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Cardiologist sues hospital, claims he was fired in retaliation
alleging that he was fired and maligned after raising concerns about poorly performed surgeries and poor ethical practices at the hospital.
Dr. Zelman, from Barnstable, Mass., has been affiliated with Cape Cod Hospital in Hyannis, Mass., for more than 30 years. He helped found the hospital’s Heart and Vascular Institute and has served as its medical director since 2018.
In his lawsuit filed Dec. 6, Dr. Zelman alleges that the defendants, under Mr. Lauf’s leadership, “placed profit above all else, including by prioritizing revenue generation over patient safety and public health.”
Dr. Zelman says the defendants supported him “to the extent his actions were profitable.”
Yet, when he raised patient safety concerns that harmed that bottom line, Dr. Zelman says the defendants retaliated against him, including by threatening his career and reputation and unlawfully terminating his employment with the hospital.
The complaint notes Dr. Zelman is bringing this action “to recover damages for violations of the Massachusetts Healthcare Provider Whistleblower Statute ... as well as for breach of contract and common law claims.”
Dr. Zelman’s complaint alleges the defendants refused to adequately address the “dangerous care and violations of the professional standards of practice” that he reported, “resulting in harmful and tragic consequences.”
It also alleges Mr. Lauf restricted the use of a cerebral protection device used in patients undergoing transcatheter aortic-valve replacement (TAVR) deemed to be at high risk for periprocedural stroke to only those patients whose insurance reimbursed at higher rates.
Dr. Zelman says he objected to this prohibition “in accordance with his contractual and ethical obligations to ensure treatment of patients without regard to their ability to pay.”
Dr. Zelman’s lawsuit further alleges that Mr. Lauf launched a “trumped-up” and “baseless, biased, and retaliatory sham” investigation against him.
In a statement sent to the Boston Globe, Cape Cod Hospital denied Dr. Zelman’s claims that the cardiologist was retaliated against for raising patient safety issues, or that the hospital didn’t take action to improve cardiac care at the facility.
Voiced concerns
In a statement sent to this news organization, Dr. Zelman, now in private practice, said, “Over the past 25 years, I have been instrumental in bringing advanced cardiac care to Cape Cod. My commitment has always been to delivering the same quality outcomes and safety as the academic centers in Boston.
“Unfortunately, over the past 5 years, there has been inadequate oversight by the hospital administration and problems have occurred that in my opinion have led to serious patient consequences,” Dr. Zelman stated.
He said he has “voiced concerns over several years and they have been ignored.”
He added that Cape Cod Hospital offered him a million-dollar contract as long as he agreed to immediately issue a written statement endorsing the quality and safety of the cardiac surgical program that no longer exists.
“No amount of money was going to buy my silence,” Dr. Zelman told this news organization.
In his lawsuit, Dr. Zelman is seeking an undisclosed amount in damages, including back and front pay, lost benefits, physical and emotional distress, and attorneys’ fees.
This news organization reached out to Cape Cod Hospital for comment but has not yet received a response.
A version of this article first appeared on Medscape.com.
alleging that he was fired and maligned after raising concerns about poorly performed surgeries and poor ethical practices at the hospital.
Dr. Zelman, from Barnstable, Mass., has been affiliated with Cape Cod Hospital in Hyannis, Mass., for more than 30 years. He helped found the hospital’s Heart and Vascular Institute and has served as its medical director since 2018.
In his lawsuit filed Dec. 6, Dr. Zelman alleges that the defendants, under Mr. Lauf’s leadership, “placed profit above all else, including by prioritizing revenue generation over patient safety and public health.”
Dr. Zelman says the defendants supported him “to the extent his actions were profitable.”
Yet, when he raised patient safety concerns that harmed that bottom line, Dr. Zelman says the defendants retaliated against him, including by threatening his career and reputation and unlawfully terminating his employment with the hospital.
The complaint notes Dr. Zelman is bringing this action “to recover damages for violations of the Massachusetts Healthcare Provider Whistleblower Statute ... as well as for breach of contract and common law claims.”
Dr. Zelman’s complaint alleges the defendants refused to adequately address the “dangerous care and violations of the professional standards of practice” that he reported, “resulting in harmful and tragic consequences.”
It also alleges Mr. Lauf restricted the use of a cerebral protection device used in patients undergoing transcatheter aortic-valve replacement (TAVR) deemed to be at high risk for periprocedural stroke to only those patients whose insurance reimbursed at higher rates.
Dr. Zelman says he objected to this prohibition “in accordance with his contractual and ethical obligations to ensure treatment of patients without regard to their ability to pay.”
Dr. Zelman’s lawsuit further alleges that Mr. Lauf launched a “trumped-up” and “baseless, biased, and retaliatory sham” investigation against him.
In a statement sent to the Boston Globe, Cape Cod Hospital denied Dr. Zelman’s claims that the cardiologist was retaliated against for raising patient safety issues, or that the hospital didn’t take action to improve cardiac care at the facility.
Voiced concerns
In a statement sent to this news organization, Dr. Zelman, now in private practice, said, “Over the past 25 years, I have been instrumental in bringing advanced cardiac care to Cape Cod. My commitment has always been to delivering the same quality outcomes and safety as the academic centers in Boston.
“Unfortunately, over the past 5 years, there has been inadequate oversight by the hospital administration and problems have occurred that in my opinion have led to serious patient consequences,” Dr. Zelman stated.
He said he has “voiced concerns over several years and they have been ignored.”
He added that Cape Cod Hospital offered him a million-dollar contract as long as he agreed to immediately issue a written statement endorsing the quality and safety of the cardiac surgical program that no longer exists.
“No amount of money was going to buy my silence,” Dr. Zelman told this news organization.
In his lawsuit, Dr. Zelman is seeking an undisclosed amount in damages, including back and front pay, lost benefits, physical and emotional distress, and attorneys’ fees.
This news organization reached out to Cape Cod Hospital for comment but has not yet received a response.
A version of this article first appeared on Medscape.com.
alleging that he was fired and maligned after raising concerns about poorly performed surgeries and poor ethical practices at the hospital.
Dr. Zelman, from Barnstable, Mass., has been affiliated with Cape Cod Hospital in Hyannis, Mass., for more than 30 years. He helped found the hospital’s Heart and Vascular Institute and has served as its medical director since 2018.
In his lawsuit filed Dec. 6, Dr. Zelman alleges that the defendants, under Mr. Lauf’s leadership, “placed profit above all else, including by prioritizing revenue generation over patient safety and public health.”
Dr. Zelman says the defendants supported him “to the extent his actions were profitable.”
Yet, when he raised patient safety concerns that harmed that bottom line, Dr. Zelman says the defendants retaliated against him, including by threatening his career and reputation and unlawfully terminating his employment with the hospital.
The complaint notes Dr. Zelman is bringing this action “to recover damages for violations of the Massachusetts Healthcare Provider Whistleblower Statute ... as well as for breach of contract and common law claims.”
Dr. Zelman’s complaint alleges the defendants refused to adequately address the “dangerous care and violations of the professional standards of practice” that he reported, “resulting in harmful and tragic consequences.”
It also alleges Mr. Lauf restricted the use of a cerebral protection device used in patients undergoing transcatheter aortic-valve replacement (TAVR) deemed to be at high risk for periprocedural stroke to only those patients whose insurance reimbursed at higher rates.
Dr. Zelman says he objected to this prohibition “in accordance with his contractual and ethical obligations to ensure treatment of patients without regard to their ability to pay.”
Dr. Zelman’s lawsuit further alleges that Mr. Lauf launched a “trumped-up” and “baseless, biased, and retaliatory sham” investigation against him.
In a statement sent to the Boston Globe, Cape Cod Hospital denied Dr. Zelman’s claims that the cardiologist was retaliated against for raising patient safety issues, or that the hospital didn’t take action to improve cardiac care at the facility.
Voiced concerns
In a statement sent to this news organization, Dr. Zelman, now in private practice, said, “Over the past 25 years, I have been instrumental in bringing advanced cardiac care to Cape Cod. My commitment has always been to delivering the same quality outcomes and safety as the academic centers in Boston.
“Unfortunately, over the past 5 years, there has been inadequate oversight by the hospital administration and problems have occurred that in my opinion have led to serious patient consequences,” Dr. Zelman stated.
He said he has “voiced concerns over several years and they have been ignored.”
He added that Cape Cod Hospital offered him a million-dollar contract as long as he agreed to immediately issue a written statement endorsing the quality and safety of the cardiac surgical program that no longer exists.
“No amount of money was going to buy my silence,” Dr. Zelman told this news organization.
In his lawsuit, Dr. Zelman is seeking an undisclosed amount in damages, including back and front pay, lost benefits, physical and emotional distress, and attorneys’ fees.
This news organization reached out to Cape Cod Hospital for comment but has not yet received a response.
A version of this article first appeared on Medscape.com.
Bempedoic acid cuts CV risk in the statin-intolerant: CLEAR top-line results
The randomized, placebo-controlled CLEAR Outcomes trial has shown a significant reduction in risk for a composite cardiovascular (CV) endpoint among its patients treated with the lipid-lowering agent bempedoic acid (Nexletol), the drug’s owner, Esperion, announced today.
The trial marks the first time an ATP-citrate lyase inhibitor has shown significant and “clinically meaningful” benefit for patients not adequately managed with standard lipid-modifying agents, Esperion president and CEO Sheldon Koenig said in a press release.
The brief statement provided only top-line results, without P values or other evidence of the magnitude of benefit in the active-therapy group. The company expects to present more complete results “at a key medical conference in the first quarter of 2023.”
CLEAR Outcomes had entered 14,014 patients with a history of or at high risk for CV disease events, elevated low-density lipoprotein cholesterol (LDL-C) levels, and demonstrated intolerance to at least two statins.
They were randomly assigned to bempedoic acid 180 mg once daily or placebo and followed for the primary endpoint of CV death, nonfatal myocardial infarction, nonfatal stroke, or coronary revascularization. The trial, conducted in 32 countries, launched in December 2016.
Bempedoic acid is currently approved for adults with heterozygous familial hypercholesterolemia or established atherosclerotic cardiovascular disease on maximally tolerated statins who require additional LDL-C lowering, the company states.
Concomitant use of bempedoic acid with simvastatin or pravastatin, the press release says, may lead to increased statin concentrations and risk for “simvastatin- or pravastatin-related myopathy.” Therefore, “use with greater than 20 mg of simvastatin or 40 mg of pravastatin should be avoided.”
A version of this article first appeared on Medscape.com.
The randomized, placebo-controlled CLEAR Outcomes trial has shown a significant reduction in risk for a composite cardiovascular (CV) endpoint among its patients treated with the lipid-lowering agent bempedoic acid (Nexletol), the drug’s owner, Esperion, announced today.
The trial marks the first time an ATP-citrate lyase inhibitor has shown significant and “clinically meaningful” benefit for patients not adequately managed with standard lipid-modifying agents, Esperion president and CEO Sheldon Koenig said in a press release.
The brief statement provided only top-line results, without P values or other evidence of the magnitude of benefit in the active-therapy group. The company expects to present more complete results “at a key medical conference in the first quarter of 2023.”
CLEAR Outcomes had entered 14,014 patients with a history of or at high risk for CV disease events, elevated low-density lipoprotein cholesterol (LDL-C) levels, and demonstrated intolerance to at least two statins.
They were randomly assigned to bempedoic acid 180 mg once daily or placebo and followed for the primary endpoint of CV death, nonfatal myocardial infarction, nonfatal stroke, or coronary revascularization. The trial, conducted in 32 countries, launched in December 2016.
Bempedoic acid is currently approved for adults with heterozygous familial hypercholesterolemia or established atherosclerotic cardiovascular disease on maximally tolerated statins who require additional LDL-C lowering, the company states.
Concomitant use of bempedoic acid with simvastatin or pravastatin, the press release says, may lead to increased statin concentrations and risk for “simvastatin- or pravastatin-related myopathy.” Therefore, “use with greater than 20 mg of simvastatin or 40 mg of pravastatin should be avoided.”
A version of this article first appeared on Medscape.com.
The randomized, placebo-controlled CLEAR Outcomes trial has shown a significant reduction in risk for a composite cardiovascular (CV) endpoint among its patients treated with the lipid-lowering agent bempedoic acid (Nexletol), the drug’s owner, Esperion, announced today.
The trial marks the first time an ATP-citrate lyase inhibitor has shown significant and “clinically meaningful” benefit for patients not adequately managed with standard lipid-modifying agents, Esperion president and CEO Sheldon Koenig said in a press release.
The brief statement provided only top-line results, without P values or other evidence of the magnitude of benefit in the active-therapy group. The company expects to present more complete results “at a key medical conference in the first quarter of 2023.”
CLEAR Outcomes had entered 14,014 patients with a history of or at high risk for CV disease events, elevated low-density lipoprotein cholesterol (LDL-C) levels, and demonstrated intolerance to at least two statins.
They were randomly assigned to bempedoic acid 180 mg once daily or placebo and followed for the primary endpoint of CV death, nonfatal myocardial infarction, nonfatal stroke, or coronary revascularization. The trial, conducted in 32 countries, launched in December 2016.
Bempedoic acid is currently approved for adults with heterozygous familial hypercholesterolemia or established atherosclerotic cardiovascular disease on maximally tolerated statins who require additional LDL-C lowering, the company states.
Concomitant use of bempedoic acid with simvastatin or pravastatin, the press release says, may lead to increased statin concentrations and risk for “simvastatin- or pravastatin-related myopathy.” Therefore, “use with greater than 20 mg of simvastatin or 40 mg of pravastatin should be avoided.”
A version of this article first appeared on Medscape.com.
Hospital financial decisions play a role in the critical shortage of pediatric beds for RSV patients
The dire shortage of pediatric hospital beds plaguing the nation in the fall of 2022 is a byproduct of financial decisions made by hospitals over the past decade, as they shuttered children’s wards, which often operate in the red, and expanded the number of beds available for more profitable endeavors like joint replacements and cancer care.
To cope with the flood of young patients sickened by a sweeping convergence of nasty bugs – especially respiratory syncytial virus, influenza, and coronavirus – medical centers nationwide have deployed triage tents, delayed elective surgeries, and transferred critically ill children out of state.
A major factor in the bed shortage is a years-long trend among hospitals of eliminating pediatric units, which tend to be less profitable than adult units, said Mark Wietecha, MS, MBA, CEO of the Children’s Hospital Association. Hospitals optimize revenue by striving to keep their beds 100% full – and filled with patients whose conditions command generous insurance reimbursements.
“It really has to do with dollars,” said Scott Krugman, MD, MS, vice chair of pediatrics at the Herman and Walter Samuelson Children’s Hospital at Sinai in Baltimore. “Hospitals rely on high-volume, high-reimbursement procedures from good payers to make money. There’s no incentive for hospitals to provide money-losing services.”
The number of pediatric inpatient units in hospitals fell 19% from 2008 to 2018, according to a study published in 2021 in the journal Pediatrics. Just this year, hospitals have closed pediatric units in Boston and Springfield, Mass.; Richmond, Va.; and Tulsa, Okla.
The current surge in dangerous respiratory illnesses among children is yet another example of how COVID-19 has upended the health care system. The lockdowns and isolation that marked the first years of the pandemic left kids largely unexposed – and still vulnerable – to viruses other than COVID for two winters, and doctors are now essentially treating multiple years’ worth of respiratory ailments.
The pandemic also accelerated changes in the health care industry that have left many communities with fewer hospital beds available for children who are acutely ill, along with fewer doctors and nurses to care for them.
When intensive care units were flooded with older COVID patients in 2020, some hospitals began using children’s beds to treat adults. Many of those pediatric beds haven’t been restored, said Daniel Rauch, MD, chair of the American Academy of Pediatrics’ committee on hospital care.
In addition, the relentless pace of the pandemic has spurred more than 230,000 health care providers – including doctors, nurses, and physician assistants – to quit. Before the pandemic, about 10% of nurses left their jobs every year; the rate has risen to about 20%, Dr. Wietecha said. He estimates that pediatric hospitals are unable to maintain as many as 10% of their beds because of staffing shortages.
“There is just not enough space for all the kids who need beds,” said Megan Ranney, MD, MPH, who works in several emergency departments in Providence, R.I., including Hasbro Children’s Hospital. The number of children seeking emergency care in recent weeks was 25% higher than the hospital’s previous record.
“We have doctors who are cleaning beds so we can get children into them faster,” said Dr. Ranney, a deputy dean at Brown University’s School of Public Health.
There’s not great money in treating kids. About 40% of U.S. children are covered by Medicaid, a joint federal-state program for low-income patients and people with disabilities. Base Medicaid rates are typically more than 20% below those paid by Medicare, the government insurance program for older adults, and are even lower when compared with private insurance. While specialty care for a range of common adult procedures, from knee and hip replacements to heart surgeries and cancer treatments, generates major profits for medical centers, hospitals complain they typically lose money on inpatient pediatric care.
When Tufts Children’s Hospital closed 41 pediatric beds this summer, hospital officials assured residents that young patients could receive care at nearby Boston Children’s Hospital. Now, Boston Children’s is delaying some elective surgeries to make room for kids who are acutely ill.
Dr. Rauch noted that children’s hospitals, which specialize in treating rare and serious conditions such as pediatric cancer, cystic fibrosis, and heart defects, simply aren’t designed to handle this season’s crush of kids acutely ill with respiratory bugs.
Even before the autumn’s viral trifecta, pediatric units were straining to absorb rising numbers of young people in acute mental distress. Stories abound of children in mental crises being marooned for weeks in emergency departments while awaiting transfer to a pediatric psychiatric unit. On a good day, Dr. Ranney said, 20% of pediatric emergency room beds at Hasbro Children’s Hospital are occupied by children experiencing mental health issues.
In hopes of adding pediatric capacity, the American Academy of Pediatrics joined the Children’s Hospital Association last month in calling on the White House to declare a national emergency due to child respiratory infections and provide additional resources to help cover the costs of care. The Biden administration has said that the flexibility hospital systems and providers have been given during the pandemic to sidestep certain staffing requirements also applies to RSV and flu.
Doernbecher Children’s Hospital at Oregon Health & Science University has shifted to “crisis standards of care,” enabling intensive care nurses to treat more patients than they’re usually assigned. Hospitals in Atlanta, Pittsburgh, and Aurora, Colorado, meanwhile, have resorted to treating young patients in overflow tents in parking lots.
Alex Kon, MD, a pediatric critical care physician at Community Medical Center in Missoula, Mont., said providers there have made plans to care for older kids in the adult intensive care unit, and to divert ambulances to other facilities when necessary. With only three pediatric ICUs in the state, that means young patients may be flown as far as Seattle or Spokane, Wash., or Idaho.
Hollis Lillard took her 1-year-old son, Calder, to an Army hospital in Northern Virginia last month after he experienced several days of fever, coughing, and labored breathing. They spent 7 anguished hours in the emergency room before the hospital found an open bed and transferred them by ambulance to Walter Reed National Military Medical Center in Maryland.
With proper therapy and instructions for home care, Calder’s virus was readily treatable: He recovered after he was given oxygen and treated with steroids, which fight inflammation, and albuterol, which counteracts bronchospasms. He was discharged the next day.
Although hospitalizations for RSV are falling, rates remain well above the norm for this time of year. And hospitals may not get much relief.
People can be infected with RSV more than once a year, and Dr. Krugman worries about a resurgence in the months to come. Because of the coronavirus, which competes with other viruses, “the usual seasonal pattern of viruses has gone out the window,” he said.
Like RSV, influenza arrived early this season. Both viruses usually peak around January. Three strains of flu are circulating and have caused an estimated 8.7 million illnesses, 78,000 hospitalizations, and 4,500 deaths, according to the Centers for Disease Control and Prevention.
Dr. Krugman doubts the health care industry will learn any quick lessons from the current crisis. “Unless there is a radical change in how we pay for pediatric hospital care,” Dr. Krugman said, “the bed shortage is only going to get worse.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
The dire shortage of pediatric hospital beds plaguing the nation in the fall of 2022 is a byproduct of financial decisions made by hospitals over the past decade, as they shuttered children’s wards, which often operate in the red, and expanded the number of beds available for more profitable endeavors like joint replacements and cancer care.
To cope with the flood of young patients sickened by a sweeping convergence of nasty bugs – especially respiratory syncytial virus, influenza, and coronavirus – medical centers nationwide have deployed triage tents, delayed elective surgeries, and transferred critically ill children out of state.
A major factor in the bed shortage is a years-long trend among hospitals of eliminating pediatric units, which tend to be less profitable than adult units, said Mark Wietecha, MS, MBA, CEO of the Children’s Hospital Association. Hospitals optimize revenue by striving to keep their beds 100% full – and filled with patients whose conditions command generous insurance reimbursements.
“It really has to do with dollars,” said Scott Krugman, MD, MS, vice chair of pediatrics at the Herman and Walter Samuelson Children’s Hospital at Sinai in Baltimore. “Hospitals rely on high-volume, high-reimbursement procedures from good payers to make money. There’s no incentive for hospitals to provide money-losing services.”
The number of pediatric inpatient units in hospitals fell 19% from 2008 to 2018, according to a study published in 2021 in the journal Pediatrics. Just this year, hospitals have closed pediatric units in Boston and Springfield, Mass.; Richmond, Va.; and Tulsa, Okla.
The current surge in dangerous respiratory illnesses among children is yet another example of how COVID-19 has upended the health care system. The lockdowns and isolation that marked the first years of the pandemic left kids largely unexposed – and still vulnerable – to viruses other than COVID for two winters, and doctors are now essentially treating multiple years’ worth of respiratory ailments.
The pandemic also accelerated changes in the health care industry that have left many communities with fewer hospital beds available for children who are acutely ill, along with fewer doctors and nurses to care for them.
When intensive care units were flooded with older COVID patients in 2020, some hospitals began using children’s beds to treat adults. Many of those pediatric beds haven’t been restored, said Daniel Rauch, MD, chair of the American Academy of Pediatrics’ committee on hospital care.
In addition, the relentless pace of the pandemic has spurred more than 230,000 health care providers – including doctors, nurses, and physician assistants – to quit. Before the pandemic, about 10% of nurses left their jobs every year; the rate has risen to about 20%, Dr. Wietecha said. He estimates that pediatric hospitals are unable to maintain as many as 10% of their beds because of staffing shortages.
“There is just not enough space for all the kids who need beds,” said Megan Ranney, MD, MPH, who works in several emergency departments in Providence, R.I., including Hasbro Children’s Hospital. The number of children seeking emergency care in recent weeks was 25% higher than the hospital’s previous record.
“We have doctors who are cleaning beds so we can get children into them faster,” said Dr. Ranney, a deputy dean at Brown University’s School of Public Health.
There’s not great money in treating kids. About 40% of U.S. children are covered by Medicaid, a joint federal-state program for low-income patients and people with disabilities. Base Medicaid rates are typically more than 20% below those paid by Medicare, the government insurance program for older adults, and are even lower when compared with private insurance. While specialty care for a range of common adult procedures, from knee and hip replacements to heart surgeries and cancer treatments, generates major profits for medical centers, hospitals complain they typically lose money on inpatient pediatric care.
When Tufts Children’s Hospital closed 41 pediatric beds this summer, hospital officials assured residents that young patients could receive care at nearby Boston Children’s Hospital. Now, Boston Children’s is delaying some elective surgeries to make room for kids who are acutely ill.
Dr. Rauch noted that children’s hospitals, which specialize in treating rare and serious conditions such as pediatric cancer, cystic fibrosis, and heart defects, simply aren’t designed to handle this season’s crush of kids acutely ill with respiratory bugs.
Even before the autumn’s viral trifecta, pediatric units were straining to absorb rising numbers of young people in acute mental distress. Stories abound of children in mental crises being marooned for weeks in emergency departments while awaiting transfer to a pediatric psychiatric unit. On a good day, Dr. Ranney said, 20% of pediatric emergency room beds at Hasbro Children’s Hospital are occupied by children experiencing mental health issues.
In hopes of adding pediatric capacity, the American Academy of Pediatrics joined the Children’s Hospital Association last month in calling on the White House to declare a national emergency due to child respiratory infections and provide additional resources to help cover the costs of care. The Biden administration has said that the flexibility hospital systems and providers have been given during the pandemic to sidestep certain staffing requirements also applies to RSV and flu.
Doernbecher Children’s Hospital at Oregon Health & Science University has shifted to “crisis standards of care,” enabling intensive care nurses to treat more patients than they’re usually assigned. Hospitals in Atlanta, Pittsburgh, and Aurora, Colorado, meanwhile, have resorted to treating young patients in overflow tents in parking lots.
Alex Kon, MD, a pediatric critical care physician at Community Medical Center in Missoula, Mont., said providers there have made plans to care for older kids in the adult intensive care unit, and to divert ambulances to other facilities when necessary. With only three pediatric ICUs in the state, that means young patients may be flown as far as Seattle or Spokane, Wash., or Idaho.
Hollis Lillard took her 1-year-old son, Calder, to an Army hospital in Northern Virginia last month after he experienced several days of fever, coughing, and labored breathing. They spent 7 anguished hours in the emergency room before the hospital found an open bed and transferred them by ambulance to Walter Reed National Military Medical Center in Maryland.
With proper therapy and instructions for home care, Calder’s virus was readily treatable: He recovered after he was given oxygen and treated with steroids, which fight inflammation, and albuterol, which counteracts bronchospasms. He was discharged the next day.
Although hospitalizations for RSV are falling, rates remain well above the norm for this time of year. And hospitals may not get much relief.
People can be infected with RSV more than once a year, and Dr. Krugman worries about a resurgence in the months to come. Because of the coronavirus, which competes with other viruses, “the usual seasonal pattern of viruses has gone out the window,” he said.
Like RSV, influenza arrived early this season. Both viruses usually peak around January. Three strains of flu are circulating and have caused an estimated 8.7 million illnesses, 78,000 hospitalizations, and 4,500 deaths, according to the Centers for Disease Control and Prevention.
Dr. Krugman doubts the health care industry will learn any quick lessons from the current crisis. “Unless there is a radical change in how we pay for pediatric hospital care,” Dr. Krugman said, “the bed shortage is only going to get worse.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
The dire shortage of pediatric hospital beds plaguing the nation in the fall of 2022 is a byproduct of financial decisions made by hospitals over the past decade, as they shuttered children’s wards, which often operate in the red, and expanded the number of beds available for more profitable endeavors like joint replacements and cancer care.
To cope with the flood of young patients sickened by a sweeping convergence of nasty bugs – especially respiratory syncytial virus, influenza, and coronavirus – medical centers nationwide have deployed triage tents, delayed elective surgeries, and transferred critically ill children out of state.
A major factor in the bed shortage is a years-long trend among hospitals of eliminating pediatric units, which tend to be less profitable than adult units, said Mark Wietecha, MS, MBA, CEO of the Children’s Hospital Association. Hospitals optimize revenue by striving to keep their beds 100% full – and filled with patients whose conditions command generous insurance reimbursements.
“It really has to do with dollars,” said Scott Krugman, MD, MS, vice chair of pediatrics at the Herman and Walter Samuelson Children’s Hospital at Sinai in Baltimore. “Hospitals rely on high-volume, high-reimbursement procedures from good payers to make money. There’s no incentive for hospitals to provide money-losing services.”
The number of pediatric inpatient units in hospitals fell 19% from 2008 to 2018, according to a study published in 2021 in the journal Pediatrics. Just this year, hospitals have closed pediatric units in Boston and Springfield, Mass.; Richmond, Va.; and Tulsa, Okla.
The current surge in dangerous respiratory illnesses among children is yet another example of how COVID-19 has upended the health care system. The lockdowns and isolation that marked the first years of the pandemic left kids largely unexposed – and still vulnerable – to viruses other than COVID for two winters, and doctors are now essentially treating multiple years’ worth of respiratory ailments.
The pandemic also accelerated changes in the health care industry that have left many communities with fewer hospital beds available for children who are acutely ill, along with fewer doctors and nurses to care for them.
When intensive care units were flooded with older COVID patients in 2020, some hospitals began using children’s beds to treat adults. Many of those pediatric beds haven’t been restored, said Daniel Rauch, MD, chair of the American Academy of Pediatrics’ committee on hospital care.
In addition, the relentless pace of the pandemic has spurred more than 230,000 health care providers – including doctors, nurses, and physician assistants – to quit. Before the pandemic, about 10% of nurses left their jobs every year; the rate has risen to about 20%, Dr. Wietecha said. He estimates that pediatric hospitals are unable to maintain as many as 10% of their beds because of staffing shortages.
“There is just not enough space for all the kids who need beds,” said Megan Ranney, MD, MPH, who works in several emergency departments in Providence, R.I., including Hasbro Children’s Hospital. The number of children seeking emergency care in recent weeks was 25% higher than the hospital’s previous record.
“We have doctors who are cleaning beds so we can get children into them faster,” said Dr. Ranney, a deputy dean at Brown University’s School of Public Health.
There’s not great money in treating kids. About 40% of U.S. children are covered by Medicaid, a joint federal-state program for low-income patients and people with disabilities. Base Medicaid rates are typically more than 20% below those paid by Medicare, the government insurance program for older adults, and are even lower when compared with private insurance. While specialty care for a range of common adult procedures, from knee and hip replacements to heart surgeries and cancer treatments, generates major profits for medical centers, hospitals complain they typically lose money on inpatient pediatric care.
When Tufts Children’s Hospital closed 41 pediatric beds this summer, hospital officials assured residents that young patients could receive care at nearby Boston Children’s Hospital. Now, Boston Children’s is delaying some elective surgeries to make room for kids who are acutely ill.
Dr. Rauch noted that children’s hospitals, which specialize in treating rare and serious conditions such as pediatric cancer, cystic fibrosis, and heart defects, simply aren’t designed to handle this season’s crush of kids acutely ill with respiratory bugs.
Even before the autumn’s viral trifecta, pediatric units were straining to absorb rising numbers of young people in acute mental distress. Stories abound of children in mental crises being marooned for weeks in emergency departments while awaiting transfer to a pediatric psychiatric unit. On a good day, Dr. Ranney said, 20% of pediatric emergency room beds at Hasbro Children’s Hospital are occupied by children experiencing mental health issues.
In hopes of adding pediatric capacity, the American Academy of Pediatrics joined the Children’s Hospital Association last month in calling on the White House to declare a national emergency due to child respiratory infections and provide additional resources to help cover the costs of care. The Biden administration has said that the flexibility hospital systems and providers have been given during the pandemic to sidestep certain staffing requirements also applies to RSV and flu.
Doernbecher Children’s Hospital at Oregon Health & Science University has shifted to “crisis standards of care,” enabling intensive care nurses to treat more patients than they’re usually assigned. Hospitals in Atlanta, Pittsburgh, and Aurora, Colorado, meanwhile, have resorted to treating young patients in overflow tents in parking lots.
Alex Kon, MD, a pediatric critical care physician at Community Medical Center in Missoula, Mont., said providers there have made plans to care for older kids in the adult intensive care unit, and to divert ambulances to other facilities when necessary. With only three pediatric ICUs in the state, that means young patients may be flown as far as Seattle or Spokane, Wash., or Idaho.
Hollis Lillard took her 1-year-old son, Calder, to an Army hospital in Northern Virginia last month after he experienced several days of fever, coughing, and labored breathing. They spent 7 anguished hours in the emergency room before the hospital found an open bed and transferred them by ambulance to Walter Reed National Military Medical Center in Maryland.
With proper therapy and instructions for home care, Calder’s virus was readily treatable: He recovered after he was given oxygen and treated with steroids, which fight inflammation, and albuterol, which counteracts bronchospasms. He was discharged the next day.
Although hospitalizations for RSV are falling, rates remain well above the norm for this time of year. And hospitals may not get much relief.
People can be infected with RSV more than once a year, and Dr. Krugman worries about a resurgence in the months to come. Because of the coronavirus, which competes with other viruses, “the usual seasonal pattern of viruses has gone out the window,” he said.
Like RSV, influenza arrived early this season. Both viruses usually peak around January. Three strains of flu are circulating and have caused an estimated 8.7 million illnesses, 78,000 hospitalizations, and 4,500 deaths, according to the Centers for Disease Control and Prevention.
Dr. Krugman doubts the health care industry will learn any quick lessons from the current crisis. “Unless there is a radical change in how we pay for pediatric hospital care,” Dr. Krugman said, “the bed shortage is only going to get worse.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
Breaking bad news during IVF: How to soften the blow
Two years ago, Ashley Hingston had a miscarriage. The 35-year-old Floridian and her husband had been going through in vitro fertilization when they received the news no one wants to get, but which many in their position reflexively expect: “You are going to lose the pregnancy.”
On the other end of the line was Ms. Hingston’s physician, who offered her advice and comfort to ease the pain of the bad news.
“I was a complete wreck and could barely even talk,” Ms. Hingston recalled. “But I think my doctor knew what I was asking, and she was doing the best to answer the questions I had: Why did this happen? What does this mean? And she sat and listened to me.”
An estimated 2% of babies born in the United States each year are the result of IVF, according to 2019 data from the Centers for Disease Control and Prevention. The process is often emotionally, physically, and economically taxing for patients. According to the CDC, the chance a pregnancy will be successful through IVF is 21.3%. Consequently, doctors often find themselves the bearers of bad news.
But interaction with a care team or a string of nurses and providers, rather than a physician, is the norm for IVF patients, according to Aimee Eyvazzadeh, MD, a specialist in infertility and reproductive endocrinology in San Ramon, Calif.
“Patients see a doctor for all of 10 minutes and then they are handed off to a care team who don’t know their whole story,” she said.
For Dr. Eyvazzadeh and other health care professionals, physicians must improve the ways they share bad news, and how they divide tasks with care teams.
Personalized care works best
Providing personalized care will improve how IVF patients respond to bad news, according to Dr. Eyvazzadeh and others.
“When people have gone through so much trauma, anything you say to them, sometimes they can’t process it very well, so they have to see the information in different ways,” she told this news organization. “After each phone call, I’ll actually type up a summary for them, with links and articles for them to read, so they are directed in a way that I think is healthy so they aren’t pulled into a rabbit hole.”
Dr. Eyvazzadeh said she encourages her patients to seek counseling during IVF treatment, and even pays for their initial psychiatric consultation. Not many doctors do this, she noted.
“Taking the time to allow the patient to process the bad news is vital,” said Linda Kim, PhD, a psychiatrist at Moon Mental Health, to whom Dr. Eyvazzadeh refers couples. Sometimes, several calls are necessary.
“Rather than thinking of the conversation as a linear process, consider it a sphere of processing,” Dr. Kim said. “The patient may need space to grieve, may ask many questions, may need to clarify what happened, or may need to vent and release frustration. This is space that the patient needs to process the bad news.” (See below for more tips on how to share bad news with your patients.)
Many care teams are skilled in delivering bad news to patients, according to Liz Grill, PsyD, a psychologist at Weill Cornell Medicine, New York. The challenge for them is ensuring new nurses and clinicians continue to have empathy training, she said.
“You want to make sure clinicians are building relationships, and empathy. Whether there is a protocol to build that level of empathy, or if they have their own innate ability to build empathy, it’s about communicating in the right way,” Dr. Grill told this news organization.
But Mark Trolice, MD, a reproductive endocrinologist and infertility specialist at the University of Central Florida, Orlando, agreed that nurses should not deliver bad news, even if they have the expertise and the compassion to do so.
“It’s the doctor’s responsibility to make that call. It’s a very difficult call and it puts an unnecessary burden on your care team to be making these calls all the time,” Dr. Trolice said. “I feel the patient wants to hear from the physician who oversaw their cycle and did the procedure and embryo transfer. It shows a tremendous amount of responsibility and commitment on the part of the physician.”
Dr. Trolice also recommended clinicians refer to the HEART (Hearing, Empathy, Apology, Response, and Thanks) guidelines to ensure proper conversations with patients about bad news.
“You give the patient time to process the information and ask questions, and then we schedule another time to talk about plans going forward,” he said.
“Patients can feel powerless and not in control of what is happening, or even over their own bodies,” Dr. Kim added. “To counteract this, it can be helpful to outline projected steps as much as possible.”
For Dr. Eyvazzadeh, caring for an IVF patient is a matter of knowing your strengths.
Providing links to web resources, recommending an organic diet, and sending them to support groups (see below) are helpful, she said. “For some people, their strength isn’t engaging with patients on the same level that I do. But I still feel like there are ways that we can still make the patients feel cared for without being extreme.”
Tips on how to share bad news with patients
A guide often cited by clinicians when delivering bad news is the Buckman Six Step Protocol:
- Get the physical context right.
- Find out how much the patient knows.
- Find out how much the patient wants to know.
- Share the information.
- Respond to the patient’s feelings.
- Plan and follow through.
Linda Kim, PhD, notes that patient preference in receiving bad news is often culturally mediated. She recommends asking patients how they would want to receive bad news, especially in during IVF process, where there can be many challenges over the course of treatment. Dr. Kim also recommends these steps:
- Get as much information in advance as possible and ask your patient directly how they want bad news. When you are meeting a patient and their families for the first time, and they are filling out their intake paperwork or health forms, you may consider adding a section on “What is your preferred method of communication?” And after that, you might add, “What is the best way to tell you challenging or difficult news? Would you prefer to be by yourself or with a loved one? Please elaborate any additional preferences.” Everyone is different, and it can be helpful to hear from the patient directly how they would like to receive bad news. It will not only meet them where they are during a difficult time, it will also demonstrate to the patient that you are respecting their preferences and involving those preferences in the process.
- Try to leave enough time for a difficult conversation with a patient. Even better is if a clinician can prepare a patient that there is some disappointing or difficult news to share.
- Finally, offer discussion on next steps. It never hurts to ask the patient directly when they are ready to discuss next steps. This may take a few hours, a few days, or even a few months or longer.
Social media as support
Monica Wunderman, a patient of Dr. Eyvazzadeh’s since 2020, began her own social media campaign on Instagram to find support and give support to women experiencing IVF.
“I started scrolling and liking posts, and a girl reached out to me to ask if I needed help” in the form of emotional support, she recalls.
Instagram became a haven for Ms. Wunderman to share information, experiences, and support with others. It also allowed her to create a network of support and meet other women, like Ashley Hingston, going through similar struggles.
Ms. Wunderman has been through four rounds of IVF so far. Three were completely unsuccessful; the last ended in miscarriage. Although she and her husband are trying again with a surrogate, the uncertainty remains. And she feels the health care system should be offering her – and the other would-be parents she has met online – more support.
“We place such importance as a society on growing families,” she says. “But then we do very little to support those who want them and struggle.”
A version of this article first appeared on Medscape.com.
Two years ago, Ashley Hingston had a miscarriage. The 35-year-old Floridian and her husband had been going through in vitro fertilization when they received the news no one wants to get, but which many in their position reflexively expect: “You are going to lose the pregnancy.”
On the other end of the line was Ms. Hingston’s physician, who offered her advice and comfort to ease the pain of the bad news.
“I was a complete wreck and could barely even talk,” Ms. Hingston recalled. “But I think my doctor knew what I was asking, and she was doing the best to answer the questions I had: Why did this happen? What does this mean? And she sat and listened to me.”
An estimated 2% of babies born in the United States each year are the result of IVF, according to 2019 data from the Centers for Disease Control and Prevention. The process is often emotionally, physically, and economically taxing for patients. According to the CDC, the chance a pregnancy will be successful through IVF is 21.3%. Consequently, doctors often find themselves the bearers of bad news.
But interaction with a care team or a string of nurses and providers, rather than a physician, is the norm for IVF patients, according to Aimee Eyvazzadeh, MD, a specialist in infertility and reproductive endocrinology in San Ramon, Calif.
“Patients see a doctor for all of 10 minutes and then they are handed off to a care team who don’t know their whole story,” she said.
For Dr. Eyvazzadeh and other health care professionals, physicians must improve the ways they share bad news, and how they divide tasks with care teams.
Personalized care works best
Providing personalized care will improve how IVF patients respond to bad news, according to Dr. Eyvazzadeh and others.
“When people have gone through so much trauma, anything you say to them, sometimes they can’t process it very well, so they have to see the information in different ways,” she told this news organization. “After each phone call, I’ll actually type up a summary for them, with links and articles for them to read, so they are directed in a way that I think is healthy so they aren’t pulled into a rabbit hole.”
Dr. Eyvazzadeh said she encourages her patients to seek counseling during IVF treatment, and even pays for their initial psychiatric consultation. Not many doctors do this, she noted.
“Taking the time to allow the patient to process the bad news is vital,” said Linda Kim, PhD, a psychiatrist at Moon Mental Health, to whom Dr. Eyvazzadeh refers couples. Sometimes, several calls are necessary.
“Rather than thinking of the conversation as a linear process, consider it a sphere of processing,” Dr. Kim said. “The patient may need space to grieve, may ask many questions, may need to clarify what happened, or may need to vent and release frustration. This is space that the patient needs to process the bad news.” (See below for more tips on how to share bad news with your patients.)
Many care teams are skilled in delivering bad news to patients, according to Liz Grill, PsyD, a psychologist at Weill Cornell Medicine, New York. The challenge for them is ensuring new nurses and clinicians continue to have empathy training, she said.
“You want to make sure clinicians are building relationships, and empathy. Whether there is a protocol to build that level of empathy, or if they have their own innate ability to build empathy, it’s about communicating in the right way,” Dr. Grill told this news organization.
But Mark Trolice, MD, a reproductive endocrinologist and infertility specialist at the University of Central Florida, Orlando, agreed that nurses should not deliver bad news, even if they have the expertise and the compassion to do so.
“It’s the doctor’s responsibility to make that call. It’s a very difficult call and it puts an unnecessary burden on your care team to be making these calls all the time,” Dr. Trolice said. “I feel the patient wants to hear from the physician who oversaw their cycle and did the procedure and embryo transfer. It shows a tremendous amount of responsibility and commitment on the part of the physician.”
Dr. Trolice also recommended clinicians refer to the HEART (Hearing, Empathy, Apology, Response, and Thanks) guidelines to ensure proper conversations with patients about bad news.
“You give the patient time to process the information and ask questions, and then we schedule another time to talk about plans going forward,” he said.
“Patients can feel powerless and not in control of what is happening, or even over their own bodies,” Dr. Kim added. “To counteract this, it can be helpful to outline projected steps as much as possible.”
For Dr. Eyvazzadeh, caring for an IVF patient is a matter of knowing your strengths.
Providing links to web resources, recommending an organic diet, and sending them to support groups (see below) are helpful, she said. “For some people, their strength isn’t engaging with patients on the same level that I do. But I still feel like there are ways that we can still make the patients feel cared for without being extreme.”
Tips on how to share bad news with patients
A guide often cited by clinicians when delivering bad news is the Buckman Six Step Protocol:
- Get the physical context right.
- Find out how much the patient knows.
- Find out how much the patient wants to know.
- Share the information.
- Respond to the patient’s feelings.
- Plan and follow through.
Linda Kim, PhD, notes that patient preference in receiving bad news is often culturally mediated. She recommends asking patients how they would want to receive bad news, especially in during IVF process, where there can be many challenges over the course of treatment. Dr. Kim also recommends these steps:
- Get as much information in advance as possible and ask your patient directly how they want bad news. When you are meeting a patient and their families for the first time, and they are filling out their intake paperwork or health forms, you may consider adding a section on “What is your preferred method of communication?” And after that, you might add, “What is the best way to tell you challenging or difficult news? Would you prefer to be by yourself or with a loved one? Please elaborate any additional preferences.” Everyone is different, and it can be helpful to hear from the patient directly how they would like to receive bad news. It will not only meet them where they are during a difficult time, it will also demonstrate to the patient that you are respecting their preferences and involving those preferences in the process.
- Try to leave enough time for a difficult conversation with a patient. Even better is if a clinician can prepare a patient that there is some disappointing or difficult news to share.
- Finally, offer discussion on next steps. It never hurts to ask the patient directly when they are ready to discuss next steps. This may take a few hours, a few days, or even a few months or longer.
Social media as support
Monica Wunderman, a patient of Dr. Eyvazzadeh’s since 2020, began her own social media campaign on Instagram to find support and give support to women experiencing IVF.
“I started scrolling and liking posts, and a girl reached out to me to ask if I needed help” in the form of emotional support, she recalls.
Instagram became a haven for Ms. Wunderman to share information, experiences, and support with others. It also allowed her to create a network of support and meet other women, like Ashley Hingston, going through similar struggles.
Ms. Wunderman has been through four rounds of IVF so far. Three were completely unsuccessful; the last ended in miscarriage. Although she and her husband are trying again with a surrogate, the uncertainty remains. And she feels the health care system should be offering her – and the other would-be parents she has met online – more support.
“We place such importance as a society on growing families,” she says. “But then we do very little to support those who want them and struggle.”
A version of this article first appeared on Medscape.com.
Two years ago, Ashley Hingston had a miscarriage. The 35-year-old Floridian and her husband had been going through in vitro fertilization when they received the news no one wants to get, but which many in their position reflexively expect: “You are going to lose the pregnancy.”
On the other end of the line was Ms. Hingston’s physician, who offered her advice and comfort to ease the pain of the bad news.
“I was a complete wreck and could barely even talk,” Ms. Hingston recalled. “But I think my doctor knew what I was asking, and she was doing the best to answer the questions I had: Why did this happen? What does this mean? And she sat and listened to me.”
An estimated 2% of babies born in the United States each year are the result of IVF, according to 2019 data from the Centers for Disease Control and Prevention. The process is often emotionally, physically, and economically taxing for patients. According to the CDC, the chance a pregnancy will be successful through IVF is 21.3%. Consequently, doctors often find themselves the bearers of bad news.
But interaction with a care team or a string of nurses and providers, rather than a physician, is the norm for IVF patients, according to Aimee Eyvazzadeh, MD, a specialist in infertility and reproductive endocrinology in San Ramon, Calif.
“Patients see a doctor for all of 10 minutes and then they are handed off to a care team who don’t know their whole story,” she said.
For Dr. Eyvazzadeh and other health care professionals, physicians must improve the ways they share bad news, and how they divide tasks with care teams.
Personalized care works best
Providing personalized care will improve how IVF patients respond to bad news, according to Dr. Eyvazzadeh and others.
“When people have gone through so much trauma, anything you say to them, sometimes they can’t process it very well, so they have to see the information in different ways,” she told this news organization. “After each phone call, I’ll actually type up a summary for them, with links and articles for them to read, so they are directed in a way that I think is healthy so they aren’t pulled into a rabbit hole.”
Dr. Eyvazzadeh said she encourages her patients to seek counseling during IVF treatment, and even pays for their initial psychiatric consultation. Not many doctors do this, she noted.
“Taking the time to allow the patient to process the bad news is vital,” said Linda Kim, PhD, a psychiatrist at Moon Mental Health, to whom Dr. Eyvazzadeh refers couples. Sometimes, several calls are necessary.
“Rather than thinking of the conversation as a linear process, consider it a sphere of processing,” Dr. Kim said. “The patient may need space to grieve, may ask many questions, may need to clarify what happened, or may need to vent and release frustration. This is space that the patient needs to process the bad news.” (See below for more tips on how to share bad news with your patients.)
Many care teams are skilled in delivering bad news to patients, according to Liz Grill, PsyD, a psychologist at Weill Cornell Medicine, New York. The challenge for them is ensuring new nurses and clinicians continue to have empathy training, she said.
“You want to make sure clinicians are building relationships, and empathy. Whether there is a protocol to build that level of empathy, or if they have their own innate ability to build empathy, it’s about communicating in the right way,” Dr. Grill told this news organization.
But Mark Trolice, MD, a reproductive endocrinologist and infertility specialist at the University of Central Florida, Orlando, agreed that nurses should not deliver bad news, even if they have the expertise and the compassion to do so.
“It’s the doctor’s responsibility to make that call. It’s a very difficult call and it puts an unnecessary burden on your care team to be making these calls all the time,” Dr. Trolice said. “I feel the patient wants to hear from the physician who oversaw their cycle and did the procedure and embryo transfer. It shows a tremendous amount of responsibility and commitment on the part of the physician.”
Dr. Trolice also recommended clinicians refer to the HEART (Hearing, Empathy, Apology, Response, and Thanks) guidelines to ensure proper conversations with patients about bad news.
“You give the patient time to process the information and ask questions, and then we schedule another time to talk about plans going forward,” he said.
“Patients can feel powerless and not in control of what is happening, or even over their own bodies,” Dr. Kim added. “To counteract this, it can be helpful to outline projected steps as much as possible.”
For Dr. Eyvazzadeh, caring for an IVF patient is a matter of knowing your strengths.
Providing links to web resources, recommending an organic diet, and sending them to support groups (see below) are helpful, she said. “For some people, their strength isn’t engaging with patients on the same level that I do. But I still feel like there are ways that we can still make the patients feel cared for without being extreme.”
Tips on how to share bad news with patients
A guide often cited by clinicians when delivering bad news is the Buckman Six Step Protocol:
- Get the physical context right.
- Find out how much the patient knows.
- Find out how much the patient wants to know.
- Share the information.
- Respond to the patient’s feelings.
- Plan and follow through.
Linda Kim, PhD, notes that patient preference in receiving bad news is often culturally mediated. She recommends asking patients how they would want to receive bad news, especially in during IVF process, where there can be many challenges over the course of treatment. Dr. Kim also recommends these steps:
- Get as much information in advance as possible and ask your patient directly how they want bad news. When you are meeting a patient and their families for the first time, and they are filling out their intake paperwork or health forms, you may consider adding a section on “What is your preferred method of communication?” And after that, you might add, “What is the best way to tell you challenging or difficult news? Would you prefer to be by yourself or with a loved one? Please elaborate any additional preferences.” Everyone is different, and it can be helpful to hear from the patient directly how they would like to receive bad news. It will not only meet them where they are during a difficult time, it will also demonstrate to the patient that you are respecting their preferences and involving those preferences in the process.
- Try to leave enough time for a difficult conversation with a patient. Even better is if a clinician can prepare a patient that there is some disappointing or difficult news to share.
- Finally, offer discussion on next steps. It never hurts to ask the patient directly when they are ready to discuss next steps. This may take a few hours, a few days, or even a few months or longer.
Social media as support
Monica Wunderman, a patient of Dr. Eyvazzadeh’s since 2020, began her own social media campaign on Instagram to find support and give support to women experiencing IVF.
“I started scrolling and liking posts, and a girl reached out to me to ask if I needed help” in the form of emotional support, she recalls.
Instagram became a haven for Ms. Wunderman to share information, experiences, and support with others. It also allowed her to create a network of support and meet other women, like Ashley Hingston, going through similar struggles.
Ms. Wunderman has been through four rounds of IVF so far. Three were completely unsuccessful; the last ended in miscarriage. Although she and her husband are trying again with a surrogate, the uncertainty remains. And she feels the health care system should be offering her – and the other would-be parents she has met online – more support.
“We place such importance as a society on growing families,” she says. “But then we do very little to support those who want them and struggle.”
A version of this article first appeared on Medscape.com.
Have you heard of VEXAS syndrome?
Its name is an acronym: Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic. The prevalence of this syndrome is unknown, but it is not so rare. As it is an X-linked disease, men are predominantly affected.
First identification
The NIH team screened the exomes and genomes of 2,560 individuals. Of this group, 1,477 had been referred because of undiagnosed recurrent fevers, systemic inflammation, or both, and 1,083 were affected by atypical, unclassified disorders. The researchers identified 25 men with a somatic mutation in the ubiquitin-like modifier activating enzyme 1 (UBA1) gene, which is involved in the protein ubiquitylation system. This posttranslational modification has a pleiotropic function that likely explains the clinical heterogeneity seen in VEXAS patients: regulation of protein turnover, especially those involved in the cell cycle, cell death, and signal transduction. Ubiquitylation is also involved in nonproteolytic functions, such as assembly of multiprotein complexes, intracellular signaling, inflammatory signaling, and DNA repair.
Clinical presentation
The clinicobiological presentation of VEXAS syndrome is very heterogeneous. Typically, patients present with a systemic inflammatory disease with unexplained episodes of fever, involvement of the lungs, skin, blood vessels, and joints. Molecular diagnosis is made by the sequencing of UBA1.
Most patients present with the characteristic clinical signs of other inflammatory diseases, such as polyarteritis nodosa and recurrent polychondritis. But VEXAS patients are at high risk of developing hematologic conditions. Indeed, the following were seen among the 25 participants in the NIH study: macrocytic anemia (96%), venous thromboembolism (44%), myelodysplastic syndrome (24%), and multiple myeloma or monoclonal gammopathy of undetermined significance (20%).
In VEXAS patients, levels of serum inflammatory markers are increased. These markers include tumor necrosis factor, interleukin-8, interleukin-6, interferon-inducible protein-10, interferon-gamma, C-reactive protein. In addition, there is aberrant activation of innate immune-signaling pathways.
In a large-scale analysis of a multicenter case series of 116 French patients, researchers found that VEXAS syndrome primarily affected men. The disease was progressive, and onset occurred after age 50 years. These patients can be divided into three phenotypically distinct clusters on the basis of integration of clinical and biological data. In the 58 cases in which myelodysplastic syndrome was present, the mortality rates were higher. The researchers also reported that the UBA1 p.Met41L mutation was associated with a better prognosis.
Treatment data
VEXAS syndrome resists the classical therapeutic arsenal. Patients require high-dose glucocorticoids, and prognosis appears to be poor. The available treatment data are retrospective. Of the 25 participants in the NIH study, 40% died within 5 years from disease-related causes or complications related to treatment. Among the promising therapeutic avenues is the use of inhibitors of the Janus kinase pathway.
This article was translated from Univadis France. A version of this article appeared on Medscape.com.
Its name is an acronym: Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic. The prevalence of this syndrome is unknown, but it is not so rare. As it is an X-linked disease, men are predominantly affected.
First identification
The NIH team screened the exomes and genomes of 2,560 individuals. Of this group, 1,477 had been referred because of undiagnosed recurrent fevers, systemic inflammation, or both, and 1,083 were affected by atypical, unclassified disorders. The researchers identified 25 men with a somatic mutation in the ubiquitin-like modifier activating enzyme 1 (UBA1) gene, which is involved in the protein ubiquitylation system. This posttranslational modification has a pleiotropic function that likely explains the clinical heterogeneity seen in VEXAS patients: regulation of protein turnover, especially those involved in the cell cycle, cell death, and signal transduction. Ubiquitylation is also involved in nonproteolytic functions, such as assembly of multiprotein complexes, intracellular signaling, inflammatory signaling, and DNA repair.
Clinical presentation
The clinicobiological presentation of VEXAS syndrome is very heterogeneous. Typically, patients present with a systemic inflammatory disease with unexplained episodes of fever, involvement of the lungs, skin, blood vessels, and joints. Molecular diagnosis is made by the sequencing of UBA1.
Most patients present with the characteristic clinical signs of other inflammatory diseases, such as polyarteritis nodosa and recurrent polychondritis. But VEXAS patients are at high risk of developing hematologic conditions. Indeed, the following were seen among the 25 participants in the NIH study: macrocytic anemia (96%), venous thromboembolism (44%), myelodysplastic syndrome (24%), and multiple myeloma or monoclonal gammopathy of undetermined significance (20%).
In VEXAS patients, levels of serum inflammatory markers are increased. These markers include tumor necrosis factor, interleukin-8, interleukin-6, interferon-inducible protein-10, interferon-gamma, C-reactive protein. In addition, there is aberrant activation of innate immune-signaling pathways.
In a large-scale analysis of a multicenter case series of 116 French patients, researchers found that VEXAS syndrome primarily affected men. The disease was progressive, and onset occurred after age 50 years. These patients can be divided into three phenotypically distinct clusters on the basis of integration of clinical and biological data. In the 58 cases in which myelodysplastic syndrome was present, the mortality rates were higher. The researchers also reported that the UBA1 p.Met41L mutation was associated with a better prognosis.
Treatment data
VEXAS syndrome resists the classical therapeutic arsenal. Patients require high-dose glucocorticoids, and prognosis appears to be poor. The available treatment data are retrospective. Of the 25 participants in the NIH study, 40% died within 5 years from disease-related causes or complications related to treatment. Among the promising therapeutic avenues is the use of inhibitors of the Janus kinase pathway.
This article was translated from Univadis France. A version of this article appeared on Medscape.com.
Its name is an acronym: Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic. The prevalence of this syndrome is unknown, but it is not so rare. As it is an X-linked disease, men are predominantly affected.
First identification
The NIH team screened the exomes and genomes of 2,560 individuals. Of this group, 1,477 had been referred because of undiagnosed recurrent fevers, systemic inflammation, or both, and 1,083 were affected by atypical, unclassified disorders. The researchers identified 25 men with a somatic mutation in the ubiquitin-like modifier activating enzyme 1 (UBA1) gene, which is involved in the protein ubiquitylation system. This posttranslational modification has a pleiotropic function that likely explains the clinical heterogeneity seen in VEXAS patients: regulation of protein turnover, especially those involved in the cell cycle, cell death, and signal transduction. Ubiquitylation is also involved in nonproteolytic functions, such as assembly of multiprotein complexes, intracellular signaling, inflammatory signaling, and DNA repair.
Clinical presentation
The clinicobiological presentation of VEXAS syndrome is very heterogeneous. Typically, patients present with a systemic inflammatory disease with unexplained episodes of fever, involvement of the lungs, skin, blood vessels, and joints. Molecular diagnosis is made by the sequencing of UBA1.
Most patients present with the characteristic clinical signs of other inflammatory diseases, such as polyarteritis nodosa and recurrent polychondritis. But VEXAS patients are at high risk of developing hematologic conditions. Indeed, the following were seen among the 25 participants in the NIH study: macrocytic anemia (96%), venous thromboembolism (44%), myelodysplastic syndrome (24%), and multiple myeloma or monoclonal gammopathy of undetermined significance (20%).
In VEXAS patients, levels of serum inflammatory markers are increased. These markers include tumor necrosis factor, interleukin-8, interleukin-6, interferon-inducible protein-10, interferon-gamma, C-reactive protein. In addition, there is aberrant activation of innate immune-signaling pathways.
In a large-scale analysis of a multicenter case series of 116 French patients, researchers found that VEXAS syndrome primarily affected men. The disease was progressive, and onset occurred after age 50 years. These patients can be divided into three phenotypically distinct clusters on the basis of integration of clinical and biological data. In the 58 cases in which myelodysplastic syndrome was present, the mortality rates were higher. The researchers also reported that the UBA1 p.Met41L mutation was associated with a better prognosis.
Treatment data
VEXAS syndrome resists the classical therapeutic arsenal. Patients require high-dose glucocorticoids, and prognosis appears to be poor. The available treatment data are retrospective. Of the 25 participants in the NIH study, 40% died within 5 years from disease-related causes or complications related to treatment. Among the promising therapeutic avenues is the use of inhibitors of the Janus kinase pathway.
This article was translated from Univadis France. A version of this article appeared on Medscape.com.
How your voice could reveal hidden disease
: First during puberty, as the vocal cords thicken and the voice box migrates down the throat. Then a second time as aging causes structural changes that may weaken the voice.
But for some of us, there’s another voice shift, when a disease begins or when our mental health declines.
This is why more doctors are looking into voice as a biomarker – something that tells you that a disease is present.
Vital signs like blood pressure or heart rate “can give a general idea of how sick we are. But they’re not specific to certain diseases,” says Yael Bensoussan, MD, director of the University of South Florida, Tampa’s Health Voice Center and the coprincipal investigator for the National Institutes of Health’s Voice as a Biomarker of Health project.
“We’re learning that there are patterns” in voice changes that can indicate a range of conditions, including diseases of the nervous system and mental illnesses, she says.
Speaking is complicated, involving everything from the lungs and voice box to the mouth and brain. “A breakdown in any of those parts can affect the voice,” says Maria Powell, PhD, an assistant professor of otolaryngology (the study of diseases of the ear and throat) at Vanderbilt University, Nashville, Tenn., who is working on the NIH project.
You or those around you may not notice the changes. But researchers say voice analysis as a standard part of patient care – akin to blood pressure checks or cholesterol tests – could help identify those who need medical attention earlier.
Often, all it takes is a smartphone – “something that’s cheap, off-the-shelf, and that everyone can use,” says Ariana Anderson, PhD, director of the University of California, Los Angeles, Laboratory of Computational Neuropsychology.
“You can provide voice data in your pajamas, on your couch,” says Frank Rudzicz, PhD, a computer scientist for the NIH project. “It doesn’t require very complicated or expensive equipment, and it doesn’t require a lot of expertise to obtain.” Plus, multiple samples can be collected over time, giving a more accurate picture of health than a single snapshot from, say, a cognitive test.
Over the next 4 years, the Voice as a Biomarker team will receive nearly $18 million to gather a massive amount of voice data. The goal is 20,000-30,000 samples, along with health data about each person being studied. The result will be a sprawling database scientists can use to develop algorithms linking health conditions to the way we speak.
For the first 2 years, new data will be collected exclusively via universities and high-volume clinics to control quality and accuracy. Eventually, people will be invited to submit their own voice recordings, creating a crowdsourced dataset. “Google, Alexa, Amazon – they have access to tons of voice data,” says Dr. Bensoussan. “But it’s not usable in a clinical way, because they don’t have the health information.”
Dr. Bensoussan and her colleagues hope to fill that void with advance voice screening apps, which could prove especially valuable in remote communities that lack access to specialists or as a tool for telemedicine. Down the line, wearable devices with voice analysis could alert people with chronic conditions when they need to see a doctor.
“The watch says, ‘I’ve analyzed your breathing and coughing, and today, you’re really not doing well. You should go to the hospital,’ ” says Dr. Bensoussan, envisioning a wearable for patients with COPD. “It could tell people early that things are declining.”
Artificial intelligence may be better than a brain at pinpointing the right disease. For example, slurred speech could indicate Parkinson’s, a stroke, or ALS, among other things.
“We can hold approximately seven pieces of information in our head at one time,” says Dr. Rudzicz. “It’s really hard for us to get a holistic picture using dozens or hundreds of variables at once.” But a computer can consider a whole range of vocal markers at the same time, piecing them together for a more accurate assessment.
“The goal is not to outperform a ... clinician,” says Dr. Bensoussan. Yet the potential is unmistakably there: In a recent study of patients with cancer of the larynx, an automated voice analysis tool more accurately flagged the disease than laryngologists did.
“Algorithms have a larger training base,” says Dr. Anderson, who developed an app called ChatterBaby that analyzes infant cries. “We have a million samples at our disposal to train our algorithms. I don’t know if I’ve heard a million different babies crying in my life.”
So which health conditions show the most promise for voice analysis? The Voice as a Biomarker project will focus on five categories.
Voice disorders (cancers of the larynx, vocal fold paralysis, benign lesions on the larynx)
Obviously, vocal changes are a hallmark of these conditions, which cause things like breathiness or “roughness,” a type of vocal irregularity. Hoarseness that lasts at least 2 weeks is often one of the earliest signs of laryngeal cancer. Yet it can take months – one study found 16 weeks was the average – for patients to see a doctor after noticing the changes. Even then, laryngologists still misdiagnosed some cases of cancer when relying on vocal cues alone.
Now imagine a different scenario: The patient speaks into a smartphone app. An algorithm compares the vocal sample with the voices of laryngeal cancer patients. The app spits out the estimated odds of laryngeal cancer, helping providers decide whether to offer the patient specialist care.
Or consider spasmodic dysphonia, a neurological voice disorder that triggers spasms in the muscles of the voice box, causing a strained or breathy voice. Doctors who lack experience with vocal disorders may miss the condition. This is why diagnosis takes an average of nearly 4.5 years, according to a study in the Journal of Voice, and may include everything from allergy testing to psychiatric evaluation, says Dr. Powell. Artificial intelligence technology trained to recognize the disorder could help eliminate such unnecessary testing.
Neurological and neurodegenerative disorders (Alzheimer’s, Parkinson’s, stroke, ALS)
For Alzheimer’s and Parkinson’s, “one of the first changes that’s notable is voice,” usually appearing before a formal diagnosis, says Anais Rameau, MD, an assistant professor of laryngology at Weill Cornell Medicine, New York, and another member of the NIH project. Parkinson’s may soften the voice or make it sound monotone, while Alzheimer’s disease may change the content of speech, leading to an uptick in “umms” and a preference for pronouns over nouns.
With Parkinson’s, vocal changes can occur decades before movement is affected. If doctors could detect the disease at this stage, before tremor emerged, they might be able to flag patients for early intervention, says Max Little, PhD, project director for the Parkinson’s Voice Initiative. “That is the ‘holy grail’ for finding an eventual cure.”
Again, the smartphone shows potential. In a 2022 Australian study, an AI-powered app was able to identify people with Parkinson’s based on brief voice recordings, although the sample size was small. On a larger scale, the Parkinson’s Voice Initiative collected some 17,000 samples from people across the world. “The aim was to remotely detect those with the condition using a telephone call,” says Dr. Little. It did so with about 65% accuracy. “While this is not accurate enough for clinical use, it shows the potential of the idea,” he says.
Dr. Rudzicz worked on the team behind Winterlight, an iPad app that analyzes 550 features of speech to detect dementia and Alzheimer’s (as well as mental illness). “We deployed it in long-term care facilities,” he says, identifying patients who need further review of their mental skills. Stroke is another area of interest, because slurred speech is a highly subjective measure, says Dr. Anderson. AI technology could provide a more objective evaluation.
Mood and psychiatric disorders (depression, schizophrenia, bipolar disorders)
No established biomarkers exist for diagnosing depression. Yet if you’re feeling down, there’s a good chance your friends can tell – even over the phone.
“We carry a lot of our mood in our voice,” says Dr. Powell. Bipolar disorder can also alter voice, making it louder and faster during manic periods, then slower and quieter during depressive bouts. The catatonic stage of schizophrenia often comes with “a very monotone, robotic voice,” says Dr. Anderson. “These are all something an algorithm can measure.”
Apps are already being used – often in research settings – to monitor voices during phone calls, analyzing rate, rhythm, volume, and pitch, to predict mood changes. For example, the PRIORI project at the University of Michigan is working on a smartphone app to identify mood changes in people with bipolar disorder, especially shifts that could increase suicide risk.
The content of speech may also offer clues. In a University of California, Los Angeles, study published in the journal PLoS One, people with mental illnesses answered computer-programmed questions (like “How have you been over the past few days?”) over the phone. An app analyzed their word choices, paying attention to how they changed over time. The researchers found that AI analysis of mood aligned well with doctors’ assessments and that some people in the study actually felt more comfortable talking to a computer.
Respiratory disorders (pneumonia, COPD)
Beyond talking, respiratory sounds like gasping or coughing may point to specific conditions. “Emphysema cough is different, COPD cough is different,” says Dr. Bensoussan. Researchers are trying to find out if COVID-19 has a distinct cough.
Breathing sounds can also serve as signposts. “There are different sounds when we can’t breathe,” says Dr. Bensoussan. One is called stridor, a high-pitched wheezing often resulting from a blocked airway. “I see tons of people [with stridor] misdiagnosed for years – they’ve been told they have asthma, but they don’t,” says Dr. Bensoussan. AI analysis of these sounds could help doctors more quickly identify respiratory disorders.
Pediatric voice and speech disorders (speech and language delays, autism)
Babies who later have autism cry differently as early as 6 months of age, which means an app like ChatterBaby could help flag children for early intervention, says Dr. Anderson. Autism is linked to several other diagnoses, such as epilepsy and sleep disorders. So analyzing an infant’s cry could prompt pediatricians to screen for a range of conditions.
ChatterBaby has been “incredibly accurate” in identifying when babies are in pain, says Dr. Anderson, because pain increases muscle tension, resulting in a louder, more energetic cry. The next goal: “We’re collecting voices from babies around the world,” she says, and then tracking those children for 7 years, looking to see if early vocal signs could predict developmental disorders. Vocal samples from young children could serve a similar purpose.
And that’s only the beginning
Eventually, AI technology may pick up disease-related voice changes that we can’t even hear. In a new Mayo Clinic study, certain vocal features detectable by AI – but not by the human ear – were linked to a three-fold increase in the likelihood of having plaque buildup in the arteries.
“Voice is a huge spectrum of vibrations,” explains study author Amir Lerman, MD. “We hear a very narrow range.”
The researchers aren’t sure why heart disease alters voice, but the autonomic nervous system may play a role, because it regulates the voice box as well as blood pressure and heart rate. Dr. Lerman says other conditions, like diseases of the nerves and gut, may similarly alter the voice. Beyond patient screening, this discovery could help doctors adjust medication doses remotely, in line with these inaudible vocal signals.
“Hopefully, in the next few years, this is going to come to practice,” says Dr. Lerman.
Still, in the face of that hope, privacy concerns remain. Voice is an identifier that’s protected by the federal Health Insurance Portability and Accountability Act, which requires privacy of personal health information. That is a major reason why no large voice databases exist yet, says Dr. Bensoussan. (This makes collecting samples from children especially challenging.) Perhaps more concerning is the potential for diagnosing disease based on voice alone. “You could use that tool on anyone, including officials like the president,” says Dr. Rameau.
But the primary hurdle is the ethical sourcing of data to ensure a diversity of vocal samples. For the Voice as a Biomarker project, the researchers will establish voice quotas for different races and ethnicities, ensuring algorithms can accurately analyze a range of accents. Data from people with speech impediments will also be gathered.
Despite these challenges, researchers are optimistic. “Vocal analysis is going to be a great equalizer and improve health outcomes,” predicts Dr. Anderson. “I’m really happy that we are beginning to understand the strength of the voice.”
A version of this article first appeared on WebMD.com.
: First during puberty, as the vocal cords thicken and the voice box migrates down the throat. Then a second time as aging causes structural changes that may weaken the voice.
But for some of us, there’s another voice shift, when a disease begins or when our mental health declines.
This is why more doctors are looking into voice as a biomarker – something that tells you that a disease is present.
Vital signs like blood pressure or heart rate “can give a general idea of how sick we are. But they’re not specific to certain diseases,” says Yael Bensoussan, MD, director of the University of South Florida, Tampa’s Health Voice Center and the coprincipal investigator for the National Institutes of Health’s Voice as a Biomarker of Health project.
“We’re learning that there are patterns” in voice changes that can indicate a range of conditions, including diseases of the nervous system and mental illnesses, she says.
Speaking is complicated, involving everything from the lungs and voice box to the mouth and brain. “A breakdown in any of those parts can affect the voice,” says Maria Powell, PhD, an assistant professor of otolaryngology (the study of diseases of the ear and throat) at Vanderbilt University, Nashville, Tenn., who is working on the NIH project.
You or those around you may not notice the changes. But researchers say voice analysis as a standard part of patient care – akin to blood pressure checks or cholesterol tests – could help identify those who need medical attention earlier.
Often, all it takes is a smartphone – “something that’s cheap, off-the-shelf, and that everyone can use,” says Ariana Anderson, PhD, director of the University of California, Los Angeles, Laboratory of Computational Neuropsychology.
“You can provide voice data in your pajamas, on your couch,” says Frank Rudzicz, PhD, a computer scientist for the NIH project. “It doesn’t require very complicated or expensive equipment, and it doesn’t require a lot of expertise to obtain.” Plus, multiple samples can be collected over time, giving a more accurate picture of health than a single snapshot from, say, a cognitive test.
Over the next 4 years, the Voice as a Biomarker team will receive nearly $18 million to gather a massive amount of voice data. The goal is 20,000-30,000 samples, along with health data about each person being studied. The result will be a sprawling database scientists can use to develop algorithms linking health conditions to the way we speak.
For the first 2 years, new data will be collected exclusively via universities and high-volume clinics to control quality and accuracy. Eventually, people will be invited to submit their own voice recordings, creating a crowdsourced dataset. “Google, Alexa, Amazon – they have access to tons of voice data,” says Dr. Bensoussan. “But it’s not usable in a clinical way, because they don’t have the health information.”
Dr. Bensoussan and her colleagues hope to fill that void with advance voice screening apps, which could prove especially valuable in remote communities that lack access to specialists or as a tool for telemedicine. Down the line, wearable devices with voice analysis could alert people with chronic conditions when they need to see a doctor.
“The watch says, ‘I’ve analyzed your breathing and coughing, and today, you’re really not doing well. You should go to the hospital,’ ” says Dr. Bensoussan, envisioning a wearable for patients with COPD. “It could tell people early that things are declining.”
Artificial intelligence may be better than a brain at pinpointing the right disease. For example, slurred speech could indicate Parkinson’s, a stroke, or ALS, among other things.
“We can hold approximately seven pieces of information in our head at one time,” says Dr. Rudzicz. “It’s really hard for us to get a holistic picture using dozens or hundreds of variables at once.” But a computer can consider a whole range of vocal markers at the same time, piecing them together for a more accurate assessment.
“The goal is not to outperform a ... clinician,” says Dr. Bensoussan. Yet the potential is unmistakably there: In a recent study of patients with cancer of the larynx, an automated voice analysis tool more accurately flagged the disease than laryngologists did.
“Algorithms have a larger training base,” says Dr. Anderson, who developed an app called ChatterBaby that analyzes infant cries. “We have a million samples at our disposal to train our algorithms. I don’t know if I’ve heard a million different babies crying in my life.”
So which health conditions show the most promise for voice analysis? The Voice as a Biomarker project will focus on five categories.
Voice disorders (cancers of the larynx, vocal fold paralysis, benign lesions on the larynx)
Obviously, vocal changes are a hallmark of these conditions, which cause things like breathiness or “roughness,” a type of vocal irregularity. Hoarseness that lasts at least 2 weeks is often one of the earliest signs of laryngeal cancer. Yet it can take months – one study found 16 weeks was the average – for patients to see a doctor after noticing the changes. Even then, laryngologists still misdiagnosed some cases of cancer when relying on vocal cues alone.
Now imagine a different scenario: The patient speaks into a smartphone app. An algorithm compares the vocal sample with the voices of laryngeal cancer patients. The app spits out the estimated odds of laryngeal cancer, helping providers decide whether to offer the patient specialist care.
Or consider spasmodic dysphonia, a neurological voice disorder that triggers spasms in the muscles of the voice box, causing a strained or breathy voice. Doctors who lack experience with vocal disorders may miss the condition. This is why diagnosis takes an average of nearly 4.5 years, according to a study in the Journal of Voice, and may include everything from allergy testing to psychiatric evaluation, says Dr. Powell. Artificial intelligence technology trained to recognize the disorder could help eliminate such unnecessary testing.
Neurological and neurodegenerative disorders (Alzheimer’s, Parkinson’s, stroke, ALS)
For Alzheimer’s and Parkinson’s, “one of the first changes that’s notable is voice,” usually appearing before a formal diagnosis, says Anais Rameau, MD, an assistant professor of laryngology at Weill Cornell Medicine, New York, and another member of the NIH project. Parkinson’s may soften the voice or make it sound monotone, while Alzheimer’s disease may change the content of speech, leading to an uptick in “umms” and a preference for pronouns over nouns.
With Parkinson’s, vocal changes can occur decades before movement is affected. If doctors could detect the disease at this stage, before tremor emerged, they might be able to flag patients for early intervention, says Max Little, PhD, project director for the Parkinson’s Voice Initiative. “That is the ‘holy grail’ for finding an eventual cure.”
Again, the smartphone shows potential. In a 2022 Australian study, an AI-powered app was able to identify people with Parkinson’s based on brief voice recordings, although the sample size was small. On a larger scale, the Parkinson’s Voice Initiative collected some 17,000 samples from people across the world. “The aim was to remotely detect those with the condition using a telephone call,” says Dr. Little. It did so with about 65% accuracy. “While this is not accurate enough for clinical use, it shows the potential of the idea,” he says.
Dr. Rudzicz worked on the team behind Winterlight, an iPad app that analyzes 550 features of speech to detect dementia and Alzheimer’s (as well as mental illness). “We deployed it in long-term care facilities,” he says, identifying patients who need further review of their mental skills. Stroke is another area of interest, because slurred speech is a highly subjective measure, says Dr. Anderson. AI technology could provide a more objective evaluation.
Mood and psychiatric disorders (depression, schizophrenia, bipolar disorders)
No established biomarkers exist for diagnosing depression. Yet if you’re feeling down, there’s a good chance your friends can tell – even over the phone.
“We carry a lot of our mood in our voice,” says Dr. Powell. Bipolar disorder can also alter voice, making it louder and faster during manic periods, then slower and quieter during depressive bouts. The catatonic stage of schizophrenia often comes with “a very monotone, robotic voice,” says Dr. Anderson. “These are all something an algorithm can measure.”
Apps are already being used – often in research settings – to monitor voices during phone calls, analyzing rate, rhythm, volume, and pitch, to predict mood changes. For example, the PRIORI project at the University of Michigan is working on a smartphone app to identify mood changes in people with bipolar disorder, especially shifts that could increase suicide risk.
The content of speech may also offer clues. In a University of California, Los Angeles, study published in the journal PLoS One, people with mental illnesses answered computer-programmed questions (like “How have you been over the past few days?”) over the phone. An app analyzed their word choices, paying attention to how they changed over time. The researchers found that AI analysis of mood aligned well with doctors’ assessments and that some people in the study actually felt more comfortable talking to a computer.
Respiratory disorders (pneumonia, COPD)
Beyond talking, respiratory sounds like gasping or coughing may point to specific conditions. “Emphysema cough is different, COPD cough is different,” says Dr. Bensoussan. Researchers are trying to find out if COVID-19 has a distinct cough.
Breathing sounds can also serve as signposts. “There are different sounds when we can’t breathe,” says Dr. Bensoussan. One is called stridor, a high-pitched wheezing often resulting from a blocked airway. “I see tons of people [with stridor] misdiagnosed for years – they’ve been told they have asthma, but they don’t,” says Dr. Bensoussan. AI analysis of these sounds could help doctors more quickly identify respiratory disorders.
Pediatric voice and speech disorders (speech and language delays, autism)
Babies who later have autism cry differently as early as 6 months of age, which means an app like ChatterBaby could help flag children for early intervention, says Dr. Anderson. Autism is linked to several other diagnoses, such as epilepsy and sleep disorders. So analyzing an infant’s cry could prompt pediatricians to screen for a range of conditions.
ChatterBaby has been “incredibly accurate” in identifying when babies are in pain, says Dr. Anderson, because pain increases muscle tension, resulting in a louder, more energetic cry. The next goal: “We’re collecting voices from babies around the world,” she says, and then tracking those children for 7 years, looking to see if early vocal signs could predict developmental disorders. Vocal samples from young children could serve a similar purpose.
And that’s only the beginning
Eventually, AI technology may pick up disease-related voice changes that we can’t even hear. In a new Mayo Clinic study, certain vocal features detectable by AI – but not by the human ear – were linked to a three-fold increase in the likelihood of having plaque buildup in the arteries.
“Voice is a huge spectrum of vibrations,” explains study author Amir Lerman, MD. “We hear a very narrow range.”
The researchers aren’t sure why heart disease alters voice, but the autonomic nervous system may play a role, because it regulates the voice box as well as blood pressure and heart rate. Dr. Lerman says other conditions, like diseases of the nerves and gut, may similarly alter the voice. Beyond patient screening, this discovery could help doctors adjust medication doses remotely, in line with these inaudible vocal signals.
“Hopefully, in the next few years, this is going to come to practice,” says Dr. Lerman.
Still, in the face of that hope, privacy concerns remain. Voice is an identifier that’s protected by the federal Health Insurance Portability and Accountability Act, which requires privacy of personal health information. That is a major reason why no large voice databases exist yet, says Dr. Bensoussan. (This makes collecting samples from children especially challenging.) Perhaps more concerning is the potential for diagnosing disease based on voice alone. “You could use that tool on anyone, including officials like the president,” says Dr. Rameau.
But the primary hurdle is the ethical sourcing of data to ensure a diversity of vocal samples. For the Voice as a Biomarker project, the researchers will establish voice quotas for different races and ethnicities, ensuring algorithms can accurately analyze a range of accents. Data from people with speech impediments will also be gathered.
Despite these challenges, researchers are optimistic. “Vocal analysis is going to be a great equalizer and improve health outcomes,” predicts Dr. Anderson. “I’m really happy that we are beginning to understand the strength of the voice.”
A version of this article first appeared on WebMD.com.
: First during puberty, as the vocal cords thicken and the voice box migrates down the throat. Then a second time as aging causes structural changes that may weaken the voice.
But for some of us, there’s another voice shift, when a disease begins or when our mental health declines.
This is why more doctors are looking into voice as a biomarker – something that tells you that a disease is present.
Vital signs like blood pressure or heart rate “can give a general idea of how sick we are. But they’re not specific to certain diseases,” says Yael Bensoussan, MD, director of the University of South Florida, Tampa’s Health Voice Center and the coprincipal investigator for the National Institutes of Health’s Voice as a Biomarker of Health project.
“We’re learning that there are patterns” in voice changes that can indicate a range of conditions, including diseases of the nervous system and mental illnesses, she says.
Speaking is complicated, involving everything from the lungs and voice box to the mouth and brain. “A breakdown in any of those parts can affect the voice,” says Maria Powell, PhD, an assistant professor of otolaryngology (the study of diseases of the ear and throat) at Vanderbilt University, Nashville, Tenn., who is working on the NIH project.
You or those around you may not notice the changes. But researchers say voice analysis as a standard part of patient care – akin to blood pressure checks or cholesterol tests – could help identify those who need medical attention earlier.
Often, all it takes is a smartphone – “something that’s cheap, off-the-shelf, and that everyone can use,” says Ariana Anderson, PhD, director of the University of California, Los Angeles, Laboratory of Computational Neuropsychology.
“You can provide voice data in your pajamas, on your couch,” says Frank Rudzicz, PhD, a computer scientist for the NIH project. “It doesn’t require very complicated or expensive equipment, and it doesn’t require a lot of expertise to obtain.” Plus, multiple samples can be collected over time, giving a more accurate picture of health than a single snapshot from, say, a cognitive test.
Over the next 4 years, the Voice as a Biomarker team will receive nearly $18 million to gather a massive amount of voice data. The goal is 20,000-30,000 samples, along with health data about each person being studied. The result will be a sprawling database scientists can use to develop algorithms linking health conditions to the way we speak.
For the first 2 years, new data will be collected exclusively via universities and high-volume clinics to control quality and accuracy. Eventually, people will be invited to submit their own voice recordings, creating a crowdsourced dataset. “Google, Alexa, Amazon – they have access to tons of voice data,” says Dr. Bensoussan. “But it’s not usable in a clinical way, because they don’t have the health information.”
Dr. Bensoussan and her colleagues hope to fill that void with advance voice screening apps, which could prove especially valuable in remote communities that lack access to specialists or as a tool for telemedicine. Down the line, wearable devices with voice analysis could alert people with chronic conditions when they need to see a doctor.
“The watch says, ‘I’ve analyzed your breathing and coughing, and today, you’re really not doing well. You should go to the hospital,’ ” says Dr. Bensoussan, envisioning a wearable for patients with COPD. “It could tell people early that things are declining.”
Artificial intelligence may be better than a brain at pinpointing the right disease. For example, slurred speech could indicate Parkinson’s, a stroke, or ALS, among other things.
“We can hold approximately seven pieces of information in our head at one time,” says Dr. Rudzicz. “It’s really hard for us to get a holistic picture using dozens or hundreds of variables at once.” But a computer can consider a whole range of vocal markers at the same time, piecing them together for a more accurate assessment.
“The goal is not to outperform a ... clinician,” says Dr. Bensoussan. Yet the potential is unmistakably there: In a recent study of patients with cancer of the larynx, an automated voice analysis tool more accurately flagged the disease than laryngologists did.
“Algorithms have a larger training base,” says Dr. Anderson, who developed an app called ChatterBaby that analyzes infant cries. “We have a million samples at our disposal to train our algorithms. I don’t know if I’ve heard a million different babies crying in my life.”
So which health conditions show the most promise for voice analysis? The Voice as a Biomarker project will focus on five categories.
Voice disorders (cancers of the larynx, vocal fold paralysis, benign lesions on the larynx)
Obviously, vocal changes are a hallmark of these conditions, which cause things like breathiness or “roughness,” a type of vocal irregularity. Hoarseness that lasts at least 2 weeks is often one of the earliest signs of laryngeal cancer. Yet it can take months – one study found 16 weeks was the average – for patients to see a doctor after noticing the changes. Even then, laryngologists still misdiagnosed some cases of cancer when relying on vocal cues alone.
Now imagine a different scenario: The patient speaks into a smartphone app. An algorithm compares the vocal sample with the voices of laryngeal cancer patients. The app spits out the estimated odds of laryngeal cancer, helping providers decide whether to offer the patient specialist care.
Or consider spasmodic dysphonia, a neurological voice disorder that triggers spasms in the muscles of the voice box, causing a strained or breathy voice. Doctors who lack experience with vocal disorders may miss the condition. This is why diagnosis takes an average of nearly 4.5 years, according to a study in the Journal of Voice, and may include everything from allergy testing to psychiatric evaluation, says Dr. Powell. Artificial intelligence technology trained to recognize the disorder could help eliminate such unnecessary testing.
Neurological and neurodegenerative disorders (Alzheimer’s, Parkinson’s, stroke, ALS)
For Alzheimer’s and Parkinson’s, “one of the first changes that’s notable is voice,” usually appearing before a formal diagnosis, says Anais Rameau, MD, an assistant professor of laryngology at Weill Cornell Medicine, New York, and another member of the NIH project. Parkinson’s may soften the voice or make it sound monotone, while Alzheimer’s disease may change the content of speech, leading to an uptick in “umms” and a preference for pronouns over nouns.
With Parkinson’s, vocal changes can occur decades before movement is affected. If doctors could detect the disease at this stage, before tremor emerged, they might be able to flag patients for early intervention, says Max Little, PhD, project director for the Parkinson’s Voice Initiative. “That is the ‘holy grail’ for finding an eventual cure.”
Again, the smartphone shows potential. In a 2022 Australian study, an AI-powered app was able to identify people with Parkinson’s based on brief voice recordings, although the sample size was small. On a larger scale, the Parkinson’s Voice Initiative collected some 17,000 samples from people across the world. “The aim was to remotely detect those with the condition using a telephone call,” says Dr. Little. It did so with about 65% accuracy. “While this is not accurate enough for clinical use, it shows the potential of the idea,” he says.
Dr. Rudzicz worked on the team behind Winterlight, an iPad app that analyzes 550 features of speech to detect dementia and Alzheimer’s (as well as mental illness). “We deployed it in long-term care facilities,” he says, identifying patients who need further review of their mental skills. Stroke is another area of interest, because slurred speech is a highly subjective measure, says Dr. Anderson. AI technology could provide a more objective evaluation.
Mood and psychiatric disorders (depression, schizophrenia, bipolar disorders)
No established biomarkers exist for diagnosing depression. Yet if you’re feeling down, there’s a good chance your friends can tell – even over the phone.
“We carry a lot of our mood in our voice,” says Dr. Powell. Bipolar disorder can also alter voice, making it louder and faster during manic periods, then slower and quieter during depressive bouts. The catatonic stage of schizophrenia often comes with “a very monotone, robotic voice,” says Dr. Anderson. “These are all something an algorithm can measure.”
Apps are already being used – often in research settings – to monitor voices during phone calls, analyzing rate, rhythm, volume, and pitch, to predict mood changes. For example, the PRIORI project at the University of Michigan is working on a smartphone app to identify mood changes in people with bipolar disorder, especially shifts that could increase suicide risk.
The content of speech may also offer clues. In a University of California, Los Angeles, study published in the journal PLoS One, people with mental illnesses answered computer-programmed questions (like “How have you been over the past few days?”) over the phone. An app analyzed their word choices, paying attention to how they changed over time. The researchers found that AI analysis of mood aligned well with doctors’ assessments and that some people in the study actually felt more comfortable talking to a computer.
Respiratory disorders (pneumonia, COPD)
Beyond talking, respiratory sounds like gasping or coughing may point to specific conditions. “Emphysema cough is different, COPD cough is different,” says Dr. Bensoussan. Researchers are trying to find out if COVID-19 has a distinct cough.
Breathing sounds can also serve as signposts. “There are different sounds when we can’t breathe,” says Dr. Bensoussan. One is called stridor, a high-pitched wheezing often resulting from a blocked airway. “I see tons of people [with stridor] misdiagnosed for years – they’ve been told they have asthma, but they don’t,” says Dr. Bensoussan. AI analysis of these sounds could help doctors more quickly identify respiratory disorders.
Pediatric voice and speech disorders (speech and language delays, autism)
Babies who later have autism cry differently as early as 6 months of age, which means an app like ChatterBaby could help flag children for early intervention, says Dr. Anderson. Autism is linked to several other diagnoses, such as epilepsy and sleep disorders. So analyzing an infant’s cry could prompt pediatricians to screen for a range of conditions.
ChatterBaby has been “incredibly accurate” in identifying when babies are in pain, says Dr. Anderson, because pain increases muscle tension, resulting in a louder, more energetic cry. The next goal: “We’re collecting voices from babies around the world,” she says, and then tracking those children for 7 years, looking to see if early vocal signs could predict developmental disorders. Vocal samples from young children could serve a similar purpose.
And that’s only the beginning
Eventually, AI technology may pick up disease-related voice changes that we can’t even hear. In a new Mayo Clinic study, certain vocal features detectable by AI – but not by the human ear – were linked to a three-fold increase in the likelihood of having plaque buildup in the arteries.
“Voice is a huge spectrum of vibrations,” explains study author Amir Lerman, MD. “We hear a very narrow range.”
The researchers aren’t sure why heart disease alters voice, but the autonomic nervous system may play a role, because it regulates the voice box as well as blood pressure and heart rate. Dr. Lerman says other conditions, like diseases of the nerves and gut, may similarly alter the voice. Beyond patient screening, this discovery could help doctors adjust medication doses remotely, in line with these inaudible vocal signals.
“Hopefully, in the next few years, this is going to come to practice,” says Dr. Lerman.
Still, in the face of that hope, privacy concerns remain. Voice is an identifier that’s protected by the federal Health Insurance Portability and Accountability Act, which requires privacy of personal health information. That is a major reason why no large voice databases exist yet, says Dr. Bensoussan. (This makes collecting samples from children especially challenging.) Perhaps more concerning is the potential for diagnosing disease based on voice alone. “You could use that tool on anyone, including officials like the president,” says Dr. Rameau.
But the primary hurdle is the ethical sourcing of data to ensure a diversity of vocal samples. For the Voice as a Biomarker project, the researchers will establish voice quotas for different races and ethnicities, ensuring algorithms can accurately analyze a range of accents. Data from people with speech impediments will also be gathered.
Despite these challenges, researchers are optimistic. “Vocal analysis is going to be a great equalizer and improve health outcomes,” predicts Dr. Anderson. “I’m really happy that we are beginning to understand the strength of the voice.”
A version of this article first appeared on WebMD.com.
Cold water immersion can have benefits
according to researchers from the Arctic University of Norway and the University Hospital of North Norway.
What to know
- Immersion in cold water has a major impact on the body. It elevates the heart rate and has positive effects on brown adipose tissue, a type of “good” body fat that is activated by cold and may protect against and cardiovascular disease.
- Exposure to cold water or cold air also appears to increase the production of the protein adiponectin by adipose tissue. Adiponectin plays a key role in protecting against , diabetes, and other diseases.
- Repeated cold-water immersions by inexperienced as well as experienced swimmers during the winter months significantly increased sensitivity and decreased insulin concentrations.
- Numerous health and well-being claims from regular exposure to the cold, such as weight loss, better mental health, and increased libido, may be explained by other factors, including an active lifestyle, trained stress handling, and social interactions, as well as a positive mindset.
- Those seeking to voluntarily practice cold-water immersion need to be educated about possible health risks associated with taking a dip in icy water, which include the consequences of hypothermia, and of heart and lung problems, which are often related to the shock from the cold.
This is a summary of the article, “Health effects of voluntary exposure to cold water – a continuing subject of debate,” published by the International Journal of Circumpolar Health.
A version of this article first appeared on Medscape.com.
according to researchers from the Arctic University of Norway and the University Hospital of North Norway.
What to know
- Immersion in cold water has a major impact on the body. It elevates the heart rate and has positive effects on brown adipose tissue, a type of “good” body fat that is activated by cold and may protect against and cardiovascular disease.
- Exposure to cold water or cold air also appears to increase the production of the protein adiponectin by adipose tissue. Adiponectin plays a key role in protecting against , diabetes, and other diseases.
- Repeated cold-water immersions by inexperienced as well as experienced swimmers during the winter months significantly increased sensitivity and decreased insulin concentrations.
- Numerous health and well-being claims from regular exposure to the cold, such as weight loss, better mental health, and increased libido, may be explained by other factors, including an active lifestyle, trained stress handling, and social interactions, as well as a positive mindset.
- Those seeking to voluntarily practice cold-water immersion need to be educated about possible health risks associated with taking a dip in icy water, which include the consequences of hypothermia, and of heart and lung problems, which are often related to the shock from the cold.
This is a summary of the article, “Health effects of voluntary exposure to cold water – a continuing subject of debate,” published by the International Journal of Circumpolar Health.
A version of this article first appeared on Medscape.com.
according to researchers from the Arctic University of Norway and the University Hospital of North Norway.
What to know
- Immersion in cold water has a major impact on the body. It elevates the heart rate and has positive effects on brown adipose tissue, a type of “good” body fat that is activated by cold and may protect against and cardiovascular disease.
- Exposure to cold water or cold air also appears to increase the production of the protein adiponectin by adipose tissue. Adiponectin plays a key role in protecting against , diabetes, and other diseases.
- Repeated cold-water immersions by inexperienced as well as experienced swimmers during the winter months significantly increased sensitivity and decreased insulin concentrations.
- Numerous health and well-being claims from regular exposure to the cold, such as weight loss, better mental health, and increased libido, may be explained by other factors, including an active lifestyle, trained stress handling, and social interactions, as well as a positive mindset.
- Those seeking to voluntarily practice cold-water immersion need to be educated about possible health risks associated with taking a dip in icy water, which include the consequences of hypothermia, and of heart and lung problems, which are often related to the shock from the cold.
This is a summary of the article, “Health effects of voluntary exposure to cold water – a continuing subject of debate,” published by the International Journal of Circumpolar Health.
A version of this article first appeared on Medscape.com.
FROM THE INTERNATIONAL JOURNAL OF CIRCUMPOLAR HEALTH
More states to consider extending postpartum Medicaid coverage beyond 2 months
Lawmakers in several conservative-led states – including Montana, Wyoming, Missouri, and Mississippi – are expected to consider proposals to provide a year of continuous health coverage to new mothers enrolled in Medicaid.
Medicaid beneficiaries nationwide are guaranteed continuous postpartum coverage during the ongoing covid-19 public health emergency. But momentum has been building for states to extend the default 60-day required coverage period ahead of the emergency’s eventual end. Approximately 42% of births nationwide are covered under Medicaid, the federal-state health insurance program for low-income people, and extending postpartum coverage aims to reduce the risk of pregnancy-related deaths and illnesses by ensuring that new mothers’ medical care isn’t interrupted.
The push comes as a provision in the American Rescue Plan Act makes extending postpartum Medicaid coverage easier because states no longer need to apply for a waiver. A renewed focus on maternal health amid high U.S. maternal mortality rates also is driving the proposals, as is the expectation that more women will need postpartum care as state abortion bans proliferate in the wake of the U.S. Supreme Court’s decision to eliminate federal protections.
Thirty-five states and Washington have already extended, or plan to extend, postpartum eligibility in their Medicaid programs. That number includes Texas and Wisconsin, which did not implement the ARPA provision but have proposed limited extensions of 6 months and 90 days, respectively.
The 15 states that limit postpartum Medicaid eligibility to 60 days are predominantly a swath of Republican-led states that stretch from the Mountain West to the South. But that could change when legislative sessions start in the new year.
In Montana, Republican Gov. Greg Gianforte and Department of Public Health and Human Services Director Charlie Brereton included 12-month postpartum eligibility in the governor’s proposed state budget. It would cost $9.2 million in federal and state funding over the next 2 years, according to the proposal, with the federal government covering nearly 70%.
A 2021 U.S. Department of Health and Human Services report estimated about 2,000 women in Montana would benefit from the change. State health department spokesperson Jon Ebelt said state officials’ estimate is half that number. The reason for the disparity was not immediately clear.
Mr. Brereton considers the “extension of coverage for new mothers to be a pro-life, pro-family reform,” Mr. Ebelt said.
To become law, the proposal must be approved by state lawmakers once the legislative session begins in January. It has already received enthusiastic support from the senior Democrat on the committee that oversees the health department’s budget. “Continuous eligibility for women after they have a baby is really important,” said state Rep. Mary Caferro during the Children’s Legislative Forum in Helena on Nov. 30.
The top Republican on the committee, state Rep.-elect Bob Keenan, said he hasn’t dug in on the governor’s budget proposal but added that he plans to survey his fellow lawmakers and health care providers on the postpartum extension. “I wouldn’t dare venture a guess as to its acceptance,” he said.
Nationwide, more than 1 in 5 mothers whose pregnancies were covered by Medicaid lose their insurance within 6 months of giving birth, and 1 in 3 pregnancy-related deaths happen between a week and a year after a birth occurs, according to federal health officials.
The United States had the highest overall maternal mortality rate, by far, among wealthy nations in 2020, at 23.8 deaths per 100,000 births, according to a report by the Commonwealth Fund, a foundation that supports research focused on health care issues. The rate for Black women in the United States is even higher, 55.3 deaths.
“Many maternal deaths result from missed or delayed opportunities for treatment,” the report said.
The maternal mortality rate in Montana is not publicly available because the Centers for Disease Control and Prevention suppressed the state data in 2020 “due to reliability and confidentiality restrictions.” Mr. Ebelt, the state health department spokesperson, could not provide a rate before this article’s publication.
Annie Glover, a senior research scientist for the University of Montana’s Rural Institute for Inclusive Communities, said the governor’s proposal to extend postpartum Medicaid coverage could make a significant difference in improving overall maternal health in Montana. The university was awarded a federal grant this year for such efforts, particularly to lower the mortality rate among Native Americans, and Ms. Glover said the state measure could further reduce rates.
“The reason really has to do with maintaining access to care during this very critical period,” Ms. Glover said. That goes for helping mothers with postpartum depression, as well as medical conditions like high blood pressure that require follow-ups with a physician well after delivery, she said.
In Wyoming, a legislative committee voted 6-5 in August to introduce a bill in the next session; dissenters cited the cost and their reluctance to further entangle the state in federal government programs.
About a third of Wyoming births are covered by Medicaid, and state officials estimate about 1,250 women would benefit from the change.
Postpartum eligibility bills are also expected to be taken up by legislators in Missouri and Mississippi, two states that have previously grappled with the issue. Both states have outlawed most abortions since the U.S. Supreme Court lifted federal protections in June, and Mississippi leaders have said additional postpartum care is needed because of the thousands of additional births expected as a result of the state’s ban.
A proposed coverage expansion died in the Mississippi House last session, but Lt. Gov. Delbert Hosemann said the Senate will revive the measure, according to Mississippi Today.
Last year, federal officials approved a Medicaid waiver for Missouri that allows the state to extend postpartum eligibility. But state officials delayed implementing the change to determine how enrollment would be affected by Missouri voters’ decision in August 2020 to expand Medicaid eligibility to more people. The delay prompted a bill to be filed last session that would have extended postpartum coverage by a year. That measure died, but a state lawmaker has pre-filed a bill that will bring back the debate in the upcoming session.
In Idaho, a children’s advocacy group said it will press lawmakers to approve a postpartum eligibility extension, among other measures, after the state banned nearly all abortions this year.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
Lawmakers in several conservative-led states – including Montana, Wyoming, Missouri, and Mississippi – are expected to consider proposals to provide a year of continuous health coverage to new mothers enrolled in Medicaid.
Medicaid beneficiaries nationwide are guaranteed continuous postpartum coverage during the ongoing covid-19 public health emergency. But momentum has been building for states to extend the default 60-day required coverage period ahead of the emergency’s eventual end. Approximately 42% of births nationwide are covered under Medicaid, the federal-state health insurance program for low-income people, and extending postpartum coverage aims to reduce the risk of pregnancy-related deaths and illnesses by ensuring that new mothers’ medical care isn’t interrupted.
The push comes as a provision in the American Rescue Plan Act makes extending postpartum Medicaid coverage easier because states no longer need to apply for a waiver. A renewed focus on maternal health amid high U.S. maternal mortality rates also is driving the proposals, as is the expectation that more women will need postpartum care as state abortion bans proliferate in the wake of the U.S. Supreme Court’s decision to eliminate federal protections.
Thirty-five states and Washington have already extended, or plan to extend, postpartum eligibility in their Medicaid programs. That number includes Texas and Wisconsin, which did not implement the ARPA provision but have proposed limited extensions of 6 months and 90 days, respectively.
The 15 states that limit postpartum Medicaid eligibility to 60 days are predominantly a swath of Republican-led states that stretch from the Mountain West to the South. But that could change when legislative sessions start in the new year.
In Montana, Republican Gov. Greg Gianforte and Department of Public Health and Human Services Director Charlie Brereton included 12-month postpartum eligibility in the governor’s proposed state budget. It would cost $9.2 million in federal and state funding over the next 2 years, according to the proposal, with the federal government covering nearly 70%.
A 2021 U.S. Department of Health and Human Services report estimated about 2,000 women in Montana would benefit from the change. State health department spokesperson Jon Ebelt said state officials’ estimate is half that number. The reason for the disparity was not immediately clear.
Mr. Brereton considers the “extension of coverage for new mothers to be a pro-life, pro-family reform,” Mr. Ebelt said.
To become law, the proposal must be approved by state lawmakers once the legislative session begins in January. It has already received enthusiastic support from the senior Democrat on the committee that oversees the health department’s budget. “Continuous eligibility for women after they have a baby is really important,” said state Rep. Mary Caferro during the Children’s Legislative Forum in Helena on Nov. 30.
The top Republican on the committee, state Rep.-elect Bob Keenan, said he hasn’t dug in on the governor’s budget proposal but added that he plans to survey his fellow lawmakers and health care providers on the postpartum extension. “I wouldn’t dare venture a guess as to its acceptance,” he said.
Nationwide, more than 1 in 5 mothers whose pregnancies were covered by Medicaid lose their insurance within 6 months of giving birth, and 1 in 3 pregnancy-related deaths happen between a week and a year after a birth occurs, according to federal health officials.
The United States had the highest overall maternal mortality rate, by far, among wealthy nations in 2020, at 23.8 deaths per 100,000 births, according to a report by the Commonwealth Fund, a foundation that supports research focused on health care issues. The rate for Black women in the United States is even higher, 55.3 deaths.
“Many maternal deaths result from missed or delayed opportunities for treatment,” the report said.
The maternal mortality rate in Montana is not publicly available because the Centers for Disease Control and Prevention suppressed the state data in 2020 “due to reliability and confidentiality restrictions.” Mr. Ebelt, the state health department spokesperson, could not provide a rate before this article’s publication.
Annie Glover, a senior research scientist for the University of Montana’s Rural Institute for Inclusive Communities, said the governor’s proposal to extend postpartum Medicaid coverage could make a significant difference in improving overall maternal health in Montana. The university was awarded a federal grant this year for such efforts, particularly to lower the mortality rate among Native Americans, and Ms. Glover said the state measure could further reduce rates.
“The reason really has to do with maintaining access to care during this very critical period,” Ms. Glover said. That goes for helping mothers with postpartum depression, as well as medical conditions like high blood pressure that require follow-ups with a physician well after delivery, she said.
In Wyoming, a legislative committee voted 6-5 in August to introduce a bill in the next session; dissenters cited the cost and their reluctance to further entangle the state in federal government programs.
About a third of Wyoming births are covered by Medicaid, and state officials estimate about 1,250 women would benefit from the change.
Postpartum eligibility bills are also expected to be taken up by legislators in Missouri and Mississippi, two states that have previously grappled with the issue. Both states have outlawed most abortions since the U.S. Supreme Court lifted federal protections in June, and Mississippi leaders have said additional postpartum care is needed because of the thousands of additional births expected as a result of the state’s ban.
A proposed coverage expansion died in the Mississippi House last session, but Lt. Gov. Delbert Hosemann said the Senate will revive the measure, according to Mississippi Today.
Last year, federal officials approved a Medicaid waiver for Missouri that allows the state to extend postpartum eligibility. But state officials delayed implementing the change to determine how enrollment would be affected by Missouri voters’ decision in August 2020 to expand Medicaid eligibility to more people. The delay prompted a bill to be filed last session that would have extended postpartum coverage by a year. That measure died, but a state lawmaker has pre-filed a bill that will bring back the debate in the upcoming session.
In Idaho, a children’s advocacy group said it will press lawmakers to approve a postpartum eligibility extension, among other measures, after the state banned nearly all abortions this year.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
Lawmakers in several conservative-led states – including Montana, Wyoming, Missouri, and Mississippi – are expected to consider proposals to provide a year of continuous health coverage to new mothers enrolled in Medicaid.
Medicaid beneficiaries nationwide are guaranteed continuous postpartum coverage during the ongoing covid-19 public health emergency. But momentum has been building for states to extend the default 60-day required coverage period ahead of the emergency’s eventual end. Approximately 42% of births nationwide are covered under Medicaid, the federal-state health insurance program for low-income people, and extending postpartum coverage aims to reduce the risk of pregnancy-related deaths and illnesses by ensuring that new mothers’ medical care isn’t interrupted.
The push comes as a provision in the American Rescue Plan Act makes extending postpartum Medicaid coverage easier because states no longer need to apply for a waiver. A renewed focus on maternal health amid high U.S. maternal mortality rates also is driving the proposals, as is the expectation that more women will need postpartum care as state abortion bans proliferate in the wake of the U.S. Supreme Court’s decision to eliminate federal protections.
Thirty-five states and Washington have already extended, or plan to extend, postpartum eligibility in their Medicaid programs. That number includes Texas and Wisconsin, which did not implement the ARPA provision but have proposed limited extensions of 6 months and 90 days, respectively.
The 15 states that limit postpartum Medicaid eligibility to 60 days are predominantly a swath of Republican-led states that stretch from the Mountain West to the South. But that could change when legislative sessions start in the new year.
In Montana, Republican Gov. Greg Gianforte and Department of Public Health and Human Services Director Charlie Brereton included 12-month postpartum eligibility in the governor’s proposed state budget. It would cost $9.2 million in federal and state funding over the next 2 years, according to the proposal, with the federal government covering nearly 70%.
A 2021 U.S. Department of Health and Human Services report estimated about 2,000 women in Montana would benefit from the change. State health department spokesperson Jon Ebelt said state officials’ estimate is half that number. The reason for the disparity was not immediately clear.
Mr. Brereton considers the “extension of coverage for new mothers to be a pro-life, pro-family reform,” Mr. Ebelt said.
To become law, the proposal must be approved by state lawmakers once the legislative session begins in January. It has already received enthusiastic support from the senior Democrat on the committee that oversees the health department’s budget. “Continuous eligibility for women after they have a baby is really important,” said state Rep. Mary Caferro during the Children’s Legislative Forum in Helena on Nov. 30.
The top Republican on the committee, state Rep.-elect Bob Keenan, said he hasn’t dug in on the governor’s budget proposal but added that he plans to survey his fellow lawmakers and health care providers on the postpartum extension. “I wouldn’t dare venture a guess as to its acceptance,” he said.
Nationwide, more than 1 in 5 mothers whose pregnancies were covered by Medicaid lose their insurance within 6 months of giving birth, and 1 in 3 pregnancy-related deaths happen between a week and a year after a birth occurs, according to federal health officials.
The United States had the highest overall maternal mortality rate, by far, among wealthy nations in 2020, at 23.8 deaths per 100,000 births, according to a report by the Commonwealth Fund, a foundation that supports research focused on health care issues. The rate for Black women in the United States is even higher, 55.3 deaths.
“Many maternal deaths result from missed or delayed opportunities for treatment,” the report said.
The maternal mortality rate in Montana is not publicly available because the Centers for Disease Control and Prevention suppressed the state data in 2020 “due to reliability and confidentiality restrictions.” Mr. Ebelt, the state health department spokesperson, could not provide a rate before this article’s publication.
Annie Glover, a senior research scientist for the University of Montana’s Rural Institute for Inclusive Communities, said the governor’s proposal to extend postpartum Medicaid coverage could make a significant difference in improving overall maternal health in Montana. The university was awarded a federal grant this year for such efforts, particularly to lower the mortality rate among Native Americans, and Ms. Glover said the state measure could further reduce rates.
“The reason really has to do with maintaining access to care during this very critical period,” Ms. Glover said. That goes for helping mothers with postpartum depression, as well as medical conditions like high blood pressure that require follow-ups with a physician well after delivery, she said.
In Wyoming, a legislative committee voted 6-5 in August to introduce a bill in the next session; dissenters cited the cost and their reluctance to further entangle the state in federal government programs.
About a third of Wyoming births are covered by Medicaid, and state officials estimate about 1,250 women would benefit from the change.
Postpartum eligibility bills are also expected to be taken up by legislators in Missouri and Mississippi, two states that have previously grappled with the issue. Both states have outlawed most abortions since the U.S. Supreme Court lifted federal protections in June, and Mississippi leaders have said additional postpartum care is needed because of the thousands of additional births expected as a result of the state’s ban.
A proposed coverage expansion died in the Mississippi House last session, but Lt. Gov. Delbert Hosemann said the Senate will revive the measure, according to Mississippi Today.
Last year, federal officials approved a Medicaid waiver for Missouri that allows the state to extend postpartum eligibility. But state officials delayed implementing the change to determine how enrollment would be affected by Missouri voters’ decision in August 2020 to expand Medicaid eligibility to more people. The delay prompted a bill to be filed last session that would have extended postpartum coverage by a year. That measure died, but a state lawmaker has pre-filed a bill that will bring back the debate in the upcoming session.
In Idaho, a children’s advocacy group said it will press lawmakers to approve a postpartum eligibility extension, among other measures, after the state banned nearly all abortions this year.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
States cracking down harder on docs who sexually abuse patients
It’s the latest example of states taking doctor sexual misconduct more seriously after longstanding criticism that medical boards have been too lenient.
The law, which takes effect in January 2023, requires the state’s medical board to permanently revoke these doctors’ licenses instead of allowing them to petition the board for reinstatement after 3 years.
“Physician licenses should not be reinstated after egregious sexual misconduct with patients. The doctor-patient relationship has to remain sacrosanct and trusted,” said Peter Yellowlees, MD, a professor of psychiatry at the University of California, Davis.
Although the vast majority of the nation’s estimated 1 million doctors don’t sexually abuse patients, the problem is a national one.
The Federation of State Medical Boards defines sexual misconduct as the exploitation of the physician-patient relationship in a sexual way. The exploitation may be verbal or physical and can occur in person or virtually.
The FSMB conducted a 2-year review of how medical boards handled cases of sexual misconduct, issuing a report in 2020 that contained 38 recommended actions.
Four states in addition to California have enacted laws that incorporate some FSMB recommendations. These include revoking doctors’ licenses after a single egregious act of sexual misconduct (including sexual assault), regardless of whether the physician was charged or convicted; increased reporting by hospitals and doctors of sexual misconduct; and training of physicians to recognize and report sexual misconduct.
The four state laws are:
- Georgia’s HB 458. It was signed into law in May 2021, and it authorizes the medical board to revoke or suspend a license if a physician is found guilty of sexually assaulting a patient in a criminal case. Doctors are required to report other doctors who have sexually abused patients and to take continuing medical education (CME) units on sexual misconduct.
- Florida’s SB 1934. This legislation was signed into law in June 2021, and it bars physicians charged with serious crimes such as sexual assault, sexual misconduct against patients, or possession of child pornography from seeing patients until those charges are resolved by the legal system.
- West Virginia’s SB 603. Signed into law in March 2022 it prohibits the medical board from issuing a license to a physician who engaged in sexual activity or misconduct with a patient whose license was revoked in another state or was involved in other violations.
- Tennessee HB 1045. It was signed into law in May 2021, and authorizes the medical board, upon learning of an indictment against a physician for a controlled substance violation or sexual offense, to immediately suspend the doctor’s ability to prescribe controlled substances until the doctor’s case is resolved.
A published study identified a total of 1,721 reports of physician sexual misconduct that were submitted to the National Practitioner Data Bank between 2000 and 2019. The annual incidence of sexual misconduct reports averaged 10.8 per 100,000 U.S. physician licensees, said the researchers.
In a groundbreaking 2016 investigation, the Atlanta Journal-Constitution reviewed thousands of documents and found more than 2,400 doctors whose sexual misconduct cases clearly involved patients since 1999.
Physician sexual misconduct is likely underreported
The actual incidence of physician-patient sexual misconduct is likely higher as a result of underreporting, according to the researchers.
Because a substantial power differential exists between patients and their physicians, the researchers noted, it follows that patient victims, like other sexual assault victims, may be unwilling or unable to report the incident in question.
Many violations involving physician sexual misconduct of patients never came to the attention of state regulators, according to the Journal-Constitution investigation. Reporting showed that hospitals, clinics, and fellow doctors fail to report sexual misconduct to regulators, despite laws in most states requiring them to do so.
Media investigations highlight medical board shortcomings
Public pressure on the California Medical Board increased after the Los Angeles Times investigated what happened to doctors who surrendered or had their licenses revoked after being reported for sexual abuse with patients. The Times revealed in 2021 that the board reinstated 10 of 17 doctors who petitioned for reinstatement.
They include Esmail Nadjmabadi, MD, of Bakersfield, Calif., who had sexually abused six female patients, including one in her mid-teens. The Times reported that, in 2009, he pleaded no contest to a criminal charge that he sexually exploited two or more women and surrendered his medical license the following year.
Five years later, Dr. Nadjmabadi petitioned the medical board to be reinstated and the board approved his request.
The California board has also reinstated several doctors who underwent sex offender rehabilitation. Board members rely heavily on a doctor’s evidence of rehabilitation, usually with the testimony of therapists hired by the doctor, and no input from the patients who were harmed, according to the Times’ investigation.
High-profile sexual misconduct or abuse cases involving Larry Nassar, MD, and Robert Anderson, MD, in Michigan; Richard Strauss, MD, in Ohio; and Ricardo Cruciani, MD, in New York, added to the mounting criticism that medical boards were too lenient in their handling of complaints of sexual misconduct.
Another state tackles sexual misconduct
Ohio’s medical board created an administrative rule stating that licensed physicians have a legal and ethical duty to report colleagues for sexual misconduct with patients and to complete a 1-hour CME training. Failure to report sexual misconduct complaints can lead to a doctor being permanently stripped of his license.
This happened to Robert S. Geiger, MD, in 2016 after not reporting his colleague James Bressi, MD, to the medical board after receiving complaints that Dr. Bressi was sexually abusing female patients at their pain clinic.
Dr. Bressi was convicted of sexual misconduct with a patient, stripped of his medical license, and sentenced to 59 days in prison.
“I think all of these reforms are a step in the right direction and will help to deter doctors from committing sexual misconduct to some extent,” said California activist Marian Hollingsworth, cofounder of the Patient Safety League.
But there’s room for improvement, she said, since “most states fall short in not requiring medical boards to notify law enforcement when they get a complaint of doctor sexual misconduct so the public can be aware of it.”
A version of this article first appeared on Medscape.com.
It’s the latest example of states taking doctor sexual misconduct more seriously after longstanding criticism that medical boards have been too lenient.
The law, which takes effect in January 2023, requires the state’s medical board to permanently revoke these doctors’ licenses instead of allowing them to petition the board for reinstatement after 3 years.
“Physician licenses should not be reinstated after egregious sexual misconduct with patients. The doctor-patient relationship has to remain sacrosanct and trusted,” said Peter Yellowlees, MD, a professor of psychiatry at the University of California, Davis.
Although the vast majority of the nation’s estimated 1 million doctors don’t sexually abuse patients, the problem is a national one.
The Federation of State Medical Boards defines sexual misconduct as the exploitation of the physician-patient relationship in a sexual way. The exploitation may be verbal or physical and can occur in person or virtually.
The FSMB conducted a 2-year review of how medical boards handled cases of sexual misconduct, issuing a report in 2020 that contained 38 recommended actions.
Four states in addition to California have enacted laws that incorporate some FSMB recommendations. These include revoking doctors’ licenses after a single egregious act of sexual misconduct (including sexual assault), regardless of whether the physician was charged or convicted; increased reporting by hospitals and doctors of sexual misconduct; and training of physicians to recognize and report sexual misconduct.
The four state laws are:
- Georgia’s HB 458. It was signed into law in May 2021, and it authorizes the medical board to revoke or suspend a license if a physician is found guilty of sexually assaulting a patient in a criminal case. Doctors are required to report other doctors who have sexually abused patients and to take continuing medical education (CME) units on sexual misconduct.
- Florida’s SB 1934. This legislation was signed into law in June 2021, and it bars physicians charged with serious crimes such as sexual assault, sexual misconduct against patients, or possession of child pornography from seeing patients until those charges are resolved by the legal system.
- West Virginia’s SB 603. Signed into law in March 2022 it prohibits the medical board from issuing a license to a physician who engaged in sexual activity or misconduct with a patient whose license was revoked in another state or was involved in other violations.
- Tennessee HB 1045. It was signed into law in May 2021, and authorizes the medical board, upon learning of an indictment against a physician for a controlled substance violation or sexual offense, to immediately suspend the doctor’s ability to prescribe controlled substances until the doctor’s case is resolved.
A published study identified a total of 1,721 reports of physician sexual misconduct that were submitted to the National Practitioner Data Bank between 2000 and 2019. The annual incidence of sexual misconduct reports averaged 10.8 per 100,000 U.S. physician licensees, said the researchers.
In a groundbreaking 2016 investigation, the Atlanta Journal-Constitution reviewed thousands of documents and found more than 2,400 doctors whose sexual misconduct cases clearly involved patients since 1999.
Physician sexual misconduct is likely underreported
The actual incidence of physician-patient sexual misconduct is likely higher as a result of underreporting, according to the researchers.
Because a substantial power differential exists between patients and their physicians, the researchers noted, it follows that patient victims, like other sexual assault victims, may be unwilling or unable to report the incident in question.
Many violations involving physician sexual misconduct of patients never came to the attention of state regulators, according to the Journal-Constitution investigation. Reporting showed that hospitals, clinics, and fellow doctors fail to report sexual misconduct to regulators, despite laws in most states requiring them to do so.
Media investigations highlight medical board shortcomings
Public pressure on the California Medical Board increased after the Los Angeles Times investigated what happened to doctors who surrendered or had their licenses revoked after being reported for sexual abuse with patients. The Times revealed in 2021 that the board reinstated 10 of 17 doctors who petitioned for reinstatement.
They include Esmail Nadjmabadi, MD, of Bakersfield, Calif., who had sexually abused six female patients, including one in her mid-teens. The Times reported that, in 2009, he pleaded no contest to a criminal charge that he sexually exploited two or more women and surrendered his medical license the following year.
Five years later, Dr. Nadjmabadi petitioned the medical board to be reinstated and the board approved his request.
The California board has also reinstated several doctors who underwent sex offender rehabilitation. Board members rely heavily on a doctor’s evidence of rehabilitation, usually with the testimony of therapists hired by the doctor, and no input from the patients who were harmed, according to the Times’ investigation.
High-profile sexual misconduct or abuse cases involving Larry Nassar, MD, and Robert Anderson, MD, in Michigan; Richard Strauss, MD, in Ohio; and Ricardo Cruciani, MD, in New York, added to the mounting criticism that medical boards were too lenient in their handling of complaints of sexual misconduct.
Another state tackles sexual misconduct
Ohio’s medical board created an administrative rule stating that licensed physicians have a legal and ethical duty to report colleagues for sexual misconduct with patients and to complete a 1-hour CME training. Failure to report sexual misconduct complaints can lead to a doctor being permanently stripped of his license.
This happened to Robert S. Geiger, MD, in 2016 after not reporting his colleague James Bressi, MD, to the medical board after receiving complaints that Dr. Bressi was sexually abusing female patients at their pain clinic.
Dr. Bressi was convicted of sexual misconduct with a patient, stripped of his medical license, and sentenced to 59 days in prison.
“I think all of these reforms are a step in the right direction and will help to deter doctors from committing sexual misconduct to some extent,” said California activist Marian Hollingsworth, cofounder of the Patient Safety League.
But there’s room for improvement, she said, since “most states fall short in not requiring medical boards to notify law enforcement when they get a complaint of doctor sexual misconduct so the public can be aware of it.”
A version of this article first appeared on Medscape.com.
It’s the latest example of states taking doctor sexual misconduct more seriously after longstanding criticism that medical boards have been too lenient.
The law, which takes effect in January 2023, requires the state’s medical board to permanently revoke these doctors’ licenses instead of allowing them to petition the board for reinstatement after 3 years.
“Physician licenses should not be reinstated after egregious sexual misconduct with patients. The doctor-patient relationship has to remain sacrosanct and trusted,” said Peter Yellowlees, MD, a professor of psychiatry at the University of California, Davis.
Although the vast majority of the nation’s estimated 1 million doctors don’t sexually abuse patients, the problem is a national one.
The Federation of State Medical Boards defines sexual misconduct as the exploitation of the physician-patient relationship in a sexual way. The exploitation may be verbal or physical and can occur in person or virtually.
The FSMB conducted a 2-year review of how medical boards handled cases of sexual misconduct, issuing a report in 2020 that contained 38 recommended actions.
Four states in addition to California have enacted laws that incorporate some FSMB recommendations. These include revoking doctors’ licenses after a single egregious act of sexual misconduct (including sexual assault), regardless of whether the physician was charged or convicted; increased reporting by hospitals and doctors of sexual misconduct; and training of physicians to recognize and report sexual misconduct.
The four state laws are:
- Georgia’s HB 458. It was signed into law in May 2021, and it authorizes the medical board to revoke or suspend a license if a physician is found guilty of sexually assaulting a patient in a criminal case. Doctors are required to report other doctors who have sexually abused patients and to take continuing medical education (CME) units on sexual misconduct.
- Florida’s SB 1934. This legislation was signed into law in June 2021, and it bars physicians charged with serious crimes such as sexual assault, sexual misconduct against patients, or possession of child pornography from seeing patients until those charges are resolved by the legal system.
- West Virginia’s SB 603. Signed into law in March 2022 it prohibits the medical board from issuing a license to a physician who engaged in sexual activity or misconduct with a patient whose license was revoked in another state or was involved in other violations.
- Tennessee HB 1045. It was signed into law in May 2021, and authorizes the medical board, upon learning of an indictment against a physician for a controlled substance violation or sexual offense, to immediately suspend the doctor’s ability to prescribe controlled substances until the doctor’s case is resolved.
A published study identified a total of 1,721 reports of physician sexual misconduct that were submitted to the National Practitioner Data Bank between 2000 and 2019. The annual incidence of sexual misconduct reports averaged 10.8 per 100,000 U.S. physician licensees, said the researchers.
In a groundbreaking 2016 investigation, the Atlanta Journal-Constitution reviewed thousands of documents and found more than 2,400 doctors whose sexual misconduct cases clearly involved patients since 1999.
Physician sexual misconduct is likely underreported
The actual incidence of physician-patient sexual misconduct is likely higher as a result of underreporting, according to the researchers.
Because a substantial power differential exists between patients and their physicians, the researchers noted, it follows that patient victims, like other sexual assault victims, may be unwilling or unable to report the incident in question.
Many violations involving physician sexual misconduct of patients never came to the attention of state regulators, according to the Journal-Constitution investigation. Reporting showed that hospitals, clinics, and fellow doctors fail to report sexual misconduct to regulators, despite laws in most states requiring them to do so.
Media investigations highlight medical board shortcomings
Public pressure on the California Medical Board increased after the Los Angeles Times investigated what happened to doctors who surrendered or had their licenses revoked after being reported for sexual abuse with patients. The Times revealed in 2021 that the board reinstated 10 of 17 doctors who petitioned for reinstatement.
They include Esmail Nadjmabadi, MD, of Bakersfield, Calif., who had sexually abused six female patients, including one in her mid-teens. The Times reported that, in 2009, he pleaded no contest to a criminal charge that he sexually exploited two or more women and surrendered his medical license the following year.
Five years later, Dr. Nadjmabadi petitioned the medical board to be reinstated and the board approved his request.
The California board has also reinstated several doctors who underwent sex offender rehabilitation. Board members rely heavily on a doctor’s evidence of rehabilitation, usually with the testimony of therapists hired by the doctor, and no input from the patients who were harmed, according to the Times’ investigation.
High-profile sexual misconduct or abuse cases involving Larry Nassar, MD, and Robert Anderson, MD, in Michigan; Richard Strauss, MD, in Ohio; and Ricardo Cruciani, MD, in New York, added to the mounting criticism that medical boards were too lenient in their handling of complaints of sexual misconduct.
Another state tackles sexual misconduct
Ohio’s medical board created an administrative rule stating that licensed physicians have a legal and ethical duty to report colleagues for sexual misconduct with patients and to complete a 1-hour CME training. Failure to report sexual misconduct complaints can lead to a doctor being permanently stripped of his license.
This happened to Robert S. Geiger, MD, in 2016 after not reporting his colleague James Bressi, MD, to the medical board after receiving complaints that Dr. Bressi was sexually abusing female patients at their pain clinic.
Dr. Bressi was convicted of sexual misconduct with a patient, stripped of his medical license, and sentenced to 59 days in prison.
“I think all of these reforms are a step in the right direction and will help to deter doctors from committing sexual misconduct to some extent,” said California activist Marian Hollingsworth, cofounder of the Patient Safety League.
But there’s room for improvement, she said, since “most states fall short in not requiring medical boards to notify law enforcement when they get a complaint of doctor sexual misconduct so the public can be aware of it.”
A version of this article first appeared on Medscape.com.
Don’t lift weights – lower them instead
as you would do with a typical rep.
That means, for example, that you could use two hands to lift a dumbbell, then one hand to slowly lower it, while sacrificing little in the way of results. Focusing on the lowering – or the “eccentric” contraction – can lead to a more efficient gym session, Japanese researchers say.
In the study, published in the European Journal of Applied Physiology, researchers divided people into three groups of 14 for a 5-week, twice-weekly comparison.
One group performed dumbbell curls from full extension to about one-quarter of the way up, for 2 seconds up and 2 seconds down, in three sets of 10 reps. Another 14 people performed only the lift portion of the movement (a researcher helped them reset the weight after each rep), and another 14 did only the lowering part of the move.
The group that both lifted and lowered the weights increased the maximum force they could produce on a lift by 18% and increased the thickness of the biceps muscle by 11%.
The people who only lowered the weights nearly matched that, increasing their maximum force by 14% and muscle size by 10%. The lifting-only group increased their max force by 11%, while muscle size increase was insignificant.
Your muscle fibers work two ways. When you lift a dumbbell from a straight arm up to your shoulder, your biceps muscle is using a “concentric” contraction. As you lower that dumbbell back down, the biceps muscle is working to put the brakes on the descent – that’s called an “eccentric” contraction.
The lifting-plus-lowering group saw the biggest gains because they were pretty much doing twice the number of reps. The lowering-only group made similar improvements in strength and muscle with only half the work.
Study author Masatoshi Nakamura, PhD, a professor at Nishikyushu University, Japan, believes that eccentric muscle contractions produce greater neurological adaptations in the spine and brain than concentric contractions. In other words, your nerves learn to send more of the “pull harder” signal to your muscles.
At the same time, the spring action of a large protein called “titin” in the muscle fibers produces greater force during eccentric contractions while using less energy, and more titin could account for the increase in muscle size, which is called hypertrophy.
“Titin in the muscle fibers could be the best explanation for muscle hypertrophy,” Dr. Nakamura says. “However, we believe that other factors, such as neurological adaptations, also play a large role in increasing muscle strength.”
The short range of motion used in the dumbbell curls was an important factor. A study, published in the Journal of Strength and Conditioning Research, found that a partial range-of-motion triceps exercise produced greater muscle growth than full range-of-motion movements.
Although the people in this newest study only performed dumbbell curls, “we think the effect is similar in other muscles,” Dr. Nakamura says.
Your muscles are much stronger when lowering than they are lifting, so Dr. Nakamura suggests choosing a heavy weight to perform single-arm dumbbell curls. Use both arms to raise the dumbbell into the 50-degree position, then lower it over a 2-second count. For two-handed bent- or straight-bar curls, you can ask a spotter to help you lift the weights into position between slow lowering moves.
You can also try the same trick with leg curl or leg extension exercise machines, using two legs to lift the weight and allowing one leg to lower it.
In the near future, your gym might contain more equipment that was designed specifically around lowering movements.
“Other machines that can emphasize eccentric contraction are gradually being developed,” Dr. Nakamura says.
A version of this article first appeared on WebMD.com.
as you would do with a typical rep.
That means, for example, that you could use two hands to lift a dumbbell, then one hand to slowly lower it, while sacrificing little in the way of results. Focusing on the lowering – or the “eccentric” contraction – can lead to a more efficient gym session, Japanese researchers say.
In the study, published in the European Journal of Applied Physiology, researchers divided people into three groups of 14 for a 5-week, twice-weekly comparison.
One group performed dumbbell curls from full extension to about one-quarter of the way up, for 2 seconds up and 2 seconds down, in three sets of 10 reps. Another 14 people performed only the lift portion of the movement (a researcher helped them reset the weight after each rep), and another 14 did only the lowering part of the move.
The group that both lifted and lowered the weights increased the maximum force they could produce on a lift by 18% and increased the thickness of the biceps muscle by 11%.
The people who only lowered the weights nearly matched that, increasing their maximum force by 14% and muscle size by 10%. The lifting-only group increased their max force by 11%, while muscle size increase was insignificant.
Your muscle fibers work two ways. When you lift a dumbbell from a straight arm up to your shoulder, your biceps muscle is using a “concentric” contraction. As you lower that dumbbell back down, the biceps muscle is working to put the brakes on the descent – that’s called an “eccentric” contraction.
The lifting-plus-lowering group saw the biggest gains because they were pretty much doing twice the number of reps. The lowering-only group made similar improvements in strength and muscle with only half the work.
Study author Masatoshi Nakamura, PhD, a professor at Nishikyushu University, Japan, believes that eccentric muscle contractions produce greater neurological adaptations in the spine and brain than concentric contractions. In other words, your nerves learn to send more of the “pull harder” signal to your muscles.
At the same time, the spring action of a large protein called “titin” in the muscle fibers produces greater force during eccentric contractions while using less energy, and more titin could account for the increase in muscle size, which is called hypertrophy.
“Titin in the muscle fibers could be the best explanation for muscle hypertrophy,” Dr. Nakamura says. “However, we believe that other factors, such as neurological adaptations, also play a large role in increasing muscle strength.”
The short range of motion used in the dumbbell curls was an important factor. A study, published in the Journal of Strength and Conditioning Research, found that a partial range-of-motion triceps exercise produced greater muscle growth than full range-of-motion movements.
Although the people in this newest study only performed dumbbell curls, “we think the effect is similar in other muscles,” Dr. Nakamura says.
Your muscles are much stronger when lowering than they are lifting, so Dr. Nakamura suggests choosing a heavy weight to perform single-arm dumbbell curls. Use both arms to raise the dumbbell into the 50-degree position, then lower it over a 2-second count. For two-handed bent- or straight-bar curls, you can ask a spotter to help you lift the weights into position between slow lowering moves.
You can also try the same trick with leg curl or leg extension exercise machines, using two legs to lift the weight and allowing one leg to lower it.
In the near future, your gym might contain more equipment that was designed specifically around lowering movements.
“Other machines that can emphasize eccentric contraction are gradually being developed,” Dr. Nakamura says.
A version of this article first appeared on WebMD.com.
as you would do with a typical rep.
That means, for example, that you could use two hands to lift a dumbbell, then one hand to slowly lower it, while sacrificing little in the way of results. Focusing on the lowering – or the “eccentric” contraction – can lead to a more efficient gym session, Japanese researchers say.
In the study, published in the European Journal of Applied Physiology, researchers divided people into three groups of 14 for a 5-week, twice-weekly comparison.
One group performed dumbbell curls from full extension to about one-quarter of the way up, for 2 seconds up and 2 seconds down, in three sets of 10 reps. Another 14 people performed only the lift portion of the movement (a researcher helped them reset the weight after each rep), and another 14 did only the lowering part of the move.
The group that both lifted and lowered the weights increased the maximum force they could produce on a lift by 18% and increased the thickness of the biceps muscle by 11%.
The people who only lowered the weights nearly matched that, increasing their maximum force by 14% and muscle size by 10%. The lifting-only group increased their max force by 11%, while muscle size increase was insignificant.
Your muscle fibers work two ways. When you lift a dumbbell from a straight arm up to your shoulder, your biceps muscle is using a “concentric” contraction. As you lower that dumbbell back down, the biceps muscle is working to put the brakes on the descent – that’s called an “eccentric” contraction.
The lifting-plus-lowering group saw the biggest gains because they were pretty much doing twice the number of reps. The lowering-only group made similar improvements in strength and muscle with only half the work.
Study author Masatoshi Nakamura, PhD, a professor at Nishikyushu University, Japan, believes that eccentric muscle contractions produce greater neurological adaptations in the spine and brain than concentric contractions. In other words, your nerves learn to send more of the “pull harder” signal to your muscles.
At the same time, the spring action of a large protein called “titin” in the muscle fibers produces greater force during eccentric contractions while using less energy, and more titin could account for the increase in muscle size, which is called hypertrophy.
“Titin in the muscle fibers could be the best explanation for muscle hypertrophy,” Dr. Nakamura says. “However, we believe that other factors, such as neurological adaptations, also play a large role in increasing muscle strength.”
The short range of motion used in the dumbbell curls was an important factor. A study, published in the Journal of Strength and Conditioning Research, found that a partial range-of-motion triceps exercise produced greater muscle growth than full range-of-motion movements.
Although the people in this newest study only performed dumbbell curls, “we think the effect is similar in other muscles,” Dr. Nakamura says.
Your muscles are much stronger when lowering than they are lifting, so Dr. Nakamura suggests choosing a heavy weight to perform single-arm dumbbell curls. Use both arms to raise the dumbbell into the 50-degree position, then lower it over a 2-second count. For two-handed bent- or straight-bar curls, you can ask a spotter to help you lift the weights into position between slow lowering moves.
You can also try the same trick with leg curl or leg extension exercise machines, using two legs to lift the weight and allowing one leg to lower it.
In the near future, your gym might contain more equipment that was designed specifically around lowering movements.
“Other machines that can emphasize eccentric contraction are gradually being developed,” Dr. Nakamura says.
A version of this article first appeared on WebMD.com.
FROM THE EUROPEAN JOURNAL OF APPLIED PHYSIOLOGY