Mixed Topics

Background: Studies show better outcomes, decreased length of stay, increased patient satisfaction, improved quality, and decreased readmission rates when hospitalist services are used. This study looks at how hospitalist schedules affect these outcomes.

The primary outcome was mortality within 30 days of discharge and secondary outcomes were 30-day readmission rates, discharge destination, and 30-day postdischarge costs.

Patients receiving care from hospitalists working several days in a row had better outcomes. It is postulated that continuity of care by one hospitalist is important for several reasons. Most importantly, the development of rapport with patient and family is key to deciding the plan of care and destination post discharge as it is quite challenging to effectively transfer all important information during verbal or written handoffs.

Bottom line: Care provided by hospitalists working more days in a row improved patient outcomes. A variety of hospitalist schedules are being practiced currently; however, these findings must be taken into account as schedules are designed.

Citation: Goodwin JS et al. Association of the work schedules of hospitalists with patient outcomes of hospitalization. JAMA Intern Med. 2020;180(2):215-22. doi: 10.1001/jamainternmed.2019.5193.

Dr. Ahmed is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.

Background: Studies show better outcomes, decreased length of stay, increased patient satisfaction, improved quality, and decreased readmission rates when hospitalist services are used. This study looks at how hospitalist schedules affect these outcomes.

The primary outcome was mortality within 30 days of discharge and secondary outcomes were 30-day readmission rates, discharge destination, and 30-day postdischarge costs.

Patients receiving care from hospitalists working several days in a row had better outcomes. It is postulated that continuity of care by one hospitalist is important for several reasons. Most importantly, the development of rapport with patient and family is key to deciding the plan of care and destination post discharge as it is quite challenging to effectively transfer all important information during verbal or written handoffs.

Bottom line: Care provided by hospitalists working more days in a row improved patient outcomes. A variety of hospitalist schedules are being practiced currently; however, these findings must be taken into account as schedules are designed.

Citation: Goodwin JS et al. Association of the work schedules of hospitalists with patient outcomes of hospitalization. JAMA Intern Med. 2020;180(2):215-22. doi: 10.1001/jamainternmed.2019.5193.

Dr. Ahmed is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.

Background: Studies show better outcomes, decreased length of stay, increased patient satisfaction, improved quality, and decreased readmission rates when hospitalist services are used. This study looks at how hospitalist schedules affect these outcomes.

The primary outcome was mortality within 30 days of discharge and secondary outcomes were 30-day readmission rates, discharge destination, and 30-day postdischarge costs.

Patients receiving care from hospitalists working several days in a row had better outcomes. It is postulated that continuity of care by one hospitalist is important for several reasons. Most importantly, the development of rapport with patient and family is key to deciding the plan of care and destination post discharge as it is quite challenging to effectively transfer all important information during verbal or written handoffs.

Bottom line: Care provided by hospitalists working more days in a row improved patient outcomes. A variety of hospitalist schedules are being practiced currently; however, these findings must be taken into account as schedules are designed.

Citation: Goodwin JS et al. Association of the work schedules of hospitalists with patient outcomes of hospitalization. JAMA Intern Med. 2020;180(2):215-22. doi: 10.1001/jamainternmed.2019.5193.

Dr. Ahmed is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.

When I was a medical student, I always found it gratifying when there was a unifying mechanism that explained the symptoms of a disease. Part of the reason I chose dermatology as a specialty was how frequently we are able to “see” these mechanisms in the skin, both clinically and histologically. VEXAS syndrome – which stands for vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic – provides one of those explanations that satisfies my need to understand the cause of a disease. What’s even more interesting is that this condition is caused by a postzygotic somatic mutation, an apparently underrecognized cause of disease that we are just now beginning to understand. An example of a postzygotic somatic mutation causing a disease that we all learned about in medical school is paroxysmal nocturnal hemoglobinuria.
 

Using a “bottom-up” approach, researchers at the National Institutes of Health and in the United Kingdom identified 25 patients with somatic UBA1 mutations and noticed that they had strikingly similar autoinflammatory syndromes. UBA1 encodes ubiquitin E1, which is part of the pathway the breaks down proteins as part of the normal cellular machine. It is localized to the X chromosome, so all 25 affected patients were males, and most were aged between 40 and 70 years. These patients had an autoinflammatory syndrome characterized by fever, chondritis (similar to relapsing polychondritis), vasculitis, and neutrophilic dermatoses. Many patients also had features of myelodysplastic syndrome and plasma cell dyscrasia. The inflammatory pattern in this condition seems to show elevations in tumor necrosis factor, interleukin-6, and interferon-gamma.

So why is this syndrome relevant to dermatology? We are often asked to evaluate patients for neutrophilic dermatosis and vasculitis, and many affected patients had clinical and histologic findings compatible with polyarteritis nodosa and Sweet syndrome. When confronted with a neutrophilic dermatosis, we’ve all been taught to evaluate for myelodysplastic syndrome, which many of these patients appeared to have, at least on the surface. When bone marrow biopsies were done, the myeloid cell precursors that give rise to neutrophils were noted to have prominent cytoplasmic vacuoles, hence the “V” in VEXAS.

In reading the article describing 25 patients with this syndrome, which was published in the New England Journal of Medicine, I was struck by how refractory they were to treatment. Most patients had been treated with systemic steroids, multiple biologics, and several nonbiologic medications that are mainstays of treatment for neutrophilic dermatosis like dapsone and colchicine. I was fortunate enough to speak to Amanda Ombrello, MD, of the National Human Genome Research Institute, one of the lead authors of the paper, who drew my attention to the supplementary appendix, which showed the marked injection-site reactions some patients had to anakinra – yet another reason why a patient might end up in a dermatology clinic. In my mind, all of these features could be a clue to a diagnosis of VEXAS syndrome.

Many patients seemed to fare poorly, with 40% of patients dying before the completion of the study. When it comes to extremely rare diseases, it seems that the more physicians who are aware of the existence of a particular syndrome, the more likely it is a patient will come under our care and be correctly diagnosed.

Dr. Saardi is a dermatologist and internist, and is director of the inpatient dermatology service at the George Washington University Hospital, Washington. He has no disclosures.

When I was a medical student, I always found it gratifying when there was a unifying mechanism that explained the symptoms of a disease. Part of the reason I chose dermatology as a specialty was how frequently we are able to “see” these mechanisms in the skin, both clinically and histologically. VEXAS syndrome – which stands for vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic – provides one of those explanations that satisfies my need to understand the cause of a disease. What’s even more interesting is that this condition is caused by a postzygotic somatic mutation, an apparently underrecognized cause of disease that we are just now beginning to understand. An example of a postzygotic somatic mutation causing a disease that we all learned about in medical school is paroxysmal nocturnal hemoglobinuria.
 

Using a “bottom-up” approach, researchers at the National Institutes of Health and in the United Kingdom identified 25 patients with somatic UBA1 mutations and noticed that they had strikingly similar autoinflammatory syndromes. UBA1 encodes ubiquitin E1, which is part of the pathway the breaks down proteins as part of the normal cellular machine. It is localized to the X chromosome, so all 25 affected patients were males, and most were aged between 40 and 70 years. These patients had an autoinflammatory syndrome characterized by fever, chondritis (similar to relapsing polychondritis), vasculitis, and neutrophilic dermatoses. Many patients also had features of myelodysplastic syndrome and plasma cell dyscrasia. The inflammatory pattern in this condition seems to show elevations in tumor necrosis factor, interleukin-6, and interferon-gamma.

So why is this syndrome relevant to dermatology? We are often asked to evaluate patients for neutrophilic dermatosis and vasculitis, and many affected patients had clinical and histologic findings compatible with polyarteritis nodosa and Sweet syndrome. When confronted with a neutrophilic dermatosis, we’ve all been taught to evaluate for myelodysplastic syndrome, which many of these patients appeared to have, at least on the surface. When bone marrow biopsies were done, the myeloid cell precursors that give rise to neutrophils were noted to have prominent cytoplasmic vacuoles, hence the “V” in VEXAS.

In reading the article describing 25 patients with this syndrome, which was published in the New England Journal of Medicine, I was struck by how refractory they were to treatment. Most patients had been treated with systemic steroids, multiple biologics, and several nonbiologic medications that are mainstays of treatment for neutrophilic dermatosis like dapsone and colchicine. I was fortunate enough to speak to Amanda Ombrello, MD, of the National Human Genome Research Institute, one of the lead authors of the paper, who drew my attention to the supplementary appendix, which showed the marked injection-site reactions some patients had to anakinra – yet another reason why a patient might end up in a dermatology clinic. In my mind, all of these features could be a clue to a diagnosis of VEXAS syndrome.

Many patients seemed to fare poorly, with 40% of patients dying before the completion of the study. When it comes to extremely rare diseases, it seems that the more physicians who are aware of the existence of a particular syndrome, the more likely it is a patient will come under our care and be correctly diagnosed.

Dr. Saardi is a dermatologist and internist, and is director of the inpatient dermatology service at the George Washington University Hospital, Washington. He has no disclosures.

When I was a medical student, I always found it gratifying when there was a unifying mechanism that explained the symptoms of a disease. Part of the reason I chose dermatology as a specialty was how frequently we are able to “see” these mechanisms in the skin, both clinically and histologically. VEXAS syndrome – which stands for vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic – provides one of those explanations that satisfies my need to understand the cause of a disease. What’s even more interesting is that this condition is caused by a postzygotic somatic mutation, an apparently underrecognized cause of disease that we are just now beginning to understand. An example of a postzygotic somatic mutation causing a disease that we all learned about in medical school is paroxysmal nocturnal hemoglobinuria.
 

Using a “bottom-up” approach, researchers at the National Institutes of Health and in the United Kingdom identified 25 patients with somatic UBA1 mutations and noticed that they had strikingly similar autoinflammatory syndromes. UBA1 encodes ubiquitin E1, which is part of the pathway the breaks down proteins as part of the normal cellular machine. It is localized to the X chromosome, so all 25 affected patients were males, and most were aged between 40 and 70 years. These patients had an autoinflammatory syndrome characterized by fever, chondritis (similar to relapsing polychondritis), vasculitis, and neutrophilic dermatoses. Many patients also had features of myelodysplastic syndrome and plasma cell dyscrasia. The inflammatory pattern in this condition seems to show elevations in tumor necrosis factor, interleukin-6, and interferon-gamma.

So why is this syndrome relevant to dermatology? We are often asked to evaluate patients for neutrophilic dermatosis and vasculitis, and many affected patients had clinical and histologic findings compatible with polyarteritis nodosa and Sweet syndrome. When confronted with a neutrophilic dermatosis, we’ve all been taught to evaluate for myelodysplastic syndrome, which many of these patients appeared to have, at least on the surface. When bone marrow biopsies were done, the myeloid cell precursors that give rise to neutrophils were noted to have prominent cytoplasmic vacuoles, hence the “V” in VEXAS.

In reading the article describing 25 patients with this syndrome, which was published in the New England Journal of Medicine, I was struck by how refractory they were to treatment. Most patients had been treated with systemic steroids, multiple biologics, and several nonbiologic medications that are mainstays of treatment for neutrophilic dermatosis like dapsone and colchicine. I was fortunate enough to speak to Amanda Ombrello, MD, of the National Human Genome Research Institute, one of the lead authors of the paper, who drew my attention to the supplementary appendix, which showed the marked injection-site reactions some patients had to anakinra – yet another reason why a patient might end up in a dermatology clinic. In my mind, all of these features could be a clue to a diagnosis of VEXAS syndrome.

Many patients seemed to fare poorly, with 40% of patients dying before the completion of the study. When it comes to extremely rare diseases, it seems that the more physicians who are aware of the existence of a particular syndrome, the more likely it is a patient will come under our care and be correctly diagnosed.

Dr. Saardi is a dermatologist and internist, and is director of the inpatient dermatology service at the George Washington University Hospital, Washington. He has no disclosures.

G. Gayle Stephens, MD, who is roundly regarded as one of the founders of family medicine, gave his talk “Family Medicine as Counterculture” at the Society of Teachers of Family Medicine annual conference in 1979, 10 years after the specialty’s establishment.

The speech was then published, republished 10 years later, and, like many of Dr. Stephen’s other essays and articles, remains very much alive in the minds of practicing family physicians, in the teachings of FP academicians, and in the Google searches of budding FPs.

The late Dr. Stephens saw family medicine as a counterculture within medicine, rooted in social change. In his speech he examined these roots – in reform initiatives in the 1960s, and in certain philosophies and “minority” movements such as agrarianism and the preservation of rural life, utopianism, humanism, consumerism, and feminism.

He also looked forward, challenging the specialty to remain true to itself and its roots – to its belief in “uninhibited access” to medical care for everyone, for instance, and to continual whole-person and family-oriented care – and cautioned against moving to resemble the “rest of the medical bureaucracy.”

“Clearly we have been on the side of change in American life. We have identified ourselves with certain minorities and minority positions ... [and] been counter to many of the dominant forces in society,” Dr. Stephens said in his talk. Family practice “succeeded in the decade just past because we were identified with reforms that are more pervasive and powerful than ourselves.”

The family practice movement has “more in common with [the] counterculture than it does with the dominant scientific medical establishment,” he said.
 

A teacher and founder of medical education programs

Larry A. Green, MD, who was pursuing his own residency training as Dr. Stephens was leading a department of family practice, said Dr. Stephens “insisted that family medicine adhere to the notion that medicine is a moral vocation.”

“It was from this philosophical position that he became a synthesizer and observer and interpreter of what was going on in the development of family medicine,” said Dr. Green, Distinguished Professor and Epperson Zorn Chair for Innovation in Family Medicine and Primary Care at the University of Colorado at Denver, Aurora.

Dr. Stephens, who died at home in 2014 at the age of 85, was “probably the most important person in exposing what I now consider to be a fact – that family medicine was the product of social changes ... of social movements related to women’s rights, civil rights, and social responsibility,” Dr. Green said. “He could recall lessons from the past and forecast the challenges of the future. And there was no one more effective in clarifying the importance of personal [doctor-patient] relationships in family medicine.”

After years of general practice in rural Wichita, Kan., his wife Eula Jean’s hometown, Dr. Stephens founded and led one of the first family medicine residencies at Wesley Hospital in Wichita in 1967. His core principles, as described on today’s Wesley Family Medicine Residency website, included that a family physician consider the whole person, be honest, have a full scope of training including behavioral and mental health, and be “reflective about him/herself ... [learning about] his/her assets, liabilities, foibles, and idiosyncrasies.” Dr. Stephens, who had grown up in rural Ashburn, Mo., later became the founding dean of the School of Primary Medical Care at the University of Alabama in Huntsville and then chaired the department of family practice at the University of Alabama at Birmingham.
 

A thought leader for family medicine

He held numerous state and national leadership positions, and initiated what became the Keystone Conference Series – an invitational gathering of leaders in family medicine that examined and discuss the specialty’s ongoing development. In 2006, he was elected to the Institute of Medicine of the National Academies of Science.

Dr. Stephens authored a textbook, The Intellectual Basis of Family Medicine (Tucson, Ariz.: Winter Publishing Company, 1982), and authored essays, which Dr. Green said will stand the test of time.

“Some of us refer to him as the poet laureate of family medicine,” Dr. Green noted.

In a 1974 article on clinical wisdom, Dr. Stephens wrote that “it is not enough to determine what condition the patient has, but also what patient has the condition.” In another of these essays, which was published in 1979, Dr. Stephens wrote that “physicians need to keep in touch with their own tradition and with public welfare if they are to be considered moral by the society that sponsors them, and from which they take their strength and privilege.”

These excerpts are featured in an article by John P. Geyman, MD, published in 2011 in Family Medicine, called “G. Gayle Stephens Festschrift”.
 

A ‘progressive force’

Linda Prine, MD, professor of family and community medicine at the Icahn School of Medicine at Mount Sinai, New York, knows of Dr. Stephens from her teachers. “The people I looked up to when I was a younger physician were quoting his Counterculture article,” she said.

“It’s not that I studied him. But whenever I heard someone speak about the values of family medicine, his name would come up [and] the values of universal health care and community care and putting the patients’ interests first ahead of the insurance companies and being a doctor for the whole family,” Dr. Prine said. Dr. Stephens was a “progressive force that our specialty has not always lived up to.”

Dr. Stephens voiced serious concerns about the impact of managed care in the 1980s and of “gatekeeping,” a practice intended to control access to specialists and reduce costs.

“He was many times not welcomed by family medicine [for his warnings] against the temptations that managed care presented,” said Dr. Green, the founding director of the Robert Graham Center, Washington. “He saw the conflict of interest of being a gatekeeper, how that would erode trust in a personal relationship with your personal doctor.”

“Gayle thought it was a disaster waiting to happen, and it was,” he said, referring to the eventual rejection by the public of barriers to direct access to specialists.

Through the 1990s and more recently, Dr. Stephens expressed frustration with the “medical-industrial complex” and the decline of family medicine after its surge in the 1970s and 1980s, Dr. Green said. “But in my opinion, near the end of his life, he was encouraged by young leaders who he saw grasped the important ideas from the ages.”

Dr. Stephens’ interest in medical education extended to nurses and nurse practitioners (the latter of whom had begun their discipline in the mid-1960s), and to optometrists, for whom he taught a recurring course in “physical diagnosis.”
 

A listener and proponent of listening

Linda Tompkins, RN, FNP, of Newton, Kan., trained with Dr. Stephens at part of a year-long nurse education program in the early 1970s at Wichita (Kan.) State University, where he was leading the department of family practice (prior to moving to Alabama). “You couldn’t ask too many questions,” she said. “And he never talked down to us, he wasn’t condescending. There were not a lot of doctors like that.”

Dr. Stephens spoke and wrote often about the importance of listening –about how it was vital to the “durable clinical relationship.” It was also vital to his writing and to his impact on the teachers of family medicine, said Dan Ostergaard, MD, who served as a residency director and in various staff leadership positions at the American Academy of Family Physicians, including in its division of education.

“He created a lot of aha moments for me, about where we came from and what we really need to be [as a specialty] and where we need to go,” said Dr. Ostergaard. “To be such a great thinker and a great writer, you have to be a great listener.”

“I can just visualize him,” he said, “leaning back in his chair while we were talking about residency criteria [or other issues], with a half-smile on his face and his reading glasses down his note, smoking his pipe and just looking at all of us, listening.”

Dr. Stephens’ papers are housed in the Center for the History of Family Medicine, a project of the AAFP Foundation.

G. Gayle Stephens, MD, who is roundly regarded as one of the founders of family medicine, gave his talk “Family Medicine as Counterculture” at the Society of Teachers of Family Medicine annual conference in 1979, 10 years after the specialty’s establishment.

The speech was then published, republished 10 years later, and, like many of Dr. Stephen’s other essays and articles, remains very much alive in the minds of practicing family physicians, in the teachings of FP academicians, and in the Google searches of budding FPs.

The late Dr. Stephens saw family medicine as a counterculture within medicine, rooted in social change. In his speech he examined these roots – in reform initiatives in the 1960s, and in certain philosophies and “minority” movements such as agrarianism and the preservation of rural life, utopianism, humanism, consumerism, and feminism.

He also looked forward, challenging the specialty to remain true to itself and its roots – to its belief in “uninhibited access” to medical care for everyone, for instance, and to continual whole-person and family-oriented care – and cautioned against moving to resemble the “rest of the medical bureaucracy.”

“Clearly we have been on the side of change in American life. We have identified ourselves with certain minorities and minority positions ... [and] been counter to many of the dominant forces in society,” Dr. Stephens said in his talk. Family practice “succeeded in the decade just past because we were identified with reforms that are more pervasive and powerful than ourselves.”

The family practice movement has “more in common with [the] counterculture than it does with the dominant scientific medical establishment,” he said.
 

A teacher and founder of medical education programs

Larry A. Green, MD, who was pursuing his own residency training as Dr. Stephens was leading a department of family practice, said Dr. Stephens “insisted that family medicine adhere to the notion that medicine is a moral vocation.”

“It was from this philosophical position that he became a synthesizer and observer and interpreter of what was going on in the development of family medicine,” said Dr. Green, Distinguished Professor and Epperson Zorn Chair for Innovation in Family Medicine and Primary Care at the University of Colorado at Denver, Aurora.

Dr. Stephens, who died at home in 2014 at the age of 85, was “probably the most important person in exposing what I now consider to be a fact – that family medicine was the product of social changes ... of social movements related to women’s rights, civil rights, and social responsibility,” Dr. Green said. “He could recall lessons from the past and forecast the challenges of the future. And there was no one more effective in clarifying the importance of personal [doctor-patient] relationships in family medicine.”

After years of general practice in rural Wichita, Kan., his wife Eula Jean’s hometown, Dr. Stephens founded and led one of the first family medicine residencies at Wesley Hospital in Wichita in 1967. His core principles, as described on today’s Wesley Family Medicine Residency website, included that a family physician consider the whole person, be honest, have a full scope of training including behavioral and mental health, and be “reflective about him/herself ... [learning about] his/her assets, liabilities, foibles, and idiosyncrasies.” Dr. Stephens, who had grown up in rural Ashburn, Mo., later became the founding dean of the School of Primary Medical Care at the University of Alabama in Huntsville and then chaired the department of family practice at the University of Alabama at Birmingham.
 

A thought leader for family medicine

He held numerous state and national leadership positions, and initiated what became the Keystone Conference Series – an invitational gathering of leaders in family medicine that examined and discuss the specialty’s ongoing development. In 2006, he was elected to the Institute of Medicine of the National Academies of Science.

Dr. Stephens authored a textbook, The Intellectual Basis of Family Medicine (Tucson, Ariz.: Winter Publishing Company, 1982), and authored essays, which Dr. Green said will stand the test of time.

“Some of us refer to him as the poet laureate of family medicine,” Dr. Green noted.

In a 1974 article on clinical wisdom, Dr. Stephens wrote that “it is not enough to determine what condition the patient has, but also what patient has the condition.” In another of these essays, which was published in 1979, Dr. Stephens wrote that “physicians need to keep in touch with their own tradition and with public welfare if they are to be considered moral by the society that sponsors them, and from which they take their strength and privilege.”

These excerpts are featured in an article by John P. Geyman, MD, published in 2011 in Family Medicine, called “G. Gayle Stephens Festschrift”.
 

A ‘progressive force’

Linda Prine, MD, professor of family and community medicine at the Icahn School of Medicine at Mount Sinai, New York, knows of Dr. Stephens from her teachers. “The people I looked up to when I was a younger physician were quoting his Counterculture article,” she said.

“It’s not that I studied him. But whenever I heard someone speak about the values of family medicine, his name would come up [and] the values of universal health care and community care and putting the patients’ interests first ahead of the insurance companies and being a doctor for the whole family,” Dr. Prine said. Dr. Stephens was a “progressive force that our specialty has not always lived up to.”

Dr. Stephens voiced serious concerns about the impact of managed care in the 1980s and of “gatekeeping,” a practice intended to control access to specialists and reduce costs.

“He was many times not welcomed by family medicine [for his warnings] against the temptations that managed care presented,” said Dr. Green, the founding director of the Robert Graham Center, Washington. “He saw the conflict of interest of being a gatekeeper, how that would erode trust in a personal relationship with your personal doctor.”

“Gayle thought it was a disaster waiting to happen, and it was,” he said, referring to the eventual rejection by the public of barriers to direct access to specialists.

Through the 1990s and more recently, Dr. Stephens expressed frustration with the “medical-industrial complex” and the decline of family medicine after its surge in the 1970s and 1980s, Dr. Green said. “But in my opinion, near the end of his life, he was encouraged by young leaders who he saw grasped the important ideas from the ages.”

Dr. Stephens’ interest in medical education extended to nurses and nurse practitioners (the latter of whom had begun their discipline in the mid-1960s), and to optometrists, for whom he taught a recurring course in “physical diagnosis.”
 

A listener and proponent of listening

Linda Tompkins, RN, FNP, of Newton, Kan., trained with Dr. Stephens at part of a year-long nurse education program in the early 1970s at Wichita (Kan.) State University, where he was leading the department of family practice (prior to moving to Alabama). “You couldn’t ask too many questions,” she said. “And he never talked down to us, he wasn’t condescending. There were not a lot of doctors like that.”

Dr. Stephens spoke and wrote often about the importance of listening –about how it was vital to the “durable clinical relationship.” It was also vital to his writing and to his impact on the teachers of family medicine, said Dan Ostergaard, MD, who served as a residency director and in various staff leadership positions at the American Academy of Family Physicians, including in its division of education.

“He created a lot of aha moments for me, about where we came from and what we really need to be [as a specialty] and where we need to go,” said Dr. Ostergaard. “To be such a great thinker and a great writer, you have to be a great listener.”

“I can just visualize him,” he said, “leaning back in his chair while we were talking about residency criteria [or other issues], with a half-smile on his face and his reading glasses down his note, smoking his pipe and just looking at all of us, listening.”

Dr. Stephens’ papers are housed in the Center for the History of Family Medicine, a project of the AAFP Foundation.

G. Gayle Stephens, MD, who is roundly regarded as one of the founders of family medicine, gave his talk “Family Medicine as Counterculture” at the Society of Teachers of Family Medicine annual conference in 1979, 10 years after the specialty’s establishment.

The speech was then published, republished 10 years later, and, like many of Dr. Stephen’s other essays and articles, remains very much alive in the minds of practicing family physicians, in the teachings of FP academicians, and in the Google searches of budding FPs.

The late Dr. Stephens saw family medicine as a counterculture within medicine, rooted in social change. In his speech he examined these roots – in reform initiatives in the 1960s, and in certain philosophies and “minority” movements such as agrarianism and the preservation of rural life, utopianism, humanism, consumerism, and feminism.

He also looked forward, challenging the specialty to remain true to itself and its roots – to its belief in “uninhibited access” to medical care for everyone, for instance, and to continual whole-person and family-oriented care – and cautioned against moving to resemble the “rest of the medical bureaucracy.”

“Clearly we have been on the side of change in American life. We have identified ourselves with certain minorities and minority positions ... [and] been counter to many of the dominant forces in society,” Dr. Stephens said in his talk. Family practice “succeeded in the decade just past because we were identified with reforms that are more pervasive and powerful than ourselves.”

The family practice movement has “more in common with [the] counterculture than it does with the dominant scientific medical establishment,” he said.
 

A teacher and founder of medical education programs

Larry A. Green, MD, who was pursuing his own residency training as Dr. Stephens was leading a department of family practice, said Dr. Stephens “insisted that family medicine adhere to the notion that medicine is a moral vocation.”

“It was from this philosophical position that he became a synthesizer and observer and interpreter of what was going on in the development of family medicine,” said Dr. Green, Distinguished Professor and Epperson Zorn Chair for Innovation in Family Medicine and Primary Care at the University of Colorado at Denver, Aurora.

Dr. Stephens, who died at home in 2014 at the age of 85, was “probably the most important person in exposing what I now consider to be a fact – that family medicine was the product of social changes ... of social movements related to women’s rights, civil rights, and social responsibility,” Dr. Green said. “He could recall lessons from the past and forecast the challenges of the future. And there was no one more effective in clarifying the importance of personal [doctor-patient] relationships in family medicine.”

After years of general practice in rural Wichita, Kan., his wife Eula Jean’s hometown, Dr. Stephens founded and led one of the first family medicine residencies at Wesley Hospital in Wichita in 1967. His core principles, as described on today’s Wesley Family Medicine Residency website, included that a family physician consider the whole person, be honest, have a full scope of training including behavioral and mental health, and be “reflective about him/herself ... [learning about] his/her assets, liabilities, foibles, and idiosyncrasies.” Dr. Stephens, who had grown up in rural Ashburn, Mo., later became the founding dean of the School of Primary Medical Care at the University of Alabama in Huntsville and then chaired the department of family practice at the University of Alabama at Birmingham.
 

A thought leader for family medicine

He held numerous state and national leadership positions, and initiated what became the Keystone Conference Series – an invitational gathering of leaders in family medicine that examined and discuss the specialty’s ongoing development. In 2006, he was elected to the Institute of Medicine of the National Academies of Science.

Dr. Stephens authored a textbook, The Intellectual Basis of Family Medicine (Tucson, Ariz.: Winter Publishing Company, 1982), and authored essays, which Dr. Green said will stand the test of time.

“Some of us refer to him as the poet laureate of family medicine,” Dr. Green noted.

In a 1974 article on clinical wisdom, Dr. Stephens wrote that “it is not enough to determine what condition the patient has, but also what patient has the condition.” In another of these essays, which was published in 1979, Dr. Stephens wrote that “physicians need to keep in touch with their own tradition and with public welfare if they are to be considered moral by the society that sponsors them, and from which they take their strength and privilege.”

These excerpts are featured in an article by John P. Geyman, MD, published in 2011 in Family Medicine, called “G. Gayle Stephens Festschrift”.
 

A ‘progressive force’

Linda Prine, MD, professor of family and community medicine at the Icahn School of Medicine at Mount Sinai, New York, knows of Dr. Stephens from her teachers. “The people I looked up to when I was a younger physician were quoting his Counterculture article,” she said.

“It’s not that I studied him. But whenever I heard someone speak about the values of family medicine, his name would come up [and] the values of universal health care and community care and putting the patients’ interests first ahead of the insurance companies and being a doctor for the whole family,” Dr. Prine said. Dr. Stephens was a “progressive force that our specialty has not always lived up to.”

Dr. Stephens voiced serious concerns about the impact of managed care in the 1980s and of “gatekeeping,” a practice intended to control access to specialists and reduce costs.

“He was many times not welcomed by family medicine [for his warnings] against the temptations that managed care presented,” said Dr. Green, the founding director of the Robert Graham Center, Washington. “He saw the conflict of interest of being a gatekeeper, how that would erode trust in a personal relationship with your personal doctor.”

“Gayle thought it was a disaster waiting to happen, and it was,” he said, referring to the eventual rejection by the public of barriers to direct access to specialists.

Through the 1990s and more recently, Dr. Stephens expressed frustration with the “medical-industrial complex” and the decline of family medicine after its surge in the 1970s and 1980s, Dr. Green said. “But in my opinion, near the end of his life, he was encouraged by young leaders who he saw grasped the important ideas from the ages.”

Dr. Stephens’ interest in medical education extended to nurses and nurse practitioners (the latter of whom had begun their discipline in the mid-1960s), and to optometrists, for whom he taught a recurring course in “physical diagnosis.”
 

A listener and proponent of listening

Linda Tompkins, RN, FNP, of Newton, Kan., trained with Dr. Stephens at part of a year-long nurse education program in the early 1970s at Wichita (Kan.) State University, where he was leading the department of family practice (prior to moving to Alabama). “You couldn’t ask too many questions,” she said. “And he never talked down to us, he wasn’t condescending. There were not a lot of doctors like that.”

Dr. Stephens spoke and wrote often about the importance of listening –about how it was vital to the “durable clinical relationship.” It was also vital to his writing and to his impact on the teachers of family medicine, said Dan Ostergaard, MD, who served as a residency director and in various staff leadership positions at the American Academy of Family Physicians, including in its division of education.

“He created a lot of aha moments for me, about where we came from and what we really need to be [as a specialty] and where we need to go,” said Dr. Ostergaard. “To be such a great thinker and a great writer, you have to be a great listener.”

“I can just visualize him,” he said, “leaning back in his chair while we were talking about residency criteria [or other issues], with a half-smile on his face and his reading glasses down his note, smoking his pipe and just looking at all of us, listening.”

Dr. Stephens’ papers are housed in the Center for the History of Family Medicine, a project of the AAFP Foundation.

Approximately three-quarters of Mohs surgeons recommended nicotinamide for prevention of keratinocyte carcinoma, in a survey of members of the American College of Mohs Surgeons.

Although nicotinamide, a vitamin B3 derivative, has been shown to reduce keratinocyte carcinoma (KC) in high-risk patients, it is not approved by the Food and Drug Administration for chemoprevention, and no safe upper limit has been established in clinical trials to date, wrote Sheena Desai of Brigham and Women’s Hospital and Harvard Medical School, Boston, and colleagues.

The investigators emailed an anonymous 12-question survey to 1,500 members of the American College of Mohs Surgeons. Of the 170 who responded, 10 were excluded for discordant responses, leaving 160 participants whose replies were included in a multiple logistic regression analysis. The respondents were mainly U.S. board-certified dermatologists and Mohs surgeons (99.4% for both); 86.9% were in clinical practice, including 78.8% in private practice, according to the report of the results, published in Dermatologic Surgery.

Overall, 76.9% of the respondents said they recommended nicotinamide for preventing KC, and 20% said they had recommended nicotinamide to more than 100 patients in the past year. In addition, 45% of respondents reported patients who had been taking nicotinamide for 2 years or more. Overall, 63.8% of the respondents expressed no concerns about long-term safety of nicotinamide, compared with 28.1% who said they were uncertain about long-term safety. Those who expressed concern or uncertainty about long-term safety were significantly less likely to recommend nicotinamide for KC prevention in the past year (odds ratio, 0.30; 95% confidence interval [CI] 0.13-0.71). Clinicians with more than 10 years in practice were significantly less likely to recommend nicotinamide for chemoprevention (OR, 0.20; 95% CI 0.05-0.82).

The study findings were limited by several factors, including the low number of responses and the potential lack of generalizability to clinicians other than Mohs surgeons, the researchers noted. “Additional studies on nicotinamide safety and use patterns, including cost-effectiveness analyses, are needed given the widespread use identified in this study,” they concluded.

Limited safety data highlight research gaps

The study is particularly important at this time because nicotinamide has been increasingly used for KC chemoprevention since a randomized, controlled trial published in 2015 in the New England Journal of Medicine showed benefits, corresponding author Rebecca I. Hartman, MD, of the department of dermatology, Brigham and Women’s Hospital and Harvard University, Boston, said in an interview. That study of high-risk patients found that nicotinamide, 500 mg twice a day, was safe and effective in lowering the rates of new nonmelanoma skin cancers and AKs after 12 months .

“However, because this is not a prescription medication, but rather an OTC vitamin supplement, data on its use are not available,” she said.

Dr. Hartman said she was not surprised that nicotinamide is being used frequently by a majority of the survey respondents. “Most are using this if someone has two KCs over 2 years, which is a quite common occurrence,” she noted. However, “I was a bit surprised that nearly two-thirds had no safety concerns with long-term use, even though this has not been well-studied,” she added.

“Like anything we recommend, we must consider the risks and benefits,” Dr. Hartman said of nicotinamide. “Unfortunately, we don’t know the risks well, since this hasn’t been well-characterized with regular long-term use in these doses,” and more research is needed, she said. “The risks are likely low, as this is a vitamin that has been used for years in various OTC supplements,” she added. “However, there are some data showing slightly increased all-cause mortality with similar doses of a related medicine, niacin, in cardiovascular patients. For this reason, I recommend the medication when a patient’s KCs are really becoming burdensome – several KCs in a year or two – or when they are high-risk due to immunosuppression,” she explained.

“We also must consider the individual patient. For a healthy younger patient who has a public-facing job and as a result is very averse to developing any KCs on his or her face and very motivated to try prevention, it may make sense to try nicotinamide,” Dr. Hartman said. But for an older patient with cardiovascular comorbidities who is not bothered by a KC on his or her back or extremities, “this medication may not have a favorable risk-benefit profile.”

To address safety concerns, “researchers need to examine whether there are any harms in long-term regular nicotinamide use for KC prevention,” Dr. Hartman said. “This is something we hope to do in our patients; however, it is challenging to study in a retrospective way since the harm is likely small and there are so many other features that influence mortality as an outcome,” she noted.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Approximately three-quarters of Mohs surgeons recommended nicotinamide for prevention of keratinocyte carcinoma, in a survey of members of the American College of Mohs Surgeons.

Although nicotinamide, a vitamin B3 derivative, has been shown to reduce keratinocyte carcinoma (KC) in high-risk patients, it is not approved by the Food and Drug Administration for chemoprevention, and no safe upper limit has been established in clinical trials to date, wrote Sheena Desai of Brigham and Women’s Hospital and Harvard Medical School, Boston, and colleagues.

The investigators emailed an anonymous 12-question survey to 1,500 members of the American College of Mohs Surgeons. Of the 170 who responded, 10 were excluded for discordant responses, leaving 160 participants whose replies were included in a multiple logistic regression analysis. The respondents were mainly U.S. board-certified dermatologists and Mohs surgeons (99.4% for both); 86.9% were in clinical practice, including 78.8% in private practice, according to the report of the results, published in Dermatologic Surgery.

Overall, 76.9% of the respondents said they recommended nicotinamide for preventing KC, and 20% said they had recommended nicotinamide to more than 100 patients in the past year. In addition, 45% of respondents reported patients who had been taking nicotinamide for 2 years or more. Overall, 63.8% of the respondents expressed no concerns about long-term safety of nicotinamide, compared with 28.1% who said they were uncertain about long-term safety. Those who expressed concern or uncertainty about long-term safety were significantly less likely to recommend nicotinamide for KC prevention in the past year (odds ratio, 0.30; 95% confidence interval [CI] 0.13-0.71). Clinicians with more than 10 years in practice were significantly less likely to recommend nicotinamide for chemoprevention (OR, 0.20; 95% CI 0.05-0.82).

The study findings were limited by several factors, including the low number of responses and the potential lack of generalizability to clinicians other than Mohs surgeons, the researchers noted. “Additional studies on nicotinamide safety and use patterns, including cost-effectiveness analyses, are needed given the widespread use identified in this study,” they concluded.

Limited safety data highlight research gaps

The study is particularly important at this time because nicotinamide has been increasingly used for KC chemoprevention since a randomized, controlled trial published in 2015 in the New England Journal of Medicine showed benefits, corresponding author Rebecca I. Hartman, MD, of the department of dermatology, Brigham and Women’s Hospital and Harvard University, Boston, said in an interview. That study of high-risk patients found that nicotinamide, 500 mg twice a day, was safe and effective in lowering the rates of new nonmelanoma skin cancers and AKs after 12 months .

“However, because this is not a prescription medication, but rather an OTC vitamin supplement, data on its use are not available,” she said.

Dr. Hartman said she was not surprised that nicotinamide is being used frequently by a majority of the survey respondents. “Most are using this if someone has two KCs over 2 years, which is a quite common occurrence,” she noted. However, “I was a bit surprised that nearly two-thirds had no safety concerns with long-term use, even though this has not been well-studied,” she added.

“Like anything we recommend, we must consider the risks and benefits,” Dr. Hartman said of nicotinamide. “Unfortunately, we don’t know the risks well, since this hasn’t been well-characterized with regular long-term use in these doses,” and more research is needed, she said. “The risks are likely low, as this is a vitamin that has been used for years in various OTC supplements,” she added. “However, there are some data showing slightly increased all-cause mortality with similar doses of a related medicine, niacin, in cardiovascular patients. For this reason, I recommend the medication when a patient’s KCs are really becoming burdensome – several KCs in a year or two – or when they are high-risk due to immunosuppression,” she explained.

“We also must consider the individual patient. For a healthy younger patient who has a public-facing job and as a result is very averse to developing any KCs on his or her face and very motivated to try prevention, it may make sense to try nicotinamide,” Dr. Hartman said. But for an older patient with cardiovascular comorbidities who is not bothered by a KC on his or her back or extremities, “this medication may not have a favorable risk-benefit profile.”

To address safety concerns, “researchers need to examine whether there are any harms in long-term regular nicotinamide use for KC prevention,” Dr. Hartman said. “This is something we hope to do in our patients; however, it is challenging to study in a retrospective way since the harm is likely small and there are so many other features that influence mortality as an outcome,” she noted.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Approximately three-quarters of Mohs surgeons recommended nicotinamide for prevention of keratinocyte carcinoma, in a survey of members of the American College of Mohs Surgeons.

Although nicotinamide, a vitamin B3 derivative, has been shown to reduce keratinocyte carcinoma (KC) in high-risk patients, it is not approved by the Food and Drug Administration for chemoprevention, and no safe upper limit has been established in clinical trials to date, wrote Sheena Desai of Brigham and Women’s Hospital and Harvard Medical School, Boston, and colleagues.

The investigators emailed an anonymous 12-question survey to 1,500 members of the American College of Mohs Surgeons. Of the 170 who responded, 10 were excluded for discordant responses, leaving 160 participants whose replies were included in a multiple logistic regression analysis. The respondents were mainly U.S. board-certified dermatologists and Mohs surgeons (99.4% for both); 86.9% were in clinical practice, including 78.8% in private practice, according to the report of the results, published in Dermatologic Surgery.

Overall, 76.9% of the respondents said they recommended nicotinamide for preventing KC, and 20% said they had recommended nicotinamide to more than 100 patients in the past year. In addition, 45% of respondents reported patients who had been taking nicotinamide for 2 years or more. Overall, 63.8% of the respondents expressed no concerns about long-term safety of nicotinamide, compared with 28.1% who said they were uncertain about long-term safety. Those who expressed concern or uncertainty about long-term safety were significantly less likely to recommend nicotinamide for KC prevention in the past year (odds ratio, 0.30; 95% confidence interval [CI] 0.13-0.71). Clinicians with more than 10 years in practice were significantly less likely to recommend nicotinamide for chemoprevention (OR, 0.20; 95% CI 0.05-0.82).

The study findings were limited by several factors, including the low number of responses and the potential lack of generalizability to clinicians other than Mohs surgeons, the researchers noted. “Additional studies on nicotinamide safety and use patterns, including cost-effectiveness analyses, are needed given the widespread use identified in this study,” they concluded.

Limited safety data highlight research gaps

The study is particularly important at this time because nicotinamide has been increasingly used for KC chemoprevention since a randomized, controlled trial published in 2015 in the New England Journal of Medicine showed benefits, corresponding author Rebecca I. Hartman, MD, of the department of dermatology, Brigham and Women’s Hospital and Harvard University, Boston, said in an interview. That study of high-risk patients found that nicotinamide, 500 mg twice a day, was safe and effective in lowering the rates of new nonmelanoma skin cancers and AKs after 12 months .

“However, because this is not a prescription medication, but rather an OTC vitamin supplement, data on its use are not available,” she said.

Dr. Hartman said she was not surprised that nicotinamide is being used frequently by a majority of the survey respondents. “Most are using this if someone has two KCs over 2 years, which is a quite common occurrence,” she noted. However, “I was a bit surprised that nearly two-thirds had no safety concerns with long-term use, even though this has not been well-studied,” she added.

“Like anything we recommend, we must consider the risks and benefits,” Dr. Hartman said of nicotinamide. “Unfortunately, we don’t know the risks well, since this hasn’t been well-characterized with regular long-term use in these doses,” and more research is needed, she said. “The risks are likely low, as this is a vitamin that has been used for years in various OTC supplements,” she added. “However, there are some data showing slightly increased all-cause mortality with similar doses of a related medicine, niacin, in cardiovascular patients. For this reason, I recommend the medication when a patient’s KCs are really becoming burdensome – several KCs in a year or two – or when they are high-risk due to immunosuppression,” she explained.

“We also must consider the individual patient. For a healthy younger patient who has a public-facing job and as a result is very averse to developing any KCs on his or her face and very motivated to try prevention, it may make sense to try nicotinamide,” Dr. Hartman said. But for an older patient with cardiovascular comorbidities who is not bothered by a KC on his or her back or extremities, “this medication may not have a favorable risk-benefit profile.”

To address safety concerns, “researchers need to examine whether there are any harms in long-term regular nicotinamide use for KC prevention,” Dr. Hartman said. “This is something we hope to do in our patients; however, it is challenging to study in a retrospective way since the harm is likely small and there are so many other features that influence mortality as an outcome,” she noted.

The study received no outside funding. The researchers had no financial conflicts to disclose.

AGAF applications now open

Applications are now open for the 2022 American Gastroenterological Association Fellowship cohort. AGA is proud to formally recognize its exemplary members whose accomplishments and contributions demonstrate a deep commitment to gastroenterology through the AGA Fellows Program. Those in clinical practice, education, or research (basic or clinical) are encouraged to apply today.

Longstanding members who apply and meet the program criteria are granted the distinguished honor of AGA Fellowship and receive the following:

• The privilege of using the designation “AGAF” in professional activities. 
• An official certificate and pin denoting your status. 
• International acknowledgment at Digestive Disease Week® (DDW).
• A listing on the AGA website alongside esteemed peers.  
• A prewritten, fill-in press release and a digital badge to inform others of your accomplishment.

Apply for consideration and gain recognition worldwide for your commitment to the field. The deadline is Aug. 24.
 

Call for new AGA guideline topics

The AGA Institute Clinical Guidelines Committee wants your input on the next set of guidelines to be developed. By completing this online form, you can submit recommendations for guideline topics that will be developed within the next two years. The deadline to submit your ideas is Monday, May 3.  

It’s easy – just take the following 3 steps to submit a guideline idea:

• Check out the guidelines that AGA has already developed or are in progress. 
• Complete the survey. You can submit more than one guideline topic by filling out the form multiple times. 
• Stay tuned for follow-up questions in case the committee needs more information on your recommendations.  

The AGA Institute Clinical Guidelines Committee will review guideline topics in May, prioritizing and ranking topics based on the following criteria: prevalence of disease, resource utilization, variation in care, other existing guidelines, new data/changes in diagnosis or treatment, and potential for measure/quality development. Once vetted, four or more new guidelines will be recommended for development throughout the year. Complete the online survey at www.surveymonkey.com/r/AGAtopicsubmission
 

Get to know DDW® 2021 Virtual

The world’s premier meeting for gastroenterology, hepatology, endoscopy, and gastrointestinal surgery professionals will be a fully virtual event, May 21-23, 2021. We invite you to take advantage of this unique opportunity to exchange knowledge with colleagues from all over the world and explore the latest advances in the field – all from the convenience of your home. Plus, your registration grants you access to everything offered at Digestive Disease Week® (DDW) this year (no additional ticketed sessions). Learn more and register at ddw.org.

AGAF applications now open

Applications are now open for the 2022 American Gastroenterological Association Fellowship cohort. AGA is proud to formally recognize its exemplary members whose accomplishments and contributions demonstrate a deep commitment to gastroenterology through the AGA Fellows Program. Those in clinical practice, education, or research (basic or clinical) are encouraged to apply today.

Longstanding members who apply and meet the program criteria are granted the distinguished honor of AGA Fellowship and receive the following:

• The privilege of using the designation “AGAF” in professional activities. 
• An official certificate and pin denoting your status. 
• International acknowledgment at Digestive Disease Week® (DDW).
• A listing on the AGA website alongside esteemed peers.  
• A prewritten, fill-in press release and a digital badge to inform others of your accomplishment.

Apply for consideration and gain recognition worldwide for your commitment to the field. The deadline is Aug. 24.
 

Call for new AGA guideline topics

The AGA Institute Clinical Guidelines Committee wants your input on the next set of guidelines to be developed. By completing this online form, you can submit recommendations for guideline topics that will be developed within the next two years. The deadline to submit your ideas is Monday, May 3.  

It’s easy – just take the following 3 steps to submit a guideline idea:

• Check out the guidelines that AGA has already developed or are in progress. 
• Complete the survey. You can submit more than one guideline topic by filling out the form multiple times. 
• Stay tuned for follow-up questions in case the committee needs more information on your recommendations.  

The AGA Institute Clinical Guidelines Committee will review guideline topics in May, prioritizing and ranking topics based on the following criteria: prevalence of disease, resource utilization, variation in care, other existing guidelines, new data/changes in diagnosis or treatment, and potential for measure/quality development. Once vetted, four or more new guidelines will be recommended for development throughout the year. Complete the online survey at www.surveymonkey.com/r/AGAtopicsubmission
 

Get to know DDW® 2021 Virtual

The world’s premier meeting for gastroenterology, hepatology, endoscopy, and gastrointestinal surgery professionals will be a fully virtual event, May 21-23, 2021. We invite you to take advantage of this unique opportunity to exchange knowledge with colleagues from all over the world and explore the latest advances in the field – all from the convenience of your home. Plus, your registration grants you access to everything offered at Digestive Disease Week® (DDW) this year (no additional ticketed sessions). Learn more and register at ddw.org.

AGAF applications now open

Applications are now open for the 2022 American Gastroenterological Association Fellowship cohort. AGA is proud to formally recognize its exemplary members whose accomplishments and contributions demonstrate a deep commitment to gastroenterology through the AGA Fellows Program. Those in clinical practice, education, or research (basic or clinical) are encouraged to apply today.

Longstanding members who apply and meet the program criteria are granted the distinguished honor of AGA Fellowship and receive the following:

• The privilege of using the designation “AGAF” in professional activities. 
• An official certificate and pin denoting your status. 
• International acknowledgment at Digestive Disease Week® (DDW).
• A listing on the AGA website alongside esteemed peers.  
• A prewritten, fill-in press release and a digital badge to inform others of your accomplishment.

Apply for consideration and gain recognition worldwide for your commitment to the field. The deadline is Aug. 24.
 

Call for new AGA guideline topics

The AGA Institute Clinical Guidelines Committee wants your input on the next set of guidelines to be developed. By completing this online form, you can submit recommendations for guideline topics that will be developed within the next two years. The deadline to submit your ideas is Monday, May 3.  

It’s easy – just take the following 3 steps to submit a guideline idea:

• Check out the guidelines that AGA has already developed or are in progress. 
• Complete the survey. You can submit more than one guideline topic by filling out the form multiple times. 
• Stay tuned for follow-up questions in case the committee needs more information on your recommendations.  

The AGA Institute Clinical Guidelines Committee will review guideline topics in May, prioritizing and ranking topics based on the following criteria: prevalence of disease, resource utilization, variation in care, other existing guidelines, new data/changes in diagnosis or treatment, and potential for measure/quality development. Once vetted, four or more new guidelines will be recommended for development throughout the year. Complete the online survey at www.surveymonkey.com/r/AGAtopicsubmission
 

Get to know DDW® 2021 Virtual

The world’s premier meeting for gastroenterology, hepatology, endoscopy, and gastrointestinal surgery professionals will be a fully virtual event, May 21-23, 2021. We invite you to take advantage of this unique opportunity to exchange knowledge with colleagues from all over the world and explore the latest advances in the field – all from the convenience of your home. Plus, your registration grants you access to everything offered at Digestive Disease Week® (DDW) this year (no additional ticketed sessions). Learn more and register at ddw.org.

Gastroenterology

February 2021

Worldwide burden of, risk factors for, and trends in pancreatic cancer
Huang J et al. Gastroenterology. 2021 Mar 1;160(4):744-54. doi: 10.1053/j.gastro.2020.10.007.

Fibrates for Itch (FITCH) in fibrosing cholangiopathies: A double-blind, randomized, placebo-controlled trial
de Vries E et al. Gastroenterology. 2021 Mar 1;160(4):734-43.e6. doi: 10.1053/j.gastro.2020.10.001.



March 2021

How to integrate a medical ethics curriculum into gastroenterology fellowships
Rao VL et al. Gastroenterology. 2021 Mar 1;160(4):1003-6. https://doi.org/10.1053/j.gastro.2021.01.211.

Colonoscopist performance and colorectal cancer risk after adenoma removal to stratify surveillance: two nationwide observational studies
Wieszczy P et al. Gastroenterology. 2021 Mar 1;160(4):1067-74. doi: 10.1053/j.gastro.2020.10.009.

Pregnancy and neonatal outcomes after fetal exposure to biologics and thiopurines among women with inflammatory bowel disease
Mahadevan U et al. Gastroenterology. 2021 Mar 1;160(4):1131-9. doi: 10.1053/j.gastro.2020.11.038.


April 2021

AGA Clinical Practice Guidelines on intragastric balloons in the management of obesity
Muniraj T et al. Gastroenterology. 2021 Apr 1;160(5):1799-808. doi: 10.1053/j.gastro.2021.03.003.

How to strategically build your network for early career gastroenterologists
Gaidos JKJ et al. Gastroenterology. 2021 Apr 1;160(5):1461-6. doi: 10.1053/j.gastro.2021.01.025.

The microbiota-gut-brain axis: From motility to mood
Margolis KG et al. Gastroenterology. 2021 Apr 1;160(5):1486-501. doi: 10.1053/j.gastro.2020.10.066.

The association of histologic and noninvasive tests with adverse clinical and patient-reported outcomes in patients with advanced fibrosis due to nonalcoholic steatohepatitis
Younossi ZM et al. Gastroenterology. 2021 Apr 1;160(5):1608-19. doi: 10.1053/j.gastro.2020.12.003.
 

Clinical Gastroenterology and Hepatology

February 2021

Management of chronic abdominal distension and bloating
Lacy BE et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):219-31. doi: 10.1016/j.cgh.2020.03.056.

Prevalence of gastric intestinal metaplasia in a multiethnic US veterans population
Nguyen TH et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):269-76. doi: 10.1016/j.cgh.2020.03.015.

Rome IV functional gastrointestinal disorders and health impairment in subjects with hypermobility spectrum disorders or hypermobile Ehlers-Danlos syndrome
Lam CY et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):277-87. doi: 10.1016/j.cgh.2020.02.034.

Factors that affect adequacy of colon cleansing for colonoscopy in hospitalized patients
Fucci L et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):339-48. doi: org/10.1016/j.cgh.2020.02.055.


March 2021

Real-world gluten exposure in patients with celiac disease on gluten-free diets, determined from gliadin immunogenic peptides in urine and fecal samples
Stefanolo JP et al. Clin Gastroenterol Hepatol. 2021 Mar 1;19(3):484-91. doi: 10.1016/j.cgh.2020.03.038.



Factors associated with response to anorectal biofeedback therapy in patients with fecal incontinence

Mazor Y et al. Clin Gastroenterol Hepatol. 2021 Mar 1;19(3):492-502. doi: 10.1016/j.cgh.2020.03.050.



April 2021

Long-term outcome of gastric per-oral endoscopic pyloromyotomy in treatment of gastroparesis

Abdelfatah MM et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):816-24. doi: 10.1016/j.cgh.2020.05.039.



What gastroenterologists should know about COVID-19 vaccines

Rolak S et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):657-61. doi: 10.1016/j.cgh.2021.01.001.



No benefit of concomitant immunomodulator therapy on efficacy of biologics that are not tumor necrosis factor antagonists in patients with inflammatory bowel diseases: A meta-analysis

Yzet C et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):668-78. doi: 10.1016/j.cgh.2020.06.071.



Patient safety reporting in GI: All hands on deck

Wall A and Kothari D. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):626-32. doi: 10.1016/j.cgh.2020.11.007.

Techniques and Innovations in Gastrointestinal Endoscopy

Barriers and pitfalls for artificial intelligence in gastroenterology: Ethical and regulatory issues

Ahmad OF et al. Tech Innov Gastrointest Endosc. 2020 Apr 1;22(2):80-4. doi: 10.1016/j.tgie.2019.150636.



Development of a scoring system to predict a positive diagnosis on video capsule endoscopy for suspected small bowel bleeding

Marya NB et al. Tech Innov Gastrointest Endosc. 2020 Oct 1;22(4):178-84. doi: 10.1016/j.tige.2020.06.001.



Training for Advanced Endoscopic Imaging in Gastrointestinal Diseases

Hoogenboom SA et al. Tech Innov Gastrointest Endosc. 2021 Jan 1;23(1):99-106. doi: 10.1016/j.tige.2020.09.001.



Chromoendoscopy techniques in imaging of colorectal polyps and cancer: Overview and practical applications for detection and characterization.

Rivero-Sanchez L et al. Tech Innov Gastrointest Endosc. 2021 Jan 1;23(1):30-41. doi: 10.1016/j.tige.2020.10.006.




 

Gastroenterology

February 2021

Worldwide burden of, risk factors for, and trends in pancreatic cancer
Huang J et al. Gastroenterology. 2021 Mar 1;160(4):744-54. doi: 10.1053/j.gastro.2020.10.007.

Fibrates for Itch (FITCH) in fibrosing cholangiopathies: A double-blind, randomized, placebo-controlled trial
de Vries E et al. Gastroenterology. 2021 Mar 1;160(4):734-43.e6. doi: 10.1053/j.gastro.2020.10.001.



March 2021

How to integrate a medical ethics curriculum into gastroenterology fellowships
Rao VL et al. Gastroenterology. 2021 Mar 1;160(4):1003-6. https://doi.org/10.1053/j.gastro.2021.01.211.

Colonoscopist performance and colorectal cancer risk after adenoma removal to stratify surveillance: two nationwide observational studies
Wieszczy P et al. Gastroenterology. 2021 Mar 1;160(4):1067-74. doi: 10.1053/j.gastro.2020.10.009.

Pregnancy and neonatal outcomes after fetal exposure to biologics and thiopurines among women with inflammatory bowel disease
Mahadevan U et al. Gastroenterology. 2021 Mar 1;160(4):1131-9. doi: 10.1053/j.gastro.2020.11.038.


April 2021

AGA Clinical Practice Guidelines on intragastric balloons in the management of obesity
Muniraj T et al. Gastroenterology. 2021 Apr 1;160(5):1799-808. doi: 10.1053/j.gastro.2021.03.003.

How to strategically build your network for early career gastroenterologists
Gaidos JKJ et al. Gastroenterology. 2021 Apr 1;160(5):1461-6. doi: 10.1053/j.gastro.2021.01.025.

The microbiota-gut-brain axis: From motility to mood
Margolis KG et al. Gastroenterology. 2021 Apr 1;160(5):1486-501. doi: 10.1053/j.gastro.2020.10.066.

The association of histologic and noninvasive tests with adverse clinical and patient-reported outcomes in patients with advanced fibrosis due to nonalcoholic steatohepatitis
Younossi ZM et al. Gastroenterology. 2021 Apr 1;160(5):1608-19. doi: 10.1053/j.gastro.2020.12.003.
 

Clinical Gastroenterology and Hepatology

February 2021

Management of chronic abdominal distension and bloating
Lacy BE et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):219-31. doi: 10.1016/j.cgh.2020.03.056.

Prevalence of gastric intestinal metaplasia in a multiethnic US veterans population
Nguyen TH et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):269-76. doi: 10.1016/j.cgh.2020.03.015.

Rome IV functional gastrointestinal disorders and health impairment in subjects with hypermobility spectrum disorders or hypermobile Ehlers-Danlos syndrome
Lam CY et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):277-87. doi: 10.1016/j.cgh.2020.02.034.

Factors that affect adequacy of colon cleansing for colonoscopy in hospitalized patients
Fucci L et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):339-48. doi: org/10.1016/j.cgh.2020.02.055.


March 2021

Real-world gluten exposure in patients with celiac disease on gluten-free diets, determined from gliadin immunogenic peptides in urine and fecal samples
Stefanolo JP et al. Clin Gastroenterol Hepatol. 2021 Mar 1;19(3):484-91. doi: 10.1016/j.cgh.2020.03.038.



Factors associated with response to anorectal biofeedback therapy in patients with fecal incontinence

Mazor Y et al. Clin Gastroenterol Hepatol. 2021 Mar 1;19(3):492-502. doi: 10.1016/j.cgh.2020.03.050.



April 2021

Long-term outcome of gastric per-oral endoscopic pyloromyotomy in treatment of gastroparesis

Abdelfatah MM et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):816-24. doi: 10.1016/j.cgh.2020.05.039.



What gastroenterologists should know about COVID-19 vaccines

Rolak S et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):657-61. doi: 10.1016/j.cgh.2021.01.001.



No benefit of concomitant immunomodulator therapy on efficacy of biologics that are not tumor necrosis factor antagonists in patients with inflammatory bowel diseases: A meta-analysis

Yzet C et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):668-78. doi: 10.1016/j.cgh.2020.06.071.



Patient safety reporting in GI: All hands on deck

Wall A and Kothari D. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):626-32. doi: 10.1016/j.cgh.2020.11.007.

Techniques and Innovations in Gastrointestinal Endoscopy

Barriers and pitfalls for artificial intelligence in gastroenterology: Ethical and regulatory issues

Ahmad OF et al. Tech Innov Gastrointest Endosc. 2020 Apr 1;22(2):80-4. doi: 10.1016/j.tgie.2019.150636.



Development of a scoring system to predict a positive diagnosis on video capsule endoscopy for suspected small bowel bleeding

Marya NB et al. Tech Innov Gastrointest Endosc. 2020 Oct 1;22(4):178-84. doi: 10.1016/j.tige.2020.06.001.



Training for Advanced Endoscopic Imaging in Gastrointestinal Diseases

Hoogenboom SA et al. Tech Innov Gastrointest Endosc. 2021 Jan 1;23(1):99-106. doi: 10.1016/j.tige.2020.09.001.



Chromoendoscopy techniques in imaging of colorectal polyps and cancer: Overview and practical applications for detection and characterization.

Rivero-Sanchez L et al. Tech Innov Gastrointest Endosc. 2021 Jan 1;23(1):30-41. doi: 10.1016/j.tige.2020.10.006.




 

Gastroenterology

February 2021

Worldwide burden of, risk factors for, and trends in pancreatic cancer
Huang J et al. Gastroenterology. 2021 Mar 1;160(4):744-54. doi: 10.1053/j.gastro.2020.10.007.

Fibrates for Itch (FITCH) in fibrosing cholangiopathies: A double-blind, randomized, placebo-controlled trial
de Vries E et al. Gastroenterology. 2021 Mar 1;160(4):734-43.e6. doi: 10.1053/j.gastro.2020.10.001.



March 2021

How to integrate a medical ethics curriculum into gastroenterology fellowships
Rao VL et al. Gastroenterology. 2021 Mar 1;160(4):1003-6. https://doi.org/10.1053/j.gastro.2021.01.211.

Colonoscopist performance and colorectal cancer risk after adenoma removal to stratify surveillance: two nationwide observational studies
Wieszczy P et al. Gastroenterology. 2021 Mar 1;160(4):1067-74. doi: 10.1053/j.gastro.2020.10.009.

Pregnancy and neonatal outcomes after fetal exposure to biologics and thiopurines among women with inflammatory bowel disease
Mahadevan U et al. Gastroenterology. 2021 Mar 1;160(4):1131-9. doi: 10.1053/j.gastro.2020.11.038.


April 2021

AGA Clinical Practice Guidelines on intragastric balloons in the management of obesity
Muniraj T et al. Gastroenterology. 2021 Apr 1;160(5):1799-808. doi: 10.1053/j.gastro.2021.03.003.

How to strategically build your network for early career gastroenterologists
Gaidos JKJ et al. Gastroenterology. 2021 Apr 1;160(5):1461-6. doi: 10.1053/j.gastro.2021.01.025.

The microbiota-gut-brain axis: From motility to mood
Margolis KG et al. Gastroenterology. 2021 Apr 1;160(5):1486-501. doi: 10.1053/j.gastro.2020.10.066.

The association of histologic and noninvasive tests with adverse clinical and patient-reported outcomes in patients with advanced fibrosis due to nonalcoholic steatohepatitis
Younossi ZM et al. Gastroenterology. 2021 Apr 1;160(5):1608-19. doi: 10.1053/j.gastro.2020.12.003.
 

Clinical Gastroenterology and Hepatology

February 2021

Management of chronic abdominal distension and bloating
Lacy BE et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):219-31. doi: 10.1016/j.cgh.2020.03.056.

Prevalence of gastric intestinal metaplasia in a multiethnic US veterans population
Nguyen TH et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):269-76. doi: 10.1016/j.cgh.2020.03.015.

Rome IV functional gastrointestinal disorders and health impairment in subjects with hypermobility spectrum disorders or hypermobile Ehlers-Danlos syndrome
Lam CY et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):277-87. doi: 10.1016/j.cgh.2020.02.034.

Factors that affect adequacy of colon cleansing for colonoscopy in hospitalized patients
Fucci L et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):339-48. doi: org/10.1016/j.cgh.2020.02.055.


March 2021

Real-world gluten exposure in patients with celiac disease on gluten-free diets, determined from gliadin immunogenic peptides in urine and fecal samples
Stefanolo JP et al. Clin Gastroenterol Hepatol. 2021 Mar 1;19(3):484-91. doi: 10.1016/j.cgh.2020.03.038.



Factors associated with response to anorectal biofeedback therapy in patients with fecal incontinence

Mazor Y et al. Clin Gastroenterol Hepatol. 2021 Mar 1;19(3):492-502. doi: 10.1016/j.cgh.2020.03.050.



April 2021

Long-term outcome of gastric per-oral endoscopic pyloromyotomy in treatment of gastroparesis

Abdelfatah MM et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):816-24. doi: 10.1016/j.cgh.2020.05.039.



What gastroenterologists should know about COVID-19 vaccines

Rolak S et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):657-61. doi: 10.1016/j.cgh.2021.01.001.



No benefit of concomitant immunomodulator therapy on efficacy of biologics that are not tumor necrosis factor antagonists in patients with inflammatory bowel diseases: A meta-analysis

Yzet C et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):668-78. doi: 10.1016/j.cgh.2020.06.071.



Patient safety reporting in GI: All hands on deck

Wall A and Kothari D. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):626-32. doi: 10.1016/j.cgh.2020.11.007.

Techniques and Innovations in Gastrointestinal Endoscopy

Barriers and pitfalls for artificial intelligence in gastroenterology: Ethical and regulatory issues

Ahmad OF et al. Tech Innov Gastrointest Endosc. 2020 Apr 1;22(2):80-4. doi: 10.1016/j.tgie.2019.150636.



Development of a scoring system to predict a positive diagnosis on video capsule endoscopy for suspected small bowel bleeding

Marya NB et al. Tech Innov Gastrointest Endosc. 2020 Oct 1;22(4):178-84. doi: 10.1016/j.tige.2020.06.001.



Training for Advanced Endoscopic Imaging in Gastrointestinal Diseases

Hoogenboom SA et al. Tech Innov Gastrointest Endosc. 2021 Jan 1;23(1):99-106. doi: 10.1016/j.tige.2020.09.001.



Chromoendoscopy techniques in imaging of colorectal polyps and cancer: Overview and practical applications for detection and characterization.

Rivero-Sanchez L et al. Tech Innov Gastrointest Endosc. 2021 Jan 1;23(1):30-41. doi: 10.1016/j.tige.2020.10.006.




 

Patients with prurigo nodularis tend to make a greater number of visits to health care specialists and are burdened by a greater number of medical comorbidities, compared with age-matched controls, as well those with atopic dermatitis and psoriasis.

Those are key findings from a retrospective analysis of claims data that was published online April 3, 2021, in the Journal of Investigative Dermatology.

“Prurigo nodularis is a tremendously understudied inflammatory skin disease,” one of the study’s cosenior authors, Shawn G. Kwatra, MD, of the department of dermatology, Johns Hopkins University, Baltimore, said in an interview. “Prurigo nodularis patients have uncontrolled itch, which leads to reduced quality of life, and the association with many disease comorbidities. We focused on better understanding in this work the unique comorbidities of prurigo nodularis, compared to other inflammatory skin diseases.”

For the study, Dr. Kwatra, cosenior author Yevgeniy R. Semenov, MD, of the department of dermatology, Massachusetts General Hospital, Boston, and colleagues evaluated nationally representative, private insurance claims data from October 2015 to December 2019 to identify prurigo nodularis (PN) patients, who were defined as individuals with two or more medical claims for PN using ICD-10-CM codes. For comparison with patients with inflammatory skin diseases, they used the same claims data to identify patients with atopic dermatitis (AD) and psoriasis as well as to select controls who were age and gender matched to PN patients. Next, they quantified the overall comorbidity burden with the Charlson Comorbidity Index (CCI).

In 2016, the claims database included 2,658 patients with PN, 21,482 patients with AD, 21,073 patients with psoriasis, and 13,290 controls. The number of patients in each category rose each subsequent year, so that by the end of 2019 there were 9,426 patients with PN, 70,298 patients with AD, 59,509 patients with psoriasis, and 47,130 controls. Between 2016 and 2019 the mean age of PN patients increased from 57.5 to 59.8 years and the percent of male patients rose from 44.5% to 46.5%.

Between 2016 and 2019, the overall PN prevalence rates rose from 18 per 100,000 to 58 per 100,000, while the PN prevalence rates among adults increased from 22 per 100,000 to 70 per 100,000, and the rates among children rose grew from 2 per 100,000 to 7 per 100,000. “Our report shows an estimated disease prevalence of around 335,000 cases of PN in the United States,” said Dr. Kwatra, who was among a group of researchers to recently report on systemic Th22-polarized inflammation in PN patients.

The researchers also found that patients with PN had the highest mean CCI in both 2016 and 2019. In 2016, their mean CCI was 1.53, compared with 0.98 among controls, 0.53 among those with AD, and 1.16 among those with psoriasis. In 2019, the mean CCI had increased in all groups of patients, to 2.32 among those with PN, 1.57 among controls, 0.75 among those with AD patients, and 1.71 among those with psoriasis.

The top five medical specialties who cared for PN patients, defined as the estimated number of visits per year per patient, were internal medicine (2.01 visits), dermatology (1.87 visits), family practice (1.60 visits), cardiology or cardiovascular disease (0.85 visits), and orthopedics or orthopedic surgery (0.49 visits).

“If you encounter a patient with prurigo nodularis, it’s important to perform a screening for chronic kidney disease, diabetes, and liver disease,” Dr. Kwatra said. “These comorbidities along with emerging studies on circulating blood biomarkers suggest prurigo nodularis is a systemic inflammatory disorder; thus systemic agents are needed for most patients as part of multimodal therapy in prurigo nodularis.”

The researchers acknowledged certain limitations of the study, including its retrospective design and the identification of patients with PN with the ICD-10-CM code, which require further validation. “Furthermore, the increase in annual prevalence estimates for PN, AD, and psoriasis observed in the study could also be a result of increasing coding of these diagnoses in the claims data along with rising awareness by the medical profession,” they wrote.

Dr. Kwatra disclosed that he is an advisory board member/consultant for AbbVie, Galderma, Incyte, Pfizer, Regeneron, and Kiniksa Pharmaceuticals, and has received grant funding from Galderma, Pfizer, and Kiniksa. He has also received a Dermatology Foundation Medical Dermatology Career Development Award, a research grant from the Skin of Color Society, and is supported by the National Institutes of Health. One coauthor has been funded by NIH grants.

[email protected]

Patients with prurigo nodularis tend to make a greater number of visits to health care specialists and are burdened by a greater number of medical comorbidities, compared with age-matched controls, as well those with atopic dermatitis and psoriasis.

Those are key findings from a retrospective analysis of claims data that was published online April 3, 2021, in the Journal of Investigative Dermatology.

“Prurigo nodularis is a tremendously understudied inflammatory skin disease,” one of the study’s cosenior authors, Shawn G. Kwatra, MD, of the department of dermatology, Johns Hopkins University, Baltimore, said in an interview. “Prurigo nodularis patients have uncontrolled itch, which leads to reduced quality of life, and the association with many disease comorbidities. We focused on better understanding in this work the unique comorbidities of prurigo nodularis, compared to other inflammatory skin diseases.”

For the study, Dr. Kwatra, cosenior author Yevgeniy R. Semenov, MD, of the department of dermatology, Massachusetts General Hospital, Boston, and colleagues evaluated nationally representative, private insurance claims data from October 2015 to December 2019 to identify prurigo nodularis (PN) patients, who were defined as individuals with two or more medical claims for PN using ICD-10-CM codes. For comparison with patients with inflammatory skin diseases, they used the same claims data to identify patients with atopic dermatitis (AD) and psoriasis as well as to select controls who were age and gender matched to PN patients. Next, they quantified the overall comorbidity burden with the Charlson Comorbidity Index (CCI).

In 2016, the claims database included 2,658 patients with PN, 21,482 patients with AD, 21,073 patients with psoriasis, and 13,290 controls. The number of patients in each category rose each subsequent year, so that by the end of 2019 there were 9,426 patients with PN, 70,298 patients with AD, 59,509 patients with psoriasis, and 47,130 controls. Between 2016 and 2019 the mean age of PN patients increased from 57.5 to 59.8 years and the percent of male patients rose from 44.5% to 46.5%.

Between 2016 and 2019, the overall PN prevalence rates rose from 18 per 100,000 to 58 per 100,000, while the PN prevalence rates among adults increased from 22 per 100,000 to 70 per 100,000, and the rates among children rose grew from 2 per 100,000 to 7 per 100,000. “Our report shows an estimated disease prevalence of around 335,000 cases of PN in the United States,” said Dr. Kwatra, who was among a group of researchers to recently report on systemic Th22-polarized inflammation in PN patients.

The researchers also found that patients with PN had the highest mean CCI in both 2016 and 2019. In 2016, their mean CCI was 1.53, compared with 0.98 among controls, 0.53 among those with AD, and 1.16 among those with psoriasis. In 2019, the mean CCI had increased in all groups of patients, to 2.32 among those with PN, 1.57 among controls, 0.75 among those with AD patients, and 1.71 among those with psoriasis.

The top five medical specialties who cared for PN patients, defined as the estimated number of visits per year per patient, were internal medicine (2.01 visits), dermatology (1.87 visits), family practice (1.60 visits), cardiology or cardiovascular disease (0.85 visits), and orthopedics or orthopedic surgery (0.49 visits).

“If you encounter a patient with prurigo nodularis, it’s important to perform a screening for chronic kidney disease, diabetes, and liver disease,” Dr. Kwatra said. “These comorbidities along with emerging studies on circulating blood biomarkers suggest prurigo nodularis is a systemic inflammatory disorder; thus systemic agents are needed for most patients as part of multimodal therapy in prurigo nodularis.”

The researchers acknowledged certain limitations of the study, including its retrospective design and the identification of patients with PN with the ICD-10-CM code, which require further validation. “Furthermore, the increase in annual prevalence estimates for PN, AD, and psoriasis observed in the study could also be a result of increasing coding of these diagnoses in the claims data along with rising awareness by the medical profession,” they wrote.

Dr. Kwatra disclosed that he is an advisory board member/consultant for AbbVie, Galderma, Incyte, Pfizer, Regeneron, and Kiniksa Pharmaceuticals, and has received grant funding from Galderma, Pfizer, and Kiniksa. He has also received a Dermatology Foundation Medical Dermatology Career Development Award, a research grant from the Skin of Color Society, and is supported by the National Institutes of Health. One coauthor has been funded by NIH grants.

[email protected]

Patients with prurigo nodularis tend to make a greater number of visits to health care specialists and are burdened by a greater number of medical comorbidities, compared with age-matched controls, as well those with atopic dermatitis and psoriasis.

Those are key findings from a retrospective analysis of claims data that was published online April 3, 2021, in the Journal of Investigative Dermatology.

“Prurigo nodularis is a tremendously understudied inflammatory skin disease,” one of the study’s cosenior authors, Shawn G. Kwatra, MD, of the department of dermatology, Johns Hopkins University, Baltimore, said in an interview. “Prurigo nodularis patients have uncontrolled itch, which leads to reduced quality of life, and the association with many disease comorbidities. We focused on better understanding in this work the unique comorbidities of prurigo nodularis, compared to other inflammatory skin diseases.”

For the study, Dr. Kwatra, cosenior author Yevgeniy R. Semenov, MD, of the department of dermatology, Massachusetts General Hospital, Boston, and colleagues evaluated nationally representative, private insurance claims data from October 2015 to December 2019 to identify prurigo nodularis (PN) patients, who were defined as individuals with two or more medical claims for PN using ICD-10-CM codes. For comparison with patients with inflammatory skin diseases, they used the same claims data to identify patients with atopic dermatitis (AD) and psoriasis as well as to select controls who were age and gender matched to PN patients. Next, they quantified the overall comorbidity burden with the Charlson Comorbidity Index (CCI).

In 2016, the claims database included 2,658 patients with PN, 21,482 patients with AD, 21,073 patients with psoriasis, and 13,290 controls. The number of patients in each category rose each subsequent year, so that by the end of 2019 there were 9,426 patients with PN, 70,298 patients with AD, 59,509 patients with psoriasis, and 47,130 controls. Between 2016 and 2019 the mean age of PN patients increased from 57.5 to 59.8 years and the percent of male patients rose from 44.5% to 46.5%.

Between 2016 and 2019, the overall PN prevalence rates rose from 18 per 100,000 to 58 per 100,000, while the PN prevalence rates among adults increased from 22 per 100,000 to 70 per 100,000, and the rates among children rose grew from 2 per 100,000 to 7 per 100,000. “Our report shows an estimated disease prevalence of around 335,000 cases of PN in the United States,” said Dr. Kwatra, who was among a group of researchers to recently report on systemic Th22-polarized inflammation in PN patients.

The researchers also found that patients with PN had the highest mean CCI in both 2016 and 2019. In 2016, their mean CCI was 1.53, compared with 0.98 among controls, 0.53 among those with AD, and 1.16 among those with psoriasis. In 2019, the mean CCI had increased in all groups of patients, to 2.32 among those with PN, 1.57 among controls, 0.75 among those with AD patients, and 1.71 among those with psoriasis.

The top five medical specialties who cared for PN patients, defined as the estimated number of visits per year per patient, were internal medicine (2.01 visits), dermatology (1.87 visits), family practice (1.60 visits), cardiology or cardiovascular disease (0.85 visits), and orthopedics or orthopedic surgery (0.49 visits).

“If you encounter a patient with prurigo nodularis, it’s important to perform a screening for chronic kidney disease, diabetes, and liver disease,” Dr. Kwatra said. “These comorbidities along with emerging studies on circulating blood biomarkers suggest prurigo nodularis is a systemic inflammatory disorder; thus systemic agents are needed for most patients as part of multimodal therapy in prurigo nodularis.”

The researchers acknowledged certain limitations of the study, including its retrospective design and the identification of patients with PN with the ICD-10-CM code, which require further validation. “Furthermore, the increase in annual prevalence estimates for PN, AD, and psoriasis observed in the study could also be a result of increasing coding of these diagnoses in the claims data along with rising awareness by the medical profession,” they wrote.

Dr. Kwatra disclosed that he is an advisory board member/consultant for AbbVie, Galderma, Incyte, Pfizer, Regeneron, and Kiniksa Pharmaceuticals, and has received grant funding from Galderma, Pfizer, and Kiniksa. He has also received a Dermatology Foundation Medical Dermatology Career Development Award, a research grant from the Skin of Color Society, and is supported by the National Institutes of Health. One coauthor has been funded by NIH grants.

[email protected]

An investigational polymerase chain reaction (PCR) test that detects the presence of a viral gene in Lyme disease–causing bacteria can distinguish between early and late infection, according to the results of a study that the authors described as “systematic and comprehensive.”

“The current way of diagnosing Lyme disease is struggling to reflect the ‘true’ incidence of Lyme disease,” study investigator Jinyu Shan, PhD, said in an interview. Although there are tests for Lyme disease approved by the Food and Drug Administration, they are based on the development of antibodies in the blood, and the problem is that antibodies might not develop until several weeks after an infection.

Diagnosis therefore still relies heavily on the clinician’s experience. There are often telltale signs – such as a “bullseye” skin rash or having been to an area known to be infested with ticks that carry Lyme disease – but this might not always be the case.

For the new test, “we’re not targeting bacteria. We’re targeting bacteriophages,” said Dr. Shan, a research fellow in the department of genetics and genome biology at the University of Leicester (England).

Fortunately, there’s high correlation between the presence of the terL gene and the presence of Borrelia burgdorferi, the spirochete that causes Lyme disease. “If you find the bacteriophages, the bacteria are there,” said Dr. Shan.

“Importantly, there are 10 times more bacteriophages, compared with the bacteria, so you have a lot more targets,” he added.

In an evaluation of a total of 312 samples (156 whole blood and 156 serum samples), significantly fewer copies of the terL gene were found in samples from people with early Lyme disease than in those with late Lyme disease, whereas the fewest copies of terL were seen in healthy volunteers.

Most pathogenic bacteria carry viral DNA either as multiple complete or partial prophages, Dr. Shan explained. Knowing the prophage sequences means that quantitative PCR primers and probes can be designed and used to detect the presence of the associated bacteria.

Although the novel test still needs evaluation in a clinical trial, it could represent a “step-change” in the detection of Lyme disease, Dr. Shan and associates suggested in their report published in Frontiers in Microbiology.

CDC/ Dr. Amanda Loftis, Dr. William Nicholson, Dr. Will Reeves, Dr. Chris Paddock

Early treatment is key to the prevention of longer-term consequences of Lyme disease. Clinicians familiar with the treatment of Lyme disease might choose to initiate antibiotic treatment without a positive lab test. However, the lack of a test that can pick out people with Lyme disease in the first few weeks of infection means that many people are not diagnosed or treated early enough.

The new phage-based PCR test Dr. Shan and associates have developed could change all that. With only 0.3 mL of blood being needed, it can potentially be developed as a simple point-of-care test, but that’s a long way off.

At this stage, the research is very much a “proof of concept,” Dr. Shan said. One of the things he plans to try to work out next is whether the test can distinguish between active and dormant disease, which is a “big question” in the diagnosis of Lyme disease.

“Bacteriophages can only be sustained by actively growing bacteria,” explained Dr. Shan, so there is a chance that if they are present in a substantive amount the disease is active, and if they are not – or are in very low numbers – then the disease is dormant. The cutoff value, however, “is not trivial to establish, but we are working toward it,” added Dr. Shan.

Over the past 2 years, Dr. Shan and associates have been working with the Belgian-based diagnostics company, R.E.D Laboratories, to see how the test will fare in a real-world environment. This relationship is providing useful information to add to their bid to perform a clinical trial for which they are now seeking additional sponsorship.

“The lack of an early and effective diagnosis of Lyme disease remains a major cause of misdiagnosis and long-term patient suffering,” commented Rosie Milsom, charity manager for Caudwell LymeCo Charity in the United Kingdom.

It could be a game changer if the test passes the necessary clinical trial testing and validation stages, noted Ms. Milsom, who was not involved in the research.

“Not only would the test help to establish the level or length of infection,” she said, “but it could also act as a way to test after treatment to see if the infection levels are decreasing.” If levels are still high, “you would know more treatment is needed.

The research is being funded by the charity Phelix Research and Development with support from the University of Leicester and the Dutch-based Lyme Fund, Lymefonds. Dr. Shan is named as coinventor of the phage-targeting PCR test, alongside Martha R.J. Clokie, professor of microbiology at the University of Leicester and the senior author of the study. Dr. Shan is chief scientific officer for Phelix Research and Development. Ms. Clokie and other coauthors hold key positions within the medical research charity.

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

An investigational polymerase chain reaction (PCR) test that detects the presence of a viral gene in Lyme disease–causing bacteria can distinguish between early and late infection, according to the results of a study that the authors described as “systematic and comprehensive.”

“The current way of diagnosing Lyme disease is struggling to reflect the ‘true’ incidence of Lyme disease,” study investigator Jinyu Shan, PhD, said in an interview. Although there are tests for Lyme disease approved by the Food and Drug Administration, they are based on the development of antibodies in the blood, and the problem is that antibodies might not develop until several weeks after an infection.

Diagnosis therefore still relies heavily on the clinician’s experience. There are often telltale signs – such as a “bullseye” skin rash or having been to an area known to be infested with ticks that carry Lyme disease – but this might not always be the case.

For the new test, “we’re not targeting bacteria. We’re targeting bacteriophages,” said Dr. Shan, a research fellow in the department of genetics and genome biology at the University of Leicester (England).

Fortunately, there’s high correlation between the presence of the terL gene and the presence of Borrelia burgdorferi, the spirochete that causes Lyme disease. “If you find the bacteriophages, the bacteria are there,” said Dr. Shan.

“Importantly, there are 10 times more bacteriophages, compared with the bacteria, so you have a lot more targets,” he added.

In an evaluation of a total of 312 samples (156 whole blood and 156 serum samples), significantly fewer copies of the terL gene were found in samples from people with early Lyme disease than in those with late Lyme disease, whereas the fewest copies of terL were seen in healthy volunteers.

Most pathogenic bacteria carry viral DNA either as multiple complete or partial prophages, Dr. Shan explained. Knowing the prophage sequences means that quantitative PCR primers and probes can be designed and used to detect the presence of the associated bacteria.

Although the novel test still needs evaluation in a clinical trial, it could represent a “step-change” in the detection of Lyme disease, Dr. Shan and associates suggested in their report published in Frontiers in Microbiology.

CDC/ Dr. Amanda Loftis, Dr. William Nicholson, Dr. Will Reeves, Dr. Chris Paddock

Early treatment is key to the prevention of longer-term consequences of Lyme disease. Clinicians familiar with the treatment of Lyme disease might choose to initiate antibiotic treatment without a positive lab test. However, the lack of a test that can pick out people with Lyme disease in the first few weeks of infection means that many people are not diagnosed or treated early enough.

The new phage-based PCR test Dr. Shan and associates have developed could change all that. With only 0.3 mL of blood being needed, it can potentially be developed as a simple point-of-care test, but that’s a long way off.

At this stage, the research is very much a “proof of concept,” Dr. Shan said. One of the things he plans to try to work out next is whether the test can distinguish between active and dormant disease, which is a “big question” in the diagnosis of Lyme disease.

“Bacteriophages can only be sustained by actively growing bacteria,” explained Dr. Shan, so there is a chance that if they are present in a substantive amount the disease is active, and if they are not – or are in very low numbers – then the disease is dormant. The cutoff value, however, “is not trivial to establish, but we are working toward it,” added Dr. Shan.

Over the past 2 years, Dr. Shan and associates have been working with the Belgian-based diagnostics company, R.E.D Laboratories, to see how the test will fare in a real-world environment. This relationship is providing useful information to add to their bid to perform a clinical trial for which they are now seeking additional sponsorship.

“The lack of an early and effective diagnosis of Lyme disease remains a major cause of misdiagnosis and long-term patient suffering,” commented Rosie Milsom, charity manager for Caudwell LymeCo Charity in the United Kingdom.

It could be a game changer if the test passes the necessary clinical trial testing and validation stages, noted Ms. Milsom, who was not involved in the research.

“Not only would the test help to establish the level or length of infection,” she said, “but it could also act as a way to test after treatment to see if the infection levels are decreasing.” If levels are still high, “you would know more treatment is needed.

The research is being funded by the charity Phelix Research and Development with support from the University of Leicester and the Dutch-based Lyme Fund, Lymefonds. Dr. Shan is named as coinventor of the phage-targeting PCR test, alongside Martha R.J. Clokie, professor of microbiology at the University of Leicester and the senior author of the study. Dr. Shan is chief scientific officer for Phelix Research and Development. Ms. Clokie and other coauthors hold key positions within the medical research charity.

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

An investigational polymerase chain reaction (PCR) test that detects the presence of a viral gene in Lyme disease–causing bacteria can distinguish between early and late infection, according to the results of a study that the authors described as “systematic and comprehensive.”

“The current way of diagnosing Lyme disease is struggling to reflect the ‘true’ incidence of Lyme disease,” study investigator Jinyu Shan, PhD, said in an interview. Although there are tests for Lyme disease approved by the Food and Drug Administration, they are based on the development of antibodies in the blood, and the problem is that antibodies might not develop until several weeks after an infection.

Diagnosis therefore still relies heavily on the clinician’s experience. There are often telltale signs – such as a “bullseye” skin rash or having been to an area known to be infested with ticks that carry Lyme disease – but this might not always be the case.

For the new test, “we’re not targeting bacteria. We’re targeting bacteriophages,” said Dr. Shan, a research fellow in the department of genetics and genome biology at the University of Leicester (England).

Fortunately, there’s high correlation between the presence of the terL gene and the presence of Borrelia burgdorferi, the spirochete that causes Lyme disease. “If you find the bacteriophages, the bacteria are there,” said Dr. Shan.

“Importantly, there are 10 times more bacteriophages, compared with the bacteria, so you have a lot more targets,” he added.

In an evaluation of a total of 312 samples (156 whole blood and 156 serum samples), significantly fewer copies of the terL gene were found in samples from people with early Lyme disease than in those with late Lyme disease, whereas the fewest copies of terL were seen in healthy volunteers.

Most pathogenic bacteria carry viral DNA either as multiple complete or partial prophages, Dr. Shan explained. Knowing the prophage sequences means that quantitative PCR primers and probes can be designed and used to detect the presence of the associated bacteria.

Although the novel test still needs evaluation in a clinical trial, it could represent a “step-change” in the detection of Lyme disease, Dr. Shan and associates suggested in their report published in Frontiers in Microbiology.

CDC/ Dr. Amanda Loftis, Dr. William Nicholson, Dr. Will Reeves, Dr. Chris Paddock

Early treatment is key to the prevention of longer-term consequences of Lyme disease. Clinicians familiar with the treatment of Lyme disease might choose to initiate antibiotic treatment without a positive lab test. However, the lack of a test that can pick out people with Lyme disease in the first few weeks of infection means that many people are not diagnosed or treated early enough.

The new phage-based PCR test Dr. Shan and associates have developed could change all that. With only 0.3 mL of blood being needed, it can potentially be developed as a simple point-of-care test, but that’s a long way off.

At this stage, the research is very much a “proof of concept,” Dr. Shan said. One of the things he plans to try to work out next is whether the test can distinguish between active and dormant disease, which is a “big question” in the diagnosis of Lyme disease.

“Bacteriophages can only be sustained by actively growing bacteria,” explained Dr. Shan, so there is a chance that if they are present in a substantive amount the disease is active, and if they are not – or are in very low numbers – then the disease is dormant. The cutoff value, however, “is not trivial to establish, but we are working toward it,” added Dr. Shan.

Over the past 2 years, Dr. Shan and associates have been working with the Belgian-based diagnostics company, R.E.D Laboratories, to see how the test will fare in a real-world environment. This relationship is providing useful information to add to their bid to perform a clinical trial for which they are now seeking additional sponsorship.

“The lack of an early and effective diagnosis of Lyme disease remains a major cause of misdiagnosis and long-term patient suffering,” commented Rosie Milsom, charity manager for Caudwell LymeCo Charity in the United Kingdom.

It could be a game changer if the test passes the necessary clinical trial testing and validation stages, noted Ms. Milsom, who was not involved in the research.

“Not only would the test help to establish the level or length of infection,” she said, “but it could also act as a way to test after treatment to see if the infection levels are decreasing.” If levels are still high, “you would know more treatment is needed.

The research is being funded by the charity Phelix Research and Development with support from the University of Leicester and the Dutch-based Lyme Fund, Lymefonds. Dr. Shan is named as coinventor of the phage-targeting PCR test, alongside Martha R.J. Clokie, professor of microbiology at the University of Leicester and the senior author of the study. Dr. Shan is chief scientific officer for Phelix Research and Development. Ms. Clokie and other coauthors hold key positions within the medical research charity.

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

Hospitalists around the country are devoting large portions of their spare time to a wide range of advocacy efforts. From health policy to caring for the unhoused population to diversity and equity to advocating for fellow hospitalists, these physicians are passionate about their causes and determined to make a difference.

Championing the unhoused

Sarah Stella, MD, FHM, a hospitalist at Denver Health, was initially drawn there because of the population the hospital serves, which includes a high concentration of people experiencing homelessness. As she cared for her patients, Dr. Stella, who is also associate professor of hospital medicine at the University of Colorado, increasingly felt the desire to help prevent the negative downstream outcomes the hospital sees.

To understand the experiences of the unhoused outside the hospital, Dr. Stella started talking to her patients and people in community-based organizations that serve this population. “I learned a ton,” she said. “Homelessness feels like such an intractable, hopeless thing, but the more I talked to people, the more opportunities I saw to work toward something better.”

This led to a pilot grant to work with the Colorado Coalition for the Homeless to set up a community advisory panel. “My goal was to better understand their experiences and to develop a shared vision for how we collectively can do better,” said Dr. Stella. Eventually, she also received a grant from the University of Colorado, and multiple opportunities have sprung up ever since.

For the past several years, Dr. Stella has worked with Denver Health leadership to improve care for the homeless. “Right now, I’m working with a community team on developing an idea to provide peer support from people with a shared lived experience for people who are experiencing homelessness when they’re hospitalized. That’s really where my passion has been in working on the partnership,” she said.

Her advocacy role has been beneficial in her work as a hospitalist, particularly when COVID began. Dr. Stella again partnered with the Colorado Coalition for the Homeless to start a joint task force. “Everyone on our task force is motivated by this powerful desire to improve the health and lives of this community and that’s one of the silver linings in this pandemic for me,” said Dr. Stella.

Advocacy work has also increased Dr. Stella’s knowledge of what community support options are available for the unhoused. This allows her to educate her patients about their options and how to access them.

While she has colleagues who are able to compartmentalize their work, “I absolutely could not be a hospitalist without being an advocate,” Dr. Stella said. “For me, it has been a protective strategy in terms of burnout because I have to feel like I’m working to advocate for better policies and more appropriate resources to address the gaps that I’m seeing.”

Dr. Stella believes that physicians have a special credibility to advocate, tell stories, and use data to back their stories up. “We have to realize that we have this power, and we have it so we can empower others,” she said. “The people I’ve seen in my community who are working so hard to help people who are experiencing homelessness are the heroes. Understanding that and giving power to those people through our voice and our well-respected place in society drives me.”
 

Strengthening diversity, equity, and inclusion

In September 2020, Michael Bryant, MD, became the inaugural vice chair of Diversity, Equity, and Inclusion for the department of pediatrics at Children’s Hospital Los Angeles, where he is also the division head of pediatric hospital medicine. “I was motivated to apply for this position because I wanted to be an agent for change to eliminate the institutional racism, social injustice, and marginalization that continues to threaten the lives and well-beings of so many Americans,” Dr. Bryant said.

Between the pandemic, the economic decline it has created, and the divisive political landscape, people of color have been especially affected. “These are poignant examples of the ever-widening divide and disenfranchisement many Americans feel,” said Dr. Bryant. “Gandhi said, ‘Be the change that you want to see,’ and that is what I want to model.”

At work, advocacy for diversity, equality, and inclusion is an innate part of everything he does. From the new physicians he recruits to the candidates he considers for leadership positions, Dr. Bryant strives “to have a workforce that mirrors the diversity of the patients we humbly care for and serve.”

Advocacy is intrinsic to Dr. Bryant’s worldview, in his quest to understand and accept each individual’s uniqueness, his desire “to embrace cultural humility,” his recognition that “our differences enhance us instead of diminishing us,” and his willingness to engage in difficult conversations.

“Advocacy means that I acknowledge that intent does not equal impact and that I must accept that what I do and what I say may have unintended consequences,” he said. “When that happens, I must resist becoming defensive and instead be willing to listen and learn.”

Dr. Bryant is proud of his accomplishments and enjoys his advocacy work. In his workplace, there are few African Americans in leadership roles. This means that he is in high demand when it comes to making sure there’s representation during various processes such as hiring and vetting, a disparity known as the “minority tax.”

“I am thankful for the opportunities, but it does take a toll at times,” Dr. Bryant said, which is yet another reason why he is a proponent of increasing diversity and inclusion. “This allows us to build the resource pool as these needs arise and minimizes the toll of the ‘minority tax’ on any single person or small group of individuals.”

This summer, physicians from Dr. Bryant’s hospital participated in the national “White Coats for Black Lives” effort. He found it to be “an incredibly moving event” that hundreds of his colleagues participated in.

Dr. Bryant’s advice for hospitalists who want to get involved in advocacy efforts is to check out the movie “John Lewis: Good Trouble.” “He was a champion of human rights and fought for these rights until his death,” Dr. Bryant said. “He is a true American hero and a wonderful example.”
 

Bolstering health care change

Since his residency, Joshua Lenchus, DO, FACP, SFHM, has developed an ever-increasing interest in legislative advocacy, particularly health policy. Getting involved in this arena requires an understanding of civics and government that goes beyond just the basics. “My desire to affect change in my own profession really served as the catalyst to get involved,” said Dr. Lenchus, the regional chief medical officer at Broward Health Medical Center in Fort Lauderdale, Fla. “What better way to do that than by combining what we do on a daily basis in the practice of medicine with this new understanding of how laws are passed and promulgated?”

Dr. Lenchus has been involved with both state and national medical organizations and has served on public policy committees as a member and as a chair. “The charge of these committees is to monitor and navigate position statements and policies that will drive the entire organization,” he said. This means becoming knowledgeable enough about a topic to be able to talk about it eloquently and adding supporting personal or professional illustrations that reinforce the position to lawmakers.

He finds his advocacy efforts “incredibly rewarding” because they contribute to his endeavors “to help my colleagues practice medicine in a safe, efficient, and productive manner.” For instance, some of the organizations Dr. Lenchus was involved with helped make changes to the Affordable Care Act that ended up in its final version, as well as changes after it passed. “There are tangible things that advocacy enables us to do in our daily practice,” he said.

When something his organizations have advocated for does not pass, they know they need to try a different outlet. “You can’t win every fight,” he said. “Every time you go and comment on an issue, you have to understand that you’re there to do your best, and to the extent that the people you’re talking to are willing to listen to what you have to say, that’s where I think you can make the most impact.” When changes he has helped fight for do pass, “it really is amazing that you can tell your colleagues about your role in achieving meaningful change in the profession.”

Dr. Lenchus acknowledges that advocacy “can be all-consuming at times. We have to understand our limits.” That said, he thinks not engaging in advocacy could increase stress and potential burnout. “I think being involved in advocacy efforts really helps people conduct meaningful work and educates them about what it means not just to them, but to the rest of the medical profession and the patients that we serve,” he said.

For hospitalists who are interested in health policy advocacy, there are many ways to get involved, Dr. Lenchus said. You could join an organization (many organized medical societies have public policy committees), participate in advocacy activities, work on a political campaign, or even run for office yourself. “Ultimately, education and some level of involvement really will make the difference in who navigates our future as hospitalists,” he said.
 

Questioning co-management practices

Though he says he’s in the minority, Hardik Vora, MD, SFHM, medical director for hospital medicine at Riverside Regional Medical Center in Newport News, Va., believes that co-management is going to “make or break hospital medicine. It’s going to have a huge impact on our specialty.”

In the roughly 25-year history of hospital medicine, it has evolved from admitting and caring for patients of primary care physicians to patients of specialists and, more recently, surgical patients. “Now there are (hospital medicine) programs across the country that are pretty much admitting everything,” said Dr. Vora.

As a recruiter for the Riverside Health System for the past eight years, “I have not met a single resident who is trained to do what we’re doing in hospital medicine, because you’re admitting surgical patients all the time and you have primary attending responsibility,” Dr. Vora said. “I see that as a cause of a significant amount of stress because now you’re responsible for something that you don’t have adequate training for.”

In the co-management discussion, Dr. Vora notes that people often bring up the research that shows that the practice has improved surgeon satisfaction. “What bothers me is that…you need to add one more question – how does it affect your hospitalists? And I bet the answer to that question is ‘it has a terrible effect.’”

The expectations surrounding hospitalists these days is a big concern in terms of burnout, Dr. Vora said. “We talk a lot about the drivers of burnout, whether it’s schedule or COVID,” he said. The biggest issue when it comes to burnout, as he sees it, is not COVID; it’s when hospitalists are performing tasks that make them feel they aren’t adding value. “I think that’s a huge topic in hospital medicine right now.”

Dr. Vora believes there should be more discussion and awareness of the potential pitfalls. “Hospitalists should get involved in co-management where they are adding value and certainly not take up the attending responsibility where they’re not adding value and it’s out of the scope of their training and expertise,” he said. “Preventing scope creep and burnout from co-management are some of the key issues I’m really passionate about.”

Dr. Vora said it is important to set realistic goals and remember that it takes time to make change when it comes to advocacy. “You still have to operate within whatever environment is given to you and then you can make change from within,” he said.

His enthusiasm for co-management awareness has led to creating a co-management forum through SHM in his local Hampton Roads chapter. He was also a panelist for an SHM webinar in February 2021 in which the panelists debated co-management.

“I think we really need to look at this as a specialty. Are we going in the right direction?” Dr. Vora asked. “We need to come together as a specialty and make a decision, which is going to be hard because there are competing financial interests and various practice models.”
 

Improving patient care

Working as a hospitalist at University Medical Center, a safety net hospital in New Orleans, Celeste Newby, MD, PhD, sees plenty of patients who are underinsured or not insured at all. “A lot of my interest in health policy stems from that,” she said.

During her residency, which she finished in 2015, Louisiana became a Medicaid expansion state. This impressed upon Dr. Newby how much Medicaid improved the lives of patients who had previously been uninsured. “We saw procedures getting done that had been put on hold because of financial concerns or medicines that were now affordable that weren’t before,” she said. “It really did make a difference.”

When repeated attempts to repeal the Affordable Care Act began, “it was a call to do health policy work for me personally that just hadn’t come up in the past,” said Dr. Newby, who is also assistant professor of medicine at Tulane University in New Orleans. “I personally found that the best way to do (advocacy work) was to go through medical societies because there is a much stronger voice when you have more people saying the same thing,” she said.

Dr. Newby sits on the Council of Legislation for the Louisiana State Medical Society and participates in the Leadership and Health Policy (LEAHP) Program through the Society of General Internal Medicine.

The LEAHP Program has been instrumental in expanding Dr. Newby’s knowledge of how health policy is made and the mechanisms behind it. It has also taught her “how we can either advise, guide, leverage, or advocate for things that we think would be important for change and moving the country in the right direction in terms of health care.”

Another reason involvement in medical societies is helpful is because, as a busy clinician, it is impossible to keep up with everything. “Working with medical societies, you have people who are more directly involved in the legislature and can give you quicker notice about things that are coming up that are going to be important to you or your co-workers or your patients,” Dr. Newby said.

Dr. Newby feels her advocacy work is an outlet for stress and “a way to work at more of a macro level on problems that I see with my individual patients. It’s a nice compliment.” At the hospital, she can only help one person at a time, but with her advocacy efforts, there’s potential to make changes for many.

“Advocacy now is such a large umbrella that encompasses so many different projects at all kinds of levels,” Dr. Newby said. She suggests looking around your community to see where the needs lie. If you’re passionate about a certain topic or population, see what you can do to help advocate for change there.




 

Hospitalists around the country are devoting large portions of their spare time to a wide range of advocacy efforts. From health policy to caring for the unhoused population to diversity and equity to advocating for fellow hospitalists, these physicians are passionate about their causes and determined to make a difference.

Championing the unhoused

Sarah Stella, MD, FHM, a hospitalist at Denver Health, was initially drawn there because of the population the hospital serves, which includes a high concentration of people experiencing homelessness. As she cared for her patients, Dr. Stella, who is also associate professor of hospital medicine at the University of Colorado, increasingly felt the desire to help prevent the negative downstream outcomes the hospital sees.

To understand the experiences of the unhoused outside the hospital, Dr. Stella started talking to her patients and people in community-based organizations that serve this population. “I learned a ton,” she said. “Homelessness feels like such an intractable, hopeless thing, but the more I talked to people, the more opportunities I saw to work toward something better.”

This led to a pilot grant to work with the Colorado Coalition for the Homeless to set up a community advisory panel. “My goal was to better understand their experiences and to develop a shared vision for how we collectively can do better,” said Dr. Stella. Eventually, she also received a grant from the University of Colorado, and multiple opportunities have sprung up ever since.

For the past several years, Dr. Stella has worked with Denver Health leadership to improve care for the homeless. “Right now, I’m working with a community team on developing an idea to provide peer support from people with a shared lived experience for people who are experiencing homelessness when they’re hospitalized. That’s really where my passion has been in working on the partnership,” she said.

Her advocacy role has been beneficial in her work as a hospitalist, particularly when COVID began. Dr. Stella again partnered with the Colorado Coalition for the Homeless to start a joint task force. “Everyone on our task force is motivated by this powerful desire to improve the health and lives of this community and that’s one of the silver linings in this pandemic for me,” said Dr. Stella.

Advocacy work has also increased Dr. Stella’s knowledge of what community support options are available for the unhoused. This allows her to educate her patients about their options and how to access them.

While she has colleagues who are able to compartmentalize their work, “I absolutely could not be a hospitalist without being an advocate,” Dr. Stella said. “For me, it has been a protective strategy in terms of burnout because I have to feel like I’m working to advocate for better policies and more appropriate resources to address the gaps that I’m seeing.”

Dr. Stella believes that physicians have a special credibility to advocate, tell stories, and use data to back their stories up. “We have to realize that we have this power, and we have it so we can empower others,” she said. “The people I’ve seen in my community who are working so hard to help people who are experiencing homelessness are the heroes. Understanding that and giving power to those people through our voice and our well-respected place in society drives me.”
 

Strengthening diversity, equity, and inclusion

In September 2020, Michael Bryant, MD, became the inaugural vice chair of Diversity, Equity, and Inclusion for the department of pediatrics at Children’s Hospital Los Angeles, where he is also the division head of pediatric hospital medicine. “I was motivated to apply for this position because I wanted to be an agent for change to eliminate the institutional racism, social injustice, and marginalization that continues to threaten the lives and well-beings of so many Americans,” Dr. Bryant said.

Between the pandemic, the economic decline it has created, and the divisive political landscape, people of color have been especially affected. “These are poignant examples of the ever-widening divide and disenfranchisement many Americans feel,” said Dr. Bryant. “Gandhi said, ‘Be the change that you want to see,’ and that is what I want to model.”

At work, advocacy for diversity, equality, and inclusion is an innate part of everything he does. From the new physicians he recruits to the candidates he considers for leadership positions, Dr. Bryant strives “to have a workforce that mirrors the diversity of the patients we humbly care for and serve.”

Advocacy is intrinsic to Dr. Bryant’s worldview, in his quest to understand and accept each individual’s uniqueness, his desire “to embrace cultural humility,” his recognition that “our differences enhance us instead of diminishing us,” and his willingness to engage in difficult conversations.

“Advocacy means that I acknowledge that intent does not equal impact and that I must accept that what I do and what I say may have unintended consequences,” he said. “When that happens, I must resist becoming defensive and instead be willing to listen and learn.”

Dr. Bryant is proud of his accomplishments and enjoys his advocacy work. In his workplace, there are few African Americans in leadership roles. This means that he is in high demand when it comes to making sure there’s representation during various processes such as hiring and vetting, a disparity known as the “minority tax.”

“I am thankful for the opportunities, but it does take a toll at times,” Dr. Bryant said, which is yet another reason why he is a proponent of increasing diversity and inclusion. “This allows us to build the resource pool as these needs arise and minimizes the toll of the ‘minority tax’ on any single person or small group of individuals.”

This summer, physicians from Dr. Bryant’s hospital participated in the national “White Coats for Black Lives” effort. He found it to be “an incredibly moving event” that hundreds of his colleagues participated in.

Dr. Bryant’s advice for hospitalists who want to get involved in advocacy efforts is to check out the movie “John Lewis: Good Trouble.” “He was a champion of human rights and fought for these rights until his death,” Dr. Bryant said. “He is a true American hero and a wonderful example.”
 

Bolstering health care change

Since his residency, Joshua Lenchus, DO, FACP, SFHM, has developed an ever-increasing interest in legislative advocacy, particularly health policy. Getting involved in this arena requires an understanding of civics and government that goes beyond just the basics. “My desire to affect change in my own profession really served as the catalyst to get involved,” said Dr. Lenchus, the regional chief medical officer at Broward Health Medical Center in Fort Lauderdale, Fla. “What better way to do that than by combining what we do on a daily basis in the practice of medicine with this new understanding of how laws are passed and promulgated?”

Dr. Lenchus has been involved with both state and national medical organizations and has served on public policy committees as a member and as a chair. “The charge of these committees is to monitor and navigate position statements and policies that will drive the entire organization,” he said. This means becoming knowledgeable enough about a topic to be able to talk about it eloquently and adding supporting personal or professional illustrations that reinforce the position to lawmakers.

He finds his advocacy efforts “incredibly rewarding” because they contribute to his endeavors “to help my colleagues practice medicine in a safe, efficient, and productive manner.” For instance, some of the organizations Dr. Lenchus was involved with helped make changes to the Affordable Care Act that ended up in its final version, as well as changes after it passed. “There are tangible things that advocacy enables us to do in our daily practice,” he said.

When something his organizations have advocated for does not pass, they know they need to try a different outlet. “You can’t win every fight,” he said. “Every time you go and comment on an issue, you have to understand that you’re there to do your best, and to the extent that the people you’re talking to are willing to listen to what you have to say, that’s where I think you can make the most impact.” When changes he has helped fight for do pass, “it really is amazing that you can tell your colleagues about your role in achieving meaningful change in the profession.”

Dr. Lenchus acknowledges that advocacy “can be all-consuming at times. We have to understand our limits.” That said, he thinks not engaging in advocacy could increase stress and potential burnout. “I think being involved in advocacy efforts really helps people conduct meaningful work and educates them about what it means not just to them, but to the rest of the medical profession and the patients that we serve,” he said.

For hospitalists who are interested in health policy advocacy, there are many ways to get involved, Dr. Lenchus said. You could join an organization (many organized medical societies have public policy committees), participate in advocacy activities, work on a political campaign, or even run for office yourself. “Ultimately, education and some level of involvement really will make the difference in who navigates our future as hospitalists,” he said.
 

Questioning co-management practices

Though he says he’s in the minority, Hardik Vora, MD, SFHM, medical director for hospital medicine at Riverside Regional Medical Center in Newport News, Va., believes that co-management is going to “make or break hospital medicine. It’s going to have a huge impact on our specialty.”

In the roughly 25-year history of hospital medicine, it has evolved from admitting and caring for patients of primary care physicians to patients of specialists and, more recently, surgical patients. “Now there are (hospital medicine) programs across the country that are pretty much admitting everything,” said Dr. Vora.

As a recruiter for the Riverside Health System for the past eight years, “I have not met a single resident who is trained to do what we’re doing in hospital medicine, because you’re admitting surgical patients all the time and you have primary attending responsibility,” Dr. Vora said. “I see that as a cause of a significant amount of stress because now you’re responsible for something that you don’t have adequate training for.”

In the co-management discussion, Dr. Vora notes that people often bring up the research that shows that the practice has improved surgeon satisfaction. “What bothers me is that…you need to add one more question – how does it affect your hospitalists? And I bet the answer to that question is ‘it has a terrible effect.’”

The expectations surrounding hospitalists these days is a big concern in terms of burnout, Dr. Vora said. “We talk a lot about the drivers of burnout, whether it’s schedule or COVID,” he said. The biggest issue when it comes to burnout, as he sees it, is not COVID; it’s when hospitalists are performing tasks that make them feel they aren’t adding value. “I think that’s a huge topic in hospital medicine right now.”

Dr. Vora believes there should be more discussion and awareness of the potential pitfalls. “Hospitalists should get involved in co-management where they are adding value and certainly not take up the attending responsibility where they’re not adding value and it’s out of the scope of their training and expertise,” he said. “Preventing scope creep and burnout from co-management are some of the key issues I’m really passionate about.”

Dr. Vora said it is important to set realistic goals and remember that it takes time to make change when it comes to advocacy. “You still have to operate within whatever environment is given to you and then you can make change from within,” he said.

His enthusiasm for co-management awareness has led to creating a co-management forum through SHM in his local Hampton Roads chapter. He was also a panelist for an SHM webinar in February 2021 in which the panelists debated co-management.

“I think we really need to look at this as a specialty. Are we going in the right direction?” Dr. Vora asked. “We need to come together as a specialty and make a decision, which is going to be hard because there are competing financial interests and various practice models.”
 

Improving patient care

Working as a hospitalist at University Medical Center, a safety net hospital in New Orleans, Celeste Newby, MD, PhD, sees plenty of patients who are underinsured or not insured at all. “A lot of my interest in health policy stems from that,” she said.

During her residency, which she finished in 2015, Louisiana became a Medicaid expansion state. This impressed upon Dr. Newby how much Medicaid improved the lives of patients who had previously been uninsured. “We saw procedures getting done that had been put on hold because of financial concerns or medicines that were now affordable that weren’t before,” she said. “It really did make a difference.”

When repeated attempts to repeal the Affordable Care Act began, “it was a call to do health policy work for me personally that just hadn’t come up in the past,” said Dr. Newby, who is also assistant professor of medicine at Tulane University in New Orleans. “I personally found that the best way to do (advocacy work) was to go through medical societies because there is a much stronger voice when you have more people saying the same thing,” she said.

Dr. Newby sits on the Council of Legislation for the Louisiana State Medical Society and participates in the Leadership and Health Policy (LEAHP) Program through the Society of General Internal Medicine.

The LEAHP Program has been instrumental in expanding Dr. Newby’s knowledge of how health policy is made and the mechanisms behind it. It has also taught her “how we can either advise, guide, leverage, or advocate for things that we think would be important for change and moving the country in the right direction in terms of health care.”

Another reason involvement in medical societies is helpful is because, as a busy clinician, it is impossible to keep up with everything. “Working with medical societies, you have people who are more directly involved in the legislature and can give you quicker notice about things that are coming up that are going to be important to you or your co-workers or your patients,” Dr. Newby said.

Dr. Newby feels her advocacy work is an outlet for stress and “a way to work at more of a macro level on problems that I see with my individual patients. It’s a nice compliment.” At the hospital, she can only help one person at a time, but with her advocacy efforts, there’s potential to make changes for many.

“Advocacy now is such a large umbrella that encompasses so many different projects at all kinds of levels,” Dr. Newby said. She suggests looking around your community to see where the needs lie. If you’re passionate about a certain topic or population, see what you can do to help advocate for change there.




 

Hospitalists around the country are devoting large portions of their spare time to a wide range of advocacy efforts. From health policy to caring for the unhoused population to diversity and equity to advocating for fellow hospitalists, these physicians are passionate about their causes and determined to make a difference.

Championing the unhoused

Sarah Stella, MD, FHM, a hospitalist at Denver Health, was initially drawn there because of the population the hospital serves, which includes a high concentration of people experiencing homelessness. As she cared for her patients, Dr. Stella, who is also associate professor of hospital medicine at the University of Colorado, increasingly felt the desire to help prevent the negative downstream outcomes the hospital sees.

To understand the experiences of the unhoused outside the hospital, Dr. Stella started talking to her patients and people in community-based organizations that serve this population. “I learned a ton,” she said. “Homelessness feels like such an intractable, hopeless thing, but the more I talked to people, the more opportunities I saw to work toward something better.”

This led to a pilot grant to work with the Colorado Coalition for the Homeless to set up a community advisory panel. “My goal was to better understand their experiences and to develop a shared vision for how we collectively can do better,” said Dr. Stella. Eventually, she also received a grant from the University of Colorado, and multiple opportunities have sprung up ever since.

For the past several years, Dr. Stella has worked with Denver Health leadership to improve care for the homeless. “Right now, I’m working with a community team on developing an idea to provide peer support from people with a shared lived experience for people who are experiencing homelessness when they’re hospitalized. That’s really where my passion has been in working on the partnership,” she said.

Her advocacy role has been beneficial in her work as a hospitalist, particularly when COVID began. Dr. Stella again partnered with the Colorado Coalition for the Homeless to start a joint task force. “Everyone on our task force is motivated by this powerful desire to improve the health and lives of this community and that’s one of the silver linings in this pandemic for me,” said Dr. Stella.

Advocacy work has also increased Dr. Stella’s knowledge of what community support options are available for the unhoused. This allows her to educate her patients about their options and how to access them.

While she has colleagues who are able to compartmentalize their work, “I absolutely could not be a hospitalist without being an advocate,” Dr. Stella said. “For me, it has been a protective strategy in terms of burnout because I have to feel like I’m working to advocate for better policies and more appropriate resources to address the gaps that I’m seeing.”

Dr. Stella believes that physicians have a special credibility to advocate, tell stories, and use data to back their stories up. “We have to realize that we have this power, and we have it so we can empower others,” she said. “The people I’ve seen in my community who are working so hard to help people who are experiencing homelessness are the heroes. Understanding that and giving power to those people through our voice and our well-respected place in society drives me.”
 

Strengthening diversity, equity, and inclusion

In September 2020, Michael Bryant, MD, became the inaugural vice chair of Diversity, Equity, and Inclusion for the department of pediatrics at Children’s Hospital Los Angeles, where he is also the division head of pediatric hospital medicine. “I was motivated to apply for this position because I wanted to be an agent for change to eliminate the institutional racism, social injustice, and marginalization that continues to threaten the lives and well-beings of so many Americans,” Dr. Bryant said.

Between the pandemic, the economic decline it has created, and the divisive political landscape, people of color have been especially affected. “These are poignant examples of the ever-widening divide and disenfranchisement many Americans feel,” said Dr. Bryant. “Gandhi said, ‘Be the change that you want to see,’ and that is what I want to model.”

At work, advocacy for diversity, equality, and inclusion is an innate part of everything he does. From the new physicians he recruits to the candidates he considers for leadership positions, Dr. Bryant strives “to have a workforce that mirrors the diversity of the patients we humbly care for and serve.”

Advocacy is intrinsic to Dr. Bryant’s worldview, in his quest to understand and accept each individual’s uniqueness, his desire “to embrace cultural humility,” his recognition that “our differences enhance us instead of diminishing us,” and his willingness to engage in difficult conversations.

“Advocacy means that I acknowledge that intent does not equal impact and that I must accept that what I do and what I say may have unintended consequences,” he said. “When that happens, I must resist becoming defensive and instead be willing to listen and learn.”

Dr. Bryant is proud of his accomplishments and enjoys his advocacy work. In his workplace, there are few African Americans in leadership roles. This means that he is in high demand when it comes to making sure there’s representation during various processes such as hiring and vetting, a disparity known as the “minority tax.”

“I am thankful for the opportunities, but it does take a toll at times,” Dr. Bryant said, which is yet another reason why he is a proponent of increasing diversity and inclusion. “This allows us to build the resource pool as these needs arise and minimizes the toll of the ‘minority tax’ on any single person or small group of individuals.”

This summer, physicians from Dr. Bryant’s hospital participated in the national “White Coats for Black Lives” effort. He found it to be “an incredibly moving event” that hundreds of his colleagues participated in.

Dr. Bryant’s advice for hospitalists who want to get involved in advocacy efforts is to check out the movie “John Lewis: Good Trouble.” “He was a champion of human rights and fought for these rights until his death,” Dr. Bryant said. “He is a true American hero and a wonderful example.”
 

Bolstering health care change

Since his residency, Joshua Lenchus, DO, FACP, SFHM, has developed an ever-increasing interest in legislative advocacy, particularly health policy. Getting involved in this arena requires an understanding of civics and government that goes beyond just the basics. “My desire to affect change in my own profession really served as the catalyst to get involved,” said Dr. Lenchus, the regional chief medical officer at Broward Health Medical Center in Fort Lauderdale, Fla. “What better way to do that than by combining what we do on a daily basis in the practice of medicine with this new understanding of how laws are passed and promulgated?”

Dr. Lenchus has been involved with both state and national medical organizations and has served on public policy committees as a member and as a chair. “The charge of these committees is to monitor and navigate position statements and policies that will drive the entire organization,” he said. This means becoming knowledgeable enough about a topic to be able to talk about it eloquently and adding supporting personal or professional illustrations that reinforce the position to lawmakers.

He finds his advocacy efforts “incredibly rewarding” because they contribute to his endeavors “to help my colleagues practice medicine in a safe, efficient, and productive manner.” For instance, some of the organizations Dr. Lenchus was involved with helped make changes to the Affordable Care Act that ended up in its final version, as well as changes after it passed. “There are tangible things that advocacy enables us to do in our daily practice,” he said.

When something his organizations have advocated for does not pass, they know they need to try a different outlet. “You can’t win every fight,” he said. “Every time you go and comment on an issue, you have to understand that you’re there to do your best, and to the extent that the people you’re talking to are willing to listen to what you have to say, that’s where I think you can make the most impact.” When changes he has helped fight for do pass, “it really is amazing that you can tell your colleagues about your role in achieving meaningful change in the profession.”

Dr. Lenchus acknowledges that advocacy “can be all-consuming at times. We have to understand our limits.” That said, he thinks not engaging in advocacy could increase stress and potential burnout. “I think being involved in advocacy efforts really helps people conduct meaningful work and educates them about what it means not just to them, but to the rest of the medical profession and the patients that we serve,” he said.

For hospitalists who are interested in health policy advocacy, there are many ways to get involved, Dr. Lenchus said. You could join an organization (many organized medical societies have public policy committees), participate in advocacy activities, work on a political campaign, or even run for office yourself. “Ultimately, education and some level of involvement really will make the difference in who navigates our future as hospitalists,” he said.
 

Questioning co-management practices

Though he says he’s in the minority, Hardik Vora, MD, SFHM, medical director for hospital medicine at Riverside Regional Medical Center in Newport News, Va., believes that co-management is going to “make or break hospital medicine. It’s going to have a huge impact on our specialty.”

In the roughly 25-year history of hospital medicine, it has evolved from admitting and caring for patients of primary care physicians to patients of specialists and, more recently, surgical patients. “Now there are (hospital medicine) programs across the country that are pretty much admitting everything,” said Dr. Vora.

As a recruiter for the Riverside Health System for the past eight years, “I have not met a single resident who is trained to do what we’re doing in hospital medicine, because you’re admitting surgical patients all the time and you have primary attending responsibility,” Dr. Vora said. “I see that as a cause of a significant amount of stress because now you’re responsible for something that you don’t have adequate training for.”

In the co-management discussion, Dr. Vora notes that people often bring up the research that shows that the practice has improved surgeon satisfaction. “What bothers me is that…you need to add one more question – how does it affect your hospitalists? And I bet the answer to that question is ‘it has a terrible effect.’”

The expectations surrounding hospitalists these days is a big concern in terms of burnout, Dr. Vora said. “We talk a lot about the drivers of burnout, whether it’s schedule or COVID,” he said. The biggest issue when it comes to burnout, as he sees it, is not COVID; it’s when hospitalists are performing tasks that make them feel they aren’t adding value. “I think that’s a huge topic in hospital medicine right now.”

Dr. Vora believes there should be more discussion and awareness of the potential pitfalls. “Hospitalists should get involved in co-management where they are adding value and certainly not take up the attending responsibility where they’re not adding value and it’s out of the scope of their training and expertise,” he said. “Preventing scope creep and burnout from co-management are some of the key issues I’m really passionate about.”

Dr. Vora said it is important to set realistic goals and remember that it takes time to make change when it comes to advocacy. “You still have to operate within whatever environment is given to you and then you can make change from within,” he said.

His enthusiasm for co-management awareness has led to creating a co-management forum through SHM in his local Hampton Roads chapter. He was also a panelist for an SHM webinar in February 2021 in which the panelists debated co-management.

“I think we really need to look at this as a specialty. Are we going in the right direction?” Dr. Vora asked. “We need to come together as a specialty and make a decision, which is going to be hard because there are competing financial interests and various practice models.”
 

Improving patient care

Working as a hospitalist at University Medical Center, a safety net hospital in New Orleans, Celeste Newby, MD, PhD, sees plenty of patients who are underinsured or not insured at all. “A lot of my interest in health policy stems from that,” she said.

During her residency, which she finished in 2015, Louisiana became a Medicaid expansion state. This impressed upon Dr. Newby how much Medicaid improved the lives of patients who had previously been uninsured. “We saw procedures getting done that had been put on hold because of financial concerns or medicines that were now affordable that weren’t before,” she said. “It really did make a difference.”

When repeated attempts to repeal the Affordable Care Act began, “it was a call to do health policy work for me personally that just hadn’t come up in the past,” said Dr. Newby, who is also assistant professor of medicine at Tulane University in New Orleans. “I personally found that the best way to do (advocacy work) was to go through medical societies because there is a much stronger voice when you have more people saying the same thing,” she said.

Dr. Newby sits on the Council of Legislation for the Louisiana State Medical Society and participates in the Leadership and Health Policy (LEAHP) Program through the Society of General Internal Medicine.

The LEAHP Program has been instrumental in expanding Dr. Newby’s knowledge of how health policy is made and the mechanisms behind it. It has also taught her “how we can either advise, guide, leverage, or advocate for things that we think would be important for change and moving the country in the right direction in terms of health care.”

Another reason involvement in medical societies is helpful is because, as a busy clinician, it is impossible to keep up with everything. “Working with medical societies, you have people who are more directly involved in the legislature and can give you quicker notice about things that are coming up that are going to be important to you or your co-workers or your patients,” Dr. Newby said.

Dr. Newby feels her advocacy work is an outlet for stress and “a way to work at more of a macro level on problems that I see with my individual patients. It’s a nice compliment.” At the hospital, she can only help one person at a time, but with her advocacy efforts, there’s potential to make changes for many.

“Advocacy now is such a large umbrella that encompasses so many different projects at all kinds of levels,” Dr. Newby said. She suggests looking around your community to see where the needs lie. If you’re passionate about a certain topic or population, see what you can do to help advocate for change there.




 

Dietary intervention that involves the target manipulation of microbiota components may improve the growth rate in children with moderate acute malnutrition, according to new research.

Moderate acute malnutrition affects more than 30 million children worldwide, according to the Food and Nutrition Bulletin. The World Health Organization defines the condition by a weight-for-height measurement that is 2 or 3 standard deviations below the international standard.

A 2014 study published in Nature has shown that malnourishment is associated with defects in children’s gut microbiota, including having microbial communities that are immature and younger than those of their healthy counterparts. Microbiota immaturity also correlates with stunted growth.

The authors of new study, which was published in the New England Journal of Medicine on April 7, 2021, wrote that nutritional interventions and treatments, such as therapeutic calorie-dense foods, have limited effectiveness because they don’t restore growth or fully address repairing the gut microbiome.

“This work supports the notion that healthy growth of children is linked to healthy development of their gut microbiota,” study author Jeffrey Gordon, MD, director of the Edison Family Center for Genome Sciences & Systems Biology at Washington University, St. Louis, said in an interview. “This, in turn, indicates that we need to have a more encompassing view of human developmental biology – one that considers both our ‘human’ and ‘microbial’ parts.”

The study establishes the impact of microbiota repair on a child’s growth rate, which may have implications on policies related to complementary feeding practices, Dr. Gorden noted.
 

Better outcomes seen with microbiota-directed complementary food prototype

For the research, 123 children with moderate acute malnutrition aged between 12 and 18 months were randomly assigned to receive a microbiota-directed complementary food prototype (MDCF-2) or ready-to-use supplementary food (RUSF). The supplementation was given to the kids twice daily for 3 months, followed by 1 month of monitoring. They looked at the weekly rate of change in the weight-for-length z score, weight-for-age z score, mid-upper-arm circumference, length-for-age z score, medical complication, gut microbiota, and blood samples in the group to determine the effectiveness of each food intervention therapy.

They found that, of the 118 children who completed the study, those in the MDCF-2 group had better outcomes than those in the RUSF group based on greater weekly growth in z scores, indicating faster growth rates. For those in the MDCF-2 group, the mean weekly change in weight-for-length z score was 0.021, compared to the RUSF group’s 0.010. When it came to weight-for-age z score, the mean weekly change was 0.017 in the MDCF-2 group and 0.010 in the RUSF group. The mean weekly changes in the mid-upper-arm circumference and length-for-age z scores were similar in both groups.

When examining blood samples of the cohort, researchers noted that 714 proteins were significantly altered after 3-month MDCF-2 supplementation, compared with 82 proteins having shown significant alterations in the RUSF group.

Overall, the findings show that repairing gut microbiota was accompanied by improved weight gain and marked changes in circulating levels of protein biomarkers and mediators of numerous aspects of healthy growth.
 

Results need to be verified on a larger scale

Tim Joos, MD, who was not part of the study, said it is surprising that MDCF-2 was better at promoting growth than existing nutritional supplements.

“The study suggests that remedying malnutrition requires more than just ensuring adequate calorie and nutrient intake,” Dr. Joos, a pediatrician at NeighborCare Health in Seattle, noted in an interview. “It is a small study and needs to be verified on a larger scale and in more diverse locations and pediatric ages (outside of the 12- to 18-month-old cohort studied).”

Wendy S. Garrett, MD, PhD, who also didn’t participate in the study, wrote in an accompanying editorial that overarching questions remain concerning the long-lasting effects of the intervention on children’s growth trajectory and cognitive development. She also said that the study “provides an abundance of fascinating microbiome profile data, plasma protein correlates, and metadata to sift through.”

Dr. Gordon and colleagues said the findings underscore the broad effects gut microbiota has on human biology and they hope this will open the door to better definitions of wellness for infants/children.

Dr. Garrett is the Irene Heinz Given Professor of Immunology and Infectious Diseases in the departments of immunology and infectious diseases and of molecular metabolism at the Harvard School of Public Health, Boston, and she has no disclosures. Dr. Gordon is the recipient of a Thought Leader award from Agilent Technologies. Dr. Joos disclosed no relevant financial relationships.

Dietary intervention that involves the target manipulation of microbiota components may improve the growth rate in children with moderate acute malnutrition, according to new research.

Moderate acute malnutrition affects more than 30 million children worldwide, according to the Food and Nutrition Bulletin. The World Health Organization defines the condition by a weight-for-height measurement that is 2 or 3 standard deviations below the international standard.

A 2014 study published in Nature has shown that malnourishment is associated with defects in children’s gut microbiota, including having microbial communities that are immature and younger than those of their healthy counterparts. Microbiota immaturity also correlates with stunted growth.

The authors of new study, which was published in the New England Journal of Medicine on April 7, 2021, wrote that nutritional interventions and treatments, such as therapeutic calorie-dense foods, have limited effectiveness because they don’t restore growth or fully address repairing the gut microbiome.

“This work supports the notion that healthy growth of children is linked to healthy development of their gut microbiota,” study author Jeffrey Gordon, MD, director of the Edison Family Center for Genome Sciences & Systems Biology at Washington University, St. Louis, said in an interview. “This, in turn, indicates that we need to have a more encompassing view of human developmental biology – one that considers both our ‘human’ and ‘microbial’ parts.”

The study establishes the impact of microbiota repair on a child’s growth rate, which may have implications on policies related to complementary feeding practices, Dr. Gorden noted.
 

Better outcomes seen with microbiota-directed complementary food prototype

For the research, 123 children with moderate acute malnutrition aged between 12 and 18 months were randomly assigned to receive a microbiota-directed complementary food prototype (MDCF-2) or ready-to-use supplementary food (RUSF). The supplementation was given to the kids twice daily for 3 months, followed by 1 month of monitoring. They looked at the weekly rate of change in the weight-for-length z score, weight-for-age z score, mid-upper-arm circumference, length-for-age z score, medical complication, gut microbiota, and blood samples in the group to determine the effectiveness of each food intervention therapy.

They found that, of the 118 children who completed the study, those in the MDCF-2 group had better outcomes than those in the RUSF group based on greater weekly growth in z scores, indicating faster growth rates. For those in the MDCF-2 group, the mean weekly change in weight-for-length z score was 0.021, compared to the RUSF group’s 0.010. When it came to weight-for-age z score, the mean weekly change was 0.017 in the MDCF-2 group and 0.010 in the RUSF group. The mean weekly changes in the mid-upper-arm circumference and length-for-age z scores were similar in both groups.

When examining blood samples of the cohort, researchers noted that 714 proteins were significantly altered after 3-month MDCF-2 supplementation, compared with 82 proteins having shown significant alterations in the RUSF group.

Overall, the findings show that repairing gut microbiota was accompanied by improved weight gain and marked changes in circulating levels of protein biomarkers and mediators of numerous aspects of healthy growth.
 

Results need to be verified on a larger scale

Tim Joos, MD, who was not part of the study, said it is surprising that MDCF-2 was better at promoting growth than existing nutritional supplements.

“The study suggests that remedying malnutrition requires more than just ensuring adequate calorie and nutrient intake,” Dr. Joos, a pediatrician at NeighborCare Health in Seattle, noted in an interview. “It is a small study and needs to be verified on a larger scale and in more diverse locations and pediatric ages (outside of the 12- to 18-month-old cohort studied).”

Wendy S. Garrett, MD, PhD, who also didn’t participate in the study, wrote in an accompanying editorial that overarching questions remain concerning the long-lasting effects of the intervention on children’s growth trajectory and cognitive development. She also said that the study “provides an abundance of fascinating microbiome profile data, plasma protein correlates, and metadata to sift through.”

Dr. Gordon and colleagues said the findings underscore the broad effects gut microbiota has on human biology and they hope this will open the door to better definitions of wellness for infants/children.

Dr. Garrett is the Irene Heinz Given Professor of Immunology and Infectious Diseases in the departments of immunology and infectious diseases and of molecular metabolism at the Harvard School of Public Health, Boston, and she has no disclosures. Dr. Gordon is the recipient of a Thought Leader award from Agilent Technologies. Dr. Joos disclosed no relevant financial relationships.

Dietary intervention that involves the target manipulation of microbiota components may improve the growth rate in children with moderate acute malnutrition, according to new research.

Moderate acute malnutrition affects more than 30 million children worldwide, according to the Food and Nutrition Bulletin. The World Health Organization defines the condition by a weight-for-height measurement that is 2 or 3 standard deviations below the international standard.

A 2014 study published in Nature has shown that malnourishment is associated with defects in children’s gut microbiota, including having microbial communities that are immature and younger than those of their healthy counterparts. Microbiota immaturity also correlates with stunted growth.

The authors of new study, which was published in the New England Journal of Medicine on April 7, 2021, wrote that nutritional interventions and treatments, such as therapeutic calorie-dense foods, have limited effectiveness because they don’t restore growth or fully address repairing the gut microbiome.

“This work supports the notion that healthy growth of children is linked to healthy development of their gut microbiota,” study author Jeffrey Gordon, MD, director of the Edison Family Center for Genome Sciences & Systems Biology at Washington University, St. Louis, said in an interview. “This, in turn, indicates that we need to have a more encompassing view of human developmental biology – one that considers both our ‘human’ and ‘microbial’ parts.”

The study establishes the impact of microbiota repair on a child’s growth rate, which may have implications on policies related to complementary feeding practices, Dr. Gorden noted.
 

Better outcomes seen with microbiota-directed complementary food prototype

For the research, 123 children with moderate acute malnutrition aged between 12 and 18 months were randomly assigned to receive a microbiota-directed complementary food prototype (MDCF-2) or ready-to-use supplementary food (RUSF). The supplementation was given to the kids twice daily for 3 months, followed by 1 month of monitoring. They looked at the weekly rate of change in the weight-for-length z score, weight-for-age z score, mid-upper-arm circumference, length-for-age z score, medical complication, gut microbiota, and blood samples in the group to determine the effectiveness of each food intervention therapy.

They found that, of the 118 children who completed the study, those in the MDCF-2 group had better outcomes than those in the RUSF group based on greater weekly growth in z scores, indicating faster growth rates. For those in the MDCF-2 group, the mean weekly change in weight-for-length z score was 0.021, compared to the RUSF group’s 0.010. When it came to weight-for-age z score, the mean weekly change was 0.017 in the MDCF-2 group and 0.010 in the RUSF group. The mean weekly changes in the mid-upper-arm circumference and length-for-age z scores were similar in both groups.

When examining blood samples of the cohort, researchers noted that 714 proteins were significantly altered after 3-month MDCF-2 supplementation, compared with 82 proteins having shown significant alterations in the RUSF group.

Overall, the findings show that repairing gut microbiota was accompanied by improved weight gain and marked changes in circulating levels of protein biomarkers and mediators of numerous aspects of healthy growth.
 

Results need to be verified on a larger scale

Tim Joos, MD, who was not part of the study, said it is surprising that MDCF-2 was better at promoting growth than existing nutritional supplements.

“The study suggests that remedying malnutrition requires more than just ensuring adequate calorie and nutrient intake,” Dr. Joos, a pediatrician at NeighborCare Health in Seattle, noted in an interview. “It is a small study and needs to be verified on a larger scale and in more diverse locations and pediatric ages (outside of the 12- to 18-month-old cohort studied).”

Wendy S. Garrett, MD, PhD, who also didn’t participate in the study, wrote in an accompanying editorial that overarching questions remain concerning the long-lasting effects of the intervention on children’s growth trajectory and cognitive development. She also said that the study “provides an abundance of fascinating microbiome profile data, plasma protein correlates, and metadata to sift through.”

Dr. Gordon and colleagues said the findings underscore the broad effects gut microbiota has on human biology and they hope this will open the door to better definitions of wellness for infants/children.

Dr. Garrett is the Irene Heinz Given Professor of Immunology and Infectious Diseases in the departments of immunology and infectious diseases and of molecular metabolism at the Harvard School of Public Health, Boston, and she has no disclosures. Dr. Gordon is the recipient of a Thought Leader award from Agilent Technologies. Dr. Joos disclosed no relevant financial relationships.