It was a quiet day. I got up around 3 o’clock in the afternoon for my shift at 6 p.m. I was shaking off the cobwebs and making coffee at our front window that overlooked Brown Street in North Philadelphia. I looked out the window and saw a man stumbling down the street, grabbing his abdomen and yelling for help. There was nobody else around so I went outside to see what was going on.

He was in his 50s or 60s, bleeding and obviously in distress. I had him sit down. Then I ran back inside and grabbed a dish towel and some exam gloves that I had in the house.

I ran back out and assessed him. A bullet had gone through one of his hands, but he had other wounds. I had to expose him, so I trauma stripped him on the sidewalk. I got his pants and his shirt off and saw a gunshot going through his lower pelvis. He was bleeding out from there.

I got the towel and started applying deep pressure down into the iliac vein in case they hit something, which I found out later, they had. I held it there. The man was just lying there begging not to die.

I’m someone who is very calm, maybe abnormally calm, as people tell me. I try to use that during my resuscitations and traumas. Just keeping everybody calm makes the situation easier. Afterwards, people asked me, “Weren’t you worried that you were going to get shot?” That does happen in North Philadelphia. But it didn’t even cross my mind.

I didn’t have to think at all about what I was doing. We saw so many gunshots, especially at Einstein Medical Center. We saw them daily. I’d sometimes get more than half a dozen gunshots in one shift.

So, I was holding pressure and some people started to come over. I got somebody to call 911 and asked the man about his medical history. I found out he had diabetes. Five or 10 minutes later, EMS showed up. They looked pretty stunned when I was able to give the handoff presentation to them. I told them what happened and his back-story. I wanted to make sure they would check his sugar and take extra precautions.

They got him on the stretcher, and he eventually made it to the hospital where he had surgery. They had to have a vascular surgeon work on him. I called later, and they told me, “Yeah, he’s alive.” But that’s about the extent of the update I got.

After the ambulance left, it was kind of chaos. All the neighbors poured out of their houses. People were panicked, talking and getting excited about it. I didn’t know, but everyone else had actually been home the whole time. They didn’t come out until then.

I went back inside and tried to get ready for work. I wasn’t planning on talking to the media, but my next door neighbor just walked the news camera crew over to my house and knocked on my door. I wasn’t exactly dressed to be on TV, but they talked to me on camera, and it was on the news later that night.

I went to work and didn’t say anything about it. To be honest, I was trying to avoid telling anyone. Our team had a close-knit bond, and we would often tease each other when we received any type of recognition.

Naturally one of my attendings saw it on the local news and told everybody. So, I got a lot of happy harassment for quite some time. Someone baked me a cake that said, “Hero of Fairmount” (the Philly neighborhood in which I live). Someone else printed out a photo of me that said, “Stop the Bleed Hero of Fairmount,” and put it on every single computer screen.

The man came to see me about 2 weeks later (a neighbor told him where I lived). The man was very tearful and gave me a big hug. We just embraced for a while, and he said how thankful he was. He brought me a bottle of wine, which I thought was really nice.

He told me what happened to him: There was a lot of construction on our street and he was the contractor overseeing a couple of home remodels and demolitions. Sometimes he paid workers in cash and carried it with him. Somebody had tipped off somebody else that he was going to be there that day. The contractor walked into one of the houses and a guy in a ski mask waited there with a gun. The guy shot him and took the cash. The bullet went through his hand into his pelvis.

I had never had to deal with something that intense before outside of work. Most of it really comes down to the basics – the ABCs and bleeding control. You do whatever you can with what you have. In this case, it was just a dish towel, gloves, and my hands to put as much pressure as possible.

It really was strange that I happened to be looking out the window at that moment. I don’t know if it was just a coincidence. The man told me he believed God had put somebody there at the right place at the right time to save his life. I just felt very fortunate to have been able to help him. I never saw him again.

I think something like this gives you a little confidence that you can actually do something and make a meaningful impact anywhere when it’s needed. It lets you know that you’re capable of doing it. You always think about it, but you don’t know until it happens.

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

It was a quiet day. I got up around 3 o’clock in the afternoon for my shift at 6 p.m. I was shaking off the cobwebs and making coffee at our front window that overlooked Brown Street in North Philadelphia. I looked out the window and saw a man stumbling down the street, grabbing his abdomen and yelling for help. There was nobody else around so I went outside to see what was going on.

He was in his 50s or 60s, bleeding and obviously in distress. I had him sit down. Then I ran back inside and grabbed a dish towel and some exam gloves that I had in the house.

I ran back out and assessed him. A bullet had gone through one of his hands, but he had other wounds. I had to expose him, so I trauma stripped him on the sidewalk. I got his pants and his shirt off and saw a gunshot going through his lower pelvis. He was bleeding out from there.

I got the towel and started applying deep pressure down into the iliac vein in case they hit something, which I found out later, they had. I held it there. The man was just lying there begging not to die.

I’m someone who is very calm, maybe abnormally calm, as people tell me. I try to use that during my resuscitations and traumas. Just keeping everybody calm makes the situation easier. Afterwards, people asked me, “Weren’t you worried that you were going to get shot?” That does happen in North Philadelphia. But it didn’t even cross my mind.

I didn’t have to think at all about what I was doing. We saw so many gunshots, especially at Einstein Medical Center. We saw them daily. I’d sometimes get more than half a dozen gunshots in one shift.

So, I was holding pressure and some people started to come over. I got somebody to call 911 and asked the man about his medical history. I found out he had diabetes. Five or 10 minutes later, EMS showed up. They looked pretty stunned when I was able to give the handoff presentation to them. I told them what happened and his back-story. I wanted to make sure they would check his sugar and take extra precautions.

They got him on the stretcher, and he eventually made it to the hospital where he had surgery. They had to have a vascular surgeon work on him. I called later, and they told me, “Yeah, he’s alive.” But that’s about the extent of the update I got.

After the ambulance left, it was kind of chaos. All the neighbors poured out of their houses. People were panicked, talking and getting excited about it. I didn’t know, but everyone else had actually been home the whole time. They didn’t come out until then.

I went back inside and tried to get ready for work. I wasn’t planning on talking to the media, but my next door neighbor just walked the news camera crew over to my house and knocked on my door. I wasn’t exactly dressed to be on TV, but they talked to me on camera, and it was on the news later that night.

I went to work and didn’t say anything about it. To be honest, I was trying to avoid telling anyone. Our team had a close-knit bond, and we would often tease each other when we received any type of recognition.

Naturally one of my attendings saw it on the local news and told everybody. So, I got a lot of happy harassment for quite some time. Someone baked me a cake that said, “Hero of Fairmount” (the Philly neighborhood in which I live). Someone else printed out a photo of me that said, “Stop the Bleed Hero of Fairmount,” and put it on every single computer screen.

The man came to see me about 2 weeks later (a neighbor told him where I lived). The man was very tearful and gave me a big hug. We just embraced for a while, and he said how thankful he was. He brought me a bottle of wine, which I thought was really nice.

He told me what happened to him: There was a lot of construction on our street and he was the contractor overseeing a couple of home remodels and demolitions. Sometimes he paid workers in cash and carried it with him. Somebody had tipped off somebody else that he was going to be there that day. The contractor walked into one of the houses and a guy in a ski mask waited there with a gun. The guy shot him and took the cash. The bullet went through his hand into his pelvis.

I had never had to deal with something that intense before outside of work. Most of it really comes down to the basics – the ABCs and bleeding control. You do whatever you can with what you have. In this case, it was just a dish towel, gloves, and my hands to put as much pressure as possible.

It really was strange that I happened to be looking out the window at that moment. I don’t know if it was just a coincidence. The man told me he believed God had put somebody there at the right place at the right time to save his life. I just felt very fortunate to have been able to help him. I never saw him again.

I think something like this gives you a little confidence that you can actually do something and make a meaningful impact anywhere when it’s needed. It lets you know that you’re capable of doing it. You always think about it, but you don’t know until it happens.

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

It was a quiet day. I got up around 3 o’clock in the afternoon for my shift at 6 p.m. I was shaking off the cobwebs and making coffee at our front window that overlooked Brown Street in North Philadelphia. I looked out the window and saw a man stumbling down the street, grabbing his abdomen and yelling for help. There was nobody else around so I went outside to see what was going on.

He was in his 50s or 60s, bleeding and obviously in distress. I had him sit down. Then I ran back inside and grabbed a dish towel and some exam gloves that I had in the house.

I ran back out and assessed him. A bullet had gone through one of his hands, but he had other wounds. I had to expose him, so I trauma stripped him on the sidewalk. I got his pants and his shirt off and saw a gunshot going through his lower pelvis. He was bleeding out from there.

I got the towel and started applying deep pressure down into the iliac vein in case they hit something, which I found out later, they had. I held it there. The man was just lying there begging not to die.

I’m someone who is very calm, maybe abnormally calm, as people tell me. I try to use that during my resuscitations and traumas. Just keeping everybody calm makes the situation easier. Afterwards, people asked me, “Weren’t you worried that you were going to get shot?” That does happen in North Philadelphia. But it didn’t even cross my mind.

I didn’t have to think at all about what I was doing. We saw so many gunshots, especially at Einstein Medical Center. We saw them daily. I’d sometimes get more than half a dozen gunshots in one shift.

So, I was holding pressure and some people started to come over. I got somebody to call 911 and asked the man about his medical history. I found out he had diabetes. Five or 10 minutes later, EMS showed up. They looked pretty stunned when I was able to give the handoff presentation to them. I told them what happened and his back-story. I wanted to make sure they would check his sugar and take extra precautions.

They got him on the stretcher, and he eventually made it to the hospital where he had surgery. They had to have a vascular surgeon work on him. I called later, and they told me, “Yeah, he’s alive.” But that’s about the extent of the update I got.

After the ambulance left, it was kind of chaos. All the neighbors poured out of their houses. People were panicked, talking and getting excited about it. I didn’t know, but everyone else had actually been home the whole time. They didn’t come out until then.

I went back inside and tried to get ready for work. I wasn’t planning on talking to the media, but my next door neighbor just walked the news camera crew over to my house and knocked on my door. I wasn’t exactly dressed to be on TV, but they talked to me on camera, and it was on the news later that night.

I went to work and didn’t say anything about it. To be honest, I was trying to avoid telling anyone. Our team had a close-knit bond, and we would often tease each other when we received any type of recognition.

Naturally one of my attendings saw it on the local news and told everybody. So, I got a lot of happy harassment for quite some time. Someone baked me a cake that said, “Hero of Fairmount” (the Philly neighborhood in which I live). Someone else printed out a photo of me that said, “Stop the Bleed Hero of Fairmount,” and put it on every single computer screen.

The man came to see me about 2 weeks later (a neighbor told him where I lived). The man was very tearful and gave me a big hug. We just embraced for a while, and he said how thankful he was. He brought me a bottle of wine, which I thought was really nice.

He told me what happened to him: There was a lot of construction on our street and he was the contractor overseeing a couple of home remodels and demolitions. Sometimes he paid workers in cash and carried it with him. Somebody had tipped off somebody else that he was going to be there that day. The contractor walked into one of the houses and a guy in a ski mask waited there with a gun. The guy shot him and took the cash. The bullet went through his hand into his pelvis.

I had never had to deal with something that intense before outside of work. Most of it really comes down to the basics – the ABCs and bleeding control. You do whatever you can with what you have. In this case, it was just a dish towel, gloves, and my hands to put as much pressure as possible.

It really was strange that I happened to be looking out the window at that moment. I don’t know if it was just a coincidence. The man told me he believed God had put somebody there at the right place at the right time to save his life. I just felt very fortunate to have been able to help him. I never saw him again.

I think something like this gives you a little confidence that you can actually do something and make a meaningful impact anywhere when it’s needed. It lets you know that you’re capable of doing it. You always think about it, but you don’t know until it happens.

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

Recently, my family had a conversation about the volume of news reports on overdose deaths from the illicit use of opioid drugs—a phenomenon that is complex and stems from many factors. We decided, as a family, that we could have a small impact on the problem. How? By carrying naloxone with us and administering it if we encounter a person with potential opioid overdose. Our decision was made possible by the recent US Food and Drug Administration (FDA) approval of naloxone nasal spray for over-the-counter use.¹ At a cost of about $50 for 2 nasal sprays, we decided it would be a reasonable price to pay to potentially save a life.

The CDC encourages clinicians to find a balance of the potential benefits and harms and to avoid inflexibility.

Prescribing opioids in clinical practice is a different side of the problem. The Centers for Disease Control and Prevention (CDC) reports that prescription opioids account for about one-quarter of opioid overdose deaths.² This is not trivial, and much effort has gone into addressing how clinicians can do better by their patients. There are training programs and risk-mitigation strategies for opioid prescribing. States have developed prescribing registries to identify patients who receive controlled substances from multiple prescribers, at higher-than-recommended doses, and too early in the pain management process. These efforts have reduced the number of opioid prescriptions and rates of high-dose prescribing (> 90 morphine milligram equivalents). However, that hasn’t translated into a reduction in the number of deaths.²

The article by Posen et al³ in this issue further reminded me how trends in health care, including opioid prescribing, are like a pendulum—swinging from one extreme to the other before eventually centering. I recall conversations with colleagues about how often we undertreated pain—and then later, how relieved we were when new approaches to pain management, using newer opiates, emerged and were reported to be much safer, even for long-term use. We now know the rest of that story: more prescriptions, higher doses, longer duration, addiction, death, and deception by manufacturers.

In our efforts to prevent addiction and decrease opioid deaths, we tried to get patients off opioids completely, thereby increasing demand for addiction therapy, including medication-assisted recovery. This also drove many of our patients to seek opioids from nefarious suppliers, resulting in even more deaths from fentanyl-laced drugs.

At least one positive has arisen from the “no more opioids” movement: We have re-evaluated their true effect on managing pain. Initially, we were told opioids were safe and highly effective—and, having few tools to help our patients, we were ­Pollyanna-ish in accepting this. But many recent studies have demonstrated that using opioids for pain is no more effective than using other analgesics.^4-9 In addition to overdose deaths and addiction, these studies show significantly higher rates of opioid discontinuation due to adverse effects.

We certainly can manage most patients’ pain effectively with other approaches. For some, though—patients whose pain is not adequately controlled and/or interferes with their ability to function, and those who are terminally ill—opioid nihilism has had unintended consequences. Recognizing these issues, the CDC updated its guideline for prescribing opioids in 2022.¹⁰ Four areas were addressed: whether to initiate opioids; opioid selection and dosing; duration of therapy and need for follow-up; and assessing risk and addressing potential harms of opioid use. The CDC encourages clinicians to find a balance of the potential benefits and harms and to avoid inflexibility. Finally, the CDC encourages clinicians to identify and treat patients with opioid use disorders.

Clearly, opioid overuse and overdose result from complex medical, economic, and societal factors. Individual clinicians are well equipped to manage things “in their own backyards.” However, what we do can be perceived as a bandage for a much larger problem. Our public health system has the potential for greater impact, but the “cure” will require multimodal solutions addressing many facets of society and government.¹¹ At the very least, we should keep some naloxone close by and vote for political candidates who see broader solutions for addressing this life-and-death crisis.

Recently, my family had a conversation about the volume of news reports on overdose deaths from the illicit use of opioid drugs—a phenomenon that is complex and stems from many factors. We decided, as a family, that we could have a small impact on the problem. How? By carrying naloxone with us and administering it if we encounter a person with potential opioid overdose. Our decision was made possible by the recent US Food and Drug Administration (FDA) approval of naloxone nasal spray for over-the-counter use.¹ At a cost of about $50 for 2 nasal sprays, we decided it would be a reasonable price to pay to potentially save a life.

The CDC encourages clinicians to find a balance of the potential benefits and harms and to avoid inflexibility.

Prescribing opioids in clinical practice is a different side of the problem. The Centers for Disease Control and Prevention (CDC) reports that prescription opioids account for about one-quarter of opioid overdose deaths.² This is not trivial, and much effort has gone into addressing how clinicians can do better by their patients. There are training programs and risk-mitigation strategies for opioid prescribing. States have developed prescribing registries to identify patients who receive controlled substances from multiple prescribers, at higher-than-recommended doses, and too early in the pain management process. These efforts have reduced the number of opioid prescriptions and rates of high-dose prescribing (> 90 morphine milligram equivalents). However, that hasn’t translated into a reduction in the number of deaths.²

The article by Posen et al³ in this issue further reminded me how trends in health care, including opioid prescribing, are like a pendulum—swinging from one extreme to the other before eventually centering. I recall conversations with colleagues about how often we undertreated pain—and then later, how relieved we were when new approaches to pain management, using newer opiates, emerged and were reported to be much safer, even for long-term use. We now know the rest of that story: more prescriptions, higher doses, longer duration, addiction, death, and deception by manufacturers.

In our efforts to prevent addiction and decrease opioid deaths, we tried to get patients off opioids completely, thereby increasing demand for addiction therapy, including medication-assisted recovery. This also drove many of our patients to seek opioids from nefarious suppliers, resulting in even more deaths from fentanyl-laced drugs.

At least one positive has arisen from the “no more opioids” movement: We have re-evaluated their true effect on managing pain. Initially, we were told opioids were safe and highly effective—and, having few tools to help our patients, we were ­Pollyanna-ish in accepting this. But many recent studies have demonstrated that using opioids for pain is no more effective than using other analgesics.^4-9 In addition to overdose deaths and addiction, these studies show significantly higher rates of opioid discontinuation due to adverse effects.

We certainly can manage most patients’ pain effectively with other approaches. For some, though—patients whose pain is not adequately controlled and/or interferes with their ability to function, and those who are terminally ill—opioid nihilism has had unintended consequences. Recognizing these issues, the CDC updated its guideline for prescribing opioids in 2022.¹⁰ Four areas were addressed: whether to initiate opioids; opioid selection and dosing; duration of therapy and need for follow-up; and assessing risk and addressing potential harms of opioid use. The CDC encourages clinicians to find a balance of the potential benefits and harms and to avoid inflexibility. Finally, the CDC encourages clinicians to identify and treat patients with opioid use disorders.

Clearly, opioid overuse and overdose result from complex medical, economic, and societal factors. Individual clinicians are well equipped to manage things “in their own backyards.” However, what we do can be perceived as a bandage for a much larger problem. Our public health system has the potential for greater impact, but the “cure” will require multimodal solutions addressing many facets of society and government.¹¹ At the very least, we should keep some naloxone close by and vote for political candidates who see broader solutions for addressing this life-and-death crisis.

Recently, my family had a conversation about the volume of news reports on overdose deaths from the illicit use of opioid drugs—a phenomenon that is complex and stems from many factors. We decided, as a family, that we could have a small impact on the problem. How? By carrying naloxone with us and administering it if we encounter a person with potential opioid overdose. Our decision was made possible by the recent US Food and Drug Administration (FDA) approval of naloxone nasal spray for over-the-counter use.¹ At a cost of about $50 for 2 nasal sprays, we decided it would be a reasonable price to pay to potentially save a life.

The CDC encourages clinicians to find a balance of the potential benefits and harms and to avoid inflexibility.

Prescribing opioids in clinical practice is a different side of the problem. The Centers for Disease Control and Prevention (CDC) reports that prescription opioids account for about one-quarter of opioid overdose deaths.² This is not trivial, and much effort has gone into addressing how clinicians can do better by their patients. There are training programs and risk-mitigation strategies for opioid prescribing. States have developed prescribing registries to identify patients who receive controlled substances from multiple prescribers, at higher-than-recommended doses, and too early in the pain management process. These efforts have reduced the number of opioid prescriptions and rates of high-dose prescribing (> 90 morphine milligram equivalents). However, that hasn’t translated into a reduction in the number of deaths.²

The article by Posen et al³ in this issue further reminded me how trends in health care, including opioid prescribing, are like a pendulum—swinging from one extreme to the other before eventually centering. I recall conversations with colleagues about how often we undertreated pain—and then later, how relieved we were when new approaches to pain management, using newer opiates, emerged and were reported to be much safer, even for long-term use. We now know the rest of that story: more prescriptions, higher doses, longer duration, addiction, death, and deception by manufacturers.

In our efforts to prevent addiction and decrease opioid deaths, we tried to get patients off opioids completely, thereby increasing demand for addiction therapy, including medication-assisted recovery. This also drove many of our patients to seek opioids from nefarious suppliers, resulting in even more deaths from fentanyl-laced drugs.

At least one positive has arisen from the “no more opioids” movement: We have re-evaluated their true effect on managing pain. Initially, we were told opioids were safe and highly effective—and, having few tools to help our patients, we were ­Pollyanna-ish in accepting this. But many recent studies have demonstrated that using opioids for pain is no more effective than using other analgesics.^4-9 In addition to overdose deaths and addiction, these studies show significantly higher rates of opioid discontinuation due to adverse effects.

We certainly can manage most patients’ pain effectively with other approaches. For some, though—patients whose pain is not adequately controlled and/or interferes with their ability to function, and those who are terminally ill—opioid nihilism has had unintended consequences. Recognizing these issues, the CDC updated its guideline for prescribing opioids in 2022.¹⁰ Four areas were addressed: whether to initiate opioids; opioid selection and dosing; duration of therapy and need for follow-up; and assessing risk and addressing potential harms of opioid use. The CDC encourages clinicians to find a balance of the potential benefits and harms and to avoid inflexibility. Finally, the CDC encourages clinicians to identify and treat patients with opioid use disorders.

Clearly, opioid overuse and overdose result from complex medical, economic, and societal factors. Individual clinicians are well equipped to manage things “in their own backyards.” However, what we do can be perceived as a bandage for a much larger problem. Our public health system has the potential for greater impact, but the “cure” will require multimodal solutions addressing many facets of society and government.¹¹ At the very least, we should keep some naloxone close by and vote for political candidates who see broader solutions for addressing this life-and-death crisis.

The past few years have seen major transformations in the way health care websites operate and interact with patients. To stay competitive, it is important to ensure that your website is adapting to this changing environment, and that it continues adapting as future changes further impact its performance and ranking.

In mid-2018, a major Google algorithm change, known to the IT community as the “Medic Update,” significantly changed search criteria for most health and wellness websites. Another big update went live in late 2021. Websites that have not evolved with these changes have dropped in search rankings and provide a poorer user experience all around.

Many potential patients are searching for your services online, so your website cannot be an afterthought. Not only does it need to be designed with your target audience in mind, but it is also important to consider the metrics Google and other search engines now use when assessing the quality of your website so that patients will find it in the first place.

Here are some features that you (or your website company) need to prioritize to keep your site current and atop search results in 2023 and beyond.

Begin with an understandable URL. Search engines use URLs to determine how well your site, or a portion of it, matches search criteria. URLs also need to make sense to searchers, especially when they link specific areas of expertise (more on that in a minute). For example, a URL like “jonesdermatology.com/?p=89021” is meaningless to anyone except programmers; but “jonesdermatology.com/psoriasistreatments” obviously leads to a page about psoriasis treatments. Search engines look for not only the most relevant, but also the most helpful and user-friendly answers to a user’s query.

Incidentally, if the URL for your site is not your own name, you should register your name as a separate domain name – even if you never use it – to be sure that a trickster or troll, or someone with the same name but a bad reputation, doesn’t get it.

Continue with a good meta description. That’s the grayish text that follows the title and URL in search results. Searchers will read it to confirm that your site is what they seek, so make sure it describes exactly what you do, including any areas of special expertise.

Make your practice approachable with photos. New patients are more comfortable when they know what you look like, so real photos of you and your staff are always more effective than stock photos of models. Photos or a video tour of your office will reassure prospective patients that they will be visiting a clean, modern, professional facility.

Describe your principal services in detail. You never know which specific service a prospective patient is searching for, so describe everything you offer. Don’t try to summarize everything on a single page; relevance is determined by how deeply a topic is covered, so each principal service should have a detailed description on its own page. Not only will your skills become more visible to search engines, but you can also use the space to enumerate your qualifications and expertise in each area. Whenever possible, write your descriptions in question-and-answer form. Searchers tend to ask questions (“what is the best ... ?”), particularly in voice searches. Search engines increasingly value sites that ask and answer common questions.

Make your site interactive. “Interactivity” is a major buzzword in modern search engine parlance. Once searchers make an appointment, they stop searching. If they have to wait until the next day to call your office, they may keep looking – and might find a competitor with online scheduling. HIPAA-compliant chatbots, secure messaging, and online patient portals to access medical records, lab results, and other important information will also set your site apart.

Testimonials are essential. Amazon.com taught us that candid reviews from customers go a long way toward building the trust necessary to buy products and services, and nowhere is that truer than for medical services. According to one study, when it comes to finding a doctor, 88% of people trust online reviews as much as a personal recommendation. Loyal patients will be happy to write you glowing reviews; feature them prominently.

How does your site look on small screens? More than half of all searches are now made on smartphones, so the more mobile-friendly your site is, the higher it will be ranked. Prospective patients who are forced to scroll forever, or zoom in to tap a link, are likely to become frustrated and move on. Mobile searchers prefer sites that provide the best experience for the least amount of effort, and rankings tend to reflect that preference. You can test how easily a visitor can use your website on a mobile device with Google’s free Mobile-Friendly Test..

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

The past few years have seen major transformations in the way health care websites operate and interact with patients. To stay competitive, it is important to ensure that your website is adapting to this changing environment, and that it continues adapting as future changes further impact its performance and ranking.

In mid-2018, a major Google algorithm change, known to the IT community as the “Medic Update,” significantly changed search criteria for most health and wellness websites. Another big update went live in late 2021. Websites that have not evolved with these changes have dropped in search rankings and provide a poorer user experience all around.

Many potential patients are searching for your services online, so your website cannot be an afterthought. Not only does it need to be designed with your target audience in mind, but it is also important to consider the metrics Google and other search engines now use when assessing the quality of your website so that patients will find it in the first place.

Here are some features that you (or your website company) need to prioritize to keep your site current and atop search results in 2023 and beyond.

Begin with an understandable URL. Search engines use URLs to determine how well your site, or a portion of it, matches search criteria. URLs also need to make sense to searchers, especially when they link specific areas of expertise (more on that in a minute). For example, a URL like “jonesdermatology.com/?p=89021” is meaningless to anyone except programmers; but “jonesdermatology.com/psoriasistreatments” obviously leads to a page about psoriasis treatments. Search engines look for not only the most relevant, but also the most helpful and user-friendly answers to a user’s query.

Incidentally, if the URL for your site is not your own name, you should register your name as a separate domain name – even if you never use it – to be sure that a trickster or troll, or someone with the same name but a bad reputation, doesn’t get it.

Continue with a good meta description. That’s the grayish text that follows the title and URL in search results. Searchers will read it to confirm that your site is what they seek, so make sure it describes exactly what you do, including any areas of special expertise.

Make your practice approachable with photos. New patients are more comfortable when they know what you look like, so real photos of you and your staff are always more effective than stock photos of models. Photos or a video tour of your office will reassure prospective patients that they will be visiting a clean, modern, professional facility.

Describe your principal services in detail. You never know which specific service a prospective patient is searching for, so describe everything you offer. Don’t try to summarize everything on a single page; relevance is determined by how deeply a topic is covered, so each principal service should have a detailed description on its own page. Not only will your skills become more visible to search engines, but you can also use the space to enumerate your qualifications and expertise in each area. Whenever possible, write your descriptions in question-and-answer form. Searchers tend to ask questions (“what is the best ... ?”), particularly in voice searches. Search engines increasingly value sites that ask and answer common questions.

Make your site interactive. “Interactivity” is a major buzzword in modern search engine parlance. Once searchers make an appointment, they stop searching. If they have to wait until the next day to call your office, they may keep looking – and might find a competitor with online scheduling. HIPAA-compliant chatbots, secure messaging, and online patient portals to access medical records, lab results, and other important information will also set your site apart.

Testimonials are essential. Amazon.com taught us that candid reviews from customers go a long way toward building the trust necessary to buy products and services, and nowhere is that truer than for medical services. According to one study, when it comes to finding a doctor, 88% of people trust online reviews as much as a personal recommendation. Loyal patients will be happy to write you glowing reviews; feature them prominently.

How does your site look on small screens? More than half of all searches are now made on smartphones, so the more mobile-friendly your site is, the higher it will be ranked. Prospective patients who are forced to scroll forever, or zoom in to tap a link, are likely to become frustrated and move on. Mobile searchers prefer sites that provide the best experience for the least amount of effort, and rankings tend to reflect that preference. You can test how easily a visitor can use your website on a mobile device with Google’s free Mobile-Friendly Test..

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

The past few years have seen major transformations in the way health care websites operate and interact with patients. To stay competitive, it is important to ensure that your website is adapting to this changing environment, and that it continues adapting as future changes further impact its performance and ranking.

In mid-2018, a major Google algorithm change, known to the IT community as the “Medic Update,” significantly changed search criteria for most health and wellness websites. Another big update went live in late 2021. Websites that have not evolved with these changes have dropped in search rankings and provide a poorer user experience all around.

Many potential patients are searching for your services online, so your website cannot be an afterthought. Not only does it need to be designed with your target audience in mind, but it is also important to consider the metrics Google and other search engines now use when assessing the quality of your website so that patients will find it in the first place.

Here are some features that you (or your website company) need to prioritize to keep your site current and atop search results in 2023 and beyond.

Begin with an understandable URL. Search engines use URLs to determine how well your site, or a portion of it, matches search criteria. URLs also need to make sense to searchers, especially when they link specific areas of expertise (more on that in a minute). For example, a URL like “jonesdermatology.com/?p=89021” is meaningless to anyone except programmers; but “jonesdermatology.com/psoriasistreatments” obviously leads to a page about psoriasis treatments. Search engines look for not only the most relevant, but also the most helpful and user-friendly answers to a user’s query.

Incidentally, if the URL for your site is not your own name, you should register your name as a separate domain name – even if you never use it – to be sure that a trickster or troll, or someone with the same name but a bad reputation, doesn’t get it.

Continue with a good meta description. That’s the grayish text that follows the title and URL in search results. Searchers will read it to confirm that your site is what they seek, so make sure it describes exactly what you do, including any areas of special expertise.

Make your practice approachable with photos. New patients are more comfortable when they know what you look like, so real photos of you and your staff are always more effective than stock photos of models. Photos or a video tour of your office will reassure prospective patients that they will be visiting a clean, modern, professional facility.

Describe your principal services in detail. You never know which specific service a prospective patient is searching for, so describe everything you offer. Don’t try to summarize everything on a single page; relevance is determined by how deeply a topic is covered, so each principal service should have a detailed description on its own page. Not only will your skills become more visible to search engines, but you can also use the space to enumerate your qualifications and expertise in each area. Whenever possible, write your descriptions in question-and-answer form. Searchers tend to ask questions (“what is the best ... ?”), particularly in voice searches. Search engines increasingly value sites that ask and answer common questions.

Make your site interactive. “Interactivity” is a major buzzword in modern search engine parlance. Once searchers make an appointment, they stop searching. If they have to wait until the next day to call your office, they may keep looking – and might find a competitor with online scheduling. HIPAA-compliant chatbots, secure messaging, and online patient portals to access medical records, lab results, and other important information will also set your site apart.

Testimonials are essential. Amazon.com taught us that candid reviews from customers go a long way toward building the trust necessary to buy products and services, and nowhere is that truer than for medical services. According to one study, when it comes to finding a doctor, 88% of people trust online reviews as much as a personal recommendation. Loyal patients will be happy to write you glowing reviews; feature them prominently.

How does your site look on small screens? More than half of all searches are now made on smartphones, so the more mobile-friendly your site is, the higher it will be ranked. Prospective patients who are forced to scroll forever, or zoom in to tap a link, are likely to become frustrated and move on. Mobile searchers prefer sites that provide the best experience for the least amount of effort, and rankings tend to reflect that preference. You can test how easily a visitor can use your website on a mobile device with Google’s free Mobile-Friendly Test..

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

Subclinical hypothyroidism (SCH) is a biochemical state in which the thyroid-stimulating hormone (TSH) is elevated while the free thyroxine (T4) level is normal. Overt hypothyroidism is not diagnosed until the free T4 level is decreased, regardless of the degree of TSH elevation.

The overall prevalence of SCH in iodine-rich areas is 4% to 10%, with a risk for progression to overt hypothyroidism of between 2% and 6% annually.¹ The prevalence of SCH varies depending on the TSH reference range used.¹ The normal reference range for TSH varies depending on the laboratory and/or the reference population surveyed, with the range likely widening with increasing age.

SCH is most common among women, the elderly, and White individuals.² The discovery of SCH is often incidental, given that usually it is detected by laboratory findings alone without associated symptoms of overt hypothyroidism.³

The not-so-significant role of symptoms in subclinical hypothyroidism

Symptoms associated with overt hypothyroidism include constipation, dry skin, fatigue, slow thinking, poor memory, muscle cramps, weakness, and cold intolerance. In SCH, these symptoms are inconsistent, with around 1 in 3 patients having no symptoms at all.⁴

One study reported that roughly 18% of euthyroid individuals, 22% of SCH patients, and 26% of those with overt hypothyroidism reported 4 or more symptoms classically thought to be related to hypothyroidism.⁴ A large Danish cohort study found that hypothyroid symptoms were no more common in patients with SCH than in euthyroid individuals in the general population.⁵ These studies question the validity of attributing symptoms to SCH.

Adverse health associations

Observational data suggest that SCH is associated with an increased risk for dyslipidemia, coronary heart disease, heart failure, and cardiovascular mortality, particularly in those with TSH levels ≥ 10 mIU/L.^6,7 Such associations were not found for most adults with TSH levels between 5 and 10 mIU/L.⁸ There are also potential associations of SCH with obesity, nonalcoholic fatty liver disease, and nonalcoholic steatohepatitis.^9,10 Despite thyroid studies being commonly ordered as part of a mental health evaluation, SCH has not been statistically associated with depressive symptoms.^11,12

Caveats with laboratory testing

There are several issues to consider when performing a laboratory assessment of thyroid function. TSH levels fluctuate considerably during the day, as TSH secretion has a circadian rhythm. TSH values are 50% higher at night and in the early morning than during the rest of the day.¹³ TSH values also may rise in response to current illness or stress. Due to this biologic variability, repeat testing to confirm TSH levels is recommended if an initial test result is abnormal.¹⁴

Continue to: An exact reference range...

Supplements containing biotin should be withheld for several days before assessing thyroid function.

An exact reference range for TSH is not widely agreed upon—although most laboratories regard 4.0 to 5.0 mIU/L as the high-end cutoff for normal. Also, “normal” TSH levels appear to differ by age. Accordingly, some experts have recommended an age-based reference range for TSH levels,¹⁵ although this is not implemented widely by laboratories. A TSH level of 6.0 mIU/L (or even higher) may be more appropriate for adults older than 65 years.¹

Biotin supplementation has been shown to cause spurious thyroid testing results (TSH, T3, T4) depending on the type of assay used. Therefore, supplements containing biotin should be withheld for several days before assessing thyroid function.¹⁶Patients with SCH are often categorized as having TSH levels between 4.5 and 10 mIU/L (around 90% of patients) or levels ≥ 10 mIU/L.^8,17 If followed for 5 years, approximately 60% of patients with SCH and TSH levels between 4 and 10 mIU/L will normalize without intervention.¹⁸ Normalization is less common in patients with a TSH level greater than 10 mIU/L.¹⁸

The risk for progression to overt hypothyroidism also appears to be higher for those with certain risk factors. These include higher baseline TSH levels, presence of thyroid peroxidase antibodies (TPOAbs), or history of neck irradiation or radioactive iodine uptake.¹ Other risk factors for eventual thyroid dysfunction include female sex, older age, goiter, and high iodine intake.¹³

Evidence for treatment varies

Guidelines for the treatment of SCH (TABLE 1^8,14,19,20) are founded on the condition’s risk for progression to overt hypothyroidism and its association with health consequences such as cardiovascular disease. Guidelines of the American Thyroid Association (ATA) and European Thyroid Association (ETA), and those of the United Kingdom–based National Institute for Health and Care Excellence (NICE), prioritize treatment for individuals with a TSH level > 10 mIU/L^a and for those with TSH values < 10 mIU/L but still elevated and apparent symptoms of hypothyroidism.^14,19,20 The strength of evidence behind this guidance is challenged by a lack of data from prospective randomized controlled trials (RCTs) demonstrating health benefits following treatment of SCH. The British Medical Journal (BMJ) Guideline cites this lack of evidence and recommends against treating SCH at any TSH level, regardless of symptoms.⁸

There are few large RCTs of treatment outcomes for SCH. A 2017 RCT (the Thyroid Hormone Replacement for Untreated Older Adults with Subclinical Hypothyroidism, or TRUST, trial) of 737 adults older than 65 years with SCH evaluated the ability of levothyroxine to normalize TSH values compared with placebo. At 1 year, there was no difference in hypothyroid symptoms or tiredness scale scores with levothyroxine treatment compared with placebo.²¹ This finding was consistent even in the subgroup with a higher baseline symptom burden.²²

Continue to: Two small RCTs evaluated...

Two small RCTs evaluated treatment of SCH with depressive symptoms and cognitive function, neither finding benefit compared with placebo.^12,23 A 2018 systematic review and meta-analysis of 21 studies and 2192 adults did not show a benefit to quality of life or thyroid-specific symptoms in those treated for SCH compared with controls.²⁴

RCT support also is lacking for a reduction in cardiovascular mortality following treatment for SCH. A large population-level retrospective cohort from Denmark showed no difference in cardiovascular mortality or myocardial infarction in those treated for SCH compared with controls.²⁵ Pooled results from 2 RCTs (for patients older than 65 years, and those older than 80 years) showed no change in risk for cardiovascular outcomes in older adults treated for SCH.²⁶ Older adults treated for SCH in the TRUST trial showed no improvements in systolic or diastolic­ function on echocardiography.^27­ Two trials showed no difference in carotid intima-media thickness with treatment of SCH compared with placebo.^28,29

While most of the RCT data come from older adults, a retrospective cohort study in the United Kingdom of younger (ages 40-70 years; n = 3093) and older (age > 70 years; n = 1642) patients showed a reduction in cardiovascular mortality among treated patients who were younger (hazard ratio [HR] = 0.61; 4.2% vs. 6.6%) but not those who were older (HR = 0.99; 12.7% vs. 10.7%).³⁰ There is also evidence that thyroid size in those with goiter can be reduced with treatment of SCH.³¹

A measured approach to treating subclinical hypothyroidism

Consider several factors when deciding whether to treat SCH. For instance, RCT data suggest a lack of treatment benefit in relieving depression, improving cognition, or reducing general hypothyroid symptoms. Treatment of SCH in older adults does not appear to improve cardiovascular outcomes. The question of whether long-term treatment of SCH in younger patients reduces cardiovascular morbidity or mortality lacks answers from RCTs. Before diagnosing SCH or starting treatment, always confirm SCH with repeat testing in 2 to 3 months, as a high percentage of those with untreated SCH will have normal thyroid function on repeat testing.

Before diagnosing subclinical hypothyroidism (SCH) or starting treatment, always confirm SCH with repeat testing in 2 to 3 months.

In the event you and your patient elect to treat SCH, guidelines and trials generally support a low initial daily dose of 25 to 50 mcg of levothyroxine (T4), followed with dose changes­ every 4 to 8 weeks and a goal of normalizing TSH to within the lower half of the reference range (0.4-2.5 mIU/L).¹⁴ This is generally similar to published treatment goals for primary hypothyroidism and is based on studies suggesting the lower half of the reference range is normal for young, healthy, euthyroid individuals.³² Though full replacement doses (1.6-1.8 mcg/kg of ideal body weight) can be started for those who are elderly or who have ischemic heart disease or angina, this approach should be avoided in favor of low-dose initial therapy.³³ Thyroid supplements are best absorbed when taken apart from food, calcium, or iron supplements. The ATA suggests taking thyroid medication 60 minutes before breakfast or at bedtime (3 or more hours after the evening meal).³³

Continue to: Screening guidelines differ

Lacking population-level screening data from RCTs, most organizations do not recommend screening for thyroid dysfunction or they note insufficient evidence to make a screening recommendation (TABLE 2^17,19,20,34). In their most recent recommendation statement on the subject in 2015, the US Preventive Services Task Force (USPSTF) concluded the current evidence was insufficient to recommend for or against thyroid dysfunction screening in nonpregnant, asymptomatic adults.¹⁷ This differs from the ATA and the American Association of Clinical Endocrinology (AACE; formerly known as the American Association of Clinical Endocrinologists), which both recommend targeted screening for thyroid dysfunction based on symptoms or risk factors.²⁰

What about subclinical hypothyroidism in pregnancy?

Overt hypothyroidism is associated with adverse events during pregnancy and with subsequent neurodevelopmental complications in children, although the effects of SCH during pregnancy remain less certain. Concerns have been raised over the potential association of SCH with pregnancy loss, placental abruption, premature rupture of membranes, and neonatal death.³⁵ Historically, the prevalence of SCH during pregnancy has ranged from 2% to 2.5%, but using lower trimester-based TSH reference ranges, the prevalence of SCH in pregnancy may be as high as 15%.³⁵

Guided by a large RCT that failed to find benefit (pregnancy outcomes, neurodevelopmental outcomes in children) following treatment of SCH in pregnancy,³⁶ the American College of Obstetricians and Gynecologists (ACOG) recommends against routine screening for thyroid disease in pregnancy.³⁴ The ATA notes insufficient evidence to rec-ommend universal screening for thyroid dysfunction in pregnancy but recommends targeted screening of those with risk factors.³⁷ Data are conflicting on the benefit of treating known or recently detected SCH on pregnancy outcomes including pregnancy loss.^35,38 As such, the American Society of Reproductive Medicine and the ATA both generally recommend treatment of SCH in pregnant patients, particularly when the TSH is ≥ 4.0 mIU/L and TPOAbs are present.^37,39

^a The ATA, ETA, and NICE have slightly different recommendations when a TSH level = 10 mIU/L. ETA and NICE recommend prioritizing treatment for individuals with this level, while ATA recommends treatment when individual factors are also considered.

ACKNOWLEDGEMENT
The authors thank Family Medicine Medical Librarian Gwen Wilson, MLS, AHIP, for her assistance with literature searches.

CORRESPONDENCE
Nicholas LeFevre, MD, Family and Community Medicine, University of Missouri–Columbia School of Medicine, One Hospital Drive, M224 Medical Science Building, Columbia, MO 65212; [email protected]

Subclinical hypothyroidism (SCH) is a biochemical state in which the thyroid-stimulating hormone (TSH) is elevated while the free thyroxine (T4) level is normal. Overt hypothyroidism is not diagnosed until the free T4 level is decreased, regardless of the degree of TSH elevation.

The overall prevalence of SCH in iodine-rich areas is 4% to 10%, with a risk for progression to overt hypothyroidism of between 2% and 6% annually.¹ The prevalence of SCH varies depending on the TSH reference range used.¹ The normal reference range for TSH varies depending on the laboratory and/or the reference population surveyed, with the range likely widening with increasing age.

SCH is most common among women, the elderly, and White individuals.² The discovery of SCH is often incidental, given that usually it is detected by laboratory findings alone without associated symptoms of overt hypothyroidism.³

The not-so-significant role of symptoms in subclinical hypothyroidism

Symptoms associated with overt hypothyroidism include constipation, dry skin, fatigue, slow thinking, poor memory, muscle cramps, weakness, and cold intolerance. In SCH, these symptoms are inconsistent, with around 1 in 3 patients having no symptoms at all.⁴

One study reported that roughly 18% of euthyroid individuals, 22% of SCH patients, and 26% of those with overt hypothyroidism reported 4 or more symptoms classically thought to be related to hypothyroidism.⁴ A large Danish cohort study found that hypothyroid symptoms were no more common in patients with SCH than in euthyroid individuals in the general population.⁵ These studies question the validity of attributing symptoms to SCH.

Adverse health associations

Observational data suggest that SCH is associated with an increased risk for dyslipidemia, coronary heart disease, heart failure, and cardiovascular mortality, particularly in those with TSH levels ≥ 10 mIU/L.^6,7 Such associations were not found for most adults with TSH levels between 5 and 10 mIU/L.⁸ There are also potential associations of SCH with obesity, nonalcoholic fatty liver disease, and nonalcoholic steatohepatitis.^9,10 Despite thyroid studies being commonly ordered as part of a mental health evaluation, SCH has not been statistically associated with depressive symptoms.^11,12

Caveats with laboratory testing

There are several issues to consider when performing a laboratory assessment of thyroid function. TSH levels fluctuate considerably during the day, as TSH secretion has a circadian rhythm. TSH values are 50% higher at night and in the early morning than during the rest of the day.¹³ TSH values also may rise in response to current illness or stress. Due to this biologic variability, repeat testing to confirm TSH levels is recommended if an initial test result is abnormal.¹⁴

Continue to: An exact reference range...

Supplements containing biotin should be withheld for several days before assessing thyroid function.

An exact reference range for TSH is not widely agreed upon—although most laboratories regard 4.0 to 5.0 mIU/L as the high-end cutoff for normal. Also, “normal” TSH levels appear to differ by age. Accordingly, some experts have recommended an age-based reference range for TSH levels,¹⁵ although this is not implemented widely by laboratories. A TSH level of 6.0 mIU/L (or even higher) may be more appropriate for adults older than 65 years.¹

Biotin supplementation has been shown to cause spurious thyroid testing results (TSH, T3, T4) depending on the type of assay used. Therefore, supplements containing biotin should be withheld for several days before assessing thyroid function.¹⁶Patients with SCH are often categorized as having TSH levels between 4.5 and 10 mIU/L (around 90% of patients) or levels ≥ 10 mIU/L.^8,17 If followed for 5 years, approximately 60% of patients with SCH and TSH levels between 4 and 10 mIU/L will normalize without intervention.¹⁸ Normalization is less common in patients with a TSH level greater than 10 mIU/L.¹⁸

The risk for progression to overt hypothyroidism also appears to be higher for those with certain risk factors. These include higher baseline TSH levels, presence of thyroid peroxidase antibodies (TPOAbs), or history of neck irradiation or radioactive iodine uptake.¹ Other risk factors for eventual thyroid dysfunction include female sex, older age, goiter, and high iodine intake.¹³

Evidence for treatment varies

Guidelines for the treatment of SCH (TABLE 1^8,14,19,20) are founded on the condition’s risk for progression to overt hypothyroidism and its association with health consequences such as cardiovascular disease. Guidelines of the American Thyroid Association (ATA) and European Thyroid Association (ETA), and those of the United Kingdom–based National Institute for Health and Care Excellence (NICE), prioritize treatment for individuals with a TSH level > 10 mIU/L^a and for those with TSH values < 10 mIU/L but still elevated and apparent symptoms of hypothyroidism.^14,19,20 The strength of evidence behind this guidance is challenged by a lack of data from prospective randomized controlled trials (RCTs) demonstrating health benefits following treatment of SCH. The British Medical Journal (BMJ) Guideline cites this lack of evidence and recommends against treating SCH at any TSH level, regardless of symptoms.⁸

There are few large RCTs of treatment outcomes for SCH. A 2017 RCT (the Thyroid Hormone Replacement for Untreated Older Adults with Subclinical Hypothyroidism, or TRUST, trial) of 737 adults older than 65 years with SCH evaluated the ability of levothyroxine to normalize TSH values compared with placebo. At 1 year, there was no difference in hypothyroid symptoms or tiredness scale scores with levothyroxine treatment compared with placebo.²¹ This finding was consistent even in the subgroup with a higher baseline symptom burden.²²

Continue to: Two small RCTs evaluated...

Two small RCTs evaluated treatment of SCH with depressive symptoms and cognitive function, neither finding benefit compared with placebo.^12,23 A 2018 systematic review and meta-analysis of 21 studies and 2192 adults did not show a benefit to quality of life or thyroid-specific symptoms in those treated for SCH compared with controls.²⁴

RCT support also is lacking for a reduction in cardiovascular mortality following treatment for SCH. A large population-level retrospective cohort from Denmark showed no difference in cardiovascular mortality or myocardial infarction in those treated for SCH compared with controls.²⁵ Pooled results from 2 RCTs (for patients older than 65 years, and those older than 80 years) showed no change in risk for cardiovascular outcomes in older adults treated for SCH.²⁶ Older adults treated for SCH in the TRUST trial showed no improvements in systolic or diastolic­ function on echocardiography.^27­ Two trials showed no difference in carotid intima-media thickness with treatment of SCH compared with placebo.^28,29

While most of the RCT data come from older adults, a retrospective cohort study in the United Kingdom of younger (ages 40-70 years; n = 3093) and older (age > 70 years; n = 1642) patients showed a reduction in cardiovascular mortality among treated patients who were younger (hazard ratio [HR] = 0.61; 4.2% vs. 6.6%) but not those who were older (HR = 0.99; 12.7% vs. 10.7%).³⁰ There is also evidence that thyroid size in those with goiter can be reduced with treatment of SCH.³¹

A measured approach to treating subclinical hypothyroidism

Consider several factors when deciding whether to treat SCH. For instance, RCT data suggest a lack of treatment benefit in relieving depression, improving cognition, or reducing general hypothyroid symptoms. Treatment of SCH in older adults does not appear to improve cardiovascular outcomes. The question of whether long-term treatment of SCH in younger patients reduces cardiovascular morbidity or mortality lacks answers from RCTs. Before diagnosing SCH or starting treatment, always confirm SCH with repeat testing in 2 to 3 months, as a high percentage of those with untreated SCH will have normal thyroid function on repeat testing.

Before diagnosing subclinical hypothyroidism (SCH) or starting treatment, always confirm SCH with repeat testing in 2 to 3 months.

In the event you and your patient elect to treat SCH, guidelines and trials generally support a low initial daily dose of 25 to 50 mcg of levothyroxine (T4), followed with dose changes­ every 4 to 8 weeks and a goal of normalizing TSH to within the lower half of the reference range (0.4-2.5 mIU/L).¹⁴ This is generally similar to published treatment goals for primary hypothyroidism and is based on studies suggesting the lower half of the reference range is normal for young, healthy, euthyroid individuals.³² Though full replacement doses (1.6-1.8 mcg/kg of ideal body weight) can be started for those who are elderly or who have ischemic heart disease or angina, this approach should be avoided in favor of low-dose initial therapy.³³ Thyroid supplements are best absorbed when taken apart from food, calcium, or iron supplements. The ATA suggests taking thyroid medication 60 minutes before breakfast or at bedtime (3 or more hours after the evening meal).³³

Continue to: Screening guidelines differ

Lacking population-level screening data from RCTs, most organizations do not recommend screening for thyroid dysfunction or they note insufficient evidence to make a screening recommendation (TABLE 2^17,19,20,34). In their most recent recommendation statement on the subject in 2015, the US Preventive Services Task Force (USPSTF) concluded the current evidence was insufficient to recommend for or against thyroid dysfunction screening in nonpregnant, asymptomatic adults.¹⁷ This differs from the ATA and the American Association of Clinical Endocrinology (AACE; formerly known as the American Association of Clinical Endocrinologists), which both recommend targeted screening for thyroid dysfunction based on symptoms or risk factors.²⁰

What about subclinical hypothyroidism in pregnancy?

Overt hypothyroidism is associated with adverse events during pregnancy and with subsequent neurodevelopmental complications in children, although the effects of SCH during pregnancy remain less certain. Concerns have been raised over the potential association of SCH with pregnancy loss, placental abruption, premature rupture of membranes, and neonatal death.³⁵ Historically, the prevalence of SCH during pregnancy has ranged from 2% to 2.5%, but using lower trimester-based TSH reference ranges, the prevalence of SCH in pregnancy may be as high as 15%.³⁵

Guided by a large RCT that failed to find benefit (pregnancy outcomes, neurodevelopmental outcomes in children) following treatment of SCH in pregnancy,³⁶ the American College of Obstetricians and Gynecologists (ACOG) recommends against routine screening for thyroid disease in pregnancy.³⁴ The ATA notes insufficient evidence to rec-ommend universal screening for thyroid dysfunction in pregnancy but recommends targeted screening of those with risk factors.³⁷ Data are conflicting on the benefit of treating known or recently detected SCH on pregnancy outcomes including pregnancy loss.^35,38 As such, the American Society of Reproductive Medicine and the ATA both generally recommend treatment of SCH in pregnant patients, particularly when the TSH is ≥ 4.0 mIU/L and TPOAbs are present.^37,39

^a The ATA, ETA, and NICE have slightly different recommendations when a TSH level = 10 mIU/L. ETA and NICE recommend prioritizing treatment for individuals with this level, while ATA recommends treatment when individual factors are also considered.

ACKNOWLEDGEMENT
The authors thank Family Medicine Medical Librarian Gwen Wilson, MLS, AHIP, for her assistance with literature searches.

CORRESPONDENCE
Nicholas LeFevre, MD, Family and Community Medicine, University of Missouri–Columbia School of Medicine, One Hospital Drive, M224 Medical Science Building, Columbia, MO 65212; [email protected]

Subclinical hypothyroidism (SCH) is a biochemical state in which the thyroid-stimulating hormone (TSH) is elevated while the free thyroxine (T4) level is normal. Overt hypothyroidism is not diagnosed until the free T4 level is decreased, regardless of the degree of TSH elevation.

The overall prevalence of SCH in iodine-rich areas is 4% to 10%, with a risk for progression to overt hypothyroidism of between 2% and 6% annually.¹ The prevalence of SCH varies depending on the TSH reference range used.¹ The normal reference range for TSH varies depending on the laboratory and/or the reference population surveyed, with the range likely widening with increasing age.

SCH is most common among women, the elderly, and White individuals.² The discovery of SCH is often incidental, given that usually it is detected by laboratory findings alone without associated symptoms of overt hypothyroidism.³

The not-so-significant role of symptoms in subclinical hypothyroidism

Symptoms associated with overt hypothyroidism include constipation, dry skin, fatigue, slow thinking, poor memory, muscle cramps, weakness, and cold intolerance. In SCH, these symptoms are inconsistent, with around 1 in 3 patients having no symptoms at all.⁴

One study reported that roughly 18% of euthyroid individuals, 22% of SCH patients, and 26% of those with overt hypothyroidism reported 4 or more symptoms classically thought to be related to hypothyroidism.⁴ A large Danish cohort study found that hypothyroid symptoms were no more common in patients with SCH than in euthyroid individuals in the general population.⁵ These studies question the validity of attributing symptoms to SCH.

Adverse health associations

Observational data suggest that SCH is associated with an increased risk for dyslipidemia, coronary heart disease, heart failure, and cardiovascular mortality, particularly in those with TSH levels ≥ 10 mIU/L.^6,7 Such associations were not found for most adults with TSH levels between 5 and 10 mIU/L.⁸ There are also potential associations of SCH with obesity, nonalcoholic fatty liver disease, and nonalcoholic steatohepatitis.^9,10 Despite thyroid studies being commonly ordered as part of a mental health evaluation, SCH has not been statistically associated with depressive symptoms.^11,12

Caveats with laboratory testing

There are several issues to consider when performing a laboratory assessment of thyroid function. TSH levels fluctuate considerably during the day, as TSH secretion has a circadian rhythm. TSH values are 50% higher at night and in the early morning than during the rest of the day.¹³ TSH values also may rise in response to current illness or stress. Due to this biologic variability, repeat testing to confirm TSH levels is recommended if an initial test result is abnormal.¹⁴

Continue to: An exact reference range...

Supplements containing biotin should be withheld for several days before assessing thyroid function.

An exact reference range for TSH is not widely agreed upon—although most laboratories regard 4.0 to 5.0 mIU/L as the high-end cutoff for normal. Also, “normal” TSH levels appear to differ by age. Accordingly, some experts have recommended an age-based reference range for TSH levels,¹⁵ although this is not implemented widely by laboratories. A TSH level of 6.0 mIU/L (or even higher) may be more appropriate for adults older than 65 years.¹

Biotin supplementation has been shown to cause spurious thyroid testing results (TSH, T3, T4) depending on the type of assay used. Therefore, supplements containing biotin should be withheld for several days before assessing thyroid function.¹⁶Patients with SCH are often categorized as having TSH levels between 4.5 and 10 mIU/L (around 90% of patients) or levels ≥ 10 mIU/L.^8,17 If followed for 5 years, approximately 60% of patients with SCH and TSH levels between 4 and 10 mIU/L will normalize without intervention.¹⁸ Normalization is less common in patients with a TSH level greater than 10 mIU/L.¹⁸

The risk for progression to overt hypothyroidism also appears to be higher for those with certain risk factors. These include higher baseline TSH levels, presence of thyroid peroxidase antibodies (TPOAbs), or history of neck irradiation or radioactive iodine uptake.¹ Other risk factors for eventual thyroid dysfunction include female sex, older age, goiter, and high iodine intake.¹³

Evidence for treatment varies

Guidelines for the treatment of SCH (TABLE 1^8,14,19,20) are founded on the condition’s risk for progression to overt hypothyroidism and its association with health consequences such as cardiovascular disease. Guidelines of the American Thyroid Association (ATA) and European Thyroid Association (ETA), and those of the United Kingdom–based National Institute for Health and Care Excellence (NICE), prioritize treatment for individuals with a TSH level > 10 mIU/L^a and for those with TSH values < 10 mIU/L but still elevated and apparent symptoms of hypothyroidism.^14,19,20 The strength of evidence behind this guidance is challenged by a lack of data from prospective randomized controlled trials (RCTs) demonstrating health benefits following treatment of SCH. The British Medical Journal (BMJ) Guideline cites this lack of evidence and recommends against treating SCH at any TSH level, regardless of symptoms.⁸

There are few large RCTs of treatment outcomes for SCH. A 2017 RCT (the Thyroid Hormone Replacement for Untreated Older Adults with Subclinical Hypothyroidism, or TRUST, trial) of 737 adults older than 65 years with SCH evaluated the ability of levothyroxine to normalize TSH values compared with placebo. At 1 year, there was no difference in hypothyroid symptoms or tiredness scale scores with levothyroxine treatment compared with placebo.²¹ This finding was consistent even in the subgroup with a higher baseline symptom burden.²²

Continue to: Two small RCTs evaluated...

Two small RCTs evaluated treatment of SCH with depressive symptoms and cognitive function, neither finding benefit compared with placebo.^12,23 A 2018 systematic review and meta-analysis of 21 studies and 2192 adults did not show a benefit to quality of life or thyroid-specific symptoms in those treated for SCH compared with controls.²⁴

RCT support also is lacking for a reduction in cardiovascular mortality following treatment for SCH. A large population-level retrospective cohort from Denmark showed no difference in cardiovascular mortality or myocardial infarction in those treated for SCH compared with controls.²⁵ Pooled results from 2 RCTs (for patients older than 65 years, and those older than 80 years) showed no change in risk for cardiovascular outcomes in older adults treated for SCH.²⁶ Older adults treated for SCH in the TRUST trial showed no improvements in systolic or diastolic­ function on echocardiography.^27­ Two trials showed no difference in carotid intima-media thickness with treatment of SCH compared with placebo.^28,29

While most of the RCT data come from older adults, a retrospective cohort study in the United Kingdom of younger (ages 40-70 years; n = 3093) and older (age > 70 years; n = 1642) patients showed a reduction in cardiovascular mortality among treated patients who were younger (hazard ratio [HR] = 0.61; 4.2% vs. 6.6%) but not those who were older (HR = 0.99; 12.7% vs. 10.7%).³⁰ There is also evidence that thyroid size in those with goiter can be reduced with treatment of SCH.³¹

A measured approach to treating subclinical hypothyroidism

Consider several factors when deciding whether to treat SCH. For instance, RCT data suggest a lack of treatment benefit in relieving depression, improving cognition, or reducing general hypothyroid symptoms. Treatment of SCH in older adults does not appear to improve cardiovascular outcomes. The question of whether long-term treatment of SCH in younger patients reduces cardiovascular morbidity or mortality lacks answers from RCTs. Before diagnosing SCH or starting treatment, always confirm SCH with repeat testing in 2 to 3 months, as a high percentage of those with untreated SCH will have normal thyroid function on repeat testing.

Before diagnosing subclinical hypothyroidism (SCH) or starting treatment, always confirm SCH with repeat testing in 2 to 3 months.

In the event you and your patient elect to treat SCH, guidelines and trials generally support a low initial daily dose of 25 to 50 mcg of levothyroxine (T4), followed with dose changes­ every 4 to 8 weeks and a goal of normalizing TSH to within the lower half of the reference range (0.4-2.5 mIU/L).¹⁴ This is generally similar to published treatment goals for primary hypothyroidism and is based on studies suggesting the lower half of the reference range is normal for young, healthy, euthyroid individuals.³² Though full replacement doses (1.6-1.8 mcg/kg of ideal body weight) can be started for those who are elderly or who have ischemic heart disease or angina, this approach should be avoided in favor of low-dose initial therapy.³³ Thyroid supplements are best absorbed when taken apart from food, calcium, or iron supplements. The ATA suggests taking thyroid medication 60 minutes before breakfast or at bedtime (3 or more hours after the evening meal).³³

Continue to: Screening guidelines differ

Lacking population-level screening data from RCTs, most organizations do not recommend screening for thyroid dysfunction or they note insufficient evidence to make a screening recommendation (TABLE 2^17,19,20,34). In their most recent recommendation statement on the subject in 2015, the US Preventive Services Task Force (USPSTF) concluded the current evidence was insufficient to recommend for or against thyroid dysfunction screening in nonpregnant, asymptomatic adults.¹⁷ This differs from the ATA and the American Association of Clinical Endocrinology (AACE; formerly known as the American Association of Clinical Endocrinologists), which both recommend targeted screening for thyroid dysfunction based on symptoms or risk factors.²⁰

What about subclinical hypothyroidism in pregnancy?

Overt hypothyroidism is associated with adverse events during pregnancy and with subsequent neurodevelopmental complications in children, although the effects of SCH during pregnancy remain less certain. Concerns have been raised over the potential association of SCH with pregnancy loss, placental abruption, premature rupture of membranes, and neonatal death.³⁵ Historically, the prevalence of SCH during pregnancy has ranged from 2% to 2.5%, but using lower trimester-based TSH reference ranges, the prevalence of SCH in pregnancy may be as high as 15%.³⁵

Guided by a large RCT that failed to find benefit (pregnancy outcomes, neurodevelopmental outcomes in children) following treatment of SCH in pregnancy,³⁶ the American College of Obstetricians and Gynecologists (ACOG) recommends against routine screening for thyroid disease in pregnancy.³⁴ The ATA notes insufficient evidence to rec-ommend universal screening for thyroid dysfunction in pregnancy but recommends targeted screening of those with risk factors.³⁷ Data are conflicting on the benefit of treating known or recently detected SCH on pregnancy outcomes including pregnancy loss.^35,38 As such, the American Society of Reproductive Medicine and the ATA both generally recommend treatment of SCH in pregnant patients, particularly when the TSH is ≥ 4.0 mIU/L and TPOAbs are present.^37,39

^a The ATA, ETA, and NICE have slightly different recommendations when a TSH level = 10 mIU/L. ETA and NICE recommend prioritizing treatment for individuals with this level, while ATA recommends treatment when individual factors are also considered.

ACKNOWLEDGEMENT
The authors thank Family Medicine Medical Librarian Gwen Wilson, MLS, AHIP, for her assistance with literature searches.

CORRESPONDENCE
Nicholas LeFevre, MD, Family and Community Medicine, University of Missouri–Columbia School of Medicine, One Hospital Drive, M224 Medical Science Building, Columbia, MO 65212; [email protected]

Meet Dr. A and Dr. M

Dr. A is a 50-year-old family physician who provides prenatal care in a busy practice. She sees patients in eight 4-hour clinic sessions per week and is on inpatient call 1 week out of every 2 months. Dr. A has become disillusioned with her practice. She typically works until 7 pm and arrives home exhausted, with little energy to interact with her family. She spends hours in the evenings and on weekends completing charts and answering phone calls. Dr. A is concerned because she recently gained weight and lacks an established fitness routine. The COVID-19 pandemic made life more difficult as she dealt with the risk of getting infected and the changing recommendations for treatment and prevention. After 20 years of practice, Dr. A wonders whether she should leave clinical medicine.

Dr. M is a single, 32-year-old family physician working at an academic medical center. Dr. M is unhappy in his job, is trying to grow his practice, and views himself as having little impact or autonomy. He finds himself lost while navigating the electronic health record (EHR) and struggles to be efficient in the clinic. Dr. M has multiple administrative responsibilities that require him to work evenings and weekends. Debt from medical school loans also motivates him to moonlight several weekends per month. Over the past few months, Dr. M has become frustrated and discouraged, making his depression more difficult to manage. He feels drained by the time he arrives home, where he lives alone. He has stopped exercising, socializing with friends, and dating. Dr. M often wonders if he is in the wrong profession.

Defining burnout, stress, and wellness

Dr. A and Dr. M are experiencing symptoms of burnout, common to physicians and other health care professionals. Recent studies showed an increase in burnout during the COVID-19 pandemic.^1,2 In a survey using the Maslach Burnout Inventory (MBI), approximately 44% of physicians reported at least one symptom of burnout.³ After adjusting for age, gender, relationship status, and hours worked per week, physicians were found to be at greater risk for burnout than nonphysician workers.³ The latest Medscape physician burnout survey found an increase in burnout among US physicians from 42% in 2021 to 47% in 2022 during the COVID-19 pandemic.¹ Rates of burnout were even higher among family physicians and other frontline (eg, emergency, infectious disease, and critical care) physicians.¹

Burnout has 3 key dimensions: (1) overwhelming exhaustion; (2) feelings of cynicism and detachment from the job; and (3) a sense of ineffectiveness and lack of accomplishment.⁴ The MBI is considered the standard tool for research in the field of burnout and has been repeatedly assessed for reliability and validity.⁴ The original MBI includes such items as: “I feel emotionally drained from my work,” “I feel like I’m working too hard on my job,” and “I worry that this job is hardening me emotionally.”⁵

According to the World Health Organization, burnout is an occupational phenomenon associated with chronic work-related stress that is not successfully managed.⁶ This definition emphasizes work stress as the cause of burnout, thus highlighting the importance of addressing the work environment.⁷ Physician burnout can affect physician health and wellness and the quality of patient care.^8-13 Because of the cost of burnout to individuals and the health care system, it is important to understand stressors that can lead to physician burnout.

Stress has been described as “physical, mental, or emotional strain or tension … when a person perceives that demands exceed the personal and social resources the individual is able to mobilize.”¹⁴ Work-related sources of stress affecting practicing physicians include long workdays, multiple bureaucratic tasks, lack of autonomy/control, and complex patients.^1,15

The COVID-19 pandemic is a stressor that increased physicians’ exposure to patient suffering and deaths and physicians’ vulnerability to disease at work.¹⁶ Physicians taking care of patients with COVID-19 risk infection and the possibility of infecting others.Online health records are another source of stress for many physicians.^17,18 Access to online health records on personal devices can blur the line between work and home. For each hour of direct patient contact, a physician spends an additional 2 hours interacting with an EHR.¹⁹ Among family physicians and other primary care physicians, increased EHR interaction outside clinic hours has been associated with decreased workplace satisfaction and increased rates of burnout.^11,19,20 Time spent on non-patient-facing clinical tasks, such as peer-to-peer reviews and billing queries, contributes more to burnout than clinic time alone.¹⁷

Continue to: These and other organizational factors...

A physician burnout survey found an increase in burnout among US physicians from 42% in 2021 to 47% in 2022 during the COVID-19 pandemic.

These and other organizational factors contribute to the stress experienced by physicians. Many describe themselves as feeling consumed by their work. At the beginning of the COVID-19 pandemic, physicians (and the rest of the health care team) had to quickly­ learn how to conduct virtual office visits. Clerical responsibilities increased as patients relied more on patient portals and telephone calls to receive care.

Who is predisposed to burnout? Although burnout is a work-related syndrome, studies have shown an increase in burnout associated with individual (ie, personal) factors. For example, female physicians have been shown to have higher rates of burnout compared with male physicians.^1,3 The stress of balancing the demands of the profession can begin during medical school and residency, with younger physicians having nearly­ twice the risk for stress-related symptoms when compared with older colleagues.^15,20-23 Having a child younger than 21 years old, and other personal factors related to balancing family and life demands, increases the likelihood of burnout.^11,21,22

Physicians with certain personality types and predispositions are at increased risk for burnout.^23-25 For example, neuroticism on the Big Five Personality Inventory (one of the most well-known of the psychology inventories) is associated with an increased risk for burnout. Neuroticism may manifest as sadness or related emotional dysregulation (eg, irritability, anxiety).²⁶ Other traits measured by the Big Five Personality Inventory include extraversion, agreeableness, conscientiousness, and openness to experience.²⁶

Physicians who were depressed were more likely to experience burnout symptoms (87.5%); however, only 26.2% of physicians experiencing burnout were diagnosed as having depression.

A history of depression is also associated with an increased risk for burnout.²⁷ Although depression and burnout are separate conditions, a 2016 study found significant overlap between the two.²⁷ Physicians in this study who were depressed were more likely to experience burnout symptoms (87.5%); however, only 26.2% of physicians experiencing burnout were diagnosed as having depression.²⁷ Rates of depression are higher among physicians when compared with nonphysicians, yet physicians are less likely to seek help due to fear of stigma and potential licensing concerns.^28,29 Because of this, when physicians experience depressive symptoms, they may respond by working harder rather than seeking professional counseling or emotional support. They might believe that “asking for help is a sign of weakness,” thus sacrificing their wellness.

Wellness encompasses a sense of thriving characterized by thoughts and feelings of contentment, joy, and fulfillment—and the absence of severe distress.³⁰ Wellness is a multifaceted condition that includes physical, psychological, and social aspects of an individual’s personal and professional life. Individuals experience a sense of wellness when they nurture their physical selves, minds, and relationships. People experience a sense of wellness when they balance their schedules, eat well, and maintain physical activity. Making time to enjoy family and friends also contributes to wellness.

Continue to: The culture of medicine often rewards...

The culture of medicine often rewards physician attitudes and behaviors that detract from wellness.³¹ Physicians internalize the culture of medicine that promotes perfectionism and downplays personal vulnerability.³² Physicians are reluctant to protect and preserve their wellness, believing self-sacrifice makes them good doctors. Physicians may spend countless hours counseling patients on the importance of wellness, but then work when ill or neglect their personal health needs and self-care—potentially decreasing their resilience and increasing the risk for burnout.³¹

Two paths to managing stress and preventing burnout

Patel and colleagues distinguish between 2 burnout intervention categories: (1) those that focus on individual physicians and (2) those that focus on the organizational environment.³³ We find these distinctions useful and offer strategies for enhancing individual physician wellness (TABLE 1^34-41). Similar to West and colleagues,¹¹ we offer strategies for addressing organizational sources of stress (TABLE 2^42-48). The following text describes these burnout intervention categories, emphasizing increasing self-care and changes that enable physicians to adapt effectively.

The recommendations outlined in this article are based on published stress and burnout literature, as well as the experiences of the authors. However, the number of randomized controlled studies of interventions aimed at reducing physician stress and burnout is limited. In addition, strategies proposed to reduce burnout in other professions may not address the unique stressors physicians encounter. Hence, our recommendations are limited. We have included interventions that seem optimal for individual physicians and the organizations that employ them.

Individual strategies target physical, psychological, and social wellness

Physician wellness strategies are divided into 3 categories: physical, psychological, and social wellness. Most strategies to improve physical wellness are widely known, evidence based, and recommended to patients by physicians.^34-36 For example, most physicians advise their patients to eat healthy balanced meals, avoid unhealthy foods and beverages, maintain a healthy body weight, get daily exercise and adequate sleep, avoid excessive alcohol use, and abstain from tobacco use. However, discrepancies between physicians’ advice to patients and their own behaviors are common. Simply stated, physicians are well advised to follow their own advice regarding physical self-care.

CBT and mindfulness are key to psychological wellness. Recommendations for enhancing psychological wellness are primarily derived from cognitive behavioral therapy (CBT) and mindfulness principles and practices.^37,38 CBT has been called the “gold standard” of psychotherapy, based on the breadth of research demonstrating that “no other form of psychotherapy has been shown to be systematically superior to CBT.”³⁹

Continue to: CBT is based on the premise...

CBT is based on the premise that individuals’ thoughts and beliefs largely determine how they feel (emotions) and act (behaviors). Certain thoughts lead to positive feelings and effective behaviors, while others lead to negative feelings and less effective behaviors. For example, when a physician has self-critical or helpless thoughts (eg, “I’m just no good at managing my life”), they are more likely to feel unhappy and abandon problem-solving. In contrast, when a physician has self-affirming or hopeful thoughts (eg, “This is difficult, but I have the personal resources to succeed”), they are more likely to feel confident and act to solve problems.

Physicians vacillate between these thoughts and beliefs, and their emotions and behaviors follow accordingly. When hyper-focused on “the hassles of medicine,” physicians feel defeated, depressed, and anxious about their work. In contrast, when physicians recognize and challenge problematic thoughts and focus on what they love about medicine, they feel good and interact with patients and coworkers in positive and self-reinforcing ways.

Mindfulness can help reduce psychological stress and increase personal fulfillment. Mindfulness is characterized as being in the present moment, fully accepting “what is,” and having a sense of gratitude and compassion for self and others.⁴⁰ In practice, mindfulness involves being intentional.

Dahl and colleagues⁴¹ describe a framework for human flourishing that includes 4 core dimensions of well-being (awareness, insight, connection, and purpose) that are all closely linked to mindful, intentional living. Based on their work, it is apparent that those who maintain a “heightened and flexible attentiveness” to their thoughts and feelings are likely to benefit by experiencing “improved mental health and psychological well-being.”⁴¹

However, the utility of CBT and mindfulness practices depends on receptivity to psychological interventions. Individuals who are not receptive may be hesitant to use these practices or likely will not benefit from them. Given these limitations of behavioral interventions, it would be helpful if more attention were paid to preventing and managing physician stress and burnout, especially through research focused on organizational changes.

Continue to: Supportive relationships are powerful

Supportive relationships are powerful. Finally, to enhance social wellness, it would be difficult to overstate the potential benefits of positive, supportive, close relationships.⁴² However, the demands of a career in medicine, starting in medical school, have the potential for inhibiting (rather than enhancing) close relationships.

Placing value on relationships with friends and family members is essential. As Dr. M began experiencing burnout, he felt increasingly lonely, yet he isolated himself from those who cared about him. Dr. A felt lonely at home, even though she was surrounded by family. Physicians are often reluctant to initiate vulnerable communication with others, believing “no one wants to hear about my problems.” However, by realizing the need for help and asking friends and family for emotional support, physicians can improve their wellness. Fostering supportive relationships can help provide the resilience needed to address organizational stressors.

Tackling organizational challenges

Long hours and pressure to see large numbers of patients (production demands) are a challenge across practice settings. Limiting work hours has been effective in improving the well-being of physician trainees but has had an inconsistent effect on burnout.^43,44

Organizations can offer flexible scheduling, and physicians considering limiting work hours may switch to part-time status or shift work. However, decreasing work hours may have the unintended consequence of increased stress as some physicians feel pressure to do more in less time.⁴⁵ Therefore, it’s important to set clear boundaries around work time and when and where work tasks are completed (eg, home vs office).

How we use technology matters. Given­ technology’s ever-increasing role in medicine, organizations must identify and use the most efficient, effective technology for managing clerical processes. When physicians participate in these decisions and share their experiences, technology is likely to be more user-friendly and impose less stress.⁴⁶

Continue to: If technology contributes to stress...

When physicians recognize and challenge problematic thoughts and focus on what they love about medicine, they feel good and interact with patients and coworkers in positive ways.

If technology contributes to stress by being too complex or impractical, it’s important to identify individuals in the workplace (eg, IT support or “super-users”) to help address these challenges. Organizations can implement multidisciplinary teams to address EHR challenges and decrease physician stress and burnout by training support staff to assist with clerical duties, allowing physicians to focus on patient care.^47,48 Such organizational-­directed interventions will be most successful when physicians are included in the decision-making process.⁴⁷

Take on leadership roles to influence change. Leadership may be formal (involving a title and authority) or informal (leading by example). Health care organizations that are committed to the well-being of physicians will make the effort to improve the systems in which physicians work. Physicians working in organizations that are reluctant to change have several choices: implement individual strategies, take on leadership roles to influence change, or reconsider their fit for the organization. Physicians in solo practice might consider joining others in solo practices to share systems (call, phone triage, technical resources, etc) to implement some of these interventions.

Dr. A and Dr. M implement new wellness strategies

Dr. A and Dr. M have recently committed to addressing stressors in their lives and improving their wellness. Dr. A has become more assertive at work, highlighting her need for additional resources to function effectively. In response, her practice has hired scribes to assist in documenting visits. This success has inspired Dr. A to pay attention to her lifestyle choices. Gradually, she has begun to exercise and engage in healthy eating.

Dr. M has begun to utilize resources at his medical center to improve his EHR efficiency and patient flow. He has taken steps to address his financial concerns, developing a budget and spending judiciously. He practices mindfulness and ensures that he gets at least 7 hours of sleep per night, improving his mental and physical health. By doing so, he has more energy to connect with friends, ­exercise, and date.

CORRESPONDENCE
Margaret L. Smith, MD, MPH, MHSA, KUMC, Family Medicine and Community Health, 3901 Rainbow Boulevard – Mailstop 4010, Kansas City, KS 66160; [email protected]

Meet Dr. A and Dr. M

Dr. A is a 50-year-old family physician who provides prenatal care in a busy practice. She sees patients in eight 4-hour clinic sessions per week and is on inpatient call 1 week out of every 2 months. Dr. A has become disillusioned with her practice. She typically works until 7 pm and arrives home exhausted, with little energy to interact with her family. She spends hours in the evenings and on weekends completing charts and answering phone calls. Dr. A is concerned because she recently gained weight and lacks an established fitness routine. The COVID-19 pandemic made life more difficult as she dealt with the risk of getting infected and the changing recommendations for treatment and prevention. After 20 years of practice, Dr. A wonders whether she should leave clinical medicine.

Dr. M is a single, 32-year-old family physician working at an academic medical center. Dr. M is unhappy in his job, is trying to grow his practice, and views himself as having little impact or autonomy. He finds himself lost while navigating the electronic health record (EHR) and struggles to be efficient in the clinic. Dr. M has multiple administrative responsibilities that require him to work evenings and weekends. Debt from medical school loans also motivates him to moonlight several weekends per month. Over the past few months, Dr. M has become frustrated and discouraged, making his depression more difficult to manage. He feels drained by the time he arrives home, where he lives alone. He has stopped exercising, socializing with friends, and dating. Dr. M often wonders if he is in the wrong profession.

Defining burnout, stress, and wellness

Dr. A and Dr. M are experiencing symptoms of burnout, common to physicians and other health care professionals. Recent studies showed an increase in burnout during the COVID-19 pandemic.^1,2 In a survey using the Maslach Burnout Inventory (MBI), approximately 44% of physicians reported at least one symptom of burnout.³ After adjusting for age, gender, relationship status, and hours worked per week, physicians were found to be at greater risk for burnout than nonphysician workers.³ The latest Medscape physician burnout survey found an increase in burnout among US physicians from 42% in 2021 to 47% in 2022 during the COVID-19 pandemic.¹ Rates of burnout were even higher among family physicians and other frontline (eg, emergency, infectious disease, and critical care) physicians.¹

Burnout has 3 key dimensions: (1) overwhelming exhaustion; (2) feelings of cynicism and detachment from the job; and (3) a sense of ineffectiveness and lack of accomplishment.⁴ The MBI is considered the standard tool for research in the field of burnout and has been repeatedly assessed for reliability and validity.⁴ The original MBI includes such items as: “I feel emotionally drained from my work,” “I feel like I’m working too hard on my job,” and “I worry that this job is hardening me emotionally.”⁵

According to the World Health Organization, burnout is an occupational phenomenon associated with chronic work-related stress that is not successfully managed.⁶ This definition emphasizes work stress as the cause of burnout, thus highlighting the importance of addressing the work environment.⁷ Physician burnout can affect physician health and wellness and the quality of patient care.^8-13 Because of the cost of burnout to individuals and the health care system, it is important to understand stressors that can lead to physician burnout.

Stress has been described as “physical, mental, or emotional strain or tension … when a person perceives that demands exceed the personal and social resources the individual is able to mobilize.”¹⁴ Work-related sources of stress affecting practicing physicians include long workdays, multiple bureaucratic tasks, lack of autonomy/control, and complex patients.^1,15

The COVID-19 pandemic is a stressor that increased physicians’ exposure to patient suffering and deaths and physicians’ vulnerability to disease at work.¹⁶ Physicians taking care of patients with COVID-19 risk infection and the possibility of infecting others.Online health records are another source of stress for many physicians.^17,18 Access to online health records on personal devices can blur the line between work and home. For each hour of direct patient contact, a physician spends an additional 2 hours interacting with an EHR.¹⁹ Among family physicians and other primary care physicians, increased EHR interaction outside clinic hours has been associated with decreased workplace satisfaction and increased rates of burnout.^11,19,20 Time spent on non-patient-facing clinical tasks, such as peer-to-peer reviews and billing queries, contributes more to burnout than clinic time alone.¹⁷

Continue to: These and other organizational factors...

A physician burnout survey found an increase in burnout among US physicians from 42% in 2021 to 47% in 2022 during the COVID-19 pandemic.

These and other organizational factors contribute to the stress experienced by physicians. Many describe themselves as feeling consumed by their work. At the beginning of the COVID-19 pandemic, physicians (and the rest of the health care team) had to quickly­ learn how to conduct virtual office visits. Clerical responsibilities increased as patients relied more on patient portals and telephone calls to receive care.

Who is predisposed to burnout? Although burnout is a work-related syndrome, studies have shown an increase in burnout associated with individual (ie, personal) factors. For example, female physicians have been shown to have higher rates of burnout compared with male physicians.^1,3 The stress of balancing the demands of the profession can begin during medical school and residency, with younger physicians having nearly­ twice the risk for stress-related symptoms when compared with older colleagues.^15,20-23 Having a child younger than 21 years old, and other personal factors related to balancing family and life demands, increases the likelihood of burnout.^11,21,22

Physicians with certain personality types and predispositions are at increased risk for burnout.^23-25 For example, neuroticism on the Big Five Personality Inventory (one of the most well-known of the psychology inventories) is associated with an increased risk for burnout. Neuroticism may manifest as sadness or related emotional dysregulation (eg, irritability, anxiety).²⁶ Other traits measured by the Big Five Personality Inventory include extraversion, agreeableness, conscientiousness, and openness to experience.²⁶

Physicians who were depressed were more likely to experience burnout symptoms (87.5%); however, only 26.2% of physicians experiencing burnout were diagnosed as having depression.

A history of depression is also associated with an increased risk for burnout.²⁷ Although depression and burnout are separate conditions, a 2016 study found significant overlap between the two.²⁷ Physicians in this study who were depressed were more likely to experience burnout symptoms (87.5%); however, only 26.2% of physicians experiencing burnout were diagnosed as having depression.²⁷ Rates of depression are higher among physicians when compared with nonphysicians, yet physicians are less likely to seek help due to fear of stigma and potential licensing concerns.^28,29 Because of this, when physicians experience depressive symptoms, they may respond by working harder rather than seeking professional counseling or emotional support. They might believe that “asking for help is a sign of weakness,” thus sacrificing their wellness.

Wellness encompasses a sense of thriving characterized by thoughts and feelings of contentment, joy, and fulfillment—and the absence of severe distress.³⁰ Wellness is a multifaceted condition that includes physical, psychological, and social aspects of an individual’s personal and professional life. Individuals experience a sense of wellness when they nurture their physical selves, minds, and relationships. People experience a sense of wellness when they balance their schedules, eat well, and maintain physical activity. Making time to enjoy family and friends also contributes to wellness.

Continue to: The culture of medicine often rewards...

The culture of medicine often rewards physician attitudes and behaviors that detract from wellness.³¹ Physicians internalize the culture of medicine that promotes perfectionism and downplays personal vulnerability.³² Physicians are reluctant to protect and preserve their wellness, believing self-sacrifice makes them good doctors. Physicians may spend countless hours counseling patients on the importance of wellness, but then work when ill or neglect their personal health needs and self-care—potentially decreasing their resilience and increasing the risk for burnout.³¹

Two paths to managing stress and preventing burnout

Patel and colleagues distinguish between 2 burnout intervention categories: (1) those that focus on individual physicians and (2) those that focus on the organizational environment.³³ We find these distinctions useful and offer strategies for enhancing individual physician wellness (TABLE 1^34-41). Similar to West and colleagues,¹¹ we offer strategies for addressing organizational sources of stress (TABLE 2^42-48). The following text describes these burnout intervention categories, emphasizing increasing self-care and changes that enable physicians to adapt effectively.

The recommendations outlined in this article are based on published stress and burnout literature, as well as the experiences of the authors. However, the number of randomized controlled studies of interventions aimed at reducing physician stress and burnout is limited. In addition, strategies proposed to reduce burnout in other professions may not address the unique stressors physicians encounter. Hence, our recommendations are limited. We have included interventions that seem optimal for individual physicians and the organizations that employ them.

Individual strategies target physical, psychological, and social wellness

Physician wellness strategies are divided into 3 categories: physical, psychological, and social wellness. Most strategies to improve physical wellness are widely known, evidence based, and recommended to patients by physicians.^34-36 For example, most physicians advise their patients to eat healthy balanced meals, avoid unhealthy foods and beverages, maintain a healthy body weight, get daily exercise and adequate sleep, avoid excessive alcohol use, and abstain from tobacco use. However, discrepancies between physicians’ advice to patients and their own behaviors are common. Simply stated, physicians are well advised to follow their own advice regarding physical self-care.

CBT and mindfulness are key to psychological wellness. Recommendations for enhancing psychological wellness are primarily derived from cognitive behavioral therapy (CBT) and mindfulness principles and practices.^37,38 CBT has been called the “gold standard” of psychotherapy, based on the breadth of research demonstrating that “no other form of psychotherapy has been shown to be systematically superior to CBT.”³⁹

Continue to: CBT is based on the premise...

CBT is based on the premise that individuals’ thoughts and beliefs largely determine how they feel (emotions) and act (behaviors). Certain thoughts lead to positive feelings and effective behaviors, while others lead to negative feelings and less effective behaviors. For example, when a physician has self-critical or helpless thoughts (eg, “I’m just no good at managing my life”), they are more likely to feel unhappy and abandon problem-solving. In contrast, when a physician has self-affirming or hopeful thoughts (eg, “This is difficult, but I have the personal resources to succeed”), they are more likely to feel confident and act to solve problems.

Physicians vacillate between these thoughts and beliefs, and their emotions and behaviors follow accordingly. When hyper-focused on “the hassles of medicine,” physicians feel defeated, depressed, and anxious about their work. In contrast, when physicians recognize and challenge problematic thoughts and focus on what they love about medicine, they feel good and interact with patients and coworkers in positive and self-reinforcing ways.

Mindfulness can help reduce psychological stress and increase personal fulfillment. Mindfulness is characterized as being in the present moment, fully accepting “what is,” and having a sense of gratitude and compassion for self and others.⁴⁰ In practice, mindfulness involves being intentional.

Dahl and colleagues⁴¹ describe a framework for human flourishing that includes 4 core dimensions of well-being (awareness, insight, connection, and purpose) that are all closely linked to mindful, intentional living. Based on their work, it is apparent that those who maintain a “heightened and flexible attentiveness” to their thoughts and feelings are likely to benefit by experiencing “improved mental health and psychological well-being.”⁴¹

However, the utility of CBT and mindfulness practices depends on receptivity to psychological interventions. Individuals who are not receptive may be hesitant to use these practices or likely will not benefit from them. Given these limitations of behavioral interventions, it would be helpful if more attention were paid to preventing and managing physician stress and burnout, especially through research focused on organizational changes.

Continue to: Supportive relationships are powerful

Supportive relationships are powerful. Finally, to enhance social wellness, it would be difficult to overstate the potential benefits of positive, supportive, close relationships.⁴² However, the demands of a career in medicine, starting in medical school, have the potential for inhibiting (rather than enhancing) close relationships.

Placing value on relationships with friends and family members is essential. As Dr. M began experiencing burnout, he felt increasingly lonely, yet he isolated himself from those who cared about him. Dr. A felt lonely at home, even though she was surrounded by family. Physicians are often reluctant to initiate vulnerable communication with others, believing “no one wants to hear about my problems.” However, by realizing the need for help and asking friends and family for emotional support, physicians can improve their wellness. Fostering supportive relationships can help provide the resilience needed to address organizational stressors.

Tackling organizational challenges

Long hours and pressure to see large numbers of patients (production demands) are a challenge across practice settings. Limiting work hours has been effective in improving the well-being of physician trainees but has had an inconsistent effect on burnout.^43,44

Organizations can offer flexible scheduling, and physicians considering limiting work hours may switch to part-time status or shift work. However, decreasing work hours may have the unintended consequence of increased stress as some physicians feel pressure to do more in less time.⁴⁵ Therefore, it’s important to set clear boundaries around work time and when and where work tasks are completed (eg, home vs office).

How we use technology matters. Given­ technology’s ever-increasing role in medicine, organizations must identify and use the most efficient, effective technology for managing clerical processes. When physicians participate in these decisions and share their experiences, technology is likely to be more user-friendly and impose less stress.⁴⁶

Continue to: If technology contributes to stress...

When physicians recognize and challenge problematic thoughts and focus on what they love about medicine, they feel good and interact with patients and coworkers in positive ways.

If technology contributes to stress by being too complex or impractical, it’s important to identify individuals in the workplace (eg, IT support or “super-users”) to help address these challenges. Organizations can implement multidisciplinary teams to address EHR challenges and decrease physician stress and burnout by training support staff to assist with clerical duties, allowing physicians to focus on patient care.^47,48 Such organizational-­directed interventions will be most successful when physicians are included in the decision-making process.⁴⁷

Take on leadership roles to influence change. Leadership may be formal (involving a title and authority) or informal (leading by example). Health care organizations that are committed to the well-being of physicians will make the effort to improve the systems in which physicians work. Physicians working in organizations that are reluctant to change have several choices: implement individual strategies, take on leadership roles to influence change, or reconsider their fit for the organization. Physicians in solo practice might consider joining others in solo practices to share systems (call, phone triage, technical resources, etc) to implement some of these interventions.

Dr. A and Dr. M implement new wellness strategies

Dr. A and Dr. M have recently committed to addressing stressors in their lives and improving their wellness. Dr. A has become more assertive at work, highlighting her need for additional resources to function effectively. In response, her practice has hired scribes to assist in documenting visits. This success has inspired Dr. A to pay attention to her lifestyle choices. Gradually, she has begun to exercise and engage in healthy eating.

Dr. M has begun to utilize resources at his medical center to improve his EHR efficiency and patient flow. He has taken steps to address his financial concerns, developing a budget and spending judiciously. He practices mindfulness and ensures that he gets at least 7 hours of sleep per night, improving his mental and physical health. By doing so, he has more energy to connect with friends, ­exercise, and date.

CORRESPONDENCE
Margaret L. Smith, MD, MPH, MHSA, KUMC, Family Medicine and Community Health, 3901 Rainbow Boulevard – Mailstop 4010, Kansas City, KS 66160; [email protected]

Meet Dr. A and Dr. M

Dr. A is a 50-year-old family physician who provides prenatal care in a busy practice. She sees patients in eight 4-hour clinic sessions per week and is on inpatient call 1 week out of every 2 months. Dr. A has become disillusioned with her practice. She typically works until 7 pm and arrives home exhausted, with little energy to interact with her family. She spends hours in the evenings and on weekends completing charts and answering phone calls. Dr. A is concerned because she recently gained weight and lacks an established fitness routine. The COVID-19 pandemic made life more difficult as she dealt with the risk of getting infected and the changing recommendations for treatment and prevention. After 20 years of practice, Dr. A wonders whether she should leave clinical medicine.

Dr. M is a single, 32-year-old family physician working at an academic medical center. Dr. M is unhappy in his job, is trying to grow his practice, and views himself as having little impact or autonomy. He finds himself lost while navigating the electronic health record (EHR) and struggles to be efficient in the clinic. Dr. M has multiple administrative responsibilities that require him to work evenings and weekends. Debt from medical school loans also motivates him to moonlight several weekends per month. Over the past few months, Dr. M has become frustrated and discouraged, making his depression more difficult to manage. He feels drained by the time he arrives home, where he lives alone. He has stopped exercising, socializing with friends, and dating. Dr. M often wonders if he is in the wrong profession.

Defining burnout, stress, and wellness

Dr. A and Dr. M are experiencing symptoms of burnout, common to physicians and other health care professionals. Recent studies showed an increase in burnout during the COVID-19 pandemic.^1,2 In a survey using the Maslach Burnout Inventory (MBI), approximately 44% of physicians reported at least one symptom of burnout.³ After adjusting for age, gender, relationship status, and hours worked per week, physicians were found to be at greater risk for burnout than nonphysician workers.³ The latest Medscape physician burnout survey found an increase in burnout among US physicians from 42% in 2021 to 47% in 2022 during the COVID-19 pandemic.¹ Rates of burnout were even higher among family physicians and other frontline (eg, emergency, infectious disease, and critical care) physicians.¹

Burnout has 3 key dimensions: (1) overwhelming exhaustion; (2) feelings of cynicism and detachment from the job; and (3) a sense of ineffectiveness and lack of accomplishment.⁴ The MBI is considered the standard tool for research in the field of burnout and has been repeatedly assessed for reliability and validity.⁴ The original MBI includes such items as: “I feel emotionally drained from my work,” “I feel like I’m working too hard on my job,” and “I worry that this job is hardening me emotionally.”⁵

According to the World Health Organization, burnout is an occupational phenomenon associated with chronic work-related stress that is not successfully managed.⁶ This definition emphasizes work stress as the cause of burnout, thus highlighting the importance of addressing the work environment.⁷ Physician burnout can affect physician health and wellness and the quality of patient care.^8-13 Because of the cost of burnout to individuals and the health care system, it is important to understand stressors that can lead to physician burnout.

Stress has been described as “physical, mental, or emotional strain or tension … when a person perceives that demands exceed the personal and social resources the individual is able to mobilize.”¹⁴ Work-related sources of stress affecting practicing physicians include long workdays, multiple bureaucratic tasks, lack of autonomy/control, and complex patients.^1,15

The COVID-19 pandemic is a stressor that increased physicians’ exposure to patient suffering and deaths and physicians’ vulnerability to disease at work.¹⁶ Physicians taking care of patients with COVID-19 risk infection and the possibility of infecting others.Online health records are another source of stress for many physicians.^17,18 Access to online health records on personal devices can blur the line between work and home. For each hour of direct patient contact, a physician spends an additional 2 hours interacting with an EHR.¹⁹ Among family physicians and other primary care physicians, increased EHR interaction outside clinic hours has been associated with decreased workplace satisfaction and increased rates of burnout.^11,19,20 Time spent on non-patient-facing clinical tasks, such as peer-to-peer reviews and billing queries, contributes more to burnout than clinic time alone.¹⁷

Continue to: These and other organizational factors...

A physician burnout survey found an increase in burnout among US physicians from 42% in 2021 to 47% in 2022 during the COVID-19 pandemic.

These and other organizational factors contribute to the stress experienced by physicians. Many describe themselves as feeling consumed by their work. At the beginning of the COVID-19 pandemic, physicians (and the rest of the health care team) had to quickly­ learn how to conduct virtual office visits. Clerical responsibilities increased as patients relied more on patient portals and telephone calls to receive care.

Who is predisposed to burnout? Although burnout is a work-related syndrome, studies have shown an increase in burnout associated with individual (ie, personal) factors. For example, female physicians have been shown to have higher rates of burnout compared with male physicians.^1,3 The stress of balancing the demands of the profession can begin during medical school and residency, with younger physicians having nearly­ twice the risk for stress-related symptoms when compared with older colleagues.^15,20-23 Having a child younger than 21 years old, and other personal factors related to balancing family and life demands, increases the likelihood of burnout.^11,21,22

Physicians with certain personality types and predispositions are at increased risk for burnout.^23-25 For example, neuroticism on the Big Five Personality Inventory (one of the most well-known of the psychology inventories) is associated with an increased risk for burnout. Neuroticism may manifest as sadness or related emotional dysregulation (eg, irritability, anxiety).²⁶ Other traits measured by the Big Five Personality Inventory include extraversion, agreeableness, conscientiousness, and openness to experience.²⁶

Physicians who were depressed were more likely to experience burnout symptoms (87.5%); however, only 26.2% of physicians experiencing burnout were diagnosed as having depression.

A history of depression is also associated with an increased risk for burnout.²⁷ Although depression and burnout are separate conditions, a 2016 study found significant overlap between the two.²⁷ Physicians in this study who were depressed were more likely to experience burnout symptoms (87.5%); however, only 26.2% of physicians experiencing burnout were diagnosed as having depression.²⁷ Rates of depression are higher among physicians when compared with nonphysicians, yet physicians are less likely to seek help due to fear of stigma and potential licensing concerns.^28,29 Because of this, when physicians experience depressive symptoms, they may respond by working harder rather than seeking professional counseling or emotional support. They might believe that “asking for help is a sign of weakness,” thus sacrificing their wellness.

Wellness encompasses a sense of thriving characterized by thoughts and feelings of contentment, joy, and fulfillment—and the absence of severe distress.³⁰ Wellness is a multifaceted condition that includes physical, psychological, and social aspects of an individual’s personal and professional life. Individuals experience a sense of wellness when they nurture their physical selves, minds, and relationships. People experience a sense of wellness when they balance their schedules, eat well, and maintain physical activity. Making time to enjoy family and friends also contributes to wellness.

Continue to: The culture of medicine often rewards...

The culture of medicine often rewards physician attitudes and behaviors that detract from wellness.³¹ Physicians internalize the culture of medicine that promotes perfectionism and downplays personal vulnerability.³² Physicians are reluctant to protect and preserve their wellness, believing self-sacrifice makes them good doctors. Physicians may spend countless hours counseling patients on the importance of wellness, but then work when ill or neglect their personal health needs and self-care—potentially decreasing their resilience and increasing the risk for burnout.³¹

Two paths to managing stress and preventing burnout

Patel and colleagues distinguish between 2 burnout intervention categories: (1) those that focus on individual physicians and (2) those that focus on the organizational environment.³³ We find these distinctions useful and offer strategies for enhancing individual physician wellness (TABLE 1^34-41). Similar to West and colleagues,¹¹ we offer strategies for addressing organizational sources of stress (TABLE 2^42-48). The following text describes these burnout intervention categories, emphasizing increasing self-care and changes that enable physicians to adapt effectively.

The recommendations outlined in this article are based on published stress and burnout literature, as well as the experiences of the authors. However, the number of randomized controlled studies of interventions aimed at reducing physician stress and burnout is limited. In addition, strategies proposed to reduce burnout in other professions may not address the unique stressors physicians encounter. Hence, our recommendations are limited. We have included interventions that seem optimal for individual physicians and the organizations that employ them.

Individual strategies target physical, psychological, and social wellness

Physician wellness strategies are divided into 3 categories: physical, psychological, and social wellness. Most strategies to improve physical wellness are widely known, evidence based, and recommended to patients by physicians.^34-36 For example, most physicians advise their patients to eat healthy balanced meals, avoid unhealthy foods and beverages, maintain a healthy body weight, get daily exercise and adequate sleep, avoid excessive alcohol use, and abstain from tobacco use. However, discrepancies between physicians’ advice to patients and their own behaviors are common. Simply stated, physicians are well advised to follow their own advice regarding physical self-care.

CBT and mindfulness are key to psychological wellness. Recommendations for enhancing psychological wellness are primarily derived from cognitive behavioral therapy (CBT) and mindfulness principles and practices.^37,38 CBT has been called the “gold standard” of psychotherapy, based on the breadth of research demonstrating that “no other form of psychotherapy has been shown to be systematically superior to CBT.”³⁹

Continue to: CBT is based on the premise...

CBT is based on the premise that individuals’ thoughts and beliefs largely determine how they feel (emotions) and act (behaviors). Certain thoughts lead to positive feelings and effective behaviors, while others lead to negative feelings and less effective behaviors. For example, when a physician has self-critical or helpless thoughts (eg, “I’m just no good at managing my life”), they are more likely to feel unhappy and abandon problem-solving. In contrast, when a physician has self-affirming or hopeful thoughts (eg, “This is difficult, but I have the personal resources to succeed”), they are more likely to feel confident and act to solve problems.

Physicians vacillate between these thoughts and beliefs, and their emotions and behaviors follow accordingly. When hyper-focused on “the hassles of medicine,” physicians feel defeated, depressed, and anxious about their work. In contrast, when physicians recognize and challenge problematic thoughts and focus on what they love about medicine, they feel good and interact with patients and coworkers in positive and self-reinforcing ways.

Mindfulness can help reduce psychological stress and increase personal fulfillment. Mindfulness is characterized as being in the present moment, fully accepting “what is,” and having a sense of gratitude and compassion for self and others.⁴⁰ In practice, mindfulness involves being intentional.

Dahl and colleagues⁴¹ describe a framework for human flourishing that includes 4 core dimensions of well-being (awareness, insight, connection, and purpose) that are all closely linked to mindful, intentional living. Based on their work, it is apparent that those who maintain a “heightened and flexible attentiveness” to their thoughts and feelings are likely to benefit by experiencing “improved mental health and psychological well-being.”⁴¹

However, the utility of CBT and mindfulness practices depends on receptivity to psychological interventions. Individuals who are not receptive may be hesitant to use these practices or likely will not benefit from them. Given these limitations of behavioral interventions, it would be helpful if more attention were paid to preventing and managing physician stress and burnout, especially through research focused on organizational changes.

Continue to: Supportive relationships are powerful

Supportive relationships are powerful. Finally, to enhance social wellness, it would be difficult to overstate the potential benefits of positive, supportive, close relationships.⁴² However, the demands of a career in medicine, starting in medical school, have the potential for inhibiting (rather than enhancing) close relationships.

Placing value on relationships with friends and family members is essential. As Dr. M began experiencing burnout, he felt increasingly lonely, yet he isolated himself from those who cared about him. Dr. A felt lonely at home, even though she was surrounded by family. Physicians are often reluctant to initiate vulnerable communication with others, believing “no one wants to hear about my problems.” However, by realizing the need for help and asking friends and family for emotional support, physicians can improve their wellness. Fostering supportive relationships can help provide the resilience needed to address organizational stressors.

Tackling organizational challenges

Long hours and pressure to see large numbers of patients (production demands) are a challenge across practice settings. Limiting work hours has been effective in improving the well-being of physician trainees but has had an inconsistent effect on burnout.^43,44

Organizations can offer flexible scheduling, and physicians considering limiting work hours may switch to part-time status or shift work. However, decreasing work hours may have the unintended consequence of increased stress as some physicians feel pressure to do more in less time.⁴⁵ Therefore, it’s important to set clear boundaries around work time and when and where work tasks are completed (eg, home vs office).

How we use technology matters. Given­ technology’s ever-increasing role in medicine, organizations must identify and use the most efficient, effective technology for managing clerical processes. When physicians participate in these decisions and share their experiences, technology is likely to be more user-friendly and impose less stress.⁴⁶

Continue to: If technology contributes to stress...

When physicians recognize and challenge problematic thoughts and focus on what they love about medicine, they feel good and interact with patients and coworkers in positive ways.

If technology contributes to stress by being too complex or impractical, it’s important to identify individuals in the workplace (eg, IT support or “super-users”) to help address these challenges. Organizations can implement multidisciplinary teams to address EHR challenges and decrease physician stress and burnout by training support staff to assist with clerical duties, allowing physicians to focus on patient care.^47,48 Such organizational-­directed interventions will be most successful when physicians are included in the decision-making process.⁴⁷

Take on leadership roles to influence change. Leadership may be formal (involving a title and authority) or informal (leading by example). Health care organizations that are committed to the well-being of physicians will make the effort to improve the systems in which physicians work. Physicians working in organizations that are reluctant to change have several choices: implement individual strategies, take on leadership roles to influence change, or reconsider their fit for the organization. Physicians in solo practice might consider joining others in solo practices to share systems (call, phone triage, technical resources, etc) to implement some of these interventions.

Dr. A and Dr. M implement new wellness strategies

Dr. A and Dr. M have recently committed to addressing stressors in their lives and improving their wellness. Dr. A has become more assertive at work, highlighting her need for additional resources to function effectively. In response, her practice has hired scribes to assist in documenting visits. This success has inspired Dr. A to pay attention to her lifestyle choices. Gradually, she has begun to exercise and engage in healthy eating.

Dr. M has begun to utilize resources at his medical center to improve his EHR efficiency and patient flow. He has taken steps to address his financial concerns, developing a budget and spending judiciously. He practices mindfulness and ensures that he gets at least 7 hours of sleep per night, improving his mental and physical health. By doing so, he has more energy to connect with friends, ­exercise, and date.

CORRESPONDENCE
Margaret L. Smith, MD, MPH, MHSA, KUMC, Family Medicine and Community Health, 3901 Rainbow Boulevard – Mailstop 4010, Kansas City, KS 66160; [email protected]

A common gut bacteria may play a role in the development of Parkinson’s disease (PD) by causing aggregation of the alpha-synuclein protein, a key feature in the pathology of PD, a small study suggests.

Environmental factors as well as genetics are also suspected to play a role in PD etiology, although the exact cause remains unknown.

“Our findings indicate that specific strains of Desulfovibrio bacteria are likely to cause Parkinson’s disease,” study investigator Per Erik Saris, PhD, from the University of Helsinki, Finland, says in a news release.

The study was published online in Frontiers in Cellular and Infection Microbiology.
 

Screen and treat?

It builds on earlier work by the researchers that showed that Desulfovibrio bacteria were more prevalent and more abundant in quantity in patients with PD, especially patients with more severe disease, than in healthy individuals.

Desulfovibrio is a genus of gram-negative bacteria commonly found in aquatic environments in which levels of organic material are elevated, as well as in waterlogged soils.

In their latest study, Dr. Saris and colleagues looked for Desulfovibrio species in fecal samples from 10 patients with PD and their healthy spouses. Isolated Desulfovibrio strains were fed to a strain of Caenorhabditis elegans roundworms that expressed human alpha-syn fused with yellow fluorescent protein.

They found that worms fed Desulfovibrio bacteria from patients with PD harbored significantly more (P < .001) and larger alpha-syn aggregates (P < .001) than worms fed Desulfovibrio bacteria from healthy individuals or worms fed Escherichia coli strains.

In addition, worms fed Desulfovibrio strains from patients with PD died in significantly higher quantities than worms fed E. coli bacteria (P < .01).

Desulfovibrio strains isolated from patients with PD and strains isolated from healthy individuals appear to have different traits. Comparative genomics studies are needed to identify genetic differences and pathogenic genes from Desulfovibrio strains from patients with PD, the researchers note.

“Taking into account that aggregation of alpha-syn is a hallmark of PD, the ability of Desulfovibrio bacteria to induce alpha-syn aggregation in large numbers and sizes, as demonstrated in the present study, provides further evidence for the pathogenic role of Desulfovibrio bacteria in PD, as previously suggested,” they add.

The findings highlight the potential for screening and targeted removal of harmful Desulfovibrio bacteria, Dr. Saris suggests in the news release.
 

No clinical implications

In a comment, James Beck, PhD, chief scientific officer at the Parkinson’s Foundation, cautioned that “this research is in a very early stage, uses a nonvertebrate animal model, and the number of participants is small.

“Understanding the role of the gut microbiome in influencing PD is in its infancy. These are important steps to determining what – if any – link may be between gut bacteria and PD,” Dr. Beck said.

“Right now, there are no implications for the screening/treatment of carriers,” Dr. Beck said.

“It seems that a lot of people, whether with PD or not, harbor Desulfovibrio bacteria in their gut. More research is needed to understand what is different between the Desulfovibrio bacteria of people with PD vs. those who do not have PD,” Dr. Beck added.

The study was supported by the Magnus Ehrnrooth Foundation and the Jane and Aatos Erkko Foundation. Dr. Saris and Dr. Beck have disclosed no relevant financial relationships.

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

A common gut bacteria may play a role in the development of Parkinson’s disease (PD) by causing aggregation of the alpha-synuclein protein, a key feature in the pathology of PD, a small study suggests.

Environmental factors as well as genetics are also suspected to play a role in PD etiology, although the exact cause remains unknown.

“Our findings indicate that specific strains of Desulfovibrio bacteria are likely to cause Parkinson’s disease,” study investigator Per Erik Saris, PhD, from the University of Helsinki, Finland, says in a news release.

The study was published online in Frontiers in Cellular and Infection Microbiology.
 

Screen and treat?

It builds on earlier work by the researchers that showed that Desulfovibrio bacteria were more prevalent and more abundant in quantity in patients with PD, especially patients with more severe disease, than in healthy individuals.

Desulfovibrio is a genus of gram-negative bacteria commonly found in aquatic environments in which levels of organic material are elevated, as well as in waterlogged soils.

In their latest study, Dr. Saris and colleagues looked for Desulfovibrio species in fecal samples from 10 patients with PD and their healthy spouses. Isolated Desulfovibrio strains were fed to a strain of Caenorhabditis elegans roundworms that expressed human alpha-syn fused with yellow fluorescent protein.

They found that worms fed Desulfovibrio bacteria from patients with PD harbored significantly more (P < .001) and larger alpha-syn aggregates (P < .001) than worms fed Desulfovibrio bacteria from healthy individuals or worms fed Escherichia coli strains.

In addition, worms fed Desulfovibrio strains from patients with PD died in significantly higher quantities than worms fed E. coli bacteria (P < .01).

Desulfovibrio strains isolated from patients with PD and strains isolated from healthy individuals appear to have different traits. Comparative genomics studies are needed to identify genetic differences and pathogenic genes from Desulfovibrio strains from patients with PD, the researchers note.

“Taking into account that aggregation of alpha-syn is a hallmark of PD, the ability of Desulfovibrio bacteria to induce alpha-syn aggregation in large numbers and sizes, as demonstrated in the present study, provides further evidence for the pathogenic role of Desulfovibrio bacteria in PD, as previously suggested,” they add.

The findings highlight the potential for screening and targeted removal of harmful Desulfovibrio bacteria, Dr. Saris suggests in the news release.
 

No clinical implications

In a comment, James Beck, PhD, chief scientific officer at the Parkinson’s Foundation, cautioned that “this research is in a very early stage, uses a nonvertebrate animal model, and the number of participants is small.

“Understanding the role of the gut microbiome in influencing PD is in its infancy. These are important steps to determining what – if any – link may be between gut bacteria and PD,” Dr. Beck said.

“Right now, there are no implications for the screening/treatment of carriers,” Dr. Beck said.

“It seems that a lot of people, whether with PD or not, harbor Desulfovibrio bacteria in their gut. More research is needed to understand what is different between the Desulfovibrio bacteria of people with PD vs. those who do not have PD,” Dr. Beck added.

The study was supported by the Magnus Ehrnrooth Foundation and the Jane and Aatos Erkko Foundation. Dr. Saris and Dr. Beck have disclosed no relevant financial relationships.

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

A common gut bacteria may play a role in the development of Parkinson’s disease (PD) by causing aggregation of the alpha-synuclein protein, a key feature in the pathology of PD, a small study suggests.

Environmental factors as well as genetics are also suspected to play a role in PD etiology, although the exact cause remains unknown.

“Our findings indicate that specific strains of Desulfovibrio bacteria are likely to cause Parkinson’s disease,” study investigator Per Erik Saris, PhD, from the University of Helsinki, Finland, says in a news release.

The study was published online in Frontiers in Cellular and Infection Microbiology.
 

Screen and treat?

It builds on earlier work by the researchers that showed that Desulfovibrio bacteria were more prevalent and more abundant in quantity in patients with PD, especially patients with more severe disease, than in healthy individuals.

Desulfovibrio is a genus of gram-negative bacteria commonly found in aquatic environments in which levels of organic material are elevated, as well as in waterlogged soils.

In their latest study, Dr. Saris and colleagues looked for Desulfovibrio species in fecal samples from 10 patients with PD and their healthy spouses. Isolated Desulfovibrio strains were fed to a strain of Caenorhabditis elegans roundworms that expressed human alpha-syn fused with yellow fluorescent protein.

They found that worms fed Desulfovibrio bacteria from patients with PD harbored significantly more (P < .001) and larger alpha-syn aggregates (P < .001) than worms fed Desulfovibrio bacteria from healthy individuals or worms fed Escherichia coli strains.

In addition, worms fed Desulfovibrio strains from patients with PD died in significantly higher quantities than worms fed E. coli bacteria (P < .01).

Desulfovibrio strains isolated from patients with PD and strains isolated from healthy individuals appear to have different traits. Comparative genomics studies are needed to identify genetic differences and pathogenic genes from Desulfovibrio strains from patients with PD, the researchers note.

“Taking into account that aggregation of alpha-syn is a hallmark of PD, the ability of Desulfovibrio bacteria to induce alpha-syn aggregation in large numbers and sizes, as demonstrated in the present study, provides further evidence for the pathogenic role of Desulfovibrio bacteria in PD, as previously suggested,” they add.

The findings highlight the potential for screening and targeted removal of harmful Desulfovibrio bacteria, Dr. Saris suggests in the news release.
 

No clinical implications

In a comment, James Beck, PhD, chief scientific officer at the Parkinson’s Foundation, cautioned that “this research is in a very early stage, uses a nonvertebrate animal model, and the number of participants is small.

“Understanding the role of the gut microbiome in influencing PD is in its infancy. These are important steps to determining what – if any – link may be between gut bacteria and PD,” Dr. Beck said.

“Right now, there are no implications for the screening/treatment of carriers,” Dr. Beck said.

“It seems that a lot of people, whether with PD or not, harbor Desulfovibrio bacteria in their gut. More research is needed to understand what is different between the Desulfovibrio bacteria of people with PD vs. those who do not have PD,” Dr. Beck added.

The study was supported by the Magnus Ehrnrooth Foundation and the Jane and Aatos Erkko Foundation. Dr. Saris and Dr. Beck have disclosed no relevant financial relationships.

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

SEATTLE – Tissue accumulation of advanced glycation end products (AGEs) is associated with the presence of hypercortisolism, suggesting a potential future noninvasive method to assist in the diagnosis of Cushing syndrome, new research suggests.
 

Tissue accumulation of AGEs – harmful compounds formed by glycation of macromolecules – has been implicated in aging, diabetes, and cardiovascular disease. Now, in a new single-center prospective study, a group of 208 patients with endogenous hypercortisolism was found to have significantly higher median tissue AGE levels than 103 reference subjects without hypercortisolism.

The findings were presented at the annual meeting of the American Association of Clinical Endocrinology by Rashi Sandooja, MD, an endocrinology fellow at the Mayo Clinic, Rochester, Minn.

“Diagnosis of endogenous hypercortisolism can be quite challenging. Often patients can have nonspecific symptoms with biochemical testing being equivocal. In these situations, new biomarkers of hypercortisolism such as AGE measurement could potentially be useful,” Dr. Sandooja said in an interview.

“After proper validation, it could help clinicians in cases which may not be straightforward and could serve as an additional” instrument in the toolkit to reach a conclusive diagnosis, she added.

Asked to comment, session moderator Anupam Kotwal, MD, said in an interview: “I think it’s very exciting data. ... I envision its use in mild autonomous cortisol secretion, where there are not a lot of overt Cushing features but they may have a small adrenal mass. ... It might be used to guide care when there’s not a clear-cut answer.”

However, he cautioned that more validation is needed to determine the correlates of AGEs by different etiologies and magnitudes of cortisol excess.

Moreover, “skin can become thin in hypercortisolism, so is [the reader device] just detecting it more with skin testing? I think a blood test for validation would be a very good next step,” added Dr. Kotwal, who is an assistant professor in the division of diabetes, endocrinology and metabolism at the University of Nebraska, Omaha.
 

More work will be needed

Future directions for research should include adding a longitudinal arm and looking at the impact on AGE after patients undergo curative surgery and achieve remission, Dr. Sandooja explained.

“It will be interesting to see if AGE levels continue to be persistently high or decrease after patients achieve sustained remission of hypercortisolism. We are also interested in whether AGE measurement at baseline, prior to surgery may be associated with glucocorticoid withdrawal, myopathy, and metabolic outcomes following the surgery.”

Dr. Kotwal observed: “If the answer is clear for Cushing disease, I don’t know what extra information this would give. Maybe they would monitor people more closely afterward. It would be useful to see, but I think the first low-hanging fruit is use it in a way to guide the care of patients where we’re unclear as to whether initial treatment of this [mild autonomous cortisol secretion] is going to improve their outcomes.”

But, he added, “keeping in mind issues of skin ... we don’t want to distract clinicians and patients from using the tried and tested methods of characterizing Cushing syndrome. I’m always hesitant to bring something into practice before there is a little more information on how it can be used.”

Dr. Sandooja and Dr. Kotwal reported no relevant financial relationships.

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

SEATTLE – Tissue accumulation of advanced glycation end products (AGEs) is associated with the presence of hypercortisolism, suggesting a potential future noninvasive method to assist in the diagnosis of Cushing syndrome, new research suggests.
 

Tissue accumulation of AGEs – harmful compounds formed by glycation of macromolecules – has been implicated in aging, diabetes, and cardiovascular disease. Now, in a new single-center prospective study, a group of 208 patients with endogenous hypercortisolism was found to have significantly higher median tissue AGE levels than 103 reference subjects without hypercortisolism.

The findings were presented at the annual meeting of the American Association of Clinical Endocrinology by Rashi Sandooja, MD, an endocrinology fellow at the Mayo Clinic, Rochester, Minn.

“Diagnosis of endogenous hypercortisolism can be quite challenging. Often patients can have nonspecific symptoms with biochemical testing being equivocal. In these situations, new biomarkers of hypercortisolism such as AGE measurement could potentially be useful,” Dr. Sandooja said in an interview.

“After proper validation, it could help clinicians in cases which may not be straightforward and could serve as an additional” instrument in the toolkit to reach a conclusive diagnosis, she added.

Asked to comment, session moderator Anupam Kotwal, MD, said in an interview: “I think it’s very exciting data. ... I envision its use in mild autonomous cortisol secretion, where there are not a lot of overt Cushing features but they may have a small adrenal mass. ... It might be used to guide care when there’s not a clear-cut answer.”

However, he cautioned that more validation is needed to determine the correlates of AGEs by different etiologies and magnitudes of cortisol excess.

Moreover, “skin can become thin in hypercortisolism, so is [the reader device] just detecting it more with skin testing? I think a blood test for validation would be a very good next step,” added Dr. Kotwal, who is an assistant professor in the division of diabetes, endocrinology and metabolism at the University of Nebraska, Omaha.
 

More work will be needed

Future directions for research should include adding a longitudinal arm and looking at the impact on AGE after patients undergo curative surgery and achieve remission, Dr. Sandooja explained.

“It will be interesting to see if AGE levels continue to be persistently high or decrease after patients achieve sustained remission of hypercortisolism. We are also interested in whether AGE measurement at baseline, prior to surgery may be associated with glucocorticoid withdrawal, myopathy, and metabolic outcomes following the surgery.”

Dr. Kotwal observed: “If the answer is clear for Cushing disease, I don’t know what extra information this would give. Maybe they would monitor people more closely afterward. It would be useful to see, but I think the first low-hanging fruit is use it in a way to guide the care of patients where we’re unclear as to whether initial treatment of this [mild autonomous cortisol secretion] is going to improve their outcomes.”

But, he added, “keeping in mind issues of skin ... we don’t want to distract clinicians and patients from using the tried and tested methods of characterizing Cushing syndrome. I’m always hesitant to bring something into practice before there is a little more information on how it can be used.”

Dr. Sandooja and Dr. Kotwal reported no relevant financial relationships.

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

SEATTLE – Tissue accumulation of advanced glycation end products (AGEs) is associated with the presence of hypercortisolism, suggesting a potential future noninvasive method to assist in the diagnosis of Cushing syndrome, new research suggests.
 

Tissue accumulation of AGEs – harmful compounds formed by glycation of macromolecules – has been implicated in aging, diabetes, and cardiovascular disease. Now, in a new single-center prospective study, a group of 208 patients with endogenous hypercortisolism was found to have significantly higher median tissue AGE levels than 103 reference subjects without hypercortisolism.

The findings were presented at the annual meeting of the American Association of Clinical Endocrinology by Rashi Sandooja, MD, an endocrinology fellow at the Mayo Clinic, Rochester, Minn.

“Diagnosis of endogenous hypercortisolism can be quite challenging. Often patients can have nonspecific symptoms with biochemical testing being equivocal. In these situations, new biomarkers of hypercortisolism such as AGE measurement could potentially be useful,” Dr. Sandooja said in an interview.

“After proper validation, it could help clinicians in cases which may not be straightforward and could serve as an additional” instrument in the toolkit to reach a conclusive diagnosis, she added.

Asked to comment, session moderator Anupam Kotwal, MD, said in an interview: “I think it’s very exciting data. ... I envision its use in mild autonomous cortisol secretion, where there are not a lot of overt Cushing features but they may have a small adrenal mass. ... It might be used to guide care when there’s not a clear-cut answer.”

However, he cautioned that more validation is needed to determine the correlates of AGEs by different etiologies and magnitudes of cortisol excess.

Moreover, “skin can become thin in hypercortisolism, so is [the reader device] just detecting it more with skin testing? I think a blood test for validation would be a very good next step,” added Dr. Kotwal, who is an assistant professor in the division of diabetes, endocrinology and metabolism at the University of Nebraska, Omaha.
 

More work will be needed

Future directions for research should include adding a longitudinal arm and looking at the impact on AGE after patients undergo curative surgery and achieve remission, Dr. Sandooja explained.

“It will be interesting to see if AGE levels continue to be persistently high or decrease after patients achieve sustained remission of hypercortisolism. We are also interested in whether AGE measurement at baseline, prior to surgery may be associated with glucocorticoid withdrawal, myopathy, and metabolic outcomes following the surgery.”

Dr. Kotwal observed: “If the answer is clear for Cushing disease, I don’t know what extra information this would give. Maybe they would monitor people more closely afterward. It would be useful to see, but I think the first low-hanging fruit is use it in a way to guide the care of patients where we’re unclear as to whether initial treatment of this [mild autonomous cortisol secretion] is going to improve their outcomes.”

But, he added, “keeping in mind issues of skin ... we don’t want to distract clinicians and patients from using the tried and tested methods of characterizing Cushing syndrome. I’m always hesitant to bring something into practice before there is a little more information on how it can be used.”

Dr. Sandooja and Dr. Kotwal reported no relevant financial relationships.

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

PHOENIX – Compared with women, far fewer men are represented in clinical trials of laser hair removal, according to the results from a systematic review of medical literature.

Nari Lee

PHOENIX – Compared with women, far fewer men are represented in clinical trials of laser hair removal, according to the results from a systematic review of medical literature.

Nari Lee

PHOENIX – Compared with women, far fewer men are represented in clinical trials of laser hair removal, according to the results from a systematic review of medical literature.

Nari Lee

There’s been some recent news about medical schools gradually dropping the long-established practice of legacy admissions. This is where people related to successful alumni and/or big donors can get preferential admission, possibly over more qualified people.

All of us likely experienced this from one side or another, though realistically I haven’t thought about it years. My kids went to the same state school I did, but I’m pretty sure I had nothing to do with their being accepted. I never gave the school a single donation, nor did I call anyone there to try and get them in. Not that anyone would have known who I was if I’d tried. I’m just another one of many who went there, preserved only in some filing cabinet of transcripts somewhere.

I’m all for the legacy system ending, though, for one simple reason: It’s not fair.

If someone is qualified, great. They should be admitted on their own merits. But if they’re not, they shouldn’t get into medical school just because one (or both) of their parents went there, or is a VIP, or paid for a new library wing.

The reason I’m writing this is because the recent reporting did bring back a memory.

A long time ago, when I was in college, I hung out with other premed students. We knew we were all competing with each other for the same spots at the state medical school, but also knew that we wouldn’t all get in there. That didn’t make us enemies, it was just the truth. It’s that point in life where ANY medical school admission is all you want.

Pete (not his real name) was a nice guy, but his grades weren’t the best. His MCAT scores lagged behind the rest of us in the clique, and ... he didn’t care.

Pete’s dad had graduated from the state medical school, and was still on staff there. He was now on the teaching staff ... and on the school’s admissions board. To Pete, tests and grades didn’t matter. His admission was assured.

So it was no surprise when he got in ahead of the rest of us with better qualifications. Most of us, including me, did get in somewhere, so we were still happy. We just had to move farther and pay more, but that’s life.

I really didn’t think much about Pete again after that. I was now in medical school, I had a whole new social group, and more importantly I didn’t really have time to think of much beyond when the next exam was.

Then I moved home, and started residency. During my PGY-2 year we had a changing group of medical students assigned to my wards rotation.

And, as you probably guessed, one of them was Pete.

Pete was in his last year of medical school. But we’d both started in the same year, and now I was 2 years ahead of him. I didn’t ask him what happened, but another medical student told me he wasn’t known to be the best student, but the university refused to drop him, and just kept setting him back a class here, a year there.

Maybe they’d have done the same for anyone, but I doubt it.

I never saw Pete again after that. When I looked him up online tonight he’s not listed as being a doctor, and isn’t even in medicine. Granted, a lot of doctors have left medicine, and maybe he did too.

But the more likely reason is that Pete never should have been there in the first place. He got in as a legacy, taking a medical school slot from someone who may have been more capable and driven.

And that just doesn’t seem right to me. It didn’t then and it doesn’t now.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

There’s been some recent news about medical schools gradually dropping the long-established practice of legacy admissions. This is where people related to successful alumni and/or big donors can get preferential admission, possibly over more qualified people.

All of us likely experienced this from one side or another, though realistically I haven’t thought about it years. My kids went to the same state school I did, but I’m pretty sure I had nothing to do with their being accepted. I never gave the school a single donation, nor did I call anyone there to try and get them in. Not that anyone would have known who I was if I’d tried. I’m just another one of many who went there, preserved only in some filing cabinet of transcripts somewhere.

I’m all for the legacy system ending, though, for one simple reason: It’s not fair.

If someone is qualified, great. They should be admitted on their own merits. But if they’re not, they shouldn’t get into medical school just because one (or both) of their parents went there, or is a VIP, or paid for a new library wing.

The reason I’m writing this is because the recent reporting did bring back a memory.

A long time ago, when I was in college, I hung out with other premed students. We knew we were all competing with each other for the same spots at the state medical school, but also knew that we wouldn’t all get in there. That didn’t make us enemies, it was just the truth. It’s that point in life where ANY medical school admission is all you want.

Pete (not his real name) was a nice guy, but his grades weren’t the best. His MCAT scores lagged behind the rest of us in the clique, and ... he didn’t care.

Pete’s dad had graduated from the state medical school, and was still on staff there. He was now on the teaching staff ... and on the school’s admissions board. To Pete, tests and grades didn’t matter. His admission was assured.

So it was no surprise when he got in ahead of the rest of us with better qualifications. Most of us, including me, did get in somewhere, so we were still happy. We just had to move farther and pay more, but that’s life.

I really didn’t think much about Pete again after that. I was now in medical school, I had a whole new social group, and more importantly I didn’t really have time to think of much beyond when the next exam was.

Then I moved home, and started residency. During my PGY-2 year we had a changing group of medical students assigned to my wards rotation.

And, as you probably guessed, one of them was Pete.

Pete was in his last year of medical school. But we’d both started in the same year, and now I was 2 years ahead of him. I didn’t ask him what happened, but another medical student told me he wasn’t known to be the best student, but the university refused to drop him, and just kept setting him back a class here, a year there.

Maybe they’d have done the same for anyone, but I doubt it.

I never saw Pete again after that. When I looked him up online tonight he’s not listed as being a doctor, and isn’t even in medicine. Granted, a lot of doctors have left medicine, and maybe he did too.

But the more likely reason is that Pete never should have been there in the first place. He got in as a legacy, taking a medical school slot from someone who may have been more capable and driven.

And that just doesn’t seem right to me. It didn’t then and it doesn’t now.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

There’s been some recent news about medical schools gradually dropping the long-established practice of legacy admissions. This is where people related to successful alumni and/or big donors can get preferential admission, possibly over more qualified people.

All of us likely experienced this from one side or another, though realistically I haven’t thought about it years. My kids went to the same state school I did, but I’m pretty sure I had nothing to do with their being accepted. I never gave the school a single donation, nor did I call anyone there to try and get them in. Not that anyone would have known who I was if I’d tried. I’m just another one of many who went there, preserved only in some filing cabinet of transcripts somewhere.

I’m all for the legacy system ending, though, for one simple reason: It’s not fair.

If someone is qualified, great. They should be admitted on their own merits. But if they’re not, they shouldn’t get into medical school just because one (or both) of their parents went there, or is a VIP, or paid for a new library wing.

The reason I’m writing this is because the recent reporting did bring back a memory.

A long time ago, when I was in college, I hung out with other premed students. We knew we were all competing with each other for the same spots at the state medical school, but also knew that we wouldn’t all get in there. That didn’t make us enemies, it was just the truth. It’s that point in life where ANY medical school admission is all you want.

Pete (not his real name) was a nice guy, but his grades weren’t the best. His MCAT scores lagged behind the rest of us in the clique, and ... he didn’t care.

Pete’s dad had graduated from the state medical school, and was still on staff there. He was now on the teaching staff ... and on the school’s admissions board. To Pete, tests and grades didn’t matter. His admission was assured.

So it was no surprise when he got in ahead of the rest of us with better qualifications. Most of us, including me, did get in somewhere, so we were still happy. We just had to move farther and pay more, but that’s life.

I really didn’t think much about Pete again after that. I was now in medical school, I had a whole new social group, and more importantly I didn’t really have time to think of much beyond when the next exam was.

Then I moved home, and started residency. During my PGY-2 year we had a changing group of medical students assigned to my wards rotation.

And, as you probably guessed, one of them was Pete.

Pete was in his last year of medical school. But we’d both started in the same year, and now I was 2 years ahead of him. I didn’t ask him what happened, but another medical student told me he wasn’t known to be the best student, but the university refused to drop him, and just kept setting him back a class here, a year there.

Maybe they’d have done the same for anyone, but I doubt it.

I never saw Pete again after that. When I looked him up online tonight he’s not listed as being a doctor, and isn’t even in medicine. Granted, a lot of doctors have left medicine, and maybe he did too.

But the more likely reason is that Pete never should have been there in the first place. He got in as a legacy, taking a medical school slot from someone who may have been more capable and driven.

And that just doesn’t seem right to me. It didn’t then and it doesn’t now.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The Food and Drug Administration has announced new action to address ongoing concerns about misuse, abuse, addiction, and overdose of prescription stimulants used to treat attention-deficit/hyperactivity disorder (ADHD).

“The current prescribing information for some prescription stimulants does not provide up-to-date warnings about the harms of misuse and abuse, and particularly that most individuals who misuse prescription stimulants get their drugs from other family members or peers,” the FDA said in a drug safety communication.

Going forward, updated drug labels will clearly state that patients should never share their prescription stimulants with anyone, and the boxed warning will describe the risks of misuse, abuse, addiction, and overdose consistently for all medicines in the class, the FDA said.

The boxed warning will also advise heath care professionals to monitor patients closely for signs and symptoms of misuse, abuse, and addiction.

Patient medication guides will be updated to educate patients and caregivers about these risks.

The FDA encourages prescribers to assess patient risk of misuse, abuse, and addiction before prescribing a stimulant and to counsel patients not to share the medication.
 

Friends and family

A recent literature review by the FDA found that friends and family members are the most common source of prescription stimulant misuse and abuse (nonmedical use). Estimates of such use range from 56% to 80%.

Misuse/abuse of a patient’s own prescription make up 10%-20% of people who report nonmedical stimulant use.

Less commonly reported sources include drug dealers or strangers (4%-7% of people who report nonmedical use) and the Internet (1%-2%).

The groups at highest risk for misuse/abuse of prescription stimulants are young adults aged 18-25 years, college students, and adolescents and young adults who have been diagnosed with ADHD, the FDA said.

Recent data from the Centers for Disease Control and Prevention show that during the first year of the COVID-19 pandemic, prescriptions for stimulants increased 10% among older children and adults.
 

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

The Food and Drug Administration has announced new action to address ongoing concerns about misuse, abuse, addiction, and overdose of prescription stimulants used to treat attention-deficit/hyperactivity disorder (ADHD).

“The current prescribing information for some prescription stimulants does not provide up-to-date warnings about the harms of misuse and abuse, and particularly that most individuals who misuse prescription stimulants get their drugs from other family members or peers,” the FDA said in a drug safety communication.

Going forward, updated drug labels will clearly state that patients should never share their prescription stimulants with anyone, and the boxed warning will describe the risks of misuse, abuse, addiction, and overdose consistently for all medicines in the class, the FDA said.

The boxed warning will also advise heath care professionals to monitor patients closely for signs and symptoms of misuse, abuse, and addiction.

Patient medication guides will be updated to educate patients and caregivers about these risks.

The FDA encourages prescribers to assess patient risk of misuse, abuse, and addiction before prescribing a stimulant and to counsel patients not to share the medication.
 

Friends and family

A recent literature review by the FDA found that friends and family members are the most common source of prescription stimulant misuse and abuse (nonmedical use). Estimates of such use range from 56% to 80%.

Misuse/abuse of a patient’s own prescription make up 10%-20% of people who report nonmedical stimulant use.

Less commonly reported sources include drug dealers or strangers (4%-7% of people who report nonmedical use) and the Internet (1%-2%).

The groups at highest risk for misuse/abuse of prescription stimulants are young adults aged 18-25 years, college students, and adolescents and young adults who have been diagnosed with ADHD, the FDA said.

Recent data from the Centers for Disease Control and Prevention show that during the first year of the COVID-19 pandemic, prescriptions for stimulants increased 10% among older children and adults.
 

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

The Food and Drug Administration has announced new action to address ongoing concerns about misuse, abuse, addiction, and overdose of prescription stimulants used to treat attention-deficit/hyperactivity disorder (ADHD).

“The current prescribing information for some prescription stimulants does not provide up-to-date warnings about the harms of misuse and abuse, and particularly that most individuals who misuse prescription stimulants get their drugs from other family members or peers,” the FDA said in a drug safety communication.

Going forward, updated drug labels will clearly state that patients should never share their prescription stimulants with anyone, and the boxed warning will describe the risks of misuse, abuse, addiction, and overdose consistently for all medicines in the class, the FDA said.

The boxed warning will also advise heath care professionals to monitor patients closely for signs and symptoms of misuse, abuse, and addiction.

Patient medication guides will be updated to educate patients and caregivers about these risks.

The FDA encourages prescribers to assess patient risk of misuse, abuse, and addiction before prescribing a stimulant and to counsel patients not to share the medication.
 

Friends and family

A recent literature review by the FDA found that friends and family members are the most common source of prescription stimulant misuse and abuse (nonmedical use). Estimates of such use range from 56% to 80%.

Misuse/abuse of a patient’s own prescription make up 10%-20% of people who report nonmedical stimulant use.

Less commonly reported sources include drug dealers or strangers (4%-7% of people who report nonmedical use) and the Internet (1%-2%).

The groups at highest risk for misuse/abuse of prescription stimulants are young adults aged 18-25 years, college students, and adolescents and young adults who have been diagnosed with ADHD, the FDA said.

Recent data from the Centers for Disease Control and Prevention show that during the first year of the COVID-19 pandemic, prescriptions for stimulants increased 10% among older children and adults.
 

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