Mixed Topics

The workload of individual hospitalists has long been a hot-button issue. In a 2013 survey of hospitalists, 40% felt workloads were unsafe on a monthly basis, and 22% reported ordering unnecessary testing or procedures because of time pressure.¹ In a 2014 analysis of over 20,000 admissions to an academic hospital medicine service, increasing workload led to increased length of stay and cost per case.² Although these studies suggest a “sweet spot” for hospitalist workload, many groups face constant pressure to increase revenue.

Over the past decade there has been a significant change in how hospital medicine programs are financed. In the 2010 State of Hospital Medicine (SoHM), the median financial support per physician hospitalist in adult hospital medicine groups (HMGs) was $98,253. By the 2020 SoHM, the financial support was $198,750, an increase of $100,497 in just 10 years. When this is combined with the explosive growth in the number of hospitalists, there is one inescapable conclusion – hospital medicine is expensive.

Over this same 10 years, net collections per hospitalist grew from $194,440 in 2010 to $216,779 in 2020, an increase of $22,339. The increase was caused by higher collections per encounter, not more encounters. Additionally, median compensation for adult/internal medicine hospitalists increased over the same period from $215,000 to $307,336, an increase of $92,336, or 43%. That is an increase of 3.7% per year, more than twice the rate of inflation or wage growth in the general economy over the same period. About 75% of this increase was funded by hospital support. It is clear – health care systems continue to find value in investing in hospitalists and hospital medicine programs.

With mounting costs for hospitals, there is pressure for the hospitalist model of care to change or for yearly billable encounters per hospitalist full-time equivalent to increase. Yet, the productivity of hospitalists, as measured by median billable encounters per year has remained flat. The 2010 SoHM listed median number of billable encounters per year for an internal medicine hospitalist as 2,230. In 2020, the number is 2,246 – a trivial 0.7% increase per decade, what amounts to a rounding error. There has been wiggle up and down over the years, but I suspect these are not trends but noise.

So the question is why. I think it is partly because hospital medicine leaders together with the leaders of their health care systems seem to be reaching an equilibrium. Productivity will always remain an expectation. This expectation will vary based on local circumstances. But for many HMGs, the days when productivity is pushed as the primary objective seem to be disappearing. Most hospital leaders seem to now understand that high productivity can be detrimental to other program goals.

But if productivity is flat, do 40% of hospitalists still feel they are providing unsafe care on a monthly basis? Without another study we don’t know, but here are some reasons why I’m hopeful. First, the hospitalist workforce is more experienced than 10 years ago and may be more efficient. Second, hospital medicine groups are larger and are therefore enabled to schedule more flexibly or enact jeopardy systems to level out workload on busy days. And lastly, hospitalists who feel they are providing unsafe care find greener pastures. The 2010 SoHM reported adult hospital medicine programs had a median 14.3% turnover rate. The 2020 SoHM turnover was 10.9%. While this is up from 2018 (7.4%) and 2016 (6.9%), the general trend is down.

Additionally, we all need to consider the possibility that there will be a disruptive innovation that will allow greater productivity for individual hospitalists while maintaining value. It is apparent the EHR is not yet that breakthrough. We all need to keep our eyes open, stay flexible, and be prepared to meet evolving demands on our programs.

We will see constant demands on hospitalists. But I’m hopeful that going forward expectations will increasingly shift away from simply working harder and seeing more patients, toward goals related to improving performance. Training programs generally produce excellent clinicians, but they often do not equip physicians to be excellent hospitalists. Successful hospital medicine programs will recruit lifelong learners and career hospitalists who are flexible and willing to innovate and adapt. The best programs will have structures in place to help excellent clinicians mature into the role of excellent hospitalists, and leaders that create and foster an environment of excellence.

Discover more 2020 SoHM Report data at www.hospitalmedicine.org/sohm.

Dr. Frederickson is medical director, hospital medicine and palliative care, at CHI Health, Omaha, Neb., and assistant professor at Creighton University, Omaha.

References

1. Michtalik HJ et al. Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists. JAMA Intern Med. 2013;173(5):375-7. doi: 10.1001/jamainternmed.2013.1864.

2. Elliott DJ et al. Effect of Hospitalist Workload on the Quality and Efficiency of Care. JAMA Intern Med. 2014;174(5):786-93. doi: 10.1001/jamainternmed.2014.300.

The workload of individual hospitalists has long been a hot-button issue. In a 2013 survey of hospitalists, 40% felt workloads were unsafe on a monthly basis, and 22% reported ordering unnecessary testing or procedures because of time pressure.¹ In a 2014 analysis of over 20,000 admissions to an academic hospital medicine service, increasing workload led to increased length of stay and cost per case.² Although these studies suggest a “sweet spot” for hospitalist workload, many groups face constant pressure to increase revenue.

Over the past decade there has been a significant change in how hospital medicine programs are financed. In the 2010 State of Hospital Medicine (SoHM), the median financial support per physician hospitalist in adult hospital medicine groups (HMGs) was $98,253. By the 2020 SoHM, the financial support was $198,750, an increase of $100,497 in just 10 years. When this is combined with the explosive growth in the number of hospitalists, there is one inescapable conclusion – hospital medicine is expensive.

Over this same 10 years, net collections per hospitalist grew from $194,440 in 2010 to $216,779 in 2020, an increase of $22,339. The increase was caused by higher collections per encounter, not more encounters. Additionally, median compensation for adult/internal medicine hospitalists increased over the same period from $215,000 to $307,336, an increase of $92,336, or 43%. That is an increase of 3.7% per year, more than twice the rate of inflation or wage growth in the general economy over the same period. About 75% of this increase was funded by hospital support. It is clear – health care systems continue to find value in investing in hospitalists and hospital medicine programs.

With mounting costs for hospitals, there is pressure for the hospitalist model of care to change or for yearly billable encounters per hospitalist full-time equivalent to increase. Yet, the productivity of hospitalists, as measured by median billable encounters per year has remained flat. The 2010 SoHM listed median number of billable encounters per year for an internal medicine hospitalist as 2,230. In 2020, the number is 2,246 – a trivial 0.7% increase per decade, what amounts to a rounding error. There has been wiggle up and down over the years, but I suspect these are not trends but noise.

So the question is why. I think it is partly because hospital medicine leaders together with the leaders of their health care systems seem to be reaching an equilibrium. Productivity will always remain an expectation. This expectation will vary based on local circumstances. But for many HMGs, the days when productivity is pushed as the primary objective seem to be disappearing. Most hospital leaders seem to now understand that high productivity can be detrimental to other program goals.

But if productivity is flat, do 40% of hospitalists still feel they are providing unsafe care on a monthly basis? Without another study we don’t know, but here are some reasons why I’m hopeful. First, the hospitalist workforce is more experienced than 10 years ago and may be more efficient. Second, hospital medicine groups are larger and are therefore enabled to schedule more flexibly or enact jeopardy systems to level out workload on busy days. And lastly, hospitalists who feel they are providing unsafe care find greener pastures. The 2010 SoHM reported adult hospital medicine programs had a median 14.3% turnover rate. The 2020 SoHM turnover was 10.9%. While this is up from 2018 (7.4%) and 2016 (6.9%), the general trend is down.

Additionally, we all need to consider the possibility that there will be a disruptive innovation that will allow greater productivity for individual hospitalists while maintaining value. It is apparent the EHR is not yet that breakthrough. We all need to keep our eyes open, stay flexible, and be prepared to meet evolving demands on our programs.

We will see constant demands on hospitalists. But I’m hopeful that going forward expectations will increasingly shift away from simply working harder and seeing more patients, toward goals related to improving performance. Training programs generally produce excellent clinicians, but they often do not equip physicians to be excellent hospitalists. Successful hospital medicine programs will recruit lifelong learners and career hospitalists who are flexible and willing to innovate and adapt. The best programs will have structures in place to help excellent clinicians mature into the role of excellent hospitalists, and leaders that create and foster an environment of excellence.

Discover more 2020 SoHM Report data at www.hospitalmedicine.org/sohm.

Dr. Frederickson is medical director, hospital medicine and palliative care, at CHI Health, Omaha, Neb., and assistant professor at Creighton University, Omaha.

References

1. Michtalik HJ et al. Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists. JAMA Intern Med. 2013;173(5):375-7. doi: 10.1001/jamainternmed.2013.1864.

2. Elliott DJ et al. Effect of Hospitalist Workload on the Quality and Efficiency of Care. JAMA Intern Med. 2014;174(5):786-93. doi: 10.1001/jamainternmed.2014.300.

The workload of individual hospitalists has long been a hot-button issue. In a 2013 survey of hospitalists, 40% felt workloads were unsafe on a monthly basis, and 22% reported ordering unnecessary testing or procedures because of time pressure.¹ In a 2014 analysis of over 20,000 admissions to an academic hospital medicine service, increasing workload led to increased length of stay and cost per case.² Although these studies suggest a “sweet spot” for hospitalist workload, many groups face constant pressure to increase revenue.

Over the past decade there has been a significant change in how hospital medicine programs are financed. In the 2010 State of Hospital Medicine (SoHM), the median financial support per physician hospitalist in adult hospital medicine groups (HMGs) was $98,253. By the 2020 SoHM, the financial support was $198,750, an increase of $100,497 in just 10 years. When this is combined with the explosive growth in the number of hospitalists, there is one inescapable conclusion – hospital medicine is expensive.

Over this same 10 years, net collections per hospitalist grew from $194,440 in 2010 to $216,779 in 2020, an increase of $22,339. The increase was caused by higher collections per encounter, not more encounters. Additionally, median compensation for adult/internal medicine hospitalists increased over the same period from $215,000 to $307,336, an increase of $92,336, or 43%. That is an increase of 3.7% per year, more than twice the rate of inflation or wage growth in the general economy over the same period. About 75% of this increase was funded by hospital support. It is clear – health care systems continue to find value in investing in hospitalists and hospital medicine programs.

With mounting costs for hospitals, there is pressure for the hospitalist model of care to change or for yearly billable encounters per hospitalist full-time equivalent to increase. Yet, the productivity of hospitalists, as measured by median billable encounters per year has remained flat. The 2010 SoHM listed median number of billable encounters per year for an internal medicine hospitalist as 2,230. In 2020, the number is 2,246 – a trivial 0.7% increase per decade, what amounts to a rounding error. There has been wiggle up and down over the years, but I suspect these are not trends but noise.

So the question is why. I think it is partly because hospital medicine leaders together with the leaders of their health care systems seem to be reaching an equilibrium. Productivity will always remain an expectation. This expectation will vary based on local circumstances. But for many HMGs, the days when productivity is pushed as the primary objective seem to be disappearing. Most hospital leaders seem to now understand that high productivity can be detrimental to other program goals.

But if productivity is flat, do 40% of hospitalists still feel they are providing unsafe care on a monthly basis? Without another study we don’t know, but here are some reasons why I’m hopeful. First, the hospitalist workforce is more experienced than 10 years ago and may be more efficient. Second, hospital medicine groups are larger and are therefore enabled to schedule more flexibly or enact jeopardy systems to level out workload on busy days. And lastly, hospitalists who feel they are providing unsafe care find greener pastures. The 2010 SoHM reported adult hospital medicine programs had a median 14.3% turnover rate. The 2020 SoHM turnover was 10.9%. While this is up from 2018 (7.4%) and 2016 (6.9%), the general trend is down.

Additionally, we all need to consider the possibility that there will be a disruptive innovation that will allow greater productivity for individual hospitalists while maintaining value. It is apparent the EHR is not yet that breakthrough. We all need to keep our eyes open, stay flexible, and be prepared to meet evolving demands on our programs.

We will see constant demands on hospitalists. But I’m hopeful that going forward expectations will increasingly shift away from simply working harder and seeing more patients, toward goals related to improving performance. Training programs generally produce excellent clinicians, but they often do not equip physicians to be excellent hospitalists. Successful hospital medicine programs will recruit lifelong learners and career hospitalists who are flexible and willing to innovate and adapt. The best programs will have structures in place to help excellent clinicians mature into the role of excellent hospitalists, and leaders that create and foster an environment of excellence.

Discover more 2020 SoHM Report data at www.hospitalmedicine.org/sohm.

Dr. Frederickson is medical director, hospital medicine and palliative care, at CHI Health, Omaha, Neb., and assistant professor at Creighton University, Omaha.

References

1. Michtalik HJ et al. Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists. JAMA Intern Med. 2013;173(5):375-7. doi: 10.1001/jamainternmed.2013.1864.

2. Elliott DJ et al. Effect of Hospitalist Workload on the Quality and Efficiency of Care. JAMA Intern Med. 2014;174(5):786-93. doi: 10.1001/jamainternmed.2014.300.

It is not an exaggeration to say that everything in my gastroenterology practice changed in response to COVID-19.

Due to the overwhelming surge that Massachusetts saw in the early days of the pandemic, the Department of Public Health issued a moratorium on elective procedures in mid-March of 2020, for both hospitals and ambulatory surgery centers. The moratorium included colorectal cancer (CRC) screenings and other procedures that make up a significant portion of the services we provide to our community. Greater Boston Gastroenterology treats patients in and around the area of Framingham, Mass. – not too far outside of Boston. In our practice, we have seven physicians and three nurse practitioners, with one main office and two satellite offices. By national standards, our practice would be considered small, but it is on the larger side of independent GI physician practices in the commonwealth.

Nationally, moratoria on elective procedures led to one of the steepest drop-offs in screenings for cancers, including colorectal cancer. In late summer of 2020, it was estimated that CRC screenings dropped by 86 percent. Two-thirds of independent GI practices saw a significant decline in patient volume, and many believe that they may not get it back.

However, I’m an optimist in this situation, and I believe that as life gets more normal, people will get back to screenings. With the recommendation by the U.S. Preventative Services Task Force that CRC screening should begin at age 45, I expect that there will be an additional increase in screening soon.
 

Pivoting and developing a reopening plan

Almost immediately after the Department of Public Health issued the moratorium, Greater Boston Gastroenterology began putting together a reopening plan that would allow us to continue treating some patients and prepare for a surge once restrictions were lifted.

Part of our plan was to stay informed by talking with other practices about what they were doing and to stay abreast of policy changes at the local, state, and federal levels.

We also needed to keep our patients informed to alleviate safety concerns. Just prior to our reopening, we developed videos of the precautions that we were taking in all our facilities to assure our patients that we were doing everything possible to keep them safe. We also put information on our website through every stage of reopening so patients could know what to expect at their visits.

Helping our staff feel safe as they returned to work was also an important focus of our reopening plan. We prepared for our eventual reopening by installing safety measures such as plexiglass barriers and HEPA filter machines for our common areas and exam rooms. We also procured access to rapid turnaround polymerase chain reaction (PCR) testing that allowed us to regularly test all patients seeking elective procedures. Additionally, we invested in point-of-care antigen tests for the office, and we regularly test all our patient-facing staff.

We had corralled enough personal protective equipment to keep our office infusion services operating with our nurses and patients feeling safe. The preparation allowed us to resume in-person visits almost immediately after the Department of Public Health allowed us to reopen.

Once we reopened, we concentrated on in-office visits for patients who were under 65 and at lower risk for COVID-19, while focusing our telemedicine efforts on patients who were older and at higher risk. We’re now back to seeing all patients who want to have in-office visits and are actually above par for our visits. The number of procedures we have performed in the last 3 months is similar to the 3 months before the pandemic.

During the pandemic, Massachusetts had the best conversion to telehealth in the nation, and it worked well for patients and providers. The key was to use several telehealth apps, as using only one may not work for everyone. Having several options made it likely that we would be able to do complete visits and connect with patients. When we needed to, we switched to telephone visits.

All the physicians and staff in our practice are telemedicine enthusiasts, and it will remain a significant part of our practices as long as Medicare, the state health plans, and commercial payers remain supportive.
 

Planning for a surge in screenings

There may be a surge in screenings once more people are vaccinated and comfortable getting back into the office, and we’re planning for this as well. We’ve recruited new physicians and have expanded our available hours for procedures at our ambulatory surgery centers (ASCs). Surprisingly, we have found that there is a lot of interest from physicians for weekend shifts at the ASC, and we now have a physician waiting list for Saturday procedure time.

With the new lower age for recommended screening, there will be a lag with primary care physicians referring their younger patients. This may provide some time to prepare for an increase in screenings resulting from this new policy.

Another strategy that has worked well for us is to train and develop our advanced practitioners into nonphysician experts in GI and liver disease. Greater Boston Gastroenterology has used this strategy since its founding, and we think our most experienced nurse practitioners could rival any office-based gastroenterologist in their acumen and capabilities.

Over the last 3 years we have transitioned our nonphysician practitioners into the inpatient setting. As a result, consults are completed earlier in the day, and we are better able to help coordinate inpatient procedure scheduling, discharge planning, and outpatient follow-up.

The time we spend on training is worth it. It improves customer service, allows us to book appointments with shorter notice, and overall has a positive effect on our bottom line. Utilizing our advanced providers in this capacity will help us manage any volume increases we see in the near future. In addition, most patients in our community are used to seeing advanced providers in their physician’s office, so the acceptance among our patients is high.
 

Being flexible and favoring strategic planning

Overall, I think the greatest thing we learned during the pandemic is that we need to be flexible. It was a helpful reminder that, in medicine, things are constantly changing. I remember when passing the GI boards seemed like my final step, but everyone comes to realize it is just the first step in the journey.

As an early-career physician, you should remember the hard work that helped you get to medical school, land a good residency, stand out to get a fellowship, and master your specialty. Harness that personal drive and energy and keep moving forward. Remember that your first job is unlikely to be your last. Try not to see your choices as either/or – either academic or private practice, hospital-employed or self-employed. The boundaries are blurring. We have long careers and face myriad opportunities for professional advancement.

Be patient. Some goals take time to achieve. At each stage be prepared to work hard, use your time wisely, and try not to lose sight of maximizing your professional happiness.
 

Dr. Dickstein is a practicing gastroenterologist at Greater Boston Gastroenterology in Framingham, Mass., and serves on the executive committee of the Digestive Health Physicians Association. He has no conflicts to declare.

It is not an exaggeration to say that everything in my gastroenterology practice changed in response to COVID-19.

Due to the overwhelming surge that Massachusetts saw in the early days of the pandemic, the Department of Public Health issued a moratorium on elective procedures in mid-March of 2020, for both hospitals and ambulatory surgery centers. The moratorium included colorectal cancer (CRC) screenings and other procedures that make up a significant portion of the services we provide to our community. Greater Boston Gastroenterology treats patients in and around the area of Framingham, Mass. – not too far outside of Boston. In our practice, we have seven physicians and three nurse practitioners, with one main office and two satellite offices. By national standards, our practice would be considered small, but it is on the larger side of independent GI physician practices in the commonwealth.

Nationally, moratoria on elective procedures led to one of the steepest drop-offs in screenings for cancers, including colorectal cancer. In late summer of 2020, it was estimated that CRC screenings dropped by 86 percent. Two-thirds of independent GI practices saw a significant decline in patient volume, and many believe that they may not get it back.

However, I’m an optimist in this situation, and I believe that as life gets more normal, people will get back to screenings. With the recommendation by the U.S. Preventative Services Task Force that CRC screening should begin at age 45, I expect that there will be an additional increase in screening soon.
 

Pivoting and developing a reopening plan

Almost immediately after the Department of Public Health issued the moratorium, Greater Boston Gastroenterology began putting together a reopening plan that would allow us to continue treating some patients and prepare for a surge once restrictions were lifted.

Part of our plan was to stay informed by talking with other practices about what they were doing and to stay abreast of policy changes at the local, state, and federal levels.

We also needed to keep our patients informed to alleviate safety concerns. Just prior to our reopening, we developed videos of the precautions that we were taking in all our facilities to assure our patients that we were doing everything possible to keep them safe. We also put information on our website through every stage of reopening so patients could know what to expect at their visits.

Helping our staff feel safe as they returned to work was also an important focus of our reopening plan. We prepared for our eventual reopening by installing safety measures such as plexiglass barriers and HEPA filter machines for our common areas and exam rooms. We also procured access to rapid turnaround polymerase chain reaction (PCR) testing that allowed us to regularly test all patients seeking elective procedures. Additionally, we invested in point-of-care antigen tests for the office, and we regularly test all our patient-facing staff.

We had corralled enough personal protective equipment to keep our office infusion services operating with our nurses and patients feeling safe. The preparation allowed us to resume in-person visits almost immediately after the Department of Public Health allowed us to reopen.

Once we reopened, we concentrated on in-office visits for patients who were under 65 and at lower risk for COVID-19, while focusing our telemedicine efforts on patients who were older and at higher risk. We’re now back to seeing all patients who want to have in-office visits and are actually above par for our visits. The number of procedures we have performed in the last 3 months is similar to the 3 months before the pandemic.

During the pandemic, Massachusetts had the best conversion to telehealth in the nation, and it worked well for patients and providers. The key was to use several telehealth apps, as using only one may not work for everyone. Having several options made it likely that we would be able to do complete visits and connect with patients. When we needed to, we switched to telephone visits.

All the physicians and staff in our practice are telemedicine enthusiasts, and it will remain a significant part of our practices as long as Medicare, the state health plans, and commercial payers remain supportive.
 

Planning for a surge in screenings

There may be a surge in screenings once more people are vaccinated and comfortable getting back into the office, and we’re planning for this as well. We’ve recruited new physicians and have expanded our available hours for procedures at our ambulatory surgery centers (ASCs). Surprisingly, we have found that there is a lot of interest from physicians for weekend shifts at the ASC, and we now have a physician waiting list for Saturday procedure time.

With the new lower age for recommended screening, there will be a lag with primary care physicians referring their younger patients. This may provide some time to prepare for an increase in screenings resulting from this new policy.

Another strategy that has worked well for us is to train and develop our advanced practitioners into nonphysician experts in GI and liver disease. Greater Boston Gastroenterology has used this strategy since its founding, and we think our most experienced nurse practitioners could rival any office-based gastroenterologist in their acumen and capabilities.

Over the last 3 years we have transitioned our nonphysician practitioners into the inpatient setting. As a result, consults are completed earlier in the day, and we are better able to help coordinate inpatient procedure scheduling, discharge planning, and outpatient follow-up.

The time we spend on training is worth it. It improves customer service, allows us to book appointments with shorter notice, and overall has a positive effect on our bottom line. Utilizing our advanced providers in this capacity will help us manage any volume increases we see in the near future. In addition, most patients in our community are used to seeing advanced providers in their physician’s office, so the acceptance among our patients is high.
 

Being flexible and favoring strategic planning

Overall, I think the greatest thing we learned during the pandemic is that we need to be flexible. It was a helpful reminder that, in medicine, things are constantly changing. I remember when passing the GI boards seemed like my final step, but everyone comes to realize it is just the first step in the journey.

As an early-career physician, you should remember the hard work that helped you get to medical school, land a good residency, stand out to get a fellowship, and master your specialty. Harness that personal drive and energy and keep moving forward. Remember that your first job is unlikely to be your last. Try not to see your choices as either/or – either academic or private practice, hospital-employed or self-employed. The boundaries are blurring. We have long careers and face myriad opportunities for professional advancement.

Be patient. Some goals take time to achieve. At each stage be prepared to work hard, use your time wisely, and try not to lose sight of maximizing your professional happiness.
 

Dr. Dickstein is a practicing gastroenterologist at Greater Boston Gastroenterology in Framingham, Mass., and serves on the executive committee of the Digestive Health Physicians Association. He has no conflicts to declare.

It is not an exaggeration to say that everything in my gastroenterology practice changed in response to COVID-19.

Due to the overwhelming surge that Massachusetts saw in the early days of the pandemic, the Department of Public Health issued a moratorium on elective procedures in mid-March of 2020, for both hospitals and ambulatory surgery centers. The moratorium included colorectal cancer (CRC) screenings and other procedures that make up a significant portion of the services we provide to our community. Greater Boston Gastroenterology treats patients in and around the area of Framingham, Mass. – not too far outside of Boston. In our practice, we have seven physicians and three nurse practitioners, with one main office and two satellite offices. By national standards, our practice would be considered small, but it is on the larger side of independent GI physician practices in the commonwealth.

Nationally, moratoria on elective procedures led to one of the steepest drop-offs in screenings for cancers, including colorectal cancer. In late summer of 2020, it was estimated that CRC screenings dropped by 86 percent. Two-thirds of independent GI practices saw a significant decline in patient volume, and many believe that they may not get it back.

However, I’m an optimist in this situation, and I believe that as life gets more normal, people will get back to screenings. With the recommendation by the U.S. Preventative Services Task Force that CRC screening should begin at age 45, I expect that there will be an additional increase in screening soon.
 

Pivoting and developing a reopening plan

Almost immediately after the Department of Public Health issued the moratorium, Greater Boston Gastroenterology began putting together a reopening plan that would allow us to continue treating some patients and prepare for a surge once restrictions were lifted.

Part of our plan was to stay informed by talking with other practices about what they were doing and to stay abreast of policy changes at the local, state, and federal levels.

We also needed to keep our patients informed to alleviate safety concerns. Just prior to our reopening, we developed videos of the precautions that we were taking in all our facilities to assure our patients that we were doing everything possible to keep them safe. We also put information on our website through every stage of reopening so patients could know what to expect at their visits.

Helping our staff feel safe as they returned to work was also an important focus of our reopening plan. We prepared for our eventual reopening by installing safety measures such as plexiglass barriers and HEPA filter machines for our common areas and exam rooms. We also procured access to rapid turnaround polymerase chain reaction (PCR) testing that allowed us to regularly test all patients seeking elective procedures. Additionally, we invested in point-of-care antigen tests for the office, and we regularly test all our patient-facing staff.

We had corralled enough personal protective equipment to keep our office infusion services operating with our nurses and patients feeling safe. The preparation allowed us to resume in-person visits almost immediately after the Department of Public Health allowed us to reopen.

Once we reopened, we concentrated on in-office visits for patients who were under 65 and at lower risk for COVID-19, while focusing our telemedicine efforts on patients who were older and at higher risk. We’re now back to seeing all patients who want to have in-office visits and are actually above par for our visits. The number of procedures we have performed in the last 3 months is similar to the 3 months before the pandemic.

During the pandemic, Massachusetts had the best conversion to telehealth in the nation, and it worked well for patients and providers. The key was to use several telehealth apps, as using only one may not work for everyone. Having several options made it likely that we would be able to do complete visits and connect with patients. When we needed to, we switched to telephone visits.

All the physicians and staff in our practice are telemedicine enthusiasts, and it will remain a significant part of our practices as long as Medicare, the state health plans, and commercial payers remain supportive.
 

Planning for a surge in screenings

There may be a surge in screenings once more people are vaccinated and comfortable getting back into the office, and we’re planning for this as well. We’ve recruited new physicians and have expanded our available hours for procedures at our ambulatory surgery centers (ASCs). Surprisingly, we have found that there is a lot of interest from physicians for weekend shifts at the ASC, and we now have a physician waiting list for Saturday procedure time.

With the new lower age for recommended screening, there will be a lag with primary care physicians referring their younger patients. This may provide some time to prepare for an increase in screenings resulting from this new policy.

Another strategy that has worked well for us is to train and develop our advanced practitioners into nonphysician experts in GI and liver disease. Greater Boston Gastroenterology has used this strategy since its founding, and we think our most experienced nurse practitioners could rival any office-based gastroenterologist in their acumen and capabilities.

Over the last 3 years we have transitioned our nonphysician practitioners into the inpatient setting. As a result, consults are completed earlier in the day, and we are better able to help coordinate inpatient procedure scheduling, discharge planning, and outpatient follow-up.

The time we spend on training is worth it. It improves customer service, allows us to book appointments with shorter notice, and overall has a positive effect on our bottom line. Utilizing our advanced providers in this capacity will help us manage any volume increases we see in the near future. In addition, most patients in our community are used to seeing advanced providers in their physician’s office, so the acceptance among our patients is high.
 

Being flexible and favoring strategic planning

Overall, I think the greatest thing we learned during the pandemic is that we need to be flexible. It was a helpful reminder that, in medicine, things are constantly changing. I remember when passing the GI boards seemed like my final step, but everyone comes to realize it is just the first step in the journey.

As an early-career physician, you should remember the hard work that helped you get to medical school, land a good residency, stand out to get a fellowship, and master your specialty. Harness that personal drive and energy and keep moving forward. Remember that your first job is unlikely to be your last. Try not to see your choices as either/or – either academic or private practice, hospital-employed or self-employed. The boundaries are blurring. We have long careers and face myriad opportunities for professional advancement.

Be patient. Some goals take time to achieve. At each stage be prepared to work hard, use your time wisely, and try not to lose sight of maximizing your professional happiness.
 

Dr. Dickstein is a practicing gastroenterologist at Greater Boston Gastroenterology in Framingham, Mass., and serves on the executive committee of the Digestive Health Physicians Association. He has no conflicts to declare.

I arrived on the 6th floor nursing unit one day last fall to find halls abuzz with people. Something didn’t feel right, and then I a saw a nursing colleague with tears streaming down her face. My heart dropped. She looked up at me and said, “Dr Hass, K died last night.” She started to sob. I stood dumbfounded for a moment. We had lost a beloved coworker to COVID.

There has been a collective sense of grief in our country since the beginning of the COVID-19 pandemic as we have all been suffering losses: smiles, touch, in-person relationships, a “normal life.” But it went to another level for us at Alta Bates Summit Medical Center in Oakland, Calif., with the passing of a couple of our beloved teammates in the fall. Strong emotions triggered by these events caused me to pause and think: “What is grief? Is it another word for sadness? How do we work through it?”

What is the difference between sadness and grief? While related, they are temporally and functionally quite different. Sadness is an emotion, and like all emotions, we feel it in brief episodes. Those moments of profound sadness only last minutes at a time. Sadness leads to decreased physiological arousal, especially after crying. When less intense, the physiological slowing is thought to allow for some mental clarity that lets the loss sink in and moves us toward a recalibration process. These episodes of sadness occur more frequently and with greater intensity the closer we are to the triggering event.

While emotions last minutes, mood, another affective state, lasts hours to days and is less intense and specific in content. A sad mood can be present much of the time after a significant loss. Emotions predispose to moods and vice versa.

Grief, on the other hand, is a complex and lengthy process that moves us from a place of loss to a new place with a new equilibrium without the lost object. While sadness is about fully acknowledging the loss, the grieving process is about getting beyond it. The bigger the loss, the bigger the hole in your life and the longer the grieving process. Grief is a multi-emotional process with people often experiencing a range of emotions, such as shock, anger, and fear in addition to sadness.

As I grappled with my sense of loss, I realized that understanding the grieving process was going to help me as I navigate this world now full of loss. Here are a few things we should all keep in mind.
 

A sense of mindful self-awareness

As we work through our grief, a mindful self-awareness can help us identify our emotions and see them as part of the grieving process. Simply anticipating emotions can lessen the impact of them when they come. As they come on, try to name the emotion, e.g., “I am so sad,” and feel the experience in the body. The sadness can be cathartic, and by focusing on the body and not the head, we can also drop the sometimes healthy, sometimes unhealthy rants and ruminations that can accompany these events. If we experience the emotions with mindful self-awareness, we can see our emotions as part of a healing, grieving process, and we will likely be able to handle them more gracefully.

In the days after the death of my nursing colleague, my sad mood would be interrupted with flares of anger triggered by thoughts of those not wearing masks or spreading misinformation. Moving my thoughts to the emotions, I would say to myself, “I am really angry, and I am angry because of these deaths.” I felt the recognition of the emotions helped me better ride the big waves on the grieving journey.

Counter to the thinking of the 20th century, research by George Bonanno at Columbia University found that the majority of bereavement is met with resilience. We will be sad, we might have moments of anger or denial or fear, but for most of us, despite the gravity of the loss, our innate resilience will lead about 50-80% of us to recover to near our baseline in months. It is nice to know we are not repressing things if we don’t pass through all the stages postulated by Elizabeth Kubler-Ross, the dominate paradigm in the field.¹

For those grieving, this idea of resilience being the norm can provide reassurance during tough moments. While our degree of resilience will depend on our loss and our circumstance, the work of Lucy Hone, PhD, suggests that resilience can be fostered. Many of the negative feelings we experience have a flip side we can seek out. We can be grateful for what remains and what the departed has left us with. We can aid in our grieving journey by using many of the resources available from UC Berkeley’s Greater Good in Action (https://ggia.berkeley.edu/).

While most grief is met with resilience, complicated grieving with persistent negative moods and emotions is common. We should consider seeking professional help if our emotions and pattern of thought continue to feel unhealthy.
 

Meaning and wisdom, not acceptance

Another change in our understanding of grief is this: Instead of “acceptance” being seen as the end result of grieving, meaning and wisdom are now recognized as the outcomes. Research has found that efforts to find meaning in loss facilitates the grieving process. As time passes and our sadness lessens, the loved one doesn’t leave us but stays with us as a better understanding of the beauty and complexity of life. The loss, through grieving, is transformed to wisdom that will guide us through future challenges and help us make sense of the world.

Last week, masked and robed and with an iPad in hand so the family could join the conversation, I was talking to Ms. B who is hospitalized with COVID-19. She said, “I just keep thinking, ‘Why is this happening to me? To all of us?’ And then I realized that it is a message from God that we need to do a better job of taking care of each other, and I suddenly felt a little better. What do you think, Dr. Hass?”

“Wow,” I said. “Thank you for sharing that. There is definitely some truth there. There is a lot to learn from the pandemic about how we care for each other. I need to keep that in mind when I start feeling down.”

So much is going on now: climate change, racial violence, frightening political dysfunction, and a global pandemic that has upended our daily routines and the economy. It is hard to keep track of all the loss and uncertainty. We might not know why feelings of sadness, anger and anxiety come on, but if we can meet these emotions with mindful equanimity, see them as part of our intrinsic healing process and keep in mind that our path will likely be towards one of wisdom and sense-making, we can better navigate these profoundly unsettling times.

Just as sadness is not grief, joy alone does not lead to happiness. A happy life comes as much from meaning as joy. While unbridled joy might be in short supply, our grief, our work as hospitalists with the suffering, and confronting the many problems our world faces gives us the opportunity to lead a meaningful life. If we couple this search for meaning with healthy habits that promote wellbeing, such as hugs, investing in relationships, and moving our body in the natural world, we can survive these crazy times and be wiser beings as a result of our experiences.
 

Dr. Hass is a hospitalist at Sutter East Bay Medical Group in Oakland, Calif. He is a member of the clinical faculty at the University of California, Berkeley-UC San Francisco joint medical program, and an adviser on health and health care at the Greater Good Science Center at UC Berkeley.

Reference

1. Bonanno GA, and Boerner K. The stage theory of grief. JAMA. 2007;297(24):2692-2694. doi:10.1001/jama.297.24.2693-a.

I arrived on the 6th floor nursing unit one day last fall to find halls abuzz with people. Something didn’t feel right, and then I a saw a nursing colleague with tears streaming down her face. My heart dropped. She looked up at me and said, “Dr Hass, K died last night.” She started to sob. I stood dumbfounded for a moment. We had lost a beloved coworker to COVID.

There has been a collective sense of grief in our country since the beginning of the COVID-19 pandemic as we have all been suffering losses: smiles, touch, in-person relationships, a “normal life.” But it went to another level for us at Alta Bates Summit Medical Center in Oakland, Calif., with the passing of a couple of our beloved teammates in the fall. Strong emotions triggered by these events caused me to pause and think: “What is grief? Is it another word for sadness? How do we work through it?”

What is the difference between sadness and grief? While related, they are temporally and functionally quite different. Sadness is an emotion, and like all emotions, we feel it in brief episodes. Those moments of profound sadness only last minutes at a time. Sadness leads to decreased physiological arousal, especially after crying. When less intense, the physiological slowing is thought to allow for some mental clarity that lets the loss sink in and moves us toward a recalibration process. These episodes of sadness occur more frequently and with greater intensity the closer we are to the triggering event.

While emotions last minutes, mood, another affective state, lasts hours to days and is less intense and specific in content. A sad mood can be present much of the time after a significant loss. Emotions predispose to moods and vice versa.

Grief, on the other hand, is a complex and lengthy process that moves us from a place of loss to a new place with a new equilibrium without the lost object. While sadness is about fully acknowledging the loss, the grieving process is about getting beyond it. The bigger the loss, the bigger the hole in your life and the longer the grieving process. Grief is a multi-emotional process with people often experiencing a range of emotions, such as shock, anger, and fear in addition to sadness.

As I grappled with my sense of loss, I realized that understanding the grieving process was going to help me as I navigate this world now full of loss. Here are a few things we should all keep in mind.
 

A sense of mindful self-awareness

As we work through our grief, a mindful self-awareness can help us identify our emotions and see them as part of the grieving process. Simply anticipating emotions can lessen the impact of them when they come. As they come on, try to name the emotion, e.g., “I am so sad,” and feel the experience in the body. The sadness can be cathartic, and by focusing on the body and not the head, we can also drop the sometimes healthy, sometimes unhealthy rants and ruminations that can accompany these events. If we experience the emotions with mindful self-awareness, we can see our emotions as part of a healing, grieving process, and we will likely be able to handle them more gracefully.

In the days after the death of my nursing colleague, my sad mood would be interrupted with flares of anger triggered by thoughts of those not wearing masks or spreading misinformation. Moving my thoughts to the emotions, I would say to myself, “I am really angry, and I am angry because of these deaths.” I felt the recognition of the emotions helped me better ride the big waves on the grieving journey.

Counter to the thinking of the 20th century, research by George Bonanno at Columbia University found that the majority of bereavement is met with resilience. We will be sad, we might have moments of anger or denial or fear, but for most of us, despite the gravity of the loss, our innate resilience will lead about 50-80% of us to recover to near our baseline in months. It is nice to know we are not repressing things if we don’t pass through all the stages postulated by Elizabeth Kubler-Ross, the dominate paradigm in the field.¹

For those grieving, this idea of resilience being the norm can provide reassurance during tough moments. While our degree of resilience will depend on our loss and our circumstance, the work of Lucy Hone, PhD, suggests that resilience can be fostered. Many of the negative feelings we experience have a flip side we can seek out. We can be grateful for what remains and what the departed has left us with. We can aid in our grieving journey by using many of the resources available from UC Berkeley’s Greater Good in Action (https://ggia.berkeley.edu/).

While most grief is met with resilience, complicated grieving with persistent negative moods and emotions is common. We should consider seeking professional help if our emotions and pattern of thought continue to feel unhealthy.
 

Meaning and wisdom, not acceptance

Another change in our understanding of grief is this: Instead of “acceptance” being seen as the end result of grieving, meaning and wisdom are now recognized as the outcomes. Research has found that efforts to find meaning in loss facilitates the grieving process. As time passes and our sadness lessens, the loved one doesn’t leave us but stays with us as a better understanding of the beauty and complexity of life. The loss, through grieving, is transformed to wisdom that will guide us through future challenges and help us make sense of the world.

Last week, masked and robed and with an iPad in hand so the family could join the conversation, I was talking to Ms. B who is hospitalized with COVID-19. She said, “I just keep thinking, ‘Why is this happening to me? To all of us?’ And then I realized that it is a message from God that we need to do a better job of taking care of each other, and I suddenly felt a little better. What do you think, Dr. Hass?”

“Wow,” I said. “Thank you for sharing that. There is definitely some truth there. There is a lot to learn from the pandemic about how we care for each other. I need to keep that in mind when I start feeling down.”

So much is going on now: climate change, racial violence, frightening political dysfunction, and a global pandemic that has upended our daily routines and the economy. It is hard to keep track of all the loss and uncertainty. We might not know why feelings of sadness, anger and anxiety come on, but if we can meet these emotions with mindful equanimity, see them as part of our intrinsic healing process and keep in mind that our path will likely be towards one of wisdom and sense-making, we can better navigate these profoundly unsettling times.

Just as sadness is not grief, joy alone does not lead to happiness. A happy life comes as much from meaning as joy. While unbridled joy might be in short supply, our grief, our work as hospitalists with the suffering, and confronting the many problems our world faces gives us the opportunity to lead a meaningful life. If we couple this search for meaning with healthy habits that promote wellbeing, such as hugs, investing in relationships, and moving our body in the natural world, we can survive these crazy times and be wiser beings as a result of our experiences.
 

Dr. Hass is a hospitalist at Sutter East Bay Medical Group in Oakland, Calif. He is a member of the clinical faculty at the University of California, Berkeley-UC San Francisco joint medical program, and an adviser on health and health care at the Greater Good Science Center at UC Berkeley.

Reference

1. Bonanno GA, and Boerner K. The stage theory of grief. JAMA. 2007;297(24):2692-2694. doi:10.1001/jama.297.24.2693-a.

I arrived on the 6th floor nursing unit one day last fall to find halls abuzz with people. Something didn’t feel right, and then I a saw a nursing colleague with tears streaming down her face. My heart dropped. She looked up at me and said, “Dr Hass, K died last night.” She started to sob. I stood dumbfounded for a moment. We had lost a beloved coworker to COVID.

There has been a collective sense of grief in our country since the beginning of the COVID-19 pandemic as we have all been suffering losses: smiles, touch, in-person relationships, a “normal life.” But it went to another level for us at Alta Bates Summit Medical Center in Oakland, Calif., with the passing of a couple of our beloved teammates in the fall. Strong emotions triggered by these events caused me to pause and think: “What is grief? Is it another word for sadness? How do we work through it?”

What is the difference between sadness and grief? While related, they are temporally and functionally quite different. Sadness is an emotion, and like all emotions, we feel it in brief episodes. Those moments of profound sadness only last minutes at a time. Sadness leads to decreased physiological arousal, especially after crying. When less intense, the physiological slowing is thought to allow for some mental clarity that lets the loss sink in and moves us toward a recalibration process. These episodes of sadness occur more frequently and with greater intensity the closer we are to the triggering event.

While emotions last minutes, mood, another affective state, lasts hours to days and is less intense and specific in content. A sad mood can be present much of the time after a significant loss. Emotions predispose to moods and vice versa.

Grief, on the other hand, is a complex and lengthy process that moves us from a place of loss to a new place with a new equilibrium without the lost object. While sadness is about fully acknowledging the loss, the grieving process is about getting beyond it. The bigger the loss, the bigger the hole in your life and the longer the grieving process. Grief is a multi-emotional process with people often experiencing a range of emotions, such as shock, anger, and fear in addition to sadness.

As I grappled with my sense of loss, I realized that understanding the grieving process was going to help me as I navigate this world now full of loss. Here are a few things we should all keep in mind.
 

A sense of mindful self-awareness

As we work through our grief, a mindful self-awareness can help us identify our emotions and see them as part of the grieving process. Simply anticipating emotions can lessen the impact of them when they come. As they come on, try to name the emotion, e.g., “I am so sad,” and feel the experience in the body. The sadness can be cathartic, and by focusing on the body and not the head, we can also drop the sometimes healthy, sometimes unhealthy rants and ruminations that can accompany these events. If we experience the emotions with mindful self-awareness, we can see our emotions as part of a healing, grieving process, and we will likely be able to handle them more gracefully.

In the days after the death of my nursing colleague, my sad mood would be interrupted with flares of anger triggered by thoughts of those not wearing masks or spreading misinformation. Moving my thoughts to the emotions, I would say to myself, “I am really angry, and I am angry because of these deaths.” I felt the recognition of the emotions helped me better ride the big waves on the grieving journey.

Counter to the thinking of the 20th century, research by George Bonanno at Columbia University found that the majority of bereavement is met with resilience. We will be sad, we might have moments of anger or denial or fear, but for most of us, despite the gravity of the loss, our innate resilience will lead about 50-80% of us to recover to near our baseline in months. It is nice to know we are not repressing things if we don’t pass through all the stages postulated by Elizabeth Kubler-Ross, the dominate paradigm in the field.¹

For those grieving, this idea of resilience being the norm can provide reassurance during tough moments. While our degree of resilience will depend on our loss and our circumstance, the work of Lucy Hone, PhD, suggests that resilience can be fostered. Many of the negative feelings we experience have a flip side we can seek out. We can be grateful for what remains and what the departed has left us with. We can aid in our grieving journey by using many of the resources available from UC Berkeley’s Greater Good in Action (https://ggia.berkeley.edu/).

While most grief is met with resilience, complicated grieving with persistent negative moods and emotions is common. We should consider seeking professional help if our emotions and pattern of thought continue to feel unhealthy.
 

Meaning and wisdom, not acceptance

Another change in our understanding of grief is this: Instead of “acceptance” being seen as the end result of grieving, meaning and wisdom are now recognized as the outcomes. Research has found that efforts to find meaning in loss facilitates the grieving process. As time passes and our sadness lessens, the loved one doesn’t leave us but stays with us as a better understanding of the beauty and complexity of life. The loss, through grieving, is transformed to wisdom that will guide us through future challenges and help us make sense of the world.

Last week, masked and robed and with an iPad in hand so the family could join the conversation, I was talking to Ms. B who is hospitalized with COVID-19. She said, “I just keep thinking, ‘Why is this happening to me? To all of us?’ And then I realized that it is a message from God that we need to do a better job of taking care of each other, and I suddenly felt a little better. What do you think, Dr. Hass?”

“Wow,” I said. “Thank you for sharing that. There is definitely some truth there. There is a lot to learn from the pandemic about how we care for each other. I need to keep that in mind when I start feeling down.”

So much is going on now: climate change, racial violence, frightening political dysfunction, and a global pandemic that has upended our daily routines and the economy. It is hard to keep track of all the loss and uncertainty. We might not know why feelings of sadness, anger and anxiety come on, but if we can meet these emotions with mindful equanimity, see them as part of our intrinsic healing process and keep in mind that our path will likely be towards one of wisdom and sense-making, we can better navigate these profoundly unsettling times.

Just as sadness is not grief, joy alone does not lead to happiness. A happy life comes as much from meaning as joy. While unbridled joy might be in short supply, our grief, our work as hospitalists with the suffering, and confronting the many problems our world faces gives us the opportunity to lead a meaningful life. If we couple this search for meaning with healthy habits that promote wellbeing, such as hugs, investing in relationships, and moving our body in the natural world, we can survive these crazy times and be wiser beings as a result of our experiences.
 

Dr. Hass is a hospitalist at Sutter East Bay Medical Group in Oakland, Calif. He is a member of the clinical faculty at the University of California, Berkeley-UC San Francisco joint medical program, and an adviser on health and health care at the Greater Good Science Center at UC Berkeley.

Reference

1. Bonanno GA, and Boerner K. The stage theory of grief. JAMA. 2007;297(24):2692-2694. doi:10.1001/jama.297.24.2693-a.

The U.S. Supreme Court upheld the Affordable Care Act June 17 in a 7 to 2 vote, rejecting claims by the challengers that the requirement for all Americans to obtain health insurance is unconstitutional.

ETIENJones/thinkstockphotos

The challengers were comprised of 18 GOP-dominated states, led by Texas, that took issue with the ACA’s individual mandate – which required most Americans to have health insurance or pay a tax penalty.

But Congress reduced the penalty to zero in 2017. Challengers argued that without the mandate,  the rest of the law should be scrapped, too. The court ruled that eliminated the harm the states were claiming.

“To have standing, a plaintiff must ‘allege personal injury fairly traceable to the defendant’s allegedly unlawful conduct and likely to be redressed by the requested relief,’” the majority wrote. “No plaintiff has shown such an injury ‘fairly traceable’ to the ‘allegedly unlawful conduct’ challenged here.”

Justice Stephen Breyer authored the opinion. Justices Samuel Alito and Neil Gorsuch dissented.

The decision said that the mandate in question did not require the 18 states that brought the complaint to pay anything, and therefore they had no standing.

President Joe Biden has said he plans to build on the ACA – which was enacted while he was vice president – to offer coverage to more Americans.

This marks the third time the Supreme Court spared the Obama-era law from GOP attacks. The mandate was also upheld in 2012 in a 5 to 4 ruling.

American Medical Association president Gerald Harmon, MD, also called for building on the ruling to expand the law.

“With yet another court decision upholding the ACA now behind us, we remain committed to strengthening the current law and look forward to policymakers advancing solutions to improve the ACA,” Dr. Harmon said in a statement. “The AMA will continue working to expand access to health care and ensure that all Americans have meaningful, comprehensive, and affordable health coverage to improve the health of the nation.”

House Speaker Nancy Pelosi (D-Calif.), a longtime advocate for the ACA, called the decision a “landmark victory for Democrats.”

“Thanks to the tireless advocacy of Americans across the country and Democrats in Congress, the Affordable Care Act endures as a pillar of American health and economic security alongside Medicare, Medicaid and Social Security,” she said in a statement.

Senate Majority Leader Chuck Schumer (D-N.Y.) also celebrated the ruling.

“The Affordable Care Act has won. The Supreme Court has just ruled: the ACA is here to stay and now we’re going to try to make it bigger and better,” he said, according to CNN. “For more than a decade, the assault on our health care law was relentless from Republicans in Congress, from the executive branch itself and from Republican attorneys general in the courts. Each time in each arena, the ACA has prevailed.”

This article was updated June 17, 2021.

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

The U.S. Supreme Court upheld the Affordable Care Act June 17 in a 7 to 2 vote, rejecting claims by the challengers that the requirement for all Americans to obtain health insurance is unconstitutional.

ETIENJones/thinkstockphotos

The challengers were comprised of 18 GOP-dominated states, led by Texas, that took issue with the ACA’s individual mandate – which required most Americans to have health insurance or pay a tax penalty.

But Congress reduced the penalty to zero in 2017. Challengers argued that without the mandate,  the rest of the law should be scrapped, too. The court ruled that eliminated the harm the states were claiming.

“To have standing, a plaintiff must ‘allege personal injury fairly traceable to the defendant’s allegedly unlawful conduct and likely to be redressed by the requested relief,’” the majority wrote. “No plaintiff has shown such an injury ‘fairly traceable’ to the ‘allegedly unlawful conduct’ challenged here.”

Justice Stephen Breyer authored the opinion. Justices Samuel Alito and Neil Gorsuch dissented.

The decision said that the mandate in question did not require the 18 states that brought the complaint to pay anything, and therefore they had no standing.

President Joe Biden has said he plans to build on the ACA – which was enacted while he was vice president – to offer coverage to more Americans.

This marks the third time the Supreme Court spared the Obama-era law from GOP attacks. The mandate was also upheld in 2012 in a 5 to 4 ruling.

American Medical Association president Gerald Harmon, MD, also called for building on the ruling to expand the law.

“With yet another court decision upholding the ACA now behind us, we remain committed to strengthening the current law and look forward to policymakers advancing solutions to improve the ACA,” Dr. Harmon said in a statement. “The AMA will continue working to expand access to health care and ensure that all Americans have meaningful, comprehensive, and affordable health coverage to improve the health of the nation.”

House Speaker Nancy Pelosi (D-Calif.), a longtime advocate for the ACA, called the decision a “landmark victory for Democrats.”

“Thanks to the tireless advocacy of Americans across the country and Democrats in Congress, the Affordable Care Act endures as a pillar of American health and economic security alongside Medicare, Medicaid and Social Security,” she said in a statement.

Senate Majority Leader Chuck Schumer (D-N.Y.) also celebrated the ruling.

“The Affordable Care Act has won. The Supreme Court has just ruled: the ACA is here to stay and now we’re going to try to make it bigger and better,” he said, according to CNN. “For more than a decade, the assault on our health care law was relentless from Republicans in Congress, from the executive branch itself and from Republican attorneys general in the courts. Each time in each arena, the ACA has prevailed.”

This article was updated June 17, 2021.

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

The U.S. Supreme Court upheld the Affordable Care Act June 17 in a 7 to 2 vote, rejecting claims by the challengers that the requirement for all Americans to obtain health insurance is unconstitutional.

ETIENJones/thinkstockphotos

The challengers were comprised of 18 GOP-dominated states, led by Texas, that took issue with the ACA’s individual mandate – which required most Americans to have health insurance or pay a tax penalty.

But Congress reduced the penalty to zero in 2017. Challengers argued that without the mandate,  the rest of the law should be scrapped, too. The court ruled that eliminated the harm the states were claiming.

“To have standing, a plaintiff must ‘allege personal injury fairly traceable to the defendant’s allegedly unlawful conduct and likely to be redressed by the requested relief,’” the majority wrote. “No plaintiff has shown such an injury ‘fairly traceable’ to the ‘allegedly unlawful conduct’ challenged here.”

Justice Stephen Breyer authored the opinion. Justices Samuel Alito and Neil Gorsuch dissented.

The decision said that the mandate in question did not require the 18 states that brought the complaint to pay anything, and therefore they had no standing.

President Joe Biden has said he plans to build on the ACA – which was enacted while he was vice president – to offer coverage to more Americans.

This marks the third time the Supreme Court spared the Obama-era law from GOP attacks. The mandate was also upheld in 2012 in a 5 to 4 ruling.

American Medical Association president Gerald Harmon, MD, also called for building on the ruling to expand the law.

“With yet another court decision upholding the ACA now behind us, we remain committed to strengthening the current law and look forward to policymakers advancing solutions to improve the ACA,” Dr. Harmon said in a statement. “The AMA will continue working to expand access to health care and ensure that all Americans have meaningful, comprehensive, and affordable health coverage to improve the health of the nation.”

House Speaker Nancy Pelosi (D-Calif.), a longtime advocate for the ACA, called the decision a “landmark victory for Democrats.”

“Thanks to the tireless advocacy of Americans across the country and Democrats in Congress, the Affordable Care Act endures as a pillar of American health and economic security alongside Medicare, Medicaid and Social Security,” she said in a statement.

Senate Majority Leader Chuck Schumer (D-N.Y.) also celebrated the ruling.

“The Affordable Care Act has won. The Supreme Court has just ruled: the ACA is here to stay and now we’re going to try to make it bigger and better,” he said, according to CNN. “For more than a decade, the assault on our health care law was relentless from Republicans in Congress, from the executive branch itself and from Republican attorneys general in the courts. Each time in each arena, the ACA has prevailed.”

This article was updated June 17, 2021.

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

How did your career pathway lead you to working at a health tech startup?

I’ve always had an interest in technology – in fact, it was part of the reason I chose gastroenterology. When I finished GI fellowship, I decided to stay in academics because of an opportunity to lead clinical innovation efforts at my institution’s patient safety institute. This role provided protected time to foster external and internal partnerships around technology. It also gave me an opportunity to pursue clinical research and administrative experiences. While I enjoyed all three paths, it became clear that health technology was my passion. While the opportunity to join a startup was largely serendipitous – I met the founder of the company after presenting at a digital medicine conference – it also happened as a result of the steps outlined in a subsequent question. Not long after learning about the company, I made the transition to part-time faculty/clinical status and full-time chief medical officer (CMO).

What do you do as CMO?

There is no one answer to this question. It will depend on a number of variables, especially the type of business (for example, diagnostic, drug, digital, direct care management, and so on), stage of company (for example, concept, seed, series A/B/C, public), and the existing background of company founders (for example, technical, clinical, operations, and so on). Generally speaking, the earlier the stage of the company, the more hats you’ll wear (though this also means more risk; more on that later). An early-stage company was appealing to me because it gave me an opportunity to apply many of the same critical-thinking and problem-solving skills in clinical medicine to a host of other challenges. For example, as a practicing gastroenterologist, I know the pain points in the delivery of GI care and the challenges that my patients encounter. I then ask how can I develop our technology and product platform to address these issues. Also understanding how value and quality are measured in GI practice makes it easier to convey the effect of the solutions that are built and prioritize their development. In my current role I contribute to the following areas:

• Clinical strategy and vision. This means understanding the clinical need the company is trying to address at a fundamental level and designing how the technology or solution can address that need in a meaningful way. This includes working directly with technology and product teams to create a roadmap for how the technology/solution will continue to drive impact.
• Clinical care leadership. If the company employs or works with health professionals in any capacity, this usually involves developing clinical protocols and providing clinical direction. 
• Clinical outcomes. This means being responsible for understanding and/or developing the metrics that will be used to demonstrate impact of the technology/solution. This includes designing clinical studies and being responsible for their execution.
• Stakeholder engagement. This means interfacing internally with nearly every aspect of the company and interacting externally with customers (usually medical peers and executives), investors, other companies, and key opinion leaders in the field.
• Regulatory. For companies pursuing Food and Drug Administration clearance or approval for their product, this entails developing a strategy and executing it.
• Research & development. This involves creating and executing a roadmap for integrating new technologies/ideas that generally complement the initial problem you are trying to solve.  

What do you enjoy most about working at a startup?

The variety of experience, the flexibility, the fast pace, the ability to work creatively, and the potential to make a large-scale impact are all aspects of the job that I enjoy. The ability to continue clinical practice is important to me and is a major plus. 
 

What do you find most challenging about working at a startup?

One of the biggest differences between a startup and a traditional clinical role is the degree of uncertainty that permeates the entire experience. It took some time for me to adjust to the relative volatility/risk associated with this type of work. Unlike an academic, administrative, or private practice job, things can change very quickly (as in a 24-hour period or less!). This can encompass a number of changes, such as funding, leadership, strategic direction, business model, and staffing, to name a few. What I’ve learned is that this doesn’t always mean changing for the worse, but it does mean things changing near constantly. Being mentally prepared to adapt quickly and frequently to big changes is part of the experience. 
 

What are the ways that GIs can get involved in startups?

Gastroenterologists have more opportunities than most physicians due to the diversity of conditions we treat and the large corresponding number of unmet needs we encounter. There is also the inherent innovation potential associated with new applications in endoscopy, diagnostics, and drug therapies. As a result, there are a number of ways to get involved:

• This often takes the form of “spinning out” research from an academic institution but can also be done successfully from private practice, particularly in the context of new devices/services. Another related option is to license your technology to a company, which offloads the operational aspects of running a business.
• Provide consulting/advisory support. Many early-stage companies cannot afford to hire a full-time physician, but they are open to consulting arrangements (and of course volunteer work). Don’t hesitate to directly contact companies that are interesting to you. These opportunities are possible even while in clinical training.
• Work part time or full time. The majority of startups are supportive of physicians continuing to practice clinically. This makes engaging in a part-time position financially feasible for both parties. Given the relatively high remuneration for gastroenterologists working clinically, a full-time position at a startup may require a financial tradeoff (that is, lower short-term salary for a potential larger long-term gain – note the emphasis on “potential”).  
• Invest in early-stage companies. Physicians can become angel investors for early-stage companies. Given the relatively time-intensive process of finding new opportunities and conducting due diligence, this often takes the form of pooling funds into angel networks that can distribute the execution of investments more efficiently. 

How would a fellow or early-career GI who is interested in startups pursue this career pathway?

The first step I recommend is self-reflection – what about the startup experience is interesting to you? Not all aspects appeal to everyone, and not all options provide the same opportunities. Spending time deciding which specific aspects of the startup experience appeal to you will make it easier to find the right opportunity. A concurrent step is to build expertise. This can take many forms, including traditional basic science or clinical research, but also includes implementation, evaluation/analysis, design, education, regulation, policy, and so on. The next step is to proactively meet people who are doing what you are interested in doing. Reach out to mentors, alumni, faculty, and friends. Conferences and social media are also great places to network. Other potential paths can include developing expertise in an allied functional area that can be later leveraged into a startup role (for example, experience at pharma, payer, regulatory, and so on). Many of these organizations have programs specifically geared toward physicians making a transition. In addition, another potential option is to seek additional education through an MBA where internships, recruitment programs, and robust alumni networks can be helpful in finding placement.

What if I want to learn more about the health technology startup experience?

The AGA Center for GI Innovation and Technology (CGIT) has a number of programs throughout the year, including the annual Tech Summit where you can learn about new companies, ideas, and technologies from like-minded individuals. I also invite you to reach out to me directly via Twitter, LinkedIn, or email with specific questions. As gastroenterologists, we are fortunate to work in a field full of innovation and new ideas. As a result, there are many meaningful career paths available to those interested in gastroenterology and technology. Whether providing direct clinical care with the latest endoscopic techniques or developing the next digital therapy, the opportunities for gastroenterologists will only continue to grow.

Dr. Mathews is chief medical officer at Vivante Health and assistant professor of medicine at Johns Hopkins Medicine in Baltimore. He is an officer at Vivante Health with stock options, but he reports having nothing else to disclose.

How did your career pathway lead you to working at a health tech startup?

I’ve always had an interest in technology – in fact, it was part of the reason I chose gastroenterology. When I finished GI fellowship, I decided to stay in academics because of an opportunity to lead clinical innovation efforts at my institution’s patient safety institute. This role provided protected time to foster external and internal partnerships around technology. It also gave me an opportunity to pursue clinical research and administrative experiences. While I enjoyed all three paths, it became clear that health technology was my passion. While the opportunity to join a startup was largely serendipitous – I met the founder of the company after presenting at a digital medicine conference – it also happened as a result of the steps outlined in a subsequent question. Not long after learning about the company, I made the transition to part-time faculty/clinical status and full-time chief medical officer (CMO).

What do you do as CMO?

There is no one answer to this question. It will depend on a number of variables, especially the type of business (for example, diagnostic, drug, digital, direct care management, and so on), stage of company (for example, concept, seed, series A/B/C, public), and the existing background of company founders (for example, technical, clinical, operations, and so on). Generally speaking, the earlier the stage of the company, the more hats you’ll wear (though this also means more risk; more on that later). An early-stage company was appealing to me because it gave me an opportunity to apply many of the same critical-thinking and problem-solving skills in clinical medicine to a host of other challenges. For example, as a practicing gastroenterologist, I know the pain points in the delivery of GI care and the challenges that my patients encounter. I then ask how can I develop our technology and product platform to address these issues. Also understanding how value and quality are measured in GI practice makes it easier to convey the effect of the solutions that are built and prioritize their development. In my current role I contribute to the following areas:

• Clinical strategy and vision. This means understanding the clinical need the company is trying to address at a fundamental level and designing how the technology or solution can address that need in a meaningful way. This includes working directly with technology and product teams to create a roadmap for how the technology/solution will continue to drive impact.
• Clinical care leadership. If the company employs or works with health professionals in any capacity, this usually involves developing clinical protocols and providing clinical direction. 
• Clinical outcomes. This means being responsible for understanding and/or developing the metrics that will be used to demonstrate impact of the technology/solution. This includes designing clinical studies and being responsible for their execution.
• Stakeholder engagement. This means interfacing internally with nearly every aspect of the company and interacting externally with customers (usually medical peers and executives), investors, other companies, and key opinion leaders in the field.
• Regulatory. For companies pursuing Food and Drug Administration clearance or approval for their product, this entails developing a strategy and executing it.
• Research & development. This involves creating and executing a roadmap for integrating new technologies/ideas that generally complement the initial problem you are trying to solve.  

What do you enjoy most about working at a startup?

The variety of experience, the flexibility, the fast pace, the ability to work creatively, and the potential to make a large-scale impact are all aspects of the job that I enjoy. The ability to continue clinical practice is important to me and is a major plus. 
 

What do you find most challenging about working at a startup?

One of the biggest differences between a startup and a traditional clinical role is the degree of uncertainty that permeates the entire experience. It took some time for me to adjust to the relative volatility/risk associated with this type of work. Unlike an academic, administrative, or private practice job, things can change very quickly (as in a 24-hour period or less!). This can encompass a number of changes, such as funding, leadership, strategic direction, business model, and staffing, to name a few. What I’ve learned is that this doesn’t always mean changing for the worse, but it does mean things changing near constantly. Being mentally prepared to adapt quickly and frequently to big changes is part of the experience. 
 

What are the ways that GIs can get involved in startups?

Gastroenterologists have more opportunities than most physicians due to the diversity of conditions we treat and the large corresponding number of unmet needs we encounter. There is also the inherent innovation potential associated with new applications in endoscopy, diagnostics, and drug therapies. As a result, there are a number of ways to get involved:

• This often takes the form of “spinning out” research from an academic institution but can also be done successfully from private practice, particularly in the context of new devices/services. Another related option is to license your technology to a company, which offloads the operational aspects of running a business.
• Provide consulting/advisory support. Many early-stage companies cannot afford to hire a full-time physician, but they are open to consulting arrangements (and of course volunteer work). Don’t hesitate to directly contact companies that are interesting to you. These opportunities are possible even while in clinical training.
• Work part time or full time. The majority of startups are supportive of physicians continuing to practice clinically. This makes engaging in a part-time position financially feasible for both parties. Given the relatively high remuneration for gastroenterologists working clinically, a full-time position at a startup may require a financial tradeoff (that is, lower short-term salary for a potential larger long-term gain – note the emphasis on “potential”).  
• Invest in early-stage companies. Physicians can become angel investors for early-stage companies. Given the relatively time-intensive process of finding new opportunities and conducting due diligence, this often takes the form of pooling funds into angel networks that can distribute the execution of investments more efficiently. 

How would a fellow or early-career GI who is interested in startups pursue this career pathway?

The first step I recommend is self-reflection – what about the startup experience is interesting to you? Not all aspects appeal to everyone, and not all options provide the same opportunities. Spending time deciding which specific aspects of the startup experience appeal to you will make it easier to find the right opportunity. A concurrent step is to build expertise. This can take many forms, including traditional basic science or clinical research, but also includes implementation, evaluation/analysis, design, education, regulation, policy, and so on. The next step is to proactively meet people who are doing what you are interested in doing. Reach out to mentors, alumni, faculty, and friends. Conferences and social media are also great places to network. Other potential paths can include developing expertise in an allied functional area that can be later leveraged into a startup role (for example, experience at pharma, payer, regulatory, and so on). Many of these organizations have programs specifically geared toward physicians making a transition. In addition, another potential option is to seek additional education through an MBA where internships, recruitment programs, and robust alumni networks can be helpful in finding placement.

What if I want to learn more about the health technology startup experience?

The AGA Center for GI Innovation and Technology (CGIT) has a number of programs throughout the year, including the annual Tech Summit where you can learn about new companies, ideas, and technologies from like-minded individuals. I also invite you to reach out to me directly via Twitter, LinkedIn, or email with specific questions. As gastroenterologists, we are fortunate to work in a field full of innovation and new ideas. As a result, there are many meaningful career paths available to those interested in gastroenterology and technology. Whether providing direct clinical care with the latest endoscopic techniques or developing the next digital therapy, the opportunities for gastroenterologists will only continue to grow.

Dr. Mathews is chief medical officer at Vivante Health and assistant professor of medicine at Johns Hopkins Medicine in Baltimore. He is an officer at Vivante Health with stock options, but he reports having nothing else to disclose.

How did your career pathway lead you to working at a health tech startup?

I’ve always had an interest in technology – in fact, it was part of the reason I chose gastroenterology. When I finished GI fellowship, I decided to stay in academics because of an opportunity to lead clinical innovation efforts at my institution’s patient safety institute. This role provided protected time to foster external and internal partnerships around technology. It also gave me an opportunity to pursue clinical research and administrative experiences. While I enjoyed all three paths, it became clear that health technology was my passion. While the opportunity to join a startup was largely serendipitous – I met the founder of the company after presenting at a digital medicine conference – it also happened as a result of the steps outlined in a subsequent question. Not long after learning about the company, I made the transition to part-time faculty/clinical status and full-time chief medical officer (CMO).

What do you do as CMO?

There is no one answer to this question. It will depend on a number of variables, especially the type of business (for example, diagnostic, drug, digital, direct care management, and so on), stage of company (for example, concept, seed, series A/B/C, public), and the existing background of company founders (for example, technical, clinical, operations, and so on). Generally speaking, the earlier the stage of the company, the more hats you’ll wear (though this also means more risk; more on that later). An early-stage company was appealing to me because it gave me an opportunity to apply many of the same critical-thinking and problem-solving skills in clinical medicine to a host of other challenges. For example, as a practicing gastroenterologist, I know the pain points in the delivery of GI care and the challenges that my patients encounter. I then ask how can I develop our technology and product platform to address these issues. Also understanding how value and quality are measured in GI practice makes it easier to convey the effect of the solutions that are built and prioritize their development. In my current role I contribute to the following areas:

• Clinical strategy and vision. This means understanding the clinical need the company is trying to address at a fundamental level and designing how the technology or solution can address that need in a meaningful way. This includes working directly with technology and product teams to create a roadmap for how the technology/solution will continue to drive impact.
• Clinical care leadership. If the company employs or works with health professionals in any capacity, this usually involves developing clinical protocols and providing clinical direction. 
• Clinical outcomes. This means being responsible for understanding and/or developing the metrics that will be used to demonstrate impact of the technology/solution. This includes designing clinical studies and being responsible for their execution.
• Stakeholder engagement. This means interfacing internally with nearly every aspect of the company and interacting externally with customers (usually medical peers and executives), investors, other companies, and key opinion leaders in the field.
• Regulatory. For companies pursuing Food and Drug Administration clearance or approval for their product, this entails developing a strategy and executing it.
• Research & development. This involves creating and executing a roadmap for integrating new technologies/ideas that generally complement the initial problem you are trying to solve.  

What do you enjoy most about working at a startup?

The variety of experience, the flexibility, the fast pace, the ability to work creatively, and the potential to make a large-scale impact are all aspects of the job that I enjoy. The ability to continue clinical practice is important to me and is a major plus. 
 

What do you find most challenging about working at a startup?

One of the biggest differences between a startup and a traditional clinical role is the degree of uncertainty that permeates the entire experience. It took some time for me to adjust to the relative volatility/risk associated with this type of work. Unlike an academic, administrative, or private practice job, things can change very quickly (as in a 24-hour period or less!). This can encompass a number of changes, such as funding, leadership, strategic direction, business model, and staffing, to name a few. What I’ve learned is that this doesn’t always mean changing for the worse, but it does mean things changing near constantly. Being mentally prepared to adapt quickly and frequently to big changes is part of the experience. 
 

What are the ways that GIs can get involved in startups?

Gastroenterologists have more opportunities than most physicians due to the diversity of conditions we treat and the large corresponding number of unmet needs we encounter. There is also the inherent innovation potential associated with new applications in endoscopy, diagnostics, and drug therapies. As a result, there are a number of ways to get involved:

• This often takes the form of “spinning out” research from an academic institution but can also be done successfully from private practice, particularly in the context of new devices/services. Another related option is to license your technology to a company, which offloads the operational aspects of running a business.
• Provide consulting/advisory support. Many early-stage companies cannot afford to hire a full-time physician, but they are open to consulting arrangements (and of course volunteer work). Don’t hesitate to directly contact companies that are interesting to you. These opportunities are possible even while in clinical training.
• Work part time or full time. The majority of startups are supportive of physicians continuing to practice clinically. This makes engaging in a part-time position financially feasible for both parties. Given the relatively high remuneration for gastroenterologists working clinically, a full-time position at a startup may require a financial tradeoff (that is, lower short-term salary for a potential larger long-term gain – note the emphasis on “potential”).  
• Invest in early-stage companies. Physicians can become angel investors for early-stage companies. Given the relatively time-intensive process of finding new opportunities and conducting due diligence, this often takes the form of pooling funds into angel networks that can distribute the execution of investments more efficiently. 

How would a fellow or early-career GI who is interested in startups pursue this career pathway?

The first step I recommend is self-reflection – what about the startup experience is interesting to you? Not all aspects appeal to everyone, and not all options provide the same opportunities. Spending time deciding which specific aspects of the startup experience appeal to you will make it easier to find the right opportunity. A concurrent step is to build expertise. This can take many forms, including traditional basic science or clinical research, but also includes implementation, evaluation/analysis, design, education, regulation, policy, and so on. The next step is to proactively meet people who are doing what you are interested in doing. Reach out to mentors, alumni, faculty, and friends. Conferences and social media are also great places to network. Other potential paths can include developing expertise in an allied functional area that can be later leveraged into a startup role (for example, experience at pharma, payer, regulatory, and so on). Many of these organizations have programs specifically geared toward physicians making a transition. In addition, another potential option is to seek additional education through an MBA where internships, recruitment programs, and robust alumni networks can be helpful in finding placement.

What if I want to learn more about the health technology startup experience?

The AGA Center for GI Innovation and Technology (CGIT) has a number of programs throughout the year, including the annual Tech Summit where you can learn about new companies, ideas, and technologies from like-minded individuals. I also invite you to reach out to me directly via Twitter, LinkedIn, or email with specific questions. As gastroenterologists, we are fortunate to work in a field full of innovation and new ideas. As a result, there are many meaningful career paths available to those interested in gastroenterology and technology. Whether providing direct clinical care with the latest endoscopic techniques or developing the next digital therapy, the opportunities for gastroenterologists will only continue to grow.

Dr. Mathews is chief medical officer at Vivante Health and assistant professor of medicine at Johns Hopkins Medicine in Baltimore. He is an officer at Vivante Health with stock options, but he reports having nothing else to disclose.

Sex should be removed as a legal designation on the public part of birth certificates, the American Medical Association said June 15.

Requiring the designation can lead to discrimination and unnecessary burden on individuals whose current gender identity does not align with their designation at birth when they register for school or sports, adopt, get married, or request personal records.

A person’s sex designation at birth would still be submitted to the U.S. Standard Certificate of Live Birth for medical, public health, and statistical use only, report authors note.

Willie Underwood III, MD, MSc, author of Board Report 15, explained in reference committee testimony that a standard certificate of live birth is critical for uniformly collecting and processing data, but birth certificates are issued by the government to individuals.
 

Ten states allow gender-neutral designation

According to the report, 48 states (Tennessee and Ohio are the exceptions) and the District of Columbia allow people to amend their sex designation on their birth certificate to reflect their gender identities, but only 10 states allow for a gender-neutral designation, usually “X,” on birth certificates. The U.S. Department of State does not currently offer an option for a gender-neutral designation on U.S. passports.

“Assigning sex using binary variables in the public portion of the birth certificate fails to recognize the medical spectrum of gender identity,” Dr. Underwood said, and it can be used to discriminate.

Jeremy Toler, MD, a delegate from GLMA: Health Professionals Advancing LGBTQ Equality, testified that there is precedent for information to be removed from the public portion of the birth certificates. And much data is collected for each live birth that doesn’t show up on individuals’ birth certificates, he noted.

Dr. Toler said transgender, gender nonbinary, and individuals with differences in sex development can be placed at a disadvantage by the sex label on the birth certificate.

“We unfortunately still live in a world where it is unsafe in many cases for one’s gender to vary from the sex assigned at birth,” Dr. Toler said.

Not having this data on the widely used form will reduce unnecessary reliance on sex as a stand-in for gender, he said, and would “serve as an equalizer” since policies differ by state.

Robert Jackson, MD, an alternate delegate from the American Academy of Cosmetic Surgery, spoke against the measure.

“We as physicians need to report things accurately,” Dr. Jackson said. “All through medical school, residency, and specialty training we were supposed to delegate all of the physical findings of the patient we’re taking care of. I think when the child is born, they do have physical characteristics either male or female, and I think that probably should be on the public record. That’s just my personal opinion.”

Sarah Mae Smith, MD, delegate from California, speaking on behalf of the Women Physicians Section, said removing the sex designation is important for moving toward gender equity.

“We need to recognize [that] gender is not a binary but a spectrum,” she said. “Obligating our patients to jump through numerous administrative hoops to identify as who they are based on a sex assigned at birth primarily on genitalia is not only unnecessary but actively deleterious to their health.”
 

Race was once public on birth certificates

She noted that the report mentions that previously, information on the race of a person’s parents was included on the public portion of the birth certificate and that information was recognized to facilitate discrimination.

“Thankfully, a change was made to obviate at least that avenue for discriminatory practices,” she said. “Now, likewise, the information on sex assigned at birth is being used to undermine the rights of our transgender, intersex, and nonbinary patients.”

Arlene Seid, MD, MPH, an alternate delegate from the American Association of Public Health Physicians, said the resolution protects the aggregate data “without the discrimination associated with the individual data.”

Sex no longer has a role to play in the jobs people do, she noted, and the designation shouldn’t have to be evaluated for something like a job interview.

“Our society doesn’t need it on an individual basis for most of what occurs in public life,” Dr. Seid said.

Dr. Underwood, Dr. Toler, Dr. Jackson, Dr. Smith, and Dr. Seid declared no relevant financial relationships.

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

Sex should be removed as a legal designation on the public part of birth certificates, the American Medical Association said June 15.

Requiring the designation can lead to discrimination and unnecessary burden on individuals whose current gender identity does not align with their designation at birth when they register for school or sports, adopt, get married, or request personal records.

A person’s sex designation at birth would still be submitted to the U.S. Standard Certificate of Live Birth for medical, public health, and statistical use only, report authors note.

Willie Underwood III, MD, MSc, author of Board Report 15, explained in reference committee testimony that a standard certificate of live birth is critical for uniformly collecting and processing data, but birth certificates are issued by the government to individuals.
 

Ten states allow gender-neutral designation

According to the report, 48 states (Tennessee and Ohio are the exceptions) and the District of Columbia allow people to amend their sex designation on their birth certificate to reflect their gender identities, but only 10 states allow for a gender-neutral designation, usually “X,” on birth certificates. The U.S. Department of State does not currently offer an option for a gender-neutral designation on U.S. passports.

“Assigning sex using binary variables in the public portion of the birth certificate fails to recognize the medical spectrum of gender identity,” Dr. Underwood said, and it can be used to discriminate.

Jeremy Toler, MD, a delegate from GLMA: Health Professionals Advancing LGBTQ Equality, testified that there is precedent for information to be removed from the public portion of the birth certificates. And much data is collected for each live birth that doesn’t show up on individuals’ birth certificates, he noted.

Dr. Toler said transgender, gender nonbinary, and individuals with differences in sex development can be placed at a disadvantage by the sex label on the birth certificate.

“We unfortunately still live in a world where it is unsafe in many cases for one’s gender to vary from the sex assigned at birth,” Dr. Toler said.

Not having this data on the widely used form will reduce unnecessary reliance on sex as a stand-in for gender, he said, and would “serve as an equalizer” since policies differ by state.

Robert Jackson, MD, an alternate delegate from the American Academy of Cosmetic Surgery, spoke against the measure.

“We as physicians need to report things accurately,” Dr. Jackson said. “All through medical school, residency, and specialty training we were supposed to delegate all of the physical findings of the patient we’re taking care of. I think when the child is born, they do have physical characteristics either male or female, and I think that probably should be on the public record. That’s just my personal opinion.”

Sarah Mae Smith, MD, delegate from California, speaking on behalf of the Women Physicians Section, said removing the sex designation is important for moving toward gender equity.

“We need to recognize [that] gender is not a binary but a spectrum,” she said. “Obligating our patients to jump through numerous administrative hoops to identify as who they are based on a sex assigned at birth primarily on genitalia is not only unnecessary but actively deleterious to their health.”
 

Race was once public on birth certificates

She noted that the report mentions that previously, information on the race of a person’s parents was included on the public portion of the birth certificate and that information was recognized to facilitate discrimination.

“Thankfully, a change was made to obviate at least that avenue for discriminatory practices,” she said. “Now, likewise, the information on sex assigned at birth is being used to undermine the rights of our transgender, intersex, and nonbinary patients.”

Arlene Seid, MD, MPH, an alternate delegate from the American Association of Public Health Physicians, said the resolution protects the aggregate data “without the discrimination associated with the individual data.”

Sex no longer has a role to play in the jobs people do, she noted, and the designation shouldn’t have to be evaluated for something like a job interview.

“Our society doesn’t need it on an individual basis for most of what occurs in public life,” Dr. Seid said.

Dr. Underwood, Dr. Toler, Dr. Jackson, Dr. Smith, and Dr. Seid declared no relevant financial relationships.

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

Sex should be removed as a legal designation on the public part of birth certificates, the American Medical Association said June 15.

Requiring the designation can lead to discrimination and unnecessary burden on individuals whose current gender identity does not align with their designation at birth when they register for school or sports, adopt, get married, or request personal records.

A person’s sex designation at birth would still be submitted to the U.S. Standard Certificate of Live Birth for medical, public health, and statistical use only, report authors note.

Willie Underwood III, MD, MSc, author of Board Report 15, explained in reference committee testimony that a standard certificate of live birth is critical for uniformly collecting and processing data, but birth certificates are issued by the government to individuals.
 

Ten states allow gender-neutral designation

According to the report, 48 states (Tennessee and Ohio are the exceptions) and the District of Columbia allow people to amend their sex designation on their birth certificate to reflect their gender identities, but only 10 states allow for a gender-neutral designation, usually “X,” on birth certificates. The U.S. Department of State does not currently offer an option for a gender-neutral designation on U.S. passports.

“Assigning sex using binary variables in the public portion of the birth certificate fails to recognize the medical spectrum of gender identity,” Dr. Underwood said, and it can be used to discriminate.

Jeremy Toler, MD, a delegate from GLMA: Health Professionals Advancing LGBTQ Equality, testified that there is precedent for information to be removed from the public portion of the birth certificates. And much data is collected for each live birth that doesn’t show up on individuals’ birth certificates, he noted.

Dr. Toler said transgender, gender nonbinary, and individuals with differences in sex development can be placed at a disadvantage by the sex label on the birth certificate.

“We unfortunately still live in a world where it is unsafe in many cases for one’s gender to vary from the sex assigned at birth,” Dr. Toler said.

Not having this data on the widely used form will reduce unnecessary reliance on sex as a stand-in for gender, he said, and would “serve as an equalizer” since policies differ by state.

Robert Jackson, MD, an alternate delegate from the American Academy of Cosmetic Surgery, spoke against the measure.

“We as physicians need to report things accurately,” Dr. Jackson said. “All through medical school, residency, and specialty training we were supposed to delegate all of the physical findings of the patient we’re taking care of. I think when the child is born, they do have physical characteristics either male or female, and I think that probably should be on the public record. That’s just my personal opinion.”

Sarah Mae Smith, MD, delegate from California, speaking on behalf of the Women Physicians Section, said removing the sex designation is important for moving toward gender equity.

“We need to recognize [that] gender is not a binary but a spectrum,” she said. “Obligating our patients to jump through numerous administrative hoops to identify as who they are based on a sex assigned at birth primarily on genitalia is not only unnecessary but actively deleterious to their health.”
 

Race was once public on birth certificates

She noted that the report mentions that previously, information on the race of a person’s parents was included on the public portion of the birth certificate and that information was recognized to facilitate discrimination.

“Thankfully, a change was made to obviate at least that avenue for discriminatory practices,” she said. “Now, likewise, the information on sex assigned at birth is being used to undermine the rights of our transgender, intersex, and nonbinary patients.”

Arlene Seid, MD, MPH, an alternate delegate from the American Association of Public Health Physicians, said the resolution protects the aggregate data “without the discrimination associated with the individual data.”

Sex no longer has a role to play in the jobs people do, she noted, and the designation shouldn’t have to be evaluated for something like a job interview.

“Our society doesn’t need it on an individual basis for most of what occurs in public life,” Dr. Seid said.

Dr. Underwood, Dr. Toler, Dr. Jackson, Dr. Smith, and Dr. Seid declared no relevant financial relationships.

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

People may be absorbing and ingesting potentially toxic chemicals from their cosmetic products, a new study suggests.

Researchers found high fluorine levels in most of the waterproof mascara, liquid lipsticks, and foundations they tested, indicating the probable presence of what’s known as PFAS – per- and polyfluoroalkyl substances. Many of these chemicals were not included on the product labels, making it difficult for consumers to consciously avoid them.

Environmental Science & Technology

“This study is very helpful for elucidating the PFAS content of different types of cosmetics in the U.S. and Canadian markets,” said Elsie Sunderland, PhD, an environmental scientist who was not involved with the study.

“Previously, all the data had been collected in Europe, and this study shows we are dealing with similar problems in the North American marketplace,” said Dr. Sunderland, a professor of environmental chemistry at the Harvard School of Public Health, Boston.

PFAS are a class of chemicals used in a variety of consumer products, such as nonstick cookware, stain-resistant carpeting, and water-repellent clothing, according to the Centers for Disease Control and Prevention. They are added to cosmetics to make the products more durable and spreadable, researchers said in the study.

“[PFAS] are added to change the properties of surfaces, to make them nonstick or resistant to stay in water or oils,” said study coauthor Tom Bruton, PhD, senior scientist at the Green Science Policy Institute in Berkeley, Calif. “The concerning thing about cosmetics is that these are products that you’re applying to your skin and face every day, so there’s the skin absorption route that’s of concern, but also incidental ingestion of cosmetics is also a concern as well.”

The CDC says some of the potential health effects of PFAS exposure includes increased cholesterol levels, increased risk of kidney and testicular cancer, changes in liver enzymes, decreased vaccine response in children, and a higher risk of high blood pressure or preeclampsia in pregnant women.

JackF/iStock/Getty Images

“PFAS are a large class of chemicals. In humans, exposure to some of these chemicals has been associated with impaired immune function, certain cancers, increased risks of diabetes, obesity and endocrine disruption,” Dr. Sunderland said. “They appear to be harmful to every major organ system in the human body.”

For the current study, published online in Environmental Science & Technology Letters, Dr. Bruton and colleagues purchased 231 cosmetic products in the United States and Canada from retailers such as Ulta Beauty, Sephora, Target, and Bed Bath & Beyond. They then screened them for fluorine.Three-quarters of waterproof mascara samples contained high fluorine concentrations, as did nearly two-thirds of foundations and liquid lipsticks, and more than half of the eye and lip products tested.

The authors found that different categories of makeup tended to have higher or lower fluorine concentrations. “High fluorine levels were found in products commonly advertised as ‘wear-resistant’ to water and oils or ‘long-lasting,’ including foundations, liquid lipsticks, and waterproof mascaras,” Dr. Bruton and colleagues wrote.

When they further analyzed a subset of 29 products to determine what types of chemicals were present, they found that each cosmetic product contained at least 4 PFAS, with one product containing 13.The PFAS substances found included some that break down into other chemicals that are known to be highly toxic and environmentally harmful.

“It’s concerning that some of the products we tested appear to be intentionally using PFAS, but not listing those ingredients on the label,” Dr. Bruton said. “I do think that it is helpful for consumers to read labels, but beyond that, there’s not a lot of ways that consumers themselves can solve this problem. ... We think that the industry needs to be more proactive about moving away from this group of chemicals.”

Dr. Sunderland said a resource people can use when trying to avoid PFAS is the Environmental Working Group, a nonprofit organization that maintains an extensive database of cosmetics and personal care products.

“At this point, there is very little regulatory activity related to PFAS in cosmetics,” Dr. Sunderland said. “The best thing to happen now would be for consumers to indicate that they prefer products without PFAS and to demand better transparency in product ingredient lists.”

A similar study done in 2018 by the Danish Environmental Protection Agency found high levels of PFAS in nearly one-third of the cosmetics products it tested.

People can also be exposed to PFAS by eating or drinking contaminated food or water and through food packaging. Dr. Sunderland said some wild foods like seafood are known to accumulate these compounds in the environment.

“There are examples of contaminated biosolids leading to accumulation of PFAS in vegetables and milk,” Dr. Sunderland explained. “Food packaging is another concern because it can also result in PFAS accumulation in the foods we eat.”

Although it’s difficult to avoid PFAS altogether, the CDC suggests lowering exposure rates by avoiding contaminated water and food. If you’re not sure if your water is contaminated, you should ask your local or state health and environmental quality departments for fish or water advisories in your area.

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

People may be absorbing and ingesting potentially toxic chemicals from their cosmetic products, a new study suggests.

Researchers found high fluorine levels in most of the waterproof mascara, liquid lipsticks, and foundations they tested, indicating the probable presence of what’s known as PFAS – per- and polyfluoroalkyl substances. Many of these chemicals were not included on the product labels, making it difficult for consumers to consciously avoid them.

Environmental Science & Technology

“This study is very helpful for elucidating the PFAS content of different types of cosmetics in the U.S. and Canadian markets,” said Elsie Sunderland, PhD, an environmental scientist who was not involved with the study.

“Previously, all the data had been collected in Europe, and this study shows we are dealing with similar problems in the North American marketplace,” said Dr. Sunderland, a professor of environmental chemistry at the Harvard School of Public Health, Boston.

PFAS are a class of chemicals used in a variety of consumer products, such as nonstick cookware, stain-resistant carpeting, and water-repellent clothing, according to the Centers for Disease Control and Prevention. They are added to cosmetics to make the products more durable and spreadable, researchers said in the study.

“[PFAS] are added to change the properties of surfaces, to make them nonstick or resistant to stay in water or oils,” said study coauthor Tom Bruton, PhD, senior scientist at the Green Science Policy Institute in Berkeley, Calif. “The concerning thing about cosmetics is that these are products that you’re applying to your skin and face every day, so there’s the skin absorption route that’s of concern, but also incidental ingestion of cosmetics is also a concern as well.”

The CDC says some of the potential health effects of PFAS exposure includes increased cholesterol levels, increased risk of kidney and testicular cancer, changes in liver enzymes, decreased vaccine response in children, and a higher risk of high blood pressure or preeclampsia in pregnant women.

JackF/iStock/Getty Images

“PFAS are a large class of chemicals. In humans, exposure to some of these chemicals has been associated with impaired immune function, certain cancers, increased risks of diabetes, obesity and endocrine disruption,” Dr. Sunderland said. “They appear to be harmful to every major organ system in the human body.”

For the current study, published online in Environmental Science & Technology Letters, Dr. Bruton and colleagues purchased 231 cosmetic products in the United States and Canada from retailers such as Ulta Beauty, Sephora, Target, and Bed Bath & Beyond. They then screened them for fluorine.Three-quarters of waterproof mascara samples contained high fluorine concentrations, as did nearly two-thirds of foundations and liquid lipsticks, and more than half of the eye and lip products tested.

The authors found that different categories of makeup tended to have higher or lower fluorine concentrations. “High fluorine levels were found in products commonly advertised as ‘wear-resistant’ to water and oils or ‘long-lasting,’ including foundations, liquid lipsticks, and waterproof mascaras,” Dr. Bruton and colleagues wrote.

When they further analyzed a subset of 29 products to determine what types of chemicals were present, they found that each cosmetic product contained at least 4 PFAS, with one product containing 13.The PFAS substances found included some that break down into other chemicals that are known to be highly toxic and environmentally harmful.

“It’s concerning that some of the products we tested appear to be intentionally using PFAS, but not listing those ingredients on the label,” Dr. Bruton said. “I do think that it is helpful for consumers to read labels, but beyond that, there’s not a lot of ways that consumers themselves can solve this problem. ... We think that the industry needs to be more proactive about moving away from this group of chemicals.”

Dr. Sunderland said a resource people can use when trying to avoid PFAS is the Environmental Working Group, a nonprofit organization that maintains an extensive database of cosmetics and personal care products.

“At this point, there is very little regulatory activity related to PFAS in cosmetics,” Dr. Sunderland said. “The best thing to happen now would be for consumers to indicate that they prefer products without PFAS and to demand better transparency in product ingredient lists.”

A similar study done in 2018 by the Danish Environmental Protection Agency found high levels of PFAS in nearly one-third of the cosmetics products it tested.

People can also be exposed to PFAS by eating or drinking contaminated food or water and through food packaging. Dr. Sunderland said some wild foods like seafood are known to accumulate these compounds in the environment.

“There are examples of contaminated biosolids leading to accumulation of PFAS in vegetables and milk,” Dr. Sunderland explained. “Food packaging is another concern because it can also result in PFAS accumulation in the foods we eat.”

Although it’s difficult to avoid PFAS altogether, the CDC suggests lowering exposure rates by avoiding contaminated water and food. If you’re not sure if your water is contaminated, you should ask your local or state health and environmental quality departments for fish or water advisories in your area.

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

People may be absorbing and ingesting potentially toxic chemicals from their cosmetic products, a new study suggests.

Researchers found high fluorine levels in most of the waterproof mascara, liquid lipsticks, and foundations they tested, indicating the probable presence of what’s known as PFAS – per- and polyfluoroalkyl substances. Many of these chemicals were not included on the product labels, making it difficult for consumers to consciously avoid them.

Environmental Science & Technology

“This study is very helpful for elucidating the PFAS content of different types of cosmetics in the U.S. and Canadian markets,” said Elsie Sunderland, PhD, an environmental scientist who was not involved with the study.

“Previously, all the data had been collected in Europe, and this study shows we are dealing with similar problems in the North American marketplace,” said Dr. Sunderland, a professor of environmental chemistry at the Harvard School of Public Health, Boston.

PFAS are a class of chemicals used in a variety of consumer products, such as nonstick cookware, stain-resistant carpeting, and water-repellent clothing, according to the Centers for Disease Control and Prevention. They are added to cosmetics to make the products more durable and spreadable, researchers said in the study.

“[PFAS] are added to change the properties of surfaces, to make them nonstick or resistant to stay in water or oils,” said study coauthor Tom Bruton, PhD, senior scientist at the Green Science Policy Institute in Berkeley, Calif. “The concerning thing about cosmetics is that these are products that you’re applying to your skin and face every day, so there’s the skin absorption route that’s of concern, but also incidental ingestion of cosmetics is also a concern as well.”

The CDC says some of the potential health effects of PFAS exposure includes increased cholesterol levels, increased risk of kidney and testicular cancer, changes in liver enzymes, decreased vaccine response in children, and a higher risk of high blood pressure or preeclampsia in pregnant women.

JackF/iStock/Getty Images

“PFAS are a large class of chemicals. In humans, exposure to some of these chemicals has been associated with impaired immune function, certain cancers, increased risks of diabetes, obesity and endocrine disruption,” Dr. Sunderland said. “They appear to be harmful to every major organ system in the human body.”

For the current study, published online in Environmental Science & Technology Letters, Dr. Bruton and colleagues purchased 231 cosmetic products in the United States and Canada from retailers such as Ulta Beauty, Sephora, Target, and Bed Bath & Beyond. They then screened them for fluorine.Three-quarters of waterproof mascara samples contained high fluorine concentrations, as did nearly two-thirds of foundations and liquid lipsticks, and more than half of the eye and lip products tested.

The authors found that different categories of makeup tended to have higher or lower fluorine concentrations. “High fluorine levels were found in products commonly advertised as ‘wear-resistant’ to water and oils or ‘long-lasting,’ including foundations, liquid lipsticks, and waterproof mascaras,” Dr. Bruton and colleagues wrote.

When they further analyzed a subset of 29 products to determine what types of chemicals were present, they found that each cosmetic product contained at least 4 PFAS, with one product containing 13.The PFAS substances found included some that break down into other chemicals that are known to be highly toxic and environmentally harmful.

“It’s concerning that some of the products we tested appear to be intentionally using PFAS, but not listing those ingredients on the label,” Dr. Bruton said. “I do think that it is helpful for consumers to read labels, but beyond that, there’s not a lot of ways that consumers themselves can solve this problem. ... We think that the industry needs to be more proactive about moving away from this group of chemicals.”

Dr. Sunderland said a resource people can use when trying to avoid PFAS is the Environmental Working Group, a nonprofit organization that maintains an extensive database of cosmetics and personal care products.

“At this point, there is very little regulatory activity related to PFAS in cosmetics,” Dr. Sunderland said. “The best thing to happen now would be for consumers to indicate that they prefer products without PFAS and to demand better transparency in product ingredient lists.”

A similar study done in 2018 by the Danish Environmental Protection Agency found high levels of PFAS in nearly one-third of the cosmetics products it tested.

People can also be exposed to PFAS by eating or drinking contaminated food or water and through food packaging. Dr. Sunderland said some wild foods like seafood are known to accumulate these compounds in the environment.

“There are examples of contaminated biosolids leading to accumulation of PFAS in vegetables and milk,” Dr. Sunderland explained. “Food packaging is another concern because it can also result in PFAS accumulation in the foods we eat.”

Although it’s difficult to avoid PFAS altogether, the CDC suggests lowering exposure rates by avoiding contaminated water and food. If you’re not sure if your water is contaminated, you should ask your local or state health and environmental quality departments for fish or water advisories in your area.

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

Advances in photobiomodulation have propelled the use of therapeutic applications in a variety of medical specialties, according to Juanita J. Anders, PhD.

During the annual conference of the American Society for Laser Medicine and Surgery, Dr. Anders, professor of anatomy, physiology, and genetics at the Uniformed Services University of the Health Sciences, Bethesda, Md., defined photobiomodulation (PBM) as the mechanism by which nonionizing optical radiation in the visible and near-infrared spectral range is absorbed by endogenous chromophores to elicit photophysical and photochemical events at various biological scales. Photobiomodulation therapy (PBMT) involves the use of light sources including lasers, LEDs, and broadband light, that emit visible and/or near-infrared light to cause physiological changes in cells and tissues and result in therapeutic benefits.

In dermatology, LED light therapy devices are commonly used for PBMT in wavelengths that range from blue (415 nm) and red (633 nm) to near infrared (830 nm). “Often, when PBMT is referred to by dermatologists it’s called LED therapy or LED light therapy,” Dr. Anders noted. “Some people are under the impression that this is different from PBMT. But remember: It’s not the device that’s producing the photons that is clinically relevant, but it’s the photons themselves. In both cases, the same radiances and fluence ranges are being used and the mechanisms are the same, so it’s all PBMT.”

The therapy is used to treat a wide variety of medical and aesthetic disorders including acne vulgaris, psoriasis, burns, and wound healing. It has also been used in conjunction with surgical aesthetic and resurfacing procedures and has been reported to reduce erythema, edema, bruising, and days to healing. It’s been shown that PBMT stimulates fibroblast proliferation, collagen synthesis, and extracellular matrix resulting in lifting and tightening lax skin.

According to Dr. Anders, French dermatologists Linda Fouque, MD, and Michele Pelletier, MD, performed a series of in vivo and in vitro studies in which they tested the effects of yellow and red light for skin rejuvenation when used individually or in combination. “They found that fibroblasts and keratinocytes in vitro had great improvement in their morphology both with the yellow and red light, but the best improvement was seen with combination therapy,” Dr. Anders said. “This held true in their work looking at epidermal and dermal markers in the skin, where they found the best up-regulation in protein synthesis of such markers as collagens and fibronectin were produced when a combination wavelength light was used.”

Oral mucositis and pain

PBMT is also being used to treat oral mucositis (OM), a common adverse response to chemotherapy and/or radiation therapy, which causes pain, difficulty in swallowing and eating, and oral ulceration, and often interrupts the course of treatments. Authors of a recently published review on the risks and benefits of PBMT concluded that there is consistent evidence from a small number of high-quality studies that PBMT can help prevent the development of cancer therapy–induced OM, reduce pain intensity, as well as promote healing, and enhance patient quality of life.

“They also cautioned that, due to the limited long-term follow-up of patients, there is still concern for the potential long-term risks of PBMT in cancer cell mutation and amplification,” Dr. Anders said. “They advised that PBMT should be used carefully when the irradiation beam is in the direction of the tumor zone.”

Using PBMT for modulation of pain is another area of active research. Based on work from the laboratory of Dr. Anders and others, there are two methods to modulate pain. The first is to target tissue at irradiances below 100 mW/cm².

“In my laboratory, based on in vivo preclinical animal models of neuropathic pain, we used a 980-nm wavelength laser at 43.25 mW/cm² transcutaneously delivered to the level of the nerve for 20 seconds,” said Dr. Anders, who is a past president of the ASLMS. “Essentially, we found that the pain was modulated by reducing sensitivity to mechanical stimulation and also by causing an anti-inflammatory shift in microglial and macrophage phenotype in the dorsal root ganglion and spinal cord of affected segments.”

The second way to modulate pain, she continued, is to target tissue at irradiances above 250 mW/cm². She and her colleagues have conducted in vitro and in vivo studies, which indicate that treatment with an irradiance/fluence rate at 270 mW/cm² or higher at the nerve can rapidly block pain transmission.

“In vitro, we found that if we used an 810-nm wavelength light at 300 mW/cm², we got a disruption of microtubules in the DRG neurons in culture, specifically the small neurons, the nociceptive fibers, but we did not affect the proprioceptive fibers unless we increased the length of the treatment,” she said. “We essentially found the same thing in vivo in a rodent model of neuropathic pain.”

In a pilot study, Dr. Anders and coauthors examined the efficacy of laser irradiation of the dorsal root ganglion of the second lumbar spinal nerve for patients with chronic back pain.

They found that PBMT effectively reduced back pain equal to the effects of lidocaine.

Based on these two irradiation approaches of targeting tissue, Dr. Anders recommends that a combination therapy be used to modulate neuropathic pain going forward. “This approach would involve the initial use of a high-irradiance treatment [at least 250 mW/cm²] at the nerve to block the pain transmission,” she said. “That treatment would be followed by a series of low-irradiance treatments [10-100 mW/cm²] along the course of the involved nerve to alter chronic pathology and inflammation.”
 

Potential applications in neurology

Dr. Anders also discussed research efforts under way involving transcranial PBMT: the delivery of near-infrared light through the tissues of the scalp and skull to targeted brain regions to treat neurologic injuries and disorders. “There have been some exciting results in preclinical animal work and in small clinical pilot work that show that there could be possible beneficial effects in Parkinson’s disease, Alzheimer’s disease, depression, and improvement in cognition and memory after a brain injury, such as a TBI,” she said.

“Initially, though, there were a lot of questions about whether you could really deliver light to the brain through the scalp. In my laboratory, we used slices of nonfixed brain and found that the sulci within the human brain act as light-wave guides. We used an 808-nm near-infrared wavelength of light, so that the light could penetrate more deeply.” Using nonfixed cadaver heads, where the light was applied at the scalp surface, Dr. Anders and colleagues were able to measure photons down to the depth of 4 cm. “It’s generally agreed now, though, that it’s to a maximum depth of 2.5-3 cm that enough photons are delivered that would cause a beneficial therapeutic effect,” she said.

Dr. Anders disclosed that she has received equipment from LiteCure, grant funding from the Department of Defense, and that she holds advisory board roles with LiteCure and Neurothera. She has also served in leadership roles for the Optical Society and holds intellectual property rights for the Henry M. Jackson Foundation for the Advancement of Military Medicine.

[email protected]

Advances in photobiomodulation have propelled the use of therapeutic applications in a variety of medical specialties, according to Juanita J. Anders, PhD.

During the annual conference of the American Society for Laser Medicine and Surgery, Dr. Anders, professor of anatomy, physiology, and genetics at the Uniformed Services University of the Health Sciences, Bethesda, Md., defined photobiomodulation (PBM) as the mechanism by which nonionizing optical radiation in the visible and near-infrared spectral range is absorbed by endogenous chromophores to elicit photophysical and photochemical events at various biological scales. Photobiomodulation therapy (PBMT) involves the use of light sources including lasers, LEDs, and broadband light, that emit visible and/or near-infrared light to cause physiological changes in cells and tissues and result in therapeutic benefits.

In dermatology, LED light therapy devices are commonly used for PBMT in wavelengths that range from blue (415 nm) and red (633 nm) to near infrared (830 nm). “Often, when PBMT is referred to by dermatologists it’s called LED therapy or LED light therapy,” Dr. Anders noted. “Some people are under the impression that this is different from PBMT. But remember: It’s not the device that’s producing the photons that is clinically relevant, but it’s the photons themselves. In both cases, the same radiances and fluence ranges are being used and the mechanisms are the same, so it’s all PBMT.”

The therapy is used to treat a wide variety of medical and aesthetic disorders including acne vulgaris, psoriasis, burns, and wound healing. It has also been used in conjunction with surgical aesthetic and resurfacing procedures and has been reported to reduce erythema, edema, bruising, and days to healing. It’s been shown that PBMT stimulates fibroblast proliferation, collagen synthesis, and extracellular matrix resulting in lifting and tightening lax skin.

According to Dr. Anders, French dermatologists Linda Fouque, MD, and Michele Pelletier, MD, performed a series of in vivo and in vitro studies in which they tested the effects of yellow and red light for skin rejuvenation when used individually or in combination. “They found that fibroblasts and keratinocytes in vitro had great improvement in their morphology both with the yellow and red light, but the best improvement was seen with combination therapy,” Dr. Anders said. “This held true in their work looking at epidermal and dermal markers in the skin, where they found the best up-regulation in protein synthesis of such markers as collagens and fibronectin were produced when a combination wavelength light was used.”

Oral mucositis and pain

PBMT is also being used to treat oral mucositis (OM), a common adverse response to chemotherapy and/or radiation therapy, which causes pain, difficulty in swallowing and eating, and oral ulceration, and often interrupts the course of treatments. Authors of a recently published review on the risks and benefits of PBMT concluded that there is consistent evidence from a small number of high-quality studies that PBMT can help prevent the development of cancer therapy–induced OM, reduce pain intensity, as well as promote healing, and enhance patient quality of life.

“They also cautioned that, due to the limited long-term follow-up of patients, there is still concern for the potential long-term risks of PBMT in cancer cell mutation and amplification,” Dr. Anders said. “They advised that PBMT should be used carefully when the irradiation beam is in the direction of the tumor zone.”

Using PBMT for modulation of pain is another area of active research. Based on work from the laboratory of Dr. Anders and others, there are two methods to modulate pain. The first is to target tissue at irradiances below 100 mW/cm².

“In my laboratory, based on in vivo preclinical animal models of neuropathic pain, we used a 980-nm wavelength laser at 43.25 mW/cm² transcutaneously delivered to the level of the nerve for 20 seconds,” said Dr. Anders, who is a past president of the ASLMS. “Essentially, we found that the pain was modulated by reducing sensitivity to mechanical stimulation and also by causing an anti-inflammatory shift in microglial and macrophage phenotype in the dorsal root ganglion and spinal cord of affected segments.”

The second way to modulate pain, she continued, is to target tissue at irradiances above 250 mW/cm². She and her colleagues have conducted in vitro and in vivo studies, which indicate that treatment with an irradiance/fluence rate at 270 mW/cm² or higher at the nerve can rapidly block pain transmission.

“In vitro, we found that if we used an 810-nm wavelength light at 300 mW/cm², we got a disruption of microtubules in the DRG neurons in culture, specifically the small neurons, the nociceptive fibers, but we did not affect the proprioceptive fibers unless we increased the length of the treatment,” she said. “We essentially found the same thing in vivo in a rodent model of neuropathic pain.”

In a pilot study, Dr. Anders and coauthors examined the efficacy of laser irradiation of the dorsal root ganglion of the second lumbar spinal nerve for patients with chronic back pain.

They found that PBMT effectively reduced back pain equal to the effects of lidocaine.

Based on these two irradiation approaches of targeting tissue, Dr. Anders recommends that a combination therapy be used to modulate neuropathic pain going forward. “This approach would involve the initial use of a high-irradiance treatment [at least 250 mW/cm²] at the nerve to block the pain transmission,” she said. “That treatment would be followed by a series of low-irradiance treatments [10-100 mW/cm²] along the course of the involved nerve to alter chronic pathology and inflammation.”
 

Potential applications in neurology

Dr. Anders also discussed research efforts under way involving transcranial PBMT: the delivery of near-infrared light through the tissues of the scalp and skull to targeted brain regions to treat neurologic injuries and disorders. “There have been some exciting results in preclinical animal work and in small clinical pilot work that show that there could be possible beneficial effects in Parkinson’s disease, Alzheimer’s disease, depression, and improvement in cognition and memory after a brain injury, such as a TBI,” she said.

“Initially, though, there were a lot of questions about whether you could really deliver light to the brain through the scalp. In my laboratory, we used slices of nonfixed brain and found that the sulci within the human brain act as light-wave guides. We used an 808-nm near-infrared wavelength of light, so that the light could penetrate more deeply.” Using nonfixed cadaver heads, where the light was applied at the scalp surface, Dr. Anders and colleagues were able to measure photons down to the depth of 4 cm. “It’s generally agreed now, though, that it’s to a maximum depth of 2.5-3 cm that enough photons are delivered that would cause a beneficial therapeutic effect,” she said.

Dr. Anders disclosed that she has received equipment from LiteCure, grant funding from the Department of Defense, and that she holds advisory board roles with LiteCure and Neurothera. She has also served in leadership roles for the Optical Society and holds intellectual property rights for the Henry M. Jackson Foundation for the Advancement of Military Medicine.

[email protected]

Advances in photobiomodulation have propelled the use of therapeutic applications in a variety of medical specialties, according to Juanita J. Anders, PhD.

During the annual conference of the American Society for Laser Medicine and Surgery, Dr. Anders, professor of anatomy, physiology, and genetics at the Uniformed Services University of the Health Sciences, Bethesda, Md., defined photobiomodulation (PBM) as the mechanism by which nonionizing optical radiation in the visible and near-infrared spectral range is absorbed by endogenous chromophores to elicit photophysical and photochemical events at various biological scales. Photobiomodulation therapy (PBMT) involves the use of light sources including lasers, LEDs, and broadband light, that emit visible and/or near-infrared light to cause physiological changes in cells and tissues and result in therapeutic benefits.

In dermatology, LED light therapy devices are commonly used for PBMT in wavelengths that range from blue (415 nm) and red (633 nm) to near infrared (830 nm). “Often, when PBMT is referred to by dermatologists it’s called LED therapy or LED light therapy,” Dr. Anders noted. “Some people are under the impression that this is different from PBMT. But remember: It’s not the device that’s producing the photons that is clinically relevant, but it’s the photons themselves. In both cases, the same radiances and fluence ranges are being used and the mechanisms are the same, so it’s all PBMT.”

The therapy is used to treat a wide variety of medical and aesthetic disorders including acne vulgaris, psoriasis, burns, and wound healing. It has also been used in conjunction with surgical aesthetic and resurfacing procedures and has been reported to reduce erythema, edema, bruising, and days to healing. It’s been shown that PBMT stimulates fibroblast proliferation, collagen synthesis, and extracellular matrix resulting in lifting and tightening lax skin.

According to Dr. Anders, French dermatologists Linda Fouque, MD, and Michele Pelletier, MD, performed a series of in vivo and in vitro studies in which they tested the effects of yellow and red light for skin rejuvenation when used individually or in combination. “They found that fibroblasts and keratinocytes in vitro had great improvement in their morphology both with the yellow and red light, but the best improvement was seen with combination therapy,” Dr. Anders said. “This held true in their work looking at epidermal and dermal markers in the skin, where they found the best up-regulation in protein synthesis of such markers as collagens and fibronectin were produced when a combination wavelength light was used.”

Oral mucositis and pain

PBMT is also being used to treat oral mucositis (OM), a common adverse response to chemotherapy and/or radiation therapy, which causes pain, difficulty in swallowing and eating, and oral ulceration, and often interrupts the course of treatments. Authors of a recently published review on the risks and benefits of PBMT concluded that there is consistent evidence from a small number of high-quality studies that PBMT can help prevent the development of cancer therapy–induced OM, reduce pain intensity, as well as promote healing, and enhance patient quality of life.

“They also cautioned that, due to the limited long-term follow-up of patients, there is still concern for the potential long-term risks of PBMT in cancer cell mutation and amplification,” Dr. Anders said. “They advised that PBMT should be used carefully when the irradiation beam is in the direction of the tumor zone.”

Using PBMT for modulation of pain is another area of active research. Based on work from the laboratory of Dr. Anders and others, there are two methods to modulate pain. The first is to target tissue at irradiances below 100 mW/cm².

“In my laboratory, based on in vivo preclinical animal models of neuropathic pain, we used a 980-nm wavelength laser at 43.25 mW/cm² transcutaneously delivered to the level of the nerve for 20 seconds,” said Dr. Anders, who is a past president of the ASLMS. “Essentially, we found that the pain was modulated by reducing sensitivity to mechanical stimulation and also by causing an anti-inflammatory shift in microglial and macrophage phenotype in the dorsal root ganglion and spinal cord of affected segments.”

The second way to modulate pain, she continued, is to target tissue at irradiances above 250 mW/cm². She and her colleagues have conducted in vitro and in vivo studies, which indicate that treatment with an irradiance/fluence rate at 270 mW/cm² or higher at the nerve can rapidly block pain transmission.

“In vitro, we found that if we used an 810-nm wavelength light at 300 mW/cm², we got a disruption of microtubules in the DRG neurons in culture, specifically the small neurons, the nociceptive fibers, but we did not affect the proprioceptive fibers unless we increased the length of the treatment,” she said. “We essentially found the same thing in vivo in a rodent model of neuropathic pain.”

In a pilot study, Dr. Anders and coauthors examined the efficacy of laser irradiation of the dorsal root ganglion of the second lumbar spinal nerve for patients with chronic back pain.

They found that PBMT effectively reduced back pain equal to the effects of lidocaine.

Based on these two irradiation approaches of targeting tissue, Dr. Anders recommends that a combination therapy be used to modulate neuropathic pain going forward. “This approach would involve the initial use of a high-irradiance treatment [at least 250 mW/cm²] at the nerve to block the pain transmission,” she said. “That treatment would be followed by a series of low-irradiance treatments [10-100 mW/cm²] along the course of the involved nerve to alter chronic pathology and inflammation.”
 

Potential applications in neurology

Dr. Anders also discussed research efforts under way involving transcranial PBMT: the delivery of near-infrared light through the tissues of the scalp and skull to targeted brain regions to treat neurologic injuries and disorders. “There have been some exciting results in preclinical animal work and in small clinical pilot work that show that there could be possible beneficial effects in Parkinson’s disease, Alzheimer’s disease, depression, and improvement in cognition and memory after a brain injury, such as a TBI,” she said.

“Initially, though, there were a lot of questions about whether you could really deliver light to the brain through the scalp. In my laboratory, we used slices of nonfixed brain and found that the sulci within the human brain act as light-wave guides. We used an 808-nm near-infrared wavelength of light, so that the light could penetrate more deeply.” Using nonfixed cadaver heads, where the light was applied at the scalp surface, Dr. Anders and colleagues were able to measure photons down to the depth of 4 cm. “It’s generally agreed now, though, that it’s to a maximum depth of 2.5-3 cm that enough photons are delivered that would cause a beneficial therapeutic effect,” she said.

Dr. Anders disclosed that she has received equipment from LiteCure, grant funding from the Department of Defense, and that she holds advisory board roles with LiteCure and Neurothera. She has also served in leadership roles for the Optical Society and holds intellectual property rights for the Henry M. Jackson Foundation for the Advancement of Military Medicine.

[email protected]

Last month we converged virtually for our annual conference, SHM Converge – the second time since the start of the coronavirus pandemic. We are thankful for innovations and advancements in technology that have allowed the world, including SHM, to continue connecting us all together. And yet, 18 months in, having forged new roads, experienced unique and life-changing events, we long for the in-person human connection that allows us to share a common experience. At a time of imperatives in our world – a global pandemic, systemic racism, and deep geopolitical divides – more than ever, we need to converge. Isolation only festers, deepening our divisions and conflicts.

In high school, I read Robert Frost’s poem “The Road Not Taken” and clung to the notion of diverging roads and choosing the road less traveled. Like most young people, my years since reading the poem were filled with attempts at forging new paths and experiencing great things – and yet, always feeling unaccomplished. Was Oscar Wilde right when he wrote: “Life imitates Art far more than Art imitates Life?” After all, these past 18 months, we have shared in the traumas of our times, and still, we remain isolated and alone. Our diverse experiences have been real, both tragic and heroic, from east to west, city to country, black to white, and red to blue.

At SHM, it’s time to converge and face the great challenges of our lifetime. A deadly pandemic continues to rage around the world, bringing unprecedented human suffering and loss of lives. In its wake, this pandemic also laid bare the ugly face of systemic racism, brought our deepest divisions to the surface – all threatening the very fabric of our society. This pandemic has been a stress test for health care systems, revealing our vulnerabilities and expanding the chasm of care between urban and rural communities, all in turn worsening our growing health disparities. This moment needs convergence to rekindle connection and solidarity.

Scholars do not interpret “The Road Not Taken” as a recommendation to take the road less traveled. Instead, it is a suggestion that the diverging roads lead to a common place having been “worn about the same” as they “equally lay.” It is true that our roads are unique and shape our lives, but so, too, does the destination and common place our roads lead us to. At that common place, during these taxing times, SHM enables hospitalists to tackle these great challenges.

For over 2 decades of dynamic changes in health care, SHM has been the workshop where hospitalists converged to sharpen clinical skills, improve quality and safety, develop acute care models inside and outside of hospitals, advocate for better health policy and blaze new trails. Though the issues evolved, and new ones emerge, today is no different.

Indeed, this is an historic time. This weighted moment meets us at the crossroads. A moment that demands synergy, cooperation, and creativity. A dynamic change to health care policy, advances in care innovation, renewed prioritization of public health, and rich national discourse on our social fabric; hospitalists are essential to every one of those conversations. SHM has evolved to meet our growing needs, equipping hospitalists with tools to engage at every level, and most importantly, enabled us to find our common place.

Where do we go now? I suggest we continue to take the roads not taken and at the destination, build the map of tomorrow, together.

Dr. Siy is division medical director, hospital specialties, in the departments of hospital medicine and community senior and palliative care at HealthPartners in Bloomington, Minn. He is the new president of SHM.

Last month we converged virtually for our annual conference, SHM Converge – the second time since the start of the coronavirus pandemic. We are thankful for innovations and advancements in technology that have allowed the world, including SHM, to continue connecting us all together. And yet, 18 months in, having forged new roads, experienced unique and life-changing events, we long for the in-person human connection that allows us to share a common experience. At a time of imperatives in our world – a global pandemic, systemic racism, and deep geopolitical divides – more than ever, we need to converge. Isolation only festers, deepening our divisions and conflicts.

In high school, I read Robert Frost’s poem “The Road Not Taken” and clung to the notion of diverging roads and choosing the road less traveled. Like most young people, my years since reading the poem were filled with attempts at forging new paths and experiencing great things – and yet, always feeling unaccomplished. Was Oscar Wilde right when he wrote: “Life imitates Art far more than Art imitates Life?” After all, these past 18 months, we have shared in the traumas of our times, and still, we remain isolated and alone. Our diverse experiences have been real, both tragic and heroic, from east to west, city to country, black to white, and red to blue.

At SHM, it’s time to converge and face the great challenges of our lifetime. A deadly pandemic continues to rage around the world, bringing unprecedented human suffering and loss of lives. In its wake, this pandemic also laid bare the ugly face of systemic racism, brought our deepest divisions to the surface – all threatening the very fabric of our society. This pandemic has been a stress test for health care systems, revealing our vulnerabilities and expanding the chasm of care between urban and rural communities, all in turn worsening our growing health disparities. This moment needs convergence to rekindle connection and solidarity.

Scholars do not interpret “The Road Not Taken” as a recommendation to take the road less traveled. Instead, it is a suggestion that the diverging roads lead to a common place having been “worn about the same” as they “equally lay.” It is true that our roads are unique and shape our lives, but so, too, does the destination and common place our roads lead us to. At that common place, during these taxing times, SHM enables hospitalists to tackle these great challenges.

For over 2 decades of dynamic changes in health care, SHM has been the workshop where hospitalists converged to sharpen clinical skills, improve quality and safety, develop acute care models inside and outside of hospitals, advocate for better health policy and blaze new trails. Though the issues evolved, and new ones emerge, today is no different.

Indeed, this is an historic time. This weighted moment meets us at the crossroads. A moment that demands synergy, cooperation, and creativity. A dynamic change to health care policy, advances in care innovation, renewed prioritization of public health, and rich national discourse on our social fabric; hospitalists are essential to every one of those conversations. SHM has evolved to meet our growing needs, equipping hospitalists with tools to engage at every level, and most importantly, enabled us to find our common place.

Where do we go now? I suggest we continue to take the roads not taken and at the destination, build the map of tomorrow, together.

Dr. Siy is division medical director, hospital specialties, in the departments of hospital medicine and community senior and palliative care at HealthPartners in Bloomington, Minn. He is the new president of SHM.

Last month we converged virtually for our annual conference, SHM Converge – the second time since the start of the coronavirus pandemic. We are thankful for innovations and advancements in technology that have allowed the world, including SHM, to continue connecting us all together. And yet, 18 months in, having forged new roads, experienced unique and life-changing events, we long for the in-person human connection that allows us to share a common experience. At a time of imperatives in our world – a global pandemic, systemic racism, and deep geopolitical divides – more than ever, we need to converge. Isolation only festers, deepening our divisions and conflicts.

In high school, I read Robert Frost’s poem “The Road Not Taken” and clung to the notion of diverging roads and choosing the road less traveled. Like most young people, my years since reading the poem were filled with attempts at forging new paths and experiencing great things – and yet, always feeling unaccomplished. Was Oscar Wilde right when he wrote: “Life imitates Art far more than Art imitates Life?” After all, these past 18 months, we have shared in the traumas of our times, and still, we remain isolated and alone. Our diverse experiences have been real, both tragic and heroic, from east to west, city to country, black to white, and red to blue.

At SHM, it’s time to converge and face the great challenges of our lifetime. A deadly pandemic continues to rage around the world, bringing unprecedented human suffering and loss of lives. In its wake, this pandemic also laid bare the ugly face of systemic racism, brought our deepest divisions to the surface – all threatening the very fabric of our society. This pandemic has been a stress test for health care systems, revealing our vulnerabilities and expanding the chasm of care between urban and rural communities, all in turn worsening our growing health disparities. This moment needs convergence to rekindle connection and solidarity.

Scholars do not interpret “The Road Not Taken” as a recommendation to take the road less traveled. Instead, it is a suggestion that the diverging roads lead to a common place having been “worn about the same” as they “equally lay.” It is true that our roads are unique and shape our lives, but so, too, does the destination and common place our roads lead us to. At that common place, during these taxing times, SHM enables hospitalists to tackle these great challenges.

For over 2 decades of dynamic changes in health care, SHM has been the workshop where hospitalists converged to sharpen clinical skills, improve quality and safety, develop acute care models inside and outside of hospitals, advocate for better health policy and blaze new trails. Though the issues evolved, and new ones emerge, today is no different.

Indeed, this is an historic time. This weighted moment meets us at the crossroads. A moment that demands synergy, cooperation, and creativity. A dynamic change to health care policy, advances in care innovation, renewed prioritization of public health, and rich national discourse on our social fabric; hospitalists are essential to every one of those conversations. SHM has evolved to meet our growing needs, equipping hospitalists with tools to engage at every level, and most importantly, enabled us to find our common place.

Where do we go now? I suggest we continue to take the roads not taken and at the destination, build the map of tomorrow, together.

Dr. Siy is division medical director, hospital specialties, in the departments of hospital medicine and community senior and palliative care at HealthPartners in Bloomington, Minn. He is the new president of SHM.

Clinical scenario

An 83-year-old man is admitted with a hemiplegic cerebrovascular accident. He is found to have dysphagia, and a nasogastric feeding tube is placed. Over the next several days, his strength begins to recover, and he tolerates his tube feeding well. Discharge to a skilled nursing facility (SNF) for subacute rehabilitation is planned. His swallowing is showing signs of recovery; it has not recovered adequately but is expected to continue to improve such that he is predicted to be independent of tube feeding within 7-14 days. None of the facilities in the region are willing to admit a patient with a nasal feeding tube, despite the anticipated short duration. The patient is medically ready for discharge but is refusing the feeding gastrostomy. “Why would I want a hole in my stomach, if I’m only going to need it for 1-2 weeks and this tube in my nose is working fine and is comfortable?” he pleads with tears in his eyes.

Feeding dysphagic patients after stroke

Dysphagia, potentially leading to aspiration and/or pneumonia, is a common sequela of stroke – up to half of hospitalized patients are affected.¹ When oral intake is contraindicated, patients are often fed by nasogastric tube (NGT) or by surgically or endoscopically placed gastrostomy tube (GT). Without good justification based on outcomes, NGTs are traditionally used when the need for feeding is thought to be short term (<4 weeks) and GTs are used for long term (>4 weeks). However, in 2005, a large multicenter randomized control trial found that the majority of stroke patients with dysphagia that would resolve had resolution within 2-3 weeks. Moreover, outcomes were equivalent or better for patients fed with an NGT versus GT.

The authors concluded by recommending feeding via NGT for 2-3 weeks, after which conversion to GT can be considered if dysphagia persists.¹ Notably, the recommendation allows consideration, and no evidence-based guideline requires or recommends GT be placed based on duration of tube feed dependence. Currently, while nutrition and neurology authorities have adopted these recommendations,^2,3 many authors have noted poor adherence to this guideline, and many find that the median period between stroke and GT placement is 7 days rather than the recommended minimum of 14.^4,5,6 While ignorance can partially explain the lack of widespread compliance,⁶ the policies of posthospital facilities are another culprit. Increasingly, and for a variety of reasons unsupported by the literature, SNFs refuse NGT and require GT.^4,7,8,9

Ethical considerations

The four principles of medical ethics – autonomy, beneficence, nonmaleficence, and justice – can guide clinicians, patients, and family members in decision-making. In our case, by withholding needed and desired treatment (discharge to and treatment by a rehabilitation facility) the patient is being coerced to undergo a procedure he does not want, and clinicians participate in denying him autonomy. Further, given that the evidence, national guidelines, and in fact federal regulations indicate that his preferences are congruent with best practices, pressuring him to accept gastrostomy placement runs afoul of the principles of beneficence and nonmaleficence. Though the mechanism is unclear, early gastrostomy (<14-21 days) is associated with increased risk of death, worse functional outcomes, and a lower rate of return to oral feeding, as well as a significant procedure-specific complication rate.^1,10 By insisting on gastrostomy, we neither act in this patient’s best interests nor “do no harm.”

However, the medical system is complex. The clinician at the bedside can evaluate this scenario, review the national guidelines, discuss the procedure and risks with the patient and family, and conclude that the patient should be discharged with a nasal feeding tube. Nevertheless, if no facility is willing to accept him without a gastrostomy, our decision-making model – previously limited to our patient’s best interests alone – is forced to change. Despite our misgivings, we often conclude that the harm done by an early gastrostomy is outweighed by the harm of remaining unnecessarily in the acute hospital setting. We further worry about other patients lingering in the emergency department for lack of an inpatient bed and the possible – though unknowable – harm done to them.
 

Looking forward

It is an unfortunate fact that medical decision-making must often include factors unrelated to the patient’s best interests, with financial considerations and structural barriers frequently driving deviation from ideal care. Providers and patients navigate these decisions to their best abilities, making compromises when forced. However, with education and professional activism, providers can advocate for the elimination of barriers to providing medically sound and ethically appropriate care. In our experience, delay of gastrostomy placement, until discharge is imminent and planning for postdischarge care is initiated, has resulted in a decrease by half the fraction of patients with tracheostomies who had gastrostomies placed prior to discharge.¹¹ With aggressive outreach and education, we now have nursing homes willing to accept patients with NGTs.

Criteria for admission to discharge facilities can drive medical decision-making that is unethical and unsupported by evidence. Continued efforts to eliminate barriers to appropriate and ethical care have been successful and are encouraged.
 

Dr. Cowan is administrative chief resident in the department of surgery at Columbia University Irving Medical Center, New York. Dr. Seres is professor of medicine in the Institute of Human Nutrition and associate clinical ethicist at Columbia University Irving Medical Center. The authors have no conflicts of interest to disclose.

References

1. Dennis MS et al. Lancet. 2005 Feb 26-Mar 4;365(9461):764-72.

2. Powers W. et al. Stroke. 2018 Mar;49(3):e46-e110.

3. Burgos R et al. Clin Nutr. 2018 Feb;37(1):354-96.

4. Wilmskoetter J et al. J Stroke Cerebrovasc Dis. 2016 Nov;25(11):2694-700.

5. George BP et al. Stroke. 2017 Feb;48(2):420-7.

6. Fessler TA. et al. Surg Endosc. 2019 Dec;33(12):4089-97.

7. Burgermaster M et al. Nutr Clin Pract. 2016 Jun;31(3):342-8.

8. Moran C and O’Mahoney S. Curr Opin Gastroenterol. 2015 Mar;31(2):137-42.

9. Gomes CA et al. Cochrane Database Syst Rev. 2010 Nov 10;(11):CD008096.

10. Joundi RA et al. Neurology. 2018 Feb 13;90(7):e544-52.

11. Bothra A et al. J Parenter Enteral Nutr. 2018 Feb;42(2):491.

Clinical scenario

An 83-year-old man is admitted with a hemiplegic cerebrovascular accident. He is found to have dysphagia, and a nasogastric feeding tube is placed. Over the next several days, his strength begins to recover, and he tolerates his tube feeding well. Discharge to a skilled nursing facility (SNF) for subacute rehabilitation is planned. His swallowing is showing signs of recovery; it has not recovered adequately but is expected to continue to improve such that he is predicted to be independent of tube feeding within 7-14 days. None of the facilities in the region are willing to admit a patient with a nasal feeding tube, despite the anticipated short duration. The patient is medically ready for discharge but is refusing the feeding gastrostomy. “Why would I want a hole in my stomach, if I’m only going to need it for 1-2 weeks and this tube in my nose is working fine and is comfortable?” he pleads with tears in his eyes.

Feeding dysphagic patients after stroke

Dysphagia, potentially leading to aspiration and/or pneumonia, is a common sequela of stroke – up to half of hospitalized patients are affected.¹ When oral intake is contraindicated, patients are often fed by nasogastric tube (NGT) or by surgically or endoscopically placed gastrostomy tube (GT). Without good justification based on outcomes, NGTs are traditionally used when the need for feeding is thought to be short term (<4 weeks) and GTs are used for long term (>4 weeks). However, in 2005, a large multicenter randomized control trial found that the majority of stroke patients with dysphagia that would resolve had resolution within 2-3 weeks. Moreover, outcomes were equivalent or better for patients fed with an NGT versus GT.

The authors concluded by recommending feeding via NGT for 2-3 weeks, after which conversion to GT can be considered if dysphagia persists.¹ Notably, the recommendation allows consideration, and no evidence-based guideline requires or recommends GT be placed based on duration of tube feed dependence. Currently, while nutrition and neurology authorities have adopted these recommendations,^2,3 many authors have noted poor adherence to this guideline, and many find that the median period between stroke and GT placement is 7 days rather than the recommended minimum of 14.^4,5,6 While ignorance can partially explain the lack of widespread compliance,⁶ the policies of posthospital facilities are another culprit. Increasingly, and for a variety of reasons unsupported by the literature, SNFs refuse NGT and require GT.^4,7,8,9

Ethical considerations

The four principles of medical ethics – autonomy, beneficence, nonmaleficence, and justice – can guide clinicians, patients, and family members in decision-making. In our case, by withholding needed and desired treatment (discharge to and treatment by a rehabilitation facility) the patient is being coerced to undergo a procedure he does not want, and clinicians participate in denying him autonomy. Further, given that the evidence, national guidelines, and in fact federal regulations indicate that his preferences are congruent with best practices, pressuring him to accept gastrostomy placement runs afoul of the principles of beneficence and nonmaleficence. Though the mechanism is unclear, early gastrostomy (<14-21 days) is associated with increased risk of death, worse functional outcomes, and a lower rate of return to oral feeding, as well as a significant procedure-specific complication rate.^1,10 By insisting on gastrostomy, we neither act in this patient’s best interests nor “do no harm.”

However, the medical system is complex. The clinician at the bedside can evaluate this scenario, review the national guidelines, discuss the procedure and risks with the patient and family, and conclude that the patient should be discharged with a nasal feeding tube. Nevertheless, if no facility is willing to accept him without a gastrostomy, our decision-making model – previously limited to our patient’s best interests alone – is forced to change. Despite our misgivings, we often conclude that the harm done by an early gastrostomy is outweighed by the harm of remaining unnecessarily in the acute hospital setting. We further worry about other patients lingering in the emergency department for lack of an inpatient bed and the possible – though unknowable – harm done to them.
 

Looking forward

It is an unfortunate fact that medical decision-making must often include factors unrelated to the patient’s best interests, with financial considerations and structural barriers frequently driving deviation from ideal care. Providers and patients navigate these decisions to their best abilities, making compromises when forced. However, with education and professional activism, providers can advocate for the elimination of barriers to providing medically sound and ethically appropriate care. In our experience, delay of gastrostomy placement, until discharge is imminent and planning for postdischarge care is initiated, has resulted in a decrease by half the fraction of patients with tracheostomies who had gastrostomies placed prior to discharge.¹¹ With aggressive outreach and education, we now have nursing homes willing to accept patients with NGTs.

Criteria for admission to discharge facilities can drive medical decision-making that is unethical and unsupported by evidence. Continued efforts to eliminate barriers to appropriate and ethical care have been successful and are encouraged.
 

Dr. Cowan is administrative chief resident in the department of surgery at Columbia University Irving Medical Center, New York. Dr. Seres is professor of medicine in the Institute of Human Nutrition and associate clinical ethicist at Columbia University Irving Medical Center. The authors have no conflicts of interest to disclose.

References

1. Dennis MS et al. Lancet. 2005 Feb 26-Mar 4;365(9461):764-72.

2. Powers W. et al. Stroke. 2018 Mar;49(3):e46-e110.

3. Burgos R et al. Clin Nutr. 2018 Feb;37(1):354-96.

4. Wilmskoetter J et al. J Stroke Cerebrovasc Dis. 2016 Nov;25(11):2694-700.

5. George BP et al. Stroke. 2017 Feb;48(2):420-7.

6. Fessler TA. et al. Surg Endosc. 2019 Dec;33(12):4089-97.

7. Burgermaster M et al. Nutr Clin Pract. 2016 Jun;31(3):342-8.

8. Moran C and O’Mahoney S. Curr Opin Gastroenterol. 2015 Mar;31(2):137-42.

9. Gomes CA et al. Cochrane Database Syst Rev. 2010 Nov 10;(11):CD008096.

10. Joundi RA et al. Neurology. 2018 Feb 13;90(7):e544-52.

11. Bothra A et al. J Parenter Enteral Nutr. 2018 Feb;42(2):491.

Clinical scenario

An 83-year-old man is admitted with a hemiplegic cerebrovascular accident. He is found to have dysphagia, and a nasogastric feeding tube is placed. Over the next several days, his strength begins to recover, and he tolerates his tube feeding well. Discharge to a skilled nursing facility (SNF) for subacute rehabilitation is planned. His swallowing is showing signs of recovery; it has not recovered adequately but is expected to continue to improve such that he is predicted to be independent of tube feeding within 7-14 days. None of the facilities in the region are willing to admit a patient with a nasal feeding tube, despite the anticipated short duration. The patient is medically ready for discharge but is refusing the feeding gastrostomy. “Why would I want a hole in my stomach, if I’m only going to need it for 1-2 weeks and this tube in my nose is working fine and is comfortable?” he pleads with tears in his eyes.

Feeding dysphagic patients after stroke

Dysphagia, potentially leading to aspiration and/or pneumonia, is a common sequela of stroke – up to half of hospitalized patients are affected.¹ When oral intake is contraindicated, patients are often fed by nasogastric tube (NGT) or by surgically or endoscopically placed gastrostomy tube (GT). Without good justification based on outcomes, NGTs are traditionally used when the need for feeding is thought to be short term (<4 weeks) and GTs are used for long term (>4 weeks). However, in 2005, a large multicenter randomized control trial found that the majority of stroke patients with dysphagia that would resolve had resolution within 2-3 weeks. Moreover, outcomes were equivalent or better for patients fed with an NGT versus GT.

The authors concluded by recommending feeding via NGT for 2-3 weeks, after which conversion to GT can be considered if dysphagia persists.¹ Notably, the recommendation allows consideration, and no evidence-based guideline requires or recommends GT be placed based on duration of tube feed dependence. Currently, while nutrition and neurology authorities have adopted these recommendations,^2,3 many authors have noted poor adherence to this guideline, and many find that the median period between stroke and GT placement is 7 days rather than the recommended minimum of 14.^4,5,6 While ignorance can partially explain the lack of widespread compliance,⁶ the policies of posthospital facilities are another culprit. Increasingly, and for a variety of reasons unsupported by the literature, SNFs refuse NGT and require GT.^4,7,8,9

Ethical considerations

The four principles of medical ethics – autonomy, beneficence, nonmaleficence, and justice – can guide clinicians, patients, and family members in decision-making. In our case, by withholding needed and desired treatment (discharge to and treatment by a rehabilitation facility) the patient is being coerced to undergo a procedure he does not want, and clinicians participate in denying him autonomy. Further, given that the evidence, national guidelines, and in fact federal regulations indicate that his preferences are congruent with best practices, pressuring him to accept gastrostomy placement runs afoul of the principles of beneficence and nonmaleficence. Though the mechanism is unclear, early gastrostomy (<14-21 days) is associated with increased risk of death, worse functional outcomes, and a lower rate of return to oral feeding, as well as a significant procedure-specific complication rate.^1,10 By insisting on gastrostomy, we neither act in this patient’s best interests nor “do no harm.”

However, the medical system is complex. The clinician at the bedside can evaluate this scenario, review the national guidelines, discuss the procedure and risks with the patient and family, and conclude that the patient should be discharged with a nasal feeding tube. Nevertheless, if no facility is willing to accept him without a gastrostomy, our decision-making model – previously limited to our patient’s best interests alone – is forced to change. Despite our misgivings, we often conclude that the harm done by an early gastrostomy is outweighed by the harm of remaining unnecessarily in the acute hospital setting. We further worry about other patients lingering in the emergency department for lack of an inpatient bed and the possible – though unknowable – harm done to them.
 

Looking forward

It is an unfortunate fact that medical decision-making must often include factors unrelated to the patient’s best interests, with financial considerations and structural barriers frequently driving deviation from ideal care. Providers and patients navigate these decisions to their best abilities, making compromises when forced. However, with education and professional activism, providers can advocate for the elimination of barriers to providing medically sound and ethically appropriate care. In our experience, delay of gastrostomy placement, until discharge is imminent and planning for postdischarge care is initiated, has resulted in a decrease by half the fraction of patients with tracheostomies who had gastrostomies placed prior to discharge.¹¹ With aggressive outreach and education, we now have nursing homes willing to accept patients with NGTs.

Criteria for admission to discharge facilities can drive medical decision-making that is unethical and unsupported by evidence. Continued efforts to eliminate barriers to appropriate and ethical care have been successful and are encouraged.
 

Dr. Cowan is administrative chief resident in the department of surgery at Columbia University Irving Medical Center, New York. Dr. Seres is professor of medicine in the Institute of Human Nutrition and associate clinical ethicist at Columbia University Irving Medical Center. The authors have no conflicts of interest to disclose.

References

1. Dennis MS et al. Lancet. 2005 Feb 26-Mar 4;365(9461):764-72.

2. Powers W. et al. Stroke. 2018 Mar;49(3):e46-e110.

3. Burgos R et al. Clin Nutr. 2018 Feb;37(1):354-96.

4. Wilmskoetter J et al. J Stroke Cerebrovasc Dis. 2016 Nov;25(11):2694-700.

5. George BP et al. Stroke. 2017 Feb;48(2):420-7.

6. Fessler TA. et al. Surg Endosc. 2019 Dec;33(12):4089-97.

7. Burgermaster M et al. Nutr Clin Pract. 2016 Jun;31(3):342-8.

8. Moran C and O’Mahoney S. Curr Opin Gastroenterol. 2015 Mar;31(2):137-42.

9. Gomes CA et al. Cochrane Database Syst Rev. 2010 Nov 10;(11):CD008096.

10. Joundi RA et al. Neurology. 2018 Feb 13;90(7):e544-52.

11. Bothra A et al. J Parenter Enteral Nutr. 2018 Feb;42(2):491.