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Upper airway ultrasound: Easy to learn, facile to use!
Thoracic Oncology & Chest Procedures Network
Ultrasound & Chest Imaging Section
Point-of-care ultrasound (POCUS) is integral to the delivery of high-quality patient care. The benefits of POCUS for timely diagnosis and procedural assistance are well documented. With continued innovation, its novel benefits can extend to the upper airway evaluation in both inpatient and outpatient settings.
Adi et al notes that POCUS can serve as an adjunct to traditional airway checklists and help intensivists/anesthesiologists identify potentially difficult laryngoscopies, choose the correct endotracheal tube size to reduce the risk of subglottic stenosis, and help confirm appropriate endotracheal tube placement (Adi, et al. J Emerg Crit Care Med. 2019;3:31).
The prediction of a difficult airway is a potentially lifesaving use for this technology. The authors note that smaller studies demonstrate promising results in four techniques: the inability to visualize the hyoid bone using the sublingual approach, a shorter hyomental distance in morbidly obese patients, anterior neck thickness at different anatomical levels (vocal cords, hyoid bone, and thyroid membrane), and a tongue thickness of more than 6.1 cm from the submental approach were all capable of predicting difficult tracheal intubation with varying degrees of sensitivity and specificity.
In the outpatient setting, an understanding of the upper airway anatomy can help with sleep apnea screenings. Korotun, et al. demonstrated in a small sample that ultrasound evaluation of hyoid bone excursion during hypoglossal nerve stimulation may be a useful tool to predict response to therapy and guide hypoglossal nerve stimulator settings (Korotun, et al. Sleep. 2020;43[Suppl_1]:A247-A248).Upper airway ultrasound is easy to learn. The anatomical landmarks are similar in most patients. This convenient tool can be added to your patient care repertoire in a variety of clinical settings.
Sameer Khanijo, MD, FCCP
Section Member-at-Large
Navitha Ramesh, MD, FCCP
Section Vice-Chair
Thoracic Oncology & Chest Procedures Network
Ultrasound & Chest Imaging Section
Point-of-care ultrasound (POCUS) is integral to the delivery of high-quality patient care. The benefits of POCUS for timely diagnosis and procedural assistance are well documented. With continued innovation, its novel benefits can extend to the upper airway evaluation in both inpatient and outpatient settings.
Adi et al notes that POCUS can serve as an adjunct to traditional airway checklists and help intensivists/anesthesiologists identify potentially difficult laryngoscopies, choose the correct endotracheal tube size to reduce the risk of subglottic stenosis, and help confirm appropriate endotracheal tube placement (Adi, et al. J Emerg Crit Care Med. 2019;3:31).
The prediction of a difficult airway is a potentially lifesaving use for this technology. The authors note that smaller studies demonstrate promising results in four techniques: the inability to visualize the hyoid bone using the sublingual approach, a shorter hyomental distance in morbidly obese patients, anterior neck thickness at different anatomical levels (vocal cords, hyoid bone, and thyroid membrane), and a tongue thickness of more than 6.1 cm from the submental approach were all capable of predicting difficult tracheal intubation with varying degrees of sensitivity and specificity.
In the outpatient setting, an understanding of the upper airway anatomy can help with sleep apnea screenings. Korotun, et al. demonstrated in a small sample that ultrasound evaluation of hyoid bone excursion during hypoglossal nerve stimulation may be a useful tool to predict response to therapy and guide hypoglossal nerve stimulator settings (Korotun, et al. Sleep. 2020;43[Suppl_1]:A247-A248).Upper airway ultrasound is easy to learn. The anatomical landmarks are similar in most patients. This convenient tool can be added to your patient care repertoire in a variety of clinical settings.
Sameer Khanijo, MD, FCCP
Section Member-at-Large
Navitha Ramesh, MD, FCCP
Section Vice-Chair
Thoracic Oncology & Chest Procedures Network
Ultrasound & Chest Imaging Section
Point-of-care ultrasound (POCUS) is integral to the delivery of high-quality patient care. The benefits of POCUS for timely diagnosis and procedural assistance are well documented. With continued innovation, its novel benefits can extend to the upper airway evaluation in both inpatient and outpatient settings.
Adi et al notes that POCUS can serve as an adjunct to traditional airway checklists and help intensivists/anesthesiologists identify potentially difficult laryngoscopies, choose the correct endotracheal tube size to reduce the risk of subglottic stenosis, and help confirm appropriate endotracheal tube placement (Adi, et al. J Emerg Crit Care Med. 2019;3:31).
The prediction of a difficult airway is a potentially lifesaving use for this technology. The authors note that smaller studies demonstrate promising results in four techniques: the inability to visualize the hyoid bone using the sublingual approach, a shorter hyomental distance in morbidly obese patients, anterior neck thickness at different anatomical levels (vocal cords, hyoid bone, and thyroid membrane), and a tongue thickness of more than 6.1 cm from the submental approach were all capable of predicting difficult tracheal intubation with varying degrees of sensitivity and specificity.
In the outpatient setting, an understanding of the upper airway anatomy can help with sleep apnea screenings. Korotun, et al. demonstrated in a small sample that ultrasound evaluation of hyoid bone excursion during hypoglossal nerve stimulation may be a useful tool to predict response to therapy and guide hypoglossal nerve stimulator settings (Korotun, et al. Sleep. 2020;43[Suppl_1]:A247-A248).Upper airway ultrasound is easy to learn. The anatomical landmarks are similar in most patients. This convenient tool can be added to your patient care repertoire in a variety of clinical settings.
Sameer Khanijo, MD, FCCP
Section Member-at-Large
Navitha Ramesh, MD, FCCP
Section Vice-Chair
On the best way to exercise
This transcript has been edited for clarity.
I’m going to talk about something important to a lot of us, based on a new study that has just come out that promises to tell us the right way to exercise. This is a major issue as we think about the best ways to stay healthy.
There are basically two main types of exercise that exercise physiologists think about. There are aerobic exercises: the cardiovascular things like running on a treadmill or outside. Then there are muscle-strengthening exercises: lifting weights, calisthenics, and so on. And of course, plenty of exercises do both at the same time.
It seems that the era of aerobic exercise as the main way to improve health was the 1980s and early 1990s. Then we started to increasingly recognize that muscle-strengthening exercise was really important too. We’ve got a ton of data on the benefits of cardiovascular and aerobic exercise (a reduced risk for cardiovascular disease, cancer, and all-cause mortality, and even improved cognitive function) across a variety of study designs, including cohort studies, but also some randomized controlled trials where people were randomized to aerobic activity.
We’re starting to get more data on the benefits of muscle-strengthening exercises, although it hasn’t been in the zeitgeist as much. Obviously, this increases strength and may reduce visceral fat, increase anaerobic capacity and muscle mass, and therefore [increase the] basal metabolic rate. What is really interesting about muscle strengthening is that muscle just takes up more energy at rest, so building bigger muscles increases your basal energy expenditure and increases insulin sensitivity because muscle is a good insulin sensitizer.
So, do you do both? Do you do one? Do you do the other? What’s the right answer here?
it depends on who you ask. The Center for Disease Control and Prevention’s recommendation, which changes from time to time, is that you should do at least 150 minutes a week of moderate-intensity aerobic activity. Anything that gets your heart beating faster counts here. So that’s 30 minutes, 5 days a week. They also say you can do 75 minutes a week of vigorous-intensity aerobic activity – something that really gets your heart rate up and you are breaking a sweat. Now they also recommend at least 2 days a week of a muscle-strengthening activity that makes your muscles work harder than usual, whether that’s push-ups or lifting weights or something like that.
The World Health Organization is similar. They don’t target 150 minutes a week. They actually say at least 150 and up to 300 minutes of moderate-intensity physical activity or 75-150 minutes of vigorous intensity aerobic physical activity. They are setting the floor, whereas the CDC sets its target and then they go a bit higher. They also recommend 2 days of muscle strengthening per week for optimal health.
But what do the data show? Why am I talking about this? It’s because of this new study in JAMA Internal Medicine by Ruben Lopez Bueno and colleagues. I’m going to focus on all-cause mortality for brevity, but the results are broadly similar.
The data source is the U.S. National Health Interview Survey. A total of 500,705 people took part in the survey and answered a slew of questions (including self-reports on their exercise amounts), with a median follow-up of about 10 years looking for things like cardiovascular deaths, cancer deaths, and so on.
The survey classified people into different exercise categories – how much time they spent doing moderate physical activity (MPA), vigorous physical activity (VPA), or muscle-strengthening activity (MSA).
There are six categories based on duration of MPA (the WHO targets are highlighted in green), four categories based on length of time of VPA, and two categories of MSA (≥ or < two times per week). This gives a total of 48 possible combinations of exercise you could do in a typical week.
Here are the percentages of people who fell into each of these 48 potential categories. The largest is the 35% of people who fell into the “nothing” category (no MPA, no VPA, and less than two sessions per week of MSA). These “nothing” people are going to be a reference category moving forward.
So who are these people? On the far left are the 361,000 people (the vast majority) who don’t hit that 150 minutes a week of MPA or 75 minutes a week of VPA, and they don’t do 2 days a week of MSA. The other three categories are increasing amounts of exercise. Younger people seem to be doing more exercise at the higher ends, and men are more likely to be doing exercise at the higher end. There are also some interesting findings from the alcohol drinking survey. The people who do more exercise are more likely to be current drinkers. This is interesting. I confirmed these data with the investigator. This might suggest one of the reasons why some studies have shown that drinkers have better outcomes in terms of either cardiovascular or cognitive outcomes over time. There’s a lot of conflicting data there, but in part, it might be that healthier people might drink more alcohol. It could be a socioeconomic phenomenon as well.
Now, what blew my mind were these smoker numbers, but don’t get too excited about it. What it looks like from the table in JAMA Internal Medicine is that 20% of the people who don’t do much exercise smoke, and then something like 60% of the people who do more exercise smoke. That can’t be right. So I checked with the lead study author. There is a mistake in these columns for smoking. They were supposed to flip the “never smoker” and “current smoker” numbers. You can actually see that just 15.2% of those who exercise a lot are current smokers, not 63.8%. This has been fixed online, but just in case you saw this and you were as confused as I was that these incredibly healthy smokers are out there exercising all the time, it was just a typo.
There is bias here. One of the big ones is called reverse causation bias. This is what might happen if, let’s say you’re already sick, you have cancer, you have some serious cardiovascular disease, or heart failure. You can’t exercise that much. You physically can’t do it. And then if you die, we wouldn’t find that exercise is beneficial. We would see that sicker people aren’t as able to exercise. The investigators got around this a bit by excluding mortality events within 2 years of the initial survey. Anyone who died within 2 years after saying how often they exercised was not included in this analysis.
This is known as the healthy exerciser or healthy user effect. Sometimes this means that people who exercise a lot probably do other healthy things; they might eat better or get out in the sun more. Researchers try to get around this through multivariable adjustment. They adjust for age, sex, race, marital status, etc. No adjustment is perfect. There’s always residual confounding. But this is probably the best you can do with the dataset like the one they had access to.
Let’s go to the results, which are nicely heat-mapped in the paper. They’re divided into people who have less or more than 2 days of MSA. Our reference groups that we want to pay attention to are the people who don’t do anything. The highest mortality of 9.8 individuals per 1,000 person-years is seen in the group that reported no moderate physical activity, no VPA, and less than 2 days a week of MSA.
As you move up and to the right (more VPA and MPA), you see lower numbers. The lowest number was 4.9 among people who reported more than 150 minutes per week of VPA and 2 days of MSA.
Looking at these data, the benefit, or the bang for your buck is higher for VPA than for MPA. Getting 2 days of MSA does have a tendency to reduce overall mortality. This is not necessarily causal, but it is rather potent and consistent across all the different groups.
So, what are we supposed to do here? I think the most clear finding from the study is that anything is better than nothing. This study suggests that if you are going to get activity, push on the vigorous activity if you’re physically able to do it. And of course, layering in the MSA as well seems to be associated with benefit.
Like everything in life, there’s no one simple solution. It’s a mix. But telling ourselves and our patients to get out there if you can and break a sweat as often as you can during the week, and take a couple of days to get those muscles a little bigger, may increase insulin sensitivity and basal metabolic rate – is it guaranteed to extend life? No. This is an observational study. We can’t say; we don’t have causal data here, but it’s unlikely to cause much harm. I’m particularly happy that people are doing a much better job now of really dissecting out the kinds of physical activity that are beneficial. It turns out that all of it is, and probably a mixture is best.
Dr. Wilson is associate professor, department of medicine, and interim director, program of applied translational research, Yale University, New Haven, Conn. He disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
I’m going to talk about something important to a lot of us, based on a new study that has just come out that promises to tell us the right way to exercise. This is a major issue as we think about the best ways to stay healthy.
There are basically two main types of exercise that exercise physiologists think about. There are aerobic exercises: the cardiovascular things like running on a treadmill or outside. Then there are muscle-strengthening exercises: lifting weights, calisthenics, and so on. And of course, plenty of exercises do both at the same time.
It seems that the era of aerobic exercise as the main way to improve health was the 1980s and early 1990s. Then we started to increasingly recognize that muscle-strengthening exercise was really important too. We’ve got a ton of data on the benefits of cardiovascular and aerobic exercise (a reduced risk for cardiovascular disease, cancer, and all-cause mortality, and even improved cognitive function) across a variety of study designs, including cohort studies, but also some randomized controlled trials where people were randomized to aerobic activity.
We’re starting to get more data on the benefits of muscle-strengthening exercises, although it hasn’t been in the zeitgeist as much. Obviously, this increases strength and may reduce visceral fat, increase anaerobic capacity and muscle mass, and therefore [increase the] basal metabolic rate. What is really interesting about muscle strengthening is that muscle just takes up more energy at rest, so building bigger muscles increases your basal energy expenditure and increases insulin sensitivity because muscle is a good insulin sensitizer.
So, do you do both? Do you do one? Do you do the other? What’s the right answer here?
it depends on who you ask. The Center for Disease Control and Prevention’s recommendation, which changes from time to time, is that you should do at least 150 minutes a week of moderate-intensity aerobic activity. Anything that gets your heart beating faster counts here. So that’s 30 minutes, 5 days a week. They also say you can do 75 minutes a week of vigorous-intensity aerobic activity – something that really gets your heart rate up and you are breaking a sweat. Now they also recommend at least 2 days a week of a muscle-strengthening activity that makes your muscles work harder than usual, whether that’s push-ups or lifting weights or something like that.
The World Health Organization is similar. They don’t target 150 minutes a week. They actually say at least 150 and up to 300 minutes of moderate-intensity physical activity or 75-150 minutes of vigorous intensity aerobic physical activity. They are setting the floor, whereas the CDC sets its target and then they go a bit higher. They also recommend 2 days of muscle strengthening per week for optimal health.
But what do the data show? Why am I talking about this? It’s because of this new study in JAMA Internal Medicine by Ruben Lopez Bueno and colleagues. I’m going to focus on all-cause mortality for brevity, but the results are broadly similar.
The data source is the U.S. National Health Interview Survey. A total of 500,705 people took part in the survey and answered a slew of questions (including self-reports on their exercise amounts), with a median follow-up of about 10 years looking for things like cardiovascular deaths, cancer deaths, and so on.
The survey classified people into different exercise categories – how much time they spent doing moderate physical activity (MPA), vigorous physical activity (VPA), or muscle-strengthening activity (MSA).
There are six categories based on duration of MPA (the WHO targets are highlighted in green), four categories based on length of time of VPA, and two categories of MSA (≥ or < two times per week). This gives a total of 48 possible combinations of exercise you could do in a typical week.
Here are the percentages of people who fell into each of these 48 potential categories. The largest is the 35% of people who fell into the “nothing” category (no MPA, no VPA, and less than two sessions per week of MSA). These “nothing” people are going to be a reference category moving forward.
So who are these people? On the far left are the 361,000 people (the vast majority) who don’t hit that 150 minutes a week of MPA or 75 minutes a week of VPA, and they don’t do 2 days a week of MSA. The other three categories are increasing amounts of exercise. Younger people seem to be doing more exercise at the higher ends, and men are more likely to be doing exercise at the higher end. There are also some interesting findings from the alcohol drinking survey. The people who do more exercise are more likely to be current drinkers. This is interesting. I confirmed these data with the investigator. This might suggest one of the reasons why some studies have shown that drinkers have better outcomes in terms of either cardiovascular or cognitive outcomes over time. There’s a lot of conflicting data there, but in part, it might be that healthier people might drink more alcohol. It could be a socioeconomic phenomenon as well.
Now, what blew my mind were these smoker numbers, but don’t get too excited about it. What it looks like from the table in JAMA Internal Medicine is that 20% of the people who don’t do much exercise smoke, and then something like 60% of the people who do more exercise smoke. That can’t be right. So I checked with the lead study author. There is a mistake in these columns for smoking. They were supposed to flip the “never smoker” and “current smoker” numbers. You can actually see that just 15.2% of those who exercise a lot are current smokers, not 63.8%. This has been fixed online, but just in case you saw this and you were as confused as I was that these incredibly healthy smokers are out there exercising all the time, it was just a typo.
There is bias here. One of the big ones is called reverse causation bias. This is what might happen if, let’s say you’re already sick, you have cancer, you have some serious cardiovascular disease, or heart failure. You can’t exercise that much. You physically can’t do it. And then if you die, we wouldn’t find that exercise is beneficial. We would see that sicker people aren’t as able to exercise. The investigators got around this a bit by excluding mortality events within 2 years of the initial survey. Anyone who died within 2 years after saying how often they exercised was not included in this analysis.
This is known as the healthy exerciser or healthy user effect. Sometimes this means that people who exercise a lot probably do other healthy things; they might eat better or get out in the sun more. Researchers try to get around this through multivariable adjustment. They adjust for age, sex, race, marital status, etc. No adjustment is perfect. There’s always residual confounding. But this is probably the best you can do with the dataset like the one they had access to.
Let’s go to the results, which are nicely heat-mapped in the paper. They’re divided into people who have less or more than 2 days of MSA. Our reference groups that we want to pay attention to are the people who don’t do anything. The highest mortality of 9.8 individuals per 1,000 person-years is seen in the group that reported no moderate physical activity, no VPA, and less than 2 days a week of MSA.
As you move up and to the right (more VPA and MPA), you see lower numbers. The lowest number was 4.9 among people who reported more than 150 minutes per week of VPA and 2 days of MSA.
Looking at these data, the benefit, or the bang for your buck is higher for VPA than for MPA. Getting 2 days of MSA does have a tendency to reduce overall mortality. This is not necessarily causal, but it is rather potent and consistent across all the different groups.
So, what are we supposed to do here? I think the most clear finding from the study is that anything is better than nothing. This study suggests that if you are going to get activity, push on the vigorous activity if you’re physically able to do it. And of course, layering in the MSA as well seems to be associated with benefit.
Like everything in life, there’s no one simple solution. It’s a mix. But telling ourselves and our patients to get out there if you can and break a sweat as often as you can during the week, and take a couple of days to get those muscles a little bigger, may increase insulin sensitivity and basal metabolic rate – is it guaranteed to extend life? No. This is an observational study. We can’t say; we don’t have causal data here, but it’s unlikely to cause much harm. I’m particularly happy that people are doing a much better job now of really dissecting out the kinds of physical activity that are beneficial. It turns out that all of it is, and probably a mixture is best.
Dr. Wilson is associate professor, department of medicine, and interim director, program of applied translational research, Yale University, New Haven, Conn. He disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
I’m going to talk about something important to a lot of us, based on a new study that has just come out that promises to tell us the right way to exercise. This is a major issue as we think about the best ways to stay healthy.
There are basically two main types of exercise that exercise physiologists think about. There are aerobic exercises: the cardiovascular things like running on a treadmill or outside. Then there are muscle-strengthening exercises: lifting weights, calisthenics, and so on. And of course, plenty of exercises do both at the same time.
It seems that the era of aerobic exercise as the main way to improve health was the 1980s and early 1990s. Then we started to increasingly recognize that muscle-strengthening exercise was really important too. We’ve got a ton of data on the benefits of cardiovascular and aerobic exercise (a reduced risk for cardiovascular disease, cancer, and all-cause mortality, and even improved cognitive function) across a variety of study designs, including cohort studies, but also some randomized controlled trials where people were randomized to aerobic activity.
We’re starting to get more data on the benefits of muscle-strengthening exercises, although it hasn’t been in the zeitgeist as much. Obviously, this increases strength and may reduce visceral fat, increase anaerobic capacity and muscle mass, and therefore [increase the] basal metabolic rate. What is really interesting about muscle strengthening is that muscle just takes up more energy at rest, so building bigger muscles increases your basal energy expenditure and increases insulin sensitivity because muscle is a good insulin sensitizer.
So, do you do both? Do you do one? Do you do the other? What’s the right answer here?
it depends on who you ask. The Center for Disease Control and Prevention’s recommendation, which changes from time to time, is that you should do at least 150 minutes a week of moderate-intensity aerobic activity. Anything that gets your heart beating faster counts here. So that’s 30 minutes, 5 days a week. They also say you can do 75 minutes a week of vigorous-intensity aerobic activity – something that really gets your heart rate up and you are breaking a sweat. Now they also recommend at least 2 days a week of a muscle-strengthening activity that makes your muscles work harder than usual, whether that’s push-ups or lifting weights or something like that.
The World Health Organization is similar. They don’t target 150 minutes a week. They actually say at least 150 and up to 300 minutes of moderate-intensity physical activity or 75-150 minutes of vigorous intensity aerobic physical activity. They are setting the floor, whereas the CDC sets its target and then they go a bit higher. They also recommend 2 days of muscle strengthening per week for optimal health.
But what do the data show? Why am I talking about this? It’s because of this new study in JAMA Internal Medicine by Ruben Lopez Bueno and colleagues. I’m going to focus on all-cause mortality for brevity, but the results are broadly similar.
The data source is the U.S. National Health Interview Survey. A total of 500,705 people took part in the survey and answered a slew of questions (including self-reports on their exercise amounts), with a median follow-up of about 10 years looking for things like cardiovascular deaths, cancer deaths, and so on.
The survey classified people into different exercise categories – how much time they spent doing moderate physical activity (MPA), vigorous physical activity (VPA), or muscle-strengthening activity (MSA).
There are six categories based on duration of MPA (the WHO targets are highlighted in green), four categories based on length of time of VPA, and two categories of MSA (≥ or < two times per week). This gives a total of 48 possible combinations of exercise you could do in a typical week.
Here are the percentages of people who fell into each of these 48 potential categories. The largest is the 35% of people who fell into the “nothing” category (no MPA, no VPA, and less than two sessions per week of MSA). These “nothing” people are going to be a reference category moving forward.
So who are these people? On the far left are the 361,000 people (the vast majority) who don’t hit that 150 minutes a week of MPA or 75 minutes a week of VPA, and they don’t do 2 days a week of MSA. The other three categories are increasing amounts of exercise. Younger people seem to be doing more exercise at the higher ends, and men are more likely to be doing exercise at the higher end. There are also some interesting findings from the alcohol drinking survey. The people who do more exercise are more likely to be current drinkers. This is interesting. I confirmed these data with the investigator. This might suggest one of the reasons why some studies have shown that drinkers have better outcomes in terms of either cardiovascular or cognitive outcomes over time. There’s a lot of conflicting data there, but in part, it might be that healthier people might drink more alcohol. It could be a socioeconomic phenomenon as well.
Now, what blew my mind were these smoker numbers, but don’t get too excited about it. What it looks like from the table in JAMA Internal Medicine is that 20% of the people who don’t do much exercise smoke, and then something like 60% of the people who do more exercise smoke. That can’t be right. So I checked with the lead study author. There is a mistake in these columns for smoking. They were supposed to flip the “never smoker” and “current smoker” numbers. You can actually see that just 15.2% of those who exercise a lot are current smokers, not 63.8%. This has been fixed online, but just in case you saw this and you were as confused as I was that these incredibly healthy smokers are out there exercising all the time, it was just a typo.
There is bias here. One of the big ones is called reverse causation bias. This is what might happen if, let’s say you’re already sick, you have cancer, you have some serious cardiovascular disease, or heart failure. You can’t exercise that much. You physically can’t do it. And then if you die, we wouldn’t find that exercise is beneficial. We would see that sicker people aren’t as able to exercise. The investigators got around this a bit by excluding mortality events within 2 years of the initial survey. Anyone who died within 2 years after saying how often they exercised was not included in this analysis.
This is known as the healthy exerciser or healthy user effect. Sometimes this means that people who exercise a lot probably do other healthy things; they might eat better or get out in the sun more. Researchers try to get around this through multivariable adjustment. They adjust for age, sex, race, marital status, etc. No adjustment is perfect. There’s always residual confounding. But this is probably the best you can do with the dataset like the one they had access to.
Let’s go to the results, which are nicely heat-mapped in the paper. They’re divided into people who have less or more than 2 days of MSA. Our reference groups that we want to pay attention to are the people who don’t do anything. The highest mortality of 9.8 individuals per 1,000 person-years is seen in the group that reported no moderate physical activity, no VPA, and less than 2 days a week of MSA.
As you move up and to the right (more VPA and MPA), you see lower numbers. The lowest number was 4.9 among people who reported more than 150 minutes per week of VPA and 2 days of MSA.
Looking at these data, the benefit, or the bang for your buck is higher for VPA than for MPA. Getting 2 days of MSA does have a tendency to reduce overall mortality. This is not necessarily causal, but it is rather potent and consistent across all the different groups.
So, what are we supposed to do here? I think the most clear finding from the study is that anything is better than nothing. This study suggests that if you are going to get activity, push on the vigorous activity if you’re physically able to do it. And of course, layering in the MSA as well seems to be associated with benefit.
Like everything in life, there’s no one simple solution. It’s a mix. But telling ourselves and our patients to get out there if you can and break a sweat as often as you can during the week, and take a couple of days to get those muscles a little bigger, may increase insulin sensitivity and basal metabolic rate – is it guaranteed to extend life? No. This is an observational study. We can’t say; we don’t have causal data here, but it’s unlikely to cause much harm. I’m particularly happy that people are doing a much better job now of really dissecting out the kinds of physical activity that are beneficial. It turns out that all of it is, and probably a mixture is best.
Dr. Wilson is associate professor, department of medicine, and interim director, program of applied translational research, Yale University, New Haven, Conn. He disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Drug name confusion: More than 80 new drug pairs added to the list
Zolpidem (Ambien) is a well-known sedative for sleep. Letairis (Ambrisentan) is a vasodilator for the treatment of pulmonary arterial hypertension. Citalopram (Celexa) is an antidepressant; escitalopram (Lexapro) is prescribed for anxiety and depression.
The aim is to increase awareness about the potential for a serious medication mistake when the wrong drug is given because of drug names that look and sound similar.
Awareness of these drug names, however, is just the first step in preventing medication mistakes. Health care providers should take a number of other steps as well, experts said.
ISMP launched its confusing drug names list, previously called look-alike, sound-alike (LASA) drugs, in 2008. The new list is an update of the 2019 version, said Michael J. Gaunt, PharmD, senior manager of error reporting programs for the ISMP, which focuses on the prevention of medication mistakes. The new entries were chosen on the basis of a number of factors, including ISMP’s analysis of recent medication mishap reports that were submitted to it.
The ISMP list now includes about 528 drug pairs, Dr. Gaunt said. The list is long, he said, partly because each pair is listed twice, so readers can cross reference. For instance, hydralazine and hydroxyzine are listed in one entry in the list, and hydroxyzine and hydralazine are listed in another.
Brand Institute in Miami has named, among other drugs, Entresto, Rybelsus, and Lunesta. The regulatory arm of the company, the Drug Safety Institute, “considers drug names that have been confused as an important part of our comprehensive drug name assessments,” Todd Bridges, global president of the institute, said in an emailed statement. Information on the confusing drug names are incorporated into the company’s proprietary algorithm and is used when developing brand names for drugs. “We continually update this algorithm as new drug names that are often confused are identified,” Mr. Bridges said.
Confusing drug names: Ongoing issue
The length of the list, as well as the latest additions, are not surprising, said Mary Ann Kliethermes, PharmD, director of medication safety and quality for the American Society of Health-System Pharmacists, a membership organization of about 60,000 pharmacists who practice in inpatient and outpatient settings.
“I’ve been in practice over 45 years,” she said, “and this has been a problem ever since I have been in practice.” The sheer volume of new drugs is one reason, she said. From 2013 through 2022, the U.S. Food and Drug Administration approved an average of 43 novel drugs per year, according to a report from its Center for Drug Evaluation and Research. “Since the 90s, this [confusion about similar drug names] has happened,” Dr. Kliethermes said.
According to a 2023 report, about 7,000-9,000 people die each year in the United States as the result of a medication error. However, it’s impossible to say for sure what percentage of those errors involve name confusion, Dr. Gaunt said.
Not all the mistakes are reported. Some that are reported are dramatic and deadly. In 2022, a Tennessee nurse was convicted of gross neglect and negligent homicide. She was sentenced to 3 years’ probation after she mistakenly gave vercuronium, an anesthetic agent, instead of the sedative Versed to a patient, and the woman died.
Updated list: A closer look
Many of the new drug pairs that are listed in the update are cephalosporins, said Dr. Kliethermes, who reviewed the new list for this news organization. In all, 20 of the latest 82 additions are cephalosporins. These include drugs such as cefazolin, which can be confused with cefotetan, and vice versa. These drugs have been around since the 1980s, she said, but “they needed to be on there.” Even in the 1980s, it was becoming difficult to differentiate them, and there were fewer drugs in that class then, she said.
Influenza vaccines made the new list, too. Fluzone High-Dose Quadrivalent can be confused with fluzone quadrivalent. Other new additions: hydrochlorothiazide and hydroxychloroquine, Lasik and Wakix, Pitressin and Pitocin, Remeron and Rozerem.
Beyond the list
While it’s not possible to pinpoint how big a problem name confusion is in causing medication mistakes, “it is certainly still an issue,” Dr. Gaunt said. A variety of practices can reduce that risk substantially, Dr. Gaunt and Dr. Kliethermes agreed.
Tall-man lettering. Both the FDA and the ISMP recommend the use of so-called tall-man lettering (TML), which involves the use of uppercase letters, sometimes in boldface, to distinguish similar names on product labels and elsewhere. Examples include vinBLAStine and vinCRIStine.
Electronic prescribing. “It eliminates the risk of handwriting confusion,” Dr. Gaunt said. However, electronic prescribing can have a downside, Dr. Kliethermes said. When ordering medication, a person may type in a few letters and may then be presented with a prompt that lists several drug names, and it can be easy to click the wrong one. For that reason, ISMP and other experts recommend typing at least five letters when searching for a medication in an electronic system.
Use both brand and generic names on labels and prescriptions.
Write the indication. That can serve as a double check. If a prescription for Ambien says “For sleep,” there’s probably less risk of filling a prescription for ambrisentan, the vasodilator.
Smart formulary additions. When hospitals add medications to their formularies, “part of that formulary assessment should include looking at the potential risk for errors,” Dr. Gaunt said. This involves keeping an eye out for confusing names and similar packaging. “Do that analysis up front and put in strategies to minimize that. Maybe you look for a different drug [for the same use] that has a different name.” Or choose a different manufacturer, so the medication would at least have a different container.
Use bar code scanning. Suppose a pharmacist goes to the shelf and pulls the wrong drug. “Bar code scanning provides the opportunity to catch the error,” Dr. Gaunt said. Many community pharmacies now have bar code scanning. ISMP just issued best practices for community pharmacies, Dr. Gaunt said, and these include the use of bar code scanning and other measures.
Educate consumers. Health care providers can educate consumers on how to minimize the risk of getting the wrong drug, Dr. Gaunt said. When patients are picking up a prescription, suggest they look at the container label; if it looks different from previous prescriptions of the same medicine, ask the pharmacist for an explanation. Some patients just pass it off, Dr. Gaunt said, figuring the pharmacist or health plan switched manufacturers of their medication.
Access the list. The entire list is on the ISMP site and is accessible after free registration.
Goal: Preventing confusion
The FDA has provided guidance for industry on naming drugs not yet approved so that the proposed names are not too similar in sound or appearance to those already on the market. Included in the lengthy document are checklists, such as, “Across a range of dialects, are the names consistently pronounced differently?” and “Are the lengths of the names dissimilar when scripted?” (Lengths are considered different if they differ by two or more letters.)
The FDA also offers the phonetic and orthographic computer analysis (POCA) program, a software tool that employs an advanced algorithm to evaluate similarities between two drug names. The data sources are updated regularly as new drugs are approved.
Liability update
The problem may be decreasing. In a 2020 report, researchers used pharmacists’ professional liability claim data from the Healthcare Providers Service Organization. They compared 2018 data on claims with 2013 data. The percentage of claims associated with wrong drug dispensing errors declined from 43.8% in 2013 to 36.8% in 2018. Wrong dose claims also declined, from 31.5% to 15.3%.
These researchers concluded that technology and automation have contributed to the prevention of medication errors caused by the use of the wrong drug and the wrong dose, but mistakes continue, owing to system and human errors.
A version of this article first appeared on Medscape.com.
Zolpidem (Ambien) is a well-known sedative for sleep. Letairis (Ambrisentan) is a vasodilator for the treatment of pulmonary arterial hypertension. Citalopram (Celexa) is an antidepressant; escitalopram (Lexapro) is prescribed for anxiety and depression.
The aim is to increase awareness about the potential for a serious medication mistake when the wrong drug is given because of drug names that look and sound similar.
Awareness of these drug names, however, is just the first step in preventing medication mistakes. Health care providers should take a number of other steps as well, experts said.
ISMP launched its confusing drug names list, previously called look-alike, sound-alike (LASA) drugs, in 2008. The new list is an update of the 2019 version, said Michael J. Gaunt, PharmD, senior manager of error reporting programs for the ISMP, which focuses on the prevention of medication mistakes. The new entries were chosen on the basis of a number of factors, including ISMP’s analysis of recent medication mishap reports that were submitted to it.
The ISMP list now includes about 528 drug pairs, Dr. Gaunt said. The list is long, he said, partly because each pair is listed twice, so readers can cross reference. For instance, hydralazine and hydroxyzine are listed in one entry in the list, and hydroxyzine and hydralazine are listed in another.
Brand Institute in Miami has named, among other drugs, Entresto, Rybelsus, and Lunesta. The regulatory arm of the company, the Drug Safety Institute, “considers drug names that have been confused as an important part of our comprehensive drug name assessments,” Todd Bridges, global president of the institute, said in an emailed statement. Information on the confusing drug names are incorporated into the company’s proprietary algorithm and is used when developing brand names for drugs. “We continually update this algorithm as new drug names that are often confused are identified,” Mr. Bridges said.
Confusing drug names: Ongoing issue
The length of the list, as well as the latest additions, are not surprising, said Mary Ann Kliethermes, PharmD, director of medication safety and quality for the American Society of Health-System Pharmacists, a membership organization of about 60,000 pharmacists who practice in inpatient and outpatient settings.
“I’ve been in practice over 45 years,” she said, “and this has been a problem ever since I have been in practice.” The sheer volume of new drugs is one reason, she said. From 2013 through 2022, the U.S. Food and Drug Administration approved an average of 43 novel drugs per year, according to a report from its Center for Drug Evaluation and Research. “Since the 90s, this [confusion about similar drug names] has happened,” Dr. Kliethermes said.
According to a 2023 report, about 7,000-9,000 people die each year in the United States as the result of a medication error. However, it’s impossible to say for sure what percentage of those errors involve name confusion, Dr. Gaunt said.
Not all the mistakes are reported. Some that are reported are dramatic and deadly. In 2022, a Tennessee nurse was convicted of gross neglect and negligent homicide. She was sentenced to 3 years’ probation after she mistakenly gave vercuronium, an anesthetic agent, instead of the sedative Versed to a patient, and the woman died.
Updated list: A closer look
Many of the new drug pairs that are listed in the update are cephalosporins, said Dr. Kliethermes, who reviewed the new list for this news organization. In all, 20 of the latest 82 additions are cephalosporins. These include drugs such as cefazolin, which can be confused with cefotetan, and vice versa. These drugs have been around since the 1980s, she said, but “they needed to be on there.” Even in the 1980s, it was becoming difficult to differentiate them, and there were fewer drugs in that class then, she said.
Influenza vaccines made the new list, too. Fluzone High-Dose Quadrivalent can be confused with fluzone quadrivalent. Other new additions: hydrochlorothiazide and hydroxychloroquine, Lasik and Wakix, Pitressin and Pitocin, Remeron and Rozerem.
Beyond the list
While it’s not possible to pinpoint how big a problem name confusion is in causing medication mistakes, “it is certainly still an issue,” Dr. Gaunt said. A variety of practices can reduce that risk substantially, Dr. Gaunt and Dr. Kliethermes agreed.
Tall-man lettering. Both the FDA and the ISMP recommend the use of so-called tall-man lettering (TML), which involves the use of uppercase letters, sometimes in boldface, to distinguish similar names on product labels and elsewhere. Examples include vinBLAStine and vinCRIStine.
Electronic prescribing. “It eliminates the risk of handwriting confusion,” Dr. Gaunt said. However, electronic prescribing can have a downside, Dr. Kliethermes said. When ordering medication, a person may type in a few letters and may then be presented with a prompt that lists several drug names, and it can be easy to click the wrong one. For that reason, ISMP and other experts recommend typing at least five letters when searching for a medication in an electronic system.
Use both brand and generic names on labels and prescriptions.
Write the indication. That can serve as a double check. If a prescription for Ambien says “For sleep,” there’s probably less risk of filling a prescription for ambrisentan, the vasodilator.
Smart formulary additions. When hospitals add medications to their formularies, “part of that formulary assessment should include looking at the potential risk for errors,” Dr. Gaunt said. This involves keeping an eye out for confusing names and similar packaging. “Do that analysis up front and put in strategies to minimize that. Maybe you look for a different drug [for the same use] that has a different name.” Or choose a different manufacturer, so the medication would at least have a different container.
Use bar code scanning. Suppose a pharmacist goes to the shelf and pulls the wrong drug. “Bar code scanning provides the opportunity to catch the error,” Dr. Gaunt said. Many community pharmacies now have bar code scanning. ISMP just issued best practices for community pharmacies, Dr. Gaunt said, and these include the use of bar code scanning and other measures.
Educate consumers. Health care providers can educate consumers on how to minimize the risk of getting the wrong drug, Dr. Gaunt said. When patients are picking up a prescription, suggest they look at the container label; if it looks different from previous prescriptions of the same medicine, ask the pharmacist for an explanation. Some patients just pass it off, Dr. Gaunt said, figuring the pharmacist or health plan switched manufacturers of their medication.
Access the list. The entire list is on the ISMP site and is accessible after free registration.
Goal: Preventing confusion
The FDA has provided guidance for industry on naming drugs not yet approved so that the proposed names are not too similar in sound or appearance to those already on the market. Included in the lengthy document are checklists, such as, “Across a range of dialects, are the names consistently pronounced differently?” and “Are the lengths of the names dissimilar when scripted?” (Lengths are considered different if they differ by two or more letters.)
The FDA also offers the phonetic and orthographic computer analysis (POCA) program, a software tool that employs an advanced algorithm to evaluate similarities between two drug names. The data sources are updated regularly as new drugs are approved.
Liability update
The problem may be decreasing. In a 2020 report, researchers used pharmacists’ professional liability claim data from the Healthcare Providers Service Organization. They compared 2018 data on claims with 2013 data. The percentage of claims associated with wrong drug dispensing errors declined from 43.8% in 2013 to 36.8% in 2018. Wrong dose claims also declined, from 31.5% to 15.3%.
These researchers concluded that technology and automation have contributed to the prevention of medication errors caused by the use of the wrong drug and the wrong dose, but mistakes continue, owing to system and human errors.
A version of this article first appeared on Medscape.com.
Zolpidem (Ambien) is a well-known sedative for sleep. Letairis (Ambrisentan) is a vasodilator for the treatment of pulmonary arterial hypertension. Citalopram (Celexa) is an antidepressant; escitalopram (Lexapro) is prescribed for anxiety and depression.
The aim is to increase awareness about the potential for a serious medication mistake when the wrong drug is given because of drug names that look and sound similar.
Awareness of these drug names, however, is just the first step in preventing medication mistakes. Health care providers should take a number of other steps as well, experts said.
ISMP launched its confusing drug names list, previously called look-alike, sound-alike (LASA) drugs, in 2008. The new list is an update of the 2019 version, said Michael J. Gaunt, PharmD, senior manager of error reporting programs for the ISMP, which focuses on the prevention of medication mistakes. The new entries were chosen on the basis of a number of factors, including ISMP’s analysis of recent medication mishap reports that were submitted to it.
The ISMP list now includes about 528 drug pairs, Dr. Gaunt said. The list is long, he said, partly because each pair is listed twice, so readers can cross reference. For instance, hydralazine and hydroxyzine are listed in one entry in the list, and hydroxyzine and hydralazine are listed in another.
Brand Institute in Miami has named, among other drugs, Entresto, Rybelsus, and Lunesta. The regulatory arm of the company, the Drug Safety Institute, “considers drug names that have been confused as an important part of our comprehensive drug name assessments,” Todd Bridges, global president of the institute, said in an emailed statement. Information on the confusing drug names are incorporated into the company’s proprietary algorithm and is used when developing brand names for drugs. “We continually update this algorithm as new drug names that are often confused are identified,” Mr. Bridges said.
Confusing drug names: Ongoing issue
The length of the list, as well as the latest additions, are not surprising, said Mary Ann Kliethermes, PharmD, director of medication safety and quality for the American Society of Health-System Pharmacists, a membership organization of about 60,000 pharmacists who practice in inpatient and outpatient settings.
“I’ve been in practice over 45 years,” she said, “and this has been a problem ever since I have been in practice.” The sheer volume of new drugs is one reason, she said. From 2013 through 2022, the U.S. Food and Drug Administration approved an average of 43 novel drugs per year, according to a report from its Center for Drug Evaluation and Research. “Since the 90s, this [confusion about similar drug names] has happened,” Dr. Kliethermes said.
According to a 2023 report, about 7,000-9,000 people die each year in the United States as the result of a medication error. However, it’s impossible to say for sure what percentage of those errors involve name confusion, Dr. Gaunt said.
Not all the mistakes are reported. Some that are reported are dramatic and deadly. In 2022, a Tennessee nurse was convicted of gross neglect and negligent homicide. She was sentenced to 3 years’ probation after she mistakenly gave vercuronium, an anesthetic agent, instead of the sedative Versed to a patient, and the woman died.
Updated list: A closer look
Many of the new drug pairs that are listed in the update are cephalosporins, said Dr. Kliethermes, who reviewed the new list for this news organization. In all, 20 of the latest 82 additions are cephalosporins. These include drugs such as cefazolin, which can be confused with cefotetan, and vice versa. These drugs have been around since the 1980s, she said, but “they needed to be on there.” Even in the 1980s, it was becoming difficult to differentiate them, and there were fewer drugs in that class then, she said.
Influenza vaccines made the new list, too. Fluzone High-Dose Quadrivalent can be confused with fluzone quadrivalent. Other new additions: hydrochlorothiazide and hydroxychloroquine, Lasik and Wakix, Pitressin and Pitocin, Remeron and Rozerem.
Beyond the list
While it’s not possible to pinpoint how big a problem name confusion is in causing medication mistakes, “it is certainly still an issue,” Dr. Gaunt said. A variety of practices can reduce that risk substantially, Dr. Gaunt and Dr. Kliethermes agreed.
Tall-man lettering. Both the FDA and the ISMP recommend the use of so-called tall-man lettering (TML), which involves the use of uppercase letters, sometimes in boldface, to distinguish similar names on product labels and elsewhere. Examples include vinBLAStine and vinCRIStine.
Electronic prescribing. “It eliminates the risk of handwriting confusion,” Dr. Gaunt said. However, electronic prescribing can have a downside, Dr. Kliethermes said. When ordering medication, a person may type in a few letters and may then be presented with a prompt that lists several drug names, and it can be easy to click the wrong one. For that reason, ISMP and other experts recommend typing at least five letters when searching for a medication in an electronic system.
Use both brand and generic names on labels and prescriptions.
Write the indication. That can serve as a double check. If a prescription for Ambien says “For sleep,” there’s probably less risk of filling a prescription for ambrisentan, the vasodilator.
Smart formulary additions. When hospitals add medications to their formularies, “part of that formulary assessment should include looking at the potential risk for errors,” Dr. Gaunt said. This involves keeping an eye out for confusing names and similar packaging. “Do that analysis up front and put in strategies to minimize that. Maybe you look for a different drug [for the same use] that has a different name.” Or choose a different manufacturer, so the medication would at least have a different container.
Use bar code scanning. Suppose a pharmacist goes to the shelf and pulls the wrong drug. “Bar code scanning provides the opportunity to catch the error,” Dr. Gaunt said. Many community pharmacies now have bar code scanning. ISMP just issued best practices for community pharmacies, Dr. Gaunt said, and these include the use of bar code scanning and other measures.
Educate consumers. Health care providers can educate consumers on how to minimize the risk of getting the wrong drug, Dr. Gaunt said. When patients are picking up a prescription, suggest they look at the container label; if it looks different from previous prescriptions of the same medicine, ask the pharmacist for an explanation. Some patients just pass it off, Dr. Gaunt said, figuring the pharmacist or health plan switched manufacturers of their medication.
Access the list. The entire list is on the ISMP site and is accessible after free registration.
Goal: Preventing confusion
The FDA has provided guidance for industry on naming drugs not yet approved so that the proposed names are not too similar in sound or appearance to those already on the market. Included in the lengthy document are checklists, such as, “Across a range of dialects, are the names consistently pronounced differently?” and “Are the lengths of the names dissimilar when scripted?” (Lengths are considered different if they differ by two or more letters.)
The FDA also offers the phonetic and orthographic computer analysis (POCA) program, a software tool that employs an advanced algorithm to evaluate similarities between two drug names. The data sources are updated regularly as new drugs are approved.
Liability update
The problem may be decreasing. In a 2020 report, researchers used pharmacists’ professional liability claim data from the Healthcare Providers Service Organization. They compared 2018 data on claims with 2013 data. The percentage of claims associated with wrong drug dispensing errors declined from 43.8% in 2013 to 36.8% in 2018. Wrong dose claims also declined, from 31.5% to 15.3%.
These researchers concluded that technology and automation have contributed to the prevention of medication errors caused by the use of the wrong drug and the wrong dose, but mistakes continue, owing to system and human errors.
A version of this article first appeared on Medscape.com.
Antibody shows promise in preventing GVHD
Early, intriguing research suggests that preventing acute graft-versus-host disease (GVHD) in the gut – a potentially life-threatening complication of allogeneic hematopoietic cell transplantation (allo-HCT) – could be accomplished by the administration of a single antibody that targets the anti-DLL4 Notch signaling pathway, without compromising the stem cell transplant.
“The major surprise was that none of the anti–DLL4-treated animals developed acute gastrointestinal GVHD for the entire duration of the study. This was a remarkable finding, given that intestinal GVHD is otherwise seen in the vast majority of nonhuman primate transplant recipients that receive either no prophylaxis, or prophylaxis with agents other than anti-DLL4 antibodies,” co–senior author Ivan Maillard, MD, PhD, a professor of medicine and vice chief for research in hematology-oncology at the University of Pennsylvania, Philadelphia, said in an interview.
“The timing was critical,” the authors noted in the study, recently published in Science Translational Medicine. “Intervening before any symptoms of GvHD appear made the long-term protection possible.”
While GVHD may be mild to moderate in chronic forms, acute cases can be serious, if not fatal, and nearly all severe acute GVHD prominently involves the gastrointestinal tract, which can drive activation of pathogenic T cells and potentially lead to tissue damage following allo-HCT.
Systemic corticosteroids are standard first-line treatment for acute GVHD. However, response rates generally range only from 40% to 60%, and there are concerns of side effects. Meanwhile, second-line treatments are of inconsistent benefit.
With previous studies on mice showing benefits of targeting Notch pathway inhibition, particularly DLL4, Dr. Maillard and colleagues further investigated the effects in nonhuman primates that were allo-HCT recipients, using the anti-DLL4 antibody REGN421, which has pharmacokinetic and toxicity information available from previous studies.
The nonhuman primates were treated with one of two dosing regimens: a single dose of REGN421 3 mg/kg at baseline, post HCT, (n = 7) or three weekly doses at days 0, 7 and 14, post transplant (n = 4). Those primates were compared with 11 primates receiving allo-HCT transplants that received supportive care only.
Primates receiving three weekly doses of REGN421 showed antibody concentrations of greater than 2 mcg/mL for more than 30 days post HCT. A single dose of REGN421 was associated with protection from acute GVHD at day 0, while three weekly doses showed protection at day 0, 7, and 14, consistent with an impact of REGN421 during the early phases of T-cell activation.
Compared with animals receiving only supportive care, prophylaxis with REGN421 was associated with delayed acute GVHD onset and lengthened survival.
Of the 11 primates treated with REGN421, none developed clinical signs of gastrointestinal acute GVHD, whereas the majority of those receiving standard care or other preventive interventions did.
“Detailed analysis of acute GVHD clinical presentations in REGN421-treated animals in comparison to no treatment controls revealed near complete protection from GI-acute GvHD with REGN421,” the authors reported.
Furthermore, pathology scores in the gastrointestinal tract were lower with REGN421 treatment, compared with the no-treatment cohort, and the scores matched those of healthy nontransplanted nonhuman primates.
The primates treated with REGN421 did ultimately develop other clinical and pathologic signs of skin, hepatic or pulmonary acute GVHD, but without gastrointestinal disease.
The treatment was not associated with any adverse effects on the allo-HCT, with primates receiving either a single dose or three weekly doses of REGN421 showing rapid donor engraftment after allo-HCT, including high bone marrow, whole blood, and T-cell donor chimerism.
“Reassuringly, short-term systemic DLL4 blockade with REGN421 did not trigger unexpected side effects in our nonhuman primate model, while preserving rapid engraftment as well hematopoietic and immune reconstitution.”
The mechanism preserving the engraftment, described as a “major surprise,” specifically involved DLL4 inhibition blocking the homing of pathogenic T cells to the gut while preserving homing of regulatory T cells that dampen the immune response, Dr. Maillard explained.
“This effect turned out to be at least in part through a posttranslational effect of DLL4/Notch blockade on integrin pairing at the T-cell surface,” he explained. “This was a novel and quite unexpected mechanism of action conserved from mice to nonhuman primates.”
The results are encouraging in terms of translating to humans because of their closer similarities in various physiological factors, Dr. Maillard said.
“The nonhuman primate model of transplantation [offers] a transplantation model very close to what is being performed in humans, as well as the opportunity to study an immune system very similar to that of humans in nonhuman primates,” he said.
Dr. Maillard noted that, while trials in humans are not underway yet, “we are in active discussions about it,” and the team is indeed interested in testing REGN421 itself, with the effects likely to be as a prophylactic strategy.
There are currently no approved anti-DLL4 antibody drugs for use in humans.
“Our approach is mostly promising as a preventive treatment, rather than as a secondary treatment for GVHD, because DLL4/Notch blockade seems most active when applied early after transplantation during the time of initial seeding of the gut by T cells (in mice, we had observed the critical time window for a successful intervention to be within 48 hours of transplantation),” Dr. Maillard said.“There remain questions about which other prophylactic treatments we should ideally combine anti-DLL4 antibodies with.”
Dr. Maillard has received research funding from Regeneron and Genentech and is a member of Garuda Therapeutics’s scientific advisory board.
Early, intriguing research suggests that preventing acute graft-versus-host disease (GVHD) in the gut – a potentially life-threatening complication of allogeneic hematopoietic cell transplantation (allo-HCT) – could be accomplished by the administration of a single antibody that targets the anti-DLL4 Notch signaling pathway, without compromising the stem cell transplant.
“The major surprise was that none of the anti–DLL4-treated animals developed acute gastrointestinal GVHD for the entire duration of the study. This was a remarkable finding, given that intestinal GVHD is otherwise seen in the vast majority of nonhuman primate transplant recipients that receive either no prophylaxis, or prophylaxis with agents other than anti-DLL4 antibodies,” co–senior author Ivan Maillard, MD, PhD, a professor of medicine and vice chief for research in hematology-oncology at the University of Pennsylvania, Philadelphia, said in an interview.
“The timing was critical,” the authors noted in the study, recently published in Science Translational Medicine. “Intervening before any symptoms of GvHD appear made the long-term protection possible.”
While GVHD may be mild to moderate in chronic forms, acute cases can be serious, if not fatal, and nearly all severe acute GVHD prominently involves the gastrointestinal tract, which can drive activation of pathogenic T cells and potentially lead to tissue damage following allo-HCT.
Systemic corticosteroids are standard first-line treatment for acute GVHD. However, response rates generally range only from 40% to 60%, and there are concerns of side effects. Meanwhile, second-line treatments are of inconsistent benefit.
With previous studies on mice showing benefits of targeting Notch pathway inhibition, particularly DLL4, Dr. Maillard and colleagues further investigated the effects in nonhuman primates that were allo-HCT recipients, using the anti-DLL4 antibody REGN421, which has pharmacokinetic and toxicity information available from previous studies.
The nonhuman primates were treated with one of two dosing regimens: a single dose of REGN421 3 mg/kg at baseline, post HCT, (n = 7) or three weekly doses at days 0, 7 and 14, post transplant (n = 4). Those primates were compared with 11 primates receiving allo-HCT transplants that received supportive care only.
Primates receiving three weekly doses of REGN421 showed antibody concentrations of greater than 2 mcg/mL for more than 30 days post HCT. A single dose of REGN421 was associated with protection from acute GVHD at day 0, while three weekly doses showed protection at day 0, 7, and 14, consistent with an impact of REGN421 during the early phases of T-cell activation.
Compared with animals receiving only supportive care, prophylaxis with REGN421 was associated with delayed acute GVHD onset and lengthened survival.
Of the 11 primates treated with REGN421, none developed clinical signs of gastrointestinal acute GVHD, whereas the majority of those receiving standard care or other preventive interventions did.
“Detailed analysis of acute GVHD clinical presentations in REGN421-treated animals in comparison to no treatment controls revealed near complete protection from GI-acute GvHD with REGN421,” the authors reported.
Furthermore, pathology scores in the gastrointestinal tract were lower with REGN421 treatment, compared with the no-treatment cohort, and the scores matched those of healthy nontransplanted nonhuman primates.
The primates treated with REGN421 did ultimately develop other clinical and pathologic signs of skin, hepatic or pulmonary acute GVHD, but without gastrointestinal disease.
The treatment was not associated with any adverse effects on the allo-HCT, with primates receiving either a single dose or three weekly doses of REGN421 showing rapid donor engraftment after allo-HCT, including high bone marrow, whole blood, and T-cell donor chimerism.
“Reassuringly, short-term systemic DLL4 blockade with REGN421 did not trigger unexpected side effects in our nonhuman primate model, while preserving rapid engraftment as well hematopoietic and immune reconstitution.”
The mechanism preserving the engraftment, described as a “major surprise,” specifically involved DLL4 inhibition blocking the homing of pathogenic T cells to the gut while preserving homing of regulatory T cells that dampen the immune response, Dr. Maillard explained.
“This effect turned out to be at least in part through a posttranslational effect of DLL4/Notch blockade on integrin pairing at the T-cell surface,” he explained. “This was a novel and quite unexpected mechanism of action conserved from mice to nonhuman primates.”
The results are encouraging in terms of translating to humans because of their closer similarities in various physiological factors, Dr. Maillard said.
“The nonhuman primate model of transplantation [offers] a transplantation model very close to what is being performed in humans, as well as the opportunity to study an immune system very similar to that of humans in nonhuman primates,” he said.
Dr. Maillard noted that, while trials in humans are not underway yet, “we are in active discussions about it,” and the team is indeed interested in testing REGN421 itself, with the effects likely to be as a prophylactic strategy.
There are currently no approved anti-DLL4 antibody drugs for use in humans.
“Our approach is mostly promising as a preventive treatment, rather than as a secondary treatment for GVHD, because DLL4/Notch blockade seems most active when applied early after transplantation during the time of initial seeding of the gut by T cells (in mice, we had observed the critical time window for a successful intervention to be within 48 hours of transplantation),” Dr. Maillard said.“There remain questions about which other prophylactic treatments we should ideally combine anti-DLL4 antibodies with.”
Dr. Maillard has received research funding from Regeneron and Genentech and is a member of Garuda Therapeutics’s scientific advisory board.
Early, intriguing research suggests that preventing acute graft-versus-host disease (GVHD) in the gut – a potentially life-threatening complication of allogeneic hematopoietic cell transplantation (allo-HCT) – could be accomplished by the administration of a single antibody that targets the anti-DLL4 Notch signaling pathway, without compromising the stem cell transplant.
“The major surprise was that none of the anti–DLL4-treated animals developed acute gastrointestinal GVHD for the entire duration of the study. This was a remarkable finding, given that intestinal GVHD is otherwise seen in the vast majority of nonhuman primate transplant recipients that receive either no prophylaxis, or prophylaxis with agents other than anti-DLL4 antibodies,” co–senior author Ivan Maillard, MD, PhD, a professor of medicine and vice chief for research in hematology-oncology at the University of Pennsylvania, Philadelphia, said in an interview.
“The timing was critical,” the authors noted in the study, recently published in Science Translational Medicine. “Intervening before any symptoms of GvHD appear made the long-term protection possible.”
While GVHD may be mild to moderate in chronic forms, acute cases can be serious, if not fatal, and nearly all severe acute GVHD prominently involves the gastrointestinal tract, which can drive activation of pathogenic T cells and potentially lead to tissue damage following allo-HCT.
Systemic corticosteroids are standard first-line treatment for acute GVHD. However, response rates generally range only from 40% to 60%, and there are concerns of side effects. Meanwhile, second-line treatments are of inconsistent benefit.
With previous studies on mice showing benefits of targeting Notch pathway inhibition, particularly DLL4, Dr. Maillard and colleagues further investigated the effects in nonhuman primates that were allo-HCT recipients, using the anti-DLL4 antibody REGN421, which has pharmacokinetic and toxicity information available from previous studies.
The nonhuman primates were treated with one of two dosing regimens: a single dose of REGN421 3 mg/kg at baseline, post HCT, (n = 7) or three weekly doses at days 0, 7 and 14, post transplant (n = 4). Those primates were compared with 11 primates receiving allo-HCT transplants that received supportive care only.
Primates receiving three weekly doses of REGN421 showed antibody concentrations of greater than 2 mcg/mL for more than 30 days post HCT. A single dose of REGN421 was associated with protection from acute GVHD at day 0, while three weekly doses showed protection at day 0, 7, and 14, consistent with an impact of REGN421 during the early phases of T-cell activation.
Compared with animals receiving only supportive care, prophylaxis with REGN421 was associated with delayed acute GVHD onset and lengthened survival.
Of the 11 primates treated with REGN421, none developed clinical signs of gastrointestinal acute GVHD, whereas the majority of those receiving standard care or other preventive interventions did.
“Detailed analysis of acute GVHD clinical presentations in REGN421-treated animals in comparison to no treatment controls revealed near complete protection from GI-acute GvHD with REGN421,” the authors reported.
Furthermore, pathology scores in the gastrointestinal tract were lower with REGN421 treatment, compared with the no-treatment cohort, and the scores matched those of healthy nontransplanted nonhuman primates.
The primates treated with REGN421 did ultimately develop other clinical and pathologic signs of skin, hepatic or pulmonary acute GVHD, but without gastrointestinal disease.
The treatment was not associated with any adverse effects on the allo-HCT, with primates receiving either a single dose or three weekly doses of REGN421 showing rapid donor engraftment after allo-HCT, including high bone marrow, whole blood, and T-cell donor chimerism.
“Reassuringly, short-term systemic DLL4 blockade with REGN421 did not trigger unexpected side effects in our nonhuman primate model, while preserving rapid engraftment as well hematopoietic and immune reconstitution.”
The mechanism preserving the engraftment, described as a “major surprise,” specifically involved DLL4 inhibition blocking the homing of pathogenic T cells to the gut while preserving homing of regulatory T cells that dampen the immune response, Dr. Maillard explained.
“This effect turned out to be at least in part through a posttranslational effect of DLL4/Notch blockade on integrin pairing at the T-cell surface,” he explained. “This was a novel and quite unexpected mechanism of action conserved from mice to nonhuman primates.”
The results are encouraging in terms of translating to humans because of their closer similarities in various physiological factors, Dr. Maillard said.
“The nonhuman primate model of transplantation [offers] a transplantation model very close to what is being performed in humans, as well as the opportunity to study an immune system very similar to that of humans in nonhuman primates,” he said.
Dr. Maillard noted that, while trials in humans are not underway yet, “we are in active discussions about it,” and the team is indeed interested in testing REGN421 itself, with the effects likely to be as a prophylactic strategy.
There are currently no approved anti-DLL4 antibody drugs for use in humans.
“Our approach is mostly promising as a preventive treatment, rather than as a secondary treatment for GVHD, because DLL4/Notch blockade seems most active when applied early after transplantation during the time of initial seeding of the gut by T cells (in mice, we had observed the critical time window for a successful intervention to be within 48 hours of transplantation),” Dr. Maillard said.“There remain questions about which other prophylactic treatments we should ideally combine anti-DLL4 antibodies with.”
Dr. Maillard has received research funding from Regeneron and Genentech and is a member of Garuda Therapeutics’s scientific advisory board.
FROM SCIENCE TRANSLATIONAL MEDICINE
Increasing number of children being poisoned by liquid nicotine
Doctors say a 2016 law aimed at lowering the risk contained a big flaw, NBC News reported. The Child Nicotine Poisoning Prevention Act required child-resistant packaging on vaping liquid – but not on the vaping devices themselves.
Contact with the vaping liquid, or liquid nicotine, can cause children to get dizzy, pass out, and suffer drops in blood pressure. A few drops of the liquid can be fatal for a toddler.
Last year, 6,731 cases of vaping-related nicotine exposure were reported, according to Poison Help. “As of June 30, 2023, poison centers have managed 3,863 exposure cases about e-cigarette devices and liquid nicotine,” the organization said.
“Poison centers began receiving calls about e-cigarettes and liquid nicotine products in 2011, which coincides with the initial period where these products reached the U.S. market,” according to Poison Help.
“These products often contain a greater concentration of nicotine, a stimulant, than other nicotine/tobacco products on the market. Some children and toddlers who come in contact with e-cigarette devices or liquid nicotine have become very ill; some even requiring emergency department visits with nausea and vomiting being the most significant symptoms.”
Toxicologist Ryan Marino, MD, told NBC that refillable vapes are designed to hold liquid nicotine in a central reservoir, making them dangerous to children.
“Even vapes that appear more child-resistant – because their nicotine is sealed inside a removable cartridge – present a risk, because the cartridges can be pried open,” NBC said. “And some disposable e-cigarettes, now the top-selling type on the market, allow users to take thousands of ‘puffs’ and contain as much nicotine as multiple packs of cigarettes.”
A spokesperson for the vaping industry said all e-liquid bottles made in this country conform to U.S. law.
“Not only are the caps child-resistant, but the flow of liquid is restricted so that only small amounts can be dispensed,” said April Meyers of the Smoke-Free Alternatives Trade Association, which represents the vaping industry.
A version of this article first appeared on WebMD.com.
Doctors say a 2016 law aimed at lowering the risk contained a big flaw, NBC News reported. The Child Nicotine Poisoning Prevention Act required child-resistant packaging on vaping liquid – but not on the vaping devices themselves.
Contact with the vaping liquid, or liquid nicotine, can cause children to get dizzy, pass out, and suffer drops in blood pressure. A few drops of the liquid can be fatal for a toddler.
Last year, 6,731 cases of vaping-related nicotine exposure were reported, according to Poison Help. “As of June 30, 2023, poison centers have managed 3,863 exposure cases about e-cigarette devices and liquid nicotine,” the organization said.
“Poison centers began receiving calls about e-cigarettes and liquid nicotine products in 2011, which coincides with the initial period where these products reached the U.S. market,” according to Poison Help.
“These products often contain a greater concentration of nicotine, a stimulant, than other nicotine/tobacco products on the market. Some children and toddlers who come in contact with e-cigarette devices or liquid nicotine have become very ill; some even requiring emergency department visits with nausea and vomiting being the most significant symptoms.”
Toxicologist Ryan Marino, MD, told NBC that refillable vapes are designed to hold liquid nicotine in a central reservoir, making them dangerous to children.
“Even vapes that appear more child-resistant – because their nicotine is sealed inside a removable cartridge – present a risk, because the cartridges can be pried open,” NBC said. “And some disposable e-cigarettes, now the top-selling type on the market, allow users to take thousands of ‘puffs’ and contain as much nicotine as multiple packs of cigarettes.”
A spokesperson for the vaping industry said all e-liquid bottles made in this country conform to U.S. law.
“Not only are the caps child-resistant, but the flow of liquid is restricted so that only small amounts can be dispensed,” said April Meyers of the Smoke-Free Alternatives Trade Association, which represents the vaping industry.
A version of this article first appeared on WebMD.com.
Doctors say a 2016 law aimed at lowering the risk contained a big flaw, NBC News reported. The Child Nicotine Poisoning Prevention Act required child-resistant packaging on vaping liquid – but not on the vaping devices themselves.
Contact with the vaping liquid, or liquid nicotine, can cause children to get dizzy, pass out, and suffer drops in blood pressure. A few drops of the liquid can be fatal for a toddler.
Last year, 6,731 cases of vaping-related nicotine exposure were reported, according to Poison Help. “As of June 30, 2023, poison centers have managed 3,863 exposure cases about e-cigarette devices and liquid nicotine,” the organization said.
“Poison centers began receiving calls about e-cigarettes and liquid nicotine products in 2011, which coincides with the initial period where these products reached the U.S. market,” according to Poison Help.
“These products often contain a greater concentration of nicotine, a stimulant, than other nicotine/tobacco products on the market. Some children and toddlers who come in contact with e-cigarette devices or liquid nicotine have become very ill; some even requiring emergency department visits with nausea and vomiting being the most significant symptoms.”
Toxicologist Ryan Marino, MD, told NBC that refillable vapes are designed to hold liquid nicotine in a central reservoir, making them dangerous to children.
“Even vapes that appear more child-resistant – because their nicotine is sealed inside a removable cartridge – present a risk, because the cartridges can be pried open,” NBC said. “And some disposable e-cigarettes, now the top-selling type on the market, allow users to take thousands of ‘puffs’ and contain as much nicotine as multiple packs of cigarettes.”
A spokesperson for the vaping industry said all e-liquid bottles made in this country conform to U.S. law.
“Not only are the caps child-resistant, but the flow of liquid is restricted so that only small amounts can be dispensed,” said April Meyers of the Smoke-Free Alternatives Trade Association, which represents the vaping industry.
A version of this article first appeared on WebMD.com.
Black women weigh emerging risks of ‘creamy crack’ hair straighteners
Deanna Denham Hughes was stunned when she was diagnosed with ovarian cancer in 2022. She was only 32. She had no family history of cancer, and tests found no genetic link. Ms. Hughes wondered why she, an otherwise healthy Black mother of two, would develop a malignancy known as a “silent killer.”
After emergency surgery to remove the mass, along with her ovaries, uterus, fallopian tubes, and appendix, Ms. Hughes said, she saw an Instagram post in which a woman with uterine cancer linked her condition to chemical hair straighteners.
“I almost fell over,” she said from her home in Smyrna, Ga.
When Ms. Hughes was about 4, her mother began applying a chemical straightener, or relaxer, to her hair every 6-8 weeks. “It burned, and it smelled awful,” Ms. Hughes recalled. “But it was just part of our routine to ‘deal with my hair.’ ”
The routine continued until she went to college and met other Black women who wore their hair naturally. Soon, Ms. Hughes quit relaxers.
Social and economic pressures have long compelled Black girls and women to straighten their hair to conform to Eurocentric beauty standards. But chemical straighteners are stinky and costly and sometimes cause painful scalp burns. Mounting evidence now shows they could be a health hazard.
Relaxers can contain carcinogens, such as formaldehyde-releasing agents, phthalates, and other endocrine-disrupting compounds, according to National Institutes of Health studies. The compounds can mimic the body’s hormones and have been linked to breast, uterine, and ovarian cancers, studies show.
African American women’s often frequent and lifelong application of chemical relaxers to their hair and scalp might explain why hormone-related cancers kill disproportionately more Black than White women, say researchers and cancer doctors.
“What’s in these products is harmful,” said Tamarra James-Todd, PhD, an epidemiology professor at Harvard T.H. Chan School of Public Health, Boston, who has studied straightening products for the past 20 years.
She believes manufacturers, policymakers, and physicians should warn consumers that relaxers might cause cancer and other health problems.
But regulators have been slow to act, physicians have been reluctant to take up the cause, and racism continues to dictate fashion standards that make it tough for women to quit relaxers, products so addictive they’re known as “creamy crack.”
Michelle Obama straightened her hair when Barack Obama served as president because she believed Americans were “not ready” to see her in braids, the former first lady said after leaving the White House. The U.S. military still prohibited popular Black hairstyles such as dreadlocks and twists while the nation’s first Black president was in office.
California in 2019 became the first of nearly two dozen states to ban race-based hair discrimination. Last year, the U.S. House of Representatives passed similar legislation, known as the CROWN Act, for Creating a Respectful and Open World for Natural Hair. But the bill failed in the Senate.
The need for legislation underscores the challenges Black girls and women face at school and in the workplace.
“You have to pick your struggles,” said Atlanta-based surgical oncologist Ryland J. Gore, MD. She informs her breast cancer patients about the increased cancer risk from relaxers. Despite her knowledge, however, Dr. Gore continues to use chemical straighteners on her own hair, as she has since she was about 7 years old.
“Your hair tells a story,” she said.
In conversations with patients, Dr. Gore sometimes talks about how African American women once wove messages into their braids about the route to take on the Underground Railroad as they sought freedom from slavery.
“It’s just a deep discussion,” one that touches on culture, history, and research into current hairstyling practices, she said. “The data is out there. So patients should be warned, and then they can make a decision.”
The first hint of a connection between hair products and health issues surfaced in the 1990s. Doctors began seeing signs of sexual maturation in Black babies and young girls who developed breasts and pubic hair after using shampoo containing estrogen or placental extract. When the girls stopped using the shampoo, the hair and breast development receded, according to a study published in the journal Clinical Pediatrics in 1998.
Since then, Dr. James-Todd and other researchers have linked chemicals in hair products to a variety of health issues more prevalent among Black women – from early puberty to preterm birth, obesity, and diabetes.
In recent years, researchers have focused on a possible connection between ingredients in chemical relaxers and hormone-related cancers, like the one Ms. Hughes developed, which tend to be more aggressive and deadly in Black women.
A 2017 study found White women who used chemical relaxers were nearly twice as likely to develop breast cancer as those who did not use them. Because the vast majority of the Black study participants used relaxers, researchers could not effectively test the association in Black women, said lead author Adana Llanos, PhD, associate professor of epidemiology at Columbia University’s Mailman School of Public Health, New York.
Researchers did test it in 2020.
The so-called Sister Study, a landmark National Institute of Environmental Health Sciences investigation into the causes of breast cancer and related diseases, followed 50,000 U.S. women whose sisters had been diagnosed with breast cancer and who were cancer-free when they enrolled. Regardless of race, women who reported using relaxers in the prior year were 18% more likely to be diagnosed with breast cancer. Those who used relaxers at least every 5-8 weeks had a 31% higher breast cancer risk.
Nearly 75% of the Black sisters used relaxers in the prior year, compared with 3% of the non-Hispanic White sisters. Three-quarters of Black women self-reported using the straighteners as adolescents, and frequent use of chemical straighteners during adolescence raised the risk of premenopausal breast cancer, a 2021 NIH-funded study in the International Journal of Cancer found.
Another 2021 analysis of the Sister Study data showed sisters who self-reported that they frequently used relaxers or pressing products doubled their ovarian cancer risk. In 2022, another study found frequent use more than doubled uterine cancer risk.
After researchers discovered the link with uterine cancer, some called for policy changes and other measures to reduce exposure to chemical relaxers.
“It is time to intervene,” Dr. Llanos and her colleagues wrote in a Journal of the National Cancer Institute editorial accompanying the uterine cancer analysis. While acknowledging the need for more research, they issued a “call for action.”
No one can say that using permanent hair straighteners will give you cancer, Dr. Llanos said in an interview. “That’s not how cancer works,” she said, noting that some smokers never develop lung cancer, despite tobacco use being a known risk factor.
The body of research linking hair straighteners and cancer is more limited, said Dr. Llanos, who quit using chemical relaxers 15 years ago. But, she asked rhetorically, “Do we need to do the research for 50 more years to know that chemical relaxers are harmful?”
Charlotte R. Gamble, MD, a gynecological oncologist whose Washington, D.C., practice includes Black women with uterine and ovarian cancer, said she and her colleagues see the uterine cancer study findings as worthy of further exploration – but not yet worthy of discussion with patients.
“The jury’s out for me personally,” she said. “There’s so much more data that’s needed.”
Meanwhile, Dr. James-Todd and other researchers believe they have built a solid body of evidence.
“There are enough things we do know to begin taking action, developing interventions, providing useful information to clinicians and patients and the general public,” said Traci N. Bethea, PhD, assistant professor in the Office of Minority Health and Health Disparities Research at Georgetown University.
Responsibility for regulating personal-care products, including chemical hair straighteners and hair dyes – which also have been linked to hormone-related cancers – lies with the Food and Drug Administration. But the FDA does not subject personal-care products to the same approval process it uses for food and drugs. The FDA restricts only 11 categories of chemicals used in cosmetics, while concerns about health effects have prompted the European Union to restrict the use of at least 2,400 substances.
In March, Reps. Ayanna Pressley (D-Mass.) and Shontel Brown (D-Ohio) asked the FDA to investigate the potential health threat posed by chemical relaxers. An FDA representative said the agency would look into it.
Natural hairstyles are enjoying a resurgence among Black girls and women, but many continue to rely on the creamy crack, said Dede Teteh, DrPH, assistant professor of public health at Chapman University, Irvine, Calif.
She had her first straightening perm at 8 and has struggled to withdraw from relaxers as an adult, said Dr. Teteh, who now wears locs. Not long ago, she considered chemically straightening her hair for an academic job interview because she didn’t want her hair to “be a hindrance” when she appeared before White professors.
Dr. Teteh led “The Cost of Beauty,” a hair-health research project published in 2017. She and her team interviewed 91 Black women in Southern California. Some became “combative” at the idea of quitting relaxers and claimed “everything can cause cancer.”
Their reactions speak to the challenges Black women face in America, Dr. Teteh said.
“It’s not that people do not want to hear the information related to their health,” she said. “But they want people to share the information in a way that it’s really empathetic to the plight of being Black here in the United States.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.
Deanna Denham Hughes was stunned when she was diagnosed with ovarian cancer in 2022. She was only 32. She had no family history of cancer, and tests found no genetic link. Ms. Hughes wondered why she, an otherwise healthy Black mother of two, would develop a malignancy known as a “silent killer.”
After emergency surgery to remove the mass, along with her ovaries, uterus, fallopian tubes, and appendix, Ms. Hughes said, she saw an Instagram post in which a woman with uterine cancer linked her condition to chemical hair straighteners.
“I almost fell over,” she said from her home in Smyrna, Ga.
When Ms. Hughes was about 4, her mother began applying a chemical straightener, or relaxer, to her hair every 6-8 weeks. “It burned, and it smelled awful,” Ms. Hughes recalled. “But it was just part of our routine to ‘deal with my hair.’ ”
The routine continued until she went to college and met other Black women who wore their hair naturally. Soon, Ms. Hughes quit relaxers.
Social and economic pressures have long compelled Black girls and women to straighten their hair to conform to Eurocentric beauty standards. But chemical straighteners are stinky and costly and sometimes cause painful scalp burns. Mounting evidence now shows they could be a health hazard.
Relaxers can contain carcinogens, such as formaldehyde-releasing agents, phthalates, and other endocrine-disrupting compounds, according to National Institutes of Health studies. The compounds can mimic the body’s hormones and have been linked to breast, uterine, and ovarian cancers, studies show.
African American women’s often frequent and lifelong application of chemical relaxers to their hair and scalp might explain why hormone-related cancers kill disproportionately more Black than White women, say researchers and cancer doctors.
“What’s in these products is harmful,” said Tamarra James-Todd, PhD, an epidemiology professor at Harvard T.H. Chan School of Public Health, Boston, who has studied straightening products for the past 20 years.
She believes manufacturers, policymakers, and physicians should warn consumers that relaxers might cause cancer and other health problems.
But regulators have been slow to act, physicians have been reluctant to take up the cause, and racism continues to dictate fashion standards that make it tough for women to quit relaxers, products so addictive they’re known as “creamy crack.”
Michelle Obama straightened her hair when Barack Obama served as president because she believed Americans were “not ready” to see her in braids, the former first lady said after leaving the White House. The U.S. military still prohibited popular Black hairstyles such as dreadlocks and twists while the nation’s first Black president was in office.
California in 2019 became the first of nearly two dozen states to ban race-based hair discrimination. Last year, the U.S. House of Representatives passed similar legislation, known as the CROWN Act, for Creating a Respectful and Open World for Natural Hair. But the bill failed in the Senate.
The need for legislation underscores the challenges Black girls and women face at school and in the workplace.
“You have to pick your struggles,” said Atlanta-based surgical oncologist Ryland J. Gore, MD. She informs her breast cancer patients about the increased cancer risk from relaxers. Despite her knowledge, however, Dr. Gore continues to use chemical straighteners on her own hair, as she has since she was about 7 years old.
“Your hair tells a story,” she said.
In conversations with patients, Dr. Gore sometimes talks about how African American women once wove messages into their braids about the route to take on the Underground Railroad as they sought freedom from slavery.
“It’s just a deep discussion,” one that touches on culture, history, and research into current hairstyling practices, she said. “The data is out there. So patients should be warned, and then they can make a decision.”
The first hint of a connection between hair products and health issues surfaced in the 1990s. Doctors began seeing signs of sexual maturation in Black babies and young girls who developed breasts and pubic hair after using shampoo containing estrogen or placental extract. When the girls stopped using the shampoo, the hair and breast development receded, according to a study published in the journal Clinical Pediatrics in 1998.
Since then, Dr. James-Todd and other researchers have linked chemicals in hair products to a variety of health issues more prevalent among Black women – from early puberty to preterm birth, obesity, and diabetes.
In recent years, researchers have focused on a possible connection between ingredients in chemical relaxers and hormone-related cancers, like the one Ms. Hughes developed, which tend to be more aggressive and deadly in Black women.
A 2017 study found White women who used chemical relaxers were nearly twice as likely to develop breast cancer as those who did not use them. Because the vast majority of the Black study participants used relaxers, researchers could not effectively test the association in Black women, said lead author Adana Llanos, PhD, associate professor of epidemiology at Columbia University’s Mailman School of Public Health, New York.
Researchers did test it in 2020.
The so-called Sister Study, a landmark National Institute of Environmental Health Sciences investigation into the causes of breast cancer and related diseases, followed 50,000 U.S. women whose sisters had been diagnosed with breast cancer and who were cancer-free when they enrolled. Regardless of race, women who reported using relaxers in the prior year were 18% more likely to be diagnosed with breast cancer. Those who used relaxers at least every 5-8 weeks had a 31% higher breast cancer risk.
Nearly 75% of the Black sisters used relaxers in the prior year, compared with 3% of the non-Hispanic White sisters. Three-quarters of Black women self-reported using the straighteners as adolescents, and frequent use of chemical straighteners during adolescence raised the risk of premenopausal breast cancer, a 2021 NIH-funded study in the International Journal of Cancer found.
Another 2021 analysis of the Sister Study data showed sisters who self-reported that they frequently used relaxers or pressing products doubled their ovarian cancer risk. In 2022, another study found frequent use more than doubled uterine cancer risk.
After researchers discovered the link with uterine cancer, some called for policy changes and other measures to reduce exposure to chemical relaxers.
“It is time to intervene,” Dr. Llanos and her colleagues wrote in a Journal of the National Cancer Institute editorial accompanying the uterine cancer analysis. While acknowledging the need for more research, they issued a “call for action.”
No one can say that using permanent hair straighteners will give you cancer, Dr. Llanos said in an interview. “That’s not how cancer works,” she said, noting that some smokers never develop lung cancer, despite tobacco use being a known risk factor.
The body of research linking hair straighteners and cancer is more limited, said Dr. Llanos, who quit using chemical relaxers 15 years ago. But, she asked rhetorically, “Do we need to do the research for 50 more years to know that chemical relaxers are harmful?”
Charlotte R. Gamble, MD, a gynecological oncologist whose Washington, D.C., practice includes Black women with uterine and ovarian cancer, said she and her colleagues see the uterine cancer study findings as worthy of further exploration – but not yet worthy of discussion with patients.
“The jury’s out for me personally,” she said. “There’s so much more data that’s needed.”
Meanwhile, Dr. James-Todd and other researchers believe they have built a solid body of evidence.
“There are enough things we do know to begin taking action, developing interventions, providing useful information to clinicians and patients and the general public,” said Traci N. Bethea, PhD, assistant professor in the Office of Minority Health and Health Disparities Research at Georgetown University.
Responsibility for regulating personal-care products, including chemical hair straighteners and hair dyes – which also have been linked to hormone-related cancers – lies with the Food and Drug Administration. But the FDA does not subject personal-care products to the same approval process it uses for food and drugs. The FDA restricts only 11 categories of chemicals used in cosmetics, while concerns about health effects have prompted the European Union to restrict the use of at least 2,400 substances.
In March, Reps. Ayanna Pressley (D-Mass.) and Shontel Brown (D-Ohio) asked the FDA to investigate the potential health threat posed by chemical relaxers. An FDA representative said the agency would look into it.
Natural hairstyles are enjoying a resurgence among Black girls and women, but many continue to rely on the creamy crack, said Dede Teteh, DrPH, assistant professor of public health at Chapman University, Irvine, Calif.
She had her first straightening perm at 8 and has struggled to withdraw from relaxers as an adult, said Dr. Teteh, who now wears locs. Not long ago, she considered chemically straightening her hair for an academic job interview because she didn’t want her hair to “be a hindrance” when she appeared before White professors.
Dr. Teteh led “The Cost of Beauty,” a hair-health research project published in 2017. She and her team interviewed 91 Black women in Southern California. Some became “combative” at the idea of quitting relaxers and claimed “everything can cause cancer.”
Their reactions speak to the challenges Black women face in America, Dr. Teteh said.
“It’s not that people do not want to hear the information related to their health,” she said. “But they want people to share the information in a way that it’s really empathetic to the plight of being Black here in the United States.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.
Deanna Denham Hughes was stunned when she was diagnosed with ovarian cancer in 2022. She was only 32. She had no family history of cancer, and tests found no genetic link. Ms. Hughes wondered why she, an otherwise healthy Black mother of two, would develop a malignancy known as a “silent killer.”
After emergency surgery to remove the mass, along with her ovaries, uterus, fallopian tubes, and appendix, Ms. Hughes said, she saw an Instagram post in which a woman with uterine cancer linked her condition to chemical hair straighteners.
“I almost fell over,” she said from her home in Smyrna, Ga.
When Ms. Hughes was about 4, her mother began applying a chemical straightener, or relaxer, to her hair every 6-8 weeks. “It burned, and it smelled awful,” Ms. Hughes recalled. “But it was just part of our routine to ‘deal with my hair.’ ”
The routine continued until she went to college and met other Black women who wore their hair naturally. Soon, Ms. Hughes quit relaxers.
Social and economic pressures have long compelled Black girls and women to straighten their hair to conform to Eurocentric beauty standards. But chemical straighteners are stinky and costly and sometimes cause painful scalp burns. Mounting evidence now shows they could be a health hazard.
Relaxers can contain carcinogens, such as formaldehyde-releasing agents, phthalates, and other endocrine-disrupting compounds, according to National Institutes of Health studies. The compounds can mimic the body’s hormones and have been linked to breast, uterine, and ovarian cancers, studies show.
African American women’s often frequent and lifelong application of chemical relaxers to their hair and scalp might explain why hormone-related cancers kill disproportionately more Black than White women, say researchers and cancer doctors.
“What’s in these products is harmful,” said Tamarra James-Todd, PhD, an epidemiology professor at Harvard T.H. Chan School of Public Health, Boston, who has studied straightening products for the past 20 years.
She believes manufacturers, policymakers, and physicians should warn consumers that relaxers might cause cancer and other health problems.
But regulators have been slow to act, physicians have been reluctant to take up the cause, and racism continues to dictate fashion standards that make it tough for women to quit relaxers, products so addictive they’re known as “creamy crack.”
Michelle Obama straightened her hair when Barack Obama served as president because she believed Americans were “not ready” to see her in braids, the former first lady said after leaving the White House. The U.S. military still prohibited popular Black hairstyles such as dreadlocks and twists while the nation’s first Black president was in office.
California in 2019 became the first of nearly two dozen states to ban race-based hair discrimination. Last year, the U.S. House of Representatives passed similar legislation, known as the CROWN Act, for Creating a Respectful and Open World for Natural Hair. But the bill failed in the Senate.
The need for legislation underscores the challenges Black girls and women face at school and in the workplace.
“You have to pick your struggles,” said Atlanta-based surgical oncologist Ryland J. Gore, MD. She informs her breast cancer patients about the increased cancer risk from relaxers. Despite her knowledge, however, Dr. Gore continues to use chemical straighteners on her own hair, as she has since she was about 7 years old.
“Your hair tells a story,” she said.
In conversations with patients, Dr. Gore sometimes talks about how African American women once wove messages into their braids about the route to take on the Underground Railroad as they sought freedom from slavery.
“It’s just a deep discussion,” one that touches on culture, history, and research into current hairstyling practices, she said. “The data is out there. So patients should be warned, and then they can make a decision.”
The first hint of a connection between hair products and health issues surfaced in the 1990s. Doctors began seeing signs of sexual maturation in Black babies and young girls who developed breasts and pubic hair after using shampoo containing estrogen or placental extract. When the girls stopped using the shampoo, the hair and breast development receded, according to a study published in the journal Clinical Pediatrics in 1998.
Since then, Dr. James-Todd and other researchers have linked chemicals in hair products to a variety of health issues more prevalent among Black women – from early puberty to preterm birth, obesity, and diabetes.
In recent years, researchers have focused on a possible connection between ingredients in chemical relaxers and hormone-related cancers, like the one Ms. Hughes developed, which tend to be more aggressive and deadly in Black women.
A 2017 study found White women who used chemical relaxers were nearly twice as likely to develop breast cancer as those who did not use them. Because the vast majority of the Black study participants used relaxers, researchers could not effectively test the association in Black women, said lead author Adana Llanos, PhD, associate professor of epidemiology at Columbia University’s Mailman School of Public Health, New York.
Researchers did test it in 2020.
The so-called Sister Study, a landmark National Institute of Environmental Health Sciences investigation into the causes of breast cancer and related diseases, followed 50,000 U.S. women whose sisters had been diagnosed with breast cancer and who were cancer-free when they enrolled. Regardless of race, women who reported using relaxers in the prior year were 18% more likely to be diagnosed with breast cancer. Those who used relaxers at least every 5-8 weeks had a 31% higher breast cancer risk.
Nearly 75% of the Black sisters used relaxers in the prior year, compared with 3% of the non-Hispanic White sisters. Three-quarters of Black women self-reported using the straighteners as adolescents, and frequent use of chemical straighteners during adolescence raised the risk of premenopausal breast cancer, a 2021 NIH-funded study in the International Journal of Cancer found.
Another 2021 analysis of the Sister Study data showed sisters who self-reported that they frequently used relaxers or pressing products doubled their ovarian cancer risk. In 2022, another study found frequent use more than doubled uterine cancer risk.
After researchers discovered the link with uterine cancer, some called for policy changes and other measures to reduce exposure to chemical relaxers.
“It is time to intervene,” Dr. Llanos and her colleagues wrote in a Journal of the National Cancer Institute editorial accompanying the uterine cancer analysis. While acknowledging the need for more research, they issued a “call for action.”
No one can say that using permanent hair straighteners will give you cancer, Dr. Llanos said in an interview. “That’s not how cancer works,” she said, noting that some smokers never develop lung cancer, despite tobacco use being a known risk factor.
The body of research linking hair straighteners and cancer is more limited, said Dr. Llanos, who quit using chemical relaxers 15 years ago. But, she asked rhetorically, “Do we need to do the research for 50 more years to know that chemical relaxers are harmful?”
Charlotte R. Gamble, MD, a gynecological oncologist whose Washington, D.C., practice includes Black women with uterine and ovarian cancer, said she and her colleagues see the uterine cancer study findings as worthy of further exploration – but not yet worthy of discussion with patients.
“The jury’s out for me personally,” she said. “There’s so much more data that’s needed.”
Meanwhile, Dr. James-Todd and other researchers believe they have built a solid body of evidence.
“There are enough things we do know to begin taking action, developing interventions, providing useful information to clinicians and patients and the general public,” said Traci N. Bethea, PhD, assistant professor in the Office of Minority Health and Health Disparities Research at Georgetown University.
Responsibility for regulating personal-care products, including chemical hair straighteners and hair dyes – which also have been linked to hormone-related cancers – lies with the Food and Drug Administration. But the FDA does not subject personal-care products to the same approval process it uses for food and drugs. The FDA restricts only 11 categories of chemicals used in cosmetics, while concerns about health effects have prompted the European Union to restrict the use of at least 2,400 substances.
In March, Reps. Ayanna Pressley (D-Mass.) and Shontel Brown (D-Ohio) asked the FDA to investigate the potential health threat posed by chemical relaxers. An FDA representative said the agency would look into it.
Natural hairstyles are enjoying a resurgence among Black girls and women, but many continue to rely on the creamy crack, said Dede Teteh, DrPH, assistant professor of public health at Chapman University, Irvine, Calif.
She had her first straightening perm at 8 and has struggled to withdraw from relaxers as an adult, said Dr. Teteh, who now wears locs. Not long ago, she considered chemically straightening her hair for an academic job interview because she didn’t want her hair to “be a hindrance” when she appeared before White professors.
Dr. Teteh led “The Cost of Beauty,” a hair-health research project published in 2017. She and her team interviewed 91 Black women in Southern California. Some became “combative” at the idea of quitting relaxers and claimed “everything can cause cancer.”
Their reactions speak to the challenges Black women face in America, Dr. Teteh said.
“It’s not that people do not want to hear the information related to their health,” she said. “But they want people to share the information in a way that it’s really empathetic to the plight of being Black here in the United States.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.
Managing clinician burnout: Challenges and opportunities
Physicians have some of the highest rates of burnout among all professions.1 Complicating matters is that clinicians (including residents)2 may avoid seeking treatment out of fear it will affect their license or privileges.3 In this article, we consider burnout in greater detail, as well as ways of successfully addressing the level of burnout in the profession (FIGURE 1), including steps individual practitioners, health care entities, and regulators should consider to reduce burnout and its harmful effects.
How burnout becomes a problem
Six general factors are commonly identified as leading to clinician career dissatisfaction and burnout:4
1. work overload
2. lack of autonomy and control
3. inadequate rewards, financial and otherwise
4. work-home schedules
5. perception of lack of fairness
6. values conflict between the clinician and employer (including a breakdown of professional community).
At the top of the list of causes of burnout is often “administrative and bureaucratic headaches.”5 More specifically, electronic health records (EHRs), including computerized order entry, is commonly cited as a major cause of burnout.6,7 According to some studies, clinicians spend as much as 49% of working time doing clerical work,8 and studies found the extension of work into home life.9
Increased measurement of performance metrics in health care services are a significant contributor to physician burnout.10 These include pressure to see more patients, perform more procedures, and respond quickly to patient requests (eg, through email).7 As we will see, medical malpractice cases, or the risk of such cases, have also played a role in burnout in some medical specialties.11 The pandemic also contributed, at least temporarily, to burnout.12,13
Rates of burnout among physicians are notably higher than among the general population14 or other professions.6 Although physicians have generally entered clinical practice with lower rates of burnout than the general population,15 The American College of Obstetricians and Gynecologists (ACOG) reports that 40% to 75% of ObGyns “experience some form of professional burnout.”16,17 Other source(s) cite that 53% of ObGyns report burnout (TABLE 1).
Code QD85
Burnout is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by 3 dimensions:
- feelings of energy depletion or exhaustion
- increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job
- a sense of ineffectiveness and lack of accomplishment. Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life. Exclusions to burnout diagnosis include adjustment disorder, disorders specifically associated with stress, anxiety or fear-related disorders, and mood disorders.
Reference
1. International Classification of Diseases Eleventh Revision (ICD-11). Geneva, Switzerland: World Health Organization; 2022.
Burnout undoubtedly contributes to professionals leaving practice, leading to a significant shortage of ObGyns.18 It also raises several significant legal concerns. Despite the enormity and seriousness of the problem, there is considerable optimism and assurance that the epidemic of burnout is solvable on the individual, specialty, and profession-wide levels. ACOG and other organizations have made suggestions for physicians, the profession, and to health care institutions for reducing burnout.19 This is not to say that solutions are simple or easy for individual professionals or institutions, but they are within the reach of the profession (FIGURE 2).
Suicide among health care professionals is one other concern (TABLE 2)20 and theoretically can stem from burnout, depression, and other psychosocial concerns.
Costs of clinician burnout
Burnout is endemic among health care providers, with numerous studies detailing the professional, emotional, and financial costs. Prior to the pandemic, one analysis of nationwide fiscal costs associated with burnout estimated an annual cost of $4.6B due to physician turnover and reduced clinical hours.21 The COVID-19 epidemic has by all accounts worsened rates of health care worker burnout, particularly for those in high patient-contact positions.22
Female clinicians appear to be differentially affected; in one recent study women reported symptoms of burnout at twice the rate of their male counterparts.23 Whether burnout rates will return to pre-pandemic levels remains an open question, but since burnout is frequently related to one’s own assessment of work-life balance, it is possible that a longer term shift in burnout rates associated with post-pandemic occupational attitudes will be observed.
Combining factors contribute to burnout
Burnout is a universal occupational hazard, but extant data suggest that physicians and other health care providers may be at higher risk. Among physicians, younger age, female gender, and front-line specialty status appear associated with higher burnout rates.24 Given that ObGyn physicians are overwhelmingly female (60% of physicians and 86% of residents),25,26 gender-related burnout factors exist alongside other specific occupational burnout risks. While gender parity has been achieved among health care providers, gender disparities persist in terms of those in leadership positions, compensation, and other factors.22
The smattering of evidence suggesting that ObGyns have higher rates of burnout than many other specialties is understandable given the unique legal challenges confronting ObGyn practice. This may be of special significance because ObGyn malpractice insurance rates are among the highest of all specialties.27 The overall shortage of ObGyns has been exacerbated by the demonstrated negative effects on training and workforce representation stemming from recent legislation that has the effect of criminalizing certain aspects of ObGyn practice;28 for instance, uncertainty regarding abortion regulations.
These negative effects are particularly heightened in states in which the law is in flux or where there are continuing efforts to substantially limit access to abortion. The efforts to increase civil and even criminal penalties related to abortion care challenge ObGyns’ professional practices, as legal rules are frequently changing. In some states, ObGyns may face additional workloads secondary to a flight of ObGyns from restrictive jurisdictions in addition to legal and professional repercussions. In a small study of 19 genetic counselors dealing with restrictive legislation in the state of Ohio,29 increased stress and burnout rates were identified as a consequence of practice uncertainties under this legislation. It is certain that other professionals working in reproductive health care are similarly affected.30
The programs provide individual resources to providers in distress, periodically survey initiatives at Stanford to assess burnout at the organizational level, and provide input designed to spur organizational change to reduce the burden of burnout. Ways that they build community and connections include:
- Live Story Rounds events (as told by Stanford Medicine physicians)
- Commensality Groups (facilitated small discussion groups built around tested evidence)
- Aim to increase sense of connection and collegiality among physicians and build comradery at work
- CME-accredited physician wellness forum, including annual doctor’s day events
Continue to: Assessment of burnout...
Assessment of burnout
Numerous scales for the assessment of burnout exist. Of these, the 22-item Maslach Burnout Inventory (MBI) is the best studied. The MBI is a well-investigated tool for assessing burnout. The MBI consists of 3 major subscales measuring overall burnout, emotional exhaustion, depersonalization, and low personal accomplishment. It exists in numerous forms. For instance, the MBI-HSS (MP), adapted for medical personnel, is available. However, the most commonly used form for assessing burnout in clinicians is the MBI-HHS (Human Services Survey); approximately 85% of all burnout studies examined in a recent meta-analysis used this survey version.31 As those authors commented, while burnout is a recognized phenomenon, a great deal of variability in study design, interpretation of subscale scores, and sample selection makes generalizations regarding burnout difficult to assess.
The MBI in various forms has been extensively used over the past 40 years to assess burnout amongst physicians and physicians in training. While not the only instrument designed to measure such factors, it is by far the most prevalent. Williamson and colleagues32 compared the MBI with several other measures of quality of life and found good correlation between the various instruments used, a finding replicated by other studies.33 Brady and colleagues compared item responses to the Stanford Professional Fulfillment Index and the Min-Z Single-item Burnout scale (a 1-item screening measure) to MBI’s Emotional Exhaustion and Depersonalization subscales. Basing their findings on a survey of more than 1,300 physicians, they found that all analyzed scales were significantly correlated with such adverse outcomes as depression, distress, or intent to leave the profession.
It is important to note that most surveys of clinician burnout were conducted prior to the pandemic. While the psychometric analyses of the MBI and other scales are likely still germane, observed rates of clinician burnout have likely increased. Thus, comparisons of pre- and post-pandemic studies should factor in an increase in the incidence and prevalence of burnout.
Management strategies
In general, there are several interventions for managing burnout34:
- individual-focused (including self-care and communications-skills workshops)
- mindfulness training
- yoga
- meditation
- organizational/structural (workload reduction, schedule realignment, teamwork training, and group-delivered stress management interventions)
- combination(s) of the above.
There is little evidence to suggest that any particular individual intervention (whether delivered in individual or group-based formats) is superior to any other in treating clinician burnout. A recent analysis of 24 studies employing mindfulness-based interventions demonstrated generally positive results for such interventions.35 Other studies have also found general support for mindfulness-based interventions, although mindfulness is often integrated with other stress-reduction techniques, such as meditation, yoga, and communication skills. Such interventions are nonspecific but generally effective.
An accumulation of evidence to date suggests that a combination of individual and organizational interventions is most effective in combatting clinician burnout. No individual intervention can be successful without addressing root causes, such as overscheduling, lack of organizational support, and the effect of restrictive legislation on practice.
Several large teaching hospitals have established programs to address physician and health care provider burnout. Notable among these is the Stanford University School of Medicine’s WellMD and WellPhD programs (https://wellmd.stanford.edu/about.html). These programs were described by Olson and colleagues36 as using a model focused on practice efficiency, organizational culture, and personal resilience to enhance physicians’ well-being. (See “Aspects of the WellMD and WellPhD programs from Stanford University.”)
A growing number of institutions have established burnout programs to support physicians experiencing work/life imbalances and other aspects of burnout.37 In general, these share common features of assessment, individual and/or group intervention, and organizational change. Fear of repercussion may be one factor preventing physicians from seeking individual treatment for burnout.38 Importantly, they emphasize the need for professional confidentiality when offering treatment to patients within organizational settings. Those authors also reported that a focus on organizational engagement may be an important factor in addressing burnout in female physicians, as they tend to report lower levels of organizational engagement.
Continue to: Legal considerations...
Legal considerations
Until recently, physician burnout “received little notice in the legal literature.”39 Although there have been burnout legal consequences in the past, the legal issues are now becoming more visible.40
Medical malpractice
A well-documented consequence of burnout is an increase in errors.14 Medical errors, of course, are at the heart of malpractice claims. Technically, malpractice is medical or professional negligence. It is the breach of a duty owed by the physician, or other provider, or organization (defendant) to the patient, which causes injury to the plaintiff/patient.41
“Medical error” is generally a meaningful deviation from the “standard of care” or accepted medical practice.42 Many medical errors do not cause injury to the patient; in those cases, the negligence does not result in liability. In instances in which the negligence causes harm, the clinician and health care facility may be subject to liability for that injury. Fortunately, however, for a variety of reasons, most harmful medical errors do not result in a medical malpractice claim or lawsuit. The absence of a good clinician-patient relationship is likely associated with an increased inclination of a patient to file a malpractice action.43Clinician burnout may, therefore, contribute to increased malpractice claims in two ways. First, burnout likely leads to increased medical errors, perhaps because burnout is associated with lower concentration, inattention, reduced cognitive vigilance, and fatigue.8,44 It may also lead to less time with patients, reduced patient empathy, and lower patient rapport, which may make injured patients more likely to file a claim or lawsuit.45 Because the relationshipbetween burnout and medical error is bidirectional, malpractice claims tend to increase burnout, which increases error. Given the time it takes to resolve most malpractice claims, the uncertainty of medical malpractice may be especially stressful for health care providers.46,47
Burnout is not a mitigating factor in malpractice. Our sympathies may go out to a professional suffering from burnout, but it does not excuse or reduce liability—it may, indeed, be an aggravating factor. Clinicians who can diagnose burnout and know its negative consequences but fail to deal with their own burnout may be demonstrating negligence if there has been harm to a patient related to the burnout.48
Institutional or corporate liability to patients
Health care institutions have obligations to avoid injury to patients. Just as poorly maintained medical equipment may harm patients, so may burned-out professionals. Therefore, institutions have some obligation to supervise and avoid the increased risks to patients posed by professionals suffering from burnout.
Respondeat superior and institutional negligence. Institutional liability may arise in two ways, the first through agency, or respondeat superior. That is, if the physician or other professional is an employee (or similar agent) of the health care institution, that institution is generally responsible for the physician’s negligence during the employment.49 Even if the physician is not an employee (for example, an independent contractor providing care or using the hospital facilities), the health care facility may be liable for the physician’s negligence.50 Liability may occur, for example, if the health care facility was aware that the physician was engaged in careless practice or was otherwise a risk to patients but the facility did not take steps to avoid those risks.51 The basis for liability is that the health care organization owes a duty to patients to take reasonable care to ensure that its facilities are not used to injure patients negligently.52 Just as it must take care that unqualified physicians are not granted privileges to practice, it also must take reasonable steps to protect patients when it is aware (through nurses or other agents) of a physician’s negligent practice.
In one case, for example, the court found liability where a staff member had “severe” burnout in a physician’s office and failed to read fetal monitoring strips. The physician was found negligent for relying on the staff member who was obviously making errors in interpretation of fetal distress.53
Continue to: Legal obligations of health care organizations to physicians and others...
Legal obligations of health care organizations to physicians and others
In addition to obligations to patients, health care organizations may have obligations to employees (and others) at risk for injury. For example, assume a patient is diagnosed with a highly contagious disease. The health care organization would be obligated to warn, and take reasonable steps to protect, the staff (employees and independent contractors) from being harmed from exposure to the disease. This principle may apply to coworkers of employees with significant burnout, thereby presenting a danger in the workplace. The liability issue is more difficult for employees experiencing job-related burnout themselves. Organizations generally compensate injured employees through no-fault workers’ compensation (an insurance-like system); for independent contractors, the liability is usually through a tort claim (negligence).54
In modern times, a focus has been on preventing those injuries, not just providing compensation after injuries have occurred. Notably, federal and state occupational health and safety laws (particularly the Occupational Safety and Health Administration [OSHA]) require most organizations (including those employing health care providers) to take steps to mitigate various kinds of worker injuries.55
Although these worker protections have commonly been applied to hospitals and other health care providers, burnout has not traditionally been a significant concern in federal or state OSHA enforcement. For example, no formal federal OSHA regulations govern work-related burnout. Regulators, including OSHA, are increasingly interested in burnout that may affect many employees. OSHA has several recommendations for reducing health care work burnout.56 The Surgeon General has expressed similar concerns.57 The federal government recently allocated $103 million from the American Rescue Plan to address burnout among health care workers.58 Also, OSHA appears to be increasing its oversight of healthcare-institution-worker injuries.55
Is burnout a “disability”?
The federal Americans with Disabilities Act (ADA) and similar state laws prohibit discrimination based on disability.59 A disability is defined as a “physical or mental impairment that substantially limits one or more major life activities” or “perceived as having such an impairment.”60 The initial issue is whether burnout is a “mental impairment.” As noted earlier, it is not officially a “medical condition.”61 To date, the United Nations has classified it as an “occupational phenomenon.”62 It may, therefore, not qualify under the ADA, even if it “interferes with a major life activity.” There is, however, some movement toward defining burnout as a mental condition. Even if defined as a disability, there would still be legal issues of how severe it must be to qualify as a disability and the proper accommodation. Apart from the legal definition of an ADA disability, as a practical matter it likely is in the best interest of health care facilities to provide accommodations that reduce burnout. A number of strategies to decrease the incidence of burnout include the role of health care systems (FIGURE 2).
In conclusion we look at several things that can be done to “treat” or reduce burnout. That effort requires the cooperation of physicians and other providers, health care facilities, training programs, licensing authorities, and professional organizations. See suggestions below.
Conclusion
There are many excellent suggestions for reducing burnout and improving patient care and practitioner satisfaction.63-65 We conclude with a summary of some of these suggestions for individual practitioners, health care organizations, the profession, and licensing. It is worth remembering, however, that it will require the efforts of each area to reduce burnout substantially.
For practitioners:
- Engage in quality coaching/therapy on mindfulness and stress management.
- Practice self-care, including exercise and relaxation techniques.
- Make work-life balance a priority.
- Take opportunities for collegial social and professional discussions.
- Prioritize (and periodically assess) your own professional satisfaction and burnout risk.
- Smile—enjoy a sense of humor (endorphins and cortisol).
For health care organizations:
- Urgently work with vendors and regulators to revise electronic health records to reduce their substantial impact on burnout.
- Reduce physicians’ time on clerical and administrative tasks (eg, by enhancing the use of quality AI, scribes, and automated notes from appointments. (This may increase the time they spend with patients.) Eliminate “pajama-time” charting.
- Provide various kinds of confidential professional counseling, therapy, and support related to burnout prevention and treatment, and avoid any penalty or stigma related to their use.
- Provide reasonable flexibility in scheduling.
- Routinely provide employees with information about burnout prevention and services.
- Appoint a wellness officer with authority to ensure the organization maximizes its prevention and treatment services.
- Constantly seek input from practitioners on how to improve the atmosphere for practice to maximize patient care and practitioner satisfaction.
- Provide ample professional and social opportunities for discussing and learning about work-life balance, resilience, intellectual stimulation, and career development.
For regulators, licensors, and professional organizations:
- Work with health care organizations and EHR vendors to substantially reduce the complexity, physician effort, and stress associated with those record systems. Streamlining should, in the future, be part of formally certifying EHR systems.
- Reduce the administrative burden on physicians by modifying complex regulations and using AI and other technology to the extent possible to obtain necessary reimbursement information.
- Eliminate unnecessary data gathering that requires practitioner time or attention.
- Licensing, educational, and certifying bodies should eliminate any questions regarding the diagnosis or treatment of mental health and focus on current (or very recent) impairments.
- Seek funding for research on burnout prevention and treatment.
Dr. H is a 58-year-old ObGyn who, after completing residency, went into solo practice. The practice grew, and Dr. H found it increasingly more challenging to cover, especially the obstetrics sector. Dr. H then merged the practice with a group of 3 other ObGyns. Their practice expanded, and began recruiting recent residency graduates. In time, the practice was bought out by the local hospital health care system. Dr. H was faced with complying with the rules and regulations of that health care system. The electronic health record (EHR) component proved challenging, as did the restrictions on staff hiring (and firing), but Dr. H did receive a paycheck each month and complied with it all. The health care system administrators had clear financial targets Dr. H was to meet each quarter, which created additional pressure. Dr. H used to love being an OB and providing excellent care for every patient, but that sense of accomplishment was being lost.
Dr. H increasingly found it difficult to focus because of mind wandering, especially in the operating room (OR). Thoughts occurred about retirement, the current challenges imposed by “the new way of practicing medicine” (more focused on financial productivity restraints and reimbursement), and EHR challenges. Then Dr. H’s attention would return to the OR case at hand. All of this resulted in considerable stress and emotional exhaustion, and sometimes a sense of being disconnected. A few times, colleagues or nurses had asked Dr. H if everything was “okay,” or if a break would help. Dr. H made more small errors than usual, but Dr. H’s self-assessment was “doing an adequate job.” Patient satisfaction scores (collected routinely by the health care system) declined over the last 9 months.
Six months ago, Dr. H finished doing a laparoscopic total hysterectomy and bilateral salpingo-oophorectomy and got into the right uterine artery. The estimated blood loss was 3,500 mL. Using minimally invasive techniques, Dr. H identified the bleeder and, with monopolar current, got everything under control. The patient went to the post-anesthesia care unit, and all appeared to be in order. Her vital signs were stable, and she was discharged home the same day.
The patient presented 1 week later with lower abdominal and right flank pain. Dr. H addressed the problem in the emergency department and admitted the patient for further evaluation and urology consultation. The right ureter was damaged and obstructed; ultimately, the urologist performed a psoas bladder hitch. The patient recovered slowly, lost several weeks of work, experienced significant pain, and had other disruptions and costs. Additional medical care related to the surgery is ongoing. A health care system committee asked Dr. H to explain the problem. Over the last 6 months, Dr. H’s frustration with practice and being tired and disconnected have increased.
Dr. H has received a letter from a law firm saying that he and the health care system are being sued for malpractice focused on an iatrogenic ureter injury. The letter names two very reputable experts who are prepared to testify that the patient’s injury resulted from clear negligence. Dr. H has told the malpractice carrier absolutely not to settle this case—it is “a sham— without merit.” The health care system has asked Dr. H to take a “burnout test.”
Legal considerations
Dr. H exhibits relatively clear signs of professional burnout. The fact that there was a bad outcome while Dr. H was experiencing burnout is not proof of negligence (or, breach of duty of care to the patient). Nor is it a defense or mitigation to any malpractice that occurred.
In the malpractice case, the plaintiff will have the burden of proving that Dr. H’s treatment was negligent in that it fell below the standard of care. Even if it was a medical error, the question is whether it was negligence. If the patient/plaintiff, using expert witnesses, can prove that Dr. H fell below the standard of care that caused injury, Dr. H may be liable for the resulting extra costs, loss of income, and pain and suffering resulting from the negligent care.
The health care system likely will also be responsible for Dr. H’s negligence, either through respondeat superior (for example, if Dr. H is an employee) or for its own negligence. The case for its negligence is that the nurses and assistants had repeatedly seen him making errors and becoming disengaged (to the extent that they asked Dr. H if “everything is okay” or if a break would help). Furthermore, Dr. H’s patient satisfaction scores have been declining for several months. The plaintiff will argue that Dr. H exhibited classic burnout symptoms with the attendant risks of medical errors. However, the health care system did not take action to protect patients or to assist Dr. H. In short, one way or another, there is some likelihood that the health care system may also be liable if patient injuries are found to have been caused by negligence.
At this point, the health care system also faces the question of how to work with Dr. H in the future. The most pressing question is whether or not to allow Dr. H to continue practicing. If, as it appears, Dr. H is dealing with burnout, the pressure of the malpractice claim could well increase the probability of other medical mistakes. The institution has asked Dr. H to take a burnout test, but it is unclear where things go if the test (as likely) demonstrates significant burnout. This is a counseling and human relations question, at least as much as a legal issue, and the institution should probably proceed in that way—which is, trying to understand and support Dr. H and determining what can be done to address the burnout. At the same time, the system must reasonably assess Dr. H’s fitness to continue practicing as the matters are resolved. Almost everyone shares the goal to provide every individual and corporate opportunity for Dr. H to deal with burnout issues and return to successful practice.
Dr. H will be represented in the malpractice case by counsel provided through the insurance carrier. However, Dr. H would be well advised to retain a trusted and knowledgeable personal attorney. For example, the instruction not to consider settlement is likely misguided, but Dr. H needs to talk with an attorney that Dr. H has chosen and trusts. In addition, the attorney can help guide Dr. H through a rational process of dealing with the health care system, putting the practice in order, and considering the options for the future.
The health care system should reconsider its processes to deal with burnout to ensure the quality of care, patient satisfaction, professional retention, and economic stability. Several burnoutresponse programs have had success in achieving these goals.
What’s the Verdict?
Dr. H received good mental health, legal, and professional advice. As a result, an out of court settlement was reached following pretrial discovery. Dr. H has continued consultation regarding burnout and has returned to productive practice.
- Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clinic Proceed. 2019;94:1681-1694.
- Smith R, Rayburn W. Burnout in obstetrician-gynecologists. Its prevalence, identification, prevention, and reversal. Obstet Gynecol Clin North Am. 2021;48:231-245. https://doi. org/10.1016/j.ogc.2021.06.003
- Patti MG, Schlottmann F, Sarr MG. The problem of burnout among surgeons. JAMA Surg. 2018;153:403-404. doi:10.1001 /jamasurg.2018.0047
- Carrau D, Janis JE. Physician burnout: solutions for individuals and organizations. Plastic and Reconstructive Surgery Global Open. 2021;91-97.
- Southwick R. The key to fixing physician burnout is the workplace not the worker. Contemporary Ob/Gyn. March 13, 2023.
- Patel RS, Bachu R, Adikey A, et al. Factors related to physician burnout and its consequences: a review. Behav Sciences. 2018;8:98.
- Melnick ER, Dyrbye LN, Sinsky CA, et al. The association between perceived electronic health record usability and professional burnout among US physicians. Mayo Clinic Proceed. 2020;95:476-487.
- Shanafelt TD, Dyrbye LN, West CP. Addressing physician burnout: the way forward. JAMA. 2017;317:901-902. doi:10.1001/jama.2017.0076
- Ommaya AK, Cipriano PF, Hoyt DB, et al. Care-centered clinical documentation in the digital environment: Solutions to alleviate burnout. National Academy of Medicine Perspectives. 2018.
- Hartzband P, Groopman J. Physician burnout, interrupted. N Engl J Med. 2020;382:2485-2487. Discussion Paper, National Academy of Medicine. Accessed July 21, 2023. https://nam .edu/care
- Ji YD, Robertson FC, Patel NA, et al. Assessment of risk factors for suicide among US health care professionals. JAMA Surg. 2020;155:713-721. centered-clinical-documentation-digital -environment-solutions-alleviate-burnout/
- Shanafelt TD, West CP, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic. Mayo Clinic Proceed. 2022;97:2248-2258.
- Herber-Valdez C, Kupesic-Plavsic S. Satisfaction and shortfall of OB-GYN physicians and radiologists. J. Ultrasound Obstet Gynecol. 2021;15:387-392.
- Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Burnout among health care professionals: a call to explore and address this underrecognized threat to safe, high-quality care. National Academy of Medicine Perspectives. Accessed July 5, 2017. https://iuhcpe.org/file_manager/1501524077-Burnout -Among-Health-Care-Professionals-A-Call-to-Explore-and -Address-This-Underrecognized-Threat.pdf
- Olson KD. Physician burnout—a leading indicator of health system performance? Mayo Clinic Proceed. 2017;92: 1608-1611.
- American College of Obstetricians and Gynecologists. Why obgyns are burning out. October 28, 2019. Accessed July 21, 2023. https://www.acog.org/news/news-articles/2019/10/why-ob -gyns-are-burning-out#:~:text=A%202017%20report%20 by%20the,exhaustion%20or%20lack%20of%20motivation
- Peckham C. National physician burnout & depression report 2018. Medscape. January 17, 2018. https://nap. nationalacademies.org/catalog/25521/taking-action -against-clinician-burnout-a-systems-approach-to -professional
- Marsa L. Labor pains: The OB-GYN shortage. AAMC News. Nov. 15, 2018. Accessed July 21, 2023. https://www.aamc.org /news-insights/labor-pains-ob-gyn-shortage
- American College of Obstetricians and Gynecologists. Coping with the stress of medical professional liability litigation. ACOG Committee Opinion. February 2005;309:453454. Accessed July 21, 2023. https://www.acog.org/clinical /clinical-guidance/committee-opinion/articles/2013/01 /coping-with-the-stress-of-medical-professional-liability -litigation
- Reith TP. Burnout in United States healthcare professionals: a narrative review. Cureus. 2018;10:e3681. doi: 10.7759 /cureus.3681
- Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. 2019;4:784-790.
- Sullivan D, Sullivan V, Weatherspoon D, et al. Comparison of nurse burnout, before and during the COVID-19 pandemic. Nurs Clin North Am. 2022;57:79-99. doi: 10.1016 /j.cnur.2021.11.006
- Chandawarkar A, Chaparro JD. Burnout in clinicians. Curr Prob Pediatr Adolesc Health Care. 2021;51:101-104. https ://doi.org/10.1016/j.cppeds.2021.101104
- Brady KJS, Sheldrick RC, Ni P, et al. Examining the measurement equivalence of the Maslach Burnout Inventory across age, gender, and specialty groups in US physicians. J Patient-Reported Outcomes. 2021;5.
- Association of American Medical Colleges. Physician Specialty Data Report—Active Physicians by Sex and Specialty, 2021. Accessed June 19, 2023. https://www.aamc .org/data-reports/workforce/data/active-physicians-sex -specialty-2021
- Association of American Medical Colleges. Physician Specialty Data Report—ACGME Residents and Fellows by Sex and Specialty, 2021. Accessed June 19, 2023. https://www .aamc.org/data-reports/workforce/data/acgme-residents -fellows-sex-and-specialty-2021
- Painter LM, Biggans KA, Turner CT. Risk managementobstetrics and gynecology perspective. Clin Obstet Gynecol. 2023;66:331-341. DOI:10.1097/GRF.0000000000000775
- Darney BG, Boniface E, Liberty A. Assessing the effect of abortion restrictions. Obstetr Gynecol. 2023;141:233-235.
- Heuerman AC, Bessett D, Antommaria AHM, et al. Experiences of reproductive genetic counselors with abortion regulations in Ohio. J Genet Counseling. 2022;31:641-652.
- Brandi K, Gill P. Abortion restrictions threaten all reproductive health care clinicians. Am J Public Health. 2023;113:384-385.
- Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of burnout among physicians: a systematic review. JAMA. 2018;320:1131-1150. doi: 10.1001/jama.2018.1277
- Williamson K, Lank PM, Cheema N, et al. Comparing the Maslach Burnout Inventory to other well-being instruments in emergency medicine residents. J Graduate Med Education. 2018;532-536. DOI: http://dx.doi.org/10.4300 /JGME-D-18-00155.1
- Brady KJS, Sheldrick RC, Ni P, et al. Establishing crosswalks between common measures of burnout in US physicians. J Gen Intern Med. 2022;37:777-784.
- Zhang X, Song Y, Jiang T, et al. Interventions to reduce burnout of physicians and nurses: an overview of systematic reviews and meta-analyses. Medicine (Baltimore). 2020;26:e20992. DOI: 10.1097/MD.0000000000020992
- Scheepers RA, Emke H, Ronald M, et al. The impact of mindfulness-based interventions on doctors’ well-being and performance: a systematic review. Med Education. 2020;54:138-149. https://doi.org/10.1111/medu.14020
- Olson K, Marchalik D, Farley H, et al. Organizational strategies to reduce physician burnout and improve professional fulfillment. Curr Prob Pediatr Adolesc Health Care. 2019;49:12. https://doi.org/10.1016/j.cppeds.2019.100664
- Berry LL, Awdish RLA, Swensen SJ. 5 ways to restore depleted health care workers. Harvard Business Rev. February 11, 2022.
- Sullivan AB, Hersh CM, Rensel M, et al. Leadership inequity, burnout, and lower engagement of women in medicine. J Health Serv Psychol. 2023;49:33-39.
- Hoffman S. Healing the healers: legal remedies for physician burnout. Yale J Health Policy Law Ethics. 2018;18:56-113.
- Federation of State Medical Boards. Physician wellness and burnout: report and recommendations of the workgroup on physician wellness and burnout. (Policy adopted by FSMB). April 2018. Accessed July 21, 2023. https://www.fsmb.org /siteassets/advocacy/policies/policy-on-wellness-and -burnout.pdf
- Robinson C, Kettering C, Sanfilippo JS. Medical malpractice lawsuits. Clin Obstet Gynecol. 2023;66:256-260. DOI: https ://doi.org/10.1097/GRF.0000000000000777
- Gittler GJ, Goldstein EJ. The elements of medical malpractice: an overview. Clin Infect Dis. 1996;23:1152-1155.
- Bal BS. An introduction to medical malpractice in the United States. Clin Orthop Relat Res. 2009;467:339-347.
- Tawfik DS, Profit J, Morgenthaler TI, et al. Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Mayo Clinic Proceed. 2018;93: 1571-1580.
- Sundholm B. Elevating physician-patient relationships in the shadow of metric mania. Drexel L Rev. 2020;12:287-330.
- Ghaith S, Campbell RL, Pollock JR, et al. Medical malpractice lawsuits involving trainees in obstetrics and gynecology in the USA. Healthcare. 2022;10:1328.
- Muller TM, Warsi S. Litigation culture causing burnout in American physicians. Trauma Mental Health Report. April 9, 2021.
- Levine AS. Legal 101: Tort law and medical malpractice for physicians. Contemp OBGYN. 2015:60;26-28, 30.
- Regan JJ, Regan WM. Medical malpractice and respondeat superior. Southern Med J. 2002;95.5:545-549. DOI 10.1097/00007611-200295050-00018
- Levin H. Hospital vicarious liability for negligence by independent contractor physicians: new rule for new times. Univ Illinois Law Rev. 2005:1291-1332.
- Darling v Charleston Hospital, 33 Ill. 2d 326, 211 N.E.2d 253 (Ill. 1965).
- Dangel R. Hospital liability for physician malpractice. Ohio State Law J. 1986;47:1077-1098.
- Reffitt v Hajjar, 892 S.W.2d 599, 605 (Ky. Ct. App. 1994).
- McMichael BJ. Malpractice. In Laws of Medicine: Core Legal Aspects for the Healthcare Professional. New York, NY: Springer International; 2022:129-150.
- Occupational Safety and Health Administration. Worker safety in hospitals: caring for our caregivers. Accessed June 8, 2023. https://www.osha.gov/hospitals
- Occupational Safety and Health Administration. Workplace stress. Accessed June 8, 2023. https://www.osha.gov /workplace-stress/understanding-the-problem
- U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce. Addressing health worker burnout. Accessed July 21, 2023. https://www.hhs.gov/sites/default/files/health -worker-wellbeing-advisory.pdf
- Department of Health & Human Services. Biden-Harris administration awards $103 Million in American Rescue Plan funds to reduce burnout and promote mental health and wellness among health care workforce. January 20, 2022. Accessed July 24, 2023. https://www.hhs.gov/about /news/2022/01/20/biden-harris-administration-awards -103-million-american-rescue-plan-funds-reduce-burnout -promote-mental-health-wellness-among-health-care -workforce.html
- Rothstein LF, Irzyk J. Disabilities and the Law. 4th ed. Toronto, Canada: Thompson Reuters; 2023.
- Department of Labor. Guide to disability rights laws. February 28, 2020. Accessed July 24, 2023. https://www .ada.gov/resources/disability-rights-guide/#:~:text=An%20 individual%20with%20a%20disability%20is%20defined%20 by%20the%20ADA,as%20having%20such%20an%20 impairment
- Nadon L, De Beer LT, Morin AJS. Should burnout be conceptualized as a mental disorder? Behavioral Sci. 2022;12:82.
- World Health Organization. Burn-out an “occupational phenomenon”: International Classification of Diseases. May 28, 2019. Accessed July 21, 2023. https://www.who.int/news /item/28-05-2019-burn-out-an-occupational-phenomenon -international-classification-of-diseases
- Hoffman S. Physician burnout: why legal and regulatory systems may need to step in. The Conversation. July 9, 2019. https://theconversation.com/physician-burnout-why-legal -and-regulatory-systems-may-need-to-step-in-119705
- Jha A, Iliff A, Chaoi A, et al. A crisis in healthcare: a call to action on physician burnout. Harvard Global Health Institute. 2019. Accessed July 21, 2023. https://www.massmed.org /Publications/Research,-Studies,-and-Reports/Physician -Burnout-Report-2018/
- Arnsten AF, Shanafelt T. Physician distress and burnout: the neurobiological perspective. Mayo Clin Proceed. 2021;96:763-769.
Mr. Smith is Professor Emeritus and Dean Emeritus at California Western School of Law, San Diego, California.
Dr. Sanfilippo is Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, and Academic Division Director, Reproductive Endocrinology and Infertility, Magee Womens Hospital, Pittsburgh, Pennsylvania. He also serves on the OBG Management Board of Editors.
Dr. Sammons is past CEO, National Register of Health Service Psychologists.
The authors report no financial relationships relevant to this article.
*The case presented is hypothetical. The facts are a composite of several cases.
Mr. Smith is Professor Emeritus and Dean Emeritus at California Western School of Law, San Diego, California.
Dr. Sanfilippo is Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, and Academic Division Director, Reproductive Endocrinology and Infertility, Magee Womens Hospital, Pittsburgh, Pennsylvania. He also serves on the OBG Management Board of Editors.
Dr. Sammons is past CEO, National Register of Health Service Psychologists.
The authors report no financial relationships relevant to this article.
*The case presented is hypothetical. The facts are a composite of several cases.
Mr. Smith is Professor Emeritus and Dean Emeritus at California Western School of Law, San Diego, California.
Dr. Sanfilippo is Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, and Academic Division Director, Reproductive Endocrinology and Infertility, Magee Womens Hospital, Pittsburgh, Pennsylvania. He also serves on the OBG Management Board of Editors.
Dr. Sammons is past CEO, National Register of Health Service Psychologists.
The authors report no financial relationships relevant to this article.
*The case presented is hypothetical. The facts are a composite of several cases.
Physicians have some of the highest rates of burnout among all professions.1 Complicating matters is that clinicians (including residents)2 may avoid seeking treatment out of fear it will affect their license or privileges.3 In this article, we consider burnout in greater detail, as well as ways of successfully addressing the level of burnout in the profession (FIGURE 1), including steps individual practitioners, health care entities, and regulators should consider to reduce burnout and its harmful effects.
How burnout becomes a problem
Six general factors are commonly identified as leading to clinician career dissatisfaction and burnout:4
1. work overload
2. lack of autonomy and control
3. inadequate rewards, financial and otherwise
4. work-home schedules
5. perception of lack of fairness
6. values conflict between the clinician and employer (including a breakdown of professional community).
At the top of the list of causes of burnout is often “administrative and bureaucratic headaches.”5 More specifically, electronic health records (EHRs), including computerized order entry, is commonly cited as a major cause of burnout.6,7 According to some studies, clinicians spend as much as 49% of working time doing clerical work,8 and studies found the extension of work into home life.9
Increased measurement of performance metrics in health care services are a significant contributor to physician burnout.10 These include pressure to see more patients, perform more procedures, and respond quickly to patient requests (eg, through email).7 As we will see, medical malpractice cases, or the risk of such cases, have also played a role in burnout in some medical specialties.11 The pandemic also contributed, at least temporarily, to burnout.12,13
Rates of burnout among physicians are notably higher than among the general population14 or other professions.6 Although physicians have generally entered clinical practice with lower rates of burnout than the general population,15 The American College of Obstetricians and Gynecologists (ACOG) reports that 40% to 75% of ObGyns “experience some form of professional burnout.”16,17 Other source(s) cite that 53% of ObGyns report burnout (TABLE 1).
Code QD85
Burnout is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by 3 dimensions:
- feelings of energy depletion or exhaustion
- increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job
- a sense of ineffectiveness and lack of accomplishment. Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life. Exclusions to burnout diagnosis include adjustment disorder, disorders specifically associated with stress, anxiety or fear-related disorders, and mood disorders.
Reference
1. International Classification of Diseases Eleventh Revision (ICD-11). Geneva, Switzerland: World Health Organization; 2022.
Burnout undoubtedly contributes to professionals leaving practice, leading to a significant shortage of ObGyns.18 It also raises several significant legal concerns. Despite the enormity and seriousness of the problem, there is considerable optimism and assurance that the epidemic of burnout is solvable on the individual, specialty, and profession-wide levels. ACOG and other organizations have made suggestions for physicians, the profession, and to health care institutions for reducing burnout.19 This is not to say that solutions are simple or easy for individual professionals or institutions, but they are within the reach of the profession (FIGURE 2).
Suicide among health care professionals is one other concern (TABLE 2)20 and theoretically can stem from burnout, depression, and other psychosocial concerns.
Costs of clinician burnout
Burnout is endemic among health care providers, with numerous studies detailing the professional, emotional, and financial costs. Prior to the pandemic, one analysis of nationwide fiscal costs associated with burnout estimated an annual cost of $4.6B due to physician turnover and reduced clinical hours.21 The COVID-19 epidemic has by all accounts worsened rates of health care worker burnout, particularly for those in high patient-contact positions.22
Female clinicians appear to be differentially affected; in one recent study women reported symptoms of burnout at twice the rate of their male counterparts.23 Whether burnout rates will return to pre-pandemic levels remains an open question, but since burnout is frequently related to one’s own assessment of work-life balance, it is possible that a longer term shift in burnout rates associated with post-pandemic occupational attitudes will be observed.
Combining factors contribute to burnout
Burnout is a universal occupational hazard, but extant data suggest that physicians and other health care providers may be at higher risk. Among physicians, younger age, female gender, and front-line specialty status appear associated with higher burnout rates.24 Given that ObGyn physicians are overwhelmingly female (60% of physicians and 86% of residents),25,26 gender-related burnout factors exist alongside other specific occupational burnout risks. While gender parity has been achieved among health care providers, gender disparities persist in terms of those in leadership positions, compensation, and other factors.22
The smattering of evidence suggesting that ObGyns have higher rates of burnout than many other specialties is understandable given the unique legal challenges confronting ObGyn practice. This may be of special significance because ObGyn malpractice insurance rates are among the highest of all specialties.27 The overall shortage of ObGyns has been exacerbated by the demonstrated negative effects on training and workforce representation stemming from recent legislation that has the effect of criminalizing certain aspects of ObGyn practice;28 for instance, uncertainty regarding abortion regulations.
These negative effects are particularly heightened in states in which the law is in flux or where there are continuing efforts to substantially limit access to abortion. The efforts to increase civil and even criminal penalties related to abortion care challenge ObGyns’ professional practices, as legal rules are frequently changing. In some states, ObGyns may face additional workloads secondary to a flight of ObGyns from restrictive jurisdictions in addition to legal and professional repercussions. In a small study of 19 genetic counselors dealing with restrictive legislation in the state of Ohio,29 increased stress and burnout rates were identified as a consequence of practice uncertainties under this legislation. It is certain that other professionals working in reproductive health care are similarly affected.30
The programs provide individual resources to providers in distress, periodically survey initiatives at Stanford to assess burnout at the organizational level, and provide input designed to spur organizational change to reduce the burden of burnout. Ways that they build community and connections include:
- Live Story Rounds events (as told by Stanford Medicine physicians)
- Commensality Groups (facilitated small discussion groups built around tested evidence)
- Aim to increase sense of connection and collegiality among physicians and build comradery at work
- CME-accredited physician wellness forum, including annual doctor’s day events
Continue to: Assessment of burnout...
Assessment of burnout
Numerous scales for the assessment of burnout exist. Of these, the 22-item Maslach Burnout Inventory (MBI) is the best studied. The MBI is a well-investigated tool for assessing burnout. The MBI consists of 3 major subscales measuring overall burnout, emotional exhaustion, depersonalization, and low personal accomplishment. It exists in numerous forms. For instance, the MBI-HSS (MP), adapted for medical personnel, is available. However, the most commonly used form for assessing burnout in clinicians is the MBI-HHS (Human Services Survey); approximately 85% of all burnout studies examined in a recent meta-analysis used this survey version.31 As those authors commented, while burnout is a recognized phenomenon, a great deal of variability in study design, interpretation of subscale scores, and sample selection makes generalizations regarding burnout difficult to assess.
The MBI in various forms has been extensively used over the past 40 years to assess burnout amongst physicians and physicians in training. While not the only instrument designed to measure such factors, it is by far the most prevalent. Williamson and colleagues32 compared the MBI with several other measures of quality of life and found good correlation between the various instruments used, a finding replicated by other studies.33 Brady and colleagues compared item responses to the Stanford Professional Fulfillment Index and the Min-Z Single-item Burnout scale (a 1-item screening measure) to MBI’s Emotional Exhaustion and Depersonalization subscales. Basing their findings on a survey of more than 1,300 physicians, they found that all analyzed scales were significantly correlated with such adverse outcomes as depression, distress, or intent to leave the profession.
It is important to note that most surveys of clinician burnout were conducted prior to the pandemic. While the psychometric analyses of the MBI and other scales are likely still germane, observed rates of clinician burnout have likely increased. Thus, comparisons of pre- and post-pandemic studies should factor in an increase in the incidence and prevalence of burnout.
Management strategies
In general, there are several interventions for managing burnout34:
- individual-focused (including self-care and communications-skills workshops)
- mindfulness training
- yoga
- meditation
- organizational/structural (workload reduction, schedule realignment, teamwork training, and group-delivered stress management interventions)
- combination(s) of the above.
There is little evidence to suggest that any particular individual intervention (whether delivered in individual or group-based formats) is superior to any other in treating clinician burnout. A recent analysis of 24 studies employing mindfulness-based interventions demonstrated generally positive results for such interventions.35 Other studies have also found general support for mindfulness-based interventions, although mindfulness is often integrated with other stress-reduction techniques, such as meditation, yoga, and communication skills. Such interventions are nonspecific but generally effective.
An accumulation of evidence to date suggests that a combination of individual and organizational interventions is most effective in combatting clinician burnout. No individual intervention can be successful without addressing root causes, such as overscheduling, lack of organizational support, and the effect of restrictive legislation on practice.
Several large teaching hospitals have established programs to address physician and health care provider burnout. Notable among these is the Stanford University School of Medicine’s WellMD and WellPhD programs (https://wellmd.stanford.edu/about.html). These programs were described by Olson and colleagues36 as using a model focused on practice efficiency, organizational culture, and personal resilience to enhance physicians’ well-being. (See “Aspects of the WellMD and WellPhD programs from Stanford University.”)
A growing number of institutions have established burnout programs to support physicians experiencing work/life imbalances and other aspects of burnout.37 In general, these share common features of assessment, individual and/or group intervention, and organizational change. Fear of repercussion may be one factor preventing physicians from seeking individual treatment for burnout.38 Importantly, they emphasize the need for professional confidentiality when offering treatment to patients within organizational settings. Those authors also reported that a focus on organizational engagement may be an important factor in addressing burnout in female physicians, as they tend to report lower levels of organizational engagement.
Continue to: Legal considerations...
Legal considerations
Until recently, physician burnout “received little notice in the legal literature.”39 Although there have been burnout legal consequences in the past, the legal issues are now becoming more visible.40
Medical malpractice
A well-documented consequence of burnout is an increase in errors.14 Medical errors, of course, are at the heart of malpractice claims. Technically, malpractice is medical or professional negligence. It is the breach of a duty owed by the physician, or other provider, or organization (defendant) to the patient, which causes injury to the plaintiff/patient.41
“Medical error” is generally a meaningful deviation from the “standard of care” or accepted medical practice.42 Many medical errors do not cause injury to the patient; in those cases, the negligence does not result in liability. In instances in which the negligence causes harm, the clinician and health care facility may be subject to liability for that injury. Fortunately, however, for a variety of reasons, most harmful medical errors do not result in a medical malpractice claim or lawsuit. The absence of a good clinician-patient relationship is likely associated with an increased inclination of a patient to file a malpractice action.43Clinician burnout may, therefore, contribute to increased malpractice claims in two ways. First, burnout likely leads to increased medical errors, perhaps because burnout is associated with lower concentration, inattention, reduced cognitive vigilance, and fatigue.8,44 It may also lead to less time with patients, reduced patient empathy, and lower patient rapport, which may make injured patients more likely to file a claim or lawsuit.45 Because the relationshipbetween burnout and medical error is bidirectional, malpractice claims tend to increase burnout, which increases error. Given the time it takes to resolve most malpractice claims, the uncertainty of medical malpractice may be especially stressful for health care providers.46,47
Burnout is not a mitigating factor in malpractice. Our sympathies may go out to a professional suffering from burnout, but it does not excuse or reduce liability—it may, indeed, be an aggravating factor. Clinicians who can diagnose burnout and know its negative consequences but fail to deal with their own burnout may be demonstrating negligence if there has been harm to a patient related to the burnout.48
Institutional or corporate liability to patients
Health care institutions have obligations to avoid injury to patients. Just as poorly maintained medical equipment may harm patients, so may burned-out professionals. Therefore, institutions have some obligation to supervise and avoid the increased risks to patients posed by professionals suffering from burnout.
Respondeat superior and institutional negligence. Institutional liability may arise in two ways, the first through agency, or respondeat superior. That is, if the physician or other professional is an employee (or similar agent) of the health care institution, that institution is generally responsible for the physician’s negligence during the employment.49 Even if the physician is not an employee (for example, an independent contractor providing care or using the hospital facilities), the health care facility may be liable for the physician’s negligence.50 Liability may occur, for example, if the health care facility was aware that the physician was engaged in careless practice or was otherwise a risk to patients but the facility did not take steps to avoid those risks.51 The basis for liability is that the health care organization owes a duty to patients to take reasonable care to ensure that its facilities are not used to injure patients negligently.52 Just as it must take care that unqualified physicians are not granted privileges to practice, it also must take reasonable steps to protect patients when it is aware (through nurses or other agents) of a physician’s negligent practice.
In one case, for example, the court found liability where a staff member had “severe” burnout in a physician’s office and failed to read fetal monitoring strips. The physician was found negligent for relying on the staff member who was obviously making errors in interpretation of fetal distress.53
Continue to: Legal obligations of health care organizations to physicians and others...
Legal obligations of health care organizations to physicians and others
In addition to obligations to patients, health care organizations may have obligations to employees (and others) at risk for injury. For example, assume a patient is diagnosed with a highly contagious disease. The health care organization would be obligated to warn, and take reasonable steps to protect, the staff (employees and independent contractors) from being harmed from exposure to the disease. This principle may apply to coworkers of employees with significant burnout, thereby presenting a danger in the workplace. The liability issue is more difficult for employees experiencing job-related burnout themselves. Organizations generally compensate injured employees through no-fault workers’ compensation (an insurance-like system); for independent contractors, the liability is usually through a tort claim (negligence).54
In modern times, a focus has been on preventing those injuries, not just providing compensation after injuries have occurred. Notably, federal and state occupational health and safety laws (particularly the Occupational Safety and Health Administration [OSHA]) require most organizations (including those employing health care providers) to take steps to mitigate various kinds of worker injuries.55
Although these worker protections have commonly been applied to hospitals and other health care providers, burnout has not traditionally been a significant concern in federal or state OSHA enforcement. For example, no formal federal OSHA regulations govern work-related burnout. Regulators, including OSHA, are increasingly interested in burnout that may affect many employees. OSHA has several recommendations for reducing health care work burnout.56 The Surgeon General has expressed similar concerns.57 The federal government recently allocated $103 million from the American Rescue Plan to address burnout among health care workers.58 Also, OSHA appears to be increasing its oversight of healthcare-institution-worker injuries.55
Is burnout a “disability”?
The federal Americans with Disabilities Act (ADA) and similar state laws prohibit discrimination based on disability.59 A disability is defined as a “physical or mental impairment that substantially limits one or more major life activities” or “perceived as having such an impairment.”60 The initial issue is whether burnout is a “mental impairment.” As noted earlier, it is not officially a “medical condition.”61 To date, the United Nations has classified it as an “occupational phenomenon.”62 It may, therefore, not qualify under the ADA, even if it “interferes with a major life activity.” There is, however, some movement toward defining burnout as a mental condition. Even if defined as a disability, there would still be legal issues of how severe it must be to qualify as a disability and the proper accommodation. Apart from the legal definition of an ADA disability, as a practical matter it likely is in the best interest of health care facilities to provide accommodations that reduce burnout. A number of strategies to decrease the incidence of burnout include the role of health care systems (FIGURE 2).
In conclusion we look at several things that can be done to “treat” or reduce burnout. That effort requires the cooperation of physicians and other providers, health care facilities, training programs, licensing authorities, and professional organizations. See suggestions below.
Conclusion
There are many excellent suggestions for reducing burnout and improving patient care and practitioner satisfaction.63-65 We conclude with a summary of some of these suggestions for individual practitioners, health care organizations, the profession, and licensing. It is worth remembering, however, that it will require the efforts of each area to reduce burnout substantially.
For practitioners:
- Engage in quality coaching/therapy on mindfulness and stress management.
- Practice self-care, including exercise and relaxation techniques.
- Make work-life balance a priority.
- Take opportunities for collegial social and professional discussions.
- Prioritize (and periodically assess) your own professional satisfaction and burnout risk.
- Smile—enjoy a sense of humor (endorphins and cortisol).
For health care organizations:
- Urgently work with vendors and regulators to revise electronic health records to reduce their substantial impact on burnout.
- Reduce physicians’ time on clerical and administrative tasks (eg, by enhancing the use of quality AI, scribes, and automated notes from appointments. (This may increase the time they spend with patients.) Eliminate “pajama-time” charting.
- Provide various kinds of confidential professional counseling, therapy, and support related to burnout prevention and treatment, and avoid any penalty or stigma related to their use.
- Provide reasonable flexibility in scheduling.
- Routinely provide employees with information about burnout prevention and services.
- Appoint a wellness officer with authority to ensure the organization maximizes its prevention and treatment services.
- Constantly seek input from practitioners on how to improve the atmosphere for practice to maximize patient care and practitioner satisfaction.
- Provide ample professional and social opportunities for discussing and learning about work-life balance, resilience, intellectual stimulation, and career development.
For regulators, licensors, and professional organizations:
- Work with health care organizations and EHR vendors to substantially reduce the complexity, physician effort, and stress associated with those record systems. Streamlining should, in the future, be part of formally certifying EHR systems.
- Reduce the administrative burden on physicians by modifying complex regulations and using AI and other technology to the extent possible to obtain necessary reimbursement information.
- Eliminate unnecessary data gathering that requires practitioner time or attention.
- Licensing, educational, and certifying bodies should eliminate any questions regarding the diagnosis or treatment of mental health and focus on current (or very recent) impairments.
- Seek funding for research on burnout prevention and treatment.
Dr. H is a 58-year-old ObGyn who, after completing residency, went into solo practice. The practice grew, and Dr. H found it increasingly more challenging to cover, especially the obstetrics sector. Dr. H then merged the practice with a group of 3 other ObGyns. Their practice expanded, and began recruiting recent residency graduates. In time, the practice was bought out by the local hospital health care system. Dr. H was faced with complying with the rules and regulations of that health care system. The electronic health record (EHR) component proved challenging, as did the restrictions on staff hiring (and firing), but Dr. H did receive a paycheck each month and complied with it all. The health care system administrators had clear financial targets Dr. H was to meet each quarter, which created additional pressure. Dr. H used to love being an OB and providing excellent care for every patient, but that sense of accomplishment was being lost.
Dr. H increasingly found it difficult to focus because of mind wandering, especially in the operating room (OR). Thoughts occurred about retirement, the current challenges imposed by “the new way of practicing medicine” (more focused on financial productivity restraints and reimbursement), and EHR challenges. Then Dr. H’s attention would return to the OR case at hand. All of this resulted in considerable stress and emotional exhaustion, and sometimes a sense of being disconnected. A few times, colleagues or nurses had asked Dr. H if everything was “okay,” or if a break would help. Dr. H made more small errors than usual, but Dr. H’s self-assessment was “doing an adequate job.” Patient satisfaction scores (collected routinely by the health care system) declined over the last 9 months.
Six months ago, Dr. H finished doing a laparoscopic total hysterectomy and bilateral salpingo-oophorectomy and got into the right uterine artery. The estimated blood loss was 3,500 mL. Using minimally invasive techniques, Dr. H identified the bleeder and, with monopolar current, got everything under control. The patient went to the post-anesthesia care unit, and all appeared to be in order. Her vital signs were stable, and she was discharged home the same day.
The patient presented 1 week later with lower abdominal and right flank pain. Dr. H addressed the problem in the emergency department and admitted the patient for further evaluation and urology consultation. The right ureter was damaged and obstructed; ultimately, the urologist performed a psoas bladder hitch. The patient recovered slowly, lost several weeks of work, experienced significant pain, and had other disruptions and costs. Additional medical care related to the surgery is ongoing. A health care system committee asked Dr. H to explain the problem. Over the last 6 months, Dr. H’s frustration with practice and being tired and disconnected have increased.
Dr. H has received a letter from a law firm saying that he and the health care system are being sued for malpractice focused on an iatrogenic ureter injury. The letter names two very reputable experts who are prepared to testify that the patient’s injury resulted from clear negligence. Dr. H has told the malpractice carrier absolutely not to settle this case—it is “a sham— without merit.” The health care system has asked Dr. H to take a “burnout test.”
Legal considerations
Dr. H exhibits relatively clear signs of professional burnout. The fact that there was a bad outcome while Dr. H was experiencing burnout is not proof of negligence (or, breach of duty of care to the patient). Nor is it a defense or mitigation to any malpractice that occurred.
In the malpractice case, the plaintiff will have the burden of proving that Dr. H’s treatment was negligent in that it fell below the standard of care. Even if it was a medical error, the question is whether it was negligence. If the patient/plaintiff, using expert witnesses, can prove that Dr. H fell below the standard of care that caused injury, Dr. H may be liable for the resulting extra costs, loss of income, and pain and suffering resulting from the negligent care.
The health care system likely will also be responsible for Dr. H’s negligence, either through respondeat superior (for example, if Dr. H is an employee) or for its own negligence. The case for its negligence is that the nurses and assistants had repeatedly seen him making errors and becoming disengaged (to the extent that they asked Dr. H if “everything is okay” or if a break would help). Furthermore, Dr. H’s patient satisfaction scores have been declining for several months. The plaintiff will argue that Dr. H exhibited classic burnout symptoms with the attendant risks of medical errors. However, the health care system did not take action to protect patients or to assist Dr. H. In short, one way or another, there is some likelihood that the health care system may also be liable if patient injuries are found to have been caused by negligence.
At this point, the health care system also faces the question of how to work with Dr. H in the future. The most pressing question is whether or not to allow Dr. H to continue practicing. If, as it appears, Dr. H is dealing with burnout, the pressure of the malpractice claim could well increase the probability of other medical mistakes. The institution has asked Dr. H to take a burnout test, but it is unclear where things go if the test (as likely) demonstrates significant burnout. This is a counseling and human relations question, at least as much as a legal issue, and the institution should probably proceed in that way—which is, trying to understand and support Dr. H and determining what can be done to address the burnout. At the same time, the system must reasonably assess Dr. H’s fitness to continue practicing as the matters are resolved. Almost everyone shares the goal to provide every individual and corporate opportunity for Dr. H to deal with burnout issues and return to successful practice.
Dr. H will be represented in the malpractice case by counsel provided through the insurance carrier. However, Dr. H would be well advised to retain a trusted and knowledgeable personal attorney. For example, the instruction not to consider settlement is likely misguided, but Dr. H needs to talk with an attorney that Dr. H has chosen and trusts. In addition, the attorney can help guide Dr. H through a rational process of dealing with the health care system, putting the practice in order, and considering the options for the future.
The health care system should reconsider its processes to deal with burnout to ensure the quality of care, patient satisfaction, professional retention, and economic stability. Several burnoutresponse programs have had success in achieving these goals.
What’s the Verdict?
Dr. H received good mental health, legal, and professional advice. As a result, an out of court settlement was reached following pretrial discovery. Dr. H has continued consultation regarding burnout and has returned to productive practice.
Physicians have some of the highest rates of burnout among all professions.1 Complicating matters is that clinicians (including residents)2 may avoid seeking treatment out of fear it will affect their license or privileges.3 In this article, we consider burnout in greater detail, as well as ways of successfully addressing the level of burnout in the profession (FIGURE 1), including steps individual practitioners, health care entities, and regulators should consider to reduce burnout and its harmful effects.
How burnout becomes a problem
Six general factors are commonly identified as leading to clinician career dissatisfaction and burnout:4
1. work overload
2. lack of autonomy and control
3. inadequate rewards, financial and otherwise
4. work-home schedules
5. perception of lack of fairness
6. values conflict between the clinician and employer (including a breakdown of professional community).
At the top of the list of causes of burnout is often “administrative and bureaucratic headaches.”5 More specifically, electronic health records (EHRs), including computerized order entry, is commonly cited as a major cause of burnout.6,7 According to some studies, clinicians spend as much as 49% of working time doing clerical work,8 and studies found the extension of work into home life.9
Increased measurement of performance metrics in health care services are a significant contributor to physician burnout.10 These include pressure to see more patients, perform more procedures, and respond quickly to patient requests (eg, through email).7 As we will see, medical malpractice cases, or the risk of such cases, have also played a role in burnout in some medical specialties.11 The pandemic also contributed, at least temporarily, to burnout.12,13
Rates of burnout among physicians are notably higher than among the general population14 or other professions.6 Although physicians have generally entered clinical practice with lower rates of burnout than the general population,15 The American College of Obstetricians and Gynecologists (ACOG) reports that 40% to 75% of ObGyns “experience some form of professional burnout.”16,17 Other source(s) cite that 53% of ObGyns report burnout (TABLE 1).
Code QD85
Burnout is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by 3 dimensions:
- feelings of energy depletion or exhaustion
- increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job
- a sense of ineffectiveness and lack of accomplishment. Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life. Exclusions to burnout diagnosis include adjustment disorder, disorders specifically associated with stress, anxiety or fear-related disorders, and mood disorders.
Reference
1. International Classification of Diseases Eleventh Revision (ICD-11). Geneva, Switzerland: World Health Organization; 2022.
Burnout undoubtedly contributes to professionals leaving practice, leading to a significant shortage of ObGyns.18 It also raises several significant legal concerns. Despite the enormity and seriousness of the problem, there is considerable optimism and assurance that the epidemic of burnout is solvable on the individual, specialty, and profession-wide levels. ACOG and other organizations have made suggestions for physicians, the profession, and to health care institutions for reducing burnout.19 This is not to say that solutions are simple or easy for individual professionals or institutions, but they are within the reach of the profession (FIGURE 2).
Suicide among health care professionals is one other concern (TABLE 2)20 and theoretically can stem from burnout, depression, and other psychosocial concerns.
Costs of clinician burnout
Burnout is endemic among health care providers, with numerous studies detailing the professional, emotional, and financial costs. Prior to the pandemic, one analysis of nationwide fiscal costs associated with burnout estimated an annual cost of $4.6B due to physician turnover and reduced clinical hours.21 The COVID-19 epidemic has by all accounts worsened rates of health care worker burnout, particularly for those in high patient-contact positions.22
Female clinicians appear to be differentially affected; in one recent study women reported symptoms of burnout at twice the rate of their male counterparts.23 Whether burnout rates will return to pre-pandemic levels remains an open question, but since burnout is frequently related to one’s own assessment of work-life balance, it is possible that a longer term shift in burnout rates associated with post-pandemic occupational attitudes will be observed.
Combining factors contribute to burnout
Burnout is a universal occupational hazard, but extant data suggest that physicians and other health care providers may be at higher risk. Among physicians, younger age, female gender, and front-line specialty status appear associated with higher burnout rates.24 Given that ObGyn physicians are overwhelmingly female (60% of physicians and 86% of residents),25,26 gender-related burnout factors exist alongside other specific occupational burnout risks. While gender parity has been achieved among health care providers, gender disparities persist in terms of those in leadership positions, compensation, and other factors.22
The smattering of evidence suggesting that ObGyns have higher rates of burnout than many other specialties is understandable given the unique legal challenges confronting ObGyn practice. This may be of special significance because ObGyn malpractice insurance rates are among the highest of all specialties.27 The overall shortage of ObGyns has been exacerbated by the demonstrated negative effects on training and workforce representation stemming from recent legislation that has the effect of criminalizing certain aspects of ObGyn practice;28 for instance, uncertainty regarding abortion regulations.
These negative effects are particularly heightened in states in which the law is in flux or where there are continuing efforts to substantially limit access to abortion. The efforts to increase civil and even criminal penalties related to abortion care challenge ObGyns’ professional practices, as legal rules are frequently changing. In some states, ObGyns may face additional workloads secondary to a flight of ObGyns from restrictive jurisdictions in addition to legal and professional repercussions. In a small study of 19 genetic counselors dealing with restrictive legislation in the state of Ohio,29 increased stress and burnout rates were identified as a consequence of practice uncertainties under this legislation. It is certain that other professionals working in reproductive health care are similarly affected.30
The programs provide individual resources to providers in distress, periodically survey initiatives at Stanford to assess burnout at the organizational level, and provide input designed to spur organizational change to reduce the burden of burnout. Ways that they build community and connections include:
- Live Story Rounds events (as told by Stanford Medicine physicians)
- Commensality Groups (facilitated small discussion groups built around tested evidence)
- Aim to increase sense of connection and collegiality among physicians and build comradery at work
- CME-accredited physician wellness forum, including annual doctor’s day events
Continue to: Assessment of burnout...
Assessment of burnout
Numerous scales for the assessment of burnout exist. Of these, the 22-item Maslach Burnout Inventory (MBI) is the best studied. The MBI is a well-investigated tool for assessing burnout. The MBI consists of 3 major subscales measuring overall burnout, emotional exhaustion, depersonalization, and low personal accomplishment. It exists in numerous forms. For instance, the MBI-HSS (MP), adapted for medical personnel, is available. However, the most commonly used form for assessing burnout in clinicians is the MBI-HHS (Human Services Survey); approximately 85% of all burnout studies examined in a recent meta-analysis used this survey version.31 As those authors commented, while burnout is a recognized phenomenon, a great deal of variability in study design, interpretation of subscale scores, and sample selection makes generalizations regarding burnout difficult to assess.
The MBI in various forms has been extensively used over the past 40 years to assess burnout amongst physicians and physicians in training. While not the only instrument designed to measure such factors, it is by far the most prevalent. Williamson and colleagues32 compared the MBI with several other measures of quality of life and found good correlation between the various instruments used, a finding replicated by other studies.33 Brady and colleagues compared item responses to the Stanford Professional Fulfillment Index and the Min-Z Single-item Burnout scale (a 1-item screening measure) to MBI’s Emotional Exhaustion and Depersonalization subscales. Basing their findings on a survey of more than 1,300 physicians, they found that all analyzed scales were significantly correlated with such adverse outcomes as depression, distress, or intent to leave the profession.
It is important to note that most surveys of clinician burnout were conducted prior to the pandemic. While the psychometric analyses of the MBI and other scales are likely still germane, observed rates of clinician burnout have likely increased. Thus, comparisons of pre- and post-pandemic studies should factor in an increase in the incidence and prevalence of burnout.
Management strategies
In general, there are several interventions for managing burnout34:
- individual-focused (including self-care and communications-skills workshops)
- mindfulness training
- yoga
- meditation
- organizational/structural (workload reduction, schedule realignment, teamwork training, and group-delivered stress management interventions)
- combination(s) of the above.
There is little evidence to suggest that any particular individual intervention (whether delivered in individual or group-based formats) is superior to any other in treating clinician burnout. A recent analysis of 24 studies employing mindfulness-based interventions demonstrated generally positive results for such interventions.35 Other studies have also found general support for mindfulness-based interventions, although mindfulness is often integrated with other stress-reduction techniques, such as meditation, yoga, and communication skills. Such interventions are nonspecific but generally effective.
An accumulation of evidence to date suggests that a combination of individual and organizational interventions is most effective in combatting clinician burnout. No individual intervention can be successful without addressing root causes, such as overscheduling, lack of organizational support, and the effect of restrictive legislation on practice.
Several large teaching hospitals have established programs to address physician and health care provider burnout. Notable among these is the Stanford University School of Medicine’s WellMD and WellPhD programs (https://wellmd.stanford.edu/about.html). These programs were described by Olson and colleagues36 as using a model focused on practice efficiency, organizational culture, and personal resilience to enhance physicians’ well-being. (See “Aspects of the WellMD and WellPhD programs from Stanford University.”)
A growing number of institutions have established burnout programs to support physicians experiencing work/life imbalances and other aspects of burnout.37 In general, these share common features of assessment, individual and/or group intervention, and organizational change. Fear of repercussion may be one factor preventing physicians from seeking individual treatment for burnout.38 Importantly, they emphasize the need for professional confidentiality when offering treatment to patients within organizational settings. Those authors also reported that a focus on organizational engagement may be an important factor in addressing burnout in female physicians, as they tend to report lower levels of organizational engagement.
Continue to: Legal considerations...
Legal considerations
Until recently, physician burnout “received little notice in the legal literature.”39 Although there have been burnout legal consequences in the past, the legal issues are now becoming more visible.40
Medical malpractice
A well-documented consequence of burnout is an increase in errors.14 Medical errors, of course, are at the heart of malpractice claims. Technically, malpractice is medical or professional negligence. It is the breach of a duty owed by the physician, or other provider, or organization (defendant) to the patient, which causes injury to the plaintiff/patient.41
“Medical error” is generally a meaningful deviation from the “standard of care” or accepted medical practice.42 Many medical errors do not cause injury to the patient; in those cases, the negligence does not result in liability. In instances in which the negligence causes harm, the clinician and health care facility may be subject to liability for that injury. Fortunately, however, for a variety of reasons, most harmful medical errors do not result in a medical malpractice claim or lawsuit. The absence of a good clinician-patient relationship is likely associated with an increased inclination of a patient to file a malpractice action.43Clinician burnout may, therefore, contribute to increased malpractice claims in two ways. First, burnout likely leads to increased medical errors, perhaps because burnout is associated with lower concentration, inattention, reduced cognitive vigilance, and fatigue.8,44 It may also lead to less time with patients, reduced patient empathy, and lower patient rapport, which may make injured patients more likely to file a claim or lawsuit.45 Because the relationshipbetween burnout and medical error is bidirectional, malpractice claims tend to increase burnout, which increases error. Given the time it takes to resolve most malpractice claims, the uncertainty of medical malpractice may be especially stressful for health care providers.46,47
Burnout is not a mitigating factor in malpractice. Our sympathies may go out to a professional suffering from burnout, but it does not excuse or reduce liability—it may, indeed, be an aggravating factor. Clinicians who can diagnose burnout and know its negative consequences but fail to deal with their own burnout may be demonstrating negligence if there has been harm to a patient related to the burnout.48
Institutional or corporate liability to patients
Health care institutions have obligations to avoid injury to patients. Just as poorly maintained medical equipment may harm patients, so may burned-out professionals. Therefore, institutions have some obligation to supervise and avoid the increased risks to patients posed by professionals suffering from burnout.
Respondeat superior and institutional negligence. Institutional liability may arise in two ways, the first through agency, or respondeat superior. That is, if the physician or other professional is an employee (or similar agent) of the health care institution, that institution is generally responsible for the physician’s negligence during the employment.49 Even if the physician is not an employee (for example, an independent contractor providing care or using the hospital facilities), the health care facility may be liable for the physician’s negligence.50 Liability may occur, for example, if the health care facility was aware that the physician was engaged in careless practice or was otherwise a risk to patients but the facility did not take steps to avoid those risks.51 The basis for liability is that the health care organization owes a duty to patients to take reasonable care to ensure that its facilities are not used to injure patients negligently.52 Just as it must take care that unqualified physicians are not granted privileges to practice, it also must take reasonable steps to protect patients when it is aware (through nurses or other agents) of a physician’s negligent practice.
In one case, for example, the court found liability where a staff member had “severe” burnout in a physician’s office and failed to read fetal monitoring strips. The physician was found negligent for relying on the staff member who was obviously making errors in interpretation of fetal distress.53
Continue to: Legal obligations of health care organizations to physicians and others...
Legal obligations of health care organizations to physicians and others
In addition to obligations to patients, health care organizations may have obligations to employees (and others) at risk for injury. For example, assume a patient is diagnosed with a highly contagious disease. The health care organization would be obligated to warn, and take reasonable steps to protect, the staff (employees and independent contractors) from being harmed from exposure to the disease. This principle may apply to coworkers of employees with significant burnout, thereby presenting a danger in the workplace. The liability issue is more difficult for employees experiencing job-related burnout themselves. Organizations generally compensate injured employees through no-fault workers’ compensation (an insurance-like system); for independent contractors, the liability is usually through a tort claim (negligence).54
In modern times, a focus has been on preventing those injuries, not just providing compensation after injuries have occurred. Notably, federal and state occupational health and safety laws (particularly the Occupational Safety and Health Administration [OSHA]) require most organizations (including those employing health care providers) to take steps to mitigate various kinds of worker injuries.55
Although these worker protections have commonly been applied to hospitals and other health care providers, burnout has not traditionally been a significant concern in federal or state OSHA enforcement. For example, no formal federal OSHA regulations govern work-related burnout. Regulators, including OSHA, are increasingly interested in burnout that may affect many employees. OSHA has several recommendations for reducing health care work burnout.56 The Surgeon General has expressed similar concerns.57 The federal government recently allocated $103 million from the American Rescue Plan to address burnout among health care workers.58 Also, OSHA appears to be increasing its oversight of healthcare-institution-worker injuries.55
Is burnout a “disability”?
The federal Americans with Disabilities Act (ADA) and similar state laws prohibit discrimination based on disability.59 A disability is defined as a “physical or mental impairment that substantially limits one or more major life activities” or “perceived as having such an impairment.”60 The initial issue is whether burnout is a “mental impairment.” As noted earlier, it is not officially a “medical condition.”61 To date, the United Nations has classified it as an “occupational phenomenon.”62 It may, therefore, not qualify under the ADA, even if it “interferes with a major life activity.” There is, however, some movement toward defining burnout as a mental condition. Even if defined as a disability, there would still be legal issues of how severe it must be to qualify as a disability and the proper accommodation. Apart from the legal definition of an ADA disability, as a practical matter it likely is in the best interest of health care facilities to provide accommodations that reduce burnout. A number of strategies to decrease the incidence of burnout include the role of health care systems (FIGURE 2).
In conclusion we look at several things that can be done to “treat” or reduce burnout. That effort requires the cooperation of physicians and other providers, health care facilities, training programs, licensing authorities, and professional organizations. See suggestions below.
Conclusion
There are many excellent suggestions for reducing burnout and improving patient care and practitioner satisfaction.63-65 We conclude with a summary of some of these suggestions for individual practitioners, health care organizations, the profession, and licensing. It is worth remembering, however, that it will require the efforts of each area to reduce burnout substantially.
For practitioners:
- Engage in quality coaching/therapy on mindfulness and stress management.
- Practice self-care, including exercise and relaxation techniques.
- Make work-life balance a priority.
- Take opportunities for collegial social and professional discussions.
- Prioritize (and periodically assess) your own professional satisfaction and burnout risk.
- Smile—enjoy a sense of humor (endorphins and cortisol).
For health care organizations:
- Urgently work with vendors and regulators to revise electronic health records to reduce their substantial impact on burnout.
- Reduce physicians’ time on clerical and administrative tasks (eg, by enhancing the use of quality AI, scribes, and automated notes from appointments. (This may increase the time they spend with patients.) Eliminate “pajama-time” charting.
- Provide various kinds of confidential professional counseling, therapy, and support related to burnout prevention and treatment, and avoid any penalty or stigma related to their use.
- Provide reasonable flexibility in scheduling.
- Routinely provide employees with information about burnout prevention and services.
- Appoint a wellness officer with authority to ensure the organization maximizes its prevention and treatment services.
- Constantly seek input from practitioners on how to improve the atmosphere for practice to maximize patient care and practitioner satisfaction.
- Provide ample professional and social opportunities for discussing and learning about work-life balance, resilience, intellectual stimulation, and career development.
For regulators, licensors, and professional organizations:
- Work with health care organizations and EHR vendors to substantially reduce the complexity, physician effort, and stress associated with those record systems. Streamlining should, in the future, be part of formally certifying EHR systems.
- Reduce the administrative burden on physicians by modifying complex regulations and using AI and other technology to the extent possible to obtain necessary reimbursement information.
- Eliminate unnecessary data gathering that requires practitioner time or attention.
- Licensing, educational, and certifying bodies should eliminate any questions regarding the diagnosis or treatment of mental health and focus on current (or very recent) impairments.
- Seek funding for research on burnout prevention and treatment.
Dr. H is a 58-year-old ObGyn who, after completing residency, went into solo practice. The practice grew, and Dr. H found it increasingly more challenging to cover, especially the obstetrics sector. Dr. H then merged the practice with a group of 3 other ObGyns. Their practice expanded, and began recruiting recent residency graduates. In time, the practice was bought out by the local hospital health care system. Dr. H was faced with complying with the rules and regulations of that health care system. The electronic health record (EHR) component proved challenging, as did the restrictions on staff hiring (and firing), but Dr. H did receive a paycheck each month and complied with it all. The health care system administrators had clear financial targets Dr. H was to meet each quarter, which created additional pressure. Dr. H used to love being an OB and providing excellent care for every patient, but that sense of accomplishment was being lost.
Dr. H increasingly found it difficult to focus because of mind wandering, especially in the operating room (OR). Thoughts occurred about retirement, the current challenges imposed by “the new way of practicing medicine” (more focused on financial productivity restraints and reimbursement), and EHR challenges. Then Dr. H’s attention would return to the OR case at hand. All of this resulted in considerable stress and emotional exhaustion, and sometimes a sense of being disconnected. A few times, colleagues or nurses had asked Dr. H if everything was “okay,” or if a break would help. Dr. H made more small errors than usual, but Dr. H’s self-assessment was “doing an adequate job.” Patient satisfaction scores (collected routinely by the health care system) declined over the last 9 months.
Six months ago, Dr. H finished doing a laparoscopic total hysterectomy and bilateral salpingo-oophorectomy and got into the right uterine artery. The estimated blood loss was 3,500 mL. Using minimally invasive techniques, Dr. H identified the bleeder and, with monopolar current, got everything under control. The patient went to the post-anesthesia care unit, and all appeared to be in order. Her vital signs were stable, and she was discharged home the same day.
The patient presented 1 week later with lower abdominal and right flank pain. Dr. H addressed the problem in the emergency department and admitted the patient for further evaluation and urology consultation. The right ureter was damaged and obstructed; ultimately, the urologist performed a psoas bladder hitch. The patient recovered slowly, lost several weeks of work, experienced significant pain, and had other disruptions and costs. Additional medical care related to the surgery is ongoing. A health care system committee asked Dr. H to explain the problem. Over the last 6 months, Dr. H’s frustration with practice and being tired and disconnected have increased.
Dr. H has received a letter from a law firm saying that he and the health care system are being sued for malpractice focused on an iatrogenic ureter injury. The letter names two very reputable experts who are prepared to testify that the patient’s injury resulted from clear negligence. Dr. H has told the malpractice carrier absolutely not to settle this case—it is “a sham— without merit.” The health care system has asked Dr. H to take a “burnout test.”
Legal considerations
Dr. H exhibits relatively clear signs of professional burnout. The fact that there was a bad outcome while Dr. H was experiencing burnout is not proof of negligence (or, breach of duty of care to the patient). Nor is it a defense or mitigation to any malpractice that occurred.
In the malpractice case, the plaintiff will have the burden of proving that Dr. H’s treatment was negligent in that it fell below the standard of care. Even if it was a medical error, the question is whether it was negligence. If the patient/plaintiff, using expert witnesses, can prove that Dr. H fell below the standard of care that caused injury, Dr. H may be liable for the resulting extra costs, loss of income, and pain and suffering resulting from the negligent care.
The health care system likely will also be responsible for Dr. H’s negligence, either through respondeat superior (for example, if Dr. H is an employee) or for its own negligence. The case for its negligence is that the nurses and assistants had repeatedly seen him making errors and becoming disengaged (to the extent that they asked Dr. H if “everything is okay” or if a break would help). Furthermore, Dr. H’s patient satisfaction scores have been declining for several months. The plaintiff will argue that Dr. H exhibited classic burnout symptoms with the attendant risks of medical errors. However, the health care system did not take action to protect patients or to assist Dr. H. In short, one way or another, there is some likelihood that the health care system may also be liable if patient injuries are found to have been caused by negligence.
At this point, the health care system also faces the question of how to work with Dr. H in the future. The most pressing question is whether or not to allow Dr. H to continue practicing. If, as it appears, Dr. H is dealing with burnout, the pressure of the malpractice claim could well increase the probability of other medical mistakes. The institution has asked Dr. H to take a burnout test, but it is unclear where things go if the test (as likely) demonstrates significant burnout. This is a counseling and human relations question, at least as much as a legal issue, and the institution should probably proceed in that way—which is, trying to understand and support Dr. H and determining what can be done to address the burnout. At the same time, the system must reasonably assess Dr. H’s fitness to continue practicing as the matters are resolved. Almost everyone shares the goal to provide every individual and corporate opportunity for Dr. H to deal with burnout issues and return to successful practice.
Dr. H will be represented in the malpractice case by counsel provided through the insurance carrier. However, Dr. H would be well advised to retain a trusted and knowledgeable personal attorney. For example, the instruction not to consider settlement is likely misguided, but Dr. H needs to talk with an attorney that Dr. H has chosen and trusts. In addition, the attorney can help guide Dr. H through a rational process of dealing with the health care system, putting the practice in order, and considering the options for the future.
The health care system should reconsider its processes to deal with burnout to ensure the quality of care, patient satisfaction, professional retention, and economic stability. Several burnoutresponse programs have had success in achieving these goals.
What’s the Verdict?
Dr. H received good mental health, legal, and professional advice. As a result, an out of court settlement was reached following pretrial discovery. Dr. H has continued consultation regarding burnout and has returned to productive practice.
- Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clinic Proceed. 2019;94:1681-1694.
- Smith R, Rayburn W. Burnout in obstetrician-gynecologists. Its prevalence, identification, prevention, and reversal. Obstet Gynecol Clin North Am. 2021;48:231-245. https://doi. org/10.1016/j.ogc.2021.06.003
- Patti MG, Schlottmann F, Sarr MG. The problem of burnout among surgeons. JAMA Surg. 2018;153:403-404. doi:10.1001 /jamasurg.2018.0047
- Carrau D, Janis JE. Physician burnout: solutions for individuals and organizations. Plastic and Reconstructive Surgery Global Open. 2021;91-97.
- Southwick R. The key to fixing physician burnout is the workplace not the worker. Contemporary Ob/Gyn. March 13, 2023.
- Patel RS, Bachu R, Adikey A, et al. Factors related to physician burnout and its consequences: a review. Behav Sciences. 2018;8:98.
- Melnick ER, Dyrbye LN, Sinsky CA, et al. The association between perceived electronic health record usability and professional burnout among US physicians. Mayo Clinic Proceed. 2020;95:476-487.
- Shanafelt TD, Dyrbye LN, West CP. Addressing physician burnout: the way forward. JAMA. 2017;317:901-902. doi:10.1001/jama.2017.0076
- Ommaya AK, Cipriano PF, Hoyt DB, et al. Care-centered clinical documentation in the digital environment: Solutions to alleviate burnout. National Academy of Medicine Perspectives. 2018.
- Hartzband P, Groopman J. Physician burnout, interrupted. N Engl J Med. 2020;382:2485-2487. Discussion Paper, National Academy of Medicine. Accessed July 21, 2023. https://nam .edu/care
- Ji YD, Robertson FC, Patel NA, et al. Assessment of risk factors for suicide among US health care professionals. JAMA Surg. 2020;155:713-721. centered-clinical-documentation-digital -environment-solutions-alleviate-burnout/
- Shanafelt TD, West CP, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic. Mayo Clinic Proceed. 2022;97:2248-2258.
- Herber-Valdez C, Kupesic-Plavsic S. Satisfaction and shortfall of OB-GYN physicians and radiologists. J. Ultrasound Obstet Gynecol. 2021;15:387-392.
- Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Burnout among health care professionals: a call to explore and address this underrecognized threat to safe, high-quality care. National Academy of Medicine Perspectives. Accessed July 5, 2017. https://iuhcpe.org/file_manager/1501524077-Burnout -Among-Health-Care-Professionals-A-Call-to-Explore-and -Address-This-Underrecognized-Threat.pdf
- Olson KD. Physician burnout—a leading indicator of health system performance? Mayo Clinic Proceed. 2017;92: 1608-1611.
- American College of Obstetricians and Gynecologists. Why obgyns are burning out. October 28, 2019. Accessed July 21, 2023. https://www.acog.org/news/news-articles/2019/10/why-ob -gyns-are-burning-out#:~:text=A%202017%20report%20 by%20the,exhaustion%20or%20lack%20of%20motivation
- Peckham C. National physician burnout & depression report 2018. Medscape. January 17, 2018. https://nap. nationalacademies.org/catalog/25521/taking-action -against-clinician-burnout-a-systems-approach-to -professional
- Marsa L. Labor pains: The OB-GYN shortage. AAMC News. Nov. 15, 2018. Accessed July 21, 2023. https://www.aamc.org /news-insights/labor-pains-ob-gyn-shortage
- American College of Obstetricians and Gynecologists. Coping with the stress of medical professional liability litigation. ACOG Committee Opinion. February 2005;309:453454. Accessed July 21, 2023. https://www.acog.org/clinical /clinical-guidance/committee-opinion/articles/2013/01 /coping-with-the-stress-of-medical-professional-liability -litigation
- Reith TP. Burnout in United States healthcare professionals: a narrative review. Cureus. 2018;10:e3681. doi: 10.7759 /cureus.3681
- Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. 2019;4:784-790.
- Sullivan D, Sullivan V, Weatherspoon D, et al. Comparison of nurse burnout, before and during the COVID-19 pandemic. Nurs Clin North Am. 2022;57:79-99. doi: 10.1016 /j.cnur.2021.11.006
- Chandawarkar A, Chaparro JD. Burnout in clinicians. Curr Prob Pediatr Adolesc Health Care. 2021;51:101-104. https ://doi.org/10.1016/j.cppeds.2021.101104
- Brady KJS, Sheldrick RC, Ni P, et al. Examining the measurement equivalence of the Maslach Burnout Inventory across age, gender, and specialty groups in US physicians. J Patient-Reported Outcomes. 2021;5.
- Association of American Medical Colleges. Physician Specialty Data Report—Active Physicians by Sex and Specialty, 2021. Accessed June 19, 2023. https://www.aamc .org/data-reports/workforce/data/active-physicians-sex -specialty-2021
- Association of American Medical Colleges. Physician Specialty Data Report—ACGME Residents and Fellows by Sex and Specialty, 2021. Accessed June 19, 2023. https://www .aamc.org/data-reports/workforce/data/acgme-residents -fellows-sex-and-specialty-2021
- Painter LM, Biggans KA, Turner CT. Risk managementobstetrics and gynecology perspective. Clin Obstet Gynecol. 2023;66:331-341. DOI:10.1097/GRF.0000000000000775
- Darney BG, Boniface E, Liberty A. Assessing the effect of abortion restrictions. Obstetr Gynecol. 2023;141:233-235.
- Heuerman AC, Bessett D, Antommaria AHM, et al. Experiences of reproductive genetic counselors with abortion regulations in Ohio. J Genet Counseling. 2022;31:641-652.
- Brandi K, Gill P. Abortion restrictions threaten all reproductive health care clinicians. Am J Public Health. 2023;113:384-385.
- Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of burnout among physicians: a systematic review. JAMA. 2018;320:1131-1150. doi: 10.1001/jama.2018.1277
- Williamson K, Lank PM, Cheema N, et al. Comparing the Maslach Burnout Inventory to other well-being instruments in emergency medicine residents. J Graduate Med Education. 2018;532-536. DOI: http://dx.doi.org/10.4300 /JGME-D-18-00155.1
- Brady KJS, Sheldrick RC, Ni P, et al. Establishing crosswalks between common measures of burnout in US physicians. J Gen Intern Med. 2022;37:777-784.
- Zhang X, Song Y, Jiang T, et al. Interventions to reduce burnout of physicians and nurses: an overview of systematic reviews and meta-analyses. Medicine (Baltimore). 2020;26:e20992. DOI: 10.1097/MD.0000000000020992
- Scheepers RA, Emke H, Ronald M, et al. The impact of mindfulness-based interventions on doctors’ well-being and performance: a systematic review. Med Education. 2020;54:138-149. https://doi.org/10.1111/medu.14020
- Olson K, Marchalik D, Farley H, et al. Organizational strategies to reduce physician burnout and improve professional fulfillment. Curr Prob Pediatr Adolesc Health Care. 2019;49:12. https://doi.org/10.1016/j.cppeds.2019.100664
- Berry LL, Awdish RLA, Swensen SJ. 5 ways to restore depleted health care workers. Harvard Business Rev. February 11, 2022.
- Sullivan AB, Hersh CM, Rensel M, et al. Leadership inequity, burnout, and lower engagement of women in medicine. J Health Serv Psychol. 2023;49:33-39.
- Hoffman S. Healing the healers: legal remedies for physician burnout. Yale J Health Policy Law Ethics. 2018;18:56-113.
- Federation of State Medical Boards. Physician wellness and burnout: report and recommendations of the workgroup on physician wellness and burnout. (Policy adopted by FSMB). April 2018. Accessed July 21, 2023. https://www.fsmb.org /siteassets/advocacy/policies/policy-on-wellness-and -burnout.pdf
- Robinson C, Kettering C, Sanfilippo JS. Medical malpractice lawsuits. Clin Obstet Gynecol. 2023;66:256-260. DOI: https ://doi.org/10.1097/GRF.0000000000000777
- Gittler GJ, Goldstein EJ. The elements of medical malpractice: an overview. Clin Infect Dis. 1996;23:1152-1155.
- Bal BS. An introduction to medical malpractice in the United States. Clin Orthop Relat Res. 2009;467:339-347.
- Tawfik DS, Profit J, Morgenthaler TI, et al. Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Mayo Clinic Proceed. 2018;93: 1571-1580.
- Sundholm B. Elevating physician-patient relationships in the shadow of metric mania. Drexel L Rev. 2020;12:287-330.
- Ghaith S, Campbell RL, Pollock JR, et al. Medical malpractice lawsuits involving trainees in obstetrics and gynecology in the USA. Healthcare. 2022;10:1328.
- Muller TM, Warsi S. Litigation culture causing burnout in American physicians. Trauma Mental Health Report. April 9, 2021.
- Levine AS. Legal 101: Tort law and medical malpractice for physicians. Contemp OBGYN. 2015:60;26-28, 30.
- Regan JJ, Regan WM. Medical malpractice and respondeat superior. Southern Med J. 2002;95.5:545-549. DOI 10.1097/00007611-200295050-00018
- Levin H. Hospital vicarious liability for negligence by independent contractor physicians: new rule for new times. Univ Illinois Law Rev. 2005:1291-1332.
- Darling v Charleston Hospital, 33 Ill. 2d 326, 211 N.E.2d 253 (Ill. 1965).
- Dangel R. Hospital liability for physician malpractice. Ohio State Law J. 1986;47:1077-1098.
- Reffitt v Hajjar, 892 S.W.2d 599, 605 (Ky. Ct. App. 1994).
- McMichael BJ. Malpractice. In Laws of Medicine: Core Legal Aspects for the Healthcare Professional. New York, NY: Springer International; 2022:129-150.
- Occupational Safety and Health Administration. Worker safety in hospitals: caring for our caregivers. Accessed June 8, 2023. https://www.osha.gov/hospitals
- Occupational Safety and Health Administration. Workplace stress. Accessed June 8, 2023. https://www.osha.gov /workplace-stress/understanding-the-problem
- U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce. Addressing health worker burnout. Accessed July 21, 2023. https://www.hhs.gov/sites/default/files/health -worker-wellbeing-advisory.pdf
- Department of Health & Human Services. Biden-Harris administration awards $103 Million in American Rescue Plan funds to reduce burnout and promote mental health and wellness among health care workforce. January 20, 2022. Accessed July 24, 2023. https://www.hhs.gov/about /news/2022/01/20/biden-harris-administration-awards -103-million-american-rescue-plan-funds-reduce-burnout -promote-mental-health-wellness-among-health-care -workforce.html
- Rothstein LF, Irzyk J. Disabilities and the Law. 4th ed. Toronto, Canada: Thompson Reuters; 2023.
- Department of Labor. Guide to disability rights laws. February 28, 2020. Accessed July 24, 2023. https://www .ada.gov/resources/disability-rights-guide/#:~:text=An%20 individual%20with%20a%20disability%20is%20defined%20 by%20the%20ADA,as%20having%20such%20an%20 impairment
- Nadon L, De Beer LT, Morin AJS. Should burnout be conceptualized as a mental disorder? Behavioral Sci. 2022;12:82.
- World Health Organization. Burn-out an “occupational phenomenon”: International Classification of Diseases. May 28, 2019. Accessed July 21, 2023. https://www.who.int/news /item/28-05-2019-burn-out-an-occupational-phenomenon -international-classification-of-diseases
- Hoffman S. Physician burnout: why legal and regulatory systems may need to step in. The Conversation. July 9, 2019. https://theconversation.com/physician-burnout-why-legal -and-regulatory-systems-may-need-to-step-in-119705
- Jha A, Iliff A, Chaoi A, et al. A crisis in healthcare: a call to action on physician burnout. Harvard Global Health Institute. 2019. Accessed July 21, 2023. https://www.massmed.org /Publications/Research,-Studies,-and-Reports/Physician -Burnout-Report-2018/
- Arnsten AF, Shanafelt T. Physician distress and burnout: the neurobiological perspective. Mayo Clin Proceed. 2021;96:763-769.
- Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clinic Proceed. 2019;94:1681-1694.
- Smith R, Rayburn W. Burnout in obstetrician-gynecologists. Its prevalence, identification, prevention, and reversal. Obstet Gynecol Clin North Am. 2021;48:231-245. https://doi. org/10.1016/j.ogc.2021.06.003
- Patti MG, Schlottmann F, Sarr MG. The problem of burnout among surgeons. JAMA Surg. 2018;153:403-404. doi:10.1001 /jamasurg.2018.0047
- Carrau D, Janis JE. Physician burnout: solutions for individuals and organizations. Plastic and Reconstructive Surgery Global Open. 2021;91-97.
- Southwick R. The key to fixing physician burnout is the workplace not the worker. Contemporary Ob/Gyn. March 13, 2023.
- Patel RS, Bachu R, Adikey A, et al. Factors related to physician burnout and its consequences: a review. Behav Sciences. 2018;8:98.
- Melnick ER, Dyrbye LN, Sinsky CA, et al. The association between perceived electronic health record usability and professional burnout among US physicians. Mayo Clinic Proceed. 2020;95:476-487.
- Shanafelt TD, Dyrbye LN, West CP. Addressing physician burnout: the way forward. JAMA. 2017;317:901-902. doi:10.1001/jama.2017.0076
- Ommaya AK, Cipriano PF, Hoyt DB, et al. Care-centered clinical documentation in the digital environment: Solutions to alleviate burnout. National Academy of Medicine Perspectives. 2018.
- Hartzband P, Groopman J. Physician burnout, interrupted. N Engl J Med. 2020;382:2485-2487. Discussion Paper, National Academy of Medicine. Accessed July 21, 2023. https://nam .edu/care
- Ji YD, Robertson FC, Patel NA, et al. Assessment of risk factors for suicide among US health care professionals. JAMA Surg. 2020;155:713-721. centered-clinical-documentation-digital -environment-solutions-alleviate-burnout/
- Shanafelt TD, West CP, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic. Mayo Clinic Proceed. 2022;97:2248-2258.
- Herber-Valdez C, Kupesic-Plavsic S. Satisfaction and shortfall of OB-GYN physicians and radiologists. J. Ultrasound Obstet Gynecol. 2021;15:387-392.
- Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Burnout among health care professionals: a call to explore and address this underrecognized threat to safe, high-quality care. National Academy of Medicine Perspectives. Accessed July 5, 2017. https://iuhcpe.org/file_manager/1501524077-Burnout -Among-Health-Care-Professionals-A-Call-to-Explore-and -Address-This-Underrecognized-Threat.pdf
- Olson KD. Physician burnout—a leading indicator of health system performance? Mayo Clinic Proceed. 2017;92: 1608-1611.
- American College of Obstetricians and Gynecologists. Why obgyns are burning out. October 28, 2019. Accessed July 21, 2023. https://www.acog.org/news/news-articles/2019/10/why-ob -gyns-are-burning-out#:~:text=A%202017%20report%20 by%20the,exhaustion%20or%20lack%20of%20motivation
- Peckham C. National physician burnout & depression report 2018. Medscape. January 17, 2018. https://nap. nationalacademies.org/catalog/25521/taking-action -against-clinician-burnout-a-systems-approach-to -professional
- Marsa L. Labor pains: The OB-GYN shortage. AAMC News. Nov. 15, 2018. Accessed July 21, 2023. https://www.aamc.org /news-insights/labor-pains-ob-gyn-shortage
- American College of Obstetricians and Gynecologists. Coping with the stress of medical professional liability litigation. ACOG Committee Opinion. February 2005;309:453454. Accessed July 21, 2023. https://www.acog.org/clinical /clinical-guidance/committee-opinion/articles/2013/01 /coping-with-the-stress-of-medical-professional-liability -litigation
- Reith TP. Burnout in United States healthcare professionals: a narrative review. Cureus. 2018;10:e3681. doi: 10.7759 /cureus.3681
- Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. 2019;4:784-790.
- Sullivan D, Sullivan V, Weatherspoon D, et al. Comparison of nurse burnout, before and during the COVID-19 pandemic. Nurs Clin North Am. 2022;57:79-99. doi: 10.1016 /j.cnur.2021.11.006
- Chandawarkar A, Chaparro JD. Burnout in clinicians. Curr Prob Pediatr Adolesc Health Care. 2021;51:101-104. https ://doi.org/10.1016/j.cppeds.2021.101104
- Brady KJS, Sheldrick RC, Ni P, et al. Examining the measurement equivalence of the Maslach Burnout Inventory across age, gender, and specialty groups in US physicians. J Patient-Reported Outcomes. 2021;5.
- Association of American Medical Colleges. Physician Specialty Data Report—Active Physicians by Sex and Specialty, 2021. Accessed June 19, 2023. https://www.aamc .org/data-reports/workforce/data/active-physicians-sex -specialty-2021
- Association of American Medical Colleges. Physician Specialty Data Report—ACGME Residents and Fellows by Sex and Specialty, 2021. Accessed June 19, 2023. https://www .aamc.org/data-reports/workforce/data/acgme-residents -fellows-sex-and-specialty-2021
- Painter LM, Biggans KA, Turner CT. Risk managementobstetrics and gynecology perspective. Clin Obstet Gynecol. 2023;66:331-341. DOI:10.1097/GRF.0000000000000775
- Darney BG, Boniface E, Liberty A. Assessing the effect of abortion restrictions. Obstetr Gynecol. 2023;141:233-235.
- Heuerman AC, Bessett D, Antommaria AHM, et al. Experiences of reproductive genetic counselors with abortion regulations in Ohio. J Genet Counseling. 2022;31:641-652.
- Brandi K, Gill P. Abortion restrictions threaten all reproductive health care clinicians. Am J Public Health. 2023;113:384-385.
- Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of burnout among physicians: a systematic review. JAMA. 2018;320:1131-1150. doi: 10.1001/jama.2018.1277
- Williamson K, Lank PM, Cheema N, et al. Comparing the Maslach Burnout Inventory to other well-being instruments in emergency medicine residents. J Graduate Med Education. 2018;532-536. DOI: http://dx.doi.org/10.4300 /JGME-D-18-00155.1
- Brady KJS, Sheldrick RC, Ni P, et al. Establishing crosswalks between common measures of burnout in US physicians. J Gen Intern Med. 2022;37:777-784.
- Zhang X, Song Y, Jiang T, et al. Interventions to reduce burnout of physicians and nurses: an overview of systematic reviews and meta-analyses. Medicine (Baltimore). 2020;26:e20992. DOI: 10.1097/MD.0000000000020992
- Scheepers RA, Emke H, Ronald M, et al. The impact of mindfulness-based interventions on doctors’ well-being and performance: a systematic review. Med Education. 2020;54:138-149. https://doi.org/10.1111/medu.14020
- Olson K, Marchalik D, Farley H, et al. Organizational strategies to reduce physician burnout and improve professional fulfillment. Curr Prob Pediatr Adolesc Health Care. 2019;49:12. https://doi.org/10.1016/j.cppeds.2019.100664
- Berry LL, Awdish RLA, Swensen SJ. 5 ways to restore depleted health care workers. Harvard Business Rev. February 11, 2022.
- Sullivan AB, Hersh CM, Rensel M, et al. Leadership inequity, burnout, and lower engagement of women in medicine. J Health Serv Psychol. 2023;49:33-39.
- Hoffman S. Healing the healers: legal remedies for physician burnout. Yale J Health Policy Law Ethics. 2018;18:56-113.
- Federation of State Medical Boards. Physician wellness and burnout: report and recommendations of the workgroup on physician wellness and burnout. (Policy adopted by FSMB). April 2018. Accessed July 21, 2023. https://www.fsmb.org /siteassets/advocacy/policies/policy-on-wellness-and -burnout.pdf
- Robinson C, Kettering C, Sanfilippo JS. Medical malpractice lawsuits. Clin Obstet Gynecol. 2023;66:256-260. DOI: https ://doi.org/10.1097/GRF.0000000000000777
- Gittler GJ, Goldstein EJ. The elements of medical malpractice: an overview. Clin Infect Dis. 1996;23:1152-1155.
- Bal BS. An introduction to medical malpractice in the United States. Clin Orthop Relat Res. 2009;467:339-347.
- Tawfik DS, Profit J, Morgenthaler TI, et al. Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Mayo Clinic Proceed. 2018;93: 1571-1580.
- Sundholm B. Elevating physician-patient relationships in the shadow of metric mania. Drexel L Rev. 2020;12:287-330.
- Ghaith S, Campbell RL, Pollock JR, et al. Medical malpractice lawsuits involving trainees in obstetrics and gynecology in the USA. Healthcare. 2022;10:1328.
- Muller TM, Warsi S. Litigation culture causing burnout in American physicians. Trauma Mental Health Report. April 9, 2021.
- Levine AS. Legal 101: Tort law and medical malpractice for physicians. Contemp OBGYN. 2015:60;26-28, 30.
- Regan JJ, Regan WM. Medical malpractice and respondeat superior. Southern Med J. 2002;95.5:545-549. DOI 10.1097/00007611-200295050-00018
- Levin H. Hospital vicarious liability for negligence by independent contractor physicians: new rule for new times. Univ Illinois Law Rev. 2005:1291-1332.
- Darling v Charleston Hospital, 33 Ill. 2d 326, 211 N.E.2d 253 (Ill. 1965).
- Dangel R. Hospital liability for physician malpractice. Ohio State Law J. 1986;47:1077-1098.
- Reffitt v Hajjar, 892 S.W.2d 599, 605 (Ky. Ct. App. 1994).
- McMichael BJ. Malpractice. In Laws of Medicine: Core Legal Aspects for the Healthcare Professional. New York, NY: Springer International; 2022:129-150.
- Occupational Safety and Health Administration. Worker safety in hospitals: caring for our caregivers. Accessed June 8, 2023. https://www.osha.gov/hospitals
- Occupational Safety and Health Administration. Workplace stress. Accessed June 8, 2023. https://www.osha.gov /workplace-stress/understanding-the-problem
- U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce. Addressing health worker burnout. Accessed July 21, 2023. https://www.hhs.gov/sites/default/files/health -worker-wellbeing-advisory.pdf
- Department of Health & Human Services. Biden-Harris administration awards $103 Million in American Rescue Plan funds to reduce burnout and promote mental health and wellness among health care workforce. January 20, 2022. Accessed July 24, 2023. https://www.hhs.gov/about /news/2022/01/20/biden-harris-administration-awards -103-million-american-rescue-plan-funds-reduce-burnout -promote-mental-health-wellness-among-health-care -workforce.html
- Rothstein LF, Irzyk J. Disabilities and the Law. 4th ed. Toronto, Canada: Thompson Reuters; 2023.
- Department of Labor. Guide to disability rights laws. February 28, 2020. Accessed July 24, 2023. https://www .ada.gov/resources/disability-rights-guide/#:~:text=An%20 individual%20with%20a%20disability%20is%20defined%20 by%20the%20ADA,as%20having%20such%20an%20 impairment
- Nadon L, De Beer LT, Morin AJS. Should burnout be conceptualized as a mental disorder? Behavioral Sci. 2022;12:82.
- World Health Organization. Burn-out an “occupational phenomenon”: International Classification of Diseases. May 28, 2019. Accessed July 21, 2023. https://www.who.int/news /item/28-05-2019-burn-out-an-occupational-phenomenon -international-classification-of-diseases
- Hoffman S. Physician burnout: why legal and regulatory systems may need to step in. The Conversation. July 9, 2019. https://theconversation.com/physician-burnout-why-legal -and-regulatory-systems-may-need-to-step-in-119705
- Jha A, Iliff A, Chaoi A, et al. A crisis in healthcare: a call to action on physician burnout. Harvard Global Health Institute. 2019. Accessed July 21, 2023. https://www.massmed.org /Publications/Research,-Studies,-and-Reports/Physician -Burnout-Report-2018/
- Arnsten AF, Shanafelt T. Physician distress and burnout: the neurobiological perspective. Mayo Clin Proceed. 2021;96:763-769.
Autoantibodies could help predict cancer risk in scleroderma
TOPLINE:
METHODOLOGY:
- Included patients from the Johns Hopkins Scleroderma Center Research Registry and the University of Pittsburgh Scleroderma Center, Pittsburgh.
- A total of 676 patients with scleroderma and a history of cancer were compared with 687 control patients with scleroderma but without a history of cancer.
- Serum tested via line blot and enzyme-linked immunosorbent assay for an array of scleroderma autoantibodies.
- Examined association between autoantibodies and overall cancer risk.
TAKEAWAYS:
- Anti-POLR3 and monospecific anti-Ro52 were associated with significantly increased overall cancer risk.
- Anti-centromere and anti-U1RNP were associated with a decreased cancer risk.
- These associations remained when looking specifically at cancer-associated scleroderma.
- Patients positive for anti-Ro52 in combination with either anti-U1RNP or anti-Th/To had a decreased risk of cancer, compared with those who had anti-Ro52 alone.
IN PRACTICE:
This study is too preliminary to have practice application.
SOURCE:
Ji Soo Kim, PhD, of John Hopkins University, Baltimore, was the first author of the study, published in Arthritis & Rheumatology on July 24, 2023. Fellow Johns Hopkins researchers Livia Casciola-Rosen, PhD, and Ami A. Shah, MD, were joint senior authors.
DISCLOSURES:
The study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the Donald B. and Dorothy L. Stabler Foundation, the Jerome L. Greene Foundation, the Chresanthe Staurulakis Memorial Discovery Fund, the Martha McCrory Professorship, and the Johns Hopkins inHealth initiative. The authors disclosed the following patents or patent applications: Autoimmune Antigens and Cancer, Materials and Methods for Assessing Cancer Risk and Treating Cancer.
A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Included patients from the Johns Hopkins Scleroderma Center Research Registry and the University of Pittsburgh Scleroderma Center, Pittsburgh.
- A total of 676 patients with scleroderma and a history of cancer were compared with 687 control patients with scleroderma but without a history of cancer.
- Serum tested via line blot and enzyme-linked immunosorbent assay for an array of scleroderma autoantibodies.
- Examined association between autoantibodies and overall cancer risk.
TAKEAWAYS:
- Anti-POLR3 and monospecific anti-Ro52 were associated with significantly increased overall cancer risk.
- Anti-centromere and anti-U1RNP were associated with a decreased cancer risk.
- These associations remained when looking specifically at cancer-associated scleroderma.
- Patients positive for anti-Ro52 in combination with either anti-U1RNP or anti-Th/To had a decreased risk of cancer, compared with those who had anti-Ro52 alone.
IN PRACTICE:
This study is too preliminary to have practice application.
SOURCE:
Ji Soo Kim, PhD, of John Hopkins University, Baltimore, was the first author of the study, published in Arthritis & Rheumatology on July 24, 2023. Fellow Johns Hopkins researchers Livia Casciola-Rosen, PhD, and Ami A. Shah, MD, were joint senior authors.
DISCLOSURES:
The study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the Donald B. and Dorothy L. Stabler Foundation, the Jerome L. Greene Foundation, the Chresanthe Staurulakis Memorial Discovery Fund, the Martha McCrory Professorship, and the Johns Hopkins inHealth initiative. The authors disclosed the following patents or patent applications: Autoimmune Antigens and Cancer, Materials and Methods for Assessing Cancer Risk and Treating Cancer.
A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Included patients from the Johns Hopkins Scleroderma Center Research Registry and the University of Pittsburgh Scleroderma Center, Pittsburgh.
- A total of 676 patients with scleroderma and a history of cancer were compared with 687 control patients with scleroderma but without a history of cancer.
- Serum tested via line blot and enzyme-linked immunosorbent assay for an array of scleroderma autoantibodies.
- Examined association between autoantibodies and overall cancer risk.
TAKEAWAYS:
- Anti-POLR3 and monospecific anti-Ro52 were associated with significantly increased overall cancer risk.
- Anti-centromere and anti-U1RNP were associated with a decreased cancer risk.
- These associations remained when looking specifically at cancer-associated scleroderma.
- Patients positive for anti-Ro52 in combination with either anti-U1RNP or anti-Th/To had a decreased risk of cancer, compared with those who had anti-Ro52 alone.
IN PRACTICE:
This study is too preliminary to have practice application.
SOURCE:
Ji Soo Kim, PhD, of John Hopkins University, Baltimore, was the first author of the study, published in Arthritis & Rheumatology on July 24, 2023. Fellow Johns Hopkins researchers Livia Casciola-Rosen, PhD, and Ami A. Shah, MD, were joint senior authors.
DISCLOSURES:
The study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the Donald B. and Dorothy L. Stabler Foundation, the Jerome L. Greene Foundation, the Chresanthe Staurulakis Memorial Discovery Fund, the Martha McCrory Professorship, and the Johns Hopkins inHealth initiative. The authors disclosed the following patents or patent applications: Autoimmune Antigens and Cancer, Materials and Methods for Assessing Cancer Risk and Treating Cancer.
A version of this article appeared on Medscape.com.
FROM ARTHRITIS & RHEUMATOLOGY
Scrubs & Heels Summit 2023: Filling a void for women in GI
.1-3 This gender disparity arises from a multitude of factors including lack of effective mentoring, unequal leadership and career advancement opportunities, and pay inequity. In this context, The Scrubs & Heels Leadership Summit (S&H) was launched in 2022 focused on the professional and personal development of women in gastroenterology.
I had the great pleasure and honor of attending the 2023 summit which took place in February in Rancho Palos Verdes, Calif. There were nearly 200 attendees ranging from trainees to midcareer and senior gastroenterologists and other health care professionals from both academia and private practices across the nation. The weekend course was directed by S&H cofounders, Dr. Aline Charabaty and Dr. Anita Afzali, and cochaired by Dr. Amy Oxentenko and Dr. Aja McCutchen.
The 2-day summit opened with a presentation by Sally Helgesen, author of How Women Rise, describing the 12 common habits that often hold women back in career advancement, promotion, or opportunities. Dr. Aline Charabaty addressed the myth of women needing to fulfill the role of superwoman or have suprahuman abilities. Attendees were challenged to reframe this societal construct and begin to find balance and the reasonable choice to switch to part-time work and, as Dr. Aja McCutch emphasized, dial-down responsibilities to maintain wellness when life has competing priorities.
Dr. Amy Oxentenko shared her personal journey to success and instilled the importance of engaging with community and society at large. We then heard from Dr. Neena Abraham on how to gracefully embrace transitions in our professional lives, whether intentionally sought or natural progressions of a career. She encouraged attendees to control our own narrative and seek challenges that promote growth. We explored different practice models with Dr. Caroline Hwang and learned strategies of switching from academics to private practice or vice versa. We also heard from cofounder Dr. Anita Afzali on becoming a physician executive and the importance of staying connected to patient care when rising in ranks of leadership.
The second day opened with a keynote address delivered by Dr. Marla Dubinsky detailing her journey of becoming a CEO of a publicly-traded company while retaining her role as professor and chief of pediatric gastroenterology in a large academic institution. Attendees were provided with a master class on discovering ways to inspire our inner entrepreneur and highlighted the benefit of physicians, especially women, in being effective business leaders. This talk was followed by a talk by Phil Schoenfeld, MD, FACS, editor-in-chief of Evidence-Based GI for the American College of Gastroenterology. He spoke on the importance of male allyship for women in GI and shared his personal experiences and challenges with allyship.
The summit included a breakout session by Dr. Rashmi Advani designed for residents to hear tips on how to have a successful fellowship match and for fellows to embrace a steep learning curve when starting and included tips for efficiency. Additional breakout sessions included learning ergonomic strategies for positioning and scope-holding, vocal-cord exercises before giving oral presentations, and how to formulate a business plan and negotiate a contract.
We ended the summit with uplifting advice from executive coaches Sonia Narang and Dr. Dawn Sears who taught us the art of leaning into opportunities, mansizing aspirations, finding coconspirators for amplification of female GI leaders, and supporting our colleagues personally and professionally.
Three key takeaway messages:
- Recognize your self-worth and the contributions you bring to your patients and community as a whole.
- Lean into the importance of vocalizing your asks, advocating for yourself, building your brand, and showcasing your accomplishments.
- Be mindful of the balance between the time and energy you dedicate towards goals that bring you recognition and fuel your passion and your mental, physical, and emotional health.
As a trainee, I benefited tremendously from attending and expanding my professional network of mentors, sponsors and colleagues. I am encouraged by this programming and hope to see more of it in the future.
Contributors to this article included: Rashmi Advani, MD2; Anita Afzali, MD3; Aline Charabaty, MD.4
Neither Dr. Syed, nor the article contributors, had financial conflicts of interest associated with this article. The AGA was represented at the Scrubs and Heels Summit as a society partner committed to the advancement of women in GI. AGA is building on years of efforts to bolster leadership, mentorship, and sponsorship among women in GI through its annual women’s leadership conference and most recently with its 2022 regional women in GI workshops held around the country that led to the development of a comprehensive gender equity strategy designed to build an environment of gender equity in the field of GI so that all can thrive.
Institutions and social media handle
1. Santa Clara Valley Medical Center (San Jose, Calif), @noorannemd
2. Cedars Sinai (Los Angeles), @AdvaniRashmiMD
3. University of Cincinnati, @IBD_Afzali
4. Johns Hopkins Medicine (Washington), @DCharabaty
References
Advani R et al. Gender-specific attitudes of internal medicine residents toward gastroenterology. Dig Dis Sci. 2022 Nov;67(11):5044-52.
American Association of Medical Colleges. Diversity in Medicine: Facts and Figures (2019).
Elta GH. The challenges of being a female gastroenterologist. Gastroenterol Clin North Am. 2011 Jun;40(2):441-7.
Burke CA et al. Gender disparity in the practice of gastroenterology: The first 5 years of a career. Am J Gastroenterol 2005;100:259-64
David, Yakira N. et al. Gender-specific factors influencing gastroenterologists to pursue careers in advanced endoscopy: perceptions vs reality. Journal of the American College of Gastroenterology, ACG 116.3 (2021):539-50.
Rabinowitz LG et al. Gender dynamics in education and practice of gastroenterology. Gastrointest Endosc. 2021;93:1047-56.
Rabinowitz LG et al. Survey finds gender disparities impact both women mentors and mentees in gastroenterology. Journal of the American College of Gastroenterology, ACG 2021;116:1876-84.
.1-3 This gender disparity arises from a multitude of factors including lack of effective mentoring, unequal leadership and career advancement opportunities, and pay inequity. In this context, The Scrubs & Heels Leadership Summit (S&H) was launched in 2022 focused on the professional and personal development of women in gastroenterology.
I had the great pleasure and honor of attending the 2023 summit which took place in February in Rancho Palos Verdes, Calif. There were nearly 200 attendees ranging from trainees to midcareer and senior gastroenterologists and other health care professionals from both academia and private practices across the nation. The weekend course was directed by S&H cofounders, Dr. Aline Charabaty and Dr. Anita Afzali, and cochaired by Dr. Amy Oxentenko and Dr. Aja McCutchen.
The 2-day summit opened with a presentation by Sally Helgesen, author of How Women Rise, describing the 12 common habits that often hold women back in career advancement, promotion, or opportunities. Dr. Aline Charabaty addressed the myth of women needing to fulfill the role of superwoman or have suprahuman abilities. Attendees were challenged to reframe this societal construct and begin to find balance and the reasonable choice to switch to part-time work and, as Dr. Aja McCutch emphasized, dial-down responsibilities to maintain wellness when life has competing priorities.
Dr. Amy Oxentenko shared her personal journey to success and instilled the importance of engaging with community and society at large. We then heard from Dr. Neena Abraham on how to gracefully embrace transitions in our professional lives, whether intentionally sought or natural progressions of a career. She encouraged attendees to control our own narrative and seek challenges that promote growth. We explored different practice models with Dr. Caroline Hwang and learned strategies of switching from academics to private practice or vice versa. We also heard from cofounder Dr. Anita Afzali on becoming a physician executive and the importance of staying connected to patient care when rising in ranks of leadership.
The second day opened with a keynote address delivered by Dr. Marla Dubinsky detailing her journey of becoming a CEO of a publicly-traded company while retaining her role as professor and chief of pediatric gastroenterology in a large academic institution. Attendees were provided with a master class on discovering ways to inspire our inner entrepreneur and highlighted the benefit of physicians, especially women, in being effective business leaders. This talk was followed by a talk by Phil Schoenfeld, MD, FACS, editor-in-chief of Evidence-Based GI for the American College of Gastroenterology. He spoke on the importance of male allyship for women in GI and shared his personal experiences and challenges with allyship.
The summit included a breakout session by Dr. Rashmi Advani designed for residents to hear tips on how to have a successful fellowship match and for fellows to embrace a steep learning curve when starting and included tips for efficiency. Additional breakout sessions included learning ergonomic strategies for positioning and scope-holding, vocal-cord exercises before giving oral presentations, and how to formulate a business plan and negotiate a contract.
We ended the summit with uplifting advice from executive coaches Sonia Narang and Dr. Dawn Sears who taught us the art of leaning into opportunities, mansizing aspirations, finding coconspirators for amplification of female GI leaders, and supporting our colleagues personally and professionally.
Three key takeaway messages:
- Recognize your self-worth and the contributions you bring to your patients and community as a whole.
- Lean into the importance of vocalizing your asks, advocating for yourself, building your brand, and showcasing your accomplishments.
- Be mindful of the balance between the time and energy you dedicate towards goals that bring you recognition and fuel your passion and your mental, physical, and emotional health.
As a trainee, I benefited tremendously from attending and expanding my professional network of mentors, sponsors and colleagues. I am encouraged by this programming and hope to see more of it in the future.
Contributors to this article included: Rashmi Advani, MD2; Anita Afzali, MD3; Aline Charabaty, MD.4
Neither Dr. Syed, nor the article contributors, had financial conflicts of interest associated with this article. The AGA was represented at the Scrubs and Heels Summit as a society partner committed to the advancement of women in GI. AGA is building on years of efforts to bolster leadership, mentorship, and sponsorship among women in GI through its annual women’s leadership conference and most recently with its 2022 regional women in GI workshops held around the country that led to the development of a comprehensive gender equity strategy designed to build an environment of gender equity in the field of GI so that all can thrive.
Institutions and social media handle
1. Santa Clara Valley Medical Center (San Jose, Calif), @noorannemd
2. Cedars Sinai (Los Angeles), @AdvaniRashmiMD
3. University of Cincinnati, @IBD_Afzali
4. Johns Hopkins Medicine (Washington), @DCharabaty
References
Advani R et al. Gender-specific attitudes of internal medicine residents toward gastroenterology. Dig Dis Sci. 2022 Nov;67(11):5044-52.
American Association of Medical Colleges. Diversity in Medicine: Facts and Figures (2019).
Elta GH. The challenges of being a female gastroenterologist. Gastroenterol Clin North Am. 2011 Jun;40(2):441-7.
Burke CA et al. Gender disparity in the practice of gastroenterology: The first 5 years of a career. Am J Gastroenterol 2005;100:259-64
David, Yakira N. et al. Gender-specific factors influencing gastroenterologists to pursue careers in advanced endoscopy: perceptions vs reality. Journal of the American College of Gastroenterology, ACG 116.3 (2021):539-50.
Rabinowitz LG et al. Gender dynamics in education and practice of gastroenterology. Gastrointest Endosc. 2021;93:1047-56.
Rabinowitz LG et al. Survey finds gender disparities impact both women mentors and mentees in gastroenterology. Journal of the American College of Gastroenterology, ACG 2021;116:1876-84.
.1-3 This gender disparity arises from a multitude of factors including lack of effective mentoring, unequal leadership and career advancement opportunities, and pay inequity. In this context, The Scrubs & Heels Leadership Summit (S&H) was launched in 2022 focused on the professional and personal development of women in gastroenterology.
I had the great pleasure and honor of attending the 2023 summit which took place in February in Rancho Palos Verdes, Calif. There were nearly 200 attendees ranging from trainees to midcareer and senior gastroenterologists and other health care professionals from both academia and private practices across the nation. The weekend course was directed by S&H cofounders, Dr. Aline Charabaty and Dr. Anita Afzali, and cochaired by Dr. Amy Oxentenko and Dr. Aja McCutchen.
The 2-day summit opened with a presentation by Sally Helgesen, author of How Women Rise, describing the 12 common habits that often hold women back in career advancement, promotion, or opportunities. Dr. Aline Charabaty addressed the myth of women needing to fulfill the role of superwoman or have suprahuman abilities. Attendees were challenged to reframe this societal construct and begin to find balance and the reasonable choice to switch to part-time work and, as Dr. Aja McCutch emphasized, dial-down responsibilities to maintain wellness when life has competing priorities.
Dr. Amy Oxentenko shared her personal journey to success and instilled the importance of engaging with community and society at large. We then heard from Dr. Neena Abraham on how to gracefully embrace transitions in our professional lives, whether intentionally sought or natural progressions of a career. She encouraged attendees to control our own narrative and seek challenges that promote growth. We explored different practice models with Dr. Caroline Hwang and learned strategies of switching from academics to private practice or vice versa. We also heard from cofounder Dr. Anita Afzali on becoming a physician executive and the importance of staying connected to patient care when rising in ranks of leadership.
The second day opened with a keynote address delivered by Dr. Marla Dubinsky detailing her journey of becoming a CEO of a publicly-traded company while retaining her role as professor and chief of pediatric gastroenterology in a large academic institution. Attendees were provided with a master class on discovering ways to inspire our inner entrepreneur and highlighted the benefit of physicians, especially women, in being effective business leaders. This talk was followed by a talk by Phil Schoenfeld, MD, FACS, editor-in-chief of Evidence-Based GI for the American College of Gastroenterology. He spoke on the importance of male allyship for women in GI and shared his personal experiences and challenges with allyship.
The summit included a breakout session by Dr. Rashmi Advani designed for residents to hear tips on how to have a successful fellowship match and for fellows to embrace a steep learning curve when starting and included tips for efficiency. Additional breakout sessions included learning ergonomic strategies for positioning and scope-holding, vocal-cord exercises before giving oral presentations, and how to formulate a business plan and negotiate a contract.
We ended the summit with uplifting advice from executive coaches Sonia Narang and Dr. Dawn Sears who taught us the art of leaning into opportunities, mansizing aspirations, finding coconspirators for amplification of female GI leaders, and supporting our colleagues personally and professionally.
Three key takeaway messages:
- Recognize your self-worth and the contributions you bring to your patients and community as a whole.
- Lean into the importance of vocalizing your asks, advocating for yourself, building your brand, and showcasing your accomplishments.
- Be mindful of the balance between the time and energy you dedicate towards goals that bring you recognition and fuel your passion and your mental, physical, and emotional health.
As a trainee, I benefited tremendously from attending and expanding my professional network of mentors, sponsors and colleagues. I am encouraged by this programming and hope to see more of it in the future.
Contributors to this article included: Rashmi Advani, MD2; Anita Afzali, MD3; Aline Charabaty, MD.4
Neither Dr. Syed, nor the article contributors, had financial conflicts of interest associated with this article. The AGA was represented at the Scrubs and Heels Summit as a society partner committed to the advancement of women in GI. AGA is building on years of efforts to bolster leadership, mentorship, and sponsorship among women in GI through its annual women’s leadership conference and most recently with its 2022 regional women in GI workshops held around the country that led to the development of a comprehensive gender equity strategy designed to build an environment of gender equity in the field of GI so that all can thrive.
Institutions and social media handle
1. Santa Clara Valley Medical Center (San Jose, Calif), @noorannemd
2. Cedars Sinai (Los Angeles), @AdvaniRashmiMD
3. University of Cincinnati, @IBD_Afzali
4. Johns Hopkins Medicine (Washington), @DCharabaty
References
Advani R et al. Gender-specific attitudes of internal medicine residents toward gastroenterology. Dig Dis Sci. 2022 Nov;67(11):5044-52.
American Association of Medical Colleges. Diversity in Medicine: Facts and Figures (2019).
Elta GH. The challenges of being a female gastroenterologist. Gastroenterol Clin North Am. 2011 Jun;40(2):441-7.
Burke CA et al. Gender disparity in the practice of gastroenterology: The first 5 years of a career. Am J Gastroenterol 2005;100:259-64
David, Yakira N. et al. Gender-specific factors influencing gastroenterologists to pursue careers in advanced endoscopy: perceptions vs reality. Journal of the American College of Gastroenterology, ACG 116.3 (2021):539-50.
Rabinowitz LG et al. Gender dynamics in education and practice of gastroenterology. Gastrointest Endosc. 2021;93:1047-56.
Rabinowitz LG et al. Survey finds gender disparities impact both women mentors and mentees in gastroenterology. Journal of the American College of Gastroenterology, ACG 2021;116:1876-84.
Evaluation of Micrographic Surgery and Dermatologic Oncology Fellowship Program Websites
To the Editor:
Micrographic surgery and dermatologic oncology (MSDO) is a highly competitive subspecialty fellowship in dermatology. Prospective applicants often depend on the Internet to obtain pertinent information about fellowship programs to navigate the application process. An up-to-date and comprehensive fellowship website has the potential to be advantageous for both applicants and programs—applicants can more readily identify programs that align with their goals and values, and programs can effectively attract compatible applicants. These advantages are increasingly relevant with the virtual application process that has become essential considering the COVID-19 pandemic. At the height of the COVID-19 pandemic in 2020, we sought to evaluate the comprehensiveness of the content of Accreditation Council for Graduate Medical Education (ACGME) MSDO fellowship program websites to identify possible areas for improvement.
We obtained a list of all ACGME MSDO fellowships from the ACGME website (https://www.acgme.org/) and verified it against the list of MSDO programs in FREIDA, the American Medical Association residency and fellowship database (https://freida.ama-assn.org/). All programs without a website were excluded from further analysis. All data collection from currently accessible fellowship websites and evaluation occurred in April 2020.
The remaining MSDO fellowship program websites were evaluated using 25 criteria distributed among 5 domains: education/research, clinical training, program information, application process, and incentives. These criteria were determined based on earlier studies that similarly evaluated the website content of fellowship programs with inclusion of information that was considered valuable in the appraisal of fellowship programs.1,2 Criteria were further refined by direct consideration of relevance and importance to MSDO fellowship applicants (eg, inclusion of case volume, exclusion of call schedule).
Each criterion was independently assessed by 2 investigators (J.Y.C. and S.J.E.S.). A third investigator (J.R.P.) then independently evaluated those 2 assessments for agreement. Where disagreement was discovered, the third evaluator (J.R.P.) provided a final appraisal. Cohen’s kappa (κ) was conducted to evaluate for concordance between the 2 primary website evaluators. We found there to be substantial agreement between the reviewers within the education/research (κ [SD]=0.772 [0.077]), clinical training (κ [SD]=0.740 [0.051]), application process (κ [SD]=0.726 [0.103]), and incentives domains (κ [SD]=0.730 [0.110]). There was moderate agreement (κ [SD]=0.603 [0.128]) between the reviewers within the program information domain.
We identified 77 active MSDO fellowship programs. Sixty of those 77 programs (77.9%) had a dedicated fellowship website that was readily accessible. Most programs that had a dedicated fellowship website had a core or affiliated residency program (49/60 [81.7%]).
Websites that we evaluated fulfilled a mean (SD) of 9.37 (4.17) of the 25 identified criteria. Only 13 of 60 (21.7%) websites fulfilled more than 50% of evaluated criteria.
There was no statistical difference in the number of criteria fulfilled based on whether the fellowship program had a core or affiliated residency program.
Upon reviewing website accessibility directly from FREIDA, only 5 of 60 programs (8.3%) provided applicants with a link directly to their fellowship page (Table). Most programs (41 [68.3%]) provided a link to the dermatology department website, not to the specific fellowship program page, thus requiring a multistep process to find the fellowship-specific page. The remaining programs had an inaccessible (4 [6.7%]) or absent (10 [16.7%]) link on FREIDA, though a fellowship website could be identified by an Internet search of the program name.
The domain most fulfilled was program information with an average of 51.1% of programs satisfying the criteria, whereas the incentives domain was least fulfilled with an average of only 20.8% of programs satisfying the criteria. Across the various criteria, websites more often included a description of the program (58 [96.6%]), mentioned accreditation (53 [88.3%]), and provided case descriptions (48 [80.0%]). They less often reported information regarding a fellow’s call responsibility (3 [5%]); evaluation criteria (5 [8.3%]); and rotation schedule or options (6 [10.0%]).
The highest number of criteria fulfilled by a single program was 19 (76%). The lowest number of criteria met was 2 (8%). These findings suggest a large variation in comprehensiveness across fellowship websites.
Our research suggests that many current MSDO fellowship programs have room to maximize the information provided to applicants through their websites, which is particularly relevant following the COVID-19 pandemic, as the value of providing comprehensive and transparent information through an online platform is greater than ever. Given the ongoing desire to limit travel, virtual methods for navigating the application process have been readily used, including online videoconferencing for interviews and virtual program visits. This scenario has placed applicants in a challenging situation—their ability to directly evaluate their compatibility with a given program has been limited.3
Earlier studies that analyzed rheumatology fellowship recruitment during the COVID-19 pandemic found that programs may have more difficulty highlighting the strengths of their institution (eg, clinical facilities, professional opportunities, educational environment).4 An updated and comprehensive fellowship website was recommended4 as a key part in facing these new challenges. On the other hand, given the large number of applicants each year for fellowship positions in any given program, we acknowledge the potential benefit programs may obtain from limiting electronic information that is readily accessible to all applicants, as doing so may encourage applicants to communicate directly with a program and allow programs to identify candidates who are more interested.
In light of the movement to a more virtual-friendly and technology-driven fellowship application process, we identified 25 content areas that fellowships may want to include on their websites so that potential applicants can be well informed about the program before submitting an application and scheduling an interview. Efforts to improve accessibility and maximize the content of these websites may help programs attract compatible candidates, improve transparency, and guide applicants throughout the application process.
- Lu F, Vijayasarathi A, Murray N, et al. Evaluation of pediatric radiology fellowship website content in USA and Canada. Curr Prob Diagn Radiol. 2021;50:151-155. doi:10.1067/j.cpradiol.2020.01.007
- Cantrell CK, Bergstresser SL, Schuh AC, et al. Accessibility and content of abdominal transplant fellowship program websites in the United States. J Surg Res. 2018;232:271-274. doi:10.1016/j.jss.2018.06.052
- Nesemeier BR, Lebo NL, Schmalbach CE, et al. Impact of the COVID-19 global pandemic on the otolaryngology fellowship application process. Otolaryngol Head Neck Surg. 2020;163:712-713. doi:10.1177/0194599820934370
- Kilian A, Dua AB, Bolster MB, et al. Rheumatology fellowship recruitment in 2020: benefits, challenges, and adaptations. Arthritis Care Res (Hoboken). 2021;73:459-461. doi:10.1002/acr.24445
To the Editor:
Micrographic surgery and dermatologic oncology (MSDO) is a highly competitive subspecialty fellowship in dermatology. Prospective applicants often depend on the Internet to obtain pertinent information about fellowship programs to navigate the application process. An up-to-date and comprehensive fellowship website has the potential to be advantageous for both applicants and programs—applicants can more readily identify programs that align with their goals and values, and programs can effectively attract compatible applicants. These advantages are increasingly relevant with the virtual application process that has become essential considering the COVID-19 pandemic. At the height of the COVID-19 pandemic in 2020, we sought to evaluate the comprehensiveness of the content of Accreditation Council for Graduate Medical Education (ACGME) MSDO fellowship program websites to identify possible areas for improvement.
We obtained a list of all ACGME MSDO fellowships from the ACGME website (https://www.acgme.org/) and verified it against the list of MSDO programs in FREIDA, the American Medical Association residency and fellowship database (https://freida.ama-assn.org/). All programs without a website were excluded from further analysis. All data collection from currently accessible fellowship websites and evaluation occurred in April 2020.
The remaining MSDO fellowship program websites were evaluated using 25 criteria distributed among 5 domains: education/research, clinical training, program information, application process, and incentives. These criteria were determined based on earlier studies that similarly evaluated the website content of fellowship programs with inclusion of information that was considered valuable in the appraisal of fellowship programs.1,2 Criteria were further refined by direct consideration of relevance and importance to MSDO fellowship applicants (eg, inclusion of case volume, exclusion of call schedule).
Each criterion was independently assessed by 2 investigators (J.Y.C. and S.J.E.S.). A third investigator (J.R.P.) then independently evaluated those 2 assessments for agreement. Where disagreement was discovered, the third evaluator (J.R.P.) provided a final appraisal. Cohen’s kappa (κ) was conducted to evaluate for concordance between the 2 primary website evaluators. We found there to be substantial agreement between the reviewers within the education/research (κ [SD]=0.772 [0.077]), clinical training (κ [SD]=0.740 [0.051]), application process (κ [SD]=0.726 [0.103]), and incentives domains (κ [SD]=0.730 [0.110]). There was moderate agreement (κ [SD]=0.603 [0.128]) between the reviewers within the program information domain.
We identified 77 active MSDO fellowship programs. Sixty of those 77 programs (77.9%) had a dedicated fellowship website that was readily accessible. Most programs that had a dedicated fellowship website had a core or affiliated residency program (49/60 [81.7%]).
Websites that we evaluated fulfilled a mean (SD) of 9.37 (4.17) of the 25 identified criteria. Only 13 of 60 (21.7%) websites fulfilled more than 50% of evaluated criteria.
There was no statistical difference in the number of criteria fulfilled based on whether the fellowship program had a core or affiliated residency program.
Upon reviewing website accessibility directly from FREIDA, only 5 of 60 programs (8.3%) provided applicants with a link directly to their fellowship page (Table). Most programs (41 [68.3%]) provided a link to the dermatology department website, not to the specific fellowship program page, thus requiring a multistep process to find the fellowship-specific page. The remaining programs had an inaccessible (4 [6.7%]) or absent (10 [16.7%]) link on FREIDA, though a fellowship website could be identified by an Internet search of the program name.
The domain most fulfilled was program information with an average of 51.1% of programs satisfying the criteria, whereas the incentives domain was least fulfilled with an average of only 20.8% of programs satisfying the criteria. Across the various criteria, websites more often included a description of the program (58 [96.6%]), mentioned accreditation (53 [88.3%]), and provided case descriptions (48 [80.0%]). They less often reported information regarding a fellow’s call responsibility (3 [5%]); evaluation criteria (5 [8.3%]); and rotation schedule or options (6 [10.0%]).
The highest number of criteria fulfilled by a single program was 19 (76%). The lowest number of criteria met was 2 (8%). These findings suggest a large variation in comprehensiveness across fellowship websites.
Our research suggests that many current MSDO fellowship programs have room to maximize the information provided to applicants through their websites, which is particularly relevant following the COVID-19 pandemic, as the value of providing comprehensive and transparent information through an online platform is greater than ever. Given the ongoing desire to limit travel, virtual methods for navigating the application process have been readily used, including online videoconferencing for interviews and virtual program visits. This scenario has placed applicants in a challenging situation—their ability to directly evaluate their compatibility with a given program has been limited.3
Earlier studies that analyzed rheumatology fellowship recruitment during the COVID-19 pandemic found that programs may have more difficulty highlighting the strengths of their institution (eg, clinical facilities, professional opportunities, educational environment).4 An updated and comprehensive fellowship website was recommended4 as a key part in facing these new challenges. On the other hand, given the large number of applicants each year for fellowship positions in any given program, we acknowledge the potential benefit programs may obtain from limiting electronic information that is readily accessible to all applicants, as doing so may encourage applicants to communicate directly with a program and allow programs to identify candidates who are more interested.
In light of the movement to a more virtual-friendly and technology-driven fellowship application process, we identified 25 content areas that fellowships may want to include on their websites so that potential applicants can be well informed about the program before submitting an application and scheduling an interview. Efforts to improve accessibility and maximize the content of these websites may help programs attract compatible candidates, improve transparency, and guide applicants throughout the application process.
To the Editor:
Micrographic surgery and dermatologic oncology (MSDO) is a highly competitive subspecialty fellowship in dermatology. Prospective applicants often depend on the Internet to obtain pertinent information about fellowship programs to navigate the application process. An up-to-date and comprehensive fellowship website has the potential to be advantageous for both applicants and programs—applicants can more readily identify programs that align with their goals and values, and programs can effectively attract compatible applicants. These advantages are increasingly relevant with the virtual application process that has become essential considering the COVID-19 pandemic. At the height of the COVID-19 pandemic in 2020, we sought to evaluate the comprehensiveness of the content of Accreditation Council for Graduate Medical Education (ACGME) MSDO fellowship program websites to identify possible areas for improvement.
We obtained a list of all ACGME MSDO fellowships from the ACGME website (https://www.acgme.org/) and verified it against the list of MSDO programs in FREIDA, the American Medical Association residency and fellowship database (https://freida.ama-assn.org/). All programs without a website were excluded from further analysis. All data collection from currently accessible fellowship websites and evaluation occurred in April 2020.
The remaining MSDO fellowship program websites were evaluated using 25 criteria distributed among 5 domains: education/research, clinical training, program information, application process, and incentives. These criteria were determined based on earlier studies that similarly evaluated the website content of fellowship programs with inclusion of information that was considered valuable in the appraisal of fellowship programs.1,2 Criteria were further refined by direct consideration of relevance and importance to MSDO fellowship applicants (eg, inclusion of case volume, exclusion of call schedule).
Each criterion was independently assessed by 2 investigators (J.Y.C. and S.J.E.S.). A third investigator (J.R.P.) then independently evaluated those 2 assessments for agreement. Where disagreement was discovered, the third evaluator (J.R.P.) provided a final appraisal. Cohen’s kappa (κ) was conducted to evaluate for concordance between the 2 primary website evaluators. We found there to be substantial agreement between the reviewers within the education/research (κ [SD]=0.772 [0.077]), clinical training (κ [SD]=0.740 [0.051]), application process (κ [SD]=0.726 [0.103]), and incentives domains (κ [SD]=0.730 [0.110]). There was moderate agreement (κ [SD]=0.603 [0.128]) between the reviewers within the program information domain.
We identified 77 active MSDO fellowship programs. Sixty of those 77 programs (77.9%) had a dedicated fellowship website that was readily accessible. Most programs that had a dedicated fellowship website had a core or affiliated residency program (49/60 [81.7%]).
Websites that we evaluated fulfilled a mean (SD) of 9.37 (4.17) of the 25 identified criteria. Only 13 of 60 (21.7%) websites fulfilled more than 50% of evaluated criteria.
There was no statistical difference in the number of criteria fulfilled based on whether the fellowship program had a core or affiliated residency program.
Upon reviewing website accessibility directly from FREIDA, only 5 of 60 programs (8.3%) provided applicants with a link directly to their fellowship page (Table). Most programs (41 [68.3%]) provided a link to the dermatology department website, not to the specific fellowship program page, thus requiring a multistep process to find the fellowship-specific page. The remaining programs had an inaccessible (4 [6.7%]) or absent (10 [16.7%]) link on FREIDA, though a fellowship website could be identified by an Internet search of the program name.
The domain most fulfilled was program information with an average of 51.1% of programs satisfying the criteria, whereas the incentives domain was least fulfilled with an average of only 20.8% of programs satisfying the criteria. Across the various criteria, websites more often included a description of the program (58 [96.6%]), mentioned accreditation (53 [88.3%]), and provided case descriptions (48 [80.0%]). They less often reported information regarding a fellow’s call responsibility (3 [5%]); evaluation criteria (5 [8.3%]); and rotation schedule or options (6 [10.0%]).
The highest number of criteria fulfilled by a single program was 19 (76%). The lowest number of criteria met was 2 (8%). These findings suggest a large variation in comprehensiveness across fellowship websites.
Our research suggests that many current MSDO fellowship programs have room to maximize the information provided to applicants through their websites, which is particularly relevant following the COVID-19 pandemic, as the value of providing comprehensive and transparent information through an online platform is greater than ever. Given the ongoing desire to limit travel, virtual methods for navigating the application process have been readily used, including online videoconferencing for interviews and virtual program visits. This scenario has placed applicants in a challenging situation—their ability to directly evaluate their compatibility with a given program has been limited.3
Earlier studies that analyzed rheumatology fellowship recruitment during the COVID-19 pandemic found that programs may have more difficulty highlighting the strengths of their institution (eg, clinical facilities, professional opportunities, educational environment).4 An updated and comprehensive fellowship website was recommended4 as a key part in facing these new challenges. On the other hand, given the large number of applicants each year for fellowship positions in any given program, we acknowledge the potential benefit programs may obtain from limiting electronic information that is readily accessible to all applicants, as doing so may encourage applicants to communicate directly with a program and allow programs to identify candidates who are more interested.
In light of the movement to a more virtual-friendly and technology-driven fellowship application process, we identified 25 content areas that fellowships may want to include on their websites so that potential applicants can be well informed about the program before submitting an application and scheduling an interview. Efforts to improve accessibility and maximize the content of these websites may help programs attract compatible candidates, improve transparency, and guide applicants throughout the application process.
- Lu F, Vijayasarathi A, Murray N, et al. Evaluation of pediatric radiology fellowship website content in USA and Canada. Curr Prob Diagn Radiol. 2021;50:151-155. doi:10.1067/j.cpradiol.2020.01.007
- Cantrell CK, Bergstresser SL, Schuh AC, et al. Accessibility and content of abdominal transplant fellowship program websites in the United States. J Surg Res. 2018;232:271-274. doi:10.1016/j.jss.2018.06.052
- Nesemeier BR, Lebo NL, Schmalbach CE, et al. Impact of the COVID-19 global pandemic on the otolaryngology fellowship application process. Otolaryngol Head Neck Surg. 2020;163:712-713. doi:10.1177/0194599820934370
- Kilian A, Dua AB, Bolster MB, et al. Rheumatology fellowship recruitment in 2020: benefits, challenges, and adaptations. Arthritis Care Res (Hoboken). 2021;73:459-461. doi:10.1002/acr.24445
- Lu F, Vijayasarathi A, Murray N, et al. Evaluation of pediatric radiology fellowship website content in USA and Canada. Curr Prob Diagn Radiol. 2021;50:151-155. doi:10.1067/j.cpradiol.2020.01.007
- Cantrell CK, Bergstresser SL, Schuh AC, et al. Accessibility and content of abdominal transplant fellowship program websites in the United States. J Surg Res. 2018;232:271-274. doi:10.1016/j.jss.2018.06.052
- Nesemeier BR, Lebo NL, Schmalbach CE, et al. Impact of the COVID-19 global pandemic on the otolaryngology fellowship application process. Otolaryngol Head Neck Surg. 2020;163:712-713. doi:10.1177/0194599820934370
- Kilian A, Dua AB, Bolster MB, et al. Rheumatology fellowship recruitment in 2020: benefits, challenges, and adaptations. Arthritis Care Res (Hoboken). 2021;73:459-461. doi:10.1002/acr.24445
Practice Points
- With the COVID-19 pandemic and the movement to a virtual fellowship application process, fellowship program websites that are comprehensive and accessible may help programs attract compatible candidates, improve transparency, and guide applicants through the application process.
- There is variation in the content of current micrographic surgery and dermatologic oncology fellowship program websites and areas upon which programs may seek to augment their website content to better reflect program strengths while attracting competitive candidates best suited for their program.