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Who can call themselves ‘doctor’? The debate heats up
Who Should Get to Be Called ‘Doctor’? shows. The topic has clearly struck a nerve, since a record number of respondents – over 12,000 – voted in the poll.
Most physicians think it’s appropriate for people with other doctorate degrees such as a PhD or EdD to call themselves ‘doctor,’ although slightly more than half said it depends on the context.
The controversy over who gets to be called a doctor was reignited when a Wall Street Journal opinion piece criticized First Lady Jill Biden, EdD, for wanting to be called “Dr Biden.” The piece also challenged the idea that having a PhD is worth the honorific of ‘doctor.’
Medical ethicist Arthur Caplan, PhD, disagreed with that viewpoint, saying the context matters. For example, he prefers to be called “professor” when he’s introduced to the public rather than “doctor” to avoid any confusion about his professional status.
More than 12,000 clinicians including physicians, medical students, nurses, pharmacists, and other health care professionals responded to the poll. The non-MD clinicians were the most likely to say it was always appropriate to be called “doctor” while physicians were the least likely.
Context matters
Large percentages of clinicians – 54% of doctors, 62% of medical students, and 41% of nurses – said that the context matters for being called “doctor.’’
“I earned my PhD in 1995 and my MD in 2000. I think it is contextual. In a research or University setting, “Dr.” seems appropriate for a PhD. That same person in public should probably not hold themselves out as “Dr.” So, maybe MDs and DOs can choose, while others maintain the title in their specific setting.”
Some readers proposed that people with MDs call themselves physicians rather than doctors. Said one: “Anyone with a terminal doctorate degree has the right to use the word doctor. As a physician when someone asks what I do, I say: ‘I am a physician.’ Problem solved. There can only be one physician but there are many types of doctors.”
Physicians and nurses differed most in their views. Just 24% of physicians said it was always appropriate for people with other doctorate degrees to call themselves doctor whereas about an equal number (22%) thought it was never appropriate.
In contrast, 43% of nurses (including advance practice nurses) said it was always appropriate for people with non-MD doctorates to be called doctor. Only 16% said it’s never appropriate.
This difference may reflect the growing number of nurses with doctorate degrees, either a DNP or PhD, who want to be called doctor in clinical settings.
Age made a difference too. Only 16% of physicians younger than age 45 said it was always appropriate for people with non-MD doctorate degrees to be called doctor, compared with 27% of physicians aged 45 and up.
Medical students (31%) were also more likely than physicians to say it was always appropriate for non-MD doctorates to use the title “doctor” and 64% said it depends on the context. This was noteworthy because twice as many medical students as physicians (16% vs. 8%) said they work in academia, research, or military government settings.
Too many ‘doctors’ confuse the public
Physicians (70%) were also more likely to say it was always or often confusing for the public to hear someone without a medical degree addressed as “doctor.” Only 6% of physicians thought it was never or rarely confusing.
Nurses disagreed. Just 45% said that it was always or often confusing while 16% said it was never or rarely confusing.
Medical students were more aligned with physicians on this issue – 60% said it was always or often confusing to the public and just 10% said it was never or rarely confusing.
One reader commented, “The problem is the confusion the ‘doctor’ title causes for patients, especially in a hospital setting. Is the ‘doctor’ a physician, a pharmacist, a psychologist, a nurse, etc., etc.? We need to think not of our own egos but if and how the confusion about this plethora of titles may be hindering good patient care.”
These concerns are not unfounded. The American Medical Association reported in its Truth in Advertising campaign that “patients mistake physicians with nonphysician providers” based on an online survey of 802 adults in 2018. The participants thought these specialists were MDs: dentists (61%), podiatrists (67%), optometrists (47%), psychologists (43%), doctors of nursing (39%), and chiropractors (27%).
The AMA has advocated that states pass the “Health Care Professional Transparency Act,” which New Jersey has enacted. The law requires all health care professionals dealing with patients to wear a name tag that clearly identifies their licensure. Health care professionals must also display their education, training, and licensure in their office.
A version of this article first appeared on Medscape.com.
Who Should Get to Be Called ‘Doctor’? shows. The topic has clearly struck a nerve, since a record number of respondents – over 12,000 – voted in the poll.
Most physicians think it’s appropriate for people with other doctorate degrees such as a PhD or EdD to call themselves ‘doctor,’ although slightly more than half said it depends on the context.
The controversy over who gets to be called a doctor was reignited when a Wall Street Journal opinion piece criticized First Lady Jill Biden, EdD, for wanting to be called “Dr Biden.” The piece also challenged the idea that having a PhD is worth the honorific of ‘doctor.’
Medical ethicist Arthur Caplan, PhD, disagreed with that viewpoint, saying the context matters. For example, he prefers to be called “professor” when he’s introduced to the public rather than “doctor” to avoid any confusion about his professional status.
More than 12,000 clinicians including physicians, medical students, nurses, pharmacists, and other health care professionals responded to the poll. The non-MD clinicians were the most likely to say it was always appropriate to be called “doctor” while physicians were the least likely.
Context matters
Large percentages of clinicians – 54% of doctors, 62% of medical students, and 41% of nurses – said that the context matters for being called “doctor.’’
“I earned my PhD in 1995 and my MD in 2000. I think it is contextual. In a research or University setting, “Dr.” seems appropriate for a PhD. That same person in public should probably not hold themselves out as “Dr.” So, maybe MDs and DOs can choose, while others maintain the title in their specific setting.”
Some readers proposed that people with MDs call themselves physicians rather than doctors. Said one: “Anyone with a terminal doctorate degree has the right to use the word doctor. As a physician when someone asks what I do, I say: ‘I am a physician.’ Problem solved. There can only be one physician but there are many types of doctors.”
Physicians and nurses differed most in their views. Just 24% of physicians said it was always appropriate for people with other doctorate degrees to call themselves doctor whereas about an equal number (22%) thought it was never appropriate.
In contrast, 43% of nurses (including advance practice nurses) said it was always appropriate for people with non-MD doctorates to be called doctor. Only 16% said it’s never appropriate.
This difference may reflect the growing number of nurses with doctorate degrees, either a DNP or PhD, who want to be called doctor in clinical settings.
Age made a difference too. Only 16% of physicians younger than age 45 said it was always appropriate for people with non-MD doctorate degrees to be called doctor, compared with 27% of physicians aged 45 and up.
Medical students (31%) were also more likely than physicians to say it was always appropriate for non-MD doctorates to use the title “doctor” and 64% said it depends on the context. This was noteworthy because twice as many medical students as physicians (16% vs. 8%) said they work in academia, research, or military government settings.
Too many ‘doctors’ confuse the public
Physicians (70%) were also more likely to say it was always or often confusing for the public to hear someone without a medical degree addressed as “doctor.” Only 6% of physicians thought it was never or rarely confusing.
Nurses disagreed. Just 45% said that it was always or often confusing while 16% said it was never or rarely confusing.
Medical students were more aligned with physicians on this issue – 60% said it was always or often confusing to the public and just 10% said it was never or rarely confusing.
One reader commented, “The problem is the confusion the ‘doctor’ title causes for patients, especially in a hospital setting. Is the ‘doctor’ a physician, a pharmacist, a psychologist, a nurse, etc., etc.? We need to think not of our own egos but if and how the confusion about this plethora of titles may be hindering good patient care.”
These concerns are not unfounded. The American Medical Association reported in its Truth in Advertising campaign that “patients mistake physicians with nonphysician providers” based on an online survey of 802 adults in 2018. The participants thought these specialists were MDs: dentists (61%), podiatrists (67%), optometrists (47%), psychologists (43%), doctors of nursing (39%), and chiropractors (27%).
The AMA has advocated that states pass the “Health Care Professional Transparency Act,” which New Jersey has enacted. The law requires all health care professionals dealing with patients to wear a name tag that clearly identifies their licensure. Health care professionals must also display their education, training, and licensure in their office.
A version of this article first appeared on Medscape.com.
Who Should Get to Be Called ‘Doctor’? shows. The topic has clearly struck a nerve, since a record number of respondents – over 12,000 – voted in the poll.
Most physicians think it’s appropriate for people with other doctorate degrees such as a PhD or EdD to call themselves ‘doctor,’ although slightly more than half said it depends on the context.
The controversy over who gets to be called a doctor was reignited when a Wall Street Journal opinion piece criticized First Lady Jill Biden, EdD, for wanting to be called “Dr Biden.” The piece also challenged the idea that having a PhD is worth the honorific of ‘doctor.’
Medical ethicist Arthur Caplan, PhD, disagreed with that viewpoint, saying the context matters. For example, he prefers to be called “professor” when he’s introduced to the public rather than “doctor” to avoid any confusion about his professional status.
More than 12,000 clinicians including physicians, medical students, nurses, pharmacists, and other health care professionals responded to the poll. The non-MD clinicians were the most likely to say it was always appropriate to be called “doctor” while physicians were the least likely.
Context matters
Large percentages of clinicians – 54% of doctors, 62% of medical students, and 41% of nurses – said that the context matters for being called “doctor.’’
“I earned my PhD in 1995 and my MD in 2000. I think it is contextual. In a research or University setting, “Dr.” seems appropriate for a PhD. That same person in public should probably not hold themselves out as “Dr.” So, maybe MDs and DOs can choose, while others maintain the title in their specific setting.”
Some readers proposed that people with MDs call themselves physicians rather than doctors. Said one: “Anyone with a terminal doctorate degree has the right to use the word doctor. As a physician when someone asks what I do, I say: ‘I am a physician.’ Problem solved. There can only be one physician but there are many types of doctors.”
Physicians and nurses differed most in their views. Just 24% of physicians said it was always appropriate for people with other doctorate degrees to call themselves doctor whereas about an equal number (22%) thought it was never appropriate.
In contrast, 43% of nurses (including advance practice nurses) said it was always appropriate for people with non-MD doctorates to be called doctor. Only 16% said it’s never appropriate.
This difference may reflect the growing number of nurses with doctorate degrees, either a DNP or PhD, who want to be called doctor in clinical settings.
Age made a difference too. Only 16% of physicians younger than age 45 said it was always appropriate for people with non-MD doctorate degrees to be called doctor, compared with 27% of physicians aged 45 and up.
Medical students (31%) were also more likely than physicians to say it was always appropriate for non-MD doctorates to use the title “doctor” and 64% said it depends on the context. This was noteworthy because twice as many medical students as physicians (16% vs. 8%) said they work in academia, research, or military government settings.
Too many ‘doctors’ confuse the public
Physicians (70%) were also more likely to say it was always or often confusing for the public to hear someone without a medical degree addressed as “doctor.” Only 6% of physicians thought it was never or rarely confusing.
Nurses disagreed. Just 45% said that it was always or often confusing while 16% said it was never or rarely confusing.
Medical students were more aligned with physicians on this issue – 60% said it was always or often confusing to the public and just 10% said it was never or rarely confusing.
One reader commented, “The problem is the confusion the ‘doctor’ title causes for patients, especially in a hospital setting. Is the ‘doctor’ a physician, a pharmacist, a psychologist, a nurse, etc., etc.? We need to think not of our own egos but if and how the confusion about this plethora of titles may be hindering good patient care.”
These concerns are not unfounded. The American Medical Association reported in its Truth in Advertising campaign that “patients mistake physicians with nonphysician providers” based on an online survey of 802 adults in 2018. The participants thought these specialists were MDs: dentists (61%), podiatrists (67%), optometrists (47%), psychologists (43%), doctors of nursing (39%), and chiropractors (27%).
The AMA has advocated that states pass the “Health Care Professional Transparency Act,” which New Jersey has enacted. The law requires all health care professionals dealing with patients to wear a name tag that clearly identifies their licensure. Health care professionals must also display their education, training, and licensure in their office.
A version of this article first appeared on Medscape.com.
Progress stalling on malaria elimination
In its final report on the E-2020 initiative, the World Health Organization touted its progress on its goal of eliminating malaria throughout the world. But critics are charging that progress has stalled.
The E-2020 initiative supported the efforts of 21 countries in eliminating malaria. In a remarkable achievement, especially during the COVID-19 pandemic, eight E-2020 member countries reported zero cases of malaria in 2020. The WHO’s next target is the elimination of malaria in 20 of those countries by 2025.
While applauding these successes, in an interview with this news organization, Sir Nicholas J. White, FRS, professor of tropical medicine, Mahidol University, Salaya, Thailand, and Oxford (England) University, also put those successes in perspective. For one thing, the original 2020 goal was the elimination of malaria in 10 countries. Prof. White acknowledged that there had been very “substantial reductions in global morbidity and mortality” from 2000 to 2015, but he pointed out that those advances have not been sustained.
Prof. White added, “There has never been a really good, detailed inquiry as to why progress has stalled” in the high-burden countries.
Prof. White also provided important historical context, explaining that “100 years ago, malaria was pretty much a global disease. There were few places in the world which did not have malaria. You had malaria up to the Arctic Circle. You had malaria in the United States, particularly in the Tennessee Valley in the southeastern part of the United States. The Centers for Disease Control was formed specifically to counter malaria and malaria interfering with the building of the Erie and Ottawa canals.”
Kim Lindblade, PhD, malaria elimination team lead of the WHO’s Global Malaria Program, addressed those concerns with this news organization. “It’s not completely clear why [progress] has stalled,” she said. “There are lots of potential reasons for it, including stagnating funding.”
Dr. Lindblade added that high-burden countries are “facing big challenges. [Since 2015] there’s this stagnation. We’re fighting against population growth, and countries need to get back on track to continue to decrease their malaria burden. So that’s the big focus right now, to reorganize efforts to help countries achieve the goals of the World Health Assembly.”
Asked how these countries might approach the problem differently, Dr. Lindblade said that in the recent past, there was “almost a one-size-fits-all strategy. Now we’re looking much more carefully at conditions at the district level or provincial level and saying, What is it that this particular district or province needs? … It’s becoming much more tailored to the environment and to the specific epidemiological situation. … and I think that’s gotten a lot of people very excited.”
Because of travel restrictions and lockdowns because of COVID-19, the number of imported cases of malaria has declined. That’s the good news. But the pandemic has made elimination more difficult in other ways. For example, the delivery of insecticide-treated bed nets has been delayed in some areas, as has targeted indoor spraying. People in many areas have put off seeking medical care. Diagnostic capabilities have been reduced because of health care personnel having been diverted to address the COVID-19 crisis.
Still, some of the successes in eliminating malaria have been striking. Iran, for example, reduced its cases from about 98,000 in 1991 to 12,000 just 10 years later. Since then, Iran has established rapid response teams equipped with insecticide-impregnated nets, rapid diagnostic tests, and antimalarials. A network of more than 3,700 community health volunteers has been trained and deployed throughout the country.
A key element of Iran’s success – and that of some of the other countries – is the political will to tackle malaria. This translates to funding. Notably, the most successful countries provide free primary health care to everyone, regardless of their legal or residency status. Volunteer migrant workers are trained to diagnose malaria and to educate fellow migrants about the disease and prevention strategies.
Malaysia and China are examples of two countries at risk of importing malaria through their many people who work abroad in malaria-endemic regions. They have had to increase their surveillance.
Although Malaysia has eliminated most malaria species – those transmitted through people – they still have problems with the malaria parasite hosted by monkeys.
The WHO report stresses the lessons learned through their E-2020 program. Two key criteria are political commitment and associated funding. Next are surveillance and efforts to reach everyone, even in geographically remote or marginalized communities. Close surveillance also enables strategies to be modified to local needs.
Countries need to cooperate, especially along border areas and in regard to communications. The WHO stressed the need for countries to have an integrated response in their approach to malaria, including accurate surveillance, diagnostic testing, treatment, and robust education in preventive measures.
Although these successes were not as evident in some high-burden countries, Prof. White applauded their perseverance, noting, “It’s quite difficult to sustain the political momentum. … That endgame to keep the motivation, keep the support, to getting rid of something is hard.”
Prof. White and Dr. Lindberg have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
In its final report on the E-2020 initiative, the World Health Organization touted its progress on its goal of eliminating malaria throughout the world. But critics are charging that progress has stalled.
The E-2020 initiative supported the efforts of 21 countries in eliminating malaria. In a remarkable achievement, especially during the COVID-19 pandemic, eight E-2020 member countries reported zero cases of malaria in 2020. The WHO’s next target is the elimination of malaria in 20 of those countries by 2025.
While applauding these successes, in an interview with this news organization, Sir Nicholas J. White, FRS, professor of tropical medicine, Mahidol University, Salaya, Thailand, and Oxford (England) University, also put those successes in perspective. For one thing, the original 2020 goal was the elimination of malaria in 10 countries. Prof. White acknowledged that there had been very “substantial reductions in global morbidity and mortality” from 2000 to 2015, but he pointed out that those advances have not been sustained.
Prof. White added, “There has never been a really good, detailed inquiry as to why progress has stalled” in the high-burden countries.
Prof. White also provided important historical context, explaining that “100 years ago, malaria was pretty much a global disease. There were few places in the world which did not have malaria. You had malaria up to the Arctic Circle. You had malaria in the United States, particularly in the Tennessee Valley in the southeastern part of the United States. The Centers for Disease Control was formed specifically to counter malaria and malaria interfering with the building of the Erie and Ottawa canals.”
Kim Lindblade, PhD, malaria elimination team lead of the WHO’s Global Malaria Program, addressed those concerns with this news organization. “It’s not completely clear why [progress] has stalled,” she said. “There are lots of potential reasons for it, including stagnating funding.”
Dr. Lindblade added that high-burden countries are “facing big challenges. [Since 2015] there’s this stagnation. We’re fighting against population growth, and countries need to get back on track to continue to decrease their malaria burden. So that’s the big focus right now, to reorganize efforts to help countries achieve the goals of the World Health Assembly.”
Asked how these countries might approach the problem differently, Dr. Lindblade said that in the recent past, there was “almost a one-size-fits-all strategy. Now we’re looking much more carefully at conditions at the district level or provincial level and saying, What is it that this particular district or province needs? … It’s becoming much more tailored to the environment and to the specific epidemiological situation. … and I think that’s gotten a lot of people very excited.”
Because of travel restrictions and lockdowns because of COVID-19, the number of imported cases of malaria has declined. That’s the good news. But the pandemic has made elimination more difficult in other ways. For example, the delivery of insecticide-treated bed nets has been delayed in some areas, as has targeted indoor spraying. People in many areas have put off seeking medical care. Diagnostic capabilities have been reduced because of health care personnel having been diverted to address the COVID-19 crisis.
Still, some of the successes in eliminating malaria have been striking. Iran, for example, reduced its cases from about 98,000 in 1991 to 12,000 just 10 years later. Since then, Iran has established rapid response teams equipped with insecticide-impregnated nets, rapid diagnostic tests, and antimalarials. A network of more than 3,700 community health volunteers has been trained and deployed throughout the country.
A key element of Iran’s success – and that of some of the other countries – is the political will to tackle malaria. This translates to funding. Notably, the most successful countries provide free primary health care to everyone, regardless of their legal or residency status. Volunteer migrant workers are trained to diagnose malaria and to educate fellow migrants about the disease and prevention strategies.
Malaysia and China are examples of two countries at risk of importing malaria through their many people who work abroad in malaria-endemic regions. They have had to increase their surveillance.
Although Malaysia has eliminated most malaria species – those transmitted through people – they still have problems with the malaria parasite hosted by monkeys.
The WHO report stresses the lessons learned through their E-2020 program. Two key criteria are political commitment and associated funding. Next are surveillance and efforts to reach everyone, even in geographically remote or marginalized communities. Close surveillance also enables strategies to be modified to local needs.
Countries need to cooperate, especially along border areas and in regard to communications. The WHO stressed the need for countries to have an integrated response in their approach to malaria, including accurate surveillance, diagnostic testing, treatment, and robust education in preventive measures.
Although these successes were not as evident in some high-burden countries, Prof. White applauded their perseverance, noting, “It’s quite difficult to sustain the political momentum. … That endgame to keep the motivation, keep the support, to getting rid of something is hard.”
Prof. White and Dr. Lindberg have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
In its final report on the E-2020 initiative, the World Health Organization touted its progress on its goal of eliminating malaria throughout the world. But critics are charging that progress has stalled.
The E-2020 initiative supported the efforts of 21 countries in eliminating malaria. In a remarkable achievement, especially during the COVID-19 pandemic, eight E-2020 member countries reported zero cases of malaria in 2020. The WHO’s next target is the elimination of malaria in 20 of those countries by 2025.
While applauding these successes, in an interview with this news organization, Sir Nicholas J. White, FRS, professor of tropical medicine, Mahidol University, Salaya, Thailand, and Oxford (England) University, also put those successes in perspective. For one thing, the original 2020 goal was the elimination of malaria in 10 countries. Prof. White acknowledged that there had been very “substantial reductions in global morbidity and mortality” from 2000 to 2015, but he pointed out that those advances have not been sustained.
Prof. White added, “There has never been a really good, detailed inquiry as to why progress has stalled” in the high-burden countries.
Prof. White also provided important historical context, explaining that “100 years ago, malaria was pretty much a global disease. There were few places in the world which did not have malaria. You had malaria up to the Arctic Circle. You had malaria in the United States, particularly in the Tennessee Valley in the southeastern part of the United States. The Centers for Disease Control was formed specifically to counter malaria and malaria interfering with the building of the Erie and Ottawa canals.”
Kim Lindblade, PhD, malaria elimination team lead of the WHO’s Global Malaria Program, addressed those concerns with this news organization. “It’s not completely clear why [progress] has stalled,” she said. “There are lots of potential reasons for it, including stagnating funding.”
Dr. Lindblade added that high-burden countries are “facing big challenges. [Since 2015] there’s this stagnation. We’re fighting against population growth, and countries need to get back on track to continue to decrease their malaria burden. So that’s the big focus right now, to reorganize efforts to help countries achieve the goals of the World Health Assembly.”
Asked how these countries might approach the problem differently, Dr. Lindblade said that in the recent past, there was “almost a one-size-fits-all strategy. Now we’re looking much more carefully at conditions at the district level or provincial level and saying, What is it that this particular district or province needs? … It’s becoming much more tailored to the environment and to the specific epidemiological situation. … and I think that’s gotten a lot of people very excited.”
Because of travel restrictions and lockdowns because of COVID-19, the number of imported cases of malaria has declined. That’s the good news. But the pandemic has made elimination more difficult in other ways. For example, the delivery of insecticide-treated bed nets has been delayed in some areas, as has targeted indoor spraying. People in many areas have put off seeking medical care. Diagnostic capabilities have been reduced because of health care personnel having been diverted to address the COVID-19 crisis.
Still, some of the successes in eliminating malaria have been striking. Iran, for example, reduced its cases from about 98,000 in 1991 to 12,000 just 10 years later. Since then, Iran has established rapid response teams equipped with insecticide-impregnated nets, rapid diagnostic tests, and antimalarials. A network of more than 3,700 community health volunteers has been trained and deployed throughout the country.
A key element of Iran’s success – and that of some of the other countries – is the political will to tackle malaria. This translates to funding. Notably, the most successful countries provide free primary health care to everyone, regardless of their legal or residency status. Volunteer migrant workers are trained to diagnose malaria and to educate fellow migrants about the disease and prevention strategies.
Malaysia and China are examples of two countries at risk of importing malaria through their many people who work abroad in malaria-endemic regions. They have had to increase their surveillance.
Although Malaysia has eliminated most malaria species – those transmitted through people – they still have problems with the malaria parasite hosted by monkeys.
The WHO report stresses the lessons learned through their E-2020 program. Two key criteria are political commitment and associated funding. Next are surveillance and efforts to reach everyone, even in geographically remote or marginalized communities. Close surveillance also enables strategies to be modified to local needs.
Countries need to cooperate, especially along border areas and in regard to communications. The WHO stressed the need for countries to have an integrated response in their approach to malaria, including accurate surveillance, diagnostic testing, treatment, and robust education in preventive measures.
Although these successes were not as evident in some high-burden countries, Prof. White applauded their perseverance, noting, “It’s quite difficult to sustain the political momentum. … That endgame to keep the motivation, keep the support, to getting rid of something is hard.”
Prof. White and Dr. Lindberg have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Formal geriatric assessment should be routine
a geriatric oncologist said during a presentation at the American College of Physicians annual Internal Medicine meeting.
A 2020 ASCO survey, which the speaker, Grant R. Williams, MD, coauthored, found that 9 out of 10 community oncologists assessed at least some older patients differently than younger patients. But only 1 out of 3 did so in a formal manner, Dr. Williams, director of the cancer and aging program at the University of Alabama at Birmingham, said during presentation at virtual meeting.
In most cases, informal geriatric assessment considers only the tip of the ‘geriatric oncology iceberg,’ including chronological age, performance status, tumor characteristics, and organ function, Dr. Williams noted.
In contrast, formal geriatric assessment dives deeper, measuring a series of additional outcome-associated factors: polypharmacy, comorbidities, falls, psychosocial dysfunction, social support, sarcopenia, nutritional deficits, cognitive impairment, and functional issues.
“All these other factors under the surface are critically important to developing a personalized and individualized cancer treatment plan for older adults,” Dr. Williams said.
He went on to explain that elderly cancer patients can be sorted into three broad categories: fit, vulnerable, and frail. Fit and frail patients are relatively easy to identify, but most elderly patients fall into the vulnerable category, Dr. Williams noted.
“It’s really more challenging to identify those individuals across the spectrum than those at the extremes,” Dr. Williams said, noting that formal geriatric assessment can detect problems not found routinely.
Formal geriatric assessment’s value
Geriatric assessment can be used for risk modeling and making life-expectancy calculations. It can also be used as an interventional tool, guiding cancer treatment selection, he said. Furthermore, it can open doors to general health interventions, such as occupational therapy, to reduce fall risk.
Beneficial interventions identified by geriatric assessment have been shown to improve function, reduce chemotherapy toxicities, improve quality of life, and extend survival, Dr. Williams noted.
Formal geriatric assessment may be particularly useful for primary care providers considering referral to an oncologist, he said.
“I think performing a geriatric assessment [prior to referral] would be a great idea. And that’s twofold: Even before you send them to the oncologist, it gives you an idea of how they may tolerate treatment, and frankly, it may give you an idea that they don’t need a referral to the oncologist if they’re particularly frail,” noted Dr. Williams.
Alternatives to formal assessments
When asked how providers can incorporate formal assessments into a busy day at the clinic, Dr. Williams encouraged the use of abbreviated formal assessments, then adding further testing if needed.
“Given known time and support staff restraints, modified geriatric assessment tools have been developed that are either mostly or completely patient-reported,” he said in an interview, referring to the Cancer and Aging Research Group (CARG) Geriatric Assessment and the Cancer and Aging Resilience Evaluation (CARE), respectively.
“[These assessments] can easily be completed before clinical visits or while in the waiting room,” Dr. Williams noted. “The additional objective tests, such as Timed Up and Go, and Mental Status Exam, can be completed if deemed necessary based on these initial assessments.”
Martine Extermann, MD, PhD, provided her suggestions in an interview for what physicians can do to get better outcomes for this patient group.
“The secret of successful anti-cancer treatment in an older person is to be proactive with supportive care,” said Dr. Extermann, leader of the senior adult oncology program at H. Lee Moffitt Cancer Center & Research Institute, Tampa, Fla. “You have to really plan ahead, identify the support gaps, identify the potential problems, and prevent them thoroughly. The upfront work of good patient evaluation will save you a lot of trouble down the line,” she added.
Ms. Extermann also mentioned the challenges to providing care to geriatric patients with cancer, including a lack of financial incentive for physicians to specialize in geriatrics.
Gerontology remains a practice gap
Oncologists who don’t perform geriatric assessments are probably missing more than they think, Dr. Extermann said in an interview.
“Many oncologists don’t fully realize the importance of [geriatric assessment] yet,” Dr. Extermann said. “They kind of think that their internal medicine training will carry through, and they’ll be able to identify everything; actually, we know very well we miss half of what is found by geriatric assessment clinically.”
Gerontology remains a practice gap, Dr. Extermann said, not only within oncology, but across specialties.
“One of the big problems with the U.S. health care system is we don’t have enough geriatricians, and the reason we don’t have enough geriatricians is because we don’t pay them,” she said.
“Geriatrics is the only specialty where you do more training to be paid less, because Medicare doesn’t reimburse geriatric assessment, [and] it doesn’t reimburse geriatric consultation. [This] doesn’t motivate universities to create geriatric clinics and geriatric programs because they will lose money, basically, doing that. If we want to really solve the problem, we have to solve the reimbursement problem up front,” she explained.
Dr. Williams disclosed financial relationships with Carevive Health Systems, Cardinal Health, the National Cancer Institute, and the American Cancer Society. Dr. Extermann reported no conflicts of interest.
a geriatric oncologist said during a presentation at the American College of Physicians annual Internal Medicine meeting.
A 2020 ASCO survey, which the speaker, Grant R. Williams, MD, coauthored, found that 9 out of 10 community oncologists assessed at least some older patients differently than younger patients. But only 1 out of 3 did so in a formal manner, Dr. Williams, director of the cancer and aging program at the University of Alabama at Birmingham, said during presentation at virtual meeting.
In most cases, informal geriatric assessment considers only the tip of the ‘geriatric oncology iceberg,’ including chronological age, performance status, tumor characteristics, and organ function, Dr. Williams noted.
In contrast, formal geriatric assessment dives deeper, measuring a series of additional outcome-associated factors: polypharmacy, comorbidities, falls, psychosocial dysfunction, social support, sarcopenia, nutritional deficits, cognitive impairment, and functional issues.
“All these other factors under the surface are critically important to developing a personalized and individualized cancer treatment plan for older adults,” Dr. Williams said.
He went on to explain that elderly cancer patients can be sorted into three broad categories: fit, vulnerable, and frail. Fit and frail patients are relatively easy to identify, but most elderly patients fall into the vulnerable category, Dr. Williams noted.
“It’s really more challenging to identify those individuals across the spectrum than those at the extremes,” Dr. Williams said, noting that formal geriatric assessment can detect problems not found routinely.
Formal geriatric assessment’s value
Geriatric assessment can be used for risk modeling and making life-expectancy calculations. It can also be used as an interventional tool, guiding cancer treatment selection, he said. Furthermore, it can open doors to general health interventions, such as occupational therapy, to reduce fall risk.
Beneficial interventions identified by geriatric assessment have been shown to improve function, reduce chemotherapy toxicities, improve quality of life, and extend survival, Dr. Williams noted.
Formal geriatric assessment may be particularly useful for primary care providers considering referral to an oncologist, he said.
“I think performing a geriatric assessment [prior to referral] would be a great idea. And that’s twofold: Even before you send them to the oncologist, it gives you an idea of how they may tolerate treatment, and frankly, it may give you an idea that they don’t need a referral to the oncologist if they’re particularly frail,” noted Dr. Williams.
Alternatives to formal assessments
When asked how providers can incorporate formal assessments into a busy day at the clinic, Dr. Williams encouraged the use of abbreviated formal assessments, then adding further testing if needed.
“Given known time and support staff restraints, modified geriatric assessment tools have been developed that are either mostly or completely patient-reported,” he said in an interview, referring to the Cancer and Aging Research Group (CARG) Geriatric Assessment and the Cancer and Aging Resilience Evaluation (CARE), respectively.
“[These assessments] can easily be completed before clinical visits or while in the waiting room,” Dr. Williams noted. “The additional objective tests, such as Timed Up and Go, and Mental Status Exam, can be completed if deemed necessary based on these initial assessments.”
Martine Extermann, MD, PhD, provided her suggestions in an interview for what physicians can do to get better outcomes for this patient group.
“The secret of successful anti-cancer treatment in an older person is to be proactive with supportive care,” said Dr. Extermann, leader of the senior adult oncology program at H. Lee Moffitt Cancer Center & Research Institute, Tampa, Fla. “You have to really plan ahead, identify the support gaps, identify the potential problems, and prevent them thoroughly. The upfront work of good patient evaluation will save you a lot of trouble down the line,” she added.
Ms. Extermann also mentioned the challenges to providing care to geriatric patients with cancer, including a lack of financial incentive for physicians to specialize in geriatrics.
Gerontology remains a practice gap
Oncologists who don’t perform geriatric assessments are probably missing more than they think, Dr. Extermann said in an interview.
“Many oncologists don’t fully realize the importance of [geriatric assessment] yet,” Dr. Extermann said. “They kind of think that their internal medicine training will carry through, and they’ll be able to identify everything; actually, we know very well we miss half of what is found by geriatric assessment clinically.”
Gerontology remains a practice gap, Dr. Extermann said, not only within oncology, but across specialties.
“One of the big problems with the U.S. health care system is we don’t have enough geriatricians, and the reason we don’t have enough geriatricians is because we don’t pay them,” she said.
“Geriatrics is the only specialty where you do more training to be paid less, because Medicare doesn’t reimburse geriatric assessment, [and] it doesn’t reimburse geriatric consultation. [This] doesn’t motivate universities to create geriatric clinics and geriatric programs because they will lose money, basically, doing that. If we want to really solve the problem, we have to solve the reimbursement problem up front,” she explained.
Dr. Williams disclosed financial relationships with Carevive Health Systems, Cardinal Health, the National Cancer Institute, and the American Cancer Society. Dr. Extermann reported no conflicts of interest.
a geriatric oncologist said during a presentation at the American College of Physicians annual Internal Medicine meeting.
A 2020 ASCO survey, which the speaker, Grant R. Williams, MD, coauthored, found that 9 out of 10 community oncologists assessed at least some older patients differently than younger patients. But only 1 out of 3 did so in a formal manner, Dr. Williams, director of the cancer and aging program at the University of Alabama at Birmingham, said during presentation at virtual meeting.
In most cases, informal geriatric assessment considers only the tip of the ‘geriatric oncology iceberg,’ including chronological age, performance status, tumor characteristics, and organ function, Dr. Williams noted.
In contrast, formal geriatric assessment dives deeper, measuring a series of additional outcome-associated factors: polypharmacy, comorbidities, falls, psychosocial dysfunction, social support, sarcopenia, nutritional deficits, cognitive impairment, and functional issues.
“All these other factors under the surface are critically important to developing a personalized and individualized cancer treatment plan for older adults,” Dr. Williams said.
He went on to explain that elderly cancer patients can be sorted into three broad categories: fit, vulnerable, and frail. Fit and frail patients are relatively easy to identify, but most elderly patients fall into the vulnerable category, Dr. Williams noted.
“It’s really more challenging to identify those individuals across the spectrum than those at the extremes,” Dr. Williams said, noting that formal geriatric assessment can detect problems not found routinely.
Formal geriatric assessment’s value
Geriatric assessment can be used for risk modeling and making life-expectancy calculations. It can also be used as an interventional tool, guiding cancer treatment selection, he said. Furthermore, it can open doors to general health interventions, such as occupational therapy, to reduce fall risk.
Beneficial interventions identified by geriatric assessment have been shown to improve function, reduce chemotherapy toxicities, improve quality of life, and extend survival, Dr. Williams noted.
Formal geriatric assessment may be particularly useful for primary care providers considering referral to an oncologist, he said.
“I think performing a geriatric assessment [prior to referral] would be a great idea. And that’s twofold: Even before you send them to the oncologist, it gives you an idea of how they may tolerate treatment, and frankly, it may give you an idea that they don’t need a referral to the oncologist if they’re particularly frail,” noted Dr. Williams.
Alternatives to formal assessments
When asked how providers can incorporate formal assessments into a busy day at the clinic, Dr. Williams encouraged the use of abbreviated formal assessments, then adding further testing if needed.
“Given known time and support staff restraints, modified geriatric assessment tools have been developed that are either mostly or completely patient-reported,” he said in an interview, referring to the Cancer and Aging Research Group (CARG) Geriatric Assessment and the Cancer and Aging Resilience Evaluation (CARE), respectively.
“[These assessments] can easily be completed before clinical visits or while in the waiting room,” Dr. Williams noted. “The additional objective tests, such as Timed Up and Go, and Mental Status Exam, can be completed if deemed necessary based on these initial assessments.”
Martine Extermann, MD, PhD, provided her suggestions in an interview for what physicians can do to get better outcomes for this patient group.
“The secret of successful anti-cancer treatment in an older person is to be proactive with supportive care,” said Dr. Extermann, leader of the senior adult oncology program at H. Lee Moffitt Cancer Center & Research Institute, Tampa, Fla. “You have to really plan ahead, identify the support gaps, identify the potential problems, and prevent them thoroughly. The upfront work of good patient evaluation will save you a lot of trouble down the line,” she added.
Ms. Extermann also mentioned the challenges to providing care to geriatric patients with cancer, including a lack of financial incentive for physicians to specialize in geriatrics.
Gerontology remains a practice gap
Oncologists who don’t perform geriatric assessments are probably missing more than they think, Dr. Extermann said in an interview.
“Many oncologists don’t fully realize the importance of [geriatric assessment] yet,” Dr. Extermann said. “They kind of think that their internal medicine training will carry through, and they’ll be able to identify everything; actually, we know very well we miss half of what is found by geriatric assessment clinically.”
Gerontology remains a practice gap, Dr. Extermann said, not only within oncology, but across specialties.
“One of the big problems with the U.S. health care system is we don’t have enough geriatricians, and the reason we don’t have enough geriatricians is because we don’t pay them,” she said.
“Geriatrics is the only specialty where you do more training to be paid less, because Medicare doesn’t reimburse geriatric assessment, [and] it doesn’t reimburse geriatric consultation. [This] doesn’t motivate universities to create geriatric clinics and geriatric programs because they will lose money, basically, doing that. If we want to really solve the problem, we have to solve the reimbursement problem up front,” she explained.
Dr. Williams disclosed financial relationships with Carevive Health Systems, Cardinal Health, the National Cancer Institute, and the American Cancer Society. Dr. Extermann reported no conflicts of interest.
FROM INTERNAL MEDICINE 2021
Jack Remington, MD, noted toxoplasmosis researcher, dies at 90
Jack. S. Remington, MD, the Stanford (Calif.) University clinical scientist who developed a test to identify babies at risk for dangerous toxoplasmosis, died on April 8 at the age of 90.
Dr. Remington was professor emeritus of infectious diseases at Stanford Medicine. A legendary researcher, Dr. Remington was described by colleagues and trainees as a dogged clinician. Known as “Stat Jack” for his sense of urgency, he retired in 2005.
He died after a fall; it was the last of many. When he wasn’t treating patients or conducting research, Dr. Remington was often rock climbing. Friends said he had broken many bones but was always a passionate climber.
Dr. Remington was retired when Upinder Singh, MD, arrived at Stanford. Now she is chief of infectious diseases and geographic medicine at Stanford Medicine. Dr. Singh said in an interview that Dr. Remington was a bright, forward-thinking scientist.
Dr. Remington conducted research at the Palo Alto Medical Foundation (PAMF), part of the Sutter Health network. He ran a toxoplasmosis serology lab, and it was his baby, Dr. Singh said. In 2019, it was renamed for him: The Dr Jack S. Remington Laboratory for Specialty Diagnostics.
While he conducted research at PAMF, he treated patients at Stanford, where he could see his research benefit them.
“What he held closest to his heart was that scientific endeavors should help patients,” Dr. Singh said.
Born in Chicago in 1931, Dr. Remington did his undergraduate work at Loyola University in Chicago and the University of Illinois, where he graduated from medical school in 1956, according to a statement from Stanford. He spent 2 years as a senior assistant surgeon for the United States Public Health Service and as a researcher at the National Institute of Allergy and Infectious Diseases.
There, he conducted key research on Toxoplasma gondii, a usually dormant parasite that poses a serious risk to anyone with a compromised immune system – a group that includes babies, transplant recipients, and people with HIV. T gondii is the reason pregnant women are told not to clean out litter boxes, because it can be spread through cat feces. Humans also contract toxoplasmosis by eating contaminated meat. The Centers for Disease Control and Prevention estimates that 300 to 4,000 babies are exposed each year and develop toxoplasmosis. Often symptom-free for a period, the children can go on to develop vision problems or developmental delays.
Dr. Remington developed a blood test that measures a baby’s exposure and, therefore, risk for toxoplasmosis. According to the Stanford announcement, “The test distinguished between antibodies that a newborn has passively acquired from its mother through the placental barrier and antibodies that indicate a newborn has actually been infected in the womb by pathogens, notably T. gondii, that had been residing in the mother’s tissues. The latter case meant a baby needed immediate treatment to stave off active toxoplasmosis.”
Dr. Remington also led clinical trials and developed drugs to treat the condition. Stanford reports that he authored or coauthored more than 600 articles and held 11 patents.
He also coauthored the most authoritative textbook in the field. Remington and Klein’s Infectious Diseases of the Fetus and Newborn Infant is now in its eighth edition.
Dr. Remington was elected a fellow of the American College of Physicians in 1966, the London-based Royal College of Physicians in 1999, the American Association for the Advancement of Science in 2000, and the American Academy of Microbiology in 2000. He was a past president of the Western Society for Clinical Research, the Infectious Diseases Society of America, and the International Immunocompromised Host Society.
Friends and colleagues remember him as a dedicated mentor, evidenced by the many trainees who traveled to his 70th birthday party, said Philip Pizzo, MD, professor of pediatrics and immunology at Stanford Medicine. Dr. Pizzo, the former dean of the School of Medicine, met Dr. Remington in 1977 after presenting a research paper on the subject of the immunocompromised host at a New York meeting of the Infectious Diseases Society of America. They became lifelong colleagues and friends.
Dr. Remington had his own kind of confidence and self-assurance, Dr. Pizzo said: “He climbed the most challenging rock faces in the world. It takes a certain kind of personality to do that.”
A version of this article first appeared on Medscape.com.
Jack. S. Remington, MD, the Stanford (Calif.) University clinical scientist who developed a test to identify babies at risk for dangerous toxoplasmosis, died on April 8 at the age of 90.
Dr. Remington was professor emeritus of infectious diseases at Stanford Medicine. A legendary researcher, Dr. Remington was described by colleagues and trainees as a dogged clinician. Known as “Stat Jack” for his sense of urgency, he retired in 2005.
He died after a fall; it was the last of many. When he wasn’t treating patients or conducting research, Dr. Remington was often rock climbing. Friends said he had broken many bones but was always a passionate climber.
Dr. Remington was retired when Upinder Singh, MD, arrived at Stanford. Now she is chief of infectious diseases and geographic medicine at Stanford Medicine. Dr. Singh said in an interview that Dr. Remington was a bright, forward-thinking scientist.
Dr. Remington conducted research at the Palo Alto Medical Foundation (PAMF), part of the Sutter Health network. He ran a toxoplasmosis serology lab, and it was his baby, Dr. Singh said. In 2019, it was renamed for him: The Dr Jack S. Remington Laboratory for Specialty Diagnostics.
While he conducted research at PAMF, he treated patients at Stanford, where he could see his research benefit them.
“What he held closest to his heart was that scientific endeavors should help patients,” Dr. Singh said.
Born in Chicago in 1931, Dr. Remington did his undergraduate work at Loyola University in Chicago and the University of Illinois, where he graduated from medical school in 1956, according to a statement from Stanford. He spent 2 years as a senior assistant surgeon for the United States Public Health Service and as a researcher at the National Institute of Allergy and Infectious Diseases.
There, he conducted key research on Toxoplasma gondii, a usually dormant parasite that poses a serious risk to anyone with a compromised immune system – a group that includes babies, transplant recipients, and people with HIV. T gondii is the reason pregnant women are told not to clean out litter boxes, because it can be spread through cat feces. Humans also contract toxoplasmosis by eating contaminated meat. The Centers for Disease Control and Prevention estimates that 300 to 4,000 babies are exposed each year and develop toxoplasmosis. Often symptom-free for a period, the children can go on to develop vision problems or developmental delays.
Dr. Remington developed a blood test that measures a baby’s exposure and, therefore, risk for toxoplasmosis. According to the Stanford announcement, “The test distinguished between antibodies that a newborn has passively acquired from its mother through the placental barrier and antibodies that indicate a newborn has actually been infected in the womb by pathogens, notably T. gondii, that had been residing in the mother’s tissues. The latter case meant a baby needed immediate treatment to stave off active toxoplasmosis.”
Dr. Remington also led clinical trials and developed drugs to treat the condition. Stanford reports that he authored or coauthored more than 600 articles and held 11 patents.
He also coauthored the most authoritative textbook in the field. Remington and Klein’s Infectious Diseases of the Fetus and Newborn Infant is now in its eighth edition.
Dr. Remington was elected a fellow of the American College of Physicians in 1966, the London-based Royal College of Physicians in 1999, the American Association for the Advancement of Science in 2000, and the American Academy of Microbiology in 2000. He was a past president of the Western Society for Clinical Research, the Infectious Diseases Society of America, and the International Immunocompromised Host Society.
Friends and colleagues remember him as a dedicated mentor, evidenced by the many trainees who traveled to his 70th birthday party, said Philip Pizzo, MD, professor of pediatrics and immunology at Stanford Medicine. Dr. Pizzo, the former dean of the School of Medicine, met Dr. Remington in 1977 after presenting a research paper on the subject of the immunocompromised host at a New York meeting of the Infectious Diseases Society of America. They became lifelong colleagues and friends.
Dr. Remington had his own kind of confidence and self-assurance, Dr. Pizzo said: “He climbed the most challenging rock faces in the world. It takes a certain kind of personality to do that.”
A version of this article first appeared on Medscape.com.
Jack. S. Remington, MD, the Stanford (Calif.) University clinical scientist who developed a test to identify babies at risk for dangerous toxoplasmosis, died on April 8 at the age of 90.
Dr. Remington was professor emeritus of infectious diseases at Stanford Medicine. A legendary researcher, Dr. Remington was described by colleagues and trainees as a dogged clinician. Known as “Stat Jack” for his sense of urgency, he retired in 2005.
He died after a fall; it was the last of many. When he wasn’t treating patients or conducting research, Dr. Remington was often rock climbing. Friends said he had broken many bones but was always a passionate climber.
Dr. Remington was retired when Upinder Singh, MD, arrived at Stanford. Now she is chief of infectious diseases and geographic medicine at Stanford Medicine. Dr. Singh said in an interview that Dr. Remington was a bright, forward-thinking scientist.
Dr. Remington conducted research at the Palo Alto Medical Foundation (PAMF), part of the Sutter Health network. He ran a toxoplasmosis serology lab, and it was his baby, Dr. Singh said. In 2019, it was renamed for him: The Dr Jack S. Remington Laboratory for Specialty Diagnostics.
While he conducted research at PAMF, he treated patients at Stanford, where he could see his research benefit them.
“What he held closest to his heart was that scientific endeavors should help patients,” Dr. Singh said.
Born in Chicago in 1931, Dr. Remington did his undergraduate work at Loyola University in Chicago and the University of Illinois, where he graduated from medical school in 1956, according to a statement from Stanford. He spent 2 years as a senior assistant surgeon for the United States Public Health Service and as a researcher at the National Institute of Allergy and Infectious Diseases.
There, he conducted key research on Toxoplasma gondii, a usually dormant parasite that poses a serious risk to anyone with a compromised immune system – a group that includes babies, transplant recipients, and people with HIV. T gondii is the reason pregnant women are told not to clean out litter boxes, because it can be spread through cat feces. Humans also contract toxoplasmosis by eating contaminated meat. The Centers for Disease Control and Prevention estimates that 300 to 4,000 babies are exposed each year and develop toxoplasmosis. Often symptom-free for a period, the children can go on to develop vision problems or developmental delays.
Dr. Remington developed a blood test that measures a baby’s exposure and, therefore, risk for toxoplasmosis. According to the Stanford announcement, “The test distinguished between antibodies that a newborn has passively acquired from its mother through the placental barrier and antibodies that indicate a newborn has actually been infected in the womb by pathogens, notably T. gondii, that had been residing in the mother’s tissues. The latter case meant a baby needed immediate treatment to stave off active toxoplasmosis.”
Dr. Remington also led clinical trials and developed drugs to treat the condition. Stanford reports that he authored or coauthored more than 600 articles and held 11 patents.
He also coauthored the most authoritative textbook in the field. Remington and Klein’s Infectious Diseases of the Fetus and Newborn Infant is now in its eighth edition.
Dr. Remington was elected a fellow of the American College of Physicians in 1966, the London-based Royal College of Physicians in 1999, the American Association for the Advancement of Science in 2000, and the American Academy of Microbiology in 2000. He was a past president of the Western Society for Clinical Research, the Infectious Diseases Society of America, and the International Immunocompromised Host Society.
Friends and colleagues remember him as a dedicated mentor, evidenced by the many trainees who traveled to his 70th birthday party, said Philip Pizzo, MD, professor of pediatrics and immunology at Stanford Medicine. Dr. Pizzo, the former dean of the School of Medicine, met Dr. Remington in 1977 after presenting a research paper on the subject of the immunocompromised host at a New York meeting of the Infectious Diseases Society of America. They became lifelong colleagues and friends.
Dr. Remington had his own kind of confidence and self-assurance, Dr. Pizzo said: “He climbed the most challenging rock faces in the world. It takes a certain kind of personality to do that.”
A version of this article first appeared on Medscape.com.
COVID-19 outcomes similar with ECMO or mechanical ventilation
Severely ill COVID-19 patients treated with extracorporeal membrane oxygenation (ECMO) had similar survival to hospital discharge and long-term outcomes as survivors treated with mechanical ventilation alone, results of a new, multicenter study suggest.
Importantly, the study also showed that survivors, regardless of the treatment they received, experienced significant deficits following their stay in the ICU and were suffering problems with physical, psychological, and cognitive functioning for months afterward.
At 3 months after discharge, 50% of the survivors reported cognitive dysfunction, ICU-acquired weakness and depression, anxiety, or PTSD; over 25% still required supplemental oxygen; and only one in six survivors were back at work.
The findings were presented April 30 at the American Association for Thoracic Surgery annual meeting.
The study represents the efforts of a multidisciplinary team that included cardiothoracic surgeons, critical care doctors, medical staff at long-term care facilities, and physical therapists in addition to other specialists. The research followed patients at five academic centers: the University of Colorado, the University of Virginia, the University of Kentucky, Johns Hopkins University, and Vanderbilt University.
“We were a multidisciplinary team, a whole variety of people to really track the long-term outcomes for patients who have been critically ill from COVID-19 and survived to hospital discharge,” presenting author Lauren J. Taylor, MD, fellow at the University of Colorado at Denver, Aurora, said in an interview.
It’s unclear currently what happens to these patients once they leave the hospital, she noted. “This is information we have not had, but when we followed these patients in these multidisciplinary clinics, there was a high level of either physical, emotional, or cognitive dysfunction, even for patients who were well enough to be living at home at the time of follow-up.
“So, if you have somebody living at home and they come into the clinic, you assume they are functioning pretty well, but when you actually provide them with cognitive and psychological testing and check their physical capabilities, you find a high degree of deficits throughout the entire cohort of this study,” she said.
The study was prompted by discussion with patients’ family members about the rationale, risks, and benefits of ECMO cannulation in patients with COVID-19 failing mechanical ventilation, senior author Jessica V. Rove, MD, also from the University of Colorado, said in an interview.
“We wanted to find out what their hospital course would be like and what cognitive, physical, or emotional deficits might they experience if they survive,” Dr. Rove said.
The investigators compared 262 mechanically ventilated patients with 46 patients cannulated for ECMO who were hospitalized between March and May 2020.
ECMO patients were younger and traveled farther but there were no significant differences in gender, race, or body mass index.
ECMO patients were mechanically ventilated for longer durations (median, 26 days vs. 13 days) and were more likely to receive inhaled pulmonary vasodilators, neuromuscular blockade, investigational COVID-19 therapies, blood transfusions, and inotropes.
They also experienced greater bleeding and clotting events (P < .01).
Despite a more complex critical illness course, patients treated with ECMO had similar survival at discharge and long-term outcomes, compared with those who were treated with mechanical ventilation alone.
The survival rate for ECMO patients was 69.9%, and for mechanically ventilated patients it was 69.6%.
Of the 215 survivors, 66.5% had documented follow-up within 3 months of discharge from hospital. Most survivors (93.9%) were living at home; a small percentage (16.1%) had returned to work or their usual activities, and 26.2% were still using supplemental oxygen.
These rates did not differ significantly based on ECMO status and rates of physical, psychological, and cognitive deficits did not differ significantly.
“The cognitive, emotional, and physical deficits seen in survivors of critical illness from COVID-19 can only be treated if diagnosed,” Dr. Rove said.
“Detrimental effects can potentially be ameliorated with use of best practices in the ICU, maximizing acute rehabilitation services where indicated, and follow-up with providers in multidisciplinary post-ICU clinics who can assess and treat these patients to optimize survivorship,” she said.
A version of this article first appeared on Medscape.com.
Severely ill COVID-19 patients treated with extracorporeal membrane oxygenation (ECMO) had similar survival to hospital discharge and long-term outcomes as survivors treated with mechanical ventilation alone, results of a new, multicenter study suggest.
Importantly, the study also showed that survivors, regardless of the treatment they received, experienced significant deficits following their stay in the ICU and were suffering problems with physical, psychological, and cognitive functioning for months afterward.
At 3 months after discharge, 50% of the survivors reported cognitive dysfunction, ICU-acquired weakness and depression, anxiety, or PTSD; over 25% still required supplemental oxygen; and only one in six survivors were back at work.
The findings were presented April 30 at the American Association for Thoracic Surgery annual meeting.
The study represents the efforts of a multidisciplinary team that included cardiothoracic surgeons, critical care doctors, medical staff at long-term care facilities, and physical therapists in addition to other specialists. The research followed patients at five academic centers: the University of Colorado, the University of Virginia, the University of Kentucky, Johns Hopkins University, and Vanderbilt University.
“We were a multidisciplinary team, a whole variety of people to really track the long-term outcomes for patients who have been critically ill from COVID-19 and survived to hospital discharge,” presenting author Lauren J. Taylor, MD, fellow at the University of Colorado at Denver, Aurora, said in an interview.
It’s unclear currently what happens to these patients once they leave the hospital, she noted. “This is information we have not had, but when we followed these patients in these multidisciplinary clinics, there was a high level of either physical, emotional, or cognitive dysfunction, even for patients who were well enough to be living at home at the time of follow-up.
“So, if you have somebody living at home and they come into the clinic, you assume they are functioning pretty well, but when you actually provide them with cognitive and psychological testing and check their physical capabilities, you find a high degree of deficits throughout the entire cohort of this study,” she said.
The study was prompted by discussion with patients’ family members about the rationale, risks, and benefits of ECMO cannulation in patients with COVID-19 failing mechanical ventilation, senior author Jessica V. Rove, MD, also from the University of Colorado, said in an interview.
“We wanted to find out what their hospital course would be like and what cognitive, physical, or emotional deficits might they experience if they survive,” Dr. Rove said.
The investigators compared 262 mechanically ventilated patients with 46 patients cannulated for ECMO who were hospitalized between March and May 2020.
ECMO patients were younger and traveled farther but there were no significant differences in gender, race, or body mass index.
ECMO patients were mechanically ventilated for longer durations (median, 26 days vs. 13 days) and were more likely to receive inhaled pulmonary vasodilators, neuromuscular blockade, investigational COVID-19 therapies, blood transfusions, and inotropes.
They also experienced greater bleeding and clotting events (P < .01).
Despite a more complex critical illness course, patients treated with ECMO had similar survival at discharge and long-term outcomes, compared with those who were treated with mechanical ventilation alone.
The survival rate for ECMO patients was 69.9%, and for mechanically ventilated patients it was 69.6%.
Of the 215 survivors, 66.5% had documented follow-up within 3 months of discharge from hospital. Most survivors (93.9%) were living at home; a small percentage (16.1%) had returned to work or their usual activities, and 26.2% were still using supplemental oxygen.
These rates did not differ significantly based on ECMO status and rates of physical, psychological, and cognitive deficits did not differ significantly.
“The cognitive, emotional, and physical deficits seen in survivors of critical illness from COVID-19 can only be treated if diagnosed,” Dr. Rove said.
“Detrimental effects can potentially be ameliorated with use of best practices in the ICU, maximizing acute rehabilitation services where indicated, and follow-up with providers in multidisciplinary post-ICU clinics who can assess and treat these patients to optimize survivorship,” she said.
A version of this article first appeared on Medscape.com.
Severely ill COVID-19 patients treated with extracorporeal membrane oxygenation (ECMO) had similar survival to hospital discharge and long-term outcomes as survivors treated with mechanical ventilation alone, results of a new, multicenter study suggest.
Importantly, the study also showed that survivors, regardless of the treatment they received, experienced significant deficits following their stay in the ICU and were suffering problems with physical, psychological, and cognitive functioning for months afterward.
At 3 months after discharge, 50% of the survivors reported cognitive dysfunction, ICU-acquired weakness and depression, anxiety, or PTSD; over 25% still required supplemental oxygen; and only one in six survivors were back at work.
The findings were presented April 30 at the American Association for Thoracic Surgery annual meeting.
The study represents the efforts of a multidisciplinary team that included cardiothoracic surgeons, critical care doctors, medical staff at long-term care facilities, and physical therapists in addition to other specialists. The research followed patients at five academic centers: the University of Colorado, the University of Virginia, the University of Kentucky, Johns Hopkins University, and Vanderbilt University.
“We were a multidisciplinary team, a whole variety of people to really track the long-term outcomes for patients who have been critically ill from COVID-19 and survived to hospital discharge,” presenting author Lauren J. Taylor, MD, fellow at the University of Colorado at Denver, Aurora, said in an interview.
It’s unclear currently what happens to these patients once they leave the hospital, she noted. “This is information we have not had, but when we followed these patients in these multidisciplinary clinics, there was a high level of either physical, emotional, or cognitive dysfunction, even for patients who were well enough to be living at home at the time of follow-up.
“So, if you have somebody living at home and they come into the clinic, you assume they are functioning pretty well, but when you actually provide them with cognitive and psychological testing and check their physical capabilities, you find a high degree of deficits throughout the entire cohort of this study,” she said.
The study was prompted by discussion with patients’ family members about the rationale, risks, and benefits of ECMO cannulation in patients with COVID-19 failing mechanical ventilation, senior author Jessica V. Rove, MD, also from the University of Colorado, said in an interview.
“We wanted to find out what their hospital course would be like and what cognitive, physical, or emotional deficits might they experience if they survive,” Dr. Rove said.
The investigators compared 262 mechanically ventilated patients with 46 patients cannulated for ECMO who were hospitalized between March and May 2020.
ECMO patients were younger and traveled farther but there were no significant differences in gender, race, or body mass index.
ECMO patients were mechanically ventilated for longer durations (median, 26 days vs. 13 days) and were more likely to receive inhaled pulmonary vasodilators, neuromuscular blockade, investigational COVID-19 therapies, blood transfusions, and inotropes.
They also experienced greater bleeding and clotting events (P < .01).
Despite a more complex critical illness course, patients treated with ECMO had similar survival at discharge and long-term outcomes, compared with those who were treated with mechanical ventilation alone.
The survival rate for ECMO patients was 69.9%, and for mechanically ventilated patients it was 69.6%.
Of the 215 survivors, 66.5% had documented follow-up within 3 months of discharge from hospital. Most survivors (93.9%) were living at home; a small percentage (16.1%) had returned to work or their usual activities, and 26.2% were still using supplemental oxygen.
These rates did not differ significantly based on ECMO status and rates of physical, psychological, and cognitive deficits did not differ significantly.
“The cognitive, emotional, and physical deficits seen in survivors of critical illness from COVID-19 can only be treated if diagnosed,” Dr. Rove said.
“Detrimental effects can potentially be ameliorated with use of best practices in the ICU, maximizing acute rehabilitation services where indicated, and follow-up with providers in multidisciplinary post-ICU clinics who can assess and treat these patients to optimize survivorship,” she said.
A version of this article first appeared on Medscape.com.
New child COVID-19 cases drop for second consecutive week
New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.
Despite that drop, however, based on data in the weekly AAP/CHA report.
New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.
Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.
The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.
There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.
The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.
New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.
Despite that drop, however, based on data in the weekly AAP/CHA report.
New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.
Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.
The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.
There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.
The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.
New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.
Despite that drop, however, based on data in the weekly AAP/CHA report.
New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.
Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.
The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.
There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.
The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.
For cervical cancer screening, any strategy is acceptable
Cytology testing every 3 years, cytology/human papillomavirus cotesting every 5 years, and primary HPV testing every 5 years are similarly effective at reducing cervical cancer risk, said Rachel P. Brook, MD, of the University of California, Los Angeles Health Iris Cantor Women’s Health Center, during a presentation at the annual meeting of the American College of Physicians.
“The most important thing a primary care provider can do is to screen with whatever test is most accessible,” Dr. Brook said in an interview. She also noted that access to screening remains a pressing concern, particularly among underrepresented groups and women in rural areas. Even when women can access testing, follow-up after abnormal results can be inadequate, leading to increased risk of cervical cancer mortality.
To address some of these shortcomings, Dr. Brook provided an overview of current guidelines and appropriate responses to abnormal test results.
First, during her presentation, she noted that guideline recommendations do not apply to patients with additional risk factors, including a compromised immune system, HIV infection, previous treatment of cervical cancer or a high-grade cancerous lesion, or in utero exposure to diethylstilbestrol.
“This is very important,” Dr. Brook said during her presentation. “They should receive individualized care due to their above average risk of cervical cancer.”
Among women with average risk, both the USPSTF 2018 guideline and the ACS 2020 guideline recommend against screening women aged less than 21 years.
In a major change to the most recent ACS guideline, screening women aged 21-24 years is no longer recommended, in contrast with the USPSTF guideline, which still calls for cytology every 3 years for this age group. This recommendation by the USPSTF extends to women aged 25-29 years, a group for which the ACS recommends primary HPV testing every 5 years, cytology/HPV cotesting every 5 years, or cytology testing every 3 years. For both organizations, any of these three testing methods is recommended for women aged 30-65 years, followed by discontinuation of testing after 65 years, given adequate prior screening.
“For all these recommendations and guidelines, they’re pertinent to patients regardless of HPV vaccination status,” Dr. Brook said. But she added that increased rates of HPV vaccination may affect future screening guidelines, as vaccinated patients are more likely to have false positive cytology results because of low-risk HPV strains. This trend may steer future recommendations toward primary HPV testing, Dr. Brook said.
Presently, for applicable age groups, the ACS guideline favors HPV testing alone over cytology alone or cotesting, whereas the USPSTF guideline offers no preference between the three testing strategies.
Primary HPV vs. cytology testing
Dr. Brook said a single negative HPV test provides more than 95% assurance that a patient will not develop cervical cancer or a cancer precursor within the next 5 years. One negative HPV test offers similar reliability to about 3 negative cytology tests.
Switching to a 5-year testing cycle may be unsettling for patients who are used to getting a Pap test every year, but having a conversation about test accuracy can help assuage patient concerns, she said.
Still, Dr. Brook emphasized that any of the three testing strategies is ultimately acceptable.
“The take-home message here is – truly – that any of the recommended screening options will greatly reduce cervical cancer risk,” Dr. Brook said. “So, screen. And if there is any confusion or concern with your patients about which [screening strategy to use], just help them decide on any of the three. But please screen.”
Self-swabbing could improve screening in certain groups
To improve screening rates, particularly for women with poor access and those averse to a speculum exam, Dr. Brook highlighted self-swabbing primary HPV tests, which may soon be available. While no self-swabbing HPV tests are yet approved by the Food and Drug Administration, they offer a 76% sensitivity rate for cervical intraepithelial neoplasia grade 2, and a rate of 85% for CIN3, compared with 91% for physician-collected samples.
Regardless of the exact HPV test, Dr. Brook advised appropriate reflex testing.
“We need to make sure all primary HPV screening tests positive for types other than HPV-16 or -18 will require additional reflex triage testing with cytology,” Dr. Brook said in interview. “If not – if a woman has a primary HPV screening test that is positive and I cannot perform reflex cytology – I have to bring her back for an additional test and speculum exam to get cytology, which is an unnecessary burden to the patient, and also increases testing.”
Kathy L. MacLaughlin, MD, associate professor of family medicine at Mayo Clinic, Rochester, Minn., said this is one drawback to self-swabbing tests in an interview.
“If there is a positive HPV result [with a self-swabbing test], the patient will need to have a clinic appointment for Pap collection [if one of the ‘other’ 12 HPV types are identified], or be referred for a colposcopy [if HPV types 16 or 18 are identified],” Dr. MacLaughlin said. “There need to be plans in place for access to those services.”
Incidentally, it may be women who face barriers to access that need self-swabbing HPV tests the most, according to Dr. MacLaughlin.
“I think there is significant potential to improve screening rates among never-screened and underscreened women and those are the groups for whom this makes the most sense,” she said. “I don’t think anyone is suggesting that women who have the means and interest in scheduling a face-to-face visit for clinician-collected screening switch to self-screening, but it is a promising option [once FDA approved] for reaching other women and reducing disparities in screening rates.”
Dr. MacLaughlin suggested that self-screening programs could operate outside of normal business hours in a variety of settings, such as homes, community centers, and churches.
Until self-screening is an option, Dr. MacLaughlin agreed with Dr. Brook that any of the three testing strategies is suitable for screening, and recommended that primary care providers seize the opportunities presented to them.
“Individual primary care providers can improve screening rates by offering to update cervical cancer screening at a clinic appointment even if that was not the primary indication for the visit, especially for women who are long overdue,” Dr. MacLaughlin said. “If there is just no time to fit in the screening or the patient declines, then order a return visit and have the patient stop at the appointment desk as they leave.”
“I recognize we are asked to fit in more and more in less time, but I’ve found this to be effective when I have capacity in the clinic day to offer it,” she added.
Dr. Brook and Dr. MacLaughlin reported no conflicts of interest.
Cytology testing every 3 years, cytology/human papillomavirus cotesting every 5 years, and primary HPV testing every 5 years are similarly effective at reducing cervical cancer risk, said Rachel P. Brook, MD, of the University of California, Los Angeles Health Iris Cantor Women’s Health Center, during a presentation at the annual meeting of the American College of Physicians.
“The most important thing a primary care provider can do is to screen with whatever test is most accessible,” Dr. Brook said in an interview. She also noted that access to screening remains a pressing concern, particularly among underrepresented groups and women in rural areas. Even when women can access testing, follow-up after abnormal results can be inadequate, leading to increased risk of cervical cancer mortality.
To address some of these shortcomings, Dr. Brook provided an overview of current guidelines and appropriate responses to abnormal test results.
First, during her presentation, she noted that guideline recommendations do not apply to patients with additional risk factors, including a compromised immune system, HIV infection, previous treatment of cervical cancer or a high-grade cancerous lesion, or in utero exposure to diethylstilbestrol.
“This is very important,” Dr. Brook said during her presentation. “They should receive individualized care due to their above average risk of cervical cancer.”
Among women with average risk, both the USPSTF 2018 guideline and the ACS 2020 guideline recommend against screening women aged less than 21 years.
In a major change to the most recent ACS guideline, screening women aged 21-24 years is no longer recommended, in contrast with the USPSTF guideline, which still calls for cytology every 3 years for this age group. This recommendation by the USPSTF extends to women aged 25-29 years, a group for which the ACS recommends primary HPV testing every 5 years, cytology/HPV cotesting every 5 years, or cytology testing every 3 years. For both organizations, any of these three testing methods is recommended for women aged 30-65 years, followed by discontinuation of testing after 65 years, given adequate prior screening.
“For all these recommendations and guidelines, they’re pertinent to patients regardless of HPV vaccination status,” Dr. Brook said. But she added that increased rates of HPV vaccination may affect future screening guidelines, as vaccinated patients are more likely to have false positive cytology results because of low-risk HPV strains. This trend may steer future recommendations toward primary HPV testing, Dr. Brook said.
Presently, for applicable age groups, the ACS guideline favors HPV testing alone over cytology alone or cotesting, whereas the USPSTF guideline offers no preference between the three testing strategies.
Primary HPV vs. cytology testing
Dr. Brook said a single negative HPV test provides more than 95% assurance that a patient will not develop cervical cancer or a cancer precursor within the next 5 years. One negative HPV test offers similar reliability to about 3 negative cytology tests.
Switching to a 5-year testing cycle may be unsettling for patients who are used to getting a Pap test every year, but having a conversation about test accuracy can help assuage patient concerns, she said.
Still, Dr. Brook emphasized that any of the three testing strategies is ultimately acceptable.
“The take-home message here is – truly – that any of the recommended screening options will greatly reduce cervical cancer risk,” Dr. Brook said. “So, screen. And if there is any confusion or concern with your patients about which [screening strategy to use], just help them decide on any of the three. But please screen.”
Self-swabbing could improve screening in certain groups
To improve screening rates, particularly for women with poor access and those averse to a speculum exam, Dr. Brook highlighted self-swabbing primary HPV tests, which may soon be available. While no self-swabbing HPV tests are yet approved by the Food and Drug Administration, they offer a 76% sensitivity rate for cervical intraepithelial neoplasia grade 2, and a rate of 85% for CIN3, compared with 91% for physician-collected samples.
Regardless of the exact HPV test, Dr. Brook advised appropriate reflex testing.
“We need to make sure all primary HPV screening tests positive for types other than HPV-16 or -18 will require additional reflex triage testing with cytology,” Dr. Brook said in interview. “If not – if a woman has a primary HPV screening test that is positive and I cannot perform reflex cytology – I have to bring her back for an additional test and speculum exam to get cytology, which is an unnecessary burden to the patient, and also increases testing.”
Kathy L. MacLaughlin, MD, associate professor of family medicine at Mayo Clinic, Rochester, Minn., said this is one drawback to self-swabbing tests in an interview.
“If there is a positive HPV result [with a self-swabbing test], the patient will need to have a clinic appointment for Pap collection [if one of the ‘other’ 12 HPV types are identified], or be referred for a colposcopy [if HPV types 16 or 18 are identified],” Dr. MacLaughlin said. “There need to be plans in place for access to those services.”
Incidentally, it may be women who face barriers to access that need self-swabbing HPV tests the most, according to Dr. MacLaughlin.
“I think there is significant potential to improve screening rates among never-screened and underscreened women and those are the groups for whom this makes the most sense,” she said. “I don’t think anyone is suggesting that women who have the means and interest in scheduling a face-to-face visit for clinician-collected screening switch to self-screening, but it is a promising option [once FDA approved] for reaching other women and reducing disparities in screening rates.”
Dr. MacLaughlin suggested that self-screening programs could operate outside of normal business hours in a variety of settings, such as homes, community centers, and churches.
Until self-screening is an option, Dr. MacLaughlin agreed with Dr. Brook that any of the three testing strategies is suitable for screening, and recommended that primary care providers seize the opportunities presented to them.
“Individual primary care providers can improve screening rates by offering to update cervical cancer screening at a clinic appointment even if that was not the primary indication for the visit, especially for women who are long overdue,” Dr. MacLaughlin said. “If there is just no time to fit in the screening or the patient declines, then order a return visit and have the patient stop at the appointment desk as they leave.”
“I recognize we are asked to fit in more and more in less time, but I’ve found this to be effective when I have capacity in the clinic day to offer it,” she added.
Dr. Brook and Dr. MacLaughlin reported no conflicts of interest.
Cytology testing every 3 years, cytology/human papillomavirus cotesting every 5 years, and primary HPV testing every 5 years are similarly effective at reducing cervical cancer risk, said Rachel P. Brook, MD, of the University of California, Los Angeles Health Iris Cantor Women’s Health Center, during a presentation at the annual meeting of the American College of Physicians.
“The most important thing a primary care provider can do is to screen with whatever test is most accessible,” Dr. Brook said in an interview. She also noted that access to screening remains a pressing concern, particularly among underrepresented groups and women in rural areas. Even when women can access testing, follow-up after abnormal results can be inadequate, leading to increased risk of cervical cancer mortality.
To address some of these shortcomings, Dr. Brook provided an overview of current guidelines and appropriate responses to abnormal test results.
First, during her presentation, she noted that guideline recommendations do not apply to patients with additional risk factors, including a compromised immune system, HIV infection, previous treatment of cervical cancer or a high-grade cancerous lesion, or in utero exposure to diethylstilbestrol.
“This is very important,” Dr. Brook said during her presentation. “They should receive individualized care due to their above average risk of cervical cancer.”
Among women with average risk, both the USPSTF 2018 guideline and the ACS 2020 guideline recommend against screening women aged less than 21 years.
In a major change to the most recent ACS guideline, screening women aged 21-24 years is no longer recommended, in contrast with the USPSTF guideline, which still calls for cytology every 3 years for this age group. This recommendation by the USPSTF extends to women aged 25-29 years, a group for which the ACS recommends primary HPV testing every 5 years, cytology/HPV cotesting every 5 years, or cytology testing every 3 years. For both organizations, any of these three testing methods is recommended for women aged 30-65 years, followed by discontinuation of testing after 65 years, given adequate prior screening.
“For all these recommendations and guidelines, they’re pertinent to patients regardless of HPV vaccination status,” Dr. Brook said. But she added that increased rates of HPV vaccination may affect future screening guidelines, as vaccinated patients are more likely to have false positive cytology results because of low-risk HPV strains. This trend may steer future recommendations toward primary HPV testing, Dr. Brook said.
Presently, for applicable age groups, the ACS guideline favors HPV testing alone over cytology alone or cotesting, whereas the USPSTF guideline offers no preference between the three testing strategies.
Primary HPV vs. cytology testing
Dr. Brook said a single negative HPV test provides more than 95% assurance that a patient will not develop cervical cancer or a cancer precursor within the next 5 years. One negative HPV test offers similar reliability to about 3 negative cytology tests.
Switching to a 5-year testing cycle may be unsettling for patients who are used to getting a Pap test every year, but having a conversation about test accuracy can help assuage patient concerns, she said.
Still, Dr. Brook emphasized that any of the three testing strategies is ultimately acceptable.
“The take-home message here is – truly – that any of the recommended screening options will greatly reduce cervical cancer risk,” Dr. Brook said. “So, screen. And if there is any confusion or concern with your patients about which [screening strategy to use], just help them decide on any of the three. But please screen.”
Self-swabbing could improve screening in certain groups
To improve screening rates, particularly for women with poor access and those averse to a speculum exam, Dr. Brook highlighted self-swabbing primary HPV tests, which may soon be available. While no self-swabbing HPV tests are yet approved by the Food and Drug Administration, they offer a 76% sensitivity rate for cervical intraepithelial neoplasia grade 2, and a rate of 85% for CIN3, compared with 91% for physician-collected samples.
Regardless of the exact HPV test, Dr. Brook advised appropriate reflex testing.
“We need to make sure all primary HPV screening tests positive for types other than HPV-16 or -18 will require additional reflex triage testing with cytology,” Dr. Brook said in interview. “If not – if a woman has a primary HPV screening test that is positive and I cannot perform reflex cytology – I have to bring her back for an additional test and speculum exam to get cytology, which is an unnecessary burden to the patient, and also increases testing.”
Kathy L. MacLaughlin, MD, associate professor of family medicine at Mayo Clinic, Rochester, Minn., said this is one drawback to self-swabbing tests in an interview.
“If there is a positive HPV result [with a self-swabbing test], the patient will need to have a clinic appointment for Pap collection [if one of the ‘other’ 12 HPV types are identified], or be referred for a colposcopy [if HPV types 16 or 18 are identified],” Dr. MacLaughlin said. “There need to be plans in place for access to those services.”
Incidentally, it may be women who face barriers to access that need self-swabbing HPV tests the most, according to Dr. MacLaughlin.
“I think there is significant potential to improve screening rates among never-screened and underscreened women and those are the groups for whom this makes the most sense,” she said. “I don’t think anyone is suggesting that women who have the means and interest in scheduling a face-to-face visit for clinician-collected screening switch to self-screening, but it is a promising option [once FDA approved] for reaching other women and reducing disparities in screening rates.”
Dr. MacLaughlin suggested that self-screening programs could operate outside of normal business hours in a variety of settings, such as homes, community centers, and churches.
Until self-screening is an option, Dr. MacLaughlin agreed with Dr. Brook that any of the three testing strategies is suitable for screening, and recommended that primary care providers seize the opportunities presented to them.
“Individual primary care providers can improve screening rates by offering to update cervical cancer screening at a clinic appointment even if that was not the primary indication for the visit, especially for women who are long overdue,” Dr. MacLaughlin said. “If there is just no time to fit in the screening or the patient declines, then order a return visit and have the patient stop at the appointment desk as they leave.”
“I recognize we are asked to fit in more and more in less time, but I’ve found this to be effective when I have capacity in the clinic day to offer it,” she added.
Dr. Brook and Dr. MacLaughlin reported no conflicts of interest.
FROM INTERNAL MEDICINE 2021
The cloudy role of cannabis as a neuropsychiatric treatment
Although the healing properties of cannabis have been touted for millennia, research into its potential neuropsychiatric applications truly began to take off in the 1990s following the discovery of the cannabinoid system in the brain. This led to speculation that cannabis could play a therapeutic role in regulating dopamine, serotonin, and other neurotransmitters and offer a new means of treating various ailments.
At the same time, efforts to liberalize marijuana laws have successfully played out in several nations, including the United States, where, as of April 29, 36 states provide some access to cannabis. These dual tracks – medical and political – have made cannabis an increasingly accepted part of the cultural fabric.
Yet with this development has come a new quandary for clinicians. Medical cannabis has been made widely available to patients and has largely outpaced the clinical evidence, leaving it unclear how and for which indications it should be used.
The many forms of medical cannabis
Cannabis is a genus of plants that includes marijuana (Cannabis sativa) and hemp. These plants contain over 100 compounds, including terpenes, flavonoids, and – most importantly for medicinal applications – cannabinoids.
The most abundant cannabinoid in marijuana is the psychotropic delta-9-tetrahydrocannabinol (THC), which imparts the “high” sensation. The next most abundant cannabinoid is cannabidiol (CBD), which is the nonpsychotropic. THC and CBD are the most extensively studied cannabinoids, together and in isolation. Evidence suggests that other cannabinoids and terpenoids may also hold medical promise and that cannabis’ various compounds can work synergistically to produce a so-called entourage effect.
Patients walking into a typical medical cannabis dispensary will be faced with several plant-derived and synthetic options, which can differ considerably in terms of the ratios and amounts of THC and CBD they contain, as well in how they are consumed (i.e., via smoke, vapor, ingestion, topical administration, or oromucosal spray), all of which can alter their effects. Further complicating matters is the varying level of oversight each state and country has in how and whether they test for and accurately label products’ potency, cannabinoid content, and possible impurities.
Medically authorized, prescription cannabis products go through an official regulatory review process, and indications/contraindications have been established for them. To date, the Food and Drug Administration has approved one cannabis-derived drug product – Epidiolex (purified CBD) – for the treatment of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome in patients aged 2 years and older. The FDA has also approved three synthetic cannabis-related drug products – Marinol, Syndros (or dronabinol, created from synthetic THC), and Cesamet (or nabilone, a synthetic cannabinoid similar to THC) – all of which are indicated for treatment-related nausea and anorexia associated with weight loss in AIDS patients.
Surveys of medical cannabis consumers indicate that most people cannot distinguish between THC and CBD, so the first role that physicians find themselves in when recommending this treatment may be in helping patients navigate the volume of options.
Promising treatment for pain
Chronic pain is the leading reason patients seek out medical cannabis. It is also the indication that most researchers agree has the strongest evidence to support its use.
“In my mind, the most promising immediate use for medical cannabis is with THC for pain,” Diana M. Martinez, MD, a professor of psychiatry at Columbia University, New York, who specializes in addiction research, said in a recent MDedge podcast. “THC could be added to the armamentarium of pain medications that we use today.”
In a 2015 systematic literature review, researchers assessed 28 randomized, controlled trials (RCTs) of the use of cannabinoids for chronic pain. They reported that a variety of formulations resulted in at least a 30% reduction in the odds of pain, compared with placebo. A meta-analysis of five RCTs involving patients with neuropathic pain found a 30% reduction in pain over placebo with inhaled, vaporized cannabis. Varying results have been reported in additional studies for this indication. The National Academies of Sciences, Engineering, and Medicine concluded that there was a substantial body of evidence that cannabis is an effective treatment for chronic pain in adults.
The ongoing opioid epidemic has lent these results additional relevance.
Seeing this firsthand has caused Mark Steven Wallace, MD, a pain management specialist and chair of the division of pain medicine at the University of California San Diego Health, to reconsider offering cannabis to his patients.
“I think it’s probably more efficacious, just from my personal experience, and it’s a much lower risk of abuse and dependence than the opioids,” he said.
Dr. Wallace advised that clinicians who treat pain consider the ratios of cannabinoids.
“This is anecdotal, but we do find that with the combination of the two, CBD reduces the psychoactive effects of the THC. The ratios we use during the daytime range around 20 mg of CBD to 1 mg of THC,” he said.
In a recent secondary analysis of an RCT involving patients with painful diabetic peripheral neuropathy, Dr. Wallace and colleagues showed that THC’s effects appear to reverse themselves at a certain level.
“As the THC level goes up, the pain reduces until you reach about 16 ng/mL; then it starts going in the opposite direction, and pain will start to increase,” he said. “Even recreational cannabis users have reported that they avoid high doses because it’s very aversive. Using cannabis is all about, start low and go slow.”
A mixed bag for neurologic indications
There are relatively limited data on the use of medical cannabis for other neurologic conditions, and results have varied. For uses other than pain management, the evidence that does exist is strongest regarding epilepsy, said Daniel Freedman, DO, assistant professor of neurology at the University of Texas at Austin. He noted “multiple high-quality RCTs showing that pharmaceutical-grade CBD can reduce seizures associated with two particular epilepsy syndromes: Dravet Syndrome and Lennox Gastaut.”
These findings led to the FDA’s 2018 approval of Epidiolex for these syndromes. In earlier years, interest in CBD for pediatric seizures was largely driven by anecdotal parental reports of its benefits. NASEM’s 2017 overview on medical cannabis found evidence from subsequent RCTs in this indication to be insufficient. Clinicians who prescribe CBD for this indication must be vigilant because it can interact with several commonly used antiepileptic drugs.
Cannabinoid treatments have also shown success in alleviating muscle spasticity resulting from multiple sclerosis, most prominently in the form of nabiximols (Sativex), a standardized oralmucosal spray containing approximately equal quantities of THC and CBD. Nabiximols is approved in Europe but not in the United States. Moderate evidence supports the efficacy of these and other treatments over placebo in reducing muscle spasticity. Patient ratings of its effects tend to be higher than clinician assessment.
Parkinson’s disease has not yet been approved as an indication for treatment with cannabis or cannabinoids, yet a growing body of preclinical data suggests these could influence the dopaminergic system, said Carsten Buhmann, MD, from the department of neurology at the University Medical Center Hamburg-Eppendorf (Germany).
“In general, cannabinoids modulate basal-ganglia function on two levels which are especially relevant in Parkinson’s disease, i.e., the glutamatergic/dopaminergic synaptic neurotransmission and the corticostriatal plasticity,” he said. “Furthermore, activation of the endocannabinoid system might induce neuroprotective effects related to direct receptor-independent mechanisms, activation of anti-inflammatory cascades in glial cells via the cannabinoid receptor type 2, and antiglutamatergic antiexcitotoxic properties.”
Dr. Buhmann said that currently, clinical evidence is scarce, consisting of only four double-blind, placebo-controlled RCTs involving 49 patients. Various cannabinoids and methods of administering treatment were employed. Improvement was only observed in one of these RCTs, which found that the cannabinoid receptor agonist nabilone significantly reduced levodopa-induced dyskinesia for patients with Parkinson’s disease. Subjective data support a beneficial effect. In a nationwide survey of 1,348 respondents conducted by Dr. Buhmann and colleagues, the majority of medical cannabis users reported that it improved their symptoms (54% with oral CBD and 68% with inhaled THC-containing cannabis).
NASEM concluded that there was insufficient evidence to support the efficacy of medical cannabis for other neurologic conditions, including Tourette syndrome, amyotrophic lateral sclerosis, Huntington disease, dystonia, or dementia. A 2020 position statement from the American Academy of Neurology cited the lack of sufficient peer-reviewed research as the reason it could not currently support the use of cannabis for neurologic disorders.
Yet, according to Dr. Freedman, who served as a coauthor of the AAN position statement, this hasn’t stymied research interest in the topic. He’s seen a substantial uptick in studies of CBD over the past 2 years. “The body of evidence grows, but I still see many claims being made without evidence. And no one seems to care about all the negative trials.”
Cannabis as a treatment for, and cause of, psychiatric disorders
Mental health problems – such as anxiety, depression, and PTSD – are among the most common reasons patients seek out medical cannabis. There is an understandable interest in using cannabis and cannabinoids to treat psychiatric disorders. Preclinical studies suggest that the endocannabinoid system plays a prominent role in modulating feelings of anxiety, mood, and fear. As with opioids and chronic pain management, there is hope that medical cannabis may provide a means of reducing prescription anxiolytics and their associated risks.
The authors of the first systematic review (BMC Psychiatry. 2020 Jan 16;20[1]:24) of the use of medical cannabis for major psychiatric disorders noted that the current evidence was “encouraging, albeit embryonic.”
Meta-analyses have indicated a small but positive association between cannabis use and anxiety, although this may reflect the fact that patients with anxiety sought out this treatment. Given the risks for substance use disorders among patients with anxiety, CBD may present a more viable option. Positive results have been shown as treatment for generalized social anxiety disorder.
Limited but encouraging results have also been reported regarding the alleviation of PTSD symptoms with both cannabis and CBD, although the body of high-quality evidence hasn’t notably progressed since 2017, when NASEM declared that the evidence was insufficient. Supportive evidence is similarly lacking regarding the treatment of depression. Longitudinal studies suggest that cannabis use, particularly heavy use, may increase the risk of developing this disorder. Because THC is psychoactive, it is advised that it be avoided by patients at risk for psychotic disorders. However, CBD has yielded limited benefits for patients with treatment-resistant schizophrenia and for young people at risk for psychosis.
The use of medical cannabis for psychiatric conditions requires a complex balancing act, inasmuch as these treatments may exacerbate the very problems they are intended to alleviate.
Marta Di Forti, MD, PhD, professor of psychiatric research at Kings College London, has been at the forefront of determining the mental health risks of continued cannabis use. In 2019, Dr. Di Forti developed the first and only Cannabis Clinic for Patients With Psychosis in London where she and her colleagues have continued to elucidate this connection.
Dr. Di Forti and colleagues have linked daily cannabis use to an increase in the risk of experiencing psychotic disorder, compared with never using it. That risk was further increased among users of high-potency cannabis (≥10% THC). The latter finding has troubling implications, because concentrations of THC have steadily risen since 1970. By contrast, CBD concentrations have remained generally stable. High-potency cannabis products are common in both recreational and medicinal settings.
“For somebody prescribing medicinal cannabis that has a ≥10% concentration of THC, I’d be particularly wary of the risk of psychosis,” said Dr. Di Forti. “If you’re expecting people to use a high content of THC daily to medicate pain or a chronic condition, you even more so need to be aware that this is a potential side effect.”
Dr. Di Forti noted that her findings come from a cohort of recreational users, most of whom were aged 18-35 years.
“There have actually not been studies developed from collecting data in this area from groups specifically using cannabis for medicinal rather than recreational purposes,” she said.
She added that she personally has no concerns about the use of medical cannabis but wants clinicians to be aware of the risk for psychosis, to structure their patient conversations to identify risk factors or family histories of psychosis, and to become knowledgeable in detecting the often subtle signs of its initial onset.
When cannabis-associated psychosis occurs, Dr. Di Forti said it is primarily treated with conventional means, such as antipsychotics and therapeutic interventions and by refraining from using cannabis. Achieving the latter goal can be a challenge for patients who are daily users of high-potency cannabis. Currently, there are no treatment options such as those offered to patients withdrawing from the use of alcohol or opioids. Dr. Di Forti and colleagues are currently researching a solution to that problem through the use of another medical cannabis, the oromucosal spray Sativex, which has been approved in the European Union.
The regulatory obstacles to clarifying cannabis’ role in medicine
That currently there is limited or no evidence to support the use of medical cannabis for the treatment of neuropsychiatric conditions points to the inherent difficulties in conducting high-level research in this area.
“There’s a tremendous shortage of reliable data, largely due to regulatory barriers,” said Dr. Martinez.
Since 1970, cannabis has been listed as a Schedule I drug that is illegal to prescribe (the Agriculture Improvement Act of 2018 removed hemp from such restrictions). The FDA has issued guidance for researchers who wish to investigate treatments using Cannabis sativa or its derivatives in which the THC content is greater than 0.3%. Such research requires regular interactions with several federal agencies, including the Drug Enforcement Administration.
“It’s impossible to do multicenter RCTs with large numbers of patients, because you can’t transport cannabis across state lines,” said Dr. Wallace.
Regulatory restrictions regarding medical cannabis vary considerably throughout the world (the European Monitoring Center for Drugs and Drug Addiction provides a useful breakdown of this on their website). The lack of consistency in regulatory oversight acts as an impediment for conducting large-scale international multicenter studies on the topic.
Dr. Buhmann noted that, in Germany, cannabis has been broadly approved for treatment-resistant conditions with severe symptoms that impair quality of life. In addition, it is easy to be reimbursed for the use of cannabis as a medical treatment. These factors serve as disincentives for the funding of high-quality studies.
“It’s likely that no pharmaceutical company will do an expensive RCT to get an approval for Parkinson’s disease because it is already possible to prescribe medical cannabis of any type of THC-containing cannabinoid, dose, or route of application,” Dr. Buhmann said.
In the face of such restrictions and barriers, researchers are turning to ambitious real-world data projects to better understand medical cannabis’ efficacy and safety. A notable example is ProjectTwenty21, which is supported by the Royal College of Psychiatrists. The project is collecting outcomes of the use of medical cannabis among 20,000 U.K. patients whose conventional treatments of chronic pain, anxiety disorder, epilepsy, multiple sclerosis, PTSD, substance use disorder, and Tourette syndrome failed.
Dr. Freedman noted that the continued lack of high-quality data creates a void that commercial interests fill with unfounded claims.
“The danger is that patients might abandon a medication or intervention backed by robust science in favor of something without any science or evidence behind it,” he said. “There is no reason not to expect the same level of data for claims about cannabis products as we would expect from pharmaceutical products.”
Getting to that point, however, will require that the authorities governing clinical trials begin to view cannabis as the research community does, as a possible treatment with potential value, rather than as an illicit drug that needs to be tamped down.
A version of this article first appeared on Medscape.com.
Although the healing properties of cannabis have been touted for millennia, research into its potential neuropsychiatric applications truly began to take off in the 1990s following the discovery of the cannabinoid system in the brain. This led to speculation that cannabis could play a therapeutic role in regulating dopamine, serotonin, and other neurotransmitters and offer a new means of treating various ailments.
At the same time, efforts to liberalize marijuana laws have successfully played out in several nations, including the United States, where, as of April 29, 36 states provide some access to cannabis. These dual tracks – medical and political – have made cannabis an increasingly accepted part of the cultural fabric.
Yet with this development has come a new quandary for clinicians. Medical cannabis has been made widely available to patients and has largely outpaced the clinical evidence, leaving it unclear how and for which indications it should be used.
The many forms of medical cannabis
Cannabis is a genus of plants that includes marijuana (Cannabis sativa) and hemp. These plants contain over 100 compounds, including terpenes, flavonoids, and – most importantly for medicinal applications – cannabinoids.
The most abundant cannabinoid in marijuana is the psychotropic delta-9-tetrahydrocannabinol (THC), which imparts the “high” sensation. The next most abundant cannabinoid is cannabidiol (CBD), which is the nonpsychotropic. THC and CBD are the most extensively studied cannabinoids, together and in isolation. Evidence suggests that other cannabinoids and terpenoids may also hold medical promise and that cannabis’ various compounds can work synergistically to produce a so-called entourage effect.
Patients walking into a typical medical cannabis dispensary will be faced with several plant-derived and synthetic options, which can differ considerably in terms of the ratios and amounts of THC and CBD they contain, as well in how they are consumed (i.e., via smoke, vapor, ingestion, topical administration, or oromucosal spray), all of which can alter their effects. Further complicating matters is the varying level of oversight each state and country has in how and whether they test for and accurately label products’ potency, cannabinoid content, and possible impurities.
Medically authorized, prescription cannabis products go through an official regulatory review process, and indications/contraindications have been established for them. To date, the Food and Drug Administration has approved one cannabis-derived drug product – Epidiolex (purified CBD) – for the treatment of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome in patients aged 2 years and older. The FDA has also approved three synthetic cannabis-related drug products – Marinol, Syndros (or dronabinol, created from synthetic THC), and Cesamet (or nabilone, a synthetic cannabinoid similar to THC) – all of which are indicated for treatment-related nausea and anorexia associated with weight loss in AIDS patients.
Surveys of medical cannabis consumers indicate that most people cannot distinguish between THC and CBD, so the first role that physicians find themselves in when recommending this treatment may be in helping patients navigate the volume of options.
Promising treatment for pain
Chronic pain is the leading reason patients seek out medical cannabis. It is also the indication that most researchers agree has the strongest evidence to support its use.
“In my mind, the most promising immediate use for medical cannabis is with THC for pain,” Diana M. Martinez, MD, a professor of psychiatry at Columbia University, New York, who specializes in addiction research, said in a recent MDedge podcast. “THC could be added to the armamentarium of pain medications that we use today.”
In a 2015 systematic literature review, researchers assessed 28 randomized, controlled trials (RCTs) of the use of cannabinoids for chronic pain. They reported that a variety of formulations resulted in at least a 30% reduction in the odds of pain, compared with placebo. A meta-analysis of five RCTs involving patients with neuropathic pain found a 30% reduction in pain over placebo with inhaled, vaporized cannabis. Varying results have been reported in additional studies for this indication. The National Academies of Sciences, Engineering, and Medicine concluded that there was a substantial body of evidence that cannabis is an effective treatment for chronic pain in adults.
The ongoing opioid epidemic has lent these results additional relevance.
Seeing this firsthand has caused Mark Steven Wallace, MD, a pain management specialist and chair of the division of pain medicine at the University of California San Diego Health, to reconsider offering cannabis to his patients.
“I think it’s probably more efficacious, just from my personal experience, and it’s a much lower risk of abuse and dependence than the opioids,” he said.
Dr. Wallace advised that clinicians who treat pain consider the ratios of cannabinoids.
“This is anecdotal, but we do find that with the combination of the two, CBD reduces the psychoactive effects of the THC. The ratios we use during the daytime range around 20 mg of CBD to 1 mg of THC,” he said.
In a recent secondary analysis of an RCT involving patients with painful diabetic peripheral neuropathy, Dr. Wallace and colleagues showed that THC’s effects appear to reverse themselves at a certain level.
“As the THC level goes up, the pain reduces until you reach about 16 ng/mL; then it starts going in the opposite direction, and pain will start to increase,” he said. “Even recreational cannabis users have reported that they avoid high doses because it’s very aversive. Using cannabis is all about, start low and go slow.”
A mixed bag for neurologic indications
There are relatively limited data on the use of medical cannabis for other neurologic conditions, and results have varied. For uses other than pain management, the evidence that does exist is strongest regarding epilepsy, said Daniel Freedman, DO, assistant professor of neurology at the University of Texas at Austin. He noted “multiple high-quality RCTs showing that pharmaceutical-grade CBD can reduce seizures associated with two particular epilepsy syndromes: Dravet Syndrome and Lennox Gastaut.”
These findings led to the FDA’s 2018 approval of Epidiolex for these syndromes. In earlier years, interest in CBD for pediatric seizures was largely driven by anecdotal parental reports of its benefits. NASEM’s 2017 overview on medical cannabis found evidence from subsequent RCTs in this indication to be insufficient. Clinicians who prescribe CBD for this indication must be vigilant because it can interact with several commonly used antiepileptic drugs.
Cannabinoid treatments have also shown success in alleviating muscle spasticity resulting from multiple sclerosis, most prominently in the form of nabiximols (Sativex), a standardized oralmucosal spray containing approximately equal quantities of THC and CBD. Nabiximols is approved in Europe but not in the United States. Moderate evidence supports the efficacy of these and other treatments over placebo in reducing muscle spasticity. Patient ratings of its effects tend to be higher than clinician assessment.
Parkinson’s disease has not yet been approved as an indication for treatment with cannabis or cannabinoids, yet a growing body of preclinical data suggests these could influence the dopaminergic system, said Carsten Buhmann, MD, from the department of neurology at the University Medical Center Hamburg-Eppendorf (Germany).
“In general, cannabinoids modulate basal-ganglia function on two levels which are especially relevant in Parkinson’s disease, i.e., the glutamatergic/dopaminergic synaptic neurotransmission and the corticostriatal plasticity,” he said. “Furthermore, activation of the endocannabinoid system might induce neuroprotective effects related to direct receptor-independent mechanisms, activation of anti-inflammatory cascades in glial cells via the cannabinoid receptor type 2, and antiglutamatergic antiexcitotoxic properties.”
Dr. Buhmann said that currently, clinical evidence is scarce, consisting of only four double-blind, placebo-controlled RCTs involving 49 patients. Various cannabinoids and methods of administering treatment were employed. Improvement was only observed in one of these RCTs, which found that the cannabinoid receptor agonist nabilone significantly reduced levodopa-induced dyskinesia for patients with Parkinson’s disease. Subjective data support a beneficial effect. In a nationwide survey of 1,348 respondents conducted by Dr. Buhmann and colleagues, the majority of medical cannabis users reported that it improved their symptoms (54% with oral CBD and 68% with inhaled THC-containing cannabis).
NASEM concluded that there was insufficient evidence to support the efficacy of medical cannabis for other neurologic conditions, including Tourette syndrome, amyotrophic lateral sclerosis, Huntington disease, dystonia, or dementia. A 2020 position statement from the American Academy of Neurology cited the lack of sufficient peer-reviewed research as the reason it could not currently support the use of cannabis for neurologic disorders.
Yet, according to Dr. Freedman, who served as a coauthor of the AAN position statement, this hasn’t stymied research interest in the topic. He’s seen a substantial uptick in studies of CBD over the past 2 years. “The body of evidence grows, but I still see many claims being made without evidence. And no one seems to care about all the negative trials.”
Cannabis as a treatment for, and cause of, psychiatric disorders
Mental health problems – such as anxiety, depression, and PTSD – are among the most common reasons patients seek out medical cannabis. There is an understandable interest in using cannabis and cannabinoids to treat psychiatric disorders. Preclinical studies suggest that the endocannabinoid system plays a prominent role in modulating feelings of anxiety, mood, and fear. As with opioids and chronic pain management, there is hope that medical cannabis may provide a means of reducing prescription anxiolytics and their associated risks.
The authors of the first systematic review (BMC Psychiatry. 2020 Jan 16;20[1]:24) of the use of medical cannabis for major psychiatric disorders noted that the current evidence was “encouraging, albeit embryonic.”
Meta-analyses have indicated a small but positive association between cannabis use and anxiety, although this may reflect the fact that patients with anxiety sought out this treatment. Given the risks for substance use disorders among patients with anxiety, CBD may present a more viable option. Positive results have been shown as treatment for generalized social anxiety disorder.
Limited but encouraging results have also been reported regarding the alleviation of PTSD symptoms with both cannabis and CBD, although the body of high-quality evidence hasn’t notably progressed since 2017, when NASEM declared that the evidence was insufficient. Supportive evidence is similarly lacking regarding the treatment of depression. Longitudinal studies suggest that cannabis use, particularly heavy use, may increase the risk of developing this disorder. Because THC is psychoactive, it is advised that it be avoided by patients at risk for psychotic disorders. However, CBD has yielded limited benefits for patients with treatment-resistant schizophrenia and for young people at risk for psychosis.
The use of medical cannabis for psychiatric conditions requires a complex balancing act, inasmuch as these treatments may exacerbate the very problems they are intended to alleviate.
Marta Di Forti, MD, PhD, professor of psychiatric research at Kings College London, has been at the forefront of determining the mental health risks of continued cannabis use. In 2019, Dr. Di Forti developed the first and only Cannabis Clinic for Patients With Psychosis in London where she and her colleagues have continued to elucidate this connection.
Dr. Di Forti and colleagues have linked daily cannabis use to an increase in the risk of experiencing psychotic disorder, compared with never using it. That risk was further increased among users of high-potency cannabis (≥10% THC). The latter finding has troubling implications, because concentrations of THC have steadily risen since 1970. By contrast, CBD concentrations have remained generally stable. High-potency cannabis products are common in both recreational and medicinal settings.
“For somebody prescribing medicinal cannabis that has a ≥10% concentration of THC, I’d be particularly wary of the risk of psychosis,” said Dr. Di Forti. “If you’re expecting people to use a high content of THC daily to medicate pain or a chronic condition, you even more so need to be aware that this is a potential side effect.”
Dr. Di Forti noted that her findings come from a cohort of recreational users, most of whom were aged 18-35 years.
“There have actually not been studies developed from collecting data in this area from groups specifically using cannabis for medicinal rather than recreational purposes,” she said.
She added that she personally has no concerns about the use of medical cannabis but wants clinicians to be aware of the risk for psychosis, to structure their patient conversations to identify risk factors or family histories of psychosis, and to become knowledgeable in detecting the often subtle signs of its initial onset.
When cannabis-associated psychosis occurs, Dr. Di Forti said it is primarily treated with conventional means, such as antipsychotics and therapeutic interventions and by refraining from using cannabis. Achieving the latter goal can be a challenge for patients who are daily users of high-potency cannabis. Currently, there are no treatment options such as those offered to patients withdrawing from the use of alcohol or opioids. Dr. Di Forti and colleagues are currently researching a solution to that problem through the use of another medical cannabis, the oromucosal spray Sativex, which has been approved in the European Union.
The regulatory obstacles to clarifying cannabis’ role in medicine
That currently there is limited or no evidence to support the use of medical cannabis for the treatment of neuropsychiatric conditions points to the inherent difficulties in conducting high-level research in this area.
“There’s a tremendous shortage of reliable data, largely due to regulatory barriers,” said Dr. Martinez.
Since 1970, cannabis has been listed as a Schedule I drug that is illegal to prescribe (the Agriculture Improvement Act of 2018 removed hemp from such restrictions). The FDA has issued guidance for researchers who wish to investigate treatments using Cannabis sativa or its derivatives in which the THC content is greater than 0.3%. Such research requires regular interactions with several federal agencies, including the Drug Enforcement Administration.
“It’s impossible to do multicenter RCTs with large numbers of patients, because you can’t transport cannabis across state lines,” said Dr. Wallace.
Regulatory restrictions regarding medical cannabis vary considerably throughout the world (the European Monitoring Center for Drugs and Drug Addiction provides a useful breakdown of this on their website). The lack of consistency in regulatory oversight acts as an impediment for conducting large-scale international multicenter studies on the topic.
Dr. Buhmann noted that, in Germany, cannabis has been broadly approved for treatment-resistant conditions with severe symptoms that impair quality of life. In addition, it is easy to be reimbursed for the use of cannabis as a medical treatment. These factors serve as disincentives for the funding of high-quality studies.
“It’s likely that no pharmaceutical company will do an expensive RCT to get an approval for Parkinson’s disease because it is already possible to prescribe medical cannabis of any type of THC-containing cannabinoid, dose, or route of application,” Dr. Buhmann said.
In the face of such restrictions and barriers, researchers are turning to ambitious real-world data projects to better understand medical cannabis’ efficacy and safety. A notable example is ProjectTwenty21, which is supported by the Royal College of Psychiatrists. The project is collecting outcomes of the use of medical cannabis among 20,000 U.K. patients whose conventional treatments of chronic pain, anxiety disorder, epilepsy, multiple sclerosis, PTSD, substance use disorder, and Tourette syndrome failed.
Dr. Freedman noted that the continued lack of high-quality data creates a void that commercial interests fill with unfounded claims.
“The danger is that patients might abandon a medication or intervention backed by robust science in favor of something without any science or evidence behind it,” he said. “There is no reason not to expect the same level of data for claims about cannabis products as we would expect from pharmaceutical products.”
Getting to that point, however, will require that the authorities governing clinical trials begin to view cannabis as the research community does, as a possible treatment with potential value, rather than as an illicit drug that needs to be tamped down.
A version of this article first appeared on Medscape.com.
Although the healing properties of cannabis have been touted for millennia, research into its potential neuropsychiatric applications truly began to take off in the 1990s following the discovery of the cannabinoid system in the brain. This led to speculation that cannabis could play a therapeutic role in regulating dopamine, serotonin, and other neurotransmitters and offer a new means of treating various ailments.
At the same time, efforts to liberalize marijuana laws have successfully played out in several nations, including the United States, where, as of April 29, 36 states provide some access to cannabis. These dual tracks – medical and political – have made cannabis an increasingly accepted part of the cultural fabric.
Yet with this development has come a new quandary for clinicians. Medical cannabis has been made widely available to patients and has largely outpaced the clinical evidence, leaving it unclear how and for which indications it should be used.
The many forms of medical cannabis
Cannabis is a genus of plants that includes marijuana (Cannabis sativa) and hemp. These plants contain over 100 compounds, including terpenes, flavonoids, and – most importantly for medicinal applications – cannabinoids.
The most abundant cannabinoid in marijuana is the psychotropic delta-9-tetrahydrocannabinol (THC), which imparts the “high” sensation. The next most abundant cannabinoid is cannabidiol (CBD), which is the nonpsychotropic. THC and CBD are the most extensively studied cannabinoids, together and in isolation. Evidence suggests that other cannabinoids and terpenoids may also hold medical promise and that cannabis’ various compounds can work synergistically to produce a so-called entourage effect.
Patients walking into a typical medical cannabis dispensary will be faced with several plant-derived and synthetic options, which can differ considerably in terms of the ratios and amounts of THC and CBD they contain, as well in how they are consumed (i.e., via smoke, vapor, ingestion, topical administration, or oromucosal spray), all of which can alter their effects. Further complicating matters is the varying level of oversight each state and country has in how and whether they test for and accurately label products’ potency, cannabinoid content, and possible impurities.
Medically authorized, prescription cannabis products go through an official regulatory review process, and indications/contraindications have been established for them. To date, the Food and Drug Administration has approved one cannabis-derived drug product – Epidiolex (purified CBD) – for the treatment of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome in patients aged 2 years and older. The FDA has also approved three synthetic cannabis-related drug products – Marinol, Syndros (or dronabinol, created from synthetic THC), and Cesamet (or nabilone, a synthetic cannabinoid similar to THC) – all of which are indicated for treatment-related nausea and anorexia associated with weight loss in AIDS patients.
Surveys of medical cannabis consumers indicate that most people cannot distinguish between THC and CBD, so the first role that physicians find themselves in when recommending this treatment may be in helping patients navigate the volume of options.
Promising treatment for pain
Chronic pain is the leading reason patients seek out medical cannabis. It is also the indication that most researchers agree has the strongest evidence to support its use.
“In my mind, the most promising immediate use for medical cannabis is with THC for pain,” Diana M. Martinez, MD, a professor of psychiatry at Columbia University, New York, who specializes in addiction research, said in a recent MDedge podcast. “THC could be added to the armamentarium of pain medications that we use today.”
In a 2015 systematic literature review, researchers assessed 28 randomized, controlled trials (RCTs) of the use of cannabinoids for chronic pain. They reported that a variety of formulations resulted in at least a 30% reduction in the odds of pain, compared with placebo. A meta-analysis of five RCTs involving patients with neuropathic pain found a 30% reduction in pain over placebo with inhaled, vaporized cannabis. Varying results have been reported in additional studies for this indication. The National Academies of Sciences, Engineering, and Medicine concluded that there was a substantial body of evidence that cannabis is an effective treatment for chronic pain in adults.
The ongoing opioid epidemic has lent these results additional relevance.
Seeing this firsthand has caused Mark Steven Wallace, MD, a pain management specialist and chair of the division of pain medicine at the University of California San Diego Health, to reconsider offering cannabis to his patients.
“I think it’s probably more efficacious, just from my personal experience, and it’s a much lower risk of abuse and dependence than the opioids,” he said.
Dr. Wallace advised that clinicians who treat pain consider the ratios of cannabinoids.
“This is anecdotal, but we do find that with the combination of the two, CBD reduces the psychoactive effects of the THC. The ratios we use during the daytime range around 20 mg of CBD to 1 mg of THC,” he said.
In a recent secondary analysis of an RCT involving patients with painful diabetic peripheral neuropathy, Dr. Wallace and colleagues showed that THC’s effects appear to reverse themselves at a certain level.
“As the THC level goes up, the pain reduces until you reach about 16 ng/mL; then it starts going in the opposite direction, and pain will start to increase,” he said. “Even recreational cannabis users have reported that they avoid high doses because it’s very aversive. Using cannabis is all about, start low and go slow.”
A mixed bag for neurologic indications
There are relatively limited data on the use of medical cannabis for other neurologic conditions, and results have varied. For uses other than pain management, the evidence that does exist is strongest regarding epilepsy, said Daniel Freedman, DO, assistant professor of neurology at the University of Texas at Austin. He noted “multiple high-quality RCTs showing that pharmaceutical-grade CBD can reduce seizures associated with two particular epilepsy syndromes: Dravet Syndrome and Lennox Gastaut.”
These findings led to the FDA’s 2018 approval of Epidiolex for these syndromes. In earlier years, interest in CBD for pediatric seizures was largely driven by anecdotal parental reports of its benefits. NASEM’s 2017 overview on medical cannabis found evidence from subsequent RCTs in this indication to be insufficient. Clinicians who prescribe CBD for this indication must be vigilant because it can interact with several commonly used antiepileptic drugs.
Cannabinoid treatments have also shown success in alleviating muscle spasticity resulting from multiple sclerosis, most prominently in the form of nabiximols (Sativex), a standardized oralmucosal spray containing approximately equal quantities of THC and CBD. Nabiximols is approved in Europe but not in the United States. Moderate evidence supports the efficacy of these and other treatments over placebo in reducing muscle spasticity. Patient ratings of its effects tend to be higher than clinician assessment.
Parkinson’s disease has not yet been approved as an indication for treatment with cannabis or cannabinoids, yet a growing body of preclinical data suggests these could influence the dopaminergic system, said Carsten Buhmann, MD, from the department of neurology at the University Medical Center Hamburg-Eppendorf (Germany).
“In general, cannabinoids modulate basal-ganglia function on two levels which are especially relevant in Parkinson’s disease, i.e., the glutamatergic/dopaminergic synaptic neurotransmission and the corticostriatal plasticity,” he said. “Furthermore, activation of the endocannabinoid system might induce neuroprotective effects related to direct receptor-independent mechanisms, activation of anti-inflammatory cascades in glial cells via the cannabinoid receptor type 2, and antiglutamatergic antiexcitotoxic properties.”
Dr. Buhmann said that currently, clinical evidence is scarce, consisting of only four double-blind, placebo-controlled RCTs involving 49 patients. Various cannabinoids and methods of administering treatment were employed. Improvement was only observed in one of these RCTs, which found that the cannabinoid receptor agonist nabilone significantly reduced levodopa-induced dyskinesia for patients with Parkinson’s disease. Subjective data support a beneficial effect. In a nationwide survey of 1,348 respondents conducted by Dr. Buhmann and colleagues, the majority of medical cannabis users reported that it improved their symptoms (54% with oral CBD and 68% with inhaled THC-containing cannabis).
NASEM concluded that there was insufficient evidence to support the efficacy of medical cannabis for other neurologic conditions, including Tourette syndrome, amyotrophic lateral sclerosis, Huntington disease, dystonia, or dementia. A 2020 position statement from the American Academy of Neurology cited the lack of sufficient peer-reviewed research as the reason it could not currently support the use of cannabis for neurologic disorders.
Yet, according to Dr. Freedman, who served as a coauthor of the AAN position statement, this hasn’t stymied research interest in the topic. He’s seen a substantial uptick in studies of CBD over the past 2 years. “The body of evidence grows, but I still see many claims being made without evidence. And no one seems to care about all the negative trials.”
Cannabis as a treatment for, and cause of, psychiatric disorders
Mental health problems – such as anxiety, depression, and PTSD – are among the most common reasons patients seek out medical cannabis. There is an understandable interest in using cannabis and cannabinoids to treat psychiatric disorders. Preclinical studies suggest that the endocannabinoid system plays a prominent role in modulating feelings of anxiety, mood, and fear. As with opioids and chronic pain management, there is hope that medical cannabis may provide a means of reducing prescription anxiolytics and their associated risks.
The authors of the first systematic review (BMC Psychiatry. 2020 Jan 16;20[1]:24) of the use of medical cannabis for major psychiatric disorders noted that the current evidence was “encouraging, albeit embryonic.”
Meta-analyses have indicated a small but positive association between cannabis use and anxiety, although this may reflect the fact that patients with anxiety sought out this treatment. Given the risks for substance use disorders among patients with anxiety, CBD may present a more viable option. Positive results have been shown as treatment for generalized social anxiety disorder.
Limited but encouraging results have also been reported regarding the alleviation of PTSD symptoms with both cannabis and CBD, although the body of high-quality evidence hasn’t notably progressed since 2017, when NASEM declared that the evidence was insufficient. Supportive evidence is similarly lacking regarding the treatment of depression. Longitudinal studies suggest that cannabis use, particularly heavy use, may increase the risk of developing this disorder. Because THC is psychoactive, it is advised that it be avoided by patients at risk for psychotic disorders. However, CBD has yielded limited benefits for patients with treatment-resistant schizophrenia and for young people at risk for psychosis.
The use of medical cannabis for psychiatric conditions requires a complex balancing act, inasmuch as these treatments may exacerbate the very problems they are intended to alleviate.
Marta Di Forti, MD, PhD, professor of psychiatric research at Kings College London, has been at the forefront of determining the mental health risks of continued cannabis use. In 2019, Dr. Di Forti developed the first and only Cannabis Clinic for Patients With Psychosis in London where she and her colleagues have continued to elucidate this connection.
Dr. Di Forti and colleagues have linked daily cannabis use to an increase in the risk of experiencing psychotic disorder, compared with never using it. That risk was further increased among users of high-potency cannabis (≥10% THC). The latter finding has troubling implications, because concentrations of THC have steadily risen since 1970. By contrast, CBD concentrations have remained generally stable. High-potency cannabis products are common in both recreational and medicinal settings.
“For somebody prescribing medicinal cannabis that has a ≥10% concentration of THC, I’d be particularly wary of the risk of psychosis,” said Dr. Di Forti. “If you’re expecting people to use a high content of THC daily to medicate pain or a chronic condition, you even more so need to be aware that this is a potential side effect.”
Dr. Di Forti noted that her findings come from a cohort of recreational users, most of whom were aged 18-35 years.
“There have actually not been studies developed from collecting data in this area from groups specifically using cannabis for medicinal rather than recreational purposes,” she said.
She added that she personally has no concerns about the use of medical cannabis but wants clinicians to be aware of the risk for psychosis, to structure their patient conversations to identify risk factors or family histories of psychosis, and to become knowledgeable in detecting the often subtle signs of its initial onset.
When cannabis-associated psychosis occurs, Dr. Di Forti said it is primarily treated with conventional means, such as antipsychotics and therapeutic interventions and by refraining from using cannabis. Achieving the latter goal can be a challenge for patients who are daily users of high-potency cannabis. Currently, there are no treatment options such as those offered to patients withdrawing from the use of alcohol or opioids. Dr. Di Forti and colleagues are currently researching a solution to that problem through the use of another medical cannabis, the oromucosal spray Sativex, which has been approved in the European Union.
The regulatory obstacles to clarifying cannabis’ role in medicine
That currently there is limited or no evidence to support the use of medical cannabis for the treatment of neuropsychiatric conditions points to the inherent difficulties in conducting high-level research in this area.
“There’s a tremendous shortage of reliable data, largely due to regulatory barriers,” said Dr. Martinez.
Since 1970, cannabis has been listed as a Schedule I drug that is illegal to prescribe (the Agriculture Improvement Act of 2018 removed hemp from such restrictions). The FDA has issued guidance for researchers who wish to investigate treatments using Cannabis sativa or its derivatives in which the THC content is greater than 0.3%. Such research requires regular interactions with several federal agencies, including the Drug Enforcement Administration.
“It’s impossible to do multicenter RCTs with large numbers of patients, because you can’t transport cannabis across state lines,” said Dr. Wallace.
Regulatory restrictions regarding medical cannabis vary considerably throughout the world (the European Monitoring Center for Drugs and Drug Addiction provides a useful breakdown of this on their website). The lack of consistency in regulatory oversight acts as an impediment for conducting large-scale international multicenter studies on the topic.
Dr. Buhmann noted that, in Germany, cannabis has been broadly approved for treatment-resistant conditions with severe symptoms that impair quality of life. In addition, it is easy to be reimbursed for the use of cannabis as a medical treatment. These factors serve as disincentives for the funding of high-quality studies.
“It’s likely that no pharmaceutical company will do an expensive RCT to get an approval for Parkinson’s disease because it is already possible to prescribe medical cannabis of any type of THC-containing cannabinoid, dose, or route of application,” Dr. Buhmann said.
In the face of such restrictions and barriers, researchers are turning to ambitious real-world data projects to better understand medical cannabis’ efficacy and safety. A notable example is ProjectTwenty21, which is supported by the Royal College of Psychiatrists. The project is collecting outcomes of the use of medical cannabis among 20,000 U.K. patients whose conventional treatments of chronic pain, anxiety disorder, epilepsy, multiple sclerosis, PTSD, substance use disorder, and Tourette syndrome failed.
Dr. Freedman noted that the continued lack of high-quality data creates a void that commercial interests fill with unfounded claims.
“The danger is that patients might abandon a medication or intervention backed by robust science in favor of something without any science or evidence behind it,” he said. “There is no reason not to expect the same level of data for claims about cannabis products as we would expect from pharmaceutical products.”
Getting to that point, however, will require that the authorities governing clinical trials begin to view cannabis as the research community does, as a possible treatment with potential value, rather than as an illicit drug that needs to be tamped down.
A version of this article first appeared on Medscape.com.
Doctors lose jobs after speaking out about unsafe conditions
In April 2020, hospitalist Samantha Houston, MD, lost her job at Baptist Memorial Hospital–North, in Oxford, Miss., after she publicly campaigned to get donations of N95 masks for nurses. Dr. Houston filed a lawsuit against the hospital, saying she was improperly fired for speaking out. The lawsuit has not yet gone to trial.
In January 2017, emergency physician Raymond Brovont, MD, was fired by EmCare, an emergency physician staffing company, after reporting understaffing at hospitals with which it contracted in the Kansas City, Mo., area. Dr. Brovont sued EmCare, and the company lost the case. In February 2019, it was ordered to pay him $13.1 million in damages.
These are just two of several cases in recent years in which physicians have spoken out about problems involving patient care and have been sanctioned. Other physicians who see problems choose to stay silent.
Doctors often hesitate to speak out because of the prospect of losing their jobs. A 2013 study of emergency physicians found that nearly 20% reported a possible or real threat to their employment if they expressed concerns about quality of care.
When physicians do not speak openly about important medical issues, the quality of care in their institutions suffers, said a coauthor of the study, Larry D. Weiss, MD, JD, a retired professor of emergency medicine at the University of Maryland, Baltimore.
“Physicians can’t effectively represent patients if they are always thinking they can get fired for what they say,” Dr. Weiss said. “If you don’t have protections like due process, which is often the case, you are less likely to speak out.”
In the first few weeks, health care facilities were struggling to obtain personal protective equipment (PPE) and to create policies that would keep patients and caregivers safe.
Physicians such as Dr. Houston took the initiative to make sure their institutions were taking the right steps against COVID-19 and found themselves at loggerheads with administrators who were concerned that their organizations were being portrayed as unsafe.
The case of one physician who spoke out
One of the highest-profile cases of a physician speaking out and being removed from work during the pandemic is that of Ming Lin, MD, an emergency physician who lost a job he had held for 17 years at St. Joseph Medical Center, in Bellingham, Wash. Dr. Lin lost his job after he made a series of Facebook posts that criticized the hospital’s COVID-19 preparedness efforts.
In an interview, Dr. Lin discussed the details of his situation to a degree that rarely occurs in such cases. This is one of the most extensive interviews he has granted.
Postings on Facebook
Dr. Lin said that on the basis of an intense study of the virus at the onset of the pandemic, he developed many ideas as to what could be done to mitigate its spread. While working as a locum tenens physician on his time off, he could see how others dealt with COVID-19.
Dr. Lin said from past experiences he did not feel that he could present his ideas directly to administration and be heard, so he decided to air his ideas about how his hospital could handle COVID-19 on his Facebook page, which drew a large audience.
He said he was certain that hospital administrators were reading his posts. He said receptionists at this hospital were advised not to wear masks, evidently because it would alarm patients. Dr. Lin said he posted concerns about their safety and called for them to wear masks. Soon after, the hospital directed receptionists to wear masks.
Dr. Lin’s Facebook posts also criticized the hospital for taking what he felt was too long to get results on COVID-19 tests. “It was taking them up to 10 days to get test results, because samples were being sent to a lab in California,” he said. He suggested it would be faster to send samples to the University of Washington. Soon after, the hospital started sending samples there.
In just a couple of weeks, Dr. Lin said, he voiced almost a dozen concerns. Each time the hospital made changes in line with his recommendations. Although he didn’t get any direct acknowledgment from the hospital for his help, he said he felt he was making a positive impact.
How employers react to physicians who speak out
Physicians who speak out about conditions tend to deeply disturb administrators, said William P. Sullivan, DO, JD, an emergency physician and lawyer in Frankfort, Ill., who has written about physicians being terminated by hospitals.
“These physicians go to the news media or they use social media,” Dr. Sullivan said, “but hospital administrators don’t want the public to hear bad things about their hospital.”
Then the public might not come to the hospital, which is an administrator’s worst nightmare. Even if physicians think their criticisms are reasonable, administrators may still fear a resulting drop in patients.
Dr. Houston, for example, was helping her Mississippi hospital by collecting donations of N95 masks for nurses, but to administrators, it showed that the hospital did not have enough masks.
“It is not helpful to stoke fear and anxiety, even if the intent is sincere,” a spokesperson for the hospital said.
Administrator fires back
Dr. Lin’s posts were deeply concerning to Richard DeCarlo, chief operating officer of PeaceHealth, which runs St. Joseph Hospital. Mr. DeCarlo discussed his concerns in a video interview in April with the blogger Zubin Damania, MD, known as ZDoggMD.
Comments on Dr. Lin’s Facebook posts showed that people “were fearful to go to the hospital,” he told Dr. Damania. “They were concluding that they would need to drive to another hospital.”
Mr. DeCarlo said he was also unhappy that Dr. Lin did not directly contact administrators about his concerns. “He didn’t communicate with his medical director,” Mr. DeCarlo said in the interview. “The ED staff had been meeting three times a week with the chief medical officer to make sure they had everything they needed, but he only attended one of these meetings and didn’t ask any questions.”
Dr. Lin maintains he did ask questions at the first meeting but stopped attending because he felt he wasn’t being heeded. “I found their tone not very receptive,” he said.
Doctor allegedly offered “misinformation”
At the start of the pandemic, some hospitals made it clear what would happen to doctors who brought up lack of PPE or other problems to the media. For example, NYU Langone Medical Center in New York sent an email to staff warning that speaking to the media without permission “will be subject to disciplinary action, including termination.”
PeaceHealth took a different tack. “It’s not that we have a policy that says don’t ever talk to the media,” Mr. DeCarlo said in the ZDoggMD interview, but in Dr. Lin’s case, “what was at issue was the misinformation. His leader went to him and said, ‘Look, you’re posting things that aren’t accurate.’ ”
Dr. Lin disputes that he provided any misinformation. In the interview, Mr. DeCarlo cited just one example of alleged misinformation. He said Dr. Lin called for a tent outside the emergency department (ED) to protect patients entering the department from aerosol exposure to COVID-19. Mr. DeCarlo said the tent was not needed because fewer people were using the ED.
“To put it in an extreme way,” Mr. DeCarlo said of Dr. Lin’s posts, “it was like yelling fire in a theater where there is not a fire.”
Dr. Lin said the hospital did briefly erect a tent and then removed it, and he still insisted that a tent was a good idea. He added that Mr. DeCarlo never mentioned any of the other suggestions Dr. Lin made, nor did he state that the hospital adopted them.
Doctor gets a warning
Dr. Lin said that after he started posting his concerns, he got a call from the emergency department director who worked for TeamHealth, an emergency medicine staffing firm that contracted with PeaceHealth and employed Dr. Lin, too.
Dr. Lin said his immediate supervisor at TeamHealth told him the hospital was unhappy with his posts and that he should take them down and suggested he might be fired. Dr. Lin said the supervisor also asked him to apologize to the hospital administration for these posts, but he refused to do so.
“Retracting and apologizing was not only wrong but would have left me vulnerable to being terminated with no repercussions,” he said.
“At that point, I realized I had crossed the Rubicon,” Dr. Lin said. He thought he might well be fired, no matter what he did, so he took his story to The Seattle Times, which had a much wider platform than his Facebook page had.
Dr. Lin lost his job at St. Joseph a week after The Seattle Times story about him appeared. “About 10 minutes before my shift was supposed to start, I received a text message from TeamHealth saying that someone else would be taking the shift,” he said.
In a release, TeamHealth insisted Dr. Lin was not fired and that he was scheduled to be reassigned to work at other hospitals. Dr. Lin, however, said he was not told this at the time and that he found out later that the new assignment would involve a pay cut and a significant commute. He said he has not taken any new assignments from TeamHealth since he lost his job at St. Joseph.
Dr. Lin has filed a lawsuit against PeaceHealth, TeamHealth, and Mr. DeCarlo, asking for his job back and for an apology. He said he has not asked for any financial damages at this point.
Since leaving St. Joseph, Dr. Lin has been working as an administrator for the Indian Health Service in the upper plains states. He said he can do some of the work at home in Washington State, which allows him to be with his wife and three young children.
Dr. Lin no longer sees patients. “I feel I have lost my confidence as a clinician,” he said. “I’m not sure why, but I find it hard to make quick judgments when taking care of patients.”
He said many doctors have told him about their own troubles with speaking out, but they did not want to come forward and talk about it because they feared more repercussions.
Do doctors who speak out have any rights?
Because TeamHealth, Dr. Lin’s actual employer, asserts he was never actually terminated, Dr. Lin has not been able to appeal his case internally in accordance with due process, an option that allows doctors to get a fair hearing and to appeal decisions against them.
The American Academy of Emergency Medicine pointed out this problem. “Dr. Lin, as a member of the medical staff, is entitled to full due process and a fair hearing from his peers on the medical staff,” the academy said in a statement supporting him.
The Joint Commission, the hospital accreditor, requires that hospitals provide due process to doctors before they can be terminated. However, Dr. Sullivan said employers often make physicians waive their due process rights in the employment contract. “The result is that the employer can terminate doctors for no reason,” he said.
In the 2013 survey of emergency physicians, 62% reported that their employers could terminate them without full due process.
Dr. Weiss, the Maryland MD-JD, said that when he advises doctors on their contracts, he generally tells them to cross out the waiver language. The applicant, he says, may also tell the employer that the waivers are considered unethical by many physician professional societies. In some cases, he said, the hospital will back down.
Conclusion
To maintain quality of care, it is essential that physicians feel free to speak out about issues that concern them. They can improve their chances of being heard by working directly with management and attending meetings, but in some cases, management may be unwilling to listen.
A version of this article first appeared on Medscape.com.
In April 2020, hospitalist Samantha Houston, MD, lost her job at Baptist Memorial Hospital–North, in Oxford, Miss., after she publicly campaigned to get donations of N95 masks for nurses. Dr. Houston filed a lawsuit against the hospital, saying she was improperly fired for speaking out. The lawsuit has not yet gone to trial.
In January 2017, emergency physician Raymond Brovont, MD, was fired by EmCare, an emergency physician staffing company, after reporting understaffing at hospitals with which it contracted in the Kansas City, Mo., area. Dr. Brovont sued EmCare, and the company lost the case. In February 2019, it was ordered to pay him $13.1 million in damages.
These are just two of several cases in recent years in which physicians have spoken out about problems involving patient care and have been sanctioned. Other physicians who see problems choose to stay silent.
Doctors often hesitate to speak out because of the prospect of losing their jobs. A 2013 study of emergency physicians found that nearly 20% reported a possible or real threat to their employment if they expressed concerns about quality of care.
When physicians do not speak openly about important medical issues, the quality of care in their institutions suffers, said a coauthor of the study, Larry D. Weiss, MD, JD, a retired professor of emergency medicine at the University of Maryland, Baltimore.
“Physicians can’t effectively represent patients if they are always thinking they can get fired for what they say,” Dr. Weiss said. “If you don’t have protections like due process, which is often the case, you are less likely to speak out.”
In the first few weeks, health care facilities were struggling to obtain personal protective equipment (PPE) and to create policies that would keep patients and caregivers safe.
Physicians such as Dr. Houston took the initiative to make sure their institutions were taking the right steps against COVID-19 and found themselves at loggerheads with administrators who were concerned that their organizations were being portrayed as unsafe.
The case of one physician who spoke out
One of the highest-profile cases of a physician speaking out and being removed from work during the pandemic is that of Ming Lin, MD, an emergency physician who lost a job he had held for 17 years at St. Joseph Medical Center, in Bellingham, Wash. Dr. Lin lost his job after he made a series of Facebook posts that criticized the hospital’s COVID-19 preparedness efforts.
In an interview, Dr. Lin discussed the details of his situation to a degree that rarely occurs in such cases. This is one of the most extensive interviews he has granted.
Postings on Facebook
Dr. Lin said that on the basis of an intense study of the virus at the onset of the pandemic, he developed many ideas as to what could be done to mitigate its spread. While working as a locum tenens physician on his time off, he could see how others dealt with COVID-19.
Dr. Lin said from past experiences he did not feel that he could present his ideas directly to administration and be heard, so he decided to air his ideas about how his hospital could handle COVID-19 on his Facebook page, which drew a large audience.
He said he was certain that hospital administrators were reading his posts. He said receptionists at this hospital were advised not to wear masks, evidently because it would alarm patients. Dr. Lin said he posted concerns about their safety and called for them to wear masks. Soon after, the hospital directed receptionists to wear masks.
Dr. Lin’s Facebook posts also criticized the hospital for taking what he felt was too long to get results on COVID-19 tests. “It was taking them up to 10 days to get test results, because samples were being sent to a lab in California,” he said. He suggested it would be faster to send samples to the University of Washington. Soon after, the hospital started sending samples there.
In just a couple of weeks, Dr. Lin said, he voiced almost a dozen concerns. Each time the hospital made changes in line with his recommendations. Although he didn’t get any direct acknowledgment from the hospital for his help, he said he felt he was making a positive impact.
How employers react to physicians who speak out
Physicians who speak out about conditions tend to deeply disturb administrators, said William P. Sullivan, DO, JD, an emergency physician and lawyer in Frankfort, Ill., who has written about physicians being terminated by hospitals.
“These physicians go to the news media or they use social media,” Dr. Sullivan said, “but hospital administrators don’t want the public to hear bad things about their hospital.”
Then the public might not come to the hospital, which is an administrator’s worst nightmare. Even if physicians think their criticisms are reasonable, administrators may still fear a resulting drop in patients.
Dr. Houston, for example, was helping her Mississippi hospital by collecting donations of N95 masks for nurses, but to administrators, it showed that the hospital did not have enough masks.
“It is not helpful to stoke fear and anxiety, even if the intent is sincere,” a spokesperson for the hospital said.
Administrator fires back
Dr. Lin’s posts were deeply concerning to Richard DeCarlo, chief operating officer of PeaceHealth, which runs St. Joseph Hospital. Mr. DeCarlo discussed his concerns in a video interview in April with the blogger Zubin Damania, MD, known as ZDoggMD.
Comments on Dr. Lin’s Facebook posts showed that people “were fearful to go to the hospital,” he told Dr. Damania. “They were concluding that they would need to drive to another hospital.”
Mr. DeCarlo said he was also unhappy that Dr. Lin did not directly contact administrators about his concerns. “He didn’t communicate with his medical director,” Mr. DeCarlo said in the interview. “The ED staff had been meeting three times a week with the chief medical officer to make sure they had everything they needed, but he only attended one of these meetings and didn’t ask any questions.”
Dr. Lin maintains he did ask questions at the first meeting but stopped attending because he felt he wasn’t being heeded. “I found their tone not very receptive,” he said.
Doctor allegedly offered “misinformation”
At the start of the pandemic, some hospitals made it clear what would happen to doctors who brought up lack of PPE or other problems to the media. For example, NYU Langone Medical Center in New York sent an email to staff warning that speaking to the media without permission “will be subject to disciplinary action, including termination.”
PeaceHealth took a different tack. “It’s not that we have a policy that says don’t ever talk to the media,” Mr. DeCarlo said in the ZDoggMD interview, but in Dr. Lin’s case, “what was at issue was the misinformation. His leader went to him and said, ‘Look, you’re posting things that aren’t accurate.’ ”
Dr. Lin disputes that he provided any misinformation. In the interview, Mr. DeCarlo cited just one example of alleged misinformation. He said Dr. Lin called for a tent outside the emergency department (ED) to protect patients entering the department from aerosol exposure to COVID-19. Mr. DeCarlo said the tent was not needed because fewer people were using the ED.
“To put it in an extreme way,” Mr. DeCarlo said of Dr. Lin’s posts, “it was like yelling fire in a theater where there is not a fire.”
Dr. Lin said the hospital did briefly erect a tent and then removed it, and he still insisted that a tent was a good idea. He added that Mr. DeCarlo never mentioned any of the other suggestions Dr. Lin made, nor did he state that the hospital adopted them.
Doctor gets a warning
Dr. Lin said that after he started posting his concerns, he got a call from the emergency department director who worked for TeamHealth, an emergency medicine staffing firm that contracted with PeaceHealth and employed Dr. Lin, too.
Dr. Lin said his immediate supervisor at TeamHealth told him the hospital was unhappy with his posts and that he should take them down and suggested he might be fired. Dr. Lin said the supervisor also asked him to apologize to the hospital administration for these posts, but he refused to do so.
“Retracting and apologizing was not only wrong but would have left me vulnerable to being terminated with no repercussions,” he said.
“At that point, I realized I had crossed the Rubicon,” Dr. Lin said. He thought he might well be fired, no matter what he did, so he took his story to The Seattle Times, which had a much wider platform than his Facebook page had.
Dr. Lin lost his job at St. Joseph a week after The Seattle Times story about him appeared. “About 10 minutes before my shift was supposed to start, I received a text message from TeamHealth saying that someone else would be taking the shift,” he said.
In a release, TeamHealth insisted Dr. Lin was not fired and that he was scheduled to be reassigned to work at other hospitals. Dr. Lin, however, said he was not told this at the time and that he found out later that the new assignment would involve a pay cut and a significant commute. He said he has not taken any new assignments from TeamHealth since he lost his job at St. Joseph.
Dr. Lin has filed a lawsuit against PeaceHealth, TeamHealth, and Mr. DeCarlo, asking for his job back and for an apology. He said he has not asked for any financial damages at this point.
Since leaving St. Joseph, Dr. Lin has been working as an administrator for the Indian Health Service in the upper plains states. He said he can do some of the work at home in Washington State, which allows him to be with his wife and three young children.
Dr. Lin no longer sees patients. “I feel I have lost my confidence as a clinician,” he said. “I’m not sure why, but I find it hard to make quick judgments when taking care of patients.”
He said many doctors have told him about their own troubles with speaking out, but they did not want to come forward and talk about it because they feared more repercussions.
Do doctors who speak out have any rights?
Because TeamHealth, Dr. Lin’s actual employer, asserts he was never actually terminated, Dr. Lin has not been able to appeal his case internally in accordance with due process, an option that allows doctors to get a fair hearing and to appeal decisions against them.
The American Academy of Emergency Medicine pointed out this problem. “Dr. Lin, as a member of the medical staff, is entitled to full due process and a fair hearing from his peers on the medical staff,” the academy said in a statement supporting him.
The Joint Commission, the hospital accreditor, requires that hospitals provide due process to doctors before they can be terminated. However, Dr. Sullivan said employers often make physicians waive their due process rights in the employment contract. “The result is that the employer can terminate doctors for no reason,” he said.
In the 2013 survey of emergency physicians, 62% reported that their employers could terminate them without full due process.
Dr. Weiss, the Maryland MD-JD, said that when he advises doctors on their contracts, he generally tells them to cross out the waiver language. The applicant, he says, may also tell the employer that the waivers are considered unethical by many physician professional societies. In some cases, he said, the hospital will back down.
Conclusion
To maintain quality of care, it is essential that physicians feel free to speak out about issues that concern them. They can improve their chances of being heard by working directly with management and attending meetings, but in some cases, management may be unwilling to listen.
A version of this article first appeared on Medscape.com.
In April 2020, hospitalist Samantha Houston, MD, lost her job at Baptist Memorial Hospital–North, in Oxford, Miss., after she publicly campaigned to get donations of N95 masks for nurses. Dr. Houston filed a lawsuit against the hospital, saying she was improperly fired for speaking out. The lawsuit has not yet gone to trial.
In January 2017, emergency physician Raymond Brovont, MD, was fired by EmCare, an emergency physician staffing company, after reporting understaffing at hospitals with which it contracted in the Kansas City, Mo., area. Dr. Brovont sued EmCare, and the company lost the case. In February 2019, it was ordered to pay him $13.1 million in damages.
These are just two of several cases in recent years in which physicians have spoken out about problems involving patient care and have been sanctioned. Other physicians who see problems choose to stay silent.
Doctors often hesitate to speak out because of the prospect of losing their jobs. A 2013 study of emergency physicians found that nearly 20% reported a possible or real threat to their employment if they expressed concerns about quality of care.
When physicians do not speak openly about important medical issues, the quality of care in their institutions suffers, said a coauthor of the study, Larry D. Weiss, MD, JD, a retired professor of emergency medicine at the University of Maryland, Baltimore.
“Physicians can’t effectively represent patients if they are always thinking they can get fired for what they say,” Dr. Weiss said. “If you don’t have protections like due process, which is often the case, you are less likely to speak out.”
In the first few weeks, health care facilities were struggling to obtain personal protective equipment (PPE) and to create policies that would keep patients and caregivers safe.
Physicians such as Dr. Houston took the initiative to make sure their institutions were taking the right steps against COVID-19 and found themselves at loggerheads with administrators who were concerned that their organizations were being portrayed as unsafe.
The case of one physician who spoke out
One of the highest-profile cases of a physician speaking out and being removed from work during the pandemic is that of Ming Lin, MD, an emergency physician who lost a job he had held for 17 years at St. Joseph Medical Center, in Bellingham, Wash. Dr. Lin lost his job after he made a series of Facebook posts that criticized the hospital’s COVID-19 preparedness efforts.
In an interview, Dr. Lin discussed the details of his situation to a degree that rarely occurs in such cases. This is one of the most extensive interviews he has granted.
Postings on Facebook
Dr. Lin said that on the basis of an intense study of the virus at the onset of the pandemic, he developed many ideas as to what could be done to mitigate its spread. While working as a locum tenens physician on his time off, he could see how others dealt with COVID-19.
Dr. Lin said from past experiences he did not feel that he could present his ideas directly to administration and be heard, so he decided to air his ideas about how his hospital could handle COVID-19 on his Facebook page, which drew a large audience.
He said he was certain that hospital administrators were reading his posts. He said receptionists at this hospital were advised not to wear masks, evidently because it would alarm patients. Dr. Lin said he posted concerns about their safety and called for them to wear masks. Soon after, the hospital directed receptionists to wear masks.
Dr. Lin’s Facebook posts also criticized the hospital for taking what he felt was too long to get results on COVID-19 tests. “It was taking them up to 10 days to get test results, because samples were being sent to a lab in California,” he said. He suggested it would be faster to send samples to the University of Washington. Soon after, the hospital started sending samples there.
In just a couple of weeks, Dr. Lin said, he voiced almost a dozen concerns. Each time the hospital made changes in line with his recommendations. Although he didn’t get any direct acknowledgment from the hospital for his help, he said he felt he was making a positive impact.
How employers react to physicians who speak out
Physicians who speak out about conditions tend to deeply disturb administrators, said William P. Sullivan, DO, JD, an emergency physician and lawyer in Frankfort, Ill., who has written about physicians being terminated by hospitals.
“These physicians go to the news media or they use social media,” Dr. Sullivan said, “but hospital administrators don’t want the public to hear bad things about their hospital.”
Then the public might not come to the hospital, which is an administrator’s worst nightmare. Even if physicians think their criticisms are reasonable, administrators may still fear a resulting drop in patients.
Dr. Houston, for example, was helping her Mississippi hospital by collecting donations of N95 masks for nurses, but to administrators, it showed that the hospital did not have enough masks.
“It is not helpful to stoke fear and anxiety, even if the intent is sincere,” a spokesperson for the hospital said.
Administrator fires back
Dr. Lin’s posts were deeply concerning to Richard DeCarlo, chief operating officer of PeaceHealth, which runs St. Joseph Hospital. Mr. DeCarlo discussed his concerns in a video interview in April with the blogger Zubin Damania, MD, known as ZDoggMD.
Comments on Dr. Lin’s Facebook posts showed that people “were fearful to go to the hospital,” he told Dr. Damania. “They were concluding that they would need to drive to another hospital.”
Mr. DeCarlo said he was also unhappy that Dr. Lin did not directly contact administrators about his concerns. “He didn’t communicate with his medical director,” Mr. DeCarlo said in the interview. “The ED staff had been meeting three times a week with the chief medical officer to make sure they had everything they needed, but he only attended one of these meetings and didn’t ask any questions.”
Dr. Lin maintains he did ask questions at the first meeting but stopped attending because he felt he wasn’t being heeded. “I found their tone not very receptive,” he said.
Doctor allegedly offered “misinformation”
At the start of the pandemic, some hospitals made it clear what would happen to doctors who brought up lack of PPE or other problems to the media. For example, NYU Langone Medical Center in New York sent an email to staff warning that speaking to the media without permission “will be subject to disciplinary action, including termination.”
PeaceHealth took a different tack. “It’s not that we have a policy that says don’t ever talk to the media,” Mr. DeCarlo said in the ZDoggMD interview, but in Dr. Lin’s case, “what was at issue was the misinformation. His leader went to him and said, ‘Look, you’re posting things that aren’t accurate.’ ”
Dr. Lin disputes that he provided any misinformation. In the interview, Mr. DeCarlo cited just one example of alleged misinformation. He said Dr. Lin called for a tent outside the emergency department (ED) to protect patients entering the department from aerosol exposure to COVID-19. Mr. DeCarlo said the tent was not needed because fewer people were using the ED.
“To put it in an extreme way,” Mr. DeCarlo said of Dr. Lin’s posts, “it was like yelling fire in a theater where there is not a fire.”
Dr. Lin said the hospital did briefly erect a tent and then removed it, and he still insisted that a tent was a good idea. He added that Mr. DeCarlo never mentioned any of the other suggestions Dr. Lin made, nor did he state that the hospital adopted them.
Doctor gets a warning
Dr. Lin said that after he started posting his concerns, he got a call from the emergency department director who worked for TeamHealth, an emergency medicine staffing firm that contracted with PeaceHealth and employed Dr. Lin, too.
Dr. Lin said his immediate supervisor at TeamHealth told him the hospital was unhappy with his posts and that he should take them down and suggested he might be fired. Dr. Lin said the supervisor also asked him to apologize to the hospital administration for these posts, but he refused to do so.
“Retracting and apologizing was not only wrong but would have left me vulnerable to being terminated with no repercussions,” he said.
“At that point, I realized I had crossed the Rubicon,” Dr. Lin said. He thought he might well be fired, no matter what he did, so he took his story to The Seattle Times, which had a much wider platform than his Facebook page had.
Dr. Lin lost his job at St. Joseph a week after The Seattle Times story about him appeared. “About 10 minutes before my shift was supposed to start, I received a text message from TeamHealth saying that someone else would be taking the shift,” he said.
In a release, TeamHealth insisted Dr. Lin was not fired and that he was scheduled to be reassigned to work at other hospitals. Dr. Lin, however, said he was not told this at the time and that he found out later that the new assignment would involve a pay cut and a significant commute. He said he has not taken any new assignments from TeamHealth since he lost his job at St. Joseph.
Dr. Lin has filed a lawsuit against PeaceHealth, TeamHealth, and Mr. DeCarlo, asking for his job back and for an apology. He said he has not asked for any financial damages at this point.
Since leaving St. Joseph, Dr. Lin has been working as an administrator for the Indian Health Service in the upper plains states. He said he can do some of the work at home in Washington State, which allows him to be with his wife and three young children.
Dr. Lin no longer sees patients. “I feel I have lost my confidence as a clinician,” he said. “I’m not sure why, but I find it hard to make quick judgments when taking care of patients.”
He said many doctors have told him about their own troubles with speaking out, but they did not want to come forward and talk about it because they feared more repercussions.
Do doctors who speak out have any rights?
Because TeamHealth, Dr. Lin’s actual employer, asserts he was never actually terminated, Dr. Lin has not been able to appeal his case internally in accordance with due process, an option that allows doctors to get a fair hearing and to appeal decisions against them.
The American Academy of Emergency Medicine pointed out this problem. “Dr. Lin, as a member of the medical staff, is entitled to full due process and a fair hearing from his peers on the medical staff,” the academy said in a statement supporting him.
The Joint Commission, the hospital accreditor, requires that hospitals provide due process to doctors before they can be terminated. However, Dr. Sullivan said employers often make physicians waive their due process rights in the employment contract. “The result is that the employer can terminate doctors for no reason,” he said.
In the 2013 survey of emergency physicians, 62% reported that their employers could terminate them without full due process.
Dr. Weiss, the Maryland MD-JD, said that when he advises doctors on their contracts, he generally tells them to cross out the waiver language. The applicant, he says, may also tell the employer that the waivers are considered unethical by many physician professional societies. In some cases, he said, the hospital will back down.
Conclusion
To maintain quality of care, it is essential that physicians feel free to speak out about issues that concern them. They can improve their chances of being heard by working directly with management and attending meetings, but in some cases, management may be unwilling to listen.
A version of this article first appeared on Medscape.com.
Success in LGBTQ+ medicine requires awareness of risk
Patients who are transgender, for instance, are nine times more likely to commit suicide than the general population (2015 U.S. Transgender Survey (USTS). Inter-university Consortium for Political and Social Research. 2019 May 22. doi: 10.3886/ICPSR37229.v1), and those who are also Black have an estimated HIV prevalence of 62%, demonstrating the cumulative, negative health effects of intersectionality (www.cdc.gov/hiv/group/gender/transgender/hiv-prevalence.html).
“Experiences with marginalization and stigma directly relate to some of the poor physical and mental health outcomes that these patients experience,” Megan McNamara, MD, said during a presentation at the American College of Physicians annual Internal Medicine meeting.
Dr. McNamara, who is director of the Gender Identity Veteran’s Experience (GIVE) Clinic, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, offered a brief guide to managing LGBTQ+ patients. She emphasized increased rates of psychological distress and substance abuse, and encouraged familiarity with specific risks associated with three subgroups: men who have sex with men (MSM), women who have sex with women (WSW), and those who are transgender.
Men who have sex with men
According to Dr. McNamara, preexposure prophylaxis (PrEP) should be offered based on Centers for Disease Control and Prevention eligibility criteria, which require that the patient is HIV negative, has had a male sex partner in the past 6 months, is not in a monogamous relationship, and has had anal sex or a bacterial sexually transmitted infection in the past 6 months. The two PrEP options, emtricitabine/tenofovir disoproxil fumarate and emtricitabine/tenofovir alafenamide, are equally effective and have similar safety profiles, Dr. McNamara said, but patients with impaired renal function should receive the alafenamide formulation.
Dr. McNamara also advised screening gay men for extragenital STIs, noting a 13.3% increased risk. When asked about anal Pap testing for HPV, Dr. McNamara called the subject “very controversial,” and ultimately recommended against it, citing a lack of data linking anal HPV infection and dysplasia with later development of rectal carcinoma, as well as the nonactionable impact of a positive result.
“For me, the issue is ... if [a positive anal Pap test] is not going to change my management, if I don’t know that the anal HPV that I diagnose will result in cancer, should I continue to monitor it?” Dr. McNamara said.
Women who have sex with women
Beyond higher rates of psychological distress and substance abuse among lesbian and bisexual women, Dr. McNamara described increased risks of overweight and obesity, higher rates of smoking, and lower rates of Pap testing, all of which should prompt clinicians to advise accordingly, with cervical cancer screening in alignment with guidelines. Clinicians should also discuss HPV vaccination with patients, taking care to weigh benefits and risks, as “catch-up” HPV vaccination is not unilaterally recommended for adults older than 26 years.
Transgender patients
Discussing transgender patients, Dr. McNamara focused on cross-sex hormone therapy (CSHT), first noting the significant psychological benefits, including improvements in depression, somatization, interpersonal sensitivity, hostility, anxiety, phobic anxiety/agoraphobia, and quality of life.
According to Dr. McNamara, CSHT is relatively simple and may be safely administered by primary care providers. For transmasculine patients, testosterone supplementation is all that is needed, whereas transfeminine patients will require spironolactone or GnRH agonists to reduce testosterone and estradiol to increase feminizing hormones to pubertal levels.
CSHT is not without risks, Dr. McNamara said, including “very high” risks of erythrocytosis among transmasculine patients and venous thromboembolic disease among transfeminine patients; but these risks need to be considered in the context of an approximate 40% suicide rate among transgender individuals.
“I can tell you in my own practice that these [suicide] data ring true,” Dr. McNamara said. “Many, many of my patients have attempted suicide, so [CSHT] is something that you really want to think about right away.”
Even when additional risk factors are present, such as preexisting cardiovascular disease, Dr. McNamara suggested that “there are very few absolute contraindications to CSHT,” and described it as a “life-sustaining treatment” that should be viewed analogously with any other long-term management strategy, such as therapy for diabetes or hypertension.
Fostering a transgender-friendly practice
In an interview, Nicole Nisly, MD, codirector of the LGBTQ+ Clinic at the University of Iowa Hospitals and Clinics, Iowa City, reflected upon Dr. McNamara’s presentation, noting that primary care providers – with a little education – are the best candidates to care for transgender patients.
“I think [primary care providers] do a better job [caring for transgender patients] than endocrinologists, honestly, because they can provide care for the whole person,” Dr. Nisly said. “They can do a Pap, they can do STI screening, they can assess mood, they can [evaluate] safety, and the whole person, as opposed to endocrinologists, who do hormone therapy, but somebody else does everything else.”
Dr. Nisly emphasized the importance of personalizing care for transgender individuals, which depends upon a welcoming practice environment, with careful attention to language.
Foremost, Dr. Nisly recommended asking patients for their preferred name, sexual orientation, and gender identity.
“One of the most difficult things [for transgender patients] is to see notes with the wrong name – the name that makes them feel uncomfortable – or the wrong pronoun,” Dr. Nisly said. “That’s very important to the community.”
Dr. Nisly also recommended an alternative term for cross-sex hormone therapy.
“I hate cross-sex hormone therapy terminology, honestly,” Dr. Nisly said. “I just think it’s so unwelcoming, and I think most of our patients don’t like the terminology, so we use ‘gender-affirming hormone therapy.’”
Dr. Nisly explained that the term “cross-sex” assumes a conventional definition of sex, which is inherently flawed.
When discussing certain medical risk factors, such as pregnancy or HIV, it is helpful to know “sex assigned at birth” for both patients and their sexual partners, Dr. Nisly said. It’s best to ask in this way, instead of using terms like “boyfriend” or “girlfriend,” as “sex assigned at birth” is “terminology the community recognizes, affirms, and feels comfortable with.”
Concerning management of medical risk factors, Dr. Nisly offered some additional perspectives.
For one, she recommended giving PrEP to any patient who has a desire to be on PrEP, noting that this desire can indicate a change in future sexual practices, which the CDC criteria do not anticipate. She also advised in-hospital self-swabbing for extragenital STIs, as this can increase patient comfort and adherence. And, in contrast with Dr. McNamara, Dr. Nisly recommended anal Pap screening for any man that has sex with men and anyone with HIV of any gender. She noted that rates of anal dysplasia are “pretty high” among men who have sex with men, and that detection may reduce cancer risk.
For clinicians who would like to learn more about caring for transgender patients, Dr. Nisly recommended that they start by reading the World Professional Association for Transgender Health guidelines.
“It’s about 300 pages,” Dr. Nisly said, “but it is great.”
Dr. McNamara and Dr. Nisly reported no conflicts of interest.
Patients who are transgender, for instance, are nine times more likely to commit suicide than the general population (2015 U.S. Transgender Survey (USTS). Inter-university Consortium for Political and Social Research. 2019 May 22. doi: 10.3886/ICPSR37229.v1), and those who are also Black have an estimated HIV prevalence of 62%, demonstrating the cumulative, negative health effects of intersectionality (www.cdc.gov/hiv/group/gender/transgender/hiv-prevalence.html).
“Experiences with marginalization and stigma directly relate to some of the poor physical and mental health outcomes that these patients experience,” Megan McNamara, MD, said during a presentation at the American College of Physicians annual Internal Medicine meeting.
Dr. McNamara, who is director of the Gender Identity Veteran’s Experience (GIVE) Clinic, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, offered a brief guide to managing LGBTQ+ patients. She emphasized increased rates of psychological distress and substance abuse, and encouraged familiarity with specific risks associated with three subgroups: men who have sex with men (MSM), women who have sex with women (WSW), and those who are transgender.
Men who have sex with men
According to Dr. McNamara, preexposure prophylaxis (PrEP) should be offered based on Centers for Disease Control and Prevention eligibility criteria, which require that the patient is HIV negative, has had a male sex partner in the past 6 months, is not in a monogamous relationship, and has had anal sex or a bacterial sexually transmitted infection in the past 6 months. The two PrEP options, emtricitabine/tenofovir disoproxil fumarate and emtricitabine/tenofovir alafenamide, are equally effective and have similar safety profiles, Dr. McNamara said, but patients with impaired renal function should receive the alafenamide formulation.
Dr. McNamara also advised screening gay men for extragenital STIs, noting a 13.3% increased risk. When asked about anal Pap testing for HPV, Dr. McNamara called the subject “very controversial,” and ultimately recommended against it, citing a lack of data linking anal HPV infection and dysplasia with later development of rectal carcinoma, as well as the nonactionable impact of a positive result.
“For me, the issue is ... if [a positive anal Pap test] is not going to change my management, if I don’t know that the anal HPV that I diagnose will result in cancer, should I continue to monitor it?” Dr. McNamara said.
Women who have sex with women
Beyond higher rates of psychological distress and substance abuse among lesbian and bisexual women, Dr. McNamara described increased risks of overweight and obesity, higher rates of smoking, and lower rates of Pap testing, all of which should prompt clinicians to advise accordingly, with cervical cancer screening in alignment with guidelines. Clinicians should also discuss HPV vaccination with patients, taking care to weigh benefits and risks, as “catch-up” HPV vaccination is not unilaterally recommended for adults older than 26 years.
Transgender patients
Discussing transgender patients, Dr. McNamara focused on cross-sex hormone therapy (CSHT), first noting the significant psychological benefits, including improvements in depression, somatization, interpersonal sensitivity, hostility, anxiety, phobic anxiety/agoraphobia, and quality of life.
According to Dr. McNamara, CSHT is relatively simple and may be safely administered by primary care providers. For transmasculine patients, testosterone supplementation is all that is needed, whereas transfeminine patients will require spironolactone or GnRH agonists to reduce testosterone and estradiol to increase feminizing hormones to pubertal levels.
CSHT is not without risks, Dr. McNamara said, including “very high” risks of erythrocytosis among transmasculine patients and venous thromboembolic disease among transfeminine patients; but these risks need to be considered in the context of an approximate 40% suicide rate among transgender individuals.
“I can tell you in my own practice that these [suicide] data ring true,” Dr. McNamara said. “Many, many of my patients have attempted suicide, so [CSHT] is something that you really want to think about right away.”
Even when additional risk factors are present, such as preexisting cardiovascular disease, Dr. McNamara suggested that “there are very few absolute contraindications to CSHT,” and described it as a “life-sustaining treatment” that should be viewed analogously with any other long-term management strategy, such as therapy for diabetes or hypertension.
Fostering a transgender-friendly practice
In an interview, Nicole Nisly, MD, codirector of the LGBTQ+ Clinic at the University of Iowa Hospitals and Clinics, Iowa City, reflected upon Dr. McNamara’s presentation, noting that primary care providers – with a little education – are the best candidates to care for transgender patients.
“I think [primary care providers] do a better job [caring for transgender patients] than endocrinologists, honestly, because they can provide care for the whole person,” Dr. Nisly said. “They can do a Pap, they can do STI screening, they can assess mood, they can [evaluate] safety, and the whole person, as opposed to endocrinologists, who do hormone therapy, but somebody else does everything else.”
Dr. Nisly emphasized the importance of personalizing care for transgender individuals, which depends upon a welcoming practice environment, with careful attention to language.
Foremost, Dr. Nisly recommended asking patients for their preferred name, sexual orientation, and gender identity.
“One of the most difficult things [for transgender patients] is to see notes with the wrong name – the name that makes them feel uncomfortable – or the wrong pronoun,” Dr. Nisly said. “That’s very important to the community.”
Dr. Nisly also recommended an alternative term for cross-sex hormone therapy.
“I hate cross-sex hormone therapy terminology, honestly,” Dr. Nisly said. “I just think it’s so unwelcoming, and I think most of our patients don’t like the terminology, so we use ‘gender-affirming hormone therapy.’”
Dr. Nisly explained that the term “cross-sex” assumes a conventional definition of sex, which is inherently flawed.
When discussing certain medical risk factors, such as pregnancy or HIV, it is helpful to know “sex assigned at birth” for both patients and their sexual partners, Dr. Nisly said. It’s best to ask in this way, instead of using terms like “boyfriend” or “girlfriend,” as “sex assigned at birth” is “terminology the community recognizes, affirms, and feels comfortable with.”
Concerning management of medical risk factors, Dr. Nisly offered some additional perspectives.
For one, she recommended giving PrEP to any patient who has a desire to be on PrEP, noting that this desire can indicate a change in future sexual practices, which the CDC criteria do not anticipate. She also advised in-hospital self-swabbing for extragenital STIs, as this can increase patient comfort and adherence. And, in contrast with Dr. McNamara, Dr. Nisly recommended anal Pap screening for any man that has sex with men and anyone with HIV of any gender. She noted that rates of anal dysplasia are “pretty high” among men who have sex with men, and that detection may reduce cancer risk.
For clinicians who would like to learn more about caring for transgender patients, Dr. Nisly recommended that they start by reading the World Professional Association for Transgender Health guidelines.
“It’s about 300 pages,” Dr. Nisly said, “but it is great.”
Dr. McNamara and Dr. Nisly reported no conflicts of interest.
Patients who are transgender, for instance, are nine times more likely to commit suicide than the general population (2015 U.S. Transgender Survey (USTS). Inter-university Consortium for Political and Social Research. 2019 May 22. doi: 10.3886/ICPSR37229.v1), and those who are also Black have an estimated HIV prevalence of 62%, demonstrating the cumulative, negative health effects of intersectionality (www.cdc.gov/hiv/group/gender/transgender/hiv-prevalence.html).
“Experiences with marginalization and stigma directly relate to some of the poor physical and mental health outcomes that these patients experience,” Megan McNamara, MD, said during a presentation at the American College of Physicians annual Internal Medicine meeting.
Dr. McNamara, who is director of the Gender Identity Veteran’s Experience (GIVE) Clinic, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, offered a brief guide to managing LGBTQ+ patients. She emphasized increased rates of psychological distress and substance abuse, and encouraged familiarity with specific risks associated with three subgroups: men who have sex with men (MSM), women who have sex with women (WSW), and those who are transgender.
Men who have sex with men
According to Dr. McNamara, preexposure prophylaxis (PrEP) should be offered based on Centers for Disease Control and Prevention eligibility criteria, which require that the patient is HIV negative, has had a male sex partner in the past 6 months, is not in a monogamous relationship, and has had anal sex or a bacterial sexually transmitted infection in the past 6 months. The two PrEP options, emtricitabine/tenofovir disoproxil fumarate and emtricitabine/tenofovir alafenamide, are equally effective and have similar safety profiles, Dr. McNamara said, but patients with impaired renal function should receive the alafenamide formulation.
Dr. McNamara also advised screening gay men for extragenital STIs, noting a 13.3% increased risk. When asked about anal Pap testing for HPV, Dr. McNamara called the subject “very controversial,” and ultimately recommended against it, citing a lack of data linking anal HPV infection and dysplasia with later development of rectal carcinoma, as well as the nonactionable impact of a positive result.
“For me, the issue is ... if [a positive anal Pap test] is not going to change my management, if I don’t know that the anal HPV that I diagnose will result in cancer, should I continue to monitor it?” Dr. McNamara said.
Women who have sex with women
Beyond higher rates of psychological distress and substance abuse among lesbian and bisexual women, Dr. McNamara described increased risks of overweight and obesity, higher rates of smoking, and lower rates of Pap testing, all of which should prompt clinicians to advise accordingly, with cervical cancer screening in alignment with guidelines. Clinicians should also discuss HPV vaccination with patients, taking care to weigh benefits and risks, as “catch-up” HPV vaccination is not unilaterally recommended for adults older than 26 years.
Transgender patients
Discussing transgender patients, Dr. McNamara focused on cross-sex hormone therapy (CSHT), first noting the significant psychological benefits, including improvements in depression, somatization, interpersonal sensitivity, hostility, anxiety, phobic anxiety/agoraphobia, and quality of life.
According to Dr. McNamara, CSHT is relatively simple and may be safely administered by primary care providers. For transmasculine patients, testosterone supplementation is all that is needed, whereas transfeminine patients will require spironolactone or GnRH agonists to reduce testosterone and estradiol to increase feminizing hormones to pubertal levels.
CSHT is not without risks, Dr. McNamara said, including “very high” risks of erythrocytosis among transmasculine patients and venous thromboembolic disease among transfeminine patients; but these risks need to be considered in the context of an approximate 40% suicide rate among transgender individuals.
“I can tell you in my own practice that these [suicide] data ring true,” Dr. McNamara said. “Many, many of my patients have attempted suicide, so [CSHT] is something that you really want to think about right away.”
Even when additional risk factors are present, such as preexisting cardiovascular disease, Dr. McNamara suggested that “there are very few absolute contraindications to CSHT,” and described it as a “life-sustaining treatment” that should be viewed analogously with any other long-term management strategy, such as therapy for diabetes or hypertension.
Fostering a transgender-friendly practice
In an interview, Nicole Nisly, MD, codirector of the LGBTQ+ Clinic at the University of Iowa Hospitals and Clinics, Iowa City, reflected upon Dr. McNamara’s presentation, noting that primary care providers – with a little education – are the best candidates to care for transgender patients.
“I think [primary care providers] do a better job [caring for transgender patients] than endocrinologists, honestly, because they can provide care for the whole person,” Dr. Nisly said. “They can do a Pap, they can do STI screening, they can assess mood, they can [evaluate] safety, and the whole person, as opposed to endocrinologists, who do hormone therapy, but somebody else does everything else.”
Dr. Nisly emphasized the importance of personalizing care for transgender individuals, which depends upon a welcoming practice environment, with careful attention to language.
Foremost, Dr. Nisly recommended asking patients for their preferred name, sexual orientation, and gender identity.
“One of the most difficult things [for transgender patients] is to see notes with the wrong name – the name that makes them feel uncomfortable – or the wrong pronoun,” Dr. Nisly said. “That’s very important to the community.”
Dr. Nisly also recommended an alternative term for cross-sex hormone therapy.
“I hate cross-sex hormone therapy terminology, honestly,” Dr. Nisly said. “I just think it’s so unwelcoming, and I think most of our patients don’t like the terminology, so we use ‘gender-affirming hormone therapy.’”
Dr. Nisly explained that the term “cross-sex” assumes a conventional definition of sex, which is inherently flawed.
When discussing certain medical risk factors, such as pregnancy or HIV, it is helpful to know “sex assigned at birth” for both patients and their sexual partners, Dr. Nisly said. It’s best to ask in this way, instead of using terms like “boyfriend” or “girlfriend,” as “sex assigned at birth” is “terminology the community recognizes, affirms, and feels comfortable with.”
Concerning management of medical risk factors, Dr. Nisly offered some additional perspectives.
For one, she recommended giving PrEP to any patient who has a desire to be on PrEP, noting that this desire can indicate a change in future sexual practices, which the CDC criteria do not anticipate. She also advised in-hospital self-swabbing for extragenital STIs, as this can increase patient comfort and adherence. And, in contrast with Dr. McNamara, Dr. Nisly recommended anal Pap screening for any man that has sex with men and anyone with HIV of any gender. She noted that rates of anal dysplasia are “pretty high” among men who have sex with men, and that detection may reduce cancer risk.
For clinicians who would like to learn more about caring for transgender patients, Dr. Nisly recommended that they start by reading the World Professional Association for Transgender Health guidelines.
“It’s about 300 pages,” Dr. Nisly said, “but it is great.”
Dr. McNamara and Dr. Nisly reported no conflicts of interest.
FROM INTERNAL MEDICINE 2021