Which major organisms cause urinary tract infections (UTIs) in women?

Continue to the answer...

The most common causative organism is Escherichia coli, which is responsible for approximately 70% of all UTIs. Klebsiella pneumoniae and Proteus species are the 2 other aerobic gram-negative bacilli that are common uropathogens. In addition, 3 gram-positive cocci are important: enterococci, Staphylococcus saprophyticus, and group B streptococcus.

Which major organisms cause urinary tract infections (UTIs) in women?

Continue to the answer...

The most common causative organism is Escherichia coli, which is responsible for approximately 70% of all UTIs. Klebsiella pneumoniae and Proteus species are the 2 other aerobic gram-negative bacilli that are common uropathogens. In addition, 3 gram-positive cocci are important: enterococci, Staphylococcus saprophyticus, and group B streptococcus.

Which major organisms cause urinary tract infections (UTIs) in women?

Continue to the answer...

The most common causative organism is Escherichia coli, which is responsible for approximately 70% of all UTIs. Klebsiella pneumoniae and Proteus species are the 2 other aerobic gram-negative bacilli that are common uropathogens. In addition, 3 gram-positive cocci are important: enterococci, Staphylococcus saprophyticus, and group B streptococcus.

What are the best tests for the diagnosis of congenital cytomegalovirus (CMV) infection?

Continue to the answer...

When congenital CMV is suspected, if the patient is at least 15 weeks’ gestation, an amniocentesis should be performed to test for CMV DNA in the amniotic fluid using polymerase chain reaction (PCR) methodology. If the initial test is negative, amniocentesis should be repeated in approximately 4 weeks. Coincident with amniocentesis, a detailed ultrasound examination should be performed to search for findings suggestive of fetal injury, such as growth restriction, microcephaly, periventricular calcifications, hepatosplenomegaly, echogenic bowel, and serous effusions in the pleural space or abdomen.

What are the best tests for the diagnosis of congenital cytomegalovirus (CMV) infection?

Continue to the answer...

When congenital CMV is suspected, if the patient is at least 15 weeks’ gestation, an amniocentesis should be performed to test for CMV DNA in the amniotic fluid using polymerase chain reaction (PCR) methodology. If the initial test is negative, amniocentesis should be repeated in approximately 4 weeks. Coincident with amniocentesis, a detailed ultrasound examination should be performed to search for findings suggestive of fetal injury, such as growth restriction, microcephaly, periventricular calcifications, hepatosplenomegaly, echogenic bowel, and serous effusions in the pleural space or abdomen.

What are the best tests for the diagnosis of congenital cytomegalovirus (CMV) infection?

Continue to the answer...

When congenital CMV is suspected, if the patient is at least 15 weeks’ gestation, an amniocentesis should be performed to test for CMV DNA in the amniotic fluid using polymerase chain reaction (PCR) methodology. If the initial test is negative, amniocentesis should be repeated in approximately 4 weeks. Coincident with amniocentesis, a detailed ultrasound examination should be performed to search for findings suggestive of fetal injury, such as growth restriction, microcephaly, periventricular calcifications, hepatosplenomegaly, echogenic bowel, and serous effusions in the pleural space or abdomen.

Women with a history of stage III to stage IV breast cancer had significantly more pathologic vertebral fractures compared to those with stage I and stage II disease, based on data from approximately 5,000 adult women.

Breast cancer remains associated with increased fracture risk in part because of estrogen deficiency, aromatase inhibitors, frailty, and skeletal metastases, wrote Joan C. Lo, MD, of Kaiser Permanente Northern California, Oakland, and colleagues. Fractures associated with these factors have been studied, but many of the existing epidemiologic studies lack detail on fractures related to cancer, they noted. The researchers examined the association between pathologic fractures and major osteoporotic fractures in women with invasive breast cancer who received endocrine therapy.

In a study published in JAMA Network Open (2021 Nov 18. doi: 10.1001/jamanetworkopen.2021.33861), the researchers reviewed data from 5,010 women enrolled in the Pathways Study (3,312 women) or Research Program on Genes, Environment, and Health (RPGEH) study (1,698 women) with newly diagnosed invasive breast cancer who received endocrine therapy. The women were followed for up to 10 years for incident fracture, with a median follow-up period of 6.7 years.

The average age of the women was 60.2 years; 73.3% were non-Hispanic White, 4.9% were Black, 9.4% were Hispanic, and 1.6% were women whose ethnicity was unknown. Approximately 90% of the women were at stage I to stage II at initial diagnosis.

Overall, 340 (6.8%) had incident fractures during the follow-up period. The incident fractures included 46 hip, 104 vertebral, 78 humerus, and 137 wrist fractures. Significantly more women with hip fracture (43.5%) were age 80 years or older, compared with less than 25% of women with vertebral fractures (22.1%), humerus (19.2%), or wrist fracture (15.3%).

Pathologic fractures accounted for 22 of 104 incident vertebral fractures (21.2%) and fewer than 5 of 46 incident hip fractures (8.7%); few wrist and humerus fractures were pathologic. According to tumor stage, 15 of 87 (17.2%) vertebral fractures in women with initial stage I and II were pathologic, compared to 7 of 17 (41.2%) in women with initial stage III to stage IV breast cancer (P < .05).

The results emphasized the need to consider vertebral fracture risk in women with breast cancer, notably advanced stage cancer, as approximately one-third of the incident vertebral fractures in this subset of patients was deemed cancer-related, the researchers noted.

“As the axial skeleton is a common site for breast cancer metastasis and vertebrae a common site for pathologic fracture, primary care physicians should consider the possibility of pathologic fracture in women with higher risk based on advanced-stage cancer history,” the researchers wrote.

The study findings were limited by several factors, including the lack of data on fracture risk factors, treatment, and chemotherapy, and the inclusion only of clinically diagnosed fractures and not asymptomatic vertebral fractures, the researchers noted. However, the results were strengthened by the large sample size and comprehensive fracture assessment, they said. Additional studies to examine nonpathologic fracture risk according to breast cancer treatment, such as the use of aromatase inhibitors versus cytotoxic chemotherapy, may inform which women would benefit from more aggressive osteoporotic fracture prevention, they concluded.
 

Findings inform shared decision-making

“This study highlights the apparent association between an initial diagnosis of stage III or IV breast cancer and an increased risk for pathologic vertebral fracture,” said Constance Bohon, MD, a gynecologist in private practice in Washington, D.C., in an interview. “Most likely this finding is secondary to breast cancer metastases,” Dr. Bohon noted. However, she questioned whether there is a difference in fracture rates between women who received only aromatase inhibitors, those who received tamoxifen, and those who received both treatments.

“Additional data to determine the age of menopause, exercise frequency, current weight, and family history of osteoporosis may serve to identify those at highest risk for pathologic vertebral fracture,” said Dr. Bohon. “Until further data are available, clinicians should review this study and counsel their patients regarding options to potentially mitigate their apparent increased risk for pathologic vertebral fracture,” she emphasized.

The study was supported by the National Cancer Institute, National Institutes of Health, and the Research Program on Genes, Environment, and Health of Kaiser Permanente Northern California. The researchers had no financial conflicts to disclose. Dr. Bohon had no financial conflicts to disclose but serves on the Editorial Advisory Board of Ob.Gyn. News.

[email protected]

Women with a history of stage III to stage IV breast cancer had significantly more pathologic vertebral fractures compared to those with stage I and stage II disease, based on data from approximately 5,000 adult women.

Breast cancer remains associated with increased fracture risk in part because of estrogen deficiency, aromatase inhibitors, frailty, and skeletal metastases, wrote Joan C. Lo, MD, of Kaiser Permanente Northern California, Oakland, and colleagues. Fractures associated with these factors have been studied, but many of the existing epidemiologic studies lack detail on fractures related to cancer, they noted. The researchers examined the association between pathologic fractures and major osteoporotic fractures in women with invasive breast cancer who received endocrine therapy.

In a study published in JAMA Network Open (2021 Nov 18. doi: 10.1001/jamanetworkopen.2021.33861), the researchers reviewed data from 5,010 women enrolled in the Pathways Study (3,312 women) or Research Program on Genes, Environment, and Health (RPGEH) study (1,698 women) with newly diagnosed invasive breast cancer who received endocrine therapy. The women were followed for up to 10 years for incident fracture, with a median follow-up period of 6.7 years.

The average age of the women was 60.2 years; 73.3% were non-Hispanic White, 4.9% were Black, 9.4% were Hispanic, and 1.6% were women whose ethnicity was unknown. Approximately 90% of the women were at stage I to stage II at initial diagnosis.

Overall, 340 (6.8%) had incident fractures during the follow-up period. The incident fractures included 46 hip, 104 vertebral, 78 humerus, and 137 wrist fractures. Significantly more women with hip fracture (43.5%) were age 80 years or older, compared with less than 25% of women with vertebral fractures (22.1%), humerus (19.2%), or wrist fracture (15.3%).

Pathologic fractures accounted for 22 of 104 incident vertebral fractures (21.2%) and fewer than 5 of 46 incident hip fractures (8.7%); few wrist and humerus fractures were pathologic. According to tumor stage, 15 of 87 (17.2%) vertebral fractures in women with initial stage I and II were pathologic, compared to 7 of 17 (41.2%) in women with initial stage III to stage IV breast cancer (P < .05).

The results emphasized the need to consider vertebral fracture risk in women with breast cancer, notably advanced stage cancer, as approximately one-third of the incident vertebral fractures in this subset of patients was deemed cancer-related, the researchers noted.

“As the axial skeleton is a common site for breast cancer metastasis and vertebrae a common site for pathologic fracture, primary care physicians should consider the possibility of pathologic fracture in women with higher risk based on advanced-stage cancer history,” the researchers wrote.

The study findings were limited by several factors, including the lack of data on fracture risk factors, treatment, and chemotherapy, and the inclusion only of clinically diagnosed fractures and not asymptomatic vertebral fractures, the researchers noted. However, the results were strengthened by the large sample size and comprehensive fracture assessment, they said. Additional studies to examine nonpathologic fracture risk according to breast cancer treatment, such as the use of aromatase inhibitors versus cytotoxic chemotherapy, may inform which women would benefit from more aggressive osteoporotic fracture prevention, they concluded.
 

Findings inform shared decision-making

“This study highlights the apparent association between an initial diagnosis of stage III or IV breast cancer and an increased risk for pathologic vertebral fracture,” said Constance Bohon, MD, a gynecologist in private practice in Washington, D.C., in an interview. “Most likely this finding is secondary to breast cancer metastases,” Dr. Bohon noted. However, she questioned whether there is a difference in fracture rates between women who received only aromatase inhibitors, those who received tamoxifen, and those who received both treatments.

“Additional data to determine the age of menopause, exercise frequency, current weight, and family history of osteoporosis may serve to identify those at highest risk for pathologic vertebral fracture,” said Dr. Bohon. “Until further data are available, clinicians should review this study and counsel their patients regarding options to potentially mitigate their apparent increased risk for pathologic vertebral fracture,” she emphasized.

The study was supported by the National Cancer Institute, National Institutes of Health, and the Research Program on Genes, Environment, and Health of Kaiser Permanente Northern California. The researchers had no financial conflicts to disclose. Dr. Bohon had no financial conflicts to disclose but serves on the Editorial Advisory Board of Ob.Gyn. News.

[email protected]

Women with a history of stage III to stage IV breast cancer had significantly more pathologic vertebral fractures compared to those with stage I and stage II disease, based on data from approximately 5,000 adult women.

Breast cancer remains associated with increased fracture risk in part because of estrogen deficiency, aromatase inhibitors, frailty, and skeletal metastases, wrote Joan C. Lo, MD, of Kaiser Permanente Northern California, Oakland, and colleagues. Fractures associated with these factors have been studied, but many of the existing epidemiologic studies lack detail on fractures related to cancer, they noted. The researchers examined the association between pathologic fractures and major osteoporotic fractures in women with invasive breast cancer who received endocrine therapy.

In a study published in JAMA Network Open (2021 Nov 18. doi: 10.1001/jamanetworkopen.2021.33861), the researchers reviewed data from 5,010 women enrolled in the Pathways Study (3,312 women) or Research Program on Genes, Environment, and Health (RPGEH) study (1,698 women) with newly diagnosed invasive breast cancer who received endocrine therapy. The women were followed for up to 10 years for incident fracture, with a median follow-up period of 6.7 years.

The average age of the women was 60.2 years; 73.3% were non-Hispanic White, 4.9% were Black, 9.4% were Hispanic, and 1.6% were women whose ethnicity was unknown. Approximately 90% of the women were at stage I to stage II at initial diagnosis.

Overall, 340 (6.8%) had incident fractures during the follow-up period. The incident fractures included 46 hip, 104 vertebral, 78 humerus, and 137 wrist fractures. Significantly more women with hip fracture (43.5%) were age 80 years or older, compared with less than 25% of women with vertebral fractures (22.1%), humerus (19.2%), or wrist fracture (15.3%).

Pathologic fractures accounted for 22 of 104 incident vertebral fractures (21.2%) and fewer than 5 of 46 incident hip fractures (8.7%); few wrist and humerus fractures were pathologic. According to tumor stage, 15 of 87 (17.2%) vertebral fractures in women with initial stage I and II were pathologic, compared to 7 of 17 (41.2%) in women with initial stage III to stage IV breast cancer (P < .05).

The results emphasized the need to consider vertebral fracture risk in women with breast cancer, notably advanced stage cancer, as approximately one-third of the incident vertebral fractures in this subset of patients was deemed cancer-related, the researchers noted.

“As the axial skeleton is a common site for breast cancer metastasis and vertebrae a common site for pathologic fracture, primary care physicians should consider the possibility of pathologic fracture in women with higher risk based on advanced-stage cancer history,” the researchers wrote.

The study findings were limited by several factors, including the lack of data on fracture risk factors, treatment, and chemotherapy, and the inclusion only of clinically diagnosed fractures and not asymptomatic vertebral fractures, the researchers noted. However, the results were strengthened by the large sample size and comprehensive fracture assessment, they said. Additional studies to examine nonpathologic fracture risk according to breast cancer treatment, such as the use of aromatase inhibitors versus cytotoxic chemotherapy, may inform which women would benefit from more aggressive osteoporotic fracture prevention, they concluded.
 

Findings inform shared decision-making

“This study highlights the apparent association between an initial diagnosis of stage III or IV breast cancer and an increased risk for pathologic vertebral fracture,” said Constance Bohon, MD, a gynecologist in private practice in Washington, D.C., in an interview. “Most likely this finding is secondary to breast cancer metastases,” Dr. Bohon noted. However, she questioned whether there is a difference in fracture rates between women who received only aromatase inhibitors, those who received tamoxifen, and those who received both treatments.

“Additional data to determine the age of menopause, exercise frequency, current weight, and family history of osteoporosis may serve to identify those at highest risk for pathologic vertebral fracture,” said Dr. Bohon. “Until further data are available, clinicians should review this study and counsel their patients regarding options to potentially mitigate their apparent increased risk for pathologic vertebral fracture,” she emphasized.

The study was supported by the National Cancer Institute, National Institutes of Health, and the Research Program on Genes, Environment, and Health of Kaiser Permanente Northern California. The researchers had no financial conflicts to disclose. Dr. Bohon had no financial conflicts to disclose but serves on the Editorial Advisory Board of Ob.Gyn. News.

[email protected]

The rate of U.S. hospitalizations for three types of serious infections in patients with psoriatic arthritis (PsA) appears to have declined from 2012 to 2017, according to research presented at the virtual annual meeting of the American College of Rheumatology.

Several of the standard treatments for PsA have an increased risk of infections, but the rates vary amongst conventional disease-modifying antirheumatic drugs (DMARDs), glucocorticoids, biologics, and other therapies.

“Given the uptake of biological therapies has increased over recent years, we sought to investigate the national trends in serious infections in patients with psoriatic arthritis from the years 2012 to 2017,” Vagishwari Murugesan, MBBS, a psoriatic arthritis clinical fellow at the University of Toronto, told attendees in a prerecorded poster presentation. Dr. Murugesan was a fellow at Boston University when she conducted the research.

The researchers analyzed data from 2012 to 2017 in the U.S. National Inpatient Sample (NIS), which includes approximately 20% of all discharges from U.S. community hospitals except rehabilitation and long-term acute care institutions. Using ICD-9 and ICD-10 codes, the researchers identified all discharge records containing a diagnosis of PsA as well as pneumonia, sepsis, urinary tract infection (UTI), and skin and soft-tissue infections. After making adjustments to match U.S. population age distributions over the years, they examined trends in serious infections among patients with PsA for that 6-year period.

Demographics over those years changed little: The average age of discharged patients was 59.5 in 2012 and 60.8 in 2017. Similarly, the patient population was 56% women and 88.5% Whites in 2012 and 57.7% women and 88.4% Whites in 2017. The average length of stay was also similar: 4.7 days in 2012, compared with 4.9 days in 2017.

Among 50,700 discharges of patients with PsA in 2012, the researchers identified 125 with pneumonia, 230 with sepsis, 312 with skin and soft-tissue infections, and 174 with a UTI. Among the 179,400 discharges in 2017 of patients with PsA, 344 had pneumonia, 374 had sepsis, 681 had skin and soft-tissue infections, and 348 had a UTI. After statistical analysis, the researchers found no significant differences in pneumonia diagnoses during the years studied, but they did find a statistically significant decline in sepsis, skin and soft tissue infections, and UTI discharges (P < .001).

A notable limitation of the study is the NIS database’s lack of data on treatments or outpatient data, making it impossible to determine if more infections were occurring but simply being treated in outpatient settings, although it’s not clear why such a substantial shift would occur in just 5 years. It’s also possible that coding practices differ across hospital, but, presumably, the ways they might differ in 2012 would be similar to any differences in 2017.

Bruce Jancin/MDedge News

Arthur Kavanaugh, MD, a professor of medicine and director of the Center for Innovative Therapy at the University of California, San Diego, found the results interesting for what he considers an important topic.

“What makes these data interesting is the same thing that limits their reliability: The authors note that infections decreased ‘despite the increase in use of biologics over this time,’ ” Dr. Kavanaugh said in an interview. “These are claims data, so there is no way to support any association between those serious infections and biologic use. Indeed, multiple factors could have also impacted these data. It is not possible to tell from claims data.”

Dr. Kavanaugh said the question is worth investigating further with data from other sources.

The research was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. One study coauthor reported ties to UCB; Dr. Murugesan and her other coauthors reported no disclosures. Dr. Kavanaugh had no disclosures.

The rate of U.S. hospitalizations for three types of serious infections in patients with psoriatic arthritis (PsA) appears to have declined from 2012 to 2017, according to research presented at the virtual annual meeting of the American College of Rheumatology.

Several of the standard treatments for PsA have an increased risk of infections, but the rates vary amongst conventional disease-modifying antirheumatic drugs (DMARDs), glucocorticoids, biologics, and other therapies.

“Given the uptake of biological therapies has increased over recent years, we sought to investigate the national trends in serious infections in patients with psoriatic arthritis from the years 2012 to 2017,” Vagishwari Murugesan, MBBS, a psoriatic arthritis clinical fellow at the University of Toronto, told attendees in a prerecorded poster presentation. Dr. Murugesan was a fellow at Boston University when she conducted the research.

The researchers analyzed data from 2012 to 2017 in the U.S. National Inpatient Sample (NIS), which includes approximately 20% of all discharges from U.S. community hospitals except rehabilitation and long-term acute care institutions. Using ICD-9 and ICD-10 codes, the researchers identified all discharge records containing a diagnosis of PsA as well as pneumonia, sepsis, urinary tract infection (UTI), and skin and soft-tissue infections. After making adjustments to match U.S. population age distributions over the years, they examined trends in serious infections among patients with PsA for that 6-year period.

Demographics over those years changed little: The average age of discharged patients was 59.5 in 2012 and 60.8 in 2017. Similarly, the patient population was 56% women and 88.5% Whites in 2012 and 57.7% women and 88.4% Whites in 2017. The average length of stay was also similar: 4.7 days in 2012, compared with 4.9 days in 2017.

Among 50,700 discharges of patients with PsA in 2012, the researchers identified 125 with pneumonia, 230 with sepsis, 312 with skin and soft-tissue infections, and 174 with a UTI. Among the 179,400 discharges in 2017 of patients with PsA, 344 had pneumonia, 374 had sepsis, 681 had skin and soft-tissue infections, and 348 had a UTI. After statistical analysis, the researchers found no significant differences in pneumonia diagnoses during the years studied, but they did find a statistically significant decline in sepsis, skin and soft tissue infections, and UTI discharges (P < .001).

A notable limitation of the study is the NIS database’s lack of data on treatments or outpatient data, making it impossible to determine if more infections were occurring but simply being treated in outpatient settings, although it’s not clear why such a substantial shift would occur in just 5 years. It’s also possible that coding practices differ across hospital, but, presumably, the ways they might differ in 2012 would be similar to any differences in 2017.

Bruce Jancin/MDedge News

Arthur Kavanaugh, MD, a professor of medicine and director of the Center for Innovative Therapy at the University of California, San Diego, found the results interesting for what he considers an important topic.

“What makes these data interesting is the same thing that limits their reliability: The authors note that infections decreased ‘despite the increase in use of biologics over this time,’ ” Dr. Kavanaugh said in an interview. “These are claims data, so there is no way to support any association between those serious infections and biologic use. Indeed, multiple factors could have also impacted these data. It is not possible to tell from claims data.”

Dr. Kavanaugh said the question is worth investigating further with data from other sources.

The research was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. One study coauthor reported ties to UCB; Dr. Murugesan and her other coauthors reported no disclosures. Dr. Kavanaugh had no disclosures.

The rate of U.S. hospitalizations for three types of serious infections in patients with psoriatic arthritis (PsA) appears to have declined from 2012 to 2017, according to research presented at the virtual annual meeting of the American College of Rheumatology.

Several of the standard treatments for PsA have an increased risk of infections, but the rates vary amongst conventional disease-modifying antirheumatic drugs (DMARDs), glucocorticoids, biologics, and other therapies.

“Given the uptake of biological therapies has increased over recent years, we sought to investigate the national trends in serious infections in patients with psoriatic arthritis from the years 2012 to 2017,” Vagishwari Murugesan, MBBS, a psoriatic arthritis clinical fellow at the University of Toronto, told attendees in a prerecorded poster presentation. Dr. Murugesan was a fellow at Boston University when she conducted the research.

The researchers analyzed data from 2012 to 2017 in the U.S. National Inpatient Sample (NIS), which includes approximately 20% of all discharges from U.S. community hospitals except rehabilitation and long-term acute care institutions. Using ICD-9 and ICD-10 codes, the researchers identified all discharge records containing a diagnosis of PsA as well as pneumonia, sepsis, urinary tract infection (UTI), and skin and soft-tissue infections. After making adjustments to match U.S. population age distributions over the years, they examined trends in serious infections among patients with PsA for that 6-year period.

Demographics over those years changed little: The average age of discharged patients was 59.5 in 2012 and 60.8 in 2017. Similarly, the patient population was 56% women and 88.5% Whites in 2012 and 57.7% women and 88.4% Whites in 2017. The average length of stay was also similar: 4.7 days in 2012, compared with 4.9 days in 2017.

Among 50,700 discharges of patients with PsA in 2012, the researchers identified 125 with pneumonia, 230 with sepsis, 312 with skin and soft-tissue infections, and 174 with a UTI. Among the 179,400 discharges in 2017 of patients with PsA, 344 had pneumonia, 374 had sepsis, 681 had skin and soft-tissue infections, and 348 had a UTI. After statistical analysis, the researchers found no significant differences in pneumonia diagnoses during the years studied, but they did find a statistically significant decline in sepsis, skin and soft tissue infections, and UTI discharges (P < .001).

A notable limitation of the study is the NIS database’s lack of data on treatments or outpatient data, making it impossible to determine if more infections were occurring but simply being treated in outpatient settings, although it’s not clear why such a substantial shift would occur in just 5 years. It’s also possible that coding practices differ across hospital, but, presumably, the ways they might differ in 2012 would be similar to any differences in 2017.

Bruce Jancin/MDedge News

Arthur Kavanaugh, MD, a professor of medicine and director of the Center for Innovative Therapy at the University of California, San Diego, found the results interesting for what he considers an important topic.

“What makes these data interesting is the same thing that limits their reliability: The authors note that infections decreased ‘despite the increase in use of biologics over this time,’ ” Dr. Kavanaugh said in an interview. “These are claims data, so there is no way to support any association between those serious infections and biologic use. Indeed, multiple factors could have also impacted these data. It is not possible to tell from claims data.”

Dr. Kavanaugh said the question is worth investigating further with data from other sources.

The research was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. One study coauthor reported ties to UCB; Dr. Murugesan and her other coauthors reported no disclosures. Dr. Kavanaugh had no disclosures.

Some 30% of health care personnel who worked at the thousands of hospitals in the United States were still not fully vaccinated against COVID-19 as of mid-September, according to a new survey by the Centers for Disease Control and Prevention.

The snapshot in time – Jan. 20, 2021 to Sept. 15, 2021 – is based on voluntary weekly reports from hospitals. Only about 48% of the 5,085 hospitals in the U.S. Health and Human Services department’s Unified Hospital Data Surveillance System reported data on vaccination coverage during the period, and, after validation checks, the study included reports from 2,086 facilities, or just 41% of all hospitals, covering 3.35 million workers.

Overall, the number who were fully vaccinated rose from 36.1% in Jan. 2021 to 60.2% in April 2021, and then crept slowly up to 70% by Sept. 15, the CDC researchers reported in the American Journal of Infection Control.

The slowdown among hospital workers seems to mirror the same decline as in the general population.  

Arjun Srinivasan, MD, associate director for health care–associated infection prevention programs at the CDC, said the decline in part may be the result of misinformation.

Health care personnel “are not fully immune from vaccine misinformation,” he said, adding that such misinformation “is contributing to decreased vaccine uptake among non–health care personnel.”

“The take-home message is that there is a lot of work to do in health care settings in order to get all of our health care personnel vaccinated,” Dr. Srinivasan told this news organization. “We need them to be vaccinated to protect themselves. It is also really important that we as health care personnel get vaccinated to protect our patients.”
 

Vaccine mandates

The analysis shows that workers were more likely to be vaccinated if they worked at a children’s hospital (77%), lived in metropolitan counties (71%), or worked in a hospital with lower cumulative admissions of COVID-19 patients, or lower cumulative COVID-19 cases.

The odds of being fully vaccinated were lower if the surrounding community had lower vaccination coverage. Workers in non-metropolitan counties (63.3%) and in rural counties (65.1%) were also less likely to be fully vaccinated, as well as those who were in critical access hospitals (64%) or long-term acute care hospitals (68.8%).

Surveys have shown that health care personnel who are vaccine-hesitant cited concerns they had about vaccine efficacy, adverse effects, the speed of vaccine development, and lack of full Food and Drug Administration approval, the study authors noted. In addition, many reported low trust in the government.

A Medscape survey this past April found that 25% of health care workers said they did not plan to be fully vaccinated. Some 40% of the 9,349 workers who responded said that employers should never require a COVID-19 vaccine for clinicians.

But the Centers for Medicare & Medicaid Services is attempting to require all health care facilities that receive Medicare or Medicaid payment to vaccinate workers. All eligible staff must receive the first dose of a two-dose COVID-19 vaccine or a one-dose vaccine by Dec. 6, and a second dose by Jan. 4, 2022. The policy allows exemptions based on recognized medical conditions or religious beliefs.

Some hospitals and health systems and various states and cities have already begun implementing vaccine mandates. Northwell Health in New York, for instance, lost 1,400 workers (evenly split between clinical and nonclinical staff), or 2% of its 77,000 employees, as a result of the state’s mandate.

Northwell’s workforce is now considered 100% vaccinated, a hospital spokesman said in an interview. In addition, “we have allowed for team members who changed their minds and presented proof of vaccination to return,” said the spokesman, adding that “a couple of hundred employees have done just that.”

Ten states sued the Biden administration recently, aiming to stop the health care worker vaccine mandate. Other challenges to vaccine mandates have generally been unsuccessful. The U.S. Supreme Court, for example, in October declined to hear a challenge to Maine’s mandate for health care workers, even though it did not allow religious exemptions, according to the Washington Post.

“The courts seem to agree that health care personnel are different, and could be subject to these mandates,” said Dr. Srinivasan.

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

Some 30% of health care personnel who worked at the thousands of hospitals in the United States were still not fully vaccinated against COVID-19 as of mid-September, according to a new survey by the Centers for Disease Control and Prevention.

The snapshot in time – Jan. 20, 2021 to Sept. 15, 2021 – is based on voluntary weekly reports from hospitals. Only about 48% of the 5,085 hospitals in the U.S. Health and Human Services department’s Unified Hospital Data Surveillance System reported data on vaccination coverage during the period, and, after validation checks, the study included reports from 2,086 facilities, or just 41% of all hospitals, covering 3.35 million workers.

Overall, the number who were fully vaccinated rose from 36.1% in Jan. 2021 to 60.2% in April 2021, and then crept slowly up to 70% by Sept. 15, the CDC researchers reported in the American Journal of Infection Control.

The slowdown among hospital workers seems to mirror the same decline as in the general population.  

Arjun Srinivasan, MD, associate director for health care–associated infection prevention programs at the CDC, said the decline in part may be the result of misinformation.

Health care personnel “are not fully immune from vaccine misinformation,” he said, adding that such misinformation “is contributing to decreased vaccine uptake among non–health care personnel.”

“The take-home message is that there is a lot of work to do in health care settings in order to get all of our health care personnel vaccinated,” Dr. Srinivasan told this news organization. “We need them to be vaccinated to protect themselves. It is also really important that we as health care personnel get vaccinated to protect our patients.”
 

Vaccine mandates

The analysis shows that workers were more likely to be vaccinated if they worked at a children’s hospital (77%), lived in metropolitan counties (71%), or worked in a hospital with lower cumulative admissions of COVID-19 patients, or lower cumulative COVID-19 cases.

The odds of being fully vaccinated were lower if the surrounding community had lower vaccination coverage. Workers in non-metropolitan counties (63.3%) and in rural counties (65.1%) were also less likely to be fully vaccinated, as well as those who were in critical access hospitals (64%) or long-term acute care hospitals (68.8%).

Surveys have shown that health care personnel who are vaccine-hesitant cited concerns they had about vaccine efficacy, adverse effects, the speed of vaccine development, and lack of full Food and Drug Administration approval, the study authors noted. In addition, many reported low trust in the government.

A Medscape survey this past April found that 25% of health care workers said they did not plan to be fully vaccinated. Some 40% of the 9,349 workers who responded said that employers should never require a COVID-19 vaccine for clinicians.

But the Centers for Medicare & Medicaid Services is attempting to require all health care facilities that receive Medicare or Medicaid payment to vaccinate workers. All eligible staff must receive the first dose of a two-dose COVID-19 vaccine or a one-dose vaccine by Dec. 6, and a second dose by Jan. 4, 2022. The policy allows exemptions based on recognized medical conditions or religious beliefs.

Some hospitals and health systems and various states and cities have already begun implementing vaccine mandates. Northwell Health in New York, for instance, lost 1,400 workers (evenly split between clinical and nonclinical staff), or 2% of its 77,000 employees, as a result of the state’s mandate.

Northwell’s workforce is now considered 100% vaccinated, a hospital spokesman said in an interview. In addition, “we have allowed for team members who changed their minds and presented proof of vaccination to return,” said the spokesman, adding that “a couple of hundred employees have done just that.”

Ten states sued the Biden administration recently, aiming to stop the health care worker vaccine mandate. Other challenges to vaccine mandates have generally been unsuccessful. The U.S. Supreme Court, for example, in October declined to hear a challenge to Maine’s mandate for health care workers, even though it did not allow religious exemptions, according to the Washington Post.

“The courts seem to agree that health care personnel are different, and could be subject to these mandates,” said Dr. Srinivasan.

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

Some 30% of health care personnel who worked at the thousands of hospitals in the United States were still not fully vaccinated against COVID-19 as of mid-September, according to a new survey by the Centers for Disease Control and Prevention.

The snapshot in time – Jan. 20, 2021 to Sept. 15, 2021 – is based on voluntary weekly reports from hospitals. Only about 48% of the 5,085 hospitals in the U.S. Health and Human Services department’s Unified Hospital Data Surveillance System reported data on vaccination coverage during the period, and, after validation checks, the study included reports from 2,086 facilities, or just 41% of all hospitals, covering 3.35 million workers.

Overall, the number who were fully vaccinated rose from 36.1% in Jan. 2021 to 60.2% in April 2021, and then crept slowly up to 70% by Sept. 15, the CDC researchers reported in the American Journal of Infection Control.

The slowdown among hospital workers seems to mirror the same decline as in the general population.  

Arjun Srinivasan, MD, associate director for health care–associated infection prevention programs at the CDC, said the decline in part may be the result of misinformation.

Health care personnel “are not fully immune from vaccine misinformation,” he said, adding that such misinformation “is contributing to decreased vaccine uptake among non–health care personnel.”

“The take-home message is that there is a lot of work to do in health care settings in order to get all of our health care personnel vaccinated,” Dr. Srinivasan told this news organization. “We need them to be vaccinated to protect themselves. It is also really important that we as health care personnel get vaccinated to protect our patients.”
 

Vaccine mandates

The analysis shows that workers were more likely to be vaccinated if they worked at a children’s hospital (77%), lived in metropolitan counties (71%), or worked in a hospital with lower cumulative admissions of COVID-19 patients, or lower cumulative COVID-19 cases.

The odds of being fully vaccinated were lower if the surrounding community had lower vaccination coverage. Workers in non-metropolitan counties (63.3%) and in rural counties (65.1%) were also less likely to be fully vaccinated, as well as those who were in critical access hospitals (64%) or long-term acute care hospitals (68.8%).

Surveys have shown that health care personnel who are vaccine-hesitant cited concerns they had about vaccine efficacy, adverse effects, the speed of vaccine development, and lack of full Food and Drug Administration approval, the study authors noted. In addition, many reported low trust in the government.

A Medscape survey this past April found that 25% of health care workers said they did not plan to be fully vaccinated. Some 40% of the 9,349 workers who responded said that employers should never require a COVID-19 vaccine for clinicians.

But the Centers for Medicare & Medicaid Services is attempting to require all health care facilities that receive Medicare or Medicaid payment to vaccinate workers. All eligible staff must receive the first dose of a two-dose COVID-19 vaccine or a one-dose vaccine by Dec. 6, and a second dose by Jan. 4, 2022. The policy allows exemptions based on recognized medical conditions or religious beliefs.

Some hospitals and health systems and various states and cities have already begun implementing vaccine mandates. Northwell Health in New York, for instance, lost 1,400 workers (evenly split between clinical and nonclinical staff), or 2% of its 77,000 employees, as a result of the state’s mandate.

Northwell’s workforce is now considered 100% vaccinated, a hospital spokesman said in an interview. In addition, “we have allowed for team members who changed their minds and presented proof of vaccination to return,” said the spokesman, adding that “a couple of hundred employees have done just that.”

Ten states sued the Biden administration recently, aiming to stop the health care worker vaccine mandate. Other challenges to vaccine mandates have generally been unsuccessful. The U.S. Supreme Court, for example, in October declined to hear a challenge to Maine’s mandate for health care workers, even though it did not allow religious exemptions, according to the Washington Post.

“The courts seem to agree that health care personnel are different, and could be subject to these mandates,” said Dr. Srinivasan.

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

Medical practices will likely have to confront a doctor at some point who treats staff badly or is too impaired to practice safely. Knowing what to say and do can lead to a positive outcome for the physician involved and the organization.

Misbehaving and impaired physicians put their organizations at risk, which can lead to malpractice/patient injury lawsuits, labor law and harassment claims, and a damaged reputation through negative social media reviews, said Debra Phairas, MBA, president of Practice and Liability Consultants LLC, at the annual meeting of the Medical Group Management Association (MGMA) .

“Verbal harassment or bullying claims can result in large dollar awards against the organizations that knew about the behavior and did nothing to stop it. Organizations can be sued for that,” says Ms. Phairas.

She recalls a doctor who called a female doctor “an entitled bitch” and the administrator “incompetent” in front of other staff. “He would pick on one department manager at every meeting and humiliate them in front of the others,” says Ms. Phairas.

After working with a human resources (HR) attorney and conducting independent reviews, they used a strategy Ms. Phairas calls her “3 C’s” for dealing with disruptive doctors.
 

Confront, correct, and/or counsel

The three C’s can work individually or together, depending on the doctor’s situation. Confronting a physician can start with an informal discussion; correcting can involve seeking a written apology that directly addresses the problem or sending a letter of admonition; and coaching or counseling can be offered. If the doctor resists those efforts, practice administrators can issue a final letter of warning and then suspend or terminate the physician, says Ms. Phairas.

Sometimes having a conversation with a disruptive doctor about the risks and consequences is enough to change the offending behavior, says Ms. Phairas.

She recalled being asked by a medical group to meet with a physician who she says was “snapping the bra straps of medical assistants in the hall — everyone there was horrified. I told him that’s not appropriate, that he was placing everyone at risk and they will terminate him if he didn’t stop. I asked for his commitment to stop, and he agreed,” says Ms. Phairas.

She also recommends implementing these strategies to prevent and deal with disruptive physicians:

• Implement a code of conduct and share it during interviews;
• Have zero tolerance policies and procedures for documenting behavior;
• Get advice from a good employment attorney;
• Implement written performance improvement plans;
• Provide resources to change the behavior;
• Follow through with suspension and termination; and
• Add to shareholder agreements a clause stating that partners/shareholders can gently ask or insist that the physician obtain counseling or help.

Getting impaired doctors help

Doctors can be impaired through substance abuse, a serious medical illness, mental illness, or age-related deterioration.

Life events such as divorce or the death of a spouse, child, or a physician partner can affect a doctor’s mental health. “In those cases, you need to have the courage to say you’re really depressed and we all agree you need to get help,” says Ms. Phairas.

She recalls one occasion in which a practice administration staff member could not locate a doctor whose patients were waiting to be seen. “He was so devastated from his divorce that he had crawled into a ball beneath his desk. She had to coax him out and tell him that they were worried about him and he needed to get help.”

Another reason doctors may not be performing well may be because of an undiagnosed medical illness. Doctors in an orthopedic group were mad at another partner who had slowed down and couldn’t help pay the expenses. “They were ready to terminate him when he went to the doctor and learned he had colon cancer,” says Ms. Phairas.

Ms. Phairas recommends that practices update their partner shareholder agreements regularly with the following:

• Include “fit for duty” examinations, especially after age 65.
• Insist that a physician be evaluated by a doctor outside the practice. The doctor may be one that they agree upon or one chosen by the local medical society president.
• Include in the agreement the clause, “Partners and employees will be subject to review for impairment due to matters including but not limited to age-related, physical, or mental conditions.”
• Establish a voting mechanism for terminating a physician.

Aging doctors who won’t retire

Some doctors have retired early because of COVID, whereas others are staying on because they are feeling financial pressures — they lost a lot of money last year and need to make up for it, says Ms. Phairas.

She warned that administrators have to be careful in dealing with older doctors because of age discrimination laws.

Doctors may not notice they are declining mentally until it becomes a problem. Ms. Phairas recalls an internist senior partner who started behaving erratically when he was 78 years old. “He wrote himself a $25,000 check from the organization’s funds without telling his partners, left a patient he should have been watching and she fell over and sued the practice, and the staff started noticing that he was forgetting or not doing things,” says Ms. Phairas.

She sought guidance from a good HR attorney and involved a malpractice attorney. She then met with the senior partner. “I reminded him of his Hippocratic Oath that he took when he became a doctor and told him that his actions were harming patients. I pleaded with him that it was time to retire. He didn’t.”

Because this physician wouldn’t retire, the practice referred to their updated shareholder agreement, which stated that they could insist that the physician undergo a neuropsychiatric assessment from a certified specialist. He didn’t pass the evaluation, which then provided evidence of his declining cognitive skills.

“All the doctors, myself, and the HR attorney talked to him about this and laid out all the facts. It was hard to say these things, but he listened and left. We went through the termination process to protect the practice and avoid litigation. The malpractice insurer also refused to renew his policy,” says Ms. Phairas.

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

Medical practices will likely have to confront a doctor at some point who treats staff badly or is too impaired to practice safely. Knowing what to say and do can lead to a positive outcome for the physician involved and the organization.

Misbehaving and impaired physicians put their organizations at risk, which can lead to malpractice/patient injury lawsuits, labor law and harassment claims, and a damaged reputation through negative social media reviews, said Debra Phairas, MBA, president of Practice and Liability Consultants LLC, at the annual meeting of the Medical Group Management Association (MGMA) .

“Verbal harassment or bullying claims can result in large dollar awards against the organizations that knew about the behavior and did nothing to stop it. Organizations can be sued for that,” says Ms. Phairas.

She recalls a doctor who called a female doctor “an entitled bitch” and the administrator “incompetent” in front of other staff. “He would pick on one department manager at every meeting and humiliate them in front of the others,” says Ms. Phairas.

After working with a human resources (HR) attorney and conducting independent reviews, they used a strategy Ms. Phairas calls her “3 C’s” for dealing with disruptive doctors.
 

Confront, correct, and/or counsel

The three C’s can work individually or together, depending on the doctor’s situation. Confronting a physician can start with an informal discussion; correcting can involve seeking a written apology that directly addresses the problem or sending a letter of admonition; and coaching or counseling can be offered. If the doctor resists those efforts, practice administrators can issue a final letter of warning and then suspend or terminate the physician, says Ms. Phairas.

Sometimes having a conversation with a disruptive doctor about the risks and consequences is enough to change the offending behavior, says Ms. Phairas.

She recalled being asked by a medical group to meet with a physician who she says was “snapping the bra straps of medical assistants in the hall — everyone there was horrified. I told him that’s not appropriate, that he was placing everyone at risk and they will terminate him if he didn’t stop. I asked for his commitment to stop, and he agreed,” says Ms. Phairas.

She also recommends implementing these strategies to prevent and deal with disruptive physicians:

• Implement a code of conduct and share it during interviews;
• Have zero tolerance policies and procedures for documenting behavior;
• Get advice from a good employment attorney;
• Implement written performance improvement plans;
• Provide resources to change the behavior;
• Follow through with suspension and termination; and
• Add to shareholder agreements a clause stating that partners/shareholders can gently ask or insist that the physician obtain counseling or help.

Getting impaired doctors help

Doctors can be impaired through substance abuse, a serious medical illness, mental illness, or age-related deterioration.

Life events such as divorce or the death of a spouse, child, or a physician partner can affect a doctor’s mental health. “In those cases, you need to have the courage to say you’re really depressed and we all agree you need to get help,” says Ms. Phairas.

She recalls one occasion in which a practice administration staff member could not locate a doctor whose patients were waiting to be seen. “He was so devastated from his divorce that he had crawled into a ball beneath his desk. She had to coax him out and tell him that they were worried about him and he needed to get help.”

Another reason doctors may not be performing well may be because of an undiagnosed medical illness. Doctors in an orthopedic group were mad at another partner who had slowed down and couldn’t help pay the expenses. “They were ready to terminate him when he went to the doctor and learned he had colon cancer,” says Ms. Phairas.

Ms. Phairas recommends that practices update their partner shareholder agreements regularly with the following:

• Include “fit for duty” examinations, especially after age 65.
• Insist that a physician be evaluated by a doctor outside the practice. The doctor may be one that they agree upon or one chosen by the local medical society president.
• Include in the agreement the clause, “Partners and employees will be subject to review for impairment due to matters including but not limited to age-related, physical, or mental conditions.”
• Establish a voting mechanism for terminating a physician.

Aging doctors who won’t retire

Some doctors have retired early because of COVID, whereas others are staying on because they are feeling financial pressures — they lost a lot of money last year and need to make up for it, says Ms. Phairas.

She warned that administrators have to be careful in dealing with older doctors because of age discrimination laws.

Doctors may not notice they are declining mentally until it becomes a problem. Ms. Phairas recalls an internist senior partner who started behaving erratically when he was 78 years old. “He wrote himself a $25,000 check from the organization’s funds without telling his partners, left a patient he should have been watching and she fell over and sued the practice, and the staff started noticing that he was forgetting or not doing things,” says Ms. Phairas.

She sought guidance from a good HR attorney and involved a malpractice attorney. She then met with the senior partner. “I reminded him of his Hippocratic Oath that he took when he became a doctor and told him that his actions were harming patients. I pleaded with him that it was time to retire. He didn’t.”

Because this physician wouldn’t retire, the practice referred to their updated shareholder agreement, which stated that they could insist that the physician undergo a neuropsychiatric assessment from a certified specialist. He didn’t pass the evaluation, which then provided evidence of his declining cognitive skills.

“All the doctors, myself, and the HR attorney talked to him about this and laid out all the facts. It was hard to say these things, but he listened and left. We went through the termination process to protect the practice and avoid litigation. The malpractice insurer also refused to renew his policy,” says Ms. Phairas.

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

Medical practices will likely have to confront a doctor at some point who treats staff badly or is too impaired to practice safely. Knowing what to say and do can lead to a positive outcome for the physician involved and the organization.

Misbehaving and impaired physicians put their organizations at risk, which can lead to malpractice/patient injury lawsuits, labor law and harassment claims, and a damaged reputation through negative social media reviews, said Debra Phairas, MBA, president of Practice and Liability Consultants LLC, at the annual meeting of the Medical Group Management Association (MGMA) .

“Verbal harassment or bullying claims can result in large dollar awards against the organizations that knew about the behavior and did nothing to stop it. Organizations can be sued for that,” says Ms. Phairas.

She recalls a doctor who called a female doctor “an entitled bitch” and the administrator “incompetent” in front of other staff. “He would pick on one department manager at every meeting and humiliate them in front of the others,” says Ms. Phairas.

After working with a human resources (HR) attorney and conducting independent reviews, they used a strategy Ms. Phairas calls her “3 C’s” for dealing with disruptive doctors.
 

Confront, correct, and/or counsel

The three C’s can work individually or together, depending on the doctor’s situation. Confronting a physician can start with an informal discussion; correcting can involve seeking a written apology that directly addresses the problem or sending a letter of admonition; and coaching or counseling can be offered. If the doctor resists those efforts, practice administrators can issue a final letter of warning and then suspend or terminate the physician, says Ms. Phairas.

Sometimes having a conversation with a disruptive doctor about the risks and consequences is enough to change the offending behavior, says Ms. Phairas.

She recalled being asked by a medical group to meet with a physician who she says was “snapping the bra straps of medical assistants in the hall — everyone there was horrified. I told him that’s not appropriate, that he was placing everyone at risk and they will terminate him if he didn’t stop. I asked for his commitment to stop, and he agreed,” says Ms. Phairas.

She also recommends implementing these strategies to prevent and deal with disruptive physicians:

• Implement a code of conduct and share it during interviews;
• Have zero tolerance policies and procedures for documenting behavior;
• Get advice from a good employment attorney;
• Implement written performance improvement plans;
• Provide resources to change the behavior;
• Follow through with suspension and termination; and
• Add to shareholder agreements a clause stating that partners/shareholders can gently ask or insist that the physician obtain counseling or help.

Getting impaired doctors help

Doctors can be impaired through substance abuse, a serious medical illness, mental illness, or age-related deterioration.

Life events such as divorce or the death of a spouse, child, or a physician partner can affect a doctor’s mental health. “In those cases, you need to have the courage to say you’re really depressed and we all agree you need to get help,” says Ms. Phairas.

She recalls one occasion in which a practice administration staff member could not locate a doctor whose patients were waiting to be seen. “He was so devastated from his divorce that he had crawled into a ball beneath his desk. She had to coax him out and tell him that they were worried about him and he needed to get help.”

Another reason doctors may not be performing well may be because of an undiagnosed medical illness. Doctors in an orthopedic group were mad at another partner who had slowed down and couldn’t help pay the expenses. “They were ready to terminate him when he went to the doctor and learned he had colon cancer,” says Ms. Phairas.

Ms. Phairas recommends that practices update their partner shareholder agreements regularly with the following:

• Include “fit for duty” examinations, especially after age 65.
• Insist that a physician be evaluated by a doctor outside the practice. The doctor may be one that they agree upon or one chosen by the local medical society president.
• Include in the agreement the clause, “Partners and employees will be subject to review for impairment due to matters including but not limited to age-related, physical, or mental conditions.”
• Establish a voting mechanism for terminating a physician.

Aging doctors who won’t retire

Some doctors have retired early because of COVID, whereas others are staying on because they are feeling financial pressures — they lost a lot of money last year and need to make up for it, says Ms. Phairas.

She warned that administrators have to be careful in dealing with older doctors because of age discrimination laws.

Doctors may not notice they are declining mentally until it becomes a problem. Ms. Phairas recalls an internist senior partner who started behaving erratically when he was 78 years old. “He wrote himself a $25,000 check from the organization’s funds without telling his partners, left a patient he should have been watching and she fell over and sued the practice, and the staff started noticing that he was forgetting or not doing things,” says Ms. Phairas.

She sought guidance from a good HR attorney and involved a malpractice attorney. She then met with the senior partner. “I reminded him of his Hippocratic Oath that he took when he became a doctor and told him that his actions were harming patients. I pleaded with him that it was time to retire. He didn’t.”

Because this physician wouldn’t retire, the practice referred to their updated shareholder agreement, which stated that they could insist that the physician undergo a neuropsychiatric assessment from a certified specialist. He didn’t pass the evaluation, which then provided evidence of his declining cognitive skills.

“All the doctors, myself, and the HR attorney talked to him about this and laid out all the facts. It was hard to say these things, but he listened and left. We went through the termination process to protect the practice and avoid litigation. The malpractice insurer also refused to renew his policy,” says Ms. Phairas.

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

Background: Acute kidney injury (AKI) in the ICU is associated with high mortality. It is hypothesized that earlier initiation of RRT may benefit patients by controlling fluid overload and reducing metabolic stress caused by electrolyte and acid-base imbalances. However, prior studies have been conflicting, with the IDEAL-ICU study (2018) demonstrating no improvement in 90-day mortality with early RRT in septic shock.

Dr. Lee is a hospitalist at Northwestern Memorial Hospital and Lurie Children’s Hospital and assistant professor of medicine, Feinberg School of Medicine, all in Chicago.

Background: Acute kidney injury (AKI) in the ICU is associated with high mortality. It is hypothesized that earlier initiation of RRT may benefit patients by controlling fluid overload and reducing metabolic stress caused by electrolyte and acid-base imbalances. However, prior studies have been conflicting, with the IDEAL-ICU study (2018) demonstrating no improvement in 90-day mortality with early RRT in septic shock.

Dr. Lee is a hospitalist at Northwestern Memorial Hospital and Lurie Children’s Hospital and assistant professor of medicine, Feinberg School of Medicine, all in Chicago.

Background: Acute kidney injury (AKI) in the ICU is associated with high mortality. It is hypothesized that earlier initiation of RRT may benefit patients by controlling fluid overload and reducing metabolic stress caused by electrolyte and acid-base imbalances. However, prior studies have been conflicting, with the IDEAL-ICU study (2018) demonstrating no improvement in 90-day mortality with early RRT in septic shock.

Dr. Lee is a hospitalist at Northwestern Memorial Hospital and Lurie Children’s Hospital and assistant professor of medicine, Feinberg School of Medicine, all in Chicago.

LAS VEGAS – In a comparison of data from clinical trials for ulcerative colitis, ozanimod (Zeposia) appeared to be more useful than adalimumab (Humira) and as useful as vedolizumab (Entyvio).

The U.S. Food and Drug Administration approved ozanimod for ulcerative colitis in May of this year, and clinicians are trying to figure out where it fits into the armamentarium, said Marla Dubinsky, MD, professor of pediatrics and medicine in the Division of Pediatric Gastroenterology at Icahn School of Medicine at Mount Sinai, New York.

“It’s an extremely heterogeneous disease,” Dr. Dubinsky told this news organization. “A lot of these indirect comparisons are being done, because these therapies are coming out so quickly.”

No clinical trials have compared either ozanimod to adalimumab or ozanimod to vedolizumab head to head, so Dr. Dubinsky and colleagues pitted the drugs against each other by matching data from individual patients from the True North trial of ozanimod to published data from the ULTRA 1 and 2 trials of adalimumab and the GEMINI 1 trial of vedolizumab.

She presented the findings here at the American College of Gastroenterology (ACG) 2021 Annual Scientific Meeting.

From the 1990s until 2014, physicians relied heavily on tumor necrosis factor (TNF) inhibitors, such as adalimumab, to treat ulcerative colitis, Dr. Dubinsky said. Although often effective, these drugs can increase patients’ vulnerability to infections and malignancies.

Approved by the FDA in 2014, vedolizumab works differently: it blocks α4β7 integrin. “The safety profile was extremely favorable,” Dr. Dubinsky said. “That was a revolution, in my opinion.” Still, vedolizumab isn’t always effective, especially for patients who have already received TNF inhibitors without success.

As reported by this news organization, ozanimod works by yet another mechanism: sphingosine l-phosphate receptor modulation.
 

How does ozanimod measure up?

To see how ozanimod stacks up to the two older drugs, Dr. Dubinsky and colleagues weighted the data from True North to match the patient populations in the other trials by age, sex, baseline total Mayo score, disease extent, and prior anti-TNF treatment.

They calculated the odds that ozanimod would produce better clinical and endoscopic responses or be associated with more serious or infectious adverse events in comparison with each of the other drugs. The comparisons included both the induction and maintenance phases of the trials.

The researchers compared ozanimod to adalimumab for patients who were anti-TNF naive. They found that the patients who took ozanimod were more likely to experience a clinical response than those who took adalimumab (odds ratio, 1.68; 95% CI, 1.03-2.74). The patients who took ozanimod were also more likely to have endoscopic improvement (OR, 2.73; 95% CI, 1.44-5.17).

They found that the patients who had received a TNF inhibitor were also more likely to experience a clinical response with ozanimod than with adalimumab (OR, 2.53; 95% CI, 1.13-5.67).

In both the induction and the maintenance phases, the other differences in efficacy between ozanimod and adalimumab did not reach statistical significance.

As for safety, in the induction phases of the trials, the researchers found that 11.3% of patients who received ozanimod had infections, compared to 20.2% of those taking adalimumab, which was statistically significant (P < .01). Other differences in safety were not statistically significant.

With regard to vedolizumab, Dr. Dubinsky and colleagues found no statistically significant differences between it and ozanimod in the induction phases.

In the maintenance phases, among patients who were anti-TNF naive, the odds of clinical response were lower with ozanimod than with vedolizumab (OR, 0.40; 95% CI, 0.21-0.76). The odds of endoscopic improvement were very nearly lower (OR, 0.52; 95% CI, 0.27-1.01). The researchers attributed these findings to a higher placebo response in the True North trial (the ozanimod trial) than in GEMINI 1 (the vedolizumab trial).

There were no other significant differences in efficacy between ozanimod and vedolizumab, either in the cohort that had received a TNF inhibitor or in the cohort that had not.

As for safety, there were also no statistically significant differences between vedolizumab and ozanimod in the induction phases. During the maintenance phases, 71.3% of patients who received vedolizumab had infections, compared to 25.0% in the matched cohort of patients who received ozanimod, which was a statistically significant difference (P < .001). The other differences in this phase were not significant.

Dr. Dubinsky acknowledged that the results were not as reliable as would have been the case in a prospective, head-to-head comparison, because the researchers could not be sure that they had fully adjusted for the differences in the populations and the designs of the studies.

“In TNF-inhibitor–naive patients, I could use vedolizumab or ozanimod,” Dr. Dubinsky said. But these are not the only options, she said. She said that “in TNF failure, I would use ustekinumab or even tofacitinib.” Ustekinumab (Stelara) is a human interleukin-12 and -23 antagonist; tofacitinib (Xeljanz) is a Janus kinase inhibitor.

The study’s limitations are significant, said session moderator Jonathan Leighton, MD, a professor of medicine at the Mayo Clinic in Phoenix, Arizona, “but it certainly shows that ozanimod had a positive profile compared to adalimumab and has overall comparable benefits with vedolizumab,” he said in an interview.

Dr. Leighton added that someday researchers may find biomarkers that will identify the best drug for each patient. In the meantime, clinicians are often left choosing therapies on the basis of such factors as which route of administration the patients prefer, he said. Vedolizumab is given by intravenous infusion, ozanimod is taken orally, and adalimumab is given by subcutaneous injection.

The study was funded by Bristol-Myers Squibb. Dr. Leighton has financial relationships with Olympus and Pfizer. Dr. Dubinsky has relationships with all or most of the companies that make drugs for inflammatory bowel disease.

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

LAS VEGAS – In a comparison of data from clinical trials for ulcerative colitis, ozanimod (Zeposia) appeared to be more useful than adalimumab (Humira) and as useful as vedolizumab (Entyvio).

The U.S. Food and Drug Administration approved ozanimod for ulcerative colitis in May of this year, and clinicians are trying to figure out where it fits into the armamentarium, said Marla Dubinsky, MD, professor of pediatrics and medicine in the Division of Pediatric Gastroenterology at Icahn School of Medicine at Mount Sinai, New York.

“It’s an extremely heterogeneous disease,” Dr. Dubinsky told this news organization. “A lot of these indirect comparisons are being done, because these therapies are coming out so quickly.”

No clinical trials have compared either ozanimod to adalimumab or ozanimod to vedolizumab head to head, so Dr. Dubinsky and colleagues pitted the drugs against each other by matching data from individual patients from the True North trial of ozanimod to published data from the ULTRA 1 and 2 trials of adalimumab and the GEMINI 1 trial of vedolizumab.

She presented the findings here at the American College of Gastroenterology (ACG) 2021 Annual Scientific Meeting.

From the 1990s until 2014, physicians relied heavily on tumor necrosis factor (TNF) inhibitors, such as adalimumab, to treat ulcerative colitis, Dr. Dubinsky said. Although often effective, these drugs can increase patients’ vulnerability to infections and malignancies.

Approved by the FDA in 2014, vedolizumab works differently: it blocks α4β7 integrin. “The safety profile was extremely favorable,” Dr. Dubinsky said. “That was a revolution, in my opinion.” Still, vedolizumab isn’t always effective, especially for patients who have already received TNF inhibitors without success.

As reported by this news organization, ozanimod works by yet another mechanism: sphingosine l-phosphate receptor modulation.
 

How does ozanimod measure up?

To see how ozanimod stacks up to the two older drugs, Dr. Dubinsky and colleagues weighted the data from True North to match the patient populations in the other trials by age, sex, baseline total Mayo score, disease extent, and prior anti-TNF treatment.

They calculated the odds that ozanimod would produce better clinical and endoscopic responses or be associated with more serious or infectious adverse events in comparison with each of the other drugs. The comparisons included both the induction and maintenance phases of the trials.

The researchers compared ozanimod to adalimumab for patients who were anti-TNF naive. They found that the patients who took ozanimod were more likely to experience a clinical response than those who took adalimumab (odds ratio, 1.68; 95% CI, 1.03-2.74). The patients who took ozanimod were also more likely to have endoscopic improvement (OR, 2.73; 95% CI, 1.44-5.17).

They found that the patients who had received a TNF inhibitor were also more likely to experience a clinical response with ozanimod than with adalimumab (OR, 2.53; 95% CI, 1.13-5.67).

In both the induction and the maintenance phases, the other differences in efficacy between ozanimod and adalimumab did not reach statistical significance.

As for safety, in the induction phases of the trials, the researchers found that 11.3% of patients who received ozanimod had infections, compared to 20.2% of those taking adalimumab, which was statistically significant (P < .01). Other differences in safety were not statistically significant.

With regard to vedolizumab, Dr. Dubinsky and colleagues found no statistically significant differences between it and ozanimod in the induction phases.

In the maintenance phases, among patients who were anti-TNF naive, the odds of clinical response were lower with ozanimod than with vedolizumab (OR, 0.40; 95% CI, 0.21-0.76). The odds of endoscopic improvement were very nearly lower (OR, 0.52; 95% CI, 0.27-1.01). The researchers attributed these findings to a higher placebo response in the True North trial (the ozanimod trial) than in GEMINI 1 (the vedolizumab trial).

There were no other significant differences in efficacy between ozanimod and vedolizumab, either in the cohort that had received a TNF inhibitor or in the cohort that had not.

As for safety, there were also no statistically significant differences between vedolizumab and ozanimod in the induction phases. During the maintenance phases, 71.3% of patients who received vedolizumab had infections, compared to 25.0% in the matched cohort of patients who received ozanimod, which was a statistically significant difference (P < .001). The other differences in this phase were not significant.

Dr. Dubinsky acknowledged that the results were not as reliable as would have been the case in a prospective, head-to-head comparison, because the researchers could not be sure that they had fully adjusted for the differences in the populations and the designs of the studies.

“In TNF-inhibitor–naive patients, I could use vedolizumab or ozanimod,” Dr. Dubinsky said. But these are not the only options, she said. She said that “in TNF failure, I would use ustekinumab or even tofacitinib.” Ustekinumab (Stelara) is a human interleukin-12 and -23 antagonist; tofacitinib (Xeljanz) is a Janus kinase inhibitor.

The study’s limitations are significant, said session moderator Jonathan Leighton, MD, a professor of medicine at the Mayo Clinic in Phoenix, Arizona, “but it certainly shows that ozanimod had a positive profile compared to adalimumab and has overall comparable benefits with vedolizumab,” he said in an interview.

Dr. Leighton added that someday researchers may find biomarkers that will identify the best drug for each patient. In the meantime, clinicians are often left choosing therapies on the basis of such factors as which route of administration the patients prefer, he said. Vedolizumab is given by intravenous infusion, ozanimod is taken orally, and adalimumab is given by subcutaneous injection.

The study was funded by Bristol-Myers Squibb. Dr. Leighton has financial relationships with Olympus and Pfizer. Dr. Dubinsky has relationships with all or most of the companies that make drugs for inflammatory bowel disease.

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

LAS VEGAS – In a comparison of data from clinical trials for ulcerative colitis, ozanimod (Zeposia) appeared to be more useful than adalimumab (Humira) and as useful as vedolizumab (Entyvio).

The U.S. Food and Drug Administration approved ozanimod for ulcerative colitis in May of this year, and clinicians are trying to figure out where it fits into the armamentarium, said Marla Dubinsky, MD, professor of pediatrics and medicine in the Division of Pediatric Gastroenterology at Icahn School of Medicine at Mount Sinai, New York.

“It’s an extremely heterogeneous disease,” Dr. Dubinsky told this news organization. “A lot of these indirect comparisons are being done, because these therapies are coming out so quickly.”

No clinical trials have compared either ozanimod to adalimumab or ozanimod to vedolizumab head to head, so Dr. Dubinsky and colleagues pitted the drugs against each other by matching data from individual patients from the True North trial of ozanimod to published data from the ULTRA 1 and 2 trials of adalimumab and the GEMINI 1 trial of vedolizumab.

She presented the findings here at the American College of Gastroenterology (ACG) 2021 Annual Scientific Meeting.

From the 1990s until 2014, physicians relied heavily on tumor necrosis factor (TNF) inhibitors, such as adalimumab, to treat ulcerative colitis, Dr. Dubinsky said. Although often effective, these drugs can increase patients’ vulnerability to infections and malignancies.

Approved by the FDA in 2014, vedolizumab works differently: it blocks α4β7 integrin. “The safety profile was extremely favorable,” Dr. Dubinsky said. “That was a revolution, in my opinion.” Still, vedolizumab isn’t always effective, especially for patients who have already received TNF inhibitors without success.

As reported by this news organization, ozanimod works by yet another mechanism: sphingosine l-phosphate receptor modulation.
 

How does ozanimod measure up?

To see how ozanimod stacks up to the two older drugs, Dr. Dubinsky and colleagues weighted the data from True North to match the patient populations in the other trials by age, sex, baseline total Mayo score, disease extent, and prior anti-TNF treatment.

They calculated the odds that ozanimod would produce better clinical and endoscopic responses or be associated with more serious or infectious adverse events in comparison with each of the other drugs. The comparisons included both the induction and maintenance phases of the trials.

The researchers compared ozanimod to adalimumab for patients who were anti-TNF naive. They found that the patients who took ozanimod were more likely to experience a clinical response than those who took adalimumab (odds ratio, 1.68; 95% CI, 1.03-2.74). The patients who took ozanimod were also more likely to have endoscopic improvement (OR, 2.73; 95% CI, 1.44-5.17).

They found that the patients who had received a TNF inhibitor were also more likely to experience a clinical response with ozanimod than with adalimumab (OR, 2.53; 95% CI, 1.13-5.67).

In both the induction and the maintenance phases, the other differences in efficacy between ozanimod and adalimumab did not reach statistical significance.

As for safety, in the induction phases of the trials, the researchers found that 11.3% of patients who received ozanimod had infections, compared to 20.2% of those taking adalimumab, which was statistically significant (P < .01). Other differences in safety were not statistically significant.

With regard to vedolizumab, Dr. Dubinsky and colleagues found no statistically significant differences between it and ozanimod in the induction phases.

In the maintenance phases, among patients who were anti-TNF naive, the odds of clinical response were lower with ozanimod than with vedolizumab (OR, 0.40; 95% CI, 0.21-0.76). The odds of endoscopic improvement were very nearly lower (OR, 0.52; 95% CI, 0.27-1.01). The researchers attributed these findings to a higher placebo response in the True North trial (the ozanimod trial) than in GEMINI 1 (the vedolizumab trial).

There were no other significant differences in efficacy between ozanimod and vedolizumab, either in the cohort that had received a TNF inhibitor or in the cohort that had not.

As for safety, there were also no statistically significant differences between vedolizumab and ozanimod in the induction phases. During the maintenance phases, 71.3% of patients who received vedolizumab had infections, compared to 25.0% in the matched cohort of patients who received ozanimod, which was a statistically significant difference (P < .001). The other differences in this phase were not significant.

Dr. Dubinsky acknowledged that the results were not as reliable as would have been the case in a prospective, head-to-head comparison, because the researchers could not be sure that they had fully adjusted for the differences in the populations and the designs of the studies.

“In TNF-inhibitor–naive patients, I could use vedolizumab or ozanimod,” Dr. Dubinsky said. But these are not the only options, she said. She said that “in TNF failure, I would use ustekinumab or even tofacitinib.” Ustekinumab (Stelara) is a human interleukin-12 and -23 antagonist; tofacitinib (Xeljanz) is a Janus kinase inhibitor.

The study’s limitations are significant, said session moderator Jonathan Leighton, MD, a professor of medicine at the Mayo Clinic in Phoenix, Arizona, “but it certainly shows that ozanimod had a positive profile compared to adalimumab and has overall comparable benefits with vedolizumab,” he said in an interview.

Dr. Leighton added that someday researchers may find biomarkers that will identify the best drug for each patient. In the meantime, clinicians are often left choosing therapies on the basis of such factors as which route of administration the patients prefer, he said. Vedolizumab is given by intravenous infusion, ozanimod is taken orally, and adalimumab is given by subcutaneous injection.

The study was funded by Bristol-Myers Squibb. Dr. Leighton has financial relationships with Olympus and Pfizer. Dr. Dubinsky has relationships with all or most of the companies that make drugs for inflammatory bowel disease.

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

My journey to becoming a family medicine physician wasn’t a linear path. However, that nonlinear path is what has led me to love this field of medicine and the connections I make with patients, while also continuing to hope for improvements within the systems that we utilize to provide care for patients.

I became interested in becoming a physician during my very last semester of college. I volunteered in a hospital psychiatric department in the unit that provided electroconvulsive therapy to patients with severe mental health diagnoses. Although this was about 15 years ago, I still vividly remember the curiosity I had walking around the hospital looking around at all the doctors and nurses and wanting to understand what their day-to-day life was like helping people to optimize their health.

Up until that time, thankfully my family and I had been relatively healthy, and, outside of routine checkups, my time spent in a hospital or clinic was limited. Therefore, those months of volunteering at the hospital were the longest periods of time I’d spent around physicians and other health care professionals really witnessing firsthand the science and the art of medicine.

During my time volunteering I saw one patient over the course of several weeks who was catatonic when I first met her, but by the end of several electroconvulsive therapy treatments she had a subtle smile on her face and we were able to have a conversation. She was a younger Black woman like myself and at that moment I knew that I wanted to become a physician and be involved in people’s lives in such a unique manner.

I worked for several years before applying to medical school. During that time two of my jobs involved doing home visits with children, young adults, and their families. I once again experienced the connection that one can make with someone and their family over a short period of time when you actively listen, understand what is important to them, and work together.

After several years of this work I got accepted into medical school and excitedly started the path to becoming a physician. While the learning curve was difficult, I genuinely enjoyed every block of medical school, including learning the anatomy, pathophysiology, and pharmacology. I could not wait to be in front of patients to use this newfound knowledge to help solve their health problems.
 

‘There is no such thing as a single issue-struggle’

As I started the third year of medical school and clinical rotations, I found joy in being in hospitals and clinics. I also came to recognize that understanding the pharmacology of why metformin helps improve the hemoglobin A1c in people with diabetes is not necessarily one of the keys to helping people optimize their health. I started to talk with patients and all sorts of questions would come to mind. Where did they grow up? What did they identify as their culture? What did they do in their day to day? Did they have a home and support at that home? Are they someone’s caretaker? What are their hopes for the future? And the list goes on.

I ultimately chose family medicine as a specialty because, as Audre Lorde said, “there is no such thing as a single-issue struggle because we do not live single-issue lives,” and family medicine allows one to look at the intersections of people’s lives and how they affect their health and well-being.

I currently practice as a family medicine physician in a setting in which I provide a lot of sexual and reproductive health care. I welcome patients of all ages and genders, and this care includes preconception counseling, contraceptive counseling, prenatal and postpartum care, STI testing and treatment, abortion care, and routine preventive care – just to name a few.

I decided to specialize in sexual and reproductive health care within family medicine because of the historic discrimination and inequitable treatment that is often experienced by young Black persons when they seek care for their sexual health and/or reproductive choices. In addition, there is often stigma within communities when it comes to talking about sex, bodies, and pleasure.

Recently, after a few minutes with a patient, she shared with me that she just completed nursing school and was studying for her exams. We talked about what type of jobs she was looking to apply for and where she wanted to work. I expressed to her that I was proud of the hard work she put in to complete nursing school and commiserated with her about the challenges in schooling and studying that it takes to start in the health care field. The conversation eventually found its way to talking about her sexual and reproductive health care. She shared with me that she was interested in having a child; however, at this time she put those plans on hold because she was scared about the racism within health care and the unacceptable high rates of maternal mortality among Black women in this country.

I listened and shared that as someone who also identifies as a Black woman, I have similar fears and anxieties surrounding my own reproductive health future. During the visit with this patient, I used my training in family medicine to better understand her physical and mental health needs and reassured her that I was going to partner with her through her health care journey.
 

Hope for the future of family medicine

As I work on a day-to-day basis I often think about my hopes for patients, as well as my hopes for medicine and the field of family medicine. My hope for the future of family medicine is that we can continue to make meaningful connections with patients to help them optimize their health and well-being.

I imagine a system in which we have the time and support to do this for all of our patients regardless of their immigration status, socioeconomic status, or any other historically excluded status. My hope for the future of family medicine is that I can write a prescription for a medication or physical therapy, and the patient is able to fill the prescription without having to worry about the financial implications of paying for it. My hope for the future of family medicine is that patients can seek out care without the fear of discrimination or racism through an increasingly diverse work force. My hope for the future of family medicine is that these improvements become a reality and that as physicians we can appreciate the connections we make with patients and the impact this has on their overall health and well-being.
 

Dr. Lockley is a family medicine physician currently living in Harlem, N.Y., and a member of the editorial advisory board of Family Practice News. She currently works for Public Health Solutions’ Sexual and Reproductive Health Centers in Brooklyn, providing primary care and reproductive health care services there, and as an abortion provider throughout the New York region. She completed both medical school and residency in Philadelphia and then did a fellowship in reproductive health care and advocacy through the Family Health Center of Harlem and the Reproductive Health Access Project. She can be reached at [email protected].

My journey to becoming a family medicine physician wasn’t a linear path. However, that nonlinear path is what has led me to love this field of medicine and the connections I make with patients, while also continuing to hope for improvements within the systems that we utilize to provide care for patients.

I became interested in becoming a physician during my very last semester of college. I volunteered in a hospital psychiatric department in the unit that provided electroconvulsive therapy to patients with severe mental health diagnoses. Although this was about 15 years ago, I still vividly remember the curiosity I had walking around the hospital looking around at all the doctors and nurses and wanting to understand what their day-to-day life was like helping people to optimize their health.

Up until that time, thankfully my family and I had been relatively healthy, and, outside of routine checkups, my time spent in a hospital or clinic was limited. Therefore, those months of volunteering at the hospital were the longest periods of time I’d spent around physicians and other health care professionals really witnessing firsthand the science and the art of medicine.

During my time volunteering I saw one patient over the course of several weeks who was catatonic when I first met her, but by the end of several electroconvulsive therapy treatments she had a subtle smile on her face and we were able to have a conversation. She was a younger Black woman like myself and at that moment I knew that I wanted to become a physician and be involved in people’s lives in such a unique manner.

I worked for several years before applying to medical school. During that time two of my jobs involved doing home visits with children, young adults, and their families. I once again experienced the connection that one can make with someone and their family over a short period of time when you actively listen, understand what is important to them, and work together.

After several years of this work I got accepted into medical school and excitedly started the path to becoming a physician. While the learning curve was difficult, I genuinely enjoyed every block of medical school, including learning the anatomy, pathophysiology, and pharmacology. I could not wait to be in front of patients to use this newfound knowledge to help solve their health problems.
 

‘There is no such thing as a single issue-struggle’

As I started the third year of medical school and clinical rotations, I found joy in being in hospitals and clinics. I also came to recognize that understanding the pharmacology of why metformin helps improve the hemoglobin A1c in people with diabetes is not necessarily one of the keys to helping people optimize their health. I started to talk with patients and all sorts of questions would come to mind. Where did they grow up? What did they identify as their culture? What did they do in their day to day? Did they have a home and support at that home? Are they someone’s caretaker? What are their hopes for the future? And the list goes on.

I ultimately chose family medicine as a specialty because, as Audre Lorde said, “there is no such thing as a single-issue struggle because we do not live single-issue lives,” and family medicine allows one to look at the intersections of people’s lives and how they affect their health and well-being.

I currently practice as a family medicine physician in a setting in which I provide a lot of sexual and reproductive health care. I welcome patients of all ages and genders, and this care includes preconception counseling, contraceptive counseling, prenatal and postpartum care, STI testing and treatment, abortion care, and routine preventive care – just to name a few.

I decided to specialize in sexual and reproductive health care within family medicine because of the historic discrimination and inequitable treatment that is often experienced by young Black persons when they seek care for their sexual health and/or reproductive choices. In addition, there is often stigma within communities when it comes to talking about sex, bodies, and pleasure.

Recently, after a few minutes with a patient, she shared with me that she just completed nursing school and was studying for her exams. We talked about what type of jobs she was looking to apply for and where she wanted to work. I expressed to her that I was proud of the hard work she put in to complete nursing school and commiserated with her about the challenges in schooling and studying that it takes to start in the health care field. The conversation eventually found its way to talking about her sexual and reproductive health care. She shared with me that she was interested in having a child; however, at this time she put those plans on hold because she was scared about the racism within health care and the unacceptable high rates of maternal mortality among Black women in this country.

I listened and shared that as someone who also identifies as a Black woman, I have similar fears and anxieties surrounding my own reproductive health future. During the visit with this patient, I used my training in family medicine to better understand her physical and mental health needs and reassured her that I was going to partner with her through her health care journey.
 

Hope for the future of family medicine

As I work on a day-to-day basis I often think about my hopes for patients, as well as my hopes for medicine and the field of family medicine. My hope for the future of family medicine is that we can continue to make meaningful connections with patients to help them optimize their health and well-being.

I imagine a system in which we have the time and support to do this for all of our patients regardless of their immigration status, socioeconomic status, or any other historically excluded status. My hope for the future of family medicine is that I can write a prescription for a medication or physical therapy, and the patient is able to fill the prescription without having to worry about the financial implications of paying for it. My hope for the future of family medicine is that patients can seek out care without the fear of discrimination or racism through an increasingly diverse work force. My hope for the future of family medicine is that these improvements become a reality and that as physicians we can appreciate the connections we make with patients and the impact this has on their overall health and well-being.
 

Dr. Lockley is a family medicine physician currently living in Harlem, N.Y., and a member of the editorial advisory board of Family Practice News. She currently works for Public Health Solutions’ Sexual and Reproductive Health Centers in Brooklyn, providing primary care and reproductive health care services there, and as an abortion provider throughout the New York region. She completed both medical school and residency in Philadelphia and then did a fellowship in reproductive health care and advocacy through the Family Health Center of Harlem and the Reproductive Health Access Project. She can be reached at [email protected].

My journey to becoming a family medicine physician wasn’t a linear path. However, that nonlinear path is what has led me to love this field of medicine and the connections I make with patients, while also continuing to hope for improvements within the systems that we utilize to provide care for patients.

I became interested in becoming a physician during my very last semester of college. I volunteered in a hospital psychiatric department in the unit that provided electroconvulsive therapy to patients with severe mental health diagnoses. Although this was about 15 years ago, I still vividly remember the curiosity I had walking around the hospital looking around at all the doctors and nurses and wanting to understand what their day-to-day life was like helping people to optimize their health.

Up until that time, thankfully my family and I had been relatively healthy, and, outside of routine checkups, my time spent in a hospital or clinic was limited. Therefore, those months of volunteering at the hospital were the longest periods of time I’d spent around physicians and other health care professionals really witnessing firsthand the science and the art of medicine.

During my time volunteering I saw one patient over the course of several weeks who was catatonic when I first met her, but by the end of several electroconvulsive therapy treatments she had a subtle smile on her face and we were able to have a conversation. She was a younger Black woman like myself and at that moment I knew that I wanted to become a physician and be involved in people’s lives in such a unique manner.

I worked for several years before applying to medical school. During that time two of my jobs involved doing home visits with children, young adults, and their families. I once again experienced the connection that one can make with someone and their family over a short period of time when you actively listen, understand what is important to them, and work together.

After several years of this work I got accepted into medical school and excitedly started the path to becoming a physician. While the learning curve was difficult, I genuinely enjoyed every block of medical school, including learning the anatomy, pathophysiology, and pharmacology. I could not wait to be in front of patients to use this newfound knowledge to help solve their health problems.
 

‘There is no such thing as a single issue-struggle’

As I started the third year of medical school and clinical rotations, I found joy in being in hospitals and clinics. I also came to recognize that understanding the pharmacology of why metformin helps improve the hemoglobin A1c in people with diabetes is not necessarily one of the keys to helping people optimize their health. I started to talk with patients and all sorts of questions would come to mind. Where did they grow up? What did they identify as their culture? What did they do in their day to day? Did they have a home and support at that home? Are they someone’s caretaker? What are their hopes for the future? And the list goes on.

I ultimately chose family medicine as a specialty because, as Audre Lorde said, “there is no such thing as a single-issue struggle because we do not live single-issue lives,” and family medicine allows one to look at the intersections of people’s lives and how they affect their health and well-being.

I currently practice as a family medicine physician in a setting in which I provide a lot of sexual and reproductive health care. I welcome patients of all ages and genders, and this care includes preconception counseling, contraceptive counseling, prenatal and postpartum care, STI testing and treatment, abortion care, and routine preventive care – just to name a few.

I decided to specialize in sexual and reproductive health care within family medicine because of the historic discrimination and inequitable treatment that is often experienced by young Black persons when they seek care for their sexual health and/or reproductive choices. In addition, there is often stigma within communities when it comes to talking about sex, bodies, and pleasure.

Recently, after a few minutes with a patient, she shared with me that she just completed nursing school and was studying for her exams. We talked about what type of jobs she was looking to apply for and where she wanted to work. I expressed to her that I was proud of the hard work she put in to complete nursing school and commiserated with her about the challenges in schooling and studying that it takes to start in the health care field. The conversation eventually found its way to talking about her sexual and reproductive health care. She shared with me that she was interested in having a child; however, at this time she put those plans on hold because she was scared about the racism within health care and the unacceptable high rates of maternal mortality among Black women in this country.

I listened and shared that as someone who also identifies as a Black woman, I have similar fears and anxieties surrounding my own reproductive health future. During the visit with this patient, I used my training in family medicine to better understand her physical and mental health needs and reassured her that I was going to partner with her through her health care journey.
 

Hope for the future of family medicine

As I work on a day-to-day basis I often think about my hopes for patients, as well as my hopes for medicine and the field of family medicine. My hope for the future of family medicine is that we can continue to make meaningful connections with patients to help them optimize their health and well-being.

I imagine a system in which we have the time and support to do this for all of our patients regardless of their immigration status, socioeconomic status, or any other historically excluded status. My hope for the future of family medicine is that I can write a prescription for a medication or physical therapy, and the patient is able to fill the prescription without having to worry about the financial implications of paying for it. My hope for the future of family medicine is that patients can seek out care without the fear of discrimination or racism through an increasingly diverse work force. My hope for the future of family medicine is that these improvements become a reality and that as physicians we can appreciate the connections we make with patients and the impact this has on their overall health and well-being.
 

Dr. Lockley is a family medicine physician currently living in Harlem, N.Y., and a member of the editorial advisory board of Family Practice News. She currently works for Public Health Solutions’ Sexual and Reproductive Health Centers in Brooklyn, providing primary care and reproductive health care services there, and as an abortion provider throughout the New York region. She completed both medical school and residency in Philadelphia and then did a fellowship in reproductive health care and advocacy through the Family Health Center of Harlem and the Reproductive Health Access Project. She can be reached at [email protected].

A newly published study that compared the accuracy of two commonly used lung cancer screening algorithms found that the American College of Radiology Lung-RADs screening tool is more accurate in detecting cancerous nodules in patients with a history of lung cancer than NELSON, a Dutch clinical trial that measures nodule volume and growth rate instead of linear measurement of nodule size as done in Lung-RADs.

The study, published in the American Journal of Roentgenology on Nov. 10, 2021,was a retrospective study of 185 patients (100 women, 85 men; mean age, 66 years) who underwent lung cancer screening at a single health care system between July 2015 and August 2018. Using Lung-RADS, seven cancers were downgraded to category 2. The weighted cancer risk was 5% for new nodules, 1% for stable existing nodules, and 44% for growing existing nodules.

“Lung-RADS scores exhibited excellent sensitivity and specificity for cancer in existing nodules and excellent sensitivity in new nodules, though low specificity in new nodules,” wrote the authors, led by Mark M. Hammer, MD, a radiologist with Brigham and Women’s Hospital in Boston.

CT scans are increasingly used for lung cancer screening, so accuracy is essential in devising an appropriate treatment plan for patients. Nearly all centers in the United States use the American College of Radiology’s Lung-RADS for lung cancer screening. In Europe, many centers use the volumetric-based approach of NELSON.

Several studies have compared the performance of nodule risk assessment algorithms, but the findings are inconsistent. Lung-RADS was found to be inferior to the Vancouver risk calculator in predicting malignancy in the National Lung Screening Trial for total nodules. Dr. Hammer previously reported that subsolid nodules classified as Lung-RADS categories 2 and 3 have a higher risk of malignancy than reported. Meanwhile, a study that followed 13,195 men and 2,594 women at high risk of lung cancer found that lung cancer mortality was lower among participants who underwent volume CT screening than among those who underwent no screening.

The authors cited the retrospective design and the small sample size as study limitations. They added that pathological proof was not obtained from benign nodules, which may represent undiagnosed cancer.

The authors declared no conflict of interest.

A newly published study that compared the accuracy of two commonly used lung cancer screening algorithms found that the American College of Radiology Lung-RADs screening tool is more accurate in detecting cancerous nodules in patients with a history of lung cancer than NELSON, a Dutch clinical trial that measures nodule volume and growth rate instead of linear measurement of nodule size as done in Lung-RADs.

The study, published in the American Journal of Roentgenology on Nov. 10, 2021,was a retrospective study of 185 patients (100 women, 85 men; mean age, 66 years) who underwent lung cancer screening at a single health care system between July 2015 and August 2018. Using Lung-RADS, seven cancers were downgraded to category 2. The weighted cancer risk was 5% for new nodules, 1% for stable existing nodules, and 44% for growing existing nodules.

“Lung-RADS scores exhibited excellent sensitivity and specificity for cancer in existing nodules and excellent sensitivity in new nodules, though low specificity in new nodules,” wrote the authors, led by Mark M. Hammer, MD, a radiologist with Brigham and Women’s Hospital in Boston.

CT scans are increasingly used for lung cancer screening, so accuracy is essential in devising an appropriate treatment plan for patients. Nearly all centers in the United States use the American College of Radiology’s Lung-RADS for lung cancer screening. In Europe, many centers use the volumetric-based approach of NELSON.

Several studies have compared the performance of nodule risk assessment algorithms, but the findings are inconsistent. Lung-RADS was found to be inferior to the Vancouver risk calculator in predicting malignancy in the National Lung Screening Trial for total nodules. Dr. Hammer previously reported that subsolid nodules classified as Lung-RADS categories 2 and 3 have a higher risk of malignancy than reported. Meanwhile, a study that followed 13,195 men and 2,594 women at high risk of lung cancer found that lung cancer mortality was lower among participants who underwent volume CT screening than among those who underwent no screening.

The authors cited the retrospective design and the small sample size as study limitations. They added that pathological proof was not obtained from benign nodules, which may represent undiagnosed cancer.

The authors declared no conflict of interest.

A newly published study that compared the accuracy of two commonly used lung cancer screening algorithms found that the American College of Radiology Lung-RADs screening tool is more accurate in detecting cancerous nodules in patients with a history of lung cancer than NELSON, a Dutch clinical trial that measures nodule volume and growth rate instead of linear measurement of nodule size as done in Lung-RADs.

The study, published in the American Journal of Roentgenology on Nov. 10, 2021,was a retrospective study of 185 patients (100 women, 85 men; mean age, 66 years) who underwent lung cancer screening at a single health care system between July 2015 and August 2018. Using Lung-RADS, seven cancers were downgraded to category 2. The weighted cancer risk was 5% for new nodules, 1% for stable existing nodules, and 44% for growing existing nodules.

“Lung-RADS scores exhibited excellent sensitivity and specificity for cancer in existing nodules and excellent sensitivity in new nodules, though low specificity in new nodules,” wrote the authors, led by Mark M. Hammer, MD, a radiologist with Brigham and Women’s Hospital in Boston.

CT scans are increasingly used for lung cancer screening, so accuracy is essential in devising an appropriate treatment plan for patients. Nearly all centers in the United States use the American College of Radiology’s Lung-RADS for lung cancer screening. In Europe, many centers use the volumetric-based approach of NELSON.

Several studies have compared the performance of nodule risk assessment algorithms, but the findings are inconsistent. Lung-RADS was found to be inferior to the Vancouver risk calculator in predicting malignancy in the National Lung Screening Trial for total nodules. Dr. Hammer previously reported that subsolid nodules classified as Lung-RADS categories 2 and 3 have a higher risk of malignancy than reported. Meanwhile, a study that followed 13,195 men and 2,594 women at high risk of lung cancer found that lung cancer mortality was lower among participants who underwent volume CT screening than among those who underwent no screening.

The authors cited the retrospective design and the small sample size as study limitations. They added that pathological proof was not obtained from benign nodules, which may represent undiagnosed cancer.

The authors declared no conflict of interest.