Patients with cutaneous Merkel cell carcinoma (MCC) have a higher risk of subsequently developing solid and hematologic cancers, according to a new analysis.

In a cohort of 6,146 patients with a first primary MCC, a total of 725 (11.8%) developed subsequent primary cancers. For solid tumors, the risk was highest for cutaneous melanoma and papillary thyroid carcinoma, while for hematologic cancers, the risk was increased for non-Hodgkin lymphoma.

“Our study does confirm that patients with MCC are at higher risk for developing other cancers,” study author Lisa C. Zaba, MD, PhD, associate professor of dermatology and director of the Merkel cell carcinoma multidisciplinary clinic, Stanford (Calif.) Cancer Center, said in an interview. “MCC is a highly malignant cancer with a 40% recurrence risk.”

Because of this high risk, Dr. Zaba noted that patients with MCC get frequent surveillance with both imaging studies (PET-CT and CT) as well as frequent visits in clinic with MCC experts. “Specifically, a patient with MCC is imaged and seen in clinic every 3-6 months for the first 3 years after diagnosis, and every 6-12 months thereafter for up to 5 years,” she said. “Interestingly, this high level of surveillance may be one reason that we find so many cancers in patients who have been diagnosed with MCC, compared to the general population.”

The study was published online in JAMA Dermatology.

With the death of “Margaritaville” singer Jimmy Buffett, who recently died of MCC 4 years after his diagnosis, this rare, aggressive skin cancer has been put in the spotlight. Survival has been increasing, primarily because of the advent of immunotherapy, and the authors note that it is therefore imperative to better understand the risk of subsequent primary tumors to inform screening and treatment recommendations.

In this cohort study, Dr. Zaba and colleagues identified 6,146 patients from 17 registries of the Surveillance, Epidemiology, and End Results (SEER) Program who had been diagnosed with a first primary cutaneous MCC between 2000 and 2018.

Endpoints were the ratio of observed to expected number of cases of subsequent cancer (Standardized incidence ratio, or SIR) and the excess risk.

Overall, there was an elevated risk of developing a subsequent primary cancer after being diagnosed with MCC (SIR, 1.28; excess risk, 57.25 per 10,000 person-years). This included the risk for all solid tumors including liver (SIR, 1.92; excess risk, 2.77 per 10,000 person-years), pancreas (SIR, 1.65; excess risk, 4.55 per 10,000 person-years), cutaneous melanoma (SIR, 2.36; excess risk, 15.27 per 10,000 person-years), and kidney (SIR, 1.64; excess risk, 3.83 per 10,000 person-years).

There was also a higher risk of developing papillary thyroid carcinoma (PTC) (SIR, 5.26; excess risk, 6.16 per 10,000 person-years).

The risk of developing hematological cancers after MCC was also increased, especially for non-Hodgkin lymphoma (SIR, 2.62; excess risk, 15.48 per 10,000 person-years) and myelodysplastic syndrome (SIR, 2.17; excess risk, 2.73 per 10,000 person-years).

The risk for developing subsequent tumors, including melanoma and non-Hodgkin lymphoma, remained significant for up to 10 years, while the risk for developing PTC and kidney cancers remained for up to 5 years.

“After 3-5 years, when a MCC patient’s risk of MCC recurrence drops below 2%, we do not currently have guidelines in place for additional cancer screening,” Dr. Zaba said. “Regarding patient education, patients with MCC are educated to let us know if they experience any symptoms of cancer between visits, including unintentional weight loss, night sweats, headaches that increasingly worsen, or growing lumps or bumps. These symptoms may occur in a multitude of cancers and not just MCC.”

Weighing in on the study, Jeffrey M. Farma, MD, interim chair, department of surgical oncology at Fox Chase Cancer Center, Philadelphia, noted that MCC is considered to be high risk because of its chances of recurring after surgical resection or spreading to lymph nodes or other areas of the body. “There are approximately 3,000 new cases of melanoma a year in the U.S., and it is 40 times rarer than melanoma,” he said. “Patients are usually diagnosed with Merkel cell carcinoma later in life, and the tumors have been associated with sun exposure and immunosuppression and have also been associated with the polyomavirus.”

That said, however, he emphasized that great strides have been made in treatment. “These tumors are very sensitive to radiation, and we generally treat earlier-stage MCC with a combination of surgery and radiation therapy,” said Dr. Farma. “More recently we have had a lot of success with the use of immunotherapy to treat more advanced MCC.”

Dr. Zaba reported receiving grants from the Kuni Foundation outside the submitted work. No other disclosures were reported. Author Eleni Linos, MD, DrPH, MPH, is supported by grant K24AR075060 from the National Institutes of Health. No other outside funding was reported. Dr. Farma had no disclosures.

Patients with cutaneous Merkel cell carcinoma (MCC) have a higher risk of subsequently developing solid and hematologic cancers, according to a new analysis.

In a cohort of 6,146 patients with a first primary MCC, a total of 725 (11.8%) developed subsequent primary cancers. For solid tumors, the risk was highest for cutaneous melanoma and papillary thyroid carcinoma, while for hematologic cancers, the risk was increased for non-Hodgkin lymphoma.

“Our study does confirm that patients with MCC are at higher risk for developing other cancers,” study author Lisa C. Zaba, MD, PhD, associate professor of dermatology and director of the Merkel cell carcinoma multidisciplinary clinic, Stanford (Calif.) Cancer Center, said in an interview. “MCC is a highly malignant cancer with a 40% recurrence risk.”

Because of this high risk, Dr. Zaba noted that patients with MCC get frequent surveillance with both imaging studies (PET-CT and CT) as well as frequent visits in clinic with MCC experts. “Specifically, a patient with MCC is imaged and seen in clinic every 3-6 months for the first 3 years after diagnosis, and every 6-12 months thereafter for up to 5 years,” she said. “Interestingly, this high level of surveillance may be one reason that we find so many cancers in patients who have been diagnosed with MCC, compared to the general population.”

The study was published online in JAMA Dermatology.

With the death of “Margaritaville” singer Jimmy Buffett, who recently died of MCC 4 years after his diagnosis, this rare, aggressive skin cancer has been put in the spotlight. Survival has been increasing, primarily because of the advent of immunotherapy, and the authors note that it is therefore imperative to better understand the risk of subsequent primary tumors to inform screening and treatment recommendations.

In this cohort study, Dr. Zaba and colleagues identified 6,146 patients from 17 registries of the Surveillance, Epidemiology, and End Results (SEER) Program who had been diagnosed with a first primary cutaneous MCC between 2000 and 2018.

Endpoints were the ratio of observed to expected number of cases of subsequent cancer (Standardized incidence ratio, or SIR) and the excess risk.

Overall, there was an elevated risk of developing a subsequent primary cancer after being diagnosed with MCC (SIR, 1.28; excess risk, 57.25 per 10,000 person-years). This included the risk for all solid tumors including liver (SIR, 1.92; excess risk, 2.77 per 10,000 person-years), pancreas (SIR, 1.65; excess risk, 4.55 per 10,000 person-years), cutaneous melanoma (SIR, 2.36; excess risk, 15.27 per 10,000 person-years), and kidney (SIR, 1.64; excess risk, 3.83 per 10,000 person-years).

There was also a higher risk of developing papillary thyroid carcinoma (PTC) (SIR, 5.26; excess risk, 6.16 per 10,000 person-years).

The risk of developing hematological cancers after MCC was also increased, especially for non-Hodgkin lymphoma (SIR, 2.62; excess risk, 15.48 per 10,000 person-years) and myelodysplastic syndrome (SIR, 2.17; excess risk, 2.73 per 10,000 person-years).

The risk for developing subsequent tumors, including melanoma and non-Hodgkin lymphoma, remained significant for up to 10 years, while the risk for developing PTC and kidney cancers remained for up to 5 years.

“After 3-5 years, when a MCC patient’s risk of MCC recurrence drops below 2%, we do not currently have guidelines in place for additional cancer screening,” Dr. Zaba said. “Regarding patient education, patients with MCC are educated to let us know if they experience any symptoms of cancer between visits, including unintentional weight loss, night sweats, headaches that increasingly worsen, or growing lumps or bumps. These symptoms may occur in a multitude of cancers and not just MCC.”

Weighing in on the study, Jeffrey M. Farma, MD, interim chair, department of surgical oncology at Fox Chase Cancer Center, Philadelphia, noted that MCC is considered to be high risk because of its chances of recurring after surgical resection or spreading to lymph nodes or other areas of the body. “There are approximately 3,000 new cases of melanoma a year in the U.S., and it is 40 times rarer than melanoma,” he said. “Patients are usually diagnosed with Merkel cell carcinoma later in life, and the tumors have been associated with sun exposure and immunosuppression and have also been associated with the polyomavirus.”

That said, however, he emphasized that great strides have been made in treatment. “These tumors are very sensitive to radiation, and we generally treat earlier-stage MCC with a combination of surgery and radiation therapy,” said Dr. Farma. “More recently we have had a lot of success with the use of immunotherapy to treat more advanced MCC.”

Dr. Zaba reported receiving grants from the Kuni Foundation outside the submitted work. No other disclosures were reported. Author Eleni Linos, MD, DrPH, MPH, is supported by grant K24AR075060 from the National Institutes of Health. No other outside funding was reported. Dr. Farma had no disclosures.

Patients with cutaneous Merkel cell carcinoma (MCC) have a higher risk of subsequently developing solid and hematologic cancers, according to a new analysis.

In a cohort of 6,146 patients with a first primary MCC, a total of 725 (11.8%) developed subsequent primary cancers. For solid tumors, the risk was highest for cutaneous melanoma and papillary thyroid carcinoma, while for hematologic cancers, the risk was increased for non-Hodgkin lymphoma.

“Our study does confirm that patients with MCC are at higher risk for developing other cancers,” study author Lisa C. Zaba, MD, PhD, associate professor of dermatology and director of the Merkel cell carcinoma multidisciplinary clinic, Stanford (Calif.) Cancer Center, said in an interview. “MCC is a highly malignant cancer with a 40% recurrence risk.”

Because of this high risk, Dr. Zaba noted that patients with MCC get frequent surveillance with both imaging studies (PET-CT and CT) as well as frequent visits in clinic with MCC experts. “Specifically, a patient with MCC is imaged and seen in clinic every 3-6 months for the first 3 years after diagnosis, and every 6-12 months thereafter for up to 5 years,” she said. “Interestingly, this high level of surveillance may be one reason that we find so many cancers in patients who have been diagnosed with MCC, compared to the general population.”

The study was published online in JAMA Dermatology.

With the death of “Margaritaville” singer Jimmy Buffett, who recently died of MCC 4 years after his diagnosis, this rare, aggressive skin cancer has been put in the spotlight. Survival has been increasing, primarily because of the advent of immunotherapy, and the authors note that it is therefore imperative to better understand the risk of subsequent primary tumors to inform screening and treatment recommendations.

In this cohort study, Dr. Zaba and colleagues identified 6,146 patients from 17 registries of the Surveillance, Epidemiology, and End Results (SEER) Program who had been diagnosed with a first primary cutaneous MCC between 2000 and 2018.

Endpoints were the ratio of observed to expected number of cases of subsequent cancer (Standardized incidence ratio, or SIR) and the excess risk.

Overall, there was an elevated risk of developing a subsequent primary cancer after being diagnosed with MCC (SIR, 1.28; excess risk, 57.25 per 10,000 person-years). This included the risk for all solid tumors including liver (SIR, 1.92; excess risk, 2.77 per 10,000 person-years), pancreas (SIR, 1.65; excess risk, 4.55 per 10,000 person-years), cutaneous melanoma (SIR, 2.36; excess risk, 15.27 per 10,000 person-years), and kidney (SIR, 1.64; excess risk, 3.83 per 10,000 person-years).

There was also a higher risk of developing papillary thyroid carcinoma (PTC) (SIR, 5.26; excess risk, 6.16 per 10,000 person-years).

The risk of developing hematological cancers after MCC was also increased, especially for non-Hodgkin lymphoma (SIR, 2.62; excess risk, 15.48 per 10,000 person-years) and myelodysplastic syndrome (SIR, 2.17; excess risk, 2.73 per 10,000 person-years).

The risk for developing subsequent tumors, including melanoma and non-Hodgkin lymphoma, remained significant for up to 10 years, while the risk for developing PTC and kidney cancers remained for up to 5 years.

“After 3-5 years, when a MCC patient’s risk of MCC recurrence drops below 2%, we do not currently have guidelines in place for additional cancer screening,” Dr. Zaba said. “Regarding patient education, patients with MCC are educated to let us know if they experience any symptoms of cancer between visits, including unintentional weight loss, night sweats, headaches that increasingly worsen, or growing lumps or bumps. These symptoms may occur in a multitude of cancers and not just MCC.”

Weighing in on the study, Jeffrey M. Farma, MD, interim chair, department of surgical oncology at Fox Chase Cancer Center, Philadelphia, noted that MCC is considered to be high risk because of its chances of recurring after surgical resection or spreading to lymph nodes or other areas of the body. “There are approximately 3,000 new cases of melanoma a year in the U.S., and it is 40 times rarer than melanoma,” he said. “Patients are usually diagnosed with Merkel cell carcinoma later in life, and the tumors have been associated with sun exposure and immunosuppression and have also been associated with the polyomavirus.”

That said, however, he emphasized that great strides have been made in treatment. “These tumors are very sensitive to radiation, and we generally treat earlier-stage MCC with a combination of surgery and radiation therapy,” said Dr. Farma. “More recently we have had a lot of success with the use of immunotherapy to treat more advanced MCC.”

Dr. Zaba reported receiving grants from the Kuni Foundation outside the submitted work. No other disclosures were reported. Author Eleni Linos, MD, DrPH, MPH, is supported by grant K24AR075060 from the National Institutes of Health. No other outside funding was reported. Dr. Farma had no disclosures.

TOPLINE:

Globally, lead exposure is linked to more than 5.5 million adult cardiovascular deaths in 2019, as well as loss of 765 million intelligence quotient (IQ) points in children younger than 5 years, which cost U.S. $6 trillion in lost productivity, new research suggests.

METHODOLOGY:

• Global lead exposure has declined substantially since leaded gasoline was phased out, but several sources of lead remain, resulting in adverse health and economic effects, particularly in low- and middle-income countries (LMICs).
• Estimates of cardiovascular disease (CVD) deaths from lead exposure have been limited to effects of increased blood pressure, but studies show that lead exposure has cardiovascular impacts through mechanisms other than hypertension.
• Drawing from various sources and studies, researchers estimated global blood lead levels and the impact of lead exposure on CVD mortality in 2019 among adults aged 25 years or older, IQ loss in children younger than 5 years, and the related economic costs.

TAKEAWAY:

• Researchers estimated that there were 5,545,000 (95% confidence interval, 2,305,000-8,271,000) cardiovascular deaths in adults from lead exposure in 2019, with as many as 90.2% of these deaths in LMICs; however, this estimate may be incomplete because it does not include the effect of lead exposure on CVD mortality mediated through hypertension.
• The estimated global IQ loss in children younger than 5 years due to lead exposure was 765 million (95% CI, 443 million-1,098 million) IQ points in 2019, 95.3% of which occurred in LMICs.
• These estimates place lead exposure on a par with ambient particulate matter and household air pollution combined, and ahead of unsafe household drinking water, sanitation, and handwashing, as an environmental risk factor.
• The estimated global cost of lead exposure from CVD mortality and IQ loss combined is U.S. $6.0 trillion (range, $2.6 trillion-9.0 trillion) in 2019, equivalent to 6.9% of the 2019 global gross domestic product.

IN PRACTICE:

Given the magnitude of the estimated health effects of lead exposure, particularly in LMICs, “it is imperative that nationally representative periodic blood lead level measurements be institutionalized,” write the authors, adding that these measurements could be incorporated into existing household surveys.

STUDY DETAILS:

The study was conducted by Bjorn Larsen, PhD, environmental economist and consultant to the World Bank, and Ernesto Sánchez-Triana. It was published online in The Lancet Planetary Health.

LIMITATIONS:

• Global blood lead level estimates may be inaccurate, given that measurements are absent for many countries.
• Certain income projections and income losses are uncertain.
• Because the study does not capture the detrimental effects of lead exposure other than IQ loss and CVD mortality, the estimates of global costs are conservative.

DISCLOSURES:

The study received support from the Korea Green Growth Trust Fund and the World Bank’s Pollution Management and Environmental Health Program. The authors have no relevant conflicts of interest.

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

TOPLINE:

Globally, lead exposure is linked to more than 5.5 million adult cardiovascular deaths in 2019, as well as loss of 765 million intelligence quotient (IQ) points in children younger than 5 years, which cost U.S. $6 trillion in lost productivity, new research suggests.

METHODOLOGY:

• Global lead exposure has declined substantially since leaded gasoline was phased out, but several sources of lead remain, resulting in adverse health and economic effects, particularly in low- and middle-income countries (LMICs).
• Estimates of cardiovascular disease (CVD) deaths from lead exposure have been limited to effects of increased blood pressure, but studies show that lead exposure has cardiovascular impacts through mechanisms other than hypertension.
• Drawing from various sources and studies, researchers estimated global blood lead levels and the impact of lead exposure on CVD mortality in 2019 among adults aged 25 years or older, IQ loss in children younger than 5 years, and the related economic costs.

TAKEAWAY:

• Researchers estimated that there were 5,545,000 (95% confidence interval, 2,305,000-8,271,000) cardiovascular deaths in adults from lead exposure in 2019, with as many as 90.2% of these deaths in LMICs; however, this estimate may be incomplete because it does not include the effect of lead exposure on CVD mortality mediated through hypertension.
• The estimated global IQ loss in children younger than 5 years due to lead exposure was 765 million (95% CI, 443 million-1,098 million) IQ points in 2019, 95.3% of which occurred in LMICs.
• These estimates place lead exposure on a par with ambient particulate matter and household air pollution combined, and ahead of unsafe household drinking water, sanitation, and handwashing, as an environmental risk factor.
• The estimated global cost of lead exposure from CVD mortality and IQ loss combined is U.S. $6.0 trillion (range, $2.6 trillion-9.0 trillion) in 2019, equivalent to 6.9% of the 2019 global gross domestic product.

IN PRACTICE:

Given the magnitude of the estimated health effects of lead exposure, particularly in LMICs, “it is imperative that nationally representative periodic blood lead level measurements be institutionalized,” write the authors, adding that these measurements could be incorporated into existing household surveys.

STUDY DETAILS:

The study was conducted by Bjorn Larsen, PhD, environmental economist and consultant to the World Bank, and Ernesto Sánchez-Triana. It was published online in The Lancet Planetary Health.

LIMITATIONS:

• Global blood lead level estimates may be inaccurate, given that measurements are absent for many countries.
• Certain income projections and income losses are uncertain.
• Because the study does not capture the detrimental effects of lead exposure other than IQ loss and CVD mortality, the estimates of global costs are conservative.

DISCLOSURES:

The study received support from the Korea Green Growth Trust Fund and the World Bank’s Pollution Management and Environmental Health Program. The authors have no relevant conflicts of interest.

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

TOPLINE:

Globally, lead exposure is linked to more than 5.5 million adult cardiovascular deaths in 2019, as well as loss of 765 million intelligence quotient (IQ) points in children younger than 5 years, which cost U.S. $6 trillion in lost productivity, new research suggests.

METHODOLOGY:

• Global lead exposure has declined substantially since leaded gasoline was phased out, but several sources of lead remain, resulting in adverse health and economic effects, particularly in low- and middle-income countries (LMICs).
• Estimates of cardiovascular disease (CVD) deaths from lead exposure have been limited to effects of increased blood pressure, but studies show that lead exposure has cardiovascular impacts through mechanisms other than hypertension.
• Drawing from various sources and studies, researchers estimated global blood lead levels and the impact of lead exposure on CVD mortality in 2019 among adults aged 25 years or older, IQ loss in children younger than 5 years, and the related economic costs.

TAKEAWAY:

• Researchers estimated that there were 5,545,000 (95% confidence interval, 2,305,000-8,271,000) cardiovascular deaths in adults from lead exposure in 2019, with as many as 90.2% of these deaths in LMICs; however, this estimate may be incomplete because it does not include the effect of lead exposure on CVD mortality mediated through hypertension.
• The estimated global IQ loss in children younger than 5 years due to lead exposure was 765 million (95% CI, 443 million-1,098 million) IQ points in 2019, 95.3% of which occurred in LMICs.
• These estimates place lead exposure on a par with ambient particulate matter and household air pollution combined, and ahead of unsafe household drinking water, sanitation, and handwashing, as an environmental risk factor.
• The estimated global cost of lead exposure from CVD mortality and IQ loss combined is U.S. $6.0 trillion (range, $2.6 trillion-9.0 trillion) in 2019, equivalent to 6.9% of the 2019 global gross domestic product.

IN PRACTICE:

Given the magnitude of the estimated health effects of lead exposure, particularly in LMICs, “it is imperative that nationally representative periodic blood lead level measurements be institutionalized,” write the authors, adding that these measurements could be incorporated into existing household surveys.

STUDY DETAILS:

The study was conducted by Bjorn Larsen, PhD, environmental economist and consultant to the World Bank, and Ernesto Sánchez-Triana. It was published online in The Lancet Planetary Health.

LIMITATIONS:

• Global blood lead level estimates may be inaccurate, given that measurements are absent for many countries.
• Certain income projections and income losses are uncertain.
• Because the study does not capture the detrimental effects of lead exposure other than IQ loss and CVD mortality, the estimates of global costs are conservative.

DISCLOSURES:

The study received support from the Korea Green Growth Trust Fund and the World Bank’s Pollution Management and Environmental Health Program. The authors have no relevant conflicts of interest.

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

A physician in your office is hot-tempered, critical, and upsets both the physicians and staff. Two of your partners are arguing over a software vendor and refuse to compromise. One doctor’s spouse is the office manager and snipes at everyone; the lead partner micromanages and second-guesses other doctors’ treatment plans, and no one will stand up to her.

If your practice has similar scenarios, you’re likely dealing with your own anger, irritation, and dread at work. You’re struggling with a toxic practice atmosphere, and you must make changes – fast.

However, this isn’t easy, given that what goes on in a doctor’s office is “high consequence,” says Leonard J. Marcus, PhD, founding director of the program for health care negotiation and conflict resolution at the Harvard School of Public Health in Boston.

The two things that tend to plague medical practices most: A culture of fear and someone who is letting ego run the day-to-day, he says.

“Fear overwhelms any chance for good morale among colleagues,” says Dr. Marcus, who is also the coauthor of “Renegotiating Health Care: Resolving Conflict to Build Collaboration.” “In a work environment where the fear is overwhelming, the ego can take over, and someone at the practice becomes overly concerned about getting credit, taking control, ordering other people around, and deciding who is on top and who is on the bottom.”

Tension, stress, back-biting, and rudeness are also symptoms of a more significant problem, says Jes Montgomery, MD, a psychiatrist and medical director of APN Dallas, a mental health–focused practice.

“If you don’t get toxicity under control, it will blow the office apart,” Dr. Montgomery says.

Here are five tips to turn around a toxic practice culture.
 

1. Recognize the signs

Part of the problem with a toxic medical practice is that, culturally, we don’t treat mental health and burnout as real illnesses. “A physician who is depressed is not going to be melancholy or bursting into tears with patients,” Dr. Montgomery says. “They’ll get behind on paperwork, skip meals, or find that it’s difficult to sleep at night. Next, they’ll yell at the partners and staff, always be in a foul mood, and gripe about inconsequential things. Their behavior affects everyone.”

Dr. Montgomery says that physicians aren’t taught to ask for help, making it difficult to see what’s really going on when someone displays toxic behavior in the practice. If it’s a partner, take time to ask what’s going on. If it’s yourself, step back and see if you can ask someone for the help you need.
 

2. Have difficult conversations

This is tough for most of us, says Jeremy Pollack, PhD, CEO and founder of Pollack Peacebuilding Systems, a conflict resolution consulting firm. If a team member is hot-tempered, disrespectful, or talking to patients in an unproductive manner, see if you can have an effective conversation with that person. The tricky part is critiquing in a way that doesn’t make them feel defensive – and wanting to push back.

For a micromanaging office manager, for example, you could say something like,”You’re doing a great job with the inventory, but I need you to let the staff have some autonomy and not hover over every supply they use in the break room, so that people won’t feel resentful toward us.” Make it clear you’re a team, and this is a team challenge. “However, if a doctor feels like they’ve tried to communicate to that colleague and are still walking on eggshells, it’s time to try to get help from someone – perhaps a practice management organization,” says Dr. Pollack.
 

3. Open lines of communication

It’s critical to create a comfortable space to speak with your colleagues, says Marisa Garshick, MD, a dermatologist in private practice in New York. “Creating an environment where there is an open line of communication, whether it’s directly to somebody in charge or having a system where you can give feedback more privately or anonymously, is important so that tension doesn’t build.”

“Being a doctor is a social enterprise,” Dr. Marcus says. “The science of medicine is critically important, but patients and the other health care workers on your team are also critically important. In the long run, the most successful physicians pay attention to both. It’s a full package.”
 

4. Emphasize the positive

Instead of discussing things only when they go wrong, try optimism, Dr. Garshick said. When positive things happen, whether it’s an excellent patient encounter or the office did something really well together, highlight it so everyone has a sense of accomplishment. If a patient compliments a medical assistant or raves about a nurse, share those compliments with the employees so that not every encounter you have calls out problems and staff missteps.

Suppose partners have a conflict with one another or are arguing over something. In that case, you may need to mediate or invest in a meaningful intervention so people can reflect on the narrative they’re contributing to the culture.
 

5. Practice self-care

Finally, the work of a physician is exhausting, so it’s crucial to practice personal TLC. That may mean taking micro breaks, getting adequate sleep, maintaining a healthy diet, and exercising well and managing stress to maintain energy levels and patience.

“Sometimes, when I’m fed up with the office, I need to get away,” Dr. Montgomery says. “I’ll take a day to go fishing, golfing, and not think about the office.” Just a small break can shift the lens that you see through when you return to the office and put problems in perspective.

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

A physician in your office is hot-tempered, critical, and upsets both the physicians and staff. Two of your partners are arguing over a software vendor and refuse to compromise. One doctor’s spouse is the office manager and snipes at everyone; the lead partner micromanages and second-guesses other doctors’ treatment plans, and no one will stand up to her.

If your practice has similar scenarios, you’re likely dealing with your own anger, irritation, and dread at work. You’re struggling with a toxic practice atmosphere, and you must make changes – fast.

However, this isn’t easy, given that what goes on in a doctor’s office is “high consequence,” says Leonard J. Marcus, PhD, founding director of the program for health care negotiation and conflict resolution at the Harvard School of Public Health in Boston.

The two things that tend to plague medical practices most: A culture of fear and someone who is letting ego run the day-to-day, he says.

“Fear overwhelms any chance for good morale among colleagues,” says Dr. Marcus, who is also the coauthor of “Renegotiating Health Care: Resolving Conflict to Build Collaboration.” “In a work environment where the fear is overwhelming, the ego can take over, and someone at the practice becomes overly concerned about getting credit, taking control, ordering other people around, and deciding who is on top and who is on the bottom.”

Tension, stress, back-biting, and rudeness are also symptoms of a more significant problem, says Jes Montgomery, MD, a psychiatrist and medical director of APN Dallas, a mental health–focused practice.

“If you don’t get toxicity under control, it will blow the office apart,” Dr. Montgomery says.

Here are five tips to turn around a toxic practice culture.
 

1. Recognize the signs

Part of the problem with a toxic medical practice is that, culturally, we don’t treat mental health and burnout as real illnesses. “A physician who is depressed is not going to be melancholy or bursting into tears with patients,” Dr. Montgomery says. “They’ll get behind on paperwork, skip meals, or find that it’s difficult to sleep at night. Next, they’ll yell at the partners and staff, always be in a foul mood, and gripe about inconsequential things. Their behavior affects everyone.”

Dr. Montgomery says that physicians aren’t taught to ask for help, making it difficult to see what’s really going on when someone displays toxic behavior in the practice. If it’s a partner, take time to ask what’s going on. If it’s yourself, step back and see if you can ask someone for the help you need.
 

2. Have difficult conversations

This is tough for most of us, says Jeremy Pollack, PhD, CEO and founder of Pollack Peacebuilding Systems, a conflict resolution consulting firm. If a team member is hot-tempered, disrespectful, or talking to patients in an unproductive manner, see if you can have an effective conversation with that person. The tricky part is critiquing in a way that doesn’t make them feel defensive – and wanting to push back.

For a micromanaging office manager, for example, you could say something like,”You’re doing a great job with the inventory, but I need you to let the staff have some autonomy and not hover over every supply they use in the break room, so that people won’t feel resentful toward us.” Make it clear you’re a team, and this is a team challenge. “However, if a doctor feels like they’ve tried to communicate to that colleague and are still walking on eggshells, it’s time to try to get help from someone – perhaps a practice management organization,” says Dr. Pollack.
 

3. Open lines of communication

It’s critical to create a comfortable space to speak with your colleagues, says Marisa Garshick, MD, a dermatologist in private practice in New York. “Creating an environment where there is an open line of communication, whether it’s directly to somebody in charge or having a system where you can give feedback more privately or anonymously, is important so that tension doesn’t build.”

“Being a doctor is a social enterprise,” Dr. Marcus says. “The science of medicine is critically important, but patients and the other health care workers on your team are also critically important. In the long run, the most successful physicians pay attention to both. It’s a full package.”
 

4. Emphasize the positive

Instead of discussing things only when they go wrong, try optimism, Dr. Garshick said. When positive things happen, whether it’s an excellent patient encounter or the office did something really well together, highlight it so everyone has a sense of accomplishment. If a patient compliments a medical assistant or raves about a nurse, share those compliments with the employees so that not every encounter you have calls out problems and staff missteps.

Suppose partners have a conflict with one another or are arguing over something. In that case, you may need to mediate or invest in a meaningful intervention so people can reflect on the narrative they’re contributing to the culture.
 

5. Practice self-care

Finally, the work of a physician is exhausting, so it’s crucial to practice personal TLC. That may mean taking micro breaks, getting adequate sleep, maintaining a healthy diet, and exercising well and managing stress to maintain energy levels and patience.

“Sometimes, when I’m fed up with the office, I need to get away,” Dr. Montgomery says. “I’ll take a day to go fishing, golfing, and not think about the office.” Just a small break can shift the lens that you see through when you return to the office and put problems in perspective.

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

A physician in your office is hot-tempered, critical, and upsets both the physicians and staff. Two of your partners are arguing over a software vendor and refuse to compromise. One doctor’s spouse is the office manager and snipes at everyone; the lead partner micromanages and second-guesses other doctors’ treatment plans, and no one will stand up to her.

If your practice has similar scenarios, you’re likely dealing with your own anger, irritation, and dread at work. You’re struggling with a toxic practice atmosphere, and you must make changes – fast.

However, this isn’t easy, given that what goes on in a doctor’s office is “high consequence,” says Leonard J. Marcus, PhD, founding director of the program for health care negotiation and conflict resolution at the Harvard School of Public Health in Boston.

The two things that tend to plague medical practices most: A culture of fear and someone who is letting ego run the day-to-day, he says.

“Fear overwhelms any chance for good morale among colleagues,” says Dr. Marcus, who is also the coauthor of “Renegotiating Health Care: Resolving Conflict to Build Collaboration.” “In a work environment where the fear is overwhelming, the ego can take over, and someone at the practice becomes overly concerned about getting credit, taking control, ordering other people around, and deciding who is on top and who is on the bottom.”

Tension, stress, back-biting, and rudeness are also symptoms of a more significant problem, says Jes Montgomery, MD, a psychiatrist and medical director of APN Dallas, a mental health–focused practice.

“If you don’t get toxicity under control, it will blow the office apart,” Dr. Montgomery says.

Here are five tips to turn around a toxic practice culture.
 

1. Recognize the signs

Part of the problem with a toxic medical practice is that, culturally, we don’t treat mental health and burnout as real illnesses. “A physician who is depressed is not going to be melancholy or bursting into tears with patients,” Dr. Montgomery says. “They’ll get behind on paperwork, skip meals, or find that it’s difficult to sleep at night. Next, they’ll yell at the partners and staff, always be in a foul mood, and gripe about inconsequential things. Their behavior affects everyone.”

Dr. Montgomery says that physicians aren’t taught to ask for help, making it difficult to see what’s really going on when someone displays toxic behavior in the practice. If it’s a partner, take time to ask what’s going on. If it’s yourself, step back and see if you can ask someone for the help you need.
 

2. Have difficult conversations

This is tough for most of us, says Jeremy Pollack, PhD, CEO and founder of Pollack Peacebuilding Systems, a conflict resolution consulting firm. If a team member is hot-tempered, disrespectful, or talking to patients in an unproductive manner, see if you can have an effective conversation with that person. The tricky part is critiquing in a way that doesn’t make them feel defensive – and wanting to push back.

For a micromanaging office manager, for example, you could say something like,”You’re doing a great job with the inventory, but I need you to let the staff have some autonomy and not hover over every supply they use in the break room, so that people won’t feel resentful toward us.” Make it clear you’re a team, and this is a team challenge. “However, if a doctor feels like they’ve tried to communicate to that colleague and are still walking on eggshells, it’s time to try to get help from someone – perhaps a practice management organization,” says Dr. Pollack.
 

3. Open lines of communication

It’s critical to create a comfortable space to speak with your colleagues, says Marisa Garshick, MD, a dermatologist in private practice in New York. “Creating an environment where there is an open line of communication, whether it’s directly to somebody in charge or having a system where you can give feedback more privately or anonymously, is important so that tension doesn’t build.”

“Being a doctor is a social enterprise,” Dr. Marcus says. “The science of medicine is critically important, but patients and the other health care workers on your team are also critically important. In the long run, the most successful physicians pay attention to both. It’s a full package.”
 

4. Emphasize the positive

Instead of discussing things only when they go wrong, try optimism, Dr. Garshick said. When positive things happen, whether it’s an excellent patient encounter or the office did something really well together, highlight it so everyone has a sense of accomplishment. If a patient compliments a medical assistant or raves about a nurse, share those compliments with the employees so that not every encounter you have calls out problems and staff missteps.

Suppose partners have a conflict with one another or are arguing over something. In that case, you may need to mediate or invest in a meaningful intervention so people can reflect on the narrative they’re contributing to the culture.
 

5. Practice self-care

Finally, the work of a physician is exhausting, so it’s crucial to practice personal TLC. That may mean taking micro breaks, getting adequate sleep, maintaining a healthy diet, and exercising well and managing stress to maintain energy levels and patience.

“Sometimes, when I’m fed up with the office, I need to get away,” Dr. Montgomery says. “I’ll take a day to go fishing, golfing, and not think about the office.” Just a small break can shift the lens that you see through when you return to the office and put problems in perspective.

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

SINGAPORE – Can the prolonged use of skin-lightening products, such as hydroquinone, lead to skin cancer?

This question was posed by Ousmane Faye, MD, PhD, director general of Mali’s Bamako Dermatology Hospital, at the World Congress of Dermatology. 

Dr. Faye explored the issue during a hot topics session at the meeting, prefacing that it was an important question to ask because “in West Africa, skin bleaching is very common.”

“There are many local names” for skin bleaching, he said. “For example, in Senegal, it’s called xessal; in Mali and Ivory Coast, its name is caco; in South Africa, there are many names, like ukutsheyisa.”

Skin bleaching refers to the cosmetic misuse of topical agents to change one’s natural skin color. It’s a centuries-old practice that people, mainly women, adopt “to increase attractiveness and self-esteem,” explained Dr. Faye.

To demonstrate how pervasive skin bleaching is on the continent, he presented a slide that summarized figures from six studies spanning the past 2 decades. Prevalence ranged from 25% in Mali (based on a 1993 survey of 210 women) to a high of 79.25% in Benin (from a sample size of 511 women in 2019). In other studies of women in Burkina Faso and Togo, the figures were 44.3% and 58.9%, respectively. The most recently conducted study, which involved 2,689 Senegalese women and was published in 2022, found that nearly 6 in 10 (59.2%) respondents used skin-lightening products.

But skin bleaching isn’t just limited to Africa, said session moderator Omar Lupi, MD, PhD, associate professor of dermatology at the Federal University of the State of Rio de Janeiro, when approached for an independent comment. “It’s a traditional practice around the world. Maybe not in the developed countries, but it’s quite common in Africa, in South America, and in Asia.”

His sentiments are echoed in a meta-analysis that was published in the International Journal of Dermatology in 2019. The work examined 68 studies involving more than 67,000 people across Africa, Asia, Europe, the Middle East, and North America. It found that the pooled lifetime prevalence of skin bleaching was 27.7% (95% confidence interval, 19.6-37.5; P < .01).

“This is an important and interesting topic because our world is shrinking,” Dr. Lupi told this news organization. “Even in countries that don’t have bleaching as a common situation, we now have patients who are migrating from one part [of the world] to another, so bleaching is something that can knock on your door and you need to be prepared.”

Misuse leads to complications

The issue is pertinent to dermatologists because skin bleaching is associated with a wide range of complications. Take, for example, topical steroids, which are the most common products used for bleaching, said Dr. Faye in his talk. 

“Clobetasol can suppress the hypothalamic-pituitary-adrenal (HPA) function,” he said, referring to the body’s main stress response system. “It can also foster skin infection, including bacterial, fungal, viral, and parasitic infection.”

In addition, topical steroids that are misused as skin lighteners have been reported to cause stretch marks, skin atrophy, inflammatory acne, and even metabolic disorders such as diabetes and hypertension, said Dr. Faye.

To further his point, he cited a 2021 prospective case-control study conducted across five sub-Saharan countries, which found that the use of “voluntary cosmetic depigmentation” significantly increased a person’s risk for necrotizing fasciitis of the lower limbs (odds ratio, 2.29; 95% CI, 1.19-3.73; P = .0226).

Similarly, mercury, another substance found in products commonly used to bleach skin, has been associated with problems ranging from rashes to renal toxicity. And because it’s so incredibly harmful, mercury is also known to cause neurologic abnormalities. 

Apart from causing certain conditions, prolonged use of skin-lightening products can change the way existing diseases present themselves as well as their severity, added Dr. Faye. 
 

An increased risk

But what about skin bleaching’s link with cancer? “Skin cancer on Black skin is uncommon, yet it occurs in skin-bleaching women,” said Dr. Faye.

“Since 2000, we have had some cases of skin cancer associated with skin bleaching,” he continued, adding that squamous cell carcinoma (SCC) is the most frequent type of cancer observed. 

If you look at what’s been published on the topic so far, you’ll see that “all the cases of skin cancer are located over the neck or some exposed area when skin bleaching products are used for more than 10 years,” said Dr. Faye. “And most of the time, the age of the patient ranges from 30 to 60 years.”

The first known case in Africa was reported in a 58-year-old woman from Ghana, who had been using skin bleaching products for close to 30 years. The patient presented with tumors on her face, neck, and arms.

Dr. Faye then proceeded to share more than 10 such carcinoma cases. “These previous reports strongly suggest a relationship between skin bleaching and skin cancers,” said Dr. Faye.

Indeed, there have been reports and publications in the literature that support his observation, including one last year, which found that use of the tyrosinase inhibitor hydroquinone was associated with approximately a threefold increased risk for skin cancer.

For some, including Brazil’s Dr. Lupi, Dr. Faye’s talk was enlightening: “I didn’t know about this relationship [of bleaching] with skin cancer, it was something new for me.”

But the prevalence of SCC is very low, compared with that of skin bleaching, Dr. Faye acknowledged. Moreover, the cancer observed in the cases reported could have resulted from a number of reasons, including exposure to harmful ultraviolet rays from the sun and genetic predisposition in addition to the use of bleaching products such as hydroquinone. “Other causes of skin cancer are not excluded,” he said.

To further explore the link between skin bleaching and cancer, “we need case-control studies to provide more evidence,” he added. Until then, dermatologists “should keep on promoting messages” to prevent SCC from occurring. This includes encouraging the use of proper sun protection in addition to discouraging the practice of skin bleaching, which still persists despite more than 10 African nations banning the use of toxic skin-lightening products.

Dr. Faye and Dr. Lupi report no relevant financial relationships.

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

SINGAPORE – Can the prolonged use of skin-lightening products, such as hydroquinone, lead to skin cancer?

This question was posed by Ousmane Faye, MD, PhD, director general of Mali’s Bamako Dermatology Hospital, at the World Congress of Dermatology. 

Dr. Faye explored the issue during a hot topics session at the meeting, prefacing that it was an important question to ask because “in West Africa, skin bleaching is very common.”

“There are many local names” for skin bleaching, he said. “For example, in Senegal, it’s called xessal; in Mali and Ivory Coast, its name is caco; in South Africa, there are many names, like ukutsheyisa.”

Skin bleaching refers to the cosmetic misuse of topical agents to change one’s natural skin color. It’s a centuries-old practice that people, mainly women, adopt “to increase attractiveness and self-esteem,” explained Dr. Faye.

To demonstrate how pervasive skin bleaching is on the continent, he presented a slide that summarized figures from six studies spanning the past 2 decades. Prevalence ranged from 25% in Mali (based on a 1993 survey of 210 women) to a high of 79.25% in Benin (from a sample size of 511 women in 2019). In other studies of women in Burkina Faso and Togo, the figures were 44.3% and 58.9%, respectively. The most recently conducted study, which involved 2,689 Senegalese women and was published in 2022, found that nearly 6 in 10 (59.2%) respondents used skin-lightening products.

But skin bleaching isn’t just limited to Africa, said session moderator Omar Lupi, MD, PhD, associate professor of dermatology at the Federal University of the State of Rio de Janeiro, when approached for an independent comment. “It’s a traditional practice around the world. Maybe not in the developed countries, but it’s quite common in Africa, in South America, and in Asia.”

His sentiments are echoed in a meta-analysis that was published in the International Journal of Dermatology in 2019. The work examined 68 studies involving more than 67,000 people across Africa, Asia, Europe, the Middle East, and North America. It found that the pooled lifetime prevalence of skin bleaching was 27.7% (95% confidence interval, 19.6-37.5; P < .01).

“This is an important and interesting topic because our world is shrinking,” Dr. Lupi told this news organization. “Even in countries that don’t have bleaching as a common situation, we now have patients who are migrating from one part [of the world] to another, so bleaching is something that can knock on your door and you need to be prepared.”

Misuse leads to complications

The issue is pertinent to dermatologists because skin bleaching is associated with a wide range of complications. Take, for example, topical steroids, which are the most common products used for bleaching, said Dr. Faye in his talk. 

“Clobetasol can suppress the hypothalamic-pituitary-adrenal (HPA) function,” he said, referring to the body’s main stress response system. “It can also foster skin infection, including bacterial, fungal, viral, and parasitic infection.”

In addition, topical steroids that are misused as skin lighteners have been reported to cause stretch marks, skin atrophy, inflammatory acne, and even metabolic disorders such as diabetes and hypertension, said Dr. Faye.

To further his point, he cited a 2021 prospective case-control study conducted across five sub-Saharan countries, which found that the use of “voluntary cosmetic depigmentation” significantly increased a person’s risk for necrotizing fasciitis of the lower limbs (odds ratio, 2.29; 95% CI, 1.19-3.73; P = .0226).

Similarly, mercury, another substance found in products commonly used to bleach skin, has been associated with problems ranging from rashes to renal toxicity. And because it’s so incredibly harmful, mercury is also known to cause neurologic abnormalities. 

Apart from causing certain conditions, prolonged use of skin-lightening products can change the way existing diseases present themselves as well as their severity, added Dr. Faye. 
 

An increased risk

But what about skin bleaching’s link with cancer? “Skin cancer on Black skin is uncommon, yet it occurs in skin-bleaching women,” said Dr. Faye.

“Since 2000, we have had some cases of skin cancer associated with skin bleaching,” he continued, adding that squamous cell carcinoma (SCC) is the most frequent type of cancer observed. 

If you look at what’s been published on the topic so far, you’ll see that “all the cases of skin cancer are located over the neck or some exposed area when skin bleaching products are used for more than 10 years,” said Dr. Faye. “And most of the time, the age of the patient ranges from 30 to 60 years.”

The first known case in Africa was reported in a 58-year-old woman from Ghana, who had been using skin bleaching products for close to 30 years. The patient presented with tumors on her face, neck, and arms.

Dr. Faye then proceeded to share more than 10 such carcinoma cases. “These previous reports strongly suggest a relationship between skin bleaching and skin cancers,” said Dr. Faye.

Indeed, there have been reports and publications in the literature that support his observation, including one last year, which found that use of the tyrosinase inhibitor hydroquinone was associated with approximately a threefold increased risk for skin cancer.

For some, including Brazil’s Dr. Lupi, Dr. Faye’s talk was enlightening: “I didn’t know about this relationship [of bleaching] with skin cancer, it was something new for me.”

But the prevalence of SCC is very low, compared with that of skin bleaching, Dr. Faye acknowledged. Moreover, the cancer observed in the cases reported could have resulted from a number of reasons, including exposure to harmful ultraviolet rays from the sun and genetic predisposition in addition to the use of bleaching products such as hydroquinone. “Other causes of skin cancer are not excluded,” he said.

To further explore the link between skin bleaching and cancer, “we need case-control studies to provide more evidence,” he added. Until then, dermatologists “should keep on promoting messages” to prevent SCC from occurring. This includes encouraging the use of proper sun protection in addition to discouraging the practice of skin bleaching, which still persists despite more than 10 African nations banning the use of toxic skin-lightening products.

Dr. Faye and Dr. Lupi report no relevant financial relationships.

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

SINGAPORE – Can the prolonged use of skin-lightening products, such as hydroquinone, lead to skin cancer?

This question was posed by Ousmane Faye, MD, PhD, director general of Mali’s Bamako Dermatology Hospital, at the World Congress of Dermatology. 

Dr. Faye explored the issue during a hot topics session at the meeting, prefacing that it was an important question to ask because “in West Africa, skin bleaching is very common.”

“There are many local names” for skin bleaching, he said. “For example, in Senegal, it’s called xessal; in Mali and Ivory Coast, its name is caco; in South Africa, there are many names, like ukutsheyisa.”

Skin bleaching refers to the cosmetic misuse of topical agents to change one’s natural skin color. It’s a centuries-old practice that people, mainly women, adopt “to increase attractiveness and self-esteem,” explained Dr. Faye.

To demonstrate how pervasive skin bleaching is on the continent, he presented a slide that summarized figures from six studies spanning the past 2 decades. Prevalence ranged from 25% in Mali (based on a 1993 survey of 210 women) to a high of 79.25% in Benin (from a sample size of 511 women in 2019). In other studies of women in Burkina Faso and Togo, the figures were 44.3% and 58.9%, respectively. The most recently conducted study, which involved 2,689 Senegalese women and was published in 2022, found that nearly 6 in 10 (59.2%) respondents used skin-lightening products.

But skin bleaching isn’t just limited to Africa, said session moderator Omar Lupi, MD, PhD, associate professor of dermatology at the Federal University of the State of Rio de Janeiro, when approached for an independent comment. “It’s a traditional practice around the world. Maybe not in the developed countries, but it’s quite common in Africa, in South America, and in Asia.”

His sentiments are echoed in a meta-analysis that was published in the International Journal of Dermatology in 2019. The work examined 68 studies involving more than 67,000 people across Africa, Asia, Europe, the Middle East, and North America. It found that the pooled lifetime prevalence of skin bleaching was 27.7% (95% confidence interval, 19.6-37.5; P < .01).

“This is an important and interesting topic because our world is shrinking,” Dr. Lupi told this news organization. “Even in countries that don’t have bleaching as a common situation, we now have patients who are migrating from one part [of the world] to another, so bleaching is something that can knock on your door and you need to be prepared.”

Misuse leads to complications

The issue is pertinent to dermatologists because skin bleaching is associated with a wide range of complications. Take, for example, topical steroids, which are the most common products used for bleaching, said Dr. Faye in his talk. 

“Clobetasol can suppress the hypothalamic-pituitary-adrenal (HPA) function,” he said, referring to the body’s main stress response system. “It can also foster skin infection, including bacterial, fungal, viral, and parasitic infection.”

In addition, topical steroids that are misused as skin lighteners have been reported to cause stretch marks, skin atrophy, inflammatory acne, and even metabolic disorders such as diabetes and hypertension, said Dr. Faye.

To further his point, he cited a 2021 prospective case-control study conducted across five sub-Saharan countries, which found that the use of “voluntary cosmetic depigmentation” significantly increased a person’s risk for necrotizing fasciitis of the lower limbs (odds ratio, 2.29; 95% CI, 1.19-3.73; P = .0226).

Similarly, mercury, another substance found in products commonly used to bleach skin, has been associated with problems ranging from rashes to renal toxicity. And because it’s so incredibly harmful, mercury is also known to cause neurologic abnormalities. 

Apart from causing certain conditions, prolonged use of skin-lightening products can change the way existing diseases present themselves as well as their severity, added Dr. Faye. 
 

An increased risk

But what about skin bleaching’s link with cancer? “Skin cancer on Black skin is uncommon, yet it occurs in skin-bleaching women,” said Dr. Faye.

“Since 2000, we have had some cases of skin cancer associated with skin bleaching,” he continued, adding that squamous cell carcinoma (SCC) is the most frequent type of cancer observed. 

If you look at what’s been published on the topic so far, you’ll see that “all the cases of skin cancer are located over the neck or some exposed area when skin bleaching products are used for more than 10 years,” said Dr. Faye. “And most of the time, the age of the patient ranges from 30 to 60 years.”

The first known case in Africa was reported in a 58-year-old woman from Ghana, who had been using skin bleaching products for close to 30 years. The patient presented with tumors on her face, neck, and arms.

Dr. Faye then proceeded to share more than 10 such carcinoma cases. “These previous reports strongly suggest a relationship between skin bleaching and skin cancers,” said Dr. Faye.

Indeed, there have been reports and publications in the literature that support his observation, including one last year, which found that use of the tyrosinase inhibitor hydroquinone was associated with approximately a threefold increased risk for skin cancer.

For some, including Brazil’s Dr. Lupi, Dr. Faye’s talk was enlightening: “I didn’t know about this relationship [of bleaching] with skin cancer, it was something new for me.”

But the prevalence of SCC is very low, compared with that of skin bleaching, Dr. Faye acknowledged. Moreover, the cancer observed in the cases reported could have resulted from a number of reasons, including exposure to harmful ultraviolet rays from the sun and genetic predisposition in addition to the use of bleaching products such as hydroquinone. “Other causes of skin cancer are not excluded,” he said.

To further explore the link between skin bleaching and cancer, “we need case-control studies to provide more evidence,” he added. Until then, dermatologists “should keep on promoting messages” to prevent SCC from occurring. This includes encouraging the use of proper sun protection in addition to discouraging the practice of skin bleaching, which still persists despite more than 10 African nations banning the use of toxic skin-lightening products.

Dr. Faye and Dr. Lupi report no relevant financial relationships.

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

In the wake of the COVID-19 pandemic, the American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and Children’s Hospital Association declared a national emergency in child and adolescent mental health. Additionally, the U.S. Surgeon General issued an advisory highlighting increased prevalence of mental health challenges in youth, impacts of the COVID-19 pandemic, and recommendations to address this crisis.

The pandemic required youth to isolate from peers and community supports, navigate remote learning environments, and cope with grief and loss; some 140,000 children in the United States experienced the death of a caregiver due to COVID-19.¹ Virtually every system that supports children was affected. Whereas schools have historically been a main provider of child and adolescent mental health services, delivery of many school-based mental health programs was disrupted by school closures and staffing challenges. Subgroups of children (for example, those with intellectual and developmental disabilities) were particularly affected by these disruptions to daily life, and their use of emergency services increased.² Surges in psychiatric emergency department visits among children led to increased boarding, reflecting unleveraged opportunities for early intervention. Families faced changes in child care, economic uncertainty, educational responsibilities, and increased rates of domestic violence.³ Communities of color were disproportionately affected in every way, from disease mortality to learning loss and increased school dropout rates.

Meaningful improvement in children’s mental health will require remodeling broken systems to ensure that children are supported early, effectively, and equitably. To address gaps in the system, we must leverage school-based mental health programs, bolster access to and support of primary care providers, and embrace new, innovative models.
 

School-based mental health programs

Schools may be an ideal setting for universal mental health screening and opportunities for training, leadership, and whole school interventions. There is promising evidence that school-based interventions can decrease the incidence of suicide attempts and increase help-seeking behavior in students.⁴ There has long been interest in mental health screening in schools, though it has not been widely implemented given the significant resources required to both facilitate screening and effectively serve students who need additional support. Mobile apps may be one solution to scalability of both screening and interventions, but these initiatives should only be implemented within a stakeholder-engaged, family-centered multi-tiered model of behavioral support.

Other school-based initiatives include providing advice and training to teachers and school counselors and increasing access to specialized mental health professionals, including school psychologists, social workers, nurses, and behavior support workers, as well as community-based mental health providers. The 2021 American Rescue Plan Act included $170 billion for school funding, which many schools used to hire mental health workers. The Student Mental Health Helpline Act, if passed, will create helplines to support teachers as they help students address mental health issues.⁵ Educators can be trained to identify mental health needs, addressing mild symptoms themselves and referring students requiring more specialized services. Specific training programs for educators include Classroom Well-Being Information and Strategies for Educators (WISE), Youth Mental Health First Aid, and other resources funded by the U.S. Department of Health and Human Services. In addition to educators, other non–mental health professions interfacing with youth, including other youth, parents, clergy, coaches, and other community members, can be empowered with additional behavioral health knowledge and skills.
 

Increasing capacity in primary care

A number of programs are designed to improve knowledge and skills in children’s mental health among primary care providers, such as pediatricians. In Project ECHO, a “hub” of specialists, typically at an academic medical center, provides didactic lectures and case presentations for primary care “spokes” using teleconferencing.⁶ The REACH Institute uses interactive group learning followed by ongoing coaching and case-based training.

Collaborative care models known as Child Psychiatry Access Programs (CPAPs) engage child and adolescent psychiatrists to support primary care management of psychiatric disorders. Consultations may be direct or indirect, and involve technology or in-person care. Available in most states, these models increase access to mental health care, expand the capacity of the existing workforce, and decrease stigma and inconvenience for patients. Collaborative care models have been shown to lead to improved patient and family satisfaction, reduced utilization of emergency room and inpatient hospitalizations, and improved clinical outcomes. Off-site integrated care models may additionally serve larger and more geographically dispersed populations, minimize changes to existing infrastructure, reduce travel costs for clinicians, and decrease isolation of specialists. These programs are feasible, desirable, and sustainable. There is currently no cost to patients for their primary care providers’ participation in these models, as they are supported by the state, local, or insurance payer sources in addition to federal funding. Financially sustainable models are essential to ensure equitable access to these services in the future.
 

New service models

For adolescents and young adults, integrated youth service hubs such as those that have emerged in Australia, the United Kingdom, Canada, and more recently in the United States may be particularly appealing. These hubs emphasize rapid access to care and early intervention, youth and family engagement, youth-friendly settings and services, evidence-informed approaches, and partnerships and collaboration.⁷ In addition to mental health, these “one-stop shops” offer physical health, vocational supports, and case management to support basic needs. They address a particular system gap by providing services for transition-age youth rather than cutting off at age 18, as many children’s mental health services do.

Emerging solutions to the high utilization of emergency departments for pediatric mental health needs include utilization of pediatric Crisis Stabilization Units (CSUs). CSUs are community-based, short-term outpatient units that provide immediate care to children and families experiencing a mental health crisis. The goal of CSUs is to quickly stabilize the individual – often within 72 hours – and refer that individual to available community resources. This model may also reduce police involvement in mental health crises, which may be particularly important for racialized populations.
 

Conclusion

The thoughtful implementation and stable funding of evidence-based models can help schools, the health care system, and communities more effectively support children’s mental health in the post–COVID-19 pandemic era. Only with sufficient investments in the mental health system and other systems designed to support children and families, as well as careful consideration of unintended consequences on equity-deserving populations, will we see an end to this crisis.

Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences; program director of the child and adolescent psychiatry fellowship; and associate medical director of the perinatal program at the University of California, Los Angeles, Semel Institute for Neuroscience and Human Behavior.

References

1. Hillis SD et al. COVID-19–Associated orphanhood and caregiver death in the United States. Pediatrics. 2021;148:e2021053760.

2. Edgcomb JB et al. Mental health‐related emergency department visits among children during the early COVID‐19 pandemic. Psychiatr Res Clin Pract. 2022;4:4-11.

3. Pereda N, Díaz-Faes DA. Family violence against children in the wake of COVID-19 pandemic: A review of current perspectives and risk factors. Child and Adolescent Psychiatry and Mental Health. 2020;4:40.

4. Gijzen MWM et al. Effectiveness of school-based preventive programs in suicidal thoughts and behaviors: A meta-analysis. Journal of Affective Disorders. 2022;298:408-420.

5. Newman M: H.R.5235 – 117th Congress (2021-2022): Student Mental Health Helpline Act of 2021 [Internet] 2021; [cited 2023 Jan 11] Available from: http://www.congress.gov.

6. Raney L et al. Digitally driven integrated primary care and behavioral health: How technology can expand access to effective treatment. Curr Psychiatry Rep. 2017;19:86.

7. Settipani CA et al. Key attributes of integrated community-based youth service hubs for mental health: A scoping review. Int J Ment Health Syst. 2019;13:52.

In the wake of the COVID-19 pandemic, the American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and Children’s Hospital Association declared a national emergency in child and adolescent mental health. Additionally, the U.S. Surgeon General issued an advisory highlighting increased prevalence of mental health challenges in youth, impacts of the COVID-19 pandemic, and recommendations to address this crisis.

The pandemic required youth to isolate from peers and community supports, navigate remote learning environments, and cope with grief and loss; some 140,000 children in the United States experienced the death of a caregiver due to COVID-19.¹ Virtually every system that supports children was affected. Whereas schools have historically been a main provider of child and adolescent mental health services, delivery of many school-based mental health programs was disrupted by school closures and staffing challenges. Subgroups of children (for example, those with intellectual and developmental disabilities) were particularly affected by these disruptions to daily life, and their use of emergency services increased.² Surges in psychiatric emergency department visits among children led to increased boarding, reflecting unleveraged opportunities for early intervention. Families faced changes in child care, economic uncertainty, educational responsibilities, and increased rates of domestic violence.³ Communities of color were disproportionately affected in every way, from disease mortality to learning loss and increased school dropout rates.

Meaningful improvement in children’s mental health will require remodeling broken systems to ensure that children are supported early, effectively, and equitably. To address gaps in the system, we must leverage school-based mental health programs, bolster access to and support of primary care providers, and embrace new, innovative models.
 

School-based mental health programs

Schools may be an ideal setting for universal mental health screening and opportunities for training, leadership, and whole school interventions. There is promising evidence that school-based interventions can decrease the incidence of suicide attempts and increase help-seeking behavior in students.⁴ There has long been interest in mental health screening in schools, though it has not been widely implemented given the significant resources required to both facilitate screening and effectively serve students who need additional support. Mobile apps may be one solution to scalability of both screening and interventions, but these initiatives should only be implemented within a stakeholder-engaged, family-centered multi-tiered model of behavioral support.

Other school-based initiatives include providing advice and training to teachers and school counselors and increasing access to specialized mental health professionals, including school psychologists, social workers, nurses, and behavior support workers, as well as community-based mental health providers. The 2021 American Rescue Plan Act included $170 billion for school funding, which many schools used to hire mental health workers. The Student Mental Health Helpline Act, if passed, will create helplines to support teachers as they help students address mental health issues.⁵ Educators can be trained to identify mental health needs, addressing mild symptoms themselves and referring students requiring more specialized services. Specific training programs for educators include Classroom Well-Being Information and Strategies for Educators (WISE), Youth Mental Health First Aid, and other resources funded by the U.S. Department of Health and Human Services. In addition to educators, other non–mental health professions interfacing with youth, including other youth, parents, clergy, coaches, and other community members, can be empowered with additional behavioral health knowledge and skills.
 

Increasing capacity in primary care

A number of programs are designed to improve knowledge and skills in children’s mental health among primary care providers, such as pediatricians. In Project ECHO, a “hub” of specialists, typically at an academic medical center, provides didactic lectures and case presentations for primary care “spokes” using teleconferencing.⁶ The REACH Institute uses interactive group learning followed by ongoing coaching and case-based training.

Collaborative care models known as Child Psychiatry Access Programs (CPAPs) engage child and adolescent psychiatrists to support primary care management of psychiatric disorders. Consultations may be direct or indirect, and involve technology or in-person care. Available in most states, these models increase access to mental health care, expand the capacity of the existing workforce, and decrease stigma and inconvenience for patients. Collaborative care models have been shown to lead to improved patient and family satisfaction, reduced utilization of emergency room and inpatient hospitalizations, and improved clinical outcomes. Off-site integrated care models may additionally serve larger and more geographically dispersed populations, minimize changes to existing infrastructure, reduce travel costs for clinicians, and decrease isolation of specialists. These programs are feasible, desirable, and sustainable. There is currently no cost to patients for their primary care providers’ participation in these models, as they are supported by the state, local, or insurance payer sources in addition to federal funding. Financially sustainable models are essential to ensure equitable access to these services in the future.
 

New service models

For adolescents and young adults, integrated youth service hubs such as those that have emerged in Australia, the United Kingdom, Canada, and more recently in the United States may be particularly appealing. These hubs emphasize rapid access to care and early intervention, youth and family engagement, youth-friendly settings and services, evidence-informed approaches, and partnerships and collaboration.⁷ In addition to mental health, these “one-stop shops” offer physical health, vocational supports, and case management to support basic needs. They address a particular system gap by providing services for transition-age youth rather than cutting off at age 18, as many children’s mental health services do.

Emerging solutions to the high utilization of emergency departments for pediatric mental health needs include utilization of pediatric Crisis Stabilization Units (CSUs). CSUs are community-based, short-term outpatient units that provide immediate care to children and families experiencing a mental health crisis. The goal of CSUs is to quickly stabilize the individual – often within 72 hours – and refer that individual to available community resources. This model may also reduce police involvement in mental health crises, which may be particularly important for racialized populations.
 

Conclusion

The thoughtful implementation and stable funding of evidence-based models can help schools, the health care system, and communities more effectively support children’s mental health in the post–COVID-19 pandemic era. Only with sufficient investments in the mental health system and other systems designed to support children and families, as well as careful consideration of unintended consequences on equity-deserving populations, will we see an end to this crisis.

Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences; program director of the child and adolescent psychiatry fellowship; and associate medical director of the perinatal program at the University of California, Los Angeles, Semel Institute for Neuroscience and Human Behavior.

References

1. Hillis SD et al. COVID-19–Associated orphanhood and caregiver death in the United States. Pediatrics. 2021;148:e2021053760.

2. Edgcomb JB et al. Mental health‐related emergency department visits among children during the early COVID‐19 pandemic. Psychiatr Res Clin Pract. 2022;4:4-11.

3. Pereda N, Díaz-Faes DA. Family violence against children in the wake of COVID-19 pandemic: A review of current perspectives and risk factors. Child and Adolescent Psychiatry and Mental Health. 2020;4:40.

4. Gijzen MWM et al. Effectiveness of school-based preventive programs in suicidal thoughts and behaviors: A meta-analysis. Journal of Affective Disorders. 2022;298:408-420.

5. Newman M: H.R.5235 – 117th Congress (2021-2022): Student Mental Health Helpline Act of 2021 [Internet] 2021; [cited 2023 Jan 11] Available from: http://www.congress.gov.

6. Raney L et al. Digitally driven integrated primary care and behavioral health: How technology can expand access to effective treatment. Curr Psychiatry Rep. 2017;19:86.

7. Settipani CA et al. Key attributes of integrated community-based youth service hubs for mental health: A scoping review. Int J Ment Health Syst. 2019;13:52.

In the wake of the COVID-19 pandemic, the American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and Children’s Hospital Association declared a national emergency in child and adolescent mental health. Additionally, the U.S. Surgeon General issued an advisory highlighting increased prevalence of mental health challenges in youth, impacts of the COVID-19 pandemic, and recommendations to address this crisis.

The pandemic required youth to isolate from peers and community supports, navigate remote learning environments, and cope with grief and loss; some 140,000 children in the United States experienced the death of a caregiver due to COVID-19.¹ Virtually every system that supports children was affected. Whereas schools have historically been a main provider of child and adolescent mental health services, delivery of many school-based mental health programs was disrupted by school closures and staffing challenges. Subgroups of children (for example, those with intellectual and developmental disabilities) were particularly affected by these disruptions to daily life, and their use of emergency services increased.² Surges in psychiatric emergency department visits among children led to increased boarding, reflecting unleveraged opportunities for early intervention. Families faced changes in child care, economic uncertainty, educational responsibilities, and increased rates of domestic violence.³ Communities of color were disproportionately affected in every way, from disease mortality to learning loss and increased school dropout rates.

Meaningful improvement in children’s mental health will require remodeling broken systems to ensure that children are supported early, effectively, and equitably. To address gaps in the system, we must leverage school-based mental health programs, bolster access to and support of primary care providers, and embrace new, innovative models.
 

School-based mental health programs

Schools may be an ideal setting for universal mental health screening and opportunities for training, leadership, and whole school interventions. There is promising evidence that school-based interventions can decrease the incidence of suicide attempts and increase help-seeking behavior in students.⁴ There has long been interest in mental health screening in schools, though it has not been widely implemented given the significant resources required to both facilitate screening and effectively serve students who need additional support. Mobile apps may be one solution to scalability of both screening and interventions, but these initiatives should only be implemented within a stakeholder-engaged, family-centered multi-tiered model of behavioral support.

Other school-based initiatives include providing advice and training to teachers and school counselors and increasing access to specialized mental health professionals, including school psychologists, social workers, nurses, and behavior support workers, as well as community-based mental health providers. The 2021 American Rescue Plan Act included $170 billion for school funding, which many schools used to hire mental health workers. The Student Mental Health Helpline Act, if passed, will create helplines to support teachers as they help students address mental health issues.⁵ Educators can be trained to identify mental health needs, addressing mild symptoms themselves and referring students requiring more specialized services. Specific training programs for educators include Classroom Well-Being Information and Strategies for Educators (WISE), Youth Mental Health First Aid, and other resources funded by the U.S. Department of Health and Human Services. In addition to educators, other non–mental health professions interfacing with youth, including other youth, parents, clergy, coaches, and other community members, can be empowered with additional behavioral health knowledge and skills.
 

Increasing capacity in primary care

A number of programs are designed to improve knowledge and skills in children’s mental health among primary care providers, such as pediatricians. In Project ECHO, a “hub” of specialists, typically at an academic medical center, provides didactic lectures and case presentations for primary care “spokes” using teleconferencing.⁶ The REACH Institute uses interactive group learning followed by ongoing coaching and case-based training.

Collaborative care models known as Child Psychiatry Access Programs (CPAPs) engage child and adolescent psychiatrists to support primary care management of psychiatric disorders. Consultations may be direct or indirect, and involve technology or in-person care. Available in most states, these models increase access to mental health care, expand the capacity of the existing workforce, and decrease stigma and inconvenience for patients. Collaborative care models have been shown to lead to improved patient and family satisfaction, reduced utilization of emergency room and inpatient hospitalizations, and improved clinical outcomes. Off-site integrated care models may additionally serve larger and more geographically dispersed populations, minimize changes to existing infrastructure, reduce travel costs for clinicians, and decrease isolation of specialists. These programs are feasible, desirable, and sustainable. There is currently no cost to patients for their primary care providers’ participation in these models, as they are supported by the state, local, or insurance payer sources in addition to federal funding. Financially sustainable models are essential to ensure equitable access to these services in the future.
 

New service models

For adolescents and young adults, integrated youth service hubs such as those that have emerged in Australia, the United Kingdom, Canada, and more recently in the United States may be particularly appealing. These hubs emphasize rapid access to care and early intervention, youth and family engagement, youth-friendly settings and services, evidence-informed approaches, and partnerships and collaboration.⁷ In addition to mental health, these “one-stop shops” offer physical health, vocational supports, and case management to support basic needs. They address a particular system gap by providing services for transition-age youth rather than cutting off at age 18, as many children’s mental health services do.

Emerging solutions to the high utilization of emergency departments for pediatric mental health needs include utilization of pediatric Crisis Stabilization Units (CSUs). CSUs are community-based, short-term outpatient units that provide immediate care to children and families experiencing a mental health crisis. The goal of CSUs is to quickly stabilize the individual – often within 72 hours – and refer that individual to available community resources. This model may also reduce police involvement in mental health crises, which may be particularly important for racialized populations.
 

Conclusion

The thoughtful implementation and stable funding of evidence-based models can help schools, the health care system, and communities more effectively support children’s mental health in the post–COVID-19 pandemic era. Only with sufficient investments in the mental health system and other systems designed to support children and families, as well as careful consideration of unintended consequences on equity-deserving populations, will we see an end to this crisis.

Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences; program director of the child and adolescent psychiatry fellowship; and associate medical director of the perinatal program at the University of California, Los Angeles, Semel Institute for Neuroscience and Human Behavior.

References

1. Hillis SD et al. COVID-19–Associated orphanhood and caregiver death in the United States. Pediatrics. 2021;148:e2021053760.

2. Edgcomb JB et al. Mental health‐related emergency department visits among children during the early COVID‐19 pandemic. Psychiatr Res Clin Pract. 2022;4:4-11.

3. Pereda N, Díaz-Faes DA. Family violence against children in the wake of COVID-19 pandemic: A review of current perspectives and risk factors. Child and Adolescent Psychiatry and Mental Health. 2020;4:40.

4. Gijzen MWM et al. Effectiveness of school-based preventive programs in suicidal thoughts and behaviors: A meta-analysis. Journal of Affective Disorders. 2022;298:408-420.

5. Newman M: H.R.5235 – 117th Congress (2021-2022): Student Mental Health Helpline Act of 2021 [Internet] 2021; [cited 2023 Jan 11] Available from: http://www.congress.gov.

6. Raney L et al. Digitally driven integrated primary care and behavioral health: How technology can expand access to effective treatment. Curr Psychiatry Rep. 2017;19:86.

7. Settipani CA et al. Key attributes of integrated community-based youth service hubs for mental health: A scoping review. Int J Ment Health Syst. 2019;13:52.

Pleural mesothelioma is generally treated by extended pleurectomy decortication, and there has been little improvement in systemic treatment of early-stage, resectable mesothelioma, which has led to the recommendations of maximum cytoreduction. U.S. and European guidelines, as well as an international consensus statement, support this approach, but it has never been tested in a randomized, controlled trial.

Now it has, and the result is surprising: Surgery led to reduced survival and more serious adverse events, compared with chemotherapy alone. The conclusion was uncomfortable for Eric Lim, MD, who presented the results of the MARS2 trial at the annual World Conference on Lung Cancer. “Ladies and gentlemen, as a surgeon standing here, you have no idea how much it pains me to conclude that extended pleurectomy decortication, an operation that we have been offering for over 70 years, has been associated with a higher risk of death, more serious complications, poorer quality of life, and higher costs, compared to mesothelioma patients who were randomized to chemotherapy alone,” said Dr. Lim of the Royal Brompton Hospital, London, during his presentation.

Although the line drew laughter and applause from the audience, Paula Ugalde Figueroa, MD, who served as a discussant, raised some concerns about the study. Disease presence in one hemithorax was assessed only by chest CT scan, which is notorious for underestimating the volume of disease during surgery. There was also no information on pleural effusion or how many patients received it prior to intervention. Existing guidelines suggest staging of mesothelioma should also use PET scans, and invasive mediastinal staging should be assessed with endobronchial ultrasound. “None of these were performed during the trial,” said Dr. Figueroa, who is an associate thoracic surgeon at Brigham and Women’s Hospital, Boston. “At this point, my question is, are the arms of this study well balanced in regard to tumor volume? We don’t know,” she added.

Dr. Figueroa noted that the 90-day mortality seemed higher than that seen in other studies. “So, does the surgeon’s experience and center volume affect the outcome of this study?” she asked. Dr. Figueroa personally made phone calls to the participating centers and found that 45% of the patients in the trial were treated at low-volume centers, defined by her as two to three patients per year. “Should we assume that their surgical outcomes are similar between those centers? In this trial, with approximately half of patients from low-volume centers, extended pleurectomy decortication for mesothelioma had no significant difference when compared to those patients that underwent chemotherapy alone. Would the outcome be different in exclusively high-volume centers?” she concluded.

The study randomized 335 patients to receive surgery and chemotherapy, or chemotherapy alone. They received two cycles of platinum-based chemotherapy and pemetrexed prior to surgery and up to four cycles after surgery. The average age was 69 years; 86.9% were male, and 85.7% of tumors were epithelioid only. Among those in the surgery group, 88.5% underwent extended pleurectomy/decortication, 8.3% underwent pleurectomy decortication, 1.9% underwent partial pleurectomy, 0.6% exploration with no pleurodesis, and 0.6% were classified as “other” surgery. Completeness of resection was R0 in 3.2% of surgeries, R1 in 80.9%, and R2 in 15.9%. In-hospital mortality occurred in 3.8% of patients, and postsurgical 90-day mortality was 8.9%.

Over the first 42 months of follow-up, the hazard ratio for overall survival was 1.28 in the no-surgery group (P = .03). “The survival was so good in this early-stage cohort that we had to extend the trial by 6 months to get the prerequisite number of deaths, underscoring the phenomenal importance of having a randomized comparative cohort for all future studies on surgery for mesothelioma,” said Dr. Lim.

After 42 months, there was no survival difference between the two groups (hazard ratio, 0.48; P = .15). Dr. Lim attributed the change at 42 months to the fact that only 15 patients remained in each arm at that stage. There was no significant difference between the two groups with respect to progression-free survival.

The survival benefit of the no-surgery group was sustained after additional analyses, including adjustment of the number of first-line chemotherapy cycles and immunotherapy received after completion of the trial protocol.

Adverse events were more common in the surgery group (incidence rate ratio, 3.6; P < .001), including any cardiac disorder (IRR, 2.73; 95% confidence interval, 1.11-6.67); any infection or infestation (IRR, 1.99; 95% CI, 1.33-2.99); any respiratory, thoracic, or mediastinal disorder (IRR, 2.40; 95% CI, 1.52-3.80); and any surgical or medical procedure (IRR, 2.23; 95% CI, 1.04-4.78). The EORTC quality of life score favored the nonsurgery group at 6 weeks, but there was no significant difference at other time points.

Dr. Lim and Dr. Figueroa have no relevant financial disclosures.

Pleural mesothelioma is generally treated by extended pleurectomy decortication, and there has been little improvement in systemic treatment of early-stage, resectable mesothelioma, which has led to the recommendations of maximum cytoreduction. U.S. and European guidelines, as well as an international consensus statement, support this approach, but it has never been tested in a randomized, controlled trial.

Now it has, and the result is surprising: Surgery led to reduced survival and more serious adverse events, compared with chemotherapy alone. The conclusion was uncomfortable for Eric Lim, MD, who presented the results of the MARS2 trial at the annual World Conference on Lung Cancer. “Ladies and gentlemen, as a surgeon standing here, you have no idea how much it pains me to conclude that extended pleurectomy decortication, an operation that we have been offering for over 70 years, has been associated with a higher risk of death, more serious complications, poorer quality of life, and higher costs, compared to mesothelioma patients who were randomized to chemotherapy alone,” said Dr. Lim of the Royal Brompton Hospital, London, during his presentation.

Although the line drew laughter and applause from the audience, Paula Ugalde Figueroa, MD, who served as a discussant, raised some concerns about the study. Disease presence in one hemithorax was assessed only by chest CT scan, which is notorious for underestimating the volume of disease during surgery. There was also no information on pleural effusion or how many patients received it prior to intervention. Existing guidelines suggest staging of mesothelioma should also use PET scans, and invasive mediastinal staging should be assessed with endobronchial ultrasound. “None of these were performed during the trial,” said Dr. Figueroa, who is an associate thoracic surgeon at Brigham and Women’s Hospital, Boston. “At this point, my question is, are the arms of this study well balanced in regard to tumor volume? We don’t know,” she added.

Dr. Figueroa noted that the 90-day mortality seemed higher than that seen in other studies. “So, does the surgeon’s experience and center volume affect the outcome of this study?” she asked. Dr. Figueroa personally made phone calls to the participating centers and found that 45% of the patients in the trial were treated at low-volume centers, defined by her as two to three patients per year. “Should we assume that their surgical outcomes are similar between those centers? In this trial, with approximately half of patients from low-volume centers, extended pleurectomy decortication for mesothelioma had no significant difference when compared to those patients that underwent chemotherapy alone. Would the outcome be different in exclusively high-volume centers?” she concluded.

The study randomized 335 patients to receive surgery and chemotherapy, or chemotherapy alone. They received two cycles of platinum-based chemotherapy and pemetrexed prior to surgery and up to four cycles after surgery. The average age was 69 years; 86.9% were male, and 85.7% of tumors were epithelioid only. Among those in the surgery group, 88.5% underwent extended pleurectomy/decortication, 8.3% underwent pleurectomy decortication, 1.9% underwent partial pleurectomy, 0.6% exploration with no pleurodesis, and 0.6% were classified as “other” surgery. Completeness of resection was R0 in 3.2% of surgeries, R1 in 80.9%, and R2 in 15.9%. In-hospital mortality occurred in 3.8% of patients, and postsurgical 90-day mortality was 8.9%.

Over the first 42 months of follow-up, the hazard ratio for overall survival was 1.28 in the no-surgery group (P = .03). “The survival was so good in this early-stage cohort that we had to extend the trial by 6 months to get the prerequisite number of deaths, underscoring the phenomenal importance of having a randomized comparative cohort for all future studies on surgery for mesothelioma,” said Dr. Lim.

After 42 months, there was no survival difference between the two groups (hazard ratio, 0.48; P = .15). Dr. Lim attributed the change at 42 months to the fact that only 15 patients remained in each arm at that stage. There was no significant difference between the two groups with respect to progression-free survival.

The survival benefit of the no-surgery group was sustained after additional analyses, including adjustment of the number of first-line chemotherapy cycles and immunotherapy received after completion of the trial protocol.

Adverse events were more common in the surgery group (incidence rate ratio, 3.6; P < .001), including any cardiac disorder (IRR, 2.73; 95% confidence interval, 1.11-6.67); any infection or infestation (IRR, 1.99; 95% CI, 1.33-2.99); any respiratory, thoracic, or mediastinal disorder (IRR, 2.40; 95% CI, 1.52-3.80); and any surgical or medical procedure (IRR, 2.23; 95% CI, 1.04-4.78). The EORTC quality of life score favored the nonsurgery group at 6 weeks, but there was no significant difference at other time points.

Dr. Lim and Dr. Figueroa have no relevant financial disclosures.

Pleural mesothelioma is generally treated by extended pleurectomy decortication, and there has been little improvement in systemic treatment of early-stage, resectable mesothelioma, which has led to the recommendations of maximum cytoreduction. U.S. and European guidelines, as well as an international consensus statement, support this approach, but it has never been tested in a randomized, controlled trial.

Now it has, and the result is surprising: Surgery led to reduced survival and more serious adverse events, compared with chemotherapy alone. The conclusion was uncomfortable for Eric Lim, MD, who presented the results of the MARS2 trial at the annual World Conference on Lung Cancer. “Ladies and gentlemen, as a surgeon standing here, you have no idea how much it pains me to conclude that extended pleurectomy decortication, an operation that we have been offering for over 70 years, has been associated with a higher risk of death, more serious complications, poorer quality of life, and higher costs, compared to mesothelioma patients who were randomized to chemotherapy alone,” said Dr. Lim of the Royal Brompton Hospital, London, during his presentation.

Although the line drew laughter and applause from the audience, Paula Ugalde Figueroa, MD, who served as a discussant, raised some concerns about the study. Disease presence in one hemithorax was assessed only by chest CT scan, which is notorious for underestimating the volume of disease during surgery. There was also no information on pleural effusion or how many patients received it prior to intervention. Existing guidelines suggest staging of mesothelioma should also use PET scans, and invasive mediastinal staging should be assessed with endobronchial ultrasound. “None of these were performed during the trial,” said Dr. Figueroa, who is an associate thoracic surgeon at Brigham and Women’s Hospital, Boston. “At this point, my question is, are the arms of this study well balanced in regard to tumor volume? We don’t know,” she added.

Dr. Figueroa noted that the 90-day mortality seemed higher than that seen in other studies. “So, does the surgeon’s experience and center volume affect the outcome of this study?” she asked. Dr. Figueroa personally made phone calls to the participating centers and found that 45% of the patients in the trial were treated at low-volume centers, defined by her as two to three patients per year. “Should we assume that their surgical outcomes are similar between those centers? In this trial, with approximately half of patients from low-volume centers, extended pleurectomy decortication for mesothelioma had no significant difference when compared to those patients that underwent chemotherapy alone. Would the outcome be different in exclusively high-volume centers?” she concluded.

The study randomized 335 patients to receive surgery and chemotherapy, or chemotherapy alone. They received two cycles of platinum-based chemotherapy and pemetrexed prior to surgery and up to four cycles after surgery. The average age was 69 years; 86.9% were male, and 85.7% of tumors were epithelioid only. Among those in the surgery group, 88.5% underwent extended pleurectomy/decortication, 8.3% underwent pleurectomy decortication, 1.9% underwent partial pleurectomy, 0.6% exploration with no pleurodesis, and 0.6% were classified as “other” surgery. Completeness of resection was R0 in 3.2% of surgeries, R1 in 80.9%, and R2 in 15.9%. In-hospital mortality occurred in 3.8% of patients, and postsurgical 90-day mortality was 8.9%.

Over the first 42 months of follow-up, the hazard ratio for overall survival was 1.28 in the no-surgery group (P = .03). “The survival was so good in this early-stage cohort that we had to extend the trial by 6 months to get the prerequisite number of deaths, underscoring the phenomenal importance of having a randomized comparative cohort for all future studies on surgery for mesothelioma,” said Dr. Lim.

After 42 months, there was no survival difference between the two groups (hazard ratio, 0.48; P = .15). Dr. Lim attributed the change at 42 months to the fact that only 15 patients remained in each arm at that stage. There was no significant difference between the two groups with respect to progression-free survival.

The survival benefit of the no-surgery group was sustained after additional analyses, including adjustment of the number of first-line chemotherapy cycles and immunotherapy received after completion of the trial protocol.

Adverse events were more common in the surgery group (incidence rate ratio, 3.6; P < .001), including any cardiac disorder (IRR, 2.73; 95% confidence interval, 1.11-6.67); any infection or infestation (IRR, 1.99; 95% CI, 1.33-2.99); any respiratory, thoracic, or mediastinal disorder (IRR, 2.40; 95% CI, 1.52-3.80); and any surgical or medical procedure (IRR, 2.23; 95% CI, 1.04-4.78). The EORTC quality of life score favored the nonsurgery group at 6 weeks, but there was no significant difference at other time points.

Dr. Lim and Dr. Figueroa have no relevant financial disclosures.

People with type 1 diabetes have not experienced the same improved survival after a heart attack over the past 15 years that has occurred in people with type 2 diabetes and those without diabetes, new research shows.

Between 2006 and 2020, the annual incidences of overall mortality and major adverse cardiovascular events after a first-time myocardial infarction dropped significantly for people with type 2 diabetes and those without diabetes (controls).

However, the same trend was not seen for people with type 1 diabetes.

“There is an urgent need for further studies understanding cardiovascular disease in people with type 1 diabetes. Clinicians have to be aware of the absence of the declined mortality trend in people with type 1 diabetes having a first-time myocardial infarction,” lead author Thomas Nyström, MD, professor of medicine at the Karolinska Institute, Stockholm, said in an interview.

The findings are scheduled to be presented Oct. 5, 2023, at the annual meeting of the European Association for the Study of Diabetes.

Discussing potential reasons for the findings, the authors say that the standard care after a heart attack has improved with more availability of, for example, percutaneous coronary intervention and better overall medical treatment. However, this standard of care should have improved in all three groups.

“Although glycemic control and diabetes duration were much different between diabetes groups, in that those with type 1 had been exposed for a longer period of glycemia, the current study cannot tell whether glucose control is behind the association between mortality trends observed. Whether this is the case must be investigated with further studies,” Nyström said.
 

Data from Swedish health care registry

Among people with a first-time MI recorded in national Swedish health care registries between 2006 and 2020, there were 2,527 individuals with type 1 diabetes, 48,321 with type 2 diabetes, and 243,170 controls with neither form of diabetes.

Those with type 1 diabetes were younger than those with type 2 diabetes and controls (62 years vs. 75 and 73 years, respectively). The type 1 diabetes group also had a higher proportion of females (43.6% vs. 38.1% of both the type 2 diabetes and control groups).

The proportions of people with the most severe type of heart attack, ST-elevation MI (STEMI), versus non-STEMI were 29% versus 71% in the type 1 diabetes group, 30% versus 70% in the type 2 diabetes group, and 39% versus 61% in the control group, respectively.

After adjustment for covariates including age, sex, comorbidities, socioeconomic factors, and medication, there was a significant decreased annual incidence trend for all-cause death among the controls (–1.9%) and persons with type 2 diabetes (–1.3%), but there was no such decrease among those with type 1 diabetes.

For cardiovascular deaths, the annual incidence declines were –2.0% and –1.6% in the control group and the type 2 diabetes group, respectively, versus a nonsignificant –0.5% decline in the type 1 diabetes group. Similarly, for major adverse cardiovascular events, those decreases were –2.0% for controls and –1.6% for those with type 2 diabetes, but –0.6% for those with type 1 diabetes – again, a nonsignificant value.

“During the last 15 years, the risk of death and major cardiovascular events in people without diabetes and with type 2 diabetes after having a first-time heart attack has decreased significantly. In contrast, this decreasing trend was absent in people with type 1 diabetes. Our study highlights the urgent need for understanding the cardiovascular risk in people with type 1 diabetes,” the authors conclude.

Dr. Nyström has received honoraria from AstraZeneca, Merck Sharp & Dohme, Novo Nordisk, Eli Lilly , Boehringer Ingelheim, Abbott, and Amgen. The authors acknowledge the ALF agreement between Stockholm County Council and Karolinska Institutet.

A version of this article appeared on Medscape.com.

People with type 1 diabetes have not experienced the same improved survival after a heart attack over the past 15 years that has occurred in people with type 2 diabetes and those without diabetes, new research shows.

Between 2006 and 2020, the annual incidences of overall mortality and major adverse cardiovascular events after a first-time myocardial infarction dropped significantly for people with type 2 diabetes and those without diabetes (controls).

However, the same trend was not seen for people with type 1 diabetes.

“There is an urgent need for further studies understanding cardiovascular disease in people with type 1 diabetes. Clinicians have to be aware of the absence of the declined mortality trend in people with type 1 diabetes having a first-time myocardial infarction,” lead author Thomas Nyström, MD, professor of medicine at the Karolinska Institute, Stockholm, said in an interview.

The findings are scheduled to be presented Oct. 5, 2023, at the annual meeting of the European Association for the Study of Diabetes.

Discussing potential reasons for the findings, the authors say that the standard care after a heart attack has improved with more availability of, for example, percutaneous coronary intervention and better overall medical treatment. However, this standard of care should have improved in all three groups.

“Although glycemic control and diabetes duration were much different between diabetes groups, in that those with type 1 had been exposed for a longer period of glycemia, the current study cannot tell whether glucose control is behind the association between mortality trends observed. Whether this is the case must be investigated with further studies,” Nyström said.
 

Data from Swedish health care registry

Among people with a first-time MI recorded in national Swedish health care registries between 2006 and 2020, there were 2,527 individuals with type 1 diabetes, 48,321 with type 2 diabetes, and 243,170 controls with neither form of diabetes.

Those with type 1 diabetes were younger than those with type 2 diabetes and controls (62 years vs. 75 and 73 years, respectively). The type 1 diabetes group also had a higher proportion of females (43.6% vs. 38.1% of both the type 2 diabetes and control groups).

The proportions of people with the most severe type of heart attack, ST-elevation MI (STEMI), versus non-STEMI were 29% versus 71% in the type 1 diabetes group, 30% versus 70% in the type 2 diabetes group, and 39% versus 61% in the control group, respectively.

After adjustment for covariates including age, sex, comorbidities, socioeconomic factors, and medication, there was a significant decreased annual incidence trend for all-cause death among the controls (–1.9%) and persons with type 2 diabetes (–1.3%), but there was no such decrease among those with type 1 diabetes.

For cardiovascular deaths, the annual incidence declines were –2.0% and –1.6% in the control group and the type 2 diabetes group, respectively, versus a nonsignificant –0.5% decline in the type 1 diabetes group. Similarly, for major adverse cardiovascular events, those decreases were –2.0% for controls and –1.6% for those with type 2 diabetes, but –0.6% for those with type 1 diabetes – again, a nonsignificant value.

“During the last 15 years, the risk of death and major cardiovascular events in people without diabetes and with type 2 diabetes after having a first-time heart attack has decreased significantly. In contrast, this decreasing trend was absent in people with type 1 diabetes. Our study highlights the urgent need for understanding the cardiovascular risk in people with type 1 diabetes,” the authors conclude.

Dr. Nyström has received honoraria from AstraZeneca, Merck Sharp & Dohme, Novo Nordisk, Eli Lilly , Boehringer Ingelheim, Abbott, and Amgen. The authors acknowledge the ALF agreement between Stockholm County Council and Karolinska Institutet.

A version of this article appeared on Medscape.com.

People with type 1 diabetes have not experienced the same improved survival after a heart attack over the past 15 years that has occurred in people with type 2 diabetes and those without diabetes, new research shows.

Between 2006 and 2020, the annual incidences of overall mortality and major adverse cardiovascular events after a first-time myocardial infarction dropped significantly for people with type 2 diabetes and those without diabetes (controls).

However, the same trend was not seen for people with type 1 diabetes.

“There is an urgent need for further studies understanding cardiovascular disease in people with type 1 diabetes. Clinicians have to be aware of the absence of the declined mortality trend in people with type 1 diabetes having a first-time myocardial infarction,” lead author Thomas Nyström, MD, professor of medicine at the Karolinska Institute, Stockholm, said in an interview.

The findings are scheduled to be presented Oct. 5, 2023, at the annual meeting of the European Association for the Study of Diabetes.

Discussing potential reasons for the findings, the authors say that the standard care after a heart attack has improved with more availability of, for example, percutaneous coronary intervention and better overall medical treatment. However, this standard of care should have improved in all three groups.

“Although glycemic control and diabetes duration were much different between diabetes groups, in that those with type 1 had been exposed for a longer period of glycemia, the current study cannot tell whether glucose control is behind the association between mortality trends observed. Whether this is the case must be investigated with further studies,” Nyström said.
 

Data from Swedish health care registry

Among people with a first-time MI recorded in national Swedish health care registries between 2006 and 2020, there were 2,527 individuals with type 1 diabetes, 48,321 with type 2 diabetes, and 243,170 controls with neither form of diabetes.

Those with type 1 diabetes were younger than those with type 2 diabetes and controls (62 years vs. 75 and 73 years, respectively). The type 1 diabetes group also had a higher proportion of females (43.6% vs. 38.1% of both the type 2 diabetes and control groups).

The proportions of people with the most severe type of heart attack, ST-elevation MI (STEMI), versus non-STEMI were 29% versus 71% in the type 1 diabetes group, 30% versus 70% in the type 2 diabetes group, and 39% versus 61% in the control group, respectively.

After adjustment for covariates including age, sex, comorbidities, socioeconomic factors, and medication, there was a significant decreased annual incidence trend for all-cause death among the controls (–1.9%) and persons with type 2 diabetes (–1.3%), but there was no such decrease among those with type 1 diabetes.

For cardiovascular deaths, the annual incidence declines were –2.0% and –1.6% in the control group and the type 2 diabetes group, respectively, versus a nonsignificant –0.5% decline in the type 1 diabetes group. Similarly, for major adverse cardiovascular events, those decreases were –2.0% for controls and –1.6% for those with type 2 diabetes, but –0.6% for those with type 1 diabetes – again, a nonsignificant value.

“During the last 15 years, the risk of death and major cardiovascular events in people without diabetes and with type 2 diabetes after having a first-time heart attack has decreased significantly. In contrast, this decreasing trend was absent in people with type 1 diabetes. Our study highlights the urgent need for understanding the cardiovascular risk in people with type 1 diabetes,” the authors conclude.

Dr. Nyström has received honoraria from AstraZeneca, Merck Sharp & Dohme, Novo Nordisk, Eli Lilly , Boehringer Ingelheim, Abbott, and Amgen. The authors acknowledge the ALF agreement between Stockholm County Council and Karolinska Institutet.

A version of this article appeared on Medscape.com.

Whether you’ve decided to retire, relocate, or work for your local hospital, unwinding your practice will take time. Physicians can avoid mistakes by planning ahead and making a checklist for what to do and when to do it.

“Doctors shouldn’t assume everything takes care of itself. Many don’t think about compliance issues, patient abandonment, or accounts receivable that they need to keep open to collect from billing, which can occur months after the dates of service,” said David Zetter, president of Zetter HealthCare management consultants in Pennsylvania.

Debra Phairas, president of Practice and Liability Consultants, LLC, in California, suggests doctors start planning for the closing of their practice at least 90-120 days from their closing date.

“Many people and entities need to be notified,” said Ms. Phairas. The list includes patients, payers, vendors, employees, licensing boards, and federal and state agencies.

Medical societies may have specific bylaws that apply; malpractice carriers have rules about how long you should retain medical records; and some state laws require that you communicate that you’re closing in a newspaper, Mr. Zetter added.

Ms. Phairas recommends that physicians decide first whether they will sell their practice or if they’ll just shut it down. If they sell and the buyer is a doctor, they may want to provide transition assistance such as introducing patients and staff, she said. Otherwise, doctors may need to terminate their staff.

After doctors make that decision, Mr. Zetter and Ms. Phairas recommend taking these 12 steps to ensure that the process goes smoothly.
 

What to do 60-90 days out

1. Check your insurance contracts. The Centers for Medicare & Medicaid Services requires physicians to notify them 90 days after deciding to retire or withdraw from Medicare or Medicaid. Other payers may also require 90 days’ notice to terminate their contracts.

You’ll also need to provide payers with a forwarding address for sending payments after the office closes, and notify your malpractice insurance carrier and any other contracted insurance carriers such as workers’ compensation or employee benefit plans.

2. Buy “tail” coverage. Doctors can be sued for malpractice years after they close their practice so this provides coverage against claims reported after the liability policy expires.

3. Check your hospital contracts. Most hospitals where you have privileges require 90 days’ notice that you are closing the practice.

4. Arrange for safe storage of medical records. If you are selling your practice to another physician, that doctor can take charge of them, as long as you obtain a patient’s consent to transfer the medical records, said Ms. Phairas. Otherwise, the practice is required to make someone the guardian of the records after the practice closes, said Mr. Zetter. This allows patients at a later date to obtain copies of their records at a cost.

“This usually means printing all the records to PDF to be retained; otherwise, doctors have to continue to pay the license fee for the EMR software to access the records, and no practice is going to continue to pay this indefinitely,” said Mr. Zetter.

Check with your malpractice insurance carrier for how long they require medical records to be retained, which may vary for adult and pediatric records.

Ms. Phairas also advises doctors to keep their original records. “The biggest mistake doctors can make is to give patients all their records. Your chart is your best defense weapon in a liability claim.”
 

What to do 30-60 days out

5. Tell your staff. They should not hear that you’re retiring or leaving the practice from other people, said Ms. Phairas. But timing is important. “If you notify them too soon, they may look for another job. I recommend telling them about 45 days out and just before you notify patients, although you may want to tell the office manager sooner.”

Doctors may need help closing the practice and should consider offering the employees a severance bonus to stay until the end, said Ms. Phairas. If they do leave sooner, then you can hire temporary staff.

6. Notify patients to avoid any claims of abandonment. You should notify all active patients, which, depending on your state, can be any patient the physician has treated sometime in the past 12-36 months.

Some state laws require the notice to be published as an advertisement in the local newspaper and will say how far in advance it needs to be published and how long the ad needs to run. Notification also should be posted throughout the practice, and patients who call or visit should be given oral reminders.

“Your biggest expense will be mailing a letter to all patients,” said Mr. Zetter. The letter should include:

• The date of closing.
• The name(s) of the physicians taking over the practice (if applicable).
• Local physicians who would be willing to accept new patients.
• Instructions for how patients can obtain or transfer medical records (with a deadline for submitting record requests).
• How to contact the practice if patients and families have any concerns about the closing.

7. Notify your professional associations. These include your state medical board, credentialing organizations, and professional memberships. It’s critical to renew your license even if you plan to practice in other states. He recalled that one doctor let his license lapse and the medical board notified Medicaid that he was no longer licensed. “CMS went after him because he didn’t notify them that he was no longer operating in Washington. CMS shut him down in every state/territory. This interventional radiologist spent 3 years with two attorneys to get it resolved,” said Mr. Zetter.

8. Terminate any leases with landlords or try to negotiate renting the office space on a month-to-month basis until you close or sell, suggests Ms. Phairas. If the practice owns the space, the partners will need to decide if the space will be sold or leased to a new business.
 

What to do 30 days out

9. Notify referring physicians of when you plan to close your practice so they don’t send new patients after that date.

10. Send a letter to the Drug Enforcement Agency to deactivate your license if you plan not to write another prescription and after you have safely disposed of prescription drugs following the federal guidelines. Destroy all prescription pads and contact drug representatives to determine what to do with unused samples, if needed.

11. Notify all vendors. Inform medical suppliers, office suppliers, collection agencies, laundry services, housekeeping services, hazardous waste disposal services, and any other vendors. Make sure to request a final statement from them so you can close out your accounts.

12. Process your accounts receivable to collect money owed to you. Consider employing a collection agency or staff member to reconcile accounts after the practice has closed.

Mr. Zetter also suggested retaining a certified accountant to handle the expenses for shutting down the business and to handle your future tax returns. “If you shut down the practice in 2023, you will still have to file a tax return for that year in 2024,” he said.

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

Whether you’ve decided to retire, relocate, or work for your local hospital, unwinding your practice will take time. Physicians can avoid mistakes by planning ahead and making a checklist for what to do and when to do it.

“Doctors shouldn’t assume everything takes care of itself. Many don’t think about compliance issues, patient abandonment, or accounts receivable that they need to keep open to collect from billing, which can occur months after the dates of service,” said David Zetter, president of Zetter HealthCare management consultants in Pennsylvania.

Debra Phairas, president of Practice and Liability Consultants, LLC, in California, suggests doctors start planning for the closing of their practice at least 90-120 days from their closing date.

“Many people and entities need to be notified,” said Ms. Phairas. The list includes patients, payers, vendors, employees, licensing boards, and federal and state agencies.

Medical societies may have specific bylaws that apply; malpractice carriers have rules about how long you should retain medical records; and some state laws require that you communicate that you’re closing in a newspaper, Mr. Zetter added.

Ms. Phairas recommends that physicians decide first whether they will sell their practice or if they’ll just shut it down. If they sell and the buyer is a doctor, they may want to provide transition assistance such as introducing patients and staff, she said. Otherwise, doctors may need to terminate their staff.

After doctors make that decision, Mr. Zetter and Ms. Phairas recommend taking these 12 steps to ensure that the process goes smoothly.
 

What to do 60-90 days out

1. Check your insurance contracts. The Centers for Medicare & Medicaid Services requires physicians to notify them 90 days after deciding to retire or withdraw from Medicare or Medicaid. Other payers may also require 90 days’ notice to terminate their contracts.

You’ll also need to provide payers with a forwarding address for sending payments after the office closes, and notify your malpractice insurance carrier and any other contracted insurance carriers such as workers’ compensation or employee benefit plans.

2. Buy “tail” coverage. Doctors can be sued for malpractice years after they close their practice so this provides coverage against claims reported after the liability policy expires.

3. Check your hospital contracts. Most hospitals where you have privileges require 90 days’ notice that you are closing the practice.

4. Arrange for safe storage of medical records. If you are selling your practice to another physician, that doctor can take charge of them, as long as you obtain a patient’s consent to transfer the medical records, said Ms. Phairas. Otherwise, the practice is required to make someone the guardian of the records after the practice closes, said Mr. Zetter. This allows patients at a later date to obtain copies of their records at a cost.

“This usually means printing all the records to PDF to be retained; otherwise, doctors have to continue to pay the license fee for the EMR software to access the records, and no practice is going to continue to pay this indefinitely,” said Mr. Zetter.

Check with your malpractice insurance carrier for how long they require medical records to be retained, which may vary for adult and pediatric records.

Ms. Phairas also advises doctors to keep their original records. “The biggest mistake doctors can make is to give patients all their records. Your chart is your best defense weapon in a liability claim.”
 

What to do 30-60 days out

5. Tell your staff. They should not hear that you’re retiring or leaving the practice from other people, said Ms. Phairas. But timing is important. “If you notify them too soon, they may look for another job. I recommend telling them about 45 days out and just before you notify patients, although you may want to tell the office manager sooner.”

Doctors may need help closing the practice and should consider offering the employees a severance bonus to stay until the end, said Ms. Phairas. If they do leave sooner, then you can hire temporary staff.

6. Notify patients to avoid any claims of abandonment. You should notify all active patients, which, depending on your state, can be any patient the physician has treated sometime in the past 12-36 months.

Some state laws require the notice to be published as an advertisement in the local newspaper and will say how far in advance it needs to be published and how long the ad needs to run. Notification also should be posted throughout the practice, and patients who call or visit should be given oral reminders.

“Your biggest expense will be mailing a letter to all patients,” said Mr. Zetter. The letter should include:

• The date of closing.
• The name(s) of the physicians taking over the practice (if applicable).
• Local physicians who would be willing to accept new patients.
• Instructions for how patients can obtain or transfer medical records (with a deadline for submitting record requests).
• How to contact the practice if patients and families have any concerns about the closing.

7. Notify your professional associations. These include your state medical board, credentialing organizations, and professional memberships. It’s critical to renew your license even if you plan to practice in other states. He recalled that one doctor let his license lapse and the medical board notified Medicaid that he was no longer licensed. “CMS went after him because he didn’t notify them that he was no longer operating in Washington. CMS shut him down in every state/territory. This interventional radiologist spent 3 years with two attorneys to get it resolved,” said Mr. Zetter.

8. Terminate any leases with landlords or try to negotiate renting the office space on a month-to-month basis until you close or sell, suggests Ms. Phairas. If the practice owns the space, the partners will need to decide if the space will be sold or leased to a new business.
 

What to do 30 days out

9. Notify referring physicians of when you plan to close your practice so they don’t send new patients after that date.

10. Send a letter to the Drug Enforcement Agency to deactivate your license if you plan not to write another prescription and after you have safely disposed of prescription drugs following the federal guidelines. Destroy all prescription pads and contact drug representatives to determine what to do with unused samples, if needed.

11. Notify all vendors. Inform medical suppliers, office suppliers, collection agencies, laundry services, housekeeping services, hazardous waste disposal services, and any other vendors. Make sure to request a final statement from them so you can close out your accounts.

12. Process your accounts receivable to collect money owed to you. Consider employing a collection agency or staff member to reconcile accounts after the practice has closed.

Mr. Zetter also suggested retaining a certified accountant to handle the expenses for shutting down the business and to handle your future tax returns. “If you shut down the practice in 2023, you will still have to file a tax return for that year in 2024,” he said.

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

Whether you’ve decided to retire, relocate, or work for your local hospital, unwinding your practice will take time. Physicians can avoid mistakes by planning ahead and making a checklist for what to do and when to do it.

“Doctors shouldn’t assume everything takes care of itself. Many don’t think about compliance issues, patient abandonment, or accounts receivable that they need to keep open to collect from billing, which can occur months after the dates of service,” said David Zetter, president of Zetter HealthCare management consultants in Pennsylvania.

Debra Phairas, president of Practice and Liability Consultants, LLC, in California, suggests doctors start planning for the closing of their practice at least 90-120 days from their closing date.

“Many people and entities need to be notified,” said Ms. Phairas. The list includes patients, payers, vendors, employees, licensing boards, and federal and state agencies.

Medical societies may have specific bylaws that apply; malpractice carriers have rules about how long you should retain medical records; and some state laws require that you communicate that you’re closing in a newspaper, Mr. Zetter added.

Ms. Phairas recommends that physicians decide first whether they will sell their practice or if they’ll just shut it down. If they sell and the buyer is a doctor, they may want to provide transition assistance such as introducing patients and staff, she said. Otherwise, doctors may need to terminate their staff.

After doctors make that decision, Mr. Zetter and Ms. Phairas recommend taking these 12 steps to ensure that the process goes smoothly.
 

What to do 60-90 days out

1. Check your insurance contracts. The Centers for Medicare & Medicaid Services requires physicians to notify them 90 days after deciding to retire or withdraw from Medicare or Medicaid. Other payers may also require 90 days’ notice to terminate their contracts.

You’ll also need to provide payers with a forwarding address for sending payments after the office closes, and notify your malpractice insurance carrier and any other contracted insurance carriers such as workers’ compensation or employee benefit plans.

2. Buy “tail” coverage. Doctors can be sued for malpractice years after they close their practice so this provides coverage against claims reported after the liability policy expires.

3. Check your hospital contracts. Most hospitals where you have privileges require 90 days’ notice that you are closing the practice.

4. Arrange for safe storage of medical records. If you are selling your practice to another physician, that doctor can take charge of them, as long as you obtain a patient’s consent to transfer the medical records, said Ms. Phairas. Otherwise, the practice is required to make someone the guardian of the records after the practice closes, said Mr. Zetter. This allows patients at a later date to obtain copies of their records at a cost.

“This usually means printing all the records to PDF to be retained; otherwise, doctors have to continue to pay the license fee for the EMR software to access the records, and no practice is going to continue to pay this indefinitely,” said Mr. Zetter.

Check with your malpractice insurance carrier for how long they require medical records to be retained, which may vary for adult and pediatric records.

Ms. Phairas also advises doctors to keep their original records. “The biggest mistake doctors can make is to give patients all their records. Your chart is your best defense weapon in a liability claim.”
 

What to do 30-60 days out

5. Tell your staff. They should not hear that you’re retiring or leaving the practice from other people, said Ms. Phairas. But timing is important. “If you notify them too soon, they may look for another job. I recommend telling them about 45 days out and just before you notify patients, although you may want to tell the office manager sooner.”

Doctors may need help closing the practice and should consider offering the employees a severance bonus to stay until the end, said Ms. Phairas. If they do leave sooner, then you can hire temporary staff.

6. Notify patients to avoid any claims of abandonment. You should notify all active patients, which, depending on your state, can be any patient the physician has treated sometime in the past 12-36 months.

Some state laws require the notice to be published as an advertisement in the local newspaper and will say how far in advance it needs to be published and how long the ad needs to run. Notification also should be posted throughout the practice, and patients who call or visit should be given oral reminders.

“Your biggest expense will be mailing a letter to all patients,” said Mr. Zetter. The letter should include:

• The date of closing.
• The name(s) of the physicians taking over the practice (if applicable).
• Local physicians who would be willing to accept new patients.
• Instructions for how patients can obtain or transfer medical records (with a deadline for submitting record requests).
• How to contact the practice if patients and families have any concerns about the closing.

7. Notify your professional associations. These include your state medical board, credentialing organizations, and professional memberships. It’s critical to renew your license even if you plan to practice in other states. He recalled that one doctor let his license lapse and the medical board notified Medicaid that he was no longer licensed. “CMS went after him because he didn’t notify them that he was no longer operating in Washington. CMS shut him down in every state/territory. This interventional radiologist spent 3 years with two attorneys to get it resolved,” said Mr. Zetter.

8. Terminate any leases with landlords or try to negotiate renting the office space on a month-to-month basis until you close or sell, suggests Ms. Phairas. If the practice owns the space, the partners will need to decide if the space will be sold or leased to a new business.
 

What to do 30 days out

9. Notify referring physicians of when you plan to close your practice so they don’t send new patients after that date.

10. Send a letter to the Drug Enforcement Agency to deactivate your license if you plan not to write another prescription and after you have safely disposed of prescription drugs following the federal guidelines. Destroy all prescription pads and contact drug representatives to determine what to do with unused samples, if needed.

11. Notify all vendors. Inform medical suppliers, office suppliers, collection agencies, laundry services, housekeeping services, hazardous waste disposal services, and any other vendors. Make sure to request a final statement from them so you can close out your accounts.

12. Process your accounts receivable to collect money owed to you. Consider employing a collection agency or staff member to reconcile accounts after the practice has closed.

Mr. Zetter also suggested retaining a certified accountant to handle the expenses for shutting down the business and to handle your future tax returns. “If you shut down the practice in 2023, you will still have to file a tax return for that year in 2024,” he said.

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

AGA is excited to announce the new co–editors-in-chief of Cellular and Molecular Gastroenterology and Hepatology (CMGH). Michele A. Battle, PhD, and Jonathan P. Katz, MD, will be taking over their new roles beginning July 1, 2024.

“In my role as co–editor-in-chief of CMGH, I look forward to working with Jonathan Katz to advance its longstanding mission to disseminate rigorous, reproducible, and impactful digestive biology research. I am excited to launch new initiatives including the addition of special topic editors who will cover themes relating to early career investigators and diversity, equity, and inclusion,” said Dr. Battle, who is a professor in the department of cell biology, neurobiology, and anatomy at the Medical College of Wisconsin, Milwaukee.

Jonathan P. Katz, MD

“I am honored to work with Michele Battle and the rest of our new CMGH board of editors. Some of our goals are to expand CMGH outreach and engagement, incorporate more programs and opportunities for junior investigators, and provide rapid advancements and technical reports that drive research in the field. As such, we will strive to ensure that CMGH remains the preeminent journal focused on high-impact, basic, mechanistic research in GI and hepatology,” said Dr. Katz, an associate professor of medicine in the department of medicine gastroenterology division, director of molecular pathology and imaging care, and director of the undergraduate student scholars program at the University of Pennsylvania, Philadelphia. He is also currently an associate editor for CMGH.

Dr. Battle and Dr. Katz are former AGA Research Foundation awardees, with Dr. Battle receiving an AGA Research Scholar Award in 2009 and Dr. Katz receiving the AGA Astra Merck Advanced Research Training Award in 1998.

Over the next year, they will meet with the current editorial board and start to plan and develop new special sections and initiatives to bring to CMGH during their term.

Please join us in congratulating Dr. Battle and Dr. Katz on their new role as incoming co–editors-in chief.
 

AGA is excited to announce the new co–editors-in-chief of Cellular and Molecular Gastroenterology and Hepatology (CMGH). Michele A. Battle, PhD, and Jonathan P. Katz, MD, will be taking over their new roles beginning July 1, 2024.

“In my role as co–editor-in-chief of CMGH, I look forward to working with Jonathan Katz to advance its longstanding mission to disseminate rigorous, reproducible, and impactful digestive biology research. I am excited to launch new initiatives including the addition of special topic editors who will cover themes relating to early career investigators and diversity, equity, and inclusion,” said Dr. Battle, who is a professor in the department of cell biology, neurobiology, and anatomy at the Medical College of Wisconsin, Milwaukee.

Jonathan P. Katz, MD

“I am honored to work with Michele Battle and the rest of our new CMGH board of editors. Some of our goals are to expand CMGH outreach and engagement, incorporate more programs and opportunities for junior investigators, and provide rapid advancements and technical reports that drive research in the field. As such, we will strive to ensure that CMGH remains the preeminent journal focused on high-impact, basic, mechanistic research in GI and hepatology,” said Dr. Katz, an associate professor of medicine in the department of medicine gastroenterology division, director of molecular pathology and imaging care, and director of the undergraduate student scholars program at the University of Pennsylvania, Philadelphia. He is also currently an associate editor for CMGH.

Dr. Battle and Dr. Katz are former AGA Research Foundation awardees, with Dr. Battle receiving an AGA Research Scholar Award in 2009 and Dr. Katz receiving the AGA Astra Merck Advanced Research Training Award in 1998.

Over the next year, they will meet with the current editorial board and start to plan and develop new special sections and initiatives to bring to CMGH during their term.

Please join us in congratulating Dr. Battle and Dr. Katz on their new role as incoming co–editors-in chief.
 

AGA is excited to announce the new co–editors-in-chief of Cellular and Molecular Gastroenterology and Hepatology (CMGH). Michele A. Battle, PhD, and Jonathan P. Katz, MD, will be taking over their new roles beginning July 1, 2024.

“In my role as co–editor-in-chief of CMGH, I look forward to working with Jonathan Katz to advance its longstanding mission to disseminate rigorous, reproducible, and impactful digestive biology research. I am excited to launch new initiatives including the addition of special topic editors who will cover themes relating to early career investigators and diversity, equity, and inclusion,” said Dr. Battle, who is a professor in the department of cell biology, neurobiology, and anatomy at the Medical College of Wisconsin, Milwaukee.

Jonathan P. Katz, MD

“I am honored to work with Michele Battle and the rest of our new CMGH board of editors. Some of our goals are to expand CMGH outreach and engagement, incorporate more programs and opportunities for junior investigators, and provide rapid advancements and technical reports that drive research in the field. As such, we will strive to ensure that CMGH remains the preeminent journal focused on high-impact, basic, mechanistic research in GI and hepatology,” said Dr. Katz, an associate professor of medicine in the department of medicine gastroenterology division, director of molecular pathology and imaging care, and director of the undergraduate student scholars program at the University of Pennsylvania, Philadelphia. He is also currently an associate editor for CMGH.

Dr. Battle and Dr. Katz are former AGA Research Foundation awardees, with Dr. Battle receiving an AGA Research Scholar Award in 2009 and Dr. Katz receiving the AGA Astra Merck Advanced Research Training Award in 1998.

Over the next year, they will meet with the current editorial board and start to plan and develop new special sections and initiatives to bring to CMGH during their term.

Please join us in congratulating Dr. Battle and Dr. Katz on their new role as incoming co–editors-in chief.