CHEST Physician

In recent years, the survival rate for patients with lung cancer has increased to the point where now, almost one-quarter of patients with lung cancer are alive 5 years after being diagnosed.

This new statistic is highlighted in the State of Lung Cancer report from the American Lung Association (ALA), published online on Nov. 16.

“If you look back, the 5-year survival rate has been very slowly eking up at about 1% over the years,” Andrea McKee, MD, volunteer spokesperson at the ALA, told this news organization. The report shows that the 5-year survival rate increased by 14.5% over the past 5 years. “To see this big jump is truly remarkable, so that is something we are all celebrating,” she added.

“But we have to change the fatalistic thinking that both patients and primary care physicians still have about lung cancer. Most people say, ‘Everybody I know who had lung cancer died,’ and that was the way it used to be,” she commented, “but that has now changed. Lung cancer is highly curable in its early stages, and even if not early-stage, there are treatments that are making an impact now.”

“So we’ve got to change that perception, as it does exist, even on the part of primary care providers, too,” Dr. McKee emphasized.
 

Lung cancer decreasing but still being diagnosed late

The report notes that the risk of being diagnosed with lung cancer varies considerably across the United States. For example, rates of lung cancer diagnoses are almost 2.5 times higher in Kentucky than in Utah.

Overall, the incidence is decreasing. “Over the last 5 years, the rate of new cases decreased 10% nationally,” the authors point out.

However, in almost half of the cases, the disease is diagnosed in late stages.

When diagnosed at a late stage, the 5-year survival rate for lung cancer drops to only 6%, whereas when the disease is diagnosed early, the 5-year survival rate is 60%.

At present, around 24% of cases of lung cancer are diagnosed at early stages, the report notes, but again, this varies across the United States. The highest rate (30%) is in Massachusetts, and the lowest rate (19%) is in Hawaii.

The percentage of lung cancer cases diagnosed early has been steadily increasing, presumably in part because of the introduction of low-dose CT screening for individuals at highest risk (such as smokers).

However, across the nation, only 5.7% of individuals at high risk for lung cancer underwent annual low-dose CT screening, the report notes.

“CT screening is so powerful at saving lives that even with only 5.7% of people that we’ve been able to screen, I believe it’s making a difference,” Dr. McKee commented. That small national percentage still represents a considerable number of patients, she noted, “so even with what we’ve done so far, I believe that screening is making a difference, at least within my own practice, where I’m definitely seeing it,” Dr. McKee emphasized.

Recent changes to the recommendations as to who should undergo lung cancer screening “have almost doubled the size of the screening population in the U.S.,” Dr. McKee commented. “So there are now about 15 million people who need to get screened, and it again helps that primary care physicians know that screening is very powerful at detecting early-stage lung cancer,” she said.

In her hospital’s own screening program, among the individuals who regularly undergo screening, the majority (88%) of lung cancer cases are detected at stage I or II, for which the cure rate is approximately 90%, she noted.

Another misconception of primary care physicians is that lung cancer screening has an unacceptably high false positive rate. Previous reports in the medical literature suggested the rate could be as high as 96%. “This is absolutely, positively wrong. That is not the false positive rate; the false positive rate for lung cancer screening is less than 10%,” Dr. McKee emphasized.

“So we have to change that in the minds of primary care providers as well,” she underscored.
 

Report highlights racial disparities

The report also highlights the racial disparities that persist in all aspects of lung cancer management – early diagnosis, surgical treatment, lack of treatment, and survival.

For example, Black Americans are 18% less likely to be diagnosed with early-stage disease and are 23% less likely to receive surgical treatment than their White counterparts. They are also 9% more likely to receive no treatment at all, and mortality from lung cancer among Black patients is 21% worse than it is for White patients.

The same trend is seen among Latinx persons, although they are just as likely as White patients to undergo surgical treatment.

First and foremost, “we have to make sure that the [Black and Latinx persons] are screened in an equal fashion,” Dr. McKee said. Providing screening for communities of color is one strategy that might improve screening rates, she suggested.

So, too, can outreach programs in which lung cancer experts work with leaders within these communities, because people are more likely to listen to their leaders regarding the importance of screening for early detection of lung cancer.

Physicians also need to emphasize that even for people who quit smoking decades ago, once those persons are in their 70s, “there is a spike again in lung cancer diagnoses, and that is true for both Black and White patients,” Dr. McKee stressed.

“Again, this is something that many doctors are not aware of,” she emphasized.

Dr. McKee has disclosed no relevant financial relationships.

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

In recent years, the survival rate for patients with lung cancer has increased to the point where now, almost one-quarter of patients with lung cancer are alive 5 years after being diagnosed.

This new statistic is highlighted in the State of Lung Cancer report from the American Lung Association (ALA), published online on Nov. 16.

“If you look back, the 5-year survival rate has been very slowly eking up at about 1% over the years,” Andrea McKee, MD, volunteer spokesperson at the ALA, told this news organization. The report shows that the 5-year survival rate increased by 14.5% over the past 5 years. “To see this big jump is truly remarkable, so that is something we are all celebrating,” she added.

“But we have to change the fatalistic thinking that both patients and primary care physicians still have about lung cancer. Most people say, ‘Everybody I know who had lung cancer died,’ and that was the way it used to be,” she commented, “but that has now changed. Lung cancer is highly curable in its early stages, and even if not early-stage, there are treatments that are making an impact now.”

“So we’ve got to change that perception, as it does exist, even on the part of primary care providers, too,” Dr. McKee emphasized.
 

Lung cancer decreasing but still being diagnosed late

The report notes that the risk of being diagnosed with lung cancer varies considerably across the United States. For example, rates of lung cancer diagnoses are almost 2.5 times higher in Kentucky than in Utah.

Overall, the incidence is decreasing. “Over the last 5 years, the rate of new cases decreased 10% nationally,” the authors point out.

However, in almost half of the cases, the disease is diagnosed in late stages.

When diagnosed at a late stage, the 5-year survival rate for lung cancer drops to only 6%, whereas when the disease is diagnosed early, the 5-year survival rate is 60%.

At present, around 24% of cases of lung cancer are diagnosed at early stages, the report notes, but again, this varies across the United States. The highest rate (30%) is in Massachusetts, and the lowest rate (19%) is in Hawaii.

The percentage of lung cancer cases diagnosed early has been steadily increasing, presumably in part because of the introduction of low-dose CT screening for individuals at highest risk (such as smokers).

However, across the nation, only 5.7% of individuals at high risk for lung cancer underwent annual low-dose CT screening, the report notes.

“CT screening is so powerful at saving lives that even with only 5.7% of people that we’ve been able to screen, I believe it’s making a difference,” Dr. McKee commented. That small national percentage still represents a considerable number of patients, she noted, “so even with what we’ve done so far, I believe that screening is making a difference, at least within my own practice, where I’m definitely seeing it,” Dr. McKee emphasized.

Recent changes to the recommendations as to who should undergo lung cancer screening “have almost doubled the size of the screening population in the U.S.,” Dr. McKee commented. “So there are now about 15 million people who need to get screened, and it again helps that primary care physicians know that screening is very powerful at detecting early-stage lung cancer,” she said.

In her hospital’s own screening program, among the individuals who regularly undergo screening, the majority (88%) of lung cancer cases are detected at stage I or II, for which the cure rate is approximately 90%, she noted.

Another misconception of primary care physicians is that lung cancer screening has an unacceptably high false positive rate. Previous reports in the medical literature suggested the rate could be as high as 96%. “This is absolutely, positively wrong. That is not the false positive rate; the false positive rate for lung cancer screening is less than 10%,” Dr. McKee emphasized.

“So we have to change that in the minds of primary care providers as well,” she underscored.
 

Report highlights racial disparities

The report also highlights the racial disparities that persist in all aspects of lung cancer management – early diagnosis, surgical treatment, lack of treatment, and survival.

For example, Black Americans are 18% less likely to be diagnosed with early-stage disease and are 23% less likely to receive surgical treatment than their White counterparts. They are also 9% more likely to receive no treatment at all, and mortality from lung cancer among Black patients is 21% worse than it is for White patients.

The same trend is seen among Latinx persons, although they are just as likely as White patients to undergo surgical treatment.

First and foremost, “we have to make sure that the [Black and Latinx persons] are screened in an equal fashion,” Dr. McKee said. Providing screening for communities of color is one strategy that might improve screening rates, she suggested.

So, too, can outreach programs in which lung cancer experts work with leaders within these communities, because people are more likely to listen to their leaders regarding the importance of screening for early detection of lung cancer.

Physicians also need to emphasize that even for people who quit smoking decades ago, once those persons are in their 70s, “there is a spike again in lung cancer diagnoses, and that is true for both Black and White patients,” Dr. McKee stressed.

“Again, this is something that many doctors are not aware of,” she emphasized.

Dr. McKee has disclosed no relevant financial relationships.

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

In recent years, the survival rate for patients with lung cancer has increased to the point where now, almost one-quarter of patients with lung cancer are alive 5 years after being diagnosed.

This new statistic is highlighted in the State of Lung Cancer report from the American Lung Association (ALA), published online on Nov. 16.

“If you look back, the 5-year survival rate has been very slowly eking up at about 1% over the years,” Andrea McKee, MD, volunteer spokesperson at the ALA, told this news organization. The report shows that the 5-year survival rate increased by 14.5% over the past 5 years. “To see this big jump is truly remarkable, so that is something we are all celebrating,” she added.

“But we have to change the fatalistic thinking that both patients and primary care physicians still have about lung cancer. Most people say, ‘Everybody I know who had lung cancer died,’ and that was the way it used to be,” she commented, “but that has now changed. Lung cancer is highly curable in its early stages, and even if not early-stage, there are treatments that are making an impact now.”

“So we’ve got to change that perception, as it does exist, even on the part of primary care providers, too,” Dr. McKee emphasized.
 

Lung cancer decreasing but still being diagnosed late

The report notes that the risk of being diagnosed with lung cancer varies considerably across the United States. For example, rates of lung cancer diagnoses are almost 2.5 times higher in Kentucky than in Utah.

Overall, the incidence is decreasing. “Over the last 5 years, the rate of new cases decreased 10% nationally,” the authors point out.

However, in almost half of the cases, the disease is diagnosed in late stages.

When diagnosed at a late stage, the 5-year survival rate for lung cancer drops to only 6%, whereas when the disease is diagnosed early, the 5-year survival rate is 60%.

At present, around 24% of cases of lung cancer are diagnosed at early stages, the report notes, but again, this varies across the United States. The highest rate (30%) is in Massachusetts, and the lowest rate (19%) is in Hawaii.

The percentage of lung cancer cases diagnosed early has been steadily increasing, presumably in part because of the introduction of low-dose CT screening for individuals at highest risk (such as smokers).

However, across the nation, only 5.7% of individuals at high risk for lung cancer underwent annual low-dose CT screening, the report notes.

“CT screening is so powerful at saving lives that even with only 5.7% of people that we’ve been able to screen, I believe it’s making a difference,” Dr. McKee commented. That small national percentage still represents a considerable number of patients, she noted, “so even with what we’ve done so far, I believe that screening is making a difference, at least within my own practice, where I’m definitely seeing it,” Dr. McKee emphasized.

Recent changes to the recommendations as to who should undergo lung cancer screening “have almost doubled the size of the screening population in the U.S.,” Dr. McKee commented. “So there are now about 15 million people who need to get screened, and it again helps that primary care physicians know that screening is very powerful at detecting early-stage lung cancer,” she said.

In her hospital’s own screening program, among the individuals who regularly undergo screening, the majority (88%) of lung cancer cases are detected at stage I or II, for which the cure rate is approximately 90%, she noted.

Another misconception of primary care physicians is that lung cancer screening has an unacceptably high false positive rate. Previous reports in the medical literature suggested the rate could be as high as 96%. “This is absolutely, positively wrong. That is not the false positive rate; the false positive rate for lung cancer screening is less than 10%,” Dr. McKee emphasized.

“So we have to change that in the minds of primary care providers as well,” she underscored.
 

Report highlights racial disparities

The report also highlights the racial disparities that persist in all aspects of lung cancer management – early diagnosis, surgical treatment, lack of treatment, and survival.

For example, Black Americans are 18% less likely to be diagnosed with early-stage disease and are 23% less likely to receive surgical treatment than their White counterparts. They are also 9% more likely to receive no treatment at all, and mortality from lung cancer among Black patients is 21% worse than it is for White patients.

The same trend is seen among Latinx persons, although they are just as likely as White patients to undergo surgical treatment.

First and foremost, “we have to make sure that the [Black and Latinx persons] are screened in an equal fashion,” Dr. McKee said. Providing screening for communities of color is one strategy that might improve screening rates, she suggested.

So, too, can outreach programs in which lung cancer experts work with leaders within these communities, because people are more likely to listen to their leaders regarding the importance of screening for early detection of lung cancer.

Physicians also need to emphasize that even for people who quit smoking decades ago, once those persons are in their 70s, “there is a spike again in lung cancer diagnoses, and that is true for both Black and White patients,” Dr. McKee stressed.

“Again, this is something that many doctors are not aware of,” she emphasized.

Dr. McKee has disclosed no relevant financial relationships.

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

Creating a stronger voice for CHEST members in pulmonary, critical care, and sleep medicine, CHEST works to provide opportunities for members to serve as expert sources for both mainstream and trade media.

Below are a few highlights of media coverage from the past few months that work to expand awareness of CHEST and to promote the expertise of CHEST members in the media.
 

The New York Times covers the Philips recall

In August, a New York Times article published quoting incoming CHEST President, David Schulman, MD, MPH, FCCP. The article covered the recent Philips recall and its impact on the COVID-19 pandemic.

Dr. Schulman is quoted saying, “Because the number of people coming into the hospital with severe respiratory symptoms has increased as a result of COVID-19, the demand for these devices has also increased, which is problematic since available supply has decreased as a result of the Philips recall.”

The full article, Breathing Machine Recall Over Possible Cancer Risk Leaves Millions Scrambling for Substitutes, can be found on the New York Times website.
 

Technical expert panel on coverage determinations

Peter Gay, MD, FCCP, was quoted in an article by McKnight’s Long-Term Care News on the recent technical expert panel recommendations for national coverage determinations for optimal noninvasive ventilation.

“Centers for Medicare & Medicaid Services was wanting rigorous scientific support necessary to clarify the ‘reasonable and necessary’ role of these new mechanical therapeutic modalities where there was none in order to move forward,” said Dr. Gay. “What we have done is create a pathway to simplify the maze of regulation and perhaps most importantly, remove the obstacles that currently exist.”

The full article, Panel on Non-Invasive Ventilation Seeks to Simplify ‘Maze’ of Regulation for Device Coverage, can be found on the McKnight’s Long-Term Care News website.
 

Asthma and HRT

Originally appearing in HealthDay, U.S. News and World Report covered a recent journal CHEST^® publication Hormone Replacement Therapy and Development of New Asthma by Erik Soeren Halvard Hansen, MD, et al.

The study included about 34,500 women who were diagnosed with asthma between 1995 and 2018, when they were 40 to 65 years of age. Each was then compared with 10 asthma-free women.

Based on that comparison, HRT use was associated with a 63% higher risk for developing asthma, according to the study.

The full article, HRT Could Raise Odds for Asthma, can be found on the U.S. News & World Report website.
 

Pediatric ICU admission and COVID-19

Healio Pulmonology covered a recent journal CHEST publication, Changes in Pediatric ICU Utilization and Clinical Trends During the Coronavirus Pandemic, by Janine E. Zee-Cheng, MD, et al.

“Severe infections, traumatic injuries, perioperative conditions and acute exacerbations of chronic illnesses such as asthma and diabetes are among the most common causes of admission to a pediatric ICU; thus, the epidemiology of pediatric critical illness was likely sensitive to the indirect effects of COVID-19,” Janine E. Zee-Cheng, MD, adjunct clinical assistant professor of pediatrics in the department of pediatrics at Indiana University School of Medicine, Indianapolis, and colleagues wrote.

The full article, Pediatric ICU admissions significantly decreased during COVID-19 pandemic, can be found on the Healio website.
 

CHEST news

CHEST also recently issued a handful of statements and press releases on a variety of topics including the spread of misinformation, support of mandatory vaccinations for health care workers, and a statement advocating for broader coverage of supplemental oxygen use.

For all recent CHEST News, including these statements, visit the CHEST Newsroom on the CHEST website and follow the hashtag #CHESTNews on Twitter.

If you have been included in a recent news article and would like it to be featured, send the coverage to [email protected].

Creating a stronger voice for CHEST members in pulmonary, critical care, and sleep medicine, CHEST works to provide opportunities for members to serve as expert sources for both mainstream and trade media.

Below are a few highlights of media coverage from the past few months that work to expand awareness of CHEST and to promote the expertise of CHEST members in the media.
 

The New York Times covers the Philips recall

In August, a New York Times article published quoting incoming CHEST President, David Schulman, MD, MPH, FCCP. The article covered the recent Philips recall and its impact on the COVID-19 pandemic.

Dr. Schulman is quoted saying, “Because the number of people coming into the hospital with severe respiratory symptoms has increased as a result of COVID-19, the demand for these devices has also increased, which is problematic since available supply has decreased as a result of the Philips recall.”

The full article, Breathing Machine Recall Over Possible Cancer Risk Leaves Millions Scrambling for Substitutes, can be found on the New York Times website.
 

Technical expert panel on coverage determinations

Peter Gay, MD, FCCP, was quoted in an article by McKnight’s Long-Term Care News on the recent technical expert panel recommendations for national coverage determinations for optimal noninvasive ventilation.

“Centers for Medicare & Medicaid Services was wanting rigorous scientific support necessary to clarify the ‘reasonable and necessary’ role of these new mechanical therapeutic modalities where there was none in order to move forward,” said Dr. Gay. “What we have done is create a pathway to simplify the maze of regulation and perhaps most importantly, remove the obstacles that currently exist.”

The full article, Panel on Non-Invasive Ventilation Seeks to Simplify ‘Maze’ of Regulation for Device Coverage, can be found on the McKnight’s Long-Term Care News website.
 

Asthma and HRT

Originally appearing in HealthDay, U.S. News and World Report covered a recent journal CHEST^® publication Hormone Replacement Therapy and Development of New Asthma by Erik Soeren Halvard Hansen, MD, et al.

The study included about 34,500 women who were diagnosed with asthma between 1995 and 2018, when they were 40 to 65 years of age. Each was then compared with 10 asthma-free women.

Based on that comparison, HRT use was associated with a 63% higher risk for developing asthma, according to the study.

The full article, HRT Could Raise Odds for Asthma, can be found on the U.S. News & World Report website.
 

Pediatric ICU admission and COVID-19

Healio Pulmonology covered a recent journal CHEST publication, Changes in Pediatric ICU Utilization and Clinical Trends During the Coronavirus Pandemic, by Janine E. Zee-Cheng, MD, et al.

“Severe infections, traumatic injuries, perioperative conditions and acute exacerbations of chronic illnesses such as asthma and diabetes are among the most common causes of admission to a pediatric ICU; thus, the epidemiology of pediatric critical illness was likely sensitive to the indirect effects of COVID-19,” Janine E. Zee-Cheng, MD, adjunct clinical assistant professor of pediatrics in the department of pediatrics at Indiana University School of Medicine, Indianapolis, and colleagues wrote.

The full article, Pediatric ICU admissions significantly decreased during COVID-19 pandemic, can be found on the Healio website.
 

CHEST news

CHEST also recently issued a handful of statements and press releases on a variety of topics including the spread of misinformation, support of mandatory vaccinations for health care workers, and a statement advocating for broader coverage of supplemental oxygen use.

For all recent CHEST News, including these statements, visit the CHEST Newsroom on the CHEST website and follow the hashtag #CHESTNews on Twitter.

If you have been included in a recent news article and would like it to be featured, send the coverage to [email protected].

Creating a stronger voice for CHEST members in pulmonary, critical care, and sleep medicine, CHEST works to provide opportunities for members to serve as expert sources for both mainstream and trade media.

Below are a few highlights of media coverage from the past few months that work to expand awareness of CHEST and to promote the expertise of CHEST members in the media.
 

The New York Times covers the Philips recall

In August, a New York Times article published quoting incoming CHEST President, David Schulman, MD, MPH, FCCP. The article covered the recent Philips recall and its impact on the COVID-19 pandemic.

Dr. Schulman is quoted saying, “Because the number of people coming into the hospital with severe respiratory symptoms has increased as a result of COVID-19, the demand for these devices has also increased, which is problematic since available supply has decreased as a result of the Philips recall.”

The full article, Breathing Machine Recall Over Possible Cancer Risk Leaves Millions Scrambling for Substitutes, can be found on the New York Times website.
 

Technical expert panel on coverage determinations

Peter Gay, MD, FCCP, was quoted in an article by McKnight’s Long-Term Care News on the recent technical expert panel recommendations for national coverage determinations for optimal noninvasive ventilation.

“Centers for Medicare & Medicaid Services was wanting rigorous scientific support necessary to clarify the ‘reasonable and necessary’ role of these new mechanical therapeutic modalities where there was none in order to move forward,” said Dr. Gay. “What we have done is create a pathway to simplify the maze of regulation and perhaps most importantly, remove the obstacles that currently exist.”

The full article, Panel on Non-Invasive Ventilation Seeks to Simplify ‘Maze’ of Regulation for Device Coverage, can be found on the McKnight’s Long-Term Care News website.
 

Asthma and HRT

Originally appearing in HealthDay, U.S. News and World Report covered a recent journal CHEST^® publication Hormone Replacement Therapy and Development of New Asthma by Erik Soeren Halvard Hansen, MD, et al.

The study included about 34,500 women who were diagnosed with asthma between 1995 and 2018, when they were 40 to 65 years of age. Each was then compared with 10 asthma-free women.

Based on that comparison, HRT use was associated with a 63% higher risk for developing asthma, according to the study.

The full article, HRT Could Raise Odds for Asthma, can be found on the U.S. News & World Report website.
 

Pediatric ICU admission and COVID-19

Healio Pulmonology covered a recent journal CHEST publication, Changes in Pediatric ICU Utilization and Clinical Trends During the Coronavirus Pandemic, by Janine E. Zee-Cheng, MD, et al.

“Severe infections, traumatic injuries, perioperative conditions and acute exacerbations of chronic illnesses such as asthma and diabetes are among the most common causes of admission to a pediatric ICU; thus, the epidemiology of pediatric critical illness was likely sensitive to the indirect effects of COVID-19,” Janine E. Zee-Cheng, MD, adjunct clinical assistant professor of pediatrics in the department of pediatrics at Indiana University School of Medicine, Indianapolis, and colleagues wrote.

The full article, Pediatric ICU admissions significantly decreased during COVID-19 pandemic, can be found on the Healio website.
 

CHEST news

CHEST also recently issued a handful of statements and press releases on a variety of topics including the spread of misinformation, support of mandatory vaccinations for health care workers, and a statement advocating for broader coverage of supplemental oxygen use.

For all recent CHEST News, including these statements, visit the CHEST Newsroom on the CHEST website and follow the hashtag #CHESTNews on Twitter.

If you have been included in a recent news article and would like it to be featured, send the coverage to [email protected].

(This post is part of Our Life as a Fellow blog post series. This series includes “fellow life lessons” from current trainees in leadership with CHEST.)

Finding your passion in fellowship is an integral part of career development and has a profound impact on a young professional’s personal satisfaction. This can be a difficult task, but it can be accomplished by finding a mentor, thinking about long-term career goals, and considering what re-energizes you. Entering fellowship, some may have a preconceived idea of who they would like to be upon completion of training: An asthma specialist, a physician-scientist, a critical care junkie, etc. For most of us, fellowship is a black box of opportunity with endless paths and permutations. It can be difficult to navigate this landscape, as the path may meander and a few initial interests may develop into true passions.

During my fellowship, I have been fortunate to have had many great teachers and experiences caring for patients with pulmonary hypertension, my current primary focus. Here are a few steps I have taken in pursuit of finding my passion over the past several years of post-graduate medical education. ***Disclaimer: I am still a work in progress.***

First, find a mentor. For me it was easy – I remember interviewing for fellowship with my mentor and thinking: “That is who I want to be.” I think this is hugely important. Use the insights, mistakes, and successes of someone you admire (from near or far) to help guide you. Initially, while getting to know my mentor, it was more comfortable to follow from a safe distance without making an official commitment. This was a slow process that allowed me to explore multiple clinical and research interests simultaneously. Once your mind is set, stating your professional interests in a concise way helps you and your mentor define and differentiate hobbies from passions. The practice of medicine is still very much an apprenticeship, so having someone to act as a sounding board remains important. Mentorship is also critical for networking, which is important for professional growth and life beyond fellowship. Our community is small, and “people know people.” What happens if you can’t find a perfect mentor? Don’t worry! Try out as many mentors as you can find. You can learn from every conversation and relationship. Sometimes the path taken is just as important as the destination.

Second, think about your 5- or 10-year plan. Ultimately, when training is over, we will graduate from fellowship and be released into the wild. The skills we have obtained in training are going to be the foundation for the rest of our careers. Where would you like to be a few years post-training? In a lab? Private practice? Rural medicine? Teaching? Does the energy you are spending in fellowship to develop your passion extend beyond fellowship? Part of the excitement of pursuing a passion is envisioning how it may develop over the period of coming years. I envision honing my skills as a master general pulmonary clinician and then narrowing my focus to create a pulmonary hypertension care center of excellence. I think these are important points to consider while you have the protected headspace of fellowship to experiment and explore, and while you are not constrained by contractual obligations.

Third, think about what personally and professionally energizes you. Especially in the context of an ongoing global pandemic, burnout and physician dissatisfaction are at an all-time high. Acknowledge that your job is tough, and try to identify the things that will keep the engine running. This sounds straightforward, but you have to decide what recharges you and acknowledge those things that don’t. The importance of determining things that energize me did not occur to me until I started searching for my first job. This forced me to make a list of things that contributed to my happiness and dissatisfaction. Most future employers are skilled at asking about these qualities. A happy employee is productive and effective at his or her job!

If you are in training, take some time to get creative and answer the questions above. Doodle, make lists, or journal—find a moment to reflect on your hard work and on the promise of your future.
 

Kevin Swiatek, DO

Dr. Swiatek is a third-year Chief Fellow in the Division of Pulmonary and Critical Care Medicine at Virginia Commonwealth University in Richmond, Virginia. Dr. Swiatek is a member of the CHEST Trainee Work Group. His clinical interests include general pulmonary medicine, care of patients with pulmonary hypertension, and using point-of-care ultrasound (POCUS) as a diagnostic tool in the medical intensive care unit. His scholarly interests include implementation of fellowship medical education, teaching POCUS, and clinical and diagnostic assessment of patients with pulmonary hypertension.

Reprinted from Thought Leader Blog. August 23, 2021. www.chestnet.org.

(This post is part of Our Life as a Fellow blog post series. This series includes “fellow life lessons” from current trainees in leadership with CHEST.)

Finding your passion in fellowship is an integral part of career development and has a profound impact on a young professional’s personal satisfaction. This can be a difficult task, but it can be accomplished by finding a mentor, thinking about long-term career goals, and considering what re-energizes you. Entering fellowship, some may have a preconceived idea of who they would like to be upon completion of training: An asthma specialist, a physician-scientist, a critical care junkie, etc. For most of us, fellowship is a black box of opportunity with endless paths and permutations. It can be difficult to navigate this landscape, as the path may meander and a few initial interests may develop into true passions.

During my fellowship, I have been fortunate to have had many great teachers and experiences caring for patients with pulmonary hypertension, my current primary focus. Here are a few steps I have taken in pursuit of finding my passion over the past several years of post-graduate medical education. ***Disclaimer: I am still a work in progress.***

First, find a mentor. For me it was easy – I remember interviewing for fellowship with my mentor and thinking: “That is who I want to be.” I think this is hugely important. Use the insights, mistakes, and successes of someone you admire (from near or far) to help guide you. Initially, while getting to know my mentor, it was more comfortable to follow from a safe distance without making an official commitment. This was a slow process that allowed me to explore multiple clinical and research interests simultaneously. Once your mind is set, stating your professional interests in a concise way helps you and your mentor define and differentiate hobbies from passions. The practice of medicine is still very much an apprenticeship, so having someone to act as a sounding board remains important. Mentorship is also critical for networking, which is important for professional growth and life beyond fellowship. Our community is small, and “people know people.” What happens if you can’t find a perfect mentor? Don’t worry! Try out as many mentors as you can find. You can learn from every conversation and relationship. Sometimes the path taken is just as important as the destination.

Second, think about your 5- or 10-year plan. Ultimately, when training is over, we will graduate from fellowship and be released into the wild. The skills we have obtained in training are going to be the foundation for the rest of our careers. Where would you like to be a few years post-training? In a lab? Private practice? Rural medicine? Teaching? Does the energy you are spending in fellowship to develop your passion extend beyond fellowship? Part of the excitement of pursuing a passion is envisioning how it may develop over the period of coming years. I envision honing my skills as a master general pulmonary clinician and then narrowing my focus to create a pulmonary hypertension care center of excellence. I think these are important points to consider while you have the protected headspace of fellowship to experiment and explore, and while you are not constrained by contractual obligations.

Third, think about what personally and professionally energizes you. Especially in the context of an ongoing global pandemic, burnout and physician dissatisfaction are at an all-time high. Acknowledge that your job is tough, and try to identify the things that will keep the engine running. This sounds straightforward, but you have to decide what recharges you and acknowledge those things that don’t. The importance of determining things that energize me did not occur to me until I started searching for my first job. This forced me to make a list of things that contributed to my happiness and dissatisfaction. Most future employers are skilled at asking about these qualities. A happy employee is productive and effective at his or her job!

If you are in training, take some time to get creative and answer the questions above. Doodle, make lists, or journal—find a moment to reflect on your hard work and on the promise of your future.
 

Kevin Swiatek, DO

Dr. Swiatek is a third-year Chief Fellow in the Division of Pulmonary and Critical Care Medicine at Virginia Commonwealth University in Richmond, Virginia. Dr. Swiatek is a member of the CHEST Trainee Work Group. His clinical interests include general pulmonary medicine, care of patients with pulmonary hypertension, and using point-of-care ultrasound (POCUS) as a diagnostic tool in the medical intensive care unit. His scholarly interests include implementation of fellowship medical education, teaching POCUS, and clinical and diagnostic assessment of patients with pulmonary hypertension.

Reprinted from Thought Leader Blog. August 23, 2021. www.chestnet.org.

(This post is part of Our Life as a Fellow blog post series. This series includes “fellow life lessons” from current trainees in leadership with CHEST.)

Finding your passion in fellowship is an integral part of career development and has a profound impact on a young professional’s personal satisfaction. This can be a difficult task, but it can be accomplished by finding a mentor, thinking about long-term career goals, and considering what re-energizes you. Entering fellowship, some may have a preconceived idea of who they would like to be upon completion of training: An asthma specialist, a physician-scientist, a critical care junkie, etc. For most of us, fellowship is a black box of opportunity with endless paths and permutations. It can be difficult to navigate this landscape, as the path may meander and a few initial interests may develop into true passions.

During my fellowship, I have been fortunate to have had many great teachers and experiences caring for patients with pulmonary hypertension, my current primary focus. Here are a few steps I have taken in pursuit of finding my passion over the past several years of post-graduate medical education. ***Disclaimer: I am still a work in progress.***

First, find a mentor. For me it was easy – I remember interviewing for fellowship with my mentor and thinking: “That is who I want to be.” I think this is hugely important. Use the insights, mistakes, and successes of someone you admire (from near or far) to help guide you. Initially, while getting to know my mentor, it was more comfortable to follow from a safe distance without making an official commitment. This was a slow process that allowed me to explore multiple clinical and research interests simultaneously. Once your mind is set, stating your professional interests in a concise way helps you and your mentor define and differentiate hobbies from passions. The practice of medicine is still very much an apprenticeship, so having someone to act as a sounding board remains important. Mentorship is also critical for networking, which is important for professional growth and life beyond fellowship. Our community is small, and “people know people.” What happens if you can’t find a perfect mentor? Don’t worry! Try out as many mentors as you can find. You can learn from every conversation and relationship. Sometimes the path taken is just as important as the destination.

Second, think about your 5- or 10-year plan. Ultimately, when training is over, we will graduate from fellowship and be released into the wild. The skills we have obtained in training are going to be the foundation for the rest of our careers. Where would you like to be a few years post-training? In a lab? Private practice? Rural medicine? Teaching? Does the energy you are spending in fellowship to develop your passion extend beyond fellowship? Part of the excitement of pursuing a passion is envisioning how it may develop over the period of coming years. I envision honing my skills as a master general pulmonary clinician and then narrowing my focus to create a pulmonary hypertension care center of excellence. I think these are important points to consider while you have the protected headspace of fellowship to experiment and explore, and while you are not constrained by contractual obligations.

Third, think about what personally and professionally energizes you. Especially in the context of an ongoing global pandemic, burnout and physician dissatisfaction are at an all-time high. Acknowledge that your job is tough, and try to identify the things that will keep the engine running. This sounds straightforward, but you have to decide what recharges you and acknowledge those things that don’t. The importance of determining things that energize me did not occur to me until I started searching for my first job. This forced me to make a list of things that contributed to my happiness and dissatisfaction. Most future employers are skilled at asking about these qualities. A happy employee is productive and effective at his or her job!

If you are in training, take some time to get creative and answer the questions above. Doodle, make lists, or journal—find a moment to reflect on your hard work and on the promise of your future.
 

Kevin Swiatek, DO

Dr. Swiatek is a third-year Chief Fellow in the Division of Pulmonary and Critical Care Medicine at Virginia Commonwealth University in Richmond, Virginia. Dr. Swiatek is a member of the CHEST Trainee Work Group. His clinical interests include general pulmonary medicine, care of patients with pulmonary hypertension, and using point-of-care ultrasound (POCUS) as a diagnostic tool in the medical intensive care unit. His scholarly interests include implementation of fellowship medical education, teaching POCUS, and clinical and diagnostic assessment of patients with pulmonary hypertension.

Reprinted from Thought Leader Blog. August 23, 2021. www.chestnet.org.

Obstructive sleep apnea (OSA) is characterized by repetitive upper airway collapse resulting in intermittent hypoxemia and hypercapnia, large intrathoracic pressure swings, and cortical arousals. The rate of apneas and hypopneas observed during sleep, the apnea-hypopnea index (AHI), has been used for decades to diagnose OSA and to classify its severity. Despite the wide acceptance of this metric by the sleep medicine community, clinical research has found poor correlations between the AHI- and OSA-related complications or symptoms. We have come to learn that the AHI is an oversimplification of a complex and diverse disease process. (Punjabi. Chest. 2016;149[1]:16-9).

The most important features of a disease metric are reliability, and the ability to predict clinically relevant outcomes. The reliability of the AHI has been in question due to substantial night-to-night variability that can lead to missed diagnosis and disease severity misclassification (Dzierzewski et al. J Clin Sleep Med. 2020;16[4]:539-44). Furthermore, the AHI fails to reflect some important physiologic derangements resulting from respiratory events. Apart from imperfectly set thresholds for scoring, it disregards the depth and the duration of ventilatory disturbances. For example, a hypopnea lasting 30 seconds and resulting in a decrease of 10% in oxyhemoglobin saturation is considered equivalent to a hypopnea lasting 10 seconds and resulting in a decrease of 4% in oxyhemoglobin saturation. The AHI also assumes that apneas and hypopneas are equal in their biological effects regardless of when they occur during sleep (NREM vs REM), despite reports suggesting that the sequalae of OSA are sleep-stage dependent (Varga, Mokhlesi. Sleep Breath. 2019;23[2]:413-23). This is further complicated by the varying hypopnea definitions and the difficulties in differentiating obstructive vs central hypopneas. It is doubtful that these events, which differ in mechanism, would result in similar outcomes.
 

Over the past decade, our understanding of the different pathophysiological mechanisms leading to OSA has grown substantially, suggesting the need for a phenotype-specific treatment approach (Zinchuk, Yaggi. Chest. 2020;157[2]:403-20). The reliance on a single metric that does not capture this heterogeneity may prove detrimental to our therapeutic efforts. One extremely important dimension that is missed by the AHI is the patient. Individual response to airway obstruction varies with age, genetics, gender, and comorbidities, among other things. This may explain the difference in symptoms and outcomes experienced by patients with the same AHI. During the era of precision medicine, the concept of defining a clinical condition by a single test result, without regard to patient characteristics, is antiquated.

Several studies have attempted to propose complementary metrics that may better characterize OSA and predict outcomes. The hypoxic burden has gained a lot of attention as it is generally felt that hypoxemia is a major factor contributing to the pathogenesis of OSA-related comorbidities. Azarbarzin, et al. reported a hypoxic burden metric by measuring the area under the oxygen desaturation curve during a respiratory event (Azarbarzin et al. Eur Heart J. 2019;40[14]:1149-57). It factors the length and depth of the desaturations into a single value that expresses the average desaturation burden per hour of sleep time. The hypoxic burden was independently predictive of cardiovascular mortality in two large cohorts. Interestingly, the AHI did not have such an association. Similarly, another novel proposed parameter, the oxygen desaturation rate (ODR), outperformed the AHI in predicting cardiovascular outcomes in severe OSA patients (Wang et al. J Clin Sleep Med. 2020;16[7]:1055-62). The ODR measures the speed of an oxygen desaturation during an apnea event. Subjects with a faster ODR were found to have higher blood pressure values and variability. The authors hypothesized that slower desaturations generate hypoxemia-conditioning that may protect from exaggerated hemodynamic changes. These findings of novel hypoxemia metrics, albeit having their own limitations, recapitulate the need to move beyond the AHI to characterize OSA.

The apnea-hypopnea event duration is another overlooked feature that may impact OSA outcomes. Butler, et al. demonstrated that shorter event duration predicted a higher all-cause mortality over and beyond that predicted by AHI (Butler et al. Am J Respir Crit Care Med. 2019;199[7]:903-12). These results contrast views that early arousals in response to respiratory events may improve outcomes as they reflect a protective mechanism to prevent further hypoxemia and sympatho-excitation. For example, Ma, et al. found that higher percentage of total sleep time spent in apnea/hypopnea (AHT%) predicted worse daytime sleepiness to a higher degree than standard AHI (Ma et al. Sci Rep. 2021;11[1]:4702). However, shorter event duration may represent lower arousal thresholds (increased excitability), and ventilatory control instability (higher loop gain), predisposing patients to augmented sympathetic activity. Along similar lines, the intensity of respiratory-related arousals (as measured by EEG wavelet transformation) was found to be independent of preceding respiratory stimulus, with higher arousal intensity levels correlating with higher respiratory and heart rate responses (Amatoury et al. Sleep. 2016;39[12]:2091-100). The contribution of arousals to OSA morbidity is of particular importance for women in whom long-term outcomes of elevated AHI are poorly understood. Bearing in mind the differences in the metrics used, these results underscore the role of event duration and arousability in the pathogenesis of OSA-related morbidity.

The AHI is certainly an important piece of data that is informative and somewhat predictive. However, when used as a sole disease-defining metric, it has yielded disappointing results, especially after OSA treatment trials failed to show cardiovascular benefits despite therapies achieving a low residual AHI. As we aim to achieve a more personalized approach for diagnosing and treating OSA, we need to explore beyond the concept of a single metric to define a heterogenous and complex disorder. Instead of relying on the frequency of respiratory events, it is time to use complementary polysomnographic data that better reflect the origin and systemic effects of these disturbances. Machine-learning methods may offer sophisticated approaches to identifying polysomnographic patterns for future research. Clinical characteristics will also likely need to be considered in OSA severity scales. The identification of symptom subtypes or blood biomarkers may help identify patient groups who may be impacted differently by OSA, and consequently have a different treatment response (Malhotra et al. Sleep. 2021;44[7]:zsab030).

Almost half a century has lapsed since the original descriptions of OSA. Since then, our understanding of the disorder has improved greatly, with much still to be discovered, but our method of disease capture is unwavering. Future research requires a focus on novel measures aimed at identifying OSA endophenotypes, which will transform our understanding of disease traits and propel us into personalized therapies.
 

Dr. Mansour is Assistant Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina. Dr. Won is Associate Professor of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine; and VA Connecticut Healthcare System, West Haven, Connecticut.

Obstructive sleep apnea (OSA) is characterized by repetitive upper airway collapse resulting in intermittent hypoxemia and hypercapnia, large intrathoracic pressure swings, and cortical arousals. The rate of apneas and hypopneas observed during sleep, the apnea-hypopnea index (AHI), has been used for decades to diagnose OSA and to classify its severity. Despite the wide acceptance of this metric by the sleep medicine community, clinical research has found poor correlations between the AHI- and OSA-related complications or symptoms. We have come to learn that the AHI is an oversimplification of a complex and diverse disease process. (Punjabi. Chest. 2016;149[1]:16-9).

The most important features of a disease metric are reliability, and the ability to predict clinically relevant outcomes. The reliability of the AHI has been in question due to substantial night-to-night variability that can lead to missed diagnosis and disease severity misclassification (Dzierzewski et al. J Clin Sleep Med. 2020;16[4]:539-44). Furthermore, the AHI fails to reflect some important physiologic derangements resulting from respiratory events. Apart from imperfectly set thresholds for scoring, it disregards the depth and the duration of ventilatory disturbances. For example, a hypopnea lasting 30 seconds and resulting in a decrease of 10% in oxyhemoglobin saturation is considered equivalent to a hypopnea lasting 10 seconds and resulting in a decrease of 4% in oxyhemoglobin saturation. The AHI also assumes that apneas and hypopneas are equal in their biological effects regardless of when they occur during sleep (NREM vs REM), despite reports suggesting that the sequalae of OSA are sleep-stage dependent (Varga, Mokhlesi. Sleep Breath. 2019;23[2]:413-23). This is further complicated by the varying hypopnea definitions and the difficulties in differentiating obstructive vs central hypopneas. It is doubtful that these events, which differ in mechanism, would result in similar outcomes.
 

Over the past decade, our understanding of the different pathophysiological mechanisms leading to OSA has grown substantially, suggesting the need for a phenotype-specific treatment approach (Zinchuk, Yaggi. Chest. 2020;157[2]:403-20). The reliance on a single metric that does not capture this heterogeneity may prove detrimental to our therapeutic efforts. One extremely important dimension that is missed by the AHI is the patient. Individual response to airway obstruction varies with age, genetics, gender, and comorbidities, among other things. This may explain the difference in symptoms and outcomes experienced by patients with the same AHI. During the era of precision medicine, the concept of defining a clinical condition by a single test result, without regard to patient characteristics, is antiquated.

Several studies have attempted to propose complementary metrics that may better characterize OSA and predict outcomes. The hypoxic burden has gained a lot of attention as it is generally felt that hypoxemia is a major factor contributing to the pathogenesis of OSA-related comorbidities. Azarbarzin, et al. reported a hypoxic burden metric by measuring the area under the oxygen desaturation curve during a respiratory event (Azarbarzin et al. Eur Heart J. 2019;40[14]:1149-57). It factors the length and depth of the desaturations into a single value that expresses the average desaturation burden per hour of sleep time. The hypoxic burden was independently predictive of cardiovascular mortality in two large cohorts. Interestingly, the AHI did not have such an association. Similarly, another novel proposed parameter, the oxygen desaturation rate (ODR), outperformed the AHI in predicting cardiovascular outcomes in severe OSA patients (Wang et al. J Clin Sleep Med. 2020;16[7]:1055-62). The ODR measures the speed of an oxygen desaturation during an apnea event. Subjects with a faster ODR were found to have higher blood pressure values and variability. The authors hypothesized that slower desaturations generate hypoxemia-conditioning that may protect from exaggerated hemodynamic changes. These findings of novel hypoxemia metrics, albeit having their own limitations, recapitulate the need to move beyond the AHI to characterize OSA.

The apnea-hypopnea event duration is another overlooked feature that may impact OSA outcomes. Butler, et al. demonstrated that shorter event duration predicted a higher all-cause mortality over and beyond that predicted by AHI (Butler et al. Am J Respir Crit Care Med. 2019;199[7]:903-12). These results contrast views that early arousals in response to respiratory events may improve outcomes as they reflect a protective mechanism to prevent further hypoxemia and sympatho-excitation. For example, Ma, et al. found that higher percentage of total sleep time spent in apnea/hypopnea (AHT%) predicted worse daytime sleepiness to a higher degree than standard AHI (Ma et al. Sci Rep. 2021;11[1]:4702). However, shorter event duration may represent lower arousal thresholds (increased excitability), and ventilatory control instability (higher loop gain), predisposing patients to augmented sympathetic activity. Along similar lines, the intensity of respiratory-related arousals (as measured by EEG wavelet transformation) was found to be independent of preceding respiratory stimulus, with higher arousal intensity levels correlating with higher respiratory and heart rate responses (Amatoury et al. Sleep. 2016;39[12]:2091-100). The contribution of arousals to OSA morbidity is of particular importance for women in whom long-term outcomes of elevated AHI are poorly understood. Bearing in mind the differences in the metrics used, these results underscore the role of event duration and arousability in the pathogenesis of OSA-related morbidity.

The AHI is certainly an important piece of data that is informative and somewhat predictive. However, when used as a sole disease-defining metric, it has yielded disappointing results, especially after OSA treatment trials failed to show cardiovascular benefits despite therapies achieving a low residual AHI. As we aim to achieve a more personalized approach for diagnosing and treating OSA, we need to explore beyond the concept of a single metric to define a heterogenous and complex disorder. Instead of relying on the frequency of respiratory events, it is time to use complementary polysomnographic data that better reflect the origin and systemic effects of these disturbances. Machine-learning methods may offer sophisticated approaches to identifying polysomnographic patterns for future research. Clinical characteristics will also likely need to be considered in OSA severity scales. The identification of symptom subtypes or blood biomarkers may help identify patient groups who may be impacted differently by OSA, and consequently have a different treatment response (Malhotra et al. Sleep. 2021;44[7]:zsab030).

Almost half a century has lapsed since the original descriptions of OSA. Since then, our understanding of the disorder has improved greatly, with much still to be discovered, but our method of disease capture is unwavering. Future research requires a focus on novel measures aimed at identifying OSA endophenotypes, which will transform our understanding of disease traits and propel us into personalized therapies.
 

Dr. Mansour is Assistant Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina. Dr. Won is Associate Professor of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine; and VA Connecticut Healthcare System, West Haven, Connecticut.

Obstructive sleep apnea (OSA) is characterized by repetitive upper airway collapse resulting in intermittent hypoxemia and hypercapnia, large intrathoracic pressure swings, and cortical arousals. The rate of apneas and hypopneas observed during sleep, the apnea-hypopnea index (AHI), has been used for decades to diagnose OSA and to classify its severity. Despite the wide acceptance of this metric by the sleep medicine community, clinical research has found poor correlations between the AHI- and OSA-related complications or symptoms. We have come to learn that the AHI is an oversimplification of a complex and diverse disease process. (Punjabi. Chest. 2016;149[1]:16-9).

The most important features of a disease metric are reliability, and the ability to predict clinically relevant outcomes. The reliability of the AHI has been in question due to substantial night-to-night variability that can lead to missed diagnosis and disease severity misclassification (Dzierzewski et al. J Clin Sleep Med. 2020;16[4]:539-44). Furthermore, the AHI fails to reflect some important physiologic derangements resulting from respiratory events. Apart from imperfectly set thresholds for scoring, it disregards the depth and the duration of ventilatory disturbances. For example, a hypopnea lasting 30 seconds and resulting in a decrease of 10% in oxyhemoglobin saturation is considered equivalent to a hypopnea lasting 10 seconds and resulting in a decrease of 4% in oxyhemoglobin saturation. The AHI also assumes that apneas and hypopneas are equal in their biological effects regardless of when they occur during sleep (NREM vs REM), despite reports suggesting that the sequalae of OSA are sleep-stage dependent (Varga, Mokhlesi. Sleep Breath. 2019;23[2]:413-23). This is further complicated by the varying hypopnea definitions and the difficulties in differentiating obstructive vs central hypopneas. It is doubtful that these events, which differ in mechanism, would result in similar outcomes.
 

Over the past decade, our understanding of the different pathophysiological mechanisms leading to OSA has grown substantially, suggesting the need for a phenotype-specific treatment approach (Zinchuk, Yaggi. Chest. 2020;157[2]:403-20). The reliance on a single metric that does not capture this heterogeneity may prove detrimental to our therapeutic efforts. One extremely important dimension that is missed by the AHI is the patient. Individual response to airway obstruction varies with age, genetics, gender, and comorbidities, among other things. This may explain the difference in symptoms and outcomes experienced by patients with the same AHI. During the era of precision medicine, the concept of defining a clinical condition by a single test result, without regard to patient characteristics, is antiquated.

Several studies have attempted to propose complementary metrics that may better characterize OSA and predict outcomes. The hypoxic burden has gained a lot of attention as it is generally felt that hypoxemia is a major factor contributing to the pathogenesis of OSA-related comorbidities. Azarbarzin, et al. reported a hypoxic burden metric by measuring the area under the oxygen desaturation curve during a respiratory event (Azarbarzin et al. Eur Heart J. 2019;40[14]:1149-57). It factors the length and depth of the desaturations into a single value that expresses the average desaturation burden per hour of sleep time. The hypoxic burden was independently predictive of cardiovascular mortality in two large cohorts. Interestingly, the AHI did not have such an association. Similarly, another novel proposed parameter, the oxygen desaturation rate (ODR), outperformed the AHI in predicting cardiovascular outcomes in severe OSA patients (Wang et al. J Clin Sleep Med. 2020;16[7]:1055-62). The ODR measures the speed of an oxygen desaturation during an apnea event. Subjects with a faster ODR were found to have higher blood pressure values and variability. The authors hypothesized that slower desaturations generate hypoxemia-conditioning that may protect from exaggerated hemodynamic changes. These findings of novel hypoxemia metrics, albeit having their own limitations, recapitulate the need to move beyond the AHI to characterize OSA.

The apnea-hypopnea event duration is another overlooked feature that may impact OSA outcomes. Butler, et al. demonstrated that shorter event duration predicted a higher all-cause mortality over and beyond that predicted by AHI (Butler et al. Am J Respir Crit Care Med. 2019;199[7]:903-12). These results contrast views that early arousals in response to respiratory events may improve outcomes as they reflect a protective mechanism to prevent further hypoxemia and sympatho-excitation. For example, Ma, et al. found that higher percentage of total sleep time spent in apnea/hypopnea (AHT%) predicted worse daytime sleepiness to a higher degree than standard AHI (Ma et al. Sci Rep. 2021;11[1]:4702). However, shorter event duration may represent lower arousal thresholds (increased excitability), and ventilatory control instability (higher loop gain), predisposing patients to augmented sympathetic activity. Along similar lines, the intensity of respiratory-related arousals (as measured by EEG wavelet transformation) was found to be independent of preceding respiratory stimulus, with higher arousal intensity levels correlating with higher respiratory and heart rate responses (Amatoury et al. Sleep. 2016;39[12]:2091-100). The contribution of arousals to OSA morbidity is of particular importance for women in whom long-term outcomes of elevated AHI are poorly understood. Bearing in mind the differences in the metrics used, these results underscore the role of event duration and arousability in the pathogenesis of OSA-related morbidity.

The AHI is certainly an important piece of data that is informative and somewhat predictive. However, when used as a sole disease-defining metric, it has yielded disappointing results, especially after OSA treatment trials failed to show cardiovascular benefits despite therapies achieving a low residual AHI. As we aim to achieve a more personalized approach for diagnosing and treating OSA, we need to explore beyond the concept of a single metric to define a heterogenous and complex disorder. Instead of relying on the frequency of respiratory events, it is time to use complementary polysomnographic data that better reflect the origin and systemic effects of these disturbances. Machine-learning methods may offer sophisticated approaches to identifying polysomnographic patterns for future research. Clinical characteristics will also likely need to be considered in OSA severity scales. The identification of symptom subtypes or blood biomarkers may help identify patient groups who may be impacted differently by OSA, and consequently have a different treatment response (Malhotra et al. Sleep. 2021;44[7]:zsab030).

Almost half a century has lapsed since the original descriptions of OSA. Since then, our understanding of the disorder has improved greatly, with much still to be discovered, but our method of disease capture is unwavering. Future research requires a focus on novel measures aimed at identifying OSA endophenotypes, which will transform our understanding of disease traits and propel us into personalized therapies.
 

Dr. Mansour is Assistant Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina. Dr. Won is Associate Professor of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine; and VA Connecticut Healthcare System, West Haven, Connecticut.

Just over 1.35 million children under age 12 years have received the COVID-19 vaccine since it was approved on Nov. 2, putting them behind the initial pace set by 12- to 15-year-olds in the spring, based on data from the Centers for Disease Control and Prevention.

Specific figures for children aged 5-11 years are not yet available, but CDC data show that 1.55 million children under the age of 12 years had received at least one dose of COVID-19 vaccine as of Nov. 15, of whom almost 204,000 already had been vaccinated before Nov. 2. For children aged 12-15, the first 2 weeks after approval on May 12 produced almost 2.1 million vaccine initiations, according to the CDC’s COVID Data Tracker.

That dataset reveals several other noteworthy differences between the two age groups in the 10 days after approval:
 

• There were over 7,000 vaccine initiations on the first day in the 12-15 group; the younger group had 32.
• The older children reached 100,000 per day in 3 days; the younger children took 8 days.
• The older group topped 200,000 vaccinations per day on six different days; the younger group didn’t get above 175,000.

Children under 12 made up 27.5% of vaccine initiations in all age groups during the 2 weeks from Nov. 2 to Nov. 15, versus 3.4% for 12- to 15-year-olds and 1.2% for 16- and 17-year-olds, the CDC said, while also reporting that 3.6% of children under age 12 had received at least one dose of the COVID vaccine, compared with 57.8% of those aged 12-15 and 64.4% of 16- to 17-year-olds.

Meanwhile, the first full week of November marked the second consecutive increase in the number of weekly child COVID cases, with 122,000 reported for Nov. 5-11. The number of new cases has now surpassed 100,000 for 14 consecutive weeks, the American Academy of Pediatrics and the Children’s Hospital Association said in their weekly COVID report. That report, which covers state health departments, has not included current information from Alabama, Nebraska, and Texas since the summer.

Regionally, the increases over the past 2 weeks were spread out among the East, the Midwest, and the West, while the decline that had been going on for several weeks in the South has largely come to a halt. The states with the highest percent increases over those 2 weeks are all in New England: Maine, New Hampshire, and Vermont, the AAP and CHA noted. In a separate report, the AAP said that Vermont has the second-highest child vaccination rate (81%) in the country, just behind Massachusetts (82%).

[email protected]

Just over 1.35 million children under age 12 years have received the COVID-19 vaccine since it was approved on Nov. 2, putting them behind the initial pace set by 12- to 15-year-olds in the spring, based on data from the Centers for Disease Control and Prevention.

Specific figures for children aged 5-11 years are not yet available, but CDC data show that 1.55 million children under the age of 12 years had received at least one dose of COVID-19 vaccine as of Nov. 15, of whom almost 204,000 already had been vaccinated before Nov. 2. For children aged 12-15, the first 2 weeks after approval on May 12 produced almost 2.1 million vaccine initiations, according to the CDC’s COVID Data Tracker.

That dataset reveals several other noteworthy differences between the two age groups in the 10 days after approval:
 

• There were over 7,000 vaccine initiations on the first day in the 12-15 group; the younger group had 32.
• The older children reached 100,000 per day in 3 days; the younger children took 8 days.
• The older group topped 200,000 vaccinations per day on six different days; the younger group didn’t get above 175,000.

Children under 12 made up 27.5% of vaccine initiations in all age groups during the 2 weeks from Nov. 2 to Nov. 15, versus 3.4% for 12- to 15-year-olds and 1.2% for 16- and 17-year-olds, the CDC said, while also reporting that 3.6% of children under age 12 had received at least one dose of the COVID vaccine, compared with 57.8% of those aged 12-15 and 64.4% of 16- to 17-year-olds.

Meanwhile, the first full week of November marked the second consecutive increase in the number of weekly child COVID cases, with 122,000 reported for Nov. 5-11. The number of new cases has now surpassed 100,000 for 14 consecutive weeks, the American Academy of Pediatrics and the Children’s Hospital Association said in their weekly COVID report. That report, which covers state health departments, has not included current information from Alabama, Nebraska, and Texas since the summer.

Regionally, the increases over the past 2 weeks were spread out among the East, the Midwest, and the West, while the decline that had been going on for several weeks in the South has largely come to a halt. The states with the highest percent increases over those 2 weeks are all in New England: Maine, New Hampshire, and Vermont, the AAP and CHA noted. In a separate report, the AAP said that Vermont has the second-highest child vaccination rate (81%) in the country, just behind Massachusetts (82%).

[email protected]

Just over 1.35 million children under age 12 years have received the COVID-19 vaccine since it was approved on Nov. 2, putting them behind the initial pace set by 12- to 15-year-olds in the spring, based on data from the Centers for Disease Control and Prevention.

Specific figures for children aged 5-11 years are not yet available, but CDC data show that 1.55 million children under the age of 12 years had received at least one dose of COVID-19 vaccine as of Nov. 15, of whom almost 204,000 already had been vaccinated before Nov. 2. For children aged 12-15, the first 2 weeks after approval on May 12 produced almost 2.1 million vaccine initiations, according to the CDC’s COVID Data Tracker.

That dataset reveals several other noteworthy differences between the two age groups in the 10 days after approval:
 

• There were over 7,000 vaccine initiations on the first day in the 12-15 group; the younger group had 32.
• The older children reached 100,000 per day in 3 days; the younger children took 8 days.
• The older group topped 200,000 vaccinations per day on six different days; the younger group didn’t get above 175,000.

Children under 12 made up 27.5% of vaccine initiations in all age groups during the 2 weeks from Nov. 2 to Nov. 15, versus 3.4% for 12- to 15-year-olds and 1.2% for 16- and 17-year-olds, the CDC said, while also reporting that 3.6% of children under age 12 had received at least one dose of the COVID vaccine, compared with 57.8% of those aged 12-15 and 64.4% of 16- to 17-year-olds.

Meanwhile, the first full week of November marked the second consecutive increase in the number of weekly child COVID cases, with 122,000 reported for Nov. 5-11. The number of new cases has now surpassed 100,000 for 14 consecutive weeks, the American Academy of Pediatrics and the Children’s Hospital Association said in their weekly COVID report. That report, which covers state health departments, has not included current information from Alabama, Nebraska, and Texas since the summer.

Regionally, the increases over the past 2 weeks were spread out among the East, the Midwest, and the West, while the decline that had been going on for several weeks in the South has largely come to a halt. The states with the highest percent increases over those 2 weeks are all in New England: Maine, New Hampshire, and Vermont, the AAP and CHA noted. In a separate report, the AAP said that Vermont has the second-highest child vaccination rate (81%) in the country, just behind Massachusetts (82%).

[email protected]

A recent article published in Nature Methods highlights how hierarchical phase-contrast tomography (HiP-CT), an x-ray phase propagation technique that uses spatial coherence to conduct three-dimensional scans of organs ex vivo, may offer clinicians greater insights into disease processes.

“It is not a clinical technique as such,” said Claire Walsh PhD, a biophysicist and senior research fellow at the Center for Advanced Biomedical Imaging, University College London, and one of the authors of the article. She stressed that HiP-CT is used ex vivo.

“This technology uses x-rays from a fourth-generation x-ray source, the European Synchrotron Radiation Facility’s Extremely Brilliant Source. It is an incredibly bright x-ray source,” said Dr. Walsh in an interview. She said synchrotron x-ray tomography provides a much enhanced view of the lungs of persons who had had COVID-19. “We are looking at a different property of the x-ray waves. We are looking at a phase shift. [HiP-CT] is much, much more sensitive to small changes in the tissue than x-ray or CT. Another massive advantage of HiP-CT is the resolution it offers. The resolution goes down to single cells inside an intact human organ,” she said.

The resolution permits researchers to view blood vessels 5 μm in diameter in an intact lung. In comparison, clinical CT images show blood vessels of around 1 mm in diameter – 200 times larger.

“This technique will help us understand the structure of organs at a more fundamental level,” said Dr. Walsh. She noted that the technology has been valuable in allowing greater understanding of COVID-19 disease process. “This is about building an understanding of what the disease is doing in our bodies. If we don’t understand what the disease is changing structurally, it is very hard to understand how to go about developing treatments,” she said.

There are few synchrotron radiation facilities, so this technology is not widely available. Because of the very high radiation dose, the technique will be used ex vivo for the foreseeable future, Dr. Walsh said.

“The x-ray dose is incredibly high; 2-kg normal CT scans are approximately 100 mG [milligauss]. This is 20,000 times more than a medical CT scan,” explained Dr. Walsh. “We don’t really have plans for this to become an in vivo human technique. We are aiming that we will be able to register clinical scans to HiP-CT in a few cases, and so HiP-CT will become a calibration for analyzing clinical techniques.”

Elsie T. Nguyen, MD, FRCPC, vice-president of the Canadian Society of Thoracic Radiology and associate professor of radiology, University of Toronto, noted that the technology will be valuable in pathology and radiology.

“HiP-CT appears to be an exciting new development that can help physicians, including radiologists, understand pathology that was once beyond the spatial resolution of computed tomography scans,” said Dr. Nguyen in an interview. “The fact that vascular abnormalities particularly relating to severe COVID-19 pneumonia can be visualized to the micron level is very novel and exciting. This will help us understand better from a mechanistic point of view what is happening to the blood vessels that contributes to worse outcomes, like shunting of blood or blood clots, and may have applications for prognostication to predict which patients are likely to survive severe COVID-19 pneumonia.”

Dr. Nguyen noted that HiP-CT could help thoracic radiologists better visualize honeycomb cysts associated with fibrotic interstitial lung disease (ILD). It could help to classify the type of fibrotic ILD and inform patient prognosis.

“Currently, we struggle to differentiate early honeycomb cysts, which are a sign of more advanced lung destruction, from traction bronchiolectasis, that is, dilated airways due to surrounding fibrotic lung, on high-resolution computed tomography of the lungs,” said Dr. Nguyen. She said HiP-CT was very promising and had many applications in addition to visualizing the lungs.

The research was funded by the Chan Zuckerberg Initiative, the ESRF, the UK-MRC, and the Royal Academy of Engineering. Dr. Walsh and Dr. Nguyen have disclosed no relevant financial relationships.

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

A recent article published in Nature Methods highlights how hierarchical phase-contrast tomography (HiP-CT), an x-ray phase propagation technique that uses spatial coherence to conduct three-dimensional scans of organs ex vivo, may offer clinicians greater insights into disease processes.

“It is not a clinical technique as such,” said Claire Walsh PhD, a biophysicist and senior research fellow at the Center for Advanced Biomedical Imaging, University College London, and one of the authors of the article. She stressed that HiP-CT is used ex vivo.

“This technology uses x-rays from a fourth-generation x-ray source, the European Synchrotron Radiation Facility’s Extremely Brilliant Source. It is an incredibly bright x-ray source,” said Dr. Walsh in an interview. She said synchrotron x-ray tomography provides a much enhanced view of the lungs of persons who had had COVID-19. “We are looking at a different property of the x-ray waves. We are looking at a phase shift. [HiP-CT] is much, much more sensitive to small changes in the tissue than x-ray or CT. Another massive advantage of HiP-CT is the resolution it offers. The resolution goes down to single cells inside an intact human organ,” she said.

The resolution permits researchers to view blood vessels 5 μm in diameter in an intact lung. In comparison, clinical CT images show blood vessels of around 1 mm in diameter – 200 times larger.

“This technique will help us understand the structure of organs at a more fundamental level,” said Dr. Walsh. She noted that the technology has been valuable in allowing greater understanding of COVID-19 disease process. “This is about building an understanding of what the disease is doing in our bodies. If we don’t understand what the disease is changing structurally, it is very hard to understand how to go about developing treatments,” she said.

There are few synchrotron radiation facilities, so this technology is not widely available. Because of the very high radiation dose, the technique will be used ex vivo for the foreseeable future, Dr. Walsh said.

“The x-ray dose is incredibly high; 2-kg normal CT scans are approximately 100 mG [milligauss]. This is 20,000 times more than a medical CT scan,” explained Dr. Walsh. “We don’t really have plans for this to become an in vivo human technique. We are aiming that we will be able to register clinical scans to HiP-CT in a few cases, and so HiP-CT will become a calibration for analyzing clinical techniques.”

Elsie T. Nguyen, MD, FRCPC, vice-president of the Canadian Society of Thoracic Radiology and associate professor of radiology, University of Toronto, noted that the technology will be valuable in pathology and radiology.

“HiP-CT appears to be an exciting new development that can help physicians, including radiologists, understand pathology that was once beyond the spatial resolution of computed tomography scans,” said Dr. Nguyen in an interview. “The fact that vascular abnormalities particularly relating to severe COVID-19 pneumonia can be visualized to the micron level is very novel and exciting. This will help us understand better from a mechanistic point of view what is happening to the blood vessels that contributes to worse outcomes, like shunting of blood or blood clots, and may have applications for prognostication to predict which patients are likely to survive severe COVID-19 pneumonia.”

Dr. Nguyen noted that HiP-CT could help thoracic radiologists better visualize honeycomb cysts associated with fibrotic interstitial lung disease (ILD). It could help to classify the type of fibrotic ILD and inform patient prognosis.

“Currently, we struggle to differentiate early honeycomb cysts, which are a sign of more advanced lung destruction, from traction bronchiolectasis, that is, dilated airways due to surrounding fibrotic lung, on high-resolution computed tomography of the lungs,” said Dr. Nguyen. She said HiP-CT was very promising and had many applications in addition to visualizing the lungs.

The research was funded by the Chan Zuckerberg Initiative, the ESRF, the UK-MRC, and the Royal Academy of Engineering. Dr. Walsh and Dr. Nguyen have disclosed no relevant financial relationships.

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

A recent article published in Nature Methods highlights how hierarchical phase-contrast tomography (HiP-CT), an x-ray phase propagation technique that uses spatial coherence to conduct three-dimensional scans of organs ex vivo, may offer clinicians greater insights into disease processes.

“It is not a clinical technique as such,” said Claire Walsh PhD, a biophysicist and senior research fellow at the Center for Advanced Biomedical Imaging, University College London, and one of the authors of the article. She stressed that HiP-CT is used ex vivo.

“This technology uses x-rays from a fourth-generation x-ray source, the European Synchrotron Radiation Facility’s Extremely Brilliant Source. It is an incredibly bright x-ray source,” said Dr. Walsh in an interview. She said synchrotron x-ray tomography provides a much enhanced view of the lungs of persons who had had COVID-19. “We are looking at a different property of the x-ray waves. We are looking at a phase shift. [HiP-CT] is much, much more sensitive to small changes in the tissue than x-ray or CT. Another massive advantage of HiP-CT is the resolution it offers. The resolution goes down to single cells inside an intact human organ,” she said.

The resolution permits researchers to view blood vessels 5 μm in diameter in an intact lung. In comparison, clinical CT images show blood vessels of around 1 mm in diameter – 200 times larger.

“This technique will help us understand the structure of organs at a more fundamental level,” said Dr. Walsh. She noted that the technology has been valuable in allowing greater understanding of COVID-19 disease process. “This is about building an understanding of what the disease is doing in our bodies. If we don’t understand what the disease is changing structurally, it is very hard to understand how to go about developing treatments,” she said.

There are few synchrotron radiation facilities, so this technology is not widely available. Because of the very high radiation dose, the technique will be used ex vivo for the foreseeable future, Dr. Walsh said.

“The x-ray dose is incredibly high; 2-kg normal CT scans are approximately 100 mG [milligauss]. This is 20,000 times more than a medical CT scan,” explained Dr. Walsh. “We don’t really have plans for this to become an in vivo human technique. We are aiming that we will be able to register clinical scans to HiP-CT in a few cases, and so HiP-CT will become a calibration for analyzing clinical techniques.”

Elsie T. Nguyen, MD, FRCPC, vice-president of the Canadian Society of Thoracic Radiology and associate professor of radiology, University of Toronto, noted that the technology will be valuable in pathology and radiology.

“HiP-CT appears to be an exciting new development that can help physicians, including radiologists, understand pathology that was once beyond the spatial resolution of computed tomography scans,” said Dr. Nguyen in an interview. “The fact that vascular abnormalities particularly relating to severe COVID-19 pneumonia can be visualized to the micron level is very novel and exciting. This will help us understand better from a mechanistic point of view what is happening to the blood vessels that contributes to worse outcomes, like shunting of blood or blood clots, and may have applications for prognostication to predict which patients are likely to survive severe COVID-19 pneumonia.”

Dr. Nguyen noted that HiP-CT could help thoracic radiologists better visualize honeycomb cysts associated with fibrotic interstitial lung disease (ILD). It could help to classify the type of fibrotic ILD and inform patient prognosis.

“Currently, we struggle to differentiate early honeycomb cysts, which are a sign of more advanced lung destruction, from traction bronchiolectasis, that is, dilated airways due to surrounding fibrotic lung, on high-resolution computed tomography of the lungs,” said Dr. Nguyen. She said HiP-CT was very promising and had many applications in addition to visualizing the lungs.

The research was funded by the Chan Zuckerberg Initiative, the ESRF, the UK-MRC, and the Royal Academy of Engineering. Dr. Walsh and Dr. Nguyen have disclosed no relevant financial relationships.

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

On day 1 of her fellowship, Francesca C. Duncan, MD, was blindsided by her first patient.

The patient, a White man who was accompanied by his wife, sat in the exam room with his sunglasses on.

“I remember him saying, ‘I need to take off my sunglasses so you don’t look so Black,’” said Dr. Duncan, a pulmonologist and intensivist at Indiana University, Indianapolis, who has a specialty in lung cancer disparities.

The patient proceeded to grill her about her experience and training. He asked where she attended college and mocked her degree from a historically Black university. His wife sat there, silent.

Dr. Duncan was shocked by the fact that she still had to defend her credentials.

“I just kind of felt like at that point in my training, my title would have earned me more respect,” said Dr. Duncan, now an assistant professor after recently completing a 3-year fellowship in pulmonary and critical care medicine. “I thought at some point [the racism and discrimination] would stop, but after all that training, all that late-night studying, I still had to prove myself.”

Unfortunately, Dr. Duncan’s experience in fellowship is not unique.

A recent survey of hematology and oncology fellows revealed that medical trainees routinely encounter discrimination during their training.

The 17 fellows who were anonymously interviewed in the survey all recalled experiencing or witnessing discriminatory behaviors during their fellowship, mostly from patients. These encounters rarely come to light. Only one respondent officially reported an incident.

The findings, published online November 8 in JAMA Network Open, underscore the need for graduate medical education programs to improve learning environments and support for trainees, lead author Rahma M. Warsame, MD, and colleagues say .
 

Discrimination at work

Initially, Dr. Warsame and co–principal investigator Katharine Price, MD, were tasked with developing strategies to mitigate instances of racism and bias that fellows encountered during training, but both felt it was critical to understand the experiences of their trainees first.

Out of 34 fellows and recent graduates of the hematology and oncology fellowship program of the Mayo Clinic, Rochester, Minn., 20 consented to participate in the study. Of those, 17 were interviewed between July and November 2018. Among the 17 interviewees, six were Asian, two were Black, three were Hispanic, two were multiracial, and four were White.

Dr. Warsame and colleagues found that everyone reported experiencing or witnessing biased or discriminatory events. The majority of these offenses were committed by patients, not faculty or other employees. The researchers largely interpreted most of the incidents as microaggressions.

From the interviews, the researchers identified six central themes. Among them: foreign fellows and U.S.-born trainees being perceived or made to feel like outsiders; inappropriate comments being made toward female employees about their looks, credentials, or marital status; lack of action after reporting incidents or concerns that reporting such incidents would be futile; and strategies fellows used to cope after negative interactions.

One interviewee said, “I was fired by a patient because I have an accent.” Another said that when she is interviewing for jobs, she is always asked if she has children: “Maybe they’re asking in an innocuous manner, but I always feel like people worry. Is this person going to take maternity leave and be less available for work?”

For Dr. Warsame, “the idea that American citizens were frequently made to feel like they do not belong was surprising.”

Not surprising to Dr. Warsame, however, was the importance of fostering diversity and inclusion during fellowship years. Fellows often noted that greater diversity within the program helped create a more inclusive environment.

“[What’s] important to reinforce is the value of creating platforms for honest discussion and intentionally seeking fellows’ voices and perspectives, which in turn makes them feel like they belong,” Dr. Warsame said.

Still, the researchers found that fellows often did not report incidents of discrimination or bias. Only six trainees were aware of policies for reporting patient misconduct or discrimination, and only one ever reported an incident.
 

Where’s the support?

For Dr. Duncan, her encounter 3 years ago with the patient with sunglasses wasn’t her first experience of discrimination on the job — or her last.

Although hurtful in the moment, she had the wherewithal to report the incident to her attending physician, who was equally shocked. Initially unsure of how to handle it, the attending ultimately stepped up and provided “immense support,” Dr. Duncan said

The issue was brought to the attention of the program director, who took swift action. The patient was documented as “disruptive,” informed of that status in writing, and was banned from receiving treatment from trainees at the center, although Dr. Duncan noted he still received the medical care he needed.

Often, however, fellows who report incidents of discrimination and racism receive little support. According to Dr. Warsame and colleagues, most trainees don’t bother reporting these experiences because they believe that doing so would be futile.

“Concerns about reporting included jeopardizing future employability, risk of retaliation, and challenges reporting experiences that could be perceived as subjective and difficult to prove,” the authors write.

For instance, one interviewee said: “I’m afraid to report these things because there’s gonna be repercussions. There’s no way it’s gonna be anonymous.... I just have to toughen up and, you know, get used [to it].”

Dr. Warsame added, “A major challenge for trainees was that they often felt unheard, and at the time, there was no formal debrief regarding discrimination issues when they arose.”

These instances of bias have implications for trainee well-being. In a 2019 study, discrimination that physicians and students experienced during training had adverse effects on their emotional health. Responses from 50 trainees and physicians revealed a wide range of discriminatory experiences, including patients rejecting care and spewing racist, sexist, or homophobic epithets. Many physicians were uncertain about how to respond effectively and appropriately.

Since that study was published and after having completed her own fellowship, Dr. Duncan said she has seen some change for the better.

“There is a lot more awareness around this, and programs are trying to do better in recognizing and responding to incidents,” she said. She noted that it’s important to ensure that those who are directly affected by discriminatory behaviors aren’t left to do all of the “heavy lifting” of addressing and resolving the issues.

The weight of discriminatory incidents, from microaggressions to overt racism, is cumulative and can adversely affect a person’s career. “It’s exhausting -- we need support,” she said.

The Mayo Clinic is working to ensure that trainees receive support. “The study has prompted communication workshops and faculty development to better equip trainees with strategies to address [and report] patients who behave or display disrespectful or discriminatory behavior,” Dr. Warsame said.

She and her colleagues noted that the anonymous hotline used for the survey cultivated a safe environment for candid discussions and that such an approach is “feasible and effective to explore sensitive topics and scalable to various geographic locations and different medical specialties.”

“We recognize that our program must seek this feedback regularly and ensure we keep a finger on the pulse of our trainees,” Dr. Warsame added.

Dr. Warsame and Dr. Duncan have disclosed no relevant financial relationships. Dr. Duncan noted that her views and comments are her own and do not necessarily reflect those of her institution.

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

On day 1 of her fellowship, Francesca C. Duncan, MD, was blindsided by her first patient.

The patient, a White man who was accompanied by his wife, sat in the exam room with his sunglasses on.

“I remember him saying, ‘I need to take off my sunglasses so you don’t look so Black,’” said Dr. Duncan, a pulmonologist and intensivist at Indiana University, Indianapolis, who has a specialty in lung cancer disparities.

The patient proceeded to grill her about her experience and training. He asked where she attended college and mocked her degree from a historically Black university. His wife sat there, silent.

Dr. Duncan was shocked by the fact that she still had to defend her credentials.

“I just kind of felt like at that point in my training, my title would have earned me more respect,” said Dr. Duncan, now an assistant professor after recently completing a 3-year fellowship in pulmonary and critical care medicine. “I thought at some point [the racism and discrimination] would stop, but after all that training, all that late-night studying, I still had to prove myself.”

Unfortunately, Dr. Duncan’s experience in fellowship is not unique.

A recent survey of hematology and oncology fellows revealed that medical trainees routinely encounter discrimination during their training.

The 17 fellows who were anonymously interviewed in the survey all recalled experiencing or witnessing discriminatory behaviors during their fellowship, mostly from patients. These encounters rarely come to light. Only one respondent officially reported an incident.

The findings, published online November 8 in JAMA Network Open, underscore the need for graduate medical education programs to improve learning environments and support for trainees, lead author Rahma M. Warsame, MD, and colleagues say .
 

Discrimination at work

Initially, Dr. Warsame and co–principal investigator Katharine Price, MD, were tasked with developing strategies to mitigate instances of racism and bias that fellows encountered during training, but both felt it was critical to understand the experiences of their trainees first.

Out of 34 fellows and recent graduates of the hematology and oncology fellowship program of the Mayo Clinic, Rochester, Minn., 20 consented to participate in the study. Of those, 17 were interviewed between July and November 2018. Among the 17 interviewees, six were Asian, two were Black, three were Hispanic, two were multiracial, and four were White.

Dr. Warsame and colleagues found that everyone reported experiencing or witnessing biased or discriminatory events. The majority of these offenses were committed by patients, not faculty or other employees. The researchers largely interpreted most of the incidents as microaggressions.

From the interviews, the researchers identified six central themes. Among them: foreign fellows and U.S.-born trainees being perceived or made to feel like outsiders; inappropriate comments being made toward female employees about their looks, credentials, or marital status; lack of action after reporting incidents or concerns that reporting such incidents would be futile; and strategies fellows used to cope after negative interactions.

One interviewee said, “I was fired by a patient because I have an accent.” Another said that when she is interviewing for jobs, she is always asked if she has children: “Maybe they’re asking in an innocuous manner, but I always feel like people worry. Is this person going to take maternity leave and be less available for work?”

For Dr. Warsame, “the idea that American citizens were frequently made to feel like they do not belong was surprising.”

Not surprising to Dr. Warsame, however, was the importance of fostering diversity and inclusion during fellowship years. Fellows often noted that greater diversity within the program helped create a more inclusive environment.

“[What’s] important to reinforce is the value of creating platforms for honest discussion and intentionally seeking fellows’ voices and perspectives, which in turn makes them feel like they belong,” Dr. Warsame said.

Still, the researchers found that fellows often did not report incidents of discrimination or bias. Only six trainees were aware of policies for reporting patient misconduct or discrimination, and only one ever reported an incident.
 

Where’s the support?

For Dr. Duncan, her encounter 3 years ago with the patient with sunglasses wasn’t her first experience of discrimination on the job — or her last.

Although hurtful in the moment, she had the wherewithal to report the incident to her attending physician, who was equally shocked. Initially unsure of how to handle it, the attending ultimately stepped up and provided “immense support,” Dr. Duncan said

The issue was brought to the attention of the program director, who took swift action. The patient was documented as “disruptive,” informed of that status in writing, and was banned from receiving treatment from trainees at the center, although Dr. Duncan noted he still received the medical care he needed.

Often, however, fellows who report incidents of discrimination and racism receive little support. According to Dr. Warsame and colleagues, most trainees don’t bother reporting these experiences because they believe that doing so would be futile.

“Concerns about reporting included jeopardizing future employability, risk of retaliation, and challenges reporting experiences that could be perceived as subjective and difficult to prove,” the authors write.

For instance, one interviewee said: “I’m afraid to report these things because there’s gonna be repercussions. There’s no way it’s gonna be anonymous.... I just have to toughen up and, you know, get used [to it].”

Dr. Warsame added, “A major challenge for trainees was that they often felt unheard, and at the time, there was no formal debrief regarding discrimination issues when they arose.”

These instances of bias have implications for trainee well-being. In a 2019 study, discrimination that physicians and students experienced during training had adverse effects on their emotional health. Responses from 50 trainees and physicians revealed a wide range of discriminatory experiences, including patients rejecting care and spewing racist, sexist, or homophobic epithets. Many physicians were uncertain about how to respond effectively and appropriately.

Since that study was published and after having completed her own fellowship, Dr. Duncan said she has seen some change for the better.

“There is a lot more awareness around this, and programs are trying to do better in recognizing and responding to incidents,” she said. She noted that it’s important to ensure that those who are directly affected by discriminatory behaviors aren’t left to do all of the “heavy lifting” of addressing and resolving the issues.

The weight of discriminatory incidents, from microaggressions to overt racism, is cumulative and can adversely affect a person’s career. “It’s exhausting -- we need support,” she said.

The Mayo Clinic is working to ensure that trainees receive support. “The study has prompted communication workshops and faculty development to better equip trainees with strategies to address [and report] patients who behave or display disrespectful or discriminatory behavior,” Dr. Warsame said.

She and her colleagues noted that the anonymous hotline used for the survey cultivated a safe environment for candid discussions and that such an approach is “feasible and effective to explore sensitive topics and scalable to various geographic locations and different medical specialties.”

“We recognize that our program must seek this feedback regularly and ensure we keep a finger on the pulse of our trainees,” Dr. Warsame added.

Dr. Warsame and Dr. Duncan have disclosed no relevant financial relationships. Dr. Duncan noted that her views and comments are her own and do not necessarily reflect those of her institution.

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

On day 1 of her fellowship, Francesca C. Duncan, MD, was blindsided by her first patient.

The patient, a White man who was accompanied by his wife, sat in the exam room with his sunglasses on.

“I remember him saying, ‘I need to take off my sunglasses so you don’t look so Black,’” said Dr. Duncan, a pulmonologist and intensivist at Indiana University, Indianapolis, who has a specialty in lung cancer disparities.

The patient proceeded to grill her about her experience and training. He asked where she attended college and mocked her degree from a historically Black university. His wife sat there, silent.

Dr. Duncan was shocked by the fact that she still had to defend her credentials.

“I just kind of felt like at that point in my training, my title would have earned me more respect,” said Dr. Duncan, now an assistant professor after recently completing a 3-year fellowship in pulmonary and critical care medicine. “I thought at some point [the racism and discrimination] would stop, but after all that training, all that late-night studying, I still had to prove myself.”

Unfortunately, Dr. Duncan’s experience in fellowship is not unique.

A recent survey of hematology and oncology fellows revealed that medical trainees routinely encounter discrimination during their training.

The 17 fellows who were anonymously interviewed in the survey all recalled experiencing or witnessing discriminatory behaviors during their fellowship, mostly from patients. These encounters rarely come to light. Only one respondent officially reported an incident.

The findings, published online November 8 in JAMA Network Open, underscore the need for graduate medical education programs to improve learning environments and support for trainees, lead author Rahma M. Warsame, MD, and colleagues say .
 

Discrimination at work

Initially, Dr. Warsame and co–principal investigator Katharine Price, MD, were tasked with developing strategies to mitigate instances of racism and bias that fellows encountered during training, but both felt it was critical to understand the experiences of their trainees first.

Out of 34 fellows and recent graduates of the hematology and oncology fellowship program of the Mayo Clinic, Rochester, Minn., 20 consented to participate in the study. Of those, 17 were interviewed between July and November 2018. Among the 17 interviewees, six were Asian, two were Black, three were Hispanic, two were multiracial, and four were White.

Dr. Warsame and colleagues found that everyone reported experiencing or witnessing biased or discriminatory events. The majority of these offenses were committed by patients, not faculty or other employees. The researchers largely interpreted most of the incidents as microaggressions.

From the interviews, the researchers identified six central themes. Among them: foreign fellows and U.S.-born trainees being perceived or made to feel like outsiders; inappropriate comments being made toward female employees about their looks, credentials, or marital status; lack of action after reporting incidents or concerns that reporting such incidents would be futile; and strategies fellows used to cope after negative interactions.

One interviewee said, “I was fired by a patient because I have an accent.” Another said that when she is interviewing for jobs, she is always asked if she has children: “Maybe they’re asking in an innocuous manner, but I always feel like people worry. Is this person going to take maternity leave and be less available for work?”

For Dr. Warsame, “the idea that American citizens were frequently made to feel like they do not belong was surprising.”

Not surprising to Dr. Warsame, however, was the importance of fostering diversity and inclusion during fellowship years. Fellows often noted that greater diversity within the program helped create a more inclusive environment.

“[What’s] important to reinforce is the value of creating platforms for honest discussion and intentionally seeking fellows’ voices and perspectives, which in turn makes them feel like they belong,” Dr. Warsame said.

Still, the researchers found that fellows often did not report incidents of discrimination or bias. Only six trainees were aware of policies for reporting patient misconduct or discrimination, and only one ever reported an incident.
 

Where’s the support?

For Dr. Duncan, her encounter 3 years ago with the patient with sunglasses wasn’t her first experience of discrimination on the job — or her last.

Although hurtful in the moment, she had the wherewithal to report the incident to her attending physician, who was equally shocked. Initially unsure of how to handle it, the attending ultimately stepped up and provided “immense support,” Dr. Duncan said

The issue was brought to the attention of the program director, who took swift action. The patient was documented as “disruptive,” informed of that status in writing, and was banned from receiving treatment from trainees at the center, although Dr. Duncan noted he still received the medical care he needed.

Often, however, fellows who report incidents of discrimination and racism receive little support. According to Dr. Warsame and colleagues, most trainees don’t bother reporting these experiences because they believe that doing so would be futile.

“Concerns about reporting included jeopardizing future employability, risk of retaliation, and challenges reporting experiences that could be perceived as subjective and difficult to prove,” the authors write.

For instance, one interviewee said: “I’m afraid to report these things because there’s gonna be repercussions. There’s no way it’s gonna be anonymous.... I just have to toughen up and, you know, get used [to it].”

Dr. Warsame added, “A major challenge for trainees was that they often felt unheard, and at the time, there was no formal debrief regarding discrimination issues when they arose.”

These instances of bias have implications for trainee well-being. In a 2019 study, discrimination that physicians and students experienced during training had adverse effects on their emotional health. Responses from 50 trainees and physicians revealed a wide range of discriminatory experiences, including patients rejecting care and spewing racist, sexist, or homophobic epithets. Many physicians were uncertain about how to respond effectively and appropriately.

Since that study was published and after having completed her own fellowship, Dr. Duncan said she has seen some change for the better.

“There is a lot more awareness around this, and programs are trying to do better in recognizing and responding to incidents,” she said. She noted that it’s important to ensure that those who are directly affected by discriminatory behaviors aren’t left to do all of the “heavy lifting” of addressing and resolving the issues.

The weight of discriminatory incidents, from microaggressions to overt racism, is cumulative and can adversely affect a person’s career. “It’s exhausting -- we need support,” she said.

The Mayo Clinic is working to ensure that trainees receive support. “The study has prompted communication workshops and faculty development to better equip trainees with strategies to address [and report] patients who behave or display disrespectful or discriminatory behavior,” Dr. Warsame said.

She and her colleagues noted that the anonymous hotline used for the survey cultivated a safe environment for candid discussions and that such an approach is “feasible and effective to explore sensitive topics and scalable to various geographic locations and different medical specialties.”

“We recognize that our program must seek this feedback regularly and ensure we keep a finger on the pulse of our trainees,” Dr. Warsame added.

Dr. Warsame and Dr. Duncan have disclosed no relevant financial relationships. Dr. Duncan noted that her views and comments are her own and do not necessarily reflect those of her institution.

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

COVID-19 has been difficult for parents trying to balance careers, home life, and keeping their loved ones safe. A new study indicates that, not only are physicians not immune to these stressors, but the long-term effects could be devastating for health care overall.

Juanmonino/Getty Images

In a study published Nov. 11, 2021, in JAMA Network Open , researchers found that stresses to work/life balance and family life caused by the pandemic have differed among men and women physicians. Women physicians have borne more of the burden, and the consequences could reach far beyond home.

Physicians and other health care workers have been at the front lines of the COVID-19 pandemic, and their work lives have been the focus of a lot of attention in the media and by researchers. Their family lives, not so much. But physicians have families, and the pandemic has upended almost everything about their lives, particularly where work life and home life intersect. School and day care closures, working from home, working extra hours, or working less – all of these changes have consequences on family life and the mental health of parents who are also physicians.

Findings from a Medscape survey published in early 2021 indicate that more female physicians than male physicians were either “conflicted” or “very conflicted” as parents because of work demands (42% vs. 23%) nearly 6 months into the pandemic.

In the current study, researchers from the University of Michigan, Harvard University, and the Medical University of South Carolina teamed up to investigate gender differences in how work/family factors affected the mental health of early-career physician parents in the United States during the first year of the COVID-19 pandemic. The results suggest that the pandemic has increased gender disparity and added disproportionately to the burden of female physicians.
 

Managing the household falls mostly on moms

Participants were physicians enrolled in the Intern Health Study, a longitudinal study that regularly surveys medical interns in the United States to assess stress and mood. When researchers compared survey results from before the onset of the pandemic (2018) with later results (2020), they found a striking gender difference in how the pandemic has changed family and work duties for physicians.

The authors of the study pointed out that previous research had found that female physicians take on a greater share of household and childcare duties than male physicians. The current study found that their share had increased with the pandemic. Physician moms are now 30 times more likely to be in charge of these tasks than physician dads.

In families in which both parents were physicians, none of the men said they took the primary role in managing the extra demands caused by the pandemic. In addition, women were twice as likely as men to work primarily from home and to work reduced hours.

The extra stress seems to be taking a toll on women physicians. In the 2020 survey, physician mothers had higher scores for anxiety and depression symptoms, compared with men. Notably, the 2018 survey did not show a significant difference in depression scores between men and women. Nor were there significant differences in depression and anxiety scores between women and men who were not parents or in reports of work/family conflict before and after the pandemic.

In general, the results indicate that the pandemic has only widened the gender gap between women and men physicians when it comes to managing family life and dealing with the stresses of maintaining a suitable work-life balance.
 

‘Long-term repercussions’ for gender equity in medicine

Although these are serious problems for women physicians and their families, the effects go beyond the home and beyond individuals. Even before the pandemic, women in medicine struggled for parity in career advancement and opportunities as well as in pay, and this new setback could make those challenges even greater.

“Even short-term adjustments can have serious long-term repercussions as they may lead to lower earnings and negatively impact opportunities for promotion, further exacerbating gender inequalities in compensation and advancement,” the study’s authors wrote.

The potential damage extends to the entire profession and the health care system itself. The profession is already struggling to retain young female physicians, and this situation is likely to make that problem worse and have long-term consequences. Citing data showing that female physicians spend more time with patients and that their patients may have better outcomes, the authors wrote that the consequences of losing more early-career female physicians “could be devastating to the U.S. health care system, particularly in the context of a global pandemic and an impending physician shortage.”

The sample size was small (276 U.S. physicians), and the study relied on self-reported data. The findings suggest that more research on this topic is needed, especially research that includes other demographic factors, such as sexual orientation and ethnicity. The authors recommend that institutional and public policymakers take into account the effects of the pandemic on physician mothers to ensure that recent gains in gender equity for women physicians do not fall victim to COVID-19.

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

COVID-19 has been difficult for parents trying to balance careers, home life, and keeping their loved ones safe. A new study indicates that, not only are physicians not immune to these stressors, but the long-term effects could be devastating for health care overall.

Juanmonino/Getty Images

In a study published Nov. 11, 2021, in JAMA Network Open , researchers found that stresses to work/life balance and family life caused by the pandemic have differed among men and women physicians. Women physicians have borne more of the burden, and the consequences could reach far beyond home.

Physicians and other health care workers have been at the front lines of the COVID-19 pandemic, and their work lives have been the focus of a lot of attention in the media and by researchers. Their family lives, not so much. But physicians have families, and the pandemic has upended almost everything about their lives, particularly where work life and home life intersect. School and day care closures, working from home, working extra hours, or working less – all of these changes have consequences on family life and the mental health of parents who are also physicians.

Findings from a Medscape survey published in early 2021 indicate that more female physicians than male physicians were either “conflicted” or “very conflicted” as parents because of work demands (42% vs. 23%) nearly 6 months into the pandemic.

In the current study, researchers from the University of Michigan, Harvard University, and the Medical University of South Carolina teamed up to investigate gender differences in how work/family factors affected the mental health of early-career physician parents in the United States during the first year of the COVID-19 pandemic. The results suggest that the pandemic has increased gender disparity and added disproportionately to the burden of female physicians.
 

Managing the household falls mostly on moms

Participants were physicians enrolled in the Intern Health Study, a longitudinal study that regularly surveys medical interns in the United States to assess stress and mood. When researchers compared survey results from before the onset of the pandemic (2018) with later results (2020), they found a striking gender difference in how the pandemic has changed family and work duties for physicians.

The authors of the study pointed out that previous research had found that female physicians take on a greater share of household and childcare duties than male physicians. The current study found that their share had increased with the pandemic. Physician moms are now 30 times more likely to be in charge of these tasks than physician dads.

In families in which both parents were physicians, none of the men said they took the primary role in managing the extra demands caused by the pandemic. In addition, women were twice as likely as men to work primarily from home and to work reduced hours.

The extra stress seems to be taking a toll on women physicians. In the 2020 survey, physician mothers had higher scores for anxiety and depression symptoms, compared with men. Notably, the 2018 survey did not show a significant difference in depression scores between men and women. Nor were there significant differences in depression and anxiety scores between women and men who were not parents or in reports of work/family conflict before and after the pandemic.

In general, the results indicate that the pandemic has only widened the gender gap between women and men physicians when it comes to managing family life and dealing with the stresses of maintaining a suitable work-life balance.
 

‘Long-term repercussions’ for gender equity in medicine

Although these are serious problems for women physicians and their families, the effects go beyond the home and beyond individuals. Even before the pandemic, women in medicine struggled for parity in career advancement and opportunities as well as in pay, and this new setback could make those challenges even greater.

“Even short-term adjustments can have serious long-term repercussions as they may lead to lower earnings and negatively impact opportunities for promotion, further exacerbating gender inequalities in compensation and advancement,” the study’s authors wrote.

The potential damage extends to the entire profession and the health care system itself. The profession is already struggling to retain young female physicians, and this situation is likely to make that problem worse and have long-term consequences. Citing data showing that female physicians spend more time with patients and that their patients may have better outcomes, the authors wrote that the consequences of losing more early-career female physicians “could be devastating to the U.S. health care system, particularly in the context of a global pandemic and an impending physician shortage.”

The sample size was small (276 U.S. physicians), and the study relied on self-reported data. The findings suggest that more research on this topic is needed, especially research that includes other demographic factors, such as sexual orientation and ethnicity. The authors recommend that institutional and public policymakers take into account the effects of the pandemic on physician mothers to ensure that recent gains in gender equity for women physicians do not fall victim to COVID-19.

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

COVID-19 has been difficult for parents trying to balance careers, home life, and keeping their loved ones safe. A new study indicates that, not only are physicians not immune to these stressors, but the long-term effects could be devastating for health care overall.

Juanmonino/Getty Images

In a study published Nov. 11, 2021, in JAMA Network Open , researchers found that stresses to work/life balance and family life caused by the pandemic have differed among men and women physicians. Women physicians have borne more of the burden, and the consequences could reach far beyond home.

Physicians and other health care workers have been at the front lines of the COVID-19 pandemic, and their work lives have been the focus of a lot of attention in the media and by researchers. Their family lives, not so much. But physicians have families, and the pandemic has upended almost everything about their lives, particularly where work life and home life intersect. School and day care closures, working from home, working extra hours, or working less – all of these changes have consequences on family life and the mental health of parents who are also physicians.

Findings from a Medscape survey published in early 2021 indicate that more female physicians than male physicians were either “conflicted” or “very conflicted” as parents because of work demands (42% vs. 23%) nearly 6 months into the pandemic.

In the current study, researchers from the University of Michigan, Harvard University, and the Medical University of South Carolina teamed up to investigate gender differences in how work/family factors affected the mental health of early-career physician parents in the United States during the first year of the COVID-19 pandemic. The results suggest that the pandemic has increased gender disparity and added disproportionately to the burden of female physicians.
 

Managing the household falls mostly on moms

Participants were physicians enrolled in the Intern Health Study, a longitudinal study that regularly surveys medical interns in the United States to assess stress and mood. When researchers compared survey results from before the onset of the pandemic (2018) with later results (2020), they found a striking gender difference in how the pandemic has changed family and work duties for physicians.

The authors of the study pointed out that previous research had found that female physicians take on a greater share of household and childcare duties than male physicians. The current study found that their share had increased with the pandemic. Physician moms are now 30 times more likely to be in charge of these tasks than physician dads.

In families in which both parents were physicians, none of the men said they took the primary role in managing the extra demands caused by the pandemic. In addition, women were twice as likely as men to work primarily from home and to work reduced hours.

The extra stress seems to be taking a toll on women physicians. In the 2020 survey, physician mothers had higher scores for anxiety and depression symptoms, compared with men. Notably, the 2018 survey did not show a significant difference in depression scores between men and women. Nor were there significant differences in depression and anxiety scores between women and men who were not parents or in reports of work/family conflict before and after the pandemic.

In general, the results indicate that the pandemic has only widened the gender gap between women and men physicians when it comes to managing family life and dealing with the stresses of maintaining a suitable work-life balance.
 

‘Long-term repercussions’ for gender equity in medicine

Although these are serious problems for women physicians and their families, the effects go beyond the home and beyond individuals. Even before the pandemic, women in medicine struggled for parity in career advancement and opportunities as well as in pay, and this new setback could make those challenges even greater.

“Even short-term adjustments can have serious long-term repercussions as they may lead to lower earnings and negatively impact opportunities for promotion, further exacerbating gender inequalities in compensation and advancement,” the study’s authors wrote.

The potential damage extends to the entire profession and the health care system itself. The profession is already struggling to retain young female physicians, and this situation is likely to make that problem worse and have long-term consequences. Citing data showing that female physicians spend more time with patients and that their patients may have better outcomes, the authors wrote that the consequences of losing more early-career female physicians “could be devastating to the U.S. health care system, particularly in the context of a global pandemic and an impending physician shortage.”

The sample size was small (276 U.S. physicians), and the study relied on self-reported data. The findings suggest that more research on this topic is needed, especially research that includes other demographic factors, such as sexual orientation and ethnicity. The authors recommend that institutional and public policymakers take into account the effects of the pandemic on physician mothers to ensure that recent gains in gender equity for women physicians do not fall victim to COVID-19.

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

Mortality from cancer has dropped substantially in the United States over the past 5 decades, according to a new analysis.

Researchers found that rates for all cancers combined declined by 27% overall between 1971 and 2019 and decreased significantly for 12 of the 15 top cancer sites analyzed.

The data revealed even greater mortality declines for certain cancers in particular years. For example, mortality from lung cancer was 44% lower in 2019, compared with its peak rate in 1993, whereas it was only 13% lower, compared with morality rates in 1971.

“The cancer mortality rate has reduced considerably since 1971 overall and for most cancer sites because of improvements in prevention, early detection, and treatment,” lead author Ahmedin Jemal, DVM, PhD, American Cancer Society, Kennesaw, Ga., and colleagues wrote.

Advances in surgery, radiotherapy, chemotherapy, precision medicine, and combinations therapies over the past 5 decades have contributed to these significant declines in mortality, Dr. Jemal and colleagues explained. The researchers also credit the “expanded investment” in the National Cancer Institute’s annual budget following the 1971 National Cancer Act, which increased the budget 25-fold from $227 million in 1971 to $6 billion in 2019.

The report, published online Nov. 11, 2021, in JAMA Oncology, analyzed mortality rates for all cancers as well as the top 15 sites using the National Center for Health Statistics.

The researchers found that, overall, deaths declined significantly for all cancers over the study period. Some of the biggest headway since 1971 occurred for stomach and cervical cancers – with 72% and 69% lower mortality rates, respectively – as well as colorectal cancer (56%), oral cavity and pharynx cancer (43%), and ovarian cancer (41%). Mortality rates of female breast cancer and prostate cancer also dropped considerably – both by 39%.

“The decline in mortality for female breast, cervical, colorectal, and prostate cancer in part reflects increased detection (and removal) of premalignant lesions and early-stage cancers,” Dr. Jemal and colleagues noted.

Data suggest that screening likely explains about half of the observed decline in mortality from colorectal cancer between 1975 and 2002. A 2018 study also found that the use of adjuvant chemotherapy was responsible for 63% of the decline in mortality from female breast cancer between 2000 and 2012.

In addition, the authors noted, “the decline in lung, oral cavity and bladder cancers largely reflects reductions in smoking because of enhanced public awareness of the health consequences, implementation of increased cigarette excise taxes, and comprehensive smoke-free laws.”

However, mortality did increase in a few categories. For instance, the mortality rate from pancreatic cancer increased by 3% between 1971 and 2019, and by 8% for both esophageal and brain cancers. Mortality rates from cancer were also greater for 29% of the U.S. counties included in the analysis, mostly those in the South.

The increase in mortality from pancreatic cancer likely reflects the growing rates of obesity in the United States, along with no real advances in pancreatic cancer prevention, early detection, or treatment, the authors suggested. In addition, lack of progress in regions of the south may be related to unequal access to improvements in treatment compared with other parts of the country.

“Improving equity through investment in the social determinants of health and implementation research is critical to furthering the national cancer-control agenda,” the authors concluded.

The authors disclosed no relevant financial relationships.

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

Mortality from cancer has dropped substantially in the United States over the past 5 decades, according to a new analysis.

Researchers found that rates for all cancers combined declined by 27% overall between 1971 and 2019 and decreased significantly for 12 of the 15 top cancer sites analyzed.

The data revealed even greater mortality declines for certain cancers in particular years. For example, mortality from lung cancer was 44% lower in 2019, compared with its peak rate in 1993, whereas it was only 13% lower, compared with morality rates in 1971.

“The cancer mortality rate has reduced considerably since 1971 overall and for most cancer sites because of improvements in prevention, early detection, and treatment,” lead author Ahmedin Jemal, DVM, PhD, American Cancer Society, Kennesaw, Ga., and colleagues wrote.

Advances in surgery, radiotherapy, chemotherapy, precision medicine, and combinations therapies over the past 5 decades have contributed to these significant declines in mortality, Dr. Jemal and colleagues explained. The researchers also credit the “expanded investment” in the National Cancer Institute’s annual budget following the 1971 National Cancer Act, which increased the budget 25-fold from $227 million in 1971 to $6 billion in 2019.

The report, published online Nov. 11, 2021, in JAMA Oncology, analyzed mortality rates for all cancers as well as the top 15 sites using the National Center for Health Statistics.

The researchers found that, overall, deaths declined significantly for all cancers over the study period. Some of the biggest headway since 1971 occurred for stomach and cervical cancers – with 72% and 69% lower mortality rates, respectively – as well as colorectal cancer (56%), oral cavity and pharynx cancer (43%), and ovarian cancer (41%). Mortality rates of female breast cancer and prostate cancer also dropped considerably – both by 39%.

“The decline in mortality for female breast, cervical, colorectal, and prostate cancer in part reflects increased detection (and removal) of premalignant lesions and early-stage cancers,” Dr. Jemal and colleagues noted.

Data suggest that screening likely explains about half of the observed decline in mortality from colorectal cancer between 1975 and 2002. A 2018 study also found that the use of adjuvant chemotherapy was responsible for 63% of the decline in mortality from female breast cancer between 2000 and 2012.

In addition, the authors noted, “the decline in lung, oral cavity and bladder cancers largely reflects reductions in smoking because of enhanced public awareness of the health consequences, implementation of increased cigarette excise taxes, and comprehensive smoke-free laws.”

However, mortality did increase in a few categories. For instance, the mortality rate from pancreatic cancer increased by 3% between 1971 and 2019, and by 8% for both esophageal and brain cancers. Mortality rates from cancer were also greater for 29% of the U.S. counties included in the analysis, mostly those in the South.

The increase in mortality from pancreatic cancer likely reflects the growing rates of obesity in the United States, along with no real advances in pancreatic cancer prevention, early detection, or treatment, the authors suggested. In addition, lack of progress in regions of the south may be related to unequal access to improvements in treatment compared with other parts of the country.

“Improving equity through investment in the social determinants of health and implementation research is critical to furthering the national cancer-control agenda,” the authors concluded.

The authors disclosed no relevant financial relationships.

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

Mortality from cancer has dropped substantially in the United States over the past 5 decades, according to a new analysis.

Researchers found that rates for all cancers combined declined by 27% overall between 1971 and 2019 and decreased significantly for 12 of the 15 top cancer sites analyzed.

The data revealed even greater mortality declines for certain cancers in particular years. For example, mortality from lung cancer was 44% lower in 2019, compared with its peak rate in 1993, whereas it was only 13% lower, compared with morality rates in 1971.

“The cancer mortality rate has reduced considerably since 1971 overall and for most cancer sites because of improvements in prevention, early detection, and treatment,” lead author Ahmedin Jemal, DVM, PhD, American Cancer Society, Kennesaw, Ga., and colleagues wrote.

Advances in surgery, radiotherapy, chemotherapy, precision medicine, and combinations therapies over the past 5 decades have contributed to these significant declines in mortality, Dr. Jemal and colleagues explained. The researchers also credit the “expanded investment” in the National Cancer Institute’s annual budget following the 1971 National Cancer Act, which increased the budget 25-fold from $227 million in 1971 to $6 billion in 2019.

The report, published online Nov. 11, 2021, in JAMA Oncology, analyzed mortality rates for all cancers as well as the top 15 sites using the National Center for Health Statistics.

The researchers found that, overall, deaths declined significantly for all cancers over the study period. Some of the biggest headway since 1971 occurred for stomach and cervical cancers – with 72% and 69% lower mortality rates, respectively – as well as colorectal cancer (56%), oral cavity and pharynx cancer (43%), and ovarian cancer (41%). Mortality rates of female breast cancer and prostate cancer also dropped considerably – both by 39%.

“The decline in mortality for female breast, cervical, colorectal, and prostate cancer in part reflects increased detection (and removal) of premalignant lesions and early-stage cancers,” Dr. Jemal and colleagues noted.

Data suggest that screening likely explains about half of the observed decline in mortality from colorectal cancer between 1975 and 2002. A 2018 study also found that the use of adjuvant chemotherapy was responsible for 63% of the decline in mortality from female breast cancer between 2000 and 2012.

In addition, the authors noted, “the decline in lung, oral cavity and bladder cancers largely reflects reductions in smoking because of enhanced public awareness of the health consequences, implementation of increased cigarette excise taxes, and comprehensive smoke-free laws.”

However, mortality did increase in a few categories. For instance, the mortality rate from pancreatic cancer increased by 3% between 1971 and 2019, and by 8% for both esophageal and brain cancers. Mortality rates from cancer were also greater for 29% of the U.S. counties included in the analysis, mostly those in the South.

The increase in mortality from pancreatic cancer likely reflects the growing rates of obesity in the United States, along with no real advances in pancreatic cancer prevention, early detection, or treatment, the authors suggested. In addition, lack of progress in regions of the south may be related to unequal access to improvements in treatment compared with other parts of the country.

“Improving equity through investment in the social determinants of health and implementation research is critical to furthering the national cancer-control agenda,” the authors concluded.

The authors disclosed no relevant financial relationships.

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

Patients with idiopathic pulmonary fibrosis (IPF) complete and respond to pulmonary rehabilitation at rates similar to patients with chronic obstructive pulmonary disease (COPD), according to results of a real-world study. The findings reported in an article published in the journal CHEST^® reinforce pulmonary rehabilitation’s benefits for this population.

A progressive decline in respiratory and physical function characterizes IPF, with median survival from diagnosis of 3-5 years, according to Claire Nolan, PhD, of Harefield Hospital, Middlesex, England, and colleagues. The effects of pharmacologic therapies on IPF on symptom burden and quality of life are modest, although lung function decline may be slowed. Supporting evidence for pulmonary rehabilitation benefit in IPF is more modest than it is for COPD, for which exercise capacity, dyspnea, and health-related quality of life improvement have been demonstrated.

“We did not design a randomized, controlled trial,” Dr. Nolan said in an interview, “as it was considered unethical by the local ethics committee to withhold pulmonary rehabilitation based on clinical guidance in the United Kingdom.” She pointed out that initial pulmonary rehabilitation trials in COPD included an intervention (pulmonary rehabilitation) and a control (standard medical care) arm.

The study aims were to compare the effects of pulmonary rehabilitation with real-world data between IPF and COPD with respect to magnitude of effect and survival. The authors’ hypothesis was that IPF patients would have a blunted response to pulmonary rehabilitation with reduced completion rates, compared with a matched COPD group, and with increased mortality.
 

Study details

Investigators use propensity score matching of 163 IPF patients with a control group of 163 patients with COPD referred to pulmonary rehabilitation. Completion rates, responses, and survival status were recorded for 1-year following pulmonary rehabilitation discharge. The 8-week outpatient program was composed of two supervised exercise and education sessions with additional unsupervised home-based exercise each week.

While spirometry data, as expected, showed a higher proportion of IPF patients using supplemental oxygen, pulmonary rehabilitation completion rates were similar for both groups (IPF, 69%; COPD, 63%; P = .24) and there was no between group difference in the number of sessions attended (P = .39). Medical Research Council (muscle strength) (MRC), incremental shuttle walk test (ISW), and Chronic Respiratory Questionnaire total score (CRQ-T) improved significantly in both groups, again with no significant difference between groups.

Over the study course, there was progressive, significant worsening of forced vital capacity percentage, predicted, prescription supplemental oxygen, resting peripheral oxygen saturation, exercise capacity, health-related quality of life and pulmonary rehabilitation adherence across groups of responders (n = 63; 38%), nonresponders (n = 50; 31%) and noncompleters (n = 50; 31%). Among the IPF patients, 6 died before completing pulmonary rehabilitation, with 42 (27%) dying during follow-up.
 

Benefits of rehabilitation

Multivariable analyses showed that noncompletion and nonresponse were associated with significantly higher risk of all-cause mortality at 1-year. Also, time to all-cause mortality was shorter (P = .001) for noncompleters and nonresponders, compared with completers. A trend toward higher completion rates in the IPF group, compared with the COPD group, may be explained, the researchers explained, by fewer hospitalizations over the prior 12 months in the IPF group.

“Although many programs are designed for people with COPD,” Dr. Nolan and colleagues concluded, “our study demonstrates that people with IPF have similar clinical benefits and completion rates to those with COPD. These data reinforce the importance of referral to and engagement in pulmonary rehabilitation amongst the IPF population.”

These findings, Dr. Nolan emphasized, emerged from a single center, and validation in other settings is needed.

This study was funded by a National Institute for Health Research Doctoral Research Fellowship (2014-07-089) and a Medical Research Council New Investigator Research Grant (98576).

Patients with idiopathic pulmonary fibrosis (IPF) complete and respond to pulmonary rehabilitation at rates similar to patients with chronic obstructive pulmonary disease (COPD), according to results of a real-world study. The findings reported in an article published in the journal CHEST^® reinforce pulmonary rehabilitation’s benefits for this population.

A progressive decline in respiratory and physical function characterizes IPF, with median survival from diagnosis of 3-5 years, according to Claire Nolan, PhD, of Harefield Hospital, Middlesex, England, and colleagues. The effects of pharmacologic therapies on IPF on symptom burden and quality of life are modest, although lung function decline may be slowed. Supporting evidence for pulmonary rehabilitation benefit in IPF is more modest than it is for COPD, for which exercise capacity, dyspnea, and health-related quality of life improvement have been demonstrated.

“We did not design a randomized, controlled trial,” Dr. Nolan said in an interview, “as it was considered unethical by the local ethics committee to withhold pulmonary rehabilitation based on clinical guidance in the United Kingdom.” She pointed out that initial pulmonary rehabilitation trials in COPD included an intervention (pulmonary rehabilitation) and a control (standard medical care) arm.

The study aims were to compare the effects of pulmonary rehabilitation with real-world data between IPF and COPD with respect to magnitude of effect and survival. The authors’ hypothesis was that IPF patients would have a blunted response to pulmonary rehabilitation with reduced completion rates, compared with a matched COPD group, and with increased mortality.
 

Study details

Investigators use propensity score matching of 163 IPF patients with a control group of 163 patients with COPD referred to pulmonary rehabilitation. Completion rates, responses, and survival status were recorded for 1-year following pulmonary rehabilitation discharge. The 8-week outpatient program was composed of two supervised exercise and education sessions with additional unsupervised home-based exercise each week.

While spirometry data, as expected, showed a higher proportion of IPF patients using supplemental oxygen, pulmonary rehabilitation completion rates were similar for both groups (IPF, 69%; COPD, 63%; P = .24) and there was no between group difference in the number of sessions attended (P = .39). Medical Research Council (muscle strength) (MRC), incremental shuttle walk test (ISW), and Chronic Respiratory Questionnaire total score (CRQ-T) improved significantly in both groups, again with no significant difference between groups.

Over the study course, there was progressive, significant worsening of forced vital capacity percentage, predicted, prescription supplemental oxygen, resting peripheral oxygen saturation, exercise capacity, health-related quality of life and pulmonary rehabilitation adherence across groups of responders (n = 63; 38%), nonresponders (n = 50; 31%) and noncompleters (n = 50; 31%). Among the IPF patients, 6 died before completing pulmonary rehabilitation, with 42 (27%) dying during follow-up.
 

Benefits of rehabilitation

Multivariable analyses showed that noncompletion and nonresponse were associated with significantly higher risk of all-cause mortality at 1-year. Also, time to all-cause mortality was shorter (P = .001) for noncompleters and nonresponders, compared with completers. A trend toward higher completion rates in the IPF group, compared with the COPD group, may be explained, the researchers explained, by fewer hospitalizations over the prior 12 months in the IPF group.

“Although many programs are designed for people with COPD,” Dr. Nolan and colleagues concluded, “our study demonstrates that people with IPF have similar clinical benefits and completion rates to those with COPD. These data reinforce the importance of referral to and engagement in pulmonary rehabilitation amongst the IPF population.”

These findings, Dr. Nolan emphasized, emerged from a single center, and validation in other settings is needed.

This study was funded by a National Institute for Health Research Doctoral Research Fellowship (2014-07-089) and a Medical Research Council New Investigator Research Grant (98576).

Patients with idiopathic pulmonary fibrosis (IPF) complete and respond to pulmonary rehabilitation at rates similar to patients with chronic obstructive pulmonary disease (COPD), according to results of a real-world study. The findings reported in an article published in the journal CHEST^® reinforce pulmonary rehabilitation’s benefits for this population.

A progressive decline in respiratory and physical function characterizes IPF, with median survival from diagnosis of 3-5 years, according to Claire Nolan, PhD, of Harefield Hospital, Middlesex, England, and colleagues. The effects of pharmacologic therapies on IPF on symptom burden and quality of life are modest, although lung function decline may be slowed. Supporting evidence for pulmonary rehabilitation benefit in IPF is more modest than it is for COPD, for which exercise capacity, dyspnea, and health-related quality of life improvement have been demonstrated.

“We did not design a randomized, controlled trial,” Dr. Nolan said in an interview, “as it was considered unethical by the local ethics committee to withhold pulmonary rehabilitation based on clinical guidance in the United Kingdom.” She pointed out that initial pulmonary rehabilitation trials in COPD included an intervention (pulmonary rehabilitation) and a control (standard medical care) arm.

The study aims were to compare the effects of pulmonary rehabilitation with real-world data between IPF and COPD with respect to magnitude of effect and survival. The authors’ hypothesis was that IPF patients would have a blunted response to pulmonary rehabilitation with reduced completion rates, compared with a matched COPD group, and with increased mortality.
 

Study details

Investigators use propensity score matching of 163 IPF patients with a control group of 163 patients with COPD referred to pulmonary rehabilitation. Completion rates, responses, and survival status were recorded for 1-year following pulmonary rehabilitation discharge. The 8-week outpatient program was composed of two supervised exercise and education sessions with additional unsupervised home-based exercise each week.

While spirometry data, as expected, showed a higher proportion of IPF patients using supplemental oxygen, pulmonary rehabilitation completion rates were similar for both groups (IPF, 69%; COPD, 63%; P = .24) and there was no between group difference in the number of sessions attended (P = .39). Medical Research Council (muscle strength) (MRC), incremental shuttle walk test (ISW), and Chronic Respiratory Questionnaire total score (CRQ-T) improved significantly in both groups, again with no significant difference between groups.

Over the study course, there was progressive, significant worsening of forced vital capacity percentage, predicted, prescription supplemental oxygen, resting peripheral oxygen saturation, exercise capacity, health-related quality of life and pulmonary rehabilitation adherence across groups of responders (n = 63; 38%), nonresponders (n = 50; 31%) and noncompleters (n = 50; 31%). Among the IPF patients, 6 died before completing pulmonary rehabilitation, with 42 (27%) dying during follow-up.
 

Benefits of rehabilitation

Multivariable analyses showed that noncompletion and nonresponse were associated with significantly higher risk of all-cause mortality at 1-year. Also, time to all-cause mortality was shorter (P = .001) for noncompleters and nonresponders, compared with completers. A trend toward higher completion rates in the IPF group, compared with the COPD group, may be explained, the researchers explained, by fewer hospitalizations over the prior 12 months in the IPF group.

“Although many programs are designed for people with COPD,” Dr. Nolan and colleagues concluded, “our study demonstrates that people with IPF have similar clinical benefits and completion rates to those with COPD. These data reinforce the importance of referral to and engagement in pulmonary rehabilitation amongst the IPF population.”

These findings, Dr. Nolan emphasized, emerged from a single center, and validation in other settings is needed.

This study was funded by a National Institute for Health Research Doctoral Research Fellowship (2014-07-089) and a Medical Research Council New Investigator Research Grant (98576).