Opinion

Primary care physicians play a critical role in identifying patients at risk for serious mental health issues, including suicidality. But the ever-increasing demands on their clinical time can hinder the ability to identify emotional distress in time to intervene. Can artificial intelligence (AI) help?

This news organization spoke with Tom Zaubler, MD, a psychiatrist and chief medical officer of NeuroFlow, about how AI can improve the ability of primary care physicians and other clinicians to screen their patients for suicidal ideation and boost rates of treatment for mental health issues in their patients. This interview has been edited for clarity and length.

Question: How can AI help in suicide prevention and mental health screening in primary care?

Answer: Recent studies have demonstrated the potential of AI in mental health screening and suicide prevention. One method is natural language processing (NLP), which can analyze patients› journal entries for signs of suicidal thoughts or behaviors. This technology has shown promise in detecting suicidal ideation in patients who may not report such thoughts on traditional screening tools like the Patient Health Questionnaire-9 (PHQ-9). AI can be part of an integrated approach to identify and provide support to individuals at risk for suicide or those without a psychiatric history but who may still be at risk.

Q: A recent study by [Maria] Oquendo and colleagues found that one fifth of patients who attempt suicide do not meet the criteria for a mental health disorder.

Improved screening is obviously important, but in some ways it’s not the most important part of the problem. The lack of accessibility to specialized mental health care is a critical obstacle to treating patients with acute psychiatric needs.

How can primary care doctors effectively connect patients with mental health support, given the scarcity of mental health professionals?

A: Primary care doctors can leverage technology to extend mental health support. This includes using platforms for safety screening and providing patients with immediate access to local and national resources and digital interventions. Alerts can be sent to professionals within the practice or employed by technology companies to offer immediate support, including suicide safety planning and counseling. Users can hit a button to “Find a Therapist.” Also, if they acknowledge feelings of self-harm, these keywords are detected within the app by NLP. “Urgent alerts” are then sent to clinicians who are overseeing patient care. If someone is flagged, a social worker or member of a response services team intervenes and calls the person at risk to tailor care. These interventions do not always require a psychiatrist or masters-prepared clinician but can be effectively managed by trained paraprofessionals. These staff members can provide suicide safety planning and lethal-means-restriction counseling, and can assess the need for escalation of care.

Q: How is technology likely to manifest in physician practices in the near future to support mental health care?

A: Automated screening platforms for depression and anxiety, alerts for physicians when patients screen positively, and integration with collaborative care models are a few of the ways technology will become part of clinical practice. Additionally, advanced data analytics and predictive modeling using electronic health records and claims data will help identify high-risk patients. Technologies like voice recognition and machine learning can analyze patient journals and possibly, in the future, social media feeds to detect mental health issues. These technologies aim to extend and augment the capabilities of healthcare practices, improving the identification and management of patients at risk for mental health issues.

Q: Are these technologies as effective in pediatric populations, and are there any specific challenges?

A: Technologies for mental health screening and support are effective in pediatric populations, with certain age-specific considerations and legal restrictions on technology use. For adolescents and older children comfortable with technology, digital tools can significantly impact mental health care. For younger children, technology must facilitate information-gathering from various sources, including parents and teachers. Despite challenges, technology is crucial for early identification and intervention in pediatric mental health, potentially shortening the time to diagnosis and improving outcomes.

The statistics are horrifying. One third of adolescent girls have seriously thought about suicide over the past year; 13% attempt suicide. So there’s a need in the adolescent population and in the preadolescent population, too, because there’s an 8- to 10-year lag between onset of symptoms and diagnosis of mental illness. If we can shorten that lag, you see improved performance in schools; you see decreased truancy; you see greater economic achievement and so on. It makes such a profound difference. Not to mention it saves lives. So, yes, technology is critical in a pediatric population. It exists and it’s happening right now. There are challenges, but the goal can be met.

Q: A 2014 study found that 45% of people who completed suicide visited a primary care physician in the preceding month. And only 23% of people who attempt suicide have not seen a primary care physician within the past year. What does that say about the importance of screening at the primary care level?

A: The fact that a significant percentage of individuals who die by suicide have visited a primary care physician within a month or year prior to their death underscores the critical role of primary care in suicide prevention. This highlights the potential for primary care settings to identify and intervene with individuals at risk for suicide, making the case for the importance of integrating effective mental health screenings and support technologies in primary care practices.

Q: In other words, we’re not talking about a marginal benefit.

A: No, the potential benefit is huge. The United States Preventive Services Task Force did not endorse universal screening for suicide in its 2023 recommendations; they felt — and I accept that conclusion — there wasn›t enough evidence [at the time] to really support that recommendation. I think when you talk to a lot of suicide researchers, what you will hear is that providing suicide assessments as far upstream as possible is critical, especially when you start seeing more and more research showing that 20% of the population who die by suicide are not likely to have any psychiatric pathology at all. I believe the evidence base will soon support a recommendation for universal screening for adults. I believe it is especially important to screen for suicidal ideation in kids, given the high rates of suicide in this population.

Dr. Zaubler has disclosed the following relevant financial relationships: chief medical officer, NeuroFlow.

A version of this article appeared on Medscape.com.

Primary care physicians play a critical role in identifying patients at risk for serious mental health issues, including suicidality. But the ever-increasing demands on their clinical time can hinder the ability to identify emotional distress in time to intervene. Can artificial intelligence (AI) help?

This news organization spoke with Tom Zaubler, MD, a psychiatrist and chief medical officer of NeuroFlow, about how AI can improve the ability of primary care physicians and other clinicians to screen their patients for suicidal ideation and boost rates of treatment for mental health issues in their patients. This interview has been edited for clarity and length.

Question: How can AI help in suicide prevention and mental health screening in primary care?

Answer: Recent studies have demonstrated the potential of AI in mental health screening and suicide prevention. One method is natural language processing (NLP), which can analyze patients› journal entries for signs of suicidal thoughts or behaviors. This technology has shown promise in detecting suicidal ideation in patients who may not report such thoughts on traditional screening tools like the Patient Health Questionnaire-9 (PHQ-9). AI can be part of an integrated approach to identify and provide support to individuals at risk for suicide or those without a psychiatric history but who may still be at risk.

Q: A recent study by [Maria] Oquendo and colleagues found that one fifth of patients who attempt suicide do not meet the criteria for a mental health disorder.

Improved screening is obviously important, but in some ways it’s not the most important part of the problem. The lack of accessibility to specialized mental health care is a critical obstacle to treating patients with acute psychiatric needs.

How can primary care doctors effectively connect patients with mental health support, given the scarcity of mental health professionals?

A: Primary care doctors can leverage technology to extend mental health support. This includes using platforms for safety screening and providing patients with immediate access to local and national resources and digital interventions. Alerts can be sent to professionals within the practice or employed by technology companies to offer immediate support, including suicide safety planning and counseling. Users can hit a button to “Find a Therapist.” Also, if they acknowledge feelings of self-harm, these keywords are detected within the app by NLP. “Urgent alerts” are then sent to clinicians who are overseeing patient care. If someone is flagged, a social worker or member of a response services team intervenes and calls the person at risk to tailor care. These interventions do not always require a psychiatrist or masters-prepared clinician but can be effectively managed by trained paraprofessionals. These staff members can provide suicide safety planning and lethal-means-restriction counseling, and can assess the need for escalation of care.

Q: How is technology likely to manifest in physician practices in the near future to support mental health care?

A: Automated screening platforms for depression and anxiety, alerts for physicians when patients screen positively, and integration with collaborative care models are a few of the ways technology will become part of clinical practice. Additionally, advanced data analytics and predictive modeling using electronic health records and claims data will help identify high-risk patients. Technologies like voice recognition and machine learning can analyze patient journals and possibly, in the future, social media feeds to detect mental health issues. These technologies aim to extend and augment the capabilities of healthcare practices, improving the identification and management of patients at risk for mental health issues.

Q: Are these technologies as effective in pediatric populations, and are there any specific challenges?

A: Technologies for mental health screening and support are effective in pediatric populations, with certain age-specific considerations and legal restrictions on technology use. For adolescents and older children comfortable with technology, digital tools can significantly impact mental health care. For younger children, technology must facilitate information-gathering from various sources, including parents and teachers. Despite challenges, technology is crucial for early identification and intervention in pediatric mental health, potentially shortening the time to diagnosis and improving outcomes.

The statistics are horrifying. One third of adolescent girls have seriously thought about suicide over the past year; 13% attempt suicide. So there’s a need in the adolescent population and in the preadolescent population, too, because there’s an 8- to 10-year lag between onset of symptoms and diagnosis of mental illness. If we can shorten that lag, you see improved performance in schools; you see decreased truancy; you see greater economic achievement and so on. It makes such a profound difference. Not to mention it saves lives. So, yes, technology is critical in a pediatric population. It exists and it’s happening right now. There are challenges, but the goal can be met.

Q: A 2014 study found that 45% of people who completed suicide visited a primary care physician in the preceding month. And only 23% of people who attempt suicide have not seen a primary care physician within the past year. What does that say about the importance of screening at the primary care level?

A: The fact that a significant percentage of individuals who die by suicide have visited a primary care physician within a month or year prior to their death underscores the critical role of primary care in suicide prevention. This highlights the potential for primary care settings to identify and intervene with individuals at risk for suicide, making the case for the importance of integrating effective mental health screenings and support technologies in primary care practices.

Q: In other words, we’re not talking about a marginal benefit.

A: No, the potential benefit is huge. The United States Preventive Services Task Force did not endorse universal screening for suicide in its 2023 recommendations; they felt — and I accept that conclusion — there wasn›t enough evidence [at the time] to really support that recommendation. I think when you talk to a lot of suicide researchers, what you will hear is that providing suicide assessments as far upstream as possible is critical, especially when you start seeing more and more research showing that 20% of the population who die by suicide are not likely to have any psychiatric pathology at all. I believe the evidence base will soon support a recommendation for universal screening for adults. I believe it is especially important to screen for suicidal ideation in kids, given the high rates of suicide in this population.

Dr. Zaubler has disclosed the following relevant financial relationships: chief medical officer, NeuroFlow.

A version of this article appeared on Medscape.com.

Primary care physicians play a critical role in identifying patients at risk for serious mental health issues, including suicidality. But the ever-increasing demands on their clinical time can hinder the ability to identify emotional distress in time to intervene. Can artificial intelligence (AI) help?

This news organization spoke with Tom Zaubler, MD, a psychiatrist and chief medical officer of NeuroFlow, about how AI can improve the ability of primary care physicians and other clinicians to screen their patients for suicidal ideation and boost rates of treatment for mental health issues in their patients. This interview has been edited for clarity and length.

Question: How can AI help in suicide prevention and mental health screening in primary care?

Answer: Recent studies have demonstrated the potential of AI in mental health screening and suicide prevention. One method is natural language processing (NLP), which can analyze patients› journal entries for signs of suicidal thoughts or behaviors. This technology has shown promise in detecting suicidal ideation in patients who may not report such thoughts on traditional screening tools like the Patient Health Questionnaire-9 (PHQ-9). AI can be part of an integrated approach to identify and provide support to individuals at risk for suicide or those without a psychiatric history but who may still be at risk.

Q: A recent study by [Maria] Oquendo and colleagues found that one fifth of patients who attempt suicide do not meet the criteria for a mental health disorder.

Improved screening is obviously important, but in some ways it’s not the most important part of the problem. The lack of accessibility to specialized mental health care is a critical obstacle to treating patients with acute psychiatric needs.

How can primary care doctors effectively connect patients with mental health support, given the scarcity of mental health professionals?

A: Primary care doctors can leverage technology to extend mental health support. This includes using platforms for safety screening and providing patients with immediate access to local and national resources and digital interventions. Alerts can be sent to professionals within the practice or employed by technology companies to offer immediate support, including suicide safety planning and counseling. Users can hit a button to “Find a Therapist.” Also, if they acknowledge feelings of self-harm, these keywords are detected within the app by NLP. “Urgent alerts” are then sent to clinicians who are overseeing patient care. If someone is flagged, a social worker or member of a response services team intervenes and calls the person at risk to tailor care. These interventions do not always require a psychiatrist or masters-prepared clinician but can be effectively managed by trained paraprofessionals. These staff members can provide suicide safety planning and lethal-means-restriction counseling, and can assess the need for escalation of care.

Q: How is technology likely to manifest in physician practices in the near future to support mental health care?

A: Automated screening platforms for depression and anxiety, alerts for physicians when patients screen positively, and integration with collaborative care models are a few of the ways technology will become part of clinical practice. Additionally, advanced data analytics and predictive modeling using electronic health records and claims data will help identify high-risk patients. Technologies like voice recognition and machine learning can analyze patient journals and possibly, in the future, social media feeds to detect mental health issues. These technologies aim to extend and augment the capabilities of healthcare practices, improving the identification and management of patients at risk for mental health issues.

Q: Are these technologies as effective in pediatric populations, and are there any specific challenges?

A: Technologies for mental health screening and support are effective in pediatric populations, with certain age-specific considerations and legal restrictions on technology use. For adolescents and older children comfortable with technology, digital tools can significantly impact mental health care. For younger children, technology must facilitate information-gathering from various sources, including parents and teachers. Despite challenges, technology is crucial for early identification and intervention in pediatric mental health, potentially shortening the time to diagnosis and improving outcomes.

The statistics are horrifying. One third of adolescent girls have seriously thought about suicide over the past year; 13% attempt suicide. So there’s a need in the adolescent population and in the preadolescent population, too, because there’s an 8- to 10-year lag between onset of symptoms and diagnosis of mental illness. If we can shorten that lag, you see improved performance in schools; you see decreased truancy; you see greater economic achievement and so on. It makes such a profound difference. Not to mention it saves lives. So, yes, technology is critical in a pediatric population. It exists and it’s happening right now. There are challenges, but the goal can be met.

Q: A 2014 study found that 45% of people who completed suicide visited a primary care physician in the preceding month. And only 23% of people who attempt suicide have not seen a primary care physician within the past year. What does that say about the importance of screening at the primary care level?

A: The fact that a significant percentage of individuals who die by suicide have visited a primary care physician within a month or year prior to their death underscores the critical role of primary care in suicide prevention. This highlights the potential for primary care settings to identify and intervene with individuals at risk for suicide, making the case for the importance of integrating effective mental health screenings and support technologies in primary care practices.

Q: In other words, we’re not talking about a marginal benefit.

A: No, the potential benefit is huge. The United States Preventive Services Task Force did not endorse universal screening for suicide in its 2023 recommendations; they felt — and I accept that conclusion — there wasn›t enough evidence [at the time] to really support that recommendation. I think when you talk to a lot of suicide researchers, what you will hear is that providing suicide assessments as far upstream as possible is critical, especially when you start seeing more and more research showing that 20% of the population who die by suicide are not likely to have any psychiatric pathology at all. I believe the evidence base will soon support a recommendation for universal screening for adults. I believe it is especially important to screen for suicidal ideation in kids, given the high rates of suicide in this population.

Dr. Zaubler has disclosed the following relevant financial relationships: chief medical officer, NeuroFlow.

A version of this article appeared on Medscape.com.

Please note that this is a commentary, an opinion piece: my opinion. The statements here do not necessarily represent those of this news organization or any of the myriad people or institutions that comprise this corner of the human universe.

Some days, speaking as a long-time physician and editor, I wish that there were no such things as race or ethnicity or even geographic origin for that matter. We can’t get away from sex, gender, disability, age, or culture. I’m not sure about religion. I wish people were just people.

But race is deeply embedded in the American experience — an almost invisible but inevitable presence in all of our thoughts and expressions about human activities.

In medical education (for eons it seems) the student has been taught to mention race in the first sentence of a given patient presentation, along with age and sex. In human epidemiologic research, race is almost always a studied variable. In clinical and basic medical research, looking at the impact of race on this, that, or the other is commonplace. “Mixed race not otherwise specified” is ubiquitous in the United States yet blithely ignored by most who tally these statistics. Race is rarely gene-specific. It is more of a social and cultural construct but with plainly visible overt phenotypic markers — an almost infinite mix of daily reality.

Our country, and much of Western civilization in 2024, is based on the principle that all men are created equal, although the originators of that notion were unaware of their own “equity-challenged” situation.

Many organizations, in and out of government, are now understanding, developing, and implementing programs (and thought/language patterns) to socialize diversity, equity, and inclusion (known as DEI) into their culture. It should not be surprising that many who prefer the status quo are not happy with the pressure from this movement and are using whatever methods are available to them to prevent full DEI. Such it always is.

The trusty Copilot from Bing provides these definitions:

• Diversity refers to the presence of variety within the organizational workforce. This includes aspects such as gender, culture, ethnicity, religion, disability, age, and opinion.
• Equity encompasses concepts of fairness and justice. It involves fair compensation, substantive equality, and addressing societal disparities. Equity also considers unique circumstances and adjusts treatment to achieve equal outcomes.
• Inclusion focuses on creating an organizational culture where all employees feel heard, fostering a sense of belonging and integration.

I am more than proud that my old domain of peer-reviewed, primary source, medical (and science) journals is taking a leading role in this noble, necessary, and long overdue movement for medicine.

As the central repository and transmitter of new medical information, including scientific studies, clinical medicine reports, ethics measures, and education, medical journals (including those deemed prestigious) have historically been among the worst offenders in perpetuating non-DEI objectives in their leadership, staffing, focus, instructions for authors, style manuals, and published materials.

This issue came to a head in March 2021 when a JAMA podcast about racism in American medicine was followed by this promotional tweet: “No physician is racist, so how can there be structural racism in health care?”

Reactions and actions were rapid, strong, and decisive. After an interregnum at JAMA, a new editor in chief, Kirsten Bibbins-Domingo, PhD, MD, MAS, was named. She and her large staff of editors and editorial board members from the multijournal JAMA Network joined a worldwide movement of (currently) 56 publishing organizations representing 15,000 journals called the Joint Commitment for Action on Inclusion and Diversity in Publishing.

A recent JAMA editorial with 29 authors describes the entire commitment initiative of publishers-editors. It reports JAMA Network data from 2023 and 2024 from surveys of 455 editors (a 91% response rate) about their own gender (five choices), ethnic origins or geographic ancestry (13 choices), and race (eight choices), demonstrating considerable progress toward DEI goals. The survey’s complex multinational classifications may not jibe with the categorizations used in some countries (too bad that “mixed” is not “mixed in” — a missed opportunity).

This encouraging movement will not fix it all. But when people of certain groups are represented at the table, that point of view is far more likely to make it into the lexicon, language, and omnipresent work products, potentially changing cultural norms. Even the measurement of movement related to disparity in healthcare is marred by frequent variations of data accuracy. More consistency in what to measure can help a lot, and the medical literature can be very influential.

A personal anecdote: When I was a professor at UC Davis in 1978, Allan Bakke, MD, was my student. Some of you will remember the saga of affirmative action on admissions, which was just revisited in the light of a recent decision by the US Supreme Court.

Back in 1978, the dean at UC Davis told me that he kept two file folders on the admission processes in different desk drawers. One categorized all applicants and enrollees by race, and the other did not. Depending on who came to visit and ask questions, he would choose one or the other file to share once he figured out what they were looking for (this is not a joke).

The strength of the current active political pushback against the entire DEI movement has deep roots and should not be underestimated. There will be a lot of to-ing and fro-ing.

French writer Victor Hugo is credited with stating, “There is nothing as powerful as an idea whose time has come.” A majority of Americans, physicians, and other healthcare professionals believe in basic fairness. The time for DEI in all aspects of medicine is now.

Dr. Lundberg, editor in chief of Cancer Commons, disclosed having no relevant financial relationships.

A version of this article appeared on Medscape.com.

Please note that this is a commentary, an opinion piece: my opinion. The statements here do not necessarily represent those of this news organization or any of the myriad people or institutions that comprise this corner of the human universe.

Some days, speaking as a long-time physician and editor, I wish that there were no such things as race or ethnicity or even geographic origin for that matter. We can’t get away from sex, gender, disability, age, or culture. I’m not sure about religion. I wish people were just people.

But race is deeply embedded in the American experience — an almost invisible but inevitable presence in all of our thoughts and expressions about human activities.

In medical education (for eons it seems) the student has been taught to mention race in the first sentence of a given patient presentation, along with age and sex. In human epidemiologic research, race is almost always a studied variable. In clinical and basic medical research, looking at the impact of race on this, that, or the other is commonplace. “Mixed race not otherwise specified” is ubiquitous in the United States yet blithely ignored by most who tally these statistics. Race is rarely gene-specific. It is more of a social and cultural construct but with plainly visible overt phenotypic markers — an almost infinite mix of daily reality.

Our country, and much of Western civilization in 2024, is based on the principle that all men are created equal, although the originators of that notion were unaware of their own “equity-challenged” situation.

Many organizations, in and out of government, are now understanding, developing, and implementing programs (and thought/language patterns) to socialize diversity, equity, and inclusion (known as DEI) into their culture. It should not be surprising that many who prefer the status quo are not happy with the pressure from this movement and are using whatever methods are available to them to prevent full DEI. Such it always is.

The trusty Copilot from Bing provides these definitions:

• Diversity refers to the presence of variety within the organizational workforce. This includes aspects such as gender, culture, ethnicity, religion, disability, age, and opinion.
• Equity encompasses concepts of fairness and justice. It involves fair compensation, substantive equality, and addressing societal disparities. Equity also considers unique circumstances and adjusts treatment to achieve equal outcomes.
• Inclusion focuses on creating an organizational culture where all employees feel heard, fostering a sense of belonging and integration.

I am more than proud that my old domain of peer-reviewed, primary source, medical (and science) journals is taking a leading role in this noble, necessary, and long overdue movement for medicine.

As the central repository and transmitter of new medical information, including scientific studies, clinical medicine reports, ethics measures, and education, medical journals (including those deemed prestigious) have historically been among the worst offenders in perpetuating non-DEI objectives in their leadership, staffing, focus, instructions for authors, style manuals, and published materials.

This issue came to a head in March 2021 when a JAMA podcast about racism in American medicine was followed by this promotional tweet: “No physician is racist, so how can there be structural racism in health care?”

Reactions and actions were rapid, strong, and decisive. After an interregnum at JAMA, a new editor in chief, Kirsten Bibbins-Domingo, PhD, MD, MAS, was named. She and her large staff of editors and editorial board members from the multijournal JAMA Network joined a worldwide movement of (currently) 56 publishing organizations representing 15,000 journals called the Joint Commitment for Action on Inclusion and Diversity in Publishing.

A recent JAMA editorial with 29 authors describes the entire commitment initiative of publishers-editors. It reports JAMA Network data from 2023 and 2024 from surveys of 455 editors (a 91% response rate) about their own gender (five choices), ethnic origins or geographic ancestry (13 choices), and race (eight choices), demonstrating considerable progress toward DEI goals. The survey’s complex multinational classifications may not jibe with the categorizations used in some countries (too bad that “mixed” is not “mixed in” — a missed opportunity).

This encouraging movement will not fix it all. But when people of certain groups are represented at the table, that point of view is far more likely to make it into the lexicon, language, and omnipresent work products, potentially changing cultural norms. Even the measurement of movement related to disparity in healthcare is marred by frequent variations of data accuracy. More consistency in what to measure can help a lot, and the medical literature can be very influential.

A personal anecdote: When I was a professor at UC Davis in 1978, Allan Bakke, MD, was my student. Some of you will remember the saga of affirmative action on admissions, which was just revisited in the light of a recent decision by the US Supreme Court.

Back in 1978, the dean at UC Davis told me that he kept two file folders on the admission processes in different desk drawers. One categorized all applicants and enrollees by race, and the other did not. Depending on who came to visit and ask questions, he would choose one or the other file to share once he figured out what they were looking for (this is not a joke).

The strength of the current active political pushback against the entire DEI movement has deep roots and should not be underestimated. There will be a lot of to-ing and fro-ing.

French writer Victor Hugo is credited with stating, “There is nothing as powerful as an idea whose time has come.” A majority of Americans, physicians, and other healthcare professionals believe in basic fairness. The time for DEI in all aspects of medicine is now.

Dr. Lundberg, editor in chief of Cancer Commons, disclosed having no relevant financial relationships.

A version of this article appeared on Medscape.com.

Please note that this is a commentary, an opinion piece: my opinion. The statements here do not necessarily represent those of this news organization or any of the myriad people or institutions that comprise this corner of the human universe.

Some days, speaking as a long-time physician and editor, I wish that there were no such things as race or ethnicity or even geographic origin for that matter. We can’t get away from sex, gender, disability, age, or culture. I’m not sure about religion. I wish people were just people.

But race is deeply embedded in the American experience — an almost invisible but inevitable presence in all of our thoughts and expressions about human activities.

In medical education (for eons it seems) the student has been taught to mention race in the first sentence of a given patient presentation, along with age and sex. In human epidemiologic research, race is almost always a studied variable. In clinical and basic medical research, looking at the impact of race on this, that, or the other is commonplace. “Mixed race not otherwise specified” is ubiquitous in the United States yet blithely ignored by most who tally these statistics. Race is rarely gene-specific. It is more of a social and cultural construct but with plainly visible overt phenotypic markers — an almost infinite mix of daily reality.

Our country, and much of Western civilization in 2024, is based on the principle that all men are created equal, although the originators of that notion were unaware of their own “equity-challenged” situation.

Many organizations, in and out of government, are now understanding, developing, and implementing programs (and thought/language patterns) to socialize diversity, equity, and inclusion (known as DEI) into their culture. It should not be surprising that many who prefer the status quo are not happy with the pressure from this movement and are using whatever methods are available to them to prevent full DEI. Such it always is.

The trusty Copilot from Bing provides these definitions:

• Diversity refers to the presence of variety within the organizational workforce. This includes aspects such as gender, culture, ethnicity, religion, disability, age, and opinion.
• Equity encompasses concepts of fairness and justice. It involves fair compensation, substantive equality, and addressing societal disparities. Equity also considers unique circumstances and adjusts treatment to achieve equal outcomes.
• Inclusion focuses on creating an organizational culture where all employees feel heard, fostering a sense of belonging and integration.

I am more than proud that my old domain of peer-reviewed, primary source, medical (and science) journals is taking a leading role in this noble, necessary, and long overdue movement for medicine.

As the central repository and transmitter of new medical information, including scientific studies, clinical medicine reports, ethics measures, and education, medical journals (including those deemed prestigious) have historically been among the worst offenders in perpetuating non-DEI objectives in their leadership, staffing, focus, instructions for authors, style manuals, and published materials.

This issue came to a head in March 2021 when a JAMA podcast about racism in American medicine was followed by this promotional tweet: “No physician is racist, so how can there be structural racism in health care?”

Reactions and actions were rapid, strong, and decisive. After an interregnum at JAMA, a new editor in chief, Kirsten Bibbins-Domingo, PhD, MD, MAS, was named. She and her large staff of editors and editorial board members from the multijournal JAMA Network joined a worldwide movement of (currently) 56 publishing organizations representing 15,000 journals called the Joint Commitment for Action on Inclusion and Diversity in Publishing.

A recent JAMA editorial with 29 authors describes the entire commitment initiative of publishers-editors. It reports JAMA Network data from 2023 and 2024 from surveys of 455 editors (a 91% response rate) about their own gender (five choices), ethnic origins or geographic ancestry (13 choices), and race (eight choices), demonstrating considerable progress toward DEI goals. The survey’s complex multinational classifications may not jibe with the categorizations used in some countries (too bad that “mixed” is not “mixed in” — a missed opportunity).

This encouraging movement will not fix it all. But when people of certain groups are represented at the table, that point of view is far more likely to make it into the lexicon, language, and omnipresent work products, potentially changing cultural norms. Even the measurement of movement related to disparity in healthcare is marred by frequent variations of data accuracy. More consistency in what to measure can help a lot, and the medical literature can be very influential.

A personal anecdote: When I was a professor at UC Davis in 1978, Allan Bakke, MD, was my student. Some of you will remember the saga of affirmative action on admissions, which was just revisited in the light of a recent decision by the US Supreme Court.

Back in 1978, the dean at UC Davis told me that he kept two file folders on the admission processes in different desk drawers. One categorized all applicants and enrollees by race, and the other did not. Depending on who came to visit and ask questions, he would choose one or the other file to share once he figured out what they were looking for (this is not a joke).

The strength of the current active political pushback against the entire DEI movement has deep roots and should not be underestimated. There will be a lot of to-ing and fro-ing.

French writer Victor Hugo is credited with stating, “There is nothing as powerful as an idea whose time has come.” A majority of Americans, physicians, and other healthcare professionals believe in basic fairness. The time for DEI in all aspects of medicine is now.

Dr. Lundberg, editor in chief of Cancer Commons, disclosed having no relevant financial relationships.

A version of this article appeared on Medscape.com.

Whether you have totally bought into the “obesity is a disease” paradigm or are still in denial, you must admit that the development of a suite of effective weight loss medications has created a tsunami of interest and economic activity in this country on a scale not seen since the Beanie Baby craze of the mid-1990s. But, obesity management is serious business. While most of those soft cuddly toys are gathering dust in shoeboxes across this country, weight loss medications are likely to be the vanguard of rapidly evolving revolution in healthcare management that will be with us for the foreseeable future.

Most thoughtful folks who purchased Beanie Babies in 1994 had no illusions and knew that in a few short years this bubble of soft cuddly toys was going to burst. However, do those of us on the front line of medical care know what the future holds for the patients who are being prescribed or are scavenging those too-good-to-be-true medications?

My guess is that in the long run we will need a combination of some serious tinkering by the pharmaceutical industry and a trek up some steep learning curves before we eventually arrive at a safe and effective chemical management for obese patients. I recently read an article by an obesity management specialist at Harvard Medical School who voiced her concerns that we are missing an opportunity to make this explosion of popularity in GLP-1 drugs into an important learning experience.

In an opinion piece in JAMA Internal Medicine, Dr. Fatima Cody Stanford and her coauthors argue that we, actually the US Food and Drug Administration (FDA), is over-focused on weight loss in determining the efficacy of anti-obesity medications. Dr. Stanford and colleagues point out that when a patient loses weight it isn’t just fat — it is complex process that may include muscle and bone mineralization as well. She has consulted for at least one obesity-drug manufacturer and says that these companies have the resources to produce data on body composition that could help clinicians create management plans that would address the patients’ overall health. However, the FDA has not demanded this broader and deeper assessment of general health when reviewing the drug trials.

I don’t think we can blame the patients for not asking whether they will healthier while taking these medications. They have already spent a lifetime, even if it is just a decade, of suffering as the “fat one.” A new outfit and a look in the mirror can’t help but make them feel better ... in the short term anyway. We as physicians must shoulder some of the blame for focusing on weight. Our spoken or unspoken message has been “Lose weight and you will be healthier.” We may make our message sound more professional by tossing around terms like “BMI,” but as Dr. Stanford points out, “we have known BMI is a flawed metric for a long time.”

There is the notion that obese people have had to build more muscle to help them carry around the extra weight, so that we should expect them to lose that extra muscle along with the fat. However, in older adults there is an entity called sarcopenic obesity, in which the patient doesn’t have that extra muscle to lose.

In a brief Internet research venture, I could find little on the subject of muscle loss and GLP-1s, other than “it can happen.” And, nothing on the effect in adolescents. And that is one of Dr. Stanford’s points. We just don’t know. She said that looking at body composition can be costly and not something that the clinician can do. However, as far as muscle mass is concerned, we need to be alert to the potential for loss. Simple assessments of strength can help us tailor our management to the specific patient’s need.

The bottom line is this ... now that we have effective medications for “weight loss,” we need to redefine the relationship between weight and health. “We” means us as clinicians. It means the folks at FDA. And, if we can improve our messaging, it will osmose to the rest of the population. Just because you’ve dropped two dress sizes doesn’t mean you’re healthy.

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].

Whether you have totally bought into the “obesity is a disease” paradigm or are still in denial, you must admit that the development of a suite of effective weight loss medications has created a tsunami of interest and economic activity in this country on a scale not seen since the Beanie Baby craze of the mid-1990s. But, obesity management is serious business. While most of those soft cuddly toys are gathering dust in shoeboxes across this country, weight loss medications are likely to be the vanguard of rapidly evolving revolution in healthcare management that will be with us for the foreseeable future.

Most thoughtful folks who purchased Beanie Babies in 1994 had no illusions and knew that in a few short years this bubble of soft cuddly toys was going to burst. However, do those of us on the front line of medical care know what the future holds for the patients who are being prescribed or are scavenging those too-good-to-be-true medications?

My guess is that in the long run we will need a combination of some serious tinkering by the pharmaceutical industry and a trek up some steep learning curves before we eventually arrive at a safe and effective chemical management for obese patients. I recently read an article by an obesity management specialist at Harvard Medical School who voiced her concerns that we are missing an opportunity to make this explosion of popularity in GLP-1 drugs into an important learning experience.

In an opinion piece in JAMA Internal Medicine, Dr. Fatima Cody Stanford and her coauthors argue that we, actually the US Food and Drug Administration (FDA), is over-focused on weight loss in determining the efficacy of anti-obesity medications. Dr. Stanford and colleagues point out that when a patient loses weight it isn’t just fat — it is complex process that may include muscle and bone mineralization as well. She has consulted for at least one obesity-drug manufacturer and says that these companies have the resources to produce data on body composition that could help clinicians create management plans that would address the patients’ overall health. However, the FDA has not demanded this broader and deeper assessment of general health when reviewing the drug trials.

I don’t think we can blame the patients for not asking whether they will healthier while taking these medications. They have already spent a lifetime, even if it is just a decade, of suffering as the “fat one.” A new outfit and a look in the mirror can’t help but make them feel better ... in the short term anyway. We as physicians must shoulder some of the blame for focusing on weight. Our spoken or unspoken message has been “Lose weight and you will be healthier.” We may make our message sound more professional by tossing around terms like “BMI,” but as Dr. Stanford points out, “we have known BMI is a flawed metric for a long time.”

There is the notion that obese people have had to build more muscle to help them carry around the extra weight, so that we should expect them to lose that extra muscle along with the fat. However, in older adults there is an entity called sarcopenic obesity, in which the patient doesn’t have that extra muscle to lose.

In a brief Internet research venture, I could find little on the subject of muscle loss and GLP-1s, other than “it can happen.” And, nothing on the effect in adolescents. And that is one of Dr. Stanford’s points. We just don’t know. She said that looking at body composition can be costly and not something that the clinician can do. However, as far as muscle mass is concerned, we need to be alert to the potential for loss. Simple assessments of strength can help us tailor our management to the specific patient’s need.

The bottom line is this ... now that we have effective medications for “weight loss,” we need to redefine the relationship between weight and health. “We” means us as clinicians. It means the folks at FDA. And, if we can improve our messaging, it will osmose to the rest of the population. Just because you’ve dropped two dress sizes doesn’t mean you’re healthy.

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].

Whether you have totally bought into the “obesity is a disease” paradigm or are still in denial, you must admit that the development of a suite of effective weight loss medications has created a tsunami of interest and economic activity in this country on a scale not seen since the Beanie Baby craze of the mid-1990s. But, obesity management is serious business. While most of those soft cuddly toys are gathering dust in shoeboxes across this country, weight loss medications are likely to be the vanguard of rapidly evolving revolution in healthcare management that will be with us for the foreseeable future.

Most thoughtful folks who purchased Beanie Babies in 1994 had no illusions and knew that in a few short years this bubble of soft cuddly toys was going to burst. However, do those of us on the front line of medical care know what the future holds for the patients who are being prescribed or are scavenging those too-good-to-be-true medications?

My guess is that in the long run we will need a combination of some serious tinkering by the pharmaceutical industry and a trek up some steep learning curves before we eventually arrive at a safe and effective chemical management for obese patients. I recently read an article by an obesity management specialist at Harvard Medical School who voiced her concerns that we are missing an opportunity to make this explosion of popularity in GLP-1 drugs into an important learning experience.

In an opinion piece in JAMA Internal Medicine, Dr. Fatima Cody Stanford and her coauthors argue that we, actually the US Food and Drug Administration (FDA), is over-focused on weight loss in determining the efficacy of anti-obesity medications. Dr. Stanford and colleagues point out that when a patient loses weight it isn’t just fat — it is complex process that may include muscle and bone mineralization as well. She has consulted for at least one obesity-drug manufacturer and says that these companies have the resources to produce data on body composition that could help clinicians create management plans that would address the patients’ overall health. However, the FDA has not demanded this broader and deeper assessment of general health when reviewing the drug trials.

I don’t think we can blame the patients for not asking whether they will healthier while taking these medications. They have already spent a lifetime, even if it is just a decade, of suffering as the “fat one.” A new outfit and a look in the mirror can’t help but make them feel better ... in the short term anyway. We as physicians must shoulder some of the blame for focusing on weight. Our spoken or unspoken message has been “Lose weight and you will be healthier.” We may make our message sound more professional by tossing around terms like “BMI,” but as Dr. Stanford points out, “we have known BMI is a flawed metric for a long time.”

There is the notion that obese people have had to build more muscle to help them carry around the extra weight, so that we should expect them to lose that extra muscle along with the fat. However, in older adults there is an entity called sarcopenic obesity, in which the patient doesn’t have that extra muscle to lose.

In a brief Internet research venture, I could find little on the subject of muscle loss and GLP-1s, other than “it can happen.” And, nothing on the effect in adolescents. And that is one of Dr. Stanford’s points. We just don’t know. She said that looking at body composition can be costly and not something that the clinician can do. However, as far as muscle mass is concerned, we need to be alert to the potential for loss. Simple assessments of strength can help us tailor our management to the specific patient’s need.

The bottom line is this ... now that we have effective medications for “weight loss,” we need to redefine the relationship between weight and health. “We” means us as clinicians. It means the folks at FDA. And, if we can improve our messaging, it will osmose to the rest of the population. Just because you’ve dropped two dress sizes doesn’t mean you’re healthy.

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].

A 27-year-old woman presents requesting antibiotics for a sinus headache. She reports she has had 3-4 episodes a year with pain in her maxillary area and congestion. She has not had fevers with these episodes. She had the onset of this headache 6 hours ago. She has had resolution of the pain within 24 hours in the past with the use of antibiotics and decongestants. What would be the best treatment for her?

A. Amoxicillin

B. Amoxicillin/clavulanate

C. Amoxicillin + fluticasone nasal spray

D. Sumatriptan

The best treatment would be sumatriptan. This is very likely a variant of migraine headache and migraine-directed therapy is the best option. In regard to sinus headache, the International Headache Society (IHS) classification states that chronic sinusitis is not a cause of headache and facial pain unless it relapses into an acute sinusitis.¹

The recurrent nature of the headaches in this patient suggests a primary headache disorder with migraine being the most likely. In a study of 2991 patients with self-diagnosed or physician-diagnosed “sinus headaches,” 88% of the patients met IHS criteria for migraine.² In this study, most of the patients had symptoms suggesting sinus problems, with the most common symptoms being sinus pressure (84%), sinus pain (82%), and nasal congestion (63%). The likely cause for these symptoms in migraine patients is vasodilation of the nasal mucosa that can be part of the migraine event.

Foroughipour and colleagues found similar results.³ In their study, 58 patients with “sinus headache” were evaluated, with the final diagnosis of migraine in 40 patients (69%), tension-type headache in 16 patients (27%), and chronic sinusitis with recurrent acute episodes in 2 patients (3%). Recurrent antibiotic therapy had been given to 73% of the tension-type headache patients and 66% of the migraine patients.

Obermann et al. looked at how common trigeminal autonomic symptoms were in patients with migraine in a population-based study.⁴ They found of 841 patients who had migraine, 226 reported accompanying unilateral trigeminal autonomic symptoms (26.9%).

Al-Hashel et al. reported on how patients with frequent migraine are misdiagnosed and how long it takes when they present with sinus symptoms. A total of 130 migraine patients were recruited for the study; of these, 81.5% were misdiagnosed with sinusitis. The mean time delay of migraine diagnosis was almost 8 years.⁵

In a study by Dr. Elina Kari and Dr. John M. DelGaudio, patients who had a history of “sinus headaches” were treated as though all these headaches were migraines. Fifty-four patients were enrolled, and 38 patients completed the study. All patients had nasal endoscopy and sinus CT scans that were negative. They were then given migraine-directed treatment to use for their headaches. Of the 38 patient who completed the study, 31 patients (82%) had a significant reduction in headache pain with triptan use, and 35 patients (92%) had a significant response to migraine-directed therapy.⁶ An expert panel consisting of otolaryngologists, neurologists, allergists, and primary care physicians concluded that the majority of sinus headaches can actually be classified as migraines.⁷

These references aren’t new. This information has been known in the medical literature for more than 2 decades, but I believe that the majority of medical professionals are not aware of it. In my own practice I have found great success treating patients with sinus headache histories with migraine-directed therapy (mostly triptans) when they have return of their headaches.


Pearl: When your patients say they have another sinus headache, think migraine.
 

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

References

1. Jones NS. Expert Rev Neurother. 2009;9:439-44.

2. Schreiber CP et al. Arch Intern Med. 2004;164:1769-72.

3. Foroughipour M et al. Eur Arch Otorhinolaryngol. 2011;268:1593-6.

4. Obermann M et al. Cephalalgia. 2007 Jun;27(6):504-9.

5. Al-Hashel JY et al. J Headache Pain. 2013 Dec 12;14(1):97.

6. Kari E and DelGaudi JM. Laryngoscope. 2008;118:2235-9.

7. Levine HL et al. Otolaryngol Head Neck Surg. 2006 Mar;134(3):516-23.

A 27-year-old woman presents requesting antibiotics for a sinus headache. She reports she has had 3-4 episodes a year with pain in her maxillary area and congestion. She has not had fevers with these episodes. She had the onset of this headache 6 hours ago. She has had resolution of the pain within 24 hours in the past with the use of antibiotics and decongestants. What would be the best treatment for her?

A. Amoxicillin

B. Amoxicillin/clavulanate

C. Amoxicillin + fluticasone nasal spray

D. Sumatriptan

The best treatment would be sumatriptan. This is very likely a variant of migraine headache and migraine-directed therapy is the best option. In regard to sinus headache, the International Headache Society (IHS) classification states that chronic sinusitis is not a cause of headache and facial pain unless it relapses into an acute sinusitis.¹

The recurrent nature of the headaches in this patient suggests a primary headache disorder with migraine being the most likely. In a study of 2991 patients with self-diagnosed or physician-diagnosed “sinus headaches,” 88% of the patients met IHS criteria for migraine.² In this study, most of the patients had symptoms suggesting sinus problems, with the most common symptoms being sinus pressure (84%), sinus pain (82%), and nasal congestion (63%). The likely cause for these symptoms in migraine patients is vasodilation of the nasal mucosa that can be part of the migraine event.

Foroughipour and colleagues found similar results.³ In their study, 58 patients with “sinus headache” were evaluated, with the final diagnosis of migraine in 40 patients (69%), tension-type headache in 16 patients (27%), and chronic sinusitis with recurrent acute episodes in 2 patients (3%). Recurrent antibiotic therapy had been given to 73% of the tension-type headache patients and 66% of the migraine patients.

Obermann et al. looked at how common trigeminal autonomic symptoms were in patients with migraine in a population-based study.⁴ They found of 841 patients who had migraine, 226 reported accompanying unilateral trigeminal autonomic symptoms (26.9%).

Al-Hashel et al. reported on how patients with frequent migraine are misdiagnosed and how long it takes when they present with sinus symptoms. A total of 130 migraine patients were recruited for the study; of these, 81.5% were misdiagnosed with sinusitis. The mean time delay of migraine diagnosis was almost 8 years.⁵

In a study by Dr. Elina Kari and Dr. John M. DelGaudio, patients who had a history of “sinus headaches” were treated as though all these headaches were migraines. Fifty-four patients were enrolled, and 38 patients completed the study. All patients had nasal endoscopy and sinus CT scans that were negative. They were then given migraine-directed treatment to use for their headaches. Of the 38 patient who completed the study, 31 patients (82%) had a significant reduction in headache pain with triptan use, and 35 patients (92%) had a significant response to migraine-directed therapy.⁶ An expert panel consisting of otolaryngologists, neurologists, allergists, and primary care physicians concluded that the majority of sinus headaches can actually be classified as migraines.⁷

These references aren’t new. This information has been known in the medical literature for more than 2 decades, but I believe that the majority of medical professionals are not aware of it. In my own practice I have found great success treating patients with sinus headache histories with migraine-directed therapy (mostly triptans) when they have return of their headaches.


Pearl: When your patients say they have another sinus headache, think migraine.
 

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

References

1. Jones NS. Expert Rev Neurother. 2009;9:439-44.

2. Schreiber CP et al. Arch Intern Med. 2004;164:1769-72.

3. Foroughipour M et al. Eur Arch Otorhinolaryngol. 2011;268:1593-6.

4. Obermann M et al. Cephalalgia. 2007 Jun;27(6):504-9.

5. Al-Hashel JY et al. J Headache Pain. 2013 Dec 12;14(1):97.

6. Kari E and DelGaudi JM. Laryngoscope. 2008;118:2235-9.

7. Levine HL et al. Otolaryngol Head Neck Surg. 2006 Mar;134(3):516-23.

A 27-year-old woman presents requesting antibiotics for a sinus headache. She reports she has had 3-4 episodes a year with pain in her maxillary area and congestion. She has not had fevers with these episodes. She had the onset of this headache 6 hours ago. She has had resolution of the pain within 24 hours in the past with the use of antibiotics and decongestants. What would be the best treatment for her?

A. Amoxicillin

B. Amoxicillin/clavulanate

C. Amoxicillin + fluticasone nasal spray

D. Sumatriptan

The best treatment would be sumatriptan. This is very likely a variant of migraine headache and migraine-directed therapy is the best option. In regard to sinus headache, the International Headache Society (IHS) classification states that chronic sinusitis is not a cause of headache and facial pain unless it relapses into an acute sinusitis.¹

The recurrent nature of the headaches in this patient suggests a primary headache disorder with migraine being the most likely. In a study of 2991 patients with self-diagnosed or physician-diagnosed “sinus headaches,” 88% of the patients met IHS criteria for migraine.² In this study, most of the patients had symptoms suggesting sinus problems, with the most common symptoms being sinus pressure (84%), sinus pain (82%), and nasal congestion (63%). The likely cause for these symptoms in migraine patients is vasodilation of the nasal mucosa that can be part of the migraine event.

Foroughipour and colleagues found similar results.³ In their study, 58 patients with “sinus headache” were evaluated, with the final diagnosis of migraine in 40 patients (69%), tension-type headache in 16 patients (27%), and chronic sinusitis with recurrent acute episodes in 2 patients (3%). Recurrent antibiotic therapy had been given to 73% of the tension-type headache patients and 66% of the migraine patients.

Obermann et al. looked at how common trigeminal autonomic symptoms were in patients with migraine in a population-based study.⁴ They found of 841 patients who had migraine, 226 reported accompanying unilateral trigeminal autonomic symptoms (26.9%).

Al-Hashel et al. reported on how patients with frequent migraine are misdiagnosed and how long it takes when they present with sinus symptoms. A total of 130 migraine patients were recruited for the study; of these, 81.5% were misdiagnosed with sinusitis. The mean time delay of migraine diagnosis was almost 8 years.⁵

In a study by Dr. Elina Kari and Dr. John M. DelGaudio, patients who had a history of “sinus headaches” were treated as though all these headaches were migraines. Fifty-four patients were enrolled, and 38 patients completed the study. All patients had nasal endoscopy and sinus CT scans that were negative. They were then given migraine-directed treatment to use for their headaches. Of the 38 patient who completed the study, 31 patients (82%) had a significant reduction in headache pain with triptan use, and 35 patients (92%) had a significant response to migraine-directed therapy.⁶ An expert panel consisting of otolaryngologists, neurologists, allergists, and primary care physicians concluded that the majority of sinus headaches can actually be classified as migraines.⁷

These references aren’t new. This information has been known in the medical literature for more than 2 decades, but I believe that the majority of medical professionals are not aware of it. In my own practice I have found great success treating patients with sinus headache histories with migraine-directed therapy (mostly triptans) when they have return of their headaches.


Pearl: When your patients say they have another sinus headache, think migraine.
 

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

References

1. Jones NS. Expert Rev Neurother. 2009;9:439-44.

2. Schreiber CP et al. Arch Intern Med. 2004;164:1769-72.

3. Foroughipour M et al. Eur Arch Otorhinolaryngol. 2011;268:1593-6.

4. Obermann M et al. Cephalalgia. 2007 Jun;27(6):504-9.

5. Al-Hashel JY et al. J Headache Pain. 2013 Dec 12;14(1):97.

6. Kari E and DelGaudi JM. Laryngoscope. 2008;118:2235-9.

7. Levine HL et al. Otolaryngol Head Neck Surg. 2006 Mar;134(3):516-23.

An article in the March 20 JAMA Network Open looked into the use of AI for responding to patient emails. Basically, they found that this led to a reduction in physician burden, but didn’t save any time.

1. Not sure that’s worth the trouble.

2. Unless the AI is simply responding with something like “message received, thank you” I don’t think this is a good idea.

Yeah, we’re all stretched for time, I understand that. From the starting gun each morning we’re racing between patients, phone calls, incoming test results, staff questions, drug reps, sample closets, dictations, and a million other things.

But AI needs to be a lot better before I let it handle patient questions and concerns.

Someday, yeah, maybe it can do this, like 2-1B, the surgical droid that replaced Luke’s hand in “The Empire Strikes Back.” But we’re not even close to that. Just because a log-in screen says “Jumping to Hyperspace” doesn’t mean you’re on the Millennium Falcon.

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

An article in the March 20 JAMA Network Open looked into the use of AI for responding to patient emails. Basically, they found that this led to a reduction in physician burden, but didn’t save any time.

1. Not sure that’s worth the trouble.

2. Unless the AI is simply responding with something like “message received, thank you” I don’t think this is a good idea.

Yeah, we’re all stretched for time, I understand that. From the starting gun each morning we’re racing between patients, phone calls, incoming test results, staff questions, drug reps, sample closets, dictations, and a million other things.

But AI needs to be a lot better before I let it handle patient questions and concerns.

Someday, yeah, maybe it can do this, like 2-1B, the surgical droid that replaced Luke’s hand in “The Empire Strikes Back.” But we’re not even close to that. Just because a log-in screen says “Jumping to Hyperspace” doesn’t mean you’re on the Millennium Falcon.

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

An article in the March 20 JAMA Network Open looked into the use of AI for responding to patient emails. Basically, they found that this led to a reduction in physician burden, but didn’t save any time.

1. Not sure that’s worth the trouble.

2. Unless the AI is simply responding with something like “message received, thank you” I don’t think this is a good idea.

Yeah, we’re all stretched for time, I understand that. From the starting gun each morning we’re racing between patients, phone calls, incoming test results, staff questions, drug reps, sample closets, dictations, and a million other things.

But AI needs to be a lot better before I let it handle patient questions and concerns.

Someday, yeah, maybe it can do this, like 2-1B, the surgical droid that replaced Luke’s hand in “The Empire Strikes Back.” But we’re not even close to that. Just because a log-in screen says “Jumping to Hyperspace” doesn’t mean you’re on the Millennium Falcon.

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

How should we define success in cancer policy — what should the endpoint be?

It’s debatable. Is it fewer cancer deaths? Perhaps improved access to therapies or a reduction in disparities?

One thing I know with certainty: The number of new cancer drugs approved by the US Food and Drug Administration (FDA) is not and should not be our primary endpoint in and of itself.

I’ll go a step further: It is not even a surrogate marker for success. The number of newly approved drugs is a meaningless metric. Here’s why.

Unfortunately, a new drug approval does not necessarily mean improved patient outcomes. In fact, the majority of cancer drugs approved these days improve neither survival nor quality of life. Our previous work has shown better mortality outcomes in other high-income countries that have not approved or do not fund several cancer drugs that the FDA has approved.

Even if a drug has a meaningful benefit, at an average cost of more than $250,000 per year, if a new drug cannot reach patients because of access or cost issues, it’s meaningless.

However, regulators and media celebrate the number (and speed) of drug approvals every year as if it were a marker of success in and of itself. But approving more drugs should not be the goal; improving outcomes should. The FDA’s current approach is akin to a university celebrating its graduation rate by lowering the requirements to pass.

When US patients lack access to cisplatin and carboplatin, any talk of a Moonshot or precision medicine ‘ending cancer as we know it’ is premature and even embarrassing.

This is exactly what the FDA has been doing with our regulatory standards for drug approval. They have gradually lowered the requirements for approval from two randomized trials to one randomized trial, then further to one randomized trial with a surrogate endpoint. In many instances, they have gone even further, demanding merely single-arm trials. They’ve also gone from requiring overall survival benefits to celebrating nondetrimental effects on overall survival. It’s no wonder that we approve more drugs today than we did in the past — the bar for approval is pretty low nowadays.

In 2019, our lab found an interesting phenomenon: The number of approvals based on surrogate endpoints has been increasing while the number of accelerated approvals has been decreasing. This made no sense at first, because you’d think surrogate-based approvals and accelerated approvals would be collinear. However, we realized that the recent approvals based on surrogate endpoints were regular approvals instead of accelerated approvals, which explained the phenomenon. Not only is the FDA approving more drugs on the basis of lower levels of evidence, but the agency is also offering regular instead of accelerated approval, thereby removing the safety net of a confirmatory trial.

Nearly everybody sees this as a cause for celebration. Pharma celebrates record profits, regulators celebrate record numbers of drug approvals, insurance companies celebrate because they can pass these costs on as insurance premiums and make even more money, and physicians and patients celebrate access to the shiniest, sexiest new cancer drug.

Everybody is happy in this system. The only problem is that patient outcomes don’t improve, resources are taken away from other priorities, and society suffers a net harm.

When you contrast this celebration with the reality on the ground, the difference is stark and sobering. In our clinics, patients lack access to even old chemotherapeutic drugs that are already generic and cheap but make a meaningful difference in patient outcomes. Citing a current lack of incentives, several generic cancer drug manufacturers have stopped making these drugs; the US supply now relies heavily on importing them from emerging economies such as India. When US patients lack access to cisplatin and carboplatin, any talk of a Moonshot or precision medicine “ending cancer as we know it” is premature and even embarrassing.

5-Fluorouracil, methotrexate, and the platinums are backbones of cancer treatment. Cisplatin and carboplatin are not drugs we use with the hope of improving survival by a couple of months; these drugs are the difference between life and death for patients with testicular and ovarian cancers. In a survey of 948 global oncologists, these were considered among the most essential cancer drugs by oncologists in high-income and low- and middle-income countries alike. Although oncologists in low- and middle-income countries sometimes argue that even these cheap generic drugs may be unaffordable to their patients, they usually remain available; access is a function of both availability and affordability. However, the shortage situation in the US is unique in that availability — rather than affordability — is impacting access.

Our profit-over-patients policy has landed us in a terrible paradox.

Generic drugs are cheap, and any industrialized country can manufacture them. This is why so few companies actually do so; the profit margins are low and companies have little incentive to produce them, despite their benefit. Meanwhile, the FDA is approving and offering access to new shiny molecules that cost more than $15,000 per month yet offer less than a month of progression-free survival benefit and no overall survival benefit (see margetuximab in breast cancer). We have a literal fatal attraction to everything new and shiny.

This is a clear misalignment of priorities in US cancer drug policy. Our profit-over-patients policy has landed us in a terrible paradox: If a drug is cheap and meaningful, it won’t be available, but if it is marginal and expensive, we will do everything to ensure patients can get it. It’s no wonder that patients on Medicaid are disproportionately affected by these drug shortages. Unless all patients have easy access to cisplatin, carboplatin, and 5-fluorouracil, it is frankly embarrassing to celebrate the number of new cancer drugs approved each year.

We all have a responsibility in this — policymakers and lawmakers, regulators and payers, manufacturers and distributors, the American Society of Clinical Oncology and other oncology societies, and physicians and patients. This is where our advocacy work should focus. The primary endpoint of our cancer policy should not be how many new treatments we can approve or how many expensive drugs a rich person with the best insurance can get at a leading cancer center. The true measure of our civilization is how it treats its most vulnerable members.

Dr. Gyawali has disclosed the following relevant financial relationship: Received consulting fees from Vivio Health.

Dr. Gyawali is an associate professor in the Departments of Oncology and Public Health Sciences and a scientist in the Division of Cancer Care and Epidemiology at Queen’s University in Kingston, Ontario, Canada, and is also affiliated faculty at the Program on Regulation, Therapeutics, and Law in the Department of Medicine at Brigham and Women’s Hospital in Boston. His clinical and research interests revolve around cancer policy, global oncology, evidence-based oncology, financial toxicities of cancer treatment, clinical trial methods, and supportive care. He tweets at @oncology_bg.

A version of this article appeared on Medscape.com.

How should we define success in cancer policy — what should the endpoint be?

It’s debatable. Is it fewer cancer deaths? Perhaps improved access to therapies or a reduction in disparities?

One thing I know with certainty: The number of new cancer drugs approved by the US Food and Drug Administration (FDA) is not and should not be our primary endpoint in and of itself.

I’ll go a step further: It is not even a surrogate marker for success. The number of newly approved drugs is a meaningless metric. Here’s why.

Unfortunately, a new drug approval does not necessarily mean improved patient outcomes. In fact, the majority of cancer drugs approved these days improve neither survival nor quality of life. Our previous work has shown better mortality outcomes in other high-income countries that have not approved or do not fund several cancer drugs that the FDA has approved.

Even if a drug has a meaningful benefit, at an average cost of more than $250,000 per year, if a new drug cannot reach patients because of access or cost issues, it’s meaningless.

However, regulators and media celebrate the number (and speed) of drug approvals every year as if it were a marker of success in and of itself. But approving more drugs should not be the goal; improving outcomes should. The FDA’s current approach is akin to a university celebrating its graduation rate by lowering the requirements to pass.

When US patients lack access to cisplatin and carboplatin, any talk of a Moonshot or precision medicine ‘ending cancer as we know it’ is premature and even embarrassing.

This is exactly what the FDA has been doing with our regulatory standards for drug approval. They have gradually lowered the requirements for approval from two randomized trials to one randomized trial, then further to one randomized trial with a surrogate endpoint. In many instances, they have gone even further, demanding merely single-arm trials. They’ve also gone from requiring overall survival benefits to celebrating nondetrimental effects on overall survival. It’s no wonder that we approve more drugs today than we did in the past — the bar for approval is pretty low nowadays.

In 2019, our lab found an interesting phenomenon: The number of approvals based on surrogate endpoints has been increasing while the number of accelerated approvals has been decreasing. This made no sense at first, because you’d think surrogate-based approvals and accelerated approvals would be collinear. However, we realized that the recent approvals based on surrogate endpoints were regular approvals instead of accelerated approvals, which explained the phenomenon. Not only is the FDA approving more drugs on the basis of lower levels of evidence, but the agency is also offering regular instead of accelerated approval, thereby removing the safety net of a confirmatory trial.

Nearly everybody sees this as a cause for celebration. Pharma celebrates record profits, regulators celebrate record numbers of drug approvals, insurance companies celebrate because they can pass these costs on as insurance premiums and make even more money, and physicians and patients celebrate access to the shiniest, sexiest new cancer drug.

Everybody is happy in this system. The only problem is that patient outcomes don’t improve, resources are taken away from other priorities, and society suffers a net harm.

When you contrast this celebration with the reality on the ground, the difference is stark and sobering. In our clinics, patients lack access to even old chemotherapeutic drugs that are already generic and cheap but make a meaningful difference in patient outcomes. Citing a current lack of incentives, several generic cancer drug manufacturers have stopped making these drugs; the US supply now relies heavily on importing them from emerging economies such as India. When US patients lack access to cisplatin and carboplatin, any talk of a Moonshot or precision medicine “ending cancer as we know it” is premature and even embarrassing.

5-Fluorouracil, methotrexate, and the platinums are backbones of cancer treatment. Cisplatin and carboplatin are not drugs we use with the hope of improving survival by a couple of months; these drugs are the difference between life and death for patients with testicular and ovarian cancers. In a survey of 948 global oncologists, these were considered among the most essential cancer drugs by oncologists in high-income and low- and middle-income countries alike. Although oncologists in low- and middle-income countries sometimes argue that even these cheap generic drugs may be unaffordable to their patients, they usually remain available; access is a function of both availability and affordability. However, the shortage situation in the US is unique in that availability — rather than affordability — is impacting access.

Our profit-over-patients policy has landed us in a terrible paradox.

Generic drugs are cheap, and any industrialized country can manufacture them. This is why so few companies actually do so; the profit margins are low and companies have little incentive to produce them, despite their benefit. Meanwhile, the FDA is approving and offering access to new shiny molecules that cost more than $15,000 per month yet offer less than a month of progression-free survival benefit and no overall survival benefit (see margetuximab in breast cancer). We have a literal fatal attraction to everything new and shiny.

This is a clear misalignment of priorities in US cancer drug policy. Our profit-over-patients policy has landed us in a terrible paradox: If a drug is cheap and meaningful, it won’t be available, but if it is marginal and expensive, we will do everything to ensure patients can get it. It’s no wonder that patients on Medicaid are disproportionately affected by these drug shortages. Unless all patients have easy access to cisplatin, carboplatin, and 5-fluorouracil, it is frankly embarrassing to celebrate the number of new cancer drugs approved each year.

We all have a responsibility in this — policymakers and lawmakers, regulators and payers, manufacturers and distributors, the American Society of Clinical Oncology and other oncology societies, and physicians and patients. This is where our advocacy work should focus. The primary endpoint of our cancer policy should not be how many new treatments we can approve or how many expensive drugs a rich person with the best insurance can get at a leading cancer center. The true measure of our civilization is how it treats its most vulnerable members.

Dr. Gyawali has disclosed the following relevant financial relationship: Received consulting fees from Vivio Health.

Dr. Gyawali is an associate professor in the Departments of Oncology and Public Health Sciences and a scientist in the Division of Cancer Care and Epidemiology at Queen’s University in Kingston, Ontario, Canada, and is also affiliated faculty at the Program on Regulation, Therapeutics, and Law in the Department of Medicine at Brigham and Women’s Hospital in Boston. His clinical and research interests revolve around cancer policy, global oncology, evidence-based oncology, financial toxicities of cancer treatment, clinical trial methods, and supportive care. He tweets at @oncology_bg.

A version of this article appeared on Medscape.com.

How should we define success in cancer policy — what should the endpoint be?

It’s debatable. Is it fewer cancer deaths? Perhaps improved access to therapies or a reduction in disparities?

One thing I know with certainty: The number of new cancer drugs approved by the US Food and Drug Administration (FDA) is not and should not be our primary endpoint in and of itself.

I’ll go a step further: It is not even a surrogate marker for success. The number of newly approved drugs is a meaningless metric. Here’s why.

Unfortunately, a new drug approval does not necessarily mean improved patient outcomes. In fact, the majority of cancer drugs approved these days improve neither survival nor quality of life. Our previous work has shown better mortality outcomes in other high-income countries that have not approved or do not fund several cancer drugs that the FDA has approved.

Even if a drug has a meaningful benefit, at an average cost of more than $250,000 per year, if a new drug cannot reach patients because of access or cost issues, it’s meaningless.

However, regulators and media celebrate the number (and speed) of drug approvals every year as if it were a marker of success in and of itself. But approving more drugs should not be the goal; improving outcomes should. The FDA’s current approach is akin to a university celebrating its graduation rate by lowering the requirements to pass.

When US patients lack access to cisplatin and carboplatin, any talk of a Moonshot or precision medicine ‘ending cancer as we know it’ is premature and even embarrassing.

This is exactly what the FDA has been doing with our regulatory standards for drug approval. They have gradually lowered the requirements for approval from two randomized trials to one randomized trial, then further to one randomized trial with a surrogate endpoint. In many instances, they have gone even further, demanding merely single-arm trials. They’ve also gone from requiring overall survival benefits to celebrating nondetrimental effects on overall survival. It’s no wonder that we approve more drugs today than we did in the past — the bar for approval is pretty low nowadays.

In 2019, our lab found an interesting phenomenon: The number of approvals based on surrogate endpoints has been increasing while the number of accelerated approvals has been decreasing. This made no sense at first, because you’d think surrogate-based approvals and accelerated approvals would be collinear. However, we realized that the recent approvals based on surrogate endpoints were regular approvals instead of accelerated approvals, which explained the phenomenon. Not only is the FDA approving more drugs on the basis of lower levels of evidence, but the agency is also offering regular instead of accelerated approval, thereby removing the safety net of a confirmatory trial.

Nearly everybody sees this as a cause for celebration. Pharma celebrates record profits, regulators celebrate record numbers of drug approvals, insurance companies celebrate because they can pass these costs on as insurance premiums and make even more money, and physicians and patients celebrate access to the shiniest, sexiest new cancer drug.

Everybody is happy in this system. The only problem is that patient outcomes don’t improve, resources are taken away from other priorities, and society suffers a net harm.

When you contrast this celebration with the reality on the ground, the difference is stark and sobering. In our clinics, patients lack access to even old chemotherapeutic drugs that are already generic and cheap but make a meaningful difference in patient outcomes. Citing a current lack of incentives, several generic cancer drug manufacturers have stopped making these drugs; the US supply now relies heavily on importing them from emerging economies such as India. When US patients lack access to cisplatin and carboplatin, any talk of a Moonshot or precision medicine “ending cancer as we know it” is premature and even embarrassing.

5-Fluorouracil, methotrexate, and the platinums are backbones of cancer treatment. Cisplatin and carboplatin are not drugs we use with the hope of improving survival by a couple of months; these drugs are the difference between life and death for patients with testicular and ovarian cancers. In a survey of 948 global oncologists, these were considered among the most essential cancer drugs by oncologists in high-income and low- and middle-income countries alike. Although oncologists in low- and middle-income countries sometimes argue that even these cheap generic drugs may be unaffordable to their patients, they usually remain available; access is a function of both availability and affordability. However, the shortage situation in the US is unique in that availability — rather than affordability — is impacting access.

Our profit-over-patients policy has landed us in a terrible paradox.

Generic drugs are cheap, and any industrialized country can manufacture them. This is why so few companies actually do so; the profit margins are low and companies have little incentive to produce them, despite their benefit. Meanwhile, the FDA is approving and offering access to new shiny molecules that cost more than $15,000 per month yet offer less than a month of progression-free survival benefit and no overall survival benefit (see margetuximab in breast cancer). We have a literal fatal attraction to everything new and shiny.

This is a clear misalignment of priorities in US cancer drug policy. Our profit-over-patients policy has landed us in a terrible paradox: If a drug is cheap and meaningful, it won’t be available, but if it is marginal and expensive, we will do everything to ensure patients can get it. It’s no wonder that patients on Medicaid are disproportionately affected by these drug shortages. Unless all patients have easy access to cisplatin, carboplatin, and 5-fluorouracil, it is frankly embarrassing to celebrate the number of new cancer drugs approved each year.

We all have a responsibility in this — policymakers and lawmakers, regulators and payers, manufacturers and distributors, the American Society of Clinical Oncology and other oncology societies, and physicians and patients. This is where our advocacy work should focus. The primary endpoint of our cancer policy should not be how many new treatments we can approve or how many expensive drugs a rich person with the best insurance can get at a leading cancer center. The true measure of our civilization is how it treats its most vulnerable members.

Dr. Gyawali has disclosed the following relevant financial relationship: Received consulting fees from Vivio Health.

Dr. Gyawali is an associate professor in the Departments of Oncology and Public Health Sciences and a scientist in the Division of Cancer Care and Epidemiology at Queen’s University in Kingston, Ontario, Canada, and is also affiliated faculty at the Program on Regulation, Therapeutics, and Law in the Department of Medicine at Brigham and Women’s Hospital in Boston. His clinical and research interests revolve around cancer policy, global oncology, evidence-based oncology, financial toxicities of cancer treatment, clinical trial methods, and supportive care. He tweets at @oncology_bg.

A version of this article appeared on Medscape.com.

“No greater opportunity, responsibility, or obligation can fall to the lot of a human being than to become a physician. In the care of the suffering, [the physician] needs technical skill, scientific knowledge, and human understanding.”¹ Internal medicine physicians have risen to this challenge for centuries. Today, it is time for us to use these skills to care for patients who need access to reproductive care — particularly medication abortion. Nationally accredited internal medicine training programs have not been required to provide abortion education, and this may evolve in the future.

However, considering the difficulty in people receiving contraception, the failure rate of contraception, the known risks from pregnancy, the increasing difficulty in accessing abortion, and the recent advocating to protect access to reproductive care by leadership of internal medicine and internal medicine subspecialty societies, we advocate that abortion must become a part of our education and practice.²

Most abortions are performed during the first trimester and can be managed with medications that are very safe.³ In fact, legal medication abortion is so safe that pregnancy in the United States has fourteen times the mortality risk as does legal medication abortion.⁴ Inability to access an abortion has widely documented negative health effects for women and their children.^5,6

Within this context, it is important for internal medicine physicians to understand that the ability to access an abortion is the ability to access a life-saving procedure and there is no medical justification for restricting such a prescription any more than restricting any other standard medical therapy. Furthermore, the recent widespread criminalization of abortion gives new urgency to expanding the pool of physicians who understand this and are trained, able, and willing to prescribe medication abortion.

We understand that reproductive health care may not now be a component of clinical practice for some, but given the heterogeneity of internal medicine, we believe that some knowledge about medical abortion is an essential competency of foundational medical knowledge.⁷ The heterogeneity of practice in internal medicine lends itself to different levels of knowledge that should be embraced. Because of poor access to abortion, both ambulatory and hospital-based physicians will increasingly be required to care for patients who need abortion for medical or other reasons.

We advocate that all physicians — including those with internal medicine training — should understand counseling about choices and options (including an unbiased discussion of the options to continue or terminate the pregnancy), the safety of medication abortion in contrast to the risks from pregnancy, and where to refer someone seeking an abortion. In addition to this information, primary care physicians with a special interest in women’s health must have basic knowledge about mifepristone and misoprostol and how they work, the benefits and risks of these, and what the pregnant person seeking an abortion will experience.⁸

Lastly, physicians who wish to provide medication abortion — including in primary care, hospital medicine, and subspecialty care — should receive training and ongoing professional development. Such professional development should include counseling, indications, contraindications, medication regimens, navigating required documentation and reporting, and anticipating possible side effects and complications.

A major challenge to internal medicine and other primary care physicians, subspecialists, and hospitalists addressing abortion is the inadequate training in and knowledge about providing this care. However, the entire spectrum of medical education (undergraduate, graduate, and continuing education) should evolve to address this lack.

Integrating this education into medical conferences and journals is a meaningful start, possibly in partnership with medical societies that have been teaching these skills for decades. Partnering with other specialties can also help us stay current on the local legal landscape and engage in collaborative advocacy.

Specifically, some resources for training can be found at:

• www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2014/11/abortion-training-and-education
• https://prochoice.org/providers/continuing-medical-education/
• www.reproductiveaccess.org/medicationabortion/

Some may have concerns that managing the possible complications of medication abortion is a reason for internal medicine to not be involved in abortion care. However, medication abortions are safe and effective for pregnancy termination and internal medicine physicians can refer patients with complications to peers in gynecology, family medicine, and emergency medicine should complications arise.^{8 We have} managed countless other conditions this way, including most recently during the pandemic.

We live in a country with increasing barriers to care – now with laws in many states that prevent basic health care for women. Internal medicine doctors increasingly may see patients who need care urgently, particularly those who practice in states that neighbor those that prevent this access. We are calling for all who practice internal medicine to educate themselves, optimizing their skills within the full scope of medical practice to provide possibly lifesaving care and thereby address increased needs for medical services.

We must continue to advocate for our patients. The COVID-19 pandemic has reinforced the fact that internal medicine–trained physicians are able to care for conditions that are new and, as a profession, we are capable of rapidly switching practices and learning new modalities of care. It is time for us to extend this competency to care for patients who constitute half the population and are at risk: women.

Dr. Barrett is an internal medicine hospitalist based in Albuquerque, New Mexico; she completed a medical justice in advocacy fellowship in 2022. Dr. Radhakrishnan is an internal medicine physician educator who completed an equity matters fellowship in 2022 and is based in Scottsdale, Arizona. Neither reports conflicts of interest.

References

1. Harrison’s Principles of Internal Medicine, 20e. Jameson J et al., eds. McGraw Hill; 2018. Accessed Sept. 27, 2023.

2. Serchen J et al. Reproductive Health Policy in the United States: An American College of Physicians Policy Brief. Ann Intern Med.2023;176:364-6. epub 28 Feb. 2023.

3. Jatlaoui TC et al. Abortion Surveillance — United States, 2016. MMWR Surveill Summ 2019;68(No. SS-11):1-41.

4. Raymond EG and Grimes DA. The comparative safety of legal induced abortion and childbirth in the United States. Obstet Gynecol. 2012;119(2 Pt 1):215-9.

5. Ralph LJ et al. Self-reported Physical Health of Women Who Did and Did Not Terminate Pregnancy After Seeking Abortion Services: A Cohort Study. Ann Intern Med.2019;171:238-47. epub 11 June 2019.

6. Gerdts C et al. Side effects, physical health consequences, and mortality associated with abortion and birth after an unwanted pregnancy. Women’s Health Issues 2016;26:55-59.

7. Nobel K et al. Patient-reported experience with discussion of all options during pregnancy options counseling in the US south. Contraception. 2022;106:68-74.

8. Liu N and Ray JG. Short-Term Adverse Outcomes After Mifepristone–Misoprostol Versus Procedural Induced Abortion: A Population-Based Propensity-Weighted Study. Ann Intern Med.2023;176:145-53. epub 3 January 2023.

“No greater opportunity, responsibility, or obligation can fall to the lot of a human being than to become a physician. In the care of the suffering, [the physician] needs technical skill, scientific knowledge, and human understanding.”¹ Internal medicine physicians have risen to this challenge for centuries. Today, it is time for us to use these skills to care for patients who need access to reproductive care — particularly medication abortion. Nationally accredited internal medicine training programs have not been required to provide abortion education, and this may evolve in the future.

However, considering the difficulty in people receiving contraception, the failure rate of contraception, the known risks from pregnancy, the increasing difficulty in accessing abortion, and the recent advocating to protect access to reproductive care by leadership of internal medicine and internal medicine subspecialty societies, we advocate that abortion must become a part of our education and practice.²

Most abortions are performed during the first trimester and can be managed with medications that are very safe.³ In fact, legal medication abortion is so safe that pregnancy in the United States has fourteen times the mortality risk as does legal medication abortion.⁴ Inability to access an abortion has widely documented negative health effects for women and their children.^5,6

Within this context, it is important for internal medicine physicians to understand that the ability to access an abortion is the ability to access a life-saving procedure and there is no medical justification for restricting such a prescription any more than restricting any other standard medical therapy. Furthermore, the recent widespread criminalization of abortion gives new urgency to expanding the pool of physicians who understand this and are trained, able, and willing to prescribe medication abortion.

We understand that reproductive health care may not now be a component of clinical practice for some, but given the heterogeneity of internal medicine, we believe that some knowledge about medical abortion is an essential competency of foundational medical knowledge.⁷ The heterogeneity of practice in internal medicine lends itself to different levels of knowledge that should be embraced. Because of poor access to abortion, both ambulatory and hospital-based physicians will increasingly be required to care for patients who need abortion for medical or other reasons.

We advocate that all physicians — including those with internal medicine training — should understand counseling about choices and options (including an unbiased discussion of the options to continue or terminate the pregnancy), the safety of medication abortion in contrast to the risks from pregnancy, and where to refer someone seeking an abortion. In addition to this information, primary care physicians with a special interest in women’s health must have basic knowledge about mifepristone and misoprostol and how they work, the benefits and risks of these, and what the pregnant person seeking an abortion will experience.⁸

Lastly, physicians who wish to provide medication abortion — including in primary care, hospital medicine, and subspecialty care — should receive training and ongoing professional development. Such professional development should include counseling, indications, contraindications, medication regimens, navigating required documentation and reporting, and anticipating possible side effects and complications.

A major challenge to internal medicine and other primary care physicians, subspecialists, and hospitalists addressing abortion is the inadequate training in and knowledge about providing this care. However, the entire spectrum of medical education (undergraduate, graduate, and continuing education) should evolve to address this lack.

Integrating this education into medical conferences and journals is a meaningful start, possibly in partnership with medical societies that have been teaching these skills for decades. Partnering with other specialties can also help us stay current on the local legal landscape and engage in collaborative advocacy.

Specifically, some resources for training can be found at:

• www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2014/11/abortion-training-and-education
• https://prochoice.org/providers/continuing-medical-education/
• www.reproductiveaccess.org/medicationabortion/

Some may have concerns that managing the possible complications of medication abortion is a reason for internal medicine to not be involved in abortion care. However, medication abortions are safe and effective for pregnancy termination and internal medicine physicians can refer patients with complications to peers in gynecology, family medicine, and emergency medicine should complications arise.^{8 We have} managed countless other conditions this way, including most recently during the pandemic.

We live in a country with increasing barriers to care – now with laws in many states that prevent basic health care for women. Internal medicine doctors increasingly may see patients who need care urgently, particularly those who practice in states that neighbor those that prevent this access. We are calling for all who practice internal medicine to educate themselves, optimizing their skills within the full scope of medical practice to provide possibly lifesaving care and thereby address increased needs for medical services.

We must continue to advocate for our patients. The COVID-19 pandemic has reinforced the fact that internal medicine–trained physicians are able to care for conditions that are new and, as a profession, we are capable of rapidly switching practices and learning new modalities of care. It is time for us to extend this competency to care for patients who constitute half the population and are at risk: women.

Dr. Barrett is an internal medicine hospitalist based in Albuquerque, New Mexico; she completed a medical justice in advocacy fellowship in 2022. Dr. Radhakrishnan is an internal medicine physician educator who completed an equity matters fellowship in 2022 and is based in Scottsdale, Arizona. Neither reports conflicts of interest.

References

1. Harrison’s Principles of Internal Medicine, 20e. Jameson J et al., eds. McGraw Hill; 2018. Accessed Sept. 27, 2023.

2. Serchen J et al. Reproductive Health Policy in the United States: An American College of Physicians Policy Brief. Ann Intern Med.2023;176:364-6. epub 28 Feb. 2023.

3. Jatlaoui TC et al. Abortion Surveillance — United States, 2016. MMWR Surveill Summ 2019;68(No. SS-11):1-41.

4. Raymond EG and Grimes DA. The comparative safety of legal induced abortion and childbirth in the United States. Obstet Gynecol. 2012;119(2 Pt 1):215-9.

5. Ralph LJ et al. Self-reported Physical Health of Women Who Did and Did Not Terminate Pregnancy After Seeking Abortion Services: A Cohort Study. Ann Intern Med.2019;171:238-47. epub 11 June 2019.

6. Gerdts C et al. Side effects, physical health consequences, and mortality associated with abortion and birth after an unwanted pregnancy. Women’s Health Issues 2016;26:55-59.

7. Nobel K et al. Patient-reported experience with discussion of all options during pregnancy options counseling in the US south. Contraception. 2022;106:68-74.

8. Liu N and Ray JG. Short-Term Adverse Outcomes After Mifepristone–Misoprostol Versus Procedural Induced Abortion: A Population-Based Propensity-Weighted Study. Ann Intern Med.2023;176:145-53. epub 3 January 2023.

“No greater opportunity, responsibility, or obligation can fall to the lot of a human being than to become a physician. In the care of the suffering, [the physician] needs technical skill, scientific knowledge, and human understanding.”¹ Internal medicine physicians have risen to this challenge for centuries. Today, it is time for us to use these skills to care for patients who need access to reproductive care — particularly medication abortion. Nationally accredited internal medicine training programs have not been required to provide abortion education, and this may evolve in the future.

However, considering the difficulty in people receiving contraception, the failure rate of contraception, the known risks from pregnancy, the increasing difficulty in accessing abortion, and the recent advocating to protect access to reproductive care by leadership of internal medicine and internal medicine subspecialty societies, we advocate that abortion must become a part of our education and practice.²

Most abortions are performed during the first trimester and can be managed with medications that are very safe.³ In fact, legal medication abortion is so safe that pregnancy in the United States has fourteen times the mortality risk as does legal medication abortion.⁴ Inability to access an abortion has widely documented negative health effects for women and their children.^5,6

Within this context, it is important for internal medicine physicians to understand that the ability to access an abortion is the ability to access a life-saving procedure and there is no medical justification for restricting such a prescription any more than restricting any other standard medical therapy. Furthermore, the recent widespread criminalization of abortion gives new urgency to expanding the pool of physicians who understand this and are trained, able, and willing to prescribe medication abortion.

We understand that reproductive health care may not now be a component of clinical practice for some, but given the heterogeneity of internal medicine, we believe that some knowledge about medical abortion is an essential competency of foundational medical knowledge.⁷ The heterogeneity of practice in internal medicine lends itself to different levels of knowledge that should be embraced. Because of poor access to abortion, both ambulatory and hospital-based physicians will increasingly be required to care for patients who need abortion for medical or other reasons.

We advocate that all physicians — including those with internal medicine training — should understand counseling about choices and options (including an unbiased discussion of the options to continue or terminate the pregnancy), the safety of medication abortion in contrast to the risks from pregnancy, and where to refer someone seeking an abortion. In addition to this information, primary care physicians with a special interest in women’s health must have basic knowledge about mifepristone and misoprostol and how they work, the benefits and risks of these, and what the pregnant person seeking an abortion will experience.⁸

Lastly, physicians who wish to provide medication abortion — including in primary care, hospital medicine, and subspecialty care — should receive training and ongoing professional development. Such professional development should include counseling, indications, contraindications, medication regimens, navigating required documentation and reporting, and anticipating possible side effects and complications.

A major challenge to internal medicine and other primary care physicians, subspecialists, and hospitalists addressing abortion is the inadequate training in and knowledge about providing this care. However, the entire spectrum of medical education (undergraduate, graduate, and continuing education) should evolve to address this lack.

Integrating this education into medical conferences and journals is a meaningful start, possibly in partnership with medical societies that have been teaching these skills for decades. Partnering with other specialties can also help us stay current on the local legal landscape and engage in collaborative advocacy.

Specifically, some resources for training can be found at:

• www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2014/11/abortion-training-and-education
• https://prochoice.org/providers/continuing-medical-education/
• www.reproductiveaccess.org/medicationabortion/

Some may have concerns that managing the possible complications of medication abortion is a reason for internal medicine to not be involved in abortion care. However, medication abortions are safe and effective for pregnancy termination and internal medicine physicians can refer patients with complications to peers in gynecology, family medicine, and emergency medicine should complications arise.^{8 We have} managed countless other conditions this way, including most recently during the pandemic.

We live in a country with increasing barriers to care – now with laws in many states that prevent basic health care for women. Internal medicine doctors increasingly may see patients who need care urgently, particularly those who practice in states that neighbor those that prevent this access. We are calling for all who practice internal medicine to educate themselves, optimizing their skills within the full scope of medical practice to provide possibly lifesaving care and thereby address increased needs for medical services.

We must continue to advocate for our patients. The COVID-19 pandemic has reinforced the fact that internal medicine–trained physicians are able to care for conditions that are new and, as a profession, we are capable of rapidly switching practices and learning new modalities of care. It is time for us to extend this competency to care for patients who constitute half the population and are at risk: women.

Dr. Barrett is an internal medicine hospitalist based in Albuquerque, New Mexico; she completed a medical justice in advocacy fellowship in 2022. Dr. Radhakrishnan is an internal medicine physician educator who completed an equity matters fellowship in 2022 and is based in Scottsdale, Arizona. Neither reports conflicts of interest.

References

1. Harrison’s Principles of Internal Medicine, 20e. Jameson J et al., eds. McGraw Hill; 2018. Accessed Sept. 27, 2023.

2. Serchen J et al. Reproductive Health Policy in the United States: An American College of Physicians Policy Brief. Ann Intern Med.2023;176:364-6. epub 28 Feb. 2023.

3. Jatlaoui TC et al. Abortion Surveillance — United States, 2016. MMWR Surveill Summ 2019;68(No. SS-11):1-41.

4. Raymond EG and Grimes DA. The comparative safety of legal induced abortion and childbirth in the United States. Obstet Gynecol. 2012;119(2 Pt 1):215-9.

5. Ralph LJ et al. Self-reported Physical Health of Women Who Did and Did Not Terminate Pregnancy After Seeking Abortion Services: A Cohort Study. Ann Intern Med.2019;171:238-47. epub 11 June 2019.

6. Gerdts C et al. Side effects, physical health consequences, and mortality associated with abortion and birth after an unwanted pregnancy. Women’s Health Issues 2016;26:55-59.

7. Nobel K et al. Patient-reported experience with discussion of all options during pregnancy options counseling in the US south. Contraception. 2022;106:68-74.

8. Liu N and Ray JG. Short-Term Adverse Outcomes After Mifepristone–Misoprostol Versus Procedural Induced Abortion: A Population-Based Propensity-Weighted Study. Ann Intern Med.2023;176:145-53. epub 3 January 2023.

The following scenario was discussed during a forum at a meeting recently:

Two employees managing the front desk are clock watchers, always the first to leave at 11:59 a.m. for lunch and at 4:59 p.m. for the end of the day no matter what is happening. This leaves the other employees stuck with their work.

I have seen clock watching often enough to know that it is widely practiced, and widely reviled by coworkers and managers alike. Generally, clock watchers — sometimes referred to in modern parlance as “quiet quitters” — radiate a palpable sense of “I don’t want to be here.”

Physicians typically can’t identify with clock watching behavior, because we learned early on that patient-care tasks must be pursued to completion; if that involves working past the usual “quitting time,” so be it. So your first task in dealing with this problem is to determine its cause. The clock watcher label may be unfair. There may be legitimate reasons for certain employees to leave work at precisely 4:59 every day. Perhaps they must pick up children, or they have a second job to get to. The label usually comes from a pattern of consistent, repeated behavior. And if more than one employee is exhibiting the same behavior in the same office, the likelihood of a valid explanation decreases proportionally.

Utamaru Kido/Moment/Getty Images

A common cause of clock watching is a lack of employees’ commitment to their jobs. They don’t see the point in putting in extra effort, so they run out the door as soon as possible. There are many reasons why this might be the case. For example, the workload in your office may be too large to be accomplished in the time available by the number of people you employ. The solution might be to simply hire additional personnel.

Another common cause is a lack of communication between physicians, managers, and lower-level employees. If staffers are raising concerns or potential solutions, and management is not listening to their opinions or ideas, they will stop offering them. Alternatively, other staff members may not be pulling their weight. When there is a large imbalance in the contribution of team members, the higher performers will stop trying.

Over my 40 plus years in practice, I have had my share of clock watchers. I try the best I can not to let employees’ time commitment practices impact my valuation of their work. I always attempt to focus on quality and productivity. It isn’t easy, but I always try to address the issues behind clock watching behavior. As such, I can’t recall ever having to fire anyone for clock watching. Here are some of the strategies that have worked for me over the years:

1. Set clear expectations. Clearly communicate job responsibilities and expectations regarding time management and patient care. Ensure that all staff understand the importance of dedicating the necessary time to each patient, regardless of the time of day.

2. Foster a patient-centered culture. Cultivate a work environment that prioritizes patient care above all. This can help shift the focus from watching the clock to ensuring high-quality patient care.

3. Provide adequate breaks. Ensure that staff schedules include sufficient breaks. Overworked staff are more likely to watch the clock. Adequate rest periods can help alleviate this issue.

4. Offer flexibility where possible. If feasible, offer some degree of scheduling flexibility. This can help staff manage their personal time more effectively, potentially reducing the tendency to watch the clock.

5. Implement time management training. Offer training sessions focused on time management and efficiency. This can help staff manage their duties more effectively, reducing the need to constantly check the time.

6. Encourage open communication. Create an environment where staff feel comfortable discussing their concerns, including issues related to workload and time management. This can help identify and address specific factors contributing to clock watching.

7. Monitor and provide feedback. Regularly monitor staff performance and provide constructive feedback. If clock watching is observed, discuss it directly with the employee, focusing on the impact on patient care and the work environment.

8. Recognize and reward. Acknowledge and reward staff who consistently provide high-quality care and demonstrate effective time management. Recognition can motivate others to adjust their behavior.

9. Evaluate workloads. Regularly assess staff workloads to ensure they are manageable. Overburdened employees are more likely to engage in clock watching.

10. Lead by example. Management should model the behavior they wish to see in their staff. Demonstrating a commitment to patient care and effective time management can set a positive example.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

The following scenario was discussed during a forum at a meeting recently:

Two employees managing the front desk are clock watchers, always the first to leave at 11:59 a.m. for lunch and at 4:59 p.m. for the end of the day no matter what is happening. This leaves the other employees stuck with their work.

I have seen clock watching often enough to know that it is widely practiced, and widely reviled by coworkers and managers alike. Generally, clock watchers — sometimes referred to in modern parlance as “quiet quitters” — radiate a palpable sense of “I don’t want to be here.”

Physicians typically can’t identify with clock watching behavior, because we learned early on that patient-care tasks must be pursued to completion; if that involves working past the usual “quitting time,” so be it. So your first task in dealing with this problem is to determine its cause. The clock watcher label may be unfair. There may be legitimate reasons for certain employees to leave work at precisely 4:59 every day. Perhaps they must pick up children, or they have a second job to get to. The label usually comes from a pattern of consistent, repeated behavior. And if more than one employee is exhibiting the same behavior in the same office, the likelihood of a valid explanation decreases proportionally.

Utamaru Kido/Moment/Getty Images

A common cause of clock watching is a lack of employees’ commitment to their jobs. They don’t see the point in putting in extra effort, so they run out the door as soon as possible. There are many reasons why this might be the case. For example, the workload in your office may be too large to be accomplished in the time available by the number of people you employ. The solution might be to simply hire additional personnel.

Another common cause is a lack of communication between physicians, managers, and lower-level employees. If staffers are raising concerns or potential solutions, and management is not listening to their opinions or ideas, they will stop offering them. Alternatively, other staff members may not be pulling their weight. When there is a large imbalance in the contribution of team members, the higher performers will stop trying.

Over my 40 plus years in practice, I have had my share of clock watchers. I try the best I can not to let employees’ time commitment practices impact my valuation of their work. I always attempt to focus on quality and productivity. It isn’t easy, but I always try to address the issues behind clock watching behavior. As such, I can’t recall ever having to fire anyone for clock watching. Here are some of the strategies that have worked for me over the years:

1. Set clear expectations. Clearly communicate job responsibilities and expectations regarding time management and patient care. Ensure that all staff understand the importance of dedicating the necessary time to each patient, regardless of the time of day.

2. Foster a patient-centered culture. Cultivate a work environment that prioritizes patient care above all. This can help shift the focus from watching the clock to ensuring high-quality patient care.

3. Provide adequate breaks. Ensure that staff schedules include sufficient breaks. Overworked staff are more likely to watch the clock. Adequate rest periods can help alleviate this issue.

4. Offer flexibility where possible. If feasible, offer some degree of scheduling flexibility. This can help staff manage their personal time more effectively, potentially reducing the tendency to watch the clock.

5. Implement time management training. Offer training sessions focused on time management and efficiency. This can help staff manage their duties more effectively, reducing the need to constantly check the time.

6. Encourage open communication. Create an environment where staff feel comfortable discussing their concerns, including issues related to workload and time management. This can help identify and address specific factors contributing to clock watching.

7. Monitor and provide feedback. Regularly monitor staff performance and provide constructive feedback. If clock watching is observed, discuss it directly with the employee, focusing on the impact on patient care and the work environment.

8. Recognize and reward. Acknowledge and reward staff who consistently provide high-quality care and demonstrate effective time management. Recognition can motivate others to adjust their behavior.

9. Evaluate workloads. Regularly assess staff workloads to ensure they are manageable. Overburdened employees are more likely to engage in clock watching.

10. Lead by example. Management should model the behavior they wish to see in their staff. Demonstrating a commitment to patient care and effective time management can set a positive example.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

The following scenario was discussed during a forum at a meeting recently:

Two employees managing the front desk are clock watchers, always the first to leave at 11:59 a.m. for lunch and at 4:59 p.m. for the end of the day no matter what is happening. This leaves the other employees stuck with their work.

I have seen clock watching often enough to know that it is widely practiced, and widely reviled by coworkers and managers alike. Generally, clock watchers — sometimes referred to in modern parlance as “quiet quitters” — radiate a palpable sense of “I don’t want to be here.”

Physicians typically can’t identify with clock watching behavior, because we learned early on that patient-care tasks must be pursued to completion; if that involves working past the usual “quitting time,” so be it. So your first task in dealing with this problem is to determine its cause. The clock watcher label may be unfair. There may be legitimate reasons for certain employees to leave work at precisely 4:59 every day. Perhaps they must pick up children, or they have a second job to get to. The label usually comes from a pattern of consistent, repeated behavior. And if more than one employee is exhibiting the same behavior in the same office, the likelihood of a valid explanation decreases proportionally.

Utamaru Kido/Moment/Getty Images

A common cause of clock watching is a lack of employees’ commitment to their jobs. They don’t see the point in putting in extra effort, so they run out the door as soon as possible. There are many reasons why this might be the case. For example, the workload in your office may be too large to be accomplished in the time available by the number of people you employ. The solution might be to simply hire additional personnel.

Another common cause is a lack of communication between physicians, managers, and lower-level employees. If staffers are raising concerns or potential solutions, and management is not listening to their opinions or ideas, they will stop offering them. Alternatively, other staff members may not be pulling their weight. When there is a large imbalance in the contribution of team members, the higher performers will stop trying.

Over my 40 plus years in practice, I have had my share of clock watchers. I try the best I can not to let employees’ time commitment practices impact my valuation of their work. I always attempt to focus on quality and productivity. It isn’t easy, but I always try to address the issues behind clock watching behavior. As such, I can’t recall ever having to fire anyone for clock watching. Here are some of the strategies that have worked for me over the years:

1. Set clear expectations. Clearly communicate job responsibilities and expectations regarding time management and patient care. Ensure that all staff understand the importance of dedicating the necessary time to each patient, regardless of the time of day.

2. Foster a patient-centered culture. Cultivate a work environment that prioritizes patient care above all. This can help shift the focus from watching the clock to ensuring high-quality patient care.

3. Provide adequate breaks. Ensure that staff schedules include sufficient breaks. Overworked staff are more likely to watch the clock. Adequate rest periods can help alleviate this issue.

4. Offer flexibility where possible. If feasible, offer some degree of scheduling flexibility. This can help staff manage their personal time more effectively, potentially reducing the tendency to watch the clock.

5. Implement time management training. Offer training sessions focused on time management and efficiency. This can help staff manage their duties more effectively, reducing the need to constantly check the time.

6. Encourage open communication. Create an environment where staff feel comfortable discussing their concerns, including issues related to workload and time management. This can help identify and address specific factors contributing to clock watching.

7. Monitor and provide feedback. Regularly monitor staff performance and provide constructive feedback. If clock watching is observed, discuss it directly with the employee, focusing on the impact on patient care and the work environment.

8. Recognize and reward. Acknowledge and reward staff who consistently provide high-quality care and demonstrate effective time management. Recognition can motivate others to adjust their behavior.

9. Evaluate workloads. Regularly assess staff workloads to ensure they are manageable. Overburdened employees are more likely to engage in clock watching.

10. Lead by example. Management should model the behavior they wish to see in their staff. Demonstrating a commitment to patient care and effective time management can set a positive example.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

Recently, Acadia Pharmaceuticals announced it was stopping trials on Nuplazid for indications outside of Parkinson’s disease psychosis.

I was impressed with what I saw in my office. Although I know there’s some controversy over the drug, the majority of studies do show efficacy, and in my little practice I clearly noticed improvements in patients with Parkinson’s disease who’d previously failed the more standard agents (note - I have no financial affiliation with Acadia Pharmaceuticals).

So, as a lay-neurologist, I expected the drug to work for other kinds of psychosis, particularly Alzheimer’s disease. All of us in practice know how much we need new options for that.

But when the clinical trials came, the drug didn’t work. It didn’t work for schizophrenia, either, Finally, Acadia threw in the towel and gave up.

I have no idea what happened. I’m sure others are wondering the same thing. On paper, I’d have thought it would work for Alzheimer’s psychosis, but in the real world it didn’t.

Is psychosis between the two disorders that different, with different neurotransmitter causes? Are the benefits in my patients with Parkinson’s disease really just from my own selection bias? Or is there just a lot we still don’t know?

Medicine, unfortunately, is littered with ideas that should have worked, but either didn’t, or at least aren’t as good as we thought they should have been. Look at the graveyard full of amyloid-targeting drugs. Yeah, I know Leqembi is out there, and donanemab is in the wings, but are they anywhere near as good as we thought they’d be? Not at all.

At the same time, we’ve been waiting for the BTK drugs (not to be confused with a Korean pop band) for multiple sclerosis. They sounded like they were the Next Big Thing.

They may be, but recent data on one of them, evobrutinib, was less than encouraging. Of course, that shouldn’t extrapolate to the group as a whole, but it does leave you wondering why.

Medicine is always improving, but it’s also still a trial-and-error process. Just because something should work doesn’t mean it will, and it may be years before we know why.

It’s just a reminder that, here in 2024, we still have a lot to learn.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Recently, Acadia Pharmaceuticals announced it was stopping trials on Nuplazid for indications outside of Parkinson’s disease psychosis.

I was impressed with what I saw in my office. Although I know there’s some controversy over the drug, the majority of studies do show efficacy, and in my little practice I clearly noticed improvements in patients with Parkinson’s disease who’d previously failed the more standard agents (note - I have no financial affiliation with Acadia Pharmaceuticals).

So, as a lay-neurologist, I expected the drug to work for other kinds of psychosis, particularly Alzheimer’s disease. All of us in practice know how much we need new options for that.

But when the clinical trials came, the drug didn’t work. It didn’t work for schizophrenia, either, Finally, Acadia threw in the towel and gave up.

I have no idea what happened. I’m sure others are wondering the same thing. On paper, I’d have thought it would work for Alzheimer’s psychosis, but in the real world it didn’t.

Is psychosis between the two disorders that different, with different neurotransmitter causes? Are the benefits in my patients with Parkinson’s disease really just from my own selection bias? Or is there just a lot we still don’t know?

Medicine, unfortunately, is littered with ideas that should have worked, but either didn’t, or at least aren’t as good as we thought they should have been. Look at the graveyard full of amyloid-targeting drugs. Yeah, I know Leqembi is out there, and donanemab is in the wings, but are they anywhere near as good as we thought they’d be? Not at all.

At the same time, we’ve been waiting for the BTK drugs (not to be confused with a Korean pop band) for multiple sclerosis. They sounded like they were the Next Big Thing.

They may be, but recent data on one of them, evobrutinib, was less than encouraging. Of course, that shouldn’t extrapolate to the group as a whole, but it does leave you wondering why.

Medicine is always improving, but it’s also still a trial-and-error process. Just because something should work doesn’t mean it will, and it may be years before we know why.

It’s just a reminder that, here in 2024, we still have a lot to learn.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Recently, Acadia Pharmaceuticals announced it was stopping trials on Nuplazid for indications outside of Parkinson’s disease psychosis.

I was impressed with what I saw in my office. Although I know there’s some controversy over the drug, the majority of studies do show efficacy, and in my little practice I clearly noticed improvements in patients with Parkinson’s disease who’d previously failed the more standard agents (note - I have no financial affiliation with Acadia Pharmaceuticals).

So, as a lay-neurologist, I expected the drug to work for other kinds of psychosis, particularly Alzheimer’s disease. All of us in practice know how much we need new options for that.

But when the clinical trials came, the drug didn’t work. It didn’t work for schizophrenia, either, Finally, Acadia threw in the towel and gave up.

I have no idea what happened. I’m sure others are wondering the same thing. On paper, I’d have thought it would work for Alzheimer’s psychosis, but in the real world it didn’t.

Is psychosis between the two disorders that different, with different neurotransmitter causes? Are the benefits in my patients with Parkinson’s disease really just from my own selection bias? Or is there just a lot we still don’t know?

Medicine, unfortunately, is littered with ideas that should have worked, but either didn’t, or at least aren’t as good as we thought they should have been. Look at the graveyard full of amyloid-targeting drugs. Yeah, I know Leqembi is out there, and donanemab is in the wings, but are they anywhere near as good as we thought they’d be? Not at all.

At the same time, we’ve been waiting for the BTK drugs (not to be confused with a Korean pop band) for multiple sclerosis. They sounded like they were the Next Big Thing.

They may be, but recent data on one of them, evobrutinib, was less than encouraging. Of course, that shouldn’t extrapolate to the group as a whole, but it does leave you wondering why.

Medicine is always improving, but it’s also still a trial-and-error process. Just because something should work doesn’t mean it will, and it may be years before we know why.

It’s just a reminder that, here in 2024, we still have a lot to learn.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I had a premed college student with me, a young lady trying to figure out if medicine was for her, and what exactly a neurologist does.

The patient, a gentlemen in his mid-70s, had just left. He had some unusual symptoms. Not implausible, but the kind of case where the answers don’t come together easily. I’d ordered tests for the usual suspects and walked him up front.

When I got back she asked me “what do you think is wrong with him?”

Without thinking I said “I have no idea.” By this time I’d turned to some scheduling messages from my secretary, and didn’t register the student’s surprise for a moment.

I mean, I’m an attending physician. To her I’m the epitome of the career. I got accepted to (and survived) medical school. I made it through residency and fellowship and have almost 26 years of trench-earned experience behind me (hard to believe for me, too, sometimes). And yet I’d just said I didn’t know what was going on.

Reversing the roles and thinking back to the late 1980s, I probably would have felt the same way she did.

Of course “I have no idea” is a bit of unintentional hyperbole. I have some idea, just not a clear answer yet. I’d turned over the possible locations and causes, and so ordered tests to help narrow it down. As one of my attendings in residency used to say, “some days you need a rifle, some days a shotgun” to figure it out.

Being a doctor, even a good one (I hope I am, but not making any guarantees) doesn’t mean you know everything, or have the ability to figure it out immediately. Otherwise we wouldn’t need imaging, labs, and a host of other tests. Sherlock Holmes was a lot of things, but Watson was the doctor.

To those at the beginning of their careers, just like it was to us then, this is a revelation. Aren’t we supposed to know everything? We probably once believed we would, too, someday.

What we learn through training and years of experience isn’t so much the answers to everything as much as the road map on how to get there. What combination of tests and decisions will hopefully lead us to the correct point.

Most of us realize that intuitively at this point, but it can be hard to explain to others. We have patients ask “what do you think is going on?” and we often have no answer other than “not sure yet, but I’ll try to find out.”

We don’t realize how far we’ve come until we see ourselves in someone who’s starting the same journey. And that’s something you can’t teach.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I had a premed college student with me, a young lady trying to figure out if medicine was for her, and what exactly a neurologist does.

The patient, a gentlemen in his mid-70s, had just left. He had some unusual symptoms. Not implausible, but the kind of case where the answers don’t come together easily. I’d ordered tests for the usual suspects and walked him up front.

When I got back she asked me “what do you think is wrong with him?”

Without thinking I said “I have no idea.” By this time I’d turned to some scheduling messages from my secretary, and didn’t register the student’s surprise for a moment.

I mean, I’m an attending physician. To her I’m the epitome of the career. I got accepted to (and survived) medical school. I made it through residency and fellowship and have almost 26 years of trench-earned experience behind me (hard to believe for me, too, sometimes). And yet I’d just said I didn’t know what was going on.

Reversing the roles and thinking back to the late 1980s, I probably would have felt the same way she did.

Of course “I have no idea” is a bit of unintentional hyperbole. I have some idea, just not a clear answer yet. I’d turned over the possible locations and causes, and so ordered tests to help narrow it down. As one of my attendings in residency used to say, “some days you need a rifle, some days a shotgun” to figure it out.

Being a doctor, even a good one (I hope I am, but not making any guarantees) doesn’t mean you know everything, or have the ability to figure it out immediately. Otherwise we wouldn’t need imaging, labs, and a host of other tests. Sherlock Holmes was a lot of things, but Watson was the doctor.

To those at the beginning of their careers, just like it was to us then, this is a revelation. Aren’t we supposed to know everything? We probably once believed we would, too, someday.

What we learn through training and years of experience isn’t so much the answers to everything as much as the road map on how to get there. What combination of tests and decisions will hopefully lead us to the correct point.

Most of us realize that intuitively at this point, but it can be hard to explain to others. We have patients ask “what do you think is going on?” and we often have no answer other than “not sure yet, but I’ll try to find out.”

We don’t realize how far we’ve come until we see ourselves in someone who’s starting the same journey. And that’s something you can’t teach.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I had a premed college student with me, a young lady trying to figure out if medicine was for her, and what exactly a neurologist does.

The patient, a gentlemen in his mid-70s, had just left. He had some unusual symptoms. Not implausible, but the kind of case where the answers don’t come together easily. I’d ordered tests for the usual suspects and walked him up front.

When I got back she asked me “what do you think is wrong with him?”

Without thinking I said “I have no idea.” By this time I’d turned to some scheduling messages from my secretary, and didn’t register the student’s surprise for a moment.

I mean, I’m an attending physician. To her I’m the epitome of the career. I got accepted to (and survived) medical school. I made it through residency and fellowship and have almost 26 years of trench-earned experience behind me (hard to believe for me, too, sometimes). And yet I’d just said I didn’t know what was going on.

Reversing the roles and thinking back to the late 1980s, I probably would have felt the same way she did.

Of course “I have no idea” is a bit of unintentional hyperbole. I have some idea, just not a clear answer yet. I’d turned over the possible locations and causes, and so ordered tests to help narrow it down. As one of my attendings in residency used to say, “some days you need a rifle, some days a shotgun” to figure it out.

Being a doctor, even a good one (I hope I am, but not making any guarantees) doesn’t mean you know everything, or have the ability to figure it out immediately. Otherwise we wouldn’t need imaging, labs, and a host of other tests. Sherlock Holmes was a lot of things, but Watson was the doctor.

To those at the beginning of their careers, just like it was to us then, this is a revelation. Aren’t we supposed to know everything? We probably once believed we would, too, someday.

What we learn through training and years of experience isn’t so much the answers to everything as much as the road map on how to get there. What combination of tests and decisions will hopefully lead us to the correct point.

Most of us realize that intuitively at this point, but it can be hard to explain to others. We have patients ask “what do you think is going on?” and we often have no answer other than “not sure yet, but I’ll try to find out.”

We don’t realize how far we’ve come until we see ourselves in someone who’s starting the same journey. And that’s something you can’t teach.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.