Dr. Margaret G. Klitzke is a board-certified child and adolescent psychiatrist who has worked across all settings of the Center for Autism and Developmental Disabilities at Bradley Hospital in East Providence, R.I.

Courtesy Dr. Margaret G. Klitzke

I spoke with Dr. Klitzke recently about her work as an outpatient psychiatrist at the center and about the important role of families in the treatment it provides. The center offers highly specialized clinical services for children and adolescents between the ages of 2 and 18 who show signs of serious emotional and behavioral problems in addition to a developmental disability, such as autism, Asperger’s, or intellectual disability.

ALISON M. HERU, MD: Hello, Dr. Klitzke and thank you for agreeing to this interview.

MARGARET G. KLITZKE, DO: My pleasure.

AMH: I admire your dedication to this population of children and adolescents. To me, it seems very hard to work with patients and families where there is significant disability and there is little hope of the patient “getting better.”

MGK: When parents come to us, they have great hopes their children can be helped. They often express understanding and acceptance of the child’s disability, and seek to understand the psychiatric or behavioral issues. These parents are often very dedicated to their children, giving up careers to care for them. But as professionals, we must be sensitive to the role each parent can play and how they can support each other and the family.

AMH: So much of your work focuses on family inclusion and family psychoeducation?

MGK: Yes. An example that stands out is a couple where the mother had become the voice for the family in dealing with professionals, but she was overwhelmed in this role. So, we invited the father in. He explained that medical professionals and school personnel would address their remarks to his wife and that he felt marginalized. We worked with the couple, now always including the father, and he has gone on to become a vocal advocate for children with disabilities. It is inspiring to watch families become advocates – to insist that others see the child’s strengths – not just weaknesses.

AMH: Do you feel that the families ever come to you with too high expectations of what you can do to help their child?

MGK: As a child psychiatrist, one must put oneself in the parents’ shoes. Charlie Zeanah Jr., MD, and others have done wonderful work in attachment. They have identified that parents have fantasies and beliefs about what the child will be like before the child is born. We all have fantasies about our babies before they come to us! For many families, they quickly come to understand that their child is not like other children. This new world of parenting is not what they expected. A mother once gave me a short piece called “Welcome to Holland,” written by a mother whose child has Down syndrome.

AMH: How do you begin to work with these families? There must be such a sense of loss and tragedy in their lives.

MGK: My first goal is to understand what it is like to have a child with developmental disability, not just for the parents but for the siblings, too. I strive to understand what the parents want for their child and how they see themselves as a family. I see us, the health care team, as agents to help the child and the family be the very best they can be.

AMH: How do you deal with parents who are not be on the same page?

MGK: It is important that parents are consistent and are able to work together. Even if they are divorced, I have seen families able to unite around the care of their child with a disability. This is quite an achievement given the high rates of divorce – although most of the families that I have worked with are intact. As in all families, each member has a role in helping the family function well. It means using the strength of each parent to help them become a parenting team.

AMH: What if the parents have unrealistic expectations of their child?

MGK: Yes, there are parents who come to us with unrealistic expectations, such as believing their nonverbal child will talk some day. In such a case, we must be certain that we have exhausted all methods to help this child communicate, and once we have done all we can, then we must accept where that child is; to accept and help the family accept, the child’s weaknesses and acknowledge their strengths. Change what you can and be a support for everything else.

AMH: I find it hard to imagine caring for a severely disabled child. How do these parents do this?

MGK: These are children who are nonverbal, and children who can be very fragile, even medically. What I see are parents who want to connect, who want to find that something inside that child, that special place where there is connection. That place of reciprocity. That is important to us all, helping the family find that place of reciprocal connection.

AMH: What language do you use to discuss this with families?

MGK: I say, “This is the child’s strength and this is the child’s weakness; capitalize on the strengths and let’s shore up their weaknesses.”

AMH: How do you approach the families? Where do you start?

MGK: I meet the family where they are. One cannot with these families or any families stand rigidly 10 feet away, and demand that they change. This never works, and we will be of no help to them. We must understand the family system and how they have arrived at their current place of functioning.

AMH: Can you give an example?

MGK: Yes, for example if a parent is drinking excessively, I help them understand why they are coping that way and see if they are willing to change.

AMH: What keeps you going ?

MGK: I think it comes back to the family work. For me, I believe the families are doing the very best they can. If the family is really impaired in some way, I see it as my job to figure out why that is their pattern of behavior, and I do what I can to help them facilitate change.

AMH: What inspires you about these families?

MGK: These families are able to recognize the strengths and beauty that their children bring them – the strength of these children, their personalities and their wills of steel! They are able to communicate what they need. Siblings, too, make life decisions based on their experiences. They often end up going down the path of caring for such children as professionals.

AMH: Do you have any recommendations for a young child psychiatrist who might be considering working with this population?

MGK: Developmental disabilities in child psychiatry is where medicine, neurology, and child development meet. The advances in genetics and neurology are major gifts to the field. It used to be that I would have to sell the field to medical students and residents. Now they are coming to me saying that they want to work in this area. It is an intellectually rich field in which to work. There is a real change happening. But the place where it becomes really magical is in working with the families.

AMH: What other changes have you seen?

MGK: With the closure of big institutions, it is less of an option for families to walk away. The families now feel that they need to take care of the child.

AMH: What has your career taught you?

MGK: These children and their families made us better people. It has taught me patience, to enter every situation without preconceived notions, and that there is something new to learn every day.

References

J Child Adolesc Psychiatry. 1975 Jun 1;14(3):387-421.

Evaluation and Treating Families: The McMaster Approach. Routledge/Taylor & Francis Group, 2005.

Movies to watch

Lorenzo’s Oil, 1992.

My Left Foot, 1989.

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (Routledge, 2013). She has no conflicts of interest.

Dr. Klitkze is a 1983 graduate of the Texas College of Osteopathic Medicine, and completed her residency and fellowship training at Brown University, Providence, R.I. She is a member of the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, and the Rhode Island Medical Society, where she serves on the Physicians’ Health Committee. She is actively involved in teaching medical students, residents, and fellows, and has received several teaching awards from the department of psychiatry and human behavior at Brown.

Dr. Margaret G. Klitzke is a board-certified child and adolescent psychiatrist who has worked across all settings of the Center for Autism and Developmental Disabilities at Bradley Hospital in East Providence, R.I.

Courtesy Dr. Margaret G. Klitzke

I spoke with Dr. Klitzke recently about her work as an outpatient psychiatrist at the center and about the important role of families in the treatment it provides. The center offers highly specialized clinical services for children and adolescents between the ages of 2 and 18 who show signs of serious emotional and behavioral problems in addition to a developmental disability, such as autism, Asperger’s, or intellectual disability.

ALISON M. HERU, MD: Hello, Dr. Klitzke and thank you for agreeing to this interview.

MARGARET G. KLITZKE, DO: My pleasure.

AMH: I admire your dedication to this population of children and adolescents. To me, it seems very hard to work with patients and families where there is significant disability and there is little hope of the patient “getting better.”

MGK: When parents come to us, they have great hopes their children can be helped. They often express understanding and acceptance of the child’s disability, and seek to understand the psychiatric or behavioral issues. These parents are often very dedicated to their children, giving up careers to care for them. But as professionals, we must be sensitive to the role each parent can play and how they can support each other and the family.

AMH: So much of your work focuses on family inclusion and family psychoeducation?

MGK: Yes. An example that stands out is a couple where the mother had become the voice for the family in dealing with professionals, but she was overwhelmed in this role. So, we invited the father in. He explained that medical professionals and school personnel would address their remarks to his wife and that he felt marginalized. We worked with the couple, now always including the father, and he has gone on to become a vocal advocate for children with disabilities. It is inspiring to watch families become advocates – to insist that others see the child’s strengths – not just weaknesses.

AMH: Do you feel that the families ever come to you with too high expectations of what you can do to help their child?

MGK: As a child psychiatrist, one must put oneself in the parents’ shoes. Charlie Zeanah Jr., MD, and others have done wonderful work in attachment. They have identified that parents have fantasies and beliefs about what the child will be like before the child is born. We all have fantasies about our babies before they come to us! For many families, they quickly come to understand that their child is not like other children. This new world of parenting is not what they expected. A mother once gave me a short piece called “Welcome to Holland,” written by a mother whose child has Down syndrome.

AMH: How do you begin to work with these families? There must be such a sense of loss and tragedy in their lives.

MGK: My first goal is to understand what it is like to have a child with developmental disability, not just for the parents but for the siblings, too. I strive to understand what the parents want for their child and how they see themselves as a family. I see us, the health care team, as agents to help the child and the family be the very best they can be.

AMH: How do you deal with parents who are not be on the same page?

MGK: It is important that parents are consistent and are able to work together. Even if they are divorced, I have seen families able to unite around the care of their child with a disability. This is quite an achievement given the high rates of divorce – although most of the families that I have worked with are intact. As in all families, each member has a role in helping the family function well. It means using the strength of each parent to help them become a parenting team.

AMH: What if the parents have unrealistic expectations of their child?

MGK: Yes, there are parents who come to us with unrealistic expectations, such as believing their nonverbal child will talk some day. In such a case, we must be certain that we have exhausted all methods to help this child communicate, and once we have done all we can, then we must accept where that child is; to accept and help the family accept, the child’s weaknesses and acknowledge their strengths. Change what you can and be a support for everything else.

AMH: I find it hard to imagine caring for a severely disabled child. How do these parents do this?

MGK: These are children who are nonverbal, and children who can be very fragile, even medically. What I see are parents who want to connect, who want to find that something inside that child, that special place where there is connection. That place of reciprocity. That is important to us all, helping the family find that place of reciprocal connection.

AMH: What language do you use to discuss this with families?

MGK: I say, “This is the child’s strength and this is the child’s weakness; capitalize on the strengths and let’s shore up their weaknesses.”

AMH: How do you approach the families? Where do you start?

MGK: I meet the family where they are. One cannot with these families or any families stand rigidly 10 feet away, and demand that they change. This never works, and we will be of no help to them. We must understand the family system and how they have arrived at their current place of functioning.

AMH: Can you give an example?

MGK: Yes, for example if a parent is drinking excessively, I help them understand why they are coping that way and see if they are willing to change.

AMH: What keeps you going ?

MGK: I think it comes back to the family work. For me, I believe the families are doing the very best they can. If the family is really impaired in some way, I see it as my job to figure out why that is their pattern of behavior, and I do what I can to help them facilitate change.

AMH: What inspires you about these families?

MGK: These families are able to recognize the strengths and beauty that their children bring them – the strength of these children, their personalities and their wills of steel! They are able to communicate what they need. Siblings, too, make life decisions based on their experiences. They often end up going down the path of caring for such children as professionals.

AMH: Do you have any recommendations for a young child psychiatrist who might be considering working with this population?

MGK: Developmental disabilities in child psychiatry is where medicine, neurology, and child development meet. The advances in genetics and neurology are major gifts to the field. It used to be that I would have to sell the field to medical students and residents. Now they are coming to me saying that they want to work in this area. It is an intellectually rich field in which to work. There is a real change happening. But the place where it becomes really magical is in working with the families.

AMH: What other changes have you seen?

MGK: With the closure of big institutions, it is less of an option for families to walk away. The families now feel that they need to take care of the child.

AMH: What has your career taught you?

MGK: These children and their families made us better people. It has taught me patience, to enter every situation without preconceived notions, and that there is something new to learn every day.

References

J Child Adolesc Psychiatry. 1975 Jun 1;14(3):387-421.

Evaluation and Treating Families: The McMaster Approach. Routledge/Taylor & Francis Group, 2005.

Movies to watch

Lorenzo’s Oil, 1992.

My Left Foot, 1989.

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (Routledge, 2013). She has no conflicts of interest.

Dr. Klitkze is a 1983 graduate of the Texas College of Osteopathic Medicine, and completed her residency and fellowship training at Brown University, Providence, R.I. She is a member of the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, and the Rhode Island Medical Society, where she serves on the Physicians’ Health Committee. She is actively involved in teaching medical students, residents, and fellows, and has received several teaching awards from the department of psychiatry and human behavior at Brown.

Dr. Margaret G. Klitzke is a board-certified child and adolescent psychiatrist who has worked across all settings of the Center for Autism and Developmental Disabilities at Bradley Hospital in East Providence, R.I.

Courtesy Dr. Margaret G. Klitzke

I spoke with Dr. Klitzke recently about her work as an outpatient psychiatrist at the center and about the important role of families in the treatment it provides. The center offers highly specialized clinical services for children and adolescents between the ages of 2 and 18 who show signs of serious emotional and behavioral problems in addition to a developmental disability, such as autism, Asperger’s, or intellectual disability.

ALISON M. HERU, MD: Hello, Dr. Klitzke and thank you for agreeing to this interview.

MARGARET G. KLITZKE, DO: My pleasure.

AMH: I admire your dedication to this population of children and adolescents. To me, it seems very hard to work with patients and families where there is significant disability and there is little hope of the patient “getting better.”

MGK: When parents come to us, they have great hopes their children can be helped. They often express understanding and acceptance of the child’s disability, and seek to understand the psychiatric or behavioral issues. These parents are often very dedicated to their children, giving up careers to care for them. But as professionals, we must be sensitive to the role each parent can play and how they can support each other and the family.

AMH: So much of your work focuses on family inclusion and family psychoeducation?

MGK: Yes. An example that stands out is a couple where the mother had become the voice for the family in dealing with professionals, but she was overwhelmed in this role. So, we invited the father in. He explained that medical professionals and school personnel would address their remarks to his wife and that he felt marginalized. We worked with the couple, now always including the father, and he has gone on to become a vocal advocate for children with disabilities. It is inspiring to watch families become advocates – to insist that others see the child’s strengths – not just weaknesses.

AMH: Do you feel that the families ever come to you with too high expectations of what you can do to help their child?

MGK: As a child psychiatrist, one must put oneself in the parents’ shoes. Charlie Zeanah Jr., MD, and others have done wonderful work in attachment. They have identified that parents have fantasies and beliefs about what the child will be like before the child is born. We all have fantasies about our babies before they come to us! For many families, they quickly come to understand that their child is not like other children. This new world of parenting is not what they expected. A mother once gave me a short piece called “Welcome to Holland,” written by a mother whose child has Down syndrome.

AMH: How do you begin to work with these families? There must be such a sense of loss and tragedy in their lives.

MGK: My first goal is to understand what it is like to have a child with developmental disability, not just for the parents but for the siblings, too. I strive to understand what the parents want for their child and how they see themselves as a family. I see us, the health care team, as agents to help the child and the family be the very best they can be.

AMH: How do you deal with parents who are not be on the same page?

MGK: It is important that parents are consistent and are able to work together. Even if they are divorced, I have seen families able to unite around the care of their child with a disability. This is quite an achievement given the high rates of divorce – although most of the families that I have worked with are intact. As in all families, each member has a role in helping the family function well. It means using the strength of each parent to help them become a parenting team.

AMH: What if the parents have unrealistic expectations of their child?

MGK: Yes, there are parents who come to us with unrealistic expectations, such as believing their nonverbal child will talk some day. In such a case, we must be certain that we have exhausted all methods to help this child communicate, and once we have done all we can, then we must accept where that child is; to accept and help the family accept, the child’s weaknesses and acknowledge their strengths. Change what you can and be a support for everything else.

AMH: I find it hard to imagine caring for a severely disabled child. How do these parents do this?

MGK: These are children who are nonverbal, and children who can be very fragile, even medically. What I see are parents who want to connect, who want to find that something inside that child, that special place where there is connection. That place of reciprocity. That is important to us all, helping the family find that place of reciprocal connection.

AMH: What language do you use to discuss this with families?

MGK: I say, “This is the child’s strength and this is the child’s weakness; capitalize on the strengths and let’s shore up their weaknesses.”

AMH: How do you approach the families? Where do you start?

MGK: I meet the family where they are. One cannot with these families or any families stand rigidly 10 feet away, and demand that they change. This never works, and we will be of no help to them. We must understand the family system and how they have arrived at their current place of functioning.

AMH: Can you give an example?

MGK: Yes, for example if a parent is drinking excessively, I help them understand why they are coping that way and see if they are willing to change.

AMH: What keeps you going ?

MGK: I think it comes back to the family work. For me, I believe the families are doing the very best they can. If the family is really impaired in some way, I see it as my job to figure out why that is their pattern of behavior, and I do what I can to help them facilitate change.

AMH: What inspires you about these families?

MGK: These families are able to recognize the strengths and beauty that their children bring them – the strength of these children, their personalities and their wills of steel! They are able to communicate what they need. Siblings, too, make life decisions based on their experiences. They often end up going down the path of caring for such children as professionals.

AMH: Do you have any recommendations for a young child psychiatrist who might be considering working with this population?

MGK: Developmental disabilities in child psychiatry is where medicine, neurology, and child development meet. The advances in genetics and neurology are major gifts to the field. It used to be that I would have to sell the field to medical students and residents. Now they are coming to me saying that they want to work in this area. It is an intellectually rich field in which to work. There is a real change happening. But the place where it becomes really magical is in working with the families.

AMH: What other changes have you seen?

MGK: With the closure of big institutions, it is less of an option for families to walk away. The families now feel that they need to take care of the child.

AMH: What has your career taught you?

MGK: These children and their families made us better people. It has taught me patience, to enter every situation without preconceived notions, and that there is something new to learn every day.

References

J Child Adolesc Psychiatry. 1975 Jun 1;14(3):387-421.

Evaluation and Treating Families: The McMaster Approach. Routledge/Taylor & Francis Group, 2005.

Movies to watch

Lorenzo’s Oil, 1992.

My Left Foot, 1989.

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (Routledge, 2013). She has no conflicts of interest.

Dr. Klitkze is a 1983 graduate of the Texas College of Osteopathic Medicine, and completed her residency and fellowship training at Brown University, Providence, R.I. She is a member of the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, and the Rhode Island Medical Society, where she serves on the Physicians’ Health Committee. She is actively involved in teaching medical students, residents, and fellows, and has received several teaching awards from the department of psychiatry and human behavior at Brown.

Pediatric dermatologists earned a mean of about $351,000 in 2019, but what else is known about the member physicians who were recently surveyed by the Society for Pediatric Dermatology?

For one thing, the median total compensation for the 162 pediatric dermatologists whose survey responses were included in the final data set was a somewhat lower $335,000, the SPD said in its 2020 Pediatric Dermatology Physician Compensation Report.

Getting back to the mean, average earnings were highest, over $505,000, among those working in hospitals/health systems, followed by independent group practices at $436,000, while those working in academic hospitals/health systems – the most popular type of ownership entity (69% of all respondents) – had a mean compensation of $323,000, the SPD said in the report.

At a more basic level, average earnings tilted toward men over women, $411,000-$335,000, although a majority of the respondents (78%) were female, according to the SPD.

Patient mix produced a strong trend of increasing earnings with decreasing pediatric case load. Average compensation was lowest among those who saw 98%-100% pediatric patients ($330,000), rose for physicians who saw 80%-97% ($345,000) and 50%-79% children ($398,000), and topped out at $444,000 for those who saw fewer than 50% children, the SPD data show.

The number of pediatric dermatologists working in a practice also had an effect: Average compensation in practices with 1-2 such specialists was almost $380,000 in 2019, compared with $340,000 in groups with 6-10 pediatric dermatologists and $314,000 for those with 3-5. There were too few groups with more than 10 to meet the sample-size criteria, the SPD noted.

Average starting salary was $286,000 for the 17 respondents who reported that they were newly hired for full-time positions, with a median of $262,500, which was “22% lower than the median clinical compensation reported by pediatric dermatology physicians hired prior to 2019,” the report indicated.

Respondents also were asked about issues of satisfaction and burnout, and these data include responses from additional physicians (for a total of 193) not included in the compensation data set.

The largest share, 79%, said that patient relationships were most satisfying factor of their profession, with intellectual stimulation next at 59% and interaction with colleagues third at 42%. The least satisfying elements were regulatory/paperwork burdens (80%), inefficient EHR design/interoperability (37%), and the commoditization of medicine (21%), the SPD said.

Feelings of burnout were common among almost a quarter of pediatric dermatologists, with 3.1% saying they always have such feelings and 21.2% disclosing that they often feel burned out. Only 5.2% said that they never have feelings of burnout, the SPD reported.

Demographically speaking, 71% of those surveyed identified as White, 22% as Asian, 8.5% as Hispanic/Latino/Spanish, 2.5% as Middle Eastern or North African, and 2.5% as Black or African American. The largest age group, with 61% of all respondents, was 36-50 years, and geography gave the East a slight edge over the West, 30% to 28%, although California had the largest share by state, 17.4%, the report said.

[email protected]

Pediatric dermatologists earned a mean of about $351,000 in 2019, but what else is known about the member physicians who were recently surveyed by the Society for Pediatric Dermatology?

For one thing, the median total compensation for the 162 pediatric dermatologists whose survey responses were included in the final data set was a somewhat lower $335,000, the SPD said in its 2020 Pediatric Dermatology Physician Compensation Report.

Getting back to the mean, average earnings were highest, over $505,000, among those working in hospitals/health systems, followed by independent group practices at $436,000, while those working in academic hospitals/health systems – the most popular type of ownership entity (69% of all respondents) – had a mean compensation of $323,000, the SPD said in the report.

At a more basic level, average earnings tilted toward men over women, $411,000-$335,000, although a majority of the respondents (78%) were female, according to the SPD.

Patient mix produced a strong trend of increasing earnings with decreasing pediatric case load. Average compensation was lowest among those who saw 98%-100% pediatric patients ($330,000), rose for physicians who saw 80%-97% ($345,000) and 50%-79% children ($398,000), and topped out at $444,000 for those who saw fewer than 50% children, the SPD data show.

The number of pediatric dermatologists working in a practice also had an effect: Average compensation in practices with 1-2 such specialists was almost $380,000 in 2019, compared with $340,000 in groups with 6-10 pediatric dermatologists and $314,000 for those with 3-5. There were too few groups with more than 10 to meet the sample-size criteria, the SPD noted.

Average starting salary was $286,000 for the 17 respondents who reported that they were newly hired for full-time positions, with a median of $262,500, which was “22% lower than the median clinical compensation reported by pediatric dermatology physicians hired prior to 2019,” the report indicated.

Respondents also were asked about issues of satisfaction and burnout, and these data include responses from additional physicians (for a total of 193) not included in the compensation data set.

The largest share, 79%, said that patient relationships were most satisfying factor of their profession, with intellectual stimulation next at 59% and interaction with colleagues third at 42%. The least satisfying elements were regulatory/paperwork burdens (80%), inefficient EHR design/interoperability (37%), and the commoditization of medicine (21%), the SPD said.

Feelings of burnout were common among almost a quarter of pediatric dermatologists, with 3.1% saying they always have such feelings and 21.2% disclosing that they often feel burned out. Only 5.2% said that they never have feelings of burnout, the SPD reported.

Demographically speaking, 71% of those surveyed identified as White, 22% as Asian, 8.5% as Hispanic/Latino/Spanish, 2.5% as Middle Eastern or North African, and 2.5% as Black or African American. The largest age group, with 61% of all respondents, was 36-50 years, and geography gave the East a slight edge over the West, 30% to 28%, although California had the largest share by state, 17.4%, the report said.

[email protected]

Pediatric dermatologists earned a mean of about $351,000 in 2019, but what else is known about the member physicians who were recently surveyed by the Society for Pediatric Dermatology?

For one thing, the median total compensation for the 162 pediatric dermatologists whose survey responses were included in the final data set was a somewhat lower $335,000, the SPD said in its 2020 Pediatric Dermatology Physician Compensation Report.

Getting back to the mean, average earnings were highest, over $505,000, among those working in hospitals/health systems, followed by independent group practices at $436,000, while those working in academic hospitals/health systems – the most popular type of ownership entity (69% of all respondents) – had a mean compensation of $323,000, the SPD said in the report.

At a more basic level, average earnings tilted toward men over women, $411,000-$335,000, although a majority of the respondents (78%) were female, according to the SPD.

Patient mix produced a strong trend of increasing earnings with decreasing pediatric case load. Average compensation was lowest among those who saw 98%-100% pediatric patients ($330,000), rose for physicians who saw 80%-97% ($345,000) and 50%-79% children ($398,000), and topped out at $444,000 for those who saw fewer than 50% children, the SPD data show.

The number of pediatric dermatologists working in a practice also had an effect: Average compensation in practices with 1-2 such specialists was almost $380,000 in 2019, compared with $340,000 in groups with 6-10 pediatric dermatologists and $314,000 for those with 3-5. There were too few groups with more than 10 to meet the sample-size criteria, the SPD noted.

Average starting salary was $286,000 for the 17 respondents who reported that they were newly hired for full-time positions, with a median of $262,500, which was “22% lower than the median clinical compensation reported by pediatric dermatology physicians hired prior to 2019,” the report indicated.

Respondents also were asked about issues of satisfaction and burnout, and these data include responses from additional physicians (for a total of 193) not included in the compensation data set.

The largest share, 79%, said that patient relationships were most satisfying factor of their profession, with intellectual stimulation next at 59% and interaction with colleagues third at 42%. The least satisfying elements were regulatory/paperwork burdens (80%), inefficient EHR design/interoperability (37%), and the commoditization of medicine (21%), the SPD said.

Feelings of burnout were common among almost a quarter of pediatric dermatologists, with 3.1% saying they always have such feelings and 21.2% disclosing that they often feel burned out. Only 5.2% said that they never have feelings of burnout, the SPD reported.

Demographically speaking, 71% of those surveyed identified as White, 22% as Asian, 8.5% as Hispanic/Latino/Spanish, 2.5% as Middle Eastern or North African, and 2.5% as Black or African American. The largest age group, with 61% of all respondents, was 36-50 years, and geography gave the East a slight edge over the West, 30% to 28%, although California had the largest share by state, 17.4%, the report said.

[email protected]

It’s likely the United States will see another surge of COVID-19 this winter, warned Christopher Murray, MD, director of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington in Seattle.

Speaking at the national conference of State of Reform on April 8, Dr. Murray cited the seasonality of the SARS-CoV-2 virus, which wanes in the summer and waxes in the winter. The “optimistic forecast” of IHME, which has modeled the course of the pandemic for the past 13 months, is that daily deaths will rise a bit in the next month, then decline from May through August, he said.

“Summer should be fairly quiet in terms of COVID, if vaccinations rise and people don’t stop wearing masks,” Dr. Murray said.

But he added that “a considerable surge will occur over next winter,” because the new variants are more transmissible, and people will likely relax social distancing and mask wearing. The IHME predicts that the percentage of Americans who usually don masks will decline from 73% today to 21% by Aug. 1.

With a rapid decline in mask use and a rise in mobility, there will still be more than 1,000 deaths each day by July 1, Dr. Murray said. In a forecast released the day after Dr. Murray spoke, the IHME predicted that by Aug. 1, there will be a total of 618,523 U.S. deaths from COVID-19. Deaths could be as high as 696,651 if mobility among the vaccinated returns to prepandemic levels, the institute forecasts.

Based on cell phone data, Dr. Murray said, the amount of mobility in the United States has already risen to the level of March 2020, when the pandemic was just getting underway.
 

Decreased infections

If there’s one piece of good news in the latest IHME report, it’s that the estimated number of people infected (including those not tested) will drop from 111,581 today to a projected 17,502 on Aug. 1. But in a worst-case scenario, with sharply higher mobility among vaccinated people, the case count on that date would only fall to 73,842.

The SARS-CoV-2 variants are another factor of concern. Dr. Murray distinguished between variants like the one first identified in the U.K. (B.1.1.7) and other “escape variants.”

B.1.1.7, which is now the dominant strain in the United States, increases transmission but doesn’t necessarily escape the immune system or vaccines, he explained.

In contrast, if someone is infected with a variant such as the South African or the Brazilian mutations, he said, a previous COVID-19 infection might not protect the person, and vaccines are less effective against those variants.

Cross-variant immunity may range from 0% to 60% for escape variants, based on the slim amount of data now available, Dr. Murray said. In his view, these variants will be the long-term driver of the pandemic in the United States, while the United Kingdom variant is the short-term driver.

The latest data, he said, show that the Pfizer/BioNTech and Moderna vaccines are 75% effective against the escape variants, with lower efficacy for other vaccines. But booster shots may still be required to protect people against some variants.
 

Human factors

Human behavior will also help determine the course of the pandemic, he noted. Vaccine hesitancy, for example, is still high in the United States.

By the end of May, he predicted, about 180 million people will have received about two doses of vaccine. After that, he said, “vaccination will flatline due to lack of demand.” The two unknowns are how much campaigns to promote vaccination will increase vaccine confidence, and when children will be vaccinated.

In the United States, he said, 69% of adults have been vaccinated or want to get a shot. But that percentage has dropped 5 points since February, and vaccine confidence varies by state.

Dr. Murray emphasized that the winter surge he predicts can be blocked if people change their behaviors. These include a rise in vaccine confidence to 80% and continued mask wearing by most people.

However, if vaccine confidence and mask wearing decline, state governments continue to drop social distancing rules, and the uptake of boosters is low, the winter surge could be more serious, he said.
 

Double surge

Murray also raised the possibility of a double surge of COVID-19 and influenza this winter. Widely expected last winter, this double surge never materialized here or elsewhere, partly because of mask wearing. But Dr. Murray said it could happen this year: History shows that the flu tends to be stronger in years after weak outbreaks.

He advised hospitals to prepare now for whatever might come later this year. Public health authorities, he said, should speed up vaccination, monitor variants closely with additional sequencing, and try to modify behavior in high-risk groups.

Asked to explain the recent surge of COVID-19 cases in Michigan, Dr. Murray attributed it partly to the spread of the B.1.1.7 (U.K.) variant. But he noted that the U.K. variant has expanded even more widely in some other states that haven’t had an explosive surge like Michigan’s.

Moreover, he noted, Michigan doesn’t have low mask use or high mobility. So the upward spiral of COVID-19 infections there is very concerning, he said.

In regard to the role of children as reservoirs of the virus, Dr. Murray pointed out that views on this have changed around the world. For a while, people thought kids didn’t spread COVID-19 very much. That view shifted when U.K. data showed that child transmission of the B.1.1.7 variant increased by half to 9% of contacts in comparison with the original virus strain.

Dutch data, similarly, showed schools contributing to the latest outbreaks, and some European nations have closed schools. In the United States, the trend is to open them.

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

It’s likely the United States will see another surge of COVID-19 this winter, warned Christopher Murray, MD, director of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington in Seattle.

Speaking at the national conference of State of Reform on April 8, Dr. Murray cited the seasonality of the SARS-CoV-2 virus, which wanes in the summer and waxes in the winter. The “optimistic forecast” of IHME, which has modeled the course of the pandemic for the past 13 months, is that daily deaths will rise a bit in the next month, then decline from May through August, he said.

“Summer should be fairly quiet in terms of COVID, if vaccinations rise and people don’t stop wearing masks,” Dr. Murray said.

But he added that “a considerable surge will occur over next winter,” because the new variants are more transmissible, and people will likely relax social distancing and mask wearing. The IHME predicts that the percentage of Americans who usually don masks will decline from 73% today to 21% by Aug. 1.

With a rapid decline in mask use and a rise in mobility, there will still be more than 1,000 deaths each day by July 1, Dr. Murray said. In a forecast released the day after Dr. Murray spoke, the IHME predicted that by Aug. 1, there will be a total of 618,523 U.S. deaths from COVID-19. Deaths could be as high as 696,651 if mobility among the vaccinated returns to prepandemic levels, the institute forecasts.

Based on cell phone data, Dr. Murray said, the amount of mobility in the United States has already risen to the level of March 2020, when the pandemic was just getting underway.
 

Decreased infections

If there’s one piece of good news in the latest IHME report, it’s that the estimated number of people infected (including those not tested) will drop from 111,581 today to a projected 17,502 on Aug. 1. But in a worst-case scenario, with sharply higher mobility among vaccinated people, the case count on that date would only fall to 73,842.

The SARS-CoV-2 variants are another factor of concern. Dr. Murray distinguished between variants like the one first identified in the U.K. (B.1.1.7) and other “escape variants.”

B.1.1.7, which is now the dominant strain in the United States, increases transmission but doesn’t necessarily escape the immune system or vaccines, he explained.

In contrast, if someone is infected with a variant such as the South African or the Brazilian mutations, he said, a previous COVID-19 infection might not protect the person, and vaccines are less effective against those variants.

Cross-variant immunity may range from 0% to 60% for escape variants, based on the slim amount of data now available, Dr. Murray said. In his view, these variants will be the long-term driver of the pandemic in the United States, while the United Kingdom variant is the short-term driver.

The latest data, he said, show that the Pfizer/BioNTech and Moderna vaccines are 75% effective against the escape variants, with lower efficacy for other vaccines. But booster shots may still be required to protect people against some variants.
 

Human factors

Human behavior will also help determine the course of the pandemic, he noted. Vaccine hesitancy, for example, is still high in the United States.

By the end of May, he predicted, about 180 million people will have received about two doses of vaccine. After that, he said, “vaccination will flatline due to lack of demand.” The two unknowns are how much campaigns to promote vaccination will increase vaccine confidence, and when children will be vaccinated.

In the United States, he said, 69% of adults have been vaccinated or want to get a shot. But that percentage has dropped 5 points since February, and vaccine confidence varies by state.

Dr. Murray emphasized that the winter surge he predicts can be blocked if people change their behaviors. These include a rise in vaccine confidence to 80% and continued mask wearing by most people.

However, if vaccine confidence and mask wearing decline, state governments continue to drop social distancing rules, and the uptake of boosters is low, the winter surge could be more serious, he said.
 

Double surge

Murray also raised the possibility of a double surge of COVID-19 and influenza this winter. Widely expected last winter, this double surge never materialized here or elsewhere, partly because of mask wearing. But Dr. Murray said it could happen this year: History shows that the flu tends to be stronger in years after weak outbreaks.

He advised hospitals to prepare now for whatever might come later this year. Public health authorities, he said, should speed up vaccination, monitor variants closely with additional sequencing, and try to modify behavior in high-risk groups.

Asked to explain the recent surge of COVID-19 cases in Michigan, Dr. Murray attributed it partly to the spread of the B.1.1.7 (U.K.) variant. But he noted that the U.K. variant has expanded even more widely in some other states that haven’t had an explosive surge like Michigan’s.

Moreover, he noted, Michigan doesn’t have low mask use or high mobility. So the upward spiral of COVID-19 infections there is very concerning, he said.

In regard to the role of children as reservoirs of the virus, Dr. Murray pointed out that views on this have changed around the world. For a while, people thought kids didn’t spread COVID-19 very much. That view shifted when U.K. data showed that child transmission of the B.1.1.7 variant increased by half to 9% of contacts in comparison with the original virus strain.

Dutch data, similarly, showed schools contributing to the latest outbreaks, and some European nations have closed schools. In the United States, the trend is to open them.

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

It’s likely the United States will see another surge of COVID-19 this winter, warned Christopher Murray, MD, director of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington in Seattle.

Speaking at the national conference of State of Reform on April 8, Dr. Murray cited the seasonality of the SARS-CoV-2 virus, which wanes in the summer and waxes in the winter. The “optimistic forecast” of IHME, which has modeled the course of the pandemic for the past 13 months, is that daily deaths will rise a bit in the next month, then decline from May through August, he said.

“Summer should be fairly quiet in terms of COVID, if vaccinations rise and people don’t stop wearing masks,” Dr. Murray said.

But he added that “a considerable surge will occur over next winter,” because the new variants are more transmissible, and people will likely relax social distancing and mask wearing. The IHME predicts that the percentage of Americans who usually don masks will decline from 73% today to 21% by Aug. 1.

With a rapid decline in mask use and a rise in mobility, there will still be more than 1,000 deaths each day by July 1, Dr. Murray said. In a forecast released the day after Dr. Murray spoke, the IHME predicted that by Aug. 1, there will be a total of 618,523 U.S. deaths from COVID-19. Deaths could be as high as 696,651 if mobility among the vaccinated returns to prepandemic levels, the institute forecasts.

Based on cell phone data, Dr. Murray said, the amount of mobility in the United States has already risen to the level of March 2020, when the pandemic was just getting underway.
 

Decreased infections

If there’s one piece of good news in the latest IHME report, it’s that the estimated number of people infected (including those not tested) will drop from 111,581 today to a projected 17,502 on Aug. 1. But in a worst-case scenario, with sharply higher mobility among vaccinated people, the case count on that date would only fall to 73,842.

The SARS-CoV-2 variants are another factor of concern. Dr. Murray distinguished between variants like the one first identified in the U.K. (B.1.1.7) and other “escape variants.”

B.1.1.7, which is now the dominant strain in the United States, increases transmission but doesn’t necessarily escape the immune system or vaccines, he explained.

In contrast, if someone is infected with a variant such as the South African or the Brazilian mutations, he said, a previous COVID-19 infection might not protect the person, and vaccines are less effective against those variants.

Cross-variant immunity may range from 0% to 60% for escape variants, based on the slim amount of data now available, Dr. Murray said. In his view, these variants will be the long-term driver of the pandemic in the United States, while the United Kingdom variant is the short-term driver.

The latest data, he said, show that the Pfizer/BioNTech and Moderna vaccines are 75% effective against the escape variants, with lower efficacy for other vaccines. But booster shots may still be required to protect people against some variants.
 

Human factors

Human behavior will also help determine the course of the pandemic, he noted. Vaccine hesitancy, for example, is still high in the United States.

By the end of May, he predicted, about 180 million people will have received about two doses of vaccine. After that, he said, “vaccination will flatline due to lack of demand.” The two unknowns are how much campaigns to promote vaccination will increase vaccine confidence, and when children will be vaccinated.

In the United States, he said, 69% of adults have been vaccinated or want to get a shot. But that percentage has dropped 5 points since February, and vaccine confidence varies by state.

Dr. Murray emphasized that the winter surge he predicts can be blocked if people change their behaviors. These include a rise in vaccine confidence to 80% and continued mask wearing by most people.

However, if vaccine confidence and mask wearing decline, state governments continue to drop social distancing rules, and the uptake of boosters is low, the winter surge could be more serious, he said.
 

Double surge

Murray also raised the possibility of a double surge of COVID-19 and influenza this winter. Widely expected last winter, this double surge never materialized here or elsewhere, partly because of mask wearing. But Dr. Murray said it could happen this year: History shows that the flu tends to be stronger in years after weak outbreaks.

He advised hospitals to prepare now for whatever might come later this year. Public health authorities, he said, should speed up vaccination, monitor variants closely with additional sequencing, and try to modify behavior in high-risk groups.

Asked to explain the recent surge of COVID-19 cases in Michigan, Dr. Murray attributed it partly to the spread of the B.1.1.7 (U.K.) variant. But he noted that the U.K. variant has expanded even more widely in some other states that haven’t had an explosive surge like Michigan’s.

Moreover, he noted, Michigan doesn’t have low mask use or high mobility. So the upward spiral of COVID-19 infections there is very concerning, he said.

In regard to the role of children as reservoirs of the virus, Dr. Murray pointed out that views on this have changed around the world. For a while, people thought kids didn’t spread COVID-19 very much. That view shifted when U.K. data showed that child transmission of the B.1.1.7 variant increased by half to 9% of contacts in comparison with the original virus strain.

Dutch data, similarly, showed schools contributing to the latest outbreaks, and some European nations have closed schools. In the United States, the trend is to open them.

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

Adhering to a healthy lifestyle may offset the heightened risk of lethal prostate cancer in patients with adverse genetic risk factors, according to results of a large U.S. study.

In men at the highest risk of dying from prostate cancer, having the highest healthy lifestyle scores cut the risk of fatal disease in half, said study author Anna Plym, PhD, of Brigham and Women’s Hospital and Harvard School of Public Health, both in Boston. She presented these findings at the American Association for Cancer Research Annual Meeting 2021: Week 1 (Abstract 822).

Dr. Plym noted that about 58% of the variability in prostate cancer risk is accounted for by genetic factors, with common single-nucleotide polymorphisms (SNPs) accounting for a substantial proportion of prostate cancer susceptibility.

A recent study showed that a polygenic risk score (PRS) derived by combining information from 269 SNPs was “highly predictive” of prostate cancer, Dr. Plym said. There was a 10-fold gradient in disease risk between the lowest and highest genetic risk deciles, and the pattern was consistent across ethnic groups.

In addition, Dr. Plym noted, previous studies have suggested that a healthy lifestyle reduces lethal prostate cancer risk.

What has remained unclear is whether the risk for both developing prostate cancer and experiencing progression to lethal disease can be offset by adherence to a healthy lifestyle.

To investigate, Dr. Plym and colleagues used the 269-SNP PRS to quantify the genetic risk of prostate cancer in 10,443 men enrolled in the Health Professionals Follow-up Study. The men were divided into quartiles according to genetic risk.

The investigators also classified the men using a validated lifestyle score. For this score, one point was given for each of the following: not currently smoking or having quit 10 or more years ago, body mass index under 30 kg/m², high vigorous physical activity, high intake of tomatoes and fatty fish, and low intake of processed meat. Patients with 1-2 points were considered the least healthy, those with 3 points were moderately healthy, and those with 4-6 points were the most healthy.

The outcomes assessed were overall prostate cancer and lethal prostate cancer (i.e., metastatic disease or prostate cancer–specific death).
 

No overall benefit of healthy lifestyle

At a median follow-up of 18 years, 2,111 cases of prostate cancer were observed. And at a median follow-up of 22 years, 238 lethal prostate cancer events occurred.

Men in the highest genetic risk quartile were five times more likely to develop prostate cancer (hazard ratio, 5.39; 95% confidence interval, 4.59-6.34) and three times more likely to develop lethal prostate cancer (HR, 3.43; 95% CI, 2.29-5.14), when compared with men in the lowest genetic risk quartile.

Adherence to a healthy lifestyle did not decrease the risk of prostate cancer overall (HR, 1.01; 95% CI, 0.84-1.22), nor did it affect men in the lower genetic risk quartiles.

However, healthy lifestyle did appear to affect men in the highest genetic risk quartile. Men with the highest healthy lifestyle scores had roughly half the risk of lethal prostate cancer, compared to men with the lowest lifestyle scores (3% vs. 6%).
 

A counterbalance to genetic risk

Dr. Plym observed that the rate of lethal disease in men with the best lifestyle scores matched the rate for the study population as a whole (3%), suggesting that healthy lifestyle may counterbalance high genetic risk.

She added that previous research has confirmed physical activity as a protective factor, but more study is needed to shed light on the relative benefit of the healthy lifestyle components.

In addition, further research is necessary to explain why the benefit was limited to lethal prostate cancer risk in men with the highest genetic risk.

Dr. Plym speculated that the genetic variants contributing to a high PRS may also be the variants that have the strongest interaction with lifestyle factors. For men with a genetic predisposition to prostate cancer, she added, these findings underscore the potential value of surveillance.

“Our findings add to current evidence suggesting that men with a high genetic risk may benefit from a targeted prostate cancer screening program, aiming at detecting a potentially lethal prostate cancer while it is still curable,” she said.

Charles Swanton, MBPhD, of the Francis Crick Institute and UCL Cancer Institute in London, raised the possibility that competing risk issues could be at play.

If a healthy lifestyle leads to longer life, he asked, does that make it more likely that patients will live long enough to die from their prostate cancer because they are not dying from cardiovascular disease, complications of diabetes, etc.? In that case, is the healthy lifestyle really affecting prostate cancer at all?

Dr. Plym responded that, among those in the highest genetic risk group with an unhealthy lifestyle, the increased risk for prostate cancer exceeded the risk for other illnesses.

This study was funded by the DiNovi Family Foundation, the National Cancer Institute, the William Casey Foundation, the Swedish Society for Medical Research, and the Prostate Cancer Foundation. Dr. Plym declared no conflicts of interest. Dr. Swanton disclosed relationships with numerous companies, including Pfizer, Novartis, and GlaxoSmithKline.

Adhering to a healthy lifestyle may offset the heightened risk of lethal prostate cancer in patients with adverse genetic risk factors, according to results of a large U.S. study.

In men at the highest risk of dying from prostate cancer, having the highest healthy lifestyle scores cut the risk of fatal disease in half, said study author Anna Plym, PhD, of Brigham and Women’s Hospital and Harvard School of Public Health, both in Boston. She presented these findings at the American Association for Cancer Research Annual Meeting 2021: Week 1 (Abstract 822).

Dr. Plym noted that about 58% of the variability in prostate cancer risk is accounted for by genetic factors, with common single-nucleotide polymorphisms (SNPs) accounting for a substantial proportion of prostate cancer susceptibility.

A recent study showed that a polygenic risk score (PRS) derived by combining information from 269 SNPs was “highly predictive” of prostate cancer, Dr. Plym said. There was a 10-fold gradient in disease risk between the lowest and highest genetic risk deciles, and the pattern was consistent across ethnic groups.

In addition, Dr. Plym noted, previous studies have suggested that a healthy lifestyle reduces lethal prostate cancer risk.

What has remained unclear is whether the risk for both developing prostate cancer and experiencing progression to lethal disease can be offset by adherence to a healthy lifestyle.

To investigate, Dr. Plym and colleagues used the 269-SNP PRS to quantify the genetic risk of prostate cancer in 10,443 men enrolled in the Health Professionals Follow-up Study. The men were divided into quartiles according to genetic risk.

The investigators also classified the men using a validated lifestyle score. For this score, one point was given for each of the following: not currently smoking or having quit 10 or more years ago, body mass index under 30 kg/m², high vigorous physical activity, high intake of tomatoes and fatty fish, and low intake of processed meat. Patients with 1-2 points were considered the least healthy, those with 3 points were moderately healthy, and those with 4-6 points were the most healthy.

The outcomes assessed were overall prostate cancer and lethal prostate cancer (i.e., metastatic disease or prostate cancer–specific death).
 

No overall benefit of healthy lifestyle

At a median follow-up of 18 years, 2,111 cases of prostate cancer were observed. And at a median follow-up of 22 years, 238 lethal prostate cancer events occurred.

Men in the highest genetic risk quartile were five times more likely to develop prostate cancer (hazard ratio, 5.39; 95% confidence interval, 4.59-6.34) and three times more likely to develop lethal prostate cancer (HR, 3.43; 95% CI, 2.29-5.14), when compared with men in the lowest genetic risk quartile.

Adherence to a healthy lifestyle did not decrease the risk of prostate cancer overall (HR, 1.01; 95% CI, 0.84-1.22), nor did it affect men in the lower genetic risk quartiles.

However, healthy lifestyle did appear to affect men in the highest genetic risk quartile. Men with the highest healthy lifestyle scores had roughly half the risk of lethal prostate cancer, compared to men with the lowest lifestyle scores (3% vs. 6%).
 

A counterbalance to genetic risk

Dr. Plym observed that the rate of lethal disease in men with the best lifestyle scores matched the rate for the study population as a whole (3%), suggesting that healthy lifestyle may counterbalance high genetic risk.

She added that previous research has confirmed physical activity as a protective factor, but more study is needed to shed light on the relative benefit of the healthy lifestyle components.

In addition, further research is necessary to explain why the benefit was limited to lethal prostate cancer risk in men with the highest genetic risk.

Dr. Plym speculated that the genetic variants contributing to a high PRS may also be the variants that have the strongest interaction with lifestyle factors. For men with a genetic predisposition to prostate cancer, she added, these findings underscore the potential value of surveillance.

“Our findings add to current evidence suggesting that men with a high genetic risk may benefit from a targeted prostate cancer screening program, aiming at detecting a potentially lethal prostate cancer while it is still curable,” she said.

Charles Swanton, MBPhD, of the Francis Crick Institute and UCL Cancer Institute in London, raised the possibility that competing risk issues could be at play.

If a healthy lifestyle leads to longer life, he asked, does that make it more likely that patients will live long enough to die from their prostate cancer because they are not dying from cardiovascular disease, complications of diabetes, etc.? In that case, is the healthy lifestyle really affecting prostate cancer at all?

Dr. Plym responded that, among those in the highest genetic risk group with an unhealthy lifestyle, the increased risk for prostate cancer exceeded the risk for other illnesses.

This study was funded by the DiNovi Family Foundation, the National Cancer Institute, the William Casey Foundation, the Swedish Society for Medical Research, and the Prostate Cancer Foundation. Dr. Plym declared no conflicts of interest. Dr. Swanton disclosed relationships with numerous companies, including Pfizer, Novartis, and GlaxoSmithKline.

Adhering to a healthy lifestyle may offset the heightened risk of lethal prostate cancer in patients with adverse genetic risk factors, according to results of a large U.S. study.

In men at the highest risk of dying from prostate cancer, having the highest healthy lifestyle scores cut the risk of fatal disease in half, said study author Anna Plym, PhD, of Brigham and Women’s Hospital and Harvard School of Public Health, both in Boston. She presented these findings at the American Association for Cancer Research Annual Meeting 2021: Week 1 (Abstract 822).

Dr. Plym noted that about 58% of the variability in prostate cancer risk is accounted for by genetic factors, with common single-nucleotide polymorphisms (SNPs) accounting for a substantial proportion of prostate cancer susceptibility.

A recent study showed that a polygenic risk score (PRS) derived by combining information from 269 SNPs was “highly predictive” of prostate cancer, Dr. Plym said. There was a 10-fold gradient in disease risk between the lowest and highest genetic risk deciles, and the pattern was consistent across ethnic groups.

In addition, Dr. Plym noted, previous studies have suggested that a healthy lifestyle reduces lethal prostate cancer risk.

What has remained unclear is whether the risk for both developing prostate cancer and experiencing progression to lethal disease can be offset by adherence to a healthy lifestyle.

To investigate, Dr. Plym and colleagues used the 269-SNP PRS to quantify the genetic risk of prostate cancer in 10,443 men enrolled in the Health Professionals Follow-up Study. The men were divided into quartiles according to genetic risk.

The investigators also classified the men using a validated lifestyle score. For this score, one point was given for each of the following: not currently smoking or having quit 10 or more years ago, body mass index under 30 kg/m², high vigorous physical activity, high intake of tomatoes and fatty fish, and low intake of processed meat. Patients with 1-2 points were considered the least healthy, those with 3 points were moderately healthy, and those with 4-6 points were the most healthy.

The outcomes assessed were overall prostate cancer and lethal prostate cancer (i.e., metastatic disease or prostate cancer–specific death).
 

No overall benefit of healthy lifestyle

At a median follow-up of 18 years, 2,111 cases of prostate cancer were observed. And at a median follow-up of 22 years, 238 lethal prostate cancer events occurred.

Men in the highest genetic risk quartile were five times more likely to develop prostate cancer (hazard ratio, 5.39; 95% confidence interval, 4.59-6.34) and three times more likely to develop lethal prostate cancer (HR, 3.43; 95% CI, 2.29-5.14), when compared with men in the lowest genetic risk quartile.

Adherence to a healthy lifestyle did not decrease the risk of prostate cancer overall (HR, 1.01; 95% CI, 0.84-1.22), nor did it affect men in the lower genetic risk quartiles.

However, healthy lifestyle did appear to affect men in the highest genetic risk quartile. Men with the highest healthy lifestyle scores had roughly half the risk of lethal prostate cancer, compared to men with the lowest lifestyle scores (3% vs. 6%).
 

A counterbalance to genetic risk

Dr. Plym observed that the rate of lethal disease in men with the best lifestyle scores matched the rate for the study population as a whole (3%), suggesting that healthy lifestyle may counterbalance high genetic risk.

She added that previous research has confirmed physical activity as a protective factor, but more study is needed to shed light on the relative benefit of the healthy lifestyle components.

In addition, further research is necessary to explain why the benefit was limited to lethal prostate cancer risk in men with the highest genetic risk.

Dr. Plym speculated that the genetic variants contributing to a high PRS may also be the variants that have the strongest interaction with lifestyle factors. For men with a genetic predisposition to prostate cancer, she added, these findings underscore the potential value of surveillance.

“Our findings add to current evidence suggesting that men with a high genetic risk may benefit from a targeted prostate cancer screening program, aiming at detecting a potentially lethal prostate cancer while it is still curable,” she said.

Charles Swanton, MBPhD, of the Francis Crick Institute and UCL Cancer Institute in London, raised the possibility that competing risk issues could be at play.

If a healthy lifestyle leads to longer life, he asked, does that make it more likely that patients will live long enough to die from their prostate cancer because they are not dying from cardiovascular disease, complications of diabetes, etc.? In that case, is the healthy lifestyle really affecting prostate cancer at all?

Dr. Plym responded that, among those in the highest genetic risk group with an unhealthy lifestyle, the increased risk for prostate cancer exceeded the risk for other illnesses.

This study was funded by the DiNovi Family Foundation, the National Cancer Institute, the William Casey Foundation, the Swedish Society for Medical Research, and the Prostate Cancer Foundation. Dr. Plym declared no conflicts of interest. Dr. Swanton disclosed relationships with numerous companies, including Pfizer, Novartis, and GlaxoSmithKline.

Dr. Crain’s excellent review, “Breaking the cycle of medication overuse headache” (J Fam Pract. 2021;70:20-28) provides an approach to the diagnosis and treatment of this common disorder that is consistent with most expert opinion and published guidelines. However, like most articles on this subject, it is missing a critical review of the evidence that supports the existence of this condition and the recommended treatments. 

The strong association between intractable headaches and quantity of medication used makes the diagnosis of medication overuse headache (MOH) attractive with plausible (if unproven) pathophysiological mechanisms. However, reversing the direction of causation (intractable headaches lead to more medication) seems just as likely. While MOH is taken as an article of faith by most headache experts, high-quality studies in support of this theory have not yet been performed.¹

On the other hand, fear of MOH often leads to rigid, arbitrary limitations of abortive medications, blaming of the patient for their symptoms, and the substitution of a host of pharmacologic and nonpharmacologic interventions that similarly lack evidence of efficacy. Patients with chronic migraine are told to take abortive medications early in the headache but not to take them more than twice per week. They hoard their medications while trying to decide if each daily headache is the “big one” that merits depleting their limited supply of medication.

Avoiding medication “overuse” and prescribing from our growing armamentarium of effective preventive medications remain important strategies. However, until we have better evidence, we need to be a little more flexible in prescribing abortive medications and avoid accepting the MOH paradigm as gospel.

David A. Silverstein, MD
Buffalo, NY

Dr. Crain’s excellent review, “Breaking the cycle of medication overuse headache” (J Fam Pract. 2021;70:20-28) provides an approach to the diagnosis and treatment of this common disorder that is consistent with most expert opinion and published guidelines. However, like most articles on this subject, it is missing a critical review of the evidence that supports the existence of this condition and the recommended treatments. 

The strong association between intractable headaches and quantity of medication used makes the diagnosis of medication overuse headache (MOH) attractive with plausible (if unproven) pathophysiological mechanisms. However, reversing the direction of causation (intractable headaches lead to more medication) seems just as likely. While MOH is taken as an article of faith by most headache experts, high-quality studies in support of this theory have not yet been performed.¹

On the other hand, fear of MOH often leads to rigid, arbitrary limitations of abortive medications, blaming of the patient for their symptoms, and the substitution of a host of pharmacologic and nonpharmacologic interventions that similarly lack evidence of efficacy. Patients with chronic migraine are told to take abortive medications early in the headache but not to take them more than twice per week. They hoard their medications while trying to decide if each daily headache is the “big one” that merits depleting their limited supply of medication.

Avoiding medication “overuse” and prescribing from our growing armamentarium of effective preventive medications remain important strategies. However, until we have better evidence, we need to be a little more flexible in prescribing abortive medications and avoid accepting the MOH paradigm as gospel.

David A. Silverstein, MD
Buffalo, NY

Dr. Crain’s excellent review, “Breaking the cycle of medication overuse headache” (J Fam Pract. 2021;70:20-28) provides an approach to the diagnosis and treatment of this common disorder that is consistent with most expert opinion and published guidelines. However, like most articles on this subject, it is missing a critical review of the evidence that supports the existence of this condition and the recommended treatments. 

The strong association between intractable headaches and quantity of medication used makes the diagnosis of medication overuse headache (MOH) attractive with plausible (if unproven) pathophysiological mechanisms. However, reversing the direction of causation (intractable headaches lead to more medication) seems just as likely. While MOH is taken as an article of faith by most headache experts, high-quality studies in support of this theory have not yet been performed.¹

On the other hand, fear of MOH often leads to rigid, arbitrary limitations of abortive medications, blaming of the patient for their symptoms, and the substitution of a host of pharmacologic and nonpharmacologic interventions that similarly lack evidence of efficacy. Patients with chronic migraine are told to take abortive medications early in the headache but not to take them more than twice per week. They hoard their medications while trying to decide if each daily headache is the “big one” that merits depleting their limited supply of medication.

Avoiding medication “overuse” and prescribing from our growing armamentarium of effective preventive medications remain important strategies. However, until we have better evidence, we need to be a little more flexible in prescribing abortive medications and avoid accepting the MOH paradigm as gospel.

David A. Silverstein, MD
Buffalo, NY

Mnemonics are often used to help remember complex groups of individual items related to a common theme. Studies have shown that college students studying with mnemonics outperform students using rote learning, suggesting that mnemonics are useful in retention of facts. ¹

In 1 study, researchers compared memory athletes and control subjects before and after mnemonic training. ² Findings showed that mnemonics created connectivity changes in the control group similar to memory athletes at baseline. These changes persisted for as long as 4 months after training, demonstrating that mnemonics have long-lasting effects on memory capacity. ²  

The most frequently used forms of medical mnemonics are acronyms or acrostics. Acronyms are words in which each letter in the word corresponds to a series of words to be remembered. ³ A familiar example of a medical acronym is “SLUDGE,” which represents the symptoms for cholinergic toxicity (salivation, lacrimation, urination, defecation, gastrointestinal upset, emesis). An acrostic involves a phrase in which the first letter of each word corresponds to the first letter of a word to be remembered. ³ A commonly used acrostic phrase for the memorization of the 12 cranial nerves is “On Old Olympus’ Towering Tops A Finn And German Viewed Some Hops”: olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, auditory (vestibulocochlear), glossopharyngeal, vagus, spinal accessory, hypoglossal.

Mnemonics are an effective way for medical students, residents, and current practitioners to effortlessly recall information. For example, COVERABCD is an acronym that stands for circulation/capnograph/color, oxygen, ventilation, endotracheal tube, review of equipment, airway, breathing, circulation, and drugs. ⁴ Runciman et al showed that the use of the acronym COVERABCD could have prevented or mitigated 60% of 2000 anesthetic incidents. ⁴ Another mnemonic, FAST, used to assess for a stroke, reduced median hospital arrival times by more than an hour. ⁵    

There are hundreds of mnemonics related to medical practice. Collections of those that might be useful for family practitioners and medical residents can be found at the following links: 

https://epomedicine.com/medical-mnemonics/  

www.oxfordmedicaleducation.com/medical-mnemonics/  

Kristyn McKnight, PharmD candidate
Hannah Lutz, PharmD candidate
Tracy Mahvan, MBA, PharmD, BCGP
School of Pharmacy, University of Wyoming, Laramie

Mnemonics are often used to help remember complex groups of individual items related to a common theme. Studies have shown that college students studying with mnemonics outperform students using rote learning, suggesting that mnemonics are useful in retention of facts. ¹

In 1 study, researchers compared memory athletes and control subjects before and after mnemonic training. ² Findings showed that mnemonics created connectivity changes in the control group similar to memory athletes at baseline. These changes persisted for as long as 4 months after training, demonstrating that mnemonics have long-lasting effects on memory capacity. ²  

The most frequently used forms of medical mnemonics are acronyms or acrostics. Acronyms are words in which each letter in the word corresponds to a series of words to be remembered. ³ A familiar example of a medical acronym is “SLUDGE,” which represents the symptoms for cholinergic toxicity (salivation, lacrimation, urination, defecation, gastrointestinal upset, emesis). An acrostic involves a phrase in which the first letter of each word corresponds to the first letter of a word to be remembered. ³ A commonly used acrostic phrase for the memorization of the 12 cranial nerves is “On Old Olympus’ Towering Tops A Finn And German Viewed Some Hops”: olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, auditory (vestibulocochlear), glossopharyngeal, vagus, spinal accessory, hypoglossal.

Mnemonics are an effective way for medical students, residents, and current practitioners to effortlessly recall information. For example, COVERABCD is an acronym that stands for circulation/capnograph/color, oxygen, ventilation, endotracheal tube, review of equipment, airway, breathing, circulation, and drugs. ⁴ Runciman et al showed that the use of the acronym COVERABCD could have prevented or mitigated 60% of 2000 anesthetic incidents. ⁴ Another mnemonic, FAST, used to assess for a stroke, reduced median hospital arrival times by more than an hour. ⁵    

There are hundreds of mnemonics related to medical practice. Collections of those that might be useful for family practitioners and medical residents can be found at the following links: 

https://epomedicine.com/medical-mnemonics/  

www.oxfordmedicaleducation.com/medical-mnemonics/  

Kristyn McKnight, PharmD candidate
Hannah Lutz, PharmD candidate
Tracy Mahvan, MBA, PharmD, BCGP
School of Pharmacy, University of Wyoming, Laramie

Mnemonics are often used to help remember complex groups of individual items related to a common theme. Studies have shown that college students studying with mnemonics outperform students using rote learning, suggesting that mnemonics are useful in retention of facts. ¹

In 1 study, researchers compared memory athletes and control subjects before and after mnemonic training. ² Findings showed that mnemonics created connectivity changes in the control group similar to memory athletes at baseline. These changes persisted for as long as 4 months after training, demonstrating that mnemonics have long-lasting effects on memory capacity. ²  

The most frequently used forms of medical mnemonics are acronyms or acrostics. Acronyms are words in which each letter in the word corresponds to a series of words to be remembered. ³ A familiar example of a medical acronym is “SLUDGE,” which represents the symptoms for cholinergic toxicity (salivation, lacrimation, urination, defecation, gastrointestinal upset, emesis). An acrostic involves a phrase in which the first letter of each word corresponds to the first letter of a word to be remembered. ³ A commonly used acrostic phrase for the memorization of the 12 cranial nerves is “On Old Olympus’ Towering Tops A Finn And German Viewed Some Hops”: olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, auditory (vestibulocochlear), glossopharyngeal, vagus, spinal accessory, hypoglossal.

Mnemonics are an effective way for medical students, residents, and current practitioners to effortlessly recall information. For example, COVERABCD is an acronym that stands for circulation/capnograph/color, oxygen, ventilation, endotracheal tube, review of equipment, airway, breathing, circulation, and drugs. ⁴ Runciman et al showed that the use of the acronym COVERABCD could have prevented or mitigated 60% of 2000 anesthetic incidents. ⁴ Another mnemonic, FAST, used to assess for a stroke, reduced median hospital arrival times by more than an hour. ⁵    

There are hundreds of mnemonics related to medical practice. Collections of those that might be useful for family practitioners and medical residents can be found at the following links: 

https://epomedicine.com/medical-mnemonics/  

www.oxfordmedicaleducation.com/medical-mnemonics/  

Kristyn McKnight, PharmD candidate
Hannah Lutz, PharmD candidate
Tracy Mahvan, MBA, PharmD, BCGP
School of Pharmacy, University of Wyoming, Laramie

Read the issue by clicking on the cover image or HERE

--

This 2021 issue is our seventh annual Rare Neurological Disease Special Report. It comes at a time when the global pandemic is still very much a part of our everyday lives. While the COVID-19 crisis is the polar opposite of a rare disease, it may offer some insights into the rare disease community. Collectively, we faced a disease no one knew much about—an untreatable condition that sent us into isolation, changed our world view, and altered our daily lives in ways we never imagined. We experienced, many of us for the first time, the fear and helplessness of a medical situation that was potentially fatal. Isn’t that what patients with rare diseases and their families face every day? Fear of the unknown; the desperate search for answers; isolation from a world and, all too often, a medical community that does not understand your situation; the terror of suspecting that time may not be on your side, and the valiant effort to press on despite desperate odds—these are things the rare disease community know all too well.

In publishing the Rare Neurological Disease Special Report, our goal has always been to educate the medical community on conditions they may rarely see and offer some hope to those who battle a rare neurological disease. I hope you enjoy reading our seventh annual issue.

Read the issue by clicking on the cover image or HERE

--

This 2021 issue is our seventh annual Rare Neurological Disease Special Report. It comes at a time when the global pandemic is still very much a part of our everyday lives. While the COVID-19 crisis is the polar opposite of a rare disease, it may offer some insights into the rare disease community. Collectively, we faced a disease no one knew much about—an untreatable condition that sent us into isolation, changed our world view, and altered our daily lives in ways we never imagined. We experienced, many of us for the first time, the fear and helplessness of a medical situation that was potentially fatal. Isn’t that what patients with rare diseases and their families face every day? Fear of the unknown; the desperate search for answers; isolation from a world and, all too often, a medical community that does not understand your situation; the terror of suspecting that time may not be on your side, and the valiant effort to press on despite desperate odds—these are things the rare disease community know all too well.

In publishing the Rare Neurological Disease Special Report, our goal has always been to educate the medical community on conditions they may rarely see and offer some hope to those who battle a rare neurological disease. I hope you enjoy reading our seventh annual issue.

Read the issue by clicking on the cover image or HERE

--

This 2021 issue is our seventh annual Rare Neurological Disease Special Report. It comes at a time when the global pandemic is still very much a part of our everyday lives. While the COVID-19 crisis is the polar opposite of a rare disease, it may offer some insights into the rare disease community. Collectively, we faced a disease no one knew much about—an untreatable condition that sent us into isolation, changed our world view, and altered our daily lives in ways we never imagined. We experienced, many of us for the first time, the fear and helplessness of a medical situation that was potentially fatal. Isn’t that what patients with rare diseases and their families face every day? Fear of the unknown; the desperate search for answers; isolation from a world and, all too often, a medical community that does not understand your situation; the terror of suspecting that time may not be on your side, and the valiant effort to press on despite desperate odds—these are things the rare disease community know all too well.

In publishing the Rare Neurological Disease Special Report, our goal has always been to educate the medical community on conditions they may rarely see and offer some hope to those who battle a rare neurological disease. I hope you enjoy reading our seventh annual issue.

Studding almost every inch of skin except the face are gray lichenified plaques coating a patient’s body like worn leather. Raking his nails across his arm, the patient reminds me how long he had waited to receive this referral and how early he had awoken for this appointment. He was well acquainted with the value of promptness; in his world, it might make the difference between sleeping on a cot and a night spent on concrete.

Over the last year, the patient had cycled through the few safety-net clinics scattered throughout the city. He had accumulated numerous different diagnoses from atopic dermatitis to disseminated tinea corporis. A few minutes, one #15 scalpel, and mineral oil were all it took for us to unravel the mystery. As the attending and I peered through the microscope at the scabies ovum, I couldn’t help but wonder about the alternative outcomes to his case. Left untreated, scabies compromises the skin barrier, paving the way for secondary infections such as cellulitis. Depending on the pathogen, this infection may in turn evolve into acute postinfectious glomerulonephritis.^1-4 An elusive diagnosis can quietly escalate into considerable morbidity for patients. This case highlights the dire consequences of dermatologic health disparities and places medicine’s primordial function into sharp focus: the alleviation of suffering.

The Dermatologic Burden of Disease

As a major contributor to global disease burden, dermatologic disease is the fourth greatest cause of disability worldwide when mortality is factored out.^5,6 Among global rural populations, dermatologic disease constitutes one of the leading causes of death and/or loss of professional capabilities.⁷ In the United States alone, nearly 27% of the population saw a physician for at least 1 dermatologic disease in 2013.⁵ The tremendous prevalence of skin disease magnifies discrepancies in access to dermatologic care, which has been observed to be influenced by age, socioeconomic background, rurality, and sex.⁸

There has been growing focus on the national shortage of dermatologists over the last 2 decades.^9,10 With an aging population and rising incidence of skin cancer, this undersupply is projected to increase and disproportionately impact ethnic minorities as well as those from socioeconomically disadvantaged backgrounds.^8,9,11-14 These trends are of particular importance to residents and medical trainees. Multiple studies have demonstrated that the patient demographic of hospital-based resident clinics includes primarily minority and disenfranchised populations with poorer overall health.^15-17 In contrast to faculty clinics, residents treat patients who are more likely to be nonwhite and more likely to be reimbursed by Medicaid.¹⁸ The unique demographic makeup of hospital-based resident clinics raises questions about the preparedness and comfort of resident physicians in managing the nuances of health care delivery in these settings.¹⁰

Providing equitable care to marginalized populations within the constraints of 15- to 30-minute visits can be challenging to physicians and trainees. Even clinicians with the best of intentions may be impeded by a lack of familiarity with the daily realities of impoverished living conditions, implicit prejudice against people living in poverty, and adapting recommendations to varying levels of health literacy among patients.^19,20 Contending with these daunting obstacles can be discouraging. Given how entrenched certain institutional barriers are, questioning them may seem an exercise in futility, yet history demonstrates that residents can and have been empowered to improve tangible outcomes for vulnerable populations. In reflecting on approaches of the general medical education system, The Josiah Macy Jr. Foundation President George E. Thibault, MD, observed that, “When appropriately trained, deployed and incented, [residents] can help achieve institutional goals to improve quality, safety and efficiency.”²¹

Start Small But Dream Big

Action begins with awareness. Medical school and teaching hospital curricula are increasingly integrating educational exercises regarding the social determinants of health and populations with unmet needs. Medical training presents an exclusive opportunity to gain exposure to and familiarity with patient populations that one might not otherwise encounter. Immersion programs provide invaluable experience in tailoring health care delivery to the needs of vulnerable communities. Although opportunities for international rotations abound, domestic rotations among underserved populations can be just as transformative, including correctional medicine, homeless clinics, the Indian Health Service, and rural communities.

Create Partnerships to Broaden Impact of Service

Affecting the largest and most visible organ, skin disease often presents a substantial concern for patients and can herald systemic disease. The nature of dermatologic disease engenders close collaboration between general practitioners and specialists. For example, while resident-run or safety-net clinics characteristically center on providing holistic care for patients through internal medicine or primary care, these overworked and understaffed clinics often are in need of evaluation by specialists for specific concerns. Some clinic models feature dermatology faculty who volunteer routinely (ie, every 2 weeks, every month) to examine all the clinic’s patients presenting with concerns pertinent to the specialty. Drawing on their respective areas of expertise, general practitioners and dermatologists therefore can collaborate to connect disadvantaged patients with the specialized care they need.

Challenges Present Opportunities for Innovation

Adhering to the social distancing requirements of the COVID-19 pandemic protocol has driven clinicians to utilize innovative approaches to patient care. The rural-urban misdistribution of the dermatologist workforce has long been established, with rural patients often experiencing lengthy wait times to see a specialist.⁹ Both synchronous and asynchronous teledermatology modalities provide an ideal platform for triaging patients with dermatologic concerns who otherwise have meager access to a dermatologist.

Final Thoughts

Residency training is a prime opportunity to gain exposure to the broad spectrum of disease within dermatology as well as the diverse range of affected patients. Drawing on the aforementioned strategies, residents can leverage this knowledge in the service of underserved patients.

Studding almost every inch of skin except the face are gray lichenified plaques coating a patient’s body like worn leather. Raking his nails across his arm, the patient reminds me how long he had waited to receive this referral and how early he had awoken for this appointment. He was well acquainted with the value of promptness; in his world, it might make the difference between sleeping on a cot and a night spent on concrete.

Over the last year, the patient had cycled through the few safety-net clinics scattered throughout the city. He had accumulated numerous different diagnoses from atopic dermatitis to disseminated tinea corporis. A few minutes, one #15 scalpel, and mineral oil were all it took for us to unravel the mystery. As the attending and I peered through the microscope at the scabies ovum, I couldn’t help but wonder about the alternative outcomes to his case. Left untreated, scabies compromises the skin barrier, paving the way for secondary infections such as cellulitis. Depending on the pathogen, this infection may in turn evolve into acute postinfectious glomerulonephritis.^1-4 An elusive diagnosis can quietly escalate into considerable morbidity for patients. This case highlights the dire consequences of dermatologic health disparities and places medicine’s primordial function into sharp focus: the alleviation of suffering.

The Dermatologic Burden of Disease

As a major contributor to global disease burden, dermatologic disease is the fourth greatest cause of disability worldwide when mortality is factored out.^5,6 Among global rural populations, dermatologic disease constitutes one of the leading causes of death and/or loss of professional capabilities.⁷ In the United States alone, nearly 27% of the population saw a physician for at least 1 dermatologic disease in 2013.⁵ The tremendous prevalence of skin disease magnifies discrepancies in access to dermatologic care, which has been observed to be influenced by age, socioeconomic background, rurality, and sex.⁸

There has been growing focus on the national shortage of dermatologists over the last 2 decades.^9,10 With an aging population and rising incidence of skin cancer, this undersupply is projected to increase and disproportionately impact ethnic minorities as well as those from socioeconomically disadvantaged backgrounds.^8,9,11-14 These trends are of particular importance to residents and medical trainees. Multiple studies have demonstrated that the patient demographic of hospital-based resident clinics includes primarily minority and disenfranchised populations with poorer overall health.^15-17 In contrast to faculty clinics, residents treat patients who are more likely to be nonwhite and more likely to be reimbursed by Medicaid.¹⁸ The unique demographic makeup of hospital-based resident clinics raises questions about the preparedness and comfort of resident physicians in managing the nuances of health care delivery in these settings.¹⁰

Providing equitable care to marginalized populations within the constraints of 15- to 30-minute visits can be challenging to physicians and trainees. Even clinicians with the best of intentions may be impeded by a lack of familiarity with the daily realities of impoverished living conditions, implicit prejudice against people living in poverty, and adapting recommendations to varying levels of health literacy among patients.^19,20 Contending with these daunting obstacles can be discouraging. Given how entrenched certain institutional barriers are, questioning them may seem an exercise in futility, yet history demonstrates that residents can and have been empowered to improve tangible outcomes for vulnerable populations. In reflecting on approaches of the general medical education system, The Josiah Macy Jr. Foundation President George E. Thibault, MD, observed that, “When appropriately trained, deployed and incented, [residents] can help achieve institutional goals to improve quality, safety and efficiency.”²¹

Start Small But Dream Big

Action begins with awareness. Medical school and teaching hospital curricula are increasingly integrating educational exercises regarding the social determinants of health and populations with unmet needs. Medical training presents an exclusive opportunity to gain exposure to and familiarity with patient populations that one might not otherwise encounter. Immersion programs provide invaluable experience in tailoring health care delivery to the needs of vulnerable communities. Although opportunities for international rotations abound, domestic rotations among underserved populations can be just as transformative, including correctional medicine, homeless clinics, the Indian Health Service, and rural communities.

Create Partnerships to Broaden Impact of Service

Affecting the largest and most visible organ, skin disease often presents a substantial concern for patients and can herald systemic disease. The nature of dermatologic disease engenders close collaboration between general practitioners and specialists. For example, while resident-run or safety-net clinics characteristically center on providing holistic care for patients through internal medicine or primary care, these overworked and understaffed clinics often are in need of evaluation by specialists for specific concerns. Some clinic models feature dermatology faculty who volunteer routinely (ie, every 2 weeks, every month) to examine all the clinic’s patients presenting with concerns pertinent to the specialty. Drawing on their respective areas of expertise, general practitioners and dermatologists therefore can collaborate to connect disadvantaged patients with the specialized care they need.

Challenges Present Opportunities for Innovation

Adhering to the social distancing requirements of the COVID-19 pandemic protocol has driven clinicians to utilize innovative approaches to patient care. The rural-urban misdistribution of the dermatologist workforce has long been established, with rural patients often experiencing lengthy wait times to see a specialist.⁹ Both synchronous and asynchronous teledermatology modalities provide an ideal platform for triaging patients with dermatologic concerns who otherwise have meager access to a dermatologist.

Final Thoughts

Residency training is a prime opportunity to gain exposure to the broad spectrum of disease within dermatology as well as the diverse range of affected patients. Drawing on the aforementioned strategies, residents can leverage this knowledge in the service of underserved patients.

Studding almost every inch of skin except the face are gray lichenified plaques coating a patient’s body like worn leather. Raking his nails across his arm, the patient reminds me how long he had waited to receive this referral and how early he had awoken for this appointment. He was well acquainted with the value of promptness; in his world, it might make the difference between sleeping on a cot and a night spent on concrete.

Over the last year, the patient had cycled through the few safety-net clinics scattered throughout the city. He had accumulated numerous different diagnoses from atopic dermatitis to disseminated tinea corporis. A few minutes, one #15 scalpel, and mineral oil were all it took for us to unravel the mystery. As the attending and I peered through the microscope at the scabies ovum, I couldn’t help but wonder about the alternative outcomes to his case. Left untreated, scabies compromises the skin barrier, paving the way for secondary infections such as cellulitis. Depending on the pathogen, this infection may in turn evolve into acute postinfectious glomerulonephritis.^1-4 An elusive diagnosis can quietly escalate into considerable morbidity for patients. This case highlights the dire consequences of dermatologic health disparities and places medicine’s primordial function into sharp focus: the alleviation of suffering.

The Dermatologic Burden of Disease

As a major contributor to global disease burden, dermatologic disease is the fourth greatest cause of disability worldwide when mortality is factored out.^5,6 Among global rural populations, dermatologic disease constitutes one of the leading causes of death and/or loss of professional capabilities.⁷ In the United States alone, nearly 27% of the population saw a physician for at least 1 dermatologic disease in 2013.⁵ The tremendous prevalence of skin disease magnifies discrepancies in access to dermatologic care, which has been observed to be influenced by age, socioeconomic background, rurality, and sex.⁸

There has been growing focus on the national shortage of dermatologists over the last 2 decades.^9,10 With an aging population and rising incidence of skin cancer, this undersupply is projected to increase and disproportionately impact ethnic minorities as well as those from socioeconomically disadvantaged backgrounds.^8,9,11-14 These trends are of particular importance to residents and medical trainees. Multiple studies have demonstrated that the patient demographic of hospital-based resident clinics includes primarily minority and disenfranchised populations with poorer overall health.^15-17 In contrast to faculty clinics, residents treat patients who are more likely to be nonwhite and more likely to be reimbursed by Medicaid.¹⁸ The unique demographic makeup of hospital-based resident clinics raises questions about the preparedness and comfort of resident physicians in managing the nuances of health care delivery in these settings.¹⁰

Providing equitable care to marginalized populations within the constraints of 15- to 30-minute visits can be challenging to physicians and trainees. Even clinicians with the best of intentions may be impeded by a lack of familiarity with the daily realities of impoverished living conditions, implicit prejudice against people living in poverty, and adapting recommendations to varying levels of health literacy among patients.^19,20 Contending with these daunting obstacles can be discouraging. Given how entrenched certain institutional barriers are, questioning them may seem an exercise in futility, yet history demonstrates that residents can and have been empowered to improve tangible outcomes for vulnerable populations. In reflecting on approaches of the general medical education system, The Josiah Macy Jr. Foundation President George E. Thibault, MD, observed that, “When appropriately trained, deployed and incented, [residents] can help achieve institutional goals to improve quality, safety and efficiency.”²¹

Start Small But Dream Big

Action begins with awareness. Medical school and teaching hospital curricula are increasingly integrating educational exercises regarding the social determinants of health and populations with unmet needs. Medical training presents an exclusive opportunity to gain exposure to and familiarity with patient populations that one might not otherwise encounter. Immersion programs provide invaluable experience in tailoring health care delivery to the needs of vulnerable communities. Although opportunities for international rotations abound, domestic rotations among underserved populations can be just as transformative, including correctional medicine, homeless clinics, the Indian Health Service, and rural communities.

Create Partnerships to Broaden Impact of Service

Affecting the largest and most visible organ, skin disease often presents a substantial concern for patients and can herald systemic disease. The nature of dermatologic disease engenders close collaboration between general practitioners and specialists. For example, while resident-run or safety-net clinics characteristically center on providing holistic care for patients through internal medicine or primary care, these overworked and understaffed clinics often are in need of evaluation by specialists for specific concerns. Some clinic models feature dermatology faculty who volunteer routinely (ie, every 2 weeks, every month) to examine all the clinic’s patients presenting with concerns pertinent to the specialty. Drawing on their respective areas of expertise, general practitioners and dermatologists therefore can collaborate to connect disadvantaged patients with the specialized care they need.

Challenges Present Opportunities for Innovation

Adhering to the social distancing requirements of the COVID-19 pandemic protocol has driven clinicians to utilize innovative approaches to patient care. The rural-urban misdistribution of the dermatologist workforce has long been established, with rural patients often experiencing lengthy wait times to see a specialist.⁹ Both synchronous and asynchronous teledermatology modalities provide an ideal platform for triaging patients with dermatologic concerns who otherwise have meager access to a dermatologist.

Final Thoughts

Residency training is a prime opportunity to gain exposure to the broad spectrum of disease within dermatology as well as the diverse range of affected patients. Drawing on the aforementioned strategies, residents can leverage this knowledge in the service of underserved patients.

The Diagnosis: Frontal Fibrosing Alopecia Overlapping With Lichen Planus Pigmentosus 

Microscopic examination revealed focal dermal pigmentation, papillary fibrosis, and epidermal atrophy. These clinical and histologic findings indicated a diagnosis of fully developed lichen planus pigmentosus (LPP) overlapping with frontal fibrosing alopecia (FFA). Other cases have demonstrated an association between LPP and FFA.^1,2  

Lichen planus pigmentosus is considered an uncommon variant of lichen planus, as it has similar histopathologic findings and occasional coexistence.^3,4 It is characterized by hyperpigmented macules primarily located in sun-exposed and flexural areas of the skin. First described in India,⁵ this disease has a predilection for darker skin (Fitzpatrick skin types III-V),^6,7 and it has been reported in other racial and ethnic groups including Latin Americans, Middle Eastern populations, Japanese, and Koreans.^4,8 Typically, lesions initially appear as ill-defined, blue-grey, round to oval macules that coalesce into hyperpigmented patches. Involvement most commonly begins at the forehead and temples, which are affected in nearly all patients. Infrequently, LPP can be generalized or affect the oral mucosa; involvement of the palms, soles, and nails does not occur. Patients may be asymptomatic, but some experience mild pruritus and burning. The disease course is chronic and insidious, with new lesions appearing over time and old lesions progressively darkening and expanding.^6,7,9  

Although the pathogenesis of LPP is unknown, several exposures have been implicated, such as amla oil, mustard oil, henna, hair dye, and environmental pollutants.⁷ Because lesions characteristically occur in sun-exposed areas, UV light also may be involved. In addition, studies have suggested that LPP is associated with endocrinopathies such as diabetes mellitus and dyslipidemias, as in our patient, as well as autoimmune conditions such as vitiligo and systemic lupus erythematosus.^10,11  

Histopathologic findings are characterized by vacuolar degeneration of the basal layer in the epidermis as well as perivascular lymphohistiocytic infiltration and the presence of melanophages in the dermis.^3,9 Lichen planus pigmentosus is difficult to treat, as no consistently effective modality has been established. Topical tacrolimus, topical corticosteroids, oral retinoids, lasers, and sun protection have been implemented with underwhelming results.¹² 

Frontal fibrosing alopecia is a variant of lichen planopilaris that predominantly affects postmenopausal women and presents with frontotemporal hair loss in a bandlike distribution.^5,13 Both terminal and vellus hairs are affected. Involvement of multiple hair-bearing sites of the skin have been reported, including the entire scalp, eyebrows, and eyelashes. Affected areas may display hypopigmentation and be accompanied by pruritus and trichodynia.^14,15 The pathogenesis currently is under investigation, with studies demonstrating autoimmune, genetic, and possibly even endocrine predispositions.^16-18 Biopsies of lesions are indistinguishable from lichen planopilaris, which shows follicular lymphocytic infiltration, perifollicular fibrosis, interface dermatitis of the follicular infundibulum and isthmus, and vertical fibrous tracks.⁵ Patients with FFA have demonstrated variable responses to treatments, with one study showing improvement with oral finasteride or dutasteride.¹⁴ Topical and intralesional corticosteroids have yielded suboptimal effects. Other modalities include hydroxychloroquine and mycophenolate mofetil.^15,19 

Co-occurrence of LPP and FFA primarily is seen in postmenopausal women with darker skin,^14,15 as in our patient, though premenopausal cases have been reported. Lichen planus pigmentosus may serve as a harbinger in most patients.^1,2 In a similar fashion, our patient presented with hyperpigmented macular lesions prior to the onset of frontotemporal hair loss.  

Our patient was started on finasteride 2.5 mg daily, minoxidil foam 5%, clobetasol solution 0.05%, triamcinolone ointment 0.1%, and hydrocortisone ointment 2.5%. She was instructed to commence treatment and follow up in 6 months. 

The differential diagnosis includes dermatologic conditions that mimic both LPP and FFA. Postinflammatory hyperpigmentation and fixed drug reaction were unlikely based on the patient's history. The lesions of ashy dermatosis are characteristically gray erythematous macules on the trunk and limbs. Riehl melanosis is a rare pigmented contact dermatitis that is associated with a history of repeated contact with sensitizing allergens. Although Hori nevus is characterized by small, blue-gray or brown macules on the face, lesions predominantly occur on the bony prominences of the cheeks. Melasma also presents with dark to gray macules that affect the face and less commonly the neck, as in our patient.² 

Early discoid lupus erythematosus presents with round erythematous plaques with overlying scale extending into the hair follicles. In pseudopalade of Brocq, an idiopathic cicatricial alopecia, lesions typically are flesh colored. Biopsy also shows epidermal atrophy with additional dermal sclerosis and fibrosis. Folliculitis decalvans is a scarring form of alopecia associated with erythema and pustules, findings that were not present in our patient. Keratosis follicularis spinulosa decalvans is a rare, X-linked inherited ichthyosis manifesting as scarring alopecia with follicular depressions and papules on the scalp in younger males. Photophobia and other manifestations may be present. Alopecia mucinosa is a nonscarring alopecia with grouped follicular erythematous patches or plaques. Mucin sometimes can be squeezed from affected areas, and histopathologic examination shows mucin accumulation.⁴ 

The Diagnosis: Frontal Fibrosing Alopecia Overlapping With Lichen Planus Pigmentosus 

Microscopic examination revealed focal dermal pigmentation, papillary fibrosis, and epidermal atrophy. These clinical and histologic findings indicated a diagnosis of fully developed lichen planus pigmentosus (LPP) overlapping with frontal fibrosing alopecia (FFA). Other cases have demonstrated an association between LPP and FFA.^1,2  

Lichen planus pigmentosus is considered an uncommon variant of lichen planus, as it has similar histopathologic findings and occasional coexistence.^3,4 It is characterized by hyperpigmented macules primarily located in sun-exposed and flexural areas of the skin. First described in India,⁵ this disease has a predilection for darker skin (Fitzpatrick skin types III-V),^6,7 and it has been reported in other racial and ethnic groups including Latin Americans, Middle Eastern populations, Japanese, and Koreans.^4,8 Typically, lesions initially appear as ill-defined, blue-grey, round to oval macules that coalesce into hyperpigmented patches. Involvement most commonly begins at the forehead and temples, which are affected in nearly all patients. Infrequently, LPP can be generalized or affect the oral mucosa; involvement of the palms, soles, and nails does not occur. Patients may be asymptomatic, but some experience mild pruritus and burning. The disease course is chronic and insidious, with new lesions appearing over time and old lesions progressively darkening and expanding.^6,7,9  

Although the pathogenesis of LPP is unknown, several exposures have been implicated, such as amla oil, mustard oil, henna, hair dye, and environmental pollutants.⁷ Because lesions characteristically occur in sun-exposed areas, UV light also may be involved. In addition, studies have suggested that LPP is associated with endocrinopathies such as diabetes mellitus and dyslipidemias, as in our patient, as well as autoimmune conditions such as vitiligo and systemic lupus erythematosus.^10,11  

Histopathologic findings are characterized by vacuolar degeneration of the basal layer in the epidermis as well as perivascular lymphohistiocytic infiltration and the presence of melanophages in the dermis.^3,9 Lichen planus pigmentosus is difficult to treat, as no consistently effective modality has been established. Topical tacrolimus, topical corticosteroids, oral retinoids, lasers, and sun protection have been implemented with underwhelming results.¹² 

Frontal fibrosing alopecia is a variant of lichen planopilaris that predominantly affects postmenopausal women and presents with frontotemporal hair loss in a bandlike distribution.^5,13 Both terminal and vellus hairs are affected. Involvement of multiple hair-bearing sites of the skin have been reported, including the entire scalp, eyebrows, and eyelashes. Affected areas may display hypopigmentation and be accompanied by pruritus and trichodynia.^14,15 The pathogenesis currently is under investigation, with studies demonstrating autoimmune, genetic, and possibly even endocrine predispositions.^16-18 Biopsies of lesions are indistinguishable from lichen planopilaris, which shows follicular lymphocytic infiltration, perifollicular fibrosis, interface dermatitis of the follicular infundibulum and isthmus, and vertical fibrous tracks.⁵ Patients with FFA have demonstrated variable responses to treatments, with one study showing improvement with oral finasteride or dutasteride.¹⁴ Topical and intralesional corticosteroids have yielded suboptimal effects. Other modalities include hydroxychloroquine and mycophenolate mofetil.^15,19 

Co-occurrence of LPP and FFA primarily is seen in postmenopausal women with darker skin,^14,15 as in our patient, though premenopausal cases have been reported. Lichen planus pigmentosus may serve as a harbinger in most patients.^1,2 In a similar fashion, our patient presented with hyperpigmented macular lesions prior to the onset of frontotemporal hair loss.  

Our patient was started on finasteride 2.5 mg daily, minoxidil foam 5%, clobetasol solution 0.05%, triamcinolone ointment 0.1%, and hydrocortisone ointment 2.5%. She was instructed to commence treatment and follow up in 6 months. 

The differential diagnosis includes dermatologic conditions that mimic both LPP and FFA. Postinflammatory hyperpigmentation and fixed drug reaction were unlikely based on the patient's history. The lesions of ashy dermatosis are characteristically gray erythematous macules on the trunk and limbs. Riehl melanosis is a rare pigmented contact dermatitis that is associated with a history of repeated contact with sensitizing allergens. Although Hori nevus is characterized by small, blue-gray or brown macules on the face, lesions predominantly occur on the bony prominences of the cheeks. Melasma also presents with dark to gray macules that affect the face and less commonly the neck, as in our patient.² 

Early discoid lupus erythematosus presents with round erythematous plaques with overlying scale extending into the hair follicles. In pseudopalade of Brocq, an idiopathic cicatricial alopecia, lesions typically are flesh colored. Biopsy also shows epidermal atrophy with additional dermal sclerosis and fibrosis. Folliculitis decalvans is a scarring form of alopecia associated with erythema and pustules, findings that were not present in our patient. Keratosis follicularis spinulosa decalvans is a rare, X-linked inherited ichthyosis manifesting as scarring alopecia with follicular depressions and papules on the scalp in younger males. Photophobia and other manifestations may be present. Alopecia mucinosa is a nonscarring alopecia with grouped follicular erythematous patches or plaques. Mucin sometimes can be squeezed from affected areas, and histopathologic examination shows mucin accumulation.⁴ 

The Diagnosis: Frontal Fibrosing Alopecia Overlapping With Lichen Planus Pigmentosus 

Microscopic examination revealed focal dermal pigmentation, papillary fibrosis, and epidermal atrophy. These clinical and histologic findings indicated a diagnosis of fully developed lichen planus pigmentosus (LPP) overlapping with frontal fibrosing alopecia (FFA). Other cases have demonstrated an association between LPP and FFA.^1,2  

Lichen planus pigmentosus is considered an uncommon variant of lichen planus, as it has similar histopathologic findings and occasional coexistence.^3,4 It is characterized by hyperpigmented macules primarily located in sun-exposed and flexural areas of the skin. First described in India,⁵ this disease has a predilection for darker skin (Fitzpatrick skin types III-V),^6,7 and it has been reported in other racial and ethnic groups including Latin Americans, Middle Eastern populations, Japanese, and Koreans.^4,8 Typically, lesions initially appear as ill-defined, blue-grey, round to oval macules that coalesce into hyperpigmented patches. Involvement most commonly begins at the forehead and temples, which are affected in nearly all patients. Infrequently, LPP can be generalized or affect the oral mucosa; involvement of the palms, soles, and nails does not occur. Patients may be asymptomatic, but some experience mild pruritus and burning. The disease course is chronic and insidious, with new lesions appearing over time and old lesions progressively darkening and expanding.^6,7,9  

Although the pathogenesis of LPP is unknown, several exposures have been implicated, such as amla oil, mustard oil, henna, hair dye, and environmental pollutants.⁷ Because lesions characteristically occur in sun-exposed areas, UV light also may be involved. In addition, studies have suggested that LPP is associated with endocrinopathies such as diabetes mellitus and dyslipidemias, as in our patient, as well as autoimmune conditions such as vitiligo and systemic lupus erythematosus.^10,11  

Histopathologic findings are characterized by vacuolar degeneration of the basal layer in the epidermis as well as perivascular lymphohistiocytic infiltration and the presence of melanophages in the dermis.^3,9 Lichen planus pigmentosus is difficult to treat, as no consistently effective modality has been established. Topical tacrolimus, topical corticosteroids, oral retinoids, lasers, and sun protection have been implemented with underwhelming results.¹² 

Frontal fibrosing alopecia is a variant of lichen planopilaris that predominantly affects postmenopausal women and presents with frontotemporal hair loss in a bandlike distribution.^5,13 Both terminal and vellus hairs are affected. Involvement of multiple hair-bearing sites of the skin have been reported, including the entire scalp, eyebrows, and eyelashes. Affected areas may display hypopigmentation and be accompanied by pruritus and trichodynia.^14,15 The pathogenesis currently is under investigation, with studies demonstrating autoimmune, genetic, and possibly even endocrine predispositions.^16-18 Biopsies of lesions are indistinguishable from lichen planopilaris, which shows follicular lymphocytic infiltration, perifollicular fibrosis, interface dermatitis of the follicular infundibulum and isthmus, and vertical fibrous tracks.⁵ Patients with FFA have demonstrated variable responses to treatments, with one study showing improvement with oral finasteride or dutasteride.¹⁴ Topical and intralesional corticosteroids have yielded suboptimal effects. Other modalities include hydroxychloroquine and mycophenolate mofetil.^15,19 

Co-occurrence of LPP and FFA primarily is seen in postmenopausal women with darker skin,^14,15 as in our patient, though premenopausal cases have been reported. Lichen planus pigmentosus may serve as a harbinger in most patients.^1,2 In a similar fashion, our patient presented with hyperpigmented macular lesions prior to the onset of frontotemporal hair loss.  

Our patient was started on finasteride 2.5 mg daily, minoxidil foam 5%, clobetasol solution 0.05%, triamcinolone ointment 0.1%, and hydrocortisone ointment 2.5%. She was instructed to commence treatment and follow up in 6 months. 

The differential diagnosis includes dermatologic conditions that mimic both LPP and FFA. Postinflammatory hyperpigmentation and fixed drug reaction were unlikely based on the patient's history. The lesions of ashy dermatosis are characteristically gray erythematous macules on the trunk and limbs. Riehl melanosis is a rare pigmented contact dermatitis that is associated with a history of repeated contact with sensitizing allergens. Although Hori nevus is characterized by small, blue-gray or brown macules on the face, lesions predominantly occur on the bony prominences of the cheeks. Melasma also presents with dark to gray macules that affect the face and less commonly the neck, as in our patient.² 

Early discoid lupus erythematosus presents with round erythematous plaques with overlying scale extending into the hair follicles. In pseudopalade of Brocq, an idiopathic cicatricial alopecia, lesions typically are flesh colored. Biopsy also shows epidermal atrophy with additional dermal sclerosis and fibrosis. Folliculitis decalvans is a scarring form of alopecia associated with erythema and pustules, findings that were not present in our patient. Keratosis follicularis spinulosa decalvans is a rare, X-linked inherited ichthyosis manifesting as scarring alopecia with follicular depressions and papules on the scalp in younger males. Photophobia and other manifestations may be present. Alopecia mucinosa is a nonscarring alopecia with grouped follicular erythematous patches or plaques. Mucin sometimes can be squeezed from affected areas, and histopathologic examination shows mucin accumulation.⁴ 

Remote cardiology clinic visits during COVID-19 were used more often by certain traditionally underserved patient groups, but were also associated with less frequent testing and prescribing, new research shows.

“The COVID-19 pandemic has led to an unprecedented shift in ambulatory cardiovascular care from in-person to remote visits,” lead author Neal Yuan, MD, a cardiology fellow at the Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, said in an interview.

Their findings were published online April 5 in JAMA Network Open.

“We wanted to explore whether the transition to remote visits was associated with disparities in how patients accessed care, and also how this transition affected diagnostic test ordering and medication prescribing,” Dr. Yuan said.

The researchers used electronic health records data for all ambulatory cardiology visits at an urban, multisite health system in Los Angeles County during two periods: April 1 to Dec. 31, 2019, the pre-COVID era; and April 1 to Dec. 31, 2020, the COVID era.

The investigators compared patient characteristics and frequencies of medication ordering and cardiology-specific testing across four visit types: pre-COVID in person, used as reference; COVID-era in person; COVID-era video; and COVID-era telephone.

The study looked at 176,781 ambulatory cardiology visits. Of these visits, 87,182 were conducted in person in the pre-COVID period; 74,498 were conducted in person in the COVID era; 4,720 were COVID-era video visits; and 10,381 were COVID-era telephone visits.

In the study cohort, 79,572 patients (45.0%) were female, 127,080 patients (71.9%) were non-Hispanic White, and the mean age was 68.1 years (standard deviation, 17.0).

Patients accessing COVID-era remote visits were more likely to be Asian, Black, or Hispanic, to have private insurance, and to have cardiovascular comorbidities, such as hypertension and heart failure.

Also, patients whose visits were conducted by video were significantly younger than patients whose visits were conducted in person or by telephone (P < .001).

In addition, the study found that clinicians ordered fewer diagnostic tests, such as electrocardiograms and echocardiograms, and were less likely to order any medication, in the pre-COVID era than during the COVID era.

“If you don’t have a patient in front of you, it’s much more difficult to get a physical exam or obtain reliable vital signs,” said Dr. Yuan. Communication can sometimes be difficult, often because of technical issues, like a bad connection. “You might be more reticent to get testing or to prescribe medications if you don’t feel confident knowing what the patient’s vital signs are.”

In addition, he added, “a lot of medications used in the cardiology setting require monitoring patients’ kidney function and electrolytes, and if you can’t do that reliably, you might be more cautious about prescribing those types of medications.”
 

An eye-opening study

Cardiologist Nieca Goldberg, MD, medical director of the New York University Langone womens’ heart program and spokesperson for the American Heart Association, recounted her experience with telemedicine at the height of the pandemic in New York, when everything, including medical outpatient offices, had to close.

“We were experienced with telemedicine because we had started a virtual urgent care program well ahead of the pandemic,” she said. “We started using that to screen people with potential COVID symptoms so that they wouldn’t have to come into the hospital, the medical center, or to the offices and expose people. We learned that it was great to have the telemedicine option from the infectious disease standpoint, and I did visits like that for my own patient population.”

An equally if not more important finding from the study is the fact that telemedicine increased access to care among traditionally underserved demographics, she said.

“This is eye-opening, that you can actually improve access to care by doing telemedicine visits. It was really important to see that telemedicine has added benefit to the way we can see people in the health care system.”

Telemedicine visits had a positive impact at a time when people were isolated at home, Dr. Goldberg said.

“It was a way for them to connect with their doctor and in some ways it was more personal,” she added. “I actually got to meet some of my patients’ family members. It was like making a remote house call.”

Stable cardiology patients can take their blood pressure at home, weigh themselves, and take their own pulse to give an excellent set of vital signs that will indicate how they are doing, said Dr. Goldberg.

“During a remote visit, we can talk to the patient and notice whether or not they are short of breath or coughing, but we can’t listen to their heart or do an EKG or any of the traditional cardiac testing. Still, for someone who is not having symptoms and is able to reliably monitor their blood pressure and weight, a remote visit is sufficient to give you a good sense of how that patient is doing,” she said. “We can talk to them about their medications, any potential side effects, and we can use their blood pressure information to adjust their medications.”

Many patients are becoming more savvy about using tech gadgets and devices to monitor their health.

“Some of my patients were using Apple watches and the Kardia app to address their heart rate. Many had purchased inexpensive pulse oximeters to check their oxygen during the pandemic, and that also reads the pulse,” Dr. Goldberg said.

In-person visits were reserved for symptomatic cardiac patients, she explained.

“Initially during the pandemic, we did mostly telemedicine visits and we organized the office so that each cardiologist would come in 1 day a week to take care of symptomatic cardiac patients. In that way, we were able to socially distance – they provided us with [personal protective equipment]; at NYU there was no problem with that – and nobody waited in the waiting room. To this day, office issues are more efficient and people are not waiting in the waiting room,” she added. “Telemedicine improves access to health care in populations where such access is limited.”

Dr. Yuan’s research is supported by a grant from the National Institutes of Health. Dr. Goldberg reported no relevant financial relationships.

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

Remote cardiology clinic visits during COVID-19 were used more often by certain traditionally underserved patient groups, but were also associated with less frequent testing and prescribing, new research shows.

“The COVID-19 pandemic has led to an unprecedented shift in ambulatory cardiovascular care from in-person to remote visits,” lead author Neal Yuan, MD, a cardiology fellow at the Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, said in an interview.

Their findings were published online April 5 in JAMA Network Open.

“We wanted to explore whether the transition to remote visits was associated with disparities in how patients accessed care, and also how this transition affected diagnostic test ordering and medication prescribing,” Dr. Yuan said.

The researchers used electronic health records data for all ambulatory cardiology visits at an urban, multisite health system in Los Angeles County during two periods: April 1 to Dec. 31, 2019, the pre-COVID era; and April 1 to Dec. 31, 2020, the COVID era.

The investigators compared patient characteristics and frequencies of medication ordering and cardiology-specific testing across four visit types: pre-COVID in person, used as reference; COVID-era in person; COVID-era video; and COVID-era telephone.

The study looked at 176,781 ambulatory cardiology visits. Of these visits, 87,182 were conducted in person in the pre-COVID period; 74,498 were conducted in person in the COVID era; 4,720 were COVID-era video visits; and 10,381 were COVID-era telephone visits.

In the study cohort, 79,572 patients (45.0%) were female, 127,080 patients (71.9%) were non-Hispanic White, and the mean age was 68.1 years (standard deviation, 17.0).

Patients accessing COVID-era remote visits were more likely to be Asian, Black, or Hispanic, to have private insurance, and to have cardiovascular comorbidities, such as hypertension and heart failure.

Also, patients whose visits were conducted by video were significantly younger than patients whose visits were conducted in person or by telephone (P < .001).

In addition, the study found that clinicians ordered fewer diagnostic tests, such as electrocardiograms and echocardiograms, and were less likely to order any medication, in the pre-COVID era than during the COVID era.

“If you don’t have a patient in front of you, it’s much more difficult to get a physical exam or obtain reliable vital signs,” said Dr. Yuan. Communication can sometimes be difficult, often because of technical issues, like a bad connection. “You might be more reticent to get testing or to prescribe medications if you don’t feel confident knowing what the patient’s vital signs are.”

In addition, he added, “a lot of medications used in the cardiology setting require monitoring patients’ kidney function and electrolytes, and if you can’t do that reliably, you might be more cautious about prescribing those types of medications.”
 

An eye-opening study

Cardiologist Nieca Goldberg, MD, medical director of the New York University Langone womens’ heart program and spokesperson for the American Heart Association, recounted her experience with telemedicine at the height of the pandemic in New York, when everything, including medical outpatient offices, had to close.

“We were experienced with telemedicine because we had started a virtual urgent care program well ahead of the pandemic,” she said. “We started using that to screen people with potential COVID symptoms so that they wouldn’t have to come into the hospital, the medical center, or to the offices and expose people. We learned that it was great to have the telemedicine option from the infectious disease standpoint, and I did visits like that for my own patient population.”

An equally if not more important finding from the study is the fact that telemedicine increased access to care among traditionally underserved demographics, she said.

“This is eye-opening, that you can actually improve access to care by doing telemedicine visits. It was really important to see that telemedicine has added benefit to the way we can see people in the health care system.”

Telemedicine visits had a positive impact at a time when people were isolated at home, Dr. Goldberg said.

“It was a way for them to connect with their doctor and in some ways it was more personal,” she added. “I actually got to meet some of my patients’ family members. It was like making a remote house call.”

Stable cardiology patients can take their blood pressure at home, weigh themselves, and take their own pulse to give an excellent set of vital signs that will indicate how they are doing, said Dr. Goldberg.

“During a remote visit, we can talk to the patient and notice whether or not they are short of breath or coughing, but we can’t listen to their heart or do an EKG or any of the traditional cardiac testing. Still, for someone who is not having symptoms and is able to reliably monitor their blood pressure and weight, a remote visit is sufficient to give you a good sense of how that patient is doing,” she said. “We can talk to them about their medications, any potential side effects, and we can use their blood pressure information to adjust their medications.”

Many patients are becoming more savvy about using tech gadgets and devices to monitor their health.

“Some of my patients were using Apple watches and the Kardia app to address their heart rate. Many had purchased inexpensive pulse oximeters to check their oxygen during the pandemic, and that also reads the pulse,” Dr. Goldberg said.

In-person visits were reserved for symptomatic cardiac patients, she explained.

“Initially during the pandemic, we did mostly telemedicine visits and we organized the office so that each cardiologist would come in 1 day a week to take care of symptomatic cardiac patients. In that way, we were able to socially distance – they provided us with [personal protective equipment]; at NYU there was no problem with that – and nobody waited in the waiting room. To this day, office issues are more efficient and people are not waiting in the waiting room,” she added. “Telemedicine improves access to health care in populations where such access is limited.”

Dr. Yuan’s research is supported by a grant from the National Institutes of Health. Dr. Goldberg reported no relevant financial relationships.

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

Remote cardiology clinic visits during COVID-19 were used more often by certain traditionally underserved patient groups, but were also associated with less frequent testing and prescribing, new research shows.

“The COVID-19 pandemic has led to an unprecedented shift in ambulatory cardiovascular care from in-person to remote visits,” lead author Neal Yuan, MD, a cardiology fellow at the Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, said in an interview.

Their findings were published online April 5 in JAMA Network Open.

“We wanted to explore whether the transition to remote visits was associated with disparities in how patients accessed care, and also how this transition affected diagnostic test ordering and medication prescribing,” Dr. Yuan said.

The researchers used electronic health records data for all ambulatory cardiology visits at an urban, multisite health system in Los Angeles County during two periods: April 1 to Dec. 31, 2019, the pre-COVID era; and April 1 to Dec. 31, 2020, the COVID era.

The investigators compared patient characteristics and frequencies of medication ordering and cardiology-specific testing across four visit types: pre-COVID in person, used as reference; COVID-era in person; COVID-era video; and COVID-era telephone.

The study looked at 176,781 ambulatory cardiology visits. Of these visits, 87,182 were conducted in person in the pre-COVID period; 74,498 were conducted in person in the COVID era; 4,720 were COVID-era video visits; and 10,381 were COVID-era telephone visits.

In the study cohort, 79,572 patients (45.0%) were female, 127,080 patients (71.9%) were non-Hispanic White, and the mean age was 68.1 years (standard deviation, 17.0).

Patients accessing COVID-era remote visits were more likely to be Asian, Black, or Hispanic, to have private insurance, and to have cardiovascular comorbidities, such as hypertension and heart failure.

Also, patients whose visits were conducted by video were significantly younger than patients whose visits were conducted in person or by telephone (P < .001).

In addition, the study found that clinicians ordered fewer diagnostic tests, such as electrocardiograms and echocardiograms, and were less likely to order any medication, in the pre-COVID era than during the COVID era.

“If you don’t have a patient in front of you, it’s much more difficult to get a physical exam or obtain reliable vital signs,” said Dr. Yuan. Communication can sometimes be difficult, often because of technical issues, like a bad connection. “You might be more reticent to get testing or to prescribe medications if you don’t feel confident knowing what the patient’s vital signs are.”

In addition, he added, “a lot of medications used in the cardiology setting require monitoring patients’ kidney function and electrolytes, and if you can’t do that reliably, you might be more cautious about prescribing those types of medications.”
 

An eye-opening study

Cardiologist Nieca Goldberg, MD, medical director of the New York University Langone womens’ heart program and spokesperson for the American Heart Association, recounted her experience with telemedicine at the height of the pandemic in New York, when everything, including medical outpatient offices, had to close.

“We were experienced with telemedicine because we had started a virtual urgent care program well ahead of the pandemic,” she said. “We started using that to screen people with potential COVID symptoms so that they wouldn’t have to come into the hospital, the medical center, or to the offices and expose people. We learned that it was great to have the telemedicine option from the infectious disease standpoint, and I did visits like that for my own patient population.”

An equally if not more important finding from the study is the fact that telemedicine increased access to care among traditionally underserved demographics, she said.

“This is eye-opening, that you can actually improve access to care by doing telemedicine visits. It was really important to see that telemedicine has added benefit to the way we can see people in the health care system.”

Telemedicine visits had a positive impact at a time when people were isolated at home, Dr. Goldberg said.

“It was a way for them to connect with their doctor and in some ways it was more personal,” she added. “I actually got to meet some of my patients’ family members. It was like making a remote house call.”

Stable cardiology patients can take their blood pressure at home, weigh themselves, and take their own pulse to give an excellent set of vital signs that will indicate how they are doing, said Dr. Goldberg.

“During a remote visit, we can talk to the patient and notice whether or not they are short of breath or coughing, but we can’t listen to their heart or do an EKG or any of the traditional cardiac testing. Still, for someone who is not having symptoms and is able to reliably monitor their blood pressure and weight, a remote visit is sufficient to give you a good sense of how that patient is doing,” she said. “We can talk to them about their medications, any potential side effects, and we can use their blood pressure information to adjust their medications.”

Many patients are becoming more savvy about using tech gadgets and devices to monitor their health.

“Some of my patients were using Apple watches and the Kardia app to address their heart rate. Many had purchased inexpensive pulse oximeters to check their oxygen during the pandemic, and that also reads the pulse,” Dr. Goldberg said.

In-person visits were reserved for symptomatic cardiac patients, she explained.

“Initially during the pandemic, we did mostly telemedicine visits and we organized the office so that each cardiologist would come in 1 day a week to take care of symptomatic cardiac patients. In that way, we were able to socially distance – they provided us with [personal protective equipment]; at NYU there was no problem with that – and nobody waited in the waiting room. To this day, office issues are more efficient and people are not waiting in the waiting room,” she added. “Telemedicine improves access to health care in populations where such access is limited.”

Dr. Yuan’s research is supported by a grant from the National Institutes of Health. Dr. Goldberg reported no relevant financial relationships.

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