Marcia Frellick

Physicians’ trust in health care system leaders has taken a steep drop during the COVID-19 pandemic, according to a survey conducted by NORC at the University of Chicago on behalf of the American Board of Internal Medicine Foundation.

Survey results, released May 21, indicate that 30% of physicians say their trust in the U.S. health care system and health care leadership has decreased during the pandemic. Only 18% reported an increase in trust.

Physicians, however, have great trust in their fellow clinicians.

In the survey of 600 physicians, 94% said they trust doctors within their practice; 85% trusted doctors outside of their practice; and 89% trusted nurses. That trust increased during the pandemic, with 41% saying their trust in fellow physicians rose and 37% saying their trust in nurses did.

In a separate survey, NORC asked patients about their trust in various aspects of health care. Among 2,069 respondents, a wide majority reported that they trust doctors (84%) and nurses (85%), but only 64% trusted the health care system as a whole. One in three consumers (32%) said their trust in the health care system decreased during the pandemic, compared with 11% who said their trust increased.

The ABIM Foundation released the research findings on May 21 as part of Building Trust, a national campaign that aims to boost trust among patients, clinicians, system leaders, researchers, and others.

Richard J. Baron, MD, president and chief executive officer of the ABIM Foundation, said in an interview, “Clearly there’s lower trust in health care organization leaders and executives, and that’s troubling.

“Science by itself is not enough,” he said. “Becoming trustworthy has to be a core project of everybody in health care.”

Deterioration in physicians’ trust during the pandemic comes in part from failed promises of adequate personal protective equipment and some physicians’ loss of income as a result of the crisis, Dr. Baron said.

He added that the vaccine rollout was very uneven and that policies as to which elective procedures could be performed were handled differently in different parts of the country.

He also noted that, early on, transparency was lacking as to how many COVID patients hospitals were treating, which may have contributed to the decrease in trust in the system.
 

Fear of being known as ‘the COVID hospital’

Hospitals were afraid of being known as “the COVID hospital” and losing patients who were afraid to come there, Dr. Baron said.

He said the COVID-19 epidemic exacerbated problems regarding trust, but that trust has been declining for some time. The Building Trust campaign will focus on solutions in breaches of trust as physicians move increasingly toward being employees of huge systems, according to Dr. Baron.

However, trust works both ways, Dr. Baron notes. Physicians can be champions for their health care system or “throw the system under the bus,” he said.

For example, if a patient complains about the appointment system, clinicians who trust their institutions may say the system usually works and that they will try to make sure the patient has a better experience next time. Clinicians without trust may say they agree that the health care system doesn’t know what it is doing, and patients may further lose confidence when physicians validate their complaint, and patients may then go elsewhere.
 

78% of patients trust primary care doctor

When asked whether they trust their primary care physician, 78% of patients said yes. However, trust in doctors was higher among people who were older (90%), White (82%), or had high income (89%). Among people reporting lower trust, 25% said their physician spends too little time with them, and 14% said their doctor does not know or listen to them.

The survey shows that government agencies have work to do to earn trust. Responses indicate that 43% of physicians said they have “complete trust” in government health care agencies, such as the U.S. Food and Drug Administration and the Centers for Disease Control and Prevention, which is substantially higher than other parts of the health care system. However, trust in agencies declined for 43% of physician respondents and increased for 21%.

Dhruv Khullar, MD, MPP, of the department of health policy and economics at Weill Cornell Medical College in New York, told this news organization the survey results match what he sees anecdotally in medicine – that physicians have been losing trust in the system but not in their colleagues.

He said the sample size of 600 is enough to be influential, though he said he would like to know the response rate, which was not calculated for this survey.

He added that, in large part, physicians’ lack of trust in their systems may come from generally being asked to see more patients and to meet more metrics during the same or shorter periods.

Physicians’ lack of trust in the system can have significant consequences, he said. It can lead to burnout, which has been linked with poorer quality of care and physician turnover, he noted.

COVID-19 led some physicians to wonder whether their system had their best interests at heart, insofar as access to adequate medicines and supplies as well as emotional support were inconsistent, Dr. Khullar said.

He said that to regain trust health care systems need to ask themselves questions in three areas. The first is whether their goals are focused on the best interest of the organization or the best interest of the patient.

“Next is competency,” Dr. Khullar said. “Maybe your motives are right, but are you able to deliver? Are you delivering a good product, whether clinical services or something else?”

The third area is transparency, he said. “Are you going to be honest and forthright in what we’re doing and where we’re going?”

Caroline Pearson, senior vice president of health care strategy for NORC, said the emailed survey was conducted between Dec. 29, 2020, and Feb. 5, 2021, with a health care survey partner that maintains a nationwide panel of physicians across specialties.

She said this report is fairly novel insofar as surveys are more typically conducted regarding patients’ trust of their doctors or of the health care system.

Ms. Pearson said because health care is delivered in teams, understanding the level of trust among the entities helps ensure that care will be delivered effectively and seamlessly with high quality.

“We want our patients to trust our doctors, but we really want doctors to trust each other and trust the hospitals and systems in which they’re working,” she said.

Dr. Baron, Ms. Pearson, and Dr. Khullar report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Physicians’ trust in health care system leaders has taken a steep drop during the COVID-19 pandemic, according to a survey conducted by NORC at the University of Chicago on behalf of the American Board of Internal Medicine Foundation.

Survey results, released May 21, indicate that 30% of physicians say their trust in the U.S. health care system and health care leadership has decreased during the pandemic. Only 18% reported an increase in trust.

Physicians, however, have great trust in their fellow clinicians.

In the survey of 600 physicians, 94% said they trust doctors within their practice; 85% trusted doctors outside of their practice; and 89% trusted nurses. That trust increased during the pandemic, with 41% saying their trust in fellow physicians rose and 37% saying their trust in nurses did.

In a separate survey, NORC asked patients about their trust in various aspects of health care. Among 2,069 respondents, a wide majority reported that they trust doctors (84%) and nurses (85%), but only 64% trusted the health care system as a whole. One in three consumers (32%) said their trust in the health care system decreased during the pandemic, compared with 11% who said their trust increased.

The ABIM Foundation released the research findings on May 21 as part of Building Trust, a national campaign that aims to boost trust among patients, clinicians, system leaders, researchers, and others.

Richard J. Baron, MD, president and chief executive officer of the ABIM Foundation, said in an interview, “Clearly there’s lower trust in health care organization leaders and executives, and that’s troubling.

“Science by itself is not enough,” he said. “Becoming trustworthy has to be a core project of everybody in health care.”

Deterioration in physicians’ trust during the pandemic comes in part from failed promises of adequate personal protective equipment and some physicians’ loss of income as a result of the crisis, Dr. Baron said.

He added that the vaccine rollout was very uneven and that policies as to which elective procedures could be performed were handled differently in different parts of the country.

He also noted that, early on, transparency was lacking as to how many COVID patients hospitals were treating, which may have contributed to the decrease in trust in the system.
 

Fear of being known as ‘the COVID hospital’

Hospitals were afraid of being known as “the COVID hospital” and losing patients who were afraid to come there, Dr. Baron said.

He said the COVID-19 epidemic exacerbated problems regarding trust, but that trust has been declining for some time. The Building Trust campaign will focus on solutions in breaches of trust as physicians move increasingly toward being employees of huge systems, according to Dr. Baron.

However, trust works both ways, Dr. Baron notes. Physicians can be champions for their health care system or “throw the system under the bus,” he said.

For example, if a patient complains about the appointment system, clinicians who trust their institutions may say the system usually works and that they will try to make sure the patient has a better experience next time. Clinicians without trust may say they agree that the health care system doesn’t know what it is doing, and patients may further lose confidence when physicians validate their complaint, and patients may then go elsewhere.
 

78% of patients trust primary care doctor

When asked whether they trust their primary care physician, 78% of patients said yes. However, trust in doctors was higher among people who were older (90%), White (82%), or had high income (89%). Among people reporting lower trust, 25% said their physician spends too little time with them, and 14% said their doctor does not know or listen to them.

The survey shows that government agencies have work to do to earn trust. Responses indicate that 43% of physicians said they have “complete trust” in government health care agencies, such as the U.S. Food and Drug Administration and the Centers for Disease Control and Prevention, which is substantially higher than other parts of the health care system. However, trust in agencies declined for 43% of physician respondents and increased for 21%.

Dhruv Khullar, MD, MPP, of the department of health policy and economics at Weill Cornell Medical College in New York, told this news organization the survey results match what he sees anecdotally in medicine – that physicians have been losing trust in the system but not in their colleagues.

He said the sample size of 600 is enough to be influential, though he said he would like to know the response rate, which was not calculated for this survey.

He added that, in large part, physicians’ lack of trust in their systems may come from generally being asked to see more patients and to meet more metrics during the same or shorter periods.

Physicians’ lack of trust in the system can have significant consequences, he said. It can lead to burnout, which has been linked with poorer quality of care and physician turnover, he noted.

COVID-19 led some physicians to wonder whether their system had their best interests at heart, insofar as access to adequate medicines and supplies as well as emotional support were inconsistent, Dr. Khullar said.

He said that to regain trust health care systems need to ask themselves questions in three areas. The first is whether their goals are focused on the best interest of the organization or the best interest of the patient.

“Next is competency,” Dr. Khullar said. “Maybe your motives are right, but are you able to deliver? Are you delivering a good product, whether clinical services or something else?”

The third area is transparency, he said. “Are you going to be honest and forthright in what we’re doing and where we’re going?”

Caroline Pearson, senior vice president of health care strategy for NORC, said the emailed survey was conducted between Dec. 29, 2020, and Feb. 5, 2021, with a health care survey partner that maintains a nationwide panel of physicians across specialties.

She said this report is fairly novel insofar as surveys are more typically conducted regarding patients’ trust of their doctors or of the health care system.

Ms. Pearson said because health care is delivered in teams, understanding the level of trust among the entities helps ensure that care will be delivered effectively and seamlessly with high quality.

“We want our patients to trust our doctors, but we really want doctors to trust each other and trust the hospitals and systems in which they’re working,” she said.

Dr. Baron, Ms. Pearson, and Dr. Khullar report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Physicians’ trust in health care system leaders has taken a steep drop during the COVID-19 pandemic, according to a survey conducted by NORC at the University of Chicago on behalf of the American Board of Internal Medicine Foundation.

Survey results, released May 21, indicate that 30% of physicians say their trust in the U.S. health care system and health care leadership has decreased during the pandemic. Only 18% reported an increase in trust.

Physicians, however, have great trust in their fellow clinicians.

In the survey of 600 physicians, 94% said they trust doctors within their practice; 85% trusted doctors outside of their practice; and 89% trusted nurses. That trust increased during the pandemic, with 41% saying their trust in fellow physicians rose and 37% saying their trust in nurses did.

In a separate survey, NORC asked patients about their trust in various aspects of health care. Among 2,069 respondents, a wide majority reported that they trust doctors (84%) and nurses (85%), but only 64% trusted the health care system as a whole. One in three consumers (32%) said their trust in the health care system decreased during the pandemic, compared with 11% who said their trust increased.

The ABIM Foundation released the research findings on May 21 as part of Building Trust, a national campaign that aims to boost trust among patients, clinicians, system leaders, researchers, and others.

Richard J. Baron, MD, president and chief executive officer of the ABIM Foundation, said in an interview, “Clearly there’s lower trust in health care organization leaders and executives, and that’s troubling.

“Science by itself is not enough,” he said. “Becoming trustworthy has to be a core project of everybody in health care.”

Deterioration in physicians’ trust during the pandemic comes in part from failed promises of adequate personal protective equipment and some physicians’ loss of income as a result of the crisis, Dr. Baron said.

He added that the vaccine rollout was very uneven and that policies as to which elective procedures could be performed were handled differently in different parts of the country.

He also noted that, early on, transparency was lacking as to how many COVID patients hospitals were treating, which may have contributed to the decrease in trust in the system.
 

Fear of being known as ‘the COVID hospital’

Hospitals were afraid of being known as “the COVID hospital” and losing patients who were afraid to come there, Dr. Baron said.

He said the COVID-19 epidemic exacerbated problems regarding trust, but that trust has been declining for some time. The Building Trust campaign will focus on solutions in breaches of trust as physicians move increasingly toward being employees of huge systems, according to Dr. Baron.

However, trust works both ways, Dr. Baron notes. Physicians can be champions for their health care system or “throw the system under the bus,” he said.

For example, if a patient complains about the appointment system, clinicians who trust their institutions may say the system usually works and that they will try to make sure the patient has a better experience next time. Clinicians without trust may say they agree that the health care system doesn’t know what it is doing, and patients may further lose confidence when physicians validate their complaint, and patients may then go elsewhere.
 

78% of patients trust primary care doctor

When asked whether they trust their primary care physician, 78% of patients said yes. However, trust in doctors was higher among people who were older (90%), White (82%), or had high income (89%). Among people reporting lower trust, 25% said their physician spends too little time with them, and 14% said their doctor does not know or listen to them.

The survey shows that government agencies have work to do to earn trust. Responses indicate that 43% of physicians said they have “complete trust” in government health care agencies, such as the U.S. Food and Drug Administration and the Centers for Disease Control and Prevention, which is substantially higher than other parts of the health care system. However, trust in agencies declined for 43% of physician respondents and increased for 21%.

Dhruv Khullar, MD, MPP, of the department of health policy and economics at Weill Cornell Medical College in New York, told this news organization the survey results match what he sees anecdotally in medicine – that physicians have been losing trust in the system but not in their colleagues.

He said the sample size of 600 is enough to be influential, though he said he would like to know the response rate, which was not calculated for this survey.

He added that, in large part, physicians’ lack of trust in their systems may come from generally being asked to see more patients and to meet more metrics during the same or shorter periods.

Physicians’ lack of trust in the system can have significant consequences, he said. It can lead to burnout, which has been linked with poorer quality of care and physician turnover, he noted.

COVID-19 led some physicians to wonder whether their system had their best interests at heart, insofar as access to adequate medicines and supplies as well as emotional support were inconsistent, Dr. Khullar said.

He said that to regain trust health care systems need to ask themselves questions in three areas. The first is whether their goals are focused on the best interest of the organization or the best interest of the patient.

“Next is competency,” Dr. Khullar said. “Maybe your motives are right, but are you able to deliver? Are you delivering a good product, whether clinical services or something else?”

The third area is transparency, he said. “Are you going to be honest and forthright in what we’re doing and where we’re going?”

Caroline Pearson, senior vice president of health care strategy for NORC, said the emailed survey was conducted between Dec. 29, 2020, and Feb. 5, 2021, with a health care survey partner that maintains a nationwide panel of physicians across specialties.

She said this report is fairly novel insofar as surveys are more typically conducted regarding patients’ trust of their doctors or of the health care system.

Ms. Pearson said because health care is delivered in teams, understanding the level of trust among the entities helps ensure that care will be delivered effectively and seamlessly with high quality.

“We want our patients to trust our doctors, but we really want doctors to trust each other and trust the hospitals and systems in which they’re working,” she said.

Dr. Baron, Ms. Pearson, and Dr. Khullar report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Family physicians again ranked near the bottom in average earnings, but pay increased slightly this year, to $236,000, up from $234,000 last year, even as many practices saw a decrease in hours and patient visits during the pandemic.

Only pediatricians earned less ($221,000) according to the Medscape Family Physician Compensation Report 2021. Plastic surgeons topped this year’s list, at $526,000, followed by orthopedists, at $511,000, and cardiologists, at $459,000.

Family physicians ranked in the middle of specialties in terms of the percentages of physicians who thought they were fairly compensated: 57% of family physicians said they were fairly paid, and 79% of oncologists said they were. Only 44% of infectious disease physicians said they were fairly compensated.

Survey answers indicate, though, that pay isn’t driving family physicians’ satisfaction.

Only 10% of family physicians in the survey said that “making good money at a job I like” was the most rewarding aspect of the job. The top two answers by far were “gratitude/relationships with patients” (chosen by 34%) and “knowing I’m making the world a better place” (27%). Respondents could choose more than one answer.

Despite the small uptick in earnings overall in the specialty, more than one-third of family physicians (36%) reported a decline in compensation in this year’s survey, which included 18,000 responses from physicians in 29 specialties.

Male family physicians continue to be paid much more than their female colleagues, this year 29% more, widening the gap from 26% last year. Overall, men in primary care earned 27% more than their female colleagues, and male specialists earned 33% more.

As for decline in patients seen in some specialties, family physicians are holding their own.

Whereas pediatricians have seen a drop of 18% in patient visits, family physicians saw a decline of just 5%, from an average of 81 to 77 patients per week.
 

Most expect return to normal pay within 3 years

Most family physicians (83%) who incurred financial losses this year said they expect that income will return to normal within 3 years. More than one-third of that group (38%) said they expect compensation to get back to normal in the next year.

Almost all of the family physicians who lost income (91%) pointed the finger at COVID-19. Respondents could choose more than one answer, and 18% said other factors were also to blame.

Family physicians averaged $27,000 in incentive bonuses, higher than those in internal medicine, pediatrics, and psychiatry. Orthopedists had by far the highest bonuses, at $116,000.

For family physicians who received a bonus this year, the amount equaled about 12% of their salary, up from 10% last year. Bonuses are usually based on productivity but can also be tied to patient satisfaction, clinical processes, and other factors.

The number of family physicians who achieved more than three-quarters of their potential annual bonus rose to 61% this year, up from 55%.
 

17 hours a week on administrative tasks

The survey also ranked specialties by the amount of time physicians spent on paperwork and administrative tasks, including participation in professional organizations and clinical reading.

Family physicians fell squarely in the middle, with 17 hours per week spent on such tasks. Infectious disease physicians spent the most time, at 24.2 hours a week, and anesthesiologists spent the least, at 10.1.

Work hours declined for many physicians during the pandemic, and some were furloughed.

But, like most physicians, family physicians are once more working normal hours. They average 49 hours per week, which is slightly more than before the pandemic.

Specialists whose weekly hours are above normal are infectious disease physicians, intensivists, and public health and preventive medicine physicians; all are working 6 to 7 hours a week more than usual, according to the survey responses.

Responses also turned up some uncertainty on the future makeup of patient panels.

Most family physicians (69%) said they would continue to take new and current Medicare/Medicaid patients.

However, close to one-third of family physicians said they would stop treating at least some patients they already have and will not take new ones or haven’t decided yet.

A version of this article first appeared on Medscape.com.

Family physicians again ranked near the bottom in average earnings, but pay increased slightly this year, to $236,000, up from $234,000 last year, even as many practices saw a decrease in hours and patient visits during the pandemic.

Only pediatricians earned less ($221,000) according to the Medscape Family Physician Compensation Report 2021. Plastic surgeons topped this year’s list, at $526,000, followed by orthopedists, at $511,000, and cardiologists, at $459,000.

Family physicians ranked in the middle of specialties in terms of the percentages of physicians who thought they were fairly compensated: 57% of family physicians said they were fairly paid, and 79% of oncologists said they were. Only 44% of infectious disease physicians said they were fairly compensated.

Survey answers indicate, though, that pay isn’t driving family physicians’ satisfaction.

Only 10% of family physicians in the survey said that “making good money at a job I like” was the most rewarding aspect of the job. The top two answers by far were “gratitude/relationships with patients” (chosen by 34%) and “knowing I’m making the world a better place” (27%). Respondents could choose more than one answer.

Despite the small uptick in earnings overall in the specialty, more than one-third of family physicians (36%) reported a decline in compensation in this year’s survey, which included 18,000 responses from physicians in 29 specialties.

Male family physicians continue to be paid much more than their female colleagues, this year 29% more, widening the gap from 26% last year. Overall, men in primary care earned 27% more than their female colleagues, and male specialists earned 33% more.

As for decline in patients seen in some specialties, family physicians are holding their own.

Whereas pediatricians have seen a drop of 18% in patient visits, family physicians saw a decline of just 5%, from an average of 81 to 77 patients per week.
 

Most expect return to normal pay within 3 years

Most family physicians (83%) who incurred financial losses this year said they expect that income will return to normal within 3 years. More than one-third of that group (38%) said they expect compensation to get back to normal in the next year.

Almost all of the family physicians who lost income (91%) pointed the finger at COVID-19. Respondents could choose more than one answer, and 18% said other factors were also to blame.

Family physicians averaged $27,000 in incentive bonuses, higher than those in internal medicine, pediatrics, and psychiatry. Orthopedists had by far the highest bonuses, at $116,000.

For family physicians who received a bonus this year, the amount equaled about 12% of their salary, up from 10% last year. Bonuses are usually based on productivity but can also be tied to patient satisfaction, clinical processes, and other factors.

The number of family physicians who achieved more than three-quarters of their potential annual bonus rose to 61% this year, up from 55%.
 

17 hours a week on administrative tasks

The survey also ranked specialties by the amount of time physicians spent on paperwork and administrative tasks, including participation in professional organizations and clinical reading.

Family physicians fell squarely in the middle, with 17 hours per week spent on such tasks. Infectious disease physicians spent the most time, at 24.2 hours a week, and anesthesiologists spent the least, at 10.1.

Work hours declined for many physicians during the pandemic, and some were furloughed.

But, like most physicians, family physicians are once more working normal hours. They average 49 hours per week, which is slightly more than before the pandemic.

Specialists whose weekly hours are above normal are infectious disease physicians, intensivists, and public health and preventive medicine physicians; all are working 6 to 7 hours a week more than usual, according to the survey responses.

Responses also turned up some uncertainty on the future makeup of patient panels.

Most family physicians (69%) said they would continue to take new and current Medicare/Medicaid patients.

However, close to one-third of family physicians said they would stop treating at least some patients they already have and will not take new ones or haven’t decided yet.

A version of this article first appeared on Medscape.com.

Family physicians again ranked near the bottom in average earnings, but pay increased slightly this year, to $236,000, up from $234,000 last year, even as many practices saw a decrease in hours and patient visits during the pandemic.

Only pediatricians earned less ($221,000) according to the Medscape Family Physician Compensation Report 2021. Plastic surgeons topped this year’s list, at $526,000, followed by orthopedists, at $511,000, and cardiologists, at $459,000.

Family physicians ranked in the middle of specialties in terms of the percentages of physicians who thought they were fairly compensated: 57% of family physicians said they were fairly paid, and 79% of oncologists said they were. Only 44% of infectious disease physicians said they were fairly compensated.

Survey answers indicate, though, that pay isn’t driving family physicians’ satisfaction.

Only 10% of family physicians in the survey said that “making good money at a job I like” was the most rewarding aspect of the job. The top two answers by far were “gratitude/relationships with patients” (chosen by 34%) and “knowing I’m making the world a better place” (27%). Respondents could choose more than one answer.

Despite the small uptick in earnings overall in the specialty, more than one-third of family physicians (36%) reported a decline in compensation in this year’s survey, which included 18,000 responses from physicians in 29 specialties.

Male family physicians continue to be paid much more than their female colleagues, this year 29% more, widening the gap from 26% last year. Overall, men in primary care earned 27% more than their female colleagues, and male specialists earned 33% more.

As for decline in patients seen in some specialties, family physicians are holding their own.

Whereas pediatricians have seen a drop of 18% in patient visits, family physicians saw a decline of just 5%, from an average of 81 to 77 patients per week.
 

Most expect return to normal pay within 3 years

Most family physicians (83%) who incurred financial losses this year said they expect that income will return to normal within 3 years. More than one-third of that group (38%) said they expect compensation to get back to normal in the next year.

Almost all of the family physicians who lost income (91%) pointed the finger at COVID-19. Respondents could choose more than one answer, and 18% said other factors were also to blame.

Family physicians averaged $27,000 in incentive bonuses, higher than those in internal medicine, pediatrics, and psychiatry. Orthopedists had by far the highest bonuses, at $116,000.

For family physicians who received a bonus this year, the amount equaled about 12% of their salary, up from 10% last year. Bonuses are usually based on productivity but can also be tied to patient satisfaction, clinical processes, and other factors.

The number of family physicians who achieved more than three-quarters of their potential annual bonus rose to 61% this year, up from 55%.
 

17 hours a week on administrative tasks

The survey also ranked specialties by the amount of time physicians spent on paperwork and administrative tasks, including participation in professional organizations and clinical reading.

Family physicians fell squarely in the middle, with 17 hours per week spent on such tasks. Infectious disease physicians spent the most time, at 24.2 hours a week, and anesthesiologists spent the least, at 10.1.

Work hours declined for many physicians during the pandemic, and some were furloughed.

But, like most physicians, family physicians are once more working normal hours. They average 49 hours per week, which is slightly more than before the pandemic.

Specialists whose weekly hours are above normal are infectious disease physicians, intensivists, and public health and preventive medicine physicians; all are working 6 to 7 hours a week more than usual, according to the survey responses.

Responses also turned up some uncertainty on the future makeup of patient panels.

Most family physicians (69%) said they would continue to take new and current Medicare/Medicaid patients.

However, close to one-third of family physicians said they would stop treating at least some patients they already have and will not take new ones or haven’t decided yet.

A version of this article first appeared on Medscape.com.

As the number of patients struggling with lingering effects of COVID-19 grows, much of the diagnosis and symptom management will fall on primary care, experts say.

“It could be as many as 5% to 10% who are still having symptoms at 12 weeks. Those numbers are higher if you’re talking about patients who had been hospitalized with COVID-19,” Russ Phillips, MD, director of the Center for Primary Care at Harvard Medical School, Boston, said in an interview.

A recent study from the Centers for Disease Control and Prevention and Kaiser Permanente Georgia found that among 3,171 nonhospitalized adult patients with COVID-19, 69% had one or more outpatient visits 28 to 180 days after the diagnosis. Two-thirds had a visit for a new primary diagnosis, and about one-third had a new specialist visit. Symptom diagnoses included cough, shortness of breath, chest or throat pain, and fatigue.

These visits have come while cases of acute COVID continue to occur, and there has been an increase in patients returning to primary care after avoiding it while the pandemic surged. For these patients, delay in seeking care has often led a worsening of chronic conditions.

Dr. Phillips pointed to a shortcoming in primary care that will need to be addressed with regard to long-COVID: “We don’t have good systems to follow patients and their symptoms over time.”

Long-COVID will require that kind of care, but current payment systems don’t support proactively reaching out to patients to track them over time, he noted.

“We do a good job of identifying these issues for patients who come in, but it’s the patients who don’t that we worry about the most,” he said.

Dr. Phillips provided examples of the kind of management plans needed to improve outcomes for patients with long-COVID. In anticoagulation clinics, patients who receive blood thinners are monitored closely, and in mental health care, patients with depression are linked with social workers and are monitored regularly.

“Around COVID, those management plans are in their infancy,” he said.

John Brooks, MD, chief medical officer for the CDC’s COVID-19 response, testified in a congressional hearing at the end of April that interim guidance concerning protocols for long-COVID in primary care are forthcoming. He also noted that the CDC is working closely with the Centers for Medicare & Medicaid Services to develop medical coding for long-COVID.

In the meantime, Dr. Phillips said, one strategy is to have patients self-monitor their condition and relay results to primary care physicians electronically.

As an example, Dr. Phillips described a patient with long-COVID who was receiving supplemental oxygen and who wanted to resume her exercise regimen.

She checked her own oxygen saturation levels before and during exercise and reported the levels every few days through their patient portal.

“Very slowly we were able to cut down on her oxygen and increase her exercise capacity until she no longer needed oxygen and could go back to her usual activities of daily living,” he said.

Nurse practitioners, social workers, and other nonphysician care team members may be increasingly relied upon to provide care for long-COVID patients as well, he said.

Additionally, telehealth, which is currently reimbursed the same way as in-person visits are, enables easier access for checking in with patients, he said.
 

Empathy and listening needed

Sabrina Assoumou, MD, MPH, assistant professor of medicine at Boston University, told this news organization that it will be crucial to address health care disparities as long-COVID cases mount.

COVID disproportionately affects communities of color, and it stands to reason that this will be the case for long-COVID as well, she said. Diversifying the workforce will be vital, inasmuch as diagnosis may depend on how well a physician listens to patients as they describe their symptoms, continued Dr. Assoumou, whose primary care practice centers on HIV patients.

The symptoms of long-COVID are vague, she explained, and include brain fog, fatigue, and shortness of breath, and it takes longer to diagnose than many conditions.

Dr. Assoumou said some people were never tested for COVID and never received a diagnosis, yet they are now experiencing the extended effects.

“Long-COVID will force us to go back to the basics – like really listening to our patients,” she said. “We’re definitely going to need to be more empathetic.”
 

No large influx yet

Charles Vega, MD, health sciences clinical professor of family medicine at the University of California, Irvine, said he is skeptical that the primary care system will be overwhelmed with long-COVID cases.

Dr. Vega is a family physician working in the largest safety net clinic in Orange County, California. About 90% of his patients are LatinX, a population disproportionately burdened by COVID, yet he hasn’t seen a surge in long-COVID cases.

He said that may be because patients know there isn’t a treatment for long-COVID. They are well connected through online forums such as Body Politic COVID-19 Support Group and may not feel they need to see a doctor.

“It wasn’t scientists finding [long-COVID], it was patients who developed this disease model themselves,” he said. “That’s where most of the data sharing is.”

Yet, for long-COVID patients who do need care, primary care is the best home for them, Dr. Vega said.

He said the most common symptoms he sees are fatigue and poor activity tolerance. “They get winded going to the bathroom,” he said.

The most difficult symptom is dyspnea, he said. Patients describe being breathless, but it’s not bad enough to qualify for supplemental oxygen.

“Being breathless is a pretty desperate thing and hurts quality of life,” he said.

Most patients describe general malaise.

Care for long-COVID will require medical care and mental health care, Dr. Vega notes. Primary care is already set up to screen and to coordinate care with the appropriate provider.

“I think there’s a role for specialists, but primary care has to be involved,” he said.

Dr. Phillips, Dr. Assoumou, and Dr. Vega report no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

As the number of patients struggling with lingering effects of COVID-19 grows, much of the diagnosis and symptom management will fall on primary care, experts say.

“It could be as many as 5% to 10% who are still having symptoms at 12 weeks. Those numbers are higher if you’re talking about patients who had been hospitalized with COVID-19,” Russ Phillips, MD, director of the Center for Primary Care at Harvard Medical School, Boston, said in an interview.

A recent study from the Centers for Disease Control and Prevention and Kaiser Permanente Georgia found that among 3,171 nonhospitalized adult patients with COVID-19, 69% had one or more outpatient visits 28 to 180 days after the diagnosis. Two-thirds had a visit for a new primary diagnosis, and about one-third had a new specialist visit. Symptom diagnoses included cough, shortness of breath, chest or throat pain, and fatigue.

These visits have come while cases of acute COVID continue to occur, and there has been an increase in patients returning to primary care after avoiding it while the pandemic surged. For these patients, delay in seeking care has often led a worsening of chronic conditions.

Dr. Phillips pointed to a shortcoming in primary care that will need to be addressed with regard to long-COVID: “We don’t have good systems to follow patients and their symptoms over time.”

Long-COVID will require that kind of care, but current payment systems don’t support proactively reaching out to patients to track them over time, he noted.

“We do a good job of identifying these issues for patients who come in, but it’s the patients who don’t that we worry about the most,” he said.

Dr. Phillips provided examples of the kind of management plans needed to improve outcomes for patients with long-COVID. In anticoagulation clinics, patients who receive blood thinners are monitored closely, and in mental health care, patients with depression are linked with social workers and are monitored regularly.

“Around COVID, those management plans are in their infancy,” he said.

John Brooks, MD, chief medical officer for the CDC’s COVID-19 response, testified in a congressional hearing at the end of April that interim guidance concerning protocols for long-COVID in primary care are forthcoming. He also noted that the CDC is working closely with the Centers for Medicare & Medicaid Services to develop medical coding for long-COVID.

In the meantime, Dr. Phillips said, one strategy is to have patients self-monitor their condition and relay results to primary care physicians electronically.

As an example, Dr. Phillips described a patient with long-COVID who was receiving supplemental oxygen and who wanted to resume her exercise regimen.

She checked her own oxygen saturation levels before and during exercise and reported the levels every few days through their patient portal.

“Very slowly we were able to cut down on her oxygen and increase her exercise capacity until she no longer needed oxygen and could go back to her usual activities of daily living,” he said.

Nurse practitioners, social workers, and other nonphysician care team members may be increasingly relied upon to provide care for long-COVID patients as well, he said.

Additionally, telehealth, which is currently reimbursed the same way as in-person visits are, enables easier access for checking in with patients, he said.
 

Empathy and listening needed

Sabrina Assoumou, MD, MPH, assistant professor of medicine at Boston University, told this news organization that it will be crucial to address health care disparities as long-COVID cases mount.

COVID disproportionately affects communities of color, and it stands to reason that this will be the case for long-COVID as well, she said. Diversifying the workforce will be vital, inasmuch as diagnosis may depend on how well a physician listens to patients as they describe their symptoms, continued Dr. Assoumou, whose primary care practice centers on HIV patients.

The symptoms of long-COVID are vague, she explained, and include brain fog, fatigue, and shortness of breath, and it takes longer to diagnose than many conditions.

Dr. Assoumou said some people were never tested for COVID and never received a diagnosis, yet they are now experiencing the extended effects.

“Long-COVID will force us to go back to the basics – like really listening to our patients,” she said. “We’re definitely going to need to be more empathetic.”
 

No large influx yet

Charles Vega, MD, health sciences clinical professor of family medicine at the University of California, Irvine, said he is skeptical that the primary care system will be overwhelmed with long-COVID cases.

Dr. Vega is a family physician working in the largest safety net clinic in Orange County, California. About 90% of his patients are LatinX, a population disproportionately burdened by COVID, yet he hasn’t seen a surge in long-COVID cases.

He said that may be because patients know there isn’t a treatment for long-COVID. They are well connected through online forums such as Body Politic COVID-19 Support Group and may not feel they need to see a doctor.

“It wasn’t scientists finding [long-COVID], it was patients who developed this disease model themselves,” he said. “That’s where most of the data sharing is.”

Yet, for long-COVID patients who do need care, primary care is the best home for them, Dr. Vega said.

He said the most common symptoms he sees are fatigue and poor activity tolerance. “They get winded going to the bathroom,” he said.

The most difficult symptom is dyspnea, he said. Patients describe being breathless, but it’s not bad enough to qualify for supplemental oxygen.

“Being breathless is a pretty desperate thing and hurts quality of life,” he said.

Most patients describe general malaise.

Care for long-COVID will require medical care and mental health care, Dr. Vega notes. Primary care is already set up to screen and to coordinate care with the appropriate provider.

“I think there’s a role for specialists, but primary care has to be involved,” he said.

Dr. Phillips, Dr. Assoumou, and Dr. Vega report no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

As the number of patients struggling with lingering effects of COVID-19 grows, much of the diagnosis and symptom management will fall on primary care, experts say.

“It could be as many as 5% to 10% who are still having symptoms at 12 weeks. Those numbers are higher if you’re talking about patients who had been hospitalized with COVID-19,” Russ Phillips, MD, director of the Center for Primary Care at Harvard Medical School, Boston, said in an interview.

A recent study from the Centers for Disease Control and Prevention and Kaiser Permanente Georgia found that among 3,171 nonhospitalized adult patients with COVID-19, 69% had one or more outpatient visits 28 to 180 days after the diagnosis. Two-thirds had a visit for a new primary diagnosis, and about one-third had a new specialist visit. Symptom diagnoses included cough, shortness of breath, chest or throat pain, and fatigue.

These visits have come while cases of acute COVID continue to occur, and there has been an increase in patients returning to primary care after avoiding it while the pandemic surged. For these patients, delay in seeking care has often led a worsening of chronic conditions.

Dr. Phillips pointed to a shortcoming in primary care that will need to be addressed with regard to long-COVID: “We don’t have good systems to follow patients and their symptoms over time.”

Long-COVID will require that kind of care, but current payment systems don’t support proactively reaching out to patients to track them over time, he noted.

“We do a good job of identifying these issues for patients who come in, but it’s the patients who don’t that we worry about the most,” he said.

Dr. Phillips provided examples of the kind of management plans needed to improve outcomes for patients with long-COVID. In anticoagulation clinics, patients who receive blood thinners are monitored closely, and in mental health care, patients with depression are linked with social workers and are monitored regularly.

“Around COVID, those management plans are in their infancy,” he said.

John Brooks, MD, chief medical officer for the CDC’s COVID-19 response, testified in a congressional hearing at the end of April that interim guidance concerning protocols for long-COVID in primary care are forthcoming. He also noted that the CDC is working closely with the Centers for Medicare & Medicaid Services to develop medical coding for long-COVID.

In the meantime, Dr. Phillips said, one strategy is to have patients self-monitor their condition and relay results to primary care physicians electronically.

As an example, Dr. Phillips described a patient with long-COVID who was receiving supplemental oxygen and who wanted to resume her exercise regimen.

She checked her own oxygen saturation levels before and during exercise and reported the levels every few days through their patient portal.

“Very slowly we were able to cut down on her oxygen and increase her exercise capacity until she no longer needed oxygen and could go back to her usual activities of daily living,” he said.

Nurse practitioners, social workers, and other nonphysician care team members may be increasingly relied upon to provide care for long-COVID patients as well, he said.

Additionally, telehealth, which is currently reimbursed the same way as in-person visits are, enables easier access for checking in with patients, he said.
 

Empathy and listening needed

Sabrina Assoumou, MD, MPH, assistant professor of medicine at Boston University, told this news organization that it will be crucial to address health care disparities as long-COVID cases mount.

COVID disproportionately affects communities of color, and it stands to reason that this will be the case for long-COVID as well, she said. Diversifying the workforce will be vital, inasmuch as diagnosis may depend on how well a physician listens to patients as they describe their symptoms, continued Dr. Assoumou, whose primary care practice centers on HIV patients.

The symptoms of long-COVID are vague, she explained, and include brain fog, fatigue, and shortness of breath, and it takes longer to diagnose than many conditions.

Dr. Assoumou said some people were never tested for COVID and never received a diagnosis, yet they are now experiencing the extended effects.

“Long-COVID will force us to go back to the basics – like really listening to our patients,” she said. “We’re definitely going to need to be more empathetic.”
 

No large influx yet

Charles Vega, MD, health sciences clinical professor of family medicine at the University of California, Irvine, said he is skeptical that the primary care system will be overwhelmed with long-COVID cases.

Dr. Vega is a family physician working in the largest safety net clinic in Orange County, California. About 90% of his patients are LatinX, a population disproportionately burdened by COVID, yet he hasn’t seen a surge in long-COVID cases.

He said that may be because patients know there isn’t a treatment for long-COVID. They are well connected through online forums such as Body Politic COVID-19 Support Group and may not feel they need to see a doctor.

“It wasn’t scientists finding [long-COVID], it was patients who developed this disease model themselves,” he said. “That’s where most of the data sharing is.”

Yet, for long-COVID patients who do need care, primary care is the best home for them, Dr. Vega said.

He said the most common symptoms he sees are fatigue and poor activity tolerance. “They get winded going to the bathroom,” he said.

The most difficult symptom is dyspnea, he said. Patients describe being breathless, but it’s not bad enough to qualify for supplemental oxygen.

“Being breathless is a pretty desperate thing and hurts quality of life,” he said.

Most patients describe general malaise.

Care for long-COVID will require medical care and mental health care, Dr. Vega notes. Primary care is already set up to screen and to coordinate care with the appropriate provider.

“I think there’s a role for specialists, but primary care has to be involved,” he said.

Dr. Phillips, Dr. Assoumou, and Dr. Vega report no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Infectious disease physicians are among the doctors carrying the largest burdens in the COVID-19 pandemic.

Perhaps not surprisingly, they were the specialists least likely to feel they were fairly compensated in the Medscape Infectious Diseases Physician Compensation Report 2021.

Only 44% said the pay was fair (down from 51% the prior year) compared with those at the high end – 79% in oncology, 69% in psychiatry, and 68% in plastic surgery who answered that way.

Income, which averaged $245,000, varied little from the previous year overall, according to the survey, but nearly one-third of ID physicians saw a decline in pay.

Again this year, ID physicians ranked near the bottom on the compensation spectrum. Pediatricians were lowest paid at $221,000. Plastic surgeons topped the chart at $526,000, followed by orthopedists at $511,000.

At the same time, the ID specialty is facing increasing shortages, a gap made even more visible in the pandemic. Medscape reported last year that nearly 80% of U.S. counties have no infectious disease specialists.

Thomas File Jr., MD, last year’s president of the Infectious Diseases Society of America, emphasized that COVID-19 is not the only threat that ID specialists have had to deal with or will have. He cited the threats that Zika and SARS posed in past years.

“COVID-19 illustrates the need for more trained ID specialists, because we know we’re going to be seeing more outbreaks in the future,” he said in an interview at the onset of the pandemic in March 2020.
 

Longer hours in pandemic

ID physicians’ hours generally increased during the pandemic, and they remain inflated by 8 hours per week (60 compared with 52 prepandemic) as the nation struggles to manage continuing COVID-19 infections. Physicians in critical care and public health and preventive medicine are seeing heavier workloads as well, by an average of 6-7 hours per week.

At the same time, ID physicians spent the most time of physicians in all specialties on paperwork and administrative tasks. Those tasks, which include electronic health record entry and clinical reading, took ID doctors 24.2 hours a week, more the twice the hours spent by those in anesthesiology (10.1), ophthalmology (10.3), and radiology (11.6).

The 24.2 hours was a substantial increase from the last report, when ID physicians said they spent 18.5 hours on the tasks.

The survey asked about the most challenging part of the job. ID physicians reported “long hours” as number one followed by “having so many rules and regulations.”

Only 4% said the danger or risk associated with treating COVID-19 patients was the most challenging part.

The top two aspects of their work they deemed most rewarding were “being very good at what I do” (chosen by 33%) and “knowing that I’m making the world a better place” (31%).
 

Patient volume up 17%

ID physicians reported seeing 78 patients per week in this report compared with 66 prepandemic, a 17% increase. Conversely, pediatricians saw an 18% drop in patient visits, followed by dermatologists, orthopedists and otolaryngologists (all down about 15%).

Despite the challenges and dissatisfaction with pay, the great majority of  ID physicians said they would choose both medicine (83%) and their specialty (89%, up from 85% last year) again.
 

A version of this article first appeared on Medscape.com.

Infectious disease physicians are among the doctors carrying the largest burdens in the COVID-19 pandemic.

Perhaps not surprisingly, they were the specialists least likely to feel they were fairly compensated in the Medscape Infectious Diseases Physician Compensation Report 2021.

Only 44% said the pay was fair (down from 51% the prior year) compared with those at the high end – 79% in oncology, 69% in psychiatry, and 68% in plastic surgery who answered that way.

Income, which averaged $245,000, varied little from the previous year overall, according to the survey, but nearly one-third of ID physicians saw a decline in pay.

Again this year, ID physicians ranked near the bottom on the compensation spectrum. Pediatricians were lowest paid at $221,000. Plastic surgeons topped the chart at $526,000, followed by orthopedists at $511,000.

At the same time, the ID specialty is facing increasing shortages, a gap made even more visible in the pandemic. Medscape reported last year that nearly 80% of U.S. counties have no infectious disease specialists.

Thomas File Jr., MD, last year’s president of the Infectious Diseases Society of America, emphasized that COVID-19 is not the only threat that ID specialists have had to deal with or will have. He cited the threats that Zika and SARS posed in past years.

“COVID-19 illustrates the need for more trained ID specialists, because we know we’re going to be seeing more outbreaks in the future,” he said in an interview at the onset of the pandemic in March 2020.
 

Longer hours in pandemic

ID physicians’ hours generally increased during the pandemic, and they remain inflated by 8 hours per week (60 compared with 52 prepandemic) as the nation struggles to manage continuing COVID-19 infections. Physicians in critical care and public health and preventive medicine are seeing heavier workloads as well, by an average of 6-7 hours per week.

At the same time, ID physicians spent the most time of physicians in all specialties on paperwork and administrative tasks. Those tasks, which include electronic health record entry and clinical reading, took ID doctors 24.2 hours a week, more the twice the hours spent by those in anesthesiology (10.1), ophthalmology (10.3), and radiology (11.6).

The 24.2 hours was a substantial increase from the last report, when ID physicians said they spent 18.5 hours on the tasks.

The survey asked about the most challenging part of the job. ID physicians reported “long hours” as number one followed by “having so many rules and regulations.”

Only 4% said the danger or risk associated with treating COVID-19 patients was the most challenging part.

The top two aspects of their work they deemed most rewarding were “being very good at what I do” (chosen by 33%) and “knowing that I’m making the world a better place” (31%).
 

Patient volume up 17%

ID physicians reported seeing 78 patients per week in this report compared with 66 prepandemic, a 17% increase. Conversely, pediatricians saw an 18% drop in patient visits, followed by dermatologists, orthopedists and otolaryngologists (all down about 15%).

Despite the challenges and dissatisfaction with pay, the great majority of  ID physicians said they would choose both medicine (83%) and their specialty (89%, up from 85% last year) again.
 

A version of this article first appeared on Medscape.com.

Infectious disease physicians are among the doctors carrying the largest burdens in the COVID-19 pandemic.

Perhaps not surprisingly, they were the specialists least likely to feel they were fairly compensated in the Medscape Infectious Diseases Physician Compensation Report 2021.

Only 44% said the pay was fair (down from 51% the prior year) compared with those at the high end – 79% in oncology, 69% in psychiatry, and 68% in plastic surgery who answered that way.

Income, which averaged $245,000, varied little from the previous year overall, according to the survey, but nearly one-third of ID physicians saw a decline in pay.

Again this year, ID physicians ranked near the bottom on the compensation spectrum. Pediatricians were lowest paid at $221,000. Plastic surgeons topped the chart at $526,000, followed by orthopedists at $511,000.

At the same time, the ID specialty is facing increasing shortages, a gap made even more visible in the pandemic. Medscape reported last year that nearly 80% of U.S. counties have no infectious disease specialists.

Thomas File Jr., MD, last year’s president of the Infectious Diseases Society of America, emphasized that COVID-19 is not the only threat that ID specialists have had to deal with or will have. He cited the threats that Zika and SARS posed in past years.

“COVID-19 illustrates the need for more trained ID specialists, because we know we’re going to be seeing more outbreaks in the future,” he said in an interview at the onset of the pandemic in March 2020.
 

Longer hours in pandemic

ID physicians’ hours generally increased during the pandemic, and they remain inflated by 8 hours per week (60 compared with 52 prepandemic) as the nation struggles to manage continuing COVID-19 infections. Physicians in critical care and public health and preventive medicine are seeing heavier workloads as well, by an average of 6-7 hours per week.

At the same time, ID physicians spent the most time of physicians in all specialties on paperwork and administrative tasks. Those tasks, which include electronic health record entry and clinical reading, took ID doctors 24.2 hours a week, more the twice the hours spent by those in anesthesiology (10.1), ophthalmology (10.3), and radiology (11.6).

The 24.2 hours was a substantial increase from the last report, when ID physicians said they spent 18.5 hours on the tasks.

The survey asked about the most challenging part of the job. ID physicians reported “long hours” as number one followed by “having so many rules and regulations.”

Only 4% said the danger or risk associated with treating COVID-19 patients was the most challenging part.

The top two aspects of their work they deemed most rewarding were “being very good at what I do” (chosen by 33%) and “knowing that I’m making the world a better place” (31%).
 

Patient volume up 17%

ID physicians reported seeing 78 patients per week in this report compared with 66 prepandemic, a 17% increase. Conversely, pediatricians saw an 18% drop in patient visits, followed by dermatologists, orthopedists and otolaryngologists (all down about 15%).

Despite the challenges and dissatisfaction with pay, the great majority of  ID physicians said they would choose both medicine (83%) and their specialty (89%, up from 85% last year) again.
 

A version of this article first appeared on Medscape.com.

Physicians in several specialties continue to see sharp drops in patient visits, but for internists, the numbers have rebounded since the beginning of the pandemic.

Internists are seeing only 3% fewer patients than they did before the COVID-19 pandemic (72 per week on average now vs. 74 before the pandemic). Comparatively, for pediatricians, patient volume remains down 18%. Dermatologists, otolaryngologists, and orthopedists report that visits are down by about 15%.

The number of hours worked also rebounded for internists. In fact, some report working slightly more hours now than they did before the pandemic (52 hours a week, up from 50).

Pay for internists continues to hover near the bottom of the scale among specialties. In this year’s Medscape Internist Compensation Report 2021, internists averaged $248,000, down from $251,000 last year. Pediatricians were the lowest paid, at $221,000, followed by family physicians, at $236,000. Plastic surgeons made the most, at $526,000, followed by orthopedists, at $511,000.

It helped to be self-employed. These internists made $276,000 on average, compared with $238,000 for their employed counterparts.
 

Half say pay is fair

Internists are also near the bottom among specialists who feel they are fairly compensated. As in last year’s survey, just more than half of internists (52%) said they felt that they were fairly paid this year. By comparison, 79% of oncologists reported they were fairly compensated, which is on the high end regarding satisfaction, but only 44% of infectious diseases specialists felt that way.

Some indicators in the survey responses may help explain the dissatisfaction.

Internists are near the top in time spent on paperwork. On average, they spent 19.7 hours on paperwork and administration this year, up slightly from 18.5 last year. Infectious disease physicians spent the most time on those tasks (24.2 hours a week), and anesthesiologists spent the fewest, at 10.1 hours per week.

Administrative work was among many frustrations internists reported. The following are the top five most challenging aspects of the job, according to the respondents:

• Having so many rules and regulations (24%)
• Having to work long hours (16%)
• Dealing with difficult patients (16%)
• Working with electronic health records systems (11%)
• Danger/risk associated with treating COVID-19 patients (10%)

Conversely, the most rewarding aspects were “gratitude/relationships with patients” (31%); “knowing that I’m making the world a better place” (26%); and “being very good at what I do” (20%).
 

More than one-third lost income

More than one-third of internists (36%) reported that they lost some income during the past year.

Among those who lost income, 81% said they expect income to return to prepandemic levels within 3 years. Half of that group expected the rebound would come within the next year.

Slightly more than one-third of internists said they would participate in the merit-based incentive payment system (MIPS), and 12% said they would participate in advanced alternative payment models. The rest either said they would participate in neither, or they hadn’t decided.

“The stakes for the Quality Payment Program – the program that incorporates MIPS – are high, with a 9% penalty applied to all Medicare reimbursement for failure to participate,” says Elizabeth Woodcock, MBA, CPC, president of the physician practice consulting firm Woodcock and Associates, in Atlanta, Georgia.

“With margins already slim,” she told this news organization, “most physicians can’t afford this massive penalty.”

If they could choose again, most internists (76%) said they would choose medicine, which was almost the same number as physicians overall who would pick medicine again. Oncologists (88%) and ophthalmologists (87%) were the specialists most likely to choose medicine again. Those in physical medicine and rehabilitation were least likely to choose medicine again, at 67%.

But asked about their specialty, internists’ enthusiasm decreased. Only 68% said that they would make that same choice again.

That was up considerably, however, from the 2015 survey: For that year, only 25% said they would choose internal medicine again.

A version of this article first appeared on Medscape.com.

Physicians in several specialties continue to see sharp drops in patient visits, but for internists, the numbers have rebounded since the beginning of the pandemic.

Internists are seeing only 3% fewer patients than they did before the COVID-19 pandemic (72 per week on average now vs. 74 before the pandemic). Comparatively, for pediatricians, patient volume remains down 18%. Dermatologists, otolaryngologists, and orthopedists report that visits are down by about 15%.

The number of hours worked also rebounded for internists. In fact, some report working slightly more hours now than they did before the pandemic (52 hours a week, up from 50).

Pay for internists continues to hover near the bottom of the scale among specialties. In this year’s Medscape Internist Compensation Report 2021, internists averaged $248,000, down from $251,000 last year. Pediatricians were the lowest paid, at $221,000, followed by family physicians, at $236,000. Plastic surgeons made the most, at $526,000, followed by orthopedists, at $511,000.

It helped to be self-employed. These internists made $276,000 on average, compared with $238,000 for their employed counterparts.
 

Half say pay is fair

Internists are also near the bottom among specialists who feel they are fairly compensated. As in last year’s survey, just more than half of internists (52%) said they felt that they were fairly paid this year. By comparison, 79% of oncologists reported they were fairly compensated, which is on the high end regarding satisfaction, but only 44% of infectious diseases specialists felt that way.

Some indicators in the survey responses may help explain the dissatisfaction.

Internists are near the top in time spent on paperwork. On average, they spent 19.7 hours on paperwork and administration this year, up slightly from 18.5 last year. Infectious disease physicians spent the most time on those tasks (24.2 hours a week), and anesthesiologists spent the fewest, at 10.1 hours per week.

Administrative work was among many frustrations internists reported. The following are the top five most challenging aspects of the job, according to the respondents:

• Having so many rules and regulations (24%)
• Having to work long hours (16%)
• Dealing with difficult patients (16%)
• Working with electronic health records systems (11%)
• Danger/risk associated with treating COVID-19 patients (10%)

Conversely, the most rewarding aspects were “gratitude/relationships with patients” (31%); “knowing that I’m making the world a better place” (26%); and “being very good at what I do” (20%).
 

More than one-third lost income

More than one-third of internists (36%) reported that they lost some income during the past year.

Among those who lost income, 81% said they expect income to return to prepandemic levels within 3 years. Half of that group expected the rebound would come within the next year.

Slightly more than one-third of internists said they would participate in the merit-based incentive payment system (MIPS), and 12% said they would participate in advanced alternative payment models. The rest either said they would participate in neither, or they hadn’t decided.

“The stakes for the Quality Payment Program – the program that incorporates MIPS – are high, with a 9% penalty applied to all Medicare reimbursement for failure to participate,” says Elizabeth Woodcock, MBA, CPC, president of the physician practice consulting firm Woodcock and Associates, in Atlanta, Georgia.

“With margins already slim,” she told this news organization, “most physicians can’t afford this massive penalty.”

If they could choose again, most internists (76%) said they would choose medicine, which was almost the same number as physicians overall who would pick medicine again. Oncologists (88%) and ophthalmologists (87%) were the specialists most likely to choose medicine again. Those in physical medicine and rehabilitation were least likely to choose medicine again, at 67%.

But asked about their specialty, internists’ enthusiasm decreased. Only 68% said that they would make that same choice again.

That was up considerably, however, from the 2015 survey: For that year, only 25% said they would choose internal medicine again.

A version of this article first appeared on Medscape.com.

Physicians in several specialties continue to see sharp drops in patient visits, but for internists, the numbers have rebounded since the beginning of the pandemic.

Internists are seeing only 3% fewer patients than they did before the COVID-19 pandemic (72 per week on average now vs. 74 before the pandemic). Comparatively, for pediatricians, patient volume remains down 18%. Dermatologists, otolaryngologists, and orthopedists report that visits are down by about 15%.

The number of hours worked also rebounded for internists. In fact, some report working slightly more hours now than they did before the pandemic (52 hours a week, up from 50).

Pay for internists continues to hover near the bottom of the scale among specialties. In this year’s Medscape Internist Compensation Report 2021, internists averaged $248,000, down from $251,000 last year. Pediatricians were the lowest paid, at $221,000, followed by family physicians, at $236,000. Plastic surgeons made the most, at $526,000, followed by orthopedists, at $511,000.

It helped to be self-employed. These internists made $276,000 on average, compared with $238,000 for their employed counterparts.
 

Half say pay is fair

Internists are also near the bottom among specialists who feel they are fairly compensated. As in last year’s survey, just more than half of internists (52%) said they felt that they were fairly paid this year. By comparison, 79% of oncologists reported they were fairly compensated, which is on the high end regarding satisfaction, but only 44% of infectious diseases specialists felt that way.

Some indicators in the survey responses may help explain the dissatisfaction.

Internists are near the top in time spent on paperwork. On average, they spent 19.7 hours on paperwork and administration this year, up slightly from 18.5 last year. Infectious disease physicians spent the most time on those tasks (24.2 hours a week), and anesthesiologists spent the fewest, at 10.1 hours per week.

Administrative work was among many frustrations internists reported. The following are the top five most challenging aspects of the job, according to the respondents:

• Having so many rules and regulations (24%)
• Having to work long hours (16%)
• Dealing with difficult patients (16%)
• Working with electronic health records systems (11%)
• Danger/risk associated with treating COVID-19 patients (10%)

Conversely, the most rewarding aspects were “gratitude/relationships with patients” (31%); “knowing that I’m making the world a better place” (26%); and “being very good at what I do” (20%).
 

More than one-third lost income

More than one-third of internists (36%) reported that they lost some income during the past year.

Among those who lost income, 81% said they expect income to return to prepandemic levels within 3 years. Half of that group expected the rebound would come within the next year.

Slightly more than one-third of internists said they would participate in the merit-based incentive payment system (MIPS), and 12% said they would participate in advanced alternative payment models. The rest either said they would participate in neither, or they hadn’t decided.

“The stakes for the Quality Payment Program – the program that incorporates MIPS – are high, with a 9% penalty applied to all Medicare reimbursement for failure to participate,” says Elizabeth Woodcock, MBA, CPC, president of the physician practice consulting firm Woodcock and Associates, in Atlanta, Georgia.

“With margins already slim,” she told this news organization, “most physicians can’t afford this massive penalty.”

If they could choose again, most internists (76%) said they would choose medicine, which was almost the same number as physicians overall who would pick medicine again. Oncologists (88%) and ophthalmologists (87%) were the specialists most likely to choose medicine again. Those in physical medicine and rehabilitation were least likely to choose medicine again, at 67%.

But asked about their specialty, internists’ enthusiasm decreased. Only 68% said that they would make that same choice again.

That was up considerably, however, from the 2015 survey: For that year, only 25% said they would choose internal medicine again.

A version of this article first appeared on Medscape.com.

Fifty-five chemicals never before reported in humans were found in pregnant women, according to a study from the University of California, San Francisco. The chemicals likely come from consumer products or industrial sources, researchers say.

Findings were published online in Environmental Science and Technology.

Co-first authors Aolin Wang, PhD, and Dimitri Panagopoulos Abrahamsson, PhD, postdoctoral fellows in UCSF’s obstetrics and gynecology department, and colleagues found 109 chemicals in the blood of pregnant women, including 42 “mystery chemicals” whose sources and uses are not known.

The chemicals were also found in their newborns, tests from umbilical cord blood show, suggesting the chemicals cross through the placenta.

Among the chemicals, 40 are used as plasticizers, 28 are used in cosmetics, another 25 are used in consumer products, 29 as pharmaceuticals, 23 as pesticides, three as flame retardants, and seven are PFAS [per- and polyfluoroalkyl substances] compounds used in multiple applications including carpeting and upholstery, the authors report.

Senior author Tracey Woodruff, PhD, MPH, characterized their discoveries as “disturbing.”

She told this news organization that it’s not only frustrating to know the chemicals are present but to know so little about them.

“We know it’s a chemical registered to be manufactured, and it’s used in commerce, but we don’t know where,” she explained. “That’s very disturbing, that we can’t trace them, and that shows a failure in public policy and government.”

“Exposures are occurring without our consent,” said Ms. Woodruff, a former U.S. Environmental Protection Agency scientist, who directs the Program on Reproductive Health and the Environment (PRHE) and the Environmental Research and Translation for Health (EaRTH) Center, both at UCSF.  

She said researchers know from previous studies that when the U.S. government acts to remove harmful chemicals from the marketplace, the levels of those chemicals measured in people drop.

“Examples include lead, certain PFAS, flame retardant chemicals, and certain phthalates,” she said. “So public policies can be effective in preventing exposures that can be harmful.”
 

Technological advances led to the discoveries

The team used high-resolution mass spectrometry (HRMS) to identify human-made chemicals in people.  

Dr. Abrahamsson said in an interview that the technology is relatively new in research and had not previously been used to scan for chemicals in pregnant women and their infants.

Because scientists often study what other scientists have studied, he said, the same chemicals tend to get attention. The wider scope made possible by the new technology helps illumine where to focus future research, he said.

A benefit of the technology is that now researchers don’t have to know which chemicals they are looking for when they scan blood samples, but they can observe whatever appears, he said.

Ms. Woodruff said, “We hope this is further data and evidence that support government policies that require industries to tell us where they are using their chemicals and how we might be exposed to them.”

She said this research will also help identify which chemicals to prioritize for monitoring in the environment.

Average age of the women in the study was 32 years. Nearly half were Hispanic; 37% were non-Hispanic Whites; and 17% were non-Hispanic Asians, Pacific Islanders, and African Americans. Half of the participants were born outside the United States and had lived in the U.S. for an average 22 years.

Sean Palfrey, MD, a professor of clinical pediatrics and public health at Boston University, said more chemical discoveries like these will come as technology continues to evolve.

Dr. Palfrey, who was not involved in the study, agrees with the authors that there is a lack of oversight as to what substances are used in products.

“Our industrial regulations are very poor and therefore our industries get away with using new and untested substances in their products,” he told this news organization.

“This lack of regulation is really important when it results in us not recognizing that known and serious toxins are being put into foods or other products, or when a new class of toxin has been invented which is a serious poison. Most of the toxins, though, are discovered in products in very low levels,” he said.

Dr. Palfrey said, however, that focus should stay on the known and serious toxins that seep into the environment from common products.

“It has taken us decades to ban certain flame retardants from home products,” he said. “TOSCA [the Toxic Substances Control Act passed by Congress in 1976] was too limited when it was passed decades ago and is now fearfully out of date. Unless we discover a COVID among the toxins discovered in studies like this, we should focus on the big stuff.”

The authors and Dr. Palfrey have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Fifty-five chemicals never before reported in humans were found in pregnant women, according to a study from the University of California, San Francisco. The chemicals likely come from consumer products or industrial sources, researchers say.

Findings were published online in Environmental Science and Technology.

Co-first authors Aolin Wang, PhD, and Dimitri Panagopoulos Abrahamsson, PhD, postdoctoral fellows in UCSF’s obstetrics and gynecology department, and colleagues found 109 chemicals in the blood of pregnant women, including 42 “mystery chemicals” whose sources and uses are not known.

The chemicals were also found in their newborns, tests from umbilical cord blood show, suggesting the chemicals cross through the placenta.

Among the chemicals, 40 are used as plasticizers, 28 are used in cosmetics, another 25 are used in consumer products, 29 as pharmaceuticals, 23 as pesticides, three as flame retardants, and seven are PFAS [per- and polyfluoroalkyl substances] compounds used in multiple applications including carpeting and upholstery, the authors report.

Senior author Tracey Woodruff, PhD, MPH, characterized their discoveries as “disturbing.”

She told this news organization that it’s not only frustrating to know the chemicals are present but to know so little about them.

“We know it’s a chemical registered to be manufactured, and it’s used in commerce, but we don’t know where,” she explained. “That’s very disturbing, that we can’t trace them, and that shows a failure in public policy and government.”

“Exposures are occurring without our consent,” said Ms. Woodruff, a former U.S. Environmental Protection Agency scientist, who directs the Program on Reproductive Health and the Environment (PRHE) and the Environmental Research and Translation for Health (EaRTH) Center, both at UCSF.  

She said researchers know from previous studies that when the U.S. government acts to remove harmful chemicals from the marketplace, the levels of those chemicals measured in people drop.

“Examples include lead, certain PFAS, flame retardant chemicals, and certain phthalates,” she said. “So public policies can be effective in preventing exposures that can be harmful.”
 

Technological advances led to the discoveries

The team used high-resolution mass spectrometry (HRMS) to identify human-made chemicals in people.  

Dr. Abrahamsson said in an interview that the technology is relatively new in research and had not previously been used to scan for chemicals in pregnant women and their infants.

Because scientists often study what other scientists have studied, he said, the same chemicals tend to get attention. The wider scope made possible by the new technology helps illumine where to focus future research, he said.

A benefit of the technology is that now researchers don’t have to know which chemicals they are looking for when they scan blood samples, but they can observe whatever appears, he said.

Ms. Woodruff said, “We hope this is further data and evidence that support government policies that require industries to tell us where they are using their chemicals and how we might be exposed to them.”

She said this research will also help identify which chemicals to prioritize for monitoring in the environment.

Average age of the women in the study was 32 years. Nearly half were Hispanic; 37% were non-Hispanic Whites; and 17% were non-Hispanic Asians, Pacific Islanders, and African Americans. Half of the participants were born outside the United States and had lived in the U.S. for an average 22 years.

Sean Palfrey, MD, a professor of clinical pediatrics and public health at Boston University, said more chemical discoveries like these will come as technology continues to evolve.

Dr. Palfrey, who was not involved in the study, agrees with the authors that there is a lack of oversight as to what substances are used in products.

“Our industrial regulations are very poor and therefore our industries get away with using new and untested substances in their products,” he told this news organization.

“This lack of regulation is really important when it results in us not recognizing that known and serious toxins are being put into foods or other products, or when a new class of toxin has been invented which is a serious poison. Most of the toxins, though, are discovered in products in very low levels,” he said.

Dr. Palfrey said, however, that focus should stay on the known and serious toxins that seep into the environment from common products.

“It has taken us decades to ban certain flame retardants from home products,” he said. “TOSCA [the Toxic Substances Control Act passed by Congress in 1976] was too limited when it was passed decades ago and is now fearfully out of date. Unless we discover a COVID among the toxins discovered in studies like this, we should focus on the big stuff.”

The authors and Dr. Palfrey have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Fifty-five chemicals never before reported in humans were found in pregnant women, according to a study from the University of California, San Francisco. The chemicals likely come from consumer products or industrial sources, researchers say.

Findings were published online in Environmental Science and Technology.

Co-first authors Aolin Wang, PhD, and Dimitri Panagopoulos Abrahamsson, PhD, postdoctoral fellows in UCSF’s obstetrics and gynecology department, and colleagues found 109 chemicals in the blood of pregnant women, including 42 “mystery chemicals” whose sources and uses are not known.

The chemicals were also found in their newborns, tests from umbilical cord blood show, suggesting the chemicals cross through the placenta.

Among the chemicals, 40 are used as plasticizers, 28 are used in cosmetics, another 25 are used in consumer products, 29 as pharmaceuticals, 23 as pesticides, three as flame retardants, and seven are PFAS [per- and polyfluoroalkyl substances] compounds used in multiple applications including carpeting and upholstery, the authors report.

Senior author Tracey Woodruff, PhD, MPH, characterized their discoveries as “disturbing.”

She told this news organization that it’s not only frustrating to know the chemicals are present but to know so little about them.

“We know it’s a chemical registered to be manufactured, and it’s used in commerce, but we don’t know where,” she explained. “That’s very disturbing, that we can’t trace them, and that shows a failure in public policy and government.”

“Exposures are occurring without our consent,” said Ms. Woodruff, a former U.S. Environmental Protection Agency scientist, who directs the Program on Reproductive Health and the Environment (PRHE) and the Environmental Research and Translation for Health (EaRTH) Center, both at UCSF.  

She said researchers know from previous studies that when the U.S. government acts to remove harmful chemicals from the marketplace, the levels of those chemicals measured in people drop.

“Examples include lead, certain PFAS, flame retardant chemicals, and certain phthalates,” she said. “So public policies can be effective in preventing exposures that can be harmful.”
 

Technological advances led to the discoveries

The team used high-resolution mass spectrometry (HRMS) to identify human-made chemicals in people.  

Dr. Abrahamsson said in an interview that the technology is relatively new in research and had not previously been used to scan for chemicals in pregnant women and their infants.

Because scientists often study what other scientists have studied, he said, the same chemicals tend to get attention. The wider scope made possible by the new technology helps illumine where to focus future research, he said.

A benefit of the technology is that now researchers don’t have to know which chemicals they are looking for when they scan blood samples, but they can observe whatever appears, he said.

Ms. Woodruff said, “We hope this is further data and evidence that support government policies that require industries to tell us where they are using their chemicals and how we might be exposed to them.”

She said this research will also help identify which chemicals to prioritize for monitoring in the environment.

Average age of the women in the study was 32 years. Nearly half were Hispanic; 37% were non-Hispanic Whites; and 17% were non-Hispanic Asians, Pacific Islanders, and African Americans. Half of the participants were born outside the United States and had lived in the U.S. for an average 22 years.

Sean Palfrey, MD, a professor of clinical pediatrics and public health at Boston University, said more chemical discoveries like these will come as technology continues to evolve.

Dr. Palfrey, who was not involved in the study, agrees with the authors that there is a lack of oversight as to what substances are used in products.

“Our industrial regulations are very poor and therefore our industries get away with using new and untested substances in their products,” he told this news organization.

“This lack of regulation is really important when it results in us not recognizing that known and serious toxins are being put into foods or other products, or when a new class of toxin has been invented which is a serious poison. Most of the toxins, though, are discovered in products in very low levels,” he said.

Dr. Palfrey said, however, that focus should stay on the known and serious toxins that seep into the environment from common products.

“It has taken us decades to ban certain flame retardants from home products,” he said. “TOSCA [the Toxic Substances Control Act passed by Congress in 1976] was too limited when it was passed decades ago and is now fearfully out of date. Unless we discover a COVID among the toxins discovered in studies like this, we should focus on the big stuff.”

The authors and Dr. Palfrey have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Chronic insomnia is often underrecognized and misunderstood in primary care, sleep expert Christopher Lettieri, MD, told attendees at the annual meeting of the American College of Physicians.

Too often, medications are the treatment of choice, and when used long term they can perpetuate a problematic cycle, said Dr. Lettieri, professor in pulmonary, critical care, and sleep medicine at Johns Hopkins University, Baltimore.

However, medications alone won’t work without other behavior modifications and they come with potential side effects, he said in his talk. Prescription medications typically don’t treat the cause of the insomnia, just the symptoms.

“In the 15 years I’ve been practicing sleep medicine, I can honestly say I only have a handful of patients that I treat with long-term pharmacotherapy,” Dr. Lettieri said.

He said he typically uses pharmacotherapy only when conservative measures have failed or to help jump-start patients to behavior modifications.

Restricted sleep is a good place to start for chronic insomnia, he continued.

Physicians should ask patients the latest time they can wake up to make it to school, work, etc. If that time is 6 a.m., the goal is to move bedtime back to 10 p.m.–11 p.m. If the patient, however, is unable to sleep until 12:30 a.m., move bedtime there, he said.

Though the 5.5-hour window is not ideal, it’s better to get into bed when ready for sleep. From there, try to get the patient to move bedtime back 15 minutes each week as they train themselves to fall asleep earlier, he said.

“I promise you this works in the majority of patients and doesn’t require any medication. You can also accomplish this with one or two office visits, so it is not a huge drain on resources,” he said.
 

Sleep specialists in short supply

Cognitive-behavioral therapy (CBT) is “without question the best way to treat chronic insomnia and it’s recommended as first-line therapy by all published guidelines,” Dr. Lettieri said.

He defined chronic insomnia as happening most nights over at least 3 months. It affects twice as many women as men.

CBT offers a formalized way of changing sleep patterns with the help of an expert in sleep behavior disorders. It combines cognitive therapies with education about sleep and stimulus control and uses techniques such as mindfulness and relaxation.

However, most programs take 4-8 sessions with a sleep medicine provider and are usually not covered by insurance. In addition, the number of insomnia specialists is not nearly adequate to meet demand, he added.

Online and mobile-platform CBT programs are widely effective, Dr. Lettieri said. Many are free and all are convenient for patients to use. He said many of his patients use Sleepio, but many other online programs are effective.

“You can provide sufficient therapy for many of your patients and reserve CBT for patients who can’t be fixed with more conservative measures,” he said.
 

Insomnia among older patients

Interest in helping older patients with insomnia dominated the chat session associated with the talk.

Insomnia increases with age and older patients have often been using prescription or over-the-counter sleep aids for decades.

Additionally, “insomnia is the second-most common reason why people get admitted to long-term care facilities, second only to urinary incontinence,” Dr. Lettieri said.

If physicians use medications with older patients, he said, extra caution is needed. Older people have more neurocognitive impairments than younger adults and may already be taking several other medications. Sleep medications may come with longer elimination half-lives. Polypharmacy may increase risk for falls and have other consequences.

“If you have to go to a medication, try something simple like melatonin,” he said, adding that it should be pharmaceutical grade and extended release.

Also, bright lights during the day, movement throughout the day, and dim lights closer to bedtime are especially important for the elderly, Dr. Lettieri said.

Andrew Corr, MD, a geriatric specialist in primary care with the Riverside (Calif.) Medical Clinic, said in an interview the main message he will take back to his physician group is more CBT and less medication.

He said that, although he has long known CBT is the top first-line treatment, it is difficult to find experts in his area who are trained to do CBT for insomnia, so he was glad to hear online programs and self-directed reading are typically effective.

He also said there’s a common misperception that there’s no harm in prescribing medications such as trazodone (Desyrel), an antidepressant commonly used off label as a sleep aid.

Dr. Lettieri’s talk highlighted his recommendation against using trazodone for sleep. “Despite several recommendations against its use for insomnia, it is still commonly prescribed. You just shouldn’t use it for insomnia,” Dr. Lettieri said.

“It has no measurable effect in a third of patients and at least unacceptable side effects in another third.  Right off the bat, it’s not efficacious in two thirds of patients.”

Additionally, priapism, a prolonged erection, has been associated with trazodone, Dr. Lettieri said, “and I have literally never met a patient on trazodone who was counseled about this.”

Trazodone also has a black box warning from the Food and Drug Administration warning about increased risk for suicidal thoughts.

Dr. Lettieri and Dr. Corr disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Chronic insomnia is often underrecognized and misunderstood in primary care, sleep expert Christopher Lettieri, MD, told attendees at the annual meeting of the American College of Physicians.

Too often, medications are the treatment of choice, and when used long term they can perpetuate a problematic cycle, said Dr. Lettieri, professor in pulmonary, critical care, and sleep medicine at Johns Hopkins University, Baltimore.

However, medications alone won’t work without other behavior modifications and they come with potential side effects, he said in his talk. Prescription medications typically don’t treat the cause of the insomnia, just the symptoms.

“In the 15 years I’ve been practicing sleep medicine, I can honestly say I only have a handful of patients that I treat with long-term pharmacotherapy,” Dr. Lettieri said.

He said he typically uses pharmacotherapy only when conservative measures have failed or to help jump-start patients to behavior modifications.

Restricted sleep is a good place to start for chronic insomnia, he continued.

Physicians should ask patients the latest time they can wake up to make it to school, work, etc. If that time is 6 a.m., the goal is to move bedtime back to 10 p.m.–11 p.m. If the patient, however, is unable to sleep until 12:30 a.m., move bedtime there, he said.

Though the 5.5-hour window is not ideal, it’s better to get into bed when ready for sleep. From there, try to get the patient to move bedtime back 15 minutes each week as they train themselves to fall asleep earlier, he said.

“I promise you this works in the majority of patients and doesn’t require any medication. You can also accomplish this with one or two office visits, so it is not a huge drain on resources,” he said.
 

Sleep specialists in short supply

Cognitive-behavioral therapy (CBT) is “without question the best way to treat chronic insomnia and it’s recommended as first-line therapy by all published guidelines,” Dr. Lettieri said.

He defined chronic insomnia as happening most nights over at least 3 months. It affects twice as many women as men.

CBT offers a formalized way of changing sleep patterns with the help of an expert in sleep behavior disorders. It combines cognitive therapies with education about sleep and stimulus control and uses techniques such as mindfulness and relaxation.

However, most programs take 4-8 sessions with a sleep medicine provider and are usually not covered by insurance. In addition, the number of insomnia specialists is not nearly adequate to meet demand, he added.

Online and mobile-platform CBT programs are widely effective, Dr. Lettieri said. Many are free and all are convenient for patients to use. He said many of his patients use Sleepio, but many other online programs are effective.

“You can provide sufficient therapy for many of your patients and reserve CBT for patients who can’t be fixed with more conservative measures,” he said.
 

Insomnia among older patients

Interest in helping older patients with insomnia dominated the chat session associated with the talk.

Insomnia increases with age and older patients have often been using prescription or over-the-counter sleep aids for decades.

Additionally, “insomnia is the second-most common reason why people get admitted to long-term care facilities, second only to urinary incontinence,” Dr. Lettieri said.

If physicians use medications with older patients, he said, extra caution is needed. Older people have more neurocognitive impairments than younger adults and may already be taking several other medications. Sleep medications may come with longer elimination half-lives. Polypharmacy may increase risk for falls and have other consequences.

“If you have to go to a medication, try something simple like melatonin,” he said, adding that it should be pharmaceutical grade and extended release.

Also, bright lights during the day, movement throughout the day, and dim lights closer to bedtime are especially important for the elderly, Dr. Lettieri said.

Andrew Corr, MD, a geriatric specialist in primary care with the Riverside (Calif.) Medical Clinic, said in an interview the main message he will take back to his physician group is more CBT and less medication.

He said that, although he has long known CBT is the top first-line treatment, it is difficult to find experts in his area who are trained to do CBT for insomnia, so he was glad to hear online programs and self-directed reading are typically effective.

He also said there’s a common misperception that there’s no harm in prescribing medications such as trazodone (Desyrel), an antidepressant commonly used off label as a sleep aid.

Dr. Lettieri’s talk highlighted his recommendation against using trazodone for sleep. “Despite several recommendations against its use for insomnia, it is still commonly prescribed. You just shouldn’t use it for insomnia,” Dr. Lettieri said.

“It has no measurable effect in a third of patients and at least unacceptable side effects in another third.  Right off the bat, it’s not efficacious in two thirds of patients.”

Additionally, priapism, a prolonged erection, has been associated with trazodone, Dr. Lettieri said, “and I have literally never met a patient on trazodone who was counseled about this.”

Trazodone also has a black box warning from the Food and Drug Administration warning about increased risk for suicidal thoughts.

Dr. Lettieri and Dr. Corr disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Chronic insomnia is often underrecognized and misunderstood in primary care, sleep expert Christopher Lettieri, MD, told attendees at the annual meeting of the American College of Physicians.

Too often, medications are the treatment of choice, and when used long term they can perpetuate a problematic cycle, said Dr. Lettieri, professor in pulmonary, critical care, and sleep medicine at Johns Hopkins University, Baltimore.

However, medications alone won’t work without other behavior modifications and they come with potential side effects, he said in his talk. Prescription medications typically don’t treat the cause of the insomnia, just the symptoms.

“In the 15 years I’ve been practicing sleep medicine, I can honestly say I only have a handful of patients that I treat with long-term pharmacotherapy,” Dr. Lettieri said.

He said he typically uses pharmacotherapy only when conservative measures have failed or to help jump-start patients to behavior modifications.

Restricted sleep is a good place to start for chronic insomnia, he continued.

Physicians should ask patients the latest time they can wake up to make it to school, work, etc. If that time is 6 a.m., the goal is to move bedtime back to 10 p.m.–11 p.m. If the patient, however, is unable to sleep until 12:30 a.m., move bedtime there, he said.

Though the 5.5-hour window is not ideal, it’s better to get into bed when ready for sleep. From there, try to get the patient to move bedtime back 15 minutes each week as they train themselves to fall asleep earlier, he said.

“I promise you this works in the majority of patients and doesn’t require any medication. You can also accomplish this with one or two office visits, so it is not a huge drain on resources,” he said.
 

Sleep specialists in short supply

Cognitive-behavioral therapy (CBT) is “without question the best way to treat chronic insomnia and it’s recommended as first-line therapy by all published guidelines,” Dr. Lettieri said.

He defined chronic insomnia as happening most nights over at least 3 months. It affects twice as many women as men.

CBT offers a formalized way of changing sleep patterns with the help of an expert in sleep behavior disorders. It combines cognitive therapies with education about sleep and stimulus control and uses techniques such as mindfulness and relaxation.

However, most programs take 4-8 sessions with a sleep medicine provider and are usually not covered by insurance. In addition, the number of insomnia specialists is not nearly adequate to meet demand, he added.

Online and mobile-platform CBT programs are widely effective, Dr. Lettieri said. Many are free and all are convenient for patients to use. He said many of his patients use Sleepio, but many other online programs are effective.

“You can provide sufficient therapy for many of your patients and reserve CBT for patients who can’t be fixed with more conservative measures,” he said.
 

Insomnia among older patients

Interest in helping older patients with insomnia dominated the chat session associated with the talk.

Insomnia increases with age and older patients have often been using prescription or over-the-counter sleep aids for decades.

Additionally, “insomnia is the second-most common reason why people get admitted to long-term care facilities, second only to urinary incontinence,” Dr. Lettieri said.

If physicians use medications with older patients, he said, extra caution is needed. Older people have more neurocognitive impairments than younger adults and may already be taking several other medications. Sleep medications may come with longer elimination half-lives. Polypharmacy may increase risk for falls and have other consequences.

“If you have to go to a medication, try something simple like melatonin,” he said, adding that it should be pharmaceutical grade and extended release.

Also, bright lights during the day, movement throughout the day, and dim lights closer to bedtime are especially important for the elderly, Dr. Lettieri said.

Andrew Corr, MD, a geriatric specialist in primary care with the Riverside (Calif.) Medical Clinic, said in an interview the main message he will take back to his physician group is more CBT and less medication.

He said that, although he has long known CBT is the top first-line treatment, it is difficult to find experts in his area who are trained to do CBT for insomnia, so he was glad to hear online programs and self-directed reading are typically effective.

He also said there’s a common misperception that there’s no harm in prescribing medications such as trazodone (Desyrel), an antidepressant commonly used off label as a sleep aid.

Dr. Lettieri’s talk highlighted his recommendation against using trazodone for sleep. “Despite several recommendations against its use for insomnia, it is still commonly prescribed. You just shouldn’t use it for insomnia,” Dr. Lettieri said.

“It has no measurable effect in a third of patients and at least unacceptable side effects in another third.  Right off the bat, it’s not efficacious in two thirds of patients.”

Additionally, priapism, a prolonged erection, has been associated with trazodone, Dr. Lettieri said, “and I have literally never met a patient on trazodone who was counseled about this.”

Trazodone also has a black box warning from the Food and Drug Administration warning about increased risk for suicidal thoughts.

Dr. Lettieri and Dr. Corr disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Asking a patient who has concerns about memory loss–particular questions can guide referral decisions, according to new research.

Initial questions should zero in on what the patient is forgetting, said Megan Richie, MD, a neurohospitalist at the University of California, San Francisco, who spoke to a virtual audience at the American College of Physicians (ACP) annual Internal Medicine meeting.

Is the patient forgetting to buy things in a store, having trouble recalling events, forgetting important dates? How often do these incidents occur?

These questions “will help get at how pervasive and how likely the memory loss is affecting their lives, versus a subjective complaint that doesn’t have much impact on the day-to-day function,” she said.

It’s also important to ask whether other neurocognitive symptoms accompany the memory loss, Dr. Richie noted.

Does the patient search for words, struggle with attention, or have problems with executive function? Does the patient have psychiatric symptoms, such as hallucinations or delusions, or other neurologic complaints, including weakness, numbness, vision change, or movement disorders?

“When you know how many neurocognitive symptoms they have, think about how [those symptoms] are affecting their safety and functional status. How are they on their activities of daily living?” Dr. Richie suggests.

Also ask whether the patient is taking medications and whether they drive a vehicle. If they do drive, do they get lost?

“These are all going to help you determine the acuity of the workup,” she said.

After a thorough history, cognitive screening is the next consideration.
 

Cognitive screening can be performed in minutes

One of the tests Dr. Richie recommends is the Mini-Cog. It takes 3 minutes to administer and has been formally recommended by the Alzheimer’s Association because it can be completed in the time frame of a Medicare wellness visit, she said.

It entails a three-word recall and clock-drawing test.

Dr. Richie said it’s important to eliminate some key causes first: “Certainly if the patient has signs and symptoms of depression, pseudodementia is a very real and treatable disease you do not want to miss and should consider in these patients,” she pointed out.

Systemic medical conditions can also lead to memory loss.

If there’s an acute component to the complaint, a new infection or medication withdrawal or a side effect could be driving it, so that’s key in questioning.

Dr. Richie explained that the American Academy of Neurology recommends a very limited workup.

“It’s really just to check their thyroid, their vitamin B12 levels, and then a one-time picture of their brain, which can be either MRI or a CT, to look for structural problems or vascular dementia or hydrocephalus, etc.”

“You do not routinely need spinal fluid testing or an EEG,” she emphasized.

Signs that a neurologist should be involved include a rapid decline, signs of potential seizures, or that the patient doesn’t seem safe in their condition.

Neuropsychological testing is helpful, but it takes nearly 3 hours and may not be a good choice for restless or aggressive patients, Dr. Richie said.

Such testing is often not available, and if it is, insurance coverage is often a barrier because many plans don’t cover it.

Patients often ask about drugs and supplements they see advertised to help with memory loss. Medications are not helpful for mild cognitive impairment, although there is evidence that some are beneficial for patients with dementia, Dr. Richie said.

Celine Goetz, MD, assistant professor of internal medicine at Rush University Medical Center, Chicago, Illinois, told this news organization that it’s easy to relate to the fear that patients and families feel when cognitive impairment begins to emerge.

“[Dr.] Richie’s talk was right on point for internists like myself who see many patients with memory complaints, cognitive impairment, and dementia. I think we’re all terrified of losing our memory and the social and functional impairment that comes with that,” she said.

Although cognitive impairment and dementia aren’t curable or reversible, Dr. Goetz noted, internists can help patients optimize management of conditions such as diabetes and heart disease, which can affect cognitive function.

Dr. Richie pointed out that some interventions lack evidence for the treatment of mild cognitive impairment, but Dr. Goetz emphasized that resources are plentiful and can be effective in combination.

“Engaging social workers, pharmacists, nutritionists, physical and occupational therapists, and, on the inpatient side, delirium protocols, chaplains, and music therapists make a huge difference in patient care,” she said.

Dr. Richie and Dr. Goetz report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Asking a patient who has concerns about memory loss–particular questions can guide referral decisions, according to new research.

Initial questions should zero in on what the patient is forgetting, said Megan Richie, MD, a neurohospitalist at the University of California, San Francisco, who spoke to a virtual audience at the American College of Physicians (ACP) annual Internal Medicine meeting.

Is the patient forgetting to buy things in a store, having trouble recalling events, forgetting important dates? How often do these incidents occur?

These questions “will help get at how pervasive and how likely the memory loss is affecting their lives, versus a subjective complaint that doesn’t have much impact on the day-to-day function,” she said.

It’s also important to ask whether other neurocognitive symptoms accompany the memory loss, Dr. Richie noted.

Does the patient search for words, struggle with attention, or have problems with executive function? Does the patient have psychiatric symptoms, such as hallucinations or delusions, or other neurologic complaints, including weakness, numbness, vision change, or movement disorders?

“When you know how many neurocognitive symptoms they have, think about how [those symptoms] are affecting their safety and functional status. How are they on their activities of daily living?” Dr. Richie suggests.

Also ask whether the patient is taking medications and whether they drive a vehicle. If they do drive, do they get lost?

“These are all going to help you determine the acuity of the workup,” she said.

After a thorough history, cognitive screening is the next consideration.
 

Cognitive screening can be performed in minutes

One of the tests Dr. Richie recommends is the Mini-Cog. It takes 3 minutes to administer and has been formally recommended by the Alzheimer’s Association because it can be completed in the time frame of a Medicare wellness visit, she said.

It entails a three-word recall and clock-drawing test.

Dr. Richie said it’s important to eliminate some key causes first: “Certainly if the patient has signs and symptoms of depression, pseudodementia is a very real and treatable disease you do not want to miss and should consider in these patients,” she pointed out.

Systemic medical conditions can also lead to memory loss.

If there’s an acute component to the complaint, a new infection or medication withdrawal or a side effect could be driving it, so that’s key in questioning.

Dr. Richie explained that the American Academy of Neurology recommends a very limited workup.

“It’s really just to check their thyroid, their vitamin B12 levels, and then a one-time picture of their brain, which can be either MRI or a CT, to look for structural problems or vascular dementia or hydrocephalus, etc.”

“You do not routinely need spinal fluid testing or an EEG,” she emphasized.

Signs that a neurologist should be involved include a rapid decline, signs of potential seizures, or that the patient doesn’t seem safe in their condition.

Neuropsychological testing is helpful, but it takes nearly 3 hours and may not be a good choice for restless or aggressive patients, Dr. Richie said.

Such testing is often not available, and if it is, insurance coverage is often a barrier because many plans don’t cover it.

Patients often ask about drugs and supplements they see advertised to help with memory loss. Medications are not helpful for mild cognitive impairment, although there is evidence that some are beneficial for patients with dementia, Dr. Richie said.

Celine Goetz, MD, assistant professor of internal medicine at Rush University Medical Center, Chicago, Illinois, told this news organization that it’s easy to relate to the fear that patients and families feel when cognitive impairment begins to emerge.

“[Dr.] Richie’s talk was right on point for internists like myself who see many patients with memory complaints, cognitive impairment, and dementia. I think we’re all terrified of losing our memory and the social and functional impairment that comes with that,” she said.

Although cognitive impairment and dementia aren’t curable or reversible, Dr. Goetz noted, internists can help patients optimize management of conditions such as diabetes and heart disease, which can affect cognitive function.

Dr. Richie pointed out that some interventions lack evidence for the treatment of mild cognitive impairment, but Dr. Goetz emphasized that resources are plentiful and can be effective in combination.

“Engaging social workers, pharmacists, nutritionists, physical and occupational therapists, and, on the inpatient side, delirium protocols, chaplains, and music therapists make a huge difference in patient care,” she said.

Dr. Richie and Dr. Goetz report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Asking a patient who has concerns about memory loss–particular questions can guide referral decisions, according to new research.

Initial questions should zero in on what the patient is forgetting, said Megan Richie, MD, a neurohospitalist at the University of California, San Francisco, who spoke to a virtual audience at the American College of Physicians (ACP) annual Internal Medicine meeting.

Is the patient forgetting to buy things in a store, having trouble recalling events, forgetting important dates? How often do these incidents occur?

These questions “will help get at how pervasive and how likely the memory loss is affecting their lives, versus a subjective complaint that doesn’t have much impact on the day-to-day function,” she said.

It’s also important to ask whether other neurocognitive symptoms accompany the memory loss, Dr. Richie noted.

Does the patient search for words, struggle with attention, or have problems with executive function? Does the patient have psychiatric symptoms, such as hallucinations or delusions, or other neurologic complaints, including weakness, numbness, vision change, or movement disorders?

“When you know how many neurocognitive symptoms they have, think about how [those symptoms] are affecting their safety and functional status. How are they on their activities of daily living?” Dr. Richie suggests.

Also ask whether the patient is taking medications and whether they drive a vehicle. If they do drive, do they get lost?

“These are all going to help you determine the acuity of the workup,” she said.

After a thorough history, cognitive screening is the next consideration.
 

Cognitive screening can be performed in minutes

One of the tests Dr. Richie recommends is the Mini-Cog. It takes 3 minutes to administer and has been formally recommended by the Alzheimer’s Association because it can be completed in the time frame of a Medicare wellness visit, she said.

It entails a three-word recall and clock-drawing test.

Dr. Richie said it’s important to eliminate some key causes first: “Certainly if the patient has signs and symptoms of depression, pseudodementia is a very real and treatable disease you do not want to miss and should consider in these patients,” she pointed out.

Systemic medical conditions can also lead to memory loss.

If there’s an acute component to the complaint, a new infection or medication withdrawal or a side effect could be driving it, so that’s key in questioning.

Dr. Richie explained that the American Academy of Neurology recommends a very limited workup.

“It’s really just to check their thyroid, their vitamin B12 levels, and then a one-time picture of their brain, which can be either MRI or a CT, to look for structural problems or vascular dementia or hydrocephalus, etc.”

“You do not routinely need spinal fluid testing or an EEG,” she emphasized.

Signs that a neurologist should be involved include a rapid decline, signs of potential seizures, or that the patient doesn’t seem safe in their condition.

Neuropsychological testing is helpful, but it takes nearly 3 hours and may not be a good choice for restless or aggressive patients, Dr. Richie said.

Such testing is often not available, and if it is, insurance coverage is often a barrier because many plans don’t cover it.

Patients often ask about drugs and supplements they see advertised to help with memory loss. Medications are not helpful for mild cognitive impairment, although there is evidence that some are beneficial for patients with dementia, Dr. Richie said.

Celine Goetz, MD, assistant professor of internal medicine at Rush University Medical Center, Chicago, Illinois, told this news organization that it’s easy to relate to the fear that patients and families feel when cognitive impairment begins to emerge.

“[Dr.] Richie’s talk was right on point for internists like myself who see many patients with memory complaints, cognitive impairment, and dementia. I think we’re all terrified of losing our memory and the social and functional impairment that comes with that,” she said.

Although cognitive impairment and dementia aren’t curable or reversible, Dr. Goetz noted, internists can help patients optimize management of conditions such as diabetes and heart disease, which can affect cognitive function.

Dr. Richie pointed out that some interventions lack evidence for the treatment of mild cognitive impairment, but Dr. Goetz emphasized that resources are plentiful and can be effective in combination.

“Engaging social workers, pharmacists, nutritionists, physical and occupational therapists, and, on the inpatient side, delirium protocols, chaplains, and music therapists make a huge difference in patient care,” she said.

Dr. Richie and Dr. Goetz report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Most people whose medical record says they are allergic to penicillin are not actually intolerant, an allergist said during the first day of sessions at the annual meeting of the American College of Physicians.

The mislabeling has implications for patient outcomes and efforts to fight antibiotic resistance, said Olajumoke Fadugba, MD, program director for the allergy and immunology fellowship at University of Pennsylvania Health System, Philadelphia.

About 10% of the general population reports a history of penicillin allergy (up to 15% of hospitalized patients), but up to 90% of patients with that label are able to tolerate penicillin, Dr. Fadugba said. The mislabeling comes either because reactions were improperly characterized early on or people have outgrown the allergy.

“There are data that tell us penicillin IgE-mediated wanes over time and that after 10 years of avoidance of a drug, greater than 80% of patients have a resolution of their penicillin IgE.”

Data also show patients outgrow their aminopenicillin reactions (including those from amoxicillin and Ampicillin) faster than parenteral penicillin reactions, she noted.

Josune Iglesias, MD, assistant professor of internal medicine at Rush University Medical Center in Chicago, said in an interview that she often sees patients who said their parents told them when they were kids that they were allergic to penicillin and that information just keeps getting entered into their records.

She said physicians are aware the penicillin-allergic label is not always accurate, but there is hesitancy to challenge those labels.

“We are cautious because of the potential side effects and the harm that we could cause if we unlabel the patient,” she said. “I think having this information will help us unlabel those patients well so we don’t cause harm.”

Also, the threat to antibiotic resistance is real, she said, when penicillin is eliminated as an option unnecessarily.

When a person is labeled allergic to penicillin, the treatment choices often go to broad-spectrum antibiotics that are more costly, have potentially worse side effects, and may contribute to resistance.

“It’s really important, especially with older people, patients sicker with chronic conditions to really make sure we unlabel those patients [who are not truly penicillin allergic],” Dr. Iglesias said.

The label can also cause harm in the hospital setting and worsen outcomes, according to Dr. Fadugba.

She noted that the penicillin allergy label has been linked with longer hospital length of stay, higher rate of readmission, acute kidney injury, multidrug-resistant organisms such as MRSA, and nosocomial infections including Clostridioides difficile.

Getting an effective drug history is an important part of determining who really has a penicillin allergy.

A questionnaire should ask whether the patient was likely to have had an immediate hypersensitivity to penicillin, such as hives or anaphylaxis, which would be more worrisome than a delayed rash.

Knowing the time frame of the reaction helps determine how likely or unlikely people are to still have the allergy, Dr. Fadugba said. “We also want to ask, have they received a penicillin antibiotic since that initial reaction and have they tolerated it?”

She continued: “If a patient received amoxicillin 2 weeks ago, and they tolerated it, you can essentially remove the allergy label and essentially change that patient’s potential hospital course – that immediate course or future outcomes.”

After obtaining the history, there are choices to make.

If a patient is not allergic, she said, the next step is removing the label and documenting why so that in the future another clinician doesn’t see the deleted label and put it back. If a person is deemed allergic by history, clinicians should document the nature of the reaction and if the patient needs a beta-lactam during a hospitalization or in clinic, make a decision based on what kind of beta-lactam they need.

“Generally, for a fourth-generation cephalosporin, for a distant history of penicillin allergy, you can probably give the full dose or – if you’re conservative – give it cautiously, perhaps 10% initially and then monitor because cross-reactivity is known to be low, about 2%,” Dr. Fadugba said.

If the patient needs a penicillin antibiotic specifically, options are guided by the resources.

If a clinician has personnel or an allergy specialist available, skin testing may be an option and “if negative, you can rule out the allergy,” Dr. Fadugba said.

“If that’s not available and the patient really needs a penicillin, you can consider desensitization,” she said.

However, she said, “If the patient is very high risk, then you have no choice but to use an alternative, especially if you can’t desensitize.”

Dr. Fadugba is a consultant for the Health Resources & Services Administration. Dr. Iglesias disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Most people whose medical record says they are allergic to penicillin are not actually intolerant, an allergist said during the first day of sessions at the annual meeting of the American College of Physicians.

The mislabeling has implications for patient outcomes and efforts to fight antibiotic resistance, said Olajumoke Fadugba, MD, program director for the allergy and immunology fellowship at University of Pennsylvania Health System, Philadelphia.

About 10% of the general population reports a history of penicillin allergy (up to 15% of hospitalized patients), but up to 90% of patients with that label are able to tolerate penicillin, Dr. Fadugba said. The mislabeling comes either because reactions were improperly characterized early on or people have outgrown the allergy.

“There are data that tell us penicillin IgE-mediated wanes over time and that after 10 years of avoidance of a drug, greater than 80% of patients have a resolution of their penicillin IgE.”

Data also show patients outgrow their aminopenicillin reactions (including those from amoxicillin and Ampicillin) faster than parenteral penicillin reactions, she noted.

Josune Iglesias, MD, assistant professor of internal medicine at Rush University Medical Center in Chicago, said in an interview that she often sees patients who said their parents told them when they were kids that they were allergic to penicillin and that information just keeps getting entered into their records.

She said physicians are aware the penicillin-allergic label is not always accurate, but there is hesitancy to challenge those labels.

“We are cautious because of the potential side effects and the harm that we could cause if we unlabel the patient,” she said. “I think having this information will help us unlabel those patients well so we don’t cause harm.”

Also, the threat to antibiotic resistance is real, she said, when penicillin is eliminated as an option unnecessarily.

When a person is labeled allergic to penicillin, the treatment choices often go to broad-spectrum antibiotics that are more costly, have potentially worse side effects, and may contribute to resistance.

“It’s really important, especially with older people, patients sicker with chronic conditions to really make sure we unlabel those patients [who are not truly penicillin allergic],” Dr. Iglesias said.

The label can also cause harm in the hospital setting and worsen outcomes, according to Dr. Fadugba.

She noted that the penicillin allergy label has been linked with longer hospital length of stay, higher rate of readmission, acute kidney injury, multidrug-resistant organisms such as MRSA, and nosocomial infections including Clostridioides difficile.

Getting an effective drug history is an important part of determining who really has a penicillin allergy.

A questionnaire should ask whether the patient was likely to have had an immediate hypersensitivity to penicillin, such as hives or anaphylaxis, which would be more worrisome than a delayed rash.

Knowing the time frame of the reaction helps determine how likely or unlikely people are to still have the allergy, Dr. Fadugba said. “We also want to ask, have they received a penicillin antibiotic since that initial reaction and have they tolerated it?”

She continued: “If a patient received amoxicillin 2 weeks ago, and they tolerated it, you can essentially remove the allergy label and essentially change that patient’s potential hospital course – that immediate course or future outcomes.”

After obtaining the history, there are choices to make.

If a patient is not allergic, she said, the next step is removing the label and documenting why so that in the future another clinician doesn’t see the deleted label and put it back. If a person is deemed allergic by history, clinicians should document the nature of the reaction and if the patient needs a beta-lactam during a hospitalization or in clinic, make a decision based on what kind of beta-lactam they need.

“Generally, for a fourth-generation cephalosporin, for a distant history of penicillin allergy, you can probably give the full dose or – if you’re conservative – give it cautiously, perhaps 10% initially and then monitor because cross-reactivity is known to be low, about 2%,” Dr. Fadugba said.

If the patient needs a penicillin antibiotic specifically, options are guided by the resources.

If a clinician has personnel or an allergy specialist available, skin testing may be an option and “if negative, you can rule out the allergy,” Dr. Fadugba said.

“If that’s not available and the patient really needs a penicillin, you can consider desensitization,” she said.

However, she said, “If the patient is very high risk, then you have no choice but to use an alternative, especially if you can’t desensitize.”

Dr. Fadugba is a consultant for the Health Resources & Services Administration. Dr. Iglesias disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Most people whose medical record says they are allergic to penicillin are not actually intolerant, an allergist said during the first day of sessions at the annual meeting of the American College of Physicians.

The mislabeling has implications for patient outcomes and efforts to fight antibiotic resistance, said Olajumoke Fadugba, MD, program director for the allergy and immunology fellowship at University of Pennsylvania Health System, Philadelphia.

About 10% of the general population reports a history of penicillin allergy (up to 15% of hospitalized patients), but up to 90% of patients with that label are able to tolerate penicillin, Dr. Fadugba said. The mislabeling comes either because reactions were improperly characterized early on or people have outgrown the allergy.

“There are data that tell us penicillin IgE-mediated wanes over time and that after 10 years of avoidance of a drug, greater than 80% of patients have a resolution of their penicillin IgE.”

Data also show patients outgrow their aminopenicillin reactions (including those from amoxicillin and Ampicillin) faster than parenteral penicillin reactions, she noted.

Josune Iglesias, MD, assistant professor of internal medicine at Rush University Medical Center in Chicago, said in an interview that she often sees patients who said their parents told them when they were kids that they were allergic to penicillin and that information just keeps getting entered into their records.

She said physicians are aware the penicillin-allergic label is not always accurate, but there is hesitancy to challenge those labels.

“We are cautious because of the potential side effects and the harm that we could cause if we unlabel the patient,” she said. “I think having this information will help us unlabel those patients well so we don’t cause harm.”

Also, the threat to antibiotic resistance is real, she said, when penicillin is eliminated as an option unnecessarily.

When a person is labeled allergic to penicillin, the treatment choices often go to broad-spectrum antibiotics that are more costly, have potentially worse side effects, and may contribute to resistance.

“It’s really important, especially with older people, patients sicker with chronic conditions to really make sure we unlabel those patients [who are not truly penicillin allergic],” Dr. Iglesias said.

The label can also cause harm in the hospital setting and worsen outcomes, according to Dr. Fadugba.

She noted that the penicillin allergy label has been linked with longer hospital length of stay, higher rate of readmission, acute kidney injury, multidrug-resistant organisms such as MRSA, and nosocomial infections including Clostridioides difficile.

Getting an effective drug history is an important part of determining who really has a penicillin allergy.

A questionnaire should ask whether the patient was likely to have had an immediate hypersensitivity to penicillin, such as hives or anaphylaxis, which would be more worrisome than a delayed rash.

Knowing the time frame of the reaction helps determine how likely or unlikely people are to still have the allergy, Dr. Fadugba said. “We also want to ask, have they received a penicillin antibiotic since that initial reaction and have they tolerated it?”

She continued: “If a patient received amoxicillin 2 weeks ago, and they tolerated it, you can essentially remove the allergy label and essentially change that patient’s potential hospital course – that immediate course or future outcomes.”

After obtaining the history, there are choices to make.

If a patient is not allergic, she said, the next step is removing the label and documenting why so that in the future another clinician doesn’t see the deleted label and put it back. If a person is deemed allergic by history, clinicians should document the nature of the reaction and if the patient needs a beta-lactam during a hospitalization or in clinic, make a decision based on what kind of beta-lactam they need.

“Generally, for a fourth-generation cephalosporin, for a distant history of penicillin allergy, you can probably give the full dose or – if you’re conservative – give it cautiously, perhaps 10% initially and then monitor because cross-reactivity is known to be low, about 2%,” Dr. Fadugba said.

If the patient needs a penicillin antibiotic specifically, options are guided by the resources.

If a clinician has personnel or an allergy specialist available, skin testing may be an option and “if negative, you can rule out the allergy,” Dr. Fadugba said.

“If that’s not available and the patient really needs a penicillin, you can consider desensitization,” she said.

However, she said, “If the patient is very high risk, then you have no choice but to use an alternative, especially if you can’t desensitize.”

Dr. Fadugba is a consultant for the Health Resources & Services Administration. Dr. Iglesias disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Use of the Johnson & Johnson COVID-19 vaccine should resume in the United States for all adults, the Food and Drug Administration and Centers for Disease Contol and Prevention said April 23, although health care providers should warn patients of the risk of developing the rare and serious blood clots that caused the agencies to pause the vaccine’s distribution earlier this month.

Johnson & Johnson

Use of the Johnson & Johnson COVID-19 vaccine should resume in the United States for all adults, the Food and Drug Administration and Centers for Disease Contol and Prevention said April 23, although health care providers should warn patients of the risk of developing the rare and serious blood clots that caused the agencies to pause the vaccine’s distribution earlier this month.

Johnson & Johnson

Use of the Johnson & Johnson COVID-19 vaccine should resume in the United States for all adults, the Food and Drug Administration and Centers for Disease Contol and Prevention said April 23, although health care providers should warn patients of the risk of developing the rare and serious blood clots that caused the agencies to pause the vaccine’s distribution earlier this month.

Johnson & Johnson