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Treating homeless patients: Book offers key insights
As a psychiatrist dedicated to working with people who are experiencing homelessness, I was very impressed with the new book edited by Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH, and Maria D. Llorente, MD, about treating and providing services to this vulnerable population.
The book, “Clinical Management of the Homeless Patient: Social, Psychiatric, and Medical Issues” (Cham, Switzerland: Springer Nature Switzerland, 2021), offers an in-depth review and analysis of the biopsychosocial complexities that affect how medical and behavioral health conditions present in those who are unhoused. Notably, the book recommends with great sensitivity best practices to address these conditions with care, understanding, and love.
This text, invaluable in particular for those of us clinicians who work with people experiencing homelessness (PEH), provides a historical context of homelessness in the United States, an evaluation of the current state, and indispensable guidance for medical and behavioral health practitioners, case managers, housing navigators, and policy makers alike. It also serves as an inspiring source for those who are considering work in the public sector while reminding those of us in the field why we continue to do this challenging and rewarding work.
Tips can provide hope to clinicians
The volume is divided into four clear sections that are easy to navigate depending on your area of expertise and interest. Each chapter consolidates an extensive literature review into an intriguing and thought-provoking analysis. Part I, “The Big Picture – Social and Medical Issues,” focuses on conditions that disproportionately affect those who are unhoused. The authors offer a glimpse into the unique challenges of managing routine health conditions. They also detail the practical knowledge that’s needed to best care for our most vulnerable neighbors; for example, promoting a shared decision-making model; simplifying treatment plans; prescribing, when possible, medications that are dosed daily – instead of multiple times per day; allowing for walk-in appointments; and addressing cultural, linguistic, and educational barriers.
Most chapters highlight informative case examples that bring the text to life. It can be heartbreaking to recognize and witness the inhumane conditions in which PEH live, and these practical tips and suggestions for future policies based on best practices can help prevent burnout and provide hope for those who care for this community.
Part II, “Psychiatric Issues and Treatments,” presents a brief yet comprehensive history on homelessness, beginning with the deep shame that PEH experienced in Colonial times as the result of cultural and religious influences. Sadly, that negative judgment continues to this day.
The authors also explain how deinstitutionalization and transinstitutionalization have shaped the current state of homelessness, including why many PEH receive their care in emergency departments while incarcerated. This section highlights the barriers of care that are created not just by the patient, but also by the clinicians and systems of care – and what’s needed practically to overcome those challenges.
I appreciate the chapter on substance use disorders. It reminds us that the most commonly used substance among PEH is tobacco, which has serious health effects and for which we have treatment; nevertheless, . This section also provides examples of the trauma-informed language to use when addressing difficult and sometimes stigmatizing topics, such as survival sex and trauma history.
The evidence-based discussion continues in Part III with a focus on topics that everyone working with PEH should understand, including food insecurity, the criminal justice system, and sex trafficking. Part IV highlights best practices that should be replicated in every community, including Housing First approaches, medical respite care, and multiple Veterans Administration programs.
Throughout the text, major themes reverberate across the chapters, beginning with empathy. All who work with PEH must understand the conditions and challenges PEH face every day that affect their physical and mental health. The authors offer a stark and pointed reminder that being unhoused amounts to a full-time job just to meet basic needs. In addition, the devastating role of trauma and structural racism in creating and promoting the conditions that lead someone to be unhoused cannot be underestimated.
Fortunately, the primary aim of the book is to highlight solutions, and it’s here that the book shines. While some interventions are well-known, such as the importance of working in multidisciplinary teams, building trust and rapport with our patients, and urging clinicians and institutions to examine their own judgments and biases that might interfere with humane treatment, other suggestions will lead some readers into new territory. The authors, for example, maintain that we need more data and evidence-based research that include PEH. They also make a case for more preventive care and enhanced professional education for all health care workers that centers on trauma-informed care, social determinants of health, and the unique needs of especially vulnerable communities, such as the unhoused LBGTQ+ community and policies that promote best practices, such as Housing First. The book is a stirring read. It offers both inspiration and practical guidance for all who are currently working with or interested in caring for people experiencing homelessness.
Dr. Bird is a psychiatrist with Alameda County Health Care for the Homeless and the TRUST Clinic in Oakland, Calif. She also is a cofounder of StreetHealth, a backpack street medicine team that provides psychiatric and substance use disorder treatment to people experiencing homelessness in downtown Oakland.
Dr. Bird has no disclosures.
As a psychiatrist dedicated to working with people who are experiencing homelessness, I was very impressed with the new book edited by Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH, and Maria D. Llorente, MD, about treating and providing services to this vulnerable population.
The book, “Clinical Management of the Homeless Patient: Social, Psychiatric, and Medical Issues” (Cham, Switzerland: Springer Nature Switzerland, 2021), offers an in-depth review and analysis of the biopsychosocial complexities that affect how medical and behavioral health conditions present in those who are unhoused. Notably, the book recommends with great sensitivity best practices to address these conditions with care, understanding, and love.
This text, invaluable in particular for those of us clinicians who work with people experiencing homelessness (PEH), provides a historical context of homelessness in the United States, an evaluation of the current state, and indispensable guidance for medical and behavioral health practitioners, case managers, housing navigators, and policy makers alike. It also serves as an inspiring source for those who are considering work in the public sector while reminding those of us in the field why we continue to do this challenging and rewarding work.
Tips can provide hope to clinicians
The volume is divided into four clear sections that are easy to navigate depending on your area of expertise and interest. Each chapter consolidates an extensive literature review into an intriguing and thought-provoking analysis. Part I, “The Big Picture – Social and Medical Issues,” focuses on conditions that disproportionately affect those who are unhoused. The authors offer a glimpse into the unique challenges of managing routine health conditions. They also detail the practical knowledge that’s needed to best care for our most vulnerable neighbors; for example, promoting a shared decision-making model; simplifying treatment plans; prescribing, when possible, medications that are dosed daily – instead of multiple times per day; allowing for walk-in appointments; and addressing cultural, linguistic, and educational barriers.
Most chapters highlight informative case examples that bring the text to life. It can be heartbreaking to recognize and witness the inhumane conditions in which PEH live, and these practical tips and suggestions for future policies based on best practices can help prevent burnout and provide hope for those who care for this community.
Part II, “Psychiatric Issues and Treatments,” presents a brief yet comprehensive history on homelessness, beginning with the deep shame that PEH experienced in Colonial times as the result of cultural and religious influences. Sadly, that negative judgment continues to this day.
The authors also explain how deinstitutionalization and transinstitutionalization have shaped the current state of homelessness, including why many PEH receive their care in emergency departments while incarcerated. This section highlights the barriers of care that are created not just by the patient, but also by the clinicians and systems of care – and what’s needed practically to overcome those challenges.
I appreciate the chapter on substance use disorders. It reminds us that the most commonly used substance among PEH is tobacco, which has serious health effects and for which we have treatment; nevertheless, . This section also provides examples of the trauma-informed language to use when addressing difficult and sometimes stigmatizing topics, such as survival sex and trauma history.
The evidence-based discussion continues in Part III with a focus on topics that everyone working with PEH should understand, including food insecurity, the criminal justice system, and sex trafficking. Part IV highlights best practices that should be replicated in every community, including Housing First approaches, medical respite care, and multiple Veterans Administration programs.
Throughout the text, major themes reverberate across the chapters, beginning with empathy. All who work with PEH must understand the conditions and challenges PEH face every day that affect their physical and mental health. The authors offer a stark and pointed reminder that being unhoused amounts to a full-time job just to meet basic needs. In addition, the devastating role of trauma and structural racism in creating and promoting the conditions that lead someone to be unhoused cannot be underestimated.
Fortunately, the primary aim of the book is to highlight solutions, and it’s here that the book shines. While some interventions are well-known, such as the importance of working in multidisciplinary teams, building trust and rapport with our patients, and urging clinicians and institutions to examine their own judgments and biases that might interfere with humane treatment, other suggestions will lead some readers into new territory. The authors, for example, maintain that we need more data and evidence-based research that include PEH. They also make a case for more preventive care and enhanced professional education for all health care workers that centers on trauma-informed care, social determinants of health, and the unique needs of especially vulnerable communities, such as the unhoused LBGTQ+ community and policies that promote best practices, such as Housing First. The book is a stirring read. It offers both inspiration and practical guidance for all who are currently working with or interested in caring for people experiencing homelessness.
Dr. Bird is a psychiatrist with Alameda County Health Care for the Homeless and the TRUST Clinic in Oakland, Calif. She also is a cofounder of StreetHealth, a backpack street medicine team that provides psychiatric and substance use disorder treatment to people experiencing homelessness in downtown Oakland.
Dr. Bird has no disclosures.
As a psychiatrist dedicated to working with people who are experiencing homelessness, I was very impressed with the new book edited by Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH, and Maria D. Llorente, MD, about treating and providing services to this vulnerable population.
The book, “Clinical Management of the Homeless Patient: Social, Psychiatric, and Medical Issues” (Cham, Switzerland: Springer Nature Switzerland, 2021), offers an in-depth review and analysis of the biopsychosocial complexities that affect how medical and behavioral health conditions present in those who are unhoused. Notably, the book recommends with great sensitivity best practices to address these conditions with care, understanding, and love.
This text, invaluable in particular for those of us clinicians who work with people experiencing homelessness (PEH), provides a historical context of homelessness in the United States, an evaluation of the current state, and indispensable guidance for medical and behavioral health practitioners, case managers, housing navigators, and policy makers alike. It also serves as an inspiring source for those who are considering work in the public sector while reminding those of us in the field why we continue to do this challenging and rewarding work.
Tips can provide hope to clinicians
The volume is divided into four clear sections that are easy to navigate depending on your area of expertise and interest. Each chapter consolidates an extensive literature review into an intriguing and thought-provoking analysis. Part I, “The Big Picture – Social and Medical Issues,” focuses on conditions that disproportionately affect those who are unhoused. The authors offer a glimpse into the unique challenges of managing routine health conditions. They also detail the practical knowledge that’s needed to best care for our most vulnerable neighbors; for example, promoting a shared decision-making model; simplifying treatment plans; prescribing, when possible, medications that are dosed daily – instead of multiple times per day; allowing for walk-in appointments; and addressing cultural, linguistic, and educational barriers.
Most chapters highlight informative case examples that bring the text to life. It can be heartbreaking to recognize and witness the inhumane conditions in which PEH live, and these practical tips and suggestions for future policies based on best practices can help prevent burnout and provide hope for those who care for this community.
Part II, “Psychiatric Issues and Treatments,” presents a brief yet comprehensive history on homelessness, beginning with the deep shame that PEH experienced in Colonial times as the result of cultural and religious influences. Sadly, that negative judgment continues to this day.
The authors also explain how deinstitutionalization and transinstitutionalization have shaped the current state of homelessness, including why many PEH receive their care in emergency departments while incarcerated. This section highlights the barriers of care that are created not just by the patient, but also by the clinicians and systems of care – and what’s needed practically to overcome those challenges.
I appreciate the chapter on substance use disorders. It reminds us that the most commonly used substance among PEH is tobacco, which has serious health effects and for which we have treatment; nevertheless, . This section also provides examples of the trauma-informed language to use when addressing difficult and sometimes stigmatizing topics, such as survival sex and trauma history.
The evidence-based discussion continues in Part III with a focus on topics that everyone working with PEH should understand, including food insecurity, the criminal justice system, and sex trafficking. Part IV highlights best practices that should be replicated in every community, including Housing First approaches, medical respite care, and multiple Veterans Administration programs.
Throughout the text, major themes reverberate across the chapters, beginning with empathy. All who work with PEH must understand the conditions and challenges PEH face every day that affect their physical and mental health. The authors offer a stark and pointed reminder that being unhoused amounts to a full-time job just to meet basic needs. In addition, the devastating role of trauma and structural racism in creating and promoting the conditions that lead someone to be unhoused cannot be underestimated.
Fortunately, the primary aim of the book is to highlight solutions, and it’s here that the book shines. While some interventions are well-known, such as the importance of working in multidisciplinary teams, building trust and rapport with our patients, and urging clinicians and institutions to examine their own judgments and biases that might interfere with humane treatment, other suggestions will lead some readers into new territory. The authors, for example, maintain that we need more data and evidence-based research that include PEH. They also make a case for more preventive care and enhanced professional education for all health care workers that centers on trauma-informed care, social determinants of health, and the unique needs of especially vulnerable communities, such as the unhoused LBGTQ+ community and policies that promote best practices, such as Housing First. The book is a stirring read. It offers both inspiration and practical guidance for all who are currently working with or interested in caring for people experiencing homelessness.
Dr. Bird is a psychiatrist with Alameda County Health Care for the Homeless and the TRUST Clinic in Oakland, Calif. She also is a cofounder of StreetHealth, a backpack street medicine team that provides psychiatric and substance use disorder treatment to people experiencing homelessness in downtown Oakland.
Dr. Bird has no disclosures.
Tap of the brakes on gender-affirming care
In the November 2021 issue of Pediatric News are two stories that on the surface present viewpoints that couldn’t be more divergent. On page 1 under the headline “Gender dysphoria” you will read about a position statement by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in which they strongly recommend a mental health evaluation for any child or adolescent with gender dysphoria “before any firm decisions are made on whether to prescribe hormonal treatments to transition, or perform surgeries.”
On page 6 is another story titled “Gender-affirming care ‘can save lives’ new research shows” that reports on a research study in which transgender and binary young people who received a year of gender-affirming care experienced less depression and fewer suicidal thoughts. Dr. David J. Inwards-Breland, chief of adolescent and young adult medicine at Rady Children’s Hospital in San Diego and one of the authors of the study is quoted as saying “The younger we can provide gender-affirming care, the less likely [our patients are] to have depression and then negative outcomes.” One can’t avoid the impression that he is in favor of moving ahead without delay in prescribing gender-affirming care.
Where does the new recommendation by the RANZCP fit in with this sense of urgency? Does requiring a mental health evaluation constitute a delay in the institution of gender-affirming care that could increase the risk of negative mental health outcomes for gender dysphoric patients?
In one of the final paragraphs in the Pediatric News article one learns that Dr. Inwards-Breland would agree with the folks of RANZCP. He acknowledges that his study relied on screening and not diagnostic testing and says that “future studies should look at a mental health evaluation and diagnosis by a mental health provider.”
When we drill into the details there are two issues that demand clarification. First, what kind of time course are we talking about for a mental health evaluation? Are we talking weeks, or months, hopefully not years? This of course depends on the availability of mental health services for the specific patient and the depth of the evaluation required. How long a delay is acceptable?
Second, will the evaluation be performed by a provider free of bias? Can it be performed without creating the impression that the patient needs to see a mental health provider because there is something wrong with being trans and we can fix it? One would hope these evaluations would be performed in the spirit of wanting to learn more about the patient with the goal of making the process go more smoothly.
Listening to neighborhood discussions around the fire pit I find that the RANZCP plea for a broader and deeper look at each gender-dysphoric child strikes a chord with the general population. More and more people are realizing that gender-dysphoria happens and that for too long it was closeted with unfortunate consequences. However, there is a feeling, in fact one in which I share, that the rapid rise in its prevalence contains an element of social contagion. And, some irreversible decisions are being made without sufficient consideration. This may or not be a valid concern but it seems to me a thorough and sensitively done mental health evaluation might minimize the collateral damage from some gender-affirming care and at least help those patients for whom it is prescribed transition more smoothly.
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 [email protected].
In the November 2021 issue of Pediatric News are two stories that on the surface present viewpoints that couldn’t be more divergent. On page 1 under the headline “Gender dysphoria” you will read about a position statement by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in which they strongly recommend a mental health evaluation for any child or adolescent with gender dysphoria “before any firm decisions are made on whether to prescribe hormonal treatments to transition, or perform surgeries.”
On page 6 is another story titled “Gender-affirming care ‘can save lives’ new research shows” that reports on a research study in which transgender and binary young people who received a year of gender-affirming care experienced less depression and fewer suicidal thoughts. Dr. David J. Inwards-Breland, chief of adolescent and young adult medicine at Rady Children’s Hospital in San Diego and one of the authors of the study is quoted as saying “The younger we can provide gender-affirming care, the less likely [our patients are] to have depression and then negative outcomes.” One can’t avoid the impression that he is in favor of moving ahead without delay in prescribing gender-affirming care.
Where does the new recommendation by the RANZCP fit in with this sense of urgency? Does requiring a mental health evaluation constitute a delay in the institution of gender-affirming care that could increase the risk of negative mental health outcomes for gender dysphoric patients?
In one of the final paragraphs in the Pediatric News article one learns that Dr. Inwards-Breland would agree with the folks of RANZCP. He acknowledges that his study relied on screening and not diagnostic testing and says that “future studies should look at a mental health evaluation and diagnosis by a mental health provider.”
When we drill into the details there are two issues that demand clarification. First, what kind of time course are we talking about for a mental health evaluation? Are we talking weeks, or months, hopefully not years? This of course depends on the availability of mental health services for the specific patient and the depth of the evaluation required. How long a delay is acceptable?
Second, will the evaluation be performed by a provider free of bias? Can it be performed without creating the impression that the patient needs to see a mental health provider because there is something wrong with being trans and we can fix it? One would hope these evaluations would be performed in the spirit of wanting to learn more about the patient with the goal of making the process go more smoothly.
Listening to neighborhood discussions around the fire pit I find that the RANZCP plea for a broader and deeper look at each gender-dysphoric child strikes a chord with the general population. More and more people are realizing that gender-dysphoria happens and that for too long it was closeted with unfortunate consequences. However, there is a feeling, in fact one in which I share, that the rapid rise in its prevalence contains an element of social contagion. And, some irreversible decisions are being made without sufficient consideration. This may or not be a valid concern but it seems to me a thorough and sensitively done mental health evaluation might minimize the collateral damage from some gender-affirming care and at least help those patients for whom it is prescribed transition more smoothly.
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 [email protected].
In the November 2021 issue of Pediatric News are two stories that on the surface present viewpoints that couldn’t be more divergent. On page 1 under the headline “Gender dysphoria” you will read about a position statement by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in which they strongly recommend a mental health evaluation for any child or adolescent with gender dysphoria “before any firm decisions are made on whether to prescribe hormonal treatments to transition, or perform surgeries.”
On page 6 is another story titled “Gender-affirming care ‘can save lives’ new research shows” that reports on a research study in which transgender and binary young people who received a year of gender-affirming care experienced less depression and fewer suicidal thoughts. Dr. David J. Inwards-Breland, chief of adolescent and young adult medicine at Rady Children’s Hospital in San Diego and one of the authors of the study is quoted as saying “The younger we can provide gender-affirming care, the less likely [our patients are] to have depression and then negative outcomes.” One can’t avoid the impression that he is in favor of moving ahead without delay in prescribing gender-affirming care.
Where does the new recommendation by the RANZCP fit in with this sense of urgency? Does requiring a mental health evaluation constitute a delay in the institution of gender-affirming care that could increase the risk of negative mental health outcomes for gender dysphoric patients?
In one of the final paragraphs in the Pediatric News article one learns that Dr. Inwards-Breland would agree with the folks of RANZCP. He acknowledges that his study relied on screening and not diagnostic testing and says that “future studies should look at a mental health evaluation and diagnosis by a mental health provider.”
When we drill into the details there are two issues that demand clarification. First, what kind of time course are we talking about for a mental health evaluation? Are we talking weeks, or months, hopefully not years? This of course depends on the availability of mental health services for the specific patient and the depth of the evaluation required. How long a delay is acceptable?
Second, will the evaluation be performed by a provider free of bias? Can it be performed without creating the impression that the patient needs to see a mental health provider because there is something wrong with being trans and we can fix it? One would hope these evaluations would be performed in the spirit of wanting to learn more about the patient with the goal of making the process go more smoothly.
Listening to neighborhood discussions around the fire pit I find that the RANZCP plea for a broader and deeper look at each gender-dysphoric child strikes a chord with the general population. More and more people are realizing that gender-dysphoria happens and that for too long it was closeted with unfortunate consequences. However, there is a feeling, in fact one in which I share, that the rapid rise in its prevalence contains an element of social contagion. And, some irreversible decisions are being made without sufficient consideration. This may or not be a valid concern but it seems to me a thorough and sensitively done mental health evaluation might minimize the collateral damage from some gender-affirming care and at least help those patients for whom it is prescribed transition more smoothly.
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 [email protected].
Benefits of low-dose CT scanning for lung cancer screening explained
According to the Centers for Disease Control and Prevention, lung cancer is the third-most common cancer in the United States and the leading cause of cancer deaths in both men and women. Approximately, 150,000 Americans die every year from this disease.
In fact, it has been shown that low-dose CT scan screening can reduce lung cancer deaths by 20%-30% in high-risk populations.
In the United States, low-dose CT scan screening for lung cancer has largely become the norm. In July 2021, CHEST released new clinical guidelines. These guidelines cover 18 evidence-based recommendations as well as inclusion of further evidence regarding the benefits, risks, and use of CT screening.
In doing the risk assessment of low-dose CT scan as a method of lung cancer screening, meta-analyses were performed on evidence obtained through a literature search using PubMed, Embase, and the Cochrane Library. It was concluded that the benefits outweigh the risks as a method of lung cancer screening and can be utilized in reducing lung cancer deaths.
Low-dose CT scan screening was recommended for the following patients:
- Asymptomatic individuals aged 55-77 years with a history of smoking 30 or more pack-years. (This includes those who continue to smoke or who have quit in the previous 15 years. Annual screening is advised.)
- Asymptomatic individuals aged 55-80 years with a history of smoking 20-30 pack-years who either continue to smoke or have quit in the previous 15 years.
- For asymptomatic individuals who do not meet the above criteria but are predicted to benefit based on life-year gained calculations.
Don’t screen these patients
CT scan screening should not be performed on any person who does not meet any of the above three criteria.
Additionally, if a person has significant comorbidities that would limit their life expectancy, it is recommended not to do CT scan screening. Symptomatic patients should have appropriate diagnostic testing rather than screening.
Additional recommendations from the updated guidelines include developing appropriate counseling strategies as well as deciding what constitutes a positive test.
A positive test should be anything that warrants further evaluation rather than a return to annual screening. It was also advised that overtreatment strategies should be implemented. Additionally, smoking cessation treatment should be provided.
CHEST suggested undertaking a comprehensive approach involving multiple specialists including pulmonologists, radiologists, oncologists, etc. Strategies to ensure compliance with annual screening should also be devised, the guidelines say.
USPSTF’s updated guidelines
It should be noted that the U.S. Preventative Task Force released their own set of updated guidelines in March 2021. In these guidelines, the age at which lung cancer screening should be started was lowered from 55 years to 50 years.
Also, the USPSTF lowered the minimum required smoking history in order to be screened from 30 to 20 pack-years. Their purpose for doing this was to include more high-risk women as well as minorities.
With the changes, 14.5 million individuals living in the United States would be eligible for lung cancer screening by low-dose CT scan, an increase of 6.5 million people, compared with the previous guidelines.
While only small differences exist between the set of guidelines issued by CHEST and the ones issues by the USPSTF, lung cancer screening is still largely underutilized.
One of the barriers to screening may be patients’ lacking insurance coverage for it. As physicians, we need to advocate for these screening tools to be covered.
Other barriers include lack of patient knowledge regarding low-dose CT scans as a screening tool, patient time, and patient visits with their doctors being too short.
Key message
Part of the duties of physicians is to give our patients the best information. We can reduce lung cancer mortality in high risk patients by performing annual low-dose CT scans.
Whichever set of guidelines we chose to follow, we fail our patients if we don’t follow either set of them. The evidence is clear that a low-dose CT scan is a valuable screening tool to add to our practice of medicine.
Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at [email protected].
According to the Centers for Disease Control and Prevention, lung cancer is the third-most common cancer in the United States and the leading cause of cancer deaths in both men and women. Approximately, 150,000 Americans die every year from this disease.
In fact, it has been shown that low-dose CT scan screening can reduce lung cancer deaths by 20%-30% in high-risk populations.
In the United States, low-dose CT scan screening for lung cancer has largely become the norm. In July 2021, CHEST released new clinical guidelines. These guidelines cover 18 evidence-based recommendations as well as inclusion of further evidence regarding the benefits, risks, and use of CT screening.
In doing the risk assessment of low-dose CT scan as a method of lung cancer screening, meta-analyses were performed on evidence obtained through a literature search using PubMed, Embase, and the Cochrane Library. It was concluded that the benefits outweigh the risks as a method of lung cancer screening and can be utilized in reducing lung cancer deaths.
Low-dose CT scan screening was recommended for the following patients:
- Asymptomatic individuals aged 55-77 years with a history of smoking 30 or more pack-years. (This includes those who continue to smoke or who have quit in the previous 15 years. Annual screening is advised.)
- Asymptomatic individuals aged 55-80 years with a history of smoking 20-30 pack-years who either continue to smoke or have quit in the previous 15 years.
- For asymptomatic individuals who do not meet the above criteria but are predicted to benefit based on life-year gained calculations.
Don’t screen these patients
CT scan screening should not be performed on any person who does not meet any of the above three criteria.
Additionally, if a person has significant comorbidities that would limit their life expectancy, it is recommended not to do CT scan screening. Symptomatic patients should have appropriate diagnostic testing rather than screening.
Additional recommendations from the updated guidelines include developing appropriate counseling strategies as well as deciding what constitutes a positive test.
A positive test should be anything that warrants further evaluation rather than a return to annual screening. It was also advised that overtreatment strategies should be implemented. Additionally, smoking cessation treatment should be provided.
CHEST suggested undertaking a comprehensive approach involving multiple specialists including pulmonologists, radiologists, oncologists, etc. Strategies to ensure compliance with annual screening should also be devised, the guidelines say.
USPSTF’s updated guidelines
It should be noted that the U.S. Preventative Task Force released their own set of updated guidelines in March 2021. In these guidelines, the age at which lung cancer screening should be started was lowered from 55 years to 50 years.
Also, the USPSTF lowered the minimum required smoking history in order to be screened from 30 to 20 pack-years. Their purpose for doing this was to include more high-risk women as well as minorities.
With the changes, 14.5 million individuals living in the United States would be eligible for lung cancer screening by low-dose CT scan, an increase of 6.5 million people, compared with the previous guidelines.
While only small differences exist between the set of guidelines issued by CHEST and the ones issues by the USPSTF, lung cancer screening is still largely underutilized.
One of the barriers to screening may be patients’ lacking insurance coverage for it. As physicians, we need to advocate for these screening tools to be covered.
Other barriers include lack of patient knowledge regarding low-dose CT scans as a screening tool, patient time, and patient visits with their doctors being too short.
Key message
Part of the duties of physicians is to give our patients the best information. We can reduce lung cancer mortality in high risk patients by performing annual low-dose CT scans.
Whichever set of guidelines we chose to follow, we fail our patients if we don’t follow either set of them. The evidence is clear that a low-dose CT scan is a valuable screening tool to add to our practice of medicine.
Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at [email protected].
According to the Centers for Disease Control and Prevention, lung cancer is the third-most common cancer in the United States and the leading cause of cancer deaths in both men and women. Approximately, 150,000 Americans die every year from this disease.
In fact, it has been shown that low-dose CT scan screening can reduce lung cancer deaths by 20%-30% in high-risk populations.
In the United States, low-dose CT scan screening for lung cancer has largely become the norm. In July 2021, CHEST released new clinical guidelines. These guidelines cover 18 evidence-based recommendations as well as inclusion of further evidence regarding the benefits, risks, and use of CT screening.
In doing the risk assessment of low-dose CT scan as a method of lung cancer screening, meta-analyses were performed on evidence obtained through a literature search using PubMed, Embase, and the Cochrane Library. It was concluded that the benefits outweigh the risks as a method of lung cancer screening and can be utilized in reducing lung cancer deaths.
Low-dose CT scan screening was recommended for the following patients:
- Asymptomatic individuals aged 55-77 years with a history of smoking 30 or more pack-years. (This includes those who continue to smoke or who have quit in the previous 15 years. Annual screening is advised.)
- Asymptomatic individuals aged 55-80 years with a history of smoking 20-30 pack-years who either continue to smoke or have quit in the previous 15 years.
- For asymptomatic individuals who do not meet the above criteria but are predicted to benefit based on life-year gained calculations.
Don’t screen these patients
CT scan screening should not be performed on any person who does not meet any of the above three criteria.
Additionally, if a person has significant comorbidities that would limit their life expectancy, it is recommended not to do CT scan screening. Symptomatic patients should have appropriate diagnostic testing rather than screening.
Additional recommendations from the updated guidelines include developing appropriate counseling strategies as well as deciding what constitutes a positive test.
A positive test should be anything that warrants further evaluation rather than a return to annual screening. It was also advised that overtreatment strategies should be implemented. Additionally, smoking cessation treatment should be provided.
CHEST suggested undertaking a comprehensive approach involving multiple specialists including pulmonologists, radiologists, oncologists, etc. Strategies to ensure compliance with annual screening should also be devised, the guidelines say.
USPSTF’s updated guidelines
It should be noted that the U.S. Preventative Task Force released their own set of updated guidelines in March 2021. In these guidelines, the age at which lung cancer screening should be started was lowered from 55 years to 50 years.
Also, the USPSTF lowered the minimum required smoking history in order to be screened from 30 to 20 pack-years. Their purpose for doing this was to include more high-risk women as well as minorities.
With the changes, 14.5 million individuals living in the United States would be eligible for lung cancer screening by low-dose CT scan, an increase of 6.5 million people, compared with the previous guidelines.
While only small differences exist between the set of guidelines issued by CHEST and the ones issues by the USPSTF, lung cancer screening is still largely underutilized.
One of the barriers to screening may be patients’ lacking insurance coverage for it. As physicians, we need to advocate for these screening tools to be covered.
Other barriers include lack of patient knowledge regarding low-dose CT scans as a screening tool, patient time, and patient visits with their doctors being too short.
Key message
Part of the duties of physicians is to give our patients the best information. We can reduce lung cancer mortality in high risk patients by performing annual low-dose CT scans.
Whichever set of guidelines we chose to follow, we fail our patients if we don’t follow either set of them. The evidence is clear that a low-dose CT scan is a valuable screening tool to add to our practice of medicine.
Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at [email protected].
Hyperprolactinemia – When, why, and how to evaluate prolactin
Because of the increasing popularity and success of in vitro fertilization, the field of reproductive endocrinology and infertility has steadily morphed toward the treatment of infertility. Nevertheless, a physician board certified in reproductive endocrinology and infertility is the referring physician of choice regarding prolactin disorders and gynecologists should be familiar with the symptoms and sequela of prolactin elevations. This month’s column will address when to obtain a serum prolactin and how to appropriately manage hyperprolactinemia.
Of all the anterior pituitary hormones (adrenocorticotropic hormone, follicle-stimulating hormone, growth hormone, luteinizing hormone, prolactin, thyroid-stimulating hormone ), prolactin is the only one under tonic inhibition by dopamine. Disturbances in this dopaminergic pathway result in elevated serum prolactin. The normal range for prolactin is approximately 5-20 ng/mL.
In the nonpregnant state, little is known regarding the purpose of prolactin, which is produced by the anterior pituitary cluster of cells called lactotrophs. To prepare the breast for postpartum lactation, increases in prolactin are necessary and sustained throughout pregnancy. Second to pregnancy, amenorrhea can occur in 10%-20% of cases of hyperprolactinemia. Outside of pregnancy, elevations in prolactin result in hypogonadism, through gonadotropin-releasing hormone suppression, resulting in infertility (48%), headache (39%), oligomenorrhea (29%) and galactorrhea (24%).1 Most hypogonadal symptoms are more likely to occur with prolactin levels greater than 100 ng/mL, whereas infertility and ovulation dysfunction can occur with mild to moderate hyperprolactinemia, respectively. Prolonged amenorrhea can risk bone mineral density loss.
While the focus of our discussion is the effect of prolactin on women, men with hyperprolactinemia can experience hypogonadotropic hypogonadism with resultant decreased libido, impotence, infertility, gynecomastia, or, rarely, galactorrhea.2
The three Ps – physiological, pharmacologic, pathological
Physiological causes of hyperprolactinemia include rising estradiol during the late follicular phase and into the secretory phase of the menstrual cycle or while taking combined oral contraception, nipple stimulation, pregnancy, lactation, meals, sleep, and stress.
Drugs can interrupt the dopaminergic pathway, thereby elevating serum prolactin but usually not above 100 ng/mL, except for the antipsychotic drug risperidone, which can cause marked elevation up to 300 or even 400 ng/mL. Medications that can cause hyperprolactinemia are estrogens, neuroleptic drugs such as risperidone, metoclopramide, antidepressant drugs, cimetidine, methyldopa, and verapamil.
A pituitary MRI can diagnose an adenoma, that is, a collection of cells in the pituitary that are responsible for hyperprolactinemia and is named based on its size. Microadenomas are less than 1 cm and are typically associated with serum prolactin values below 200 ng/mL. Macroadenomas can worsen while a patient is on combined oral contraception and during pregnancy; fortunately, this is not the case with a microadenoma.
Hypothyroidism can elevate serum prolactin since thyrotropin releasing hormone is known to stimulate prolactin secretion.3 Consequently, when a patient presents with both hypothyroidism and hyperprolactinemia, thyroid replacement should be initiated for thyroid regulation and potential restoration of prolactin levels. If hyperprolactinemia persists, then further evaluation is required. Chronic renal impairment can also elevate prolactin levels due to decreased clearance.
Management
The appropriate evaluation of hyperprolactinemia consists of a history to disclose medications, identify galactorrhea, and visual changes. Because of an adenoma compressing the optic chiasm, partial blindness may occur where vision is lost in the outer half of both the right and left visual field, called bitemporal hemianopsia. Mild elevations in prolactin should be tested at a time when physiological influences are at a minimum, that is, during menses, fasting, and in late morning.4 Persistent elevations should be appropriately evaluated rather than by using the empiric “shotgun” approach of prescribing a dopamine agonist. Laboratory testing for repeated elevations in prolactin includes a pituitary MRI looking for a mass in the hypothalamic-pituitary region that interrupts dopamine suppression.
Treatment of hyperprolactinemia begins with a dopamine agonist and is indicated when there is hypogonadism or intolerable galactorrhea. Cabergoline is the first choice because of effectiveness (reduced adenoma size in greater than 90% of patients) and lesser side effects, particularly nausea, than bromocriptine. Dopamine agonists, such as bromocriptine and cabergoline, belong to the category of ergot-derived dopamine agonists and have been used to treat Parkinson’s disease. At high doses used to treat Parkinson’s, cabergoline is associated with an increased risk of valvular heart disease. In the United States, pergolide was voluntarily withdrawn from the market in March 2007 because of this risk. At the lower doses generally used for the treatment of hyperprolactinemia, cabergoline is probably not associated with excess risk.5
Newer dopamine agonists are known as nonergot. These are pramipexole, ropinirole, rotigotine, and apomorphine. They have not been associated with a risk of heart damage and can be prescribed.
The initial prescribing dose of cabergoline should be 0.25 mg twice a week or 0.5 mg once a week. If bromocriptine is used, the starting dose is 1.25 mg after dinner or at bedtime for 1 week, then increasing to 1.25 mg twice a day (after breakfast and after dinner or at bedtime to reduce nausea and fatigue). After 1 month of a dopamine agonist, the patient should be evaluated for side effects and a serum prolactin level should be obtained. With a normal prolactin level, gonadal function will probably return within a few months. The dopamine agonist should typically be discontinued with pregnancy as pregnancy increases prolactin physiologically.
Treatment of a macroadenoma is essential when the tumor is large enough to cause neurologic symptoms, such as visual impairment or headache, and is preferable when it is invasive or when there are enlarging microadenomas since they are likely to continue to grow and become symptomatic. About 95% of microadenomas have not been shown to increase in size during 4-6 years of observation.6
Transsphenoidal surgery should be considered when there is:
- Persistent hyperprolactinemia and/or size of the adenoma, with associated symptoms or signs despite several months of dopamine agonist treatment at high doses.
- Presence of a giant lactotroph adenoma (e.g., >3 cm) with pregnancy desired including those whose adenoma responds to a dopamine agonist – to avoid significant growth during pregnancy while off medication.
Data from over 6,000 pregnancies suggest that the administration of bromocriptine during the first month of pregnancy does not harm the fetus.7
Discontinuing treatment
Three scenarios may allow for cessation of dopamine agonist therapy. The first is when a patient has had a normal serum prolactin test following 2 years of low-dose dopamine agonist. Another is the patient who had hyperprolactinemia and a microadenoma that responded to treatment with a normal prolactin level and no further evidence of an adenoma by MRI for at least 2 years. Lastly, the patient who had a macroadenoma prior to treatment and a subsequent normal serum prolactin level without an adenoma for at least 2 years.
Like the management of thyroid dysfunction, our field must be aware of prolactin disorders for early detection, prompt referral, and appropriate management to minimize long-term consequences.
Dr. Trolice is director of Fertility CARE – The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando.
References
1. Bayrak A et al. Fertil Steril. 2005 Jul;84(1):181-5.
2. Carter JN et al. N Engl J Med. 1978 Oct 19;299(16):847-52.
3. Sachson R et al. N Engl J Med. 1972;287:972.
4. Singh SP and Singh TP. Ann Endocrinol (Paris). 1984;45(2):137-41.
5. Valassi E et al. J Clin Endocrinol Metab. 2010 Mar;95(3):1025-33.
6. Sisam DA et al. Fertil Steril. 1987 Jul;48(1):67-71.
7. Molitch ME. Best Pract Res Clin Endocrinol Metab. 2011 Dec;25(6):885-96.
Because of the increasing popularity and success of in vitro fertilization, the field of reproductive endocrinology and infertility has steadily morphed toward the treatment of infertility. Nevertheless, a physician board certified in reproductive endocrinology and infertility is the referring physician of choice regarding prolactin disorders and gynecologists should be familiar with the symptoms and sequela of prolactin elevations. This month’s column will address when to obtain a serum prolactin and how to appropriately manage hyperprolactinemia.
Of all the anterior pituitary hormones (adrenocorticotropic hormone, follicle-stimulating hormone, growth hormone, luteinizing hormone, prolactin, thyroid-stimulating hormone ), prolactin is the only one under tonic inhibition by dopamine. Disturbances in this dopaminergic pathway result in elevated serum prolactin. The normal range for prolactin is approximately 5-20 ng/mL.
In the nonpregnant state, little is known regarding the purpose of prolactin, which is produced by the anterior pituitary cluster of cells called lactotrophs. To prepare the breast for postpartum lactation, increases in prolactin are necessary and sustained throughout pregnancy. Second to pregnancy, amenorrhea can occur in 10%-20% of cases of hyperprolactinemia. Outside of pregnancy, elevations in prolactin result in hypogonadism, through gonadotropin-releasing hormone suppression, resulting in infertility (48%), headache (39%), oligomenorrhea (29%) and galactorrhea (24%).1 Most hypogonadal symptoms are more likely to occur with prolactin levels greater than 100 ng/mL, whereas infertility and ovulation dysfunction can occur with mild to moderate hyperprolactinemia, respectively. Prolonged amenorrhea can risk bone mineral density loss.
While the focus of our discussion is the effect of prolactin on women, men with hyperprolactinemia can experience hypogonadotropic hypogonadism with resultant decreased libido, impotence, infertility, gynecomastia, or, rarely, galactorrhea.2
The three Ps – physiological, pharmacologic, pathological
Physiological causes of hyperprolactinemia include rising estradiol during the late follicular phase and into the secretory phase of the menstrual cycle or while taking combined oral contraception, nipple stimulation, pregnancy, lactation, meals, sleep, and stress.
Drugs can interrupt the dopaminergic pathway, thereby elevating serum prolactin but usually not above 100 ng/mL, except for the antipsychotic drug risperidone, which can cause marked elevation up to 300 or even 400 ng/mL. Medications that can cause hyperprolactinemia are estrogens, neuroleptic drugs such as risperidone, metoclopramide, antidepressant drugs, cimetidine, methyldopa, and verapamil.
A pituitary MRI can diagnose an adenoma, that is, a collection of cells in the pituitary that are responsible for hyperprolactinemia and is named based on its size. Microadenomas are less than 1 cm and are typically associated with serum prolactin values below 200 ng/mL. Macroadenomas can worsen while a patient is on combined oral contraception and during pregnancy; fortunately, this is not the case with a microadenoma.
Hypothyroidism can elevate serum prolactin since thyrotropin releasing hormone is known to stimulate prolactin secretion.3 Consequently, when a patient presents with both hypothyroidism and hyperprolactinemia, thyroid replacement should be initiated for thyroid regulation and potential restoration of prolactin levels. If hyperprolactinemia persists, then further evaluation is required. Chronic renal impairment can also elevate prolactin levels due to decreased clearance.
Management
The appropriate evaluation of hyperprolactinemia consists of a history to disclose medications, identify galactorrhea, and visual changes. Because of an adenoma compressing the optic chiasm, partial blindness may occur where vision is lost in the outer half of both the right and left visual field, called bitemporal hemianopsia. Mild elevations in prolactin should be tested at a time when physiological influences are at a minimum, that is, during menses, fasting, and in late morning.4 Persistent elevations should be appropriately evaluated rather than by using the empiric “shotgun” approach of prescribing a dopamine agonist. Laboratory testing for repeated elevations in prolactin includes a pituitary MRI looking for a mass in the hypothalamic-pituitary region that interrupts dopamine suppression.
Treatment of hyperprolactinemia begins with a dopamine agonist and is indicated when there is hypogonadism or intolerable galactorrhea. Cabergoline is the first choice because of effectiveness (reduced adenoma size in greater than 90% of patients) and lesser side effects, particularly nausea, than bromocriptine. Dopamine agonists, such as bromocriptine and cabergoline, belong to the category of ergot-derived dopamine agonists and have been used to treat Parkinson’s disease. At high doses used to treat Parkinson’s, cabergoline is associated with an increased risk of valvular heart disease. In the United States, pergolide was voluntarily withdrawn from the market in March 2007 because of this risk. At the lower doses generally used for the treatment of hyperprolactinemia, cabergoline is probably not associated with excess risk.5
Newer dopamine agonists are known as nonergot. These are pramipexole, ropinirole, rotigotine, and apomorphine. They have not been associated with a risk of heart damage and can be prescribed.
The initial prescribing dose of cabergoline should be 0.25 mg twice a week or 0.5 mg once a week. If bromocriptine is used, the starting dose is 1.25 mg after dinner or at bedtime for 1 week, then increasing to 1.25 mg twice a day (after breakfast and after dinner or at bedtime to reduce nausea and fatigue). After 1 month of a dopamine agonist, the patient should be evaluated for side effects and a serum prolactin level should be obtained. With a normal prolactin level, gonadal function will probably return within a few months. The dopamine agonist should typically be discontinued with pregnancy as pregnancy increases prolactin physiologically.
Treatment of a macroadenoma is essential when the tumor is large enough to cause neurologic symptoms, such as visual impairment or headache, and is preferable when it is invasive or when there are enlarging microadenomas since they are likely to continue to grow and become symptomatic. About 95% of microadenomas have not been shown to increase in size during 4-6 years of observation.6
Transsphenoidal surgery should be considered when there is:
- Persistent hyperprolactinemia and/or size of the adenoma, with associated symptoms or signs despite several months of dopamine agonist treatment at high doses.
- Presence of a giant lactotroph adenoma (e.g., >3 cm) with pregnancy desired including those whose adenoma responds to a dopamine agonist – to avoid significant growth during pregnancy while off medication.
Data from over 6,000 pregnancies suggest that the administration of bromocriptine during the first month of pregnancy does not harm the fetus.7
Discontinuing treatment
Three scenarios may allow for cessation of dopamine agonist therapy. The first is when a patient has had a normal serum prolactin test following 2 years of low-dose dopamine agonist. Another is the patient who had hyperprolactinemia and a microadenoma that responded to treatment with a normal prolactin level and no further evidence of an adenoma by MRI for at least 2 years. Lastly, the patient who had a macroadenoma prior to treatment and a subsequent normal serum prolactin level without an adenoma for at least 2 years.
Like the management of thyroid dysfunction, our field must be aware of prolactin disorders for early detection, prompt referral, and appropriate management to minimize long-term consequences.
Dr. Trolice is director of Fertility CARE – The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando.
References
1. Bayrak A et al. Fertil Steril. 2005 Jul;84(1):181-5.
2. Carter JN et al. N Engl J Med. 1978 Oct 19;299(16):847-52.
3. Sachson R et al. N Engl J Med. 1972;287:972.
4. Singh SP and Singh TP. Ann Endocrinol (Paris). 1984;45(2):137-41.
5. Valassi E et al. J Clin Endocrinol Metab. 2010 Mar;95(3):1025-33.
6. Sisam DA et al. Fertil Steril. 1987 Jul;48(1):67-71.
7. Molitch ME. Best Pract Res Clin Endocrinol Metab. 2011 Dec;25(6):885-96.
Because of the increasing popularity and success of in vitro fertilization, the field of reproductive endocrinology and infertility has steadily morphed toward the treatment of infertility. Nevertheless, a physician board certified in reproductive endocrinology and infertility is the referring physician of choice regarding prolactin disorders and gynecologists should be familiar with the symptoms and sequela of prolactin elevations. This month’s column will address when to obtain a serum prolactin and how to appropriately manage hyperprolactinemia.
Of all the anterior pituitary hormones (adrenocorticotropic hormone, follicle-stimulating hormone, growth hormone, luteinizing hormone, prolactin, thyroid-stimulating hormone ), prolactin is the only one under tonic inhibition by dopamine. Disturbances in this dopaminergic pathway result in elevated serum prolactin. The normal range for prolactin is approximately 5-20 ng/mL.
In the nonpregnant state, little is known regarding the purpose of prolactin, which is produced by the anterior pituitary cluster of cells called lactotrophs. To prepare the breast for postpartum lactation, increases in prolactin are necessary and sustained throughout pregnancy. Second to pregnancy, amenorrhea can occur in 10%-20% of cases of hyperprolactinemia. Outside of pregnancy, elevations in prolactin result in hypogonadism, through gonadotropin-releasing hormone suppression, resulting in infertility (48%), headache (39%), oligomenorrhea (29%) and galactorrhea (24%).1 Most hypogonadal symptoms are more likely to occur with prolactin levels greater than 100 ng/mL, whereas infertility and ovulation dysfunction can occur with mild to moderate hyperprolactinemia, respectively. Prolonged amenorrhea can risk bone mineral density loss.
While the focus of our discussion is the effect of prolactin on women, men with hyperprolactinemia can experience hypogonadotropic hypogonadism with resultant decreased libido, impotence, infertility, gynecomastia, or, rarely, galactorrhea.2
The three Ps – physiological, pharmacologic, pathological
Physiological causes of hyperprolactinemia include rising estradiol during the late follicular phase and into the secretory phase of the menstrual cycle or while taking combined oral contraception, nipple stimulation, pregnancy, lactation, meals, sleep, and stress.
Drugs can interrupt the dopaminergic pathway, thereby elevating serum prolactin but usually not above 100 ng/mL, except for the antipsychotic drug risperidone, which can cause marked elevation up to 300 or even 400 ng/mL. Medications that can cause hyperprolactinemia are estrogens, neuroleptic drugs such as risperidone, metoclopramide, antidepressant drugs, cimetidine, methyldopa, and verapamil.
A pituitary MRI can diagnose an adenoma, that is, a collection of cells in the pituitary that are responsible for hyperprolactinemia and is named based on its size. Microadenomas are less than 1 cm and are typically associated with serum prolactin values below 200 ng/mL. Macroadenomas can worsen while a patient is on combined oral contraception and during pregnancy; fortunately, this is not the case with a microadenoma.
Hypothyroidism can elevate serum prolactin since thyrotropin releasing hormone is known to stimulate prolactin secretion.3 Consequently, when a patient presents with both hypothyroidism and hyperprolactinemia, thyroid replacement should be initiated for thyroid regulation and potential restoration of prolactin levels. If hyperprolactinemia persists, then further evaluation is required. Chronic renal impairment can also elevate prolactin levels due to decreased clearance.
Management
The appropriate evaluation of hyperprolactinemia consists of a history to disclose medications, identify galactorrhea, and visual changes. Because of an adenoma compressing the optic chiasm, partial blindness may occur where vision is lost in the outer half of both the right and left visual field, called bitemporal hemianopsia. Mild elevations in prolactin should be tested at a time when physiological influences are at a minimum, that is, during menses, fasting, and in late morning.4 Persistent elevations should be appropriately evaluated rather than by using the empiric “shotgun” approach of prescribing a dopamine agonist. Laboratory testing for repeated elevations in prolactin includes a pituitary MRI looking for a mass in the hypothalamic-pituitary region that interrupts dopamine suppression.
Treatment of hyperprolactinemia begins with a dopamine agonist and is indicated when there is hypogonadism or intolerable galactorrhea. Cabergoline is the first choice because of effectiveness (reduced adenoma size in greater than 90% of patients) and lesser side effects, particularly nausea, than bromocriptine. Dopamine agonists, such as bromocriptine and cabergoline, belong to the category of ergot-derived dopamine agonists and have been used to treat Parkinson’s disease. At high doses used to treat Parkinson’s, cabergoline is associated with an increased risk of valvular heart disease. In the United States, pergolide was voluntarily withdrawn from the market in March 2007 because of this risk. At the lower doses generally used for the treatment of hyperprolactinemia, cabergoline is probably not associated with excess risk.5
Newer dopamine agonists are known as nonergot. These are pramipexole, ropinirole, rotigotine, and apomorphine. They have not been associated with a risk of heart damage and can be prescribed.
The initial prescribing dose of cabergoline should be 0.25 mg twice a week or 0.5 mg once a week. If bromocriptine is used, the starting dose is 1.25 mg after dinner or at bedtime for 1 week, then increasing to 1.25 mg twice a day (after breakfast and after dinner or at bedtime to reduce nausea and fatigue). After 1 month of a dopamine agonist, the patient should be evaluated for side effects and a serum prolactin level should be obtained. With a normal prolactin level, gonadal function will probably return within a few months. The dopamine agonist should typically be discontinued with pregnancy as pregnancy increases prolactin physiologically.
Treatment of a macroadenoma is essential when the tumor is large enough to cause neurologic symptoms, such as visual impairment or headache, and is preferable when it is invasive or when there are enlarging microadenomas since they are likely to continue to grow and become symptomatic. About 95% of microadenomas have not been shown to increase in size during 4-6 years of observation.6
Transsphenoidal surgery should be considered when there is:
- Persistent hyperprolactinemia and/or size of the adenoma, with associated symptoms or signs despite several months of dopamine agonist treatment at high doses.
- Presence of a giant lactotroph adenoma (e.g., >3 cm) with pregnancy desired including those whose adenoma responds to a dopamine agonist – to avoid significant growth during pregnancy while off medication.
Data from over 6,000 pregnancies suggest that the administration of bromocriptine during the first month of pregnancy does not harm the fetus.7
Discontinuing treatment
Three scenarios may allow for cessation of dopamine agonist therapy. The first is when a patient has had a normal serum prolactin test following 2 years of low-dose dopamine agonist. Another is the patient who had hyperprolactinemia and a microadenoma that responded to treatment with a normal prolactin level and no further evidence of an adenoma by MRI for at least 2 years. Lastly, the patient who had a macroadenoma prior to treatment and a subsequent normal serum prolactin level without an adenoma for at least 2 years.
Like the management of thyroid dysfunction, our field must be aware of prolactin disorders for early detection, prompt referral, and appropriate management to minimize long-term consequences.
Dr. Trolice is director of Fertility CARE – The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando.
References
1. Bayrak A et al. Fertil Steril. 2005 Jul;84(1):181-5.
2. Carter JN et al. N Engl J Med. 1978 Oct 19;299(16):847-52.
3. Sachson R et al. N Engl J Med. 1972;287:972.
4. Singh SP and Singh TP. Ann Endocrinol (Paris). 1984;45(2):137-41.
5. Valassi E et al. J Clin Endocrinol Metab. 2010 Mar;95(3):1025-33.
6. Sisam DA et al. Fertil Steril. 1987 Jul;48(1):67-71.
7. Molitch ME. Best Pract Res Clin Endocrinol Metab. 2011 Dec;25(6):885-96.
The mess that is matching in psychiatry
The day I interviewed at Johns Hopkins in Baltimore, like every other day of residency interviews, was a very long and draining day.
I started by meeting alone with Philip Slavney, MD, the residency director, who spoke with me about the program and gave me a schedule to follow. I was to meet with residents and psychiatrists, some of whom had graduated from my medical school, and was sent to the Bayview campus a few miles away to have lunch and attend a few meetings. By the time I boarded an Amtrak train at Baltimore Penn Station, I was tired but I liked what I had seen. By the end of the interview season, I had crossed four programs off my list and had decided to rank only three.
In 1987, there were 987 residency positions in psychiatry in the United States, and 83.6% of those positions filled with a combination of U.S. and international medical graduates. Still, this was a risky move; the programs that I decided to rank would fill, but I was matching separately for an internship year in internal medicine in New York and decided that I would rather reapply in a year than risk matching at a program I didn’t want to go to.
I wasn’t quite sure where I wanted to rank Hopkins on my list, so I called Dr. Slavney and said I wanted to come back and meet more members of the department. He did not hide his surprise and was quick to tell me that no one had ever requested a second set of interviews. I mentioned specific people I wanted to meet with, and he was kind enough to accommodate my request and set up a second day of interviews for me.
Needless to say, the residency match felt very personal – at least to me – and although I felt vulnerable, I also felt empowered. Because of the low pay, patients with stigmatized illnesses, and the rampant belief that psychiatry was not “real” medicine and the patients never got better, psychiatry was not a desired specialty.
The residency application process in psychiatry (and every other specialty) has become a much different process. In 2006, the Association of American Medical Colleges called on medical schools to increase their enrollments to address the national shortage of physicians. Soon, there were more medical schools, bigger classes, and more doctors being minted, but the Balanced Budget Act of 1997 prevented a proportional increase in residency positions.
Len Marquez, senior director of government relations at the AAMC noted: “The Resident Physician Shortage Reduction Act of 2021 (S. 834), sponsored by Sen. Robert Menendez (D-N.J.), Sen. John Boozman (R-Ark.), and Majority Leader Sen. Charles Schumer (D-N.Y.), would support 2,000 additional Medicare-supported residency positions each year for 7 years, but Congress has not yet acted on the legislation. We were very pleased that last year, Congress passed the first increase in Medicare-supported graduate medical education in 25 years by including 1,000 new slots as part of the Consolidated Appropriations Act, 2021.”
In addition, the Build Back Better Act, which is currently being debated in Congress, would provide 4,000 more graduate medical education slots, including a specific requirement that 15% of them go to “psychiatry-related residencies,” he added.
Over 90% of graduates from U.S. medical schools currently match into a residency position. That statistic for international medical graduates is notably lower, with perhaps as few as 50% of all applicants matching.
Since 2014, the number of applicants to psychiatry residencies has nearly doubled. For the 2021 match, there were 2,486 applicants applying for 1,858 positions in psychiatry – so 1.34 applicants for each slot. Of the 1,117 senior medical students at U.S. schools who applied to psychiatry residencies, 129 did not match. Overall, 99.8% of residency positions in psychiatry filled.
“It used to be less competitive,” said Kaz J. Nelson, MD, the vice chair for education at the University of Minnesota’s department of psychiatry and behavioral sciences in Minneapolis, adding that interest in psychiatry has increased over the years.
“Interest has skyrocketed as the word has gotten out about how great a field it is. It helps that reimbursements are better, that there is less bias and discrimination against patients with psychiatric issues, and that psychiatric care is seen as a legitimate part of medicine. It has been exciting to watch!” Dr. Nelson said.
The numbers are only one part of the story, however.
Application submission now involves a centralized, electronic process, and it has become easier for applicants to apply to a lot of programs indiscriminately. It’s not unusual for applicants to apply to 70 or more programs. The factors that have limited applications include the cost: Electronic Residency Application Services (ERAS) charges for each application package they send to a program, and applicants traditionally pay to travel to the programs where they interview. This all changed with the 2021 cycle when in-person interviews were halted for the pandemic and interviews became virtual. While I recall applying to 7 residency programs, this year the average number of applications was 54.7 per applicant.
“It used to be that the cap on interviewing was financial,” Dr. Nelson said. “It was discriminatory and favored those who had more money to travel to interviews. There are still the ERAS fees, but COVID has been an equalizer and we are getting more applicants, and interviewing more who are not from Minnesota or the Midwest. We have been working to make our program attractive in terms of diversity, equity, inclusion, and justice. Our hospital is located a mile from where George Floyd was murdered, and it’s our responsibility to lead the effort to ensure the psychiatry workforce is diverse, and inclusive, as possible.”
Daniel E. Gih, MD, is the program director for a new psychiatry residency at the University of Nebraska, Omaha. When the program started in 2019, there were spots for four residents and the program had 588 applications. In 2020, the program grew to five positions and this year there were 553 applicants. Dr. Gih attributed the high number of applications to his program’s strong social media presence.
“Going through the applications and meeting the students are some of the most enjoyable parts of my work,” Dr. Gih said. “I feel guilty though, that I’m likely going to miss a great applicant. Each application averages 35 pages and it’s inevitable that programs have to take shortcuts. Applicants worry that they’ll be ranked by board scores. While we certainly don’t do that here, students might feel ruled out of a program if their numbers aren’t high enough. Furthermore, wealthy students can apply to more programs. The pandemic has really highlighted the inequity issues.”
Dr. Gih noted that the Zoom interview process has not been disappointing: “Two of the people we matched had never been to Omaha, and many expressed concerns about what it is like here. Of course, on Zoom you don’t catch subtle interpersonal issues, but we have been pleasantly surprised that the people we matched were consistent with what we expected. It is exciting to meet the people who will eventually replace us as psychiatrists, they will be here to deal with future challenges!” His enthusiasm was tangible.
While the program directors remain optimistic, the system is not without its stresses, as many programs receive over 1,000 applications.
“This is difficult,” Dr. Nelson said.” It’s wonderful for the programs, but for the medical students, not matching is experienced by them as being catastrophic, so they apply to a lot of programs. Getting this many applications is a challenge, yet I don’t want to interview someone if they are going to rank our program No. 80 on their list!”
Residencies have dealt with the deluge of applicants in a number of ways. Some specialties started a “signal” protocol wherein candidates and programs receive a certain number of tokens to indicate that each would rank the other highly, but psychiatry has not done this. Early on in the Zoom process, multiple applicants would be offered interviews simultaneously, and the interview would be given to the candidate who responded first. Students vented their frustrations on Twitter when they lost interview spots at their coveted programs because they hadn’t checked their email in time or had gone to take a shower.
“The American Association of Directors of Psychiatry Residency Training Programs issued guidelines saying that it is unacceptable to offer interview spots without allowing a reasonable time for the applicant to respond, and that it is not appropriate to offer multiple candidates one spot on a first-come, first-serve basis,” Dr. Nelson explained.
Her program has managed some of the application chaos by using a software program called Scutmonkey, codeveloped by David Ross, MD, PhD, the associate program director of the Yale Adult Psychiatry Residency Program.
“It lets us screen applications for candidates who specifically are interested in being here, and for those who qualify as part of the mission we are trying to fulfill.”
One fourth-year student at a mid-Atlantic medical school who is applying in psychiatry – who I’ll call Sacha to protect his anonymity – applied to 73 psychiatry programs and to date, has interviewed at 6. He describes a stressful, roller coaster experience:
“I got those six interviews right away and that was an amazing start, but then I didn’t get any more. The interviews I had went well, but it has been disappointing not to have more. Some were all-day interviews, while other programs had me meet with residents and attendings for 20 minutes each and it was all done after 2 hours.”
He has mixed opinions about not seeing the schools in person. “There are very heavy pros and cons. I’ve saved thousands of dollars in travel expenses that would have limited my applications, so logistically it’s a dream. On the other hand, I’ve interviewed in cities I have never been to, it’s hard to get a sense of the intangibles of a program, and the shorter interviews feel very impersonal.”
Sacha expressed anxieties about the process. “With so many applicants, it’s difficult for someone with a nontraditional story to get a spot and it’s easier for the programs to toss applications. it’s common enough and everyone has seen someone who has gone through this. At times, we feel powerless; we have no real agency or control. We send stuff out and then we sit in the prayer position and wait.”
I think back on my own application process with a sense of gratitude. I certainly didn’t feel powerless, and in today’s world, postinterview communications with program directors are regulated for both parties. Dr. Slavney was kind enough to humor my request, but I don’t believe this would be feasible in the current environment.
Even though it is wonderful that more doctors have figured out that careers in psychiatry are rewarding, the current situation is overwhelming for both the applicants and the programs. With over 100 applicants for every position – many of whom will have no interest in going to some of the programs they apply to – qualified candidates who go unmatched, and a roulette wheel which requires heavily indebted students to pay to apply, this is simply not sustainable in a country with a shortage of physicians – psychiatrists in particular.
We hear that mid-level practitioners are the answer to our shortages, but perhaps we need to create a system with enough residency positions to accommodate highly trained and qualified physicians in a more inviting and targeted way.
Dinah Miller, MD, 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. A version of this article first appeared on Medscape.com.
The day I interviewed at Johns Hopkins in Baltimore, like every other day of residency interviews, was a very long and draining day.
I started by meeting alone with Philip Slavney, MD, the residency director, who spoke with me about the program and gave me a schedule to follow. I was to meet with residents and psychiatrists, some of whom had graduated from my medical school, and was sent to the Bayview campus a few miles away to have lunch and attend a few meetings. By the time I boarded an Amtrak train at Baltimore Penn Station, I was tired but I liked what I had seen. By the end of the interview season, I had crossed four programs off my list and had decided to rank only three.
In 1987, there were 987 residency positions in psychiatry in the United States, and 83.6% of those positions filled with a combination of U.S. and international medical graduates. Still, this was a risky move; the programs that I decided to rank would fill, but I was matching separately for an internship year in internal medicine in New York and decided that I would rather reapply in a year than risk matching at a program I didn’t want to go to.
I wasn’t quite sure where I wanted to rank Hopkins on my list, so I called Dr. Slavney and said I wanted to come back and meet more members of the department. He did not hide his surprise and was quick to tell me that no one had ever requested a second set of interviews. I mentioned specific people I wanted to meet with, and he was kind enough to accommodate my request and set up a second day of interviews for me.
Needless to say, the residency match felt very personal – at least to me – and although I felt vulnerable, I also felt empowered. Because of the low pay, patients with stigmatized illnesses, and the rampant belief that psychiatry was not “real” medicine and the patients never got better, psychiatry was not a desired specialty.
The residency application process in psychiatry (and every other specialty) has become a much different process. In 2006, the Association of American Medical Colleges called on medical schools to increase their enrollments to address the national shortage of physicians. Soon, there were more medical schools, bigger classes, and more doctors being minted, but the Balanced Budget Act of 1997 prevented a proportional increase in residency positions.
Len Marquez, senior director of government relations at the AAMC noted: “The Resident Physician Shortage Reduction Act of 2021 (S. 834), sponsored by Sen. Robert Menendez (D-N.J.), Sen. John Boozman (R-Ark.), and Majority Leader Sen. Charles Schumer (D-N.Y.), would support 2,000 additional Medicare-supported residency positions each year for 7 years, but Congress has not yet acted on the legislation. We were very pleased that last year, Congress passed the first increase in Medicare-supported graduate medical education in 25 years by including 1,000 new slots as part of the Consolidated Appropriations Act, 2021.”
In addition, the Build Back Better Act, which is currently being debated in Congress, would provide 4,000 more graduate medical education slots, including a specific requirement that 15% of them go to “psychiatry-related residencies,” he added.
Over 90% of graduates from U.S. medical schools currently match into a residency position. That statistic for international medical graduates is notably lower, with perhaps as few as 50% of all applicants matching.
Since 2014, the number of applicants to psychiatry residencies has nearly doubled. For the 2021 match, there were 2,486 applicants applying for 1,858 positions in psychiatry – so 1.34 applicants for each slot. Of the 1,117 senior medical students at U.S. schools who applied to psychiatry residencies, 129 did not match. Overall, 99.8% of residency positions in psychiatry filled.
“It used to be less competitive,” said Kaz J. Nelson, MD, the vice chair for education at the University of Minnesota’s department of psychiatry and behavioral sciences in Minneapolis, adding that interest in psychiatry has increased over the years.
“Interest has skyrocketed as the word has gotten out about how great a field it is. It helps that reimbursements are better, that there is less bias and discrimination against patients with psychiatric issues, and that psychiatric care is seen as a legitimate part of medicine. It has been exciting to watch!” Dr. Nelson said.
The numbers are only one part of the story, however.
Application submission now involves a centralized, electronic process, and it has become easier for applicants to apply to a lot of programs indiscriminately. It’s not unusual for applicants to apply to 70 or more programs. The factors that have limited applications include the cost: Electronic Residency Application Services (ERAS) charges for each application package they send to a program, and applicants traditionally pay to travel to the programs where they interview. This all changed with the 2021 cycle when in-person interviews were halted for the pandemic and interviews became virtual. While I recall applying to 7 residency programs, this year the average number of applications was 54.7 per applicant.
“It used to be that the cap on interviewing was financial,” Dr. Nelson said. “It was discriminatory and favored those who had more money to travel to interviews. There are still the ERAS fees, but COVID has been an equalizer and we are getting more applicants, and interviewing more who are not from Minnesota or the Midwest. We have been working to make our program attractive in terms of diversity, equity, inclusion, and justice. Our hospital is located a mile from where George Floyd was murdered, and it’s our responsibility to lead the effort to ensure the psychiatry workforce is diverse, and inclusive, as possible.”
Daniel E. Gih, MD, is the program director for a new psychiatry residency at the University of Nebraska, Omaha. When the program started in 2019, there were spots for four residents and the program had 588 applications. In 2020, the program grew to five positions and this year there were 553 applicants. Dr. Gih attributed the high number of applications to his program’s strong social media presence.
“Going through the applications and meeting the students are some of the most enjoyable parts of my work,” Dr. Gih said. “I feel guilty though, that I’m likely going to miss a great applicant. Each application averages 35 pages and it’s inevitable that programs have to take shortcuts. Applicants worry that they’ll be ranked by board scores. While we certainly don’t do that here, students might feel ruled out of a program if their numbers aren’t high enough. Furthermore, wealthy students can apply to more programs. The pandemic has really highlighted the inequity issues.”
Dr. Gih noted that the Zoom interview process has not been disappointing: “Two of the people we matched had never been to Omaha, and many expressed concerns about what it is like here. Of course, on Zoom you don’t catch subtle interpersonal issues, but we have been pleasantly surprised that the people we matched were consistent with what we expected. It is exciting to meet the people who will eventually replace us as psychiatrists, they will be here to deal with future challenges!” His enthusiasm was tangible.
While the program directors remain optimistic, the system is not without its stresses, as many programs receive over 1,000 applications.
“This is difficult,” Dr. Nelson said.” It’s wonderful for the programs, but for the medical students, not matching is experienced by them as being catastrophic, so they apply to a lot of programs. Getting this many applications is a challenge, yet I don’t want to interview someone if they are going to rank our program No. 80 on their list!”
Residencies have dealt with the deluge of applicants in a number of ways. Some specialties started a “signal” protocol wherein candidates and programs receive a certain number of tokens to indicate that each would rank the other highly, but psychiatry has not done this. Early on in the Zoom process, multiple applicants would be offered interviews simultaneously, and the interview would be given to the candidate who responded first. Students vented their frustrations on Twitter when they lost interview spots at their coveted programs because they hadn’t checked their email in time or had gone to take a shower.
“The American Association of Directors of Psychiatry Residency Training Programs issued guidelines saying that it is unacceptable to offer interview spots without allowing a reasonable time for the applicant to respond, and that it is not appropriate to offer multiple candidates one spot on a first-come, first-serve basis,” Dr. Nelson explained.
Her program has managed some of the application chaos by using a software program called Scutmonkey, codeveloped by David Ross, MD, PhD, the associate program director of the Yale Adult Psychiatry Residency Program.
“It lets us screen applications for candidates who specifically are interested in being here, and for those who qualify as part of the mission we are trying to fulfill.”
One fourth-year student at a mid-Atlantic medical school who is applying in psychiatry – who I’ll call Sacha to protect his anonymity – applied to 73 psychiatry programs and to date, has interviewed at 6. He describes a stressful, roller coaster experience:
“I got those six interviews right away and that was an amazing start, but then I didn’t get any more. The interviews I had went well, but it has been disappointing not to have more. Some were all-day interviews, while other programs had me meet with residents and attendings for 20 minutes each and it was all done after 2 hours.”
He has mixed opinions about not seeing the schools in person. “There are very heavy pros and cons. I’ve saved thousands of dollars in travel expenses that would have limited my applications, so logistically it’s a dream. On the other hand, I’ve interviewed in cities I have never been to, it’s hard to get a sense of the intangibles of a program, and the shorter interviews feel very impersonal.”
Sacha expressed anxieties about the process. “With so many applicants, it’s difficult for someone with a nontraditional story to get a spot and it’s easier for the programs to toss applications. it’s common enough and everyone has seen someone who has gone through this. At times, we feel powerless; we have no real agency or control. We send stuff out and then we sit in the prayer position and wait.”
I think back on my own application process with a sense of gratitude. I certainly didn’t feel powerless, and in today’s world, postinterview communications with program directors are regulated for both parties. Dr. Slavney was kind enough to humor my request, but I don’t believe this would be feasible in the current environment.
Even though it is wonderful that more doctors have figured out that careers in psychiatry are rewarding, the current situation is overwhelming for both the applicants and the programs. With over 100 applicants for every position – many of whom will have no interest in going to some of the programs they apply to – qualified candidates who go unmatched, and a roulette wheel which requires heavily indebted students to pay to apply, this is simply not sustainable in a country with a shortage of physicians – psychiatrists in particular.
We hear that mid-level practitioners are the answer to our shortages, but perhaps we need to create a system with enough residency positions to accommodate highly trained and qualified physicians in a more inviting and targeted way.
Dinah Miller, MD, 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. A version of this article first appeared on Medscape.com.
The day I interviewed at Johns Hopkins in Baltimore, like every other day of residency interviews, was a very long and draining day.
I started by meeting alone with Philip Slavney, MD, the residency director, who spoke with me about the program and gave me a schedule to follow. I was to meet with residents and psychiatrists, some of whom had graduated from my medical school, and was sent to the Bayview campus a few miles away to have lunch and attend a few meetings. By the time I boarded an Amtrak train at Baltimore Penn Station, I was tired but I liked what I had seen. By the end of the interview season, I had crossed four programs off my list and had decided to rank only three.
In 1987, there were 987 residency positions in psychiatry in the United States, and 83.6% of those positions filled with a combination of U.S. and international medical graduates. Still, this was a risky move; the programs that I decided to rank would fill, but I was matching separately for an internship year in internal medicine in New York and decided that I would rather reapply in a year than risk matching at a program I didn’t want to go to.
I wasn’t quite sure where I wanted to rank Hopkins on my list, so I called Dr. Slavney and said I wanted to come back and meet more members of the department. He did not hide his surprise and was quick to tell me that no one had ever requested a second set of interviews. I mentioned specific people I wanted to meet with, and he was kind enough to accommodate my request and set up a second day of interviews for me.
Needless to say, the residency match felt very personal – at least to me – and although I felt vulnerable, I also felt empowered. Because of the low pay, patients with stigmatized illnesses, and the rampant belief that psychiatry was not “real” medicine and the patients never got better, psychiatry was not a desired specialty.
The residency application process in psychiatry (and every other specialty) has become a much different process. In 2006, the Association of American Medical Colleges called on medical schools to increase their enrollments to address the national shortage of physicians. Soon, there were more medical schools, bigger classes, and more doctors being minted, but the Balanced Budget Act of 1997 prevented a proportional increase in residency positions.
Len Marquez, senior director of government relations at the AAMC noted: “The Resident Physician Shortage Reduction Act of 2021 (S. 834), sponsored by Sen. Robert Menendez (D-N.J.), Sen. John Boozman (R-Ark.), and Majority Leader Sen. Charles Schumer (D-N.Y.), would support 2,000 additional Medicare-supported residency positions each year for 7 years, but Congress has not yet acted on the legislation. We were very pleased that last year, Congress passed the first increase in Medicare-supported graduate medical education in 25 years by including 1,000 new slots as part of the Consolidated Appropriations Act, 2021.”
In addition, the Build Back Better Act, which is currently being debated in Congress, would provide 4,000 more graduate medical education slots, including a specific requirement that 15% of them go to “psychiatry-related residencies,” he added.
Over 90% of graduates from U.S. medical schools currently match into a residency position. That statistic for international medical graduates is notably lower, with perhaps as few as 50% of all applicants matching.
Since 2014, the number of applicants to psychiatry residencies has nearly doubled. For the 2021 match, there were 2,486 applicants applying for 1,858 positions in psychiatry – so 1.34 applicants for each slot. Of the 1,117 senior medical students at U.S. schools who applied to psychiatry residencies, 129 did not match. Overall, 99.8% of residency positions in psychiatry filled.
“It used to be less competitive,” said Kaz J. Nelson, MD, the vice chair for education at the University of Minnesota’s department of psychiatry and behavioral sciences in Minneapolis, adding that interest in psychiatry has increased over the years.
“Interest has skyrocketed as the word has gotten out about how great a field it is. It helps that reimbursements are better, that there is less bias and discrimination against patients with psychiatric issues, and that psychiatric care is seen as a legitimate part of medicine. It has been exciting to watch!” Dr. Nelson said.
The numbers are only one part of the story, however.
Application submission now involves a centralized, electronic process, and it has become easier for applicants to apply to a lot of programs indiscriminately. It’s not unusual for applicants to apply to 70 or more programs. The factors that have limited applications include the cost: Electronic Residency Application Services (ERAS) charges for each application package they send to a program, and applicants traditionally pay to travel to the programs where they interview. This all changed with the 2021 cycle when in-person interviews were halted for the pandemic and interviews became virtual. While I recall applying to 7 residency programs, this year the average number of applications was 54.7 per applicant.
“It used to be that the cap on interviewing was financial,” Dr. Nelson said. “It was discriminatory and favored those who had more money to travel to interviews. There are still the ERAS fees, but COVID has been an equalizer and we are getting more applicants, and interviewing more who are not from Minnesota or the Midwest. We have been working to make our program attractive in terms of diversity, equity, inclusion, and justice. Our hospital is located a mile from where George Floyd was murdered, and it’s our responsibility to lead the effort to ensure the psychiatry workforce is diverse, and inclusive, as possible.”
Daniel E. Gih, MD, is the program director for a new psychiatry residency at the University of Nebraska, Omaha. When the program started in 2019, there were spots for four residents and the program had 588 applications. In 2020, the program grew to five positions and this year there were 553 applicants. Dr. Gih attributed the high number of applications to his program’s strong social media presence.
“Going through the applications and meeting the students are some of the most enjoyable parts of my work,” Dr. Gih said. “I feel guilty though, that I’m likely going to miss a great applicant. Each application averages 35 pages and it’s inevitable that programs have to take shortcuts. Applicants worry that they’ll be ranked by board scores. While we certainly don’t do that here, students might feel ruled out of a program if their numbers aren’t high enough. Furthermore, wealthy students can apply to more programs. The pandemic has really highlighted the inequity issues.”
Dr. Gih noted that the Zoom interview process has not been disappointing: “Two of the people we matched had never been to Omaha, and many expressed concerns about what it is like here. Of course, on Zoom you don’t catch subtle interpersonal issues, but we have been pleasantly surprised that the people we matched were consistent with what we expected. It is exciting to meet the people who will eventually replace us as psychiatrists, they will be here to deal with future challenges!” His enthusiasm was tangible.
While the program directors remain optimistic, the system is not without its stresses, as many programs receive over 1,000 applications.
“This is difficult,” Dr. Nelson said.” It’s wonderful for the programs, but for the medical students, not matching is experienced by them as being catastrophic, so they apply to a lot of programs. Getting this many applications is a challenge, yet I don’t want to interview someone if they are going to rank our program No. 80 on their list!”
Residencies have dealt with the deluge of applicants in a number of ways. Some specialties started a “signal” protocol wherein candidates and programs receive a certain number of tokens to indicate that each would rank the other highly, but psychiatry has not done this. Early on in the Zoom process, multiple applicants would be offered interviews simultaneously, and the interview would be given to the candidate who responded first. Students vented their frustrations on Twitter when they lost interview spots at their coveted programs because they hadn’t checked their email in time or had gone to take a shower.
“The American Association of Directors of Psychiatry Residency Training Programs issued guidelines saying that it is unacceptable to offer interview spots without allowing a reasonable time for the applicant to respond, and that it is not appropriate to offer multiple candidates one spot on a first-come, first-serve basis,” Dr. Nelson explained.
Her program has managed some of the application chaos by using a software program called Scutmonkey, codeveloped by David Ross, MD, PhD, the associate program director of the Yale Adult Psychiatry Residency Program.
“It lets us screen applications for candidates who specifically are interested in being here, and for those who qualify as part of the mission we are trying to fulfill.”
One fourth-year student at a mid-Atlantic medical school who is applying in psychiatry – who I’ll call Sacha to protect his anonymity – applied to 73 psychiatry programs and to date, has interviewed at 6. He describes a stressful, roller coaster experience:
“I got those six interviews right away and that was an amazing start, but then I didn’t get any more. The interviews I had went well, but it has been disappointing not to have more. Some were all-day interviews, while other programs had me meet with residents and attendings for 20 minutes each and it was all done after 2 hours.”
He has mixed opinions about not seeing the schools in person. “There are very heavy pros and cons. I’ve saved thousands of dollars in travel expenses that would have limited my applications, so logistically it’s a dream. On the other hand, I’ve interviewed in cities I have never been to, it’s hard to get a sense of the intangibles of a program, and the shorter interviews feel very impersonal.”
Sacha expressed anxieties about the process. “With so many applicants, it’s difficult for someone with a nontraditional story to get a spot and it’s easier for the programs to toss applications. it’s common enough and everyone has seen someone who has gone through this. At times, we feel powerless; we have no real agency or control. We send stuff out and then we sit in the prayer position and wait.”
I think back on my own application process with a sense of gratitude. I certainly didn’t feel powerless, and in today’s world, postinterview communications with program directors are regulated for both parties. Dr. Slavney was kind enough to humor my request, but I don’t believe this would be feasible in the current environment.
Even though it is wonderful that more doctors have figured out that careers in psychiatry are rewarding, the current situation is overwhelming for both the applicants and the programs. With over 100 applicants for every position – many of whom will have no interest in going to some of the programs they apply to – qualified candidates who go unmatched, and a roulette wheel which requires heavily indebted students to pay to apply, this is simply not sustainable in a country with a shortage of physicians – psychiatrists in particular.
We hear that mid-level practitioners are the answer to our shortages, but perhaps we need to create a system with enough residency positions to accommodate highly trained and qualified physicians in a more inviting and targeted way.
Dinah Miller, MD, 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. A version of this article first appeared on Medscape.com.
A common problem improved but not solved
Phoenix has only a few months each year to use my hot tub, so winter is when I catch up on a lot of my reading. Recently I was reading the November Lancet, which had some interesting statistics about migraine.
- It’s the second leading cause (behind back pain) of years lived with disability.
- There are 10 million people with migraines in the United Kingdom (population roughly 70 million).
- In the last 5 years, migraine use of emergency rooms has increased 14%.
- According to the U.K. National Health Service, over 16,000 ER visits for migraine could be avoided.
These are compelling statistics, and probably (taking into account population differences) similar to numbers here in the United States or Canada.
Like all neurologists, I see my share of migraine.
Like many neurologists, I also get migraines. Not many, maybe 2-3 per month, effectively treated with a triptan. So I have a decent understanding that they aren’t pleasant.
Fortunately, migraine advances have been impressive, with seven new CGRP drugs in the last 3 years, bringing successful treatment closer for many.
But the problem is far from solved, a point that was driven home yesterday.
I awoke early yesterday morning with a migraine, and took an Imitrex. But instead of feeling better in an hour, it kept worsening until I was literally disabled by it. I took some Excedrin Migraine. The last time I had a migraine this bad was in 1998, during my fellowship, and my attending had to drive me home (thanks, Joe).
It was showing no signs of letting up. I thought about going to emergency department. After all, aren’t we trained for that when we hear “worst headache of my life?” but figured it was more likely just a migraine, and didn’t want to bog down my ED colleagues in the midst of another COVID-19 wave.
I took another Imitrex. I found a sample of Ubrelvy that I’d brought home out of curiosity, and took that, too. I think I have an old, nearly empty, bottle of Norco, somewhere, from a 2014 dental surgery, but was too photophobic to go looking for it (if I still have it at all).
I lay down in bed under the ceiling fan, and somehow fell asleep.
When I woke about 90 minutes later it was gone, like a switch had been flipped. Maybe it was all, or just one of, the meds I’d taken. I’ll never know. I could now resume my regularly scheduled program.
The migraine had cost me 7 hours. Like most small business owners, I’m trying to get all the year-end paperwork wrapped up, in addition to reviewing cases, writing up reports, and spending time with my family. So none of that happened that Saturday morning. If I’d had to see patients that morning there’s no way I could have done it.
Fortunately, as I said, that’s only the second time that’s happened to me, and it’s been 25 years since the last one.
But I’m lucky. There are those who have them far more frequently, limiting their ability to work, raise families, spend time with friends. … Have a life.
Migraine is far from a deadly disease. In neurology we treat far worse conditions. But in sheer numbers migraine affects far more people, and (indirectly) an even larger group of coworkers, parents, friends, and children who have to cover unpredictably when the other person is out with one.
For all of them,
Phoenix has only a few months each year to use my hot tub, so winter is when I catch up on a lot of my reading. Recently I was reading the November Lancet, which had some interesting statistics about migraine.
- It’s the second leading cause (behind back pain) of years lived with disability.
- There are 10 million people with migraines in the United Kingdom (population roughly 70 million).
- In the last 5 years, migraine use of emergency rooms has increased 14%.
- According to the U.K. National Health Service, over 16,000 ER visits for migraine could be avoided.
These are compelling statistics, and probably (taking into account population differences) similar to numbers here in the United States or Canada.
Like all neurologists, I see my share of migraine.
Like many neurologists, I also get migraines. Not many, maybe 2-3 per month, effectively treated with a triptan. So I have a decent understanding that they aren’t pleasant.
Fortunately, migraine advances have been impressive, with seven new CGRP drugs in the last 3 years, bringing successful treatment closer for many.
But the problem is far from solved, a point that was driven home yesterday.
I awoke early yesterday morning with a migraine, and took an Imitrex. But instead of feeling better in an hour, it kept worsening until I was literally disabled by it. I took some Excedrin Migraine. The last time I had a migraine this bad was in 1998, during my fellowship, and my attending had to drive me home (thanks, Joe).
It was showing no signs of letting up. I thought about going to emergency department. After all, aren’t we trained for that when we hear “worst headache of my life?” but figured it was more likely just a migraine, and didn’t want to bog down my ED colleagues in the midst of another COVID-19 wave.
I took another Imitrex. I found a sample of Ubrelvy that I’d brought home out of curiosity, and took that, too. I think I have an old, nearly empty, bottle of Norco, somewhere, from a 2014 dental surgery, but was too photophobic to go looking for it (if I still have it at all).
I lay down in bed under the ceiling fan, and somehow fell asleep.
When I woke about 90 minutes later it was gone, like a switch had been flipped. Maybe it was all, or just one of, the meds I’d taken. I’ll never know. I could now resume my regularly scheduled program.
The migraine had cost me 7 hours. Like most small business owners, I’m trying to get all the year-end paperwork wrapped up, in addition to reviewing cases, writing up reports, and spending time with my family. So none of that happened that Saturday morning. If I’d had to see patients that morning there’s no way I could have done it.
Fortunately, as I said, that’s only the second time that’s happened to me, and it’s been 25 years since the last one.
But I’m lucky. There are those who have them far more frequently, limiting their ability to work, raise families, spend time with friends. … Have a life.
Migraine is far from a deadly disease. In neurology we treat far worse conditions. But in sheer numbers migraine affects far more people, and (indirectly) an even larger group of coworkers, parents, friends, and children who have to cover unpredictably when the other person is out with one.
For all of them,
Phoenix has only a few months each year to use my hot tub, so winter is when I catch up on a lot of my reading. Recently I was reading the November Lancet, which had some interesting statistics about migraine.
- It’s the second leading cause (behind back pain) of years lived with disability.
- There are 10 million people with migraines in the United Kingdom (population roughly 70 million).
- In the last 5 years, migraine use of emergency rooms has increased 14%.
- According to the U.K. National Health Service, over 16,000 ER visits for migraine could be avoided.
These are compelling statistics, and probably (taking into account population differences) similar to numbers here in the United States or Canada.
Like all neurologists, I see my share of migraine.
Like many neurologists, I also get migraines. Not many, maybe 2-3 per month, effectively treated with a triptan. So I have a decent understanding that they aren’t pleasant.
Fortunately, migraine advances have been impressive, with seven new CGRP drugs in the last 3 years, bringing successful treatment closer for many.
But the problem is far from solved, a point that was driven home yesterday.
I awoke early yesterday morning with a migraine, and took an Imitrex. But instead of feeling better in an hour, it kept worsening until I was literally disabled by it. I took some Excedrin Migraine. The last time I had a migraine this bad was in 1998, during my fellowship, and my attending had to drive me home (thanks, Joe).
It was showing no signs of letting up. I thought about going to emergency department. After all, aren’t we trained for that when we hear “worst headache of my life?” but figured it was more likely just a migraine, and didn’t want to bog down my ED colleagues in the midst of another COVID-19 wave.
I took another Imitrex. I found a sample of Ubrelvy that I’d brought home out of curiosity, and took that, too. I think I have an old, nearly empty, bottle of Norco, somewhere, from a 2014 dental surgery, but was too photophobic to go looking for it (if I still have it at all).
I lay down in bed under the ceiling fan, and somehow fell asleep.
When I woke about 90 minutes later it was gone, like a switch had been flipped. Maybe it was all, or just one of, the meds I’d taken. I’ll never know. I could now resume my regularly scheduled program.
The migraine had cost me 7 hours. Like most small business owners, I’m trying to get all the year-end paperwork wrapped up, in addition to reviewing cases, writing up reports, and spending time with my family. So none of that happened that Saturday morning. If I’d had to see patients that morning there’s no way I could have done it.
Fortunately, as I said, that’s only the second time that’s happened to me, and it’s been 25 years since the last one.
But I’m lucky. There are those who have them far more frequently, limiting their ability to work, raise families, spend time with friends. … Have a life.
Migraine is far from a deadly disease. In neurology we treat far worse conditions. But in sheer numbers migraine affects far more people, and (indirectly) an even larger group of coworkers, parents, friends, and children who have to cover unpredictably when the other person is out with one.
For all of them,
COVID-19 and coping with superimposed traumas
While 2022 is lurking around the corner, many of us still have 2020 on our minds. Social media posts are already emerging: “No new years resolutions. It is the circumstances turn to improve [sic],” one post declares. Others proclaim that it is difficult coming to terms with the idea that 2022 is actually pronounced “2020 too.” A critical difference exists between then and now – we have experienced months of living in limbo and rolling with the punches of pandemic life.
In some ways, it has become easy to think of the early pandemic days as a distant memory, yet respect that the impact of 2020 has been indelible for virtually all of us and feels palpable as if it were yesterday.
The year 2020 was marked by the beginning of the COVID-19 pandemic, which was accompanied by extreme uncertainty, loss of all kinds, and emotional turmoil. The early pandemic had a profound economic and social impact, with added stress tethered to political and race-related division in America that created divides among families and friends, and yielded ceaseless discourse related to divergent perspectives. This only exacerbated the stress that came with the pandemic, given that providing support and leaning on one another was more important than ever. All of this was compounded by natural disasters that have plagued the country.
So much was unprecedented. There was a collective sense of feeling “worn down,” and the burnout that was felt was quite profound. Enormous amounts of mental and physical effort were allocated to simply surviving, getting basic needs met, having enough food and supplies, and completing basic tasks. Ordinary relating felt taxing. At this stage of the pandemic, the COVID-19 experience can be conceived of as a traumatic stressor capable of eliciting a traumatic response and exacerbating other mental health symptoms. Our capacity to cope has been diminished. Anxiety rates have soared, as have rates of clinical depression. Those most affected have had lower household incomes, are unmarried, and have experienced pandemic-related stressors. The links between the impact of the pandemic on mental health have been clear.
The pandemic has forced the landscape of social support to dramatically change. Initially, we felt pulled to connect and we leaned into the use of virtual platforms to connect for all matters (simple social gatherings, big birthday events, family reunions, celebration of holidays, work duties, and academic work). However, “Zoom fatigue” began to set in, and our screen time was maxed out. There has been the added dynamic of frontline workers who did not have the option to work virtually or from home. This group largely has felt disconnected from others who didn’t understand the depth of their anxiety and loneliness of their experience. Health care workers have had to make challenging, life-and-death, patient-related decisions that called into question personal morals and ethics all while their own lives were at risk.
Fast-forward to the present, and support systems have either strengthened or worn down – which has yielded a unique dichotomy. Maintaining friendships has either felt of utmost importance given the impact of the disconnect and physical distance or has felt challenging given the mental energy expended from working and connecting virtually. Empathy burnout is also a real and important facet in the equation. We begin to ask the question: Are we checking in with others in the spirit of authentic relating, to cultivate real connection, or to check a box?
Impact of layered traumas
It is interesting to think about the pandemic’s traumatic impact being “superimposed” on top of the “ordinary traumas” experienced outside of the pandemic. We are essentially at the 2-year mark, in some ways have cultivated a sense of resilience and found ways to adapt, and in other ways at times feel right back where we were in early 2020. There were moments that felt hopeful, glimmers of normalcy, and setbacks that all ebbed and flowed – but even so, there have not been many “mental breaks,” only temporary and transient reprieves. Some got sick and died; some recovered; and others are still experiencing long-hauler syndrome and have lingering sequelae. Despite adaptation and resilience, one can’t help but wonder the impact of superimposed traumas on top of this collective trauma. Many of us have not even rebounded from the pandemic, and then are faced with loss, grief, challenges, illness, hard and big life decisions. We are challenged to answer the question: How do we endure in the face of this trauma inception?
It has been a challenging time for all, including those who are ordinarily happy-go-lucky, resilient, and see the glass half-full and are struggling with the idea of struggling. I am no “resilience expert” but gleaned much wisdom from responding to the Surfside, Fla., building collapse. This was a collective trauma that took place in the summer of 2021, and the wisdom of this event highlighted the value of collective healing and unification even in spite of the times. What happened in Surfside was a shock, and the loss was felt by those directly affected, the surrounding community, and those who were part of the disaster response efforts. All of those parties had been processing losses prior to this – loss of normalcy because of the pandemic, loss of people we loved as a result, other personal losses – and this community tragedy was yet another loss to disentangle on top of a period in U.S. history demarcated by a great lack of unity, divisiveness, anger, and hatred. The collapse highlighted the small size yet interconnectedness of the community and the power of connection and authentic relating. It was overwhelming in the moment but extremely heartening and beautiful to see the amount of willingness to drop everything and help. Despite feeling worn down from the pandemic, people drew upon their internal resources, natural goodness, and kindness “reserves” to provide support.
Responding to the collapse highlighted that resilience in the context of collective trauma requires flexibility, embracing uncertainty, cultivating unity, and paying attention to meeting basic needs/self-care. The role of kindness cannot be overemphasized. In the realm of reflecting on the notion of kindness, it is worth noting how much power there is to bearing witness to someone’s experience, especially when they are in pain. People often diminish the role or at the very least do not recognize the power of showing up for someone and just listening. Pandemic resilience, and coping with coalescing traumas, is likely composed of these same facets that were essential in the context of coping with the collapse.
It is not only the immediate impact of a trauma as much as the aftermath that needs to processed and worked through. In one sense, people feel that they should be adjusted to and accustomed to this new reality, and at the same time, one has to remember and reflect on how unnatural this experience has been. There is an impact of a cumulative onslaught of negative events, and it is hard to imagine not being phased, remaining unchanged, or not feeling affected. We may feel hardened and that there are limits to the compassion we have to offer others. We may be feel empathic. There can be desensitization and an apathy to others’ suffering when our patience is worn down and we have limited bandwidth. There are data to support the idea that a level of habituation occurs to individuals who experience multiple traumas, which yields a level of “sensitization” to the negative impact of subsequent events. It becomes easy to make comparisons of suffering. The challenge will be to rise above these and make a conscious effort to connect with who and how we were before we were worn down.
I am still in awe about how much I learned from the victims’ families, survivors, and my colleagues at Surfside – about pain, suffering, loss, resilience, coping, fortitude, and meaning making. We were all forced to think beyond ourselves, show up for others, and unify in a way that remedied this period of fragmentation. With respect to the pandemic and “where we are at now,” some elements of our lives are stabilizing; other aspects feel volatile from the fatigue of what we have been experiencing. This pandemic has not fully abated, but we can find some clarity in the value of setting boundaries and knowing our limits – but not overlooking the power of unity and kindness and the value of the reciprocating those qualities.
Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of the Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures.
While 2022 is lurking around the corner, many of us still have 2020 on our minds. Social media posts are already emerging: “No new years resolutions. It is the circumstances turn to improve [sic],” one post declares. Others proclaim that it is difficult coming to terms with the idea that 2022 is actually pronounced “2020 too.” A critical difference exists between then and now – we have experienced months of living in limbo and rolling with the punches of pandemic life.
In some ways, it has become easy to think of the early pandemic days as a distant memory, yet respect that the impact of 2020 has been indelible for virtually all of us and feels palpable as if it were yesterday.
The year 2020 was marked by the beginning of the COVID-19 pandemic, which was accompanied by extreme uncertainty, loss of all kinds, and emotional turmoil. The early pandemic had a profound economic and social impact, with added stress tethered to political and race-related division in America that created divides among families and friends, and yielded ceaseless discourse related to divergent perspectives. This only exacerbated the stress that came with the pandemic, given that providing support and leaning on one another was more important than ever. All of this was compounded by natural disasters that have plagued the country.
So much was unprecedented. There was a collective sense of feeling “worn down,” and the burnout that was felt was quite profound. Enormous amounts of mental and physical effort were allocated to simply surviving, getting basic needs met, having enough food and supplies, and completing basic tasks. Ordinary relating felt taxing. At this stage of the pandemic, the COVID-19 experience can be conceived of as a traumatic stressor capable of eliciting a traumatic response and exacerbating other mental health symptoms. Our capacity to cope has been diminished. Anxiety rates have soared, as have rates of clinical depression. Those most affected have had lower household incomes, are unmarried, and have experienced pandemic-related stressors. The links between the impact of the pandemic on mental health have been clear.
The pandemic has forced the landscape of social support to dramatically change. Initially, we felt pulled to connect and we leaned into the use of virtual platforms to connect for all matters (simple social gatherings, big birthday events, family reunions, celebration of holidays, work duties, and academic work). However, “Zoom fatigue” began to set in, and our screen time was maxed out. There has been the added dynamic of frontline workers who did not have the option to work virtually or from home. This group largely has felt disconnected from others who didn’t understand the depth of their anxiety and loneliness of their experience. Health care workers have had to make challenging, life-and-death, patient-related decisions that called into question personal morals and ethics all while their own lives were at risk.
Fast-forward to the present, and support systems have either strengthened or worn down – which has yielded a unique dichotomy. Maintaining friendships has either felt of utmost importance given the impact of the disconnect and physical distance or has felt challenging given the mental energy expended from working and connecting virtually. Empathy burnout is also a real and important facet in the equation. We begin to ask the question: Are we checking in with others in the spirit of authentic relating, to cultivate real connection, or to check a box?
Impact of layered traumas
It is interesting to think about the pandemic’s traumatic impact being “superimposed” on top of the “ordinary traumas” experienced outside of the pandemic. We are essentially at the 2-year mark, in some ways have cultivated a sense of resilience and found ways to adapt, and in other ways at times feel right back where we were in early 2020. There were moments that felt hopeful, glimmers of normalcy, and setbacks that all ebbed and flowed – but even so, there have not been many “mental breaks,” only temporary and transient reprieves. Some got sick and died; some recovered; and others are still experiencing long-hauler syndrome and have lingering sequelae. Despite adaptation and resilience, one can’t help but wonder the impact of superimposed traumas on top of this collective trauma. Many of us have not even rebounded from the pandemic, and then are faced with loss, grief, challenges, illness, hard and big life decisions. We are challenged to answer the question: How do we endure in the face of this trauma inception?
It has been a challenging time for all, including those who are ordinarily happy-go-lucky, resilient, and see the glass half-full and are struggling with the idea of struggling. I am no “resilience expert” but gleaned much wisdom from responding to the Surfside, Fla., building collapse. This was a collective trauma that took place in the summer of 2021, and the wisdom of this event highlighted the value of collective healing and unification even in spite of the times. What happened in Surfside was a shock, and the loss was felt by those directly affected, the surrounding community, and those who were part of the disaster response efforts. All of those parties had been processing losses prior to this – loss of normalcy because of the pandemic, loss of people we loved as a result, other personal losses – and this community tragedy was yet another loss to disentangle on top of a period in U.S. history demarcated by a great lack of unity, divisiveness, anger, and hatred. The collapse highlighted the small size yet interconnectedness of the community and the power of connection and authentic relating. It was overwhelming in the moment but extremely heartening and beautiful to see the amount of willingness to drop everything and help. Despite feeling worn down from the pandemic, people drew upon their internal resources, natural goodness, and kindness “reserves” to provide support.
Responding to the collapse highlighted that resilience in the context of collective trauma requires flexibility, embracing uncertainty, cultivating unity, and paying attention to meeting basic needs/self-care. The role of kindness cannot be overemphasized. In the realm of reflecting on the notion of kindness, it is worth noting how much power there is to bearing witness to someone’s experience, especially when they are in pain. People often diminish the role or at the very least do not recognize the power of showing up for someone and just listening. Pandemic resilience, and coping with coalescing traumas, is likely composed of these same facets that were essential in the context of coping with the collapse.
It is not only the immediate impact of a trauma as much as the aftermath that needs to processed and worked through. In one sense, people feel that they should be adjusted to and accustomed to this new reality, and at the same time, one has to remember and reflect on how unnatural this experience has been. There is an impact of a cumulative onslaught of negative events, and it is hard to imagine not being phased, remaining unchanged, or not feeling affected. We may feel hardened and that there are limits to the compassion we have to offer others. We may be feel empathic. There can be desensitization and an apathy to others’ suffering when our patience is worn down and we have limited bandwidth. There are data to support the idea that a level of habituation occurs to individuals who experience multiple traumas, which yields a level of “sensitization” to the negative impact of subsequent events. It becomes easy to make comparisons of suffering. The challenge will be to rise above these and make a conscious effort to connect with who and how we were before we were worn down.
I am still in awe about how much I learned from the victims’ families, survivors, and my colleagues at Surfside – about pain, suffering, loss, resilience, coping, fortitude, and meaning making. We were all forced to think beyond ourselves, show up for others, and unify in a way that remedied this period of fragmentation. With respect to the pandemic and “where we are at now,” some elements of our lives are stabilizing; other aspects feel volatile from the fatigue of what we have been experiencing. This pandemic has not fully abated, but we can find some clarity in the value of setting boundaries and knowing our limits – but not overlooking the power of unity and kindness and the value of the reciprocating those qualities.
Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of the Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures.
While 2022 is lurking around the corner, many of us still have 2020 on our minds. Social media posts are already emerging: “No new years resolutions. It is the circumstances turn to improve [sic],” one post declares. Others proclaim that it is difficult coming to terms with the idea that 2022 is actually pronounced “2020 too.” A critical difference exists between then and now – we have experienced months of living in limbo and rolling with the punches of pandemic life.
In some ways, it has become easy to think of the early pandemic days as a distant memory, yet respect that the impact of 2020 has been indelible for virtually all of us and feels palpable as if it were yesterday.
The year 2020 was marked by the beginning of the COVID-19 pandemic, which was accompanied by extreme uncertainty, loss of all kinds, and emotional turmoil. The early pandemic had a profound economic and social impact, with added stress tethered to political and race-related division in America that created divides among families and friends, and yielded ceaseless discourse related to divergent perspectives. This only exacerbated the stress that came with the pandemic, given that providing support and leaning on one another was more important than ever. All of this was compounded by natural disasters that have plagued the country.
So much was unprecedented. There was a collective sense of feeling “worn down,” and the burnout that was felt was quite profound. Enormous amounts of mental and physical effort were allocated to simply surviving, getting basic needs met, having enough food and supplies, and completing basic tasks. Ordinary relating felt taxing. At this stage of the pandemic, the COVID-19 experience can be conceived of as a traumatic stressor capable of eliciting a traumatic response and exacerbating other mental health symptoms. Our capacity to cope has been diminished. Anxiety rates have soared, as have rates of clinical depression. Those most affected have had lower household incomes, are unmarried, and have experienced pandemic-related stressors. The links between the impact of the pandemic on mental health have been clear.
The pandemic has forced the landscape of social support to dramatically change. Initially, we felt pulled to connect and we leaned into the use of virtual platforms to connect for all matters (simple social gatherings, big birthday events, family reunions, celebration of holidays, work duties, and academic work). However, “Zoom fatigue” began to set in, and our screen time was maxed out. There has been the added dynamic of frontline workers who did not have the option to work virtually or from home. This group largely has felt disconnected from others who didn’t understand the depth of their anxiety and loneliness of their experience. Health care workers have had to make challenging, life-and-death, patient-related decisions that called into question personal morals and ethics all while their own lives were at risk.
Fast-forward to the present, and support systems have either strengthened or worn down – which has yielded a unique dichotomy. Maintaining friendships has either felt of utmost importance given the impact of the disconnect and physical distance or has felt challenging given the mental energy expended from working and connecting virtually. Empathy burnout is also a real and important facet in the equation. We begin to ask the question: Are we checking in with others in the spirit of authentic relating, to cultivate real connection, or to check a box?
Impact of layered traumas
It is interesting to think about the pandemic’s traumatic impact being “superimposed” on top of the “ordinary traumas” experienced outside of the pandemic. We are essentially at the 2-year mark, in some ways have cultivated a sense of resilience and found ways to adapt, and in other ways at times feel right back where we were in early 2020. There were moments that felt hopeful, glimmers of normalcy, and setbacks that all ebbed and flowed – but even so, there have not been many “mental breaks,” only temporary and transient reprieves. Some got sick and died; some recovered; and others are still experiencing long-hauler syndrome and have lingering sequelae. Despite adaptation and resilience, one can’t help but wonder the impact of superimposed traumas on top of this collective trauma. Many of us have not even rebounded from the pandemic, and then are faced with loss, grief, challenges, illness, hard and big life decisions. We are challenged to answer the question: How do we endure in the face of this trauma inception?
It has been a challenging time for all, including those who are ordinarily happy-go-lucky, resilient, and see the glass half-full and are struggling with the idea of struggling. I am no “resilience expert” but gleaned much wisdom from responding to the Surfside, Fla., building collapse. This was a collective trauma that took place in the summer of 2021, and the wisdom of this event highlighted the value of collective healing and unification even in spite of the times. What happened in Surfside was a shock, and the loss was felt by those directly affected, the surrounding community, and those who were part of the disaster response efforts. All of those parties had been processing losses prior to this – loss of normalcy because of the pandemic, loss of people we loved as a result, other personal losses – and this community tragedy was yet another loss to disentangle on top of a period in U.S. history demarcated by a great lack of unity, divisiveness, anger, and hatred. The collapse highlighted the small size yet interconnectedness of the community and the power of connection and authentic relating. It was overwhelming in the moment but extremely heartening and beautiful to see the amount of willingness to drop everything and help. Despite feeling worn down from the pandemic, people drew upon their internal resources, natural goodness, and kindness “reserves” to provide support.
Responding to the collapse highlighted that resilience in the context of collective trauma requires flexibility, embracing uncertainty, cultivating unity, and paying attention to meeting basic needs/self-care. The role of kindness cannot be overemphasized. In the realm of reflecting on the notion of kindness, it is worth noting how much power there is to bearing witness to someone’s experience, especially when they are in pain. People often diminish the role or at the very least do not recognize the power of showing up for someone and just listening. Pandemic resilience, and coping with coalescing traumas, is likely composed of these same facets that were essential in the context of coping with the collapse.
It is not only the immediate impact of a trauma as much as the aftermath that needs to processed and worked through. In one sense, people feel that they should be adjusted to and accustomed to this new reality, and at the same time, one has to remember and reflect on how unnatural this experience has been. There is an impact of a cumulative onslaught of negative events, and it is hard to imagine not being phased, remaining unchanged, or not feeling affected. We may feel hardened and that there are limits to the compassion we have to offer others. We may be feel empathic. There can be desensitization and an apathy to others’ suffering when our patience is worn down and we have limited bandwidth. There are data to support the idea that a level of habituation occurs to individuals who experience multiple traumas, which yields a level of “sensitization” to the negative impact of subsequent events. It becomes easy to make comparisons of suffering. The challenge will be to rise above these and make a conscious effort to connect with who and how we were before we were worn down.
I am still in awe about how much I learned from the victims’ families, survivors, and my colleagues at Surfside – about pain, suffering, loss, resilience, coping, fortitude, and meaning making. We were all forced to think beyond ourselves, show up for others, and unify in a way that remedied this period of fragmentation. With respect to the pandemic and “where we are at now,” some elements of our lives are stabilizing; other aspects feel volatile from the fatigue of what we have been experiencing. This pandemic has not fully abated, but we can find some clarity in the value of setting boundaries and knowing our limits – but not overlooking the power of unity and kindness and the value of the reciprocating those qualities.
Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of the Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures.
When the benchwarmer is a slugger
I still, on occasion, use Felbatol (felbamate).
Thirty years since its explosive entrance to the market, then even more explosive collapse, it remains, in my opinion, the most effective of the second generation of anti-seizure medications. Arguably, even more effective than any of the third generation, too.
That’s not to say I use a lot of it. I don’t. It’s like handling unstable dynamite. Tremendous power, but also an above-average degree of risk. Even after things hit the fan with it in the mid-90s, I remember one of my epilepsy clinic attendings telling me, “This is a home-run drug. In refractory patients you might see some benefit by adding another agent, but with this one, you could stop their seizures and hit it out of the park.”
Like most neurologists, I use other epilepsy options first and second line. But sometimes you get the patient who’s failed the usual ones. Then I start to think about Felbatol. I explain the situation to the patients and their families and let them make the final decision. I worry and watch labs very closely for a while. I probably have no more than three to five patients on it in the practice. But when it works, it’s amazing stuff.
Now, let’s jump ahead to 2021. The year of Aduhelm (and several similar agents racing up behind it).
None of these drugs are even close to hitting home runs. For that matter, I’m not convinced they’re even able to get a man on base. To stretch my baseball analogy a bit, imagine watching a game by looking only at the RBI and ERA stats changing. The numbers change slightly, but you have no evidence that either team is winning. Which is, after all, the whole point.
And, to some extent, that’s the basis of Aduhelm’s approval, and likely the same standards its competitors will be held to.
Although they treat different conditions, and are chemically unrelated, the similarities between Felbatol and the currently advancing bunch of monoclonal antibody (MAB) agents for Alzheimer’s disease make an interesting contrast.
Unlike Felbatol’s proven efficacy for epilepsy, the current MABs offer minimal statistically significant clinical benefit for Alzheimer’s disease. At the same time the risk of amyloid-related imaging abnormalities (ARIA) and its complications with them is significantly higher than that of either of Felbatol’s known, potentially lethal, idiosyncratic effects.
With those odds, In medicine, every day is an exercise in working through the risks and benefits of each patient’s individual situation.
As I’ve stated before, I’m not in the grandstand rooting for these Alzheimer’s drugs to fail. I’ve lost a few family members, and certainly my share of patients, to dementia. I’d be thrilled, and more than willing to prescribe it, if something truly effective came along for it.
Nor do I take any kind of pleasure in the recent news that, because of Aduhelm’s failings, around 1,000 Biogen employees will lose their jobs. I feel terrible for them, as most had nothing to do with the decision to forge ahead with the product. More may soon follow at other companies working with similar agents.
Here we are, though, going into 2022. I’m still, albeit rarely, writing for Felbatol 30 years after it came to market for one reason: It works. But it seems pretty unlikely that future neurologists in 2052 will say the same about the current crops of MABs for Alzheimer’s disease.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I still, on occasion, use Felbatol (felbamate).
Thirty years since its explosive entrance to the market, then even more explosive collapse, it remains, in my opinion, the most effective of the second generation of anti-seizure medications. Arguably, even more effective than any of the third generation, too.
That’s not to say I use a lot of it. I don’t. It’s like handling unstable dynamite. Tremendous power, but also an above-average degree of risk. Even after things hit the fan with it in the mid-90s, I remember one of my epilepsy clinic attendings telling me, “This is a home-run drug. In refractory patients you might see some benefit by adding another agent, but with this one, you could stop their seizures and hit it out of the park.”
Like most neurologists, I use other epilepsy options first and second line. But sometimes you get the patient who’s failed the usual ones. Then I start to think about Felbatol. I explain the situation to the patients and their families and let them make the final decision. I worry and watch labs very closely for a while. I probably have no more than three to five patients on it in the practice. But when it works, it’s amazing stuff.
Now, let’s jump ahead to 2021. The year of Aduhelm (and several similar agents racing up behind it).
None of these drugs are even close to hitting home runs. For that matter, I’m not convinced they’re even able to get a man on base. To stretch my baseball analogy a bit, imagine watching a game by looking only at the RBI and ERA stats changing. The numbers change slightly, but you have no evidence that either team is winning. Which is, after all, the whole point.
And, to some extent, that’s the basis of Aduhelm’s approval, and likely the same standards its competitors will be held to.
Although they treat different conditions, and are chemically unrelated, the similarities between Felbatol and the currently advancing bunch of monoclonal antibody (MAB) agents for Alzheimer’s disease make an interesting contrast.
Unlike Felbatol’s proven efficacy for epilepsy, the current MABs offer minimal statistically significant clinical benefit for Alzheimer’s disease. At the same time the risk of amyloid-related imaging abnormalities (ARIA) and its complications with them is significantly higher than that of either of Felbatol’s known, potentially lethal, idiosyncratic effects.
With those odds, In medicine, every day is an exercise in working through the risks and benefits of each patient’s individual situation.
As I’ve stated before, I’m not in the grandstand rooting for these Alzheimer’s drugs to fail. I’ve lost a few family members, and certainly my share of patients, to dementia. I’d be thrilled, and more than willing to prescribe it, if something truly effective came along for it.
Nor do I take any kind of pleasure in the recent news that, because of Aduhelm’s failings, around 1,000 Biogen employees will lose their jobs. I feel terrible for them, as most had nothing to do with the decision to forge ahead with the product. More may soon follow at other companies working with similar agents.
Here we are, though, going into 2022. I’m still, albeit rarely, writing for Felbatol 30 years after it came to market for one reason: It works. But it seems pretty unlikely that future neurologists in 2052 will say the same about the current crops of MABs for Alzheimer’s disease.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I still, on occasion, use Felbatol (felbamate).
Thirty years since its explosive entrance to the market, then even more explosive collapse, it remains, in my opinion, the most effective of the second generation of anti-seizure medications. Arguably, even more effective than any of the third generation, too.
That’s not to say I use a lot of it. I don’t. It’s like handling unstable dynamite. Tremendous power, but also an above-average degree of risk. Even after things hit the fan with it in the mid-90s, I remember one of my epilepsy clinic attendings telling me, “This is a home-run drug. In refractory patients you might see some benefit by adding another agent, but with this one, you could stop their seizures and hit it out of the park.”
Like most neurologists, I use other epilepsy options first and second line. But sometimes you get the patient who’s failed the usual ones. Then I start to think about Felbatol. I explain the situation to the patients and their families and let them make the final decision. I worry and watch labs very closely for a while. I probably have no more than three to five patients on it in the practice. But when it works, it’s amazing stuff.
Now, let’s jump ahead to 2021. The year of Aduhelm (and several similar agents racing up behind it).
None of these drugs are even close to hitting home runs. For that matter, I’m not convinced they’re even able to get a man on base. To stretch my baseball analogy a bit, imagine watching a game by looking only at the RBI and ERA stats changing. The numbers change slightly, but you have no evidence that either team is winning. Which is, after all, the whole point.
And, to some extent, that’s the basis of Aduhelm’s approval, and likely the same standards its competitors will be held to.
Although they treat different conditions, and are chemically unrelated, the similarities between Felbatol and the currently advancing bunch of monoclonal antibody (MAB) agents for Alzheimer’s disease make an interesting contrast.
Unlike Felbatol’s proven efficacy for epilepsy, the current MABs offer minimal statistically significant clinical benefit for Alzheimer’s disease. At the same time the risk of amyloid-related imaging abnormalities (ARIA) and its complications with them is significantly higher than that of either of Felbatol’s known, potentially lethal, idiosyncratic effects.
With those odds, In medicine, every day is an exercise in working through the risks and benefits of each patient’s individual situation.
As I’ve stated before, I’m not in the grandstand rooting for these Alzheimer’s drugs to fail. I’ve lost a few family members, and certainly my share of patients, to dementia. I’d be thrilled, and more than willing to prescribe it, if something truly effective came along for it.
Nor do I take any kind of pleasure in the recent news that, because of Aduhelm’s failings, around 1,000 Biogen employees will lose their jobs. I feel terrible for them, as most had nothing to do with the decision to forge ahead with the product. More may soon follow at other companies working with similar agents.
Here we are, though, going into 2022. I’m still, albeit rarely, writing for Felbatol 30 years after it came to market for one reason: It works. But it seems pretty unlikely that future neurologists in 2052 will say the same about the current crops of MABs for Alzheimer’s disease.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Is it OK to just be satisfied?
It is possible to talk to a patient for a brief moment and just know if he or she is a satisficer or a maximizer. A “satisficer” when presented with treatment options will invariably say: “I’ll do whatever you say, Doctor.” A “maximizer,” in contrast, would like a printed copy of treatment choices, then would seek a second opinion before ultimately buying an UpToDate subscription to research treatments for him or herself.
.
This notion that we have tendencies toward maximizing or satisficing is thanks to Nobel Memorial Prize winner and all-around smart guy, Herbert A. Simon, PhD. Dr. Simon recognized that, although each person might be expected to make optimal decisions to benefit himself or herself, this is practically impossible. To do so would require an infinite amount of time and energy. He found therefore that we actually exhibit “bounded rationality;” that is, we make the best decision given the limits of time, the price of acquiring information, and even our cognitive abilities. The amount of effort we give to make a decision also depends on the situation: You might be very invested in choosing the right spouse, but not at all invested in choosing soup or salad. (Although, we all have friends who are: “Um, is there any thyme in the soup?”)
You’ll certainly recognize that people have different set points on the spectrum between being a satisficer, one who will take the first option that meets a standard, and a maximizer, one who will seek and accept only the best, even if choosing is at great cost. There are risks and benefits of each. In getting the best job, maximizers might be more successful, but satisficers seem to be happier.
How much this extends into other spheres of life is unclear. It is clear, though, that the work of choosing can come at a cost.
The psychologist Barry Schwartz, PhD, believes that, in general, having more choices leads to more anxiety, not more contentment. For example, which Christmas tree lot would you rather visit: One with hundreds of trees of half a dozen varieties? Or one with just a few trees each of Balsam and Douglas Firs? Dr. Schwartz would argue that you might waste an entire afternoon in the first lot only to bring it home and have remorse when you realize it’s a little lopsided. Or let’s say your child applied to all the Ivy League and Public Ivy schools and also threw in all the top liberal arts colleges. The anxiety of selecting the best and the terror that the “best one” might not choose him or her could be overwhelming. A key lesson is that more in life is by chance than we realize, including how straight your tree is and who gets into Princeton this year. Yet, our expectation that things will work out perfectly if only we maximize is ubiquitous. That confidence in our ability to choose correctly is, however, unwarranted. Better to do your best and know that your tree will be festive and there are many colleges which would lead to a happy life than to fret in choosing and then suffer from dashed expectations. Sometimes good enough is good enough.
Being a satisficer or maximizer is probably somewhat fixed, a personality trait, like being extroverted or conscientious. Yet, having insight can be helpful. If choosing a restaurant in Manhattan becomes an actual project for you with spreadsheets and your own statistical analysis, then go for it! Just know that if that process causes you angst and apprehension, then there is another way. Go to Eleven Madison Park, just because I say so. You might have the best dinner of your life or maybe not. At least by not choosing you’ll have the gift of time to spend picking out a tree instead.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
It is possible to talk to a patient for a brief moment and just know if he or she is a satisficer or a maximizer. A “satisficer” when presented with treatment options will invariably say: “I’ll do whatever you say, Doctor.” A “maximizer,” in contrast, would like a printed copy of treatment choices, then would seek a second opinion before ultimately buying an UpToDate subscription to research treatments for him or herself.
.
This notion that we have tendencies toward maximizing or satisficing is thanks to Nobel Memorial Prize winner and all-around smart guy, Herbert A. Simon, PhD. Dr. Simon recognized that, although each person might be expected to make optimal decisions to benefit himself or herself, this is practically impossible. To do so would require an infinite amount of time and energy. He found therefore that we actually exhibit “bounded rationality;” that is, we make the best decision given the limits of time, the price of acquiring information, and even our cognitive abilities. The amount of effort we give to make a decision also depends on the situation: You might be very invested in choosing the right spouse, but not at all invested in choosing soup or salad. (Although, we all have friends who are: “Um, is there any thyme in the soup?”)
You’ll certainly recognize that people have different set points on the spectrum between being a satisficer, one who will take the first option that meets a standard, and a maximizer, one who will seek and accept only the best, even if choosing is at great cost. There are risks and benefits of each. In getting the best job, maximizers might be more successful, but satisficers seem to be happier.
How much this extends into other spheres of life is unclear. It is clear, though, that the work of choosing can come at a cost.
The psychologist Barry Schwartz, PhD, believes that, in general, having more choices leads to more anxiety, not more contentment. For example, which Christmas tree lot would you rather visit: One with hundreds of trees of half a dozen varieties? Or one with just a few trees each of Balsam and Douglas Firs? Dr. Schwartz would argue that you might waste an entire afternoon in the first lot only to bring it home and have remorse when you realize it’s a little lopsided. Or let’s say your child applied to all the Ivy League and Public Ivy schools and also threw in all the top liberal arts colleges. The anxiety of selecting the best and the terror that the “best one” might not choose him or her could be overwhelming. A key lesson is that more in life is by chance than we realize, including how straight your tree is and who gets into Princeton this year. Yet, our expectation that things will work out perfectly if only we maximize is ubiquitous. That confidence in our ability to choose correctly is, however, unwarranted. Better to do your best and know that your tree will be festive and there are many colleges which would lead to a happy life than to fret in choosing and then suffer from dashed expectations. Sometimes good enough is good enough.
Being a satisficer or maximizer is probably somewhat fixed, a personality trait, like being extroverted or conscientious. Yet, having insight can be helpful. If choosing a restaurant in Manhattan becomes an actual project for you with spreadsheets and your own statistical analysis, then go for it! Just know that if that process causes you angst and apprehension, then there is another way. Go to Eleven Madison Park, just because I say so. You might have the best dinner of your life or maybe not. At least by not choosing you’ll have the gift of time to spend picking out a tree instead.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
It is possible to talk to a patient for a brief moment and just know if he or she is a satisficer or a maximizer. A “satisficer” when presented with treatment options will invariably say: “I’ll do whatever you say, Doctor.” A “maximizer,” in contrast, would like a printed copy of treatment choices, then would seek a second opinion before ultimately buying an UpToDate subscription to research treatments for him or herself.
.
This notion that we have tendencies toward maximizing or satisficing is thanks to Nobel Memorial Prize winner and all-around smart guy, Herbert A. Simon, PhD. Dr. Simon recognized that, although each person might be expected to make optimal decisions to benefit himself or herself, this is practically impossible. To do so would require an infinite amount of time and energy. He found therefore that we actually exhibit “bounded rationality;” that is, we make the best decision given the limits of time, the price of acquiring information, and even our cognitive abilities. The amount of effort we give to make a decision also depends on the situation: You might be very invested in choosing the right spouse, but not at all invested in choosing soup or salad. (Although, we all have friends who are: “Um, is there any thyme in the soup?”)
You’ll certainly recognize that people have different set points on the spectrum between being a satisficer, one who will take the first option that meets a standard, and a maximizer, one who will seek and accept only the best, even if choosing is at great cost. There are risks and benefits of each. In getting the best job, maximizers might be more successful, but satisficers seem to be happier.
How much this extends into other spheres of life is unclear. It is clear, though, that the work of choosing can come at a cost.
The psychologist Barry Schwartz, PhD, believes that, in general, having more choices leads to more anxiety, not more contentment. For example, which Christmas tree lot would you rather visit: One with hundreds of trees of half a dozen varieties? Or one with just a few trees each of Balsam and Douglas Firs? Dr. Schwartz would argue that you might waste an entire afternoon in the first lot only to bring it home and have remorse when you realize it’s a little lopsided. Or let’s say your child applied to all the Ivy League and Public Ivy schools and also threw in all the top liberal arts colleges. The anxiety of selecting the best and the terror that the “best one” might not choose him or her could be overwhelming. A key lesson is that more in life is by chance than we realize, including how straight your tree is and who gets into Princeton this year. Yet, our expectation that things will work out perfectly if only we maximize is ubiquitous. That confidence in our ability to choose correctly is, however, unwarranted. Better to do your best and know that your tree will be festive and there are many colleges which would lead to a happy life than to fret in choosing and then suffer from dashed expectations. Sometimes good enough is good enough.
Being a satisficer or maximizer is probably somewhat fixed, a personality trait, like being extroverted or conscientious. Yet, having insight can be helpful. If choosing a restaurant in Manhattan becomes an actual project for you with spreadsheets and your own statistical analysis, then go for it! Just know that if that process causes you angst and apprehension, then there is another way. Go to Eleven Madison Park, just because I say so. You might have the best dinner of your life or maybe not. At least by not choosing you’ll have the gift of time to spend picking out a tree instead.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Physician gender pay gap isn’t news; health inequity is rampant
A recent study examined projected career earnings between the genders in a largely community-based physician population, finding a difference of about $2 million in career earnings. That a gender pay gap exists in medicine is not news – but the manner in which this study was done, the investigators’ ability to control for a number of confounding variables, and the size of the study group (over 80,000) are newsworthy.
Some of the key findings include that gender pay gaps start with your first job, and you never close the gap, even as you gain experience and efficiency. Also, the more highly remunerated your specialty, the larger the gap. The gender pay gap joins a growing list of inequities within health care. Although physician compensation is not the most important, given that nearly all physicians are well-paid, and we have much more significant inequities that lead to direct patient harm, the reasons for this discrepancy warrant further consideration.
When I was first being educated about social inequity as part of work in social determinants of health, I made the error of using “inequality” and “inequity” interchangeably. The subtle yet important difference between the two terms was quickly described to me. Inequality is a gastroenterologist getting paid more money to do a colonoscopy than a family physician. Inequity is a female gastroenterologist getting paid less than a male gastroenterologist. Global Health Europe boldly identifies that “inequity is the result of failure.” In looking at the inequity inherent in the gender pay gap, I consider what failed and why.
I’m currently making a major career change, leaving an executive leadership position to return to full-time clinical practice. There is a significant pay decrease that will accompany this change because I am in a primary care specialty. Beyond that, I am considering two employment contracts from different systems to do a similar clinical role.
One of the questions my husband asked was which will pay more over the long run. This is difficult to discern because the compensation formula each health system uses is different, even though they are based on standard national benchmarking data. It is possible that women, in general, are like I am and look for factors other than compensation to make a job decision – assuming, like I do, that it will be close enough to not matter or is generally fair. In fact, while compensation is most certainly a consideration for me, once I determined that it was likely to be in the same ballpark, I stopped comparing. Even as the sole breadwinner in our family, I take this (probably faulty) approach.
It’s time to reconsider how we pay physicians
Women may be more likely to gloss over compensation details that men evaluate and negotiate carefully. To change this, women must first take responsibility for being an active, informed, and engaged part of compensation negotiations. In addition, employers who value gender pay equity must negotiate in good faith, keeping in mind the well-described vulnerabilities in discussions about pay. Finally, male and female mentors and leaders should actively coach female physicians on how to approach these conversations with confidence and skill.
In primary care, female physicians spend, on average, about 15% more time with their patients during a visit. Despite spending as much time in clinic seeing patients per week, they see fewer patients, thereby generating less revenue. For compensation plans that are based on productivity, the extra time spent costs money. In this case, it costs the female physicians lost compensation.
The way in which women are more likely to practice medicine, which includes the amount of time they spend with patients, may affect clinical outcomes without directly increasing productivity. A 2017 study demonstrated that elderly patients had lower rates of mortality and readmission when cared for by a female rather than a male physician. These findings require health systems to critically evaluate what compensation plans value and to promote an appropriate balance between quality of care, quantity of care, and style of care.
Although I’ve seen gender pay inequity as blatant as two different salaries for physicians doing the same work – one male and one female – I think this is uncommon. Like many forms of inequity, the outputs are often related to a failed system rather than solely a series of individual failures. Making compensation formulas gender-blind is an important step – but it is only the first step, not the last. Recognizing that the structure of a compensation formula may be biased toward a style of medical practice more likely to be espoused by one gender is necessary as well.
The data, including the findings of this recent study, clearly identify the gender pay gap that exists in medicine, as it does in many other fields, and that it is not explainable solely by differences in specialties, work hours, family status, or title.
To address the inequity, it is imperative that women engage with employers and leaders to both understand and develop skills around effective and appropriate compensation negotiation. Recognizing that compensation plans, especially those built on productivity models, may fail to place adequate value on gender-specific practice styles.
Jennifer Frank is a family physician, physician leader, wife, and mother in Northeast Wisconsin.
A version of this article first appeared on Medscape.com.
A recent study examined projected career earnings between the genders in a largely community-based physician population, finding a difference of about $2 million in career earnings. That a gender pay gap exists in medicine is not news – but the manner in which this study was done, the investigators’ ability to control for a number of confounding variables, and the size of the study group (over 80,000) are newsworthy.
Some of the key findings include that gender pay gaps start with your first job, and you never close the gap, even as you gain experience and efficiency. Also, the more highly remunerated your specialty, the larger the gap. The gender pay gap joins a growing list of inequities within health care. Although physician compensation is not the most important, given that nearly all physicians are well-paid, and we have much more significant inequities that lead to direct patient harm, the reasons for this discrepancy warrant further consideration.
When I was first being educated about social inequity as part of work in social determinants of health, I made the error of using “inequality” and “inequity” interchangeably. The subtle yet important difference between the two terms was quickly described to me. Inequality is a gastroenterologist getting paid more money to do a colonoscopy than a family physician. Inequity is a female gastroenterologist getting paid less than a male gastroenterologist. Global Health Europe boldly identifies that “inequity is the result of failure.” In looking at the inequity inherent in the gender pay gap, I consider what failed and why.
I’m currently making a major career change, leaving an executive leadership position to return to full-time clinical practice. There is a significant pay decrease that will accompany this change because I am in a primary care specialty. Beyond that, I am considering two employment contracts from different systems to do a similar clinical role.
One of the questions my husband asked was which will pay more over the long run. This is difficult to discern because the compensation formula each health system uses is different, even though they are based on standard national benchmarking data. It is possible that women, in general, are like I am and look for factors other than compensation to make a job decision – assuming, like I do, that it will be close enough to not matter or is generally fair. In fact, while compensation is most certainly a consideration for me, once I determined that it was likely to be in the same ballpark, I stopped comparing. Even as the sole breadwinner in our family, I take this (probably faulty) approach.
It’s time to reconsider how we pay physicians
Women may be more likely to gloss over compensation details that men evaluate and negotiate carefully. To change this, women must first take responsibility for being an active, informed, and engaged part of compensation negotiations. In addition, employers who value gender pay equity must negotiate in good faith, keeping in mind the well-described vulnerabilities in discussions about pay. Finally, male and female mentors and leaders should actively coach female physicians on how to approach these conversations with confidence and skill.
In primary care, female physicians spend, on average, about 15% more time with their patients during a visit. Despite spending as much time in clinic seeing patients per week, they see fewer patients, thereby generating less revenue. For compensation plans that are based on productivity, the extra time spent costs money. In this case, it costs the female physicians lost compensation.
The way in which women are more likely to practice medicine, which includes the amount of time they spend with patients, may affect clinical outcomes without directly increasing productivity. A 2017 study demonstrated that elderly patients had lower rates of mortality and readmission when cared for by a female rather than a male physician. These findings require health systems to critically evaluate what compensation plans value and to promote an appropriate balance between quality of care, quantity of care, and style of care.
Although I’ve seen gender pay inequity as blatant as two different salaries for physicians doing the same work – one male and one female – I think this is uncommon. Like many forms of inequity, the outputs are often related to a failed system rather than solely a series of individual failures. Making compensation formulas gender-blind is an important step – but it is only the first step, not the last. Recognizing that the structure of a compensation formula may be biased toward a style of medical practice more likely to be espoused by one gender is necessary as well.
The data, including the findings of this recent study, clearly identify the gender pay gap that exists in medicine, as it does in many other fields, and that it is not explainable solely by differences in specialties, work hours, family status, or title.
To address the inequity, it is imperative that women engage with employers and leaders to both understand and develop skills around effective and appropriate compensation negotiation. Recognizing that compensation plans, especially those built on productivity models, may fail to place adequate value on gender-specific practice styles.
Jennifer Frank is a family physician, physician leader, wife, and mother in Northeast Wisconsin.
A version of this article first appeared on Medscape.com.
A recent study examined projected career earnings between the genders in a largely community-based physician population, finding a difference of about $2 million in career earnings. That a gender pay gap exists in medicine is not news – but the manner in which this study was done, the investigators’ ability to control for a number of confounding variables, and the size of the study group (over 80,000) are newsworthy.
Some of the key findings include that gender pay gaps start with your first job, and you never close the gap, even as you gain experience and efficiency. Also, the more highly remunerated your specialty, the larger the gap. The gender pay gap joins a growing list of inequities within health care. Although physician compensation is not the most important, given that nearly all physicians are well-paid, and we have much more significant inequities that lead to direct patient harm, the reasons for this discrepancy warrant further consideration.
When I was first being educated about social inequity as part of work in social determinants of health, I made the error of using “inequality” and “inequity” interchangeably. The subtle yet important difference between the two terms was quickly described to me. Inequality is a gastroenterologist getting paid more money to do a colonoscopy than a family physician. Inequity is a female gastroenterologist getting paid less than a male gastroenterologist. Global Health Europe boldly identifies that “inequity is the result of failure.” In looking at the inequity inherent in the gender pay gap, I consider what failed and why.
I’m currently making a major career change, leaving an executive leadership position to return to full-time clinical practice. There is a significant pay decrease that will accompany this change because I am in a primary care specialty. Beyond that, I am considering two employment contracts from different systems to do a similar clinical role.
One of the questions my husband asked was which will pay more over the long run. This is difficult to discern because the compensation formula each health system uses is different, even though they are based on standard national benchmarking data. It is possible that women, in general, are like I am and look for factors other than compensation to make a job decision – assuming, like I do, that it will be close enough to not matter or is generally fair. In fact, while compensation is most certainly a consideration for me, once I determined that it was likely to be in the same ballpark, I stopped comparing. Even as the sole breadwinner in our family, I take this (probably faulty) approach.
It’s time to reconsider how we pay physicians
Women may be more likely to gloss over compensation details that men evaluate and negotiate carefully. To change this, women must first take responsibility for being an active, informed, and engaged part of compensation negotiations. In addition, employers who value gender pay equity must negotiate in good faith, keeping in mind the well-described vulnerabilities in discussions about pay. Finally, male and female mentors and leaders should actively coach female physicians on how to approach these conversations with confidence and skill.
In primary care, female physicians spend, on average, about 15% more time with their patients during a visit. Despite spending as much time in clinic seeing patients per week, they see fewer patients, thereby generating less revenue. For compensation plans that are based on productivity, the extra time spent costs money. In this case, it costs the female physicians lost compensation.
The way in which women are more likely to practice medicine, which includes the amount of time they spend with patients, may affect clinical outcomes without directly increasing productivity. A 2017 study demonstrated that elderly patients had lower rates of mortality and readmission when cared for by a female rather than a male physician. These findings require health systems to critically evaluate what compensation plans value and to promote an appropriate balance between quality of care, quantity of care, and style of care.
Although I’ve seen gender pay inequity as blatant as two different salaries for physicians doing the same work – one male and one female – I think this is uncommon. Like many forms of inequity, the outputs are often related to a failed system rather than solely a series of individual failures. Making compensation formulas gender-blind is an important step – but it is only the first step, not the last. Recognizing that the structure of a compensation formula may be biased toward a style of medical practice more likely to be espoused by one gender is necessary as well.
The data, including the findings of this recent study, clearly identify the gender pay gap that exists in medicine, as it does in many other fields, and that it is not explainable solely by differences in specialties, work hours, family status, or title.
To address the inequity, it is imperative that women engage with employers and leaders to both understand and develop skills around effective and appropriate compensation negotiation. Recognizing that compensation plans, especially those built on productivity models, may fail to place adequate value on gender-specific practice styles.
Jennifer Frank is a family physician, physician leader, wife, and mother in Northeast Wisconsin.
A version of this article first appeared on Medscape.com.