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Trans youth in sports
Over the last several years, the United States has seen a substantial increase in proposed legislation directed toward transgender individuals, particularly youth.1 One type of this legislation aims to prevent participation of transgender girls on female sports teams. While at first glance these bills may seem like common sense protections, in reality they are based on little evidence and serve to further marginalize an already-vulnerable population.
The majority of the population, and thus the majority of athletes, are cisgender.2 According a limited data set from the 2017 Youth Risk Behavior Survey, only 1.8% of high school students identify as transgender.3,4 Overall, this is a very small percentage and it is unlikely that all of them, or even a majority, participate in athletics. In fact, many transgender individuals avoid athletics as it worsens their dysphoria. Winners are no more likely to be transgender than cisgender.
While proponents of this legislation say that trans women have an unfair advantage because of elevated testosterone levels (and thus theoretically increased muscle mass), there is no clear relationship between higher testosterone levels in athletes and improved athletic performance.2 In fact, there are plenty of sports in which a smaller physique may be beneficial, such as gymnastics. A systematic review showed “no direct or consistent research suggesting transgender female individuals ... have an athletic advantage at any stage of their transition.”5 Furthermore, trans women are not the only women with elevated testosterone levels. Many cisgender women who have polycystic ovary syndrome or a disorder of sexual differentiation can have higher levels of testosterone and theoretically may have higher muscle mass. Who is to decide which team would be most appropriate for them? Is the plan to require a karyotype, other genetic testing, or an invasive physical exam for every young athlete? Even if the concern is with regards to testosterone levels and muscle mass, this ignores that fact that appropriate medical intervention for transgender adolescents will alter these attributes. If a transgender girl began gonadotropin-releasing hormone agonists early in puberty, she is unlikely to have increased muscle mass or a higher testosterone level than a cisgender girl. Those trans girls who take estradiol also experience a decrease in muscle mass. Additionally, adolescents grow and develop at different rates – surely there is already significant variability among hormone levels, muscle mass, sexual maturity ratings, and ability among individual athletes, regardless of gender identity? The argument that trans women should be excluded based on a theoretical genetic advantage is reminiscent of the argument that Black athletes should be excluded because of genetic advantage. Just as with cisgender athletes, transgender athletes will naturally vary in ability.6
In addition, there are many places and organizations that already have trans-inclusive policies in place for sports, yet we have not seen transgender individuals dominate their peers. In the 8 years since implementation of a trans-inclusive sports policy in California, a trans woman has never dominated a sport.7 The same is true for Canada since the institution of their policy 2 years ago. While transgender people can participate in the Olympics, this year marks the first time a trans woman has ever qualified (Laurel Hubbard, New Zealand, women’s weightlifting). The lack of transgender Olympians may be in part because of problematic requirements (such as duration of hormone therapy and surgery requirements) for transgender individuals, which may be so onerous that they are functionally excluded.2,5
In reality, athletes are improving over time and the performance gap between genders is shrinking. For example, in 1970 Mark Spitz swam the 100-meter freestyle in 51.94 seconds, a time that has now been surpassed by both men and women, such as Sarah Sjöström (women’s world record holder at 51.71 seconds). Athletes’ physical attributes are often less important than their training and dedication to their sport.
More importantly, this discussion raises the philosophical question of the purpose of athletics for youth and young adults. Winning and good performance can – though rarely – lead to college scholarships and professional careers, the biggest benefit of athletics comes from participation. We encourage youth to play sports not to win, but to learn about leadership, dedication, and collegiality, as well as for the health benefits of exercise. Inclusion in sports and other extracurricular activities improves depression, anxiety, and suicide rates. In fact, participation in sports has been associated with improved grades, greater homework completion, higher educational and occupational aspirations, and improved self-esteem.8-12 Excluding a population that already experiences such drastic marginalization will cause more damage. Values of nondiscrimination and inclusion should be promoted among all student athletes, rather than “other-ism.”
Forcing trans women to compete with men will worsen their dysphoria and further ostracize the most vulnerable, giving credence to those that believe they are not “real women.” Allowing transgender individuals to play on the team consistent with their gender identity is appropriate, not only for scientific reasons but also for humanitarian ones. Such laws are based not on evidence, but on discrimination. Not only do trans women not do better than cisgender women in sports, but such proposed legislation also ignores the normal variability among individuals as well as the intense training and dedication involved in becoming a top athlete. Limiting trans women’s participation in sports does not raise up cisgender women, but rather brings us all down. Please advocate for your patients to participate in athletics in accordance with their gender identity to promote both their physical and emotional well-being.
Dr. Lawlis is assistant professor of pediatrics at the University of Oklahoma Health Sciences Center, Oklahoma City, and an adolescent medicine specialist at OU Children’s. She has no relevant financial disclosures.
References
1. Cooper MB. Pediatric News. 2020 Dec 11, 2020.
2. Turban J. Scientific American. 2021 May 21.
3. Redfield RR et al. Morbid Mortal Wkly Rep. 2018;67(8):1-11.
4. Johns MM et al. Morbid Mortal Wkly Rep. 2019;68(3):67-71.
5. Jones BA et al. Sports Med (Auckland, New Zealand). 2017;47(4):701-16.
6. Strangio C et al. ACLU News. 2020 Apr 30.
7. Strauss L. USA Today. 2021 Apr 9.
8. Darling N et al. J Leisure Res. 2005;37(1):51-76.
9. Fredricks JA et al. Dev Psych. 2006;42(4):698-713.
10. Marsh HW et al. J Sport Exerc Psychol. 2003;25(2):205.
11. Nelson MC et al. Pediatrics. 2006;117(4):1281-90.
12. Ortega FB et al. Int J Obes. 2008;32(1):1-11.
Over the last several years, the United States has seen a substantial increase in proposed legislation directed toward transgender individuals, particularly youth.1 One type of this legislation aims to prevent participation of transgender girls on female sports teams. While at first glance these bills may seem like common sense protections, in reality they are based on little evidence and serve to further marginalize an already-vulnerable population.
The majority of the population, and thus the majority of athletes, are cisgender.2 According a limited data set from the 2017 Youth Risk Behavior Survey, only 1.8% of high school students identify as transgender.3,4 Overall, this is a very small percentage and it is unlikely that all of them, or even a majority, participate in athletics. In fact, many transgender individuals avoid athletics as it worsens their dysphoria. Winners are no more likely to be transgender than cisgender.
While proponents of this legislation say that trans women have an unfair advantage because of elevated testosterone levels (and thus theoretically increased muscle mass), there is no clear relationship between higher testosterone levels in athletes and improved athletic performance.2 In fact, there are plenty of sports in which a smaller physique may be beneficial, such as gymnastics. A systematic review showed “no direct or consistent research suggesting transgender female individuals ... have an athletic advantage at any stage of their transition.”5 Furthermore, trans women are not the only women with elevated testosterone levels. Many cisgender women who have polycystic ovary syndrome or a disorder of sexual differentiation can have higher levels of testosterone and theoretically may have higher muscle mass. Who is to decide which team would be most appropriate for them? Is the plan to require a karyotype, other genetic testing, or an invasive physical exam for every young athlete? Even if the concern is with regards to testosterone levels and muscle mass, this ignores that fact that appropriate medical intervention for transgender adolescents will alter these attributes. If a transgender girl began gonadotropin-releasing hormone agonists early in puberty, she is unlikely to have increased muscle mass or a higher testosterone level than a cisgender girl. Those trans girls who take estradiol also experience a decrease in muscle mass. Additionally, adolescents grow and develop at different rates – surely there is already significant variability among hormone levels, muscle mass, sexual maturity ratings, and ability among individual athletes, regardless of gender identity? The argument that trans women should be excluded based on a theoretical genetic advantage is reminiscent of the argument that Black athletes should be excluded because of genetic advantage. Just as with cisgender athletes, transgender athletes will naturally vary in ability.6
In addition, there are many places and organizations that already have trans-inclusive policies in place for sports, yet we have not seen transgender individuals dominate their peers. In the 8 years since implementation of a trans-inclusive sports policy in California, a trans woman has never dominated a sport.7 The same is true for Canada since the institution of their policy 2 years ago. While transgender people can participate in the Olympics, this year marks the first time a trans woman has ever qualified (Laurel Hubbard, New Zealand, women’s weightlifting). The lack of transgender Olympians may be in part because of problematic requirements (such as duration of hormone therapy and surgery requirements) for transgender individuals, which may be so onerous that they are functionally excluded.2,5
In reality, athletes are improving over time and the performance gap between genders is shrinking. For example, in 1970 Mark Spitz swam the 100-meter freestyle in 51.94 seconds, a time that has now been surpassed by both men and women, such as Sarah Sjöström (women’s world record holder at 51.71 seconds). Athletes’ physical attributes are often less important than their training and dedication to their sport.
More importantly, this discussion raises the philosophical question of the purpose of athletics for youth and young adults. Winning and good performance can – though rarely – lead to college scholarships and professional careers, the biggest benefit of athletics comes from participation. We encourage youth to play sports not to win, but to learn about leadership, dedication, and collegiality, as well as for the health benefits of exercise. Inclusion in sports and other extracurricular activities improves depression, anxiety, and suicide rates. In fact, participation in sports has been associated with improved grades, greater homework completion, higher educational and occupational aspirations, and improved self-esteem.8-12 Excluding a population that already experiences such drastic marginalization will cause more damage. Values of nondiscrimination and inclusion should be promoted among all student athletes, rather than “other-ism.”
Forcing trans women to compete with men will worsen their dysphoria and further ostracize the most vulnerable, giving credence to those that believe they are not “real women.” Allowing transgender individuals to play on the team consistent with their gender identity is appropriate, not only for scientific reasons but also for humanitarian ones. Such laws are based not on evidence, but on discrimination. Not only do trans women not do better than cisgender women in sports, but such proposed legislation also ignores the normal variability among individuals as well as the intense training and dedication involved in becoming a top athlete. Limiting trans women’s participation in sports does not raise up cisgender women, but rather brings us all down. Please advocate for your patients to participate in athletics in accordance with their gender identity to promote both their physical and emotional well-being.
Dr. Lawlis is assistant professor of pediatrics at the University of Oklahoma Health Sciences Center, Oklahoma City, and an adolescent medicine specialist at OU Children’s. She has no relevant financial disclosures.
References
1. Cooper MB. Pediatric News. 2020 Dec 11, 2020.
2. Turban J. Scientific American. 2021 May 21.
3. Redfield RR et al. Morbid Mortal Wkly Rep. 2018;67(8):1-11.
4. Johns MM et al. Morbid Mortal Wkly Rep. 2019;68(3):67-71.
5. Jones BA et al. Sports Med (Auckland, New Zealand). 2017;47(4):701-16.
6. Strangio C et al. ACLU News. 2020 Apr 30.
7. Strauss L. USA Today. 2021 Apr 9.
8. Darling N et al. J Leisure Res. 2005;37(1):51-76.
9. Fredricks JA et al. Dev Psych. 2006;42(4):698-713.
10. Marsh HW et al. J Sport Exerc Psychol. 2003;25(2):205.
11. Nelson MC et al. Pediatrics. 2006;117(4):1281-90.
12. Ortega FB et al. Int J Obes. 2008;32(1):1-11.
Over the last several years, the United States has seen a substantial increase in proposed legislation directed toward transgender individuals, particularly youth.1 One type of this legislation aims to prevent participation of transgender girls on female sports teams. While at first glance these bills may seem like common sense protections, in reality they are based on little evidence and serve to further marginalize an already-vulnerable population.
The majority of the population, and thus the majority of athletes, are cisgender.2 According a limited data set from the 2017 Youth Risk Behavior Survey, only 1.8% of high school students identify as transgender.3,4 Overall, this is a very small percentage and it is unlikely that all of them, or even a majority, participate in athletics. In fact, many transgender individuals avoid athletics as it worsens their dysphoria. Winners are no more likely to be transgender than cisgender.
While proponents of this legislation say that trans women have an unfair advantage because of elevated testosterone levels (and thus theoretically increased muscle mass), there is no clear relationship between higher testosterone levels in athletes and improved athletic performance.2 In fact, there are plenty of sports in which a smaller physique may be beneficial, such as gymnastics. A systematic review showed “no direct or consistent research suggesting transgender female individuals ... have an athletic advantage at any stage of their transition.”5 Furthermore, trans women are not the only women with elevated testosterone levels. Many cisgender women who have polycystic ovary syndrome or a disorder of sexual differentiation can have higher levels of testosterone and theoretically may have higher muscle mass. Who is to decide which team would be most appropriate for them? Is the plan to require a karyotype, other genetic testing, or an invasive physical exam for every young athlete? Even if the concern is with regards to testosterone levels and muscle mass, this ignores that fact that appropriate medical intervention for transgender adolescents will alter these attributes. If a transgender girl began gonadotropin-releasing hormone agonists early in puberty, she is unlikely to have increased muscle mass or a higher testosterone level than a cisgender girl. Those trans girls who take estradiol also experience a decrease in muscle mass. Additionally, adolescents grow and develop at different rates – surely there is already significant variability among hormone levels, muscle mass, sexual maturity ratings, and ability among individual athletes, regardless of gender identity? The argument that trans women should be excluded based on a theoretical genetic advantage is reminiscent of the argument that Black athletes should be excluded because of genetic advantage. Just as with cisgender athletes, transgender athletes will naturally vary in ability.6
In addition, there are many places and organizations that already have trans-inclusive policies in place for sports, yet we have not seen transgender individuals dominate their peers. In the 8 years since implementation of a trans-inclusive sports policy in California, a trans woman has never dominated a sport.7 The same is true for Canada since the institution of their policy 2 years ago. While transgender people can participate in the Olympics, this year marks the first time a trans woman has ever qualified (Laurel Hubbard, New Zealand, women’s weightlifting). The lack of transgender Olympians may be in part because of problematic requirements (such as duration of hormone therapy and surgery requirements) for transgender individuals, which may be so onerous that they are functionally excluded.2,5
In reality, athletes are improving over time and the performance gap between genders is shrinking. For example, in 1970 Mark Spitz swam the 100-meter freestyle in 51.94 seconds, a time that has now been surpassed by both men and women, such as Sarah Sjöström (women’s world record holder at 51.71 seconds). Athletes’ physical attributes are often less important than their training and dedication to their sport.
More importantly, this discussion raises the philosophical question of the purpose of athletics for youth and young adults. Winning and good performance can – though rarely – lead to college scholarships and professional careers, the biggest benefit of athletics comes from participation. We encourage youth to play sports not to win, but to learn about leadership, dedication, and collegiality, as well as for the health benefits of exercise. Inclusion in sports and other extracurricular activities improves depression, anxiety, and suicide rates. In fact, participation in sports has been associated with improved grades, greater homework completion, higher educational and occupational aspirations, and improved self-esteem.8-12 Excluding a population that already experiences such drastic marginalization will cause more damage. Values of nondiscrimination and inclusion should be promoted among all student athletes, rather than “other-ism.”
Forcing trans women to compete with men will worsen their dysphoria and further ostracize the most vulnerable, giving credence to those that believe they are not “real women.” Allowing transgender individuals to play on the team consistent with their gender identity is appropriate, not only for scientific reasons but also for humanitarian ones. Such laws are based not on evidence, but on discrimination. Not only do trans women not do better than cisgender women in sports, but such proposed legislation also ignores the normal variability among individuals as well as the intense training and dedication involved in becoming a top athlete. Limiting trans women’s participation in sports does not raise up cisgender women, but rather brings us all down. Please advocate for your patients to participate in athletics in accordance with their gender identity to promote both their physical and emotional well-being.
Dr. Lawlis is assistant professor of pediatrics at the University of Oklahoma Health Sciences Center, Oklahoma City, and an adolescent medicine specialist at OU Children’s. She has no relevant financial disclosures.
References
1. Cooper MB. Pediatric News. 2020 Dec 11, 2020.
2. Turban J. Scientific American. 2021 May 21.
3. Redfield RR et al. Morbid Mortal Wkly Rep. 2018;67(8):1-11.
4. Johns MM et al. Morbid Mortal Wkly Rep. 2019;68(3):67-71.
5. Jones BA et al. Sports Med (Auckland, New Zealand). 2017;47(4):701-16.
6. Strangio C et al. ACLU News. 2020 Apr 30.
7. Strauss L. USA Today. 2021 Apr 9.
8. Darling N et al. J Leisure Res. 2005;37(1):51-76.
9. Fredricks JA et al. Dev Psych. 2006;42(4):698-713.
10. Marsh HW et al. J Sport Exerc Psychol. 2003;25(2):205.
11. Nelson MC et al. Pediatrics. 2006;117(4):1281-90.
12. Ortega FB et al. Int J Obes. 2008;32(1):1-11.
Does optimal iron absorption include vitamin C?
Her blood work shows a hematocrit level of 32, a mean corpuscular volume of 77, a platelet count of 390,000, and a ferritin level of 5.
What would you recommend for iron replacement?
A. FeSO4 325 mg three times a day with vitamin C
B. FeSO4 325 mg daily with vitamin C
C. FeSO4 325 mg every other day
Recommendations and supporting research
I think I would start with choice C, FeSO4 every other day.
Treatment of iron deficiency with oral iron has traditionally been done by giving 150-200 mg of elemental iron (which is equal to three 325 mg tablets of iron sulfate).1 This dosing regimen has considerable gastrointestinal side effects. Recent evidence has shown that iron absorption is diminished the more frequently it is given.
Stoffel and colleagues found that fractional iron absorption was higher in iron-deficient women who were given iron every other day, compared with those who received daily iron.2 They also found that the more frequently iron was administered, the higher the hepcidin levels were, and the lower the iron absorption.
Karacok and colleagues studied every other day iron versus daily iron for the treatment of iron-deficiency anemia of pregnancy.3 A total of 217 women completed randomization and participated in the study, with all women receiving 100 mg of elemental iron, either daily (111) or every other day (106). There was no significant difference in increase in ferritin levels, or hemoglobin increase between the groups. The daily iron group had more gastrointestinal symptoms (41.4%) than the every other day iron group (15.1%) (P < .0057).
Düzen Oflas and colleagues looked at the same question in nonpregnant women with iron deficiency anemia.4 Study patients either received 80 mg iron sulfate twice a day, 80 mg once a day, or 80 mg every other day. There was no statistically significant difference in hemoglobin improvement between groups, but the group that received twice a day dosing of iron had statistically significantly higher ferritin levels than the daily or every other day iron groups. This improvement in ferritin levels came at a cost, though, as 68% of patients in the twice daily iron group had gastrointestinal symptoms, compared with only 10% in the every other day iron group (P < .01).
Vitamin C is often recommended to be taken with iron to promote absorption. The evidence for this practice is scant, and dates back almost 50 years.5,6
Cook and Reddy found there was no significant difference in mean iron absorption among the three dietary periods studied in 12 patients despite a range of mean daily intakes of dietary vitamin C of 51-247 mg/d.7
Hunt and colleagues studied 25 non pregnant, healthy women with low ferritin levels.8 The women’s meals were supplemented with vitamin C (500 mg, three times a day) for 5 of the 10 weeks, in a double-blind, crossover design. Vitamin C supplementation did not lead to a difference in iron absorption, lab indices of iron deficiency, or the biological half-life of iron.
Li and colleagues looked at the effect of vitamin C supplementation on iron levels in women with iron deficiency anemia.9 A total of 440 women were recruited, with 432 completing the trial. Women were randomized to receive iron supplements plus vitamin C or iron supplements only. Their findings were that oral iron supplements alone were equivalent to oral iron supplements plus vitamin C in improving hemoglobin recovery and iron absorption.
Bottom line
Less frequent administration of iron supplements (every other day) is as effective as more frequent administration, with less GI symptoms. Also, adding vitamin C does not appear to improve absorption of iron supplements.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at imnews@mdedge.com.
References
1. 1. Fairbanks VF and Beutler E. Iron deficiency, in “Williams Textbook of Hematology, 6th ed.” (New York: McGraw-Hill, 2001).
2. Stoffel N et al. Lancet Haematology. 2017;4: e524-33.
3. Karakoc G et al. J Matern Fetal Neonatal Med. 2021 Apr 18:1-5
4. Düzen Oflas N et al. Intern Med J. 2020 Jul;50(7):854-8
5. Cook JD and Monsen ER. Am J Clin Nutr. 1977;30:235-41.
6. Hallberg L etal. Hum Nutr Appl Nutr. 1986;40: 97-113.
7. Cook JD and Reddy M. Am J Clin Nutr. 2001;73:93-8.
8. Hunt JR et al. Am J Clin Nutr. 1994 Jun;59(6):1381-5.
9. Li N et al. JAMA Netw Open. 2020 Nov 2;3(11):e2023644.
Her blood work shows a hematocrit level of 32, a mean corpuscular volume of 77, a platelet count of 390,000, and a ferritin level of 5.
What would you recommend for iron replacement?
A. FeSO4 325 mg three times a day with vitamin C
B. FeSO4 325 mg daily with vitamin C
C. FeSO4 325 mg every other day
Recommendations and supporting research
I think I would start with choice C, FeSO4 every other day.
Treatment of iron deficiency with oral iron has traditionally been done by giving 150-200 mg of elemental iron (which is equal to three 325 mg tablets of iron sulfate).1 This dosing regimen has considerable gastrointestinal side effects. Recent evidence has shown that iron absorption is diminished the more frequently it is given.
Stoffel and colleagues found that fractional iron absorption was higher in iron-deficient women who were given iron every other day, compared with those who received daily iron.2 They also found that the more frequently iron was administered, the higher the hepcidin levels were, and the lower the iron absorption.
Karacok and colleagues studied every other day iron versus daily iron for the treatment of iron-deficiency anemia of pregnancy.3 A total of 217 women completed randomization and participated in the study, with all women receiving 100 mg of elemental iron, either daily (111) or every other day (106). There was no significant difference in increase in ferritin levels, or hemoglobin increase between the groups. The daily iron group had more gastrointestinal symptoms (41.4%) than the every other day iron group (15.1%) (P < .0057).
Düzen Oflas and colleagues looked at the same question in nonpregnant women with iron deficiency anemia.4 Study patients either received 80 mg iron sulfate twice a day, 80 mg once a day, or 80 mg every other day. There was no statistically significant difference in hemoglobin improvement between groups, but the group that received twice a day dosing of iron had statistically significantly higher ferritin levels than the daily or every other day iron groups. This improvement in ferritin levels came at a cost, though, as 68% of patients in the twice daily iron group had gastrointestinal symptoms, compared with only 10% in the every other day iron group (P < .01).
Vitamin C is often recommended to be taken with iron to promote absorption. The evidence for this practice is scant, and dates back almost 50 years.5,6
Cook and Reddy found there was no significant difference in mean iron absorption among the three dietary periods studied in 12 patients despite a range of mean daily intakes of dietary vitamin C of 51-247 mg/d.7
Hunt and colleagues studied 25 non pregnant, healthy women with low ferritin levels.8 The women’s meals were supplemented with vitamin C (500 mg, three times a day) for 5 of the 10 weeks, in a double-blind, crossover design. Vitamin C supplementation did not lead to a difference in iron absorption, lab indices of iron deficiency, or the biological half-life of iron.
Li and colleagues looked at the effect of vitamin C supplementation on iron levels in women with iron deficiency anemia.9 A total of 440 women were recruited, with 432 completing the trial. Women were randomized to receive iron supplements plus vitamin C or iron supplements only. Their findings were that oral iron supplements alone were equivalent to oral iron supplements plus vitamin C in improving hemoglobin recovery and iron absorption.
Bottom line
Less frequent administration of iron supplements (every other day) is as effective as more frequent administration, with less GI symptoms. Also, adding vitamin C does not appear to improve absorption of iron supplements.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at imnews@mdedge.com.
References
1. 1. Fairbanks VF and Beutler E. Iron deficiency, in “Williams Textbook of Hematology, 6th ed.” (New York: McGraw-Hill, 2001).
2. Stoffel N et al. Lancet Haematology. 2017;4: e524-33.
3. Karakoc G et al. J Matern Fetal Neonatal Med. 2021 Apr 18:1-5
4. Düzen Oflas N et al. Intern Med J. 2020 Jul;50(7):854-8
5. Cook JD and Monsen ER. Am J Clin Nutr. 1977;30:235-41.
6. Hallberg L etal. Hum Nutr Appl Nutr. 1986;40: 97-113.
7. Cook JD and Reddy M. Am J Clin Nutr. 2001;73:93-8.
8. Hunt JR et al. Am J Clin Nutr. 1994 Jun;59(6):1381-5.
9. Li N et al. JAMA Netw Open. 2020 Nov 2;3(11):e2023644.
Her blood work shows a hematocrit level of 32, a mean corpuscular volume of 77, a platelet count of 390,000, and a ferritin level of 5.
What would you recommend for iron replacement?
A. FeSO4 325 mg three times a day with vitamin C
B. FeSO4 325 mg daily with vitamin C
C. FeSO4 325 mg every other day
Recommendations and supporting research
I think I would start with choice C, FeSO4 every other day.
Treatment of iron deficiency with oral iron has traditionally been done by giving 150-200 mg of elemental iron (which is equal to three 325 mg tablets of iron sulfate).1 This dosing regimen has considerable gastrointestinal side effects. Recent evidence has shown that iron absorption is diminished the more frequently it is given.
Stoffel and colleagues found that fractional iron absorption was higher in iron-deficient women who were given iron every other day, compared with those who received daily iron.2 They also found that the more frequently iron was administered, the higher the hepcidin levels were, and the lower the iron absorption.
Karacok and colleagues studied every other day iron versus daily iron for the treatment of iron-deficiency anemia of pregnancy.3 A total of 217 women completed randomization and participated in the study, with all women receiving 100 mg of elemental iron, either daily (111) or every other day (106). There was no significant difference in increase in ferritin levels, or hemoglobin increase between the groups. The daily iron group had more gastrointestinal symptoms (41.4%) than the every other day iron group (15.1%) (P < .0057).
Düzen Oflas and colleagues looked at the same question in nonpregnant women with iron deficiency anemia.4 Study patients either received 80 mg iron sulfate twice a day, 80 mg once a day, or 80 mg every other day. There was no statistically significant difference in hemoglobin improvement between groups, but the group that received twice a day dosing of iron had statistically significantly higher ferritin levels than the daily or every other day iron groups. This improvement in ferritin levels came at a cost, though, as 68% of patients in the twice daily iron group had gastrointestinal symptoms, compared with only 10% in the every other day iron group (P < .01).
Vitamin C is often recommended to be taken with iron to promote absorption. The evidence for this practice is scant, and dates back almost 50 years.5,6
Cook and Reddy found there was no significant difference in mean iron absorption among the three dietary periods studied in 12 patients despite a range of mean daily intakes of dietary vitamin C of 51-247 mg/d.7
Hunt and colleagues studied 25 non pregnant, healthy women with low ferritin levels.8 The women’s meals were supplemented with vitamin C (500 mg, three times a day) for 5 of the 10 weeks, in a double-blind, crossover design. Vitamin C supplementation did not lead to a difference in iron absorption, lab indices of iron deficiency, or the biological half-life of iron.
Li and colleagues looked at the effect of vitamin C supplementation on iron levels in women with iron deficiency anemia.9 A total of 440 women were recruited, with 432 completing the trial. Women were randomized to receive iron supplements plus vitamin C or iron supplements only. Their findings were that oral iron supplements alone were equivalent to oral iron supplements plus vitamin C in improving hemoglobin recovery and iron absorption.
Bottom line
Less frequent administration of iron supplements (every other day) is as effective as more frequent administration, with less GI symptoms. Also, adding vitamin C does not appear to improve absorption of iron supplements.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at imnews@mdedge.com.
References
1. 1. Fairbanks VF and Beutler E. Iron deficiency, in “Williams Textbook of Hematology, 6th ed.” (New York: McGraw-Hill, 2001).
2. Stoffel N et al. Lancet Haematology. 2017;4: e524-33.
3. Karakoc G et al. J Matern Fetal Neonatal Med. 2021 Apr 18:1-5
4. Düzen Oflas N et al. Intern Med J. 2020 Jul;50(7):854-8
5. Cook JD and Monsen ER. Am J Clin Nutr. 1977;30:235-41.
6. Hallberg L etal. Hum Nutr Appl Nutr. 1986;40: 97-113.
7. Cook JD and Reddy M. Am J Clin Nutr. 2001;73:93-8.
8. Hunt JR et al. Am J Clin Nutr. 1994 Jun;59(6):1381-5.
9. Li N et al. JAMA Netw Open. 2020 Nov 2;3(11):e2023644.
Rising rates of T1D in children: Is COVID to blame?
In early 2020, the COVID-19 pandemic changed everything about life as we know it, with widespread shutdowns across the globe. The U.S. health care system quickly adapted, pivoting to telehealth visits when able and proactively managing outpatient conditions to prevent overwhelming hospital resources and utilization. Meanwhile, at my practice, the typical rate of about one new-onset pediatric type 1 diabetes (T1D) case per week increased to about two per week.
However, the new diabetes cases continued to accumulate, and I saw more patients being diagnosed who did not have a known family history of autoimmunity. I began to ask friends at other centers whether they were noticing the same trend.
One colleague documented a 36% increase in her large center compared with the previous year. Another noted a 40% rise at his children’s hospital. We observed that there was often a respiratory illness reported several weeks before presenting with T1D. Sometimes the child was known to be COVID-positive. Sometimes the child had not been tested. Sometimes we suspected that COVID had been a preceding illness and then found negative SARS-CoV-2 antibodies – but we were not certain whether the result was meaningful given the time lapsed since infection.
Soon, reports emerged of large increases in severe diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state at initial presentation, a trend reported in other countries.
Is COVID-19 a trigger for T1D?
There is known precedent for increased risk for T1D after viral infections in patients who are already genetically susceptible. Mechanisms of immune-mediated islet cell failure would make sense following SARS-CoV-2 infection; direct islet toxicity was noted with SARS-CoV-1 and has been suspected with SARS-CoV-2 but not proven. Some have suggested that hypercoagulability with COVID-19 may lead to ischemic damage to the pancreas.
With multiple potential pathways for islet damage, increases in insulin-dependent diabetes would logically follow. Still, whether this is the case remains unclear. There is not yet definitive evidence that there is uptake of SARS-CoV-2 via receptors in the pancreatic beta cells.
Our current understanding of T1D pathogenesis is that susceptible individuals develop autoimmunity in response to an environmental trigger, with beta-cell failure developing over months to years. Perhaps vulnerable patients with genetic risk for pancreatic autoimmunity were stressed by SARS-CoV-2 infection and were diagnosed earlier than they might have been, showing some lead-time bias. Adult patients with COVID-19 demonstrated hyperglycemia that has been reversible in some cases, like the stress hyperglycemia seen with other infections and surgery in response to proinflammatory states.
The true question seems to be whether there is a unique type of diabetes related to direct viral toxicity. Do newly diagnosed patients have measurable traditional antibodies, like anti-glutamic acid decarboxylase or anti-islet cell antibodies? Is there proof of preceding SARS-CoV-2 infection? In the new cases that I thought were unusual at first glance, I found typical pancreatic autoimmunity and negative SARS-CoV-2 antibodies. The small cohorts reported thus far have had similar findings.
A stronger case can be made for the risk of developing diabetes (types 1 and 2) with rapid weight gain. Another marked pattern that pediatric endocrinologists have observed has been increased weight gain in children with closed schools, decreased activity, and more social isolation. I have seen weight change as great as 100 lb in a teen over the past year; 30- to 50-lb weight increases over the course of the pandemic have been common. Considering the “accelerator hypothesis” of faster onset of type 2 diabetes with rapid weight gain, implications for hastening of T1D with weight gain have also been considered. The full impact of these dramatic weight changes will take time to understand.
The true story may not emerge for years
Anecdotes and theoretical concerns may give us pause, but they are far from scientific truth. Efforts are underway to explore this perceived trend with international registries, including the CoviDIAB Registry as well as T1D Exchange. The true story may not emerge until years have passed to see the cumulative fallout of COVID-19. Regardless, these troubling observations should be considered as pandemic safeguards continue to loosen.
While pediatric mortality from COVID-19 has been relatively low (though sadly not zero), some have placed too little focus on possible morbidity. Long-term effects like long COVID and neuropsychiatric sequelae are becoming evident in all populations, including children. If a lifelong illness like diabetes can be directly linked to COVID-19, protecting children from infection with measures like masks becomes all the more crucial until vaccines are more readily available. Despite our rapid progress with understanding COVID-19 disease, there is still much left to learn.
A version of this article first appeared on Medscape.com.
In early 2020, the COVID-19 pandemic changed everything about life as we know it, with widespread shutdowns across the globe. The U.S. health care system quickly adapted, pivoting to telehealth visits when able and proactively managing outpatient conditions to prevent overwhelming hospital resources and utilization. Meanwhile, at my practice, the typical rate of about one new-onset pediatric type 1 diabetes (T1D) case per week increased to about two per week.
However, the new diabetes cases continued to accumulate, and I saw more patients being diagnosed who did not have a known family history of autoimmunity. I began to ask friends at other centers whether they were noticing the same trend.
One colleague documented a 36% increase in her large center compared with the previous year. Another noted a 40% rise at his children’s hospital. We observed that there was often a respiratory illness reported several weeks before presenting with T1D. Sometimes the child was known to be COVID-positive. Sometimes the child had not been tested. Sometimes we suspected that COVID had been a preceding illness and then found negative SARS-CoV-2 antibodies – but we were not certain whether the result was meaningful given the time lapsed since infection.
Soon, reports emerged of large increases in severe diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state at initial presentation, a trend reported in other countries.
Is COVID-19 a trigger for T1D?
There is known precedent for increased risk for T1D after viral infections in patients who are already genetically susceptible. Mechanisms of immune-mediated islet cell failure would make sense following SARS-CoV-2 infection; direct islet toxicity was noted with SARS-CoV-1 and has been suspected with SARS-CoV-2 but not proven. Some have suggested that hypercoagulability with COVID-19 may lead to ischemic damage to the pancreas.
With multiple potential pathways for islet damage, increases in insulin-dependent diabetes would logically follow. Still, whether this is the case remains unclear. There is not yet definitive evidence that there is uptake of SARS-CoV-2 via receptors in the pancreatic beta cells.
Our current understanding of T1D pathogenesis is that susceptible individuals develop autoimmunity in response to an environmental trigger, with beta-cell failure developing over months to years. Perhaps vulnerable patients with genetic risk for pancreatic autoimmunity were stressed by SARS-CoV-2 infection and were diagnosed earlier than they might have been, showing some lead-time bias. Adult patients with COVID-19 demonstrated hyperglycemia that has been reversible in some cases, like the stress hyperglycemia seen with other infections and surgery in response to proinflammatory states.
The true question seems to be whether there is a unique type of diabetes related to direct viral toxicity. Do newly diagnosed patients have measurable traditional antibodies, like anti-glutamic acid decarboxylase or anti-islet cell antibodies? Is there proof of preceding SARS-CoV-2 infection? In the new cases that I thought were unusual at first glance, I found typical pancreatic autoimmunity and negative SARS-CoV-2 antibodies. The small cohorts reported thus far have had similar findings.
A stronger case can be made for the risk of developing diabetes (types 1 and 2) with rapid weight gain. Another marked pattern that pediatric endocrinologists have observed has been increased weight gain in children with closed schools, decreased activity, and more social isolation. I have seen weight change as great as 100 lb in a teen over the past year; 30- to 50-lb weight increases over the course of the pandemic have been common. Considering the “accelerator hypothesis” of faster onset of type 2 diabetes with rapid weight gain, implications for hastening of T1D with weight gain have also been considered. The full impact of these dramatic weight changes will take time to understand.
The true story may not emerge for years
Anecdotes and theoretical concerns may give us pause, but they are far from scientific truth. Efforts are underway to explore this perceived trend with international registries, including the CoviDIAB Registry as well as T1D Exchange. The true story may not emerge until years have passed to see the cumulative fallout of COVID-19. Regardless, these troubling observations should be considered as pandemic safeguards continue to loosen.
While pediatric mortality from COVID-19 has been relatively low (though sadly not zero), some have placed too little focus on possible morbidity. Long-term effects like long COVID and neuropsychiatric sequelae are becoming evident in all populations, including children. If a lifelong illness like diabetes can be directly linked to COVID-19, protecting children from infection with measures like masks becomes all the more crucial until vaccines are more readily available. Despite our rapid progress with understanding COVID-19 disease, there is still much left to learn.
A version of this article first appeared on Medscape.com.
In early 2020, the COVID-19 pandemic changed everything about life as we know it, with widespread shutdowns across the globe. The U.S. health care system quickly adapted, pivoting to telehealth visits when able and proactively managing outpatient conditions to prevent overwhelming hospital resources and utilization. Meanwhile, at my practice, the typical rate of about one new-onset pediatric type 1 diabetes (T1D) case per week increased to about two per week.
However, the new diabetes cases continued to accumulate, and I saw more patients being diagnosed who did not have a known family history of autoimmunity. I began to ask friends at other centers whether they were noticing the same trend.
One colleague documented a 36% increase in her large center compared with the previous year. Another noted a 40% rise at his children’s hospital. We observed that there was often a respiratory illness reported several weeks before presenting with T1D. Sometimes the child was known to be COVID-positive. Sometimes the child had not been tested. Sometimes we suspected that COVID had been a preceding illness and then found negative SARS-CoV-2 antibodies – but we were not certain whether the result was meaningful given the time lapsed since infection.
Soon, reports emerged of large increases in severe diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state at initial presentation, a trend reported in other countries.
Is COVID-19 a trigger for T1D?
There is known precedent for increased risk for T1D after viral infections in patients who are already genetically susceptible. Mechanisms of immune-mediated islet cell failure would make sense following SARS-CoV-2 infection; direct islet toxicity was noted with SARS-CoV-1 and has been suspected with SARS-CoV-2 but not proven. Some have suggested that hypercoagulability with COVID-19 may lead to ischemic damage to the pancreas.
With multiple potential pathways for islet damage, increases in insulin-dependent diabetes would logically follow. Still, whether this is the case remains unclear. There is not yet definitive evidence that there is uptake of SARS-CoV-2 via receptors in the pancreatic beta cells.
Our current understanding of T1D pathogenesis is that susceptible individuals develop autoimmunity in response to an environmental trigger, with beta-cell failure developing over months to years. Perhaps vulnerable patients with genetic risk for pancreatic autoimmunity were stressed by SARS-CoV-2 infection and were diagnosed earlier than they might have been, showing some lead-time bias. Adult patients with COVID-19 demonstrated hyperglycemia that has been reversible in some cases, like the stress hyperglycemia seen with other infections and surgery in response to proinflammatory states.
The true question seems to be whether there is a unique type of diabetes related to direct viral toxicity. Do newly diagnosed patients have measurable traditional antibodies, like anti-glutamic acid decarboxylase or anti-islet cell antibodies? Is there proof of preceding SARS-CoV-2 infection? In the new cases that I thought were unusual at first glance, I found typical pancreatic autoimmunity and negative SARS-CoV-2 antibodies. The small cohorts reported thus far have had similar findings.
A stronger case can be made for the risk of developing diabetes (types 1 and 2) with rapid weight gain. Another marked pattern that pediatric endocrinologists have observed has been increased weight gain in children with closed schools, decreased activity, and more social isolation. I have seen weight change as great as 100 lb in a teen over the past year; 30- to 50-lb weight increases over the course of the pandemic have been common. Considering the “accelerator hypothesis” of faster onset of type 2 diabetes with rapid weight gain, implications for hastening of T1D with weight gain have also been considered. The full impact of these dramatic weight changes will take time to understand.
The true story may not emerge for years
Anecdotes and theoretical concerns may give us pause, but they are far from scientific truth. Efforts are underway to explore this perceived trend with international registries, including the CoviDIAB Registry as well as T1D Exchange. The true story may not emerge until years have passed to see the cumulative fallout of COVID-19. Regardless, these troubling observations should be considered as pandemic safeguards continue to loosen.
While pediatric mortality from COVID-19 has been relatively low (though sadly not zero), some have placed too little focus on possible morbidity. Long-term effects like long COVID and neuropsychiatric sequelae are becoming evident in all populations, including children. If a lifelong illness like diabetes can be directly linked to COVID-19, protecting children from infection with measures like masks becomes all the more crucial until vaccines are more readily available. Despite our rapid progress with understanding COVID-19 disease, there is still much left to learn.
A version of this article first appeared on Medscape.com.
The Peer Review Process During the COVID-19 Pandemic
The COVID-19 pandemic put unparalleled strain on US health care systems and individual health care providers (HCPs), which has been well documented. Like all other medical peer reviewed journals, Federal Practitioner relies heavily on the generosity and dedication of federal HCPs. As the pandemic unfolded, we questioned whether HCPs would have the time and energy to write new articles, complete research projects, and review the work of their peers. To assess the impact of COVID-19 on the journal, we compared data from a full year during the COVID-19 pandemic with that of the previous year to determine whether and how the pandemic reshaped the peer review and publication process.
For the purposes of this review, we will compare a full year of COVID-19 journal performance with the prior year. Since COVID-19 infections spiked at different times in different places, there is no clear starting point for the pandemic. Similarly, states varied widely in their vaccination rates and opening procedures. Nevertheless, the period from May 1, 2020 to April 30, 2021, most of the country experienced COVID-19 restrictions, and the number of cases rose dramatically.
From May 1, 2020 to April 30, 2021, Federal Practitioner received 208 submissions, 110% increase over the previous year (189 submissions from May 1, 2019 to April 30, 2020) and a 28% increase over a 2-year period. After submission, it took an average of 9.0 days to the first reviewer invitation compared with 10.3 days in the previous year and 4.7 days 2 years prior. Time from the initial submission to the first decision (ie, accept, reject, or revise) took 72.8 days in the COVID-19 year compared with 91.1 days in the previous year and 69.6 days 2 years prior. In both periods it took reviewers a mean 9.5 days to complete a review from the date invited, and the rate of late reviews was unchanged as well.
During the COVID-19 pandemic year, 1481 reviewer invitations were sent to potential reviewers and 498 reviews were completed (33.6%) by 195 individual reviewers: an average of 2.4 reviews per manuscript. Most reviewers recommended to accept the manuscript, and just 14.7% of reviewers recommended to reject the manuscript (Table). The previous year 1295 invitations were sent to potential reviewers and 460 reviews were completed (38.1%) by 181 individual reviewers for an average of 2.4 reviews per manuscript.
For the original submissions, the journal accepted just 26 (12.7%) articles, recommended revisions for 105 (51.2%) submissions, and rejected 74 (36.1%) submissions from May 1, 2020 to April 30, 3021. One hundred seven manuscripts were revised once, and 75.7% were accepted, and 2.8% were rejected. Twenty-two articles had a second revision and 1 had a third revision and all were published. In the year before the pandemic, just 16 (9.5%) manuscripts were accepted in their original form and 59 (39.1%) were rejected.
Federal Practitioner published 113 articles from May 2020 to April 2021. These articles included 44 (38.9%) original studies, 25 (22.1%) case studies, 20 (17.7%) program profiles, 16 (14.2%) commentaries/editorials, and 8 (7.1%) review articles; 19 (16.8%) articles were focused on COVID-19. The prior year saw Federal Practitioner publish 106 articles in 18 issues. Of these articles 36.8% were original studies, 22.6% were program profiles, 18.9% were case studies, 13.2% were commentaries/editorials, and 8.5% were review articles.
Despite the impact of COVID-19, federal HCPs continued to contribute to this journal without significant interruption. The journal saw a 10% increase in submissions during the pandemic year compared with the previous year but that was in keeping with prior increases in submissions. Similarly, the journal saw more individual reviewers submit more total reviews from May 2020 to April 2021 compared with the previous year. The broad spectrum of reviewers involved in the process and the growing volume of both reviews and submissions suggest that our reviewers remained available and committed to the peer review process despite the impact of a pandemic.
Reducing the time to first decision remains an important priority for the journal. Although the time was shortened during the pandemic, it still took longer to inform authors of the first decision compared with 2 years before. There is no indication that COVID-19 had an impact on the speed of decision making. Reviewers were as timely during the pandemic as they were the year before.
Similarly, there was little difference in the types of articles that were published, other than the obvious increase in COVID-19 submissions. Most of the articles on COVID-19 were editorials and columns, though the journal also published case studies, program profiles, and review articles on treatment. During the pandemic, a higher percentage of articles were original studies and case reports, and fewer were program profiles compared with the types the year before. It is unclear if these differences resulted from random fluctuations in unsolicited manuscripts or are part of a larger trend. The journal managed to publish slightly more articles from May 2020 to April 2021 compared with May 2019 to April 2020 despite fewer issues. This is likely due to increased submissions and articles published online.
For the original submissions, the journal accepted just 26 (12.7%) articles, recommended revisions for 105 (51.2%) submissions and rejected 74 (36.1%) submissions from May 2020 to April 3021. One hundred seven manuscripts were revised once and 75.7% were accepted and 2.8% were rejected. Twenty-two articles had a second revision and 1 had a third revision and all were published. In the year prior to the pandemic, just 16 (9.5%) manuscripts were accepted in their original form, and 59 (39.1%) were rejected.
Although Federal Practitioner improved the efficiency of its decision making, there is still significant room for improvement. We are committed to providing our authors with more rapid decisions and reducing the time to the first decision. Seventy-two days is still too long for authors to wait to hear about the initial decision on their article. Future reviews of the publication process should focus not only on the types of articles that are included, but their subjects as well. Given the great diversity of clinical care practiced across the US Department of Veterans Affairs, US Department of Defense, and the US Public Health Service, the journal must ensure that its articles reflect its diverse audience. We would like to see articles come from authors associated with all 3 major branches of our audience, as well as small portions of the readership (eg, Federal Bureau of Prisons, National Institutes of Health) and ask our readers to help us promote the journal to potential authors in all Federal Health Care organizations. We are especially interested in submissions on or from underserved populations.
Despite the significant burdens on HCPs and federal health care systems, Federal Practitioner managed to increase the speed of publication and the number of articles between May 2020 and April 2021 thanks to the work of all the authors and reviewers who contributed their time and energy to the publication during this challenging period. Their efforts are impressive and greatly appreciated. We pledge to continue to improve our process to reduce the time to publication and to continue to provide regular updates on our process and performance.
The COVID-19 pandemic put unparalleled strain on US health care systems and individual health care providers (HCPs), which has been well documented. Like all other medical peer reviewed journals, Federal Practitioner relies heavily on the generosity and dedication of federal HCPs. As the pandemic unfolded, we questioned whether HCPs would have the time and energy to write new articles, complete research projects, and review the work of their peers. To assess the impact of COVID-19 on the journal, we compared data from a full year during the COVID-19 pandemic with that of the previous year to determine whether and how the pandemic reshaped the peer review and publication process.
For the purposes of this review, we will compare a full year of COVID-19 journal performance with the prior year. Since COVID-19 infections spiked at different times in different places, there is no clear starting point for the pandemic. Similarly, states varied widely in their vaccination rates and opening procedures. Nevertheless, the period from May 1, 2020 to April 30, 2021, most of the country experienced COVID-19 restrictions, and the number of cases rose dramatically.
From May 1, 2020 to April 30, 2021, Federal Practitioner received 208 submissions, 110% increase over the previous year (189 submissions from May 1, 2019 to April 30, 2020) and a 28% increase over a 2-year period. After submission, it took an average of 9.0 days to the first reviewer invitation compared with 10.3 days in the previous year and 4.7 days 2 years prior. Time from the initial submission to the first decision (ie, accept, reject, or revise) took 72.8 days in the COVID-19 year compared with 91.1 days in the previous year and 69.6 days 2 years prior. In both periods it took reviewers a mean 9.5 days to complete a review from the date invited, and the rate of late reviews was unchanged as well.
During the COVID-19 pandemic year, 1481 reviewer invitations were sent to potential reviewers and 498 reviews were completed (33.6%) by 195 individual reviewers: an average of 2.4 reviews per manuscript. Most reviewers recommended to accept the manuscript, and just 14.7% of reviewers recommended to reject the manuscript (Table). The previous year 1295 invitations were sent to potential reviewers and 460 reviews were completed (38.1%) by 181 individual reviewers for an average of 2.4 reviews per manuscript.
For the original submissions, the journal accepted just 26 (12.7%) articles, recommended revisions for 105 (51.2%) submissions, and rejected 74 (36.1%) submissions from May 1, 2020 to April 30, 3021. One hundred seven manuscripts were revised once, and 75.7% were accepted, and 2.8% were rejected. Twenty-two articles had a second revision and 1 had a third revision and all were published. In the year before the pandemic, just 16 (9.5%) manuscripts were accepted in their original form and 59 (39.1%) were rejected.
Federal Practitioner published 113 articles from May 2020 to April 2021. These articles included 44 (38.9%) original studies, 25 (22.1%) case studies, 20 (17.7%) program profiles, 16 (14.2%) commentaries/editorials, and 8 (7.1%) review articles; 19 (16.8%) articles were focused on COVID-19. The prior year saw Federal Practitioner publish 106 articles in 18 issues. Of these articles 36.8% were original studies, 22.6% were program profiles, 18.9% were case studies, 13.2% were commentaries/editorials, and 8.5% were review articles.
Despite the impact of COVID-19, federal HCPs continued to contribute to this journal without significant interruption. The journal saw a 10% increase in submissions during the pandemic year compared with the previous year but that was in keeping with prior increases in submissions. Similarly, the journal saw more individual reviewers submit more total reviews from May 2020 to April 2021 compared with the previous year. The broad spectrum of reviewers involved in the process and the growing volume of both reviews and submissions suggest that our reviewers remained available and committed to the peer review process despite the impact of a pandemic.
Reducing the time to first decision remains an important priority for the journal. Although the time was shortened during the pandemic, it still took longer to inform authors of the first decision compared with 2 years before. There is no indication that COVID-19 had an impact on the speed of decision making. Reviewers were as timely during the pandemic as they were the year before.
Similarly, there was little difference in the types of articles that were published, other than the obvious increase in COVID-19 submissions. Most of the articles on COVID-19 were editorials and columns, though the journal also published case studies, program profiles, and review articles on treatment. During the pandemic, a higher percentage of articles were original studies and case reports, and fewer were program profiles compared with the types the year before. It is unclear if these differences resulted from random fluctuations in unsolicited manuscripts or are part of a larger trend. The journal managed to publish slightly more articles from May 2020 to April 2021 compared with May 2019 to April 2020 despite fewer issues. This is likely due to increased submissions and articles published online.
For the original submissions, the journal accepted just 26 (12.7%) articles, recommended revisions for 105 (51.2%) submissions and rejected 74 (36.1%) submissions from May 2020 to April 3021. One hundred seven manuscripts were revised once and 75.7% were accepted and 2.8% were rejected. Twenty-two articles had a second revision and 1 had a third revision and all were published. In the year prior to the pandemic, just 16 (9.5%) manuscripts were accepted in their original form, and 59 (39.1%) were rejected.
Although Federal Practitioner improved the efficiency of its decision making, there is still significant room for improvement. We are committed to providing our authors with more rapid decisions and reducing the time to the first decision. Seventy-two days is still too long for authors to wait to hear about the initial decision on their article. Future reviews of the publication process should focus not only on the types of articles that are included, but their subjects as well. Given the great diversity of clinical care practiced across the US Department of Veterans Affairs, US Department of Defense, and the US Public Health Service, the journal must ensure that its articles reflect its diverse audience. We would like to see articles come from authors associated with all 3 major branches of our audience, as well as small portions of the readership (eg, Federal Bureau of Prisons, National Institutes of Health) and ask our readers to help us promote the journal to potential authors in all Federal Health Care organizations. We are especially interested in submissions on or from underserved populations.
Despite the significant burdens on HCPs and federal health care systems, Federal Practitioner managed to increase the speed of publication and the number of articles between May 2020 and April 2021 thanks to the work of all the authors and reviewers who contributed their time and energy to the publication during this challenging period. Their efforts are impressive and greatly appreciated. We pledge to continue to improve our process to reduce the time to publication and to continue to provide regular updates on our process and performance.
The COVID-19 pandemic put unparalleled strain on US health care systems and individual health care providers (HCPs), which has been well documented. Like all other medical peer reviewed journals, Federal Practitioner relies heavily on the generosity and dedication of federal HCPs. As the pandemic unfolded, we questioned whether HCPs would have the time and energy to write new articles, complete research projects, and review the work of their peers. To assess the impact of COVID-19 on the journal, we compared data from a full year during the COVID-19 pandemic with that of the previous year to determine whether and how the pandemic reshaped the peer review and publication process.
For the purposes of this review, we will compare a full year of COVID-19 journal performance with the prior year. Since COVID-19 infections spiked at different times in different places, there is no clear starting point for the pandemic. Similarly, states varied widely in their vaccination rates and opening procedures. Nevertheless, the period from May 1, 2020 to April 30, 2021, most of the country experienced COVID-19 restrictions, and the number of cases rose dramatically.
From May 1, 2020 to April 30, 2021, Federal Practitioner received 208 submissions, 110% increase over the previous year (189 submissions from May 1, 2019 to April 30, 2020) and a 28% increase over a 2-year period. After submission, it took an average of 9.0 days to the first reviewer invitation compared with 10.3 days in the previous year and 4.7 days 2 years prior. Time from the initial submission to the first decision (ie, accept, reject, or revise) took 72.8 days in the COVID-19 year compared with 91.1 days in the previous year and 69.6 days 2 years prior. In both periods it took reviewers a mean 9.5 days to complete a review from the date invited, and the rate of late reviews was unchanged as well.
During the COVID-19 pandemic year, 1481 reviewer invitations were sent to potential reviewers and 498 reviews were completed (33.6%) by 195 individual reviewers: an average of 2.4 reviews per manuscript. Most reviewers recommended to accept the manuscript, and just 14.7% of reviewers recommended to reject the manuscript (Table). The previous year 1295 invitations were sent to potential reviewers and 460 reviews were completed (38.1%) by 181 individual reviewers for an average of 2.4 reviews per manuscript.
For the original submissions, the journal accepted just 26 (12.7%) articles, recommended revisions for 105 (51.2%) submissions, and rejected 74 (36.1%) submissions from May 1, 2020 to April 30, 3021. One hundred seven manuscripts were revised once, and 75.7% were accepted, and 2.8% were rejected. Twenty-two articles had a second revision and 1 had a third revision and all were published. In the year before the pandemic, just 16 (9.5%) manuscripts were accepted in their original form and 59 (39.1%) were rejected.
Federal Practitioner published 113 articles from May 2020 to April 2021. These articles included 44 (38.9%) original studies, 25 (22.1%) case studies, 20 (17.7%) program profiles, 16 (14.2%) commentaries/editorials, and 8 (7.1%) review articles; 19 (16.8%) articles were focused on COVID-19. The prior year saw Federal Practitioner publish 106 articles in 18 issues. Of these articles 36.8% were original studies, 22.6% were program profiles, 18.9% were case studies, 13.2% were commentaries/editorials, and 8.5% were review articles.
Despite the impact of COVID-19, federal HCPs continued to contribute to this journal without significant interruption. The journal saw a 10% increase in submissions during the pandemic year compared with the previous year but that was in keeping with prior increases in submissions. Similarly, the journal saw more individual reviewers submit more total reviews from May 2020 to April 2021 compared with the previous year. The broad spectrum of reviewers involved in the process and the growing volume of both reviews and submissions suggest that our reviewers remained available and committed to the peer review process despite the impact of a pandemic.
Reducing the time to first decision remains an important priority for the journal. Although the time was shortened during the pandemic, it still took longer to inform authors of the first decision compared with 2 years before. There is no indication that COVID-19 had an impact on the speed of decision making. Reviewers were as timely during the pandemic as they were the year before.
Similarly, there was little difference in the types of articles that were published, other than the obvious increase in COVID-19 submissions. Most of the articles on COVID-19 were editorials and columns, though the journal also published case studies, program profiles, and review articles on treatment. During the pandemic, a higher percentage of articles were original studies and case reports, and fewer were program profiles compared with the types the year before. It is unclear if these differences resulted from random fluctuations in unsolicited manuscripts or are part of a larger trend. The journal managed to publish slightly more articles from May 2020 to April 2021 compared with May 2019 to April 2020 despite fewer issues. This is likely due to increased submissions and articles published online.
For the original submissions, the journal accepted just 26 (12.7%) articles, recommended revisions for 105 (51.2%) submissions and rejected 74 (36.1%) submissions from May 2020 to April 3021. One hundred seven manuscripts were revised once and 75.7% were accepted and 2.8% were rejected. Twenty-two articles had a second revision and 1 had a third revision and all were published. In the year prior to the pandemic, just 16 (9.5%) manuscripts were accepted in their original form, and 59 (39.1%) were rejected.
Although Federal Practitioner improved the efficiency of its decision making, there is still significant room for improvement. We are committed to providing our authors with more rapid decisions and reducing the time to the first decision. Seventy-two days is still too long for authors to wait to hear about the initial decision on their article. Future reviews of the publication process should focus not only on the types of articles that are included, but their subjects as well. Given the great diversity of clinical care practiced across the US Department of Veterans Affairs, US Department of Defense, and the US Public Health Service, the journal must ensure that its articles reflect its diverse audience. We would like to see articles come from authors associated with all 3 major branches of our audience, as well as small portions of the readership (eg, Federal Bureau of Prisons, National Institutes of Health) and ask our readers to help us promote the journal to potential authors in all Federal Health Care organizations. We are especially interested in submissions on or from underserved populations.
Despite the significant burdens on HCPs and federal health care systems, Federal Practitioner managed to increase the speed of publication and the number of articles between May 2020 and April 2021 thanks to the work of all the authors and reviewers who contributed their time and energy to the publication during this challenging period. Their efforts are impressive and greatly appreciated. We pledge to continue to improve our process to reduce the time to publication and to continue to provide regular updates on our process and performance.
Isotretinoin Meets COVID-19: Revisiting a Fragmented Paradigm
We cannot solve our problems with the same thinking we used when we created them.
Albert Einstein
Amidst the myriad of disruptions and corollary solutions budding from the ongoing global COVID-19 pandemic, management of acne with isotretinoin underwent a makeover. Firstly, as with any pharmaceutical prescribed in the last 1 to 2 years, patients asked the compelling question, “Will this prescription put me at higher risk for COVID-19?”, resulting in a complex set of answers from both clinical and basic science perspectives. Further, the practical use of telemedicine for clinical visits and pregnancy test reporting altered the shape of isotretinoin physician-patient communication and follow-up. Finally, the combination of these circumstances spurred us to revisit common quandaries in prescribing this drug: Can we trust what patients tell us when they are taking isotretinoin? Do we need to monitor laboratory values and follow patients on isotretinoin as closely and as frequently as we have in the past? Does the Risk Evaluation and Mitigation Strategy (REMS) program of iPLEDGE hold true utility?
Impact of COVID-19 on Isotretinoin Use
Isotretinoin may have varying influence on the ease of host entry and virulence of COVID-19. Because the majority of patients experience some degree of mucous membrane desiccation on isotretinoin, it originally was postulated that disruption of the nasal mucosa, thereby uncovering the basal epithelial layer where angiotensin-converting enzyme 2 (ACE2) receptors are expressed, could increase the risk for viral invasion, as ACE2 is the host receptor for COVID-19 entry.1,2 On the other hand, a study of 672 medications and their effect on regulation of ACE2 levels stratified isotretinoin in the highest category of ACE2 downregulators, therefore theoretically preventing cellular entry and replication of the virus.3 In conferring with many of my colleagues and reviewing available literature, I found that these data did not summarily deter providers from initiating or continuing isotretinoin during the pandemic, and research is ongoing to particularly earmark isotretinoin as a possible COVID-19 therapy option.4,5 Despite this, and despite the lower risk for COVID-19 in the customary isotretinoin adolescent and young adult age range, an Italian study reported that 14.7% of patients (5/34) prematurely interrupted isotretinoin therapy during lockdown because of fear of COVID-19 infection.6 Data also suggest that college towns (akin to where I practice, rife with isotretinoin-eligible patients) reflected higher COVID-19 infection and death rates, likely due to dense cohabitation and intermittent migration of students and staff to and from campuses and within their communities.7 Approximately 30% of my patients on isotretinoin in the last 18 months reported having COVID-19 at some point during the pandemic, though no data exist to guide us on whether isotretinoin should be discontinued in this scenario; my patients typically continued the drug unless their primary health care team discouraged it, and in those cases, all of them resumed it after COVID-19 symptomatology resolved.
Last spring, the US Department of Health and Human Services and the US Food and Drug Administration announced that health care professionals who prescribe and/or dispense drugs subject to REMS with laboratory testing or imaging requirements should consider whether there are compelling reasons not to complete the required testing/imaging during the current public health emergency and use their best medical judgment in weighing the benefits and risks of continuing treatment in the absence of these tests. It also was stressed that prescribers should effectively communicate with their patients regarding these benefits, risks, and altered protocols.8 Further, the iPLEDGE program concurred that telemedicine was an acceptable visit type for both initiating and maintaining isotretinoin, and home pregnancy tests were valid for females of childbearing potential if an accurate testing date and results were communicated by patients to the prescriber in the required reporting windows.9 This allowed dermatologists to foster what was one of our most important roles as outpatient clinicians during the pandemic: to maintain normalcy, continuity, and support for as many patients as possible.
Isotretinoin and Telemedicine
During the pandemic, continuation of isotretinoin therapy proved easier than initiating it, given that patients could access and maintain a clear connection to the online visit platform, display understanding of the REMS mandates (along with a guardian present for a minor), perform a home pregnancy test and report the result followed by the quiz (for females), and collect the prescription in the allotted window. For new patients, the absence of a detailed in-person examination and rapport with the patient (and guardians when applicable) as well as misalignment of the date of iPLEDGE registration with the timing of the pregnancy test results and prescribing window were more onerous using digital or mailed versions of consent forms and photodocumentation of urine pregnancy test results. This tangle of requirements perpetuated missed prescribing windows, increased patient portal and phone messages, resulted in more time on the phone with the iPLEDGE help desk, and intensified angst for clinical staff.
These telemedicine visits also required validation of the patient’s geographic location to verify the billability of the visit and whether the patient was in a secure location to have a US Health Insurance Portability and Accountability Act–compliant conversation as well as the abstract notion that the timing and result of the pregnancy tests for females reflected a true nonpregnant state.10,11 Verification of the pregnancy tests in these situations was approached by either the patient reporting the outcome verbally or displaying the pregnancy test kit result in a video or photograph form for the medical record, all of which leave room for error, doubt, and lower sensitivity than laboratory-based collection. That being said, the increased implementation of telemedicine visits during the pandemic sustained patient access, decreased cost with less laboratory testing and reduced time away from work or school, and resulted in high patient satisfaction with their care.12 Additionally, it allowed providers to continue to more comfortably inch away from frequent in-person serologic cholesterol and hepatic testing during therapy based on mounting data that it is not indicated.13
Accordingly, the complicated concepts of trust, practicality, and sustainability for the safe and effective management of isotretinoin patients re-emerged. For example, prior to COVID-19, we trusted patients who said they were regularly taking their oral contraceptives or were truly practicing abstinence as a form of contraception. During the pandemic, we then added a layer of trust with home pregnancy test reporting. If the patient or guardian signed the isotretinoin consent form and understood the risks of the medication, ideally the physician-patient relationship fostered the optimal goals of honest conversation, adherence to the drug, safety, and clear skin. However, there is yet another trust assay: iPLEDGE, in turn, trusts that we are reporting patient data accurately, provoking us to reiterate questions we asked ourselves before the pandemic. Is the extra provider and staff clerical work and validation necessary, compounded by prior data that iPLEDGE’s capacity to limit pregnancy-related morbidity with isotretinoin has been called into question in the last decade?14 Do males need to be followed every month? Is laboratory monitoring still necessary for all isotretinoin candidates? Will post–COVID-19 data show that during various versions of the lockdown, an increased number of isotretinoin patients developed unmonitored morbidity, including transaminitis, hypertriglyceridemia, and an increase in pregnancies? How long will telemedicine visits for isotretinoin be reimbursable beyond the pandemic? Are there other models to enhance and improve isotretinoin teledermatology and compliance?15
Final Thoughts
Dermatologists’ experience managing high volumes of isotretinoin patients paired with the creativity to maintain meaningful (and truthful) patient connections and decrease administrative burden lie front and center in 2021. Because the COVID-19 pandemic remains ambient with a dearth of data to guide us, I pose the questions above as points for commiseration and catapults for future study, discussion, collaboration, and innovation. Perhaps the neo–COVID-19 world provided us with the spark we needed to metaphorically clean up the dusty isotretinoin tenets that have frayed our time and patience so we can maintain excellent care for this worthy population.
- Hamming I, Timens W, Bulthuis MLC, et al. Tissue disruption of ACE2 protein, the functional receptor for SARS coronavirus. a first step in understanding SARS pathogenesis. J Pathol. 2004;203:631-637.
- British Association of Dermatologists. COVID-19—isotretinoin guidance. Published March 26, 2020. Accessed June 21, 2021. https://www.bad.org.uk/shared/get-file.ashx?itemtype=document&id=6661
- Sinha S, Cheng K, Schäffer AA, et al. In vitro and in vivo identification of clinically approved drugs that modify ACE2 expression. Mol Syst Biol. 2020;16:E9628.
- Öǧüt ND, Kutlu Ö, Erbaǧcı E. Oral isotretinoin treatment in patients with acne vulgaris during the COVID-19 pandemic: a retrospective cohort study in a tertiary care hospital [published online April 22, 2021]. J Cosmet Dermatol. doi:10.1111/jocd.14168
- Isotretinoin in treatment of COVID-19. National Library of Medicine website. ClinicalTrials.gov identifier: NCT04361422. Updated September 23, 2020. Accessed June 21, 2021. https://clinicaltrials.gov/ct2/show/NCT04361422
- Donnarumma M, Nocerino M, Lauro W, et al. Isotretinoin in acne treatment during the coronavirus disease 2019 (COVID-19): a retrospective analysis of adherence to therapy and side effects [published online December 22, 2020]. Dermatol Ther. 2021;34:E14677.
- Ivory D, Gebeloff R, Mervosh S. Young people have less COVID-19 risk, but in college towns, deaths rose fast. The New York Times. December 12, 2020. Accessed June 21, 2021. https://www.nytimes.com/2020/12/12/us/covid-colleges-nursing-homes.html
- US Food and Drug Administration. Coronavirus (COVID-19) update: FDA provides update on patient access to certain REMS drugs during COVID-19 public health emergency. Published March 22, 2020. Accessed June 21, 2021. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-provides-update-patient-access-certain-rems-drugs-during-covid-19
- Haelle T. iPledge allows at-home pregnancy tests during pandemic. Dermatology News. Published April 3, 2020. Accessed June 28, 2021. https://www.mdedge.com/dermatology/article/220186/acne/ipledge-allows-home-pregnancy-tests-during-pandemic
- Bressler MY, Siegel DM, Markowitz O. Virtual dermatology: a COVID-19 update. Cutis. 2020;105:163-164; E2.
- Telemedicine key issues and policy. Federation of State Medical Boards website. Accessed June 28, 2021. https://www.fsmb.org/advocacy/telemedicine
- Ruggiero A, Megna M, Annunziata MC, et al. Teledermatology for acne during COVID-19: high patients’ satisfaction in spite of the emergency. J Eur Acad Dermatol Venereol. 2020;34:E662-E663.
- Barbieri JS, Shin DB, Wang S, et al. The clinical utility of laboratory monitoring during isotretinoin therapy for acne and changes to monitoring practices over time. J Am Acad Dermatol. 2020;82:72-79.
- Tkachenko E, Singer S, Sharma P, et al. US Food and Drug Administration reports of pregnancy and pregnancy-related adverse events associated with isotretinoin. JAMA Dermatol. 2019;155:1175-1179.
- Das S, et al. Asynchronous telemedicine for isotretinoin management: a direct care pilot [published online January 21, 2021]. J Am Acad Dermatol. doi:10.1016/j.jaad.2021.01.039
We cannot solve our problems with the same thinking we used when we created them.
Albert Einstein
Amidst the myriad of disruptions and corollary solutions budding from the ongoing global COVID-19 pandemic, management of acne with isotretinoin underwent a makeover. Firstly, as with any pharmaceutical prescribed in the last 1 to 2 years, patients asked the compelling question, “Will this prescription put me at higher risk for COVID-19?”, resulting in a complex set of answers from both clinical and basic science perspectives. Further, the practical use of telemedicine for clinical visits and pregnancy test reporting altered the shape of isotretinoin physician-patient communication and follow-up. Finally, the combination of these circumstances spurred us to revisit common quandaries in prescribing this drug: Can we trust what patients tell us when they are taking isotretinoin? Do we need to monitor laboratory values and follow patients on isotretinoin as closely and as frequently as we have in the past? Does the Risk Evaluation and Mitigation Strategy (REMS) program of iPLEDGE hold true utility?
Impact of COVID-19 on Isotretinoin Use
Isotretinoin may have varying influence on the ease of host entry and virulence of COVID-19. Because the majority of patients experience some degree of mucous membrane desiccation on isotretinoin, it originally was postulated that disruption of the nasal mucosa, thereby uncovering the basal epithelial layer where angiotensin-converting enzyme 2 (ACE2) receptors are expressed, could increase the risk for viral invasion, as ACE2 is the host receptor for COVID-19 entry.1,2 On the other hand, a study of 672 medications and their effect on regulation of ACE2 levels stratified isotretinoin in the highest category of ACE2 downregulators, therefore theoretically preventing cellular entry and replication of the virus.3 In conferring with many of my colleagues and reviewing available literature, I found that these data did not summarily deter providers from initiating or continuing isotretinoin during the pandemic, and research is ongoing to particularly earmark isotretinoin as a possible COVID-19 therapy option.4,5 Despite this, and despite the lower risk for COVID-19 in the customary isotretinoin adolescent and young adult age range, an Italian study reported that 14.7% of patients (5/34) prematurely interrupted isotretinoin therapy during lockdown because of fear of COVID-19 infection.6 Data also suggest that college towns (akin to where I practice, rife with isotretinoin-eligible patients) reflected higher COVID-19 infection and death rates, likely due to dense cohabitation and intermittent migration of students and staff to and from campuses and within their communities.7 Approximately 30% of my patients on isotretinoin in the last 18 months reported having COVID-19 at some point during the pandemic, though no data exist to guide us on whether isotretinoin should be discontinued in this scenario; my patients typically continued the drug unless their primary health care team discouraged it, and in those cases, all of them resumed it after COVID-19 symptomatology resolved.
Last spring, the US Department of Health and Human Services and the US Food and Drug Administration announced that health care professionals who prescribe and/or dispense drugs subject to REMS with laboratory testing or imaging requirements should consider whether there are compelling reasons not to complete the required testing/imaging during the current public health emergency and use their best medical judgment in weighing the benefits and risks of continuing treatment in the absence of these tests. It also was stressed that prescribers should effectively communicate with their patients regarding these benefits, risks, and altered protocols.8 Further, the iPLEDGE program concurred that telemedicine was an acceptable visit type for both initiating and maintaining isotretinoin, and home pregnancy tests were valid for females of childbearing potential if an accurate testing date and results were communicated by patients to the prescriber in the required reporting windows.9 This allowed dermatologists to foster what was one of our most important roles as outpatient clinicians during the pandemic: to maintain normalcy, continuity, and support for as many patients as possible.
Isotretinoin and Telemedicine
During the pandemic, continuation of isotretinoin therapy proved easier than initiating it, given that patients could access and maintain a clear connection to the online visit platform, display understanding of the REMS mandates (along with a guardian present for a minor), perform a home pregnancy test and report the result followed by the quiz (for females), and collect the prescription in the allotted window. For new patients, the absence of a detailed in-person examination and rapport with the patient (and guardians when applicable) as well as misalignment of the date of iPLEDGE registration with the timing of the pregnancy test results and prescribing window were more onerous using digital or mailed versions of consent forms and photodocumentation of urine pregnancy test results. This tangle of requirements perpetuated missed prescribing windows, increased patient portal and phone messages, resulted in more time on the phone with the iPLEDGE help desk, and intensified angst for clinical staff.
These telemedicine visits also required validation of the patient’s geographic location to verify the billability of the visit and whether the patient was in a secure location to have a US Health Insurance Portability and Accountability Act–compliant conversation as well as the abstract notion that the timing and result of the pregnancy tests for females reflected a true nonpregnant state.10,11 Verification of the pregnancy tests in these situations was approached by either the patient reporting the outcome verbally or displaying the pregnancy test kit result in a video or photograph form for the medical record, all of which leave room for error, doubt, and lower sensitivity than laboratory-based collection. That being said, the increased implementation of telemedicine visits during the pandemic sustained patient access, decreased cost with less laboratory testing and reduced time away from work or school, and resulted in high patient satisfaction with their care.12 Additionally, it allowed providers to continue to more comfortably inch away from frequent in-person serologic cholesterol and hepatic testing during therapy based on mounting data that it is not indicated.13
Accordingly, the complicated concepts of trust, practicality, and sustainability for the safe and effective management of isotretinoin patients re-emerged. For example, prior to COVID-19, we trusted patients who said they were regularly taking their oral contraceptives or were truly practicing abstinence as a form of contraception. During the pandemic, we then added a layer of trust with home pregnancy test reporting. If the patient or guardian signed the isotretinoin consent form and understood the risks of the medication, ideally the physician-patient relationship fostered the optimal goals of honest conversation, adherence to the drug, safety, and clear skin. However, there is yet another trust assay: iPLEDGE, in turn, trusts that we are reporting patient data accurately, provoking us to reiterate questions we asked ourselves before the pandemic. Is the extra provider and staff clerical work and validation necessary, compounded by prior data that iPLEDGE’s capacity to limit pregnancy-related morbidity with isotretinoin has been called into question in the last decade?14 Do males need to be followed every month? Is laboratory monitoring still necessary for all isotretinoin candidates? Will post–COVID-19 data show that during various versions of the lockdown, an increased number of isotretinoin patients developed unmonitored morbidity, including transaminitis, hypertriglyceridemia, and an increase in pregnancies? How long will telemedicine visits for isotretinoin be reimbursable beyond the pandemic? Are there other models to enhance and improve isotretinoin teledermatology and compliance?15
Final Thoughts
Dermatologists’ experience managing high volumes of isotretinoin patients paired with the creativity to maintain meaningful (and truthful) patient connections and decrease administrative burden lie front and center in 2021. Because the COVID-19 pandemic remains ambient with a dearth of data to guide us, I pose the questions above as points for commiseration and catapults for future study, discussion, collaboration, and innovation. Perhaps the neo–COVID-19 world provided us with the spark we needed to metaphorically clean up the dusty isotretinoin tenets that have frayed our time and patience so we can maintain excellent care for this worthy population.
We cannot solve our problems with the same thinking we used when we created them.
Albert Einstein
Amidst the myriad of disruptions and corollary solutions budding from the ongoing global COVID-19 pandemic, management of acne with isotretinoin underwent a makeover. Firstly, as with any pharmaceutical prescribed in the last 1 to 2 years, patients asked the compelling question, “Will this prescription put me at higher risk for COVID-19?”, resulting in a complex set of answers from both clinical and basic science perspectives. Further, the practical use of telemedicine for clinical visits and pregnancy test reporting altered the shape of isotretinoin physician-patient communication and follow-up. Finally, the combination of these circumstances spurred us to revisit common quandaries in prescribing this drug: Can we trust what patients tell us when they are taking isotretinoin? Do we need to monitor laboratory values and follow patients on isotretinoin as closely and as frequently as we have in the past? Does the Risk Evaluation and Mitigation Strategy (REMS) program of iPLEDGE hold true utility?
Impact of COVID-19 on Isotretinoin Use
Isotretinoin may have varying influence on the ease of host entry and virulence of COVID-19. Because the majority of patients experience some degree of mucous membrane desiccation on isotretinoin, it originally was postulated that disruption of the nasal mucosa, thereby uncovering the basal epithelial layer where angiotensin-converting enzyme 2 (ACE2) receptors are expressed, could increase the risk for viral invasion, as ACE2 is the host receptor for COVID-19 entry.1,2 On the other hand, a study of 672 medications and their effect on regulation of ACE2 levels stratified isotretinoin in the highest category of ACE2 downregulators, therefore theoretically preventing cellular entry and replication of the virus.3 In conferring with many of my colleagues and reviewing available literature, I found that these data did not summarily deter providers from initiating or continuing isotretinoin during the pandemic, and research is ongoing to particularly earmark isotretinoin as a possible COVID-19 therapy option.4,5 Despite this, and despite the lower risk for COVID-19 in the customary isotretinoin adolescent and young adult age range, an Italian study reported that 14.7% of patients (5/34) prematurely interrupted isotretinoin therapy during lockdown because of fear of COVID-19 infection.6 Data also suggest that college towns (akin to where I practice, rife with isotretinoin-eligible patients) reflected higher COVID-19 infection and death rates, likely due to dense cohabitation and intermittent migration of students and staff to and from campuses and within their communities.7 Approximately 30% of my patients on isotretinoin in the last 18 months reported having COVID-19 at some point during the pandemic, though no data exist to guide us on whether isotretinoin should be discontinued in this scenario; my patients typically continued the drug unless their primary health care team discouraged it, and in those cases, all of them resumed it after COVID-19 symptomatology resolved.
Last spring, the US Department of Health and Human Services and the US Food and Drug Administration announced that health care professionals who prescribe and/or dispense drugs subject to REMS with laboratory testing or imaging requirements should consider whether there are compelling reasons not to complete the required testing/imaging during the current public health emergency and use their best medical judgment in weighing the benefits and risks of continuing treatment in the absence of these tests. It also was stressed that prescribers should effectively communicate with their patients regarding these benefits, risks, and altered protocols.8 Further, the iPLEDGE program concurred that telemedicine was an acceptable visit type for both initiating and maintaining isotretinoin, and home pregnancy tests were valid for females of childbearing potential if an accurate testing date and results were communicated by patients to the prescriber in the required reporting windows.9 This allowed dermatologists to foster what was one of our most important roles as outpatient clinicians during the pandemic: to maintain normalcy, continuity, and support for as many patients as possible.
Isotretinoin and Telemedicine
During the pandemic, continuation of isotretinoin therapy proved easier than initiating it, given that patients could access and maintain a clear connection to the online visit platform, display understanding of the REMS mandates (along with a guardian present for a minor), perform a home pregnancy test and report the result followed by the quiz (for females), and collect the prescription in the allotted window. For new patients, the absence of a detailed in-person examination and rapport with the patient (and guardians when applicable) as well as misalignment of the date of iPLEDGE registration with the timing of the pregnancy test results and prescribing window were more onerous using digital or mailed versions of consent forms and photodocumentation of urine pregnancy test results. This tangle of requirements perpetuated missed prescribing windows, increased patient portal and phone messages, resulted in more time on the phone with the iPLEDGE help desk, and intensified angst for clinical staff.
These telemedicine visits also required validation of the patient’s geographic location to verify the billability of the visit and whether the patient was in a secure location to have a US Health Insurance Portability and Accountability Act–compliant conversation as well as the abstract notion that the timing and result of the pregnancy tests for females reflected a true nonpregnant state.10,11 Verification of the pregnancy tests in these situations was approached by either the patient reporting the outcome verbally or displaying the pregnancy test kit result in a video or photograph form for the medical record, all of which leave room for error, doubt, and lower sensitivity than laboratory-based collection. That being said, the increased implementation of telemedicine visits during the pandemic sustained patient access, decreased cost with less laboratory testing and reduced time away from work or school, and resulted in high patient satisfaction with their care.12 Additionally, it allowed providers to continue to more comfortably inch away from frequent in-person serologic cholesterol and hepatic testing during therapy based on mounting data that it is not indicated.13
Accordingly, the complicated concepts of trust, practicality, and sustainability for the safe and effective management of isotretinoin patients re-emerged. For example, prior to COVID-19, we trusted patients who said they were regularly taking their oral contraceptives or were truly practicing abstinence as a form of contraception. During the pandemic, we then added a layer of trust with home pregnancy test reporting. If the patient or guardian signed the isotretinoin consent form and understood the risks of the medication, ideally the physician-patient relationship fostered the optimal goals of honest conversation, adherence to the drug, safety, and clear skin. However, there is yet another trust assay: iPLEDGE, in turn, trusts that we are reporting patient data accurately, provoking us to reiterate questions we asked ourselves before the pandemic. Is the extra provider and staff clerical work and validation necessary, compounded by prior data that iPLEDGE’s capacity to limit pregnancy-related morbidity with isotretinoin has been called into question in the last decade?14 Do males need to be followed every month? Is laboratory monitoring still necessary for all isotretinoin candidates? Will post–COVID-19 data show that during various versions of the lockdown, an increased number of isotretinoin patients developed unmonitored morbidity, including transaminitis, hypertriglyceridemia, and an increase in pregnancies? How long will telemedicine visits for isotretinoin be reimbursable beyond the pandemic? Are there other models to enhance and improve isotretinoin teledermatology and compliance?15
Final Thoughts
Dermatologists’ experience managing high volumes of isotretinoin patients paired with the creativity to maintain meaningful (and truthful) patient connections and decrease administrative burden lie front and center in 2021. Because the COVID-19 pandemic remains ambient with a dearth of data to guide us, I pose the questions above as points for commiseration and catapults for future study, discussion, collaboration, and innovation. Perhaps the neo–COVID-19 world provided us with the spark we needed to metaphorically clean up the dusty isotretinoin tenets that have frayed our time and patience so we can maintain excellent care for this worthy population.
- Hamming I, Timens W, Bulthuis MLC, et al. Tissue disruption of ACE2 protein, the functional receptor for SARS coronavirus. a first step in understanding SARS pathogenesis. J Pathol. 2004;203:631-637.
- British Association of Dermatologists. COVID-19—isotretinoin guidance. Published March 26, 2020. Accessed June 21, 2021. https://www.bad.org.uk/shared/get-file.ashx?itemtype=document&id=6661
- Sinha S, Cheng K, Schäffer AA, et al. In vitro and in vivo identification of clinically approved drugs that modify ACE2 expression. Mol Syst Biol. 2020;16:E9628.
- Öǧüt ND, Kutlu Ö, Erbaǧcı E. Oral isotretinoin treatment in patients with acne vulgaris during the COVID-19 pandemic: a retrospective cohort study in a tertiary care hospital [published online April 22, 2021]. J Cosmet Dermatol. doi:10.1111/jocd.14168
- Isotretinoin in treatment of COVID-19. National Library of Medicine website. ClinicalTrials.gov identifier: NCT04361422. Updated September 23, 2020. Accessed June 21, 2021. https://clinicaltrials.gov/ct2/show/NCT04361422
- Donnarumma M, Nocerino M, Lauro W, et al. Isotretinoin in acne treatment during the coronavirus disease 2019 (COVID-19): a retrospective analysis of adherence to therapy and side effects [published online December 22, 2020]. Dermatol Ther. 2021;34:E14677.
- Ivory D, Gebeloff R, Mervosh S. Young people have less COVID-19 risk, but in college towns, deaths rose fast. The New York Times. December 12, 2020. Accessed June 21, 2021. https://www.nytimes.com/2020/12/12/us/covid-colleges-nursing-homes.html
- US Food and Drug Administration. Coronavirus (COVID-19) update: FDA provides update on patient access to certain REMS drugs during COVID-19 public health emergency. Published March 22, 2020. Accessed June 21, 2021. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-provides-update-patient-access-certain-rems-drugs-during-covid-19
- Haelle T. iPledge allows at-home pregnancy tests during pandemic. Dermatology News. Published April 3, 2020. Accessed June 28, 2021. https://www.mdedge.com/dermatology/article/220186/acne/ipledge-allows-home-pregnancy-tests-during-pandemic
- Bressler MY, Siegel DM, Markowitz O. Virtual dermatology: a COVID-19 update. Cutis. 2020;105:163-164; E2.
- Telemedicine key issues and policy. Federation of State Medical Boards website. Accessed June 28, 2021. https://www.fsmb.org/advocacy/telemedicine
- Ruggiero A, Megna M, Annunziata MC, et al. Teledermatology for acne during COVID-19: high patients’ satisfaction in spite of the emergency. J Eur Acad Dermatol Venereol. 2020;34:E662-E663.
- Barbieri JS, Shin DB, Wang S, et al. The clinical utility of laboratory monitoring during isotretinoin therapy for acne and changes to monitoring practices over time. J Am Acad Dermatol. 2020;82:72-79.
- Tkachenko E, Singer S, Sharma P, et al. US Food and Drug Administration reports of pregnancy and pregnancy-related adverse events associated with isotretinoin. JAMA Dermatol. 2019;155:1175-1179.
- Das S, et al. Asynchronous telemedicine for isotretinoin management: a direct care pilot [published online January 21, 2021]. J Am Acad Dermatol. doi:10.1016/j.jaad.2021.01.039
- Hamming I, Timens W, Bulthuis MLC, et al. Tissue disruption of ACE2 protein, the functional receptor for SARS coronavirus. a first step in understanding SARS pathogenesis. J Pathol. 2004;203:631-637.
- British Association of Dermatologists. COVID-19—isotretinoin guidance. Published March 26, 2020. Accessed June 21, 2021. https://www.bad.org.uk/shared/get-file.ashx?itemtype=document&id=6661
- Sinha S, Cheng K, Schäffer AA, et al. In vitro and in vivo identification of clinically approved drugs that modify ACE2 expression. Mol Syst Biol. 2020;16:E9628.
- Öǧüt ND, Kutlu Ö, Erbaǧcı E. Oral isotretinoin treatment in patients with acne vulgaris during the COVID-19 pandemic: a retrospective cohort study in a tertiary care hospital [published online April 22, 2021]. J Cosmet Dermatol. doi:10.1111/jocd.14168
- Isotretinoin in treatment of COVID-19. National Library of Medicine website. ClinicalTrials.gov identifier: NCT04361422. Updated September 23, 2020. Accessed June 21, 2021. https://clinicaltrials.gov/ct2/show/NCT04361422
- Donnarumma M, Nocerino M, Lauro W, et al. Isotretinoin in acne treatment during the coronavirus disease 2019 (COVID-19): a retrospective analysis of adherence to therapy and side effects [published online December 22, 2020]. Dermatol Ther. 2021;34:E14677.
- Ivory D, Gebeloff R, Mervosh S. Young people have less COVID-19 risk, but in college towns, deaths rose fast. The New York Times. December 12, 2020. Accessed June 21, 2021. https://www.nytimes.com/2020/12/12/us/covid-colleges-nursing-homes.html
- US Food and Drug Administration. Coronavirus (COVID-19) update: FDA provides update on patient access to certain REMS drugs during COVID-19 public health emergency. Published March 22, 2020. Accessed June 21, 2021. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-provides-update-patient-access-certain-rems-drugs-during-covid-19
- Haelle T. iPledge allows at-home pregnancy tests during pandemic. Dermatology News. Published April 3, 2020. Accessed June 28, 2021. https://www.mdedge.com/dermatology/article/220186/acne/ipledge-allows-home-pregnancy-tests-during-pandemic
- Bressler MY, Siegel DM, Markowitz O. Virtual dermatology: a COVID-19 update. Cutis. 2020;105:163-164; E2.
- Telemedicine key issues and policy. Federation of State Medical Boards website. Accessed June 28, 2021. https://www.fsmb.org/advocacy/telemedicine
- Ruggiero A, Megna M, Annunziata MC, et al. Teledermatology for acne during COVID-19: high patients’ satisfaction in spite of the emergency. J Eur Acad Dermatol Venereol. 2020;34:E662-E663.
- Barbieri JS, Shin DB, Wang S, et al. The clinical utility of laboratory monitoring during isotretinoin therapy for acne and changes to monitoring practices over time. J Am Acad Dermatol. 2020;82:72-79.
- Tkachenko E, Singer S, Sharma P, et al. US Food and Drug Administration reports of pregnancy and pregnancy-related adverse events associated with isotretinoin. JAMA Dermatol. 2019;155:1175-1179.
- Das S, et al. Asynchronous telemedicine for isotretinoin management: a direct care pilot [published online January 21, 2021]. J Am Acad Dermatol. doi:10.1016/j.jaad.2021.01.039
Ending the ED ‘boarding’ of youth with mental health needs
All over the country, high numbers of youth experiencing a mental health crisis are presenting to emergency departments, where they are assessed to need an inpatient psychiatric hospitalization but then wait for days and sometimes weeks with nowhere to go. In Colorado, one of the largest children’s hospitals in the state declared their own state of emergency to call attention to the problem after facing a 72% increase in volume for mental health emergency visits.1 This problem is hardly new, but the COVID pandemic has appeared to take the problem to new heights. In Massachusetts, the “boarding” of youth awaiting psychiatric hospitalization has more than doubled since the pandemic, according to a recent report from National Public Radio.2 Like many public health problems, there is evidence that the burden falls disproportionately on groups that have faced health inequities in the past.3
What is causing this? The proximal cause is fairly simple: Acute mental health problems in youth are rising while the supply of intensive services is dropping. The number of available inpatient psychiatric beds has steadily been falling over the years even prior to the COVID pandemic, which then took more capacity offline because of staffing shortages and requirements for additional distance between patients (such as eliminating double-occupancy rooms). Meanwhile, levels of anxiety, depression, and suicidality have been rising in youth for reasons still not adequately understood.
The stories of these youth and their families waiting for stabilization and treatment are heartbreaking, and nobody disagrees with the idea that a child being confined to a small ED room for days is not good care. What is debated, however, is how best to fix this problem both in the short and long term. In the eyes of many, the ultimate solution is clear: more inpatient beds. This may indeed be required for some areas, but a closer look at how an entire mental health system operates often reveals both more complex problems and some alternative potential solutions. For example, hospital staff will often acknowledge that they have patients ready for discharge but who need more intensive step-down services like a residential treatment or partial hospital program to be able to do so safely. You can’t have hospital admissions if you don’t have hospital discharges, so without good step-down options patients back up and the regular flow is disrupted. Upstream of the crisis that sends many youth to EDs is another opportunity area, as these tipping points are often seen coming by others, including their pediatricians, but referrals to clinicians or programs that might bring improvement and prevent the need for an ED evaluation are also in short supply.
In the short term, efforts are being directed by some EDs to make the physical space more therapeutic for individuals experiencing mental health problems and to offer more actual treatment when people are there. This can take the form of having a secure space in which to move around, or being offered some supportive psychotherapy sessions and possible medication changes while in the ED. It can also involve simple things like the availability of books, video games, and toys to help pass the time. Such efforts are greatly needed, and many feel that the notion of mental health emergencies somehow being outside the “lane” of emergency medicine training and practice should have been retired long ago.
Medium-term solutions can involve the standing up of more intensive mental health programs that are below the level of inpatient hospitalizations, such as intensive outpatient or partial hospitalization programs, or improved mobile response services that go beyond triage and actually bring supports and techniques directly to families in need. As mentioned, these levels of services can provide both a step-down option that facilitates a hospital discharge and a measure that can prevent the need for some hospitalizations in the first place.
Looking over the long term, health care systems and governments need to evaluate the degree to which more hospital or residential beds may still be needed, despite our best efforts to improve flow and prevent mental health crises from originating. This can often be a contentious topic, however, and securing public dollars to support more beds is often quite difficult even where there seems to be a clear need.
Hovering over nearly all potential solutions, of course, is the challenge of finding the mental health workforce to implement any new programs and initiatives without stealing from services already in place. This dilemma speaks to ongoing issues of parity between resources devoted to mental health versus physical health care. Some mental health care organizations are currently trying to recruit new workers with bonuses or new incentives, but longer-term fixes are likely to require a hard look at the degree to which our actual commitment to mental health care matches the political rhetoric.
Discussions of how to solve the problem of ED boarding can easily deteriorate into a lot of finger pointing of what somebody else should be doing. The truth is, however, that there are many actions that can be taken by those in very different roles.
While many of these steps require efforts from mental health organizations, emergency departments, government agencies, and hospitals, there are things that can be done within the purview of the primary care clinician. First, look for opportunities to increase your collaboration with mental health professionals through initiatives such as integrated care programs. The Health Resources and Services Administration is now using funds from the American Rescue Plan Act to strengthen integrated care programs across the country and new opportunities may well be available soon to get additional mental health supports to primary care offices. Second, get involved and advocate for the mental health of your patients by communicating with other groups to make other potential solutions a reality.
Children and adolescents waiting for days to get the mental health care they need and deserve is an unacceptable situation that we can and must overcome. Quick fixes will be hard to find, but with some collaborative effort, forward thinking, and, yes, financial investments, we can find solutions that reflect the principle of mental health being a foundation for all health.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @PediPsych. His latest book is “Parenting Made Complicated: What Science Really Knows About the Greatest Debates of Early Childhood.”
References
1. Tabachnik S. Colorado health leaders declare youth mental health state of emergency: “Our kids have run out of resilience.” Denver Post. 2021 May 25.
2. Bebinger M. Kids in mental health crisis can languish for days inside ERs. National Public Radio. 2021 Jun 23.
3. Nash KA et al. Pediatrics. 2021:147:5. e2020030692.
All over the country, high numbers of youth experiencing a mental health crisis are presenting to emergency departments, where they are assessed to need an inpatient psychiatric hospitalization but then wait for days and sometimes weeks with nowhere to go. In Colorado, one of the largest children’s hospitals in the state declared their own state of emergency to call attention to the problem after facing a 72% increase in volume for mental health emergency visits.1 This problem is hardly new, but the COVID pandemic has appeared to take the problem to new heights. In Massachusetts, the “boarding” of youth awaiting psychiatric hospitalization has more than doubled since the pandemic, according to a recent report from National Public Radio.2 Like many public health problems, there is evidence that the burden falls disproportionately on groups that have faced health inequities in the past.3
What is causing this? The proximal cause is fairly simple: Acute mental health problems in youth are rising while the supply of intensive services is dropping. The number of available inpatient psychiatric beds has steadily been falling over the years even prior to the COVID pandemic, which then took more capacity offline because of staffing shortages and requirements for additional distance between patients (such as eliminating double-occupancy rooms). Meanwhile, levels of anxiety, depression, and suicidality have been rising in youth for reasons still not adequately understood.
The stories of these youth and their families waiting for stabilization and treatment are heartbreaking, and nobody disagrees with the idea that a child being confined to a small ED room for days is not good care. What is debated, however, is how best to fix this problem both in the short and long term. In the eyes of many, the ultimate solution is clear: more inpatient beds. This may indeed be required for some areas, but a closer look at how an entire mental health system operates often reveals both more complex problems and some alternative potential solutions. For example, hospital staff will often acknowledge that they have patients ready for discharge but who need more intensive step-down services like a residential treatment or partial hospital program to be able to do so safely. You can’t have hospital admissions if you don’t have hospital discharges, so without good step-down options patients back up and the regular flow is disrupted. Upstream of the crisis that sends many youth to EDs is another opportunity area, as these tipping points are often seen coming by others, including their pediatricians, but referrals to clinicians or programs that might bring improvement and prevent the need for an ED evaluation are also in short supply.
In the short term, efforts are being directed by some EDs to make the physical space more therapeutic for individuals experiencing mental health problems and to offer more actual treatment when people are there. This can take the form of having a secure space in which to move around, or being offered some supportive psychotherapy sessions and possible medication changes while in the ED. It can also involve simple things like the availability of books, video games, and toys to help pass the time. Such efforts are greatly needed, and many feel that the notion of mental health emergencies somehow being outside the “lane” of emergency medicine training and practice should have been retired long ago.
Medium-term solutions can involve the standing up of more intensive mental health programs that are below the level of inpatient hospitalizations, such as intensive outpatient or partial hospitalization programs, or improved mobile response services that go beyond triage and actually bring supports and techniques directly to families in need. As mentioned, these levels of services can provide both a step-down option that facilitates a hospital discharge and a measure that can prevent the need for some hospitalizations in the first place.
Looking over the long term, health care systems and governments need to evaluate the degree to which more hospital or residential beds may still be needed, despite our best efforts to improve flow and prevent mental health crises from originating. This can often be a contentious topic, however, and securing public dollars to support more beds is often quite difficult even where there seems to be a clear need.
Hovering over nearly all potential solutions, of course, is the challenge of finding the mental health workforce to implement any new programs and initiatives without stealing from services already in place. This dilemma speaks to ongoing issues of parity between resources devoted to mental health versus physical health care. Some mental health care organizations are currently trying to recruit new workers with bonuses or new incentives, but longer-term fixes are likely to require a hard look at the degree to which our actual commitment to mental health care matches the political rhetoric.
Discussions of how to solve the problem of ED boarding can easily deteriorate into a lot of finger pointing of what somebody else should be doing. The truth is, however, that there are many actions that can be taken by those in very different roles.
While many of these steps require efforts from mental health organizations, emergency departments, government agencies, and hospitals, there are things that can be done within the purview of the primary care clinician. First, look for opportunities to increase your collaboration with mental health professionals through initiatives such as integrated care programs. The Health Resources and Services Administration is now using funds from the American Rescue Plan Act to strengthen integrated care programs across the country and new opportunities may well be available soon to get additional mental health supports to primary care offices. Second, get involved and advocate for the mental health of your patients by communicating with other groups to make other potential solutions a reality.
Children and adolescents waiting for days to get the mental health care they need and deserve is an unacceptable situation that we can and must overcome. Quick fixes will be hard to find, but with some collaborative effort, forward thinking, and, yes, financial investments, we can find solutions that reflect the principle of mental health being a foundation for all health.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @PediPsych. His latest book is “Parenting Made Complicated: What Science Really Knows About the Greatest Debates of Early Childhood.”
References
1. Tabachnik S. Colorado health leaders declare youth mental health state of emergency: “Our kids have run out of resilience.” Denver Post. 2021 May 25.
2. Bebinger M. Kids in mental health crisis can languish for days inside ERs. National Public Radio. 2021 Jun 23.
3. Nash KA et al. Pediatrics. 2021:147:5. e2020030692.
All over the country, high numbers of youth experiencing a mental health crisis are presenting to emergency departments, where they are assessed to need an inpatient psychiatric hospitalization but then wait for days and sometimes weeks with nowhere to go. In Colorado, one of the largest children’s hospitals in the state declared their own state of emergency to call attention to the problem after facing a 72% increase in volume for mental health emergency visits.1 This problem is hardly new, but the COVID pandemic has appeared to take the problem to new heights. In Massachusetts, the “boarding” of youth awaiting psychiatric hospitalization has more than doubled since the pandemic, according to a recent report from National Public Radio.2 Like many public health problems, there is evidence that the burden falls disproportionately on groups that have faced health inequities in the past.3
What is causing this? The proximal cause is fairly simple: Acute mental health problems in youth are rising while the supply of intensive services is dropping. The number of available inpatient psychiatric beds has steadily been falling over the years even prior to the COVID pandemic, which then took more capacity offline because of staffing shortages and requirements for additional distance between patients (such as eliminating double-occupancy rooms). Meanwhile, levels of anxiety, depression, and suicidality have been rising in youth for reasons still not adequately understood.
The stories of these youth and their families waiting for stabilization and treatment are heartbreaking, and nobody disagrees with the idea that a child being confined to a small ED room for days is not good care. What is debated, however, is how best to fix this problem both in the short and long term. In the eyes of many, the ultimate solution is clear: more inpatient beds. This may indeed be required for some areas, but a closer look at how an entire mental health system operates often reveals both more complex problems and some alternative potential solutions. For example, hospital staff will often acknowledge that they have patients ready for discharge but who need more intensive step-down services like a residential treatment or partial hospital program to be able to do so safely. You can’t have hospital admissions if you don’t have hospital discharges, so without good step-down options patients back up and the regular flow is disrupted. Upstream of the crisis that sends many youth to EDs is another opportunity area, as these tipping points are often seen coming by others, including their pediatricians, but referrals to clinicians or programs that might bring improvement and prevent the need for an ED evaluation are also in short supply.
In the short term, efforts are being directed by some EDs to make the physical space more therapeutic for individuals experiencing mental health problems and to offer more actual treatment when people are there. This can take the form of having a secure space in which to move around, or being offered some supportive psychotherapy sessions and possible medication changes while in the ED. It can also involve simple things like the availability of books, video games, and toys to help pass the time. Such efforts are greatly needed, and many feel that the notion of mental health emergencies somehow being outside the “lane” of emergency medicine training and practice should have been retired long ago.
Medium-term solutions can involve the standing up of more intensive mental health programs that are below the level of inpatient hospitalizations, such as intensive outpatient or partial hospitalization programs, or improved mobile response services that go beyond triage and actually bring supports and techniques directly to families in need. As mentioned, these levels of services can provide both a step-down option that facilitates a hospital discharge and a measure that can prevent the need for some hospitalizations in the first place.
Looking over the long term, health care systems and governments need to evaluate the degree to which more hospital or residential beds may still be needed, despite our best efforts to improve flow and prevent mental health crises from originating. This can often be a contentious topic, however, and securing public dollars to support more beds is often quite difficult even where there seems to be a clear need.
Hovering over nearly all potential solutions, of course, is the challenge of finding the mental health workforce to implement any new programs and initiatives without stealing from services already in place. This dilemma speaks to ongoing issues of parity between resources devoted to mental health versus physical health care. Some mental health care organizations are currently trying to recruit new workers with bonuses or new incentives, but longer-term fixes are likely to require a hard look at the degree to which our actual commitment to mental health care matches the political rhetoric.
Discussions of how to solve the problem of ED boarding can easily deteriorate into a lot of finger pointing of what somebody else should be doing. The truth is, however, that there are many actions that can be taken by those in very different roles.
While many of these steps require efforts from mental health organizations, emergency departments, government agencies, and hospitals, there are things that can be done within the purview of the primary care clinician. First, look for opportunities to increase your collaboration with mental health professionals through initiatives such as integrated care programs. The Health Resources and Services Administration is now using funds from the American Rescue Plan Act to strengthen integrated care programs across the country and new opportunities may well be available soon to get additional mental health supports to primary care offices. Second, get involved and advocate for the mental health of your patients by communicating with other groups to make other potential solutions a reality.
Children and adolescents waiting for days to get the mental health care they need and deserve is an unacceptable situation that we can and must overcome. Quick fixes will be hard to find, but with some collaborative effort, forward thinking, and, yes, financial investments, we can find solutions that reflect the principle of mental health being a foundation for all health.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @PediPsych. His latest book is “Parenting Made Complicated: What Science Really Knows About the Greatest Debates of Early Childhood.”
References
1. Tabachnik S. Colorado health leaders declare youth mental health state of emergency: “Our kids have run out of resilience.” Denver Post. 2021 May 25.
2. Bebinger M. Kids in mental health crisis can languish for days inside ERs. National Public Radio. 2021 Jun 23.
3. Nash KA et al. Pediatrics. 2021:147:5. e2020030692.
Britney Spears and her 13-year conservatorship: An abuse of involuntary care?
The public has watched the ongoing drama unfold in the media for the past 13 years. In 2008, pop star Britney Spears was placed on conservatorship – a court process that gave decision-making powers over her personal, legal, and financial decisions to another person.
On June 23, 2021, Ms. Spears announced in open court that she is traumatized by being conserved and wants her rights back, but we know little about what behaviors left her family and a judge to determine that she was not capable of managing her own affairs, and why this would remain the case for so many years.
Adam Nelson, MD, practices psychiatry in Marin County, Calif. He explained in an interview that there are different types of conservatorships. “Probate conservatorship is the traditional path for conservatorship of person, estate, and/or finances based on evidence of incapacity due to any medical condition. This is the type of conservatorship that Britney Spears has had and which she is now contesting.”
Ms. Spears was placed on conservatorship after two involuntary hospitalizations for psychiatric illness and/or substance abuse. Her father, Jamie Spears, was appointed by the court to be her conservator.
In a New York Times article, reporters Liz Day, Samantha Stark, and Joe Coscarelli recently wrote: “But now, confidential court records obtained by the New York Times reveal that Ms. Spears, 39, expressed serious opposition to the conservatorship earlier and more often than had previously been known, and said that it restricted everything from whom she dated to the color of her kitchen cabinets.” The article goes on to say: “The newly obtained court records show that Ms. Spears questioned [her father’s] fitness for the role. As early as 2014, in a hearing closed to the public, Ms. Spears’s court-appointed lawyer, Samuel D. Ingham III, said she wanted to explore removing her father as conservator, citing his drinking, among other objections on a ‘shopping list’ of grievances.
“As the fight drags on, the bills are piling up – and, in a quirk of the conservatorship system, Ms. Spears has to pay for lawyers on both sides, including those arguing against her wishes in court. A recent $890,000 bill from one set of Mr. Spears’s lawyers, covering about 4 months of work, included media strategizing for defending the conservatorship.”
The case heated up at the June 23 hearing, when Ms. Spears had a telephone hearing with Los Angeles probate Judge Brenda Penney. The call was transcribed and published in Variety. The purpose of the hearing was for Ms. Spears to request an expedited release from her conservatorship without a psychiatric evaluation.
Ms. Spears began her 23-minute testimony to the judge by discussing her work and how she felt compelled to perform. “My management said, if I don’t do this tour, I will have to find an attorney, and by contract my own management could sue me if I didn’t follow through with the tour. ... So out of fear, I went ahead and I did the tour.”
She then discussed concerns by her manager that she was not complying with her medication regimen.
“Three days later, after I said no to Vegas,” Ms. Spears continued, “my therapist sat me down in a room and said he had a million phone calls about how I was not cooperating in rehearsals, and I haven’t been taking my medication. All this was false. He immediately, the next day, put me on lithium out of nowhere. He took me off my normal meds I’ve been on for 5 years. ... There were six different nurses in my home and they wouldn’t let me get in my car to go anywhere for a month.”
She spoke about entering rehab at the insistence of the conservatorship, and relayed her distress about this experience. She talked poignantly about her frustration of feeling she was not being heard by the court the last time she spoke and about the financial conflicts of interest created by her conservatorship. Ms. Spears, who has appeared on national television, recorded albums, and gone on performance tours during this period, has a net worth estimated at $60 million.
“It’s been a long time since I’ve owned my money. And it’s my wish and my dream for all of this to end without being tested,” she told the judge. “Again, it makes no sense whatsoever for the state of California to sit back and literally watch me with their own two eyes, make a living for so many people, and pay so many people trucks and buses on the road with me and be told, I’m not good enough. But I’m great at what I do. And I allow these people to control what I do, ma’am. And it’s enough. It makes no sense at all.”
Finally, Ms. Spears expressed a heart-wrenching desire to have another child and she asserted that the conservatorship will not allow her to see a doctor to have her IUD removed. She talked about being required to go to therapy three times a week and contended that she is traumatized by all that has transpired.
Ms. Spears has not filed the necessary paperwork to have her conservatorship ended. In an interview with Vice, attorney Scott Rahn noted that the process to end conservatorship can be a lengthy and difficult path. To do so, she might first need to petition the court to be allowed to hire her own attorney. If uncontested, the conservatorship could possibly be ended within months, but otherwise this could entail a lengthy trial over the course of years. While ending conservatorship may entail discovery, depositions, and hearings over years, a scathing story in the New Yorker detailed how Ms. Spears was placed into this conservatorship in a matter of days, without being present to give her own testimony. In the usual circumstances, California law requires that the person being conserved must be given 5 days’ notice before a conservatorship takes place, but Ms. Spears was deemed to be at risk of substantial harm and the judge allowed for an immediate conservatorship. The article notes that even axe murderers are allowed to hire lawyers, while those placed in conservatorships are not.
Reasoning behind such actions
Often, people are appointed guardians, conservators, or payees because of concerns that their psychiatric or substance use disorders, dementia, or impaired intellectual states lead them to poor decisions that endanger their financial stability. Usually the money they may lose is from a government disability benefit, an inheritance, or former accrued wealth. In this unusual celebrity case, Britney Spears has been conserved while she maintained a rigorous work schedule and actively earned the money she is being protected from spending.
Dr. Nelson talked about how people come to be conserved. “The law regarding conservatorship is a state law, but conservatorships in California are done at the county level, and the counties don’t have a vested interest in protecting people from themselves unless a third party or a family member comes forward. I imagine there is another side to this story, I have never seen it used like this for someone who is working. Questions remain about why this conservatorship has gone on for 13 years.”
Dr. Nelson believes that the current California laws leave room for abuse. “If the children of a wealthy parent observes the parent spending their inheritance in a way they don’t approve of, they can claim the parent is impaired and needs to be conserved. Usually it doesn’t work, but it’s possible there are times when the courts are swayed.”
Why does it matter and why should psychiatrists be concerned? The issue of involuntary treatment is a contentious one, and the stakeholders on all sides are vocal when it comes to our country’s sickest and most vulnerable individuals. Any story with a whiff of abuse, or of someone who is not severely impaired being denied basic civil rights – including the right to refuse treatment – dilutes and stains the efforts of those who are trying to protect people who suffer from chronic psychotic disorders. And when society reaches further to say that an individual is not entitled to make their own basic life decisions, this further stigmatizes those with psychiatric illnesses. And people with both mental illnesses and substance use disorders often get better, so why would conservatorships be permanent?
Does our society want the courts to protect people from their own poor judgment? Should there be judges at every casino entrance? Where are the conservators for those who live in the streets? Again, this is a half-told story, one where the potential for abuse of the conserved remains a high risk, and the long-term message about involuntary care is one of taking a way a person’s rights unnecessarily.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore. She has no disclosures.
The public has watched the ongoing drama unfold in the media for the past 13 years. In 2008, pop star Britney Spears was placed on conservatorship – a court process that gave decision-making powers over her personal, legal, and financial decisions to another person.
On June 23, 2021, Ms. Spears announced in open court that she is traumatized by being conserved and wants her rights back, but we know little about what behaviors left her family and a judge to determine that she was not capable of managing her own affairs, and why this would remain the case for so many years.
Adam Nelson, MD, practices psychiatry in Marin County, Calif. He explained in an interview that there are different types of conservatorships. “Probate conservatorship is the traditional path for conservatorship of person, estate, and/or finances based on evidence of incapacity due to any medical condition. This is the type of conservatorship that Britney Spears has had and which she is now contesting.”
Ms. Spears was placed on conservatorship after two involuntary hospitalizations for psychiatric illness and/or substance abuse. Her father, Jamie Spears, was appointed by the court to be her conservator.
In a New York Times article, reporters Liz Day, Samantha Stark, and Joe Coscarelli recently wrote: “But now, confidential court records obtained by the New York Times reveal that Ms. Spears, 39, expressed serious opposition to the conservatorship earlier and more often than had previously been known, and said that it restricted everything from whom she dated to the color of her kitchen cabinets.” The article goes on to say: “The newly obtained court records show that Ms. Spears questioned [her father’s] fitness for the role. As early as 2014, in a hearing closed to the public, Ms. Spears’s court-appointed lawyer, Samuel D. Ingham III, said she wanted to explore removing her father as conservator, citing his drinking, among other objections on a ‘shopping list’ of grievances.
“As the fight drags on, the bills are piling up – and, in a quirk of the conservatorship system, Ms. Spears has to pay for lawyers on both sides, including those arguing against her wishes in court. A recent $890,000 bill from one set of Mr. Spears’s lawyers, covering about 4 months of work, included media strategizing for defending the conservatorship.”
The case heated up at the June 23 hearing, when Ms. Spears had a telephone hearing with Los Angeles probate Judge Brenda Penney. The call was transcribed and published in Variety. The purpose of the hearing was for Ms. Spears to request an expedited release from her conservatorship without a psychiatric evaluation.
Ms. Spears began her 23-minute testimony to the judge by discussing her work and how she felt compelled to perform. “My management said, if I don’t do this tour, I will have to find an attorney, and by contract my own management could sue me if I didn’t follow through with the tour. ... So out of fear, I went ahead and I did the tour.”
She then discussed concerns by her manager that she was not complying with her medication regimen.
“Three days later, after I said no to Vegas,” Ms. Spears continued, “my therapist sat me down in a room and said he had a million phone calls about how I was not cooperating in rehearsals, and I haven’t been taking my medication. All this was false. He immediately, the next day, put me on lithium out of nowhere. He took me off my normal meds I’ve been on for 5 years. ... There were six different nurses in my home and they wouldn’t let me get in my car to go anywhere for a month.”
She spoke about entering rehab at the insistence of the conservatorship, and relayed her distress about this experience. She talked poignantly about her frustration of feeling she was not being heard by the court the last time she spoke and about the financial conflicts of interest created by her conservatorship. Ms. Spears, who has appeared on national television, recorded albums, and gone on performance tours during this period, has a net worth estimated at $60 million.
“It’s been a long time since I’ve owned my money. And it’s my wish and my dream for all of this to end without being tested,” she told the judge. “Again, it makes no sense whatsoever for the state of California to sit back and literally watch me with their own two eyes, make a living for so many people, and pay so many people trucks and buses on the road with me and be told, I’m not good enough. But I’m great at what I do. And I allow these people to control what I do, ma’am. And it’s enough. It makes no sense at all.”
Finally, Ms. Spears expressed a heart-wrenching desire to have another child and she asserted that the conservatorship will not allow her to see a doctor to have her IUD removed. She talked about being required to go to therapy three times a week and contended that she is traumatized by all that has transpired.
Ms. Spears has not filed the necessary paperwork to have her conservatorship ended. In an interview with Vice, attorney Scott Rahn noted that the process to end conservatorship can be a lengthy and difficult path. To do so, she might first need to petition the court to be allowed to hire her own attorney. If uncontested, the conservatorship could possibly be ended within months, but otherwise this could entail a lengthy trial over the course of years. While ending conservatorship may entail discovery, depositions, and hearings over years, a scathing story in the New Yorker detailed how Ms. Spears was placed into this conservatorship in a matter of days, without being present to give her own testimony. In the usual circumstances, California law requires that the person being conserved must be given 5 days’ notice before a conservatorship takes place, but Ms. Spears was deemed to be at risk of substantial harm and the judge allowed for an immediate conservatorship. The article notes that even axe murderers are allowed to hire lawyers, while those placed in conservatorships are not.
Reasoning behind such actions
Often, people are appointed guardians, conservators, or payees because of concerns that their psychiatric or substance use disorders, dementia, or impaired intellectual states lead them to poor decisions that endanger their financial stability. Usually the money they may lose is from a government disability benefit, an inheritance, or former accrued wealth. In this unusual celebrity case, Britney Spears has been conserved while she maintained a rigorous work schedule and actively earned the money she is being protected from spending.
Dr. Nelson talked about how people come to be conserved. “The law regarding conservatorship is a state law, but conservatorships in California are done at the county level, and the counties don’t have a vested interest in protecting people from themselves unless a third party or a family member comes forward. I imagine there is another side to this story, I have never seen it used like this for someone who is working. Questions remain about why this conservatorship has gone on for 13 years.”
Dr. Nelson believes that the current California laws leave room for abuse. “If the children of a wealthy parent observes the parent spending their inheritance in a way they don’t approve of, they can claim the parent is impaired and needs to be conserved. Usually it doesn’t work, but it’s possible there are times when the courts are swayed.”
Why does it matter and why should psychiatrists be concerned? The issue of involuntary treatment is a contentious one, and the stakeholders on all sides are vocal when it comes to our country’s sickest and most vulnerable individuals. Any story with a whiff of abuse, or of someone who is not severely impaired being denied basic civil rights – including the right to refuse treatment – dilutes and stains the efforts of those who are trying to protect people who suffer from chronic psychotic disorders. And when society reaches further to say that an individual is not entitled to make their own basic life decisions, this further stigmatizes those with psychiatric illnesses. And people with both mental illnesses and substance use disorders often get better, so why would conservatorships be permanent?
Does our society want the courts to protect people from their own poor judgment? Should there be judges at every casino entrance? Where are the conservators for those who live in the streets? Again, this is a half-told story, one where the potential for abuse of the conserved remains a high risk, and the long-term message about involuntary care is one of taking a way a person’s rights unnecessarily.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore. She has no disclosures.
The public has watched the ongoing drama unfold in the media for the past 13 years. In 2008, pop star Britney Spears was placed on conservatorship – a court process that gave decision-making powers over her personal, legal, and financial decisions to another person.
On June 23, 2021, Ms. Spears announced in open court that she is traumatized by being conserved and wants her rights back, but we know little about what behaviors left her family and a judge to determine that she was not capable of managing her own affairs, and why this would remain the case for so many years.
Adam Nelson, MD, practices psychiatry in Marin County, Calif. He explained in an interview that there are different types of conservatorships. “Probate conservatorship is the traditional path for conservatorship of person, estate, and/or finances based on evidence of incapacity due to any medical condition. This is the type of conservatorship that Britney Spears has had and which she is now contesting.”
Ms. Spears was placed on conservatorship after two involuntary hospitalizations for psychiatric illness and/or substance abuse. Her father, Jamie Spears, was appointed by the court to be her conservator.
In a New York Times article, reporters Liz Day, Samantha Stark, and Joe Coscarelli recently wrote: “But now, confidential court records obtained by the New York Times reveal that Ms. Spears, 39, expressed serious opposition to the conservatorship earlier and more often than had previously been known, and said that it restricted everything from whom she dated to the color of her kitchen cabinets.” The article goes on to say: “The newly obtained court records show that Ms. Spears questioned [her father’s] fitness for the role. As early as 2014, in a hearing closed to the public, Ms. Spears’s court-appointed lawyer, Samuel D. Ingham III, said she wanted to explore removing her father as conservator, citing his drinking, among other objections on a ‘shopping list’ of grievances.
“As the fight drags on, the bills are piling up – and, in a quirk of the conservatorship system, Ms. Spears has to pay for lawyers on both sides, including those arguing against her wishes in court. A recent $890,000 bill from one set of Mr. Spears’s lawyers, covering about 4 months of work, included media strategizing for defending the conservatorship.”
The case heated up at the June 23 hearing, when Ms. Spears had a telephone hearing with Los Angeles probate Judge Brenda Penney. The call was transcribed and published in Variety. The purpose of the hearing was for Ms. Spears to request an expedited release from her conservatorship without a psychiatric evaluation.
Ms. Spears began her 23-minute testimony to the judge by discussing her work and how she felt compelled to perform. “My management said, if I don’t do this tour, I will have to find an attorney, and by contract my own management could sue me if I didn’t follow through with the tour. ... So out of fear, I went ahead and I did the tour.”
She then discussed concerns by her manager that she was not complying with her medication regimen.
“Three days later, after I said no to Vegas,” Ms. Spears continued, “my therapist sat me down in a room and said he had a million phone calls about how I was not cooperating in rehearsals, and I haven’t been taking my medication. All this was false. He immediately, the next day, put me on lithium out of nowhere. He took me off my normal meds I’ve been on for 5 years. ... There were six different nurses in my home and they wouldn’t let me get in my car to go anywhere for a month.”
She spoke about entering rehab at the insistence of the conservatorship, and relayed her distress about this experience. She talked poignantly about her frustration of feeling she was not being heard by the court the last time she spoke and about the financial conflicts of interest created by her conservatorship. Ms. Spears, who has appeared on national television, recorded albums, and gone on performance tours during this period, has a net worth estimated at $60 million.
“It’s been a long time since I’ve owned my money. And it’s my wish and my dream for all of this to end without being tested,” she told the judge. “Again, it makes no sense whatsoever for the state of California to sit back and literally watch me with their own two eyes, make a living for so many people, and pay so many people trucks and buses on the road with me and be told, I’m not good enough. But I’m great at what I do. And I allow these people to control what I do, ma’am. And it’s enough. It makes no sense at all.”
Finally, Ms. Spears expressed a heart-wrenching desire to have another child and she asserted that the conservatorship will not allow her to see a doctor to have her IUD removed. She talked about being required to go to therapy three times a week and contended that she is traumatized by all that has transpired.
Ms. Spears has not filed the necessary paperwork to have her conservatorship ended. In an interview with Vice, attorney Scott Rahn noted that the process to end conservatorship can be a lengthy and difficult path. To do so, she might first need to petition the court to be allowed to hire her own attorney. If uncontested, the conservatorship could possibly be ended within months, but otherwise this could entail a lengthy trial over the course of years. While ending conservatorship may entail discovery, depositions, and hearings over years, a scathing story in the New Yorker detailed how Ms. Spears was placed into this conservatorship in a matter of days, without being present to give her own testimony. In the usual circumstances, California law requires that the person being conserved must be given 5 days’ notice before a conservatorship takes place, but Ms. Spears was deemed to be at risk of substantial harm and the judge allowed for an immediate conservatorship. The article notes that even axe murderers are allowed to hire lawyers, while those placed in conservatorships are not.
Reasoning behind such actions
Often, people are appointed guardians, conservators, or payees because of concerns that their psychiatric or substance use disorders, dementia, or impaired intellectual states lead them to poor decisions that endanger their financial stability. Usually the money they may lose is from a government disability benefit, an inheritance, or former accrued wealth. In this unusual celebrity case, Britney Spears has been conserved while she maintained a rigorous work schedule and actively earned the money she is being protected from spending.
Dr. Nelson talked about how people come to be conserved. “The law regarding conservatorship is a state law, but conservatorships in California are done at the county level, and the counties don’t have a vested interest in protecting people from themselves unless a third party or a family member comes forward. I imagine there is another side to this story, I have never seen it used like this for someone who is working. Questions remain about why this conservatorship has gone on for 13 years.”
Dr. Nelson believes that the current California laws leave room for abuse. “If the children of a wealthy parent observes the parent spending their inheritance in a way they don’t approve of, they can claim the parent is impaired and needs to be conserved. Usually it doesn’t work, but it’s possible there are times when the courts are swayed.”
Why does it matter and why should psychiatrists be concerned? The issue of involuntary treatment is a contentious one, and the stakeholders on all sides are vocal when it comes to our country’s sickest and most vulnerable individuals. Any story with a whiff of abuse, or of someone who is not severely impaired being denied basic civil rights – including the right to refuse treatment – dilutes and stains the efforts of those who are trying to protect people who suffer from chronic psychotic disorders. And when society reaches further to say that an individual is not entitled to make their own basic life decisions, this further stigmatizes those with psychiatric illnesses. And people with both mental illnesses and substance use disorders often get better, so why would conservatorships be permanent?
Does our society want the courts to protect people from their own poor judgment? Should there be judges at every casino entrance? Where are the conservators for those who live in the streets? Again, this is a half-told story, one where the potential for abuse of the conserved remains a high risk, and the long-term message about involuntary care is one of taking a way a person’s rights unnecessarily.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore. She has no disclosures.
When can your hypochondria help patients?
Hypochondria has been useful to my patients. I mean my own hypochondria. It may not take one to know one, but we hypochondriacs understand each other.
Hypochondriacs worry that we are sick, worry that our fears are foolish and that we will be mocked for worrying about nothing, and worry even more that this time, we finally worried about something after all. Reassurance leaves us sheepish, then elated. Elation soon fades, and a new worry appears. Worry, rinse, repeat. . Some folks are just needy. Soothing the needs of the needy can feel like trying to drain the seven seas with a teaspoon. Those who work with people must either find ways to cope with the spectrum of neediness, or find another kind of work to do.
Some patient needs call for diagnosis and treatment. Other needs go beyond the strictly medical. Beyond knowing whether they are ill, patients have questions like, “Will this get worse?” “Will I be ashamed to go out in public?” “Can I visit my grandchildren, or will my daughter-in-law throw me out as contagious?” “Is this the beginning of the end?” or, worst of all, “Am I losing my hair?”
The list of possible patient needs is long, though not endless. Lining them up one after the other can make them sound melodramatic, even silly. (Other people’s worries often sound silly; your own never do.) Can a small growth or slight itch really cause existential agitation? Anyone who deals with complaints like these knows that the answer is yes.
Hypochondriacs with medical degrees cannot reassure themselves, but we can bring useful experience to help other members of the worry club. Doing so means paying attention not just to what doctors worry about but what patients do.
Sometimes a patient is terrified, the doctor not at all. Gentle sympathy may be enough. But the reverse can also be true: The doctor is concerned, but the patient thinks there is no problem. Sometimes I am worried enough to ask a patient to call or email an update. Patients who have already stopped worrying may not bother to answer the phone or shoot back an email. Failure to respond may mean they are fine, or in intensive care. Silence is hard to interpret.
Skin doctors have one advantageous disadvantage: Few tests help us beyond a skin scraping, the odd blood test, or a biopsy. Otherwise, most of the time all we can do is look, and perhaps apply “tincture of time,” watching the clinical course. We cannot send patients for the complex and expensive tests our colleagues use “just to be sure,” because we have no such tests to send them for.
Practice and experience help us recognize needs and worries that patients might not express. For instance, a man may show up with pimples on his back. His concerns seem intense. “What worries you?” we ask. The patient whispers, “It couldn’t be ... shingles, could it?” No, it couldn’t be shingles, because it is bilateral and for many other reasons.
The question is not whether he has shingles but why he thinks he does. Maybe his aunt suggested it. Or an article told him to watch out for it. Or his pharmacy is promoting zoster vaccination by showing huge, full-color photos of shingles cases worthy of horror movies. (Shingles the 13th!) Because he wants to visit his grandkids and his daughter is in her fourth month of pregnancy. In other words, along with the fear of cancer, fear of shingles is just out there. There are other such public concerns. Over time, we come to recognize them.
Anyone can worry, but anxiety paralyzes some to such an extent that referral to a mental health professional seems reasonable. The problem with advising it is that patients who somaticize may take exception to suggestions, however delicately put, that make us sound dismissive, locating their concern “all in the head.” Over the years, my attempts to make such referrals have met with limited success.
Dealing with needs – and neediness – can take up more of a doctor’s day than making specific diagnoses and prescribing helpful treatments. Besides, addressing needs and neediness demands skills not always stressed at school.
Practice at noting neediness makes you better at it, but no doctor nails the true wellsprings of worry all the time. We hypochondriacs can be devilishly inventive.
Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semiretired, after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His latest book, “Doctoring from the Outside In,” was recently published. Write to him at dermnews@mdedge.com.
Hypochondria has been useful to my patients. I mean my own hypochondria. It may not take one to know one, but we hypochondriacs understand each other.
Hypochondriacs worry that we are sick, worry that our fears are foolish and that we will be mocked for worrying about nothing, and worry even more that this time, we finally worried about something after all. Reassurance leaves us sheepish, then elated. Elation soon fades, and a new worry appears. Worry, rinse, repeat. . Some folks are just needy. Soothing the needs of the needy can feel like trying to drain the seven seas with a teaspoon. Those who work with people must either find ways to cope with the spectrum of neediness, or find another kind of work to do.
Some patient needs call for diagnosis and treatment. Other needs go beyond the strictly medical. Beyond knowing whether they are ill, patients have questions like, “Will this get worse?” “Will I be ashamed to go out in public?” “Can I visit my grandchildren, or will my daughter-in-law throw me out as contagious?” “Is this the beginning of the end?” or, worst of all, “Am I losing my hair?”
The list of possible patient needs is long, though not endless. Lining them up one after the other can make them sound melodramatic, even silly. (Other people’s worries often sound silly; your own never do.) Can a small growth or slight itch really cause existential agitation? Anyone who deals with complaints like these knows that the answer is yes.
Hypochondriacs with medical degrees cannot reassure themselves, but we can bring useful experience to help other members of the worry club. Doing so means paying attention not just to what doctors worry about but what patients do.
Sometimes a patient is terrified, the doctor not at all. Gentle sympathy may be enough. But the reverse can also be true: The doctor is concerned, but the patient thinks there is no problem. Sometimes I am worried enough to ask a patient to call or email an update. Patients who have already stopped worrying may not bother to answer the phone or shoot back an email. Failure to respond may mean they are fine, or in intensive care. Silence is hard to interpret.
Skin doctors have one advantageous disadvantage: Few tests help us beyond a skin scraping, the odd blood test, or a biopsy. Otherwise, most of the time all we can do is look, and perhaps apply “tincture of time,” watching the clinical course. We cannot send patients for the complex and expensive tests our colleagues use “just to be sure,” because we have no such tests to send them for.
Practice and experience help us recognize needs and worries that patients might not express. For instance, a man may show up with pimples on his back. His concerns seem intense. “What worries you?” we ask. The patient whispers, “It couldn’t be ... shingles, could it?” No, it couldn’t be shingles, because it is bilateral and for many other reasons.
The question is not whether he has shingles but why he thinks he does. Maybe his aunt suggested it. Or an article told him to watch out for it. Or his pharmacy is promoting zoster vaccination by showing huge, full-color photos of shingles cases worthy of horror movies. (Shingles the 13th!) Because he wants to visit his grandkids and his daughter is in her fourth month of pregnancy. In other words, along with the fear of cancer, fear of shingles is just out there. There are other such public concerns. Over time, we come to recognize them.
Anyone can worry, but anxiety paralyzes some to such an extent that referral to a mental health professional seems reasonable. The problem with advising it is that patients who somaticize may take exception to suggestions, however delicately put, that make us sound dismissive, locating their concern “all in the head.” Over the years, my attempts to make such referrals have met with limited success.
Dealing with needs – and neediness – can take up more of a doctor’s day than making specific diagnoses and prescribing helpful treatments. Besides, addressing needs and neediness demands skills not always stressed at school.
Practice at noting neediness makes you better at it, but no doctor nails the true wellsprings of worry all the time. We hypochondriacs can be devilishly inventive.
Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semiretired, after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His latest book, “Doctoring from the Outside In,” was recently published. Write to him at dermnews@mdedge.com.
Hypochondria has been useful to my patients. I mean my own hypochondria. It may not take one to know one, but we hypochondriacs understand each other.
Hypochondriacs worry that we are sick, worry that our fears are foolish and that we will be mocked for worrying about nothing, and worry even more that this time, we finally worried about something after all. Reassurance leaves us sheepish, then elated. Elation soon fades, and a new worry appears. Worry, rinse, repeat. . Some folks are just needy. Soothing the needs of the needy can feel like trying to drain the seven seas with a teaspoon. Those who work with people must either find ways to cope with the spectrum of neediness, or find another kind of work to do.
Some patient needs call for diagnosis and treatment. Other needs go beyond the strictly medical. Beyond knowing whether they are ill, patients have questions like, “Will this get worse?” “Will I be ashamed to go out in public?” “Can I visit my grandchildren, or will my daughter-in-law throw me out as contagious?” “Is this the beginning of the end?” or, worst of all, “Am I losing my hair?”
The list of possible patient needs is long, though not endless. Lining them up one after the other can make them sound melodramatic, even silly. (Other people’s worries often sound silly; your own never do.) Can a small growth or slight itch really cause existential agitation? Anyone who deals with complaints like these knows that the answer is yes.
Hypochondriacs with medical degrees cannot reassure themselves, but we can bring useful experience to help other members of the worry club. Doing so means paying attention not just to what doctors worry about but what patients do.
Sometimes a patient is terrified, the doctor not at all. Gentle sympathy may be enough. But the reverse can also be true: The doctor is concerned, but the patient thinks there is no problem. Sometimes I am worried enough to ask a patient to call or email an update. Patients who have already stopped worrying may not bother to answer the phone or shoot back an email. Failure to respond may mean they are fine, or in intensive care. Silence is hard to interpret.
Skin doctors have one advantageous disadvantage: Few tests help us beyond a skin scraping, the odd blood test, or a biopsy. Otherwise, most of the time all we can do is look, and perhaps apply “tincture of time,” watching the clinical course. We cannot send patients for the complex and expensive tests our colleagues use “just to be sure,” because we have no such tests to send them for.
Practice and experience help us recognize needs and worries that patients might not express. For instance, a man may show up with pimples on his back. His concerns seem intense. “What worries you?” we ask. The patient whispers, “It couldn’t be ... shingles, could it?” No, it couldn’t be shingles, because it is bilateral and for many other reasons.
The question is not whether he has shingles but why he thinks he does. Maybe his aunt suggested it. Or an article told him to watch out for it. Or his pharmacy is promoting zoster vaccination by showing huge, full-color photos of shingles cases worthy of horror movies. (Shingles the 13th!) Because he wants to visit his grandkids and his daughter is in her fourth month of pregnancy. In other words, along with the fear of cancer, fear of shingles is just out there. There are other such public concerns. Over time, we come to recognize them.
Anyone can worry, but anxiety paralyzes some to such an extent that referral to a mental health professional seems reasonable. The problem with advising it is that patients who somaticize may take exception to suggestions, however delicately put, that make us sound dismissive, locating their concern “all in the head.” Over the years, my attempts to make such referrals have met with limited success.
Dealing with needs – and neediness – can take up more of a doctor’s day than making specific diagnoses and prescribing helpful treatments. Besides, addressing needs and neediness demands skills not always stressed at school.
Practice at noting neediness makes you better at it, but no doctor nails the true wellsprings of worry all the time. We hypochondriacs can be devilishly inventive.
Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semiretired, after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His latest book, “Doctoring from the Outside In,” was recently published. Write to him at dermnews@mdedge.com.
What’s my number? Do I really need $10 million to retire from my medical practice?
“What’s my number?” When I hear this from my financial planning clients, I know they mean: In my 20-year career, this “magic number” is by far the most common thing physicians want to know.
If you look online, articles may recommend having a portfolio valued at $2 million, $5 million, and not uncommonly $10 million or more to retire. Really? $10 million? You might be thinking that surely not everyone needs that amount. Luckily, that’s true.
There’s no magic number your portfolio should be – just your number.
It’s human nature to want a simple, clear target to shoot for. But unfortunately, there’s no generic answer when it comes to saving for retirement. Even after a comprehensive hour-long review of a client’s financial plan – including insurance, investments, estate planning, and other items – the most honest answer I can give is: “It depends.” Not satisfying, I know. But there are still too many holes to fill.
By far the most important factor in getting beyond “it depends” is having an accurate estimate of annual retirement expenses. I have clients who live comfortably on $50,000 a year in retirement and others who need $250,000 or more. Knowing how much you need – your personal number – depends on the individual’s unique dream for retirement and calculating what that dream will cost.
Form a guesstimate based on savings and anticipated expenses
The total portfolio value needed to sustain an annual expense of $50,000 a year in retirement spending versus the portfolio size needed for $250,000 or more, blows apart the fiction of a universal “magic number.” It’s just not that simple. While it’s hard to gauge exactly what you will need, the right information can lead to a logical guesstimate about what size portfolio will provide you with financial independence.
In the end, it’s up to you to determine your desired retirement lifestyle. Then, the only way to get there is to calculate how much it will cost and save up for it by following a well-informed financial plan. This plan will be based on strategy that shifts from the middle to the later stages of your medical career and into retirement.
Let’s see how it works.
Early to mid-career: Focus on building up retirement savings
We ultimately want to save enough to meet our retirement expenses. But figuring out how much to save when you’re in your 40s and 50s is difficult. A mid-career physician likely has significant family- and child-related expenses. When we become empty-nesters, those expenses will decline. In retirement they may disappear entirely, but new expenses may arise.
With large variations in expenses at different life stages, it’s hard to calculate exactly how much you will need to save. Early on, the most sensible thing is putting aside a “reasonable” percentage of gross income for retirement savings.
What is a ‘reasonable’ savings goal for retirement?
As is often the case with high-income earners, many of our clients don’t have a budget or a clear picture of their current expenses and spending habits. That’s alright as long as they are building up a reasonable nest egg for the future – which begs the question of what is reasonable.
For mid-career docs, a reasonable goal to aim for is putting aside 20% of gross income for retirement. What you spend the rest of your money on is less important than how much you’re saving.
This is quite different from how you’ll handle expenses during retirement, when you no longer have a steady stream of income; rather, you have a pot of money that needs to last you another 20, 30, or even 40 years. At that point, thinking about specific expenses becomes more important (more on this topic later). That said, if you’re a mid-career doctor who is not meeting this 20% savings goal, it’s time to make a plan that will free up cash for retirement savings and investments.
Later-career docs: Calculate your spending level in retirement
Financial success means having a portfolio that can support your retirement dreams – with the confidence that your money will last and you won’t need to watch every dollar you spend. As you near retirement, your focus will shift away from accumulating savings to calculating the annual expenses you will have to meet in retirement.
A good place to start is figuring out which expenses will be necessary and which will be more flexible. To do this, separate your anticipated spending into these two categories:
- Fixed expenses: You can confidently forecast your “must-have” fixed expenses – such as property taxes, property/casualty insurance, health care costs, utilities, and groceries – because they remain steady from month to month.
- Discretionary expenses: These “like-to-have” expenses vary from month to month. This makes them harder to predict but easier to control. They might include dining out, travel, and charitable contributions.
As a retiree, understanding your fixed and discretionary expenses can help you prepare for a bear market, when the stock market can decline by 20% or more. Your portfolio won’t consist entirely of stocks, so it shouldn’t drop to that degree. Still, it will decline significantly. You may need to cut back on spending for a year or 2 to allow your portfolio to recover, particularly if the portfolio declines early in retirement.
Are you ready for retirement?
During the long bull market preceding the great recession of 2007 and 2009, many physicians retired –only to return to their practices when their portfolio values plummeted. In the exuberance of the moment, many failed to heed the warnings of many economists and got caught flat-footed.
Right now it’s a bull market, but we’re seeing concerning signs, such as an out-of-control housing market and rumblings about inflation and rising consumer costs. Sound familiar? If you hope to retire soon, take the time to objectively look around the corner so you can plan appropriately – whether your goal is to retire completely, stay in practice part-time, or even take on a new opportunity.
In an “it-depends” world, don’t be lured by a fictitious magic number, no matter what comes up when you Google: “When can I retire?” Instead, save early, imagine your dream retirement, and calculate expenses later to see what’s possible.
Dr. Greenwald is a graduate of the Albert Einstein College of Medicine, New York. Dr. Greenwald completed his internal medicine residency at the University of Minnesota, Minneapolis. He practiced internal medicine in the Twin Cities for 11 years before making the transition to financial planning for physicians, beginning in 1998.
A version of this article first appeared on Medscape.com.
“What’s my number?” When I hear this from my financial planning clients, I know they mean: In my 20-year career, this “magic number” is by far the most common thing physicians want to know.
If you look online, articles may recommend having a portfolio valued at $2 million, $5 million, and not uncommonly $10 million or more to retire. Really? $10 million? You might be thinking that surely not everyone needs that amount. Luckily, that’s true.
There’s no magic number your portfolio should be – just your number.
It’s human nature to want a simple, clear target to shoot for. But unfortunately, there’s no generic answer when it comes to saving for retirement. Even after a comprehensive hour-long review of a client’s financial plan – including insurance, investments, estate planning, and other items – the most honest answer I can give is: “It depends.” Not satisfying, I know. But there are still too many holes to fill.
By far the most important factor in getting beyond “it depends” is having an accurate estimate of annual retirement expenses. I have clients who live comfortably on $50,000 a year in retirement and others who need $250,000 or more. Knowing how much you need – your personal number – depends on the individual’s unique dream for retirement and calculating what that dream will cost.
Form a guesstimate based on savings and anticipated expenses
The total portfolio value needed to sustain an annual expense of $50,000 a year in retirement spending versus the portfolio size needed for $250,000 or more, blows apart the fiction of a universal “magic number.” It’s just not that simple. While it’s hard to gauge exactly what you will need, the right information can lead to a logical guesstimate about what size portfolio will provide you with financial independence.
In the end, it’s up to you to determine your desired retirement lifestyle. Then, the only way to get there is to calculate how much it will cost and save up for it by following a well-informed financial plan. This plan will be based on strategy that shifts from the middle to the later stages of your medical career and into retirement.
Let’s see how it works.
Early to mid-career: Focus on building up retirement savings
We ultimately want to save enough to meet our retirement expenses. But figuring out how much to save when you’re in your 40s and 50s is difficult. A mid-career physician likely has significant family- and child-related expenses. When we become empty-nesters, those expenses will decline. In retirement they may disappear entirely, but new expenses may arise.
With large variations in expenses at different life stages, it’s hard to calculate exactly how much you will need to save. Early on, the most sensible thing is putting aside a “reasonable” percentage of gross income for retirement savings.
What is a ‘reasonable’ savings goal for retirement?
As is often the case with high-income earners, many of our clients don’t have a budget or a clear picture of their current expenses and spending habits. That’s alright as long as they are building up a reasonable nest egg for the future – which begs the question of what is reasonable.
For mid-career docs, a reasonable goal to aim for is putting aside 20% of gross income for retirement. What you spend the rest of your money on is less important than how much you’re saving.
This is quite different from how you’ll handle expenses during retirement, when you no longer have a steady stream of income; rather, you have a pot of money that needs to last you another 20, 30, or even 40 years. At that point, thinking about specific expenses becomes more important (more on this topic later). That said, if you’re a mid-career doctor who is not meeting this 20% savings goal, it’s time to make a plan that will free up cash for retirement savings and investments.
Later-career docs: Calculate your spending level in retirement
Financial success means having a portfolio that can support your retirement dreams – with the confidence that your money will last and you won’t need to watch every dollar you spend. As you near retirement, your focus will shift away from accumulating savings to calculating the annual expenses you will have to meet in retirement.
A good place to start is figuring out which expenses will be necessary and which will be more flexible. To do this, separate your anticipated spending into these two categories:
- Fixed expenses: You can confidently forecast your “must-have” fixed expenses – such as property taxes, property/casualty insurance, health care costs, utilities, and groceries – because they remain steady from month to month.
- Discretionary expenses: These “like-to-have” expenses vary from month to month. This makes them harder to predict but easier to control. They might include dining out, travel, and charitable contributions.
As a retiree, understanding your fixed and discretionary expenses can help you prepare for a bear market, when the stock market can decline by 20% or more. Your portfolio won’t consist entirely of stocks, so it shouldn’t drop to that degree. Still, it will decline significantly. You may need to cut back on spending for a year or 2 to allow your portfolio to recover, particularly if the portfolio declines early in retirement.
Are you ready for retirement?
During the long bull market preceding the great recession of 2007 and 2009, many physicians retired –only to return to their practices when their portfolio values plummeted. In the exuberance of the moment, many failed to heed the warnings of many economists and got caught flat-footed.
Right now it’s a bull market, but we’re seeing concerning signs, such as an out-of-control housing market and rumblings about inflation and rising consumer costs. Sound familiar? If you hope to retire soon, take the time to objectively look around the corner so you can plan appropriately – whether your goal is to retire completely, stay in practice part-time, or even take on a new opportunity.
In an “it-depends” world, don’t be lured by a fictitious magic number, no matter what comes up when you Google: “When can I retire?” Instead, save early, imagine your dream retirement, and calculate expenses later to see what’s possible.
Dr. Greenwald is a graduate of the Albert Einstein College of Medicine, New York. Dr. Greenwald completed his internal medicine residency at the University of Minnesota, Minneapolis. He practiced internal medicine in the Twin Cities for 11 years before making the transition to financial planning for physicians, beginning in 1998.
A version of this article first appeared on Medscape.com.
“What’s my number?” When I hear this from my financial planning clients, I know they mean: In my 20-year career, this “magic number” is by far the most common thing physicians want to know.
If you look online, articles may recommend having a portfolio valued at $2 million, $5 million, and not uncommonly $10 million or more to retire. Really? $10 million? You might be thinking that surely not everyone needs that amount. Luckily, that’s true.
There’s no magic number your portfolio should be – just your number.
It’s human nature to want a simple, clear target to shoot for. But unfortunately, there’s no generic answer when it comes to saving for retirement. Even after a comprehensive hour-long review of a client’s financial plan – including insurance, investments, estate planning, and other items – the most honest answer I can give is: “It depends.” Not satisfying, I know. But there are still too many holes to fill.
By far the most important factor in getting beyond “it depends” is having an accurate estimate of annual retirement expenses. I have clients who live comfortably on $50,000 a year in retirement and others who need $250,000 or more. Knowing how much you need – your personal number – depends on the individual’s unique dream for retirement and calculating what that dream will cost.
Form a guesstimate based on savings and anticipated expenses
The total portfolio value needed to sustain an annual expense of $50,000 a year in retirement spending versus the portfolio size needed for $250,000 or more, blows apart the fiction of a universal “magic number.” It’s just not that simple. While it’s hard to gauge exactly what you will need, the right information can lead to a logical guesstimate about what size portfolio will provide you with financial independence.
In the end, it’s up to you to determine your desired retirement lifestyle. Then, the only way to get there is to calculate how much it will cost and save up for it by following a well-informed financial plan. This plan will be based on strategy that shifts from the middle to the later stages of your medical career and into retirement.
Let’s see how it works.
Early to mid-career: Focus on building up retirement savings
We ultimately want to save enough to meet our retirement expenses. But figuring out how much to save when you’re in your 40s and 50s is difficult. A mid-career physician likely has significant family- and child-related expenses. When we become empty-nesters, those expenses will decline. In retirement they may disappear entirely, but new expenses may arise.
With large variations in expenses at different life stages, it’s hard to calculate exactly how much you will need to save. Early on, the most sensible thing is putting aside a “reasonable” percentage of gross income for retirement savings.
What is a ‘reasonable’ savings goal for retirement?
As is often the case with high-income earners, many of our clients don’t have a budget or a clear picture of their current expenses and spending habits. That’s alright as long as they are building up a reasonable nest egg for the future – which begs the question of what is reasonable.
For mid-career docs, a reasonable goal to aim for is putting aside 20% of gross income for retirement. What you spend the rest of your money on is less important than how much you’re saving.
This is quite different from how you’ll handle expenses during retirement, when you no longer have a steady stream of income; rather, you have a pot of money that needs to last you another 20, 30, or even 40 years. At that point, thinking about specific expenses becomes more important (more on this topic later). That said, if you’re a mid-career doctor who is not meeting this 20% savings goal, it’s time to make a plan that will free up cash for retirement savings and investments.
Later-career docs: Calculate your spending level in retirement
Financial success means having a portfolio that can support your retirement dreams – with the confidence that your money will last and you won’t need to watch every dollar you spend. As you near retirement, your focus will shift away from accumulating savings to calculating the annual expenses you will have to meet in retirement.
A good place to start is figuring out which expenses will be necessary and which will be more flexible. To do this, separate your anticipated spending into these two categories:
- Fixed expenses: You can confidently forecast your “must-have” fixed expenses – such as property taxes, property/casualty insurance, health care costs, utilities, and groceries – because they remain steady from month to month.
- Discretionary expenses: These “like-to-have” expenses vary from month to month. This makes them harder to predict but easier to control. They might include dining out, travel, and charitable contributions.
As a retiree, understanding your fixed and discretionary expenses can help you prepare for a bear market, when the stock market can decline by 20% or more. Your portfolio won’t consist entirely of stocks, so it shouldn’t drop to that degree. Still, it will decline significantly. You may need to cut back on spending for a year or 2 to allow your portfolio to recover, particularly if the portfolio declines early in retirement.
Are you ready for retirement?
During the long bull market preceding the great recession of 2007 and 2009, many physicians retired –only to return to their practices when their portfolio values plummeted. In the exuberance of the moment, many failed to heed the warnings of many economists and got caught flat-footed.
Right now it’s a bull market, but we’re seeing concerning signs, such as an out-of-control housing market and rumblings about inflation and rising consumer costs. Sound familiar? If you hope to retire soon, take the time to objectively look around the corner so you can plan appropriately – whether your goal is to retire completely, stay in practice part-time, or even take on a new opportunity.
In an “it-depends” world, don’t be lured by a fictitious magic number, no matter what comes up when you Google: “When can I retire?” Instead, save early, imagine your dream retirement, and calculate expenses later to see what’s possible.
Dr. Greenwald is a graduate of the Albert Einstein College of Medicine, New York. Dr. Greenwald completed his internal medicine residency at the University of Minnesota, Minneapolis. He practiced internal medicine in the Twin Cities for 11 years before making the transition to financial planning for physicians, beginning in 1998.
A version of this article first appeared on Medscape.com.
The challenge of poverty to health and success: What should pediatricians do?
Some days it feels like more than half of the journal articles I encounter report data suggesting that poverty is associated with some disease entity. I realize that young postgraduates are under some pressure to publish, but I’m ready for a break. I and most pediatricians already know, or at least have assumed, that in general and with few exceptions unwellness and poverty are closely linked. Whether that association is causal or not is a more interesting question. The answer, I suspect, depends on which health condition we are talking about. For the moment I think we should assume that poverty is more likely a major contributor and not merely a fellow traveler of poor health.
Some other questions: What are we as pediatricians expected to do about poverty? Is awareness sufficient? Should I be content with having an elevated awareness that a certain patient has a given disease because I know his family is economically challenged? Or, conversely, should I be satisfied that I have asked about a family’s economic distress when I have just diagnosed a child with asthma? The answer to those questions is a very personal one for each of us to ponder and may depend on where we feel we can best invest our time and skill set.
Like me, you may feel that the focus of your professional life is better spent diagnosing and treating the collateral damage of poverty and addressing economic inequities in your philanthropic activities and your choices at the polls. On the other hand, you may choose to use your public persona as a physician to more actively address poverty whether it is on a local, national, or global stage. There is no correct answer and a hybrid may work best for you.
On the other hand, while you agree that there is some link between poverty and unwellness, perhaps the issue is overblown and we should pay more attention to other factors such as the sad state of the family in both disadvantaged and advantaged populations. Maybe if we worked harder to foster and support two-parent families the drag of economic disadvantage would be reduced.
I recently encountered a study that explores this very question. Christina Cross, PhD, a postdoctoral fellow in the department of sociology at Harvard University, reports on her soon-to-be-published study of a nationally representative sample in which she found that, using a selection of academic metrics including earned grades, likelihood of grade repetition, and rates of suspension, in low-income families there was no difference in achievement between Black youth raised in single-parent households and Black youth raised in two-parent households. However, in well-off families, Black youth raised in two-parent households had better academic metrics. (“Why living in a two-parent home isn’t a cure-all for Black students.” Christina Cross. The Harvard Gazette. 2021 Jun 3).
I guess few of us are surprised that living in a two-parent household can provide a child with some advantages. However, it is disappointing and again not surprising that poverty can rob a child of these advantages. While it may make us feel like we are doing something when we offer counseling that promotes two-family households, this may be no more valuable than supporting apple pie and motherhood. Dr. Cross concludes that President Biden’s proposed American Families Plan is more likely to succeed than those focused on counseling because it will offer direct financial support with its tax credits and subsidies.*
Let’s hope she is correct.
* This story was updated on July 6, 2021.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
Some days it feels like more than half of the journal articles I encounter report data suggesting that poverty is associated with some disease entity. I realize that young postgraduates are under some pressure to publish, but I’m ready for a break. I and most pediatricians already know, or at least have assumed, that in general and with few exceptions unwellness and poverty are closely linked. Whether that association is causal or not is a more interesting question. The answer, I suspect, depends on which health condition we are talking about. For the moment I think we should assume that poverty is more likely a major contributor and not merely a fellow traveler of poor health.
Some other questions: What are we as pediatricians expected to do about poverty? Is awareness sufficient? Should I be content with having an elevated awareness that a certain patient has a given disease because I know his family is economically challenged? Or, conversely, should I be satisfied that I have asked about a family’s economic distress when I have just diagnosed a child with asthma? The answer to those questions is a very personal one for each of us to ponder and may depend on where we feel we can best invest our time and skill set.
Like me, you may feel that the focus of your professional life is better spent diagnosing and treating the collateral damage of poverty and addressing economic inequities in your philanthropic activities and your choices at the polls. On the other hand, you may choose to use your public persona as a physician to more actively address poverty whether it is on a local, national, or global stage. There is no correct answer and a hybrid may work best for you.
On the other hand, while you agree that there is some link between poverty and unwellness, perhaps the issue is overblown and we should pay more attention to other factors such as the sad state of the family in both disadvantaged and advantaged populations. Maybe if we worked harder to foster and support two-parent families the drag of economic disadvantage would be reduced.
I recently encountered a study that explores this very question. Christina Cross, PhD, a postdoctoral fellow in the department of sociology at Harvard University, reports on her soon-to-be-published study of a nationally representative sample in which she found that, using a selection of academic metrics including earned grades, likelihood of grade repetition, and rates of suspension, in low-income families there was no difference in achievement between Black youth raised in single-parent households and Black youth raised in two-parent households. However, in well-off families, Black youth raised in two-parent households had better academic metrics. (“Why living in a two-parent home isn’t a cure-all for Black students.” Christina Cross. The Harvard Gazette. 2021 Jun 3).
I guess few of us are surprised that living in a two-parent household can provide a child with some advantages. However, it is disappointing and again not surprising that poverty can rob a child of these advantages. While it may make us feel like we are doing something when we offer counseling that promotes two-family households, this may be no more valuable than supporting apple pie and motherhood. Dr. Cross concludes that President Biden’s proposed American Families Plan is more likely to succeed than those focused on counseling because it will offer direct financial support with its tax credits and subsidies.*
Let’s hope she is correct.
* This story was updated on July 6, 2021.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
Some days it feels like more than half of the journal articles I encounter report data suggesting that poverty is associated with some disease entity. I realize that young postgraduates are under some pressure to publish, but I’m ready for a break. I and most pediatricians already know, or at least have assumed, that in general and with few exceptions unwellness and poverty are closely linked. Whether that association is causal or not is a more interesting question. The answer, I suspect, depends on which health condition we are talking about. For the moment I think we should assume that poverty is more likely a major contributor and not merely a fellow traveler of poor health.
Some other questions: What are we as pediatricians expected to do about poverty? Is awareness sufficient? Should I be content with having an elevated awareness that a certain patient has a given disease because I know his family is economically challenged? Or, conversely, should I be satisfied that I have asked about a family’s economic distress when I have just diagnosed a child with asthma? The answer to those questions is a very personal one for each of us to ponder and may depend on where we feel we can best invest our time and skill set.
Like me, you may feel that the focus of your professional life is better spent diagnosing and treating the collateral damage of poverty and addressing economic inequities in your philanthropic activities and your choices at the polls. On the other hand, you may choose to use your public persona as a physician to more actively address poverty whether it is on a local, national, or global stage. There is no correct answer and a hybrid may work best for you.
On the other hand, while you agree that there is some link between poverty and unwellness, perhaps the issue is overblown and we should pay more attention to other factors such as the sad state of the family in both disadvantaged and advantaged populations. Maybe if we worked harder to foster and support two-parent families the drag of economic disadvantage would be reduced.
I recently encountered a study that explores this very question. Christina Cross, PhD, a postdoctoral fellow in the department of sociology at Harvard University, reports on her soon-to-be-published study of a nationally representative sample in which she found that, using a selection of academic metrics including earned grades, likelihood of grade repetition, and rates of suspension, in low-income families there was no difference in achievement between Black youth raised in single-parent households and Black youth raised in two-parent households. However, in well-off families, Black youth raised in two-parent households had better academic metrics. (“Why living in a two-parent home isn’t a cure-all for Black students.” Christina Cross. The Harvard Gazette. 2021 Jun 3).
I guess few of us are surprised that living in a two-parent household can provide a child with some advantages. However, it is disappointing and again not surprising that poverty can rob a child of these advantages. While it may make us feel like we are doing something when we offer counseling that promotes two-family households, this may be no more valuable than supporting apple pie and motherhood. Dr. Cross concludes that President Biden’s proposed American Families Plan is more likely to succeed than those focused on counseling because it will offer direct financial support with its tax credits and subsidies.*
Let’s hope she is correct.
* This story was updated on July 6, 2021.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.