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Review supports continued mask-wearing in health care visits
A new study urges people to continue wearing protective masks in medical settings, even though the U.S. public health emergency declaration around COVID-19 has expired.
Masks continue to lower the risk of catching the virus during medical visits, according to the study, published in Annals of Internal Medicine. And there was not much difference between wearing surgical masks and N95 respirators in health care settings.
The researchers reviewed 3 randomized trials and 21 observational studies to compare the effectiveness of those and cloth masks in reducing COVID-19 transmission.
Tara N. Palmore, MD, of George Washington University, Washington, and David K. Henderson, MD, of the National Institutes of Health, Bethesda, Md., wrote in an opinion article accompanying the study.
“In our enthusiasm to return to the appearance and feeling of normalcy, and as institutions decide which mitigation strategies to discontinue, we strongly advocate not discarding this important lesson learned for the sake of our patients’ safety,” Dr. Palmore and Dr. Henderson wrote.
Surgical masks limit the spread of aerosols and droplets from people who have the flu, coronaviruses or other respiratory viruses, CNN reported. And while masks are not 100% effective, they substantially lower the amount of virus put into the air via coughing and talking.
The study said one reason people should wear masks to medical settings is because “health care personnel are notorious for coming to work while ill.” Transmission from patient to staff and staff to patient is still possible, but rare, when both are masked.
The review authors reported no conflicts of interest. Dr. Palmore has received grants from the NIH, Rigel, Gilead, and AbbVie, and Dr. Henderson is a past president of the Society for Healthcare Epidemiology of America.
A version of this article first appeared on WebMD.com.
A new study urges people to continue wearing protective masks in medical settings, even though the U.S. public health emergency declaration around COVID-19 has expired.
Masks continue to lower the risk of catching the virus during medical visits, according to the study, published in Annals of Internal Medicine. And there was not much difference between wearing surgical masks and N95 respirators in health care settings.
The researchers reviewed 3 randomized trials and 21 observational studies to compare the effectiveness of those and cloth masks in reducing COVID-19 transmission.
Tara N. Palmore, MD, of George Washington University, Washington, and David K. Henderson, MD, of the National Institutes of Health, Bethesda, Md., wrote in an opinion article accompanying the study.
“In our enthusiasm to return to the appearance and feeling of normalcy, and as institutions decide which mitigation strategies to discontinue, we strongly advocate not discarding this important lesson learned for the sake of our patients’ safety,” Dr. Palmore and Dr. Henderson wrote.
Surgical masks limit the spread of aerosols and droplets from people who have the flu, coronaviruses or other respiratory viruses, CNN reported. And while masks are not 100% effective, they substantially lower the amount of virus put into the air via coughing and talking.
The study said one reason people should wear masks to medical settings is because “health care personnel are notorious for coming to work while ill.” Transmission from patient to staff and staff to patient is still possible, but rare, when both are masked.
The review authors reported no conflicts of interest. Dr. Palmore has received grants from the NIH, Rigel, Gilead, and AbbVie, and Dr. Henderson is a past president of the Society for Healthcare Epidemiology of America.
A version of this article first appeared on WebMD.com.
A new study urges people to continue wearing protective masks in medical settings, even though the U.S. public health emergency declaration around COVID-19 has expired.
Masks continue to lower the risk of catching the virus during medical visits, according to the study, published in Annals of Internal Medicine. And there was not much difference between wearing surgical masks and N95 respirators in health care settings.
The researchers reviewed 3 randomized trials and 21 observational studies to compare the effectiveness of those and cloth masks in reducing COVID-19 transmission.
Tara N. Palmore, MD, of George Washington University, Washington, and David K. Henderson, MD, of the National Institutes of Health, Bethesda, Md., wrote in an opinion article accompanying the study.
“In our enthusiasm to return to the appearance and feeling of normalcy, and as institutions decide which mitigation strategies to discontinue, we strongly advocate not discarding this important lesson learned for the sake of our patients’ safety,” Dr. Palmore and Dr. Henderson wrote.
Surgical masks limit the spread of aerosols and droplets from people who have the flu, coronaviruses or other respiratory viruses, CNN reported. And while masks are not 100% effective, they substantially lower the amount of virus put into the air via coughing and talking.
The study said one reason people should wear masks to medical settings is because “health care personnel are notorious for coming to work while ill.” Transmission from patient to staff and staff to patient is still possible, but rare, when both are masked.
The review authors reported no conflicts of interest. Dr. Palmore has received grants from the NIH, Rigel, Gilead, and AbbVie, and Dr. Henderson is a past president of the Society for Healthcare Epidemiology of America.
A version of this article first appeared on WebMD.com.
FROM ANNALS OF INTERNAL MEDICINE
CDC cuts back hospital data reporting on COVID
When the federal government’s public health emergency (PHE) ended on May 11, the Centers for Disease Control and Prevention scaled back the amount of COVID-related data that it had required hospitals to collect and report during the previous 3 years. The CDC had to do this, an agency spokesman said in an interview, because “CDC’s authorizations to collect certain types of public health data” expired with the PHE.
The CDC insists that it will have enough data to keep up with the virus, which repeatedly defied scientists’ expectations during the course of the pandemic. But some experts have doubts about whether this will turn out to be the case.
While the COVID pandemic is subsiding and transitioning to an endemic phase, many things about the coronavirus are still not understood, noted Marisa Eisenberg, PhD, associate professor of epidemiology at the University of Michigan, Ann Arbor.
“COVID is here to stay, and it ebbs and flows but is staying at fairly consistent levels across the country,” she said in an interview. “Meanwhile, we haven’t established a regular seasonality for COVID that we see for most other respiratory illnesses. We’re still seeing pretty rapidly invading new waves of variants. With flu and other respiratory illnesses, you often see a particular variant in each season. There’s an established pattern. For COVID, that’s still shifting.”
Similarly, Sam Scarpino, PhD, a public health expert at Northeastern University, Boston, told the New York Times: “The CDC is shuffling COVID into the deck of infectious diseases that we’re satisfied living with. One thousand deaths a week is just unacceptable.”
William Schaffner, MD, a professor of preventive medicine and health policy at Vanderbilt University Medical Center, Nashville, Tenn., said in an interview that “how we deal with influenza is something of a template or a model for what the CDC is trying to get to with COVID.” It’s not practical for physicians and hospitals to report every flu case, and the same is now true for COVID. However, “we’re still asking for data on people who are hospitalized with COVID to be reported. That will give us a measure of the major public health impact.”
Dr. Eisenberg doesn’t fully subscribe to this notion. “COVID and influenza are both respiratory illnesses, and our initial pandemic response was based on playbooks that we’d built for potential flu pandemics. But COVID is not the flu. We still have to grapple with the fact that it’s killing a lot more people than the flu does. So maybe it’s a template, but not a perfect one.”
What data is being deleted
The CDC is now requiring hospitals to submit COVID-related data weekly, rather than daily, as it previously had. In addition, the agency has cut the number of data elements that hospitals must report from 62 to 44. Among the data fields that are now optional for hospitals to report are the numbers of hospitalized children with suspected or lab-confirmed COVID; hospitalized and ventilated COVID patients; adults in the ICU with suspected or lab-confirmed COVID; adult and pediatric admissions with suspected COVID; COVID-related emergency department visits; and inpatients with hospital-acquired COVID.
Although widely feared by health care workers and the public, hospital-acquired COVID has never been a major factor in the pandemic, Dr. Schaffner said. “So why ask for something that’s actually not so critical? Let’s keep the emphasis on rapid, accurate reporting of people who are hospitalized because of this disease.”
Akin Demehin, senior director for quality and patient safety policy for the American Hospital Association, agreed that the rate of hospital-acquired COVID cases “has been very low throughout the pandemic.” That was one reason why CDC made this measure optional.
Dr. Eisenberg concurred with this view. “We worried about [hospital-acquired COVID] a lot, and then, because people were very careful, it wasn’t as much of a problem as we feared it would be.” But she added a note of caution: “Masking and other [preventive guidelines] are shifting in hospitals, so it will be interesting to see whether that affects things.”
CDC justifies its new policy
To put the hospital data reporting changes in context, it’s important to know that CDC will no longer directly track community levels of COVID and the percentage of tests that come back positive for COVID, which until now were used to measure transmission rates. (Laboratories no longer have to report these test data, whether they are in hospitals or in the community.) To track death rates, CDC will rely on the National Vital Statistics System, which is accurate but lags other kinds of surveillance by 2-3 weeks, according to the New York Times.
In a recent MMWR report, CDC defended its new COVID surveillance system, saying: “Weekly COVID-19 hospital admission levels and the percentage of all COVID-19–associated deaths will be primary surveillance indicators. Emergency department visits and percentage of positive SARS-CoV-2 laboratory test results will help detect early changes in trends. Genomic surveillance will continue to help identify and monitor SARS-CoV-2 variants.”
Clarifying the latter point, CDC said that national genomic surveillance, along with wastewater surveillance, will continue to be used to estimate COVID variant proportions. Dr. Eisenberg stressed the importance of genomic surveillance at the hundreds of sites that CDC now maintains across the country. But currently, many of these sites are only monitoring the level of COVID.
CDC also observed that COVID-19 hospital admission levels have been shown to be “concordant” with community levels of SARS-CoV-2 infection. Therefore, rates of COVID-associated admissions and the percentages of positive test results, COVID ED visits, and COVID deaths are “suitable and timely indicators of trends in COVID-19 activity and severity.”
Ready to shift to voluntary reporting?
In a news release, AHA praised the “streamlining” of CDC requirements for data reporting but said that it hoped that mandatory reporting would be phased out as soon as possible.
The association noted that this would require action by the Centers for Medicare & Medicaid Services. CMS now enforces the CDC requirements with a “condition of participation” (COP) provision, by which noncompliant hospitals could be excluded from Medicare. CMS has extended this COP to April 30, 2024, although it could choose to ask the Secretary of Health and Human Services to terminate it earlier.
If mandatory reporting were repealed, would most hospitals still report on the key COVID metrics? Mr. Demehin noted that before CMS implemented its COP, hospitals reported COVID data voluntarily, “and the participation rate was well over 90%. So setting up a mechanism similar to that is something we’ve encouraged CMS to consider.”
Dr. Eisenberg is skeptical. While bigger hospitals with more resources might continue reporting voluntarily, she said, safety-net hospitals in underserved areas might not, because they are especially short staffed. “Then you have disparities in which hospitals will report.”
Vaccinations: The sleeping dragon
COVID continues to ravage the nation. According to CDC statistics, there were 1,109 deaths from COVID in the U.S. in the week ending May 6, and total deaths have hit 1.13 million. There were 1,333 new COVID-related hospital admissions, and 7,261 people were in the hospital because of COVID.
Another eye-catching number: Only 16.9% of the U.S. population has received an updated COVID vaccine booster. Dr. Schaffner thinks that this is what we should really keep our eye on. While the combination of vaccinations and widespread SARS-CoV-2 infections has conferred herd immunity on most Americans, he said it’s temporary. “Whether your immunity comes from the virus and recovery from disease or from the vaccines, that immunity will wane over time. Unless we keep our vaccination rate up, we may see more future cases. We’ll have to see how that works out. But I’m nervous about that, because people do appear to be nonchalant.”
A version of this article first appeared on Medscape.com.
When the federal government’s public health emergency (PHE) ended on May 11, the Centers for Disease Control and Prevention scaled back the amount of COVID-related data that it had required hospitals to collect and report during the previous 3 years. The CDC had to do this, an agency spokesman said in an interview, because “CDC’s authorizations to collect certain types of public health data” expired with the PHE.
The CDC insists that it will have enough data to keep up with the virus, which repeatedly defied scientists’ expectations during the course of the pandemic. But some experts have doubts about whether this will turn out to be the case.
While the COVID pandemic is subsiding and transitioning to an endemic phase, many things about the coronavirus are still not understood, noted Marisa Eisenberg, PhD, associate professor of epidemiology at the University of Michigan, Ann Arbor.
“COVID is here to stay, and it ebbs and flows but is staying at fairly consistent levels across the country,” she said in an interview. “Meanwhile, we haven’t established a regular seasonality for COVID that we see for most other respiratory illnesses. We’re still seeing pretty rapidly invading new waves of variants. With flu and other respiratory illnesses, you often see a particular variant in each season. There’s an established pattern. For COVID, that’s still shifting.”
Similarly, Sam Scarpino, PhD, a public health expert at Northeastern University, Boston, told the New York Times: “The CDC is shuffling COVID into the deck of infectious diseases that we’re satisfied living with. One thousand deaths a week is just unacceptable.”
William Schaffner, MD, a professor of preventive medicine and health policy at Vanderbilt University Medical Center, Nashville, Tenn., said in an interview that “how we deal with influenza is something of a template or a model for what the CDC is trying to get to with COVID.” It’s not practical for physicians and hospitals to report every flu case, and the same is now true for COVID. However, “we’re still asking for data on people who are hospitalized with COVID to be reported. That will give us a measure of the major public health impact.”
Dr. Eisenberg doesn’t fully subscribe to this notion. “COVID and influenza are both respiratory illnesses, and our initial pandemic response was based on playbooks that we’d built for potential flu pandemics. But COVID is not the flu. We still have to grapple with the fact that it’s killing a lot more people than the flu does. So maybe it’s a template, but not a perfect one.”
What data is being deleted
The CDC is now requiring hospitals to submit COVID-related data weekly, rather than daily, as it previously had. In addition, the agency has cut the number of data elements that hospitals must report from 62 to 44. Among the data fields that are now optional for hospitals to report are the numbers of hospitalized children with suspected or lab-confirmed COVID; hospitalized and ventilated COVID patients; adults in the ICU with suspected or lab-confirmed COVID; adult and pediatric admissions with suspected COVID; COVID-related emergency department visits; and inpatients with hospital-acquired COVID.
Although widely feared by health care workers and the public, hospital-acquired COVID has never been a major factor in the pandemic, Dr. Schaffner said. “So why ask for something that’s actually not so critical? Let’s keep the emphasis on rapid, accurate reporting of people who are hospitalized because of this disease.”
Akin Demehin, senior director for quality and patient safety policy for the American Hospital Association, agreed that the rate of hospital-acquired COVID cases “has been very low throughout the pandemic.” That was one reason why CDC made this measure optional.
Dr. Eisenberg concurred with this view. “We worried about [hospital-acquired COVID] a lot, and then, because people were very careful, it wasn’t as much of a problem as we feared it would be.” But she added a note of caution: “Masking and other [preventive guidelines] are shifting in hospitals, so it will be interesting to see whether that affects things.”
CDC justifies its new policy
To put the hospital data reporting changes in context, it’s important to know that CDC will no longer directly track community levels of COVID and the percentage of tests that come back positive for COVID, which until now were used to measure transmission rates. (Laboratories no longer have to report these test data, whether they are in hospitals or in the community.) To track death rates, CDC will rely on the National Vital Statistics System, which is accurate but lags other kinds of surveillance by 2-3 weeks, according to the New York Times.
In a recent MMWR report, CDC defended its new COVID surveillance system, saying: “Weekly COVID-19 hospital admission levels and the percentage of all COVID-19–associated deaths will be primary surveillance indicators. Emergency department visits and percentage of positive SARS-CoV-2 laboratory test results will help detect early changes in trends. Genomic surveillance will continue to help identify and monitor SARS-CoV-2 variants.”
Clarifying the latter point, CDC said that national genomic surveillance, along with wastewater surveillance, will continue to be used to estimate COVID variant proportions. Dr. Eisenberg stressed the importance of genomic surveillance at the hundreds of sites that CDC now maintains across the country. But currently, many of these sites are only monitoring the level of COVID.
CDC also observed that COVID-19 hospital admission levels have been shown to be “concordant” with community levels of SARS-CoV-2 infection. Therefore, rates of COVID-associated admissions and the percentages of positive test results, COVID ED visits, and COVID deaths are “suitable and timely indicators of trends in COVID-19 activity and severity.”
Ready to shift to voluntary reporting?
In a news release, AHA praised the “streamlining” of CDC requirements for data reporting but said that it hoped that mandatory reporting would be phased out as soon as possible.
The association noted that this would require action by the Centers for Medicare & Medicaid Services. CMS now enforces the CDC requirements with a “condition of participation” (COP) provision, by which noncompliant hospitals could be excluded from Medicare. CMS has extended this COP to April 30, 2024, although it could choose to ask the Secretary of Health and Human Services to terminate it earlier.
If mandatory reporting were repealed, would most hospitals still report on the key COVID metrics? Mr. Demehin noted that before CMS implemented its COP, hospitals reported COVID data voluntarily, “and the participation rate was well over 90%. So setting up a mechanism similar to that is something we’ve encouraged CMS to consider.”
Dr. Eisenberg is skeptical. While bigger hospitals with more resources might continue reporting voluntarily, she said, safety-net hospitals in underserved areas might not, because they are especially short staffed. “Then you have disparities in which hospitals will report.”
Vaccinations: The sleeping dragon
COVID continues to ravage the nation. According to CDC statistics, there were 1,109 deaths from COVID in the U.S. in the week ending May 6, and total deaths have hit 1.13 million. There were 1,333 new COVID-related hospital admissions, and 7,261 people were in the hospital because of COVID.
Another eye-catching number: Only 16.9% of the U.S. population has received an updated COVID vaccine booster. Dr. Schaffner thinks that this is what we should really keep our eye on. While the combination of vaccinations and widespread SARS-CoV-2 infections has conferred herd immunity on most Americans, he said it’s temporary. “Whether your immunity comes from the virus and recovery from disease or from the vaccines, that immunity will wane over time. Unless we keep our vaccination rate up, we may see more future cases. We’ll have to see how that works out. But I’m nervous about that, because people do appear to be nonchalant.”
A version of this article first appeared on Medscape.com.
When the federal government’s public health emergency (PHE) ended on May 11, the Centers for Disease Control and Prevention scaled back the amount of COVID-related data that it had required hospitals to collect and report during the previous 3 years. The CDC had to do this, an agency spokesman said in an interview, because “CDC’s authorizations to collect certain types of public health data” expired with the PHE.
The CDC insists that it will have enough data to keep up with the virus, which repeatedly defied scientists’ expectations during the course of the pandemic. But some experts have doubts about whether this will turn out to be the case.
While the COVID pandemic is subsiding and transitioning to an endemic phase, many things about the coronavirus are still not understood, noted Marisa Eisenberg, PhD, associate professor of epidemiology at the University of Michigan, Ann Arbor.
“COVID is here to stay, and it ebbs and flows but is staying at fairly consistent levels across the country,” she said in an interview. “Meanwhile, we haven’t established a regular seasonality for COVID that we see for most other respiratory illnesses. We’re still seeing pretty rapidly invading new waves of variants. With flu and other respiratory illnesses, you often see a particular variant in each season. There’s an established pattern. For COVID, that’s still shifting.”
Similarly, Sam Scarpino, PhD, a public health expert at Northeastern University, Boston, told the New York Times: “The CDC is shuffling COVID into the deck of infectious diseases that we’re satisfied living with. One thousand deaths a week is just unacceptable.”
William Schaffner, MD, a professor of preventive medicine and health policy at Vanderbilt University Medical Center, Nashville, Tenn., said in an interview that “how we deal with influenza is something of a template or a model for what the CDC is trying to get to with COVID.” It’s not practical for physicians and hospitals to report every flu case, and the same is now true for COVID. However, “we’re still asking for data on people who are hospitalized with COVID to be reported. That will give us a measure of the major public health impact.”
Dr. Eisenberg doesn’t fully subscribe to this notion. “COVID and influenza are both respiratory illnesses, and our initial pandemic response was based on playbooks that we’d built for potential flu pandemics. But COVID is not the flu. We still have to grapple with the fact that it’s killing a lot more people than the flu does. So maybe it’s a template, but not a perfect one.”
What data is being deleted
The CDC is now requiring hospitals to submit COVID-related data weekly, rather than daily, as it previously had. In addition, the agency has cut the number of data elements that hospitals must report from 62 to 44. Among the data fields that are now optional for hospitals to report are the numbers of hospitalized children with suspected or lab-confirmed COVID; hospitalized and ventilated COVID patients; adults in the ICU with suspected or lab-confirmed COVID; adult and pediatric admissions with suspected COVID; COVID-related emergency department visits; and inpatients with hospital-acquired COVID.
Although widely feared by health care workers and the public, hospital-acquired COVID has never been a major factor in the pandemic, Dr. Schaffner said. “So why ask for something that’s actually not so critical? Let’s keep the emphasis on rapid, accurate reporting of people who are hospitalized because of this disease.”
Akin Demehin, senior director for quality and patient safety policy for the American Hospital Association, agreed that the rate of hospital-acquired COVID cases “has been very low throughout the pandemic.” That was one reason why CDC made this measure optional.
Dr. Eisenberg concurred with this view. “We worried about [hospital-acquired COVID] a lot, and then, because people were very careful, it wasn’t as much of a problem as we feared it would be.” But she added a note of caution: “Masking and other [preventive guidelines] are shifting in hospitals, so it will be interesting to see whether that affects things.”
CDC justifies its new policy
To put the hospital data reporting changes in context, it’s important to know that CDC will no longer directly track community levels of COVID and the percentage of tests that come back positive for COVID, which until now were used to measure transmission rates. (Laboratories no longer have to report these test data, whether they are in hospitals or in the community.) To track death rates, CDC will rely on the National Vital Statistics System, which is accurate but lags other kinds of surveillance by 2-3 weeks, according to the New York Times.
In a recent MMWR report, CDC defended its new COVID surveillance system, saying: “Weekly COVID-19 hospital admission levels and the percentage of all COVID-19–associated deaths will be primary surveillance indicators. Emergency department visits and percentage of positive SARS-CoV-2 laboratory test results will help detect early changes in trends. Genomic surveillance will continue to help identify and monitor SARS-CoV-2 variants.”
Clarifying the latter point, CDC said that national genomic surveillance, along with wastewater surveillance, will continue to be used to estimate COVID variant proportions. Dr. Eisenberg stressed the importance of genomic surveillance at the hundreds of sites that CDC now maintains across the country. But currently, many of these sites are only monitoring the level of COVID.
CDC also observed that COVID-19 hospital admission levels have been shown to be “concordant” with community levels of SARS-CoV-2 infection. Therefore, rates of COVID-associated admissions and the percentages of positive test results, COVID ED visits, and COVID deaths are “suitable and timely indicators of trends in COVID-19 activity and severity.”
Ready to shift to voluntary reporting?
In a news release, AHA praised the “streamlining” of CDC requirements for data reporting but said that it hoped that mandatory reporting would be phased out as soon as possible.
The association noted that this would require action by the Centers for Medicare & Medicaid Services. CMS now enforces the CDC requirements with a “condition of participation” (COP) provision, by which noncompliant hospitals could be excluded from Medicare. CMS has extended this COP to April 30, 2024, although it could choose to ask the Secretary of Health and Human Services to terminate it earlier.
If mandatory reporting were repealed, would most hospitals still report on the key COVID metrics? Mr. Demehin noted that before CMS implemented its COP, hospitals reported COVID data voluntarily, “and the participation rate was well over 90%. So setting up a mechanism similar to that is something we’ve encouraged CMS to consider.”
Dr. Eisenberg is skeptical. While bigger hospitals with more resources might continue reporting voluntarily, she said, safety-net hospitals in underserved areas might not, because they are especially short staffed. “Then you have disparities in which hospitals will report.”
Vaccinations: The sleeping dragon
COVID continues to ravage the nation. According to CDC statistics, there were 1,109 deaths from COVID in the U.S. in the week ending May 6, and total deaths have hit 1.13 million. There were 1,333 new COVID-related hospital admissions, and 7,261 people were in the hospital because of COVID.
Another eye-catching number: Only 16.9% of the U.S. population has received an updated COVID vaccine booster. Dr. Schaffner thinks that this is what we should really keep our eye on. While the combination of vaccinations and widespread SARS-CoV-2 infections has conferred herd immunity on most Americans, he said it’s temporary. “Whether your immunity comes from the virus and recovery from disease or from the vaccines, that immunity will wane over time. Unless we keep our vaccination rate up, we may see more future cases. We’ll have to see how that works out. But I’m nervous about that, because people do appear to be nonchalant.”
A version of this article first appeared on Medscape.com.
U.S. adults report depression at record rates: Survey
In a survey, 29% of adults said they had been diagnosed with depression during their lifetime, and 18% said they currently have depression or are being treated for it. Those rates are up from the baseline 2015 rates of 20% of people ever having depression and 11% of people with a current diagnosis.
Depression had been steadily rising before the pandemic, and the Gallup analysts wrote that “social isolation, loneliness, fear of infection, psychological exhaustion (particularly among frontline responders such as health care workers), elevated substance abuse, and disruptions in mental health services have all likely played a role” in the increase.
“The fact that Americans are more depressed and struggling after this time of incredible stress and isolation is perhaps not surprising,” American Psychiatric Association president Rebecca Brendel, MD, told CNN. “There are lingering effects on our health, especially our mental health, from the past 3 years that disrupted everything we knew.”
The new estimates are based on online survey responses collected in February from 5,167 adults in the United States who answered the questions:
- Has a doctor or nurse ever told you that you have depression?
- Do you currently have or are you currently being treated for depression?
Depression, which is also called major depressive disorder, is a treatable illness that negatively affects how someone feels, thinks, and acts. The symptoms can be both emotional (such as sadness or loss of interest in activities) and physical (such as fatigue or slowed movements or speech).
The latest study found that depression rates increased the most among women, young adults, Black people, and Hispanic people. For the first time, more Black and Hispanic people than White people reported ever being diagnosed with depression. The lifetime depression rate among Black people was 34%, compared with 31% for Hispanic people and 29% for White people.
The rate of lifetime depression among women jumped 10 percentage points in the past 5 years, to 37%, in February, the survey results showed. About 1 in 4 women said they currently had depression or were being treated for it, up 6 percentage points compared with 5 years ago.
When responses were analyzed by age, those 18-44 years old were the most likely to report ever being diagnosed with depression or currently having the illness. About one-third of younger adults have ever been diagnosed, and more than 1 in 5 said they currently have depression.
Dr. Brendel said awareness and reduced stigma could be adding to the rising rates of depression.
“We’re making it easier to talk about mental health and looking at it as part of our overall wellness, just like physical health,” she said. “People are aware of depression, and people are seeking help for it.”
If you or someone you know needs help, dial 988 for support from the national Suicide & Crisis Lifeline. It’s free, confidential, and available 24 hours a day, 7 days a week. You can also visit 988lifeline.org and choose the chat feature.
A version of this article first appeared on Medscape.com.
In a survey, 29% of adults said they had been diagnosed with depression during their lifetime, and 18% said they currently have depression or are being treated for it. Those rates are up from the baseline 2015 rates of 20% of people ever having depression and 11% of people with a current diagnosis.
Depression had been steadily rising before the pandemic, and the Gallup analysts wrote that “social isolation, loneliness, fear of infection, psychological exhaustion (particularly among frontline responders such as health care workers), elevated substance abuse, and disruptions in mental health services have all likely played a role” in the increase.
“The fact that Americans are more depressed and struggling after this time of incredible stress and isolation is perhaps not surprising,” American Psychiatric Association president Rebecca Brendel, MD, told CNN. “There are lingering effects on our health, especially our mental health, from the past 3 years that disrupted everything we knew.”
The new estimates are based on online survey responses collected in February from 5,167 adults in the United States who answered the questions:
- Has a doctor or nurse ever told you that you have depression?
- Do you currently have or are you currently being treated for depression?
Depression, which is also called major depressive disorder, is a treatable illness that negatively affects how someone feels, thinks, and acts. The symptoms can be both emotional (such as sadness or loss of interest in activities) and physical (such as fatigue or slowed movements or speech).
The latest study found that depression rates increased the most among women, young adults, Black people, and Hispanic people. For the first time, more Black and Hispanic people than White people reported ever being diagnosed with depression. The lifetime depression rate among Black people was 34%, compared with 31% for Hispanic people and 29% for White people.
The rate of lifetime depression among women jumped 10 percentage points in the past 5 years, to 37%, in February, the survey results showed. About 1 in 4 women said they currently had depression or were being treated for it, up 6 percentage points compared with 5 years ago.
When responses were analyzed by age, those 18-44 years old were the most likely to report ever being diagnosed with depression or currently having the illness. About one-third of younger adults have ever been diagnosed, and more than 1 in 5 said they currently have depression.
Dr. Brendel said awareness and reduced stigma could be adding to the rising rates of depression.
“We’re making it easier to talk about mental health and looking at it as part of our overall wellness, just like physical health,” she said. “People are aware of depression, and people are seeking help for it.”
If you or someone you know needs help, dial 988 for support from the national Suicide & Crisis Lifeline. It’s free, confidential, and available 24 hours a day, 7 days a week. You can also visit 988lifeline.org and choose the chat feature.
A version of this article first appeared on Medscape.com.
In a survey, 29% of adults said they had been diagnosed with depression during their lifetime, and 18% said they currently have depression or are being treated for it. Those rates are up from the baseline 2015 rates of 20% of people ever having depression and 11% of people with a current diagnosis.
Depression had been steadily rising before the pandemic, and the Gallup analysts wrote that “social isolation, loneliness, fear of infection, psychological exhaustion (particularly among frontline responders such as health care workers), elevated substance abuse, and disruptions in mental health services have all likely played a role” in the increase.
“The fact that Americans are more depressed and struggling after this time of incredible stress and isolation is perhaps not surprising,” American Psychiatric Association president Rebecca Brendel, MD, told CNN. “There are lingering effects on our health, especially our mental health, from the past 3 years that disrupted everything we knew.”
The new estimates are based on online survey responses collected in February from 5,167 adults in the United States who answered the questions:
- Has a doctor or nurse ever told you that you have depression?
- Do you currently have or are you currently being treated for depression?
Depression, which is also called major depressive disorder, is a treatable illness that negatively affects how someone feels, thinks, and acts. The symptoms can be both emotional (such as sadness or loss of interest in activities) and physical (such as fatigue or slowed movements or speech).
The latest study found that depression rates increased the most among women, young adults, Black people, and Hispanic people. For the first time, more Black and Hispanic people than White people reported ever being diagnosed with depression. The lifetime depression rate among Black people was 34%, compared with 31% for Hispanic people and 29% for White people.
The rate of lifetime depression among women jumped 10 percentage points in the past 5 years, to 37%, in February, the survey results showed. About 1 in 4 women said they currently had depression or were being treated for it, up 6 percentage points compared with 5 years ago.
When responses were analyzed by age, those 18-44 years old were the most likely to report ever being diagnosed with depression or currently having the illness. About one-third of younger adults have ever been diagnosed, and more than 1 in 5 said they currently have depression.
Dr. Brendel said awareness and reduced stigma could be adding to the rising rates of depression.
“We’re making it easier to talk about mental health and looking at it as part of our overall wellness, just like physical health,” she said. “People are aware of depression, and people are seeking help for it.”
If you or someone you know needs help, dial 988 for support from the national Suicide & Crisis Lifeline. It’s free, confidential, and available 24 hours a day, 7 days a week. You can also visit 988lifeline.org and choose the chat feature.
A version of this article first appeared on Medscape.com.
The antimicrobial peptide that even Pharma can love
Fastest peptide north, south, east, aaaaand west of the Pecos
Bacterial infections are supposed to be simple. You get infected, you get an antibiotic to treat it. Easy. Some bacteria, though, don’t play by the rules. Those antibiotics may kill 99.9% of germs, but what about the 0.1% that gets left behind? With their fallen comrades out of the way, the accidentally drug resistant species are free to inherit the Earth.
Antibiotic resistance is thus a major concern for the medical community. Naturally, anything that prevents doctors from successfully curing sick people is a priority. Unless you’re a major pharmaceutical company that has been loath to develop new drugs that can beat antibiotic-resistant bacteria. Blah blah, time and money, blah blah, long time between development and market application, blah blah, no profit. We all know the story with pharmaceutical companies.
Research from other sources has continued, however, and Brazilian scientists recently published research involving a peptide known as plantaricin 149. This peptide, derived from the bacterium Lactobacillus plantarum, has been known for nearly 30 years to have antibacterial properties. Pln149 in its natural state, though, is not particularly efficient at bacteria-killing. Fortunately, we have science and technology on our side.
The researchers synthesized 20 analogs of Pln149, of which Pln149-PEP20 had the best results. The elegantly named compound is less than half the size of the original peptide, less toxic, and far better at killing any and all drug-resistant bacteria the researchers threw at it. How much better? Pln149-PEP20 started killing bacteria less than an hour after being introduced in lab trials.
The research is just in its early days – just because something is less toxic doesn’t necessarily mean you want to go and help yourself to it – but we can only hope that those lovely pharmaceutical companies deign to look down upon us and actually develop a drug utilizing Pln149-PEP20 to, you know, actually help sick people, instead of trying to build monopolies or avoiding paying billions in taxes. Yeah, we couldn’t keep a straight face through that last sentence either.
Speed healing: The wavy wound gets the swirl
Did you know that wavy wounds heal faster than straight wounds? Well, we didn’t, but apparently quite a few people did, because somebody has been trying to figure out why wavy wounds heal faster than straight ones. Do the surgeons know about this? How about you dermatologists? Wavy over straight? We’re the media. We’re supposed to report this kind of stuff. Maybe hit us with a tweet next time you do something important, or push a TikTok our way, okay?
You could be more like the investigators at Nanyang Technological University in Singapore, who figured out the why and then released a statement about it.
They created synthetic wounds – some straight, some wavy – in micropatterned hydrogel substrates that mimicked human skin. Then they used an advanced optical technique known as particle image velocimetry to measure fluid flow and learn how cells moved to close the wound gaps.
The wavy wounds “induced more complex collective cell movements, such as a swirly, vortex-like motion,” according to the written statement from NTU Singapore. In the straight wounds, cell movements paralleled the wound front, “moving in straight lines like a marching band,” they pointed out, unlike some researchers who never call us unless they need money.
Complex epithelial cell movements are better, it turns out. Over an observation period of 64 hours the NTU team found that the healing efficiency of wavy gaps – measured by the area covered by the cells over time – is nearly five times faster than straight gaps.
The complex motion “enabled cells to quickly connect with similar cells on the opposite site of the wound edge, forming a bridge and closing the wavy wound gaps faster than straight gaps,” explained lead author Xu Hongmei, a doctoral student at NTU’s School of Mechanical and Aerospace Engineering, who seems to have time to toss out a tumblr or two to keep the press informed.
As for the rest of you, would it kill you to pick up a phone once in a while? Maybe let a journalist know that you’re still alive? We have feelings too, you know, and we worry.
A little Jekyll, a little Hyde, and a little shop of horrors
More “Little Shop of Horrors” references are coming, so be prepared.
We begin with Triphyophyllum peltatum. This woody vine is of great interest to medical and pharmaceutical researchers because its constituents have shown promise against pancreatic cancer and leukemia cells, among others, along with the pathogens that cause malaria and other diseases. There is another side, however. T. peltatum also has a tendency to turn into a realistic Audrey II when deprived.
No, of course they’re not craving human flesh, but it does become … carnivorous in its appetite.
T. peltatum, native to the West African tropics and not found in a New York florist shop, has the unique ability to change its diet and development based on the environmental circumstances. For some unknown reason, the leaves would develop adhesive traps in the form of sticky drops that capture insect prey. The plant is notoriously hard to grow, however, so no one could study the transformation under lab conditions. Until now.
A group of German scientists “exposed the plant to different stress factors, including deficiencies of various nutrients, and studied how it responded to each,” said Dr. Traud Winkelmann of Leibniz University Hannover. “Only in one case were we able to observe the formation of traps: in the case of a lack of phosphorus.”
Well, there you have it: phosphorus. We need it for healthy bones and teeth, which this plant doesn’t have to worry about, unlike its Tony Award–nominated counterpart. The investigators hope that their findings could lead to “future molecular analyses that will help understand the origins of carnivory,” but we’re guessing that a certain singing alien species will be left out of that research.
Fastest peptide north, south, east, aaaaand west of the Pecos
Bacterial infections are supposed to be simple. You get infected, you get an antibiotic to treat it. Easy. Some bacteria, though, don’t play by the rules. Those antibiotics may kill 99.9% of germs, but what about the 0.1% that gets left behind? With their fallen comrades out of the way, the accidentally drug resistant species are free to inherit the Earth.
Antibiotic resistance is thus a major concern for the medical community. Naturally, anything that prevents doctors from successfully curing sick people is a priority. Unless you’re a major pharmaceutical company that has been loath to develop new drugs that can beat antibiotic-resistant bacteria. Blah blah, time and money, blah blah, long time between development and market application, blah blah, no profit. We all know the story with pharmaceutical companies.
Research from other sources has continued, however, and Brazilian scientists recently published research involving a peptide known as plantaricin 149. This peptide, derived from the bacterium Lactobacillus plantarum, has been known for nearly 30 years to have antibacterial properties. Pln149 in its natural state, though, is not particularly efficient at bacteria-killing. Fortunately, we have science and technology on our side.
The researchers synthesized 20 analogs of Pln149, of which Pln149-PEP20 had the best results. The elegantly named compound is less than half the size of the original peptide, less toxic, and far better at killing any and all drug-resistant bacteria the researchers threw at it. How much better? Pln149-PEP20 started killing bacteria less than an hour after being introduced in lab trials.
The research is just in its early days – just because something is less toxic doesn’t necessarily mean you want to go and help yourself to it – but we can only hope that those lovely pharmaceutical companies deign to look down upon us and actually develop a drug utilizing Pln149-PEP20 to, you know, actually help sick people, instead of trying to build monopolies or avoiding paying billions in taxes. Yeah, we couldn’t keep a straight face through that last sentence either.
Speed healing: The wavy wound gets the swirl
Did you know that wavy wounds heal faster than straight wounds? Well, we didn’t, but apparently quite a few people did, because somebody has been trying to figure out why wavy wounds heal faster than straight ones. Do the surgeons know about this? How about you dermatologists? Wavy over straight? We’re the media. We’re supposed to report this kind of stuff. Maybe hit us with a tweet next time you do something important, or push a TikTok our way, okay?
You could be more like the investigators at Nanyang Technological University in Singapore, who figured out the why and then released a statement about it.
They created synthetic wounds – some straight, some wavy – in micropatterned hydrogel substrates that mimicked human skin. Then they used an advanced optical technique known as particle image velocimetry to measure fluid flow and learn how cells moved to close the wound gaps.
The wavy wounds “induced more complex collective cell movements, such as a swirly, vortex-like motion,” according to the written statement from NTU Singapore. In the straight wounds, cell movements paralleled the wound front, “moving in straight lines like a marching band,” they pointed out, unlike some researchers who never call us unless they need money.
Complex epithelial cell movements are better, it turns out. Over an observation period of 64 hours the NTU team found that the healing efficiency of wavy gaps – measured by the area covered by the cells over time – is nearly five times faster than straight gaps.
The complex motion “enabled cells to quickly connect with similar cells on the opposite site of the wound edge, forming a bridge and closing the wavy wound gaps faster than straight gaps,” explained lead author Xu Hongmei, a doctoral student at NTU’s School of Mechanical and Aerospace Engineering, who seems to have time to toss out a tumblr or two to keep the press informed.
As for the rest of you, would it kill you to pick up a phone once in a while? Maybe let a journalist know that you’re still alive? We have feelings too, you know, and we worry.
A little Jekyll, a little Hyde, and a little shop of horrors
More “Little Shop of Horrors” references are coming, so be prepared.
We begin with Triphyophyllum peltatum. This woody vine is of great interest to medical and pharmaceutical researchers because its constituents have shown promise against pancreatic cancer and leukemia cells, among others, along with the pathogens that cause malaria and other diseases. There is another side, however. T. peltatum also has a tendency to turn into a realistic Audrey II when deprived.
No, of course they’re not craving human flesh, but it does become … carnivorous in its appetite.
T. peltatum, native to the West African tropics and not found in a New York florist shop, has the unique ability to change its diet and development based on the environmental circumstances. For some unknown reason, the leaves would develop adhesive traps in the form of sticky drops that capture insect prey. The plant is notoriously hard to grow, however, so no one could study the transformation under lab conditions. Until now.
A group of German scientists “exposed the plant to different stress factors, including deficiencies of various nutrients, and studied how it responded to each,” said Dr. Traud Winkelmann of Leibniz University Hannover. “Only in one case were we able to observe the formation of traps: in the case of a lack of phosphorus.”
Well, there you have it: phosphorus. We need it for healthy bones and teeth, which this plant doesn’t have to worry about, unlike its Tony Award–nominated counterpart. The investigators hope that their findings could lead to “future molecular analyses that will help understand the origins of carnivory,” but we’re guessing that a certain singing alien species will be left out of that research.
Fastest peptide north, south, east, aaaaand west of the Pecos
Bacterial infections are supposed to be simple. You get infected, you get an antibiotic to treat it. Easy. Some bacteria, though, don’t play by the rules. Those antibiotics may kill 99.9% of germs, but what about the 0.1% that gets left behind? With their fallen comrades out of the way, the accidentally drug resistant species are free to inherit the Earth.
Antibiotic resistance is thus a major concern for the medical community. Naturally, anything that prevents doctors from successfully curing sick people is a priority. Unless you’re a major pharmaceutical company that has been loath to develop new drugs that can beat antibiotic-resistant bacteria. Blah blah, time and money, blah blah, long time between development and market application, blah blah, no profit. We all know the story with pharmaceutical companies.
Research from other sources has continued, however, and Brazilian scientists recently published research involving a peptide known as plantaricin 149. This peptide, derived from the bacterium Lactobacillus plantarum, has been known for nearly 30 years to have antibacterial properties. Pln149 in its natural state, though, is not particularly efficient at bacteria-killing. Fortunately, we have science and technology on our side.
The researchers synthesized 20 analogs of Pln149, of which Pln149-PEP20 had the best results. The elegantly named compound is less than half the size of the original peptide, less toxic, and far better at killing any and all drug-resistant bacteria the researchers threw at it. How much better? Pln149-PEP20 started killing bacteria less than an hour after being introduced in lab trials.
The research is just in its early days – just because something is less toxic doesn’t necessarily mean you want to go and help yourself to it – but we can only hope that those lovely pharmaceutical companies deign to look down upon us and actually develop a drug utilizing Pln149-PEP20 to, you know, actually help sick people, instead of trying to build monopolies or avoiding paying billions in taxes. Yeah, we couldn’t keep a straight face through that last sentence either.
Speed healing: The wavy wound gets the swirl
Did you know that wavy wounds heal faster than straight wounds? Well, we didn’t, but apparently quite a few people did, because somebody has been trying to figure out why wavy wounds heal faster than straight ones. Do the surgeons know about this? How about you dermatologists? Wavy over straight? We’re the media. We’re supposed to report this kind of stuff. Maybe hit us with a tweet next time you do something important, or push a TikTok our way, okay?
You could be more like the investigators at Nanyang Technological University in Singapore, who figured out the why and then released a statement about it.
They created synthetic wounds – some straight, some wavy – in micropatterned hydrogel substrates that mimicked human skin. Then they used an advanced optical technique known as particle image velocimetry to measure fluid flow and learn how cells moved to close the wound gaps.
The wavy wounds “induced more complex collective cell movements, such as a swirly, vortex-like motion,” according to the written statement from NTU Singapore. In the straight wounds, cell movements paralleled the wound front, “moving in straight lines like a marching band,” they pointed out, unlike some researchers who never call us unless they need money.
Complex epithelial cell movements are better, it turns out. Over an observation period of 64 hours the NTU team found that the healing efficiency of wavy gaps – measured by the area covered by the cells over time – is nearly five times faster than straight gaps.
The complex motion “enabled cells to quickly connect with similar cells on the opposite site of the wound edge, forming a bridge and closing the wavy wound gaps faster than straight gaps,” explained lead author Xu Hongmei, a doctoral student at NTU’s School of Mechanical and Aerospace Engineering, who seems to have time to toss out a tumblr or two to keep the press informed.
As for the rest of you, would it kill you to pick up a phone once in a while? Maybe let a journalist know that you’re still alive? We have feelings too, you know, and we worry.
A little Jekyll, a little Hyde, and a little shop of horrors
More “Little Shop of Horrors” references are coming, so be prepared.
We begin with Triphyophyllum peltatum. This woody vine is of great interest to medical and pharmaceutical researchers because its constituents have shown promise against pancreatic cancer and leukemia cells, among others, along with the pathogens that cause malaria and other diseases. There is another side, however. T. peltatum also has a tendency to turn into a realistic Audrey II when deprived.
No, of course they’re not craving human flesh, but it does become … carnivorous in its appetite.
T. peltatum, native to the West African tropics and not found in a New York florist shop, has the unique ability to change its diet and development based on the environmental circumstances. For some unknown reason, the leaves would develop adhesive traps in the form of sticky drops that capture insect prey. The plant is notoriously hard to grow, however, so no one could study the transformation under lab conditions. Until now.
A group of German scientists “exposed the plant to different stress factors, including deficiencies of various nutrients, and studied how it responded to each,” said Dr. Traud Winkelmann of Leibniz University Hannover. “Only in one case were we able to observe the formation of traps: in the case of a lack of phosphorus.”
Well, there you have it: phosphorus. We need it for healthy bones and teeth, which this plant doesn’t have to worry about, unlike its Tony Award–nominated counterpart. The investigators hope that their findings could lead to “future molecular analyses that will help understand the origins of carnivory,” but we’re guessing that a certain singing alien species will be left out of that research.
DLBCL: Major new treatment breakthroughs
Significant breakthroughs have come in just the past few weeks and months, through the use of CAR T-cell and immunotherapies and with the approval in April by the Food and Drug Administration of polatuzumab for frontline DLBCL.
“Until the publishing of data from the POLARIX study (NCT03274492), which led to the approval of polatuzumab vedotin plus rituximab-cyclophosphamide, doxorubicin, and prednisone (pola + R-CHP), we had not had a breakthrough in frontline DLBCL therapies since the addition of rituximab 22 years ago,” said Dr. Charalambos Andreadis, MD, of the University of California at San Francisco’s Helen Diller Family Comprehensive Cancer Center.
“Pola + R-CHP is an improvement over the standard-of-care treatment, R-CHOP (rituximab-cyclophosphamide, doxorubicin, vincristine, and prednisone), giving treatment naive patients an increase in PFS without an increase in side effects,” Dr. Andreadis said.
R-CHP-polatuzumab was approved only for patients with an International Prognostic Indices score between 2 and 5, leaving patients with IPI scores of 0 or 1 with the frontline standard of care (SoC) treatment of R-CHOP, which has a cure rate of between 60% and 70%.
“The highest likelihood of relapse is in the first year following treatment. After 2 years in remission, patients’ chance of relapsing is the same as the general populations’ chance of getting DLBCL for the first time. This is why even a slight increase in the progression-free survival rate with the addition of pola is so significant,” Dr. Andreadis noted.
Historically, patients with relapsed or refractory (RR) DLBCL who did not respond to R-CHOP or who experienced disease relapse less than a year after primary intervention were treated with alternative chemotherapy regimens, often followed by autologous stem cell transplants (ASCT). Randomized control studies have shown that CAR T-cell therapies yield higher success rates than chemotherapy and ASCT, leading to the SoC in RR patients being CAR-T cell therapy directly following failed primary treatment.
“There are many new CAR T-cell platforms in development, as well as novel combination strategies that aim to target critical genetic pathways,” Kieron Dunleavy, MD, professor of medicine at the Lombardi Comprehensive Cancer Center at Georgetown University Hospital, said in an interview. “While access to CAR T-cell therapies is becoming easier and more feasible in many centers, fast access continues to be an issue for many patients, often depending on geography and socioeconomic factors.”
Asked about the latest breakthroughs in treating DLBCL, Dr. Dunleavy said, “A significant proportion of patients with relapsed or refractory DLBCL do not have easy access to CAR T-cell therapies, so this needs to be addressed and improved. Sometimes the rapidity of clinical progression in DLBCL can make these therapies challenging to deliver, considering logistical issues like apheresis and insurance approvals, which are frequently complex. This highlights the need for alternative and ‘easier to deliver’ CAR-T cells and our continued prioritization of developing alternative effective agents for DLBCL.
“Currently, commercially approved CAR T-cells in DLBCL target the CD-19 marker on lymphoma cells but CAR T-cells targeting other and more than one antigen as well as alternative anti CD19 agents like loncastuximab and tafasitamab are similarly FDA approved and available for patients,” Dr. Dunleavy concluded.
Dr. Dunleavy is affiliated with the MedStar Georgetown Lymphoma group, where Rep. Raskin publicly announced that he had completed 4 months of chemotherapy treatment for DLBCL. On April 27, in an open letter to the U.S. public, he wrote that he rang the bell at MedStar to mark his preliminary diagnosis of being “in remission,” with a “90% prognosis of no relapse.”
Interviewed about the latest advances in treating DLBCL, Jason Westin, MD, associate professor of lymphoma and myeloma at the MD Anderson Cancer Center in Houston, said that even with improvements in overall survival possible with CAR T-cell therapies, “usually, a clinical trial should be considered strongly, as it is often the best option for patients, both in a newly diagnosed or in a relapsed setting, as they allow access to tomorrow’s breakthrough therapies today.”
Dr. Westin cited the example of bispecific T-cell engagers (BITE) as a promising therapy that is available to patients in clinical trials. These agents bind to one side to the lymphoma cell, but they also have a binding arm for T-cells, so they activate a patient’s own immune cells to kill lymphoma cells, in some cases offering a cure when CAR T-cell therapy has failed.
The first BITE to be approved, mosunetuzumab, is authorized only for the treatment of follicular lymphoma. However, data from a recent clinical study indicated that the agent yields complete responses in 24% of heavily pretreated patients with RR DLBCL.
Another BITE, glofitamab, was approved in Canada in March 2023 for use in RR DLBCL. Based on its high efficacy, it soon may be approved elsewhere.
Dr. Andreadis noted, “We are finally at a point where for both treatment naive and RR DLBCL patients, there are several promising options on the horizon that don’t involve ASCT. Furthermore, these breakthroughs reinforce each other, as there are studies in which therapies like BITE are being brought to the front line and pola to RR cases.”
The growing field of new frontline and RR DLBCL therapies lend credence to the optimism of specialists who treat DLBCL – and to the sanguine note that Congressman Raskin struck in published comments about his treatment for DLBCL.
Dr. Andreadis reported ties with BMS, Novartis, Roche, Genmab, Merck, Gilead, AbbVie, and J&J. Dr. Dunleavy disclosed relationships with ONO Pharmaceuticals, Kymera, Merck, Genentech, AstraZeneca, Amgen, ADC Therapeutics, MorphoSys and Incyte, Kite/Gilead, Cellectar. Dr. Westin reported ties with Kite/Gilead, BMS, Novartis, Genentech, AstraZeneca, Morphosys/Incyte, ADC Therapeutics, Kymera, Nurix, and MonteRosa.
Significant breakthroughs have come in just the past few weeks and months, through the use of CAR T-cell and immunotherapies and with the approval in April by the Food and Drug Administration of polatuzumab for frontline DLBCL.
“Until the publishing of data from the POLARIX study (NCT03274492), which led to the approval of polatuzumab vedotin plus rituximab-cyclophosphamide, doxorubicin, and prednisone (pola + R-CHP), we had not had a breakthrough in frontline DLBCL therapies since the addition of rituximab 22 years ago,” said Dr. Charalambos Andreadis, MD, of the University of California at San Francisco’s Helen Diller Family Comprehensive Cancer Center.
“Pola + R-CHP is an improvement over the standard-of-care treatment, R-CHOP (rituximab-cyclophosphamide, doxorubicin, vincristine, and prednisone), giving treatment naive patients an increase in PFS without an increase in side effects,” Dr. Andreadis said.
R-CHP-polatuzumab was approved only for patients with an International Prognostic Indices score between 2 and 5, leaving patients with IPI scores of 0 or 1 with the frontline standard of care (SoC) treatment of R-CHOP, which has a cure rate of between 60% and 70%.
“The highest likelihood of relapse is in the first year following treatment. After 2 years in remission, patients’ chance of relapsing is the same as the general populations’ chance of getting DLBCL for the first time. This is why even a slight increase in the progression-free survival rate with the addition of pola is so significant,” Dr. Andreadis noted.
Historically, patients with relapsed or refractory (RR) DLBCL who did not respond to R-CHOP or who experienced disease relapse less than a year after primary intervention were treated with alternative chemotherapy regimens, often followed by autologous stem cell transplants (ASCT). Randomized control studies have shown that CAR T-cell therapies yield higher success rates than chemotherapy and ASCT, leading to the SoC in RR patients being CAR-T cell therapy directly following failed primary treatment.
“There are many new CAR T-cell platforms in development, as well as novel combination strategies that aim to target critical genetic pathways,” Kieron Dunleavy, MD, professor of medicine at the Lombardi Comprehensive Cancer Center at Georgetown University Hospital, said in an interview. “While access to CAR T-cell therapies is becoming easier and more feasible in many centers, fast access continues to be an issue for many patients, often depending on geography and socioeconomic factors.”
Asked about the latest breakthroughs in treating DLBCL, Dr. Dunleavy said, “A significant proportion of patients with relapsed or refractory DLBCL do not have easy access to CAR T-cell therapies, so this needs to be addressed and improved. Sometimes the rapidity of clinical progression in DLBCL can make these therapies challenging to deliver, considering logistical issues like apheresis and insurance approvals, which are frequently complex. This highlights the need for alternative and ‘easier to deliver’ CAR-T cells and our continued prioritization of developing alternative effective agents for DLBCL.
“Currently, commercially approved CAR T-cells in DLBCL target the CD-19 marker on lymphoma cells but CAR T-cells targeting other and more than one antigen as well as alternative anti CD19 agents like loncastuximab and tafasitamab are similarly FDA approved and available for patients,” Dr. Dunleavy concluded.
Dr. Dunleavy is affiliated with the MedStar Georgetown Lymphoma group, where Rep. Raskin publicly announced that he had completed 4 months of chemotherapy treatment for DLBCL. On April 27, in an open letter to the U.S. public, he wrote that he rang the bell at MedStar to mark his preliminary diagnosis of being “in remission,” with a “90% prognosis of no relapse.”
Interviewed about the latest advances in treating DLBCL, Jason Westin, MD, associate professor of lymphoma and myeloma at the MD Anderson Cancer Center in Houston, said that even with improvements in overall survival possible with CAR T-cell therapies, “usually, a clinical trial should be considered strongly, as it is often the best option for patients, both in a newly diagnosed or in a relapsed setting, as they allow access to tomorrow’s breakthrough therapies today.”
Dr. Westin cited the example of bispecific T-cell engagers (BITE) as a promising therapy that is available to patients in clinical trials. These agents bind to one side to the lymphoma cell, but they also have a binding arm for T-cells, so they activate a patient’s own immune cells to kill lymphoma cells, in some cases offering a cure when CAR T-cell therapy has failed.
The first BITE to be approved, mosunetuzumab, is authorized only for the treatment of follicular lymphoma. However, data from a recent clinical study indicated that the agent yields complete responses in 24% of heavily pretreated patients with RR DLBCL.
Another BITE, glofitamab, was approved in Canada in March 2023 for use in RR DLBCL. Based on its high efficacy, it soon may be approved elsewhere.
Dr. Andreadis noted, “We are finally at a point where for both treatment naive and RR DLBCL patients, there are several promising options on the horizon that don’t involve ASCT. Furthermore, these breakthroughs reinforce each other, as there are studies in which therapies like BITE are being brought to the front line and pola to RR cases.”
The growing field of new frontline and RR DLBCL therapies lend credence to the optimism of specialists who treat DLBCL – and to the sanguine note that Congressman Raskin struck in published comments about his treatment for DLBCL.
Dr. Andreadis reported ties with BMS, Novartis, Roche, Genmab, Merck, Gilead, AbbVie, and J&J. Dr. Dunleavy disclosed relationships with ONO Pharmaceuticals, Kymera, Merck, Genentech, AstraZeneca, Amgen, ADC Therapeutics, MorphoSys and Incyte, Kite/Gilead, Cellectar. Dr. Westin reported ties with Kite/Gilead, BMS, Novartis, Genentech, AstraZeneca, Morphosys/Incyte, ADC Therapeutics, Kymera, Nurix, and MonteRosa.
Significant breakthroughs have come in just the past few weeks and months, through the use of CAR T-cell and immunotherapies and with the approval in April by the Food and Drug Administration of polatuzumab for frontline DLBCL.
“Until the publishing of data from the POLARIX study (NCT03274492), which led to the approval of polatuzumab vedotin plus rituximab-cyclophosphamide, doxorubicin, and prednisone (pola + R-CHP), we had not had a breakthrough in frontline DLBCL therapies since the addition of rituximab 22 years ago,” said Dr. Charalambos Andreadis, MD, of the University of California at San Francisco’s Helen Diller Family Comprehensive Cancer Center.
“Pola + R-CHP is an improvement over the standard-of-care treatment, R-CHOP (rituximab-cyclophosphamide, doxorubicin, vincristine, and prednisone), giving treatment naive patients an increase in PFS without an increase in side effects,” Dr. Andreadis said.
R-CHP-polatuzumab was approved only for patients with an International Prognostic Indices score between 2 and 5, leaving patients with IPI scores of 0 or 1 with the frontline standard of care (SoC) treatment of R-CHOP, which has a cure rate of between 60% and 70%.
“The highest likelihood of relapse is in the first year following treatment. After 2 years in remission, patients’ chance of relapsing is the same as the general populations’ chance of getting DLBCL for the first time. This is why even a slight increase in the progression-free survival rate with the addition of pola is so significant,” Dr. Andreadis noted.
Historically, patients with relapsed or refractory (RR) DLBCL who did not respond to R-CHOP or who experienced disease relapse less than a year after primary intervention were treated with alternative chemotherapy regimens, often followed by autologous stem cell transplants (ASCT). Randomized control studies have shown that CAR T-cell therapies yield higher success rates than chemotherapy and ASCT, leading to the SoC in RR patients being CAR-T cell therapy directly following failed primary treatment.
“There are many new CAR T-cell platforms in development, as well as novel combination strategies that aim to target critical genetic pathways,” Kieron Dunleavy, MD, professor of medicine at the Lombardi Comprehensive Cancer Center at Georgetown University Hospital, said in an interview. “While access to CAR T-cell therapies is becoming easier and more feasible in many centers, fast access continues to be an issue for many patients, often depending on geography and socioeconomic factors.”
Asked about the latest breakthroughs in treating DLBCL, Dr. Dunleavy said, “A significant proportion of patients with relapsed or refractory DLBCL do not have easy access to CAR T-cell therapies, so this needs to be addressed and improved. Sometimes the rapidity of clinical progression in DLBCL can make these therapies challenging to deliver, considering logistical issues like apheresis and insurance approvals, which are frequently complex. This highlights the need for alternative and ‘easier to deliver’ CAR-T cells and our continued prioritization of developing alternative effective agents for DLBCL.
“Currently, commercially approved CAR T-cells in DLBCL target the CD-19 marker on lymphoma cells but CAR T-cells targeting other and more than one antigen as well as alternative anti CD19 agents like loncastuximab and tafasitamab are similarly FDA approved and available for patients,” Dr. Dunleavy concluded.
Dr. Dunleavy is affiliated with the MedStar Georgetown Lymphoma group, where Rep. Raskin publicly announced that he had completed 4 months of chemotherapy treatment for DLBCL. On April 27, in an open letter to the U.S. public, he wrote that he rang the bell at MedStar to mark his preliminary diagnosis of being “in remission,” with a “90% prognosis of no relapse.”
Interviewed about the latest advances in treating DLBCL, Jason Westin, MD, associate professor of lymphoma and myeloma at the MD Anderson Cancer Center in Houston, said that even with improvements in overall survival possible with CAR T-cell therapies, “usually, a clinical trial should be considered strongly, as it is often the best option for patients, both in a newly diagnosed or in a relapsed setting, as they allow access to tomorrow’s breakthrough therapies today.”
Dr. Westin cited the example of bispecific T-cell engagers (BITE) as a promising therapy that is available to patients in clinical trials. These agents bind to one side to the lymphoma cell, but they also have a binding arm for T-cells, so they activate a patient’s own immune cells to kill lymphoma cells, in some cases offering a cure when CAR T-cell therapy has failed.
The first BITE to be approved, mosunetuzumab, is authorized only for the treatment of follicular lymphoma. However, data from a recent clinical study indicated that the agent yields complete responses in 24% of heavily pretreated patients with RR DLBCL.
Another BITE, glofitamab, was approved in Canada in March 2023 for use in RR DLBCL. Based on its high efficacy, it soon may be approved elsewhere.
Dr. Andreadis noted, “We are finally at a point where for both treatment naive and RR DLBCL patients, there are several promising options on the horizon that don’t involve ASCT. Furthermore, these breakthroughs reinforce each other, as there are studies in which therapies like BITE are being brought to the front line and pola to RR cases.”
The growing field of new frontline and RR DLBCL therapies lend credence to the optimism of specialists who treat DLBCL – and to the sanguine note that Congressman Raskin struck in published comments about his treatment for DLBCL.
Dr. Andreadis reported ties with BMS, Novartis, Roche, Genmab, Merck, Gilead, AbbVie, and J&J. Dr. Dunleavy disclosed relationships with ONO Pharmaceuticals, Kymera, Merck, Genentech, AstraZeneca, Amgen, ADC Therapeutics, MorphoSys and Incyte, Kite/Gilead, Cellectar. Dr. Westin reported ties with Kite/Gilead, BMS, Novartis, Genentech, AstraZeneca, Morphosys/Incyte, ADC Therapeutics, Kymera, Nurix, and MonteRosa.
ASCO honors Hagop Kantarjian, MD, for leukemia research
This award is the society’s “highest scientific honor, and I am extremely happy and honored to receive it,” Dr. Kantarjian commented in an interview with this news organization.
Dr. Kantarjian serves as the chair of the department of leukemia and currently holds the Samsung Distinguished University Chair in Cancer Medicine at the University of Texas MD Anderson Cancer Center, Houston.
“No doubt that this is not an individual award. It represents an award for the accomplishments of all the leukemia faculty at MD Anderson across 4 decades. It’s really a teamwork effort that led to so many discoveries and improvements in treatment and care of patients with leukemia,” he commented.
The David A. Karnofsky Memorial Award has been presented annually since 1970 to recognize oncologists who have made outstanding contributions to cancer research, diagnosis, or treatment, ASCO noted.
From Lebanon to Texas
Dr. Kantarjian received his medical degree from the American University of Beirut, in Lebanon, in 1979 and completed his residency in internal medicine at the same institution in 1981.
It was his experience at MD Anderson as a young medical student and later as a fellow that fueled his interest and career in leukemia, he said.
“In 1978, I took a 4-month elective at MD Anderson, and I soon realized how different and innovative the atmosphere at MD Anderson was, compared to where I was training in Lebanon,” Dr. Kantarjian told this news organization.
Working with mentors that included MD Anderson heavyweights Emil Freireich, MD, Kenneth McCredie, MD, and Michael Keating, MD, helped shape his career and guide his leukemia research, he said.
Transformative impact on leukemia outcomes
The award citation notes that over the past 4 decades, Dr. Kantarjian’s research has transformed some standards of care and has dramatically improved survival in several leukemia subtypes, including chronic myeloid leukemia (CML), acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), and acute lymphocytic leukemia (ALL).
“Four decades ago, most of the leukemias were incurable. Today, most of the leukemias are potentially curable with targeted therapies. That’s what I am most proud of,” Dr. Kantarjian told this news organization.
Among Dr. Kantarjian’s contributions to the field of leukemia:
- Developing the HYPER-CVAD regimen (hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone) as a standard-of-care, frontline therapy for adults with ALL.
- Establishing clinical biology parameters of CML, including definitions of CML phases and cytogenetic responses, and establishing new prognostic factors that were subsequently adopted in studies of tyrosine kinase inhibitors.
- Leading the development of decitabine and epigenetic hypomethylation therapy for MDS and for older/unfit patients with AML.
- Pioneering research with hypomethylating agents (HMAs) in combination with venetoclax, which led to FDA approval of HMA-venetoclax combinations for older/unfit patients with AML.
- Championing the development of clofarabine, conducting animal toxicology studies, and leading subsequent phase 1 and 2 trials and pivotal phase 3 and 4 trials that led to FDA approval of clofarabine for pediatric ALL.
- Developing several FLT3 inhibitors, isocitrate dehydrogenase inhibitors, and venetoclax, which all received FDA approval for the treatment of AML and its subsets.
- Developing regimens for inotuzumab and blinatumomab combined with chemotherapy for adults with pre-B ALL.
- Working on the development of imatinib, dasatinib, nilotinib, bosutinib, ponatinib, and omacetaxine, which all received FDA approval for CML therapy.
“Dr. Kantarjian’s long list of accomplishments and groundbreaking discoveries are a testament to his lifelong commitment to impactful cancer research and patient care,” Giulio Draetta, MD, PhD, chief scientific officer at MD Anderson, said in a statement.
Giving back
Dr. Kantarjian has written more than 2,200 peer-reviewed articles and more than 100 book chapters. In 2012, he cofounded the Society of Hematologic Oncology, which has now expanded worldwide.
He has served on multiple ASCO committees throughout the years and served on the ASCO board of directors from 2010 to 2015.
Dr. Kantarjian is passionately involved in mentoring and education. In 2000 he created the MD Anderson Leukemia Fellowship, which now trains about 10 fellows in leukemia annually.
He is a nonresident fellow in health care at the Rice Baker Institute and has written extensively on important health care issues in cancer, including the importance of universal equitable health care, health care safety nets, health care as a human right, and the problem of drug shortages.
Dr. Kantarjian is a strong advocate for more affordable drug therapies. For years he has been outspoken about the high price of leukemia drugs and has written high-profile articles in medical journals. He has even appeared on a popular television program to publicize the issue.
“Drug costs have been increasing over time. If you think about it, even if you discover a drug that cures cancer, but the drug is affordable for the 1% of the patients, then you have no cure for cancer,” Dr. Kantarjian told this news organization.
“I started speaking about the issue of the cancer drug costs in 2012. Unfortunately, we have not made progress simply because of the for-profit nature of health care and the strong lobbying by drug companies,” he added. Dr. Kantarjian hopes new legislation will eventually turn the tide.
Dr. Kantarjian has received many other honors throughout his distinguished career, including the American Lebanese Medical Association’s Lifetime Achievement Award, the American Association for Cancer Research’s Joseph H. Burchenal Memorial Award, and the Leukemia Society of America’s Outstanding Service to Mankind Award. He also was named an ASCO Fellow and a Leukemia Society of America Special Fellow and Scholar.
Dr. Kantarjian will be presented with the 2023 David A. Karnofsky Memorial Award, which includes a $25,000 honorarium, and will give a scientific lecture about his research at the ASCO annual meeting in Chicago in early June.
A version of this article originally appeared on Medscape.com.
This award is the society’s “highest scientific honor, and I am extremely happy and honored to receive it,” Dr. Kantarjian commented in an interview with this news organization.
Dr. Kantarjian serves as the chair of the department of leukemia and currently holds the Samsung Distinguished University Chair in Cancer Medicine at the University of Texas MD Anderson Cancer Center, Houston.
“No doubt that this is not an individual award. It represents an award for the accomplishments of all the leukemia faculty at MD Anderson across 4 decades. It’s really a teamwork effort that led to so many discoveries and improvements in treatment and care of patients with leukemia,” he commented.
The David A. Karnofsky Memorial Award has been presented annually since 1970 to recognize oncologists who have made outstanding contributions to cancer research, diagnosis, or treatment, ASCO noted.
From Lebanon to Texas
Dr. Kantarjian received his medical degree from the American University of Beirut, in Lebanon, in 1979 and completed his residency in internal medicine at the same institution in 1981.
It was his experience at MD Anderson as a young medical student and later as a fellow that fueled his interest and career in leukemia, he said.
“In 1978, I took a 4-month elective at MD Anderson, and I soon realized how different and innovative the atmosphere at MD Anderson was, compared to where I was training in Lebanon,” Dr. Kantarjian told this news organization.
Working with mentors that included MD Anderson heavyweights Emil Freireich, MD, Kenneth McCredie, MD, and Michael Keating, MD, helped shape his career and guide his leukemia research, he said.
Transformative impact on leukemia outcomes
The award citation notes that over the past 4 decades, Dr. Kantarjian’s research has transformed some standards of care and has dramatically improved survival in several leukemia subtypes, including chronic myeloid leukemia (CML), acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), and acute lymphocytic leukemia (ALL).
“Four decades ago, most of the leukemias were incurable. Today, most of the leukemias are potentially curable with targeted therapies. That’s what I am most proud of,” Dr. Kantarjian told this news organization.
Among Dr. Kantarjian’s contributions to the field of leukemia:
- Developing the HYPER-CVAD regimen (hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone) as a standard-of-care, frontline therapy for adults with ALL.
- Establishing clinical biology parameters of CML, including definitions of CML phases and cytogenetic responses, and establishing new prognostic factors that were subsequently adopted in studies of tyrosine kinase inhibitors.
- Leading the development of decitabine and epigenetic hypomethylation therapy for MDS and for older/unfit patients with AML.
- Pioneering research with hypomethylating agents (HMAs) in combination with venetoclax, which led to FDA approval of HMA-venetoclax combinations for older/unfit patients with AML.
- Championing the development of clofarabine, conducting animal toxicology studies, and leading subsequent phase 1 and 2 trials and pivotal phase 3 and 4 trials that led to FDA approval of clofarabine for pediatric ALL.
- Developing several FLT3 inhibitors, isocitrate dehydrogenase inhibitors, and venetoclax, which all received FDA approval for the treatment of AML and its subsets.
- Developing regimens for inotuzumab and blinatumomab combined with chemotherapy for adults with pre-B ALL.
- Working on the development of imatinib, dasatinib, nilotinib, bosutinib, ponatinib, and omacetaxine, which all received FDA approval for CML therapy.
“Dr. Kantarjian’s long list of accomplishments and groundbreaking discoveries are a testament to his lifelong commitment to impactful cancer research and patient care,” Giulio Draetta, MD, PhD, chief scientific officer at MD Anderson, said in a statement.
Giving back
Dr. Kantarjian has written more than 2,200 peer-reviewed articles and more than 100 book chapters. In 2012, he cofounded the Society of Hematologic Oncology, which has now expanded worldwide.
He has served on multiple ASCO committees throughout the years and served on the ASCO board of directors from 2010 to 2015.
Dr. Kantarjian is passionately involved in mentoring and education. In 2000 he created the MD Anderson Leukemia Fellowship, which now trains about 10 fellows in leukemia annually.
He is a nonresident fellow in health care at the Rice Baker Institute and has written extensively on important health care issues in cancer, including the importance of universal equitable health care, health care safety nets, health care as a human right, and the problem of drug shortages.
Dr. Kantarjian is a strong advocate for more affordable drug therapies. For years he has been outspoken about the high price of leukemia drugs and has written high-profile articles in medical journals. He has even appeared on a popular television program to publicize the issue.
“Drug costs have been increasing over time. If you think about it, even if you discover a drug that cures cancer, but the drug is affordable for the 1% of the patients, then you have no cure for cancer,” Dr. Kantarjian told this news organization.
“I started speaking about the issue of the cancer drug costs in 2012. Unfortunately, we have not made progress simply because of the for-profit nature of health care and the strong lobbying by drug companies,” he added. Dr. Kantarjian hopes new legislation will eventually turn the tide.
Dr. Kantarjian has received many other honors throughout his distinguished career, including the American Lebanese Medical Association’s Lifetime Achievement Award, the American Association for Cancer Research’s Joseph H. Burchenal Memorial Award, and the Leukemia Society of America’s Outstanding Service to Mankind Award. He also was named an ASCO Fellow and a Leukemia Society of America Special Fellow and Scholar.
Dr. Kantarjian will be presented with the 2023 David A. Karnofsky Memorial Award, which includes a $25,000 honorarium, and will give a scientific lecture about his research at the ASCO annual meeting in Chicago in early June.
A version of this article originally appeared on Medscape.com.
This award is the society’s “highest scientific honor, and I am extremely happy and honored to receive it,” Dr. Kantarjian commented in an interview with this news organization.
Dr. Kantarjian serves as the chair of the department of leukemia and currently holds the Samsung Distinguished University Chair in Cancer Medicine at the University of Texas MD Anderson Cancer Center, Houston.
“No doubt that this is not an individual award. It represents an award for the accomplishments of all the leukemia faculty at MD Anderson across 4 decades. It’s really a teamwork effort that led to so many discoveries and improvements in treatment and care of patients with leukemia,” he commented.
The David A. Karnofsky Memorial Award has been presented annually since 1970 to recognize oncologists who have made outstanding contributions to cancer research, diagnosis, or treatment, ASCO noted.
From Lebanon to Texas
Dr. Kantarjian received his medical degree from the American University of Beirut, in Lebanon, in 1979 and completed his residency in internal medicine at the same institution in 1981.
It was his experience at MD Anderson as a young medical student and later as a fellow that fueled his interest and career in leukemia, he said.
“In 1978, I took a 4-month elective at MD Anderson, and I soon realized how different and innovative the atmosphere at MD Anderson was, compared to where I was training in Lebanon,” Dr. Kantarjian told this news organization.
Working with mentors that included MD Anderson heavyweights Emil Freireich, MD, Kenneth McCredie, MD, and Michael Keating, MD, helped shape his career and guide his leukemia research, he said.
Transformative impact on leukemia outcomes
The award citation notes that over the past 4 decades, Dr. Kantarjian’s research has transformed some standards of care and has dramatically improved survival in several leukemia subtypes, including chronic myeloid leukemia (CML), acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), and acute lymphocytic leukemia (ALL).
“Four decades ago, most of the leukemias were incurable. Today, most of the leukemias are potentially curable with targeted therapies. That’s what I am most proud of,” Dr. Kantarjian told this news organization.
Among Dr. Kantarjian’s contributions to the field of leukemia:
- Developing the HYPER-CVAD regimen (hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone) as a standard-of-care, frontline therapy for adults with ALL.
- Establishing clinical biology parameters of CML, including definitions of CML phases and cytogenetic responses, and establishing new prognostic factors that were subsequently adopted in studies of tyrosine kinase inhibitors.
- Leading the development of decitabine and epigenetic hypomethylation therapy for MDS and for older/unfit patients with AML.
- Pioneering research with hypomethylating agents (HMAs) in combination with venetoclax, which led to FDA approval of HMA-venetoclax combinations for older/unfit patients with AML.
- Championing the development of clofarabine, conducting animal toxicology studies, and leading subsequent phase 1 and 2 trials and pivotal phase 3 and 4 trials that led to FDA approval of clofarabine for pediatric ALL.
- Developing several FLT3 inhibitors, isocitrate dehydrogenase inhibitors, and venetoclax, which all received FDA approval for the treatment of AML and its subsets.
- Developing regimens for inotuzumab and blinatumomab combined with chemotherapy for adults with pre-B ALL.
- Working on the development of imatinib, dasatinib, nilotinib, bosutinib, ponatinib, and omacetaxine, which all received FDA approval for CML therapy.
“Dr. Kantarjian’s long list of accomplishments and groundbreaking discoveries are a testament to his lifelong commitment to impactful cancer research and patient care,” Giulio Draetta, MD, PhD, chief scientific officer at MD Anderson, said in a statement.
Giving back
Dr. Kantarjian has written more than 2,200 peer-reviewed articles and more than 100 book chapters. In 2012, he cofounded the Society of Hematologic Oncology, which has now expanded worldwide.
He has served on multiple ASCO committees throughout the years and served on the ASCO board of directors from 2010 to 2015.
Dr. Kantarjian is passionately involved in mentoring and education. In 2000 he created the MD Anderson Leukemia Fellowship, which now trains about 10 fellows in leukemia annually.
He is a nonresident fellow in health care at the Rice Baker Institute and has written extensively on important health care issues in cancer, including the importance of universal equitable health care, health care safety nets, health care as a human right, and the problem of drug shortages.
Dr. Kantarjian is a strong advocate for more affordable drug therapies. For years he has been outspoken about the high price of leukemia drugs and has written high-profile articles in medical journals. He has even appeared on a popular television program to publicize the issue.
“Drug costs have been increasing over time. If you think about it, even if you discover a drug that cures cancer, but the drug is affordable for the 1% of the patients, then you have no cure for cancer,” Dr. Kantarjian told this news organization.
“I started speaking about the issue of the cancer drug costs in 2012. Unfortunately, we have not made progress simply because of the for-profit nature of health care and the strong lobbying by drug companies,” he added. Dr. Kantarjian hopes new legislation will eventually turn the tide.
Dr. Kantarjian has received many other honors throughout his distinguished career, including the American Lebanese Medical Association’s Lifetime Achievement Award, the American Association for Cancer Research’s Joseph H. Burchenal Memorial Award, and the Leukemia Society of America’s Outstanding Service to Mankind Award. He also was named an ASCO Fellow and a Leukemia Society of America Special Fellow and Scholar.
Dr. Kantarjian will be presented with the 2023 David A. Karnofsky Memorial Award, which includes a $25,000 honorarium, and will give a scientific lecture about his research at the ASCO annual meeting in Chicago in early June.
A version of this article originally appeared on Medscape.com.
Revisiting our approach to behavioral health referrals
Approximately 1 in 4 people ages 18 years and older and 1 in 3 people ages 18 to 25 years had a mental illness in the past year, according to the 2021 National Survey of Drug Use and Health.1 The survey also found that adults ages 18 to 25 years had the highest rate of serious mental illness but the lowest treatment rate compared to other adult age groups.1 Unfortunately, more than 60% of patients receiving mental health treatment fail to benefit to a clinically meaningful degree.2
However, there is growing evidence that referring patients to behavioral health practitioners (BHPs) with outcome-measured skills that meet the patient’s specific needs can have a dramatic and positive impact. There are 2 main steps to pairing patients with an appropriate BHP: (1) use of measurement-based care data that can be analyzed at the patient and therapist level, and (2) data-driven referrals that pair patients with BHPs based on such routine outcome monitoring data (paired-on outcome data).
Psychotherapy’s slow road toward measurement-based care
Routine outcome monitoring is the systematic measurement of symptoms and functioning during treatment. It serves multiple functions, including program evaluation and benchmarking of patient improvement rates. Moreover, routine outcome monitoring–derived feedback (based on repeated patient outcome measurements) can inform personalized and responsive care decisions throughout treatment.
For all intents and purposes,
- routinely administered symptom/functioning measure, ideally before each clinical encounter,
- practitioner review of these patient-level data,
- patient review of these data with their practitioner, and
- collaborative reevaluation of the person-specific treatment plan informed by these data.
CASE SCENARIO
Violeta W is a 33-year-old woman who presented to her family physician for her annual wellness exam. Prior to the exam, the medical assistant administered a Patient Health Questionnaire-9 (PHQ-9) to screen for depressive symptoms. Ms. W’s score was 20 out of 27, suggestive of depression. To further assess the severity of depressive symptoms and their effect on daily function, the physician reviewed responses to the questionnaire with her and discussed treatment options. Ms. W was most interested in trying a low-dose selective serotonin reuptake inhibitor (SSRI).
At her follow-up visit 4 weeks later, the medical assistant re-administered the PHQ-9. The physician then reviewed Ms. W’s responses with her and, based on Ms. W’s subjective report and objective symptoms (still a score of 20 out of 27 on the PHQ-9), increased her SSRI dose. At each subsequent visit, Ms. W completed a PHQ-9 and reviewed responses and depressive symptoms with her physician.
The value of measurement-based care in mental health care
A narrative review by Lewis et al3 of 21 randomized controlled clinical trials (RCTs) across a range of age groups (eg, adolescents, young adults, adults), disorders (eg, anxiety, mood), and settings (eg, outpatient, inpatient) found that in at least 9 review articles, measurement-based care was associated with significantly improved outcomes vs usual care (ie, treatment without routine outcome monitoring plus feedback). The average increase in treatment effect size was about 30% when treatment was accompanied by measurement-based care.3
Continue to: Moreover, a recent within-patient meta-analysis...
Moreover, a recent within-patient meta-analysis by de Jong et al4 shows that measurement-based care yields a small but significant increase in therapeutic outcomes (d = .15). Use of measurement-based care also is associated with improved communication between the patient and therapist.5 In pharmacotherapy practice, measurement-based care has been shown to predict rapid dose increases and changes in medication, when necessary; faster recovery rates; higher response rates to treatment3; and fewer dropouts.4
Perhaps one of the best-studied benefits of measurement-based mental health care is the ability to predict deterioration in care (ie, patients who are off-track in a way that practitioners often miss without the help of routine outcome monitoring data).6,7 Studies show that without a data-informed approach to care, some forms of psychotherapy or therapy with BHPs who are not sufficiently skilled in treating a given diagnosis increase symptoms or create significant harmful and iatrogenic effects.8-10 Conversely, the meta-analysis by de Jong et al4 found a lower percentage of deterioration in patients receiving measurement-based care. The difference in deterioration was significant: An average of 5.4% of patients in control conditions deteriorated compared to an average of 4.6% in feedback (measurement-based care) groups. There were even larger effect sizes when therapists received training in the feedback system.4
Routine outcome monitoring without a dialogue between patient and practitioner about the assessments (eg, ignoring complete measurement-based care requirements) may be inadequate. A recent review by Muir et al6 found no differences in patient outcomes when data were used solely for aggregate quality improvement activities, suggesting the need for practitioners to review results of routine outcome monitoring assessments with patients and use data to alter care when necessary.
Measurement-based care is believed to deliver benefits and reduce harm by enhancing and encouraging active patient involvement, improving patient understanding of symptoms, promoting better communication, and facilitating better care coordination.3 The benefits of measurement-based care can be enhanced with a comprehensive core routine outcome monitoring tool and the level of monitoring-generated information delivered for multiple stakeholders (eg, patient, therapist, clinic).11
A look at multidimensional assessment
The features of routine outcome monitoring tools vary significantly.12 Some measures assess single-symptom or problem domains (eg, PHQ-9 for depression or Generalized Anxiety Disorder-7 [GAD-7] scale for anxiety) or multiple dimensions (multidimensional routine outcome monitoring). Multidimensional routine outcome monitoring may have benefits over single-domain measures. Single-domain measures and the subscales or factors of more comprehensive multidimensional routine outcome monitoring assessments should possess adequate specificity and sensitivity.
Continue to: Some recent research findings...
Some recent research findings question the construct validity of brief single-domain measures of common presenting problems, such as depression and anxiety. For example, results from a factor analysis of the PHQ-9 and GAD-7 scale in patients with traumatic brain injury suggest these tools measure 1 psychological construct that includes depression and the cognitive components of anxiety (eg, worry)13—a finding consistent with those of other tools.14 Similarly, a larger study of 7763 BH patients found that a single factor accounted for most of the variance of the 2 combined measures, with no set of factors meeting the exacting standards used to develop multidimensional routine outcome monitoring.15 These findings suggest that the PHQ-9 and GAD-7 largely overlap and are not measuring different aspects of health as most practitioners believe (eg, depression and anxiety).
In commonly used assessments, multiple-factor analytic studies with high standards have supported the construct validity of domain-specific subscales, indicating that the various questions tap into different constructs of psychological health.14,16,17
Beyond multiple domain–specific indicators, multidimensional routine outcome measurements provide a global total score that minimizes Type I (false-positive conclusion) and Type II (false-negative conclusion) errors in tracking patient improvement or deterioration.18 As one would expect, multidimensional routine outcome monitoring generally includes more items than single-domain measures; however, this comes with a trade-off. If there are specificity and sensitivity concerns with an ultra-brief single-domain measure, an alternative to a core multidimensional routine outcome measurement is to aggregate a series of single-domain measures into a battery of patient self-reports. However, this approach may take longer for patients to complete since they would have to shift among the varying response sets and wording across the unique single-domain measures.
In addition, the standardization/normalization of multidimensional routine outcome monitoring likely makes interpretation easier than referring to norms and clinical severity cutoffs for many distinct measures. Furthermore, increased specificity enhances predictive power and allows BHPs to screen and track other conditions besides depression and anxiety. (It is worth noting that there are no known studies that have looked at the difference in time to administer or ease of interpretation of multidimensional routine outcome monitoring tools vs multiple single-domain measures.)
Two multidimensional routine outcome monitoring tools that cover a comprehensive series of discrete symptom and functional domains are the Treatment Outcome Package12 and Counseling Center Assessment of Psychological Symptoms.16 These tools, which include subscales beyond general depression and anxiety (eg, sleep, substance misuse, social conflict), take 7 to 10 minutes to complete and provide outcome results across 12 symptom and 8 functional dimensions. As an example, the Treatment Outcome Package has good psychometric qualities (eg, reliability, construct and concurrent validity) for adults,12 children,14,19 and adolescents,19 and can be administered through a secure online data collection portal. The Counseling Center Assessment of Psychological Symptoms has demonstrated high construct validity and good convergent validity.16 These assessments can be administered in paper or digital (eg, electronic medical record portal, smartphone) format.20
Continue to: CASE SCENARIO
CASE SCENARIO
Ms. W’s physician asked her to go online using her phone and answer the questions in the Treatment Outcome Package. Her results, which she viewed with her physician, were displayed in graph form (FIGURE). Her scores were represented in Z scores normalized to the general population, with “0” representing the general, nontreatment-seeking population average and positive scores representing the number of standard deviations (SDs) more severe than the general population average.
Although this assessment scored Ms. W’s clinically elevated depression as mild, it revealed abnormalities in 3 other domains. Sexual functioning issues represented the most abnormal domain at greater than 3 SDs (more severe than the general population), followed by poor life quality and school/work functioning.
After reviewing Ms. W’s report, her physician decided that pharmacologic management alone (for depression) was not the most appropriate treatment course. Therefore, her physician recommended psychotherapy in addition to the SSRI she was taking. Ms. W agreed to a customized referral for psychotherapy.
Data-driven referrals
When psychotherapy is chosen as a treatment, the individual BHP is an active component of that treatment. Consequently, it is essential to customize referrals to match a patient’s most elevated mental health concerns with a therapist who will most effectively treat those domains. It is rare for a BHP to be skilled in treating every mental health domain.9 Multiple studies have shown that BHPs have identifiable treatment skills in specific domains, which physicians should consider when making referrals.9,21,22 These studies demonstrate the utility of aggregating patient-level routine outcome monitoring data to better understand therapist-level (and ultimately clinic- and system-level) outcomes.
Additionally, recent research has tested this idea prospectively. An RCT funded by the Patient-Centered Outcome Research Institute and published in JAMA Psychiatry showed a significant and positive effect on patient outcomes (ie, reductions in general impairment, impairment involving a patient’s most elevated domain, and global distress) using paired-on outcome data matching vs as-usual matching protocols (eg, therapist self-defined areas of specialty).22 In the RCT, the most effective matching protocol was a combination of eliminating harm and matching the patient on their 3 most problematic domains (the highest match level). These patients ended care as healthy as the general population after 16 weeks of treatment. A random 1-year follow-up assessment from the original RCT showed that most patients who had been matched had maintained their improvement.23
Continue to: Therefore, a multidimensional routine outcome...
Therefore, a multidimensional routine outcome monitoring tool can be used to identify a BHP’s relative strengths and weaknesses across multiple outcome domains. Within a system of care, a sample of BHPs will possess varying outcome-domain profiles. When a new patient is seeking a referral to a BHP, these profiles (or domain-specific outcome track records) can be used to support paired-on outcome data matching. Specifically, a new patient completes the multidimensional routine outcome monitoring tool at pretreatment, and the results reveal the outcome domains on which the patient is most clinically severe. This pattern of domain-specific severity then can be used to pair the new patient with a BHP who has demonstrated success in addressing the same outcome domain(s). This approach matches a new patient to a BHP with established expertise based on routine outcome monitoring.
Retrospective and prospective studies have found that most BHPs have stable performance in their strengths and weaknesses.11,21 One study found that assessing BHP performance with their most recent 30 patients can reliably predict future performance with their next 30 patients.24 This predictability in a practitioner’s outcomes suggests report cards that are updated frequently can be utilized to make case assignments within BH or referrals to a specific BHP from primary care.
Making a paired-on outcome data–matched referral
Making customized BH referrals requires access to information about a practitioner’s previous routine outcome monitoring data per clinical domain (eg, suicidality, violence, quality of life) from their most recent patients. Previous research suggests that follow-up data from a minimum of 15 patients is necessary to make a reliable evaluation of a practitioner’s strengths and weaknesses (ie, effectiveness “report card”) per clinical domain.24
Few, if any, physicians have access to this level of updated outcome data from their referral network. To facilitate widespread use of paired-on outcome data matching, a new Web system (MatchedTherapists.com) will allow the general public and PCPs to access these grades. As a public service option, this site currently allows for a self-assessment using the Treatment Outcome Package. Pending versions will generate paired-on outcome data grades, and users will receive a list of local therapists available for in-person appointments as well as therapists available for virtual appointments. The paired-on outcome data grades are delivered in school-based letter grades. An “A+,” for example, represents the best matching grade. Users also will be able to sort and filter results for other criteria such as telemedicine, insurance, age, gender, and appointment availability. Currently, there are more than 77,000 therapists listed on the site nationwide. A basic listing is free.
CASE SCENARIO
After Ms. W took the multidimensional routine outcome assessment online, she received a list of therapists rank-ordered by paired-on outcome data grade, with the “A+” matches listed first. Three of the best-matched referrals accepted her insurance and were willing to see her through telemedicine. Therapists with available in-person appointments had a “B” grade. After discussing the options with her physician, Ms. W opted for telehealth counseling with the therapist whose profile she liked best. The therapist and PCP tracked her progress through routine outcome monitoring reporting until all her symptoms became subclinical.
Continue to: The future of a "referral bridge"
The future of a “referral bridge”
In this article, we present a solution to a common issue faced by mental health care patients: failure to benefit meaningfully from mental health treatment. Matching patients to specific BHPs based on effectiveness data regarding the therapist’s strengths and skills can improve patient outcomes and reduce harm. In addition, patients appear to value this approach. A Robert Wood Johnson Foundation–funded study demonstrated that patients value seeing practitioners who have a track record of successfully treating previous patients with similar issues.25,26 In many cases, patients indicated they would prioritize this matching process over other factors such as practitioners with a higher number of years of experience or the same demographic characteristics as the patient.25,26
These findings may represent a new area in the science of health care. Over the past century, major advances in diagnosis and treatment—the 2 primary pillars of health care—have turned the art of medicine into a science. However, the art of making referrals has not advanced commensurately, as there has been little attention focused on the “referral bridge” between these 2 pillars. As the studies reviewed in this paper demonstrate, a referral bridge deserves exploration in all fields of medicine.
CORRESPONDENCE
David R. Kraus, PhD, 1 Speen Street, Framingham, MA 01701; dkraus@outcomereferrals.com
1. HHS. 2021 National Survey of Drug Use and Health (NSDUH) Releases. Accessed March 29, 2023. www.samhsa.gov/data/release/2021-national-survey-drug-use-and-health-nsduh-releases
2. Barkham M, Lambert, MJ. The efficacy and effectiveness of psychological therapies. In: Barkham M, Lutz W, Castonguay LG, eds. Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change: 50th Anniversary Edition. 7th ed. John Wiley & Sons, Inc; 2021:135-189.
3. Lewis CC, Boyd M, Puspitasari A, et al. Implementing measurement-based care in behavioral health: a review. JAMA Psychiatry. 2019;76:324-335. doi: 10.1001/jamapsychiatry.2018.3329
4. de Jong K, Conijn JM, Gallagher RAV, et al. Using progress feedback to improve outcomes and reduce drop-out, treatment duration, and deterioration: a multilevel meta-analysis. Clin Psychol Rev. 2021;85:102002. doi: 10.1016/j.cpr.2021.102002
5. Carlier IVE, Meuldijk D, Van Vliet IM, et al. Routine outcome monitoring and feedback on physical or mental health status: evidence and theory. J Eval Clin Pract. 2012;18:104-110. doi: 10.1111/j.1365-2753.2010.01543.x
6. Muir HJ, Coyne AE, Morrison NR, et al. Ethical implications of routine outcomes monitoring for patients, psychotherapists, and mental health care systems. Psychotherapy (Chic). 2019;56:459-469. doi: 10.1037/pst0000246
7. Hannan C, Lambert MJ, Harmon C, et al. A lab test and algorithms for identifying clients at risk for treatment failure. J Clin Psychol. 2005;61:155-163. doi: 10.1002/jclp.20108
8. Castonguay LG, Boswell JF, Constantino MJ, et al. Training implications of harmful effects of psychological treatments. Am Psychol. 2010;65:34-49. doi: 10.1037/a0017330
9. Kraus DR, Castonguay LG, Boswell JF, et al. Therapist effectiveness: implications for accountability and patient care. Psychother Res. 2011;21:267-276. doi: 10.1080/10503307.2011.563249
10. Lilienfeld SO. Psychological treatments that cause harm. Perspect Psychol Sci. 2007;2:53-70. doi: 10.1111/j.1745-6916.2007.00029.x
11. Boswell JF, Constantino MJ, Kraus DR, et al. The expanding relevance of routinely collected outcome data for mental health care decision making. Adm Policy Ment Health. 2016;43:482-491. doi: 10.1007/s10488-015-0649-6
12. Lyon AR, Lewis CC, Boyd MR, et al. Capabilities and characteristics of digital measurement feedback systems: results from a comprehensive review. Adm Policy Ment Health. 2016;43:441-466. doi: 10.1007/s10488-016-0719-4
13. Teymoori A, Gorbunova A, Haghish FE, et al. Factorial structure and validity of depression (PHQ-9) and anxiety (GAD-7) scales after traumatic brain injury. J Clin Med. 2020;9:873. doi: 10.3390/jcm9030873
14. Kraus DR, Seligman DA, Jordan JR. Validation of a behavioral health treatment outcome and assessment tool designed for naturalistic settings: the Treatment Outcome Package. J Clin Psychol. 2005;61:285‐314. doi: 10.1002/jclp.20084
15. Boothroyd L, Dagnan D, Muncer S. Psychometric analysis of the Generalized Anxiety Disorder Scale and the Patient Health Questionnaire using Mokken scaling and confirmatory factor analysis. Health Prim Care. 2018;2:1-4. doi: 10.15761/HPC.1000145
16. Locke BD, Buzolitz JS, Lei PW, et al. Development of the Counseling Center Assessment of Psychological Symptoms-62 (CCAPS-62). J Couns Psychol. 2011;58:97-109. doi: 10.1037/a0021282
17. Kraus DR, Boswell JF, Wright AGC, et al. Factor structure of the treatment outcome package for children. J Clin Psychol. 2010;66:627-640. doi: 10.1002/jclp.20675
18. McAleavey AA, Nordberg SS, Kraus D, et al. Errors in treatment outcome monitoring: implications for real-world psychotherapy. Can Psychol. 2010;53:105-114. doi: 10.1037/a0027833
19. Baxter EE, Alexander PC, Kraus DR, et al. Concurrent validation of the Treatment Outcome Package (TOP) for children and adolescents. J Child Fam Stud. 2016;25:2415-2422. doi: 10.1007/s10826-016-0419-4
20. Gual-Montolio P, Martínez-Borba V, Bretón-López JM, et al. How are information and communication technologies supporting routine outcome monitoring and measurement-based care in psychotherapy? A systematic review. Int J Environ Res Public Health. 2020;17:3170. doi: 10.3390/ijerph17093170
21. Kraus DR, Bentley JH, Alexander PC, et al. Predicting therapist effectiveness from their own practice-based evidence. J Consult Clin Psychol. 2016;84:473‐483. doi: 10.1037/ccp0000083
22. Constantino MJ, Boswell JF, Coyne AE, et al. Effect of matching therapists to patients vs assignment as usual on adult psychotherapy outcomes. A randomized clinical trial. JAMA Psychiatry. 2021;78:960-969. doi: 10.1001/jamapsychiatry.2021.1221
23. Constantino MJ, Boswell JF, Kraus DR, et al. Matching patients with therapists to improve mental health care. Patient-Centered Outcomes Research Institute (PCORI). 2021. Accessed March 1, 2023. www.pcori.org/research-results/2015/matching-patients-therapists-improve-mental-health-care
24. Institute of Medicine. Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders. Improving the Quality of Health Care for Mental and Substance-Use Conditions. National Academies Press; 2006. Accessed February 21, 2023. https://nap.nationalacademies.org/read/11470/chapter/1
25. Boswell JF, Constantino MJ, Oswald JM, et al. A multimethod study of mental health care patients’ attitudes toward clinician-level performance information. Psychiatr Serv. 2021;72:452-456. doi: 10.1176/appi.ps.202000366
26. Boswell JF, Constantino MJ, Oswald JM, et al. Mental health care consumers’ relative valuing of clinician performance information. J Consult Clin Psychol. 2018;86:301‐308. doi: 10.1037/ccp0000264
Approximately 1 in 4 people ages 18 years and older and 1 in 3 people ages 18 to 25 years had a mental illness in the past year, according to the 2021 National Survey of Drug Use and Health.1 The survey also found that adults ages 18 to 25 years had the highest rate of serious mental illness but the lowest treatment rate compared to other adult age groups.1 Unfortunately, more than 60% of patients receiving mental health treatment fail to benefit to a clinically meaningful degree.2
However, there is growing evidence that referring patients to behavioral health practitioners (BHPs) with outcome-measured skills that meet the patient’s specific needs can have a dramatic and positive impact. There are 2 main steps to pairing patients with an appropriate BHP: (1) use of measurement-based care data that can be analyzed at the patient and therapist level, and (2) data-driven referrals that pair patients with BHPs based on such routine outcome monitoring data (paired-on outcome data).
Psychotherapy’s slow road toward measurement-based care
Routine outcome monitoring is the systematic measurement of symptoms and functioning during treatment. It serves multiple functions, including program evaluation and benchmarking of patient improvement rates. Moreover, routine outcome monitoring–derived feedback (based on repeated patient outcome measurements) can inform personalized and responsive care decisions throughout treatment.
For all intents and purposes,
- routinely administered symptom/functioning measure, ideally before each clinical encounter,
- practitioner review of these patient-level data,
- patient review of these data with their practitioner, and
- collaborative reevaluation of the person-specific treatment plan informed by these data.
CASE SCENARIO
Violeta W is a 33-year-old woman who presented to her family physician for her annual wellness exam. Prior to the exam, the medical assistant administered a Patient Health Questionnaire-9 (PHQ-9) to screen for depressive symptoms. Ms. W’s score was 20 out of 27, suggestive of depression. To further assess the severity of depressive symptoms and their effect on daily function, the physician reviewed responses to the questionnaire with her and discussed treatment options. Ms. W was most interested in trying a low-dose selective serotonin reuptake inhibitor (SSRI).
At her follow-up visit 4 weeks later, the medical assistant re-administered the PHQ-9. The physician then reviewed Ms. W’s responses with her and, based on Ms. W’s subjective report and objective symptoms (still a score of 20 out of 27 on the PHQ-9), increased her SSRI dose. At each subsequent visit, Ms. W completed a PHQ-9 and reviewed responses and depressive symptoms with her physician.
The value of measurement-based care in mental health care
A narrative review by Lewis et al3 of 21 randomized controlled clinical trials (RCTs) across a range of age groups (eg, adolescents, young adults, adults), disorders (eg, anxiety, mood), and settings (eg, outpatient, inpatient) found that in at least 9 review articles, measurement-based care was associated with significantly improved outcomes vs usual care (ie, treatment without routine outcome monitoring plus feedback). The average increase in treatment effect size was about 30% when treatment was accompanied by measurement-based care.3
Continue to: Moreover, a recent within-patient meta-analysis...
Moreover, a recent within-patient meta-analysis by de Jong et al4 shows that measurement-based care yields a small but significant increase in therapeutic outcomes (d = .15). Use of measurement-based care also is associated with improved communication between the patient and therapist.5 In pharmacotherapy practice, measurement-based care has been shown to predict rapid dose increases and changes in medication, when necessary; faster recovery rates; higher response rates to treatment3; and fewer dropouts.4
Perhaps one of the best-studied benefits of measurement-based mental health care is the ability to predict deterioration in care (ie, patients who are off-track in a way that practitioners often miss without the help of routine outcome monitoring data).6,7 Studies show that without a data-informed approach to care, some forms of psychotherapy or therapy with BHPs who are not sufficiently skilled in treating a given diagnosis increase symptoms or create significant harmful and iatrogenic effects.8-10 Conversely, the meta-analysis by de Jong et al4 found a lower percentage of deterioration in patients receiving measurement-based care. The difference in deterioration was significant: An average of 5.4% of patients in control conditions deteriorated compared to an average of 4.6% in feedback (measurement-based care) groups. There were even larger effect sizes when therapists received training in the feedback system.4
Routine outcome monitoring without a dialogue between patient and practitioner about the assessments (eg, ignoring complete measurement-based care requirements) may be inadequate. A recent review by Muir et al6 found no differences in patient outcomes when data were used solely for aggregate quality improvement activities, suggesting the need for practitioners to review results of routine outcome monitoring assessments with patients and use data to alter care when necessary.
Measurement-based care is believed to deliver benefits and reduce harm by enhancing and encouraging active patient involvement, improving patient understanding of symptoms, promoting better communication, and facilitating better care coordination.3 The benefits of measurement-based care can be enhanced with a comprehensive core routine outcome monitoring tool and the level of monitoring-generated information delivered for multiple stakeholders (eg, patient, therapist, clinic).11
A look at multidimensional assessment
The features of routine outcome monitoring tools vary significantly.12 Some measures assess single-symptom or problem domains (eg, PHQ-9 for depression or Generalized Anxiety Disorder-7 [GAD-7] scale for anxiety) or multiple dimensions (multidimensional routine outcome monitoring). Multidimensional routine outcome monitoring may have benefits over single-domain measures. Single-domain measures and the subscales or factors of more comprehensive multidimensional routine outcome monitoring assessments should possess adequate specificity and sensitivity.
Continue to: Some recent research findings...
Some recent research findings question the construct validity of brief single-domain measures of common presenting problems, such as depression and anxiety. For example, results from a factor analysis of the PHQ-9 and GAD-7 scale in patients with traumatic brain injury suggest these tools measure 1 psychological construct that includes depression and the cognitive components of anxiety (eg, worry)13—a finding consistent with those of other tools.14 Similarly, a larger study of 7763 BH patients found that a single factor accounted for most of the variance of the 2 combined measures, with no set of factors meeting the exacting standards used to develop multidimensional routine outcome monitoring.15 These findings suggest that the PHQ-9 and GAD-7 largely overlap and are not measuring different aspects of health as most practitioners believe (eg, depression and anxiety).
In commonly used assessments, multiple-factor analytic studies with high standards have supported the construct validity of domain-specific subscales, indicating that the various questions tap into different constructs of psychological health.14,16,17
Beyond multiple domain–specific indicators, multidimensional routine outcome measurements provide a global total score that minimizes Type I (false-positive conclusion) and Type II (false-negative conclusion) errors in tracking patient improvement or deterioration.18 As one would expect, multidimensional routine outcome monitoring generally includes more items than single-domain measures; however, this comes with a trade-off. If there are specificity and sensitivity concerns with an ultra-brief single-domain measure, an alternative to a core multidimensional routine outcome measurement is to aggregate a series of single-domain measures into a battery of patient self-reports. However, this approach may take longer for patients to complete since they would have to shift among the varying response sets and wording across the unique single-domain measures.
In addition, the standardization/normalization of multidimensional routine outcome monitoring likely makes interpretation easier than referring to norms and clinical severity cutoffs for many distinct measures. Furthermore, increased specificity enhances predictive power and allows BHPs to screen and track other conditions besides depression and anxiety. (It is worth noting that there are no known studies that have looked at the difference in time to administer or ease of interpretation of multidimensional routine outcome monitoring tools vs multiple single-domain measures.)
Two multidimensional routine outcome monitoring tools that cover a comprehensive series of discrete symptom and functional domains are the Treatment Outcome Package12 and Counseling Center Assessment of Psychological Symptoms.16 These tools, which include subscales beyond general depression and anxiety (eg, sleep, substance misuse, social conflict), take 7 to 10 minutes to complete and provide outcome results across 12 symptom and 8 functional dimensions. As an example, the Treatment Outcome Package has good psychometric qualities (eg, reliability, construct and concurrent validity) for adults,12 children,14,19 and adolescents,19 and can be administered through a secure online data collection portal. The Counseling Center Assessment of Psychological Symptoms has demonstrated high construct validity and good convergent validity.16 These assessments can be administered in paper or digital (eg, electronic medical record portal, smartphone) format.20
Continue to: CASE SCENARIO
CASE SCENARIO
Ms. W’s physician asked her to go online using her phone and answer the questions in the Treatment Outcome Package. Her results, which she viewed with her physician, were displayed in graph form (FIGURE). Her scores were represented in Z scores normalized to the general population, with “0” representing the general, nontreatment-seeking population average and positive scores representing the number of standard deviations (SDs) more severe than the general population average.
Although this assessment scored Ms. W’s clinically elevated depression as mild, it revealed abnormalities in 3 other domains. Sexual functioning issues represented the most abnormal domain at greater than 3 SDs (more severe than the general population), followed by poor life quality and school/work functioning.
After reviewing Ms. W’s report, her physician decided that pharmacologic management alone (for depression) was not the most appropriate treatment course. Therefore, her physician recommended psychotherapy in addition to the SSRI she was taking. Ms. W agreed to a customized referral for psychotherapy.
Data-driven referrals
When psychotherapy is chosen as a treatment, the individual BHP is an active component of that treatment. Consequently, it is essential to customize referrals to match a patient’s most elevated mental health concerns with a therapist who will most effectively treat those domains. It is rare for a BHP to be skilled in treating every mental health domain.9 Multiple studies have shown that BHPs have identifiable treatment skills in specific domains, which physicians should consider when making referrals.9,21,22 These studies demonstrate the utility of aggregating patient-level routine outcome monitoring data to better understand therapist-level (and ultimately clinic- and system-level) outcomes.
Additionally, recent research has tested this idea prospectively. An RCT funded by the Patient-Centered Outcome Research Institute and published in JAMA Psychiatry showed a significant and positive effect on patient outcomes (ie, reductions in general impairment, impairment involving a patient’s most elevated domain, and global distress) using paired-on outcome data matching vs as-usual matching protocols (eg, therapist self-defined areas of specialty).22 In the RCT, the most effective matching protocol was a combination of eliminating harm and matching the patient on their 3 most problematic domains (the highest match level). These patients ended care as healthy as the general population after 16 weeks of treatment. A random 1-year follow-up assessment from the original RCT showed that most patients who had been matched had maintained their improvement.23
Continue to: Therefore, a multidimensional routine outcome...
Therefore, a multidimensional routine outcome monitoring tool can be used to identify a BHP’s relative strengths and weaknesses across multiple outcome domains. Within a system of care, a sample of BHPs will possess varying outcome-domain profiles. When a new patient is seeking a referral to a BHP, these profiles (or domain-specific outcome track records) can be used to support paired-on outcome data matching. Specifically, a new patient completes the multidimensional routine outcome monitoring tool at pretreatment, and the results reveal the outcome domains on which the patient is most clinically severe. This pattern of domain-specific severity then can be used to pair the new patient with a BHP who has demonstrated success in addressing the same outcome domain(s). This approach matches a new patient to a BHP with established expertise based on routine outcome monitoring.
Retrospective and prospective studies have found that most BHPs have stable performance in their strengths and weaknesses.11,21 One study found that assessing BHP performance with their most recent 30 patients can reliably predict future performance with their next 30 patients.24 This predictability in a practitioner’s outcomes suggests report cards that are updated frequently can be utilized to make case assignments within BH or referrals to a specific BHP from primary care.
Making a paired-on outcome data–matched referral
Making customized BH referrals requires access to information about a practitioner’s previous routine outcome monitoring data per clinical domain (eg, suicidality, violence, quality of life) from their most recent patients. Previous research suggests that follow-up data from a minimum of 15 patients is necessary to make a reliable evaluation of a practitioner’s strengths and weaknesses (ie, effectiveness “report card”) per clinical domain.24
Few, if any, physicians have access to this level of updated outcome data from their referral network. To facilitate widespread use of paired-on outcome data matching, a new Web system (MatchedTherapists.com) will allow the general public and PCPs to access these grades. As a public service option, this site currently allows for a self-assessment using the Treatment Outcome Package. Pending versions will generate paired-on outcome data grades, and users will receive a list of local therapists available for in-person appointments as well as therapists available for virtual appointments. The paired-on outcome data grades are delivered in school-based letter grades. An “A+,” for example, represents the best matching grade. Users also will be able to sort and filter results for other criteria such as telemedicine, insurance, age, gender, and appointment availability. Currently, there are more than 77,000 therapists listed on the site nationwide. A basic listing is free.
CASE SCENARIO
After Ms. W took the multidimensional routine outcome assessment online, she received a list of therapists rank-ordered by paired-on outcome data grade, with the “A+” matches listed first. Three of the best-matched referrals accepted her insurance and were willing to see her through telemedicine. Therapists with available in-person appointments had a “B” grade. After discussing the options with her physician, Ms. W opted for telehealth counseling with the therapist whose profile she liked best. The therapist and PCP tracked her progress through routine outcome monitoring reporting until all her symptoms became subclinical.
Continue to: The future of a "referral bridge"
The future of a “referral bridge”
In this article, we present a solution to a common issue faced by mental health care patients: failure to benefit meaningfully from mental health treatment. Matching patients to specific BHPs based on effectiveness data regarding the therapist’s strengths and skills can improve patient outcomes and reduce harm. In addition, patients appear to value this approach. A Robert Wood Johnson Foundation–funded study demonstrated that patients value seeing practitioners who have a track record of successfully treating previous patients with similar issues.25,26 In many cases, patients indicated they would prioritize this matching process over other factors such as practitioners with a higher number of years of experience or the same demographic characteristics as the patient.25,26
These findings may represent a new area in the science of health care. Over the past century, major advances in diagnosis and treatment—the 2 primary pillars of health care—have turned the art of medicine into a science. However, the art of making referrals has not advanced commensurately, as there has been little attention focused on the “referral bridge” between these 2 pillars. As the studies reviewed in this paper demonstrate, a referral bridge deserves exploration in all fields of medicine.
CORRESPONDENCE
David R. Kraus, PhD, 1 Speen Street, Framingham, MA 01701; dkraus@outcomereferrals.com
Approximately 1 in 4 people ages 18 years and older and 1 in 3 people ages 18 to 25 years had a mental illness in the past year, according to the 2021 National Survey of Drug Use and Health.1 The survey also found that adults ages 18 to 25 years had the highest rate of serious mental illness but the lowest treatment rate compared to other adult age groups.1 Unfortunately, more than 60% of patients receiving mental health treatment fail to benefit to a clinically meaningful degree.2
However, there is growing evidence that referring patients to behavioral health practitioners (BHPs) with outcome-measured skills that meet the patient’s specific needs can have a dramatic and positive impact. There are 2 main steps to pairing patients with an appropriate BHP: (1) use of measurement-based care data that can be analyzed at the patient and therapist level, and (2) data-driven referrals that pair patients with BHPs based on such routine outcome monitoring data (paired-on outcome data).
Psychotherapy’s slow road toward measurement-based care
Routine outcome monitoring is the systematic measurement of symptoms and functioning during treatment. It serves multiple functions, including program evaluation and benchmarking of patient improvement rates. Moreover, routine outcome monitoring–derived feedback (based on repeated patient outcome measurements) can inform personalized and responsive care decisions throughout treatment.
For all intents and purposes,
- routinely administered symptom/functioning measure, ideally before each clinical encounter,
- practitioner review of these patient-level data,
- patient review of these data with their practitioner, and
- collaborative reevaluation of the person-specific treatment plan informed by these data.
CASE SCENARIO
Violeta W is a 33-year-old woman who presented to her family physician for her annual wellness exam. Prior to the exam, the medical assistant administered a Patient Health Questionnaire-9 (PHQ-9) to screen for depressive symptoms. Ms. W’s score was 20 out of 27, suggestive of depression. To further assess the severity of depressive symptoms and their effect on daily function, the physician reviewed responses to the questionnaire with her and discussed treatment options. Ms. W was most interested in trying a low-dose selective serotonin reuptake inhibitor (SSRI).
At her follow-up visit 4 weeks later, the medical assistant re-administered the PHQ-9. The physician then reviewed Ms. W’s responses with her and, based on Ms. W’s subjective report and objective symptoms (still a score of 20 out of 27 on the PHQ-9), increased her SSRI dose. At each subsequent visit, Ms. W completed a PHQ-9 and reviewed responses and depressive symptoms with her physician.
The value of measurement-based care in mental health care
A narrative review by Lewis et al3 of 21 randomized controlled clinical trials (RCTs) across a range of age groups (eg, adolescents, young adults, adults), disorders (eg, anxiety, mood), and settings (eg, outpatient, inpatient) found that in at least 9 review articles, measurement-based care was associated with significantly improved outcomes vs usual care (ie, treatment without routine outcome monitoring plus feedback). The average increase in treatment effect size was about 30% when treatment was accompanied by measurement-based care.3
Continue to: Moreover, a recent within-patient meta-analysis...
Moreover, a recent within-patient meta-analysis by de Jong et al4 shows that measurement-based care yields a small but significant increase in therapeutic outcomes (d = .15). Use of measurement-based care also is associated with improved communication between the patient and therapist.5 In pharmacotherapy practice, measurement-based care has been shown to predict rapid dose increases and changes in medication, when necessary; faster recovery rates; higher response rates to treatment3; and fewer dropouts.4
Perhaps one of the best-studied benefits of measurement-based mental health care is the ability to predict deterioration in care (ie, patients who are off-track in a way that practitioners often miss without the help of routine outcome monitoring data).6,7 Studies show that without a data-informed approach to care, some forms of psychotherapy or therapy with BHPs who are not sufficiently skilled in treating a given diagnosis increase symptoms or create significant harmful and iatrogenic effects.8-10 Conversely, the meta-analysis by de Jong et al4 found a lower percentage of deterioration in patients receiving measurement-based care. The difference in deterioration was significant: An average of 5.4% of patients in control conditions deteriorated compared to an average of 4.6% in feedback (measurement-based care) groups. There were even larger effect sizes when therapists received training in the feedback system.4
Routine outcome monitoring without a dialogue between patient and practitioner about the assessments (eg, ignoring complete measurement-based care requirements) may be inadequate. A recent review by Muir et al6 found no differences in patient outcomes when data were used solely for aggregate quality improvement activities, suggesting the need for practitioners to review results of routine outcome monitoring assessments with patients and use data to alter care when necessary.
Measurement-based care is believed to deliver benefits and reduce harm by enhancing and encouraging active patient involvement, improving patient understanding of symptoms, promoting better communication, and facilitating better care coordination.3 The benefits of measurement-based care can be enhanced with a comprehensive core routine outcome monitoring tool and the level of monitoring-generated information delivered for multiple stakeholders (eg, patient, therapist, clinic).11
A look at multidimensional assessment
The features of routine outcome monitoring tools vary significantly.12 Some measures assess single-symptom or problem domains (eg, PHQ-9 for depression or Generalized Anxiety Disorder-7 [GAD-7] scale for anxiety) or multiple dimensions (multidimensional routine outcome monitoring). Multidimensional routine outcome monitoring may have benefits over single-domain measures. Single-domain measures and the subscales or factors of more comprehensive multidimensional routine outcome monitoring assessments should possess adequate specificity and sensitivity.
Continue to: Some recent research findings...
Some recent research findings question the construct validity of brief single-domain measures of common presenting problems, such as depression and anxiety. For example, results from a factor analysis of the PHQ-9 and GAD-7 scale in patients with traumatic brain injury suggest these tools measure 1 psychological construct that includes depression and the cognitive components of anxiety (eg, worry)13—a finding consistent with those of other tools.14 Similarly, a larger study of 7763 BH patients found that a single factor accounted for most of the variance of the 2 combined measures, with no set of factors meeting the exacting standards used to develop multidimensional routine outcome monitoring.15 These findings suggest that the PHQ-9 and GAD-7 largely overlap and are not measuring different aspects of health as most practitioners believe (eg, depression and anxiety).
In commonly used assessments, multiple-factor analytic studies with high standards have supported the construct validity of domain-specific subscales, indicating that the various questions tap into different constructs of psychological health.14,16,17
Beyond multiple domain–specific indicators, multidimensional routine outcome measurements provide a global total score that minimizes Type I (false-positive conclusion) and Type II (false-negative conclusion) errors in tracking patient improvement or deterioration.18 As one would expect, multidimensional routine outcome monitoring generally includes more items than single-domain measures; however, this comes with a trade-off. If there are specificity and sensitivity concerns with an ultra-brief single-domain measure, an alternative to a core multidimensional routine outcome measurement is to aggregate a series of single-domain measures into a battery of patient self-reports. However, this approach may take longer for patients to complete since they would have to shift among the varying response sets and wording across the unique single-domain measures.
In addition, the standardization/normalization of multidimensional routine outcome monitoring likely makes interpretation easier than referring to norms and clinical severity cutoffs for many distinct measures. Furthermore, increased specificity enhances predictive power and allows BHPs to screen and track other conditions besides depression and anxiety. (It is worth noting that there are no known studies that have looked at the difference in time to administer or ease of interpretation of multidimensional routine outcome monitoring tools vs multiple single-domain measures.)
Two multidimensional routine outcome monitoring tools that cover a comprehensive series of discrete symptom and functional domains are the Treatment Outcome Package12 and Counseling Center Assessment of Psychological Symptoms.16 These tools, which include subscales beyond general depression and anxiety (eg, sleep, substance misuse, social conflict), take 7 to 10 minutes to complete and provide outcome results across 12 symptom and 8 functional dimensions. As an example, the Treatment Outcome Package has good psychometric qualities (eg, reliability, construct and concurrent validity) for adults,12 children,14,19 and adolescents,19 and can be administered through a secure online data collection portal. The Counseling Center Assessment of Psychological Symptoms has demonstrated high construct validity and good convergent validity.16 These assessments can be administered in paper or digital (eg, electronic medical record portal, smartphone) format.20
Continue to: CASE SCENARIO
CASE SCENARIO
Ms. W’s physician asked her to go online using her phone and answer the questions in the Treatment Outcome Package. Her results, which she viewed with her physician, were displayed in graph form (FIGURE). Her scores were represented in Z scores normalized to the general population, with “0” representing the general, nontreatment-seeking population average and positive scores representing the number of standard deviations (SDs) more severe than the general population average.
Although this assessment scored Ms. W’s clinically elevated depression as mild, it revealed abnormalities in 3 other domains. Sexual functioning issues represented the most abnormal domain at greater than 3 SDs (more severe than the general population), followed by poor life quality and school/work functioning.
After reviewing Ms. W’s report, her physician decided that pharmacologic management alone (for depression) was not the most appropriate treatment course. Therefore, her physician recommended psychotherapy in addition to the SSRI she was taking. Ms. W agreed to a customized referral for psychotherapy.
Data-driven referrals
When psychotherapy is chosen as a treatment, the individual BHP is an active component of that treatment. Consequently, it is essential to customize referrals to match a patient’s most elevated mental health concerns with a therapist who will most effectively treat those domains. It is rare for a BHP to be skilled in treating every mental health domain.9 Multiple studies have shown that BHPs have identifiable treatment skills in specific domains, which physicians should consider when making referrals.9,21,22 These studies demonstrate the utility of aggregating patient-level routine outcome monitoring data to better understand therapist-level (and ultimately clinic- and system-level) outcomes.
Additionally, recent research has tested this idea prospectively. An RCT funded by the Patient-Centered Outcome Research Institute and published in JAMA Psychiatry showed a significant and positive effect on patient outcomes (ie, reductions in general impairment, impairment involving a patient’s most elevated domain, and global distress) using paired-on outcome data matching vs as-usual matching protocols (eg, therapist self-defined areas of specialty).22 In the RCT, the most effective matching protocol was a combination of eliminating harm and matching the patient on their 3 most problematic domains (the highest match level). These patients ended care as healthy as the general population after 16 weeks of treatment. A random 1-year follow-up assessment from the original RCT showed that most patients who had been matched had maintained their improvement.23
Continue to: Therefore, a multidimensional routine outcome...
Therefore, a multidimensional routine outcome monitoring tool can be used to identify a BHP’s relative strengths and weaknesses across multiple outcome domains. Within a system of care, a sample of BHPs will possess varying outcome-domain profiles. When a new patient is seeking a referral to a BHP, these profiles (or domain-specific outcome track records) can be used to support paired-on outcome data matching. Specifically, a new patient completes the multidimensional routine outcome monitoring tool at pretreatment, and the results reveal the outcome domains on which the patient is most clinically severe. This pattern of domain-specific severity then can be used to pair the new patient with a BHP who has demonstrated success in addressing the same outcome domain(s). This approach matches a new patient to a BHP with established expertise based on routine outcome monitoring.
Retrospective and prospective studies have found that most BHPs have stable performance in their strengths and weaknesses.11,21 One study found that assessing BHP performance with their most recent 30 patients can reliably predict future performance with their next 30 patients.24 This predictability in a practitioner’s outcomes suggests report cards that are updated frequently can be utilized to make case assignments within BH or referrals to a specific BHP from primary care.
Making a paired-on outcome data–matched referral
Making customized BH referrals requires access to information about a practitioner’s previous routine outcome monitoring data per clinical domain (eg, suicidality, violence, quality of life) from their most recent patients. Previous research suggests that follow-up data from a minimum of 15 patients is necessary to make a reliable evaluation of a practitioner’s strengths and weaknesses (ie, effectiveness “report card”) per clinical domain.24
Few, if any, physicians have access to this level of updated outcome data from their referral network. To facilitate widespread use of paired-on outcome data matching, a new Web system (MatchedTherapists.com) will allow the general public and PCPs to access these grades. As a public service option, this site currently allows for a self-assessment using the Treatment Outcome Package. Pending versions will generate paired-on outcome data grades, and users will receive a list of local therapists available for in-person appointments as well as therapists available for virtual appointments. The paired-on outcome data grades are delivered in school-based letter grades. An “A+,” for example, represents the best matching grade. Users also will be able to sort and filter results for other criteria such as telemedicine, insurance, age, gender, and appointment availability. Currently, there are more than 77,000 therapists listed on the site nationwide. A basic listing is free.
CASE SCENARIO
After Ms. W took the multidimensional routine outcome assessment online, she received a list of therapists rank-ordered by paired-on outcome data grade, with the “A+” matches listed first. Three of the best-matched referrals accepted her insurance and were willing to see her through telemedicine. Therapists with available in-person appointments had a “B” grade. After discussing the options with her physician, Ms. W opted for telehealth counseling with the therapist whose profile she liked best. The therapist and PCP tracked her progress through routine outcome monitoring reporting until all her symptoms became subclinical.
Continue to: The future of a "referral bridge"
The future of a “referral bridge”
In this article, we present a solution to a common issue faced by mental health care patients: failure to benefit meaningfully from mental health treatment. Matching patients to specific BHPs based on effectiveness data regarding the therapist’s strengths and skills can improve patient outcomes and reduce harm. In addition, patients appear to value this approach. A Robert Wood Johnson Foundation–funded study demonstrated that patients value seeing practitioners who have a track record of successfully treating previous patients with similar issues.25,26 In many cases, patients indicated they would prioritize this matching process over other factors such as practitioners with a higher number of years of experience or the same demographic characteristics as the patient.25,26
These findings may represent a new area in the science of health care. Over the past century, major advances in diagnosis and treatment—the 2 primary pillars of health care—have turned the art of medicine into a science. However, the art of making referrals has not advanced commensurately, as there has been little attention focused on the “referral bridge” between these 2 pillars. As the studies reviewed in this paper demonstrate, a referral bridge deserves exploration in all fields of medicine.
CORRESPONDENCE
David R. Kraus, PhD, 1 Speen Street, Framingham, MA 01701; dkraus@outcomereferrals.com
1. HHS. 2021 National Survey of Drug Use and Health (NSDUH) Releases. Accessed March 29, 2023. www.samhsa.gov/data/release/2021-national-survey-drug-use-and-health-nsduh-releases
2. Barkham M, Lambert, MJ. The efficacy and effectiveness of psychological therapies. In: Barkham M, Lutz W, Castonguay LG, eds. Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change: 50th Anniversary Edition. 7th ed. John Wiley & Sons, Inc; 2021:135-189.
3. Lewis CC, Boyd M, Puspitasari A, et al. Implementing measurement-based care in behavioral health: a review. JAMA Psychiatry. 2019;76:324-335. doi: 10.1001/jamapsychiatry.2018.3329
4. de Jong K, Conijn JM, Gallagher RAV, et al. Using progress feedback to improve outcomes and reduce drop-out, treatment duration, and deterioration: a multilevel meta-analysis. Clin Psychol Rev. 2021;85:102002. doi: 10.1016/j.cpr.2021.102002
5. Carlier IVE, Meuldijk D, Van Vliet IM, et al. Routine outcome monitoring and feedback on physical or mental health status: evidence and theory. J Eval Clin Pract. 2012;18:104-110. doi: 10.1111/j.1365-2753.2010.01543.x
6. Muir HJ, Coyne AE, Morrison NR, et al. Ethical implications of routine outcomes monitoring for patients, psychotherapists, and mental health care systems. Psychotherapy (Chic). 2019;56:459-469. doi: 10.1037/pst0000246
7. Hannan C, Lambert MJ, Harmon C, et al. A lab test and algorithms for identifying clients at risk for treatment failure. J Clin Psychol. 2005;61:155-163. doi: 10.1002/jclp.20108
8. Castonguay LG, Boswell JF, Constantino MJ, et al. Training implications of harmful effects of psychological treatments. Am Psychol. 2010;65:34-49. doi: 10.1037/a0017330
9. Kraus DR, Castonguay LG, Boswell JF, et al. Therapist effectiveness: implications for accountability and patient care. Psychother Res. 2011;21:267-276. doi: 10.1080/10503307.2011.563249
10. Lilienfeld SO. Psychological treatments that cause harm. Perspect Psychol Sci. 2007;2:53-70. doi: 10.1111/j.1745-6916.2007.00029.x
11. Boswell JF, Constantino MJ, Kraus DR, et al. The expanding relevance of routinely collected outcome data for mental health care decision making. Adm Policy Ment Health. 2016;43:482-491. doi: 10.1007/s10488-015-0649-6
12. Lyon AR, Lewis CC, Boyd MR, et al. Capabilities and characteristics of digital measurement feedback systems: results from a comprehensive review. Adm Policy Ment Health. 2016;43:441-466. doi: 10.1007/s10488-016-0719-4
13. Teymoori A, Gorbunova A, Haghish FE, et al. Factorial structure and validity of depression (PHQ-9) and anxiety (GAD-7) scales after traumatic brain injury. J Clin Med. 2020;9:873. doi: 10.3390/jcm9030873
14. Kraus DR, Seligman DA, Jordan JR. Validation of a behavioral health treatment outcome and assessment tool designed for naturalistic settings: the Treatment Outcome Package. J Clin Psychol. 2005;61:285‐314. doi: 10.1002/jclp.20084
15. Boothroyd L, Dagnan D, Muncer S. Psychometric analysis of the Generalized Anxiety Disorder Scale and the Patient Health Questionnaire using Mokken scaling and confirmatory factor analysis. Health Prim Care. 2018;2:1-4. doi: 10.15761/HPC.1000145
16. Locke BD, Buzolitz JS, Lei PW, et al. Development of the Counseling Center Assessment of Psychological Symptoms-62 (CCAPS-62). J Couns Psychol. 2011;58:97-109. doi: 10.1037/a0021282
17. Kraus DR, Boswell JF, Wright AGC, et al. Factor structure of the treatment outcome package for children. J Clin Psychol. 2010;66:627-640. doi: 10.1002/jclp.20675
18. McAleavey AA, Nordberg SS, Kraus D, et al. Errors in treatment outcome monitoring: implications for real-world psychotherapy. Can Psychol. 2010;53:105-114. doi: 10.1037/a0027833
19. Baxter EE, Alexander PC, Kraus DR, et al. Concurrent validation of the Treatment Outcome Package (TOP) for children and adolescents. J Child Fam Stud. 2016;25:2415-2422. doi: 10.1007/s10826-016-0419-4
20. Gual-Montolio P, Martínez-Borba V, Bretón-López JM, et al. How are information and communication technologies supporting routine outcome monitoring and measurement-based care in psychotherapy? A systematic review. Int J Environ Res Public Health. 2020;17:3170. doi: 10.3390/ijerph17093170
21. Kraus DR, Bentley JH, Alexander PC, et al. Predicting therapist effectiveness from their own practice-based evidence. J Consult Clin Psychol. 2016;84:473‐483. doi: 10.1037/ccp0000083
22. Constantino MJ, Boswell JF, Coyne AE, et al. Effect of matching therapists to patients vs assignment as usual on adult psychotherapy outcomes. A randomized clinical trial. JAMA Psychiatry. 2021;78:960-969. doi: 10.1001/jamapsychiatry.2021.1221
23. Constantino MJ, Boswell JF, Kraus DR, et al. Matching patients with therapists to improve mental health care. Patient-Centered Outcomes Research Institute (PCORI). 2021. Accessed March 1, 2023. www.pcori.org/research-results/2015/matching-patients-therapists-improve-mental-health-care
24. Institute of Medicine. Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders. Improving the Quality of Health Care for Mental and Substance-Use Conditions. National Academies Press; 2006. Accessed February 21, 2023. https://nap.nationalacademies.org/read/11470/chapter/1
25. Boswell JF, Constantino MJ, Oswald JM, et al. A multimethod study of mental health care patients’ attitudes toward clinician-level performance information. Psychiatr Serv. 2021;72:452-456. doi: 10.1176/appi.ps.202000366
26. Boswell JF, Constantino MJ, Oswald JM, et al. Mental health care consumers’ relative valuing of clinician performance information. J Consult Clin Psychol. 2018;86:301‐308. doi: 10.1037/ccp0000264
1. HHS. 2021 National Survey of Drug Use and Health (NSDUH) Releases. Accessed March 29, 2023. www.samhsa.gov/data/release/2021-national-survey-drug-use-and-health-nsduh-releases
2. Barkham M, Lambert, MJ. The efficacy and effectiveness of psychological therapies. In: Barkham M, Lutz W, Castonguay LG, eds. Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change: 50th Anniversary Edition. 7th ed. John Wiley & Sons, Inc; 2021:135-189.
3. Lewis CC, Boyd M, Puspitasari A, et al. Implementing measurement-based care in behavioral health: a review. JAMA Psychiatry. 2019;76:324-335. doi: 10.1001/jamapsychiatry.2018.3329
4. de Jong K, Conijn JM, Gallagher RAV, et al. Using progress feedback to improve outcomes and reduce drop-out, treatment duration, and deterioration: a multilevel meta-analysis. Clin Psychol Rev. 2021;85:102002. doi: 10.1016/j.cpr.2021.102002
5. Carlier IVE, Meuldijk D, Van Vliet IM, et al. Routine outcome monitoring and feedback on physical or mental health status: evidence and theory. J Eval Clin Pract. 2012;18:104-110. doi: 10.1111/j.1365-2753.2010.01543.x
6. Muir HJ, Coyne AE, Morrison NR, et al. Ethical implications of routine outcomes monitoring for patients, psychotherapists, and mental health care systems. Psychotherapy (Chic). 2019;56:459-469. doi: 10.1037/pst0000246
7. Hannan C, Lambert MJ, Harmon C, et al. A lab test and algorithms for identifying clients at risk for treatment failure. J Clin Psychol. 2005;61:155-163. doi: 10.1002/jclp.20108
8. Castonguay LG, Boswell JF, Constantino MJ, et al. Training implications of harmful effects of psychological treatments. Am Psychol. 2010;65:34-49. doi: 10.1037/a0017330
9. Kraus DR, Castonguay LG, Boswell JF, et al. Therapist effectiveness: implications for accountability and patient care. Psychother Res. 2011;21:267-276. doi: 10.1080/10503307.2011.563249
10. Lilienfeld SO. Psychological treatments that cause harm. Perspect Psychol Sci. 2007;2:53-70. doi: 10.1111/j.1745-6916.2007.00029.x
11. Boswell JF, Constantino MJ, Kraus DR, et al. The expanding relevance of routinely collected outcome data for mental health care decision making. Adm Policy Ment Health. 2016;43:482-491. doi: 10.1007/s10488-015-0649-6
12. Lyon AR, Lewis CC, Boyd MR, et al. Capabilities and characteristics of digital measurement feedback systems: results from a comprehensive review. Adm Policy Ment Health. 2016;43:441-466. doi: 10.1007/s10488-016-0719-4
13. Teymoori A, Gorbunova A, Haghish FE, et al. Factorial structure and validity of depression (PHQ-9) and anxiety (GAD-7) scales after traumatic brain injury. J Clin Med. 2020;9:873. doi: 10.3390/jcm9030873
14. Kraus DR, Seligman DA, Jordan JR. Validation of a behavioral health treatment outcome and assessment tool designed for naturalistic settings: the Treatment Outcome Package. J Clin Psychol. 2005;61:285‐314. doi: 10.1002/jclp.20084
15. Boothroyd L, Dagnan D, Muncer S. Psychometric analysis of the Generalized Anxiety Disorder Scale and the Patient Health Questionnaire using Mokken scaling and confirmatory factor analysis. Health Prim Care. 2018;2:1-4. doi: 10.15761/HPC.1000145
16. Locke BD, Buzolitz JS, Lei PW, et al. Development of the Counseling Center Assessment of Psychological Symptoms-62 (CCAPS-62). J Couns Psychol. 2011;58:97-109. doi: 10.1037/a0021282
17. Kraus DR, Boswell JF, Wright AGC, et al. Factor structure of the treatment outcome package for children. J Clin Psychol. 2010;66:627-640. doi: 10.1002/jclp.20675
18. McAleavey AA, Nordberg SS, Kraus D, et al. Errors in treatment outcome monitoring: implications for real-world psychotherapy. Can Psychol. 2010;53:105-114. doi: 10.1037/a0027833
19. Baxter EE, Alexander PC, Kraus DR, et al. Concurrent validation of the Treatment Outcome Package (TOP) for children and adolescents. J Child Fam Stud. 2016;25:2415-2422. doi: 10.1007/s10826-016-0419-4
20. Gual-Montolio P, Martínez-Borba V, Bretón-López JM, et al. How are information and communication technologies supporting routine outcome monitoring and measurement-based care in psychotherapy? A systematic review. Int J Environ Res Public Health. 2020;17:3170. doi: 10.3390/ijerph17093170
21. Kraus DR, Bentley JH, Alexander PC, et al. Predicting therapist effectiveness from their own practice-based evidence. J Consult Clin Psychol. 2016;84:473‐483. doi: 10.1037/ccp0000083
22. Constantino MJ, Boswell JF, Coyne AE, et al. Effect of matching therapists to patients vs assignment as usual on adult psychotherapy outcomes. A randomized clinical trial. JAMA Psychiatry. 2021;78:960-969. doi: 10.1001/jamapsychiatry.2021.1221
23. Constantino MJ, Boswell JF, Kraus DR, et al. Matching patients with therapists to improve mental health care. Patient-Centered Outcomes Research Institute (PCORI). 2021. Accessed March 1, 2023. www.pcori.org/research-results/2015/matching-patients-therapists-improve-mental-health-care
24. Institute of Medicine. Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders. Improving the Quality of Health Care for Mental and Substance-Use Conditions. National Academies Press; 2006. Accessed February 21, 2023. https://nap.nationalacademies.org/read/11470/chapter/1
25. Boswell JF, Constantino MJ, Oswald JM, et al. A multimethod study of mental health care patients’ attitudes toward clinician-level performance information. Psychiatr Serv. 2021;72:452-456. doi: 10.1176/appi.ps.202000366
26. Boswell JF, Constantino MJ, Oswald JM, et al. Mental health care consumers’ relative valuing of clinician performance information. J Consult Clin Psychol. 2018;86:301‐308. doi: 10.1037/ccp0000264
23-year-old woman • fever, fatigue, and sore throat • scleral icterus and hepatosplenomegaly • Dx?
THE CASE
A 23-year-old woman sought care from her primary care physician (PCP) after being sick for 7 days. The illness started with a headache and fatigue, and by Day 6, she also had fever, chills, sore throat, nausea, a poor appetite, and intractable vomiting. The patient had no significant medical history and was socially isolating due to the COVID-19 pandemic. She had no known sick contacts or recent sexual activity and did not use any illicit drugs.
On examination, her vital signs were normal although she appeared ill and diaphoretic. A shallow tonsil ulcer and tonsillar adenopathy were present. Laboratory tests included a complete blood count (CBC), comprehensive metabolic panel, Monospot test, and Epstein-Barr virus (EBV) antibody test. Results were notable for leukocytosis with atypical lymphocytes on her CBC. Her Monospot test and EBV immunoglobulin (Ig) M antibody were positive, and her EBV IgG antibody was negative. She was given a diagnosis of infectious mononucleosis (IM) and told to get adequate rest, drink a lot of fluids, and take ibuprofen or acetaminophen for pain control.
Two days later, she returned to her PCP with scleral icterus (FIGURE 1A), increasingly tender cervical lymphadenopathy, and left-side abdominal pain. Her liver function tests (LFTs) had worsened (TABLE). An abdominal ultrasound revealed mild diffuse decreased hepatic echogenicity and prominent periportal echogenicity, likely related to diffuse hepatic parenchymal disease, as well as splenomegaly and a mildly thickened gallbladder with no gallstones. She also had severe throat discomfort, with bilateral tonsillar exudates and pharyngeal erythema (FIGURE 1B).
THE DIAGNOSIS
Based on her symptoms and the results of her physical examination, LFTs, EBV serologic assays, and abdominal ultrasound, this patient was given a diagnosis of acute EBV hepatitis.
DISCUSSION
EBV infection, which is the most common cause of IM, causes asymptomatic liver enzyme abnormalities in 80% to 90% of patients.1-3 Although not common, patients can develop acute EBV hepatitis and require hospitalization.4
Be aware of potential complications. Prompt assessment of elevated liver enzymes and accurate diagnosis are key.5 Although acute EBV hepatitis is usually self-limiting, there can be serious gastrointestinal complications such as splenic rupture, liver failure due to acute and/or chronic EBV infection, autoimmune hepatitis, and hepatocellular carcinoma.2 It’s rare for EBV hepatitis to lead to acute liver failure, but when that occurs, it can be fatal.6-9 One case series revealed that while primary EBV infection accounts for less than 1% of adult acute liver failure cases, it has a high case fatality rate of 50%.9
Treatment for patients with EBV hepatitis is usually supportive and includes rest, analgesia, and avoidance of vigorous activity for 1 month to reduce the risk for splenic rupture.1 In patients with nausea and vomiting, intravenous fluids may be necessary and can be administered at an outpatient infusion center. For individuals with severe tonsillar hypertrophy, prednisone (40-60 mg/d for 2-3 days, with subsequent tapering over 1-2 weeks) is indicated to prevent airway obstruction.1 Acyclovir may be used to reduce EBV viral shedding; however, it has no significant clinical impact.1
Continue to: Patients who are hemodynamially stable...
Patients who are hemodynamically stable and have appropriate access to follow-up care can be managed at home.2 If follow-up cannot occur remotely within 1 week or the patient’s clinical status begins to worsen (ie, the patient’s liver enzymes or bilirubin levels dramatically increase), hospitalization is necessary.10
Through shared decision-making, our patient was treated as an outpatient based on her hemodynamic stability and her ability to closely follow up in the clinic and by phone and to access an outpatient infusion center. She was reexamined within 2 days and given ondansetron 8 mg IV with 2 L of normal saline at our outpatient infusion center. We also prescribed ibuprofen (400 mg every 6 hours as needed) for analgesia and issued the standard recommendations that she avoid contact sports (for at least 6 weeks) and excessive alcohol consumption.
On Day 11, the patient followed up with her PCP by telephone. The patient was started on oral prednisone (40 mg/d for 3 days with taper over the next week as symptoms improved) for her severe throat discomfort, exudates, difficulty swallowing, and muffled voice. By Day 14, her aminotransferase levels began to decrease (TABLE), and her symptoms steadily improved thereafter.
THE TAKEAWAY
When a patient presents with unexplained elevated liver enzymes or cholestasis, it is important to assess for signs and symptoms of EBV hepatitis. Although EBV hepatitis is typically self-limiting, it can have serious complications or be fatal. Prompt initiation of outpatient management may avoid these complications and hospitalization.
CORRESPONDENCE
Lydia J. Schneider, MD, 225 East Chicago Avenue, Chicago, IL 60611; lydia.schneider315@gmail.com
1. Cohen JI. Chapter 189: Epstein-Barr virus infections, including infectious mononucleosis. In: Jameson JL, Fauci AS, Kasper DL, et al, eds. Harrison’s Principles of Internal Medicine. 20th ed. McGraw Hill; 2020. Accessed March 21, 2023. accessmedicine.mhmedical.com/content.aspx?bookid=2129§ionid=192024765
2. Crum NF. Epstein Barr virus hepatitis: case series and review. South Med J. 2006;99:544-547. doi: 10.1097/01.smj.0000216469.04854.2a
3. Bunchorntavakul C, Reddy KR. Epstein-Barr virus and cytomegalovirus infections of the liver. Gastroenterol Clin North Am. 2020;49:331-346. doi: 10.1016/j.gtc.2020.01.008
4. Leonardsson H, Hreinsson JP, Löve A, et al. Hepatitis due to Epstein-Barr virus and cytomegalovirus: clinical features and outcomes. Scand J Gastroenterol. 2017;52:893-897. doi: 10.1080/ 00365521.2017.1319972
5. Banker L, Bowman PE. Epstein-Barr virus: forgotten etiology of hepatic injury. Clinical Advisor. September 23, 2021. Accessed April 18, 2023. www.clinicaladvisor.com/home/topics/infectious-diseases-information-center/epstein-barr-virus-etiology-hepatic-injury/
6. Fugl A, Lykkegaard Andersen C. Epstein-Barr virus and its association with disease: a review of relevance to general practice. BMC Fam Pract. 2019;20:62. doi: 10.1186/s12875-019-0954-3
7. Markin RS, Linder J, Zuerlein K, et al. Hepatitis in fatal infectious mononucleosis. Gastroenterology. 1987;93:1210-1217. doi: 10.1016/0016-5085(87)90246-0
8. Zhang W, Chen B, Chen Y, et al. Epstein-Barr virus-associated acute liver failure present in a 67-year-old immunocompetent female. Gastroenterology Res. 2016;9:74-78.
9. Mellinğer J, Rossaro L, Naugler W, et al. Epstein-Barr virus (EBV) related acute liver failure: a case series from the US Acute Liver Failure Study Group. Dig Dis Sci. 2014;59:1630-1637. doi: 10.1007/s10620-014-3029-2
10. Uluğ M, Kemal Celen M, Ayaz C, et al. Acute hepatitis: a rare complication of Epstein-Barr virus (EBV) infection. J Infect Dev Ctries. 2010;4:668-673. doi: 10.3855/jidc.871
THE CASE
A 23-year-old woman sought care from her primary care physician (PCP) after being sick for 7 days. The illness started with a headache and fatigue, and by Day 6, she also had fever, chills, sore throat, nausea, a poor appetite, and intractable vomiting. The patient had no significant medical history and was socially isolating due to the COVID-19 pandemic. She had no known sick contacts or recent sexual activity and did not use any illicit drugs.
On examination, her vital signs were normal although she appeared ill and diaphoretic. A shallow tonsil ulcer and tonsillar adenopathy were present. Laboratory tests included a complete blood count (CBC), comprehensive metabolic panel, Monospot test, and Epstein-Barr virus (EBV) antibody test. Results were notable for leukocytosis with atypical lymphocytes on her CBC. Her Monospot test and EBV immunoglobulin (Ig) M antibody were positive, and her EBV IgG antibody was negative. She was given a diagnosis of infectious mononucleosis (IM) and told to get adequate rest, drink a lot of fluids, and take ibuprofen or acetaminophen for pain control.
Two days later, she returned to her PCP with scleral icterus (FIGURE 1A), increasingly tender cervical lymphadenopathy, and left-side abdominal pain. Her liver function tests (LFTs) had worsened (TABLE). An abdominal ultrasound revealed mild diffuse decreased hepatic echogenicity and prominent periportal echogenicity, likely related to diffuse hepatic parenchymal disease, as well as splenomegaly and a mildly thickened gallbladder with no gallstones. She also had severe throat discomfort, with bilateral tonsillar exudates and pharyngeal erythema (FIGURE 1B).
THE DIAGNOSIS
Based on her symptoms and the results of her physical examination, LFTs, EBV serologic assays, and abdominal ultrasound, this patient was given a diagnosis of acute EBV hepatitis.
DISCUSSION
EBV infection, which is the most common cause of IM, causes asymptomatic liver enzyme abnormalities in 80% to 90% of patients.1-3 Although not common, patients can develop acute EBV hepatitis and require hospitalization.4
Be aware of potential complications. Prompt assessment of elevated liver enzymes and accurate diagnosis are key.5 Although acute EBV hepatitis is usually self-limiting, there can be serious gastrointestinal complications such as splenic rupture, liver failure due to acute and/or chronic EBV infection, autoimmune hepatitis, and hepatocellular carcinoma.2 It’s rare for EBV hepatitis to lead to acute liver failure, but when that occurs, it can be fatal.6-9 One case series revealed that while primary EBV infection accounts for less than 1% of adult acute liver failure cases, it has a high case fatality rate of 50%.9
Treatment for patients with EBV hepatitis is usually supportive and includes rest, analgesia, and avoidance of vigorous activity for 1 month to reduce the risk for splenic rupture.1 In patients with nausea and vomiting, intravenous fluids may be necessary and can be administered at an outpatient infusion center. For individuals with severe tonsillar hypertrophy, prednisone (40-60 mg/d for 2-3 days, with subsequent tapering over 1-2 weeks) is indicated to prevent airway obstruction.1 Acyclovir may be used to reduce EBV viral shedding; however, it has no significant clinical impact.1
Continue to: Patients who are hemodynamially stable...
Patients who are hemodynamically stable and have appropriate access to follow-up care can be managed at home.2 If follow-up cannot occur remotely within 1 week or the patient’s clinical status begins to worsen (ie, the patient’s liver enzymes or bilirubin levels dramatically increase), hospitalization is necessary.10
Through shared decision-making, our patient was treated as an outpatient based on her hemodynamic stability and her ability to closely follow up in the clinic and by phone and to access an outpatient infusion center. She was reexamined within 2 days and given ondansetron 8 mg IV with 2 L of normal saline at our outpatient infusion center. We also prescribed ibuprofen (400 mg every 6 hours as needed) for analgesia and issued the standard recommendations that she avoid contact sports (for at least 6 weeks) and excessive alcohol consumption.
On Day 11, the patient followed up with her PCP by telephone. The patient was started on oral prednisone (40 mg/d for 3 days with taper over the next week as symptoms improved) for her severe throat discomfort, exudates, difficulty swallowing, and muffled voice. By Day 14, her aminotransferase levels began to decrease (TABLE), and her symptoms steadily improved thereafter.
THE TAKEAWAY
When a patient presents with unexplained elevated liver enzymes or cholestasis, it is important to assess for signs and symptoms of EBV hepatitis. Although EBV hepatitis is typically self-limiting, it can have serious complications or be fatal. Prompt initiation of outpatient management may avoid these complications and hospitalization.
CORRESPONDENCE
Lydia J. Schneider, MD, 225 East Chicago Avenue, Chicago, IL 60611; lydia.schneider315@gmail.com
THE CASE
A 23-year-old woman sought care from her primary care physician (PCP) after being sick for 7 days. The illness started with a headache and fatigue, and by Day 6, she also had fever, chills, sore throat, nausea, a poor appetite, and intractable vomiting. The patient had no significant medical history and was socially isolating due to the COVID-19 pandemic. She had no known sick contacts or recent sexual activity and did not use any illicit drugs.
On examination, her vital signs were normal although she appeared ill and diaphoretic. A shallow tonsil ulcer and tonsillar adenopathy were present. Laboratory tests included a complete blood count (CBC), comprehensive metabolic panel, Monospot test, and Epstein-Barr virus (EBV) antibody test. Results were notable for leukocytosis with atypical lymphocytes on her CBC. Her Monospot test and EBV immunoglobulin (Ig) M antibody were positive, and her EBV IgG antibody was negative. She was given a diagnosis of infectious mononucleosis (IM) and told to get adequate rest, drink a lot of fluids, and take ibuprofen or acetaminophen for pain control.
Two days later, she returned to her PCP with scleral icterus (FIGURE 1A), increasingly tender cervical lymphadenopathy, and left-side abdominal pain. Her liver function tests (LFTs) had worsened (TABLE). An abdominal ultrasound revealed mild diffuse decreased hepatic echogenicity and prominent periportal echogenicity, likely related to diffuse hepatic parenchymal disease, as well as splenomegaly and a mildly thickened gallbladder with no gallstones. She also had severe throat discomfort, with bilateral tonsillar exudates and pharyngeal erythema (FIGURE 1B).
THE DIAGNOSIS
Based on her symptoms and the results of her physical examination, LFTs, EBV serologic assays, and abdominal ultrasound, this patient was given a diagnosis of acute EBV hepatitis.
DISCUSSION
EBV infection, which is the most common cause of IM, causes asymptomatic liver enzyme abnormalities in 80% to 90% of patients.1-3 Although not common, patients can develop acute EBV hepatitis and require hospitalization.4
Be aware of potential complications. Prompt assessment of elevated liver enzymes and accurate diagnosis are key.5 Although acute EBV hepatitis is usually self-limiting, there can be serious gastrointestinal complications such as splenic rupture, liver failure due to acute and/or chronic EBV infection, autoimmune hepatitis, and hepatocellular carcinoma.2 It’s rare for EBV hepatitis to lead to acute liver failure, but when that occurs, it can be fatal.6-9 One case series revealed that while primary EBV infection accounts for less than 1% of adult acute liver failure cases, it has a high case fatality rate of 50%.9
Treatment for patients with EBV hepatitis is usually supportive and includes rest, analgesia, and avoidance of vigorous activity for 1 month to reduce the risk for splenic rupture.1 In patients with nausea and vomiting, intravenous fluids may be necessary and can be administered at an outpatient infusion center. For individuals with severe tonsillar hypertrophy, prednisone (40-60 mg/d for 2-3 days, with subsequent tapering over 1-2 weeks) is indicated to prevent airway obstruction.1 Acyclovir may be used to reduce EBV viral shedding; however, it has no significant clinical impact.1
Continue to: Patients who are hemodynamially stable...
Patients who are hemodynamically stable and have appropriate access to follow-up care can be managed at home.2 If follow-up cannot occur remotely within 1 week or the patient’s clinical status begins to worsen (ie, the patient’s liver enzymes or bilirubin levels dramatically increase), hospitalization is necessary.10
Through shared decision-making, our patient was treated as an outpatient based on her hemodynamic stability and her ability to closely follow up in the clinic and by phone and to access an outpatient infusion center. She was reexamined within 2 days and given ondansetron 8 mg IV with 2 L of normal saline at our outpatient infusion center. We also prescribed ibuprofen (400 mg every 6 hours as needed) for analgesia and issued the standard recommendations that she avoid contact sports (for at least 6 weeks) and excessive alcohol consumption.
On Day 11, the patient followed up with her PCP by telephone. The patient was started on oral prednisone (40 mg/d for 3 days with taper over the next week as symptoms improved) for her severe throat discomfort, exudates, difficulty swallowing, and muffled voice. By Day 14, her aminotransferase levels began to decrease (TABLE), and her symptoms steadily improved thereafter.
THE TAKEAWAY
When a patient presents with unexplained elevated liver enzymes or cholestasis, it is important to assess for signs and symptoms of EBV hepatitis. Although EBV hepatitis is typically self-limiting, it can have serious complications or be fatal. Prompt initiation of outpatient management may avoid these complications and hospitalization.
CORRESPONDENCE
Lydia J. Schneider, MD, 225 East Chicago Avenue, Chicago, IL 60611; lydia.schneider315@gmail.com
1. Cohen JI. Chapter 189: Epstein-Barr virus infections, including infectious mononucleosis. In: Jameson JL, Fauci AS, Kasper DL, et al, eds. Harrison’s Principles of Internal Medicine. 20th ed. McGraw Hill; 2020. Accessed March 21, 2023. accessmedicine.mhmedical.com/content.aspx?bookid=2129§ionid=192024765
2. Crum NF. Epstein Barr virus hepatitis: case series and review. South Med J. 2006;99:544-547. doi: 10.1097/01.smj.0000216469.04854.2a
3. Bunchorntavakul C, Reddy KR. Epstein-Barr virus and cytomegalovirus infections of the liver. Gastroenterol Clin North Am. 2020;49:331-346. doi: 10.1016/j.gtc.2020.01.008
4. Leonardsson H, Hreinsson JP, Löve A, et al. Hepatitis due to Epstein-Barr virus and cytomegalovirus: clinical features and outcomes. Scand J Gastroenterol. 2017;52:893-897. doi: 10.1080/ 00365521.2017.1319972
5. Banker L, Bowman PE. Epstein-Barr virus: forgotten etiology of hepatic injury. Clinical Advisor. September 23, 2021. Accessed April 18, 2023. www.clinicaladvisor.com/home/topics/infectious-diseases-information-center/epstein-barr-virus-etiology-hepatic-injury/
6. Fugl A, Lykkegaard Andersen C. Epstein-Barr virus and its association with disease: a review of relevance to general practice. BMC Fam Pract. 2019;20:62. doi: 10.1186/s12875-019-0954-3
7. Markin RS, Linder J, Zuerlein K, et al. Hepatitis in fatal infectious mononucleosis. Gastroenterology. 1987;93:1210-1217. doi: 10.1016/0016-5085(87)90246-0
8. Zhang W, Chen B, Chen Y, et al. Epstein-Barr virus-associated acute liver failure present in a 67-year-old immunocompetent female. Gastroenterology Res. 2016;9:74-78.
9. Mellinğer J, Rossaro L, Naugler W, et al. Epstein-Barr virus (EBV) related acute liver failure: a case series from the US Acute Liver Failure Study Group. Dig Dis Sci. 2014;59:1630-1637. doi: 10.1007/s10620-014-3029-2
10. Uluğ M, Kemal Celen M, Ayaz C, et al. Acute hepatitis: a rare complication of Epstein-Barr virus (EBV) infection. J Infect Dev Ctries. 2010;4:668-673. doi: 10.3855/jidc.871
1. Cohen JI. Chapter 189: Epstein-Barr virus infections, including infectious mononucleosis. In: Jameson JL, Fauci AS, Kasper DL, et al, eds. Harrison’s Principles of Internal Medicine. 20th ed. McGraw Hill; 2020. Accessed March 21, 2023. accessmedicine.mhmedical.com/content.aspx?bookid=2129§ionid=192024765
2. Crum NF. Epstein Barr virus hepatitis: case series and review. South Med J. 2006;99:544-547. doi: 10.1097/01.smj.0000216469.04854.2a
3. Bunchorntavakul C, Reddy KR. Epstein-Barr virus and cytomegalovirus infections of the liver. Gastroenterol Clin North Am. 2020;49:331-346. doi: 10.1016/j.gtc.2020.01.008
4. Leonardsson H, Hreinsson JP, Löve A, et al. Hepatitis due to Epstein-Barr virus and cytomegalovirus: clinical features and outcomes. Scand J Gastroenterol. 2017;52:893-897. doi: 10.1080/ 00365521.2017.1319972
5. Banker L, Bowman PE. Epstein-Barr virus: forgotten etiology of hepatic injury. Clinical Advisor. September 23, 2021. Accessed April 18, 2023. www.clinicaladvisor.com/home/topics/infectious-diseases-information-center/epstein-barr-virus-etiology-hepatic-injury/
6. Fugl A, Lykkegaard Andersen C. Epstein-Barr virus and its association with disease: a review of relevance to general practice. BMC Fam Pract. 2019;20:62. doi: 10.1186/s12875-019-0954-3
7. Markin RS, Linder J, Zuerlein K, et al. Hepatitis in fatal infectious mononucleosis. Gastroenterology. 1987;93:1210-1217. doi: 10.1016/0016-5085(87)90246-0
8. Zhang W, Chen B, Chen Y, et al. Epstein-Barr virus-associated acute liver failure present in a 67-year-old immunocompetent female. Gastroenterology Res. 2016;9:74-78.
9. Mellinğer J, Rossaro L, Naugler W, et al. Epstein-Barr virus (EBV) related acute liver failure: a case series from the US Acute Liver Failure Study Group. Dig Dis Sci. 2014;59:1630-1637. doi: 10.1007/s10620-014-3029-2
10. Uluğ M, Kemal Celen M, Ayaz C, et al. Acute hepatitis: a rare complication of Epstein-Barr virus (EBV) infection. J Infect Dev Ctries. 2010;4:668-673. doi: 10.3855/jidc.871
► Fever, fatigue, and sore throat
► Scleral icterus and hepatosplenomegaly
Doctor spots a gunshot victim staggering down his street
It was a quiet day. I got up around 3 o’clock in the afternoon for my shift at 6 p.m. I was shaking off the cobwebs and making coffee at our front window that overlooked Brown Street in North Philadelphia. There was nobody else around so I went outside to see what was going on.
He was in his 50s or 60s, bleeding and obviously in distress. I had him sit down. Then I ran back inside and grabbed a dish towel and some exam gloves that I had in the house.
I ran back out and assessed him. A bullet had gone through one of his hands, but he had other wounds. I had to expose him, so I trauma stripped him on the sidewalk. I got his pants and his shirt off and saw a gunshot going through his lower pelvis. He was bleeding out from there.
I got the towel and started applying deep pressure down into the iliac vein in case they hit something, which I found out later, they had. I held it there. The man was just lying there begging not to die.
I’m someone who is very calm, maybe abnormally calm, as people tell me. I try to use that during my resuscitations and traumas. Just keeping everybody calm makes the situation easier. Afterwards, people asked me, “Weren’t you worried that you were going to get shot?” That does happen in North Philadelphia. But it didn’t even cross my mind.
I didn’t have to think at all about what I was doing. We saw so many gunshots, especially at Einstein Medical Center. We saw them daily. I’d sometimes get more than half a dozen gunshots in one shift.
So, I was holding pressure and some people started to come over. I got somebody to call 911 and asked the man about his medical history. I found out he had diabetes. Five or 10 minutes later, EMS showed up. They looked pretty stunned when I was able to give the handoff presentation to them. I told them what happened and his back-story. I wanted to make sure they would check his sugar and take extra precautions.
They got him on the stretcher, and he eventually made it to the hospital where he had surgery. They had to have a vascular surgeon work on him. I called later, and they told me, “Yeah, he’s alive.” But that’s about the extent of the update I got.
After the ambulance left, it was kind of chaos. All the neighbors poured out of their houses. People were panicked, talking and getting excited about it. I didn’t know, but everyone else had actually been home the whole time. They didn’t come out until then.
I went back inside and tried to get ready for work. I wasn’t planning on talking to the media, but my next door neighbor just walked the news camera crew over to my house and knocked on my door. I wasn’t exactly dressed to be on TV, but they talked to me on camera, and it was on the news later that night.
I went to work and didn’t say anything about it. To be honest, I was trying to avoid telling anyone. Our team had a close-knit bond, and we would often tease each other when we received any type of recognition.
Naturally one of my attendings saw it on the local news and told everybody. So, I got a lot of happy harassment for quite some time. Someone baked me a cake that said, “Hero of Fairmount” (the Philly neighborhood in which I live). Someone else printed out a photo of me that said, “Stop the Bleed Hero of Fairmount,” and put it on every single computer screen.
The man came to see me about 2 weeks later (a neighbor told him where I lived). The man was very tearful and gave me a big hug. We just embraced for a while, and he said how thankful he was. He brought me a bottle of wine, which I thought was really nice.
He told me what happened to him: There was a lot of construction on our street and he was the contractor overseeing a couple of home remodels and demolitions. Sometimes he paid workers in cash and carried it with him. Somebody had tipped off somebody else that he was going to be there that day. The contractor walked into one of the houses and a guy in a ski mask waited there with a gun. The guy shot him and took the cash. The bullet went through his hand into his pelvis.
I had never had to deal with something that intense before outside of work. Most of it really comes down to the basics – the ABCs and bleeding control. You do whatever you can with what you have. In this case, it was just a dish towel, gloves, and my hands to put as much pressure as possible.
It really was strange that I happened to be looking out the window at that moment. I don’t know if it was just a coincidence. The man told me he believed God had put somebody there at the right place at the right time to save his life. I just felt very fortunate to have been able to help him. I never saw him again.
I think something like this gives you a little confidence that you can actually do something and make a meaningful impact anywhere when it’s needed. It lets you know that you’re capable of doing it. You always think about it, but you don’t know until it happens.
A version of this article first appeared on Medscape.com.
It was a quiet day. I got up around 3 o’clock in the afternoon for my shift at 6 p.m. I was shaking off the cobwebs and making coffee at our front window that overlooked Brown Street in North Philadelphia. There was nobody else around so I went outside to see what was going on.
He was in his 50s or 60s, bleeding and obviously in distress. I had him sit down. Then I ran back inside and grabbed a dish towel and some exam gloves that I had in the house.
I ran back out and assessed him. A bullet had gone through one of his hands, but he had other wounds. I had to expose him, so I trauma stripped him on the sidewalk. I got his pants and his shirt off and saw a gunshot going through his lower pelvis. He was bleeding out from there.
I got the towel and started applying deep pressure down into the iliac vein in case they hit something, which I found out later, they had. I held it there. The man was just lying there begging not to die.
I’m someone who is very calm, maybe abnormally calm, as people tell me. I try to use that during my resuscitations and traumas. Just keeping everybody calm makes the situation easier. Afterwards, people asked me, “Weren’t you worried that you were going to get shot?” That does happen in North Philadelphia. But it didn’t even cross my mind.
I didn’t have to think at all about what I was doing. We saw so many gunshots, especially at Einstein Medical Center. We saw them daily. I’d sometimes get more than half a dozen gunshots in one shift.
So, I was holding pressure and some people started to come over. I got somebody to call 911 and asked the man about his medical history. I found out he had diabetes. Five or 10 minutes later, EMS showed up. They looked pretty stunned when I was able to give the handoff presentation to them. I told them what happened and his back-story. I wanted to make sure they would check his sugar and take extra precautions.
They got him on the stretcher, and he eventually made it to the hospital where he had surgery. They had to have a vascular surgeon work on him. I called later, and they told me, “Yeah, he’s alive.” But that’s about the extent of the update I got.
After the ambulance left, it was kind of chaos. All the neighbors poured out of their houses. People were panicked, talking and getting excited about it. I didn’t know, but everyone else had actually been home the whole time. They didn’t come out until then.
I went back inside and tried to get ready for work. I wasn’t planning on talking to the media, but my next door neighbor just walked the news camera crew over to my house and knocked on my door. I wasn’t exactly dressed to be on TV, but they talked to me on camera, and it was on the news later that night.
I went to work and didn’t say anything about it. To be honest, I was trying to avoid telling anyone. Our team had a close-knit bond, and we would often tease each other when we received any type of recognition.
Naturally one of my attendings saw it on the local news and told everybody. So, I got a lot of happy harassment for quite some time. Someone baked me a cake that said, “Hero of Fairmount” (the Philly neighborhood in which I live). Someone else printed out a photo of me that said, “Stop the Bleed Hero of Fairmount,” and put it on every single computer screen.
The man came to see me about 2 weeks later (a neighbor told him where I lived). The man was very tearful and gave me a big hug. We just embraced for a while, and he said how thankful he was. He brought me a bottle of wine, which I thought was really nice.
He told me what happened to him: There was a lot of construction on our street and he was the contractor overseeing a couple of home remodels and demolitions. Sometimes he paid workers in cash and carried it with him. Somebody had tipped off somebody else that he was going to be there that day. The contractor walked into one of the houses and a guy in a ski mask waited there with a gun. The guy shot him and took the cash. The bullet went through his hand into his pelvis.
I had never had to deal with something that intense before outside of work. Most of it really comes down to the basics – the ABCs and bleeding control. You do whatever you can with what you have. In this case, it was just a dish towel, gloves, and my hands to put as much pressure as possible.
It really was strange that I happened to be looking out the window at that moment. I don’t know if it was just a coincidence. The man told me he believed God had put somebody there at the right place at the right time to save his life. I just felt very fortunate to have been able to help him. I never saw him again.
I think something like this gives you a little confidence that you can actually do something and make a meaningful impact anywhere when it’s needed. It lets you know that you’re capable of doing it. You always think about it, but you don’t know until it happens.
A version of this article first appeared on Medscape.com.
It was a quiet day. I got up around 3 o’clock in the afternoon for my shift at 6 p.m. I was shaking off the cobwebs and making coffee at our front window that overlooked Brown Street in North Philadelphia. There was nobody else around so I went outside to see what was going on.
He was in his 50s or 60s, bleeding and obviously in distress. I had him sit down. Then I ran back inside and grabbed a dish towel and some exam gloves that I had in the house.
I ran back out and assessed him. A bullet had gone through one of his hands, but he had other wounds. I had to expose him, so I trauma stripped him on the sidewalk. I got his pants and his shirt off and saw a gunshot going through his lower pelvis. He was bleeding out from there.
I got the towel and started applying deep pressure down into the iliac vein in case they hit something, which I found out later, they had. I held it there. The man was just lying there begging not to die.
I’m someone who is very calm, maybe abnormally calm, as people tell me. I try to use that during my resuscitations and traumas. Just keeping everybody calm makes the situation easier. Afterwards, people asked me, “Weren’t you worried that you were going to get shot?” That does happen in North Philadelphia. But it didn’t even cross my mind.
I didn’t have to think at all about what I was doing. We saw so many gunshots, especially at Einstein Medical Center. We saw them daily. I’d sometimes get more than half a dozen gunshots in one shift.
So, I was holding pressure and some people started to come over. I got somebody to call 911 and asked the man about his medical history. I found out he had diabetes. Five or 10 minutes later, EMS showed up. They looked pretty stunned when I was able to give the handoff presentation to them. I told them what happened and his back-story. I wanted to make sure they would check his sugar and take extra precautions.
They got him on the stretcher, and he eventually made it to the hospital where he had surgery. They had to have a vascular surgeon work on him. I called later, and they told me, “Yeah, he’s alive.” But that’s about the extent of the update I got.
After the ambulance left, it was kind of chaos. All the neighbors poured out of their houses. People were panicked, talking and getting excited about it. I didn’t know, but everyone else had actually been home the whole time. They didn’t come out until then.
I went back inside and tried to get ready for work. I wasn’t planning on talking to the media, but my next door neighbor just walked the news camera crew over to my house and knocked on my door. I wasn’t exactly dressed to be on TV, but they talked to me on camera, and it was on the news later that night.
I went to work and didn’t say anything about it. To be honest, I was trying to avoid telling anyone. Our team had a close-knit bond, and we would often tease each other when we received any type of recognition.
Naturally one of my attendings saw it on the local news and told everybody. So, I got a lot of happy harassment for quite some time. Someone baked me a cake that said, “Hero of Fairmount” (the Philly neighborhood in which I live). Someone else printed out a photo of me that said, “Stop the Bleed Hero of Fairmount,” and put it on every single computer screen.
The man came to see me about 2 weeks later (a neighbor told him where I lived). The man was very tearful and gave me a big hug. We just embraced for a while, and he said how thankful he was. He brought me a bottle of wine, which I thought was really nice.
He told me what happened to him: There was a lot of construction on our street and he was the contractor overseeing a couple of home remodels and demolitions. Sometimes he paid workers in cash and carried it with him. Somebody had tipped off somebody else that he was going to be there that day. The contractor walked into one of the houses and a guy in a ski mask waited there with a gun. The guy shot him and took the cash. The bullet went through his hand into his pelvis.
I had never had to deal with something that intense before outside of work. Most of it really comes down to the basics – the ABCs and bleeding control. You do whatever you can with what you have. In this case, it was just a dish towel, gloves, and my hands to put as much pressure as possible.
It really was strange that I happened to be looking out the window at that moment. I don’t know if it was just a coincidence. The man told me he believed God had put somebody there at the right place at the right time to save his life. I just felt very fortunate to have been able to help him. I never saw him again.
I think something like this gives you a little confidence that you can actually do something and make a meaningful impact anywhere when it’s needed. It lets you know that you’re capable of doing it. You always think about it, but you don’t know until it happens.
A version of this article first appeared on Medscape.com.
Physician wellness: Managing stress and preventing burnout
Meet Dr. A and Dr. M
Dr. A is a 50-year-old family physician who provides prenatal care in a busy practice. She sees patients in eight 4-hour clinic sessions per week and is on inpatient call 1 week out of every 2 months. Dr. A has become disillusioned with her practice. She typically works until 7
Dr. M is a single, 32-year-old family physician working at an academic medical center. Dr. M is unhappy in his job, is trying to grow his practice, and views himself as having little impact or autonomy. He finds himself lost while navigating the electronic health record (EHR) and struggles to be efficient in the clinic. Dr. M has multiple administrative responsibilities that require him to work evenings and weekends. Debt from medical school loans also motivates him to moonlight several weekends per month. Over the past few months, Dr. M has become frustrated and discouraged, making his depression more difficult to manage. He feels drained by the time he arrives home, where he lives alone. He has stopped exercising, socializing with friends, and dating. Dr. M often wonders if he is in the wrong profession.
Defining burnout, stress, and wellness
Dr. A and Dr. M are experiencing symptoms of burnout, common to physicians and other health care professionals. Recent studies showed an increase in burnout during the COVID-19 pandemic.1,2 In a survey using the Maslach Burnout Inventory (MBI), approximately 44% of physicians reported at least one symptom of burnout.3 After adjusting for age, gender, relationship status, and hours worked per week, physicians were found to be at greater risk for burnout than nonphysician workers.3 The latest Medscape physician burnout survey found an increase in burnout among US physicians from 42% in 2021 to 47% in 2022 during the COVID-19 pandemic.1 Rates of burnout were even higher among family physicians and other frontline (eg, emergency, infectious disease, and critical care) physicians.1
Burnout has 3 key dimensions: (1) overwhelming exhaustion; (2) feelings of cynicism and detachment from the job; and (3) a sense of ineffectiveness and lack of accomplishment.4 The MBI is considered the standard tool for research in the field of burnout and has been repeatedly assessed for reliability and validity.4 The original MBI includes such items as: “I feel emotionally drained from my work,” “I feel like I’m working too hard on my job,” and “I worry that this job is hardening me emotionally.”5
According to the World Health Organization, burnout is an occupational phenomenon associated with chronic work-related stress that is not successfully managed.6 This definition emphasizes work stress as the cause of burnout, thus highlighting the importance of addressing the work environment.7 Physician burnout can affect physician health and wellness and the quality of patient care.8-13 Because of the cost of burnout to individuals and the health care system, it is important to understand stressors that can lead to physician burnout.
Stress has been described as “physical, mental, or emotional strain or tension … when a person perceives that demands exceed the personal and social resources the individual is able to mobilize.”14 Work-related sources of stress affecting practicing physicians include long workdays, multiple bureaucratic tasks, lack of autonomy/control, and complex patients.1,15
The COVID-19 pandemic is a stressor that increased physicians’ exposure to patient suffering and deaths and physicians’ vulnerability to disease at work.16 Physicians taking care of patients with COVID-19 risk infection and the possibility of infecting others.Online health records are another source of stress for many physicians.17,18 Access to online health records on personal devices can blur the line between work and home. For each hour of direct patient contact, a physician spends an additional 2 hours interacting with an EHR.19 Among family physicians and other primary care physicians, increased EHR interaction outside clinic hours has been associated with decreased workplace satisfaction and increased rates of burnout.11,19,20 Time spent on non-patient-facing clinical tasks, such as peer-to-peer reviews and billing queries, contributes more to burnout than clinic time alone.17
Continue to: These and other organizational factors...
These and other organizational factors contribute to the stress experienced by physicians. Many describe themselves as feeling consumed by their work. At the beginning of the COVID-19 pandemic, physicians (and the rest of the health care team) had to quickly learn how to conduct virtual office visits. Clerical responsibilities increased as patients relied more on patient portals and telephone calls to receive care.
Who is predisposed to burnout? Although burnout is a work-related syndrome, studies have shown an increase in burnout associated with individual (ie, personal) factors. For example, female physicians have been shown to have higher rates of burnout compared with male physicians.1,3 The stress of balancing the demands of the profession can begin during medical school and residency, with younger physicians having nearly twice the risk for stress-related symptoms when compared with older colleagues.15,20-23 Having a child younger than 21 years old, and other personal factors related to balancing family and life demands, increases the likelihood of burnout.11,21,22
Physicians with certain personality types and predispositions are at increased risk for burnout.23-25 For example, neuroticism on the Big Five Personality Inventory (one of the most well-known of the psychology inventories) is associated with an increased risk for burnout. Neuroticism may manifest as sadness or related emotional dysregulation (eg, irritability, anxiety).26 Other traits measured by the Big Five Personality Inventory include extraversion, agreeableness, conscientiousness, and openness to experience.26
A history of depression is also associated with an increased risk for burnout.27 Although depression and burnout are separate conditions, a 2016 study found significant overlap between the two.27 Physicians in this study who were depressed were more likely to experience burnout symptoms (87.5%); however, only 26.2% of physicians experiencing burnout were diagnosed as having depression.27 Rates of depression are higher among physicians when compared with nonphysicians, yet physicians are less likely to seek help due to fear of stigma and potential licensing concerns.28,29 Because of this, when physicians experience depressive symptoms, they may respond by working harder rather than seeking professional counseling or emotional support. They might believe that “asking for help is a sign of weakness,” thus sacrificing their wellness.
Wellness encompasses a sense of thriving characterized by thoughts and feelings of contentment, joy, and fulfillment—and the absence of severe distress.30 Wellness is a multifaceted condition that includes physical, psychological, and social aspects of an individual’s personal and professional life. Individuals experience a sense of wellness when they nurture their physical selves, minds, and relationships. People experience a sense of wellness when they balance their schedules, eat well, and maintain physical activity. Making time to enjoy family and friends also contributes to wellness.
Continue to: The culture of medicine often rewards...
The culture of medicine often rewards physician attitudes and behaviors that detract from wellness.31 Physicians internalize the culture of medicine that promotes perfectionism and downplays personal vulnerability.32 Physicians are reluctant to protect and preserve their wellness, believing self-sacrifice makes them good doctors. Physicians may spend countless hours counseling patients on the importance of wellness, but then work when ill or neglect their personal health needs and self-care—potentially decreasing their resilience and increasing the risk for burnout.31
Two paths to managing stress and preventing burnout
Patel and colleagues distinguish between 2 burnout intervention categories: (1) those that focus on individual physicians and (2) those that focus on the organizational environment.33 We find these distinctions useful and offer strategies for enhancing individual physician wellness (TABLE 134-41). Similar to West and colleagues,11 we offer strategies for addressing organizational sources of stress (TABLE 242-48). The following text describes these burnout intervention categories, emphasizing increasing self-care and changes that enable physicians to adapt effectively.
The recommendations outlined in this article are based on published stress and burnout literature, as well as the experiences of the authors. However, the number of randomized controlled studies of interventions aimed at reducing physician stress and burnout is limited. In addition, strategies proposed to reduce burnout in other professions may not address the unique stressors physicians encounter. Hence, our recommendations are limited. We have included interventions that seem optimal for individual physicians and the organizations that employ them.
Individual strategies target physical, psychological, and social wellness
Physician wellness strategies are divided into 3 categories: physical, psychological, and social wellness. Most strategies to improve physical wellness are widely known, evidence based, and recommended to patients by physicians.34-36 For example, most physicians advise their patients to eat healthy balanced meals, avoid unhealthy foods and beverages, maintain a healthy body weight, get daily exercise and adequate sleep, avoid excessive alcohol use, and abstain from tobacco use. However, discrepancies between physicians’ advice to patients and their own behaviors are common. Simply stated, physicians are well advised to follow their own advice regarding physical self-care.
CBT and mindfulness are key to psychological wellness. Recommendations for enhancing psychological wellness are primarily derived from cognitive behavioral therapy (CBT) and mindfulness principles and practices.37,38 CBT has been called the “gold standard” of psychotherapy, based on the breadth of research demonstrating that “no other form of psychotherapy has been shown to be systematically superior to CBT.”39
Continue to: CBT is based on the premise...
CBT is based on the premise that individuals’ thoughts and beliefs largely determine how they feel (emotions) and act (behaviors). Certain thoughts lead to positive feelings and effective behaviors, while others lead to negative feelings and less effective behaviors. For example, when a physician has self-critical or helpless thoughts (eg, “I’m just no good at managing my life”), they are more likely to feel unhappy and abandon problem-solving. In contrast, when a physician has self-affirming or hopeful thoughts (eg, “This is difficult, but I have the personal resources to succeed”), they are more likely to feel confident and act to solve problems.
Physicians vacillate between these thoughts and beliefs, and their emotions and behaviors follow accordingly. When hyper-focused on “the hassles of medicine,” physicians feel defeated, depressed, and anxious about their work. In contrast, when physicians recognize and challenge problematic thoughts and focus on what they love about medicine, they feel good and interact with patients and coworkers in positive and self-reinforcing ways.
Mindfulness can help reduce psychological stress and increase personal fulfillment. Mindfulness is characterized as being in the present moment, fully accepting “what is,” and having a sense of gratitude and compassion for self and others.40 In practice, mindfulness involves being intentional.
Dahl and colleagues41 describe a framework for human flourishing that includes 4 core dimensions of well-being (awareness, insight, connection, and purpose) that are all closely linked to mindful, intentional living. Based on their work, it is apparent that those who maintain a “heightened and flexible attentiveness” to their thoughts and feelings are likely to benefit by experiencing “improved mental health and psychological well-being.”41
However, the utility of CBT and mindfulness practices depends on receptivity to psychological interventions. Individuals who are not receptive may be hesitant to use these practices or likely will not benefit from them. Given these limitations of behavioral interventions, it would be helpful if more attention were paid to preventing and managing physician stress and burnout, especially through research focused on organizational changes.
Continue to: Supportive relationships are powerful
Supportive relationships are powerful. Finally, to enhance social wellness, it would be difficult to overstate the potential benefits of positive, supportive, close relationships.42 However, the demands of a career in medicine, starting in medical school, have the potential for inhibiting (rather than enhancing) close relationships.
Placing value on relationships with friends and family members is essential. As Dr. M began experiencing burnout, he felt increasingly lonely, yet he isolated himself from those who cared about him. Dr. A felt lonely at home, even though she was surrounded by family. Physicians are often reluctant to initiate vulnerable communication with others, believing “no one wants to hear about my problems.” However, by realizing the need for help and asking friends and family for emotional support, physicians can improve their wellness. Fostering supportive relationships can help provide the resilience needed to address organizational stressors.
Tackling organizational challenges
Long hours and pressure to see large numbers of patients (production demands) are a challenge across practice settings. Limiting work hours has been effective in improving the well-being of physician trainees but has had an inconsistent effect on burnout.43,44
Organizations can offer flexible scheduling, and physicians considering limiting work hours may switch to part-time status or shift work. However, decreasing work hours may have the unintended consequence of increased stress as some physicians feel pressure to do more in less time.45 Therefore, it’s important to set clear boundaries around work time and when and where work tasks are completed (eg, home vs office).
How we use technology matters. Given technology’s ever-increasing role in medicine, organizations must identify and use the most efficient, effective technology for managing clerical processes. When physicians participate in these decisions and share their experiences, technology is likely to be more user-friendly and impose less stress.46
Continue to: If technology contributes to stress...
If technology contributes to stress by being too complex or impractical, it’s important to identify individuals in the workplace (eg, IT support or “super-users”) to help address these challenges. Organizations can implement multidisciplinary teams to address EHR challenges and decrease physician stress and burnout by training support staff to assist with clerical duties, allowing physicians to focus on patient care.47,48 Such organizational-directed interventions will be most successful when physicians are included in the decision-making process.47
Take on leadership roles to influence change. Leadership may be formal (involving a title and authority) or informal (leading by example). Health care organizations that are committed to the well-being of physicians will make the effort to improve the systems in which physicians work. Physicians working in organizations that are reluctant to change have several choices: implement individual strategies, take on leadership roles to influence change, or reconsider their fit for the organization. Physicians in solo practice might consider joining others in solo practices to share systems (call, phone triage, technical resources, etc) to implement some of these interventions.
Dr. A and Dr. M implement new wellness strategies
Dr. A and Dr. M have recently committed to addressing stressors in their lives and improving their wellness. Dr. A has become more assertive at work, highlighting her need for additional resources to function effectively. In response, her practice has hired scribes to assist in documenting visits. This success has inspired Dr. A to pay attention to her lifestyle choices. Gradually, she has begun to exercise and engage in healthy eating.
Dr. M has begun to utilize resources at his medical center to improve his EHR efficiency and patient flow. He has taken steps to address his financial concerns, developing a budget and spending judiciously. He practices mindfulness and ensures that he gets at least 7 hours of sleep per night, improving his mental and physical health. By doing so, he has more energy to connect with friends, exercise, and date.
CORRESPONDENCE
Margaret L. Smith, MD, MPH, MHSA, KUMC, Family Medicine and Community Health, 3901 Rainbow Boulevard – Mailstop 4010, Kansas City, KS 66160; msmith33@kumc.edu
1. Kane L. Physician burnout & depression report: stress, anxiety, and anger. Medscape. January 21, 2022. Accessed February 23, 2023. www.medscape.com/slideshow/2022-lifestyle-burnout-6014664
2. Lockwood L, Patel N, Bukelis I. 45.5 Physician burnout and the COVID-19 pandemic: the silent epidemic. J Am Acad Child Adolesc Psychiatry. 2021;60:S242. doi: 10.1016/j.jaac.2021.09.354
3. Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clin Proc. 2019;94:1681-1694. doi: 10.1016/j.mayocp.2018.10.023
4. Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry. 2016;15:103-111. doi: 10.1002/wps.20311
5. Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behav. 1981;2:99-113. doi: 10.1002/job.4030020205
6. World Health Organization. Burn-out an “occupational phenomenon”: International Classification of Diseases. May 28, 2019. Accessed February 23, 2023. www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases
7. Berg S. WHO adds burnout to ICD-11. What it means for physicians. American Medical Association. July 23, 2019. Accessed February 23, 2023. www.ama-assn.org/practice-management/physician-health/who-adds-burnout-icd-11-what-it-means-physicians
8. Brown SD, Goske MJ, Johnson CM. Beyond substance abuse: stress, burnout, and depression as causes of physician impairment and disruptive behavior. J Am Coll Radiol. 2009;6:479-485. doi: 10.1016/j.jacr.2008.11.029
9. Williams ES, Rathert C, Buttigieg SC. The personal and professional consequences of physician burnout: a systematic review of the literature. Med Care Res Rev. 2020;77:371-386. doi: 10.1177/ 1077558719856787
10. Yates SW. Physician Stress and Burnout. Am J Med. 2020;133:160-164. doi: 10.1016/j.amjmed.2019.08.034
11. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med. 2018;283:516-529. doi: 10.1111/joim.12752
12. Firth-Cozens J, Greenhalgh J. Doctors’ perceptions of the links between stress and lowered clinical care. Soc Sci Med. 1997;44:1017-1022. doi: 10.1016/s0277-9536(96)00227-4
13. Dewa CS, Loong D, Bonato S, et al. The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: a systematic review. BMJ Open. 2017;7:e015141. doi: 10.1136/bmjopen-2016-015141
14. American Institute of Stress. What is stress? April 29, 2022. Accessed February 23, 2023. www.stress.org/daily-life
15. Regehr C, Glancy D, Pitts A, et al. Interventions to reduce the consequences of stress in physicians: a review and meta-analysis. J Nerv Ment Dis. 2014;202:353-359. doi: 10.1097/NMD. 0000000000000130
16. Fitzpatrick K, Patterson R, Morley K, et al. Physician wellness during a pandemic. West J Emerg Med. 2020;21:83-87. doi: 10.5811/westjem.2020.7.48472
17. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91:836-848. doi: 10.1016/j.mayocp.2016.05.007
18. Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med. 2017;15:419-426. doi: 10.1370/afm.2121
19. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016;165:753-760. doi: 10.7326/M16-0961
20. Robertson SL, Robinson MD, Reid A. Electronic health record effects on work-life balance and burnout within the I3 Population Collaborative. J Grad Med Educ. 2017;9:479-484. doi: 10.4300/JGME-D-16-00123.1
21. Fares J, Al Tabosh H, Saadeddin Z, et al. Stress, burnout and coping strategies in preclinical medical students. N Am J Med Sci. 2016;8:75-81. doi: 10.4103/1947-2714.177299
22. Patel RS, Bachu R, Adikey A, et al. Factors related to physician burnout and its consequences: a review. Behav Sci (Basel). 2018; 8:98. doi: 10.3390/bs8110098
23. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114:513-519. doi: 10.1016/s0002-9343(03)00117-7
24. Drummond D. Physician burnout: its origin, symptoms, and five main causes. Fam Pract Manag. 2015;22:42-47.
25. Brown PA, Slater M, Lofters A. Personality and burnout among primary care physicians: an international study. Psychol Res Behav Manag. 2019;12:169-177. doi: 10.2147/PRBM.S195633.
26. John OP, Donahue EM, Kentle RL. The Big Five Inventory – Versions 4A and 54. Institute of Personality and Social Research, University of California; 1991.
27. Wurm W, Vogel K, Holl A, et al. Depression-burnout overlap in physicians. PLoS One. 2016;11:e0149913. doi: 10.1371/journal.pone.0149913
28. Mehta SS, Edwards ML. Suffering in silence: Mental health stigma and physicians’ licensing fears. Am J Psychiatry Resid J. 2018;13:2-4.
29. Adam AR, Golu FT. Prevalence of depression among physicians: A comprehensive meta-analysis. Ro Med J. 2021;68:327-337. doi: 10.37897/RMJ.2021.3.1
30. Brady KJS, Trockel MT, Khan CT, et al. What do we mean by physician wellness? A systematic review of its definition and measurement. Acad Psychiatry. 2018;42:94-108. doi: 10.1007/s40596-017-0781-6
31. Shanafelt TD, Schein E, Minor LB, et al. Healing the professional culture of medicine. Mayo Clin Proc. 2019;94:1556-1566. doi: 10.1016/j.mayocp.2019.03.026
32. Horan S, Flaxman PE, Stride CB. The perfect recovery? Interactive influence of perfectionism and spillover work tasks on changes in exhaustion and mood around a vacation. J Occup Health Psychol. 2021;26:86-107. doi: 10.1037/ocp0000208
33. Patel RS, Sekhri S, Bhimanadham NN, et al. A review on strategies to manage physician burnout. Cureus. 2019;11:e4805. doi: 10.7759/cureus.4805
34. US Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. US Department of Health and Human Services; 2018.
35. Kim ES, Chen Y, Nakamura JS, et al. Sense of purpose in life and subsequent physical, behavioral, and psychosocial health: an outcome-wide approach. Am J Health Promot. 2022;36:137-147. doi: 10.1177/08901171211038545
36. Ogilvie RP, Patel SR. The epidemiology of sleep and obesity. Sleep Health. 2017;3:383-388. doi: 10.1016/j.sleh.2017.07.013
37. Fordham B, Sugavanam T, Edwards K, et al. The evidence for cognitive behavioural therapy in any condition, population or context: a meta-review of systematic reviews and panoramic meta-analysis. Psychol Med. 2021;51:21-29. doi: 10.1017/S0033291720005292
38. Goldberg SB, Tucker RP, Greene PA, et al. Mindfulness-based interventions for psychiatric disorders: a systematic review and meta-analysis. Clin Psychol Rev. 2018;59:52-60. doi: 10.1016/j.cpr.2017.10.011
39. David D, Cristea I, Hofmann SG. Why cognitive behavioral therapy is the current gold standard of psychotherapy. Front Psychiatry. 2018;9:4. doi: 10.3389/fpsyt.2018.00004
40. Fendel JC, Bürkle JJ, Göritz AS. Mindfulness-based interventions to reduce burnout and stress in physicians: a systematic review and meta-analysis. Acad Med. 2021;96:751-764. doi: 10.1097/ACM.0000000000003936
41. Dahl CJ, Wilson-Mendenhall CD, Davidson RJ. The plasticity of well-being: a training-based framework for the cultivation of human flourishing. Proc Natl Acad Sci USA. 2020;117:32197-32206. doi: 10.1073/pnas.2014859117
42. Holt-Lunstad J. Why social relationships are important for physical health: a systems approach to understanding and modifying risk and protection. Annu Rev Psychol. 2018;69:437-458. doi: 10.1146/annurev-psych-122216-011902
43. Desai SV, Asch DA, Bellini LM, et al. Education outcomes in a duty-hour flexibility trial in internal medicine. N Engl J Med. 2018; 378:1494-1508. doi: 10.1056/NEJMoa1800965
44. Shea JA, Bellini LM, Dinges DF, et al. Impact of protected sleep period for internal medicine interns on overnight call on depression, burnout, and empathy. J Grad Med Educ. 2014;6:256-263. doi: 10.4300/JGME-D-13-00241.1
45. Morrow G, Burford B, Carter M, et al. Have restricted working hours reduced junior doctors’ experience of fatigue? A focus group and telephone interview study. BMJ Open. 2014;4:e004222. doi: 10.1136/bmjopen-2013-004222
46. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92:129-146. doi: 10.1016/j.mayocp.2016.10.004
47. Sequeira L, Almilaji K, Strudwick G, et al. EHR “SWAT” teams: a physician engagement initiative to improve Electronic Health Record (EHR) experiences and mitigate possible causes of EHR-related burnout. JAMA Open. 2021;4:1-7. doi: 10.1093/jamiaopen/ooab018
48. Smith PC, Lyon C, English AF, et al. Practice transformation under the University of Colorado’s primary care redesign model. Ann Fam Med. 2019;17:S24-S32. doi: 10.1370/afm.2424
Meet Dr. A and Dr. M
Dr. A is a 50-year-old family physician who provides prenatal care in a busy practice. She sees patients in eight 4-hour clinic sessions per week and is on inpatient call 1 week out of every 2 months. Dr. A has become disillusioned with her practice. She typically works until 7
Dr. M is a single, 32-year-old family physician working at an academic medical center. Dr. M is unhappy in his job, is trying to grow his practice, and views himself as having little impact or autonomy. He finds himself lost while navigating the electronic health record (EHR) and struggles to be efficient in the clinic. Dr. M has multiple administrative responsibilities that require him to work evenings and weekends. Debt from medical school loans also motivates him to moonlight several weekends per month. Over the past few months, Dr. M has become frustrated and discouraged, making his depression more difficult to manage. He feels drained by the time he arrives home, where he lives alone. He has stopped exercising, socializing with friends, and dating. Dr. M often wonders if he is in the wrong profession.
Defining burnout, stress, and wellness
Dr. A and Dr. M are experiencing symptoms of burnout, common to physicians and other health care professionals. Recent studies showed an increase in burnout during the COVID-19 pandemic.1,2 In a survey using the Maslach Burnout Inventory (MBI), approximately 44% of physicians reported at least one symptom of burnout.3 After adjusting for age, gender, relationship status, and hours worked per week, physicians were found to be at greater risk for burnout than nonphysician workers.3 The latest Medscape physician burnout survey found an increase in burnout among US physicians from 42% in 2021 to 47% in 2022 during the COVID-19 pandemic.1 Rates of burnout were even higher among family physicians and other frontline (eg, emergency, infectious disease, and critical care) physicians.1
Burnout has 3 key dimensions: (1) overwhelming exhaustion; (2) feelings of cynicism and detachment from the job; and (3) a sense of ineffectiveness and lack of accomplishment.4 The MBI is considered the standard tool for research in the field of burnout and has been repeatedly assessed for reliability and validity.4 The original MBI includes such items as: “I feel emotionally drained from my work,” “I feel like I’m working too hard on my job,” and “I worry that this job is hardening me emotionally.”5
According to the World Health Organization, burnout is an occupational phenomenon associated with chronic work-related stress that is not successfully managed.6 This definition emphasizes work stress as the cause of burnout, thus highlighting the importance of addressing the work environment.7 Physician burnout can affect physician health and wellness and the quality of patient care.8-13 Because of the cost of burnout to individuals and the health care system, it is important to understand stressors that can lead to physician burnout.
Stress has been described as “physical, mental, or emotional strain or tension … when a person perceives that demands exceed the personal and social resources the individual is able to mobilize.”14 Work-related sources of stress affecting practicing physicians include long workdays, multiple bureaucratic tasks, lack of autonomy/control, and complex patients.1,15
The COVID-19 pandemic is a stressor that increased physicians’ exposure to patient suffering and deaths and physicians’ vulnerability to disease at work.16 Physicians taking care of patients with COVID-19 risk infection and the possibility of infecting others.Online health records are another source of stress for many physicians.17,18 Access to online health records on personal devices can blur the line between work and home. For each hour of direct patient contact, a physician spends an additional 2 hours interacting with an EHR.19 Among family physicians and other primary care physicians, increased EHR interaction outside clinic hours has been associated with decreased workplace satisfaction and increased rates of burnout.11,19,20 Time spent on non-patient-facing clinical tasks, such as peer-to-peer reviews and billing queries, contributes more to burnout than clinic time alone.17
Continue to: These and other organizational factors...
These and other organizational factors contribute to the stress experienced by physicians. Many describe themselves as feeling consumed by their work. At the beginning of the COVID-19 pandemic, physicians (and the rest of the health care team) had to quickly learn how to conduct virtual office visits. Clerical responsibilities increased as patients relied more on patient portals and telephone calls to receive care.
Who is predisposed to burnout? Although burnout is a work-related syndrome, studies have shown an increase in burnout associated with individual (ie, personal) factors. For example, female physicians have been shown to have higher rates of burnout compared with male physicians.1,3 The stress of balancing the demands of the profession can begin during medical school and residency, with younger physicians having nearly twice the risk for stress-related symptoms when compared with older colleagues.15,20-23 Having a child younger than 21 years old, and other personal factors related to balancing family and life demands, increases the likelihood of burnout.11,21,22
Physicians with certain personality types and predispositions are at increased risk for burnout.23-25 For example, neuroticism on the Big Five Personality Inventory (one of the most well-known of the psychology inventories) is associated with an increased risk for burnout. Neuroticism may manifest as sadness or related emotional dysregulation (eg, irritability, anxiety).26 Other traits measured by the Big Five Personality Inventory include extraversion, agreeableness, conscientiousness, and openness to experience.26
A history of depression is also associated with an increased risk for burnout.27 Although depression and burnout are separate conditions, a 2016 study found significant overlap between the two.27 Physicians in this study who were depressed were more likely to experience burnout symptoms (87.5%); however, only 26.2% of physicians experiencing burnout were diagnosed as having depression.27 Rates of depression are higher among physicians when compared with nonphysicians, yet physicians are less likely to seek help due to fear of stigma and potential licensing concerns.28,29 Because of this, when physicians experience depressive symptoms, they may respond by working harder rather than seeking professional counseling or emotional support. They might believe that “asking for help is a sign of weakness,” thus sacrificing their wellness.
Wellness encompasses a sense of thriving characterized by thoughts and feelings of contentment, joy, and fulfillment—and the absence of severe distress.30 Wellness is a multifaceted condition that includes physical, psychological, and social aspects of an individual’s personal and professional life. Individuals experience a sense of wellness when they nurture their physical selves, minds, and relationships. People experience a sense of wellness when they balance their schedules, eat well, and maintain physical activity. Making time to enjoy family and friends also contributes to wellness.
Continue to: The culture of medicine often rewards...
The culture of medicine often rewards physician attitudes and behaviors that detract from wellness.31 Physicians internalize the culture of medicine that promotes perfectionism and downplays personal vulnerability.32 Physicians are reluctant to protect and preserve their wellness, believing self-sacrifice makes them good doctors. Physicians may spend countless hours counseling patients on the importance of wellness, but then work when ill or neglect their personal health needs and self-care—potentially decreasing their resilience and increasing the risk for burnout.31
Two paths to managing stress and preventing burnout
Patel and colleagues distinguish between 2 burnout intervention categories: (1) those that focus on individual physicians and (2) those that focus on the organizational environment.33 We find these distinctions useful and offer strategies for enhancing individual physician wellness (TABLE 134-41). Similar to West and colleagues,11 we offer strategies for addressing organizational sources of stress (TABLE 242-48). The following text describes these burnout intervention categories, emphasizing increasing self-care and changes that enable physicians to adapt effectively.
The recommendations outlined in this article are based on published stress and burnout literature, as well as the experiences of the authors. However, the number of randomized controlled studies of interventions aimed at reducing physician stress and burnout is limited. In addition, strategies proposed to reduce burnout in other professions may not address the unique stressors physicians encounter. Hence, our recommendations are limited. We have included interventions that seem optimal for individual physicians and the organizations that employ them.
Individual strategies target physical, psychological, and social wellness
Physician wellness strategies are divided into 3 categories: physical, psychological, and social wellness. Most strategies to improve physical wellness are widely known, evidence based, and recommended to patients by physicians.34-36 For example, most physicians advise their patients to eat healthy balanced meals, avoid unhealthy foods and beverages, maintain a healthy body weight, get daily exercise and adequate sleep, avoid excessive alcohol use, and abstain from tobacco use. However, discrepancies between physicians’ advice to patients and their own behaviors are common. Simply stated, physicians are well advised to follow their own advice regarding physical self-care.
CBT and mindfulness are key to psychological wellness. Recommendations for enhancing psychological wellness are primarily derived from cognitive behavioral therapy (CBT) and mindfulness principles and practices.37,38 CBT has been called the “gold standard” of psychotherapy, based on the breadth of research demonstrating that “no other form of psychotherapy has been shown to be systematically superior to CBT.”39
Continue to: CBT is based on the premise...
CBT is based on the premise that individuals’ thoughts and beliefs largely determine how they feel (emotions) and act (behaviors). Certain thoughts lead to positive feelings and effective behaviors, while others lead to negative feelings and less effective behaviors. For example, when a physician has self-critical or helpless thoughts (eg, “I’m just no good at managing my life”), they are more likely to feel unhappy and abandon problem-solving. In contrast, when a physician has self-affirming or hopeful thoughts (eg, “This is difficult, but I have the personal resources to succeed”), they are more likely to feel confident and act to solve problems.
Physicians vacillate between these thoughts and beliefs, and their emotions and behaviors follow accordingly. When hyper-focused on “the hassles of medicine,” physicians feel defeated, depressed, and anxious about their work. In contrast, when physicians recognize and challenge problematic thoughts and focus on what they love about medicine, they feel good and interact with patients and coworkers in positive and self-reinforcing ways.
Mindfulness can help reduce psychological stress and increase personal fulfillment. Mindfulness is characterized as being in the present moment, fully accepting “what is,” and having a sense of gratitude and compassion for self and others.40 In practice, mindfulness involves being intentional.
Dahl and colleagues41 describe a framework for human flourishing that includes 4 core dimensions of well-being (awareness, insight, connection, and purpose) that are all closely linked to mindful, intentional living. Based on their work, it is apparent that those who maintain a “heightened and flexible attentiveness” to their thoughts and feelings are likely to benefit by experiencing “improved mental health and psychological well-being.”41
However, the utility of CBT and mindfulness practices depends on receptivity to psychological interventions. Individuals who are not receptive may be hesitant to use these practices or likely will not benefit from them. Given these limitations of behavioral interventions, it would be helpful if more attention were paid to preventing and managing physician stress and burnout, especially through research focused on organizational changes.
Continue to: Supportive relationships are powerful
Supportive relationships are powerful. Finally, to enhance social wellness, it would be difficult to overstate the potential benefits of positive, supportive, close relationships.42 However, the demands of a career in medicine, starting in medical school, have the potential for inhibiting (rather than enhancing) close relationships.
Placing value on relationships with friends and family members is essential. As Dr. M began experiencing burnout, he felt increasingly lonely, yet he isolated himself from those who cared about him. Dr. A felt lonely at home, even though she was surrounded by family. Physicians are often reluctant to initiate vulnerable communication with others, believing “no one wants to hear about my problems.” However, by realizing the need for help and asking friends and family for emotional support, physicians can improve their wellness. Fostering supportive relationships can help provide the resilience needed to address organizational stressors.
Tackling organizational challenges
Long hours and pressure to see large numbers of patients (production demands) are a challenge across practice settings. Limiting work hours has been effective in improving the well-being of physician trainees but has had an inconsistent effect on burnout.43,44
Organizations can offer flexible scheduling, and physicians considering limiting work hours may switch to part-time status or shift work. However, decreasing work hours may have the unintended consequence of increased stress as some physicians feel pressure to do more in less time.45 Therefore, it’s important to set clear boundaries around work time and when and where work tasks are completed (eg, home vs office).
How we use technology matters. Given technology’s ever-increasing role in medicine, organizations must identify and use the most efficient, effective technology for managing clerical processes. When physicians participate in these decisions and share their experiences, technology is likely to be more user-friendly and impose less stress.46
Continue to: If technology contributes to stress...
If technology contributes to stress by being too complex or impractical, it’s important to identify individuals in the workplace (eg, IT support or “super-users”) to help address these challenges. Organizations can implement multidisciplinary teams to address EHR challenges and decrease physician stress and burnout by training support staff to assist with clerical duties, allowing physicians to focus on patient care.47,48 Such organizational-directed interventions will be most successful when physicians are included in the decision-making process.47
Take on leadership roles to influence change. Leadership may be formal (involving a title and authority) or informal (leading by example). Health care organizations that are committed to the well-being of physicians will make the effort to improve the systems in which physicians work. Physicians working in organizations that are reluctant to change have several choices: implement individual strategies, take on leadership roles to influence change, or reconsider their fit for the organization. Physicians in solo practice might consider joining others in solo practices to share systems (call, phone triage, technical resources, etc) to implement some of these interventions.
Dr. A and Dr. M implement new wellness strategies
Dr. A and Dr. M have recently committed to addressing stressors in their lives and improving their wellness. Dr. A has become more assertive at work, highlighting her need for additional resources to function effectively. In response, her practice has hired scribes to assist in documenting visits. This success has inspired Dr. A to pay attention to her lifestyle choices. Gradually, she has begun to exercise and engage in healthy eating.
Dr. M has begun to utilize resources at his medical center to improve his EHR efficiency and patient flow. He has taken steps to address his financial concerns, developing a budget and spending judiciously. He practices mindfulness and ensures that he gets at least 7 hours of sleep per night, improving his mental and physical health. By doing so, he has more energy to connect with friends, exercise, and date.
CORRESPONDENCE
Margaret L. Smith, MD, MPH, MHSA, KUMC, Family Medicine and Community Health, 3901 Rainbow Boulevard – Mailstop 4010, Kansas City, KS 66160; msmith33@kumc.edu
Meet Dr. A and Dr. M
Dr. A is a 50-year-old family physician who provides prenatal care in a busy practice. She sees patients in eight 4-hour clinic sessions per week and is on inpatient call 1 week out of every 2 months. Dr. A has become disillusioned with her practice. She typically works until 7
Dr. M is a single, 32-year-old family physician working at an academic medical center. Dr. M is unhappy in his job, is trying to grow his practice, and views himself as having little impact or autonomy. He finds himself lost while navigating the electronic health record (EHR) and struggles to be efficient in the clinic. Dr. M has multiple administrative responsibilities that require him to work evenings and weekends. Debt from medical school loans also motivates him to moonlight several weekends per month. Over the past few months, Dr. M has become frustrated and discouraged, making his depression more difficult to manage. He feels drained by the time he arrives home, where he lives alone. He has stopped exercising, socializing with friends, and dating. Dr. M often wonders if he is in the wrong profession.
Defining burnout, stress, and wellness
Dr. A and Dr. M are experiencing symptoms of burnout, common to physicians and other health care professionals. Recent studies showed an increase in burnout during the COVID-19 pandemic.1,2 In a survey using the Maslach Burnout Inventory (MBI), approximately 44% of physicians reported at least one symptom of burnout.3 After adjusting for age, gender, relationship status, and hours worked per week, physicians were found to be at greater risk for burnout than nonphysician workers.3 The latest Medscape physician burnout survey found an increase in burnout among US physicians from 42% in 2021 to 47% in 2022 during the COVID-19 pandemic.1 Rates of burnout were even higher among family physicians and other frontline (eg, emergency, infectious disease, and critical care) physicians.1
Burnout has 3 key dimensions: (1) overwhelming exhaustion; (2) feelings of cynicism and detachment from the job; and (3) a sense of ineffectiveness and lack of accomplishment.4 The MBI is considered the standard tool for research in the field of burnout and has been repeatedly assessed for reliability and validity.4 The original MBI includes such items as: “I feel emotionally drained from my work,” “I feel like I’m working too hard on my job,” and “I worry that this job is hardening me emotionally.”5
According to the World Health Organization, burnout is an occupational phenomenon associated with chronic work-related stress that is not successfully managed.6 This definition emphasizes work stress as the cause of burnout, thus highlighting the importance of addressing the work environment.7 Physician burnout can affect physician health and wellness and the quality of patient care.8-13 Because of the cost of burnout to individuals and the health care system, it is important to understand stressors that can lead to physician burnout.
Stress has been described as “physical, mental, or emotional strain or tension … when a person perceives that demands exceed the personal and social resources the individual is able to mobilize.”14 Work-related sources of stress affecting practicing physicians include long workdays, multiple bureaucratic tasks, lack of autonomy/control, and complex patients.1,15
The COVID-19 pandemic is a stressor that increased physicians’ exposure to patient suffering and deaths and physicians’ vulnerability to disease at work.16 Physicians taking care of patients with COVID-19 risk infection and the possibility of infecting others.Online health records are another source of stress for many physicians.17,18 Access to online health records on personal devices can blur the line between work and home. For each hour of direct patient contact, a physician spends an additional 2 hours interacting with an EHR.19 Among family physicians and other primary care physicians, increased EHR interaction outside clinic hours has been associated with decreased workplace satisfaction and increased rates of burnout.11,19,20 Time spent on non-patient-facing clinical tasks, such as peer-to-peer reviews and billing queries, contributes more to burnout than clinic time alone.17
Continue to: These and other organizational factors...
These and other organizational factors contribute to the stress experienced by physicians. Many describe themselves as feeling consumed by their work. At the beginning of the COVID-19 pandemic, physicians (and the rest of the health care team) had to quickly learn how to conduct virtual office visits. Clerical responsibilities increased as patients relied more on patient portals and telephone calls to receive care.
Who is predisposed to burnout? Although burnout is a work-related syndrome, studies have shown an increase in burnout associated with individual (ie, personal) factors. For example, female physicians have been shown to have higher rates of burnout compared with male physicians.1,3 The stress of balancing the demands of the profession can begin during medical school and residency, with younger physicians having nearly twice the risk for stress-related symptoms when compared with older colleagues.15,20-23 Having a child younger than 21 years old, and other personal factors related to balancing family and life demands, increases the likelihood of burnout.11,21,22
Physicians with certain personality types and predispositions are at increased risk for burnout.23-25 For example, neuroticism on the Big Five Personality Inventory (one of the most well-known of the psychology inventories) is associated with an increased risk for burnout. Neuroticism may manifest as sadness or related emotional dysregulation (eg, irritability, anxiety).26 Other traits measured by the Big Five Personality Inventory include extraversion, agreeableness, conscientiousness, and openness to experience.26
A history of depression is also associated with an increased risk for burnout.27 Although depression and burnout are separate conditions, a 2016 study found significant overlap between the two.27 Physicians in this study who were depressed were more likely to experience burnout symptoms (87.5%); however, only 26.2% of physicians experiencing burnout were diagnosed as having depression.27 Rates of depression are higher among physicians when compared with nonphysicians, yet physicians are less likely to seek help due to fear of stigma and potential licensing concerns.28,29 Because of this, when physicians experience depressive symptoms, they may respond by working harder rather than seeking professional counseling or emotional support. They might believe that “asking for help is a sign of weakness,” thus sacrificing their wellness.
Wellness encompasses a sense of thriving characterized by thoughts and feelings of contentment, joy, and fulfillment—and the absence of severe distress.30 Wellness is a multifaceted condition that includes physical, psychological, and social aspects of an individual’s personal and professional life. Individuals experience a sense of wellness when they nurture their physical selves, minds, and relationships. People experience a sense of wellness when they balance their schedules, eat well, and maintain physical activity. Making time to enjoy family and friends also contributes to wellness.
Continue to: The culture of medicine often rewards...
The culture of medicine often rewards physician attitudes and behaviors that detract from wellness.31 Physicians internalize the culture of medicine that promotes perfectionism and downplays personal vulnerability.32 Physicians are reluctant to protect and preserve their wellness, believing self-sacrifice makes them good doctors. Physicians may spend countless hours counseling patients on the importance of wellness, but then work when ill or neglect their personal health needs and self-care—potentially decreasing their resilience and increasing the risk for burnout.31
Two paths to managing stress and preventing burnout
Patel and colleagues distinguish between 2 burnout intervention categories: (1) those that focus on individual physicians and (2) those that focus on the organizational environment.33 We find these distinctions useful and offer strategies for enhancing individual physician wellness (TABLE 134-41). Similar to West and colleagues,11 we offer strategies for addressing organizational sources of stress (TABLE 242-48). The following text describes these burnout intervention categories, emphasizing increasing self-care and changes that enable physicians to adapt effectively.
The recommendations outlined in this article are based on published stress and burnout literature, as well as the experiences of the authors. However, the number of randomized controlled studies of interventions aimed at reducing physician stress and burnout is limited. In addition, strategies proposed to reduce burnout in other professions may not address the unique stressors physicians encounter. Hence, our recommendations are limited. We have included interventions that seem optimal for individual physicians and the organizations that employ them.
Individual strategies target physical, psychological, and social wellness
Physician wellness strategies are divided into 3 categories: physical, psychological, and social wellness. Most strategies to improve physical wellness are widely known, evidence based, and recommended to patients by physicians.34-36 For example, most physicians advise their patients to eat healthy balanced meals, avoid unhealthy foods and beverages, maintain a healthy body weight, get daily exercise and adequate sleep, avoid excessive alcohol use, and abstain from tobacco use. However, discrepancies between physicians’ advice to patients and their own behaviors are common. Simply stated, physicians are well advised to follow their own advice regarding physical self-care.
CBT and mindfulness are key to psychological wellness. Recommendations for enhancing psychological wellness are primarily derived from cognitive behavioral therapy (CBT) and mindfulness principles and practices.37,38 CBT has been called the “gold standard” of psychotherapy, based on the breadth of research demonstrating that “no other form of psychotherapy has been shown to be systematically superior to CBT.”39
Continue to: CBT is based on the premise...
CBT is based on the premise that individuals’ thoughts and beliefs largely determine how they feel (emotions) and act (behaviors). Certain thoughts lead to positive feelings and effective behaviors, while others lead to negative feelings and less effective behaviors. For example, when a physician has self-critical or helpless thoughts (eg, “I’m just no good at managing my life”), they are more likely to feel unhappy and abandon problem-solving. In contrast, when a physician has self-affirming or hopeful thoughts (eg, “This is difficult, but I have the personal resources to succeed”), they are more likely to feel confident and act to solve problems.
Physicians vacillate between these thoughts and beliefs, and their emotions and behaviors follow accordingly. When hyper-focused on “the hassles of medicine,” physicians feel defeated, depressed, and anxious about their work. In contrast, when physicians recognize and challenge problematic thoughts and focus on what they love about medicine, they feel good and interact with patients and coworkers in positive and self-reinforcing ways.
Mindfulness can help reduce psychological stress and increase personal fulfillment. Mindfulness is characterized as being in the present moment, fully accepting “what is,” and having a sense of gratitude and compassion for self and others.40 In practice, mindfulness involves being intentional.
Dahl and colleagues41 describe a framework for human flourishing that includes 4 core dimensions of well-being (awareness, insight, connection, and purpose) that are all closely linked to mindful, intentional living. Based on their work, it is apparent that those who maintain a “heightened and flexible attentiveness” to their thoughts and feelings are likely to benefit by experiencing “improved mental health and psychological well-being.”41
However, the utility of CBT and mindfulness practices depends on receptivity to psychological interventions. Individuals who are not receptive may be hesitant to use these practices or likely will not benefit from them. Given these limitations of behavioral interventions, it would be helpful if more attention were paid to preventing and managing physician stress and burnout, especially through research focused on organizational changes.
Continue to: Supportive relationships are powerful
Supportive relationships are powerful. Finally, to enhance social wellness, it would be difficult to overstate the potential benefits of positive, supportive, close relationships.42 However, the demands of a career in medicine, starting in medical school, have the potential for inhibiting (rather than enhancing) close relationships.
Placing value on relationships with friends and family members is essential. As Dr. M began experiencing burnout, he felt increasingly lonely, yet he isolated himself from those who cared about him. Dr. A felt lonely at home, even though she was surrounded by family. Physicians are often reluctant to initiate vulnerable communication with others, believing “no one wants to hear about my problems.” However, by realizing the need for help and asking friends and family for emotional support, physicians can improve their wellness. Fostering supportive relationships can help provide the resilience needed to address organizational stressors.
Tackling organizational challenges
Long hours and pressure to see large numbers of patients (production demands) are a challenge across practice settings. Limiting work hours has been effective in improving the well-being of physician trainees but has had an inconsistent effect on burnout.43,44
Organizations can offer flexible scheduling, and physicians considering limiting work hours may switch to part-time status or shift work. However, decreasing work hours may have the unintended consequence of increased stress as some physicians feel pressure to do more in less time.45 Therefore, it’s important to set clear boundaries around work time and when and where work tasks are completed (eg, home vs office).
How we use technology matters. Given technology’s ever-increasing role in medicine, organizations must identify and use the most efficient, effective technology for managing clerical processes. When physicians participate in these decisions and share their experiences, technology is likely to be more user-friendly and impose less stress.46
Continue to: If technology contributes to stress...
If technology contributes to stress by being too complex or impractical, it’s important to identify individuals in the workplace (eg, IT support or “super-users”) to help address these challenges. Organizations can implement multidisciplinary teams to address EHR challenges and decrease physician stress and burnout by training support staff to assist with clerical duties, allowing physicians to focus on patient care.47,48 Such organizational-directed interventions will be most successful when physicians are included in the decision-making process.47
Take on leadership roles to influence change. Leadership may be formal (involving a title and authority) or informal (leading by example). Health care organizations that are committed to the well-being of physicians will make the effort to improve the systems in which physicians work. Physicians working in organizations that are reluctant to change have several choices: implement individual strategies, take on leadership roles to influence change, or reconsider their fit for the organization. Physicians in solo practice might consider joining others in solo practices to share systems (call, phone triage, technical resources, etc) to implement some of these interventions.
Dr. A and Dr. M implement new wellness strategies
Dr. A and Dr. M have recently committed to addressing stressors in their lives and improving their wellness. Dr. A has become more assertive at work, highlighting her need for additional resources to function effectively. In response, her practice has hired scribes to assist in documenting visits. This success has inspired Dr. A to pay attention to her lifestyle choices. Gradually, she has begun to exercise and engage in healthy eating.
Dr. M has begun to utilize resources at his medical center to improve his EHR efficiency and patient flow. He has taken steps to address his financial concerns, developing a budget and spending judiciously. He practices mindfulness and ensures that he gets at least 7 hours of sleep per night, improving his mental and physical health. By doing so, he has more energy to connect with friends, exercise, and date.
CORRESPONDENCE
Margaret L. Smith, MD, MPH, MHSA, KUMC, Family Medicine and Community Health, 3901 Rainbow Boulevard – Mailstop 4010, Kansas City, KS 66160; msmith33@kumc.edu
1. Kane L. Physician burnout & depression report: stress, anxiety, and anger. Medscape. January 21, 2022. Accessed February 23, 2023. www.medscape.com/slideshow/2022-lifestyle-burnout-6014664
2. Lockwood L, Patel N, Bukelis I. 45.5 Physician burnout and the COVID-19 pandemic: the silent epidemic. J Am Acad Child Adolesc Psychiatry. 2021;60:S242. doi: 10.1016/j.jaac.2021.09.354
3. Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clin Proc. 2019;94:1681-1694. doi: 10.1016/j.mayocp.2018.10.023
4. Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry. 2016;15:103-111. doi: 10.1002/wps.20311
5. Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behav. 1981;2:99-113. doi: 10.1002/job.4030020205
6. World Health Organization. Burn-out an “occupational phenomenon”: International Classification of Diseases. May 28, 2019. Accessed February 23, 2023. www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases
7. Berg S. WHO adds burnout to ICD-11. What it means for physicians. American Medical Association. July 23, 2019. Accessed February 23, 2023. www.ama-assn.org/practice-management/physician-health/who-adds-burnout-icd-11-what-it-means-physicians
8. Brown SD, Goske MJ, Johnson CM. Beyond substance abuse: stress, burnout, and depression as causes of physician impairment and disruptive behavior. J Am Coll Radiol. 2009;6:479-485. doi: 10.1016/j.jacr.2008.11.029
9. Williams ES, Rathert C, Buttigieg SC. The personal and professional consequences of physician burnout: a systematic review of the literature. Med Care Res Rev. 2020;77:371-386. doi: 10.1177/ 1077558719856787
10. Yates SW. Physician Stress and Burnout. Am J Med. 2020;133:160-164. doi: 10.1016/j.amjmed.2019.08.034
11. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med. 2018;283:516-529. doi: 10.1111/joim.12752
12. Firth-Cozens J, Greenhalgh J. Doctors’ perceptions of the links between stress and lowered clinical care. Soc Sci Med. 1997;44:1017-1022. doi: 10.1016/s0277-9536(96)00227-4
13. Dewa CS, Loong D, Bonato S, et al. The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: a systematic review. BMJ Open. 2017;7:e015141. doi: 10.1136/bmjopen-2016-015141
14. American Institute of Stress. What is stress? April 29, 2022. Accessed February 23, 2023. www.stress.org/daily-life
15. Regehr C, Glancy D, Pitts A, et al. Interventions to reduce the consequences of stress in physicians: a review and meta-analysis. J Nerv Ment Dis. 2014;202:353-359. doi: 10.1097/NMD. 0000000000000130
16. Fitzpatrick K, Patterson R, Morley K, et al. Physician wellness during a pandemic. West J Emerg Med. 2020;21:83-87. doi: 10.5811/westjem.2020.7.48472
17. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91:836-848. doi: 10.1016/j.mayocp.2016.05.007
18. Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med. 2017;15:419-426. doi: 10.1370/afm.2121
19. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016;165:753-760. doi: 10.7326/M16-0961
20. Robertson SL, Robinson MD, Reid A. Electronic health record effects on work-life balance and burnout within the I3 Population Collaborative. J Grad Med Educ. 2017;9:479-484. doi: 10.4300/JGME-D-16-00123.1
21. Fares J, Al Tabosh H, Saadeddin Z, et al. Stress, burnout and coping strategies in preclinical medical students. N Am J Med Sci. 2016;8:75-81. doi: 10.4103/1947-2714.177299
22. Patel RS, Bachu R, Adikey A, et al. Factors related to physician burnout and its consequences: a review. Behav Sci (Basel). 2018; 8:98. doi: 10.3390/bs8110098
23. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114:513-519. doi: 10.1016/s0002-9343(03)00117-7
24. Drummond D. Physician burnout: its origin, symptoms, and five main causes. Fam Pract Manag. 2015;22:42-47.
25. Brown PA, Slater M, Lofters A. Personality and burnout among primary care physicians: an international study. Psychol Res Behav Manag. 2019;12:169-177. doi: 10.2147/PRBM.S195633.
26. John OP, Donahue EM, Kentle RL. The Big Five Inventory – Versions 4A and 54. Institute of Personality and Social Research, University of California; 1991.
27. Wurm W, Vogel K, Holl A, et al. Depression-burnout overlap in physicians. PLoS One. 2016;11:e0149913. doi: 10.1371/journal.pone.0149913
28. Mehta SS, Edwards ML. Suffering in silence: Mental health stigma and physicians’ licensing fears. Am J Psychiatry Resid J. 2018;13:2-4.
29. Adam AR, Golu FT. Prevalence of depression among physicians: A comprehensive meta-analysis. Ro Med J. 2021;68:327-337. doi: 10.37897/RMJ.2021.3.1
30. Brady KJS, Trockel MT, Khan CT, et al. What do we mean by physician wellness? A systematic review of its definition and measurement. Acad Psychiatry. 2018;42:94-108. doi: 10.1007/s40596-017-0781-6
31. Shanafelt TD, Schein E, Minor LB, et al. Healing the professional culture of medicine. Mayo Clin Proc. 2019;94:1556-1566. doi: 10.1016/j.mayocp.2019.03.026
32. Horan S, Flaxman PE, Stride CB. The perfect recovery? Interactive influence of perfectionism and spillover work tasks on changes in exhaustion and mood around a vacation. J Occup Health Psychol. 2021;26:86-107. doi: 10.1037/ocp0000208
33. Patel RS, Sekhri S, Bhimanadham NN, et al. A review on strategies to manage physician burnout. Cureus. 2019;11:e4805. doi: 10.7759/cureus.4805
34. US Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. US Department of Health and Human Services; 2018.
35. Kim ES, Chen Y, Nakamura JS, et al. Sense of purpose in life and subsequent physical, behavioral, and psychosocial health: an outcome-wide approach. Am J Health Promot. 2022;36:137-147. doi: 10.1177/08901171211038545
36. Ogilvie RP, Patel SR. The epidemiology of sleep and obesity. Sleep Health. 2017;3:383-388. doi: 10.1016/j.sleh.2017.07.013
37. Fordham B, Sugavanam T, Edwards K, et al. The evidence for cognitive behavioural therapy in any condition, population or context: a meta-review of systematic reviews and panoramic meta-analysis. Psychol Med. 2021;51:21-29. doi: 10.1017/S0033291720005292
38. Goldberg SB, Tucker RP, Greene PA, et al. Mindfulness-based interventions for psychiatric disorders: a systematic review and meta-analysis. Clin Psychol Rev. 2018;59:52-60. doi: 10.1016/j.cpr.2017.10.011
39. David D, Cristea I, Hofmann SG. Why cognitive behavioral therapy is the current gold standard of psychotherapy. Front Psychiatry. 2018;9:4. doi: 10.3389/fpsyt.2018.00004
40. Fendel JC, Bürkle JJ, Göritz AS. Mindfulness-based interventions to reduce burnout and stress in physicians: a systematic review and meta-analysis. Acad Med. 2021;96:751-764. doi: 10.1097/ACM.0000000000003936
41. Dahl CJ, Wilson-Mendenhall CD, Davidson RJ. The plasticity of well-being: a training-based framework for the cultivation of human flourishing. Proc Natl Acad Sci USA. 2020;117:32197-32206. doi: 10.1073/pnas.2014859117
42. Holt-Lunstad J. Why social relationships are important for physical health: a systems approach to understanding and modifying risk and protection. Annu Rev Psychol. 2018;69:437-458. doi: 10.1146/annurev-psych-122216-011902
43. Desai SV, Asch DA, Bellini LM, et al. Education outcomes in a duty-hour flexibility trial in internal medicine. N Engl J Med. 2018; 378:1494-1508. doi: 10.1056/NEJMoa1800965
44. Shea JA, Bellini LM, Dinges DF, et al. Impact of protected sleep period for internal medicine interns on overnight call on depression, burnout, and empathy. J Grad Med Educ. 2014;6:256-263. doi: 10.4300/JGME-D-13-00241.1
45. Morrow G, Burford B, Carter M, et al. Have restricted working hours reduced junior doctors’ experience of fatigue? A focus group and telephone interview study. BMJ Open. 2014;4:e004222. doi: 10.1136/bmjopen-2013-004222
46. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92:129-146. doi: 10.1016/j.mayocp.2016.10.004
47. Sequeira L, Almilaji K, Strudwick G, et al. EHR “SWAT” teams: a physician engagement initiative to improve Electronic Health Record (EHR) experiences and mitigate possible causes of EHR-related burnout. JAMA Open. 2021;4:1-7. doi: 10.1093/jamiaopen/ooab018
48. Smith PC, Lyon C, English AF, et al. Practice transformation under the University of Colorado’s primary care redesign model. Ann Fam Med. 2019;17:S24-S32. doi: 10.1370/afm.2424
1. Kane L. Physician burnout & depression report: stress, anxiety, and anger. Medscape. January 21, 2022. Accessed February 23, 2023. www.medscape.com/slideshow/2022-lifestyle-burnout-6014664
2. Lockwood L, Patel N, Bukelis I. 45.5 Physician burnout and the COVID-19 pandemic: the silent epidemic. J Am Acad Child Adolesc Psychiatry. 2021;60:S242. doi: 10.1016/j.jaac.2021.09.354
3. Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clin Proc. 2019;94:1681-1694. doi: 10.1016/j.mayocp.2018.10.023
4. Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry. 2016;15:103-111. doi: 10.1002/wps.20311
5. Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behav. 1981;2:99-113. doi: 10.1002/job.4030020205
6. World Health Organization. Burn-out an “occupational phenomenon”: International Classification of Diseases. May 28, 2019. Accessed February 23, 2023. www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases
7. Berg S. WHO adds burnout to ICD-11. What it means for physicians. American Medical Association. July 23, 2019. Accessed February 23, 2023. www.ama-assn.org/practice-management/physician-health/who-adds-burnout-icd-11-what-it-means-physicians
8. Brown SD, Goske MJ, Johnson CM. Beyond substance abuse: stress, burnout, and depression as causes of physician impairment and disruptive behavior. J Am Coll Radiol. 2009;6:479-485. doi: 10.1016/j.jacr.2008.11.029
9. Williams ES, Rathert C, Buttigieg SC. The personal and professional consequences of physician burnout: a systematic review of the literature. Med Care Res Rev. 2020;77:371-386. doi: 10.1177/ 1077558719856787
10. Yates SW. Physician Stress and Burnout. Am J Med. 2020;133:160-164. doi: 10.1016/j.amjmed.2019.08.034
11. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med. 2018;283:516-529. doi: 10.1111/joim.12752
12. Firth-Cozens J, Greenhalgh J. Doctors’ perceptions of the links between stress and lowered clinical care. Soc Sci Med. 1997;44:1017-1022. doi: 10.1016/s0277-9536(96)00227-4
13. Dewa CS, Loong D, Bonato S, et al. The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: a systematic review. BMJ Open. 2017;7:e015141. doi: 10.1136/bmjopen-2016-015141
14. American Institute of Stress. What is stress? April 29, 2022. Accessed February 23, 2023. www.stress.org/daily-life
15. Regehr C, Glancy D, Pitts A, et al. Interventions to reduce the consequences of stress in physicians: a review and meta-analysis. J Nerv Ment Dis. 2014;202:353-359. doi: 10.1097/NMD. 0000000000000130
16. Fitzpatrick K, Patterson R, Morley K, et al. Physician wellness during a pandemic. West J Emerg Med. 2020;21:83-87. doi: 10.5811/westjem.2020.7.48472
17. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91:836-848. doi: 10.1016/j.mayocp.2016.05.007
18. Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med. 2017;15:419-426. doi: 10.1370/afm.2121
19. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016;165:753-760. doi: 10.7326/M16-0961
20. Robertson SL, Robinson MD, Reid A. Electronic health record effects on work-life balance and burnout within the I3 Population Collaborative. J Grad Med Educ. 2017;9:479-484. doi: 10.4300/JGME-D-16-00123.1
21. Fares J, Al Tabosh H, Saadeddin Z, et al. Stress, burnout and coping strategies in preclinical medical students. N Am J Med Sci. 2016;8:75-81. doi: 10.4103/1947-2714.177299
22. Patel RS, Bachu R, Adikey A, et al. Factors related to physician burnout and its consequences: a review. Behav Sci (Basel). 2018; 8:98. doi: 10.3390/bs8110098
23. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114:513-519. doi: 10.1016/s0002-9343(03)00117-7
24. Drummond D. Physician burnout: its origin, symptoms, and five main causes. Fam Pract Manag. 2015;22:42-47.
25. Brown PA, Slater M, Lofters A. Personality and burnout among primary care physicians: an international study. Psychol Res Behav Manag. 2019;12:169-177. doi: 10.2147/PRBM.S195633.
26. John OP, Donahue EM, Kentle RL. The Big Five Inventory – Versions 4A and 54. Institute of Personality and Social Research, University of California; 1991.
27. Wurm W, Vogel K, Holl A, et al. Depression-burnout overlap in physicians. PLoS One. 2016;11:e0149913. doi: 10.1371/journal.pone.0149913
28. Mehta SS, Edwards ML. Suffering in silence: Mental health stigma and physicians’ licensing fears. Am J Psychiatry Resid J. 2018;13:2-4.
29. Adam AR, Golu FT. Prevalence of depression among physicians: A comprehensive meta-analysis. Ro Med J. 2021;68:327-337. doi: 10.37897/RMJ.2021.3.1
30. Brady KJS, Trockel MT, Khan CT, et al. What do we mean by physician wellness? A systematic review of its definition and measurement. Acad Psychiatry. 2018;42:94-108. doi: 10.1007/s40596-017-0781-6
31. Shanafelt TD, Schein E, Minor LB, et al. Healing the professional culture of medicine. Mayo Clin Proc. 2019;94:1556-1566. doi: 10.1016/j.mayocp.2019.03.026
32. Horan S, Flaxman PE, Stride CB. The perfect recovery? Interactive influence of perfectionism and spillover work tasks on changes in exhaustion and mood around a vacation. J Occup Health Psychol. 2021;26:86-107. doi: 10.1037/ocp0000208
33. Patel RS, Sekhri S, Bhimanadham NN, et al. A review on strategies to manage physician burnout. Cureus. 2019;11:e4805. doi: 10.7759/cureus.4805
34. US Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. US Department of Health and Human Services; 2018.
35. Kim ES, Chen Y, Nakamura JS, et al. Sense of purpose in life and subsequent physical, behavioral, and psychosocial health: an outcome-wide approach. Am J Health Promot. 2022;36:137-147. doi: 10.1177/08901171211038545
36. Ogilvie RP, Patel SR. The epidemiology of sleep and obesity. Sleep Health. 2017;3:383-388. doi: 10.1016/j.sleh.2017.07.013
37. Fordham B, Sugavanam T, Edwards K, et al. The evidence for cognitive behavioural therapy in any condition, population or context: a meta-review of systematic reviews and panoramic meta-analysis. Psychol Med. 2021;51:21-29. doi: 10.1017/S0033291720005292
38. Goldberg SB, Tucker RP, Greene PA, et al. Mindfulness-based interventions for psychiatric disorders: a systematic review and meta-analysis. Clin Psychol Rev. 2018;59:52-60. doi: 10.1016/j.cpr.2017.10.011
39. David D, Cristea I, Hofmann SG. Why cognitive behavioral therapy is the current gold standard of psychotherapy. Front Psychiatry. 2018;9:4. doi: 10.3389/fpsyt.2018.00004
40. Fendel JC, Bürkle JJ, Göritz AS. Mindfulness-based interventions to reduce burnout and stress in physicians: a systematic review and meta-analysis. Acad Med. 2021;96:751-764. doi: 10.1097/ACM.0000000000003936
41. Dahl CJ, Wilson-Mendenhall CD, Davidson RJ. The plasticity of well-being: a training-based framework for the cultivation of human flourishing. Proc Natl Acad Sci USA. 2020;117:32197-32206. doi: 10.1073/pnas.2014859117
42. Holt-Lunstad J. Why social relationships are important for physical health: a systems approach to understanding and modifying risk and protection. Annu Rev Psychol. 2018;69:437-458. doi: 10.1146/annurev-psych-122216-011902
43. Desai SV, Asch DA, Bellini LM, et al. Education outcomes in a duty-hour flexibility trial in internal medicine. N Engl J Med. 2018; 378:1494-1508. doi: 10.1056/NEJMoa1800965
44. Shea JA, Bellini LM, Dinges DF, et al. Impact of protected sleep period for internal medicine interns on overnight call on depression, burnout, and empathy. J Grad Med Educ. 2014;6:256-263. doi: 10.4300/JGME-D-13-00241.1
45. Morrow G, Burford B, Carter M, et al. Have restricted working hours reduced junior doctors’ experience of fatigue? A focus group and telephone interview study. BMJ Open. 2014;4:e004222. doi: 10.1136/bmjopen-2013-004222
46. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92:129-146. doi: 10.1016/j.mayocp.2016.10.004
47. Sequeira L, Almilaji K, Strudwick G, et al. EHR “SWAT” teams: a physician engagement initiative to improve Electronic Health Record (EHR) experiences and mitigate possible causes of EHR-related burnout. JAMA Open. 2021;4:1-7. doi: 10.1093/jamiaopen/ooab018
48. Smith PC, Lyon C, English AF, et al. Practice transformation under the University of Colorado’s primary care redesign model. Ann Fam Med. 2019;17:S24-S32. doi: 10.1370/afm.2424
PRACTICE RECOMMENDATIONS
› Serve as a leader and positively influence the systems (ie, organizations, institutions, offices) in which you practice as a way to address organizational stress. C
› Establish and maintain positive, supportive, and close relationships with friends, family, and colleagues to improve social wellness. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
