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ASDSA warns of rogue insulin pen use for DIY fillers
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In the safety warning, issued on Feb. 18, the ASDSA reported that ASDSA members, all board-certified dermatologists, have seen evidence online of young people using so-called “hyaluron pens” to inject hyaluronic acid filler in the epidermal and upper dermal skin.
The pens being used and promoted in social media for do-it-yourself filler injections are medical devices originally developed for insulin injections. “The use of air pressure technology causes these pens to deliver the hyaluronic acid to insert nanoscale molecules of the filler through the skin,” according to the ASDSA statement. Marketing materials state that the pens can be used to create volume and shape in the lips, and to improve the appearance of nasolabial lines, marionette lines, brow lines known as “elevens,” and forehead wrinkles. Claims that the hyaluronic acid only reaches the papillary layer of the dermis, and is therefore safe, do not alleviate the risk of injury in inexperienced hands, the ASDSA statement points out.
“We are concerned about California children falling prey to products that are not appropriate and safe for them to use,” Elan Newland, MD, member of the ASDSA and the California Society for Dermatology and Dermatological Surgery (CalDerm), said in the statement. “The power of social media is very strong, especially for impressionable teenagers. CalDerm supports alerting consumers and regulators of the dangers of these pens,” he said.
“TikTok is proving to be an extremely powerful platform to communicate, entertain, and even educate, which is why many physicians are getting involved and finding success there. Unfortunately, just like the World Wide Web, there is misinformation there and even dangerous lies,” Sandra Lee, MD, who practices in Upland, Calif. (and is also known as “Dr. Pimple Popper”), said in the statement.
“It’s very concerning to see young people posting a How To on injecting their own lips with hyaluronic acid serum using an ‘airgun’ pen, which acts much like a BB gun to push with force the product under the skin,” she added. “So many things can go wrong.”
The ASDSA has contacted the Food and Drug Administration to report these safety concerns. “In addition, the ASDSA is alerting state medical and estheticians’ boards regarding these patient safety concerns and alerting consumers directly about the risks through social media and other education materials,” according to the statement.
.
In the safety warning, issued on Feb. 18, the ASDSA reported that ASDSA members, all board-certified dermatologists, have seen evidence online of young people using so-called “hyaluron pens” to inject hyaluronic acid filler in the epidermal and upper dermal skin.
The pens being used and promoted in social media for do-it-yourself filler injections are medical devices originally developed for insulin injections. “The use of air pressure technology causes these pens to deliver the hyaluronic acid to insert nanoscale molecules of the filler through the skin,” according to the ASDSA statement. Marketing materials state that the pens can be used to create volume and shape in the lips, and to improve the appearance of nasolabial lines, marionette lines, brow lines known as “elevens,” and forehead wrinkles. Claims that the hyaluronic acid only reaches the papillary layer of the dermis, and is therefore safe, do not alleviate the risk of injury in inexperienced hands, the ASDSA statement points out.
“We are concerned about California children falling prey to products that are not appropriate and safe for them to use,” Elan Newland, MD, member of the ASDSA and the California Society for Dermatology and Dermatological Surgery (CalDerm), said in the statement. “The power of social media is very strong, especially for impressionable teenagers. CalDerm supports alerting consumers and regulators of the dangers of these pens,” he said.
“TikTok is proving to be an extremely powerful platform to communicate, entertain, and even educate, which is why many physicians are getting involved and finding success there. Unfortunately, just like the World Wide Web, there is misinformation there and even dangerous lies,” Sandra Lee, MD, who practices in Upland, Calif. (and is also known as “Dr. Pimple Popper”), said in the statement.
“It’s very concerning to see young people posting a How To on injecting their own lips with hyaluronic acid serum using an ‘airgun’ pen, which acts much like a BB gun to push with force the product under the skin,” she added. “So many things can go wrong.”
The ASDSA has contacted the Food and Drug Administration to report these safety concerns. “In addition, the ASDSA is alerting state medical and estheticians’ boards regarding these patient safety concerns and alerting consumers directly about the risks through social media and other education materials,” according to the statement.
.
In the safety warning, issued on Feb. 18, the ASDSA reported that ASDSA members, all board-certified dermatologists, have seen evidence online of young people using so-called “hyaluron pens” to inject hyaluronic acid filler in the epidermal and upper dermal skin.
The pens being used and promoted in social media for do-it-yourself filler injections are medical devices originally developed for insulin injections. “The use of air pressure technology causes these pens to deliver the hyaluronic acid to insert nanoscale molecules of the filler through the skin,” according to the ASDSA statement. Marketing materials state that the pens can be used to create volume and shape in the lips, and to improve the appearance of nasolabial lines, marionette lines, brow lines known as “elevens,” and forehead wrinkles. Claims that the hyaluronic acid only reaches the papillary layer of the dermis, and is therefore safe, do not alleviate the risk of injury in inexperienced hands, the ASDSA statement points out.
“We are concerned about California children falling prey to products that are not appropriate and safe for them to use,” Elan Newland, MD, member of the ASDSA and the California Society for Dermatology and Dermatological Surgery (CalDerm), said in the statement. “The power of social media is very strong, especially for impressionable teenagers. CalDerm supports alerting consumers and regulators of the dangers of these pens,” he said.
“TikTok is proving to be an extremely powerful platform to communicate, entertain, and even educate, which is why many physicians are getting involved and finding success there. Unfortunately, just like the World Wide Web, there is misinformation there and even dangerous lies,” Sandra Lee, MD, who practices in Upland, Calif. (and is also known as “Dr. Pimple Popper”), said in the statement.
“It’s very concerning to see young people posting a How To on injecting their own lips with hyaluronic acid serum using an ‘airgun’ pen, which acts much like a BB gun to push with force the product under the skin,” she added. “So many things can go wrong.”
The ASDSA has contacted the Food and Drug Administration to report these safety concerns. “In addition, the ASDSA is alerting state medical and estheticians’ boards regarding these patient safety concerns and alerting consumers directly about the risks through social media and other education materials,” according to the statement.
Emerging research shows link between suicidality, ‘high-potency’ cannabis products
Number of suicides positive for marijuana on rise soared among Colorado youth
In the days since recreational sales of marijuana became legal in Colorado in January 2014, concerning trends have emerged among the state’s young cannabis users.
According to a report from the Rocky Mountain High Intensity Drug Trafficking Area, between 2014 and 2017, the number of suicides positive for marijuana increased 250% among those aged 10-19 years (from 4 to 14) and 22% among those aged 20 and older (from 118 to 144). “Other states are seeing something similar, and there is an emerging research showing a relationship between suicidality and the use of marijuana, especially high-potency products that are available in legalized markets,” Paula D. Riggs, MD, reported during an annual psychopharmacology update held by the Nevada Psychiatric Association.
During that same 3-year time span, the proportion of Colorado youth aged 12 years and older who used marijuana in the past month jumped by 45%, which is more than 85% above the national average. “Similarly, among college-age students, we’ve seen an 18% increase in past-month marijuana use, which is 60% above the national average,” said Dr. Riggs, professor and vice chair of psychiatry at the University of Colorado at Denver, Aurora.
Among adolescents, state health officials have observed a 5% increase in the proportion of those who used marijuana in the past month, which is more than 54% above the national average. “But a concerning trend is that we’re seeing an increase in the use of concentrates such as dabs and waxes,” she said. “That’s worrisome in terms of exposure to high-potency products.”
In other findings, 48% of young marijuana users reported going to work high (40% at least once per week), and there has been a 170% increase in youth ED urgent care visits for marijuana-related illnesses such as cannabinoid hyperemesis syndrome or first-episode psychosis. State health officials have also observed a 148% increase in marijuana-related hospitalizations.
According to Dr. Riggs, who also directs the University of Colorado’s division of addiction science, prevention, and treatment, the average marijuana joint in the 1960s contained about 3% tetrahydrocannabinol (THC), a level that crept up to the 4%-6% range in 2002. In today’s postlegalization era, the average joint now contains 13%-23% THC. “What’s concerning is that the concentrates – the dabs, waxes, shatter, and butane hash oils – contain upward of 70%-95% THC,” Dr. Riggs said. “Those are highly potent products that represent about 25% of the market share now. That’s a very big concern because the higher the potency the cannabis product used, the greater the abuse liability and addictive potential.”
The use of high-potency products also doubles the risk of developing generalized anxiety disorder, triples the risk of tobacco dependence, doubles the risk of other illicit substance disorders, and it at least quadruples the risk of developing first-episode psychosis in young people. “So, when you’re taking a cannabis use history, it’s important to ask patients about the potency of the products being used,” she said.
In the 2019 Monitoring the Future survey, 12% of U.S. 8th graders self-reported marijuana use in the past year and 7% in the past month, compared with 29% and 18% of 10th graders, respectively. Self-reported use by 12th graders was even more elevated (36% in the past year and 29% in the past month). “The concern is, this survey doesn’t really capture what’s happening with marijuana concentrates,” Dr. Riggs said.
A survey of Colorado youth conducted by the state’s Department of Public Health and Environment found that the percentage of students who reported using concentrated forms of marijuana has risen steadily in recent years and now stands at roughly 34%. “The use of edibles has also crept up,” said Dr. Riggs, who noted that marijuana dispensaries in Colorado outnumber Starbucks locations and McDonald’s restaurants. “You might not think that’s particularly concerning, except that the use of edibles is even more associated with onset of psychosis than other forms. This is probably because when you eat a marijuana product, you can’t control the exposure or the dose that you’re ingesting. We need to be concerned about these trends.”
European studies report that 30%-50% of new cases of first-onset psychosis are attributed to high-potency cannabis. “There is a dose-response relationship between cannabis and psychosis,” Dr. Riggs said. “That is, the frequency and duration of cannabis use, or the use of high-potency products, and the age of onset, are strongly associated with the risk of first-episode psychosis.
Researchers have known for some time that alterations in the endocannabinoid system are associated with psychosis independent of cannabis exposure. “Dysregulation of that endocannabinoid system occurs in patients at all stages of the psychosis continuum,” she continued. “It also means that the endocannabinoid system is a potential therapeutic target for psychosis.”
According to Dr. Riggs, THC exposure acutely increases dopamine in the ventral striatum and it can produce transient psychotomimetic effects in clinical and nonclinical populations. Genetic differences in the dopaminergic system can also interact with cannabis use to increase the risk of psychosis.
“For example, the COMT (catechol-O-methyltransferase) breaks down catecholamines such as dopamine in the prefrontal cortex,” she explained. “If you have a COMT gene polymorphism, that increases your risk of developing psychosis due to increased levels of dopamine signaling.”
She emphasized the importance of clinicians to understand that the age of cannabis use onset, the duration, frequency, and THC potency is related to the psychosis risk and worse prognosis. The earlier the initiation of marijuana use, the greater potential for first-episode psychosis. “Those who continue using cannabis after a first-episode psychosis have greater severity of psychotic illness and more treatment resistance, and they’re less likely to engage or be compliant with treatment recommendations,” Dr. Riggs said. “So, Because if they resume cannabis use, this can turn into a more chronic psychotic disorder.”
She added that, while insufficient evidence exists to determine whether cannabis plays a causal role in the development of schizophrenia or not, mounting evidence suggests that cannabis use may precipitate earlier onset of schizophrenia in those with other risk factors for the disorder. “There is considerable evidence that cannabis use increases the risk of psychosis in a dose-related manner, especially with an onset before age 16,” Dr. Riggs said. “However, this does not mean that cannabis is safe for young adults. Cannabis-induced psychotic symptoms often develop during young adulthood and may become chronic.”
Dr. Riggs disclosed that she had received grant funding from the National Institute on Drug Abuse. She is also executive director for Encompass, which provides integrated treatment for adolescents and young adults.
Number of suicides positive for marijuana on rise soared among Colorado youth
Number of suicides positive for marijuana on rise soared among Colorado youth
In the days since recreational sales of marijuana became legal in Colorado in January 2014, concerning trends have emerged among the state’s young cannabis users.
According to a report from the Rocky Mountain High Intensity Drug Trafficking Area, between 2014 and 2017, the number of suicides positive for marijuana increased 250% among those aged 10-19 years (from 4 to 14) and 22% among those aged 20 and older (from 118 to 144). “Other states are seeing something similar, and there is an emerging research showing a relationship between suicidality and the use of marijuana, especially high-potency products that are available in legalized markets,” Paula D. Riggs, MD, reported during an annual psychopharmacology update held by the Nevada Psychiatric Association.
During that same 3-year time span, the proportion of Colorado youth aged 12 years and older who used marijuana in the past month jumped by 45%, which is more than 85% above the national average. “Similarly, among college-age students, we’ve seen an 18% increase in past-month marijuana use, which is 60% above the national average,” said Dr. Riggs, professor and vice chair of psychiatry at the University of Colorado at Denver, Aurora.
Among adolescents, state health officials have observed a 5% increase in the proportion of those who used marijuana in the past month, which is more than 54% above the national average. “But a concerning trend is that we’re seeing an increase in the use of concentrates such as dabs and waxes,” she said. “That’s worrisome in terms of exposure to high-potency products.”
In other findings, 48% of young marijuana users reported going to work high (40% at least once per week), and there has been a 170% increase in youth ED urgent care visits for marijuana-related illnesses such as cannabinoid hyperemesis syndrome or first-episode psychosis. State health officials have also observed a 148% increase in marijuana-related hospitalizations.
According to Dr. Riggs, who also directs the University of Colorado’s division of addiction science, prevention, and treatment, the average marijuana joint in the 1960s contained about 3% tetrahydrocannabinol (THC), a level that crept up to the 4%-6% range in 2002. In today’s postlegalization era, the average joint now contains 13%-23% THC. “What’s concerning is that the concentrates – the dabs, waxes, shatter, and butane hash oils – contain upward of 70%-95% THC,” Dr. Riggs said. “Those are highly potent products that represent about 25% of the market share now. That’s a very big concern because the higher the potency the cannabis product used, the greater the abuse liability and addictive potential.”
The use of high-potency products also doubles the risk of developing generalized anxiety disorder, triples the risk of tobacco dependence, doubles the risk of other illicit substance disorders, and it at least quadruples the risk of developing first-episode psychosis in young people. “So, when you’re taking a cannabis use history, it’s important to ask patients about the potency of the products being used,” she said.
In the 2019 Monitoring the Future survey, 12% of U.S. 8th graders self-reported marijuana use in the past year and 7% in the past month, compared with 29% and 18% of 10th graders, respectively. Self-reported use by 12th graders was even more elevated (36% in the past year and 29% in the past month). “The concern is, this survey doesn’t really capture what’s happening with marijuana concentrates,” Dr. Riggs said.
A survey of Colorado youth conducted by the state’s Department of Public Health and Environment found that the percentage of students who reported using concentrated forms of marijuana has risen steadily in recent years and now stands at roughly 34%. “The use of edibles has also crept up,” said Dr. Riggs, who noted that marijuana dispensaries in Colorado outnumber Starbucks locations and McDonald’s restaurants. “You might not think that’s particularly concerning, except that the use of edibles is even more associated with onset of psychosis than other forms. This is probably because when you eat a marijuana product, you can’t control the exposure or the dose that you’re ingesting. We need to be concerned about these trends.”
European studies report that 30%-50% of new cases of first-onset psychosis are attributed to high-potency cannabis. “There is a dose-response relationship between cannabis and psychosis,” Dr. Riggs said. “That is, the frequency and duration of cannabis use, or the use of high-potency products, and the age of onset, are strongly associated with the risk of first-episode psychosis.
Researchers have known for some time that alterations in the endocannabinoid system are associated with psychosis independent of cannabis exposure. “Dysregulation of that endocannabinoid system occurs in patients at all stages of the psychosis continuum,” she continued. “It also means that the endocannabinoid system is a potential therapeutic target for psychosis.”
According to Dr. Riggs, THC exposure acutely increases dopamine in the ventral striatum and it can produce transient psychotomimetic effects in clinical and nonclinical populations. Genetic differences in the dopaminergic system can also interact with cannabis use to increase the risk of psychosis.
“For example, the COMT (catechol-O-methyltransferase) breaks down catecholamines such as dopamine in the prefrontal cortex,” she explained. “If you have a COMT gene polymorphism, that increases your risk of developing psychosis due to increased levels of dopamine signaling.”
She emphasized the importance of clinicians to understand that the age of cannabis use onset, the duration, frequency, and THC potency is related to the psychosis risk and worse prognosis. The earlier the initiation of marijuana use, the greater potential for first-episode psychosis. “Those who continue using cannabis after a first-episode psychosis have greater severity of psychotic illness and more treatment resistance, and they’re less likely to engage or be compliant with treatment recommendations,” Dr. Riggs said. “So, Because if they resume cannabis use, this can turn into a more chronic psychotic disorder.”
She added that, while insufficient evidence exists to determine whether cannabis plays a causal role in the development of schizophrenia or not, mounting evidence suggests that cannabis use may precipitate earlier onset of schizophrenia in those with other risk factors for the disorder. “There is considerable evidence that cannabis use increases the risk of psychosis in a dose-related manner, especially with an onset before age 16,” Dr. Riggs said. “However, this does not mean that cannabis is safe for young adults. Cannabis-induced psychotic symptoms often develop during young adulthood and may become chronic.”
Dr. Riggs disclosed that she had received grant funding from the National Institute on Drug Abuse. She is also executive director for Encompass, which provides integrated treatment for adolescents and young adults.
In the days since recreational sales of marijuana became legal in Colorado in January 2014, concerning trends have emerged among the state’s young cannabis users.
According to a report from the Rocky Mountain High Intensity Drug Trafficking Area, between 2014 and 2017, the number of suicides positive for marijuana increased 250% among those aged 10-19 years (from 4 to 14) and 22% among those aged 20 and older (from 118 to 144). “Other states are seeing something similar, and there is an emerging research showing a relationship between suicidality and the use of marijuana, especially high-potency products that are available in legalized markets,” Paula D. Riggs, MD, reported during an annual psychopharmacology update held by the Nevada Psychiatric Association.
During that same 3-year time span, the proportion of Colorado youth aged 12 years and older who used marijuana in the past month jumped by 45%, which is more than 85% above the national average. “Similarly, among college-age students, we’ve seen an 18% increase in past-month marijuana use, which is 60% above the national average,” said Dr. Riggs, professor and vice chair of psychiatry at the University of Colorado at Denver, Aurora.
Among adolescents, state health officials have observed a 5% increase in the proportion of those who used marijuana in the past month, which is more than 54% above the national average. “But a concerning trend is that we’re seeing an increase in the use of concentrates such as dabs and waxes,” she said. “That’s worrisome in terms of exposure to high-potency products.”
In other findings, 48% of young marijuana users reported going to work high (40% at least once per week), and there has been a 170% increase in youth ED urgent care visits for marijuana-related illnesses such as cannabinoid hyperemesis syndrome or first-episode psychosis. State health officials have also observed a 148% increase in marijuana-related hospitalizations.
According to Dr. Riggs, who also directs the University of Colorado’s division of addiction science, prevention, and treatment, the average marijuana joint in the 1960s contained about 3% tetrahydrocannabinol (THC), a level that crept up to the 4%-6% range in 2002. In today’s postlegalization era, the average joint now contains 13%-23% THC. “What’s concerning is that the concentrates – the dabs, waxes, shatter, and butane hash oils – contain upward of 70%-95% THC,” Dr. Riggs said. “Those are highly potent products that represent about 25% of the market share now. That’s a very big concern because the higher the potency the cannabis product used, the greater the abuse liability and addictive potential.”
The use of high-potency products also doubles the risk of developing generalized anxiety disorder, triples the risk of tobacco dependence, doubles the risk of other illicit substance disorders, and it at least quadruples the risk of developing first-episode psychosis in young people. “So, when you’re taking a cannabis use history, it’s important to ask patients about the potency of the products being used,” she said.
In the 2019 Monitoring the Future survey, 12% of U.S. 8th graders self-reported marijuana use in the past year and 7% in the past month, compared with 29% and 18% of 10th graders, respectively. Self-reported use by 12th graders was even more elevated (36% in the past year and 29% in the past month). “The concern is, this survey doesn’t really capture what’s happening with marijuana concentrates,” Dr. Riggs said.
A survey of Colorado youth conducted by the state’s Department of Public Health and Environment found that the percentage of students who reported using concentrated forms of marijuana has risen steadily in recent years and now stands at roughly 34%. “The use of edibles has also crept up,” said Dr. Riggs, who noted that marijuana dispensaries in Colorado outnumber Starbucks locations and McDonald’s restaurants. “You might not think that’s particularly concerning, except that the use of edibles is even more associated with onset of psychosis than other forms. This is probably because when you eat a marijuana product, you can’t control the exposure or the dose that you’re ingesting. We need to be concerned about these trends.”
European studies report that 30%-50% of new cases of first-onset psychosis are attributed to high-potency cannabis. “There is a dose-response relationship between cannabis and psychosis,” Dr. Riggs said. “That is, the frequency and duration of cannabis use, or the use of high-potency products, and the age of onset, are strongly associated with the risk of first-episode psychosis.
Researchers have known for some time that alterations in the endocannabinoid system are associated with psychosis independent of cannabis exposure. “Dysregulation of that endocannabinoid system occurs in patients at all stages of the psychosis continuum,” she continued. “It also means that the endocannabinoid system is a potential therapeutic target for psychosis.”
According to Dr. Riggs, THC exposure acutely increases dopamine in the ventral striatum and it can produce transient psychotomimetic effects in clinical and nonclinical populations. Genetic differences in the dopaminergic system can also interact with cannabis use to increase the risk of psychosis.
“For example, the COMT (catechol-O-methyltransferase) breaks down catecholamines such as dopamine in the prefrontal cortex,” she explained. “If you have a COMT gene polymorphism, that increases your risk of developing psychosis due to increased levels of dopamine signaling.”
She emphasized the importance of clinicians to understand that the age of cannabis use onset, the duration, frequency, and THC potency is related to the psychosis risk and worse prognosis. The earlier the initiation of marijuana use, the greater potential for first-episode psychosis. “Those who continue using cannabis after a first-episode psychosis have greater severity of psychotic illness and more treatment resistance, and they’re less likely to engage or be compliant with treatment recommendations,” Dr. Riggs said. “So, Because if they resume cannabis use, this can turn into a more chronic psychotic disorder.”
She added that, while insufficient evidence exists to determine whether cannabis plays a causal role in the development of schizophrenia or not, mounting evidence suggests that cannabis use may precipitate earlier onset of schizophrenia in those with other risk factors for the disorder. “There is considerable evidence that cannabis use increases the risk of psychosis in a dose-related manner, especially with an onset before age 16,” Dr. Riggs said. “However, this does not mean that cannabis is safe for young adults. Cannabis-induced psychotic symptoms often develop during young adulthood and may become chronic.”
Dr. Riggs disclosed that she had received grant funding from the National Institute on Drug Abuse. She is also executive director for Encompass, which provides integrated treatment for adolescents and young adults.
FROM NPA 2021
Make the Diagnosis - March 2021
Because of the lack of improvement with topical corticosteroids, a skin biopsy was performed from a lesion on the lower back which showed an epidermis with compact hyperkeratosis and a thickened granular layer. Within the dermis, there was a lichenoid infiltrate of lymphocytes with a prominent interface change and rare dyskeratotic keratinocytes consistent with lichen planus.
Lichen planus is an inflammatory condition of the skin seen mainly in the adult population and is rare in children. This condition affects 0.5%-1% of the population, with maybe a higher prevalence in woman with no racial predilection in the adult or pediatric population. Most patients diagnosed are described to be over 40 years of age, but in children, the mean age for presentation is reported between the ages of 7 and 11.8 years.1 Interestingly, most of the published larger studies of lichen planus in children originate from India. In a U.K. study, about 80% of the cases reported were from children of Indian descent, as is our patient; so it is possible that lichen planus may be more prevalent in India.1 In a study based in the United States, cases were more prevalent in African American children.2
The exact cause of this condition is not known but studies have suggested that activated T cells, particularly CD8+, attack and cause apoptosis of the basal keratinocytes.3 There appears to be an up-regulation of Th1 cytokines such as interferon‐gamma, tumor necrosis factor–alpha, interleukin‐1 alpha, IL‐6, and IL‐8, as well as other apoptosis-related molecules.3
Lichen planus has been associated with other systemic conditions especially liver disease (chronic active hepatitis C and primary biliary cirrhosis). Children and adults may also have coexistence of other autoimmune diseases such as autoimmune polyendocrinopathy, myasthenia gravis, autoimmune thyroid disease, vitiligo, and thymoma. Some reports have also found a higher prevalence of atopic dermatitis in children with lichen planus.4
The lesions are typically described as the four “Ps” for pruritic, polygonal, purpuric flat-topped papules, and plaques. The papules of lichen planus have characteristically dry fine white streaks known as Wickham’s striae. The lesions can occur anywhere on the body, but they tend to occur more commonly on the flexures of the forearms, the wrists, ankles, shins, knees, and the torso. The face is rarely affected. In some patients oral, scalp (lichen planopilaris), nails, and rarely conjunctival, genital, and esophageal involvement can occur.2
In histopathology, the lesions are characterized by a wedge-shaped hypergranulosis, marked hyperkeratosis, and irregular sawtooth-like acanthosis of rete ridges on the epidermis. The dermal-epidermal junction typically shows an interstitial dermatitis. Civatte bodies may also be seen. On direct immunofluorescence, IgM-staining of the cytoid bodies in the dermal papilla or peribasilar areas are suggestive of lichen planus.1
The differential diagnosis of lichen planus includes severe lichenified atopic dermatitis, drug-induced lichen planus, graft-versus-host disease, psoriasis, pityriasis rosea, subacute cutaneous lupus, discoid lupus, secondary syphilis, and lichen simplex chronicus. Interestingly, our patient presented with lesions that were not pruritic and more generalized. Compared with eczema, were flexures are commonly affected, our patient’s lesions were localized to the ankles, wrists, extensor knees, and elbows, and no pruritus was reported. Lichenification of skin lesions occurs as a response to chronic scratching as it occurs in atopic dermatitis and lichen simplex chronicus, was considered in our patient, but the lack of pruritus and the more acute presentation made it unlikely.
Lichen planus is considered a self-limiting disease, so treatment is focused on the control of pruritus and to accelerate resolution. The first-line therapy for classic cutaneous lichen planus is the use of potent or superpotent topical corticosteroids for localized disease on the body and extremities and mild to mid-potency for intertriginous areas and the face. Clinical response should be assessed after 2-3 weeks of treatment. For patients with more generalized or recalcitrant disease like our patient, other treatment modalities like phototherapy (narrow-band UVB), a 4- to 6-week course of oral glucocorticoids, or acitretin may be considered. Our patient recently started narrow-band UVB. Other medications that have been reported beneficial for more severe cases include methotrexate, cyclosporine, griseofulvin, hydroxychloroquine, metronidazole, dapsone, and mycophenolate. Recent studies in the adult population have shown apremilast, a phosphodiesterase inhibitor, to be a promising medication for patients with cutaneous lichen planus, though this medication has not been approved yet for use in the pediatric population.5
Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego.
References
1. Payette MJ et al. Clin Dermatol. 2015 Nov-Dec;33(6):631-43.
2. Walton KE et al. Pediatr Dermatol. 2010;27:34-8.
3. Lehman JS et al. Int J Dermatol. 2009 Jul;48(7):682-94.
4. Laughter D et al. J Am Acad Dermatol. 2000;43:649-55.
5. Paul J et al. J Am Acad Dermatol. 2013 Feb;68(2):255-61.
Because of the lack of improvement with topical corticosteroids, a skin biopsy was performed from a lesion on the lower back which showed an epidermis with compact hyperkeratosis and a thickened granular layer. Within the dermis, there was a lichenoid infiltrate of lymphocytes with a prominent interface change and rare dyskeratotic keratinocytes consistent with lichen planus.
Lichen planus is an inflammatory condition of the skin seen mainly in the adult population and is rare in children. This condition affects 0.5%-1% of the population, with maybe a higher prevalence in woman with no racial predilection in the adult or pediatric population. Most patients diagnosed are described to be over 40 years of age, but in children, the mean age for presentation is reported between the ages of 7 and 11.8 years.1 Interestingly, most of the published larger studies of lichen planus in children originate from India. In a U.K. study, about 80% of the cases reported were from children of Indian descent, as is our patient; so it is possible that lichen planus may be more prevalent in India.1 In a study based in the United States, cases were more prevalent in African American children.2
The exact cause of this condition is not known but studies have suggested that activated T cells, particularly CD8+, attack and cause apoptosis of the basal keratinocytes.3 There appears to be an up-regulation of Th1 cytokines such as interferon‐gamma, tumor necrosis factor–alpha, interleukin‐1 alpha, IL‐6, and IL‐8, as well as other apoptosis-related molecules.3
Lichen planus has been associated with other systemic conditions especially liver disease (chronic active hepatitis C and primary biliary cirrhosis). Children and adults may also have coexistence of other autoimmune diseases such as autoimmune polyendocrinopathy, myasthenia gravis, autoimmune thyroid disease, vitiligo, and thymoma. Some reports have also found a higher prevalence of atopic dermatitis in children with lichen planus.4
The lesions are typically described as the four “Ps” for pruritic, polygonal, purpuric flat-topped papules, and plaques. The papules of lichen planus have characteristically dry fine white streaks known as Wickham’s striae. The lesions can occur anywhere on the body, but they tend to occur more commonly on the flexures of the forearms, the wrists, ankles, shins, knees, and the torso. The face is rarely affected. In some patients oral, scalp (lichen planopilaris), nails, and rarely conjunctival, genital, and esophageal involvement can occur.2
In histopathology, the lesions are characterized by a wedge-shaped hypergranulosis, marked hyperkeratosis, and irregular sawtooth-like acanthosis of rete ridges on the epidermis. The dermal-epidermal junction typically shows an interstitial dermatitis. Civatte bodies may also be seen. On direct immunofluorescence, IgM-staining of the cytoid bodies in the dermal papilla or peribasilar areas are suggestive of lichen planus.1
The differential diagnosis of lichen planus includes severe lichenified atopic dermatitis, drug-induced lichen planus, graft-versus-host disease, psoriasis, pityriasis rosea, subacute cutaneous lupus, discoid lupus, secondary syphilis, and lichen simplex chronicus. Interestingly, our patient presented with lesions that were not pruritic and more generalized. Compared with eczema, were flexures are commonly affected, our patient’s lesions were localized to the ankles, wrists, extensor knees, and elbows, and no pruritus was reported. Lichenification of skin lesions occurs as a response to chronic scratching as it occurs in atopic dermatitis and lichen simplex chronicus, was considered in our patient, but the lack of pruritus and the more acute presentation made it unlikely.
Lichen planus is considered a self-limiting disease, so treatment is focused on the control of pruritus and to accelerate resolution. The first-line therapy for classic cutaneous lichen planus is the use of potent or superpotent topical corticosteroids for localized disease on the body and extremities and mild to mid-potency for intertriginous areas and the face. Clinical response should be assessed after 2-3 weeks of treatment. For patients with more generalized or recalcitrant disease like our patient, other treatment modalities like phototherapy (narrow-band UVB), a 4- to 6-week course of oral glucocorticoids, or acitretin may be considered. Our patient recently started narrow-band UVB. Other medications that have been reported beneficial for more severe cases include methotrexate, cyclosporine, griseofulvin, hydroxychloroquine, metronidazole, dapsone, and mycophenolate. Recent studies in the adult population have shown apremilast, a phosphodiesterase inhibitor, to be a promising medication for patients with cutaneous lichen planus, though this medication has not been approved yet for use in the pediatric population.5
Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego.
References
1. Payette MJ et al. Clin Dermatol. 2015 Nov-Dec;33(6):631-43.
2. Walton KE et al. Pediatr Dermatol. 2010;27:34-8.
3. Lehman JS et al. Int J Dermatol. 2009 Jul;48(7):682-94.
4. Laughter D et al. J Am Acad Dermatol. 2000;43:649-55.
5. Paul J et al. J Am Acad Dermatol. 2013 Feb;68(2):255-61.
Because of the lack of improvement with topical corticosteroids, a skin biopsy was performed from a lesion on the lower back which showed an epidermis with compact hyperkeratosis and a thickened granular layer. Within the dermis, there was a lichenoid infiltrate of lymphocytes with a prominent interface change and rare dyskeratotic keratinocytes consistent with lichen planus.
Lichen planus is an inflammatory condition of the skin seen mainly in the adult population and is rare in children. This condition affects 0.5%-1% of the population, with maybe a higher prevalence in woman with no racial predilection in the adult or pediatric population. Most patients diagnosed are described to be over 40 years of age, but in children, the mean age for presentation is reported between the ages of 7 and 11.8 years.1 Interestingly, most of the published larger studies of lichen planus in children originate from India. In a U.K. study, about 80% of the cases reported were from children of Indian descent, as is our patient; so it is possible that lichen planus may be more prevalent in India.1 In a study based in the United States, cases were more prevalent in African American children.2
The exact cause of this condition is not known but studies have suggested that activated T cells, particularly CD8+, attack and cause apoptosis of the basal keratinocytes.3 There appears to be an up-regulation of Th1 cytokines such as interferon‐gamma, tumor necrosis factor–alpha, interleukin‐1 alpha, IL‐6, and IL‐8, as well as other apoptosis-related molecules.3
Lichen planus has been associated with other systemic conditions especially liver disease (chronic active hepatitis C and primary biliary cirrhosis). Children and adults may also have coexistence of other autoimmune diseases such as autoimmune polyendocrinopathy, myasthenia gravis, autoimmune thyroid disease, vitiligo, and thymoma. Some reports have also found a higher prevalence of atopic dermatitis in children with lichen planus.4
The lesions are typically described as the four “Ps” for pruritic, polygonal, purpuric flat-topped papules, and plaques. The papules of lichen planus have characteristically dry fine white streaks known as Wickham’s striae. The lesions can occur anywhere on the body, but they tend to occur more commonly on the flexures of the forearms, the wrists, ankles, shins, knees, and the torso. The face is rarely affected. In some patients oral, scalp (lichen planopilaris), nails, and rarely conjunctival, genital, and esophageal involvement can occur.2
In histopathology, the lesions are characterized by a wedge-shaped hypergranulosis, marked hyperkeratosis, and irregular sawtooth-like acanthosis of rete ridges on the epidermis. The dermal-epidermal junction typically shows an interstitial dermatitis. Civatte bodies may also be seen. On direct immunofluorescence, IgM-staining of the cytoid bodies in the dermal papilla or peribasilar areas are suggestive of lichen planus.1
The differential diagnosis of lichen planus includes severe lichenified atopic dermatitis, drug-induced lichen planus, graft-versus-host disease, psoriasis, pityriasis rosea, subacute cutaneous lupus, discoid lupus, secondary syphilis, and lichen simplex chronicus. Interestingly, our patient presented with lesions that were not pruritic and more generalized. Compared with eczema, were flexures are commonly affected, our patient’s lesions were localized to the ankles, wrists, extensor knees, and elbows, and no pruritus was reported. Lichenification of skin lesions occurs as a response to chronic scratching as it occurs in atopic dermatitis and lichen simplex chronicus, was considered in our patient, but the lack of pruritus and the more acute presentation made it unlikely.
Lichen planus is considered a self-limiting disease, so treatment is focused on the control of pruritus and to accelerate resolution. The first-line therapy for classic cutaneous lichen planus is the use of potent or superpotent topical corticosteroids for localized disease on the body and extremities and mild to mid-potency for intertriginous areas and the face. Clinical response should be assessed after 2-3 weeks of treatment. For patients with more generalized or recalcitrant disease like our patient, other treatment modalities like phototherapy (narrow-band UVB), a 4- to 6-week course of oral glucocorticoids, or acitretin may be considered. Our patient recently started narrow-band UVB. Other medications that have been reported beneficial for more severe cases include methotrexate, cyclosporine, griseofulvin, hydroxychloroquine, metronidazole, dapsone, and mycophenolate. Recent studies in the adult population have shown apremilast, a phosphodiesterase inhibitor, to be a promising medication for patients with cutaneous lichen planus, though this medication has not been approved yet for use in the pediatric population.5
Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego.
References
1. Payette MJ et al. Clin Dermatol. 2015 Nov-Dec;33(6):631-43.
2. Walton KE et al. Pediatr Dermatol. 2010;27:34-8.
3. Lehman JS et al. Int J Dermatol. 2009 Jul;48(7):682-94.
4. Laughter D et al. J Am Acad Dermatol. 2000;43:649-55.
5. Paul J et al. J Am Acad Dermatol. 2013 Feb;68(2):255-61.
There was no prior personal or family history of atopic dermatitis or psoriasis. He has no other medical conditions and is not taking any medications.
He denied any joint pain, sun sensitivity, mouth sores, or other symptoms. After the initial consultation he was treated with fluocinonide 0.05% ointment for 2 weeks with slight improvement on the lesions.
On physical exam he presented with hyperpigmented and violaceous lichenified papules and plaques on the extremities and the torso. (photos 1 and 2). He also had hyperpigmented violaceous macules on the eyelids and around the mouth (photos 1 and 2).
Roots of physician burnout: It’s the work load
Work load, not personal vulnerability, may be at the root of the current physician burnout crisis, a recent study has concluded.
The cutting-edge research utilized cognitive theory and work load analysis to get at the source of burnout among practitioners. The findings indicate that, although some institutions continue to emphasize personal responsibility of physicians to address the issue, it may be the amount and structure of the work itself that triggers burnout in doctors.
“We evaluated the cognitive load of a clinical workday in a national sample of U.S. physicians and its relationship with burnout and professional satisfaction,” wrote Elizabeth Harry, MD, SFHM, a hospitalist at the University of Colorado at Denver, Aurora and coauthors. The results were reported in the Joint Commission Journal on Quality and Patient Safety.
The researchers investigated whether task load correlated with burnout scores in a large national study of U.S. physicians from October 2017 to March 2018.
As the delivery of health care becomes more complex, physicians are charged with ever-increasing amount of administrative and cognitive tasks. Recent evidence indicates that this growing complexity of work is tied to a greater risk of burnout in physicians, compared with workers in other fields. Cognitive load theory, pioneered by psychologist Jonathan Sweller, identified limitations in working memory that humans depend on to carry out cognitive tasks. Cognitive load refers to the amount of working memory used, which can be reduced in the presence of external emotional or physiological stressors. While a potential link between cognitive load and burnout may seem self-evident, the correlation between the cognitive load of physicians and burnout has not been evaluated in a large-scale study until recently.
Physician task load (PTL) was measured using the National Aeronautics and Space Administration Task Load Index (NASA-TLX), a validated questionnaire frequently used to evaluate the cognitive load of work environments, including health care environments. Four domains (perception of effort and mental, physical, and temporal demands) were used to calculate the total PTL score.
Burnout was evaluated using the Emotional Exhaustion and Depersonalization scales of the Maslach Burnout Inventory, a validated tool considered the gold standard for measurement.
The survey sample consisted of physicians of all specialties and was assembled using the American Medical Association Physician Masterfile, an almost complete record of all U.S. physicians independent of AMA membership. All responses were anonymous and participation was voluntary.
Results
Among 30,456 physicians who received the survey, 5,197 (17.1%) responded. In total, 5,276 physicians were included in the analysis.
The median age of respondents was 53 years, and 61.8% self-identified as male. Twenty-four specialties were identified: 23.8% were from a primary care discipline and internal medicine represented the largest respondent group (12.1%).
Almost half of respondents (49.7%) worked in private practice, and 44.8% had been in practice for 21 years or longer.
Overall, 44.0% had at least one symptom of burnout, 38.8% of participants scored in the high range for emotional exhaustion, and 27.4% scored in the high range for depersonalization. The mean score in task load dimension varied by specialty.
The mean PTL score was 260.9 (standard deviation, 71.4). The specialties with the highest PTL score were emergency medicine (369.8), urology (353.7), general surgery subspecialties (343.9), internal medicine subspecialties (342.2), and radiology (341.6).
Aside from specialty, PTL scores also varied by practice setting, gender, age, number of hours worked per week, number of nights on call per week, and years in practice.
The researchers observed a dose response relationship between PTL and risk of burnout. For every 40-point (10%) reduction in PTL, there was 33% lower odds of experiencing burnout (odds ratio, 0.67; 95% confidence interval, 0.65-0.70; P < .0001). Multivariable analyses also indicated that PTL was a significant predictor of burnout, independent of practice setting, specialty, age, gender, and hours worked.
Organizational strategies to reduce physician burnout
Coauthors of the study, Tait D. Shanafelt, MD, professor of medicine at Stanford (Calif.) University and Colin P. West, MD, PhD, of the Mayo Clinic in Rochester, Minn., are both experts on physician well-being and are passionate about finding new ways to reduce physician distress and improving health care delivery.
“Authentic efforts to address this problem must move beyond personal resilience,” Dr. Shanafelt said in an interview. “Organizations that fail to get serious about this issue are going to be left behind and struggle in the war for talent.
“Much like our efforts to improve quality, advancing clinician well-being requires organizations to make it a priority and establish the structure, process, and leadership to promote the desired outcomes,” said Dr. Shanafelt.
One potential strategy for improvement is appointing a chief wellness officer, a dedicated individual within the health care system that leads the organizational effort, explained Dr. Shanafelt. “Over 30 vanguard institutions across the United States have already taken this step.”
Dr. West, a coauthor of the study, explained that conducting an analysis of PTL is fairly straightforward for hospitals and individual institutions. “The NASA-TLX tool is widely available, free to use, and not overly complex, and it could be used to provide insight into physician effort and mental, physical, and temporal demand levels,” he said in an interview.
“Deeper evaluations could follow to identify specific potential solutions, particularly system-level approaches to alleviate PTL,” Dr. West explained. “In the short term, such analyses and solutions would have costs, but helping physicians work more optimally and with less chronic strain from excessive task load would save far more than these costs overall.”
Dr. West also noted that physician burnout is very expensive to a health care system, and strategies to promote physician well-being would be a prudent financial decision long term for health care organizations.
Dr. Harry, lead author of the study, agreed with Dr. West, noting that “quality improvement literature has demonstrated that improvements in inefficiencies that lead to increased demand in the workplace often has the benefit of reduced cost.
“Many studies have demonstrated the risk of turnover due to burnout and the significant cost of physician turn over,” she said in an interview. “This cost avoidance is well worth the investment in improved operations to minimize unnecessary task load.”
Dr. Harry also recommended the NASA-TLX tool as a free resource for health systems and organizations. She noted that future studies will further validate the reliability of the tool.
“At the core, we need to focus on system redesign at both the micro and the macro level,” Dr. Harry said. “Each health system will need to assess inefficiencies in their work flow, while regulatory bodies need to consider the downstream task load of mandates and reporting requirements, all of which contribute to more cognitive load.”
The study was supported by funding from the Stanford Medicine WellMD Center, the American Medical Association, and the Mayo Clinic department of medicine program on physician well-being. Coauthors Lotte N. Dyrbye, MD, and Dr. Shanafelt are coinventors of the Physician Well-being Index, Medical Student Well-Being Index, Nurse Well-Being, and Well-Being Index. Mayo Clinic holds the copyright to these instruments and has licensed them for external use. Dr. Dyrbye and Dr. Shanafelt receive a portion of any royalties paid to Mayo Clinic. All other authors reported no conflicts of interest.
Work load, not personal vulnerability, may be at the root of the current physician burnout crisis, a recent study has concluded.
The cutting-edge research utilized cognitive theory and work load analysis to get at the source of burnout among practitioners. The findings indicate that, although some institutions continue to emphasize personal responsibility of physicians to address the issue, it may be the amount and structure of the work itself that triggers burnout in doctors.
“We evaluated the cognitive load of a clinical workday in a national sample of U.S. physicians and its relationship with burnout and professional satisfaction,” wrote Elizabeth Harry, MD, SFHM, a hospitalist at the University of Colorado at Denver, Aurora and coauthors. The results were reported in the Joint Commission Journal on Quality and Patient Safety.
The researchers investigated whether task load correlated with burnout scores in a large national study of U.S. physicians from October 2017 to March 2018.
As the delivery of health care becomes more complex, physicians are charged with ever-increasing amount of administrative and cognitive tasks. Recent evidence indicates that this growing complexity of work is tied to a greater risk of burnout in physicians, compared with workers in other fields. Cognitive load theory, pioneered by psychologist Jonathan Sweller, identified limitations in working memory that humans depend on to carry out cognitive tasks. Cognitive load refers to the amount of working memory used, which can be reduced in the presence of external emotional or physiological stressors. While a potential link between cognitive load and burnout may seem self-evident, the correlation between the cognitive load of physicians and burnout has not been evaluated in a large-scale study until recently.
Physician task load (PTL) was measured using the National Aeronautics and Space Administration Task Load Index (NASA-TLX), a validated questionnaire frequently used to evaluate the cognitive load of work environments, including health care environments. Four domains (perception of effort and mental, physical, and temporal demands) were used to calculate the total PTL score.
Burnout was evaluated using the Emotional Exhaustion and Depersonalization scales of the Maslach Burnout Inventory, a validated tool considered the gold standard for measurement.
The survey sample consisted of physicians of all specialties and was assembled using the American Medical Association Physician Masterfile, an almost complete record of all U.S. physicians independent of AMA membership. All responses were anonymous and participation was voluntary.
Results
Among 30,456 physicians who received the survey, 5,197 (17.1%) responded. In total, 5,276 physicians were included in the analysis.
The median age of respondents was 53 years, and 61.8% self-identified as male. Twenty-four specialties were identified: 23.8% were from a primary care discipline and internal medicine represented the largest respondent group (12.1%).
Almost half of respondents (49.7%) worked in private practice, and 44.8% had been in practice for 21 years or longer.
Overall, 44.0% had at least one symptom of burnout, 38.8% of participants scored in the high range for emotional exhaustion, and 27.4% scored in the high range for depersonalization. The mean score in task load dimension varied by specialty.
The mean PTL score was 260.9 (standard deviation, 71.4). The specialties with the highest PTL score were emergency medicine (369.8), urology (353.7), general surgery subspecialties (343.9), internal medicine subspecialties (342.2), and radiology (341.6).
Aside from specialty, PTL scores also varied by practice setting, gender, age, number of hours worked per week, number of nights on call per week, and years in practice.
The researchers observed a dose response relationship between PTL and risk of burnout. For every 40-point (10%) reduction in PTL, there was 33% lower odds of experiencing burnout (odds ratio, 0.67; 95% confidence interval, 0.65-0.70; P < .0001). Multivariable analyses also indicated that PTL was a significant predictor of burnout, independent of practice setting, specialty, age, gender, and hours worked.
Organizational strategies to reduce physician burnout
Coauthors of the study, Tait D. Shanafelt, MD, professor of medicine at Stanford (Calif.) University and Colin P. West, MD, PhD, of the Mayo Clinic in Rochester, Minn., are both experts on physician well-being and are passionate about finding new ways to reduce physician distress and improving health care delivery.
“Authentic efforts to address this problem must move beyond personal resilience,” Dr. Shanafelt said in an interview. “Organizations that fail to get serious about this issue are going to be left behind and struggle in the war for talent.
“Much like our efforts to improve quality, advancing clinician well-being requires organizations to make it a priority and establish the structure, process, and leadership to promote the desired outcomes,” said Dr. Shanafelt.
One potential strategy for improvement is appointing a chief wellness officer, a dedicated individual within the health care system that leads the organizational effort, explained Dr. Shanafelt. “Over 30 vanguard institutions across the United States have already taken this step.”
Dr. West, a coauthor of the study, explained that conducting an analysis of PTL is fairly straightforward for hospitals and individual institutions. “The NASA-TLX tool is widely available, free to use, and not overly complex, and it could be used to provide insight into physician effort and mental, physical, and temporal demand levels,” he said in an interview.
“Deeper evaluations could follow to identify specific potential solutions, particularly system-level approaches to alleviate PTL,” Dr. West explained. “In the short term, such analyses and solutions would have costs, but helping physicians work more optimally and with less chronic strain from excessive task load would save far more than these costs overall.”
Dr. West also noted that physician burnout is very expensive to a health care system, and strategies to promote physician well-being would be a prudent financial decision long term for health care organizations.
Dr. Harry, lead author of the study, agreed with Dr. West, noting that “quality improvement literature has demonstrated that improvements in inefficiencies that lead to increased demand in the workplace often has the benefit of reduced cost.
“Many studies have demonstrated the risk of turnover due to burnout and the significant cost of physician turn over,” she said in an interview. “This cost avoidance is well worth the investment in improved operations to minimize unnecessary task load.”
Dr. Harry also recommended the NASA-TLX tool as a free resource for health systems and organizations. She noted that future studies will further validate the reliability of the tool.
“At the core, we need to focus on system redesign at both the micro and the macro level,” Dr. Harry said. “Each health system will need to assess inefficiencies in their work flow, while regulatory bodies need to consider the downstream task load of mandates and reporting requirements, all of which contribute to more cognitive load.”
The study was supported by funding from the Stanford Medicine WellMD Center, the American Medical Association, and the Mayo Clinic department of medicine program on physician well-being. Coauthors Lotte N. Dyrbye, MD, and Dr. Shanafelt are coinventors of the Physician Well-being Index, Medical Student Well-Being Index, Nurse Well-Being, and Well-Being Index. Mayo Clinic holds the copyright to these instruments and has licensed them for external use. Dr. Dyrbye and Dr. Shanafelt receive a portion of any royalties paid to Mayo Clinic. All other authors reported no conflicts of interest.
Work load, not personal vulnerability, may be at the root of the current physician burnout crisis, a recent study has concluded.
The cutting-edge research utilized cognitive theory and work load analysis to get at the source of burnout among practitioners. The findings indicate that, although some institutions continue to emphasize personal responsibility of physicians to address the issue, it may be the amount and structure of the work itself that triggers burnout in doctors.
“We evaluated the cognitive load of a clinical workday in a national sample of U.S. physicians and its relationship with burnout and professional satisfaction,” wrote Elizabeth Harry, MD, SFHM, a hospitalist at the University of Colorado at Denver, Aurora and coauthors. The results were reported in the Joint Commission Journal on Quality and Patient Safety.
The researchers investigated whether task load correlated with burnout scores in a large national study of U.S. physicians from October 2017 to March 2018.
As the delivery of health care becomes more complex, physicians are charged with ever-increasing amount of administrative and cognitive tasks. Recent evidence indicates that this growing complexity of work is tied to a greater risk of burnout in physicians, compared with workers in other fields. Cognitive load theory, pioneered by psychologist Jonathan Sweller, identified limitations in working memory that humans depend on to carry out cognitive tasks. Cognitive load refers to the amount of working memory used, which can be reduced in the presence of external emotional or physiological stressors. While a potential link between cognitive load and burnout may seem self-evident, the correlation between the cognitive load of physicians and burnout has not been evaluated in a large-scale study until recently.
Physician task load (PTL) was measured using the National Aeronautics and Space Administration Task Load Index (NASA-TLX), a validated questionnaire frequently used to evaluate the cognitive load of work environments, including health care environments. Four domains (perception of effort and mental, physical, and temporal demands) were used to calculate the total PTL score.
Burnout was evaluated using the Emotional Exhaustion and Depersonalization scales of the Maslach Burnout Inventory, a validated tool considered the gold standard for measurement.
The survey sample consisted of physicians of all specialties and was assembled using the American Medical Association Physician Masterfile, an almost complete record of all U.S. physicians independent of AMA membership. All responses were anonymous and participation was voluntary.
Results
Among 30,456 physicians who received the survey, 5,197 (17.1%) responded. In total, 5,276 physicians were included in the analysis.
The median age of respondents was 53 years, and 61.8% self-identified as male. Twenty-four specialties were identified: 23.8% were from a primary care discipline and internal medicine represented the largest respondent group (12.1%).
Almost half of respondents (49.7%) worked in private practice, and 44.8% had been in practice for 21 years or longer.
Overall, 44.0% had at least one symptom of burnout, 38.8% of participants scored in the high range for emotional exhaustion, and 27.4% scored in the high range for depersonalization. The mean score in task load dimension varied by specialty.
The mean PTL score was 260.9 (standard deviation, 71.4). The specialties with the highest PTL score were emergency medicine (369.8), urology (353.7), general surgery subspecialties (343.9), internal medicine subspecialties (342.2), and radiology (341.6).
Aside from specialty, PTL scores also varied by practice setting, gender, age, number of hours worked per week, number of nights on call per week, and years in practice.
The researchers observed a dose response relationship between PTL and risk of burnout. For every 40-point (10%) reduction in PTL, there was 33% lower odds of experiencing burnout (odds ratio, 0.67; 95% confidence interval, 0.65-0.70; P < .0001). Multivariable analyses also indicated that PTL was a significant predictor of burnout, independent of practice setting, specialty, age, gender, and hours worked.
Organizational strategies to reduce physician burnout
Coauthors of the study, Tait D. Shanafelt, MD, professor of medicine at Stanford (Calif.) University and Colin P. West, MD, PhD, of the Mayo Clinic in Rochester, Minn., are both experts on physician well-being and are passionate about finding new ways to reduce physician distress and improving health care delivery.
“Authentic efforts to address this problem must move beyond personal resilience,” Dr. Shanafelt said in an interview. “Organizations that fail to get serious about this issue are going to be left behind and struggle in the war for talent.
“Much like our efforts to improve quality, advancing clinician well-being requires organizations to make it a priority and establish the structure, process, and leadership to promote the desired outcomes,” said Dr. Shanafelt.
One potential strategy for improvement is appointing a chief wellness officer, a dedicated individual within the health care system that leads the organizational effort, explained Dr. Shanafelt. “Over 30 vanguard institutions across the United States have already taken this step.”
Dr. West, a coauthor of the study, explained that conducting an analysis of PTL is fairly straightforward for hospitals and individual institutions. “The NASA-TLX tool is widely available, free to use, and not overly complex, and it could be used to provide insight into physician effort and mental, physical, and temporal demand levels,” he said in an interview.
“Deeper evaluations could follow to identify specific potential solutions, particularly system-level approaches to alleviate PTL,” Dr. West explained. “In the short term, such analyses and solutions would have costs, but helping physicians work more optimally and with less chronic strain from excessive task load would save far more than these costs overall.”
Dr. West also noted that physician burnout is very expensive to a health care system, and strategies to promote physician well-being would be a prudent financial decision long term for health care organizations.
Dr. Harry, lead author of the study, agreed with Dr. West, noting that “quality improvement literature has demonstrated that improvements in inefficiencies that lead to increased demand in the workplace often has the benefit of reduced cost.
“Many studies have demonstrated the risk of turnover due to burnout and the significant cost of physician turn over,” she said in an interview. “This cost avoidance is well worth the investment in improved operations to minimize unnecessary task load.”
Dr. Harry also recommended the NASA-TLX tool as a free resource for health systems and organizations. She noted that future studies will further validate the reliability of the tool.
“At the core, we need to focus on system redesign at both the micro and the macro level,” Dr. Harry said. “Each health system will need to assess inefficiencies in their work flow, while regulatory bodies need to consider the downstream task load of mandates and reporting requirements, all of which contribute to more cognitive load.”
The study was supported by funding from the Stanford Medicine WellMD Center, the American Medical Association, and the Mayo Clinic department of medicine program on physician well-being. Coauthors Lotte N. Dyrbye, MD, and Dr. Shanafelt are coinventors of the Physician Well-being Index, Medical Student Well-Being Index, Nurse Well-Being, and Well-Being Index. Mayo Clinic holds the copyright to these instruments and has licensed them for external use. Dr. Dyrbye and Dr. Shanafelt receive a portion of any royalties paid to Mayo Clinic. All other authors reported no conflicts of interest.
FROM THE JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY
CDC chief lays out attack plan for COVID variants
earlier this week.
As part of JAMA’s Q&A series with JAMA editor in chief Howard Bauchner, MD, Dr. Walensky referenced the blueprint she coathored with Anthony Fauci, MD, the nation’s top infectious disease expert, and Henry T. Walke, MD, MPH, of the CDC, which was published on Feb. 17 in JAMA.
In the viewpoint article, they explain that the Department of Health & Human Services has established the SARS-CoV-2 Interagency Group to improve coordination among the CDC, the National Institutes of Health, the Food and Drug Administration, the Biomedical Advanced Research and Development Authority, the Department of Agriculture, and the Department of Defense.
Dr. Walensky said the first objective is to reinforce vigilance regarding public health mitigation strategies to decrease the amount of virus that’s circulating.
As part of that strategy, she said, the CDC strongly urges against nonessential travel.
In addition, public health leaders are working on a surveillance system to better understand the SARS-CoV-2 variants. That will take ramping up genome sequencing of the SARS-CoV-2 virus and ensuring that sampling is geographically representative.
She said the CDC is partnering with state health labs to obtain about 750 samples every week and is teaming up with commercial labs and academic centers to obtain an interim target of 6,000 samples per week.
She acknowledged the United States “is not where we need to be” with sequencing but has come a long way since January. At that time, they were sequencing 250 samples every week; they are currently sequencing thousands each week.
Data analysis is another concern: “We need to be able to understand at the basic science level what the information means,” Dr. Walensky said.
Researchers aren’t sure how the variants might affect use of convalescent plasma or monoclonal antibody treatments. It is expected that 5% of persons who are vaccinated against COVID-19 will nevertheless contract the disease. Sequencing will help answer whether such persons who have been vaccinated and who subsequently contract the virus are among those 5% or whether have been infected by a variant that evades the vaccine.
Accelerating vaccine administration globally and in the United States is essential, Dr. Walensky said.
As of Feb. 17, 56 million doses had been administered in the United States.
Top three threats
She updated the numbers on the three biggest variant threats.
Regarding B.1.1.7, which originated in the United Kingdom, she said: “So far, we’ve had over 1,200 cases in 41 states.” She noted that the variant is likely to be about 50% more transmissible and 30% to 50% more virulent.
“So far, it looks like that strain doesn’t have any real decrease in susceptibility to our vaccines,” she said.
The strain from South Africa (B.1.351) has been found in 19 cases in the United States.
The P.1. variant, which originated in Brazil, has been identified in two cases in two states.
Outlook for March and April
Dr. Bauchner asked Dr. Walensky what she envisions for March and April. He noted that public optimism is high in light of the continued reductions in COVID-19 case numbers, hospitalizations, and deaths, as well as the fact that warmer weather is coming and that more vaccinations are on the horizon.
“While I really am hopeful for what could happen in March and April,” Dr. Walensky said, “I really do know that this could go bad so fast. We saw it in November. We saw it in December.”
CDC models have projected that, by March, the more transmissible B.1.1.7 strain is likely to be the dominant strain, she reiterated.
“I worry that it will be spring, and we will all have had enough,” Dr. Walensky said. She noted that some states are already relaxing mask mandates.
“Around that time, life will look and feel a little better, and the motivation for those who might be vaccine hesitant may be diminished,” she said.
Dr. Bauchner also asked her to weigh in on whether a third vaccine, from Johnson & Johnson (J&J), may soon gain FDA emergency-use authorization – and whether its lower expected efficacy rate may result in a tiered system of vaccinations, with higher-risk populations receiving the more efficacious vaccines.
Dr. Walensky said more data are needed before that question can be answered.
“It may very well be that the data point us to the best populations in which to use this vaccine,” she said.
In phase 3 data, the J&J vaccine was shown to be 72% effective in the United States for moderate to severe disease.
Dr. Walensky said it’s important to remember that the projected efficacy for that vaccine is higher than that for the flu shot as well as many other vaccines currently in use for other diseases.
She said it also has several advantages. The vaccine has less-stringent storage requirements, requires just one dose, and protects against hospitalization and death, although it’s less efficacious in protecting against contracting the disease.
“I think many people would opt to get that one if they could get it sooner,” she said.
A version of this article first appeared on Medscape.com.
earlier this week.
As part of JAMA’s Q&A series with JAMA editor in chief Howard Bauchner, MD, Dr. Walensky referenced the blueprint she coathored with Anthony Fauci, MD, the nation’s top infectious disease expert, and Henry T. Walke, MD, MPH, of the CDC, which was published on Feb. 17 in JAMA.
In the viewpoint article, they explain that the Department of Health & Human Services has established the SARS-CoV-2 Interagency Group to improve coordination among the CDC, the National Institutes of Health, the Food and Drug Administration, the Biomedical Advanced Research and Development Authority, the Department of Agriculture, and the Department of Defense.
Dr. Walensky said the first objective is to reinforce vigilance regarding public health mitigation strategies to decrease the amount of virus that’s circulating.
As part of that strategy, she said, the CDC strongly urges against nonessential travel.
In addition, public health leaders are working on a surveillance system to better understand the SARS-CoV-2 variants. That will take ramping up genome sequencing of the SARS-CoV-2 virus and ensuring that sampling is geographically representative.
She said the CDC is partnering with state health labs to obtain about 750 samples every week and is teaming up with commercial labs and academic centers to obtain an interim target of 6,000 samples per week.
She acknowledged the United States “is not where we need to be” with sequencing but has come a long way since January. At that time, they were sequencing 250 samples every week; they are currently sequencing thousands each week.
Data analysis is another concern: “We need to be able to understand at the basic science level what the information means,” Dr. Walensky said.
Researchers aren’t sure how the variants might affect use of convalescent plasma or monoclonal antibody treatments. It is expected that 5% of persons who are vaccinated against COVID-19 will nevertheless contract the disease. Sequencing will help answer whether such persons who have been vaccinated and who subsequently contract the virus are among those 5% or whether have been infected by a variant that evades the vaccine.
Accelerating vaccine administration globally and in the United States is essential, Dr. Walensky said.
As of Feb. 17, 56 million doses had been administered in the United States.
Top three threats
She updated the numbers on the three biggest variant threats.
Regarding B.1.1.7, which originated in the United Kingdom, she said: “So far, we’ve had over 1,200 cases in 41 states.” She noted that the variant is likely to be about 50% more transmissible and 30% to 50% more virulent.
“So far, it looks like that strain doesn’t have any real decrease in susceptibility to our vaccines,” she said.
The strain from South Africa (B.1.351) has been found in 19 cases in the United States.
The P.1. variant, which originated in Brazil, has been identified in two cases in two states.
Outlook for March and April
Dr. Bauchner asked Dr. Walensky what she envisions for March and April. He noted that public optimism is high in light of the continued reductions in COVID-19 case numbers, hospitalizations, and deaths, as well as the fact that warmer weather is coming and that more vaccinations are on the horizon.
“While I really am hopeful for what could happen in March and April,” Dr. Walensky said, “I really do know that this could go bad so fast. We saw it in November. We saw it in December.”
CDC models have projected that, by March, the more transmissible B.1.1.7 strain is likely to be the dominant strain, she reiterated.
“I worry that it will be spring, and we will all have had enough,” Dr. Walensky said. She noted that some states are already relaxing mask mandates.
“Around that time, life will look and feel a little better, and the motivation for those who might be vaccine hesitant may be diminished,” she said.
Dr. Bauchner also asked her to weigh in on whether a third vaccine, from Johnson & Johnson (J&J), may soon gain FDA emergency-use authorization – and whether its lower expected efficacy rate may result in a tiered system of vaccinations, with higher-risk populations receiving the more efficacious vaccines.
Dr. Walensky said more data are needed before that question can be answered.
“It may very well be that the data point us to the best populations in which to use this vaccine,” she said.
In phase 3 data, the J&J vaccine was shown to be 72% effective in the United States for moderate to severe disease.
Dr. Walensky said it’s important to remember that the projected efficacy for that vaccine is higher than that for the flu shot as well as many other vaccines currently in use for other diseases.
She said it also has several advantages. The vaccine has less-stringent storage requirements, requires just one dose, and protects against hospitalization and death, although it’s less efficacious in protecting against contracting the disease.
“I think many people would opt to get that one if they could get it sooner,” she said.
A version of this article first appeared on Medscape.com.
earlier this week.
As part of JAMA’s Q&A series with JAMA editor in chief Howard Bauchner, MD, Dr. Walensky referenced the blueprint she coathored with Anthony Fauci, MD, the nation’s top infectious disease expert, and Henry T. Walke, MD, MPH, of the CDC, which was published on Feb. 17 in JAMA.
In the viewpoint article, they explain that the Department of Health & Human Services has established the SARS-CoV-2 Interagency Group to improve coordination among the CDC, the National Institutes of Health, the Food and Drug Administration, the Biomedical Advanced Research and Development Authority, the Department of Agriculture, and the Department of Defense.
Dr. Walensky said the first objective is to reinforce vigilance regarding public health mitigation strategies to decrease the amount of virus that’s circulating.
As part of that strategy, she said, the CDC strongly urges against nonessential travel.
In addition, public health leaders are working on a surveillance system to better understand the SARS-CoV-2 variants. That will take ramping up genome sequencing of the SARS-CoV-2 virus and ensuring that sampling is geographically representative.
She said the CDC is partnering with state health labs to obtain about 750 samples every week and is teaming up with commercial labs and academic centers to obtain an interim target of 6,000 samples per week.
She acknowledged the United States “is not where we need to be” with sequencing but has come a long way since January. At that time, they were sequencing 250 samples every week; they are currently sequencing thousands each week.
Data analysis is another concern: “We need to be able to understand at the basic science level what the information means,” Dr. Walensky said.
Researchers aren’t sure how the variants might affect use of convalescent plasma or monoclonal antibody treatments. It is expected that 5% of persons who are vaccinated against COVID-19 will nevertheless contract the disease. Sequencing will help answer whether such persons who have been vaccinated and who subsequently contract the virus are among those 5% or whether have been infected by a variant that evades the vaccine.
Accelerating vaccine administration globally and in the United States is essential, Dr. Walensky said.
As of Feb. 17, 56 million doses had been administered in the United States.
Top three threats
She updated the numbers on the three biggest variant threats.
Regarding B.1.1.7, which originated in the United Kingdom, she said: “So far, we’ve had over 1,200 cases in 41 states.” She noted that the variant is likely to be about 50% more transmissible and 30% to 50% more virulent.
“So far, it looks like that strain doesn’t have any real decrease in susceptibility to our vaccines,” she said.
The strain from South Africa (B.1.351) has been found in 19 cases in the United States.
The P.1. variant, which originated in Brazil, has been identified in two cases in two states.
Outlook for March and April
Dr. Bauchner asked Dr. Walensky what she envisions for March and April. He noted that public optimism is high in light of the continued reductions in COVID-19 case numbers, hospitalizations, and deaths, as well as the fact that warmer weather is coming and that more vaccinations are on the horizon.
“While I really am hopeful for what could happen in March and April,” Dr. Walensky said, “I really do know that this could go bad so fast. We saw it in November. We saw it in December.”
CDC models have projected that, by March, the more transmissible B.1.1.7 strain is likely to be the dominant strain, she reiterated.
“I worry that it will be spring, and we will all have had enough,” Dr. Walensky said. She noted that some states are already relaxing mask mandates.
“Around that time, life will look and feel a little better, and the motivation for those who might be vaccine hesitant may be diminished,” she said.
Dr. Bauchner also asked her to weigh in on whether a third vaccine, from Johnson & Johnson (J&J), may soon gain FDA emergency-use authorization – and whether its lower expected efficacy rate may result in a tiered system of vaccinations, with higher-risk populations receiving the more efficacious vaccines.
Dr. Walensky said more data are needed before that question can be answered.
“It may very well be that the data point us to the best populations in which to use this vaccine,” she said.
In phase 3 data, the J&J vaccine was shown to be 72% effective in the United States for moderate to severe disease.
Dr. Walensky said it’s important to remember that the projected efficacy for that vaccine is higher than that for the flu shot as well as many other vaccines currently in use for other diseases.
She said it also has several advantages. The vaccine has less-stringent storage requirements, requires just one dose, and protects against hospitalization and death, although it’s less efficacious in protecting against contracting the disease.
“I think many people would opt to get that one if they could get it sooner,” she said.
A version of this article first appeared on Medscape.com.
Family medicine has grown; its composition has evolved
and the men and women who practice it are no exception.
The family medicine workforce of 2021 is not the workforce of 1971. Not even close. Although we would like to give a huge shout-out to anyone who can claim to be a member of both.
Today’s FP workforce is, first of all, much larger than it was in 1971, although we can’t actually prove it because the American Medical Association’s data for that year are “only available in books that are locked away at the empty AMA headquarters,” according to a member of the AMA media relations staff who is, like so many people these days, working at home because of the pandemic.
The face of family medicine in 1975 vs. today
Today’s workforce is much larger than it was in 1975, when there were just over 12,000 family physicians in the United States. As of January 2021, the total was approaching 137,000, including all “physicians and residents in patient care, research, administration, teaching, retired, inactive, etc.,” the AMA explained.
Family physicians as a group are much more diverse than they were in 1975. That year, 8.3% of FPs were international medical graduates (IMGs). By 2010, IMGs made up almost 23% of the workforce, and in the 2020 resident match, 37% of the 4,662 available family medicine slots were filled by IMGs.
Women have made even greater inroads into the family physician ranks over the last 5 decades. In 1975, less than 5% of all FPs were females, but by 2021 the proportion of females in the specialty was just over 40%.
In the first 5 years of the family practice era, 1969-1973, only 12 women and 31 IMGs graduated from FP residency programs, those numbers representing 3.2% and 8.3%, respectively, of the total of 372, according to a 1996 study in JAMA. By 1990-1993, women made up 33% and IMGs 14% of the 9,400 graduates.
Another group that increased its presence in family medicine is doctors of osteopathy, who went from zero residency graduates in 1969-1973 to over 1,100 (11.8%) in 1990-1993, the JAMA report noted. By 2020, almost 1,400 osteopathic physicians entered family medicine residencies, filling 30% of all slots available, according to the National Resident Matching Program.
The medical schools producing all these new residents have raised their games since 1971: the number of full-time faculty in family medicine departments rose from 323 to 5,929 in 2020, based on data from the Association of American Medical Colleges (Faculty Roster, Dec. 31 snapshots, as of Dec. 31, 2020).
A shortage or a surplus of FPs?
It has been suggested, however, that all is not well in primary care land. A study conducted by the American Academy of Family Physicians in 2016 – a year after 2,463 graduates of MD- and DO-granting medical schools entered family medicine residencies – concluded “that the current medical school system is failing, collectively, to produce the primary care workforce that is needed to achieve optimal health.”
Warnings about physician shortages are nothing new, but how about the other side of the coin? The Jan. 15, 1981, issue of Family Practice News covered a somewhat controversial report from the Graduate Medical Education National Advisory Committee, which projected a surplus of 3,000 FPs, and as many as 70,000 physicians overall, by the year 1990.
Just a few months later, in the June 15, 1981, issue of FPN, an AAFP officer predicted that “the flood of new physicians in the next decade may affect family practice more than any other specialty.”
Mostly, though, the issue is shortages. In 2002, a status report on family practice from the Robert Graham Center acknowledged that “many centers of academic medicine continue to resist the development of family practice and primary care. ... Family medicine remains a true counterculture in these environments, and students may continue to face significant discouragement in response to interest they may express in becoming a family physician.”
and the men and women who practice it are no exception.
The family medicine workforce of 2021 is not the workforce of 1971. Not even close. Although we would like to give a huge shout-out to anyone who can claim to be a member of both.
Today’s FP workforce is, first of all, much larger than it was in 1971, although we can’t actually prove it because the American Medical Association’s data for that year are “only available in books that are locked away at the empty AMA headquarters,” according to a member of the AMA media relations staff who is, like so many people these days, working at home because of the pandemic.
The face of family medicine in 1975 vs. today
Today’s workforce is much larger than it was in 1975, when there were just over 12,000 family physicians in the United States. As of January 2021, the total was approaching 137,000, including all “physicians and residents in patient care, research, administration, teaching, retired, inactive, etc.,” the AMA explained.
Family physicians as a group are much more diverse than they were in 1975. That year, 8.3% of FPs were international medical graduates (IMGs). By 2010, IMGs made up almost 23% of the workforce, and in the 2020 resident match, 37% of the 4,662 available family medicine slots were filled by IMGs.
Women have made even greater inroads into the family physician ranks over the last 5 decades. In 1975, less than 5% of all FPs were females, but by 2021 the proportion of females in the specialty was just over 40%.
In the first 5 years of the family practice era, 1969-1973, only 12 women and 31 IMGs graduated from FP residency programs, those numbers representing 3.2% and 8.3%, respectively, of the total of 372, according to a 1996 study in JAMA. By 1990-1993, women made up 33% and IMGs 14% of the 9,400 graduates.
Another group that increased its presence in family medicine is doctors of osteopathy, who went from zero residency graduates in 1969-1973 to over 1,100 (11.8%) in 1990-1993, the JAMA report noted. By 2020, almost 1,400 osteopathic physicians entered family medicine residencies, filling 30% of all slots available, according to the National Resident Matching Program.
The medical schools producing all these new residents have raised their games since 1971: the number of full-time faculty in family medicine departments rose from 323 to 5,929 in 2020, based on data from the Association of American Medical Colleges (Faculty Roster, Dec. 31 snapshots, as of Dec. 31, 2020).
A shortage or a surplus of FPs?
It has been suggested, however, that all is not well in primary care land. A study conducted by the American Academy of Family Physicians in 2016 – a year after 2,463 graduates of MD- and DO-granting medical schools entered family medicine residencies – concluded “that the current medical school system is failing, collectively, to produce the primary care workforce that is needed to achieve optimal health.”
Warnings about physician shortages are nothing new, but how about the other side of the coin? The Jan. 15, 1981, issue of Family Practice News covered a somewhat controversial report from the Graduate Medical Education National Advisory Committee, which projected a surplus of 3,000 FPs, and as many as 70,000 physicians overall, by the year 1990.
Just a few months later, in the June 15, 1981, issue of FPN, an AAFP officer predicted that “the flood of new physicians in the next decade may affect family practice more than any other specialty.”
Mostly, though, the issue is shortages. In 2002, a status report on family practice from the Robert Graham Center acknowledged that “many centers of academic medicine continue to resist the development of family practice and primary care. ... Family medicine remains a true counterculture in these environments, and students may continue to face significant discouragement in response to interest they may express in becoming a family physician.”
and the men and women who practice it are no exception.
The family medicine workforce of 2021 is not the workforce of 1971. Not even close. Although we would like to give a huge shout-out to anyone who can claim to be a member of both.
Today’s FP workforce is, first of all, much larger than it was in 1971, although we can’t actually prove it because the American Medical Association’s data for that year are “only available in books that are locked away at the empty AMA headquarters,” according to a member of the AMA media relations staff who is, like so many people these days, working at home because of the pandemic.
The face of family medicine in 1975 vs. today
Today’s workforce is much larger than it was in 1975, when there were just over 12,000 family physicians in the United States. As of January 2021, the total was approaching 137,000, including all “physicians and residents in patient care, research, administration, teaching, retired, inactive, etc.,” the AMA explained.
Family physicians as a group are much more diverse than they were in 1975. That year, 8.3% of FPs were international medical graduates (IMGs). By 2010, IMGs made up almost 23% of the workforce, and in the 2020 resident match, 37% of the 4,662 available family medicine slots were filled by IMGs.
Women have made even greater inroads into the family physician ranks over the last 5 decades. In 1975, less than 5% of all FPs were females, but by 2021 the proportion of females in the specialty was just over 40%.
In the first 5 years of the family practice era, 1969-1973, only 12 women and 31 IMGs graduated from FP residency programs, those numbers representing 3.2% and 8.3%, respectively, of the total of 372, according to a 1996 study in JAMA. By 1990-1993, women made up 33% and IMGs 14% of the 9,400 graduates.
Another group that increased its presence in family medicine is doctors of osteopathy, who went from zero residency graduates in 1969-1973 to over 1,100 (11.8%) in 1990-1993, the JAMA report noted. By 2020, almost 1,400 osteopathic physicians entered family medicine residencies, filling 30% of all slots available, according to the National Resident Matching Program.
The medical schools producing all these new residents have raised their games since 1971: the number of full-time faculty in family medicine departments rose from 323 to 5,929 in 2020, based on data from the Association of American Medical Colleges (Faculty Roster, Dec. 31 snapshots, as of Dec. 31, 2020).
A shortage or a surplus of FPs?
It has been suggested, however, that all is not well in primary care land. A study conducted by the American Academy of Family Physicians in 2016 – a year after 2,463 graduates of MD- and DO-granting medical schools entered family medicine residencies – concluded “that the current medical school system is failing, collectively, to produce the primary care workforce that is needed to achieve optimal health.”
Warnings about physician shortages are nothing new, but how about the other side of the coin? The Jan. 15, 1981, issue of Family Practice News covered a somewhat controversial report from the Graduate Medical Education National Advisory Committee, which projected a surplus of 3,000 FPs, and as many as 70,000 physicians overall, by the year 1990.
Just a few months later, in the June 15, 1981, issue of FPN, an AAFP officer predicted that “the flood of new physicians in the next decade may affect family practice more than any other specialty.”
Mostly, though, the issue is shortages. In 2002, a status report on family practice from the Robert Graham Center acknowledged that “many centers of academic medicine continue to resist the development of family practice and primary care. ... Family medicine remains a true counterculture in these environments, and students may continue to face significant discouragement in response to interest they may express in becoming a family physician.”
Dried blood spot tests show sensitivity as cCMV screen
Dried blood spot testing showed sensitivity comparable to saliva as a screening method for congenital cytomegalovirus infection in newborns, based on data from more than 12,000 newborns.
Congenital cytomegalovirus (cCMV) is a common congenital virus in the United States, but remains underrecognized, wrote Sheila C. Dollard, PhD, of the Centers for Disease Control and Prevention in Atlanta, and colleagues.
“Given the burden associated with cCMV and the proven benefits of treatment and early intervention for some affected infants, there has been growing interest in universal newborn screening,” but an ideal screening strategy has yet to be determined, they said.
In a population-based cohort study published in JAMA Pediatrics, the researchers screened 12,554 newborns in Minnesota, including 56 with confirmed CMV infection. The newborns were screened for cCMV via dried blood spots (DBS) and saliva collected 1-2 days after birth. The DBS were tested for CMV DNA via polymerase chain reaction (PCR) at the University of Minnesota (UMN) and the CDC.
The overall sensitivity rate was 85.7% for a combination of laboratory results from the UMN and the CDC, which had separate sensitivities of 73.2% and 76.8%, respectively.
The specificity of the combined results was 100.0% (100% from both UMN and CDC), the combined positive predictive value was 98.0% (100.0% from UMN, 97.7% from CDC), and the combined negative predictive value was 99.9% (99.9% from both UMN and CDC).
By comparison, saliva swab test results showed sensitivity of 92.9%, specificity of 99.9%, positive predictive value of 86.7%, and negative predictive value of 100.0%.
The study findings were limited by several factors including the false-positive and false-negative results from saliva screening. Overall, the false-positive rate was 0.06%, which is comparable to rates from other screening techniques, the researchers said. “The recent Food and Drug Administration approval of a point-of-care neonatal saliva CMV test (Meridian Bioscience), underscores the importance of further clarifying the role of false-positive saliva CMV test results and underscores the requirement for urine confirmation for diagnosis of cCMV,” they added.
However, the study findings support the acceptability and feasibility of cCMV screening, as parents reported generally positive attitudes about the process, the researchers said.
The study is ongoing, and designed to follow infants with confirmed cCMV for up to age 4 years to assess clinical outcomes, they added. “Diagnostic methods are always improving, and therefore, our results show the potential of DBS to provide low-cost CMV screening with smooth integration of sample collection, laboratory testing, and follow-up,” they concluded.
Findings lay foundation for widespread use
“By using enhanced PCR methods, Dollard et al. have rekindled the hope that NBDBS [newborn dried blood spots] testing may be a viable method for large-scale, universal newborn screening for congenital CMV,” Gail J. Demmler-Harrison, MD, of Texas Children’s Hospital, Houston, wrote in an accompanying editorial. Congenital CMV is a common infection, but accurate prevalence remains uncertain because not all newborns are tested, she noted. Detection of CMV currently may involve urine, saliva, and blood, but challenges to the use of these methods include “a variety of constantly evolving DNA detection methods,” she said.
Although urine and saliva samples have been proposed for universal screening, they would require the creation of new sample collection and testing programs. “The routine of collecting the NBDBS samples on all newborns and the logistics of routing them to central laboratories and then reporting results to caregivers is already in place and are strengths of NBDBS samples for universal newborn screening,” but had been limited by a less sensitive platform than urine or saliva, said Dr. Demmler-Harrison.
“The results in the study by Dollard et al. may be a total game changer for the NBDBS proponents,” she emphasized. “Furthermore, scientists who have adapted even more sensitive DNA detection assays, such as the loop-mediated isothermal assay for detection of DNA in clinical samples from newborns, may be able to adapt loop-mediated isothermal assay methodology to detect CMV DNA in NBDBS,” she added.
“By adapting the collection methods, by using optimal filter paper to enhance DNA adherence, by improving DNA elution procedures, and by developing novel amplification and detection methods, NBDBS may soon meet the challenge and reach the sensitivity and specificity necessary for universal screening for congenital CMV,” she concluded.
The study was supported by the CDC, the Minnesota Department of Health, the National Vaccine Program Office (U.S. federal government), and the University of South Carolina Disability Research and Dissemination Center.
Dr. Dollard and Dr. Demmler-Harrison had no financial conflicts to disclose.
Dried blood spot testing showed sensitivity comparable to saliva as a screening method for congenital cytomegalovirus infection in newborns, based on data from more than 12,000 newborns.
Congenital cytomegalovirus (cCMV) is a common congenital virus in the United States, but remains underrecognized, wrote Sheila C. Dollard, PhD, of the Centers for Disease Control and Prevention in Atlanta, and colleagues.
“Given the burden associated with cCMV and the proven benefits of treatment and early intervention for some affected infants, there has been growing interest in universal newborn screening,” but an ideal screening strategy has yet to be determined, they said.
In a population-based cohort study published in JAMA Pediatrics, the researchers screened 12,554 newborns in Minnesota, including 56 with confirmed CMV infection. The newborns were screened for cCMV via dried blood spots (DBS) and saliva collected 1-2 days after birth. The DBS were tested for CMV DNA via polymerase chain reaction (PCR) at the University of Minnesota (UMN) and the CDC.
The overall sensitivity rate was 85.7% for a combination of laboratory results from the UMN and the CDC, which had separate sensitivities of 73.2% and 76.8%, respectively.
The specificity of the combined results was 100.0% (100% from both UMN and CDC), the combined positive predictive value was 98.0% (100.0% from UMN, 97.7% from CDC), and the combined negative predictive value was 99.9% (99.9% from both UMN and CDC).
By comparison, saliva swab test results showed sensitivity of 92.9%, specificity of 99.9%, positive predictive value of 86.7%, and negative predictive value of 100.0%.
The study findings were limited by several factors including the false-positive and false-negative results from saliva screening. Overall, the false-positive rate was 0.06%, which is comparable to rates from other screening techniques, the researchers said. “The recent Food and Drug Administration approval of a point-of-care neonatal saliva CMV test (Meridian Bioscience), underscores the importance of further clarifying the role of false-positive saliva CMV test results and underscores the requirement for urine confirmation for diagnosis of cCMV,” they added.
However, the study findings support the acceptability and feasibility of cCMV screening, as parents reported generally positive attitudes about the process, the researchers said.
The study is ongoing, and designed to follow infants with confirmed cCMV for up to age 4 years to assess clinical outcomes, they added. “Diagnostic methods are always improving, and therefore, our results show the potential of DBS to provide low-cost CMV screening with smooth integration of sample collection, laboratory testing, and follow-up,” they concluded.
Findings lay foundation for widespread use
“By using enhanced PCR methods, Dollard et al. have rekindled the hope that NBDBS [newborn dried blood spots] testing may be a viable method for large-scale, universal newborn screening for congenital CMV,” Gail J. Demmler-Harrison, MD, of Texas Children’s Hospital, Houston, wrote in an accompanying editorial. Congenital CMV is a common infection, but accurate prevalence remains uncertain because not all newborns are tested, she noted. Detection of CMV currently may involve urine, saliva, and blood, but challenges to the use of these methods include “a variety of constantly evolving DNA detection methods,” she said.
Although urine and saliva samples have been proposed for universal screening, they would require the creation of new sample collection and testing programs. “The routine of collecting the NBDBS samples on all newborns and the logistics of routing them to central laboratories and then reporting results to caregivers is already in place and are strengths of NBDBS samples for universal newborn screening,” but had been limited by a less sensitive platform than urine or saliva, said Dr. Demmler-Harrison.
“The results in the study by Dollard et al. may be a total game changer for the NBDBS proponents,” she emphasized. “Furthermore, scientists who have adapted even more sensitive DNA detection assays, such as the loop-mediated isothermal assay for detection of DNA in clinical samples from newborns, may be able to adapt loop-mediated isothermal assay methodology to detect CMV DNA in NBDBS,” she added.
“By adapting the collection methods, by using optimal filter paper to enhance DNA adherence, by improving DNA elution procedures, and by developing novel amplification and detection methods, NBDBS may soon meet the challenge and reach the sensitivity and specificity necessary for universal screening for congenital CMV,” she concluded.
The study was supported by the CDC, the Minnesota Department of Health, the National Vaccine Program Office (U.S. federal government), and the University of South Carolina Disability Research and Dissemination Center.
Dr. Dollard and Dr. Demmler-Harrison had no financial conflicts to disclose.
Dried blood spot testing showed sensitivity comparable to saliva as a screening method for congenital cytomegalovirus infection in newborns, based on data from more than 12,000 newborns.
Congenital cytomegalovirus (cCMV) is a common congenital virus in the United States, but remains underrecognized, wrote Sheila C. Dollard, PhD, of the Centers for Disease Control and Prevention in Atlanta, and colleagues.
“Given the burden associated with cCMV and the proven benefits of treatment and early intervention for some affected infants, there has been growing interest in universal newborn screening,” but an ideal screening strategy has yet to be determined, they said.
In a population-based cohort study published in JAMA Pediatrics, the researchers screened 12,554 newborns in Minnesota, including 56 with confirmed CMV infection. The newborns were screened for cCMV via dried blood spots (DBS) and saliva collected 1-2 days after birth. The DBS were tested for CMV DNA via polymerase chain reaction (PCR) at the University of Minnesota (UMN) and the CDC.
The overall sensitivity rate was 85.7% for a combination of laboratory results from the UMN and the CDC, which had separate sensitivities of 73.2% and 76.8%, respectively.
The specificity of the combined results was 100.0% (100% from both UMN and CDC), the combined positive predictive value was 98.0% (100.0% from UMN, 97.7% from CDC), and the combined negative predictive value was 99.9% (99.9% from both UMN and CDC).
By comparison, saliva swab test results showed sensitivity of 92.9%, specificity of 99.9%, positive predictive value of 86.7%, and negative predictive value of 100.0%.
The study findings were limited by several factors including the false-positive and false-negative results from saliva screening. Overall, the false-positive rate was 0.06%, which is comparable to rates from other screening techniques, the researchers said. “The recent Food and Drug Administration approval of a point-of-care neonatal saliva CMV test (Meridian Bioscience), underscores the importance of further clarifying the role of false-positive saliva CMV test results and underscores the requirement for urine confirmation for diagnosis of cCMV,” they added.
However, the study findings support the acceptability and feasibility of cCMV screening, as parents reported generally positive attitudes about the process, the researchers said.
The study is ongoing, and designed to follow infants with confirmed cCMV for up to age 4 years to assess clinical outcomes, they added. “Diagnostic methods are always improving, and therefore, our results show the potential of DBS to provide low-cost CMV screening with smooth integration of sample collection, laboratory testing, and follow-up,” they concluded.
Findings lay foundation for widespread use
“By using enhanced PCR methods, Dollard et al. have rekindled the hope that NBDBS [newborn dried blood spots] testing may be a viable method for large-scale, universal newborn screening for congenital CMV,” Gail J. Demmler-Harrison, MD, of Texas Children’s Hospital, Houston, wrote in an accompanying editorial. Congenital CMV is a common infection, but accurate prevalence remains uncertain because not all newborns are tested, she noted. Detection of CMV currently may involve urine, saliva, and blood, but challenges to the use of these methods include “a variety of constantly evolving DNA detection methods,” she said.
Although urine and saliva samples have been proposed for universal screening, they would require the creation of new sample collection and testing programs. “The routine of collecting the NBDBS samples on all newborns and the logistics of routing them to central laboratories and then reporting results to caregivers is already in place and are strengths of NBDBS samples for universal newborn screening,” but had been limited by a less sensitive platform than urine or saliva, said Dr. Demmler-Harrison.
“The results in the study by Dollard et al. may be a total game changer for the NBDBS proponents,” she emphasized. “Furthermore, scientists who have adapted even more sensitive DNA detection assays, such as the loop-mediated isothermal assay for detection of DNA in clinical samples from newborns, may be able to adapt loop-mediated isothermal assay methodology to detect CMV DNA in NBDBS,” she added.
“By adapting the collection methods, by using optimal filter paper to enhance DNA adherence, by improving DNA elution procedures, and by developing novel amplification and detection methods, NBDBS may soon meet the challenge and reach the sensitivity and specificity necessary for universal screening for congenital CMV,” she concluded.
The study was supported by the CDC, the Minnesota Department of Health, the National Vaccine Program Office (U.S. federal government), and the University of South Carolina Disability Research and Dissemination Center.
Dr. Dollard and Dr. Demmler-Harrison had no financial conflicts to disclose.
FROM JAMA PEDIATRICS
FDA clears novel daytime device for obstructive sleep apnea
eXciteOSA (Signifier Medical Technologies) is a prescription-only, neuromuscular stimulation device designed to improve tongue muscle function, which, over time, can help prevent the tongue from collapsing backwards and obstructing the airway during sleep, the FDA said.
The eXciteOSA mouthpiece has four electrodes that deliver a series of electrical pulses with rest periods in between. Two electrodes are located above the tongue and two are located below the tongue.
The patient uses the device for 20 minutes once a day while awake for 6 weeks, and once a week thereafter. It is indicated for adults aged 18 and older with snoring and mild OSA.
OSA is marked by the recurring collapse of the upper airways during sleep, intermittently reducing or completely blocking airflow. Common symptoms include snoring, restless sleep and daytime sleepiness. Untreated OSA can lead to serious complications such as cardiovascular disease and cognitive and behavioral disorders.
Continuous positive airway pressure therapy, administered through a face mask that is worn while asleep, is a first-line treatment for OSA.
The eXciteOSA device “offers a new option for the thousands of individuals who experience snoring or mild sleep apnea,” Malvina Eydelman, MD, director, FDA Office of Ophthalmic, Anesthesia, Respiratory, ENT, and Dental Devices, said in a news release.
The FDA reviewed data on the safety and effectiveness of the eXciteOSA device in 115 patients with snoring, including 48 patients with snoring and mild OSA. All patients used the device for 20 minutes once a day for 6 weeks, then stopped using it for 2 weeks before they were reassessed.
Overall, the percentage of time spent snoring at levels louder than 40 decibels was reduced by more than 20% in 87 out of the 115 patients.
In the subset of patients with snoring and mild OSA, the average apnea-hypopnea index score was reduced by 48%, from 10.21 to 5.27, in 41 of 48 patients. Mild OSA is defined as an AHI score greater than 5 but less than 15.
The most common adverse events were excessive salivation, tongue or tooth discomfort, tongue tingling, dental filling sensitivity, metallic taste, gagging, and tight jaw.
Before using the eXciteOSA device, patients should receive a comprehensive dental examination, the FDA said.
The device should not be used in patients with pacemakers or implanted pacing leads, or women who are pregnant. The device is also contraindicated in patients with temporary or permanent implants, dental braces, intraoral metal prosthesis/restorations, or ulcerations in or around the mouth.
The eXciteOSA device was approved under the de novo premarket review pathway for new low- to moderate-risk devices. More information on the device is available online.
A version of this article first appeared on Medscape.com.
eXciteOSA (Signifier Medical Technologies) is a prescription-only, neuromuscular stimulation device designed to improve tongue muscle function, which, over time, can help prevent the tongue from collapsing backwards and obstructing the airway during sleep, the FDA said.
The eXciteOSA mouthpiece has four electrodes that deliver a series of electrical pulses with rest periods in between. Two electrodes are located above the tongue and two are located below the tongue.
The patient uses the device for 20 minutes once a day while awake for 6 weeks, and once a week thereafter. It is indicated for adults aged 18 and older with snoring and mild OSA.
OSA is marked by the recurring collapse of the upper airways during sleep, intermittently reducing or completely blocking airflow. Common symptoms include snoring, restless sleep and daytime sleepiness. Untreated OSA can lead to serious complications such as cardiovascular disease and cognitive and behavioral disorders.
Continuous positive airway pressure therapy, administered through a face mask that is worn while asleep, is a first-line treatment for OSA.
The eXciteOSA device “offers a new option for the thousands of individuals who experience snoring or mild sleep apnea,” Malvina Eydelman, MD, director, FDA Office of Ophthalmic, Anesthesia, Respiratory, ENT, and Dental Devices, said in a news release.
The FDA reviewed data on the safety and effectiveness of the eXciteOSA device in 115 patients with snoring, including 48 patients with snoring and mild OSA. All patients used the device for 20 minutes once a day for 6 weeks, then stopped using it for 2 weeks before they were reassessed.
Overall, the percentage of time spent snoring at levels louder than 40 decibels was reduced by more than 20% in 87 out of the 115 patients.
In the subset of patients with snoring and mild OSA, the average apnea-hypopnea index score was reduced by 48%, from 10.21 to 5.27, in 41 of 48 patients. Mild OSA is defined as an AHI score greater than 5 but less than 15.
The most common adverse events were excessive salivation, tongue or tooth discomfort, tongue tingling, dental filling sensitivity, metallic taste, gagging, and tight jaw.
Before using the eXciteOSA device, patients should receive a comprehensive dental examination, the FDA said.
The device should not be used in patients with pacemakers or implanted pacing leads, or women who are pregnant. The device is also contraindicated in patients with temporary or permanent implants, dental braces, intraoral metal prosthesis/restorations, or ulcerations in or around the mouth.
The eXciteOSA device was approved under the de novo premarket review pathway for new low- to moderate-risk devices. More information on the device is available online.
A version of this article first appeared on Medscape.com.
eXciteOSA (Signifier Medical Technologies) is a prescription-only, neuromuscular stimulation device designed to improve tongue muscle function, which, over time, can help prevent the tongue from collapsing backwards and obstructing the airway during sleep, the FDA said.
The eXciteOSA mouthpiece has four electrodes that deliver a series of electrical pulses with rest periods in between. Two electrodes are located above the tongue and two are located below the tongue.
The patient uses the device for 20 minutes once a day while awake for 6 weeks, and once a week thereafter. It is indicated for adults aged 18 and older with snoring and mild OSA.
OSA is marked by the recurring collapse of the upper airways during sleep, intermittently reducing or completely blocking airflow. Common symptoms include snoring, restless sleep and daytime sleepiness. Untreated OSA can lead to serious complications such as cardiovascular disease and cognitive and behavioral disorders.
Continuous positive airway pressure therapy, administered through a face mask that is worn while asleep, is a first-line treatment for OSA.
The eXciteOSA device “offers a new option for the thousands of individuals who experience snoring or mild sleep apnea,” Malvina Eydelman, MD, director, FDA Office of Ophthalmic, Anesthesia, Respiratory, ENT, and Dental Devices, said in a news release.
The FDA reviewed data on the safety and effectiveness of the eXciteOSA device in 115 patients with snoring, including 48 patients with snoring and mild OSA. All patients used the device for 20 minutes once a day for 6 weeks, then stopped using it for 2 weeks before they were reassessed.
Overall, the percentage of time spent snoring at levels louder than 40 decibels was reduced by more than 20% in 87 out of the 115 patients.
In the subset of patients with snoring and mild OSA, the average apnea-hypopnea index score was reduced by 48%, from 10.21 to 5.27, in 41 of 48 patients. Mild OSA is defined as an AHI score greater than 5 but less than 15.
The most common adverse events were excessive salivation, tongue or tooth discomfort, tongue tingling, dental filling sensitivity, metallic taste, gagging, and tight jaw.
Before using the eXciteOSA device, patients should receive a comprehensive dental examination, the FDA said.
The device should not be used in patients with pacemakers or implanted pacing leads, or women who are pregnant. The device is also contraindicated in patients with temporary or permanent implants, dental braces, intraoral metal prosthesis/restorations, or ulcerations in or around the mouth.
The eXciteOSA device was approved under the de novo premarket review pathway for new low- to moderate-risk devices. More information on the device is available online.
A version of this article first appeared on Medscape.com.
Family medicine: Who cares for the children?
according to new research.
This the latest sign of a long-term decline, and it “poses a broader concern for a specialty that defines itself by its comprehensive scope of practice,” said the study investigators of the Robert Graham Center in Washington, D.C., in a written statement. “This is consistent with previous Robert Graham Center research that reported a similar steady decline from 1992 to 2002.”
Self-reported data from family physicians indicate that 84.3% cared for children aged 18 years and under in 2017, compared with 83.0% in 2018, based on a cross-sectional analysis of data gathered from 11,674 family physicians who completed the practice demographic questionnaire attached to the American Board of Family Medicine’s certification exam in 2017 and 2018.
“This current trend is unsettling, because family physicians provide the majority of pediatric care in rural and pediatrically underserved areas of the United States,” study author Anuradha Jetty, MPH, and coauthors said in the statement.
The analysis also offers a snapshot of the current state of pediatric care offered by family physicians. In 2017 and 2018, FPs were more likely to see patients aged 5-18 years than those under age 5 (83.0% vs. 67.0%), with variation by age, location, and race/ethnicity, said Ms. Jetty and colleagues, in their new paper.
FPs aged 60 years and older were much less likely to see pediatric patients, compared with those under age 40: odds ratios were 0.52 for children under 5 and 0.56 for children 5-18. Regional variation was even more pronounced: Compared with their colleagues in the Southern states, Midwestern FPs were 1.52 times as likely to treat children aged 5-18 and 2.52 times as likely to treat children under age 5, the investigators reported.
Non-Hispanic Asian and Hispanic family physicians had significantly lower odds of seeing pediatric patients, relative to non-Hispanic White family physicians, as did FPs who were international medical graduates (OR, 0.74), compared with those who trained in the United States, they said.
“Female gender was associated with seeing pediatric patients in a prior study using 2006-2009 [American Board of Family Medicine] data; however, we found no such association in 2017-2018,” Ms. Jetty and associates noted.
“Many diverse drivers likely influence the findings we observed, including organizational, personal, social, and economic factors,” they wrote, suggesting that the policies of some HMOs “may limit scope of practice for employed physicians,” while those who practice in areas of low pediatrician density might “capitalize on a market opportunity ... more than physicians in pediatrician-saturated areas with greater competition for young patients.”
The overall shortage of primary pediatric care may be a matter of debate, the investigators said, but “there is undoubtedly significant variability in the regional supply of pediatric primary care physicians and thus areas where family physicians are needed to meet current pediatric workforce demand.”
The authors reported no conflicts.
according to new research.
This the latest sign of a long-term decline, and it “poses a broader concern for a specialty that defines itself by its comprehensive scope of practice,” said the study investigators of the Robert Graham Center in Washington, D.C., in a written statement. “This is consistent with previous Robert Graham Center research that reported a similar steady decline from 1992 to 2002.”
Self-reported data from family physicians indicate that 84.3% cared for children aged 18 years and under in 2017, compared with 83.0% in 2018, based on a cross-sectional analysis of data gathered from 11,674 family physicians who completed the practice demographic questionnaire attached to the American Board of Family Medicine’s certification exam in 2017 and 2018.
“This current trend is unsettling, because family physicians provide the majority of pediatric care in rural and pediatrically underserved areas of the United States,” study author Anuradha Jetty, MPH, and coauthors said in the statement.
The analysis also offers a snapshot of the current state of pediatric care offered by family physicians. In 2017 and 2018, FPs were more likely to see patients aged 5-18 years than those under age 5 (83.0% vs. 67.0%), with variation by age, location, and race/ethnicity, said Ms. Jetty and colleagues, in their new paper.
FPs aged 60 years and older were much less likely to see pediatric patients, compared with those under age 40: odds ratios were 0.52 for children under 5 and 0.56 for children 5-18. Regional variation was even more pronounced: Compared with their colleagues in the Southern states, Midwestern FPs were 1.52 times as likely to treat children aged 5-18 and 2.52 times as likely to treat children under age 5, the investigators reported.
Non-Hispanic Asian and Hispanic family physicians had significantly lower odds of seeing pediatric patients, relative to non-Hispanic White family physicians, as did FPs who were international medical graduates (OR, 0.74), compared with those who trained in the United States, they said.
“Female gender was associated with seeing pediatric patients in a prior study using 2006-2009 [American Board of Family Medicine] data; however, we found no such association in 2017-2018,” Ms. Jetty and associates noted.
“Many diverse drivers likely influence the findings we observed, including organizational, personal, social, and economic factors,” they wrote, suggesting that the policies of some HMOs “may limit scope of practice for employed physicians,” while those who practice in areas of low pediatrician density might “capitalize on a market opportunity ... more than physicians in pediatrician-saturated areas with greater competition for young patients.”
The overall shortage of primary pediatric care may be a matter of debate, the investigators said, but “there is undoubtedly significant variability in the regional supply of pediatric primary care physicians and thus areas where family physicians are needed to meet current pediatric workforce demand.”
The authors reported no conflicts.
according to new research.
This the latest sign of a long-term decline, and it “poses a broader concern for a specialty that defines itself by its comprehensive scope of practice,” said the study investigators of the Robert Graham Center in Washington, D.C., in a written statement. “This is consistent with previous Robert Graham Center research that reported a similar steady decline from 1992 to 2002.”
Self-reported data from family physicians indicate that 84.3% cared for children aged 18 years and under in 2017, compared with 83.0% in 2018, based on a cross-sectional analysis of data gathered from 11,674 family physicians who completed the practice demographic questionnaire attached to the American Board of Family Medicine’s certification exam in 2017 and 2018.
“This current trend is unsettling, because family physicians provide the majority of pediatric care in rural and pediatrically underserved areas of the United States,” study author Anuradha Jetty, MPH, and coauthors said in the statement.
The analysis also offers a snapshot of the current state of pediatric care offered by family physicians. In 2017 and 2018, FPs were more likely to see patients aged 5-18 years than those under age 5 (83.0% vs. 67.0%), with variation by age, location, and race/ethnicity, said Ms. Jetty and colleagues, in their new paper.
FPs aged 60 years and older were much less likely to see pediatric patients, compared with those under age 40: odds ratios were 0.52 for children under 5 and 0.56 for children 5-18. Regional variation was even more pronounced: Compared with their colleagues in the Southern states, Midwestern FPs were 1.52 times as likely to treat children aged 5-18 and 2.52 times as likely to treat children under age 5, the investigators reported.
Non-Hispanic Asian and Hispanic family physicians had significantly lower odds of seeing pediatric patients, relative to non-Hispanic White family physicians, as did FPs who were international medical graduates (OR, 0.74), compared with those who trained in the United States, they said.
“Female gender was associated with seeing pediatric patients in a prior study using 2006-2009 [American Board of Family Medicine] data; however, we found no such association in 2017-2018,” Ms. Jetty and associates noted.
“Many diverse drivers likely influence the findings we observed, including organizational, personal, social, and economic factors,” they wrote, suggesting that the policies of some HMOs “may limit scope of practice for employed physicians,” while those who practice in areas of low pediatrician density might “capitalize on a market opportunity ... more than physicians in pediatrician-saturated areas with greater competition for young patients.”
The overall shortage of primary pediatric care may be a matter of debate, the investigators said, but “there is undoubtedly significant variability in the regional supply of pediatric primary care physicians and thus areas where family physicians are needed to meet current pediatric workforce demand.”
The authors reported no conflicts.
FROM THE JOURNAL OF THE AMERICAN BOARD OF FAMILY MEDICINE
New child COVID-19 cases decline as total passes 3 million
New COVID-19 cases in children continue to drop each week, but the total number of cases has now surpassed 3 million since the start of the pandemic, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.
It was still enough, though, to bring the total to 3.03 million children infected with SARS-CoV-19 in the United States, the AAP and the CHA said in their weekly report.
The nation also hit a couple of other ignominious milestones. The cumulative rate of COVID-19 infection now stands at 4,030 per 100,000, so 4% of all children have been infected. Also, children represented 16.9% of all new cases for the week, which equals the highest proportion seen throughout the pandemic, based on data from health departments in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.
There have been 241 COVID-19–related deaths in children so far, with 14 reported during the week of Feb. 5-11. Kansas just recorded its first pediatric death, which leaves 10 states that have had no fatalities. Texas, with 39 deaths, has had more than any other state, among the 43 that are reporting mortality by age, the AAP/CHA report showed.
New COVID-19 cases in children continue to drop each week, but the total number of cases has now surpassed 3 million since the start of the pandemic, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.
It was still enough, though, to bring the total to 3.03 million children infected with SARS-CoV-19 in the United States, the AAP and the CHA said in their weekly report.
The nation also hit a couple of other ignominious milestones. The cumulative rate of COVID-19 infection now stands at 4,030 per 100,000, so 4% of all children have been infected. Also, children represented 16.9% of all new cases for the week, which equals the highest proportion seen throughout the pandemic, based on data from health departments in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.
There have been 241 COVID-19–related deaths in children so far, with 14 reported during the week of Feb. 5-11. Kansas just recorded its first pediatric death, which leaves 10 states that have had no fatalities. Texas, with 39 deaths, has had more than any other state, among the 43 that are reporting mortality by age, the AAP/CHA report showed.
New COVID-19 cases in children continue to drop each week, but the total number of cases has now surpassed 3 million since the start of the pandemic, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.
It was still enough, though, to bring the total to 3.03 million children infected with SARS-CoV-19 in the United States, the AAP and the CHA said in their weekly report.
The nation also hit a couple of other ignominious milestones. The cumulative rate of COVID-19 infection now stands at 4,030 per 100,000, so 4% of all children have been infected. Also, children represented 16.9% of all new cases for the week, which equals the highest proportion seen throughout the pandemic, based on data from health departments in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.
There have been 241 COVID-19–related deaths in children so far, with 14 reported during the week of Feb. 5-11. Kansas just recorded its first pediatric death, which leaves 10 states that have had no fatalities. Texas, with 39 deaths, has had more than any other state, among the 43 that are reporting mortality by age, the AAP/CHA report showed.