From the Editor

It is always judicious to avoid discussing religious or political issues because inevitably someone will be offended. As a lifetime member of the American Psychiatric Association, I adhere to its "Goldwater Rule," which proscribes the gratuitous diagnosis of any president absent of a formal face-to-face psychiatric evaluation. But it is perfectly permissible to express a psychiatric opinion about the contemporary national political scene.

Frankly, the status of the political arena has become ugly. This should not be surprising, given that at its core, politics is an unquenchable thirst for power, and Machiavelli is its anointed godfather. The current political zeitgeist of the country is becoming downright grotesque and spiteful. Although fierce political rivalry is widely accepted as a tradition to achieve the national goals promulgated by each party, what we are witnessing today is a veritable blood sport fueled by “hyper-partisanship,” where drawing blood, not promoting the public good, has become an undisguised intent.

The intensity of hyper-partisanship has engulfed the collective national psyche and is bordering on the “religification” of politics. What used to be reasonable political views have been transformed into irrefutable articles of faith that do not lend themselves to rational debate or productive compromise. The metastasis of social media into our daily lives over the past decade is catalyzing the venomous crossfire across the political divide that used to be passionate and civil, but recently has degenerated into a raucous cacophony of hateful speech. Thoughtful debate of issues that promote the public good is becoming scarce. Instead of effectively defending the validity of their arguments, extremists focus on spewing accusations and ad hominem insults. It is worrisome that both fringe groups tenaciously uphold fixed and extreme political positions, the tenets of which can never be challenged.

Psychiatrically, those extreme ideological positions appear to be consistent with Jasper’s criteria for a delusion (a belief with an unparalleled degree of subjective feeling of certainty that cannot be influenced by experience or arguments) or McHugh’s definition of an overvalued idea, which resembles an egosyntonic obsession that is relished, amplified, and defended. Given that extremism is not just a “folie à deux” shared by 2 individuals but by many individuals, it may qualify as a “folie en masse.”
 

Having a political orientation is perfectly normal, a healthy evidence of absence of indolent apathy. However, the unconstrained fervor of political extremism can be as psychologically unhealthy as lethargic passivity. A significant segment of the population may see some merit on both sides of the gaping political chasm, but they are appalled by the intransigence of political extremism, which has become an impediment to the constructive compromise that is vital for progress in politics and in all human interactions.

Beliefs are a transcendent human trait. Homo sapiens represent the only animal species endowed by evolution with a large prefrontal cortex that enables each of its members to harbor a belief system. It prompts me to propose that Descartes’ famous dictum “I think, therefore I am” be revised to “I believe, therefore I am human.” But while many beliefs are reasonable and anchored in reality, irrational beliefs are odd and ambiguous, ranging from superstitions and overvalued ideas to conspiracy theories and cults, which I wrote about a decade ago.¹ In fact, epidemiologic research studies have confirmed a high prevalence of subthreshold and pre-psychotic beliefs in the general population.^2-5 Thus, radical political partisanship falls on the extreme end of that continuum.

The zeitgeist generated by extreme partisanship is intellectually stunting and emotionally numbing. Psychiatrists may wonder what consequences the intense anger and antipathy and scarcity of compromise between the opposing parties will have for the country’s citizens. Although psychiatrists cannot repair the dysfunctional political fragmentation at the national level, we can help patients who may be negatively affected by the conflicts permeating the national scene when we read or watch the daily news.

Just as it is disturbing for children to watch their parents undermine each other by arguing ferociously and hurling insults, so it is for a populace aghast at how frenzied and intolerant their leaders and their extremist followers have become, failing to work together for the common good and adversely impacting the mental health zeitgeist.

It is always judicious to avoid discussing religious or political issues because inevitably someone will be offended. As a lifetime member of the American Psychiatric Association, I adhere to its "Goldwater Rule," which proscribes the gratuitous diagnosis of any president absent of a formal face-to-face psychiatric evaluation. But it is perfectly permissible to express a psychiatric opinion about the contemporary national political scene.

Frankly, the status of the political arena has become ugly. This should not be surprising, given that at its core, politics is an unquenchable thirst for power, and Machiavelli is its anointed godfather. The current political zeitgeist of the country is becoming downright grotesque and spiteful. Although fierce political rivalry is widely accepted as a tradition to achieve the national goals promulgated by each party, what we are witnessing today is a veritable blood sport fueled by “hyper-partisanship,” where drawing blood, not promoting the public good, has become an undisguised intent.

The intensity of hyper-partisanship has engulfed the collective national psyche and is bordering on the “religification” of politics. What used to be reasonable political views have been transformed into irrefutable articles of faith that do not lend themselves to rational debate or productive compromise. The metastasis of social media into our daily lives over the past decade is catalyzing the venomous crossfire across the political divide that used to be passionate and civil, but recently has degenerated into a raucous cacophony of hateful speech. Thoughtful debate of issues that promote the public good is becoming scarce. Instead of effectively defending the validity of their arguments, extremists focus on spewing accusations and ad hominem insults. It is worrisome that both fringe groups tenaciously uphold fixed and extreme political positions, the tenets of which can never be challenged.

Psychiatrically, those extreme ideological positions appear to be consistent with Jasper’s criteria for a delusion (a belief with an unparalleled degree of subjective feeling of certainty that cannot be influenced by experience or arguments) or McHugh’s definition of an overvalued idea, which resembles an egosyntonic obsession that is relished, amplified, and defended. Given that extremism is not just a “folie à deux” shared by 2 individuals but by many individuals, it may qualify as a “folie en masse.”
 

Having a political orientation is perfectly normal, a healthy evidence of absence of indolent apathy. However, the unconstrained fervor of political extremism can be as psychologically unhealthy as lethargic passivity. A significant segment of the population may see some merit on both sides of the gaping political chasm, but they are appalled by the intransigence of political extremism, which has become an impediment to the constructive compromise that is vital for progress in politics and in all human interactions.

Beliefs are a transcendent human trait. Homo sapiens represent the only animal species endowed by evolution with a large prefrontal cortex that enables each of its members to harbor a belief system. It prompts me to propose that Descartes’ famous dictum “I think, therefore I am” be revised to “I believe, therefore I am human.” But while many beliefs are reasonable and anchored in reality, irrational beliefs are odd and ambiguous, ranging from superstitions and overvalued ideas to conspiracy theories and cults, which I wrote about a decade ago.¹ In fact, epidemiologic research studies have confirmed a high prevalence of subthreshold and pre-psychotic beliefs in the general population.^2-5 Thus, radical political partisanship falls on the extreme end of that continuum.

The zeitgeist generated by extreme partisanship is intellectually stunting and emotionally numbing. Psychiatrists may wonder what consequences the intense anger and antipathy and scarcity of compromise between the opposing parties will have for the country’s citizens. Although psychiatrists cannot repair the dysfunctional political fragmentation at the national level, we can help patients who may be negatively affected by the conflicts permeating the national scene when we read or watch the daily news.

Just as it is disturbing for children to watch their parents undermine each other by arguing ferociously and hurling insults, so it is for a populace aghast at how frenzied and intolerant their leaders and their extremist followers have become, failing to work together for the common good and adversely impacting the mental health zeitgeist.

It is always judicious to avoid discussing religious or political issues because inevitably someone will be offended. As a lifetime member of the American Psychiatric Association, I adhere to its "Goldwater Rule," which proscribes the gratuitous diagnosis of any president absent of a formal face-to-face psychiatric evaluation. But it is perfectly permissible to express a psychiatric opinion about the contemporary national political scene.

Frankly, the status of the political arena has become ugly. This should not be surprising, given that at its core, politics is an unquenchable thirst for power, and Machiavelli is its anointed godfather. The current political zeitgeist of the country is becoming downright grotesque and spiteful. Although fierce political rivalry is widely accepted as a tradition to achieve the national goals promulgated by each party, what we are witnessing today is a veritable blood sport fueled by “hyper-partisanship,” where drawing blood, not promoting the public good, has become an undisguised intent.

The intensity of hyper-partisanship has engulfed the collective national psyche and is bordering on the “religification” of politics. What used to be reasonable political views have been transformed into irrefutable articles of faith that do not lend themselves to rational debate or productive compromise. The metastasis of social media into our daily lives over the past decade is catalyzing the venomous crossfire across the political divide that used to be passionate and civil, but recently has degenerated into a raucous cacophony of hateful speech. Thoughtful debate of issues that promote the public good is becoming scarce. Instead of effectively defending the validity of their arguments, extremists focus on spewing accusations and ad hominem insults. It is worrisome that both fringe groups tenaciously uphold fixed and extreme political positions, the tenets of which can never be challenged.

Psychiatrically, those extreme ideological positions appear to be consistent with Jasper’s criteria for a delusion (a belief with an unparalleled degree of subjective feeling of certainty that cannot be influenced by experience or arguments) or McHugh’s definition of an overvalued idea, which resembles an egosyntonic obsession that is relished, amplified, and defended. Given that extremism is not just a “folie à deux” shared by 2 individuals but by many individuals, it may qualify as a “folie en masse.”
 

Having a political orientation is perfectly normal, a healthy evidence of absence of indolent apathy. However, the unconstrained fervor of political extremism can be as psychologically unhealthy as lethargic passivity. A significant segment of the population may see some merit on both sides of the gaping political chasm, but they are appalled by the intransigence of political extremism, which has become an impediment to the constructive compromise that is vital for progress in politics and in all human interactions.

Beliefs are a transcendent human trait. Homo sapiens represent the only animal species endowed by evolution with a large prefrontal cortex that enables each of its members to harbor a belief system. It prompts me to propose that Descartes’ famous dictum “I think, therefore I am” be revised to “I believe, therefore I am human.” But while many beliefs are reasonable and anchored in reality, irrational beliefs are odd and ambiguous, ranging from superstitions and overvalued ideas to conspiracy theories and cults, which I wrote about a decade ago.¹ In fact, epidemiologic research studies have confirmed a high prevalence of subthreshold and pre-psychotic beliefs in the general population.^2-5 Thus, radical political partisanship falls on the extreme end of that continuum.

The zeitgeist generated by extreme partisanship is intellectually stunting and emotionally numbing. Psychiatrists may wonder what consequences the intense anger and antipathy and scarcity of compromise between the opposing parties will have for the country’s citizens. Although psychiatrists cannot repair the dysfunctional political fragmentation at the national level, we can help patients who may be negatively affected by the conflicts permeating the national scene when we read or watch the daily news.

Just as it is disturbing for children to watch their parents undermine each other by arguing ferociously and hurling insults, so it is for a populace aghast at how frenzied and intolerant their leaders and their extremist followers have become, failing to work together for the common good and adversely impacting the mental health zeitgeist.

For many years, the approach to the diagnosis of hypertension was straight-forward—multiple blood pressure (BP) measurements ≥140/90 mm Hg established the diagnosis of hypertension, a disease associated with an increased risk of adverse cardiovascular events, including myocardial infarction and stroke. For more than a decade, hypertension experts have argued that a BP ≥130/80 mm Hg should establish the diagnosis of hypertension. Many clinicians resisted the change because it would markedly increase the number of asymptomatic adults with the diagnosis, increasing the number needing treatment. However, the findings of the Systolic Blood Pressure Intervention Trial (SPRINT) and other observational studies have catalyzed the American College of Cardiology (ACC) and the American Heart Association (AHA) to redefine normal BP as <120/80 mm Hg.¹ This change will expand the diagnosis of hypertension to include up to 50% of American adults.¹ In addition, the new definition of normal BP will result in the greater use of lifestyle interventions and antihypertensive medications to achieve the new normal, a BP of <120/80 mm Hg.

The new definition of hypertension

The new definition of hypertension is of particular importance for people at risk for developing cardiovascular disease (CVD) ^1,2 and is summarized here.

• Normal BP: systolic BP (SBP) <120 mm Hg and diastolic BP (DBP) <80 mm Hg
• Elevated BP: SBP 120–129 mm Hg and DBP <80 mm Hg
• Stage 1 hypertension: SBP 130–139 mm Hg or DBP 80–89 mm Hg.
• Stage 2 hypertension: SBP ≥140 mm Hg or DBP ≥90 mm Hg.

The new definition of hypertension will markedly increase the number of mid-life adults eligible to be treated for hypertension. I summarize the approach to treating hypertension in this article.

For mid-life adults, a SBP of <120 mm Hg is better for the heart
The heart is a pump, and not surprisingly, if a pump can achieve its job at a lower rather than a higher pressure, it is likely to last longer. The SPRINT study clearly demonstrated that in elderly hypertensive adults, an SBP target of <120 mm Hg is associated with fewer deaths than a SBP in the range of 130 to 140 mm Hg.³

In the SPRINT trial, 9,361 people with a mean age, body mass index, and BP of 68 years, 30 kg/m² and 140/78 mm Hg, respectively, were randomly assigned to intensive treatment of SBP to a goal of <120 mm Hg or to a target of <140 mm Hg. After 1 year of treatment, the intensive treatment group had a mean SBP of 121 mm Hg and the standard treatment group had a mean SBP of 136 mm Hg. To achieve a SBP <120 mm Hg, most patients required 3 antihypertensive medications, in contrast to the 2 antihypertensive medications typically needed to achieve a SBP in the range of 130 to 140 mm Hg.

After a median of 3.3 years of follow-up, significantly fewer deaths occurred in the intensive treatment group than in the standard treatment group, including deaths from all causes (3.3% vs 4.5%, P = .003) and deaths from CVD (0.8% vs 1.4%; P = .005). In addition, the risk of developing heart failure was lower in the intensive treatment than in the standard treatment group (1.3% vs 2.1%, P = .002). There was no difference between the 2 groups in the risk of stroke (1.3% vs 1.5%, P = .50) or myocardial infarction (2.1% vs 2.5%, P = .19). The rate of syncope was higher in the intensive treatment group (2.3% vs 1.7% in the standard treatment group, P = .05).³ Self-reported mental and physical health and satisfaction with treatment was similar in both groups.⁴

The investigators concluded that among people at risk for CVD, targeting a SBP of <120 mm Hg as compared to <140 mm Hg resulted in lower rates of heart failure and death, two clinically meaningful endpoints.

Read about nonpharmacologic interventions and antihypertensive medications to treat hypertension.

Diet and exercise

Nonpharmacologic interventions, including diet and exercise, are recommended for all people with a BP >120/80 mm Hg. In most situations, antihypertensive medications are not necessary if the patient has elevated BP (SBP 120–129 mm Hg and DBP <80 mm Hg) or Stage 1 hypertension (SBP 130–139 mm Hg or DBP 80–89 mm Hg) and a 10-year CVD risk of less than 10% using the ACC/AHA cardiovascular risk calculator⁵ (see http://www.cvriskcalcula tor.com/). For people at low risk for CVD, nonpharmacologic interventions, including diet and exercise, are often sufficient treatment.

The Dietary Approaches to Stop Hypertension (DASH) diet emphasizes increasing consumption of fruits, vegetables, low-fat dairy, whole-grains, fish, poultry, and nuts and decreasing the consumption of red meats, sugary drinks, sweets, sodium, and saturated and trans-fats. In randomized trials, the DASH diet is associated with a reduction in BP of approximately 5 mm Hg systolic and 3 mm Hg diastolic.⁶ The DASH trial monitored weight changes and adjusted calorie intake to ensure a stabilized weight throughout the study. Hence, the positive effect of the DASH diet was observed in the absence of any weight loss. Weight loss also can decrease BP with every 1- to 2-lb weight loss, reducing SBP by approximately 1 mm Hg.⁷ Combining the DASH diet with a low-sodium diet is especially important in people with high sodium intake, and is reported to reduce SBP by 5 to 20 mm Hg.⁸ Reducing the consumption of alcohol can result in a reduction of SBP and DBP in the range of 3 and 2 mm Hg, respectively.⁹

Exercising for 40 minutes, 3 to 4 times per week is associated with a reduction of SBP and DBP of approximately 5 and 3 mm Hg, respectively.¹⁰ Although the studies are of low quality, meditation is reported to decrease SBP and DBP by 4 and 2 mm Hg, respectively.¹¹

Antihypertensive medications

For all mid-life adults with Stage 2hypertension (SBP ≥140 mm Hg or DBP ≥90 mm Hg) or with both clinical CVD and Stage 1 hypertension, antihypertensive medications are recommended.¹ For people with Stage 1 hypertension and a 10-year CVD risk of ≥10%, antihypertensive medications are recommended. The target BP is <130/80 mm Hg for most people.

The recommended antihypertensive medications include thiazide diuretics, calcium channel blockers (CCBs), angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs). Many patients with Stage 2 hypertension will need treatment with 2 agents of different classes to achieve a BP <130/80 mm Hg. Some experts believe that an optimal 2-agent regimen includes an ACE or ARB plus a CCB based on the results of the ACCOMPLISH trial.¹² In this trial, 11,506 adults with hypertension and at very high risk for CVD, were randomly assigned to treatment with an ACE inhibitor plus CCB or with an ACE inhibitor plus hydrochlorothiazide. The BP achieved in both groups was approximately 132/73 mm Hg. The study was stopped after 3 years because participants in the ACE/thiazide group had a higher rate of adverse cardiovascular events (myocardial infarction, stroke, or death) than those in the ACE/CCB group (11.8% vs 9.6%; hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.72–0.90; P<.001). Compared to the ACE/thiazide group, the ACE/CCB group had a significantly lower rate of fatal and nonfatal myocardial infarction (2.2% vs 2.8%; HR, 0.78; 95% CI, 0.62–0.99; P = .04) and a lower rate of death from cardiovascular causes (1.9% vs 2.3%; HR, 0.80; 95% CI, 0.62–1.03, P = .08).

Worldwide, approximately 1 billion adults have a SBP ≥140 mm Hg.¹³ In the United States, 32% of adult women have Stage 2 hypertension or are taking an antihypertensive medication (TABLE).¹ There is a generally linear relationship between increasing SBP and DBP and an increased risk of a cardiovascular event, including heart failure, myocardial infarction, and stroke. An increase of SBP of 20 mm Hg or DBP of 10 mm Hg above a baseline BP of 115/75 mm Hg doubles the risk of death from CVD.¹⁴ For adults at risk for CVD, intensive treatment of hypertension clearly reduces the risk of a life-changing cardiovascular event.

It will probably take many years for the new SBP target of <120 mm Hg to be fully accepted by clinicians and patients because, although achieving a SBP of <120 mm Hg will decrease cardiovascular events, it is a very difficult target to achieve, requiring treatment with 3 antihypertensive medications for most patients. The early diagnosis and intensive treatment of hypertension is challenging because it requires clinicians to initiate a multi-decade course of treatment of asymptomatic people with the goal of preventing a life-altering cardiovascular event, including stroke and myocardial infarction.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

For many years, the approach to the diagnosis of hypertension was straight-forward—multiple blood pressure (BP) measurements ≥140/90 mm Hg established the diagnosis of hypertension, a disease associated with an increased risk of adverse cardiovascular events, including myocardial infarction and stroke. For more than a decade, hypertension experts have argued that a BP ≥130/80 mm Hg should establish the diagnosis of hypertension. Many clinicians resisted the change because it would markedly increase the number of asymptomatic adults with the diagnosis, increasing the number needing treatment. However, the findings of the Systolic Blood Pressure Intervention Trial (SPRINT) and other observational studies have catalyzed the American College of Cardiology (ACC) and the American Heart Association (AHA) to redefine normal BP as <120/80 mm Hg.¹ This change will expand the diagnosis of hypertension to include up to 50% of American adults.¹ In addition, the new definition of normal BP will result in the greater use of lifestyle interventions and antihypertensive medications to achieve the new normal, a BP of <120/80 mm Hg.

The new definition of hypertension

The new definition of hypertension is of particular importance for people at risk for developing cardiovascular disease (CVD) ^1,2 and is summarized here.

• Normal BP: systolic BP (SBP) <120 mm Hg and diastolic BP (DBP) <80 mm Hg
• Elevated BP: SBP 120–129 mm Hg and DBP <80 mm Hg
• Stage 1 hypertension: SBP 130–139 mm Hg or DBP 80–89 mm Hg.
• Stage 2 hypertension: SBP ≥140 mm Hg or DBP ≥90 mm Hg.

The new definition of hypertension will markedly increase the number of mid-life adults eligible to be treated for hypertension. I summarize the approach to treating hypertension in this article.

For mid-life adults, a SBP of <120 mm Hg is better for the heart
The heart is a pump, and not surprisingly, if a pump can achieve its job at a lower rather than a higher pressure, it is likely to last longer. The SPRINT study clearly demonstrated that in elderly hypertensive adults, an SBP target of <120 mm Hg is associated with fewer deaths than a SBP in the range of 130 to 140 mm Hg.³

In the SPRINT trial, 9,361 people with a mean age, body mass index, and BP of 68 years, 30 kg/m² and 140/78 mm Hg, respectively, were randomly assigned to intensive treatment of SBP to a goal of <120 mm Hg or to a target of <140 mm Hg. After 1 year of treatment, the intensive treatment group had a mean SBP of 121 mm Hg and the standard treatment group had a mean SBP of 136 mm Hg. To achieve a SBP <120 mm Hg, most patients required 3 antihypertensive medications, in contrast to the 2 antihypertensive medications typically needed to achieve a SBP in the range of 130 to 140 mm Hg.

After a median of 3.3 years of follow-up, significantly fewer deaths occurred in the intensive treatment group than in the standard treatment group, including deaths from all causes (3.3% vs 4.5%, P = .003) and deaths from CVD (0.8% vs 1.4%; P = .005). In addition, the risk of developing heart failure was lower in the intensive treatment than in the standard treatment group (1.3% vs 2.1%, P = .002). There was no difference between the 2 groups in the risk of stroke (1.3% vs 1.5%, P = .50) or myocardial infarction (2.1% vs 2.5%, P = .19). The rate of syncope was higher in the intensive treatment group (2.3% vs 1.7% in the standard treatment group, P = .05).³ Self-reported mental and physical health and satisfaction with treatment was similar in both groups.⁴

The investigators concluded that among people at risk for CVD, targeting a SBP of <120 mm Hg as compared to <140 mm Hg resulted in lower rates of heart failure and death, two clinically meaningful endpoints.

Read about nonpharmacologic interventions and antihypertensive medications to treat hypertension.

Diet and exercise

Nonpharmacologic interventions, including diet and exercise, are recommended for all people with a BP >120/80 mm Hg. In most situations, antihypertensive medications are not necessary if the patient has elevated BP (SBP 120–129 mm Hg and DBP <80 mm Hg) or Stage 1 hypertension (SBP 130–139 mm Hg or DBP 80–89 mm Hg) and a 10-year CVD risk of less than 10% using the ACC/AHA cardiovascular risk calculator⁵ (see http://www.cvriskcalcula tor.com/). For people at low risk for CVD, nonpharmacologic interventions, including diet and exercise, are often sufficient treatment.

The Dietary Approaches to Stop Hypertension (DASH) diet emphasizes increasing consumption of fruits, vegetables, low-fat dairy, whole-grains, fish, poultry, and nuts and decreasing the consumption of red meats, sugary drinks, sweets, sodium, and saturated and trans-fats. In randomized trials, the DASH diet is associated with a reduction in BP of approximately 5 mm Hg systolic and 3 mm Hg diastolic.⁶ The DASH trial monitored weight changes and adjusted calorie intake to ensure a stabilized weight throughout the study. Hence, the positive effect of the DASH diet was observed in the absence of any weight loss. Weight loss also can decrease BP with every 1- to 2-lb weight loss, reducing SBP by approximately 1 mm Hg.⁷ Combining the DASH diet with a low-sodium diet is especially important in people with high sodium intake, and is reported to reduce SBP by 5 to 20 mm Hg.⁸ Reducing the consumption of alcohol can result in a reduction of SBP and DBP in the range of 3 and 2 mm Hg, respectively.⁹

Exercising for 40 minutes, 3 to 4 times per week is associated with a reduction of SBP and DBP of approximately 5 and 3 mm Hg, respectively.¹⁰ Although the studies are of low quality, meditation is reported to decrease SBP and DBP by 4 and 2 mm Hg, respectively.¹¹

Antihypertensive medications

For all mid-life adults with Stage 2hypertension (SBP ≥140 mm Hg or DBP ≥90 mm Hg) or with both clinical CVD and Stage 1 hypertension, antihypertensive medications are recommended.¹ For people with Stage 1 hypertension and a 10-year CVD risk of ≥10%, antihypertensive medications are recommended. The target BP is <130/80 mm Hg for most people.

The recommended antihypertensive medications include thiazide diuretics, calcium channel blockers (CCBs), angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs). Many patients with Stage 2 hypertension will need treatment with 2 agents of different classes to achieve a BP <130/80 mm Hg. Some experts believe that an optimal 2-agent regimen includes an ACE or ARB plus a CCB based on the results of the ACCOMPLISH trial.¹² In this trial, 11,506 adults with hypertension and at very high risk for CVD, were randomly assigned to treatment with an ACE inhibitor plus CCB or with an ACE inhibitor plus hydrochlorothiazide. The BP achieved in both groups was approximately 132/73 mm Hg. The study was stopped after 3 years because participants in the ACE/thiazide group had a higher rate of adverse cardiovascular events (myocardial infarction, stroke, or death) than those in the ACE/CCB group (11.8% vs 9.6%; hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.72–0.90; P<.001). Compared to the ACE/thiazide group, the ACE/CCB group had a significantly lower rate of fatal and nonfatal myocardial infarction (2.2% vs 2.8%; HR, 0.78; 95% CI, 0.62–0.99; P = .04) and a lower rate of death from cardiovascular causes (1.9% vs 2.3%; HR, 0.80; 95% CI, 0.62–1.03, P = .08).

Worldwide, approximately 1 billion adults have a SBP ≥140 mm Hg.¹³ In the United States, 32% of adult women have Stage 2 hypertension or are taking an antihypertensive medication (TABLE).¹ There is a generally linear relationship between increasing SBP and DBP and an increased risk of a cardiovascular event, including heart failure, myocardial infarction, and stroke. An increase of SBP of 20 mm Hg or DBP of 10 mm Hg above a baseline BP of 115/75 mm Hg doubles the risk of death from CVD.¹⁴ For adults at risk for CVD, intensive treatment of hypertension clearly reduces the risk of a life-changing cardiovascular event.

It will probably take many years for the new SBP target of <120 mm Hg to be fully accepted by clinicians and patients because, although achieving a SBP of <120 mm Hg will decrease cardiovascular events, it is a very difficult target to achieve, requiring treatment with 3 antihypertensive medications for most patients. The early diagnosis and intensive treatment of hypertension is challenging because it requires clinicians to initiate a multi-decade course of treatment of asymptomatic people with the goal of preventing a life-altering cardiovascular event, including stroke and myocardial infarction.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

For many years, the approach to the diagnosis of hypertension was straight-forward—multiple blood pressure (BP) measurements ≥140/90 mm Hg established the diagnosis of hypertension, a disease associated with an increased risk of adverse cardiovascular events, including myocardial infarction and stroke. For more than a decade, hypertension experts have argued that a BP ≥130/80 mm Hg should establish the diagnosis of hypertension. Many clinicians resisted the change because it would markedly increase the number of asymptomatic adults with the diagnosis, increasing the number needing treatment. However, the findings of the Systolic Blood Pressure Intervention Trial (SPRINT) and other observational studies have catalyzed the American College of Cardiology (ACC) and the American Heart Association (AHA) to redefine normal BP as <120/80 mm Hg.¹ This change will expand the diagnosis of hypertension to include up to 50% of American adults.¹ In addition, the new definition of normal BP will result in the greater use of lifestyle interventions and antihypertensive medications to achieve the new normal, a BP of <120/80 mm Hg.

The new definition of hypertension

The new definition of hypertension is of particular importance for people at risk for developing cardiovascular disease (CVD) ^1,2 and is summarized here.

• Normal BP: systolic BP (SBP) <120 mm Hg and diastolic BP (DBP) <80 mm Hg
• Elevated BP: SBP 120–129 mm Hg and DBP <80 mm Hg
• Stage 1 hypertension: SBP 130–139 mm Hg or DBP 80–89 mm Hg.
• Stage 2 hypertension: SBP ≥140 mm Hg or DBP ≥90 mm Hg.

The new definition of hypertension will markedly increase the number of mid-life adults eligible to be treated for hypertension. I summarize the approach to treating hypertension in this article.

For mid-life adults, a SBP of <120 mm Hg is better for the heart
The heart is a pump, and not surprisingly, if a pump can achieve its job at a lower rather than a higher pressure, it is likely to last longer. The SPRINT study clearly demonstrated that in elderly hypertensive adults, an SBP target of <120 mm Hg is associated with fewer deaths than a SBP in the range of 130 to 140 mm Hg.³

In the SPRINT trial, 9,361 people with a mean age, body mass index, and BP of 68 years, 30 kg/m² and 140/78 mm Hg, respectively, were randomly assigned to intensive treatment of SBP to a goal of <120 mm Hg or to a target of <140 mm Hg. After 1 year of treatment, the intensive treatment group had a mean SBP of 121 mm Hg and the standard treatment group had a mean SBP of 136 mm Hg. To achieve a SBP <120 mm Hg, most patients required 3 antihypertensive medications, in contrast to the 2 antihypertensive medications typically needed to achieve a SBP in the range of 130 to 140 mm Hg.

After a median of 3.3 years of follow-up, significantly fewer deaths occurred in the intensive treatment group than in the standard treatment group, including deaths from all causes (3.3% vs 4.5%, P = .003) and deaths from CVD (0.8% vs 1.4%; P = .005). In addition, the risk of developing heart failure was lower in the intensive treatment than in the standard treatment group (1.3% vs 2.1%, P = .002). There was no difference between the 2 groups in the risk of stroke (1.3% vs 1.5%, P = .50) or myocardial infarction (2.1% vs 2.5%, P = .19). The rate of syncope was higher in the intensive treatment group (2.3% vs 1.7% in the standard treatment group, P = .05).³ Self-reported mental and physical health and satisfaction with treatment was similar in both groups.⁴

The investigators concluded that among people at risk for CVD, targeting a SBP of <120 mm Hg as compared to <140 mm Hg resulted in lower rates of heart failure and death, two clinically meaningful endpoints.

Read about nonpharmacologic interventions and antihypertensive medications to treat hypertension.

Diet and exercise

Nonpharmacologic interventions, including diet and exercise, are recommended for all people with a BP >120/80 mm Hg. In most situations, antihypertensive medications are not necessary if the patient has elevated BP (SBP 120–129 mm Hg and DBP <80 mm Hg) or Stage 1 hypertension (SBP 130–139 mm Hg or DBP 80–89 mm Hg) and a 10-year CVD risk of less than 10% using the ACC/AHA cardiovascular risk calculator⁵ (see http://www.cvriskcalcula tor.com/). For people at low risk for CVD, nonpharmacologic interventions, including diet and exercise, are often sufficient treatment.

The Dietary Approaches to Stop Hypertension (DASH) diet emphasizes increasing consumption of fruits, vegetables, low-fat dairy, whole-grains, fish, poultry, and nuts and decreasing the consumption of red meats, sugary drinks, sweets, sodium, and saturated and trans-fats. In randomized trials, the DASH diet is associated with a reduction in BP of approximately 5 mm Hg systolic and 3 mm Hg diastolic.⁶ The DASH trial monitored weight changes and adjusted calorie intake to ensure a stabilized weight throughout the study. Hence, the positive effect of the DASH diet was observed in the absence of any weight loss. Weight loss also can decrease BP with every 1- to 2-lb weight loss, reducing SBP by approximately 1 mm Hg.⁷ Combining the DASH diet with a low-sodium diet is especially important in people with high sodium intake, and is reported to reduce SBP by 5 to 20 mm Hg.⁸ Reducing the consumption of alcohol can result in a reduction of SBP and DBP in the range of 3 and 2 mm Hg, respectively.⁹

Exercising for 40 minutes, 3 to 4 times per week is associated with a reduction of SBP and DBP of approximately 5 and 3 mm Hg, respectively.¹⁰ Although the studies are of low quality, meditation is reported to decrease SBP and DBP by 4 and 2 mm Hg, respectively.¹¹

Antihypertensive medications

For all mid-life adults with Stage 2hypertension (SBP ≥140 mm Hg or DBP ≥90 mm Hg) or with both clinical CVD and Stage 1 hypertension, antihypertensive medications are recommended.¹ For people with Stage 1 hypertension and a 10-year CVD risk of ≥10%, antihypertensive medications are recommended. The target BP is <130/80 mm Hg for most people.

The recommended antihypertensive medications include thiazide diuretics, calcium channel blockers (CCBs), angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs). Many patients with Stage 2 hypertension will need treatment with 2 agents of different classes to achieve a BP <130/80 mm Hg. Some experts believe that an optimal 2-agent regimen includes an ACE or ARB plus a CCB based on the results of the ACCOMPLISH trial.¹² In this trial, 11,506 adults with hypertension and at very high risk for CVD, were randomly assigned to treatment with an ACE inhibitor plus CCB or with an ACE inhibitor plus hydrochlorothiazide. The BP achieved in both groups was approximately 132/73 mm Hg. The study was stopped after 3 years because participants in the ACE/thiazide group had a higher rate of adverse cardiovascular events (myocardial infarction, stroke, or death) than those in the ACE/CCB group (11.8% vs 9.6%; hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.72–0.90; P<.001). Compared to the ACE/thiazide group, the ACE/CCB group had a significantly lower rate of fatal and nonfatal myocardial infarction (2.2% vs 2.8%; HR, 0.78; 95% CI, 0.62–0.99; P = .04) and a lower rate of death from cardiovascular causes (1.9% vs 2.3%; HR, 0.80; 95% CI, 0.62–1.03, P = .08).

Worldwide, approximately 1 billion adults have a SBP ≥140 mm Hg.¹³ In the United States, 32% of adult women have Stage 2 hypertension or are taking an antihypertensive medication (TABLE).¹ There is a generally linear relationship between increasing SBP and DBP and an increased risk of a cardiovascular event, including heart failure, myocardial infarction, and stroke. An increase of SBP of 20 mm Hg or DBP of 10 mm Hg above a baseline BP of 115/75 mm Hg doubles the risk of death from CVD.¹⁴ For adults at risk for CVD, intensive treatment of hypertension clearly reduces the risk of a life-changing cardiovascular event.

It will probably take many years for the new SBP target of <120 mm Hg to be fully accepted by clinicians and patients because, although achieving a SBP of <120 mm Hg will decrease cardiovascular events, it is a very difficult target to achieve, requiring treatment with 3 antihypertensive medications for most patients. The early diagnosis and intensive treatment of hypertension is challenging because it requires clinicians to initiate a multi-decade course of treatment of asymptomatic people with the goal of preventing a life-altering cardiovascular event, including stroke and myocardial infarction.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

While basking in the fading glow of the holidays, I have been reflecting on the dynamic of stressful professional lives of surgeons combined with the negativity local and world events engender that can push us toward burnout.

The holiday season is a time when people tend to engage in activities that have been shown to improve mood and outlook: connecting with old friends, sharing memories of a happier time, spending time with children and grandchildren, sitting around a warm fire, enjoying the sights and smells of bright decorations and fragrant candles, attending traditional holiday plays, concerts, and ballets. The holiday traditions, no matter what your ethnic or religious background, create community and warm feelings. The workweek may be shortened, people take a little time out, smile a bit more. For many of us, these activities can be a tonic.

At the same time, the days become shorter, colder, and grayer in most of North America. The normal frustrations of our day-to-day professional lives may seem more profound during the winter, and some experience SAD (seasonal affective disorder) or even burnout.

Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.

While basking in the fading glow of the holidays, I have been reflecting on the dynamic of stressful professional lives of surgeons combined with the negativity local and world events engender that can push us toward burnout.

The holiday season is a time when people tend to engage in activities that have been shown to improve mood and outlook: connecting with old friends, sharing memories of a happier time, spending time with children and grandchildren, sitting around a warm fire, enjoying the sights and smells of bright decorations and fragrant candles, attending traditional holiday plays, concerts, and ballets. The holiday traditions, no matter what your ethnic or religious background, create community and warm feelings. The workweek may be shortened, people take a little time out, smile a bit more. For many of us, these activities can be a tonic.

At the same time, the days become shorter, colder, and grayer in most of North America. The normal frustrations of our day-to-day professional lives may seem more profound during the winter, and some experience SAD (seasonal affective disorder) or even burnout.

Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.

While basking in the fading glow of the holidays, I have been reflecting on the dynamic of stressful professional lives of surgeons combined with the negativity local and world events engender that can push us toward burnout.

The holiday season is a time when people tend to engage in activities that have been shown to improve mood and outlook: connecting with old friends, sharing memories of a happier time, spending time with children and grandchildren, sitting around a warm fire, enjoying the sights and smells of bright decorations and fragrant candles, attending traditional holiday plays, concerts, and ballets. The holiday traditions, no matter what your ethnic or religious background, create community and warm feelings. The workweek may be shortened, people take a little time out, smile a bit more. For many of us, these activities can be a tonic.

At the same time, the days become shorter, colder, and grayer in most of North America. The normal frustrations of our day-to-day professional lives may seem more profound during the winter, and some experience SAD (seasonal affective disorder) or even burnout.

Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.

The mission of OBG Management is to enhance the quality of women’s health care and the professional development of obstetrician-gynecologists and all women’s health care clinicians. As we celebrate the beginning of our 30th anniversary year, we recommit to our mission by providing the highest quality of health information through both print and electronic portals.

OBG Management: Print and electronic portals for knowledge acquisition

Experienced clinicians acquire new knowledge and refresh established concepts through discussions with trusted colleagues and by reading journals and books that contain information relevant to their practice. A continuing trend in professional development is the accelerating transition from a reliance on print media (print journals and books) to electronic information delivery. Many clinicians continue to enjoy reading medical journals and magazines. ObGyns are no different; 96% report reading the print edition of medical journals.¹ At OBG Management we are committed to continue to mail you a monthly copy of our journal.

However, in the time-pressured setting of office- and hospital-based patient care, critical information is now frequently accessed through an electronic portal that is web based and focused on immediately answering a high priority question necessary for optimal patient care. OBG Management provides our community with rapid access to electronic versions of the journal and all previously published editorial material. Many web exclusives are found online as well, including audio and video techniques and commentary. The OBG Management website has a powerful search engine, which permits our readers to rapidly and conveniently access all previously published articles. In addition, our community members that have provided us with electronic contact information receive regular electronic communications about recently published literature (Clinical Edge), highly read articles and topical alerts from the journal, and MD-IQ quizzes to help review recent research and guidelines in an interactive medium.

The information base needed to practice medicine is massive and continues to grow rapidly. No single print textbook or journal can cover this vast information base. Libraries of print material are cumbersome to use and ordinarily not accessible at the site of patient care. Electronic portals are the only means of providing immediate access to all medical knowledge. Electronic technology enables the aggregation of vast amounts of information in a database that is rapidly accessible from anywhere, and new search technology is making it easier to quickly locate the information you need.

The next frontier in medical information exchange is the application of artificial intelligence to cull “answers” from the vast aggregation of data. By combining all available medical information and artificial intelligence processes, in the near future, clinicians will be able to instantaneously get an answer to a question they have about how to care for a specific patient. A decade ago, when a question was entered into an Internet search engine, the response was typically a list of potential websites where the answer might be located. In the past few years, with the integration of huge databases and artificial intelligence, some advanced search engines now provide a specific answer to a question, followed by a list of relevant websites. For example, if you enter this question: “What countries have the greatest number of people?” into the Google search tool, in less than 1 second a direct answer is provided: “China has the world’s largest population (1.4 billion), followed by India (1.3 billion). The next most populous nations—the United States, Indonesia, Brazil and Pakistan—combined have less than 1 billion people.” The next step in medical information communication will be the deployment of artificial intelligence systems that can directly answer a query from a clinician about a specific patient.

Our distinguished Editorial Board and authors—the heart and mind of OBG Management

The editorial team at OBG Management is proud to work with the distinguished medical leaders who write our articles and serve on our Editorial Board. The guidance we receive from our Board and the expert editorial material generated by our authors is critical to advancing the quality of OBG Management. Our Board members and authors care deeply about improving women’s health and closing gaps between current and optimal practice. Our Board members and authors are truly expert clinicians with vast experience. Our readers can have great confidence in their recommendations.

Improving clinician wellness and resilience and reducing burnout

Clinicians throughout the world are reporting decreased levels of professional fulfillment and increased levels of burnout.^2–4 This epidemic is likely caused by many factors, including the deployment of poorly designed electronic health systems, the administrative guidance for clinicians to work faster with fewer support staff, increasing administrative and secretarial burden on clinicians, and institutional constraints on clinician autonomy. Many of these problems only can be addressed at the level of the health system, but some are in the control of individual clinicians.

In the upcoming years, OBG Management will prioritize deepening the knowledge about the factors that support clinician wellness and share approaches that may help you to improve your wellness and resilience and reduce your experience of burnout. Recent research reports that increasing your focus on showing gratitude to other important people in your life will enhance your wellness. In a study completed in a health care setting, 102 clinicians were randomly assigned to 1 of 3 groups: 1) write about gratitude and work, 2) write about hassles and work, or 3) do not write about work. Those assigned to the 2 writing groups were instructed to write on their topic twice weekly for 4 weeks. At the end of the study the clinicians assigned to the gratitude writing assignment reported less stress and fewer depressive symptoms than the clinicians assigned to the other 2 groups.⁵ The investigators concluded that among clinicians a structured exercise to focus thoughts and feelings on expressions of gratitude is an effective approach to reduce stress and depressive symptoms. I recommend that you complete “the gratitude exercise.”

The future of obstetrics and gynecology is bright

Medical students are electing to pursue a career in obstetrics and gynecology in record numbers. The students entering the field and the residents currently in training are superbly prepared and have demonstrated their commitment to advancing reproductive health by experiences in advocacy, research, and community service. We need to ensure that these super-star young physicians are able to have a 40-year career that is productive and fulfilling.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

The mission of OBG Management is to enhance the quality of women’s health care and the professional development of obstetrician-gynecologists and all women’s health care clinicians. As we celebrate the beginning of our 30th anniversary year, we recommit to our mission by providing the highest quality of health information through both print and electronic portals.

OBG Management: Print and electronic portals for knowledge acquisition

Experienced clinicians acquire new knowledge and refresh established concepts through discussions with trusted colleagues and by reading journals and books that contain information relevant to their practice. A continuing trend in professional development is the accelerating transition from a reliance on print media (print journals and books) to electronic information delivery. Many clinicians continue to enjoy reading medical journals and magazines. ObGyns are no different; 96% report reading the print edition of medical journals.¹ At OBG Management we are committed to continue to mail you a monthly copy of our journal.

However, in the time-pressured setting of office- and hospital-based patient care, critical information is now frequently accessed through an electronic portal that is web based and focused on immediately answering a high priority question necessary for optimal patient care. OBG Management provides our community with rapid access to electronic versions of the journal and all previously published editorial material. Many web exclusives are found online as well, including audio and video techniques and commentary. The OBG Management website has a powerful search engine, which permits our readers to rapidly and conveniently access all previously published articles. In addition, our community members that have provided us with electronic contact information receive regular electronic communications about recently published literature (Clinical Edge), highly read articles and topical alerts from the journal, and MD-IQ quizzes to help review recent research and guidelines in an interactive medium.

The information base needed to practice medicine is massive and continues to grow rapidly. No single print textbook or journal can cover this vast information base. Libraries of print material are cumbersome to use and ordinarily not accessible at the site of patient care. Electronic portals are the only means of providing immediate access to all medical knowledge. Electronic technology enables the aggregation of vast amounts of information in a database that is rapidly accessible from anywhere, and new search technology is making it easier to quickly locate the information you need.

The next frontier in medical information exchange is the application of artificial intelligence to cull “answers” from the vast aggregation of data. By combining all available medical information and artificial intelligence processes, in the near future, clinicians will be able to instantaneously get an answer to a question they have about how to care for a specific patient. A decade ago, when a question was entered into an Internet search engine, the response was typically a list of potential websites where the answer might be located. In the past few years, with the integration of huge databases and artificial intelligence, some advanced search engines now provide a specific answer to a question, followed by a list of relevant websites. For example, if you enter this question: “What countries have the greatest number of people?” into the Google search tool, in less than 1 second a direct answer is provided: “China has the world’s largest population (1.4 billion), followed by India (1.3 billion). The next most populous nations—the United States, Indonesia, Brazil and Pakistan—combined have less than 1 billion people.” The next step in medical information communication will be the deployment of artificial intelligence systems that can directly answer a query from a clinician about a specific patient.

Our distinguished Editorial Board and authors—the heart and mind of OBG Management

The editorial team at OBG Management is proud to work with the distinguished medical leaders who write our articles and serve on our Editorial Board. The guidance we receive from our Board and the expert editorial material generated by our authors is critical to advancing the quality of OBG Management. Our Board members and authors care deeply about improving women’s health and closing gaps between current and optimal practice. Our Board members and authors are truly expert clinicians with vast experience. Our readers can have great confidence in their recommendations.

Improving clinician wellness and resilience and reducing burnout

Clinicians throughout the world are reporting decreased levels of professional fulfillment and increased levels of burnout.^2–4 This epidemic is likely caused by many factors, including the deployment of poorly designed electronic health systems, the administrative guidance for clinicians to work faster with fewer support staff, increasing administrative and secretarial burden on clinicians, and institutional constraints on clinician autonomy. Many of these problems only can be addressed at the level of the health system, but some are in the control of individual clinicians.

In the upcoming years, OBG Management will prioritize deepening the knowledge about the factors that support clinician wellness and share approaches that may help you to improve your wellness and resilience and reduce your experience of burnout. Recent research reports that increasing your focus on showing gratitude to other important people in your life will enhance your wellness. In a study completed in a health care setting, 102 clinicians were randomly assigned to 1 of 3 groups: 1) write about gratitude and work, 2) write about hassles and work, or 3) do not write about work. Those assigned to the 2 writing groups were instructed to write on their topic twice weekly for 4 weeks. At the end of the study the clinicians assigned to the gratitude writing assignment reported less stress and fewer depressive symptoms than the clinicians assigned to the other 2 groups.⁵ The investigators concluded that among clinicians a structured exercise to focus thoughts and feelings on expressions of gratitude is an effective approach to reduce stress and depressive symptoms. I recommend that you complete “the gratitude exercise.”

The future of obstetrics and gynecology is bright

Medical students are electing to pursue a career in obstetrics and gynecology in record numbers. The students entering the field and the residents currently in training are superbly prepared and have demonstrated their commitment to advancing reproductive health by experiences in advocacy, research, and community service. We need to ensure that these super-star young physicians are able to have a 40-year career that is productive and fulfilling.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

The mission of OBG Management is to enhance the quality of women’s health care and the professional development of obstetrician-gynecologists and all women’s health care clinicians. As we celebrate the beginning of our 30th anniversary year, we recommit to our mission by providing the highest quality of health information through both print and electronic portals.

OBG Management: Print and electronic portals for knowledge acquisition

Experienced clinicians acquire new knowledge and refresh established concepts through discussions with trusted colleagues and by reading journals and books that contain information relevant to their practice. A continuing trend in professional development is the accelerating transition from a reliance on print media (print journals and books) to electronic information delivery. Many clinicians continue to enjoy reading medical journals and magazines. ObGyns are no different; 96% report reading the print edition of medical journals.¹ At OBG Management we are committed to continue to mail you a monthly copy of our journal.

However, in the time-pressured setting of office- and hospital-based patient care, critical information is now frequently accessed through an electronic portal that is web based and focused on immediately answering a high priority question necessary for optimal patient care. OBG Management provides our community with rapid access to electronic versions of the journal and all previously published editorial material. Many web exclusives are found online as well, including audio and video techniques and commentary. The OBG Management website has a powerful search engine, which permits our readers to rapidly and conveniently access all previously published articles. In addition, our community members that have provided us with electronic contact information receive regular electronic communications about recently published literature (Clinical Edge), highly read articles and topical alerts from the journal, and MD-IQ quizzes to help review recent research and guidelines in an interactive medium.

The information base needed to practice medicine is massive and continues to grow rapidly. No single print textbook or journal can cover this vast information base. Libraries of print material are cumbersome to use and ordinarily not accessible at the site of patient care. Electronic portals are the only means of providing immediate access to all medical knowledge. Electronic technology enables the aggregation of vast amounts of information in a database that is rapidly accessible from anywhere, and new search technology is making it easier to quickly locate the information you need.

The next frontier in medical information exchange is the application of artificial intelligence to cull “answers” from the vast aggregation of data. By combining all available medical information and artificial intelligence processes, in the near future, clinicians will be able to instantaneously get an answer to a question they have about how to care for a specific patient. A decade ago, when a question was entered into an Internet search engine, the response was typically a list of potential websites where the answer might be located. In the past few years, with the integration of huge databases and artificial intelligence, some advanced search engines now provide a specific answer to a question, followed by a list of relevant websites. For example, if you enter this question: “What countries have the greatest number of people?” into the Google search tool, in less than 1 second a direct answer is provided: “China has the world’s largest population (1.4 billion), followed by India (1.3 billion). The next most populous nations—the United States, Indonesia, Brazil and Pakistan—combined have less than 1 billion people.” The next step in medical information communication will be the deployment of artificial intelligence systems that can directly answer a query from a clinician about a specific patient.

Our distinguished Editorial Board and authors—the heart and mind of OBG Management

The editorial team at OBG Management is proud to work with the distinguished medical leaders who write our articles and serve on our Editorial Board. The guidance we receive from our Board and the expert editorial material generated by our authors is critical to advancing the quality of OBG Management. Our Board members and authors care deeply about improving women’s health and closing gaps between current and optimal practice. Our Board members and authors are truly expert clinicians with vast experience. Our readers can have great confidence in their recommendations.

Improving clinician wellness and resilience and reducing burnout

Clinicians throughout the world are reporting decreased levels of professional fulfillment and increased levels of burnout.^2–4 This epidemic is likely caused by many factors, including the deployment of poorly designed electronic health systems, the administrative guidance for clinicians to work faster with fewer support staff, increasing administrative and secretarial burden on clinicians, and institutional constraints on clinician autonomy. Many of these problems only can be addressed at the level of the health system, but some are in the control of individual clinicians.

In the upcoming years, OBG Management will prioritize deepening the knowledge about the factors that support clinician wellness and share approaches that may help you to improve your wellness and resilience and reduce your experience of burnout. Recent research reports that increasing your focus on showing gratitude to other important people in your life will enhance your wellness. In a study completed in a health care setting, 102 clinicians were randomly assigned to 1 of 3 groups: 1) write about gratitude and work, 2) write about hassles and work, or 3) do not write about work. Those assigned to the 2 writing groups were instructed to write on their topic twice weekly for 4 weeks. At the end of the study the clinicians assigned to the gratitude writing assignment reported less stress and fewer depressive symptoms than the clinicians assigned to the other 2 groups.⁵ The investigators concluded that among clinicians a structured exercise to focus thoughts and feelings on expressions of gratitude is an effective approach to reduce stress and depressive symptoms. I recommend that you complete “the gratitude exercise.”

The future of obstetrics and gynecology is bright

Medical students are electing to pursue a career in obstetrics and gynecology in record numbers. The students entering the field and the residents currently in training are superbly prepared and have demonstrated their commitment to advancing reproductive health by experiences in advocacy, research, and community service. We need to ensure that these super-star young physicians are able to have a 40-year career that is productive and fulfilling.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“But no perfection is so absolute,

That some impurity doth not pollute.”

– William Shakespeare

While lounging in the ivory tower of academia, we frequently find ourselves condemning the peasantry who fail to grasp limitations of clinical trials. We deride the ignorant masses who insist on flaunting the inclusion criteria of the latest study and extrapolate the results to the ineligible patient sitting in front of them. The disrespect heaped on the “referring doctor” for treating their patients in the absence of evidence from prospective, randomized, multi-institutional trials is routine in conference rooms across the National Cancer Institute’s designated cancer centers.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

“But no perfection is so absolute,

That some impurity doth not pollute.”

– William Shakespeare

While lounging in the ivory tower of academia, we frequently find ourselves condemning the peasantry who fail to grasp limitations of clinical trials. We deride the ignorant masses who insist on flaunting the inclusion criteria of the latest study and extrapolate the results to the ineligible patient sitting in front of them. The disrespect heaped on the “referring doctor” for treating their patients in the absence of evidence from prospective, randomized, multi-institutional trials is routine in conference rooms across the National Cancer Institute’s designated cancer centers.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

“But no perfection is so absolute,

That some impurity doth not pollute.”

– William Shakespeare

While lounging in the ivory tower of academia, we frequently find ourselves condemning the peasantry who fail to grasp limitations of clinical trials. We deride the ignorant masses who insist on flaunting the inclusion criteria of the latest study and extrapolate the results to the ineligible patient sitting in front of them. The disrespect heaped on the “referring doctor” for treating their patients in the absence of evidence from prospective, randomized, multi-institutional trials is routine in conference rooms across the National Cancer Institute’s designated cancer centers.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].