relevant financial relationships. Dr. Fitch has reported being an advisor to Jenny Craig.

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

Just about every child hears it growing up: An ache in the leg? “Growing pains.” A dull pain in the side? “Growing pains.”

The catch-all phrase for random pains that children and teens have is so common that it even inspired the name of a 1980s sitcom. Yet when scientists dug into the evidence to find out what growing pains actually are, they found out that no one really knows. The definitions were as random and all over the place as the very pains that kids complain about, the researchers report in the journal Pediatrics.

Although some studies have suggested that up to a third of children have growing pains, the term has long seemed more like folk medicine than an actual medical diagnosis. Even so, parents, teachers, and doctors frequently use it when they have no other obvious answer to a particular pain a child or teen might describe.

A group of researchers at the University of Sydney in Australia wanted to find out if there was any research offering a more precise definition or criteria. They combed through eight databases for any papers that mentioned growing pains or growth pains in children or adolescents. They found 145 studies and set out to look for common ground: Where do growing pains occur? At what age do they start? Are there any patterns? Risk factors? Common clinical features? Relationships to particular activities?

What they found was that there is “no consensus whatsoever as to what growing pains really are, what they mean, how they’re defined, and how they should be diagnosed,” coauthor Steven J. Kamper, PhD, explained in a video about the findings. “The definitions were really variable, really vague, and sometimes downright contradictory,” he said. “Some studies would suggest growing pains happen in the arms, some in the lower limbs only. Some said it was about muscles, some about joints.”

The closest thing to consistency that they found was that exactly half the studies mentioned the pain being in the lower limbs. Nearly half (48%) described it as happening in the evening or nighttime, 42% said it was recurring, 35% reported it as occurring in youths with an otherwise normal physical exam, and 31% said the pain occurred on both sides of the body. Besides these, no other common feature was mentioned in more than 30% of the studies.

“Really curiously,” Dr. Kamper said, “more than 80% said nothing about the age at which these growing pains come on.” And 93% of the studies didn’t even mention growth as being related to the pain at all.

Several studies did acknowledge that the cause of growing pains is unknown, and several others considered it a diagnosis of exclusion – that is, it’s the diagnosis when everything else has been ruled out.

But that’s hardly a satisfactory explanation for kids and their families, so the researchers drew the only reasonable conclusion they could from what they found: “We think it’s important that the term is not used without some qualification or clarification, whether by researchers or clinicians,” Dr. Kamper said.

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

Just about every child hears it growing up: An ache in the leg? “Growing pains.” A dull pain in the side? “Growing pains.”

The catch-all phrase for random pains that children and teens have is so common that it even inspired the name of a 1980s sitcom. Yet when scientists dug into the evidence to find out what growing pains actually are, they found out that no one really knows. The definitions were as random and all over the place as the very pains that kids complain about, the researchers report in the journal Pediatrics.

Although some studies have suggested that up to a third of children have growing pains, the term has long seemed more like folk medicine than an actual medical diagnosis. Even so, parents, teachers, and doctors frequently use it when they have no other obvious answer to a particular pain a child or teen might describe.

A group of researchers at the University of Sydney in Australia wanted to find out if there was any research offering a more precise definition or criteria. They combed through eight databases for any papers that mentioned growing pains or growth pains in children or adolescents. They found 145 studies and set out to look for common ground: Where do growing pains occur? At what age do they start? Are there any patterns? Risk factors? Common clinical features? Relationships to particular activities?

What they found was that there is “no consensus whatsoever as to what growing pains really are, what they mean, how they’re defined, and how they should be diagnosed,” coauthor Steven J. Kamper, PhD, explained in a video about the findings. “The definitions were really variable, really vague, and sometimes downright contradictory,” he said. “Some studies would suggest growing pains happen in the arms, some in the lower limbs only. Some said it was about muscles, some about joints.”

The closest thing to consistency that they found was that exactly half the studies mentioned the pain being in the lower limbs. Nearly half (48%) described it as happening in the evening or nighttime, 42% said it was recurring, 35% reported it as occurring in youths with an otherwise normal physical exam, and 31% said the pain occurred on both sides of the body. Besides these, no other common feature was mentioned in more than 30% of the studies.

“Really curiously,” Dr. Kamper said, “more than 80% said nothing about the age at which these growing pains come on.” And 93% of the studies didn’t even mention growth as being related to the pain at all.

Several studies did acknowledge that the cause of growing pains is unknown, and several others considered it a diagnosis of exclusion – that is, it’s the diagnosis when everything else has been ruled out.

But that’s hardly a satisfactory explanation for kids and their families, so the researchers drew the only reasonable conclusion they could from what they found: “We think it’s important that the term is not used without some qualification or clarification, whether by researchers or clinicians,” Dr. Kamper said.

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

Just about every child hears it growing up: An ache in the leg? “Growing pains.” A dull pain in the side? “Growing pains.”

The catch-all phrase for random pains that children and teens have is so common that it even inspired the name of a 1980s sitcom. Yet when scientists dug into the evidence to find out what growing pains actually are, they found out that no one really knows. The definitions were as random and all over the place as the very pains that kids complain about, the researchers report in the journal Pediatrics.

Although some studies have suggested that up to a third of children have growing pains, the term has long seemed more like folk medicine than an actual medical diagnosis. Even so, parents, teachers, and doctors frequently use it when they have no other obvious answer to a particular pain a child or teen might describe.

A group of researchers at the University of Sydney in Australia wanted to find out if there was any research offering a more precise definition or criteria. They combed through eight databases for any papers that mentioned growing pains or growth pains in children or adolescents. They found 145 studies and set out to look for common ground: Where do growing pains occur? At what age do they start? Are there any patterns? Risk factors? Common clinical features? Relationships to particular activities?

What they found was that there is “no consensus whatsoever as to what growing pains really are, what they mean, how they’re defined, and how they should be diagnosed,” coauthor Steven J. Kamper, PhD, explained in a video about the findings. “The definitions were really variable, really vague, and sometimes downright contradictory,” he said. “Some studies would suggest growing pains happen in the arms, some in the lower limbs only. Some said it was about muscles, some about joints.”

The closest thing to consistency that they found was that exactly half the studies mentioned the pain being in the lower limbs. Nearly half (48%) described it as happening in the evening or nighttime, 42% said it was recurring, 35% reported it as occurring in youths with an otherwise normal physical exam, and 31% said the pain occurred on both sides of the body. Besides these, no other common feature was mentioned in more than 30% of the studies.

“Really curiously,” Dr. Kamper said, “more than 80% said nothing about the age at which these growing pains come on.” And 93% of the studies didn’t even mention growth as being related to the pain at all.

Several studies did acknowledge that the cause of growing pains is unknown, and several others considered it a diagnosis of exclusion – that is, it’s the diagnosis when everything else has been ruled out.

But that’s hardly a satisfactory explanation for kids and their families, so the researchers drew the only reasonable conclusion they could from what they found: “We think it’s important that the term is not used without some qualification or clarification, whether by researchers or clinicians,” Dr. Kamper said.

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

When it comes to chemsex, the findings of various international studies all agree: 20% to 30% of men who have sex with men (MSM) engage in this practice, which is becoming more and more prevalent. Chemsex combines sex, drugs, and smartphones, and physicians know very little about it. Dedicated consultations were instituted in the fall of 2019 at the Infectious Diseases Department at the Saint-Louis Hospital in Paris. It’s estimated that 1,000 persons who were patients there practice chemsex.

Alexandre Aslan, MD, is one of the department’s physicians; he is also a sexologist and psychotherapist-psychoanalyst. At the ALBATROS International Congress of Addiction, which took place in the French capital in June, he presented the results of a study of patients who engage in chemsex and who regularly attend those consultations. Through this research, light is being shed on the phenomenon.

This news organization invited Dr. Aslan to discuss the issues connected with this practice.

Question: What exactly is chemsex, also known as party ‘n’ play (PnP)?

Dr. Aslan: Hearing the word “chemsex,” one would automatically think that it is what it sounds like it is: having sex while on drugs. That’s not really what it is. According to the definition that’s been published in the scientific literature, chemsex is a practice seen among men who have sex with men, where they take some very specific substances during sexual activity to sustain, enhance, or intensify the sexual experience, but also to “manage” issues related to intimacy, performance, and concerns about sexually transmitted infections (STIs). The substances are most commonly a cocktail of three drugs: GHB [gamma-hydroxybutyrate], cathinones, and crystal meth. In chemsex, smartphones play a central role as well, through the use of social networking and dating applications – those location-based apps that allow users to instantly find partners.

Question: In what ways does meeting through apps influence the sexual relationship and the use of substances?

Dr. Aslan: Because the plan to meet up for sex is being made through these kinds of apps, the promise to have sex is often implied – and this is before the individuals even meet up in real life. Let me explain. It’s not an encounter or a person that’s going to trigger sexual desire. Instead, it’s something within – the sexual “urge” inside of the individual – that’s going to drive them toward sexual activity. Now, finding yourself promising to have sex with someone – someone you don’t know, haven’t spoken to, and haven’t actually met – in an environment where it’s possible that you’ll meet several people and where the moments in which the sexual acts take place are predominantly characterized by pornography-related performance scripts: This can push you to take substances so you can “let go” and get to the point where you’re able to adapt to the requirements of the situation. Seeking to perform well and to not be overly inhibited, these individuals have found that this drug cocktail proves to be quite explosive, imparting a very strong capacity for experiencing excitement and even bringing about new sexual practices.

Question: Can you speak a bit about drug-enhanced sex?

Dr. Aslan: We sexologists consider it to be a very particular type of sex. People who engage in it feel that the sex is very intense, with unbelievable experiences, and that they have a deeper connection with their partner. In fact, it’s a type of sex where taking these substances does away with the very principles of sexual physiology – in other words, desire followed by excitement, plateau, orgasm, and resolution. Little by little, one’s sexual partner is no longer going to exist in the sex session, and the benefit is a succession of partners whose sole purpose is to keep the fire of excitement burning, an excitement that’s also reinforced by the substances taken. It’s “sex” under the influence rather than a sexual encounter linked to desire.

Question: What impact does it have on health?

Dr. Aslan: This practice brings with it numerous complications, such as STIs, but also physical injuries, as these sessions can last for 24 to more than 48 hours. There are also psychological complications, because these drugs can bring about depression, paranoia, self-harm, and even episodes of decompensation. And then, it should be noted that later on, the spotlight gets pulled away from the sex – the pretext from the very beginning – and shifts toward the taking of drugs: The individuals will no longer be able to separate the sexual encounter from the taking of drugs. Then, in a few years, there’s no longer the sexual encounter, only the taking of drugs. In the United States, between 2021 and 2022, there was a decrease in the number of deaths caused by heroin and prescription opioids. On the other hand, since 2020, the overdoses that have exploded in number are those related to fentanyl, nonprescription opioids, and stimulants – cocaine and methamphetamine, which can come back into the practices particularly through the seemingly “playful” arena of sex.

Question: How is it that things have gone from being a practice that’s under control to full-on drug addiction?

Dr. Aslan: You still have people who manage to keep things under control. But the kinds of drugs that are taken are highly addictive and compel the individual to take even more. It’s one big circle: The exciting sexual relationship itself, to which you add substances that cause even more dopamine to be released, and a smartphone screen with excitatory pornographic images on it all the time. In all the patients we see, we notice a trajectory that looks like the trajectory of every drug. When they’re at the beginning – in other words, the first year – after a first experience that they consider to be explosive, they may not return to the scene right away, and then they do return to it. They realize that it’s perhaps not as marvelous as the first time, but they’re going to give it another try. During this novelty phase, a strategy is pursued whereby they adapt and make adjustments in an attempt to feel again what they felt the first time. At the end of a year or two, they become disillusioned and they refocus on all activities having to do with drug use. Our hospital department conducted a survey where we asked detailed questions to over 100 individuals. It showed that people noticed the negative consequences that chemsex had on their work (60%), on their private lives and sex lives (55%), and on their relationships with friends and family (63%). This means that people are well aware of the negative effects that this practice has in very important areas of their lives. But even if they notice all of that, even if they resolve to have a certain number of sexual relations without drugs involved, these substances are so powerful in releasing a rush of dopamine that that very fact can sweep away any capacity the individual may have had to make a decision and stick to it, and they’re going to feel practically “compelled” to use. This is what’s called a craving.

Question: How do you identify patients who engage in chemsex among the patients in your infectious diseases department?

Dr. Aslan: As a rule, all patients admitted to our department are asked a series of questions. Do you use drugs to engage in sexual relations? Which drug do you prefer? How do you take it? Do you have a good time? Do you find that it’s good for you? Are you okay with how much you’re using? We also ask patients to tell us when they last had drug-free sex. It’s a very important question, because if we can identify someone who has had 10 or so partners a month but hasn’t had drug-free sex for over a month, we’ll try to steer the conversation to where they’ll come to think that it might not be such a bad idea to talk about it.

Question: Should a physician be asking younger patients whether they’re engaging in chemsex?

Dr. Aslan: Yes, but the physician has to be very careful. We often have a tendency to believe that we’re capable of speaking with our patients about relevant matters related to sex. We see ourselves as that kind of person, not to mention we’re open-minded. Now, as in all fields of medicine, we have to educate ourselves about how best to approach patients – in this case, about their sexual health. Because sometimes, despite our best intentions, we can do harm. The idea that we have of our own sexual behavior does not necessarily help provide counsel regarding another person’s sexual behavior, particularly when there are differences between the two. If you’re interested in the issue, you need to be trained on all the answers that could come up. There are training courses online. There’s a module on sexual health and chemsex at a site designed to give private practice physicians guidance about PrEP. It’s at least a place to start. This way, physicians will know what questions they can ask and when they should reach out to a specialist, such as a sexologist with training in these specific issues.

Question: What is the treatment based on?

Dr. Aslan: The traditional approach taken by addiction medicine physicians may not be comprehensive enough. Likewise, a sexologist’s approach alone can only go so far. It’s impossible to get by thinking that a single discipline can hold the solution, all the answers. So, it’s a multidisciplinary sexual health treatment. There should be a psychiatrist or addiction medicine physician who knows the drugs and is capable of navigating through this landscape of psychiatric comorbidities (such as psychoses and ADHD).

There also has to be a sexologist for the treatment of any sexual dysfunctions there may be. At Saint-Louis Hospital, 60% of patients who engage in chemsex said that engaging in the practice was related to a sexual problem that they noted – but never went to see a doctor about – before the first time they used. Be that as it may, it’s still the case that if these patients had been able to see a sexologist – who would have treated the problem – the drug may perhaps not have taken hold.

There also has to be a practitioner who can focus on risk reduction. In other words, someone capable of helping the patient get to the desired level of use where the craving, the need for instant gratification, can be kept in check.

In practice, one can sometimes, in addition to all of that, turn to medical treatments to manage the craving or medical comorbidities, an approach based on sexology to provide care for the sexual dysfunction or even to help the person learn how to evoke sexual or erotic fantasies without drugs, and an approach based on addiction medicine or psychotherapy, as some of our patients experienced sexual abuse in childhood. In the end, chemsex is just the outer layer – a problem that only seems to pertain to sex but that, in reality, covers up a wide range of issues. And not only sexual issues or issues that are related to drugs like chemsex is.

Question: What are the outcomes of this multidisciplinary treatment?

Dr. Aslan: Before we finish, I must point out and just state that the patients, when they’re cared for and when they’re provided with the appropriate treatment, change their practices. Some of our patients, even those with more advanced cases in terms of frequency, how often they’re injecting drugs – every 30 minutes over the course of 24 or 48 hours, with complications such as thrombosis, sepsis, and abscesses – they’ve completely stopped after several months of treatment. They now lead lives that, as they’ve told us, work better for them. So, those of us in the health care industry, we have to get organized and set things up in a way that will allow us to focus our efforts on treating these patients.
 

A version of this article first appeared on Medscape.com. This article was translated from the Medscape French edition.

When it comes to chemsex, the findings of various international studies all agree: 20% to 30% of men who have sex with men (MSM) engage in this practice, which is becoming more and more prevalent. Chemsex combines sex, drugs, and smartphones, and physicians know very little about it. Dedicated consultations were instituted in the fall of 2019 at the Infectious Diseases Department at the Saint-Louis Hospital in Paris. It’s estimated that 1,000 persons who were patients there practice chemsex.

Alexandre Aslan, MD, is one of the department’s physicians; he is also a sexologist and psychotherapist-psychoanalyst. At the ALBATROS International Congress of Addiction, which took place in the French capital in June, he presented the results of a study of patients who engage in chemsex and who regularly attend those consultations. Through this research, light is being shed on the phenomenon.

This news organization invited Dr. Aslan to discuss the issues connected with this practice.

Question: What exactly is chemsex, also known as party ‘n’ play (PnP)?

Dr. Aslan: Hearing the word “chemsex,” one would automatically think that it is what it sounds like it is: having sex while on drugs. That’s not really what it is. According to the definition that’s been published in the scientific literature, chemsex is a practice seen among men who have sex with men, where they take some very specific substances during sexual activity to sustain, enhance, or intensify the sexual experience, but also to “manage” issues related to intimacy, performance, and concerns about sexually transmitted infections (STIs). The substances are most commonly a cocktail of three drugs: GHB [gamma-hydroxybutyrate], cathinones, and crystal meth. In chemsex, smartphones play a central role as well, through the use of social networking and dating applications – those location-based apps that allow users to instantly find partners.

Question: In what ways does meeting through apps influence the sexual relationship and the use of substances?

Dr. Aslan: Because the plan to meet up for sex is being made through these kinds of apps, the promise to have sex is often implied – and this is before the individuals even meet up in real life. Let me explain. It’s not an encounter or a person that’s going to trigger sexual desire. Instead, it’s something within – the sexual “urge” inside of the individual – that’s going to drive them toward sexual activity. Now, finding yourself promising to have sex with someone – someone you don’t know, haven’t spoken to, and haven’t actually met – in an environment where it’s possible that you’ll meet several people and where the moments in which the sexual acts take place are predominantly characterized by pornography-related performance scripts: This can push you to take substances so you can “let go” and get to the point where you’re able to adapt to the requirements of the situation. Seeking to perform well and to not be overly inhibited, these individuals have found that this drug cocktail proves to be quite explosive, imparting a very strong capacity for experiencing excitement and even bringing about new sexual practices.

Question: Can you speak a bit about drug-enhanced sex?

Dr. Aslan: We sexologists consider it to be a very particular type of sex. People who engage in it feel that the sex is very intense, with unbelievable experiences, and that they have a deeper connection with their partner. In fact, it’s a type of sex where taking these substances does away with the very principles of sexual physiology – in other words, desire followed by excitement, plateau, orgasm, and resolution. Little by little, one’s sexual partner is no longer going to exist in the sex session, and the benefit is a succession of partners whose sole purpose is to keep the fire of excitement burning, an excitement that’s also reinforced by the substances taken. It’s “sex” under the influence rather than a sexual encounter linked to desire.

Question: What impact does it have on health?

Dr. Aslan: This practice brings with it numerous complications, such as STIs, but also physical injuries, as these sessions can last for 24 to more than 48 hours. There are also psychological complications, because these drugs can bring about depression, paranoia, self-harm, and even episodes of decompensation. And then, it should be noted that later on, the spotlight gets pulled away from the sex – the pretext from the very beginning – and shifts toward the taking of drugs: The individuals will no longer be able to separate the sexual encounter from the taking of drugs. Then, in a few years, there’s no longer the sexual encounter, only the taking of drugs. In the United States, between 2021 and 2022, there was a decrease in the number of deaths caused by heroin and prescription opioids. On the other hand, since 2020, the overdoses that have exploded in number are those related to fentanyl, nonprescription opioids, and stimulants – cocaine and methamphetamine, which can come back into the practices particularly through the seemingly “playful” arena of sex.

Question: How is it that things have gone from being a practice that’s under control to full-on drug addiction?

Dr. Aslan: You still have people who manage to keep things under control. But the kinds of drugs that are taken are highly addictive and compel the individual to take even more. It’s one big circle: The exciting sexual relationship itself, to which you add substances that cause even more dopamine to be released, and a smartphone screen with excitatory pornographic images on it all the time. In all the patients we see, we notice a trajectory that looks like the trajectory of every drug. When they’re at the beginning – in other words, the first year – after a first experience that they consider to be explosive, they may not return to the scene right away, and then they do return to it. They realize that it’s perhaps not as marvelous as the first time, but they’re going to give it another try. During this novelty phase, a strategy is pursued whereby they adapt and make adjustments in an attempt to feel again what they felt the first time. At the end of a year or two, they become disillusioned and they refocus on all activities having to do with drug use. Our hospital department conducted a survey where we asked detailed questions to over 100 individuals. It showed that people noticed the negative consequences that chemsex had on their work (60%), on their private lives and sex lives (55%), and on their relationships with friends and family (63%). This means that people are well aware of the negative effects that this practice has in very important areas of their lives. But even if they notice all of that, even if they resolve to have a certain number of sexual relations without drugs involved, these substances are so powerful in releasing a rush of dopamine that that very fact can sweep away any capacity the individual may have had to make a decision and stick to it, and they’re going to feel practically “compelled” to use. This is what’s called a craving.

Question: How do you identify patients who engage in chemsex among the patients in your infectious diseases department?

Dr. Aslan: As a rule, all patients admitted to our department are asked a series of questions. Do you use drugs to engage in sexual relations? Which drug do you prefer? How do you take it? Do you have a good time? Do you find that it’s good for you? Are you okay with how much you’re using? We also ask patients to tell us when they last had drug-free sex. It’s a very important question, because if we can identify someone who has had 10 or so partners a month but hasn’t had drug-free sex for over a month, we’ll try to steer the conversation to where they’ll come to think that it might not be such a bad idea to talk about it.

Question: Should a physician be asking younger patients whether they’re engaging in chemsex?

Dr. Aslan: Yes, but the physician has to be very careful. We often have a tendency to believe that we’re capable of speaking with our patients about relevant matters related to sex. We see ourselves as that kind of person, not to mention we’re open-minded. Now, as in all fields of medicine, we have to educate ourselves about how best to approach patients – in this case, about their sexual health. Because sometimes, despite our best intentions, we can do harm. The idea that we have of our own sexual behavior does not necessarily help provide counsel regarding another person’s sexual behavior, particularly when there are differences between the two. If you’re interested in the issue, you need to be trained on all the answers that could come up. There are training courses online. There’s a module on sexual health and chemsex at a site designed to give private practice physicians guidance about PrEP. It’s at least a place to start. This way, physicians will know what questions they can ask and when they should reach out to a specialist, such as a sexologist with training in these specific issues.

Question: What is the treatment based on?

Dr. Aslan: The traditional approach taken by addiction medicine physicians may not be comprehensive enough. Likewise, a sexologist’s approach alone can only go so far. It’s impossible to get by thinking that a single discipline can hold the solution, all the answers. So, it’s a multidisciplinary sexual health treatment. There should be a psychiatrist or addiction medicine physician who knows the drugs and is capable of navigating through this landscape of psychiatric comorbidities (such as psychoses and ADHD).

There also has to be a sexologist for the treatment of any sexual dysfunctions there may be. At Saint-Louis Hospital, 60% of patients who engage in chemsex said that engaging in the practice was related to a sexual problem that they noted – but never went to see a doctor about – before the first time they used. Be that as it may, it’s still the case that if these patients had been able to see a sexologist – who would have treated the problem – the drug may perhaps not have taken hold.

There also has to be a practitioner who can focus on risk reduction. In other words, someone capable of helping the patient get to the desired level of use where the craving, the need for instant gratification, can be kept in check.

In practice, one can sometimes, in addition to all of that, turn to medical treatments to manage the craving or medical comorbidities, an approach based on sexology to provide care for the sexual dysfunction or even to help the person learn how to evoke sexual or erotic fantasies without drugs, and an approach based on addiction medicine or psychotherapy, as some of our patients experienced sexual abuse in childhood. In the end, chemsex is just the outer layer – a problem that only seems to pertain to sex but that, in reality, covers up a wide range of issues. And not only sexual issues or issues that are related to drugs like chemsex is.

Question: What are the outcomes of this multidisciplinary treatment?

Dr. Aslan: Before we finish, I must point out and just state that the patients, when they’re cared for and when they’re provided with the appropriate treatment, change their practices. Some of our patients, even those with more advanced cases in terms of frequency, how often they’re injecting drugs – every 30 minutes over the course of 24 or 48 hours, with complications such as thrombosis, sepsis, and abscesses – they’ve completely stopped after several months of treatment. They now lead lives that, as they’ve told us, work better for them. So, those of us in the health care industry, we have to get organized and set things up in a way that will allow us to focus our efforts on treating these patients.
 

A version of this article first appeared on Medscape.com. This article was translated from the Medscape French edition.

When it comes to chemsex, the findings of various international studies all agree: 20% to 30% of men who have sex with men (MSM) engage in this practice, which is becoming more and more prevalent. Chemsex combines sex, drugs, and smartphones, and physicians know very little about it. Dedicated consultations were instituted in the fall of 2019 at the Infectious Diseases Department at the Saint-Louis Hospital in Paris. It’s estimated that 1,000 persons who were patients there practice chemsex.

Alexandre Aslan, MD, is one of the department’s physicians; he is also a sexologist and psychotherapist-psychoanalyst. At the ALBATROS International Congress of Addiction, which took place in the French capital in June, he presented the results of a study of patients who engage in chemsex and who regularly attend those consultations. Through this research, light is being shed on the phenomenon.

This news organization invited Dr. Aslan to discuss the issues connected with this practice.

Question: What exactly is chemsex, also known as party ‘n’ play (PnP)?

Dr. Aslan: Hearing the word “chemsex,” one would automatically think that it is what it sounds like it is: having sex while on drugs. That’s not really what it is. According to the definition that’s been published in the scientific literature, chemsex is a practice seen among men who have sex with men, where they take some very specific substances during sexual activity to sustain, enhance, or intensify the sexual experience, but also to “manage” issues related to intimacy, performance, and concerns about sexually transmitted infections (STIs). The substances are most commonly a cocktail of three drugs: GHB [gamma-hydroxybutyrate], cathinones, and crystal meth. In chemsex, smartphones play a central role as well, through the use of social networking and dating applications – those location-based apps that allow users to instantly find partners.

Question: In what ways does meeting through apps influence the sexual relationship and the use of substances?

Dr. Aslan: Because the plan to meet up for sex is being made through these kinds of apps, the promise to have sex is often implied – and this is before the individuals even meet up in real life. Let me explain. It’s not an encounter or a person that’s going to trigger sexual desire. Instead, it’s something within – the sexual “urge” inside of the individual – that’s going to drive them toward sexual activity. Now, finding yourself promising to have sex with someone – someone you don’t know, haven’t spoken to, and haven’t actually met – in an environment where it’s possible that you’ll meet several people and where the moments in which the sexual acts take place are predominantly characterized by pornography-related performance scripts: This can push you to take substances so you can “let go” and get to the point where you’re able to adapt to the requirements of the situation. Seeking to perform well and to not be overly inhibited, these individuals have found that this drug cocktail proves to be quite explosive, imparting a very strong capacity for experiencing excitement and even bringing about new sexual practices.

Question: Can you speak a bit about drug-enhanced sex?

Dr. Aslan: We sexologists consider it to be a very particular type of sex. People who engage in it feel that the sex is very intense, with unbelievable experiences, and that they have a deeper connection with their partner. In fact, it’s a type of sex where taking these substances does away with the very principles of sexual physiology – in other words, desire followed by excitement, plateau, orgasm, and resolution. Little by little, one’s sexual partner is no longer going to exist in the sex session, and the benefit is a succession of partners whose sole purpose is to keep the fire of excitement burning, an excitement that’s also reinforced by the substances taken. It’s “sex” under the influence rather than a sexual encounter linked to desire.

Question: What impact does it have on health?

Dr. Aslan: This practice brings with it numerous complications, such as STIs, but also physical injuries, as these sessions can last for 24 to more than 48 hours. There are also psychological complications, because these drugs can bring about depression, paranoia, self-harm, and even episodes of decompensation. And then, it should be noted that later on, the spotlight gets pulled away from the sex – the pretext from the very beginning – and shifts toward the taking of drugs: The individuals will no longer be able to separate the sexual encounter from the taking of drugs. Then, in a few years, there’s no longer the sexual encounter, only the taking of drugs. In the United States, between 2021 and 2022, there was a decrease in the number of deaths caused by heroin and prescription opioids. On the other hand, since 2020, the overdoses that have exploded in number are those related to fentanyl, nonprescription opioids, and stimulants – cocaine and methamphetamine, which can come back into the practices particularly through the seemingly “playful” arena of sex.

Question: How is it that things have gone from being a practice that’s under control to full-on drug addiction?

Dr. Aslan: You still have people who manage to keep things under control. But the kinds of drugs that are taken are highly addictive and compel the individual to take even more. It’s one big circle: The exciting sexual relationship itself, to which you add substances that cause even more dopamine to be released, and a smartphone screen with excitatory pornographic images on it all the time. In all the patients we see, we notice a trajectory that looks like the trajectory of every drug. When they’re at the beginning – in other words, the first year – after a first experience that they consider to be explosive, they may not return to the scene right away, and then they do return to it. They realize that it’s perhaps not as marvelous as the first time, but they’re going to give it another try. During this novelty phase, a strategy is pursued whereby they adapt and make adjustments in an attempt to feel again what they felt the first time. At the end of a year or two, they become disillusioned and they refocus on all activities having to do with drug use. Our hospital department conducted a survey where we asked detailed questions to over 100 individuals. It showed that people noticed the negative consequences that chemsex had on their work (60%), on their private lives and sex lives (55%), and on their relationships with friends and family (63%). This means that people are well aware of the negative effects that this practice has in very important areas of their lives. But even if they notice all of that, even if they resolve to have a certain number of sexual relations without drugs involved, these substances are so powerful in releasing a rush of dopamine that that very fact can sweep away any capacity the individual may have had to make a decision and stick to it, and they’re going to feel practically “compelled” to use. This is what’s called a craving.

Question: How do you identify patients who engage in chemsex among the patients in your infectious diseases department?

Dr. Aslan: As a rule, all patients admitted to our department are asked a series of questions. Do you use drugs to engage in sexual relations? Which drug do you prefer? How do you take it? Do you have a good time? Do you find that it’s good for you? Are you okay with how much you’re using? We also ask patients to tell us when they last had drug-free sex. It’s a very important question, because if we can identify someone who has had 10 or so partners a month but hasn’t had drug-free sex for over a month, we’ll try to steer the conversation to where they’ll come to think that it might not be such a bad idea to talk about it.

Question: Should a physician be asking younger patients whether they’re engaging in chemsex?

Dr. Aslan: Yes, but the physician has to be very careful. We often have a tendency to believe that we’re capable of speaking with our patients about relevant matters related to sex. We see ourselves as that kind of person, not to mention we’re open-minded. Now, as in all fields of medicine, we have to educate ourselves about how best to approach patients – in this case, about their sexual health. Because sometimes, despite our best intentions, we can do harm. The idea that we have of our own sexual behavior does not necessarily help provide counsel regarding another person’s sexual behavior, particularly when there are differences between the two. If you’re interested in the issue, you need to be trained on all the answers that could come up. There are training courses online. There’s a module on sexual health and chemsex at a site designed to give private practice physicians guidance about PrEP. It’s at least a place to start. This way, physicians will know what questions they can ask and when they should reach out to a specialist, such as a sexologist with training in these specific issues.

Question: What is the treatment based on?

Dr. Aslan: The traditional approach taken by addiction medicine physicians may not be comprehensive enough. Likewise, a sexologist’s approach alone can only go so far. It’s impossible to get by thinking that a single discipline can hold the solution, all the answers. So, it’s a multidisciplinary sexual health treatment. There should be a psychiatrist or addiction medicine physician who knows the drugs and is capable of navigating through this landscape of psychiatric comorbidities (such as psychoses and ADHD).

There also has to be a sexologist for the treatment of any sexual dysfunctions there may be. At Saint-Louis Hospital, 60% of patients who engage in chemsex said that engaging in the practice was related to a sexual problem that they noted – but never went to see a doctor about – before the first time they used. Be that as it may, it’s still the case that if these patients had been able to see a sexologist – who would have treated the problem – the drug may perhaps not have taken hold.

There also has to be a practitioner who can focus on risk reduction. In other words, someone capable of helping the patient get to the desired level of use where the craving, the need for instant gratification, can be kept in check.

In practice, one can sometimes, in addition to all of that, turn to medical treatments to manage the craving or medical comorbidities, an approach based on sexology to provide care for the sexual dysfunction or even to help the person learn how to evoke sexual or erotic fantasies without drugs, and an approach based on addiction medicine or psychotherapy, as some of our patients experienced sexual abuse in childhood. In the end, chemsex is just the outer layer – a problem that only seems to pertain to sex but that, in reality, covers up a wide range of issues. And not only sexual issues or issues that are related to drugs like chemsex is.

Question: What are the outcomes of this multidisciplinary treatment?

Dr. Aslan: Before we finish, I must point out and just state that the patients, when they’re cared for and when they’re provided with the appropriate treatment, change their practices. Some of our patients, even those with more advanced cases in terms of frequency, how often they’re injecting drugs – every 30 minutes over the course of 24 or 48 hours, with complications such as thrombosis, sepsis, and abscesses – they’ve completely stopped after several months of treatment. They now lead lives that, as they’ve told us, work better for them. So, those of us in the health care industry, we have to get organized and set things up in a way that will allow us to focus our efforts on treating these patients.
 

A version of this article first appeared on Medscape.com. This article was translated from the Medscape French edition.

At the beginning of July, Brazilians across the country were appalled when they heard that an anesthesiologist was accused of sexually abusing a woman he had been treating during cesarean delivery. The incident was recorded on video by nurses and nurse technicians who, having become suspicious of the excessive amount of sedatives given to mothers-to-be by this particular anesthesiologist, decided to film him during a procedure. To do this, they made a last-minute change, switching delivery rooms to one in which they had hidden a cell phone in a cabinet.

What the footage showed was horrifying and the assailant, Giovanni Quintella Bezerra, was arrested on the spot. He’s a 32-year-old, White, successful physician, and he’s now accused of rape. The authorities are looking into whether there are more victims, others who may have been abused by the physician. The police are investigating about 40 surgeries in which Dr. Bezerra participated. That same month saw the arrest of another physician, gynecologist Ricardo Teles Martins, who was arrested after being accused of sexually harassing and abusing several women in Hidrolândia, in the northeastern state of Ceará.

In gathering information about these incidents, this news organization interviewed four Brazilian specialists to get their insights on the issues that have been brought to light by these recent cases and the factors that play a role in these kinds of criminal acts. Claudio Cohen, MD, PhD, is a psychiatrist, bioethicist, and professor at the University of São Paulo in Brazil. Daniela Pedroso, MA, is a psychologist who has 25 years’ experience working with victims of sexual violence. Gynecologist and obstetrician Jefferson Drezett, MD, PhD, is a professor in the field of population genetics and reproductive and sexual health at the Federal University of ABC, São Paulo, and in the department of health, life cycles, and society at the University of São Paulo School of Public Health. Maria Alice Scardoelli, MD, is a psychiatrist who also serves as vice-chair of the São Paulo Regional Council of Medicine (Cremesp).


 

Accusations and investigations

Not all incidents of sexual violence in health care institutions are reported, and precise numbers are difficult to obtain. The fact that there are any cases at all is troubling. In 2019, journalists from The Intercept found that over a period of 6 years (2014-2019), 1,734 such attacks were recorded in nine Brazilian states. They were able to get that information from the states’ Public Security Secretariats by using the Information Access Act, a law that regulates the right to access public information.

Efforts to determine how widespread this type of sexual violence is are further complicated by the difficulties in collating the accusations filed at each state’s regional council of medicine, police stations, and public prosecutor’s office. Which investigative steps are taken depends upon where the report was filed, and only occasionally do these entities communicate with each other. According to its data, Cremesp received 78 accusations in 2019. In 2020, that number increased to 84. In 2021, it was 83; these types of attacks were the seventh most common among the investigations opened that year. In the first 6 months of 2022, there were 36 complaints. The number includes investigations opened on the basis of press reports. In such cases, enough information must be available in the press reports make it possible to initiate an evaluation and assessment of the matter. There is no information about how many accusations became the subject of professional ethics proceedings and how many were formally adjudicated.

“Each accusation received is investigated by a technical committee made up of professionals from various specialties. There really needs to be a rigorous evaluation and assessment during the investigation. We cannot be unfair: It may turn out that there was no truth to the accusation after all, and yet someone’s career may already have been destroyed,” explained Dr. Scardoelli.

After the accusation is investigated and accepted by Cremesp, there is no deadline by which the proceedings must end. They can take up to 5 years, and sometimes longer. Since March, however, a deadline for the investigation period has been in effect, after which the proceedings can commence.

“We now have 90 days to make an evaluation and assessment in the investigation phase; that time period can be extended by 3 months, starting from the date the accusation is submitted to the council. If the case is accepted, then the proceedings are opened,” Dr. Scardoelli said.

Some incidents are not reported by victims. And there are incidents that are reported only after many years have passed. This was the case with Nina Marqueti, the actress at the center of #OndeDói — “Where It Hurts” — a campaign that was launched to raise awareness about sexual violence committed by health care professionals. When she was 16, her pediatrician sexually abused her. It wasn’t until 2019, more than a decade later, that she felt able to make this accusation known publicly.

Almost immediately, the campaign received over 4,000 posts online. Most of them were people’s accounts of acts of violence committed by physicians during appointments in their offices or during treatment in a hospital. These are available on Twitter under the hashtag #ondedoi.
 

Inadequate sex education?

News reports about physicians who abuse patients have a tremendous impact on the public. People are genuinely surprised when they hear the words “health care professional” and “sex attack” in the same sentence. “One of the most disturbing aspects is that health care professionals are committing these acts of violence against women who are in a vulnerable state, typically when they’re under anesthesia, they’ve fallen ill, or when the health care professional introduces an element of deception into the procedure so as to create the opportunity to abuse the patient in some way,” said Dr. Drezett.

As Dr. Cohen sees it, to perpetrate these acts of sexual violence, physicians – as well as lawyers, religious leaders, judges, politicians, police officers, and other persons in a position of trust – make use of their power to take advantage of a person’s vulnerability. “Physicians, lawyers, police officers, religious leaders, dads, bosses, husbands – the people who commit sexual abuse all have something in common,” he said. “In terms of the emotional aspect, all of them are taking advantage of both the power that their position holds in society and the asymmetrical power dynamics that exist between them and the other person.”

Indeed, anyone who knocks on a physician’s door seeking a diagnosis or treatment, anyone who knocks on a lawyer’s door seeking assistance, is putting themselves in a fragile situation. “The abuser considers the other person an object, not a human being who has rights,” said Dr. Cohen. People who fit the psychological and behavioral profile of a sexual assailant find in these “powerful” professions and in the circumstances and opportunities these professions provide a means to fulfill their desires. In medicine, however, there is yet another imbalance, one involving consent to touch a person’s body.

The age of the recently arrested anesthesiologist is something that caught Dr. Cohen’s attention. As noted in one of his many books, Bioética e Sexualidade nas Relações Profissionais [Bioethics and Sexuality in Professional Relationships], published in 1999 by the São Paulo Medical Association, age is a characteristic that repeatedly came up in his analysis of 150 sexual abuse proceedings handled by Cremesp.

“When I looked over the cases, I saw that most of the abusers were not right out of med school in their twenties – a time when sex is at the forefront of one’s life – nor were the abusers on the older end of the age spectrum. The abusers were, in fact, those who had already had several years of experience – as was the case with this 32-year-old anesthesiologist who, at a particular moment in time, breached all prohibitions and betrayed the expectations that society had of him as a physician: to care for people’s well-being and to alleviate their suffering. There was nothing that could hold him back from fulfilling his desire, not even the presence of nurses and other physicians in the operating room.” As for the findings of Dr. Cohen’s review, the majority of the 150 cases were dismissed because of lack of evidence.

To Ms. Pedroso, who has treated more than 12,000 victims of sexual harassment, it’s the questioning and intimidation that women feel in relationship to the male physician – a person who is viewed as holding knowledge about her body – that leaves them vulnerable and more subject to acts of violence, especially in more remote places. “We’re speaking, yet again, about rape culture. Not many people know what that term means, but, generally speaking, it has to do with the objectification of women’s bodies and the issue of boys growing up thinking they have the right to touch girls and women and that they will go unpunished for doing so.”

The lack of sex education and efforts to prevent sexual abuse are contributing factors for why the situation remains unchanged. “We are long overdue. We live in a country where there’s this completely mistaken belief that talking about sex education involves teaching children how to have sex, as opposed to teaching them how to protect themselves. We teach girls that they have to protect themselves from being raped, but we don’t teach boys not to rape.”

Another point highlighted by Ms. Pedroso is the fact that to carry out their actions, sexual assailants seek out-of-the-way places, places where they believe the rules can be bent and where they won’t be caught. This is what may have happened with Dr. Bezerra. During a recent press conference, the coordinator of the Health Section of the Rio de Janeiro Public Defender’s Office, Thaísa Guerreiro, stated that although the Women’s Hospital in São João do Meriti – one of the places where the assailant worked as an anesthesiologist – had adopted protocols to protect patients, it failed to enforce them. Another observation was that the health care professionals normalized violations of a woman’s right to have a companion present throughout labor and delivery, a right guaranteed by federal law. Ms. Guerreiro went on to say that the hospital’s chief of anesthesia and the state’s health coordination office did not question this, nor did they find it strange or surprising. According to witness statements, Dr. Bezerra would ask the patients’ husbands to leave the room in the middle of the procedure.

It should be clarified, Dr. Drezett mentioned, that although obstetric violence and sexual abuse overlap in places, they do not have the same root cause or definition. “There are two sets of situations that we term ‘obstetric violence.’ One involves any type of disrespectful treatment, whether comments or neglect, during pregnancy, delivery, or the postpartum period. The other refers to health care professionals’ attitudes in imposing inadequate and outdated medical procedures at the time of birth, such as keeping the woman fasting, having her pubic hair removed, and inducing labor or speeding up the delivery with oxytocin and [routine] episiotomy, among other things.”
 

Early education crucial

How are health care institutions dealing with this problem? “Very poorly. Sexual violence perpetrated by physicians and other health care professionals is a taboo subject that people are still afraid to talk about,” Dr. Cohen observed. “Regrettably, sexual violence happens all too often. Before, maybe we weren’t talking about it much because, from our viewpoint, health care professionals, such as physicians and nurses, weren’t likely to commit acts of violence while performing their duties,” noted Dr. Drezett.

Dr. Drezett also spoke about schools and what role they can play. “Of course, schools should discuss violence against women, especially in the field of health care. This has been done for a long time now, though it’s not in every curriculum in every medical school or nursing school, nor in every school of social work or of psychology,” said Dr. Drezett. For example, in the bioethics classes taken in the third and fourth years of the University of São Paolo’s medical degree program, Dr. Cohen asks students to reflect on the significance of being in a position where you ask a patient you’ve never met to undress so you can perform an exam, and the patient promptly and readily complies. “This is not about the physician, it’s about the power of the institution,” the professor pointed out. Sexual violence is a problem on the university campus as well. Another front in the battle has formed across various schools, where groups of students have created feminist collectives to have sexual violence and other issues related to gender-based violence added to the agenda.

Dr. Drezett said it’s very unlikely that efforts made during a degree program are going to succeed in preventing students who are prone to commit sexual violence from engaging in such behavior. “We’re talking about gender-specific lessons, where discussions about gender-based violence should be started much, much earlier – parents talking to their children, teachers talking to their pupils.” He also doesn’t believe that the molesters are dissuaded by the fact that these accusations get publicized in the media. “If they were, the Roger Abdelmassih case would have done away with the problem.”

On the other hand, Dr. Drezett suggested, publicizing these stories can help to bring very positive issues out into the open. What the Bezerra case made clear was that laws were not followed and rights were not protected. An environment was thus created in which the sexual crime could be perpetrated, with nurses coming to suspect acts of obstetric violence, such as use of sedation, which prevented the woman from having skin-to-skin contact with the newborn and from breastfeeding within the first few hours of birth – two clinical practices that are recommended the world over.

“Health care professionals who act properly, in accordance with best practices for interacting with others and performing daily duties, at all times, in public or private practice – they remove themselves from situations like those described in the Bezerra case; they don’t practice medicine in a reckless manner,” said Dr. Drezett.

Another negative aspect of all this, he said, is that the suspicion and wariness that patients feel may spread far and wide. “Among my colleagues are anesthetists and anesthesiologists with impeccable ethical and professional records. They are very upset that people are now regarding them with doubt and uncertainty. We need to make it clear that those horrifying cases are the exceptions, not the rule,” he said. There is also a need to correct the misconception that such abuse is always in some way associated with obstetrics and gynecology.

“This is not true. These incidents can happen in any doctor’s office. It all depends on the physician – whether he or she has designs on committing a criminal act,” Dr. Drezett noted. He did point out that there are few sexual molesters among health care professionals, though there are numerous cases. Yet this in no way diminishes the seriousness of the incidents. “Of course, we’re speaking again about the exceptions, but in my experience of treating victims, I’ve seen, for example, more cases where it’s been a police officer, not a physician, committing an act of sexual violence against a woman,” he stated.

The nurses and nurse technicians at São João do Meriti Hospital who reported the abuser acted very assertively. If they hadn’t gathered the evidence to back up their accusations, it’s possible that the physician wouldn’t have been caught in the act and that the case would have taken a different course – including pressure being put on them and their becoming the target of retaliation.

A version of this article first appeared on Medscape.com. This article was translated from the Medscape Portuguese edition.

At the beginning of July, Brazilians across the country were appalled when they heard that an anesthesiologist was accused of sexually abusing a woman he had been treating during cesarean delivery. The incident was recorded on video by nurses and nurse technicians who, having become suspicious of the excessive amount of sedatives given to mothers-to-be by this particular anesthesiologist, decided to film him during a procedure. To do this, they made a last-minute change, switching delivery rooms to one in which they had hidden a cell phone in a cabinet.

What the footage showed was horrifying and the assailant, Giovanni Quintella Bezerra, was arrested on the spot. He’s a 32-year-old, White, successful physician, and he’s now accused of rape. The authorities are looking into whether there are more victims, others who may have been abused by the physician. The police are investigating about 40 surgeries in which Dr. Bezerra participated. That same month saw the arrest of another physician, gynecologist Ricardo Teles Martins, who was arrested after being accused of sexually harassing and abusing several women in Hidrolândia, in the northeastern state of Ceará.

In gathering information about these incidents, this news organization interviewed four Brazilian specialists to get their insights on the issues that have been brought to light by these recent cases and the factors that play a role in these kinds of criminal acts. Claudio Cohen, MD, PhD, is a psychiatrist, bioethicist, and professor at the University of São Paulo in Brazil. Daniela Pedroso, MA, is a psychologist who has 25 years’ experience working with victims of sexual violence. Gynecologist and obstetrician Jefferson Drezett, MD, PhD, is a professor in the field of population genetics and reproductive and sexual health at the Federal University of ABC, São Paulo, and in the department of health, life cycles, and society at the University of São Paulo School of Public Health. Maria Alice Scardoelli, MD, is a psychiatrist who also serves as vice-chair of the São Paulo Regional Council of Medicine (Cremesp).


 

Accusations and investigations

Not all incidents of sexual violence in health care institutions are reported, and precise numbers are difficult to obtain. The fact that there are any cases at all is troubling. In 2019, journalists from The Intercept found that over a period of 6 years (2014-2019), 1,734 such attacks were recorded in nine Brazilian states. They were able to get that information from the states’ Public Security Secretariats by using the Information Access Act, a law that regulates the right to access public information.

Efforts to determine how widespread this type of sexual violence is are further complicated by the difficulties in collating the accusations filed at each state’s regional council of medicine, police stations, and public prosecutor’s office. Which investigative steps are taken depends upon where the report was filed, and only occasionally do these entities communicate with each other. According to its data, Cremesp received 78 accusations in 2019. In 2020, that number increased to 84. In 2021, it was 83; these types of attacks were the seventh most common among the investigations opened that year. In the first 6 months of 2022, there were 36 complaints. The number includes investigations opened on the basis of press reports. In such cases, enough information must be available in the press reports make it possible to initiate an evaluation and assessment of the matter. There is no information about how many accusations became the subject of professional ethics proceedings and how many were formally adjudicated.

“Each accusation received is investigated by a technical committee made up of professionals from various specialties. There really needs to be a rigorous evaluation and assessment during the investigation. We cannot be unfair: It may turn out that there was no truth to the accusation after all, and yet someone’s career may already have been destroyed,” explained Dr. Scardoelli.

After the accusation is investigated and accepted by Cremesp, there is no deadline by which the proceedings must end. They can take up to 5 years, and sometimes longer. Since March, however, a deadline for the investigation period has been in effect, after which the proceedings can commence.

“We now have 90 days to make an evaluation and assessment in the investigation phase; that time period can be extended by 3 months, starting from the date the accusation is submitted to the council. If the case is accepted, then the proceedings are opened,” Dr. Scardoelli said.

Some incidents are not reported by victims. And there are incidents that are reported only after many years have passed. This was the case with Nina Marqueti, the actress at the center of #OndeDói — “Where It Hurts” — a campaign that was launched to raise awareness about sexual violence committed by health care professionals. When she was 16, her pediatrician sexually abused her. It wasn’t until 2019, more than a decade later, that she felt able to make this accusation known publicly.

Almost immediately, the campaign received over 4,000 posts online. Most of them were people’s accounts of acts of violence committed by physicians during appointments in their offices or during treatment in a hospital. These are available on Twitter under the hashtag #ondedoi.
 

Inadequate sex education?

News reports about physicians who abuse patients have a tremendous impact on the public. People are genuinely surprised when they hear the words “health care professional” and “sex attack” in the same sentence. “One of the most disturbing aspects is that health care professionals are committing these acts of violence against women who are in a vulnerable state, typically when they’re under anesthesia, they’ve fallen ill, or when the health care professional introduces an element of deception into the procedure so as to create the opportunity to abuse the patient in some way,” said Dr. Drezett.

As Dr. Cohen sees it, to perpetrate these acts of sexual violence, physicians – as well as lawyers, religious leaders, judges, politicians, police officers, and other persons in a position of trust – make use of their power to take advantage of a person’s vulnerability. “Physicians, lawyers, police officers, religious leaders, dads, bosses, husbands – the people who commit sexual abuse all have something in common,” he said. “In terms of the emotional aspect, all of them are taking advantage of both the power that their position holds in society and the asymmetrical power dynamics that exist between them and the other person.”

Indeed, anyone who knocks on a physician’s door seeking a diagnosis or treatment, anyone who knocks on a lawyer’s door seeking assistance, is putting themselves in a fragile situation. “The abuser considers the other person an object, not a human being who has rights,” said Dr. Cohen. People who fit the psychological and behavioral profile of a sexual assailant find in these “powerful” professions and in the circumstances and opportunities these professions provide a means to fulfill their desires. In medicine, however, there is yet another imbalance, one involving consent to touch a person’s body.

The age of the recently arrested anesthesiologist is something that caught Dr. Cohen’s attention. As noted in one of his many books, Bioética e Sexualidade nas Relações Profissionais [Bioethics and Sexuality in Professional Relationships], published in 1999 by the São Paulo Medical Association, age is a characteristic that repeatedly came up in his analysis of 150 sexual abuse proceedings handled by Cremesp.

“When I looked over the cases, I saw that most of the abusers were not right out of med school in their twenties – a time when sex is at the forefront of one’s life – nor were the abusers on the older end of the age spectrum. The abusers were, in fact, those who had already had several years of experience – as was the case with this 32-year-old anesthesiologist who, at a particular moment in time, breached all prohibitions and betrayed the expectations that society had of him as a physician: to care for people’s well-being and to alleviate their suffering. There was nothing that could hold him back from fulfilling his desire, not even the presence of nurses and other physicians in the operating room.” As for the findings of Dr. Cohen’s review, the majority of the 150 cases were dismissed because of lack of evidence.

To Ms. Pedroso, who has treated more than 12,000 victims of sexual harassment, it’s the questioning and intimidation that women feel in relationship to the male physician – a person who is viewed as holding knowledge about her body – that leaves them vulnerable and more subject to acts of violence, especially in more remote places. “We’re speaking, yet again, about rape culture. Not many people know what that term means, but, generally speaking, it has to do with the objectification of women’s bodies and the issue of boys growing up thinking they have the right to touch girls and women and that they will go unpunished for doing so.”

The lack of sex education and efforts to prevent sexual abuse are contributing factors for why the situation remains unchanged. “We are long overdue. We live in a country where there’s this completely mistaken belief that talking about sex education involves teaching children how to have sex, as opposed to teaching them how to protect themselves. We teach girls that they have to protect themselves from being raped, but we don’t teach boys not to rape.”

Another point highlighted by Ms. Pedroso is the fact that to carry out their actions, sexual assailants seek out-of-the-way places, places where they believe the rules can be bent and where they won’t be caught. This is what may have happened with Dr. Bezerra. During a recent press conference, the coordinator of the Health Section of the Rio de Janeiro Public Defender’s Office, Thaísa Guerreiro, stated that although the Women’s Hospital in São João do Meriti – one of the places where the assailant worked as an anesthesiologist – had adopted protocols to protect patients, it failed to enforce them. Another observation was that the health care professionals normalized violations of a woman’s right to have a companion present throughout labor and delivery, a right guaranteed by federal law. Ms. Guerreiro went on to say that the hospital’s chief of anesthesia and the state’s health coordination office did not question this, nor did they find it strange or surprising. According to witness statements, Dr. Bezerra would ask the patients’ husbands to leave the room in the middle of the procedure.

It should be clarified, Dr. Drezett mentioned, that although obstetric violence and sexual abuse overlap in places, they do not have the same root cause or definition. “There are two sets of situations that we term ‘obstetric violence.’ One involves any type of disrespectful treatment, whether comments or neglect, during pregnancy, delivery, or the postpartum period. The other refers to health care professionals’ attitudes in imposing inadequate and outdated medical procedures at the time of birth, such as keeping the woman fasting, having her pubic hair removed, and inducing labor or speeding up the delivery with oxytocin and [routine] episiotomy, among other things.”
 

Early education crucial

How are health care institutions dealing with this problem? “Very poorly. Sexual violence perpetrated by physicians and other health care professionals is a taboo subject that people are still afraid to talk about,” Dr. Cohen observed. “Regrettably, sexual violence happens all too often. Before, maybe we weren’t talking about it much because, from our viewpoint, health care professionals, such as physicians and nurses, weren’t likely to commit acts of violence while performing their duties,” noted Dr. Drezett.

Dr. Drezett also spoke about schools and what role they can play. “Of course, schools should discuss violence against women, especially in the field of health care. This has been done for a long time now, though it’s not in every curriculum in every medical school or nursing school, nor in every school of social work or of psychology,” said Dr. Drezett. For example, in the bioethics classes taken in the third and fourth years of the University of São Paolo’s medical degree program, Dr. Cohen asks students to reflect on the significance of being in a position where you ask a patient you’ve never met to undress so you can perform an exam, and the patient promptly and readily complies. “This is not about the physician, it’s about the power of the institution,” the professor pointed out. Sexual violence is a problem on the university campus as well. Another front in the battle has formed across various schools, where groups of students have created feminist collectives to have sexual violence and other issues related to gender-based violence added to the agenda.

Dr. Drezett said it’s very unlikely that efforts made during a degree program are going to succeed in preventing students who are prone to commit sexual violence from engaging in such behavior. “We’re talking about gender-specific lessons, where discussions about gender-based violence should be started much, much earlier – parents talking to their children, teachers talking to their pupils.” He also doesn’t believe that the molesters are dissuaded by the fact that these accusations get publicized in the media. “If they were, the Roger Abdelmassih case would have done away with the problem.”

On the other hand, Dr. Drezett suggested, publicizing these stories can help to bring very positive issues out into the open. What the Bezerra case made clear was that laws were not followed and rights were not protected. An environment was thus created in which the sexual crime could be perpetrated, with nurses coming to suspect acts of obstetric violence, such as use of sedation, which prevented the woman from having skin-to-skin contact with the newborn and from breastfeeding within the first few hours of birth – two clinical practices that are recommended the world over.

“Health care professionals who act properly, in accordance with best practices for interacting with others and performing daily duties, at all times, in public or private practice – they remove themselves from situations like those described in the Bezerra case; they don’t practice medicine in a reckless manner,” said Dr. Drezett.

Another negative aspect of all this, he said, is that the suspicion and wariness that patients feel may spread far and wide. “Among my colleagues are anesthetists and anesthesiologists with impeccable ethical and professional records. They are very upset that people are now regarding them with doubt and uncertainty. We need to make it clear that those horrifying cases are the exceptions, not the rule,” he said. There is also a need to correct the misconception that such abuse is always in some way associated with obstetrics and gynecology.

“This is not true. These incidents can happen in any doctor’s office. It all depends on the physician – whether he or she has designs on committing a criminal act,” Dr. Drezett noted. He did point out that there are few sexual molesters among health care professionals, though there are numerous cases. Yet this in no way diminishes the seriousness of the incidents. “Of course, we’re speaking again about the exceptions, but in my experience of treating victims, I’ve seen, for example, more cases where it’s been a police officer, not a physician, committing an act of sexual violence against a woman,” he stated.

The nurses and nurse technicians at São João do Meriti Hospital who reported the abuser acted very assertively. If they hadn’t gathered the evidence to back up their accusations, it’s possible that the physician wouldn’t have been caught in the act and that the case would have taken a different course – including pressure being put on them and their becoming the target of retaliation.

A version of this article first appeared on Medscape.com. This article was translated from the Medscape Portuguese edition.

At the beginning of July, Brazilians across the country were appalled when they heard that an anesthesiologist was accused of sexually abusing a woman he had been treating during cesarean delivery. The incident was recorded on video by nurses and nurse technicians who, having become suspicious of the excessive amount of sedatives given to mothers-to-be by this particular anesthesiologist, decided to film him during a procedure. To do this, they made a last-minute change, switching delivery rooms to one in which they had hidden a cell phone in a cabinet.

What the footage showed was horrifying and the assailant, Giovanni Quintella Bezerra, was arrested on the spot. He’s a 32-year-old, White, successful physician, and he’s now accused of rape. The authorities are looking into whether there are more victims, others who may have been abused by the physician. The police are investigating about 40 surgeries in which Dr. Bezerra participated. That same month saw the arrest of another physician, gynecologist Ricardo Teles Martins, who was arrested after being accused of sexually harassing and abusing several women in Hidrolândia, in the northeastern state of Ceará.

In gathering information about these incidents, this news organization interviewed four Brazilian specialists to get their insights on the issues that have been brought to light by these recent cases and the factors that play a role in these kinds of criminal acts. Claudio Cohen, MD, PhD, is a psychiatrist, bioethicist, and professor at the University of São Paulo in Brazil. Daniela Pedroso, MA, is a psychologist who has 25 years’ experience working with victims of sexual violence. Gynecologist and obstetrician Jefferson Drezett, MD, PhD, is a professor in the field of population genetics and reproductive and sexual health at the Federal University of ABC, São Paulo, and in the department of health, life cycles, and society at the University of São Paulo School of Public Health. Maria Alice Scardoelli, MD, is a psychiatrist who also serves as vice-chair of the São Paulo Regional Council of Medicine (Cremesp).


 

Accusations and investigations

Not all incidents of sexual violence in health care institutions are reported, and precise numbers are difficult to obtain. The fact that there are any cases at all is troubling. In 2019, journalists from The Intercept found that over a period of 6 years (2014-2019), 1,734 such attacks were recorded in nine Brazilian states. They were able to get that information from the states’ Public Security Secretariats by using the Information Access Act, a law that regulates the right to access public information.

Efforts to determine how widespread this type of sexual violence is are further complicated by the difficulties in collating the accusations filed at each state’s regional council of medicine, police stations, and public prosecutor’s office. Which investigative steps are taken depends upon where the report was filed, and only occasionally do these entities communicate with each other. According to its data, Cremesp received 78 accusations in 2019. In 2020, that number increased to 84. In 2021, it was 83; these types of attacks were the seventh most common among the investigations opened that year. In the first 6 months of 2022, there were 36 complaints. The number includes investigations opened on the basis of press reports. In such cases, enough information must be available in the press reports make it possible to initiate an evaluation and assessment of the matter. There is no information about how many accusations became the subject of professional ethics proceedings and how many were formally adjudicated.

“Each accusation received is investigated by a technical committee made up of professionals from various specialties. There really needs to be a rigorous evaluation and assessment during the investigation. We cannot be unfair: It may turn out that there was no truth to the accusation after all, and yet someone’s career may already have been destroyed,” explained Dr. Scardoelli.

After the accusation is investigated and accepted by Cremesp, there is no deadline by which the proceedings must end. They can take up to 5 years, and sometimes longer. Since March, however, a deadline for the investigation period has been in effect, after which the proceedings can commence.

“We now have 90 days to make an evaluation and assessment in the investigation phase; that time period can be extended by 3 months, starting from the date the accusation is submitted to the council. If the case is accepted, then the proceedings are opened,” Dr. Scardoelli said.

Some incidents are not reported by victims. And there are incidents that are reported only after many years have passed. This was the case with Nina Marqueti, the actress at the center of #OndeDói — “Where It Hurts” — a campaign that was launched to raise awareness about sexual violence committed by health care professionals. When she was 16, her pediatrician sexually abused her. It wasn’t until 2019, more than a decade later, that she felt able to make this accusation known publicly.

Almost immediately, the campaign received over 4,000 posts online. Most of them were people’s accounts of acts of violence committed by physicians during appointments in their offices or during treatment in a hospital. These are available on Twitter under the hashtag #ondedoi.
 

Inadequate sex education?

News reports about physicians who abuse patients have a tremendous impact on the public. People are genuinely surprised when they hear the words “health care professional” and “sex attack” in the same sentence. “One of the most disturbing aspects is that health care professionals are committing these acts of violence against women who are in a vulnerable state, typically when they’re under anesthesia, they’ve fallen ill, or when the health care professional introduces an element of deception into the procedure so as to create the opportunity to abuse the patient in some way,” said Dr. Drezett.

As Dr. Cohen sees it, to perpetrate these acts of sexual violence, physicians – as well as lawyers, religious leaders, judges, politicians, police officers, and other persons in a position of trust – make use of their power to take advantage of a person’s vulnerability. “Physicians, lawyers, police officers, religious leaders, dads, bosses, husbands – the people who commit sexual abuse all have something in common,” he said. “In terms of the emotional aspect, all of them are taking advantage of both the power that their position holds in society and the asymmetrical power dynamics that exist between them and the other person.”

Indeed, anyone who knocks on a physician’s door seeking a diagnosis or treatment, anyone who knocks on a lawyer’s door seeking assistance, is putting themselves in a fragile situation. “The abuser considers the other person an object, not a human being who has rights,” said Dr. Cohen. People who fit the psychological and behavioral profile of a sexual assailant find in these “powerful” professions and in the circumstances and opportunities these professions provide a means to fulfill their desires. In medicine, however, there is yet another imbalance, one involving consent to touch a person’s body.

The age of the recently arrested anesthesiologist is something that caught Dr. Cohen’s attention. As noted in one of his many books, Bioética e Sexualidade nas Relações Profissionais [Bioethics and Sexuality in Professional Relationships], published in 1999 by the São Paulo Medical Association, age is a characteristic that repeatedly came up in his analysis of 150 sexual abuse proceedings handled by Cremesp.

“When I looked over the cases, I saw that most of the abusers were not right out of med school in their twenties – a time when sex is at the forefront of one’s life – nor were the abusers on the older end of the age spectrum. The abusers were, in fact, those who had already had several years of experience – as was the case with this 32-year-old anesthesiologist who, at a particular moment in time, breached all prohibitions and betrayed the expectations that society had of him as a physician: to care for people’s well-being and to alleviate their suffering. There was nothing that could hold him back from fulfilling his desire, not even the presence of nurses and other physicians in the operating room.” As for the findings of Dr. Cohen’s review, the majority of the 150 cases were dismissed because of lack of evidence.

To Ms. Pedroso, who has treated more than 12,000 victims of sexual harassment, it’s the questioning and intimidation that women feel in relationship to the male physician – a person who is viewed as holding knowledge about her body – that leaves them vulnerable and more subject to acts of violence, especially in more remote places. “We’re speaking, yet again, about rape culture. Not many people know what that term means, but, generally speaking, it has to do with the objectification of women’s bodies and the issue of boys growing up thinking they have the right to touch girls and women and that they will go unpunished for doing so.”

The lack of sex education and efforts to prevent sexual abuse are contributing factors for why the situation remains unchanged. “We are long overdue. We live in a country where there’s this completely mistaken belief that talking about sex education involves teaching children how to have sex, as opposed to teaching them how to protect themselves. We teach girls that they have to protect themselves from being raped, but we don’t teach boys not to rape.”

Another point highlighted by Ms. Pedroso is the fact that to carry out their actions, sexual assailants seek out-of-the-way places, places where they believe the rules can be bent and where they won’t be caught. This is what may have happened with Dr. Bezerra. During a recent press conference, the coordinator of the Health Section of the Rio de Janeiro Public Defender’s Office, Thaísa Guerreiro, stated that although the Women’s Hospital in São João do Meriti – one of the places where the assailant worked as an anesthesiologist – had adopted protocols to protect patients, it failed to enforce them. Another observation was that the health care professionals normalized violations of a woman’s right to have a companion present throughout labor and delivery, a right guaranteed by federal law. Ms. Guerreiro went on to say that the hospital’s chief of anesthesia and the state’s health coordination office did not question this, nor did they find it strange or surprising. According to witness statements, Dr. Bezerra would ask the patients’ husbands to leave the room in the middle of the procedure.

It should be clarified, Dr. Drezett mentioned, that although obstetric violence and sexual abuse overlap in places, they do not have the same root cause or definition. “There are two sets of situations that we term ‘obstetric violence.’ One involves any type of disrespectful treatment, whether comments or neglect, during pregnancy, delivery, or the postpartum period. The other refers to health care professionals’ attitudes in imposing inadequate and outdated medical procedures at the time of birth, such as keeping the woman fasting, having her pubic hair removed, and inducing labor or speeding up the delivery with oxytocin and [routine] episiotomy, among other things.”
 

Early education crucial

How are health care institutions dealing with this problem? “Very poorly. Sexual violence perpetrated by physicians and other health care professionals is a taboo subject that people are still afraid to talk about,” Dr. Cohen observed. “Regrettably, sexual violence happens all too often. Before, maybe we weren’t talking about it much because, from our viewpoint, health care professionals, such as physicians and nurses, weren’t likely to commit acts of violence while performing their duties,” noted Dr. Drezett.

Dr. Drezett also spoke about schools and what role they can play. “Of course, schools should discuss violence against women, especially in the field of health care. This has been done for a long time now, though it’s not in every curriculum in every medical school or nursing school, nor in every school of social work or of psychology,” said Dr. Drezett. For example, in the bioethics classes taken in the third and fourth years of the University of São Paolo’s medical degree program, Dr. Cohen asks students to reflect on the significance of being in a position where you ask a patient you’ve never met to undress so you can perform an exam, and the patient promptly and readily complies. “This is not about the physician, it’s about the power of the institution,” the professor pointed out. Sexual violence is a problem on the university campus as well. Another front in the battle has formed across various schools, where groups of students have created feminist collectives to have sexual violence and other issues related to gender-based violence added to the agenda.

Dr. Drezett said it’s very unlikely that efforts made during a degree program are going to succeed in preventing students who are prone to commit sexual violence from engaging in such behavior. “We’re talking about gender-specific lessons, where discussions about gender-based violence should be started much, much earlier – parents talking to their children, teachers talking to their pupils.” He also doesn’t believe that the molesters are dissuaded by the fact that these accusations get publicized in the media. “If they were, the Roger Abdelmassih case would have done away with the problem.”

On the other hand, Dr. Drezett suggested, publicizing these stories can help to bring very positive issues out into the open. What the Bezerra case made clear was that laws were not followed and rights were not protected. An environment was thus created in which the sexual crime could be perpetrated, with nurses coming to suspect acts of obstetric violence, such as use of sedation, which prevented the woman from having skin-to-skin contact with the newborn and from breastfeeding within the first few hours of birth – two clinical practices that are recommended the world over.

“Health care professionals who act properly, in accordance with best practices for interacting with others and performing daily duties, at all times, in public or private practice – they remove themselves from situations like those described in the Bezerra case; they don’t practice medicine in a reckless manner,” said Dr. Drezett.

Another negative aspect of all this, he said, is that the suspicion and wariness that patients feel may spread far and wide. “Among my colleagues are anesthetists and anesthesiologists with impeccable ethical and professional records. They are very upset that people are now regarding them with doubt and uncertainty. We need to make it clear that those horrifying cases are the exceptions, not the rule,” he said. There is also a need to correct the misconception that such abuse is always in some way associated with obstetrics and gynecology.

“This is not true. These incidents can happen in any doctor’s office. It all depends on the physician – whether he or she has designs on committing a criminal act,” Dr. Drezett noted. He did point out that there are few sexual molesters among health care professionals, though there are numerous cases. Yet this in no way diminishes the seriousness of the incidents. “Of course, we’re speaking again about the exceptions, but in my experience of treating victims, I’ve seen, for example, more cases where it’s been a police officer, not a physician, committing an act of sexual violence against a woman,” he stated.

The nurses and nurse technicians at São João do Meriti Hospital who reported the abuser acted very assertively. If they hadn’t gathered the evidence to back up their accusations, it’s possible that the physician wouldn’t have been caught in the act and that the case would have taken a different course – including pressure being put on them and their becoming the target of retaliation.

A version of this article first appeared on Medscape.com. This article was translated from the Medscape Portuguese edition.

For the first time, patients with vitiligo who have long lived with patches of skin that are without pigment can now have even skin tones on their faces and other bodily regions with a Food and Drug Administration–approved, easy-to-use topical treatment.

In July, a cream formulation of ruxolitinib (Opzelura), a Janus kinase (JAK) inhibitor, became the first repigmentation treatment approved by the FDA for nonsegmental vitiligo, the most common form of the disease.

Topical ruxolitinib was first approved in September 2021 for atopic dermatitis, and dermatologists are already writing prescriptions for its new vitiligo indication.

“The FDA approval of ruxolitinib for repigmentation of vitiligo is historic and groundbreaking,” Seemal R. Desai, MD, a dermatologist at the University of Texas Southwestern Medical Center, Dallas, told this news organization.

The news brings hope to patients 12 years and older who suffer from the psychosocial effects of the disease, which is estimated to affect 1.9 million to 2.8 million adults in the United States.

The announcement followed FDA approval a month earlier of another dermatologic milestone – an oral JAK inhibitor, baricitinib, which became the first treatment for patients with alopecia areata.

For Dr. Desai, the ruxolitinib news is personal. His brother, also a physician, has lived a lifetime with vitiligo. His family experience, Dr. Desai said, showed him “what a disease like this can do to a person psychologically.”

Dr. Desai said his early exposure helped lead to his own decision to dedicate his career to pigmentary diseases.

His brother won’t personally benefit from the cream because his skin has been completely depigmented and repigmentation is not of interest to him, Dr. Desai said. But both brothers are excited as physicians. “It’s really quite an emotional moment,” he said.

Getting the news to patients

As dermatologists introduce the topical treatment to patients, common questions center on why this cream is different and whether it is safe.

David Rosmarin, MD, vice chair of research and education, department of dermatology, Tufts Medical Center, Boston, led the Topical Ruxolitinib Evaluation in Vitiligo Study 1 and 2 (TruE-V1, TruE-V2), conducted in North America and Europe.

He summarized some key findings.

“If patients have involvement on the face, trunk, or extremities, the data show that about half the patients at 52 weeks will get half or more of their pigment back,” he said in an interview. Results for the face alone are even better. “Half the patients will get 75% or more pigment back in the face,” Dr. Rosmarin said.

In addition, analysis of subgroups shows benefit for all patients. “Patients seem to respond similarly well across all subgroups – across gender, sex, age, ethnicity, and race,” Dr. Rosmarin said.

However, anatomic region matters, he pointed out. Skin of the head and neck responds the best, followed by skin of the trunk and extremities. The hands and feet are the most difficult to repigment because there are few hair follicles, which help enable repigmentation.

He added that it’s important to understand patients’ goals, and dermatologists shouldn’t assume that all who have vitiligo will want to undergo repigmentation. They may be interested in the new treatment but may not want it for themselves, he explained.

Explaining risks

Patients may ask about the boxed warning on the label that lists risk of heart attack, stroke, cancer, infections, blood clots, and death. Dermatologists can explain that the warning pertains to the whole JAK class and was based on patients with rheumatoid arthritis, Dr. Rosmarin said.

He added, “We didn’t see a signal for heart attack and stroke for patients using the topical. But it’s still important to discuss the label as the FDA states it.”

There are two main side effects, Dr. Rosmarin said: acne (about 6% of treated patients get it, and it’s usually mild) and application-site reactions. “Luckily, the medication has a tendency not to sting or burn, which is not the case with some of our other treatments. It’s very well tolerated,” he said.

Patients should also know that repigmentation can take time, because initially, the immune system is directed to calm down with treatment, and then pigment must travel back to the affected sites.

Some patients may have a response in as early as 2-3 months, and others need more time, Dr. Rosmarin said.

Treatment responses among adolescents have been particularly good. Responses regarding the skin of the face have been similar to those of adults. “However, on the body, they respond even better,” Dr. Rosmarin said. “About 60% achieve 50% or more repigmentation on the whole body.”

It’s important that ruxolitinib has been approved for persons aged 12 years and older, he said, because “about half the patients will develop vitiligo by the age of 20.”

Approval and insurance coverage

FDA approval will help with reimbursement for the expensive treatment.

The label indicates that patients should not use more than one 60-g tube a week. Currently, the out-of-pocket cost for one tube can be close to $2,000, according to GoodRx.

Raj Chovatiya, MD, PhD, assistant professor of dermatology and director of the Center for Eczema and Itch at Northwestern University, Chicago, said that in recent years, vitiligo patients, aware that their condition could be treated by JAK inhibitors, have been paying out of pocket at compounding pharmacies, which take oral versions of the medication and compound them into topical formulations.

Unlike baricitinib, which is used to treat severe alopecia areata, and other oral JAK inhibitors, testing for TB and hepatitis is not required for initiating treatment with ruxolitinib, so no delay is necessary, Dr. Chovatiya said.

He noted, however, that patients with vitiligo may have given up on effective care after experiencing little or no improvement with topical corticosteroids, phototherapy, or topical calcineurin inhibitors.

“They end up losing steam, are less motivated on therapy, and are lost to care,” he said.

Dermatologists, he said, may need to proactively find these patients and tell them the good news. “Now that we have really good targeted therapeutic options, it’s really up to us to figure out how to bring these people back to the clinic and educate them,” Dr. Chovatiya said.

Unanswered questions to address

Some questions are still unanswered, lead study author Dr. Rosmarin said.

Two big questions are how long people will need to continue using ruxolitinib cream and whether depigmentation will recur if people stop using it.

Another aspect of therapy being studied is whether the cream will be even more effective in combination with other treatments.

“The main combination we think about is ruxolitinib with phototherapy – a light treatment – because light could stimulate those pigment cells,” Dr. Rosmarin said,

He noted that light therapy was included in phase 2 testing and that patients did respond. “What we need and what’s planned is a larger study looking at the combination to see whether it is synergistic or not. The longer patients use the cream, the more benefit we see,” Dr. Rosmarin said.

Dr. Desai has served as an investigator and/or consultant to several companies, including Incyte. Dr. Rosmarin has received honoraria as a consultant and has received research support from Incyte, and has served as a paid speaker for Incyte, as well as other companies.. Dr. Chovatiya has served as an advisory board member, consultant, and/or investigator for companies that include Incyte.

For the first time, patients with vitiligo who have long lived with patches of skin that are without pigment can now have even skin tones on their faces and other bodily regions with a Food and Drug Administration–approved, easy-to-use topical treatment.

In July, a cream formulation of ruxolitinib (Opzelura), a Janus kinase (JAK) inhibitor, became the first repigmentation treatment approved by the FDA for nonsegmental vitiligo, the most common form of the disease.

Topical ruxolitinib was first approved in September 2021 for atopic dermatitis, and dermatologists are already writing prescriptions for its new vitiligo indication.

“The FDA approval of ruxolitinib for repigmentation of vitiligo is historic and groundbreaking,” Seemal R. Desai, MD, a dermatologist at the University of Texas Southwestern Medical Center, Dallas, told this news organization.

The news brings hope to patients 12 years and older who suffer from the psychosocial effects of the disease, which is estimated to affect 1.9 million to 2.8 million adults in the United States.

The announcement followed FDA approval a month earlier of another dermatologic milestone – an oral JAK inhibitor, baricitinib, which became the first treatment for patients with alopecia areata.

For Dr. Desai, the ruxolitinib news is personal. His brother, also a physician, has lived a lifetime with vitiligo. His family experience, Dr. Desai said, showed him “what a disease like this can do to a person psychologically.”

Dr. Desai said his early exposure helped lead to his own decision to dedicate his career to pigmentary diseases.

His brother won’t personally benefit from the cream because his skin has been completely depigmented and repigmentation is not of interest to him, Dr. Desai said. But both brothers are excited as physicians. “It’s really quite an emotional moment,” he said.

Getting the news to patients

As dermatologists introduce the topical treatment to patients, common questions center on why this cream is different and whether it is safe.

David Rosmarin, MD, vice chair of research and education, department of dermatology, Tufts Medical Center, Boston, led the Topical Ruxolitinib Evaluation in Vitiligo Study 1 and 2 (TruE-V1, TruE-V2), conducted in North America and Europe.

He summarized some key findings.

“If patients have involvement on the face, trunk, or extremities, the data show that about half the patients at 52 weeks will get half or more of their pigment back,” he said in an interview. Results for the face alone are even better. “Half the patients will get 75% or more pigment back in the face,” Dr. Rosmarin said.

In addition, analysis of subgroups shows benefit for all patients. “Patients seem to respond similarly well across all subgroups – across gender, sex, age, ethnicity, and race,” Dr. Rosmarin said.

However, anatomic region matters, he pointed out. Skin of the head and neck responds the best, followed by skin of the trunk and extremities. The hands and feet are the most difficult to repigment because there are few hair follicles, which help enable repigmentation.

He added that it’s important to understand patients’ goals, and dermatologists shouldn’t assume that all who have vitiligo will want to undergo repigmentation. They may be interested in the new treatment but may not want it for themselves, he explained.

Explaining risks

Patients may ask about the boxed warning on the label that lists risk of heart attack, stroke, cancer, infections, blood clots, and death. Dermatologists can explain that the warning pertains to the whole JAK class and was based on patients with rheumatoid arthritis, Dr. Rosmarin said.

He added, “We didn’t see a signal for heart attack and stroke for patients using the topical. But it’s still important to discuss the label as the FDA states it.”

There are two main side effects, Dr. Rosmarin said: acne (about 6% of treated patients get it, and it’s usually mild) and application-site reactions. “Luckily, the medication has a tendency not to sting or burn, which is not the case with some of our other treatments. It’s very well tolerated,” he said.

Patients should also know that repigmentation can take time, because initially, the immune system is directed to calm down with treatment, and then pigment must travel back to the affected sites.

Some patients may have a response in as early as 2-3 months, and others need more time, Dr. Rosmarin said.

Treatment responses among adolescents have been particularly good. Responses regarding the skin of the face have been similar to those of adults. “However, on the body, they respond even better,” Dr. Rosmarin said. “About 60% achieve 50% or more repigmentation on the whole body.”

It’s important that ruxolitinib has been approved for persons aged 12 years and older, he said, because “about half the patients will develop vitiligo by the age of 20.”

Approval and insurance coverage

FDA approval will help with reimbursement for the expensive treatment.

The label indicates that patients should not use more than one 60-g tube a week. Currently, the out-of-pocket cost for one tube can be close to $2,000, according to GoodRx.

Raj Chovatiya, MD, PhD, assistant professor of dermatology and director of the Center for Eczema and Itch at Northwestern University, Chicago, said that in recent years, vitiligo patients, aware that their condition could be treated by JAK inhibitors, have been paying out of pocket at compounding pharmacies, which take oral versions of the medication and compound them into topical formulations.

Unlike baricitinib, which is used to treat severe alopecia areata, and other oral JAK inhibitors, testing for TB and hepatitis is not required for initiating treatment with ruxolitinib, so no delay is necessary, Dr. Chovatiya said.

He noted, however, that patients with vitiligo may have given up on effective care after experiencing little or no improvement with topical corticosteroids, phototherapy, or topical calcineurin inhibitors.

“They end up losing steam, are less motivated on therapy, and are lost to care,” he said.

Dermatologists, he said, may need to proactively find these patients and tell them the good news. “Now that we have really good targeted therapeutic options, it’s really up to us to figure out how to bring these people back to the clinic and educate them,” Dr. Chovatiya said.

Unanswered questions to address

Some questions are still unanswered, lead study author Dr. Rosmarin said.

Two big questions are how long people will need to continue using ruxolitinib cream and whether depigmentation will recur if people stop using it.

Another aspect of therapy being studied is whether the cream will be even more effective in combination with other treatments.

“The main combination we think about is ruxolitinib with phototherapy – a light treatment – because light could stimulate those pigment cells,” Dr. Rosmarin said,

He noted that light therapy was included in phase 2 testing and that patients did respond. “What we need and what’s planned is a larger study looking at the combination to see whether it is synergistic or not. The longer patients use the cream, the more benefit we see,” Dr. Rosmarin said.

Dr. Desai has served as an investigator and/or consultant to several companies, including Incyte. Dr. Rosmarin has received honoraria as a consultant and has received research support from Incyte, and has served as a paid speaker for Incyte, as well as other companies.. Dr. Chovatiya has served as an advisory board member, consultant, and/or investigator for companies that include Incyte.

For the first time, patients with vitiligo who have long lived with patches of skin that are without pigment can now have even skin tones on their faces and other bodily regions with a Food and Drug Administration–approved, easy-to-use topical treatment.

In July, a cream formulation of ruxolitinib (Opzelura), a Janus kinase (JAK) inhibitor, became the first repigmentation treatment approved by the FDA for nonsegmental vitiligo, the most common form of the disease.

Topical ruxolitinib was first approved in September 2021 for atopic dermatitis, and dermatologists are already writing prescriptions for its new vitiligo indication.

“The FDA approval of ruxolitinib for repigmentation of vitiligo is historic and groundbreaking,” Seemal R. Desai, MD, a dermatologist at the University of Texas Southwestern Medical Center, Dallas, told this news organization.

The news brings hope to patients 12 years and older who suffer from the psychosocial effects of the disease, which is estimated to affect 1.9 million to 2.8 million adults in the United States.

The announcement followed FDA approval a month earlier of another dermatologic milestone – an oral JAK inhibitor, baricitinib, which became the first treatment for patients with alopecia areata.

For Dr. Desai, the ruxolitinib news is personal. His brother, also a physician, has lived a lifetime with vitiligo. His family experience, Dr. Desai said, showed him “what a disease like this can do to a person psychologically.”

Dr. Desai said his early exposure helped lead to his own decision to dedicate his career to pigmentary diseases.

His brother won’t personally benefit from the cream because his skin has been completely depigmented and repigmentation is not of interest to him, Dr. Desai said. But both brothers are excited as physicians. “It’s really quite an emotional moment,” he said.

Getting the news to patients

As dermatologists introduce the topical treatment to patients, common questions center on why this cream is different and whether it is safe.

David Rosmarin, MD, vice chair of research and education, department of dermatology, Tufts Medical Center, Boston, led the Topical Ruxolitinib Evaluation in Vitiligo Study 1 and 2 (TruE-V1, TruE-V2), conducted in North America and Europe.

He summarized some key findings.

“If patients have involvement on the face, trunk, or extremities, the data show that about half the patients at 52 weeks will get half or more of their pigment back,” he said in an interview. Results for the face alone are even better. “Half the patients will get 75% or more pigment back in the face,” Dr. Rosmarin said.

In addition, analysis of subgroups shows benefit for all patients. “Patients seem to respond similarly well across all subgroups – across gender, sex, age, ethnicity, and race,” Dr. Rosmarin said.

However, anatomic region matters, he pointed out. Skin of the head and neck responds the best, followed by skin of the trunk and extremities. The hands and feet are the most difficult to repigment because there are few hair follicles, which help enable repigmentation.

He added that it’s important to understand patients’ goals, and dermatologists shouldn’t assume that all who have vitiligo will want to undergo repigmentation. They may be interested in the new treatment but may not want it for themselves, he explained.

Explaining risks

Patients may ask about the boxed warning on the label that lists risk of heart attack, stroke, cancer, infections, blood clots, and death. Dermatologists can explain that the warning pertains to the whole JAK class and was based on patients with rheumatoid arthritis, Dr. Rosmarin said.

He added, “We didn’t see a signal for heart attack and stroke for patients using the topical. But it’s still important to discuss the label as the FDA states it.”

There are two main side effects, Dr. Rosmarin said: acne (about 6% of treated patients get it, and it’s usually mild) and application-site reactions. “Luckily, the medication has a tendency not to sting or burn, which is not the case with some of our other treatments. It’s very well tolerated,” he said.

Patients should also know that repigmentation can take time, because initially, the immune system is directed to calm down with treatment, and then pigment must travel back to the affected sites.

Some patients may have a response in as early as 2-3 months, and others need more time, Dr. Rosmarin said.

Treatment responses among adolescents have been particularly good. Responses regarding the skin of the face have been similar to those of adults. “However, on the body, they respond even better,” Dr. Rosmarin said. “About 60% achieve 50% or more repigmentation on the whole body.”

It’s important that ruxolitinib has been approved for persons aged 12 years and older, he said, because “about half the patients will develop vitiligo by the age of 20.”

Approval and insurance coverage

FDA approval will help with reimbursement for the expensive treatment.

The label indicates that patients should not use more than one 60-g tube a week. Currently, the out-of-pocket cost for one tube can be close to $2,000, according to GoodRx.

Raj Chovatiya, MD, PhD, assistant professor of dermatology and director of the Center for Eczema and Itch at Northwestern University, Chicago, said that in recent years, vitiligo patients, aware that their condition could be treated by JAK inhibitors, have been paying out of pocket at compounding pharmacies, which take oral versions of the medication and compound them into topical formulations.

Unlike baricitinib, which is used to treat severe alopecia areata, and other oral JAK inhibitors, testing for TB and hepatitis is not required for initiating treatment with ruxolitinib, so no delay is necessary, Dr. Chovatiya said.

He noted, however, that patients with vitiligo may have given up on effective care after experiencing little or no improvement with topical corticosteroids, phototherapy, or topical calcineurin inhibitors.

“They end up losing steam, are less motivated on therapy, and are lost to care,” he said.

Dermatologists, he said, may need to proactively find these patients and tell them the good news. “Now that we have really good targeted therapeutic options, it’s really up to us to figure out how to bring these people back to the clinic and educate them,” Dr. Chovatiya said.

Unanswered questions to address

Some questions are still unanswered, lead study author Dr. Rosmarin said.

Two big questions are how long people will need to continue using ruxolitinib cream and whether depigmentation will recur if people stop using it.

Another aspect of therapy being studied is whether the cream will be even more effective in combination with other treatments.

“The main combination we think about is ruxolitinib with phototherapy – a light treatment – because light could stimulate those pigment cells,” Dr. Rosmarin said,

He noted that light therapy was included in phase 2 testing and that patients did respond. “What we need and what’s planned is a larger study looking at the combination to see whether it is synergistic or not. The longer patients use the cream, the more benefit we see,” Dr. Rosmarin said.

Dr. Desai has served as an investigator and/or consultant to several companies, including Incyte. Dr. Rosmarin has received honoraria as a consultant and has received research support from Incyte, and has served as a paid speaker for Incyte, as well as other companies.. Dr. Chovatiya has served as an advisory board member, consultant, and/or investigator for companies that include Incyte.

Primary care physicians should consider referring patients with lower back pain (LBP) to physical therapists to avoid later high-cost and potentially unnecessary care, suggests new research.

The study found that patients who were referred to physical therapists within 2 weeks of seeing their physicians for LBP were significantly less likely to make visits to a chiropractor, pain specialist, or orthopedist.

Patients also filed fewer claims for advanced imaging or epidural steroid injections and were half as likely to visit an emergency department (ED) within 30 days compared with those who did not start early physical therapy (PT), according to the study, published in BMC Health Services Research.

“Some lower back pain resolves itself, but often, that recovery is incomplete, leading to increased health care and opioid use,” said Richard L. Skolasky Jr., ScD, director of the Spine Outcomes Research Center at Johns Hopkins Medicine, Baltimore, and a coauthor of the study. “Our hope is this study helps more primary care physicians embrace nonpharmacologic, first-line treatments.”

LBP accounts for an estimated $1.8 billion annually in health care costs among the patients who do not receive surgery for the condition, according to a 2019 JAMA analysis of commercial insurance and Medicare claims. In addition, LBP accounts for approximately 2.7 million ED visits annually, a 2010 study published in Spine showed.

Dr. Skolasky and his colleagues assessed 980,000 outpatient claims over a period of almost 4 years that ended in 2014. The researchers used Truven MarketScan, a group of U.S.-based administrative commercial health care insurance claims databases. Patients who had a history of conditions that cause LBP, such as endometriosis and spinal fracture, were excluded from the analysis. Approximately 11% of patients in the total sample received early PT, defined as PT received within 2 weeks of their initial visit to a primary care clinician.

After adjustment for sex, age, and Charlson Morbidity Index, patients who received PT were about half as likely as were those who didn’t to see chiropractor or a pain specialist or have an ED visit within 30 days of their initial appointment. They were about one-third as likely to receive an epidural steroid injection, and they were 43% less likely to have claims for advanced imaging, according to the researchers (P < .001 for all).

In addition, the cost of claims was lower for patients who received early PT ($747 vs. $799), the researchers found.

The effects diminished somewhat over time but remained statistically significant.

At 1 year, patients who received early PT had slightly higher health care costs than did those who did not undergo PT ($2,588 vs. $2,510). Dr. Skolasky hypothesized that the increase was attributable to therapy visits and not having as many specialist visits. He said additional research could investigate whether early PT reduces the health care costs associated with LBP over a longer period.

“Physical therapy addresses a patient’s current pain and physical limitations and arms them with resources, exercises, and nonpharmacologic ways to deal with recurrences,” Dr. Skolasky said in an interview. “If we can follow patients even longer than a year, we may see a longer-term reduction in cost.”

Michael Knight, MD, associate chief quality and population health officer at George Washington University Medical Faculty Associates, Washington, said he refers patients to physical therapists if their pain has not resolved within 2 weeks of stretching at home and taking over-the-counter analgesics.

Dr. Knight recalled one patient who had strained her back doing yard work. When home exercises did not help, Dr. Knight referred her to a physical therapist, who created a customized treatment plan. Within 4 weeks, her condition had improved.

“She was then able to take what she learned and continue those exercises at home,” Dr. Knight said. “She got better, and we avoided MRI costs for her and the health care system.”

Dr. Skolasky and his fellow researchers found significant regional differences in the number of patients referred for early PT. The odds of PT utilization within 90 days after the onset of LBP were 1.6 times higher in the Northeast and 0.82 times lower in the South.

“There are health care deserts,” Dr. Skolasky said. “This study should spark a conversation about the inadequacy of distribution of physical resources to meet the needs of patients with LBP.”

Dr. Skolasky said telehealth could be one option for serving patients in these health care deserts – including those with LBP. He has conducted several studies that concluded that patients benefit from and are happy with telehealth PT.

Dr. Knight said Dr. Skolasky’s study will help patients better understand their options.

“Sometimes patients have an expectation – they want an MRI or pain medication when it’s not necessary,” he said. “This kind of evidence helps strengthen our recommendation for early intervention that really can help.”

The study was supported by a grant from the National Institutes of Health’s National Institute on Aging. Dr. Skolasky reports no relevant financial relationships.

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

Primary care physicians should consider referring patients with lower back pain (LBP) to physical therapists to avoid later high-cost and potentially unnecessary care, suggests new research.

The study found that patients who were referred to physical therapists within 2 weeks of seeing their physicians for LBP were significantly less likely to make visits to a chiropractor, pain specialist, or orthopedist.

Patients also filed fewer claims for advanced imaging or epidural steroid injections and were half as likely to visit an emergency department (ED) within 30 days compared with those who did not start early physical therapy (PT), according to the study, published in BMC Health Services Research.

“Some lower back pain resolves itself, but often, that recovery is incomplete, leading to increased health care and opioid use,” said Richard L. Skolasky Jr., ScD, director of the Spine Outcomes Research Center at Johns Hopkins Medicine, Baltimore, and a coauthor of the study. “Our hope is this study helps more primary care physicians embrace nonpharmacologic, first-line treatments.”

LBP accounts for an estimated $1.8 billion annually in health care costs among the patients who do not receive surgery for the condition, according to a 2019 JAMA analysis of commercial insurance and Medicare claims. In addition, LBP accounts for approximately 2.7 million ED visits annually, a 2010 study published in Spine showed.

Dr. Skolasky and his colleagues assessed 980,000 outpatient claims over a period of almost 4 years that ended in 2014. The researchers used Truven MarketScan, a group of U.S.-based administrative commercial health care insurance claims databases. Patients who had a history of conditions that cause LBP, such as endometriosis and spinal fracture, were excluded from the analysis. Approximately 11% of patients in the total sample received early PT, defined as PT received within 2 weeks of their initial visit to a primary care clinician.

After adjustment for sex, age, and Charlson Morbidity Index, patients who received PT were about half as likely as were those who didn’t to see chiropractor or a pain specialist or have an ED visit within 30 days of their initial appointment. They were about one-third as likely to receive an epidural steroid injection, and they were 43% less likely to have claims for advanced imaging, according to the researchers (P < .001 for all).

In addition, the cost of claims was lower for patients who received early PT ($747 vs. $799), the researchers found.

The effects diminished somewhat over time but remained statistically significant.

At 1 year, patients who received early PT had slightly higher health care costs than did those who did not undergo PT ($2,588 vs. $2,510). Dr. Skolasky hypothesized that the increase was attributable to therapy visits and not having as many specialist visits. He said additional research could investigate whether early PT reduces the health care costs associated with LBP over a longer period.

“Physical therapy addresses a patient’s current pain and physical limitations and arms them with resources, exercises, and nonpharmacologic ways to deal with recurrences,” Dr. Skolasky said in an interview. “If we can follow patients even longer than a year, we may see a longer-term reduction in cost.”

Michael Knight, MD, associate chief quality and population health officer at George Washington University Medical Faculty Associates, Washington, said he refers patients to physical therapists if their pain has not resolved within 2 weeks of stretching at home and taking over-the-counter analgesics.

Dr. Knight recalled one patient who had strained her back doing yard work. When home exercises did not help, Dr. Knight referred her to a physical therapist, who created a customized treatment plan. Within 4 weeks, her condition had improved.

“She was then able to take what she learned and continue those exercises at home,” Dr. Knight said. “She got better, and we avoided MRI costs for her and the health care system.”

Dr. Skolasky and his fellow researchers found significant regional differences in the number of patients referred for early PT. The odds of PT utilization within 90 days after the onset of LBP were 1.6 times higher in the Northeast and 0.82 times lower in the South.

“There are health care deserts,” Dr. Skolasky said. “This study should spark a conversation about the inadequacy of distribution of physical resources to meet the needs of patients with LBP.”

Dr. Skolasky said telehealth could be one option for serving patients in these health care deserts – including those with LBP. He has conducted several studies that concluded that patients benefit from and are happy with telehealth PT.

Dr. Knight said Dr. Skolasky’s study will help patients better understand their options.

“Sometimes patients have an expectation – they want an MRI or pain medication when it’s not necessary,” he said. “This kind of evidence helps strengthen our recommendation for early intervention that really can help.”

The study was supported by a grant from the National Institutes of Health’s National Institute on Aging. Dr. Skolasky reports no relevant financial relationships.

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

Primary care physicians should consider referring patients with lower back pain (LBP) to physical therapists to avoid later high-cost and potentially unnecessary care, suggests new research.

The study found that patients who were referred to physical therapists within 2 weeks of seeing their physicians for LBP were significantly less likely to make visits to a chiropractor, pain specialist, or orthopedist.

Patients also filed fewer claims for advanced imaging or epidural steroid injections and were half as likely to visit an emergency department (ED) within 30 days compared with those who did not start early physical therapy (PT), according to the study, published in BMC Health Services Research.

“Some lower back pain resolves itself, but often, that recovery is incomplete, leading to increased health care and opioid use,” said Richard L. Skolasky Jr., ScD, director of the Spine Outcomes Research Center at Johns Hopkins Medicine, Baltimore, and a coauthor of the study. “Our hope is this study helps more primary care physicians embrace nonpharmacologic, first-line treatments.”

LBP accounts for an estimated $1.8 billion annually in health care costs among the patients who do not receive surgery for the condition, according to a 2019 JAMA analysis of commercial insurance and Medicare claims. In addition, LBP accounts for approximately 2.7 million ED visits annually, a 2010 study published in Spine showed.

Dr. Skolasky and his colleagues assessed 980,000 outpatient claims over a period of almost 4 years that ended in 2014. The researchers used Truven MarketScan, a group of U.S.-based administrative commercial health care insurance claims databases. Patients who had a history of conditions that cause LBP, such as endometriosis and spinal fracture, were excluded from the analysis. Approximately 11% of patients in the total sample received early PT, defined as PT received within 2 weeks of their initial visit to a primary care clinician.

After adjustment for sex, age, and Charlson Morbidity Index, patients who received PT were about half as likely as were those who didn’t to see chiropractor or a pain specialist or have an ED visit within 30 days of their initial appointment. They were about one-third as likely to receive an epidural steroid injection, and they were 43% less likely to have claims for advanced imaging, according to the researchers (P < .001 for all).

In addition, the cost of claims was lower for patients who received early PT ($747 vs. $799), the researchers found.

The effects diminished somewhat over time but remained statistically significant.

At 1 year, patients who received early PT had slightly higher health care costs than did those who did not undergo PT ($2,588 vs. $2,510). Dr. Skolasky hypothesized that the increase was attributable to therapy visits and not having as many specialist visits. He said additional research could investigate whether early PT reduces the health care costs associated with LBP over a longer period.

“Physical therapy addresses a patient’s current pain and physical limitations and arms them with resources, exercises, and nonpharmacologic ways to deal with recurrences,” Dr. Skolasky said in an interview. “If we can follow patients even longer than a year, we may see a longer-term reduction in cost.”

Michael Knight, MD, associate chief quality and population health officer at George Washington University Medical Faculty Associates, Washington, said he refers patients to physical therapists if their pain has not resolved within 2 weeks of stretching at home and taking over-the-counter analgesics.

Dr. Knight recalled one patient who had strained her back doing yard work. When home exercises did not help, Dr. Knight referred her to a physical therapist, who created a customized treatment plan. Within 4 weeks, her condition had improved.

“She was then able to take what she learned and continue those exercises at home,” Dr. Knight said. “She got better, and we avoided MRI costs for her and the health care system.”

Dr. Skolasky and his fellow researchers found significant regional differences in the number of patients referred for early PT. The odds of PT utilization within 90 days after the onset of LBP were 1.6 times higher in the Northeast and 0.82 times lower in the South.

“There are health care deserts,” Dr. Skolasky said. “This study should spark a conversation about the inadequacy of distribution of physical resources to meet the needs of patients with LBP.”

Dr. Skolasky said telehealth could be one option for serving patients in these health care deserts – including those with LBP. He has conducted several studies that concluded that patients benefit from and are happy with telehealth PT.

Dr. Knight said Dr. Skolasky’s study will help patients better understand their options.

“Sometimes patients have an expectation – they want an MRI or pain medication when it’s not necessary,” he said. “This kind of evidence helps strengthen our recommendation for early intervention that really can help.”

The study was supported by a grant from the National Institutes of Health’s National Institute on Aging. Dr. Skolasky reports no relevant financial relationships.

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

Managing type 1 diabetes is never easy. But if you ask 16-year-old climbing star Katie Bone, she’ll tell you that she will never let this disease get in the way of her goals.

“My motto is the same one as Bethany Hamilton’s – the surfer who lost her arm in a shark attack: ‘I don’t need easy, I just need possible,” said Ms. Bone, who lives in Albuquerque and has been a competitive rock climber since she was 8 years old. “That really stuck with me.”

Just watching her compete on NBC’s hit reality show American Ninja Warrior in June is proof of that. Not only did the nationally ranked climber fly through the obstacles with grace and grit, but she proudly showed off her two monitoring devices: a glucose monitor on one arm and a tubeless insulin pump on the other.

“I specifically decided to keep my devices visible when I went on the show,” she said. “It’s part of my life, and I wanted to show that I’m not ashamed to wear medical devices.”

Still, it has been a long journey since Bone was diagnosed in 2017. She was just 11 years old at the time and had recently done a climbing competition when she started feeling ill.

“I didn’t perform well,” she said. “I needed to go to the bathroom a lot and felt really nauseous. Three days later, we ended up in urgent care.”

When her doctor first told her she had diabetes, she started crying.

“My grandma had type 1 and was extremely sick and died from complications,” she said. “That was all I knew about diabetes, and it was scary to think my life could be like that.”

But her outlook brightened when her doctor assured her that she could keep climbing.

“When I was told that I could keep competing, a switch flipped for me and I made a decision that nothing would hold me back,” she says.

But every day isn’t easy.

“It’s sometimes really hard to manage my diabetes during competitions,” she said. “When we climb, for example, we’re not allowed to have our phones, and I manage my [glucose monitor] through my phone. This means accommodations have to be made for me.”

And managing her diabetes can be unpredictable at times.

“If my blood sugar is low or high, I might be put last in a competition,” she said. “That messes up my warm-up and my mental game. It’s a never-ending battle.”

Ultimately, Ms. Bone’s goal is to inspire others and advocate for diabetes awareness. She says she’s been overwhelmed by viewer responses to her appearance on the show.

“I heard from so many parents and kids,” she said. “I want the world to know that wearing a pump on your arm only makes you more amazing.”

She also draws inspiration from others with diabetes.

“Everyone with this disease is a role model for me, since everyone is fighting their own battles,” she said. “Diabetes is different for everyone, and seeing how people can do what they do despite the diagnosis has been incredibly inspiring.”

For now, the rising high school junior plans to continue training and competing.

“My goal is to make the 2024 Olympic climbing team in Paris,” she said. “I’ve always wanted to compete in the Olympics since I was a little kid. Nothing can stop me.”

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

Managing type 1 diabetes is never easy. But if you ask 16-year-old climbing star Katie Bone, she’ll tell you that she will never let this disease get in the way of her goals.

“My motto is the same one as Bethany Hamilton’s – the surfer who lost her arm in a shark attack: ‘I don’t need easy, I just need possible,” said Ms. Bone, who lives in Albuquerque and has been a competitive rock climber since she was 8 years old. “That really stuck with me.”

Just watching her compete on NBC’s hit reality show American Ninja Warrior in June is proof of that. Not only did the nationally ranked climber fly through the obstacles with grace and grit, but she proudly showed off her two monitoring devices: a glucose monitor on one arm and a tubeless insulin pump on the other.

“I specifically decided to keep my devices visible when I went on the show,” she said. “It’s part of my life, and I wanted to show that I’m not ashamed to wear medical devices.”

Still, it has been a long journey since Bone was diagnosed in 2017. She was just 11 years old at the time and had recently done a climbing competition when she started feeling ill.

“I didn’t perform well,” she said. “I needed to go to the bathroom a lot and felt really nauseous. Three days later, we ended up in urgent care.”

When her doctor first told her she had diabetes, she started crying.

“My grandma had type 1 and was extremely sick and died from complications,” she said. “That was all I knew about diabetes, and it was scary to think my life could be like that.”

But her outlook brightened when her doctor assured her that she could keep climbing.

“When I was told that I could keep competing, a switch flipped for me and I made a decision that nothing would hold me back,” she says.

But every day isn’t easy.

“It’s sometimes really hard to manage my diabetes during competitions,” she said. “When we climb, for example, we’re not allowed to have our phones, and I manage my [glucose monitor] through my phone. This means accommodations have to be made for me.”

And managing her diabetes can be unpredictable at times.

“If my blood sugar is low or high, I might be put last in a competition,” she said. “That messes up my warm-up and my mental game. It’s a never-ending battle.”

Ultimately, Ms. Bone’s goal is to inspire others and advocate for diabetes awareness. She says she’s been overwhelmed by viewer responses to her appearance on the show.

“I heard from so many parents and kids,” she said. “I want the world to know that wearing a pump on your arm only makes you more amazing.”

She also draws inspiration from others with diabetes.

“Everyone with this disease is a role model for me, since everyone is fighting their own battles,” she said. “Diabetes is different for everyone, and seeing how people can do what they do despite the diagnosis has been incredibly inspiring.”

For now, the rising high school junior plans to continue training and competing.

“My goal is to make the 2024 Olympic climbing team in Paris,” she said. “I’ve always wanted to compete in the Olympics since I was a little kid. Nothing can stop me.”

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

Managing type 1 diabetes is never easy. But if you ask 16-year-old climbing star Katie Bone, she’ll tell you that she will never let this disease get in the way of her goals.

“My motto is the same one as Bethany Hamilton’s – the surfer who lost her arm in a shark attack: ‘I don’t need easy, I just need possible,” said Ms. Bone, who lives in Albuquerque and has been a competitive rock climber since she was 8 years old. “That really stuck with me.”

Just watching her compete on NBC’s hit reality show American Ninja Warrior in June is proof of that. Not only did the nationally ranked climber fly through the obstacles with grace and grit, but she proudly showed off her two monitoring devices: a glucose monitor on one arm and a tubeless insulin pump on the other.

“I specifically decided to keep my devices visible when I went on the show,” she said. “It’s part of my life, and I wanted to show that I’m not ashamed to wear medical devices.”

Still, it has been a long journey since Bone was diagnosed in 2017. She was just 11 years old at the time and had recently done a climbing competition when she started feeling ill.

“I didn’t perform well,” she said. “I needed to go to the bathroom a lot and felt really nauseous. Three days later, we ended up in urgent care.”

When her doctor first told her she had diabetes, she started crying.

“My grandma had type 1 and was extremely sick and died from complications,” she said. “That was all I knew about diabetes, and it was scary to think my life could be like that.”

But her outlook brightened when her doctor assured her that she could keep climbing.

“When I was told that I could keep competing, a switch flipped for me and I made a decision that nothing would hold me back,” she says.

But every day isn’t easy.

“It’s sometimes really hard to manage my diabetes during competitions,” she said. “When we climb, for example, we’re not allowed to have our phones, and I manage my [glucose monitor] through my phone. This means accommodations have to be made for me.”

And managing her diabetes can be unpredictable at times.

“If my blood sugar is low or high, I might be put last in a competition,” she said. “That messes up my warm-up and my mental game. It’s a never-ending battle.”

Ultimately, Ms. Bone’s goal is to inspire others and advocate for diabetes awareness. She says she’s been overwhelmed by viewer responses to her appearance on the show.

“I heard from so many parents and kids,” she said. “I want the world to know that wearing a pump on your arm only makes you more amazing.”

She also draws inspiration from others with diabetes.

“Everyone with this disease is a role model for me, since everyone is fighting their own battles,” she said. “Diabetes is different for everyone, and seeing how people can do what they do despite the diagnosis has been incredibly inspiring.”

For now, the rising high school junior plans to continue training and competing.

“My goal is to make the 2024 Olympic climbing team in Paris,” she said. “I’ve always wanted to compete in the Olympics since I was a little kid. Nothing can stop me.”

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

College students who watched instructional cooking videos and committed to making healthier eating choices consumed more fruits and vegetables, a new study finds.

Obesity remains a significant risk factor for numerous diseases, and is often a problem in young adults, who often fall back on fast food and other less-healthy meals associated with a lower quality diet, lead author Carol S. O’Neal, PhD, of the University of Louisville (Ky.), said in an interview.

Previous research involving Social Cognitive Theory and goal-setting to promote self-efficacy and behavior changes has shown success in improving eating habits in young adults, but adding video technology for an additional education element has not been well studied, Dr. O’Neal and colleagues wrote in the Journal of Nutrition Education and Behavior.
 

Methods and results

In the study, 138 college students aged 18-40 years participated in a 15-week pilot intervention course at a large, metropolitan university. The course included lectures on a topic, such as carbohydrates, and included skill-based activities, such as how to read an ingredient list, and discussion of how these skills could improve healthier eating and meet nutrition goals, such as eating more whole grains.

A total of 77 completed the study in person, and 61 participated online. The majority (59%) were college sophomores, 74% were White, and 82% were female.

The course engaged the students in weekly food challenges to apply their knowledge and develop better eating habits and behaviors. The challenges were accompanied by cooking videos related to each week’s topic, such as how to make overnight oats for the healthy carbohydrates/whole grains week.

Students also selected two goals each week, such as choosing whole grain foods to increase fiber consumption, from a list of 10-15 goals, and were required to write weekly reflections to track their progress toward these goals. Goal-setting was based on the strategy of creating goals that are specific, measurable, attainable, realistic, and time-bound (the SMART method).

The main outcomes were increased consumption of fruits and vegetables, improved skills in cooking and healthy eating, and improved attitudes about healthy cooking and eating. The researchers surveyed the students to determine whether these outcomes were met.

Students participating in the study indicated that they met the goal of eating at least five servings of fruits and vegetables per day more often after the course than before, the researchers wrote.

By the course’s end, the students showed significant increases in consumption of fruits and vegetables (P < .001 for both), and in the self-efficacy related to consumption of produce (P = .004); cooking (P = .002;, and using more fruits, vegetables, and seasonings rather than salt in cooking (P = .001).

A review of the students’ written reflections illustrated positive behavior changes such as planning meals before shopping, preparing meals in advance on weekends, taking lunch to school, and using herbs and spices, the researchers noted.

“Self-directed SMART goals set you up for success by making goals specific, measurable, achievable, realistic, and timely,” Dr. O’Neal said in an interview. “The SMART method helps push you further, gives you a sense of direction, and helps you organize and reach your goals,” but self-monitoring and social support are also needed for success. The takeaway message for clinicians is that use of a self-directed goal-setting strategy may be more effective at changing dietary behaviors and promoting self-efficacy than a traditional dietary prescription.

In addition, “this model could be used to address a variety of health outcomes in dietetics, health education and community health programs,” said Dr. O’Neal. “I think the key components of this intervention are teaching SMART goal setting, self-monitoring, and social support of successes. I see time as a main barrier, but this barrier could be reduced for populations who are able to use online learning. Our intervention was successful for in-person and online learning.”

Other areas for future research include evaluation of progress that combines quantitative data and qualitative reflections, she said.
 

Real-world applications

“Clinicians have limited time to address behavioral counseling, and this study offers an opportunity to reach patients not only in class sessions, but virtually,” M. Susan Jay, MD, of the Medical College of Wisconsin, Milwaukee, said in an interview.

Although the findings from the study are not new, the knowledge can be used by clinicians to help promote behavior change. The study also showcased the use of additional tools, such as weekly food challenges, to impact college students who often consume high-fat diets in nonmedical settings, Dr. Jay said.

For consumers, the real-world implications are exciting, Dr. Jay said.

“People are increasingly attempting to “eat healthy” and despite clinicians wanting to impact healthy eating, limited office visits may not be conducive to behavioral change,” she said.

The current study was important as a way to identify tactics to improve the diet and nutrition of young adults, Margaret Thew, DNP, FNP-BC, medical director of adolescent medicine at the University of Wisconsin–Madison, said in an interview.

The study findings of increased fruit and vegetable consumption were not surprising, as the study population may have been more highly motivated to improve their diets, Dr. Thew said. However, she was surprised to see the significant improvement in cooking attitudes and cooking self-efficiency after the intervention. “This tells me that we need to offer more opportunities to educate young adults on how to cook to improve diet outcomes.”

The message for clinicians is to encourage and support young adults to learn cooking skills to promote healthier eating, said Dr. Thew.

“When patients have confidence in their ability to cook, they will explore more food options and consequently improve their diets,” she emphasized. “As clinicians, we need to advocate for nutrition education and promote cooking classes that are accessible to all if we hope to reduce obesity and improve our patients’ diets.”
 

Limitations

The study findings were limited by several factors including the use of a convenience sample that might not represent all college students, the reliance on self-reports, the inability to account for the impact of demographic factors, and the lack of a control group, the researchers wrote.

“Larger prospective studies are needed,” given the limitations of the pilot design and short study period, Dr. Jay noted.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Jay and Dr. Thew had no financial conflicts to disclose.

College students who watched instructional cooking videos and committed to making healthier eating choices consumed more fruits and vegetables, a new study finds.

Obesity remains a significant risk factor for numerous diseases, and is often a problem in young adults, who often fall back on fast food and other less-healthy meals associated with a lower quality diet, lead author Carol S. O’Neal, PhD, of the University of Louisville (Ky.), said in an interview.

Previous research involving Social Cognitive Theory and goal-setting to promote self-efficacy and behavior changes has shown success in improving eating habits in young adults, but adding video technology for an additional education element has not been well studied, Dr. O’Neal and colleagues wrote in the Journal of Nutrition Education and Behavior.
 

Methods and results

In the study, 138 college students aged 18-40 years participated in a 15-week pilot intervention course at a large, metropolitan university. The course included lectures on a topic, such as carbohydrates, and included skill-based activities, such as how to read an ingredient list, and discussion of how these skills could improve healthier eating and meet nutrition goals, such as eating more whole grains.

A total of 77 completed the study in person, and 61 participated online. The majority (59%) were college sophomores, 74% were White, and 82% were female.

The course engaged the students in weekly food challenges to apply their knowledge and develop better eating habits and behaviors. The challenges were accompanied by cooking videos related to each week’s topic, such as how to make overnight oats for the healthy carbohydrates/whole grains week.

Students also selected two goals each week, such as choosing whole grain foods to increase fiber consumption, from a list of 10-15 goals, and were required to write weekly reflections to track their progress toward these goals. Goal-setting was based on the strategy of creating goals that are specific, measurable, attainable, realistic, and time-bound (the SMART method).

The main outcomes were increased consumption of fruits and vegetables, improved skills in cooking and healthy eating, and improved attitudes about healthy cooking and eating. The researchers surveyed the students to determine whether these outcomes were met.

Students participating in the study indicated that they met the goal of eating at least five servings of fruits and vegetables per day more often after the course than before, the researchers wrote.

By the course’s end, the students showed significant increases in consumption of fruits and vegetables (P < .001 for both), and in the self-efficacy related to consumption of produce (P = .004); cooking (P = .002;, and using more fruits, vegetables, and seasonings rather than salt in cooking (P = .001).

A review of the students’ written reflections illustrated positive behavior changes such as planning meals before shopping, preparing meals in advance on weekends, taking lunch to school, and using herbs and spices, the researchers noted.

“Self-directed SMART goals set you up for success by making goals specific, measurable, achievable, realistic, and timely,” Dr. O’Neal said in an interview. “The SMART method helps push you further, gives you a sense of direction, and helps you organize and reach your goals,” but self-monitoring and social support are also needed for success. The takeaway message for clinicians is that use of a self-directed goal-setting strategy may be more effective at changing dietary behaviors and promoting self-efficacy than a traditional dietary prescription.

In addition, “this model could be used to address a variety of health outcomes in dietetics, health education and community health programs,” said Dr. O’Neal. “I think the key components of this intervention are teaching SMART goal setting, self-monitoring, and social support of successes. I see time as a main barrier, but this barrier could be reduced for populations who are able to use online learning. Our intervention was successful for in-person and online learning.”

Other areas for future research include evaluation of progress that combines quantitative data and qualitative reflections, she said.
 

Real-world applications

“Clinicians have limited time to address behavioral counseling, and this study offers an opportunity to reach patients not only in class sessions, but virtually,” M. Susan Jay, MD, of the Medical College of Wisconsin, Milwaukee, said in an interview.

Although the findings from the study are not new, the knowledge can be used by clinicians to help promote behavior change. The study also showcased the use of additional tools, such as weekly food challenges, to impact college students who often consume high-fat diets in nonmedical settings, Dr. Jay said.

For consumers, the real-world implications are exciting, Dr. Jay said.

“People are increasingly attempting to “eat healthy” and despite clinicians wanting to impact healthy eating, limited office visits may not be conducive to behavioral change,” she said.

The current study was important as a way to identify tactics to improve the diet and nutrition of young adults, Margaret Thew, DNP, FNP-BC, medical director of adolescent medicine at the University of Wisconsin–Madison, said in an interview.

The study findings of increased fruit and vegetable consumption were not surprising, as the study population may have been more highly motivated to improve their diets, Dr. Thew said. However, she was surprised to see the significant improvement in cooking attitudes and cooking self-efficiency after the intervention. “This tells me that we need to offer more opportunities to educate young adults on how to cook to improve diet outcomes.”

The message for clinicians is to encourage and support young adults to learn cooking skills to promote healthier eating, said Dr. Thew.

“When patients have confidence in their ability to cook, they will explore more food options and consequently improve their diets,” she emphasized. “As clinicians, we need to advocate for nutrition education and promote cooking classes that are accessible to all if we hope to reduce obesity and improve our patients’ diets.”
 

Limitations

The study findings were limited by several factors including the use of a convenience sample that might not represent all college students, the reliance on self-reports, the inability to account for the impact of demographic factors, and the lack of a control group, the researchers wrote.

“Larger prospective studies are needed,” given the limitations of the pilot design and short study period, Dr. Jay noted.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Jay and Dr. Thew had no financial conflicts to disclose.

College students who watched instructional cooking videos and committed to making healthier eating choices consumed more fruits and vegetables, a new study finds.

Obesity remains a significant risk factor for numerous diseases, and is often a problem in young adults, who often fall back on fast food and other less-healthy meals associated with a lower quality diet, lead author Carol S. O’Neal, PhD, of the University of Louisville (Ky.), said in an interview.

Previous research involving Social Cognitive Theory and goal-setting to promote self-efficacy and behavior changes has shown success in improving eating habits in young adults, but adding video technology for an additional education element has not been well studied, Dr. O’Neal and colleagues wrote in the Journal of Nutrition Education and Behavior.
 

Methods and results

In the study, 138 college students aged 18-40 years participated in a 15-week pilot intervention course at a large, metropolitan university. The course included lectures on a topic, such as carbohydrates, and included skill-based activities, such as how to read an ingredient list, and discussion of how these skills could improve healthier eating and meet nutrition goals, such as eating more whole grains.

A total of 77 completed the study in person, and 61 participated online. The majority (59%) were college sophomores, 74% were White, and 82% were female.

The course engaged the students in weekly food challenges to apply their knowledge and develop better eating habits and behaviors. The challenges were accompanied by cooking videos related to each week’s topic, such as how to make overnight oats for the healthy carbohydrates/whole grains week.

Students also selected two goals each week, such as choosing whole grain foods to increase fiber consumption, from a list of 10-15 goals, and were required to write weekly reflections to track their progress toward these goals. Goal-setting was based on the strategy of creating goals that are specific, measurable, attainable, realistic, and time-bound (the SMART method).

The main outcomes were increased consumption of fruits and vegetables, improved skills in cooking and healthy eating, and improved attitudes about healthy cooking and eating. The researchers surveyed the students to determine whether these outcomes were met.

Students participating in the study indicated that they met the goal of eating at least five servings of fruits and vegetables per day more often after the course than before, the researchers wrote.

By the course’s end, the students showed significant increases in consumption of fruits and vegetables (P < .001 for both), and in the self-efficacy related to consumption of produce (P = .004); cooking (P = .002;, and using more fruits, vegetables, and seasonings rather than salt in cooking (P = .001).

A review of the students’ written reflections illustrated positive behavior changes such as planning meals before shopping, preparing meals in advance on weekends, taking lunch to school, and using herbs and spices, the researchers noted.

“Self-directed SMART goals set you up for success by making goals specific, measurable, achievable, realistic, and timely,” Dr. O’Neal said in an interview. “The SMART method helps push you further, gives you a sense of direction, and helps you organize and reach your goals,” but self-monitoring and social support are also needed for success. The takeaway message for clinicians is that use of a self-directed goal-setting strategy may be more effective at changing dietary behaviors and promoting self-efficacy than a traditional dietary prescription.

In addition, “this model could be used to address a variety of health outcomes in dietetics, health education and community health programs,” said Dr. O’Neal. “I think the key components of this intervention are teaching SMART goal setting, self-monitoring, and social support of successes. I see time as a main barrier, but this barrier could be reduced for populations who are able to use online learning. Our intervention was successful for in-person and online learning.”

Other areas for future research include evaluation of progress that combines quantitative data and qualitative reflections, she said.
 

Real-world applications

“Clinicians have limited time to address behavioral counseling, and this study offers an opportunity to reach patients not only in class sessions, but virtually,” M. Susan Jay, MD, of the Medical College of Wisconsin, Milwaukee, said in an interview.

Although the findings from the study are not new, the knowledge can be used by clinicians to help promote behavior change. The study also showcased the use of additional tools, such as weekly food challenges, to impact college students who often consume high-fat diets in nonmedical settings, Dr. Jay said.

For consumers, the real-world implications are exciting, Dr. Jay said.

“People are increasingly attempting to “eat healthy” and despite clinicians wanting to impact healthy eating, limited office visits may not be conducive to behavioral change,” she said.

The current study was important as a way to identify tactics to improve the diet and nutrition of young adults, Margaret Thew, DNP, FNP-BC, medical director of adolescent medicine at the University of Wisconsin–Madison, said in an interview.

The study findings of increased fruit and vegetable consumption were not surprising, as the study population may have been more highly motivated to improve their diets, Dr. Thew said. However, she was surprised to see the significant improvement in cooking attitudes and cooking self-efficiency after the intervention. “This tells me that we need to offer more opportunities to educate young adults on how to cook to improve diet outcomes.”

The message for clinicians is to encourage and support young adults to learn cooking skills to promote healthier eating, said Dr. Thew.

“When patients have confidence in their ability to cook, they will explore more food options and consequently improve their diets,” she emphasized. “As clinicians, we need to advocate for nutrition education and promote cooking classes that are accessible to all if we hope to reduce obesity and improve our patients’ diets.”
 

Limitations

The study findings were limited by several factors including the use of a convenience sample that might not represent all college students, the reliance on self-reports, the inability to account for the impact of demographic factors, and the lack of a control group, the researchers wrote.

“Larger prospective studies are needed,” given the limitations of the pilot design and short study period, Dr. Jay noted.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Jay and Dr. Thew had no financial conflicts to disclose.

After 49 years of labor, abortion foes received the ultimate victory in June when the United States Supreme Court struck down a federal right to terminate pregnancy. Among those most heartened by the ruling was a small organization of doctors who specialize in women’s reproductive health. The group’s leader, while grateful for the win, isn’t ready for a curtain call. Instead, she sees her task as moving from a national stage to 50 regional ones.

The decision in Dobbs v. Jackson, which overturned a woman’s constitutional right to obtain an abortion, was the biggest but not final quarry for the American Association of Pro-Life Obstetricians and Gynecologists (AAPLOG). “It actually doesn’t change anything except to turn the whole discussion on abortion back to the states, which in our opinion is where it should have been 50 years ago,” Donna Harrison, MD, the group’s chief executive officer, said in a recent interview.

Dr. Harrison, an obstetrician-gynecologist and adjunct professor of bioethics at Trinity International University in Deerfield, Ind., said she was proud of “our small role in bringing science” to the top court’s attention, noting that the ruling incorporated some of AAPLOG’s medical arguments in reversing Roe v. Wade, the 1973 decision that created a right to abortion – and prompted her group’s founding. The ruling, for instance, agreed – in a departure from the generally accepted science – that a fetus is viable at 15 weeks, and the procedure is risky for mothers thereafter. “You could congratulate us for perseverance and for bringing that information, which has been in the peer-reviewed literature for a long time, to the justices’ attention,” she said.

Dr. Harrison said she was pleased that the Supreme Court agreed with the “science” that guided its decision to overturn Roe. That the court was willing to embrace that evidence troubles the American College of Obstetricians and Gynecologists (ACOG), the nation’s leading professional group for reproductive health experts.  
 

Defending the ‘second patient’

AAPLOG operates under the belief that life begins at the moment of fertilization, at which point “we defend the life of our second patient, the human being in the womb,” Dr. Harrison said. “For a very long time, ob.gyns. who valued both patients were not given a voice, and I think now we’re finding our voice.” The group will continue supporting abortion restrictions at the state level.

AAPLOG, with 6,000 members, was considered a “special interest” group within ACOG until the college discontinued such subgroups in 2013. ACOG, numbering 60,000 members, calls the Dobbs ruling “a huge step back for women and everyone who is seeking access to ob.gyn. care,” said Molly Meegan, JD, ACOG’s chief legal officer. Ms. Meegan expressed concern over the newfound influence of AAPLOG, which she called “a single-issue, single-topic, single-advocacy organization.”

Pro-choice groups, including ACOG, worry that the reversal of Roe has provided AAPLOG with an undeserved veneer of medical expertise. The decision also allowed judges and legislators to “insert themselves into nuanced and complex situations” they know little about and will rely on groups like AAPLOG to exert influence, Ms. Meegan said.

In turn, Dr. Harrison described ACOG as engaging in “rabid, pro-abortion activism.”

The number of abortions in the United States had steadily declined from a peak of 1.4 million per year in 1990 until 2017, after which it has risen slightly. In 2019, according to the U.S. Centers for Disease Control and Prevention, 625,000 abortions occurred nationally. Of those, 42.3% were medication abortions performed in the first 9 weeks, using a combination of the drugs mifepristone and misoprostol. Medication abortions now account for more than half of all pregnancy terminations in the United States, according to the Guttmacher Institute.

Dr. Harrison said that medication abortions put women at an elevated risk of serious, sometimes deadly bleeding, while ACOG points to evidence that the risk of childbirth to women is significantly higher. She also is no fan of Plan B, the “morning after” pill, which is available to women without having to consult a doctor. She described abortifacients as “a huge danger to women being harmed” by medications available over the counter.

In Dr. Harrison’s view, the 10-year-old Ohio girl who traveled to Indiana to obtain an abortion after she became pregnant as the result of rape should have continued her pregnancy. So, too, should young girls who are the victims of incest. “Incest is a horrific crime,” she said, “but aborting a girl because of incest doesn’t make her un-raped. It just adds another trauma.”

When told of Dr. Harrison’s comment, Ms. Meegan paused for 5 seconds before saying, “I think that statement speaks for itself.”

Louise Perkins King, MD, JD, an ob.gyn. and director of reproductive bioethics at Harvard Medical School, Boston, said she had the “horrific” experience of delivering a baby to an 11-year-old girl.

“Children are not fully developed, and they should not be having children,” Dr. King said.

Anne-Marie E. Amies Oelschlager, MD, vice chair of ACOG’s Clinical Consensus Committee and an ob.gyn. at Seattle Children’s in Washington, said in a statement that adolescents who are sexually assaulted are at extremely high risk of depression and posttraumatic stress disorder. “Do we expect a fourth-grader to carry a pregnancy to term, deliver, and expect that child to carry on after this horror?,” she asked.

Dr. Harrison dismissed such concerns. “Somehow abortion is a mental health treatment? Abortion doesn’t treat mental health problems,” she said. “Is there any proof that aborting in those circumstances improves their mental health? I would tell you there is very little research about it. …There are human beings involved, and this child who was raped, who also had a child, who was a human being, who is no longer.”  

Dr. Harrison said the Dobbs decision would have no effect on up to 93% of ob.gyns. who don’t perform abortions. Dr. King said the reason that most don’t perform the procedure is the “stigma” attached to abortion. “It’s still frowned upon,” she said. “We don’t talk about it as health care.”

Ms. Meegan added that ob.gyns. are fearful in the wake of the Dobbs decision because “they might find themselves subject to civil and criminal penalties.”

Dr. Harrison said that Roe was always a political decision and the science was always behind AAPLOG – something both Ms. Meegan and Dr. King dispute. Ms. Meegan and Dr. King said they are concerned about the chilling effects on both women and their clinicians, especially with laws that prevent referrals and travel to other states.

“You can’t compel me to give blood or bone marrow,” Dr. King said. “You can’t even compel me to give my hair for somebody, and you can’t compel me to give an organ. And all of a sudden when I’m pregnant, all my rights are out the window?”

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

After 49 years of labor, abortion foes received the ultimate victory in June when the United States Supreme Court struck down a federal right to terminate pregnancy. Among those most heartened by the ruling was a small organization of doctors who specialize in women’s reproductive health. The group’s leader, while grateful for the win, isn’t ready for a curtain call. Instead, she sees her task as moving from a national stage to 50 regional ones.

The decision in Dobbs v. Jackson, which overturned a woman’s constitutional right to obtain an abortion, was the biggest but not final quarry for the American Association of Pro-Life Obstetricians and Gynecologists (AAPLOG). “It actually doesn’t change anything except to turn the whole discussion on abortion back to the states, which in our opinion is where it should have been 50 years ago,” Donna Harrison, MD, the group’s chief executive officer, said in a recent interview.

Dr. Harrison, an obstetrician-gynecologist and adjunct professor of bioethics at Trinity International University in Deerfield, Ind., said she was proud of “our small role in bringing science” to the top court’s attention, noting that the ruling incorporated some of AAPLOG’s medical arguments in reversing Roe v. Wade, the 1973 decision that created a right to abortion – and prompted her group’s founding. The ruling, for instance, agreed – in a departure from the generally accepted science – that a fetus is viable at 15 weeks, and the procedure is risky for mothers thereafter. “You could congratulate us for perseverance and for bringing that information, which has been in the peer-reviewed literature for a long time, to the justices’ attention,” she said.

Dr. Harrison said she was pleased that the Supreme Court agreed with the “science” that guided its decision to overturn Roe. That the court was willing to embrace that evidence troubles the American College of Obstetricians and Gynecologists (ACOG), the nation’s leading professional group for reproductive health experts.  
 

Defending the ‘second patient’

AAPLOG operates under the belief that life begins at the moment of fertilization, at which point “we defend the life of our second patient, the human being in the womb,” Dr. Harrison said. “For a very long time, ob.gyns. who valued both patients were not given a voice, and I think now we’re finding our voice.” The group will continue supporting abortion restrictions at the state level.

AAPLOG, with 6,000 members, was considered a “special interest” group within ACOG until the college discontinued such subgroups in 2013. ACOG, numbering 60,000 members, calls the Dobbs ruling “a huge step back for women and everyone who is seeking access to ob.gyn. care,” said Molly Meegan, JD, ACOG’s chief legal officer. Ms. Meegan expressed concern over the newfound influence of AAPLOG, which she called “a single-issue, single-topic, single-advocacy organization.”

Pro-choice groups, including ACOG, worry that the reversal of Roe has provided AAPLOG with an undeserved veneer of medical expertise. The decision also allowed judges and legislators to “insert themselves into nuanced and complex situations” they know little about and will rely on groups like AAPLOG to exert influence, Ms. Meegan said.

In turn, Dr. Harrison described ACOG as engaging in “rabid, pro-abortion activism.”

The number of abortions in the United States had steadily declined from a peak of 1.4 million per year in 1990 until 2017, after which it has risen slightly. In 2019, according to the U.S. Centers for Disease Control and Prevention, 625,000 abortions occurred nationally. Of those, 42.3% were medication abortions performed in the first 9 weeks, using a combination of the drugs mifepristone and misoprostol. Medication abortions now account for more than half of all pregnancy terminations in the United States, according to the Guttmacher Institute.

Dr. Harrison said that medication abortions put women at an elevated risk of serious, sometimes deadly bleeding, while ACOG points to evidence that the risk of childbirth to women is significantly higher. She also is no fan of Plan B, the “morning after” pill, which is available to women without having to consult a doctor. She described abortifacients as “a huge danger to women being harmed” by medications available over the counter.

In Dr. Harrison’s view, the 10-year-old Ohio girl who traveled to Indiana to obtain an abortion after she became pregnant as the result of rape should have continued her pregnancy. So, too, should young girls who are the victims of incest. “Incest is a horrific crime,” she said, “but aborting a girl because of incest doesn’t make her un-raped. It just adds another trauma.”

When told of Dr. Harrison’s comment, Ms. Meegan paused for 5 seconds before saying, “I think that statement speaks for itself.”

Louise Perkins King, MD, JD, an ob.gyn. and director of reproductive bioethics at Harvard Medical School, Boston, said she had the “horrific” experience of delivering a baby to an 11-year-old girl.

“Children are not fully developed, and they should not be having children,” Dr. King said.

Anne-Marie E. Amies Oelschlager, MD, vice chair of ACOG’s Clinical Consensus Committee and an ob.gyn. at Seattle Children’s in Washington, said in a statement that adolescents who are sexually assaulted are at extremely high risk of depression and posttraumatic stress disorder. “Do we expect a fourth-grader to carry a pregnancy to term, deliver, and expect that child to carry on after this horror?,” she asked.

Dr. Harrison dismissed such concerns. “Somehow abortion is a mental health treatment? Abortion doesn’t treat mental health problems,” she said. “Is there any proof that aborting in those circumstances improves their mental health? I would tell you there is very little research about it. …There are human beings involved, and this child who was raped, who also had a child, who was a human being, who is no longer.”  

Dr. Harrison said the Dobbs decision would have no effect on up to 93% of ob.gyns. who don’t perform abortions. Dr. King said the reason that most don’t perform the procedure is the “stigma” attached to abortion. “It’s still frowned upon,” she said. “We don’t talk about it as health care.”

Ms. Meegan added that ob.gyns. are fearful in the wake of the Dobbs decision because “they might find themselves subject to civil and criminal penalties.”

Dr. Harrison said that Roe was always a political decision and the science was always behind AAPLOG – something both Ms. Meegan and Dr. King dispute. Ms. Meegan and Dr. King said they are concerned about the chilling effects on both women and their clinicians, especially with laws that prevent referrals and travel to other states.

“You can’t compel me to give blood or bone marrow,” Dr. King said. “You can’t even compel me to give my hair for somebody, and you can’t compel me to give an organ. And all of a sudden when I’m pregnant, all my rights are out the window?”

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

After 49 years of labor, abortion foes received the ultimate victory in June when the United States Supreme Court struck down a federal right to terminate pregnancy. Among those most heartened by the ruling was a small organization of doctors who specialize in women’s reproductive health. The group’s leader, while grateful for the win, isn’t ready for a curtain call. Instead, she sees her task as moving from a national stage to 50 regional ones.

The decision in Dobbs v. Jackson, which overturned a woman’s constitutional right to obtain an abortion, was the biggest but not final quarry for the American Association of Pro-Life Obstetricians and Gynecologists (AAPLOG). “It actually doesn’t change anything except to turn the whole discussion on abortion back to the states, which in our opinion is where it should have been 50 years ago,” Donna Harrison, MD, the group’s chief executive officer, said in a recent interview.

Dr. Harrison, an obstetrician-gynecologist and adjunct professor of bioethics at Trinity International University in Deerfield, Ind., said she was proud of “our small role in bringing science” to the top court’s attention, noting that the ruling incorporated some of AAPLOG’s medical arguments in reversing Roe v. Wade, the 1973 decision that created a right to abortion – and prompted her group’s founding. The ruling, for instance, agreed – in a departure from the generally accepted science – that a fetus is viable at 15 weeks, and the procedure is risky for mothers thereafter. “You could congratulate us for perseverance and for bringing that information, which has been in the peer-reviewed literature for a long time, to the justices’ attention,” she said.

Dr. Harrison said she was pleased that the Supreme Court agreed with the “science” that guided its decision to overturn Roe. That the court was willing to embrace that evidence troubles the American College of Obstetricians and Gynecologists (ACOG), the nation’s leading professional group for reproductive health experts.  
 

Defending the ‘second patient’

AAPLOG operates under the belief that life begins at the moment of fertilization, at which point “we defend the life of our second patient, the human being in the womb,” Dr. Harrison said. “For a very long time, ob.gyns. who valued both patients were not given a voice, and I think now we’re finding our voice.” The group will continue supporting abortion restrictions at the state level.

AAPLOG, with 6,000 members, was considered a “special interest” group within ACOG until the college discontinued such subgroups in 2013. ACOG, numbering 60,000 members, calls the Dobbs ruling “a huge step back for women and everyone who is seeking access to ob.gyn. care,” said Molly Meegan, JD, ACOG’s chief legal officer. Ms. Meegan expressed concern over the newfound influence of AAPLOG, which she called “a single-issue, single-topic, single-advocacy organization.”

Pro-choice groups, including ACOG, worry that the reversal of Roe has provided AAPLOG with an undeserved veneer of medical expertise. The decision also allowed judges and legislators to “insert themselves into nuanced and complex situations” they know little about and will rely on groups like AAPLOG to exert influence, Ms. Meegan said.

In turn, Dr. Harrison described ACOG as engaging in “rabid, pro-abortion activism.”

The number of abortions in the United States had steadily declined from a peak of 1.4 million per year in 1990 until 2017, after which it has risen slightly. In 2019, according to the U.S. Centers for Disease Control and Prevention, 625,000 abortions occurred nationally. Of those, 42.3% were medication abortions performed in the first 9 weeks, using a combination of the drugs mifepristone and misoprostol. Medication abortions now account for more than half of all pregnancy terminations in the United States, according to the Guttmacher Institute.

Dr. Harrison said that medication abortions put women at an elevated risk of serious, sometimes deadly bleeding, while ACOG points to evidence that the risk of childbirth to women is significantly higher. She also is no fan of Plan B, the “morning after” pill, which is available to women without having to consult a doctor. She described abortifacients as “a huge danger to women being harmed” by medications available over the counter.

In Dr. Harrison’s view, the 10-year-old Ohio girl who traveled to Indiana to obtain an abortion after she became pregnant as the result of rape should have continued her pregnancy. So, too, should young girls who are the victims of incest. “Incest is a horrific crime,” she said, “but aborting a girl because of incest doesn’t make her un-raped. It just adds another trauma.”

When told of Dr. Harrison’s comment, Ms. Meegan paused for 5 seconds before saying, “I think that statement speaks for itself.”

Louise Perkins King, MD, JD, an ob.gyn. and director of reproductive bioethics at Harvard Medical School, Boston, said she had the “horrific” experience of delivering a baby to an 11-year-old girl.

“Children are not fully developed, and they should not be having children,” Dr. King said.

Anne-Marie E. Amies Oelschlager, MD, vice chair of ACOG’s Clinical Consensus Committee and an ob.gyn. at Seattle Children’s in Washington, said in a statement that adolescents who are sexually assaulted are at extremely high risk of depression and posttraumatic stress disorder. “Do we expect a fourth-grader to carry a pregnancy to term, deliver, and expect that child to carry on after this horror?,” she asked.

Dr. Harrison dismissed such concerns. “Somehow abortion is a mental health treatment? Abortion doesn’t treat mental health problems,” she said. “Is there any proof that aborting in those circumstances improves their mental health? I would tell you there is very little research about it. …There are human beings involved, and this child who was raped, who also had a child, who was a human being, who is no longer.”  

Dr. Harrison said the Dobbs decision would have no effect on up to 93% of ob.gyns. who don’t perform abortions. Dr. King said the reason that most don’t perform the procedure is the “stigma” attached to abortion. “It’s still frowned upon,” she said. “We don’t talk about it as health care.”

Ms. Meegan added that ob.gyns. are fearful in the wake of the Dobbs decision because “they might find themselves subject to civil and criminal penalties.”

Dr. Harrison said that Roe was always a political decision and the science was always behind AAPLOG – something both Ms. Meegan and Dr. King dispute. Ms. Meegan and Dr. King said they are concerned about the chilling effects on both women and their clinicians, especially with laws that prevent referrals and travel to other states.

“You can’t compel me to give blood or bone marrow,” Dr. King said. “You can’t even compel me to give my hair for somebody, and you can’t compel me to give an organ. And all of a sudden when I’m pregnant, all my rights are out the window?”

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