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Conducting clinical research as an early career gastroenterologist can take on many forms and has varying definitions of success. This article focuses on key factors to consider and should be supplemented with mentorship tailored to personal interests, goals, and institutional criteria for success. In this article, we will discuss selected high-yield topics that assist in early-career research. We will briefly discuss 1. Defining your niche, 2. Collaboration, 3. Visibility, 4. Time management, 5. Funding, 6. Receiving mentorship, and 7. Providing mentorship. We will conclude with discussing several authors’ experience in the research lab of the first author (FELD Lab – Fostering Equity in Liver and Digestive disease).

Defining Your Niche

Defining your niche is an essential component of an early career, as when academicians must transition from a trainee, who is supporting the research of an established mentor, to defining their own subspeciality area of investigation. Early-career academics should build on their prior work, but should also explore their own passions and skill set to define what will be unique about their research program and contributions to the field. Of course, positioning oneself at the intersection of two or more seemingly unrelated fields opens much opportunity for large impact but comes at a cost of identifying mentorship and justifying the niche to funders.

Collaboration

Fostering a collaborative environment is essential for early-career physician-researchers. One effective approach is to establish collaboration circles with other early career academics. Expanding research endeavors beyond a single institution to a multi-center framework enriches both scope and impact. This collaborative approach not only amplifies the depth of research but also facilitates peer mentorship and sponsorship. Participation in such networks can significantly enhance scholarly output and broaden professional reach during this critical phase of academic progression. Furthermore, prioritizing the promotion of colleagues within these networks is crucial. Proactive sponsorship opportunities, such as inviting peers to present at institutional seminars, strengthen both individual and collective academic visibility.

Collaboration is also essential to foster between trainees involved in early-career investigators’ work. An interconnected lab environment ensures that trainees remain informed about concurrent projects, thereby fostering a culture of shared knowledge and optimized productivity. Encouraging trainees to spearhead research aligned with their interests, under mentor guidance, nurtures independent inquiry and leadership. By establishing explicit roles, responsibilities, and authorship agreements at the outset of collaborative projects, early career mentors can avoid future conflicts and preserve a collaborative culture within the lab. This structured approach cultivates a supportive ecosystem, advancing both individual and collective research achievements.

 

Visibility

Establishing visibility and developing name recognition are crucial components of career advancement for early-career academic physicians. By clearly defining their areas of expertise, faculty can position themselves as leaders within their discipline. Active participation in professional societies, both at the local and national level, engagement with interest groups, and frequent contributions to educational events can be effective strategies for gaining recognition. Leveraging social media platforms can be helpful in enhancing visibility by facilitating connections and promoting research to a broader audience.

Moreover, research visibility plays a vital role in academic promotion. A strong publication record, reflected by an increasing h-index, demonstrates the impact and relevance of one’s research. Self-citation, when appropriate, can reinforce the continuity and progression of scholarly contributions. While publishing in high-impact journals is desirable, adaptability in resubmitting to other journals following rejections ensures that research remains visible and accessible. It also clearly establishes by whom the work was first done, before someone else investigates the line of inquiry. Through a combination of strategic engagement and publication efforts, early-career physicians can effectively build their professional reputation and advance their academic careers.

 

Time Management

Time management is essential for any research, and particularly in early career when efficiency in clinical care duties is still being gained. Securing protected time for research is essential to develop a niche, build connections (both institutionally and beyond their institutions), and demonstrate productivity that can be utilized to support future grant efforts.

Similarly, using protected time efficiently is required. Without organization and planning, research time can be spent with scattered meetings and responding to various tasks that do not directly support your research. It is helpful to be introspective about the time of the day you are most productive in your research efforts and blocking off that time to focus on research tasks and minimizing distractions. Blocking monthly time for larger scale thinking and planning is also important. Weekly lab and individual one-on-one meetings also support time management for trainees and lab members, to ensure efficiency and progress. Additionally, robust clinical support is essential to ensure that research time remains protected and patient care moves forward. When negotiating for positions, and in regular meetings thereafter, it is important to advocate for sufficient clinical staffing such that non-physician tasks can be appropriately delegated to another member of the care team. 

 

Funding

Securing adequate funding poses a significant challenge for all early-career physician-scientists, particularly because of the discrepancy between National Institutes of Health salary caps and the higher average salaries in academic gastroenterology. This financial gap can deter physicians from pursuing research-intensive careers altogether and can derail early investigators who do not obtain funding rapidly. To overcome this, early-career investigators may need to adopt flexible strategies, such as accepting a lower salary that aligns with grant funding limits or funneling incentive or bonus pay to research accounts. Alternatively, they can advocate for institutional support to bridge the salary gap, ensuring their research efforts remain financially viable.

Institutions committed to fostering research excellence may offer supplemental funding or bridge programs to retain talented physician-scientists, thereby mitigating the financial strain and encouraging long-term engagement in research. Regular meetings to review salary and support sources, including philanthropy, foundation grants, and other streams, should be undertaken with leadership to align the researcher’s timeline and available funding. If career development funding appears untenable, consideration of multi–principal investigator R01s or equivalent with senior established investigators can be a promising path. 

 

Receiving Mentorship

Effective mentorship for early-career physician-scientists should be approached through a team-based model that leverages both internal and external mentors. Internal mentors, familiar with the specific culture, expectations, and advancement pathways of the institution, can provide invaluable guidance on navigating institutional metrics for success, such as promotion criteria, grant acquisition, and clinical-research balance. External mentors, on the other hand, bring a broader perspective by offering innovative career development strategies and solutions derived from experiences at their home institutions. This multimodal mentorship model ensures a well-rounded approach to professional growth.

All national gastroenterology societies, including the American Gastroenterological Association, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy, and American Association for the Study of Liver Disease, offer structured early-career mentorship programs designed to connect emerging researchers with experienced leaders in the field (see below). These programs typically require a formal application process and are highly regarded for their exceptional quality and impact. Participation in such initiatives can significantly enhance career development by expanding networks, fostering interdisciplinary collaboration, and providing tailored guidance that complements institutional support. Integrating both internal and external mentorship opportunities ensures a robust and dynamic foundation for long-term success in academic medicine.

• AGA Career Compass (https://gastro.org/fellows-and-early-career/mentoring/)
• ACG Early Career Leadership Program (https://gi.org/acg-institute/early-career-leadership-program/)
• AGA-AASLD Academic Skills Workshop (https://gastro.org/news/applications-now-being-accepted-for-the-2024-aga-aasld-academic-skills-workshop/)
• AASLD Women’s Initiative Committee Leadership Program (https://www.aasld.org/promoting-leadership-potential-women-hepatology)
• Scrubs n Heels Mentorship Matrix (https://scrubsandheels.com/matrix/)

Providing Mentorship

The trainee authors on this manuscript describe in this section what has been helpful for them as mentees in the FELD research lab.

Student doctor Nguyen describes her experience as a lab member and things she finds most helpful as a medical student in the lab:

• Upon joining the team, a one-to-one meeting to discuss trainee’s personal and professional goals, and availability, was crucial to building the mentor-mentee relationship. Establishing this meaningful mentorship early on clarified expectations on both sides, built trust, and increased motivation. As a trainee, it is essential for me to see how my work aligns with a long-term goal and to receive ample guidance throughout the process.
• One of the most impactful experiences has been joining informal lunch sessions where trainees discussed data collection protocols and exchanged insights. In doing so, Dr. Feld has cultivated a lab culture that encourages curiosity, constructive feedback, and collaborative learning.
• To increase productivity, our team of trainees created a useful group message thread where we coordinated more sessions to collaborate. This coordination formed stronger relationships between team members and fostered a sense of shared purpose.

Dr. Cooper, a third year internal medicine resident, describes her experience as both a research mentee and a mentor to the junior trainees: “As a resident pursuing a career in academic gastroenterology and hepatology, I have found three key elements to be most helpful: intentional mentorship, structured meetings, and leadership development.”

• Intentional mentorship: Prior to joining the lab, I met with Dr. Feld to discuss my research experience and my goals. She took the time to understand these within the context of my training timeline and tailored project opportunities that aligned with my interests and were both feasible and impactful for my next steps. This intentional approach not only fostered a productive research experience but also established a mentor-mentee relationship built on genuine care for my growth and development.
• Regular meetings: Frequent lab meetings promote accountability, teamwork, and shared problem-solving skills. The open exchange of ideas fosters collaboration and joint problem solving to elevate the quality of our research. They are also an opportunity to observe key decision-making points during the research process and have been a great way to learn more about solid methodology.
• Supervised leadership: I have had ample time to lead discussions and coordinate projects among the junior trainees. These monitored leadership experiences promote project management skills, mentorship, and team dynamic awareness while maintaining the safety net of senior guidance. This model helped me transition from a trainee supporting others’ research to a more independent role, contributing to multi-disciplinary projects while mentoring junior members.

Conclusion

In conclusion, many exciting opportunities and notable barriers exist to establishing a clinical research laboratory in the early career. Individual and institutional investment and support are vital to the success of junior physicians seeking a career in clinical research. While excellence in each of the areas outlined may evolve, some aspects will come easier than others and with time, persistence, and a bit of luck, the research world will be a better place because of your contributions!

Dr. Feld is assistant professor of gastroenterology and hepatology and physician executive of Diversity, Equity, Inclusion and Belonging for the department of medicine at the University of Massachusetts (UMass) Chan Medical School, Worcester. Ms. Nguyen is a medical student at UMass Chan Medical School. Dr. Cooper is a resident physician at UMass Chan Medical School. Dr. Rabinowitz is an attending physician in the Inflammatory Bowel Disease Center at Beth Israel Deaconess Medical Center, Boston, Mass. Dr. Uchida is codirector of the Multidisciplinary Eosinophilic Gastrointestinal Disease Clinic at the University of Utah School of Medicine, Salt Lake City.

Conducting clinical research as an early career gastroenterologist can take on many forms and has varying definitions of success. This article focuses on key factors to consider and should be supplemented with mentorship tailored to personal interests, goals, and institutional criteria for success. In this article, we will discuss selected high-yield topics that assist in early-career research. We will briefly discuss 1. Defining your niche, 2. Collaboration, 3. Visibility, 4. Time management, 5. Funding, 6. Receiving mentorship, and 7. Providing mentorship. We will conclude with discussing several authors’ experience in the research lab of the first author (FELD Lab – Fostering Equity in Liver and Digestive disease).

Defining Your Niche

Defining your niche is an essential component of an early career, as when academicians must transition from a trainee, who is supporting the research of an established mentor, to defining their own subspeciality area of investigation. Early-career academics should build on their prior work, but should also explore their own passions and skill set to define what will be unique about their research program and contributions to the field. Of course, positioning oneself at the intersection of two or more seemingly unrelated fields opens much opportunity for large impact but comes at a cost of identifying mentorship and justifying the niche to funders.

Collaboration

Fostering a collaborative environment is essential for early-career physician-researchers. One effective approach is to establish collaboration circles with other early career academics. Expanding research endeavors beyond a single institution to a multi-center framework enriches both scope and impact. This collaborative approach not only amplifies the depth of research but also facilitates peer mentorship and sponsorship. Participation in such networks can significantly enhance scholarly output and broaden professional reach during this critical phase of academic progression. Furthermore, prioritizing the promotion of colleagues within these networks is crucial. Proactive sponsorship opportunities, such as inviting peers to present at institutional seminars, strengthen both individual and collective academic visibility.

Collaboration is also essential to foster between trainees involved in early-career investigators’ work. An interconnected lab environment ensures that trainees remain informed about concurrent projects, thereby fostering a culture of shared knowledge and optimized productivity. Encouraging trainees to spearhead research aligned with their interests, under mentor guidance, nurtures independent inquiry and leadership. By establishing explicit roles, responsibilities, and authorship agreements at the outset of collaborative projects, early career mentors can avoid future conflicts and preserve a collaborative culture within the lab. This structured approach cultivates a supportive ecosystem, advancing both individual and collective research achievements.

 

Visibility

Establishing visibility and developing name recognition are crucial components of career advancement for early-career academic physicians. By clearly defining their areas of expertise, faculty can position themselves as leaders within their discipline. Active participation in professional societies, both at the local and national level, engagement with interest groups, and frequent contributions to educational events can be effective strategies for gaining recognition. Leveraging social media platforms can be helpful in enhancing visibility by facilitating connections and promoting research to a broader audience.

Moreover, research visibility plays a vital role in academic promotion. A strong publication record, reflected by an increasing h-index, demonstrates the impact and relevance of one’s research. Self-citation, when appropriate, can reinforce the continuity and progression of scholarly contributions. While publishing in high-impact journals is desirable, adaptability in resubmitting to other journals following rejections ensures that research remains visible and accessible. It also clearly establishes by whom the work was first done, before someone else investigates the line of inquiry. Through a combination of strategic engagement and publication efforts, early-career physicians can effectively build their professional reputation and advance their academic careers.

 

Time Management

Time management is essential for any research, and particularly in early career when efficiency in clinical care duties is still being gained. Securing protected time for research is essential to develop a niche, build connections (both institutionally and beyond their institutions), and demonstrate productivity that can be utilized to support future grant efforts.

Similarly, using protected time efficiently is required. Without organization and planning, research time can be spent with scattered meetings and responding to various tasks that do not directly support your research. It is helpful to be introspective about the time of the day you are most productive in your research efforts and blocking off that time to focus on research tasks and minimizing distractions. Blocking monthly time for larger scale thinking and planning is also important. Weekly lab and individual one-on-one meetings also support time management for trainees and lab members, to ensure efficiency and progress. Additionally, robust clinical support is essential to ensure that research time remains protected and patient care moves forward. When negotiating for positions, and in regular meetings thereafter, it is important to advocate for sufficient clinical staffing such that non-physician tasks can be appropriately delegated to another member of the care team. 

 

Funding

Securing adequate funding poses a significant challenge for all early-career physician-scientists, particularly because of the discrepancy between National Institutes of Health salary caps and the higher average salaries in academic gastroenterology. This financial gap can deter physicians from pursuing research-intensive careers altogether and can derail early investigators who do not obtain funding rapidly. To overcome this, early-career investigators may need to adopt flexible strategies, such as accepting a lower salary that aligns with grant funding limits or funneling incentive or bonus pay to research accounts. Alternatively, they can advocate for institutional support to bridge the salary gap, ensuring their research efforts remain financially viable.

Institutions committed to fostering research excellence may offer supplemental funding or bridge programs to retain talented physician-scientists, thereby mitigating the financial strain and encouraging long-term engagement in research. Regular meetings to review salary and support sources, including philanthropy, foundation grants, and other streams, should be undertaken with leadership to align the researcher’s timeline and available funding. If career development funding appears untenable, consideration of multi–principal investigator R01s or equivalent with senior established investigators can be a promising path. 

 

Receiving Mentorship

Effective mentorship for early-career physician-scientists should be approached through a team-based model that leverages both internal and external mentors. Internal mentors, familiar with the specific culture, expectations, and advancement pathways of the institution, can provide invaluable guidance on navigating institutional metrics for success, such as promotion criteria, grant acquisition, and clinical-research balance. External mentors, on the other hand, bring a broader perspective by offering innovative career development strategies and solutions derived from experiences at their home institutions. This multimodal mentorship model ensures a well-rounded approach to professional growth.

All national gastroenterology societies, including the American Gastroenterological Association, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy, and American Association for the Study of Liver Disease, offer structured early-career mentorship programs designed to connect emerging researchers with experienced leaders in the field (see below). These programs typically require a formal application process and are highly regarded for their exceptional quality and impact. Participation in such initiatives can significantly enhance career development by expanding networks, fostering interdisciplinary collaboration, and providing tailored guidance that complements institutional support. Integrating both internal and external mentorship opportunities ensures a robust and dynamic foundation for long-term success in academic medicine.

• AGA Career Compass (https://gastro.org/fellows-and-early-career/mentoring/)
• ACG Early Career Leadership Program (https://gi.org/acg-institute/early-career-leadership-program/)
• AGA-AASLD Academic Skills Workshop (https://gastro.org/news/applications-now-being-accepted-for-the-2024-aga-aasld-academic-skills-workshop/)
• AASLD Women’s Initiative Committee Leadership Program (https://www.aasld.org/promoting-leadership-potential-women-hepatology)
• Scrubs n Heels Mentorship Matrix (https://scrubsandheels.com/matrix/)

Providing Mentorship

The trainee authors on this manuscript describe in this section what has been helpful for them as mentees in the FELD research lab.

Student doctor Nguyen describes her experience as a lab member and things she finds most helpful as a medical student in the lab:

• Upon joining the team, a one-to-one meeting to discuss trainee’s personal and professional goals, and availability, was crucial to building the mentor-mentee relationship. Establishing this meaningful mentorship early on clarified expectations on both sides, built trust, and increased motivation. As a trainee, it is essential for me to see how my work aligns with a long-term goal and to receive ample guidance throughout the process.
• One of the most impactful experiences has been joining informal lunch sessions where trainees discussed data collection protocols and exchanged insights. In doing so, Dr. Feld has cultivated a lab culture that encourages curiosity, constructive feedback, and collaborative learning.
• To increase productivity, our team of trainees created a useful group message thread where we coordinated more sessions to collaborate. This coordination formed stronger relationships between team members and fostered a sense of shared purpose.

Dr. Cooper, a third year internal medicine resident, describes her experience as both a research mentee and a mentor to the junior trainees: “As a resident pursuing a career in academic gastroenterology and hepatology, I have found three key elements to be most helpful: intentional mentorship, structured meetings, and leadership development.”

• Intentional mentorship: Prior to joining the lab, I met with Dr. Feld to discuss my research experience and my goals. She took the time to understand these within the context of my training timeline and tailored project opportunities that aligned with my interests and were both feasible and impactful for my next steps. This intentional approach not only fostered a productive research experience but also established a mentor-mentee relationship built on genuine care for my growth and development.
• Regular meetings: Frequent lab meetings promote accountability, teamwork, and shared problem-solving skills. The open exchange of ideas fosters collaboration and joint problem solving to elevate the quality of our research. They are also an opportunity to observe key decision-making points during the research process and have been a great way to learn more about solid methodology.
• Supervised leadership: I have had ample time to lead discussions and coordinate projects among the junior trainees. These monitored leadership experiences promote project management skills, mentorship, and team dynamic awareness while maintaining the safety net of senior guidance. This model helped me transition from a trainee supporting others’ research to a more independent role, contributing to multi-disciplinary projects while mentoring junior members.

Conclusion

In conclusion, many exciting opportunities and notable barriers exist to establishing a clinical research laboratory in the early career. Individual and institutional investment and support are vital to the success of junior physicians seeking a career in clinical research. While excellence in each of the areas outlined may evolve, some aspects will come easier than others and with time, persistence, and a bit of luck, the research world will be a better place because of your contributions!

Dr. Feld is assistant professor of gastroenterology and hepatology and physician executive of Diversity, Equity, Inclusion and Belonging for the department of medicine at the University of Massachusetts (UMass) Chan Medical School, Worcester. Ms. Nguyen is a medical student at UMass Chan Medical School. Dr. Cooper is a resident physician at UMass Chan Medical School. Dr. Rabinowitz is an attending physician in the Inflammatory Bowel Disease Center at Beth Israel Deaconess Medical Center, Boston, Mass. Dr. Uchida is codirector of the Multidisciplinary Eosinophilic Gastrointestinal Disease Clinic at the University of Utah School of Medicine, Salt Lake City.

Conducting clinical research as an early career gastroenterologist can take on many forms and has varying definitions of success. This article focuses on key factors to consider and should be supplemented with mentorship tailored to personal interests, goals, and institutional criteria for success. In this article, we will discuss selected high-yield topics that assist in early-career research. We will briefly discuss 1. Defining your niche, 2. Collaboration, 3. Visibility, 4. Time management, 5. Funding, 6. Receiving mentorship, and 7. Providing mentorship. We will conclude with discussing several authors’ experience in the research lab of the first author (FELD Lab – Fostering Equity in Liver and Digestive disease).

Defining Your Niche

Defining your niche is an essential component of an early career, as when academicians must transition from a trainee, who is supporting the research of an established mentor, to defining their own subspeciality area of investigation. Early-career academics should build on their prior work, but should also explore their own passions and skill set to define what will be unique about their research program and contributions to the field. Of course, positioning oneself at the intersection of two or more seemingly unrelated fields opens much opportunity for large impact but comes at a cost of identifying mentorship and justifying the niche to funders.

Collaboration

Fostering a collaborative environment is essential for early-career physician-researchers. One effective approach is to establish collaboration circles with other early career academics. Expanding research endeavors beyond a single institution to a multi-center framework enriches both scope and impact. This collaborative approach not only amplifies the depth of research but also facilitates peer mentorship and sponsorship. Participation in such networks can significantly enhance scholarly output and broaden professional reach during this critical phase of academic progression. Furthermore, prioritizing the promotion of colleagues within these networks is crucial. Proactive sponsorship opportunities, such as inviting peers to present at institutional seminars, strengthen both individual and collective academic visibility.

Collaboration is also essential to foster between trainees involved in early-career investigators’ work. An interconnected lab environment ensures that trainees remain informed about concurrent projects, thereby fostering a culture of shared knowledge and optimized productivity. Encouraging trainees to spearhead research aligned with their interests, under mentor guidance, nurtures independent inquiry and leadership. By establishing explicit roles, responsibilities, and authorship agreements at the outset of collaborative projects, early career mentors can avoid future conflicts and preserve a collaborative culture within the lab. This structured approach cultivates a supportive ecosystem, advancing both individual and collective research achievements.

 

Visibility

Establishing visibility and developing name recognition are crucial components of career advancement for early-career academic physicians. By clearly defining their areas of expertise, faculty can position themselves as leaders within their discipline. Active participation in professional societies, both at the local and national level, engagement with interest groups, and frequent contributions to educational events can be effective strategies for gaining recognition. Leveraging social media platforms can be helpful in enhancing visibility by facilitating connections and promoting research to a broader audience.

Moreover, research visibility plays a vital role in academic promotion. A strong publication record, reflected by an increasing h-index, demonstrates the impact and relevance of one’s research. Self-citation, when appropriate, can reinforce the continuity and progression of scholarly contributions. While publishing in high-impact journals is desirable, adaptability in resubmitting to other journals following rejections ensures that research remains visible and accessible. It also clearly establishes by whom the work was first done, before someone else investigates the line of inquiry. Through a combination of strategic engagement and publication efforts, early-career physicians can effectively build their professional reputation and advance their academic careers.

 

Time Management

Time management is essential for any research, and particularly in early career when efficiency in clinical care duties is still being gained. Securing protected time for research is essential to develop a niche, build connections (both institutionally and beyond their institutions), and demonstrate productivity that can be utilized to support future grant efforts.

Similarly, using protected time efficiently is required. Without organization and planning, research time can be spent with scattered meetings and responding to various tasks that do not directly support your research. It is helpful to be introspective about the time of the day you are most productive in your research efforts and blocking off that time to focus on research tasks and minimizing distractions. Blocking monthly time for larger scale thinking and planning is also important. Weekly lab and individual one-on-one meetings also support time management for trainees and lab members, to ensure efficiency and progress. Additionally, robust clinical support is essential to ensure that research time remains protected and patient care moves forward. When negotiating for positions, and in regular meetings thereafter, it is important to advocate for sufficient clinical staffing such that non-physician tasks can be appropriately delegated to another member of the care team. 

 

Funding

Securing adequate funding poses a significant challenge for all early-career physician-scientists, particularly because of the discrepancy between National Institutes of Health salary caps and the higher average salaries in academic gastroenterology. This financial gap can deter physicians from pursuing research-intensive careers altogether and can derail early investigators who do not obtain funding rapidly. To overcome this, early-career investigators may need to adopt flexible strategies, such as accepting a lower salary that aligns with grant funding limits or funneling incentive or bonus pay to research accounts. Alternatively, they can advocate for institutional support to bridge the salary gap, ensuring their research efforts remain financially viable.

Institutions committed to fostering research excellence may offer supplemental funding or bridge programs to retain talented physician-scientists, thereby mitigating the financial strain and encouraging long-term engagement in research. Regular meetings to review salary and support sources, including philanthropy, foundation grants, and other streams, should be undertaken with leadership to align the researcher’s timeline and available funding. If career development funding appears untenable, consideration of multi–principal investigator R01s or equivalent with senior established investigators can be a promising path. 

 

Receiving Mentorship

Effective mentorship for early-career physician-scientists should be approached through a team-based model that leverages both internal and external mentors. Internal mentors, familiar with the specific culture, expectations, and advancement pathways of the institution, can provide invaluable guidance on navigating institutional metrics for success, such as promotion criteria, grant acquisition, and clinical-research balance. External mentors, on the other hand, bring a broader perspective by offering innovative career development strategies and solutions derived from experiences at their home institutions. This multimodal mentorship model ensures a well-rounded approach to professional growth.

All national gastroenterology societies, including the American Gastroenterological Association, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy, and American Association for the Study of Liver Disease, offer structured early-career mentorship programs designed to connect emerging researchers with experienced leaders in the field (see below). These programs typically require a formal application process and are highly regarded for their exceptional quality and impact. Participation in such initiatives can significantly enhance career development by expanding networks, fostering interdisciplinary collaboration, and providing tailored guidance that complements institutional support. Integrating both internal and external mentorship opportunities ensures a robust and dynamic foundation for long-term success in academic medicine.

• AGA Career Compass (https://gastro.org/fellows-and-early-career/mentoring/)
• ACG Early Career Leadership Program (https://gi.org/acg-institute/early-career-leadership-program/)
• AGA-AASLD Academic Skills Workshop (https://gastro.org/news/applications-now-being-accepted-for-the-2024-aga-aasld-academic-skills-workshop/)
• AASLD Women’s Initiative Committee Leadership Program (https://www.aasld.org/promoting-leadership-potential-women-hepatology)
• Scrubs n Heels Mentorship Matrix (https://scrubsandheels.com/matrix/)

Providing Mentorship

The trainee authors on this manuscript describe in this section what has been helpful for them as mentees in the FELD research lab.

Student doctor Nguyen describes her experience as a lab member and things she finds most helpful as a medical student in the lab:

• Upon joining the team, a one-to-one meeting to discuss trainee’s personal and professional goals, and availability, was crucial to building the mentor-mentee relationship. Establishing this meaningful mentorship early on clarified expectations on both sides, built trust, and increased motivation. As a trainee, it is essential for me to see how my work aligns with a long-term goal and to receive ample guidance throughout the process.
• One of the most impactful experiences has been joining informal lunch sessions where trainees discussed data collection protocols and exchanged insights. In doing so, Dr. Feld has cultivated a lab culture that encourages curiosity, constructive feedback, and collaborative learning.
• To increase productivity, our team of trainees created a useful group message thread where we coordinated more sessions to collaborate. This coordination formed stronger relationships between team members and fostered a sense of shared purpose.

Dr. Cooper, a third year internal medicine resident, describes her experience as both a research mentee and a mentor to the junior trainees: “As a resident pursuing a career in academic gastroenterology and hepatology, I have found three key elements to be most helpful: intentional mentorship, structured meetings, and leadership development.”

• Intentional mentorship: Prior to joining the lab, I met with Dr. Feld to discuss my research experience and my goals. She took the time to understand these within the context of my training timeline and tailored project opportunities that aligned with my interests and were both feasible and impactful for my next steps. This intentional approach not only fostered a productive research experience but also established a mentor-mentee relationship built on genuine care for my growth and development.
• Regular meetings: Frequent lab meetings promote accountability, teamwork, and shared problem-solving skills. The open exchange of ideas fosters collaboration and joint problem solving to elevate the quality of our research. They are also an opportunity to observe key decision-making points during the research process and have been a great way to learn more about solid methodology.
• Supervised leadership: I have had ample time to lead discussions and coordinate projects among the junior trainees. These monitored leadership experiences promote project management skills, mentorship, and team dynamic awareness while maintaining the safety net of senior guidance. This model helped me transition from a trainee supporting others’ research to a more independent role, contributing to multi-disciplinary projects while mentoring junior members.

Conclusion

In conclusion, many exciting opportunities and notable barriers exist to establishing a clinical research laboratory in the early career. Individual and institutional investment and support are vital to the success of junior physicians seeking a career in clinical research. While excellence in each of the areas outlined may evolve, some aspects will come easier than others and with time, persistence, and a bit of luck, the research world will be a better place because of your contributions!

Dr. Feld is assistant professor of gastroenterology and hepatology and physician executive of Diversity, Equity, Inclusion and Belonging for the department of medicine at the University of Massachusetts (UMass) Chan Medical School, Worcester. Ms. Nguyen is a medical student at UMass Chan Medical School. Dr. Cooper is a resident physician at UMass Chan Medical School. Dr. Rabinowitz is an attending physician in the Inflammatory Bowel Disease Center at Beth Israel Deaconess Medical Center, Boston, Mass. Dr. Uchida is codirector of the Multidisciplinary Eosinophilic Gastrointestinal Disease Clinic at the University of Utah School of Medicine, Salt Lake City.

Non-compete agreements (NCAs) in physician contracts, also termed “restrictive covenants” or “covenants not to compete,” have become a hot topic recently because of the Federal Trade Commission’s (FTC’s) April 2024 ruling invalidating almost all NCAs. But in fact, NCAs have long been controversial, and no more so than in the realm of physician NCAs, which involve substantial policy concerns.

Given its intricacies and importance of NCAs, and the fact that up to 45% of physicians currently have contracts containing NCAs, it behooves physicians to understand the foundation of the NCA, how it relates to a physician employment contract currently, and its possible evolution.

 

What is It?

Generally speaking, an NCA, usually in the form of an employment contract clause, is an agreement between the employer and the employee that the employee will not enter into post-contract competition with that employer within the limitations of a specific duration, scope of practice, and/or geography. NCAs have traditionally been regulated under state statutory law and common law and have been permitted based on policy considerations that attempt to balance competing employee and employer interests. Physicians should understand their states’ statutory treatment of an NCA.

NCAs protect important employer business interests, including the protection of proprietary information, safeguarding trade secrets, reducing employee turnover, and protecting patient lists. Employees, though, have limited mobility in changing professional positions, have less bargaining power with the employer, and may find themselves with limited options for comparable professional positions.

The NCA ostensibly appears to greatly benefit the employer’s interests over the employee’s; however, NCA protection of employer interests may also substantially benefit employees by encouraging substantial employer investment in employees whom the employer recognizes as a stable and likely long-term human resource, ultimately fostering increased employee satisfaction and innovation. Indeed, one concern with the FTC’s non-compete ban is the potential for significant underinvestment in information sharing and employee training, because employers would, without a NCA, be less likely to recoup those employee investments and would have limited ability to keep competitors from free-riding on investments in employees who leave and join competitors. Ultimately, this would lead to decreased market efficiency.

 

What is Its Status Today?

Regulation of NCAs, including physician NCAs, has traditionally been based on state statutory law and by common law. Perhaps because of the increasing use of the NCA in professional settings, the NCA has been increasingly scrutinized by courts and state legislatures in the last few decades, with an overall increasing focus on NCA reasonableness and appropriate fit in individual employment settings, and with an emphasis on employer demonstration of legitimate and significant business interests for using a NCA.

States have evolved differently in their treatment of NCAs; some states ban NCAs altogether while others allow them with varying interpretation and enforceability, frequently focused upon the NCA’s duration, scope, and geography. Similarly, in common law, courts will frequently invalidate NCAs that are found to be unreasonably overbroad, either geographically, temporally, and/or in regard to scope. 

On April 23, 2024, however, the FTC altered this existing state of affairs by issuing a rule banning new NCAs in all employment situations after September 3, 2024. The rule also holds that existing NCAs are not enforceable, with a small carve-out for some senior executives. It applies to for-profit businesses, and some, but not all, non-profit organizations. The FTC’s stated intent is to reduce healthcare spending by increasing employee compensation and mobility. The FTC’s ban is likely meant to reduce transaction costs by increasing physician mobility.

There have been several lawsuits regarding the FTC ruling, challenging it on different grounds. The US District Court for the Northern District of Texas in Ryan LLC v. FTC issued first a preliminary injunction, then a final decision overturning the FTC’s rule. The Court held that the FTC had exceeded its statutory authority, and further, that the rule was arbitrary and capricious. It noted that the rule’s “categorical ban” has no equivalent in state law, is “unreasonably overbroad without a reasonable explanation,” “provides no evidence or reasoned basis,” does not “consider the positive benefits of non-compete agreements,” and does not “address alternatives to the Rule.” The Ryan Court reasoned that as an administrative agency, the FTC can only act as Congress authorizes by statute. On Oct. 18, 2024, the FTC appealed the Court’s decision to the Fifth Circuit Court of Appeals, seeking to reverse the holding setting aside its NCA ban. 

The United States District Court for the Eastern District of Pennsylvania in ATS Tree Services LLC v. FTC denied the plaintiff’s motion to stay enforcement of the rule, refusing to issue a preliminary injunction preventing its implementation. As in Ryan, the ATS Tree Services LLC v. FTC plaintiffs argued that the FTC had exceeded its statutory authority in issuing the rule. However, the Plaintiff did not appeal the holding.

The US District Court for the Middle District of Florida in Properties of the Villages, Inc. v. FTCheld, like Ryan, that the rule exceeds the FTC’s statutory authority, noting the FTC’s prior lack of any NCA enforcement actions; however, its reasoning differed from Ryan. The Florida Court held that the FTC in fact has statutory authority to issue such rules; however, the Court held that the FTC could not enforce its rule because it violates the “major questions doctrine.” The “major questions doctrine” requires an agency such as the FTC to “point to clear congressional authorization” for any rule it issues that has “extraordinary ... economic and political significance,” as the NCA ban rule certainly does.



 

What is Its Future?

The FTC’s NCA ban remains unsettled. State legislatures, in response to the recent court holdings, are reassessing their statutory law regarding NCAs. The Ryan Court’s holding prevented the FTC’s rule from going into effect on September 4, 2024. The Texas and Florida court decisions are awaiting 5th and 11th Circuit Court of Appeals review, respectively. Assuming affirmation of either of the cases on appeal, a circuit split regarding the NCA ban may occur. The US Supreme Court may be called upon to determine the validity of the FTC rule banning NCAs. The Circuit Court decisions are likely to occur in 2025, and any Supreme Court decision would not likely occur until 2026. Meanwhile, state statutory law and common law still apply to NCAs, and the FTC may challenge the validity of NCAs on a case-by-case basis.

US antitrust law remains a potential remedy to scrutinize and restrain inappropriate business practices, including NCA-related abuses. The Sherman Act allows federal and state actors and private citizens, to sue for redress. Antitrust cases are typically considered using the “rule of reason” formulated by the Supreme Court in 1911, which requires plaintiffs show that defendant businesses possessing market power did in fact undertake anticompetitive conduct that had or likely had anticompetitive effects. In other words, the court in an antitrust case will require that the plaintiff show that the business actually had a significant controlling market presence in the geographic area; and further, that the plaintiff show that the business’ actions in fact had an anticompetitive effect, or likely had one. The latter can be found by showing an anticompetitive effect such as abusive pricing

The FTC’s ruling is legally and academically controversial and in fact may not withstand court scrutiny. The rule was put forth by the FTC as an ambitious rule to reduce healthcare spending. But businesses survive only if their revenue surpasses their costs, including personnel costs. Further, maximization of capitalization is attained when businesses require NCAs. Businesses invest heavily in recruiting, hiring, and training personnel, and increased personnel turnover increases these expenditures. NCAs arguably provide a collective benefit by ensuring force continuity, mitigating the risk of the loss of highly trained personnel with proprietary knowledge. NCAs also help a business maintain a skilled workforce, helping maximize business valuation. If FTC’s NCA ban rule were ultimately upheld, businesses would likely respond by instituting longer-term employee contracts, extended termination notice periods, and disincentives for employees who do not fully serve their contract length, including substantial financial disincentives. Business valuation might decrease, reducing investment incentives. 

NCAs have long been a method of balancing the interests of employees and employers. They protect businesses’ confidential information, trade secrets, and patient lists, at some cost to employees pursuing new opportunities. The employee, though, is also provided with some benefit from the NCA, albeit indirect. State statutory law and courts have traditionally worked to ensure an appropriate delicate balance between interests, with courts generally finding unbalanced NCAs unenforceable.

For now, physicians should understand the policy considerations of and recognize the uncertainty surrounding NCAs, become familiar with their state’s statutory NCA law, review employment contracts carefully for NCA reasonableness, and seek legal advice if necessary.

Perhaps the FTC’s approach is the correct one for our future. Or perhaps the appropriate future of NCA interpretation and enforcement should continue to rest on state statutory law and common law, where antitrust enforcement is on a case-by-case basis, rather than FTC rulemaking. The results of high court decisions, state statutory law changes in response to the FTC rule, and perhaps US congressional action will provide the final answer.

Dr. Allen is based at the University of Oklahoma Health Sciences Center in Oklahoma City. He has declared no conflicts of interest in relation to this article.

Non-compete agreements (NCAs) in physician contracts, also termed “restrictive covenants” or “covenants not to compete,” have become a hot topic recently because of the Federal Trade Commission’s (FTC’s) April 2024 ruling invalidating almost all NCAs. But in fact, NCAs have long been controversial, and no more so than in the realm of physician NCAs, which involve substantial policy concerns.

Given its intricacies and importance of NCAs, and the fact that up to 45% of physicians currently have contracts containing NCAs, it behooves physicians to understand the foundation of the NCA, how it relates to a physician employment contract currently, and its possible evolution.

 

What is It?

Generally speaking, an NCA, usually in the form of an employment contract clause, is an agreement between the employer and the employee that the employee will not enter into post-contract competition with that employer within the limitations of a specific duration, scope of practice, and/or geography. NCAs have traditionally been regulated under state statutory law and common law and have been permitted based on policy considerations that attempt to balance competing employee and employer interests. Physicians should understand their states’ statutory treatment of an NCA.

NCAs protect important employer business interests, including the protection of proprietary information, safeguarding trade secrets, reducing employee turnover, and protecting patient lists. Employees, though, have limited mobility in changing professional positions, have less bargaining power with the employer, and may find themselves with limited options for comparable professional positions.

The NCA ostensibly appears to greatly benefit the employer’s interests over the employee’s; however, NCA protection of employer interests may also substantially benefit employees by encouraging substantial employer investment in employees whom the employer recognizes as a stable and likely long-term human resource, ultimately fostering increased employee satisfaction and innovation. Indeed, one concern with the FTC’s non-compete ban is the potential for significant underinvestment in information sharing and employee training, because employers would, without a NCA, be less likely to recoup those employee investments and would have limited ability to keep competitors from free-riding on investments in employees who leave and join competitors. Ultimately, this would lead to decreased market efficiency.

 

What is Its Status Today?

Regulation of NCAs, including physician NCAs, has traditionally been based on state statutory law and by common law. Perhaps because of the increasing use of the NCA in professional settings, the NCA has been increasingly scrutinized by courts and state legislatures in the last few decades, with an overall increasing focus on NCA reasonableness and appropriate fit in individual employment settings, and with an emphasis on employer demonstration of legitimate and significant business interests for using a NCA.

States have evolved differently in their treatment of NCAs; some states ban NCAs altogether while others allow them with varying interpretation and enforceability, frequently focused upon the NCA’s duration, scope, and geography. Similarly, in common law, courts will frequently invalidate NCAs that are found to be unreasonably overbroad, either geographically, temporally, and/or in regard to scope. 

On April 23, 2024, however, the FTC altered this existing state of affairs by issuing a rule banning new NCAs in all employment situations after September 3, 2024. The rule also holds that existing NCAs are not enforceable, with a small carve-out for some senior executives. It applies to for-profit businesses, and some, but not all, non-profit organizations. The FTC’s stated intent is to reduce healthcare spending by increasing employee compensation and mobility. The FTC’s ban is likely meant to reduce transaction costs by increasing physician mobility.

There have been several lawsuits regarding the FTC ruling, challenging it on different grounds. The US District Court for the Northern District of Texas in Ryan LLC v. FTC issued first a preliminary injunction, then a final decision overturning the FTC’s rule. The Court held that the FTC had exceeded its statutory authority, and further, that the rule was arbitrary and capricious. It noted that the rule’s “categorical ban” has no equivalent in state law, is “unreasonably overbroad without a reasonable explanation,” “provides no evidence or reasoned basis,” does not “consider the positive benefits of non-compete agreements,” and does not “address alternatives to the Rule.” The Ryan Court reasoned that as an administrative agency, the FTC can only act as Congress authorizes by statute. On Oct. 18, 2024, the FTC appealed the Court’s decision to the Fifth Circuit Court of Appeals, seeking to reverse the holding setting aside its NCA ban. 

The United States District Court for the Eastern District of Pennsylvania in ATS Tree Services LLC v. FTC denied the plaintiff’s motion to stay enforcement of the rule, refusing to issue a preliminary injunction preventing its implementation. As in Ryan, the ATS Tree Services LLC v. FTC plaintiffs argued that the FTC had exceeded its statutory authority in issuing the rule. However, the Plaintiff did not appeal the holding.

The US District Court for the Middle District of Florida in Properties of the Villages, Inc. v. FTCheld, like Ryan, that the rule exceeds the FTC’s statutory authority, noting the FTC’s prior lack of any NCA enforcement actions; however, its reasoning differed from Ryan. The Florida Court held that the FTC in fact has statutory authority to issue such rules; however, the Court held that the FTC could not enforce its rule because it violates the “major questions doctrine.” The “major questions doctrine” requires an agency such as the FTC to “point to clear congressional authorization” for any rule it issues that has “extraordinary ... economic and political significance,” as the NCA ban rule certainly does.



 

What is Its Future?

The FTC’s NCA ban remains unsettled. State legislatures, in response to the recent court holdings, are reassessing their statutory law regarding NCAs. The Ryan Court’s holding prevented the FTC’s rule from going into effect on September 4, 2024. The Texas and Florida court decisions are awaiting 5th and 11th Circuit Court of Appeals review, respectively. Assuming affirmation of either of the cases on appeal, a circuit split regarding the NCA ban may occur. The US Supreme Court may be called upon to determine the validity of the FTC rule banning NCAs. The Circuit Court decisions are likely to occur in 2025, and any Supreme Court decision would not likely occur until 2026. Meanwhile, state statutory law and common law still apply to NCAs, and the FTC may challenge the validity of NCAs on a case-by-case basis.

US antitrust law remains a potential remedy to scrutinize and restrain inappropriate business practices, including NCA-related abuses. The Sherman Act allows federal and state actors and private citizens, to sue for redress. Antitrust cases are typically considered using the “rule of reason” formulated by the Supreme Court in 1911, which requires plaintiffs show that defendant businesses possessing market power did in fact undertake anticompetitive conduct that had or likely had anticompetitive effects. In other words, the court in an antitrust case will require that the plaintiff show that the business actually had a significant controlling market presence in the geographic area; and further, that the plaintiff show that the business’ actions in fact had an anticompetitive effect, or likely had one. The latter can be found by showing an anticompetitive effect such as abusive pricing

The FTC’s ruling is legally and academically controversial and in fact may not withstand court scrutiny. The rule was put forth by the FTC as an ambitious rule to reduce healthcare spending. But businesses survive only if their revenue surpasses their costs, including personnel costs. Further, maximization of capitalization is attained when businesses require NCAs. Businesses invest heavily in recruiting, hiring, and training personnel, and increased personnel turnover increases these expenditures. NCAs arguably provide a collective benefit by ensuring force continuity, mitigating the risk of the loss of highly trained personnel with proprietary knowledge. NCAs also help a business maintain a skilled workforce, helping maximize business valuation. If FTC’s NCA ban rule were ultimately upheld, businesses would likely respond by instituting longer-term employee contracts, extended termination notice periods, and disincentives for employees who do not fully serve their contract length, including substantial financial disincentives. Business valuation might decrease, reducing investment incentives. 

NCAs have long been a method of balancing the interests of employees and employers. They protect businesses’ confidential information, trade secrets, and patient lists, at some cost to employees pursuing new opportunities. The employee, though, is also provided with some benefit from the NCA, albeit indirect. State statutory law and courts have traditionally worked to ensure an appropriate delicate balance between interests, with courts generally finding unbalanced NCAs unenforceable.

For now, physicians should understand the policy considerations of and recognize the uncertainty surrounding NCAs, become familiar with their state’s statutory NCA law, review employment contracts carefully for NCA reasonableness, and seek legal advice if necessary.

Perhaps the FTC’s approach is the correct one for our future. Or perhaps the appropriate future of NCA interpretation and enforcement should continue to rest on state statutory law and common law, where antitrust enforcement is on a case-by-case basis, rather than FTC rulemaking. The results of high court decisions, state statutory law changes in response to the FTC rule, and perhaps US congressional action will provide the final answer.

Dr. Allen is based at the University of Oklahoma Health Sciences Center in Oklahoma City. He has declared no conflicts of interest in relation to this article.

Non-compete agreements (NCAs) in physician contracts, also termed “restrictive covenants” or “covenants not to compete,” have become a hot topic recently because of the Federal Trade Commission’s (FTC’s) April 2024 ruling invalidating almost all NCAs. But in fact, NCAs have long been controversial, and no more so than in the realm of physician NCAs, which involve substantial policy concerns.

Given its intricacies and importance of NCAs, and the fact that up to 45% of physicians currently have contracts containing NCAs, it behooves physicians to understand the foundation of the NCA, how it relates to a physician employment contract currently, and its possible evolution.

 

What is It?

Generally speaking, an NCA, usually in the form of an employment contract clause, is an agreement between the employer and the employee that the employee will not enter into post-contract competition with that employer within the limitations of a specific duration, scope of practice, and/or geography. NCAs have traditionally been regulated under state statutory law and common law and have been permitted based on policy considerations that attempt to balance competing employee and employer interests. Physicians should understand their states’ statutory treatment of an NCA.

NCAs protect important employer business interests, including the protection of proprietary information, safeguarding trade secrets, reducing employee turnover, and protecting patient lists. Employees, though, have limited mobility in changing professional positions, have less bargaining power with the employer, and may find themselves with limited options for comparable professional positions.

The NCA ostensibly appears to greatly benefit the employer’s interests over the employee’s; however, NCA protection of employer interests may also substantially benefit employees by encouraging substantial employer investment in employees whom the employer recognizes as a stable and likely long-term human resource, ultimately fostering increased employee satisfaction and innovation. Indeed, one concern with the FTC’s non-compete ban is the potential for significant underinvestment in information sharing and employee training, because employers would, without a NCA, be less likely to recoup those employee investments and would have limited ability to keep competitors from free-riding on investments in employees who leave and join competitors. Ultimately, this would lead to decreased market efficiency.

 

What is Its Status Today?

Regulation of NCAs, including physician NCAs, has traditionally been based on state statutory law and by common law. Perhaps because of the increasing use of the NCA in professional settings, the NCA has been increasingly scrutinized by courts and state legislatures in the last few decades, with an overall increasing focus on NCA reasonableness and appropriate fit in individual employment settings, and with an emphasis on employer demonstration of legitimate and significant business interests for using a NCA.

States have evolved differently in their treatment of NCAs; some states ban NCAs altogether while others allow them with varying interpretation and enforceability, frequently focused upon the NCA’s duration, scope, and geography. Similarly, in common law, courts will frequently invalidate NCAs that are found to be unreasonably overbroad, either geographically, temporally, and/or in regard to scope. 

On April 23, 2024, however, the FTC altered this existing state of affairs by issuing a rule banning new NCAs in all employment situations after September 3, 2024. The rule also holds that existing NCAs are not enforceable, with a small carve-out for some senior executives. It applies to for-profit businesses, and some, but not all, non-profit organizations. The FTC’s stated intent is to reduce healthcare spending by increasing employee compensation and mobility. The FTC’s ban is likely meant to reduce transaction costs by increasing physician mobility.

There have been several lawsuits regarding the FTC ruling, challenging it on different grounds. The US District Court for the Northern District of Texas in Ryan LLC v. FTC issued first a preliminary injunction, then a final decision overturning the FTC’s rule. The Court held that the FTC had exceeded its statutory authority, and further, that the rule was arbitrary and capricious. It noted that the rule’s “categorical ban” has no equivalent in state law, is “unreasonably overbroad without a reasonable explanation,” “provides no evidence or reasoned basis,” does not “consider the positive benefits of non-compete agreements,” and does not “address alternatives to the Rule.” The Ryan Court reasoned that as an administrative agency, the FTC can only act as Congress authorizes by statute. On Oct. 18, 2024, the FTC appealed the Court’s decision to the Fifth Circuit Court of Appeals, seeking to reverse the holding setting aside its NCA ban. 

The United States District Court for the Eastern District of Pennsylvania in ATS Tree Services LLC v. FTC denied the plaintiff’s motion to stay enforcement of the rule, refusing to issue a preliminary injunction preventing its implementation. As in Ryan, the ATS Tree Services LLC v. FTC plaintiffs argued that the FTC had exceeded its statutory authority in issuing the rule. However, the Plaintiff did not appeal the holding.

The US District Court for the Middle District of Florida in Properties of the Villages, Inc. v. FTCheld, like Ryan, that the rule exceeds the FTC’s statutory authority, noting the FTC’s prior lack of any NCA enforcement actions; however, its reasoning differed from Ryan. The Florida Court held that the FTC in fact has statutory authority to issue such rules; however, the Court held that the FTC could not enforce its rule because it violates the “major questions doctrine.” The “major questions doctrine” requires an agency such as the FTC to “point to clear congressional authorization” for any rule it issues that has “extraordinary ... economic and political significance,” as the NCA ban rule certainly does.



 

What is Its Future?

The FTC’s NCA ban remains unsettled. State legislatures, in response to the recent court holdings, are reassessing their statutory law regarding NCAs. The Ryan Court’s holding prevented the FTC’s rule from going into effect on September 4, 2024. The Texas and Florida court decisions are awaiting 5th and 11th Circuit Court of Appeals review, respectively. Assuming affirmation of either of the cases on appeal, a circuit split regarding the NCA ban may occur. The US Supreme Court may be called upon to determine the validity of the FTC rule banning NCAs. The Circuit Court decisions are likely to occur in 2025, and any Supreme Court decision would not likely occur until 2026. Meanwhile, state statutory law and common law still apply to NCAs, and the FTC may challenge the validity of NCAs on a case-by-case basis.

US antitrust law remains a potential remedy to scrutinize and restrain inappropriate business practices, including NCA-related abuses. The Sherman Act allows federal and state actors and private citizens, to sue for redress. Antitrust cases are typically considered using the “rule of reason” formulated by the Supreme Court in 1911, which requires plaintiffs show that defendant businesses possessing market power did in fact undertake anticompetitive conduct that had or likely had anticompetitive effects. In other words, the court in an antitrust case will require that the plaintiff show that the business actually had a significant controlling market presence in the geographic area; and further, that the plaintiff show that the business’ actions in fact had an anticompetitive effect, or likely had one. The latter can be found by showing an anticompetitive effect such as abusive pricing

The FTC’s ruling is legally and academically controversial and in fact may not withstand court scrutiny. The rule was put forth by the FTC as an ambitious rule to reduce healthcare spending. But businesses survive only if their revenue surpasses their costs, including personnel costs. Further, maximization of capitalization is attained when businesses require NCAs. Businesses invest heavily in recruiting, hiring, and training personnel, and increased personnel turnover increases these expenditures. NCAs arguably provide a collective benefit by ensuring force continuity, mitigating the risk of the loss of highly trained personnel with proprietary knowledge. NCAs also help a business maintain a skilled workforce, helping maximize business valuation. If FTC’s NCA ban rule were ultimately upheld, businesses would likely respond by instituting longer-term employee contracts, extended termination notice periods, and disincentives for employees who do not fully serve their contract length, including substantial financial disincentives. Business valuation might decrease, reducing investment incentives. 

NCAs have long been a method of balancing the interests of employees and employers. They protect businesses’ confidential information, trade secrets, and patient lists, at some cost to employees pursuing new opportunities. The employee, though, is also provided with some benefit from the NCA, albeit indirect. State statutory law and courts have traditionally worked to ensure an appropriate delicate balance between interests, with courts generally finding unbalanced NCAs unenforceable.

For now, physicians should understand the policy considerations of and recognize the uncertainty surrounding NCAs, become familiar with their state’s statutory NCA law, review employment contracts carefully for NCA reasonableness, and seek legal advice if necessary.

Perhaps the FTC’s approach is the correct one for our future. Or perhaps the appropriate future of NCA interpretation and enforcement should continue to rest on state statutory law and common law, where antitrust enforcement is on a case-by-case basis, rather than FTC rulemaking. The results of high court decisions, state statutory law changes in response to the FTC rule, and perhaps US congressional action will provide the final answer.

Dr. Allen is based at the University of Oklahoma Health Sciences Center in Oklahoma City. He has declared no conflicts of interest in relation to this article.

The U.S. Senate confirmed former Georgia congressman Doug Collins as the Secretary for the US Department of Veterans Affairs (VA) on Feb. 4 in a comfortable 77 to 23 vote. Collins received votes from every Republican Senator and 23 Democratic Senators.

“The MISSION Act, the VA Accountability and Whistleblower Protection Act and the PACT Act are 3 of the most important veterans laws in recent history,” Collins said during his confirmation hearing. “They received widespread bipartisan support because their focus is exactly where VA’s focus should be: on veteran convenience and accountability for the department.” 

Collins pledged to keep the VA strong but also to expand community care, noting: “I believe you can have both, you can have a strong VA as it currently exists, and you can have the community care aspect.”

Sen. Richard Blumenthal (D-CT), who voted to confirm Collins, urged the secretary to exempt all VA employees from the Trump Administration’s recent hiring freeze; ensure that financial assistance programs for veterans are exempt from funding pauses; work with President Trump to reappoint VA Inspector General Mike Missal, who was removed from office by the President in January; and to ensure all VA employees receive due process amid recent directives from the Office of Personnel Management.

The VA also announced a number of new political appointees, including Chris Syrek, who set to serve as chief of staff; Cheryl Mason is slated to serve as senior advisory to Secretary Collins; and Lynda Davis is set to serve as the chief officer with VA's Veterans Experience Office. No nominations have been made for the Undersecretary of Health to date.

The U.S. Senate confirmed former Georgia congressman Doug Collins as the Secretary for the US Department of Veterans Affairs (VA) on Feb. 4 in a comfortable 77 to 23 vote. Collins received votes from every Republican Senator and 23 Democratic Senators.

“The MISSION Act, the VA Accountability and Whistleblower Protection Act and the PACT Act are 3 of the most important veterans laws in recent history,” Collins said during his confirmation hearing. “They received widespread bipartisan support because their focus is exactly where VA’s focus should be: on veteran convenience and accountability for the department.” 

Collins pledged to keep the VA strong but also to expand community care, noting: “I believe you can have both, you can have a strong VA as it currently exists, and you can have the community care aspect.”

Sen. Richard Blumenthal (D-CT), who voted to confirm Collins, urged the secretary to exempt all VA employees from the Trump Administration’s recent hiring freeze; ensure that financial assistance programs for veterans are exempt from funding pauses; work with President Trump to reappoint VA Inspector General Mike Missal, who was removed from office by the President in January; and to ensure all VA employees receive due process amid recent directives from the Office of Personnel Management.

The VA also announced a number of new political appointees, including Chris Syrek, who set to serve as chief of staff; Cheryl Mason is slated to serve as senior advisory to Secretary Collins; and Lynda Davis is set to serve as the chief officer with VA's Veterans Experience Office. No nominations have been made for the Undersecretary of Health to date.

The U.S. Senate confirmed former Georgia congressman Doug Collins as the Secretary for the US Department of Veterans Affairs (VA) on Feb. 4 in a comfortable 77 to 23 vote. Collins received votes from every Republican Senator and 23 Democratic Senators.

“The MISSION Act, the VA Accountability and Whistleblower Protection Act and the PACT Act are 3 of the most important veterans laws in recent history,” Collins said during his confirmation hearing. “They received widespread bipartisan support because their focus is exactly where VA’s focus should be: on veteran convenience and accountability for the department.” 

Collins pledged to keep the VA strong but also to expand community care, noting: “I believe you can have both, you can have a strong VA as it currently exists, and you can have the community care aspect.”

Sen. Richard Blumenthal (D-CT), who voted to confirm Collins, urged the secretary to exempt all VA employees from the Trump Administration’s recent hiring freeze; ensure that financial assistance programs for veterans are exempt from funding pauses; work with President Trump to reappoint VA Inspector General Mike Missal, who was removed from office by the President in January; and to ensure all VA employees receive due process amid recent directives from the Office of Personnel Management.

The VA also announced a number of new political appointees, including Chris Syrek, who set to serve as chief of staff; Cheryl Mason is slated to serve as senior advisory to Secretary Collins; and Lynda Davis is set to serve as the chief officer with VA's Veterans Experience Office. No nominations have been made for the Undersecretary of Health to date.

Nearly 96,000 US Department of Veterans Affairs (VA) employees—about 20% of the workforce—will be required to return to in-office work by the end of February. The announcement follows a Jan. 20 presidential memorandum, which states agency heads must “take all necessary steps to terminate remote work arrangements and require employees to return to work in-person at their respective duty stations on a full-time basis.” According to a Jan. 28 email sent from the Office of Personnel Management but without a signature, federal employees who refuse will be offered “dignified, fair departure from the federal government utilizing a deferred resignation program.”

The revised VA work policy states “eligible employees must work full-time at their respective duty stations (agency worksites) unless excused due to a disability, qualifying medical condition or other compelling reason.” All nonbargaining unit employees and supervisors who are within 50 miles of their office have until Feb. 24 to return. The VA stated that further guidance is coming for those who live > 50 miles from a facility. 

“VA’s policy allows exceptions for arrangements approved for employees as a reasonable accommodation due to a disability or a qualifying medical condition. Exceptions may also be allowed for military spouses with permanent change of station orders,” according to a VA press release.

“This is a commonsense step toward treating all VA employees equally,” acting VA Secretary Todd Hunter said. “Most VA clinical staff don’t have the luxury of working remotely, and we believe the performance, collaboration and productivity of the department will improve if all VA employees are held to the same standard.” 

The impact on Veterans Health Administration operations remains difficult to determine. The order appears to include personnel providing telehealth care from remote locations, including those at the Clinical Resource Hub (CRH) program. CRH uses a hub and spoke model for limited time primary care and mental health care staffing to cover local clinician vacancies. CRH clinicians have provided > 500,000 veterans with care, averaging > 25,000 encounters in the program’s first year. Started during fiscal year 2020 amid the COVID-19 pandemic, CRH employed 636 clinicians, but more recent data are not available. The VA provided > 28 million telehealth sessions to veterans across all of its telehealth modalities in 2023. Details on how many CRH clinicians and other telehealth practitioners work remotely are also not available.

On Feb. 3, the Office of Personnel Management issued a memo to federal agency heads arguing that any collective bargaining agreements that include teleworking may “conflict with management rights” and therefore may be “unlawful and cannot be enforced.”

The American Federation of Government Employees (AFGE), which represents 800,000 federal employees, disputed the memo. “Federal employees should know that approved union contracts are enforceable by law, and the President does not have the authority to make unilateral changes to those agreements,” AFGE President Everett Kelley said. “AFGE members will not be intimidated. If our contracts are violated, we will aggressively defend them.”

The VA must decide where to put the more than 47,000 workers who may be coming back. According to the Government Accountability Office, “Federal agencies have long struggled to determine how much office space they needed to fulfill their missions efficiently.” The VA has reduced its office space by > 290,000 ft² over the last few years in the National Capital Region alone. 

In his confirmation hearing last month, VA Secretary nominee Doug Collins told lawmakers that, if confirmed, he would “encourage employees to come back to work,” but he also said he would ensure the department was following the White House’s remote work limits. “We’re going to make sure that we get people in there,” he said, “because at the end of the day, it’s about veterans.”

Nearly 96,000 US Department of Veterans Affairs (VA) employees—about 20% of the workforce—will be required to return to in-office work by the end of February. The announcement follows a Jan. 20 presidential memorandum, which states agency heads must “take all necessary steps to terminate remote work arrangements and require employees to return to work in-person at their respective duty stations on a full-time basis.” According to a Jan. 28 email sent from the Office of Personnel Management but without a signature, federal employees who refuse will be offered “dignified, fair departure from the federal government utilizing a deferred resignation program.”

The revised VA work policy states “eligible employees must work full-time at their respective duty stations (agency worksites) unless excused due to a disability, qualifying medical condition or other compelling reason.” All nonbargaining unit employees and supervisors who are within 50 miles of their office have until Feb. 24 to return. The VA stated that further guidance is coming for those who live > 50 miles from a facility. 

“VA’s policy allows exceptions for arrangements approved for employees as a reasonable accommodation due to a disability or a qualifying medical condition. Exceptions may also be allowed for military spouses with permanent change of station orders,” according to a VA press release.

“This is a commonsense step toward treating all VA employees equally,” acting VA Secretary Todd Hunter said. “Most VA clinical staff don’t have the luxury of working remotely, and we believe the performance, collaboration and productivity of the department will improve if all VA employees are held to the same standard.” 

The impact on Veterans Health Administration operations remains difficult to determine. The order appears to include personnel providing telehealth care from remote locations, including those at the Clinical Resource Hub (CRH) program. CRH uses a hub and spoke model for limited time primary care and mental health care staffing to cover local clinician vacancies. CRH clinicians have provided > 500,000 veterans with care, averaging > 25,000 encounters in the program’s first year. Started during fiscal year 2020 amid the COVID-19 pandemic, CRH employed 636 clinicians, but more recent data are not available. The VA provided > 28 million telehealth sessions to veterans across all of its telehealth modalities in 2023. Details on how many CRH clinicians and other telehealth practitioners work remotely are also not available.

On Feb. 3, the Office of Personnel Management issued a memo to federal agency heads arguing that any collective bargaining agreements that include teleworking may “conflict with management rights” and therefore may be “unlawful and cannot be enforced.”

The American Federation of Government Employees (AFGE), which represents 800,000 federal employees, disputed the memo. “Federal employees should know that approved union contracts are enforceable by law, and the President does not have the authority to make unilateral changes to those agreements,” AFGE President Everett Kelley said. “AFGE members will not be intimidated. If our contracts are violated, we will aggressively defend them.”

The VA must decide where to put the more than 47,000 workers who may be coming back. According to the Government Accountability Office, “Federal agencies have long struggled to determine how much office space they needed to fulfill their missions efficiently.” The VA has reduced its office space by > 290,000 ft² over the last few years in the National Capital Region alone. 

In his confirmation hearing last month, VA Secretary nominee Doug Collins told lawmakers that, if confirmed, he would “encourage employees to come back to work,” but he also said he would ensure the department was following the White House’s remote work limits. “We’re going to make sure that we get people in there,” he said, “because at the end of the day, it’s about veterans.”

Nearly 96,000 US Department of Veterans Affairs (VA) employees—about 20% of the workforce—will be required to return to in-office work by the end of February. The announcement follows a Jan. 20 presidential memorandum, which states agency heads must “take all necessary steps to terminate remote work arrangements and require employees to return to work in-person at their respective duty stations on a full-time basis.” According to a Jan. 28 email sent from the Office of Personnel Management but without a signature, federal employees who refuse will be offered “dignified, fair departure from the federal government utilizing a deferred resignation program.”

The revised VA work policy states “eligible employees must work full-time at their respective duty stations (agency worksites) unless excused due to a disability, qualifying medical condition or other compelling reason.” All nonbargaining unit employees and supervisors who are within 50 miles of their office have until Feb. 24 to return. The VA stated that further guidance is coming for those who live > 50 miles from a facility. 

“VA’s policy allows exceptions for arrangements approved for employees as a reasonable accommodation due to a disability or a qualifying medical condition. Exceptions may also be allowed for military spouses with permanent change of station orders,” according to a VA press release.

“This is a commonsense step toward treating all VA employees equally,” acting VA Secretary Todd Hunter said. “Most VA clinical staff don’t have the luxury of working remotely, and we believe the performance, collaboration and productivity of the department will improve if all VA employees are held to the same standard.” 

The impact on Veterans Health Administration operations remains difficult to determine. The order appears to include personnel providing telehealth care from remote locations, including those at the Clinical Resource Hub (CRH) program. CRH uses a hub and spoke model for limited time primary care and mental health care staffing to cover local clinician vacancies. CRH clinicians have provided > 500,000 veterans with care, averaging > 25,000 encounters in the program’s first year. Started during fiscal year 2020 amid the COVID-19 pandemic, CRH employed 636 clinicians, but more recent data are not available. The VA provided > 28 million telehealth sessions to veterans across all of its telehealth modalities in 2023. Details on how many CRH clinicians and other telehealth practitioners work remotely are also not available.

On Feb. 3, the Office of Personnel Management issued a memo to federal agency heads arguing that any collective bargaining agreements that include teleworking may “conflict with management rights” and therefore may be “unlawful and cannot be enforced.”

The American Federation of Government Employees (AFGE), which represents 800,000 federal employees, disputed the memo. “Federal employees should know that approved union contracts are enforceable by law, and the President does not have the authority to make unilateral changes to those agreements,” AFGE President Everett Kelley said. “AFGE members will not be intimidated. If our contracts are violated, we will aggressively defend them.”

The VA must decide where to put the more than 47,000 workers who may be coming back. According to the Government Accountability Office, “Federal agencies have long struggled to determine how much office space they needed to fulfill their missions efficiently.” The VA has reduced its office space by > 290,000 ft² over the last few years in the National Capital Region alone. 

In his confirmation hearing last month, VA Secretary nominee Doug Collins told lawmakers that, if confirmed, he would “encourage employees to come back to work,” but he also said he would ensure the department was following the White House’s remote work limits. “We’re going to make sure that we get people in there,” he said, “because at the end of the day, it’s about veterans.”

TOPLINE:

Adding cetuximab (C) to postoperative radiotherapy (RT) improves disease-free survival (DFS) but not overall survival (OS) in intermediate-risk squamous cell carcinoma of the head and neck. Benefits were specifically observed in human papillomavirus–negative patients, who represented 80.2% of the study participants.

METHODOLOGY:

• Previous research showed that adding high-dose cisplatin to postoperative RT in patients with squamous cell carcinoma of the head and neck (SCCHN) improved outcomes in those with positive margins and nodal extracapsular extension of the tumor.
• The new phase 3 randomized trial, which enrolled patients from November 2009 to March 2018 included 577 individuals with resected SCCHN of the oral cavity, oropharynx, or larynx, specifically.
• Participants were randomly assigned 1:1 to receive either intensity-modulated RT (60-66 Gy) with weekly C (400 mg/m² loading dose, followed by 250 mg/m² weekly) or RT alone.
• The primary endpoint was OS in randomly assigned eligible patients, with DFS and toxicity as secondary endpoints.
• Analysis included stratified log-rank test for OS and DFS, while toxicity was compared using Fisher’s exact test.

TAKEAWAY:

• OS was not significantly improved with RT plus C vs RT alone (hazard ratio [HR], 0.81; 95% CI, 0.60-1.08; P = .0747), though 5-year OS rates were 76.5% vs 68.7%.
• DFS showed significant improvement with combined therapy (HR, 0.75; 95% CI, 0.57-0.98; P = .0168), with 5-year rates of 71.7% vs 63.6%.
• Grade 3-4 acute toxicity rates were significantly higher with combination therapy (70.3% vs 39.7%; P < .0001), primarily affecting skin and mucosa, though late toxicity rates were similar (33.2% vs 29.0%; P = .3101).
• The benefit of RT plus C was only observed in those patients who were human papillomavirus–negative, which comprised 80.2% of trial participants.

IN PRACTICE:

RT plus C “significantly improved DFS, but not OS, with no increase in long-term toxicity, compared with RT alone for resected, intermediate-risk SCCHN. RT plus C is an appropriate option for carefully selected patients with HPV-negative disease,” the authors of the study wrote.

SOURCE:

This study was led by Mitchell Machtay, MD, Penn State Health Milton S. Hershey Medical Center in Hershey, Pennsylvania. It was published online  in Journal of Clinical Oncology.

LIMITATIONS:

According to the researchers, the OS in the control group was higher than predicted, resulting in the trial being underpowered to detect the initial targeted HR. The authors noted that the better-than-expected survival rates could be attributed to improvements in surgical and radiotherapeutic techniques, including mandatory intensity-modulated RT for all patients. Additionally, the researchers pointed out that patient selection may have influenced outcomes, as only 30% of study participants had more than two risk factors.

DISCLOSURES:

This study was supported by grants from the US National Cancer Institute and Eli Lilly Inc. Machtay received grants from Lilly/ImClone, AstraZeneca, and Merck Sharp & Dohme. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Adding cetuximab (C) to postoperative radiotherapy (RT) improves disease-free survival (DFS) but not overall survival (OS) in intermediate-risk squamous cell carcinoma of the head and neck. Benefits were specifically observed in human papillomavirus–negative patients, who represented 80.2% of the study participants.

METHODOLOGY:

• Previous research showed that adding high-dose cisplatin to postoperative RT in patients with squamous cell carcinoma of the head and neck (SCCHN) improved outcomes in those with positive margins and nodal extracapsular extension of the tumor.
• The new phase 3 randomized trial, which enrolled patients from November 2009 to March 2018 included 577 individuals with resected SCCHN of the oral cavity, oropharynx, or larynx, specifically.
• Participants were randomly assigned 1:1 to receive either intensity-modulated RT (60-66 Gy) with weekly C (400 mg/m² loading dose, followed by 250 mg/m² weekly) or RT alone.
• The primary endpoint was OS in randomly assigned eligible patients, with DFS and toxicity as secondary endpoints.
• Analysis included stratified log-rank test for OS and DFS, while toxicity was compared using Fisher’s exact test.

TAKEAWAY:

• OS was not significantly improved with RT plus C vs RT alone (hazard ratio [HR], 0.81; 95% CI, 0.60-1.08; P = .0747), though 5-year OS rates were 76.5% vs 68.7%.
• DFS showed significant improvement with combined therapy (HR, 0.75; 95% CI, 0.57-0.98; P = .0168), with 5-year rates of 71.7% vs 63.6%.
• Grade 3-4 acute toxicity rates were significantly higher with combination therapy (70.3% vs 39.7%; P < .0001), primarily affecting skin and mucosa, though late toxicity rates were similar (33.2% vs 29.0%; P = .3101).
• The benefit of RT plus C was only observed in those patients who were human papillomavirus–negative, which comprised 80.2% of trial participants.

IN PRACTICE:

RT plus C “significantly improved DFS, but not OS, with no increase in long-term toxicity, compared with RT alone for resected, intermediate-risk SCCHN. RT plus C is an appropriate option for carefully selected patients with HPV-negative disease,” the authors of the study wrote.

SOURCE:

This study was led by Mitchell Machtay, MD, Penn State Health Milton S. Hershey Medical Center in Hershey, Pennsylvania. It was published online  in Journal of Clinical Oncology.

LIMITATIONS:

According to the researchers, the OS in the control group was higher than predicted, resulting in the trial being underpowered to detect the initial targeted HR. The authors noted that the better-than-expected survival rates could be attributed to improvements in surgical and radiotherapeutic techniques, including mandatory intensity-modulated RT for all patients. Additionally, the researchers pointed out that patient selection may have influenced outcomes, as only 30% of study participants had more than two risk factors.

DISCLOSURES:

This study was supported by grants from the US National Cancer Institute and Eli Lilly Inc. Machtay received grants from Lilly/ImClone, AstraZeneca, and Merck Sharp & Dohme. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Adding cetuximab (C) to postoperative radiotherapy (RT) improves disease-free survival (DFS) but not overall survival (OS) in intermediate-risk squamous cell carcinoma of the head and neck. Benefits were specifically observed in human papillomavirus–negative patients, who represented 80.2% of the study participants.

METHODOLOGY:

• Previous research showed that adding high-dose cisplatin to postoperative RT in patients with squamous cell carcinoma of the head and neck (SCCHN) improved outcomes in those with positive margins and nodal extracapsular extension of the tumor.
• The new phase 3 randomized trial, which enrolled patients from November 2009 to March 2018 included 577 individuals with resected SCCHN of the oral cavity, oropharynx, or larynx, specifically.
• Participants were randomly assigned 1:1 to receive either intensity-modulated RT (60-66 Gy) with weekly C (400 mg/m² loading dose, followed by 250 mg/m² weekly) or RT alone.
• The primary endpoint was OS in randomly assigned eligible patients, with DFS and toxicity as secondary endpoints.
• Analysis included stratified log-rank test for OS and DFS, while toxicity was compared using Fisher’s exact test.

TAKEAWAY:

• OS was not significantly improved with RT plus C vs RT alone (hazard ratio [HR], 0.81; 95% CI, 0.60-1.08; P = .0747), though 5-year OS rates were 76.5% vs 68.7%.
• DFS showed significant improvement with combined therapy (HR, 0.75; 95% CI, 0.57-0.98; P = .0168), with 5-year rates of 71.7% vs 63.6%.
• Grade 3-4 acute toxicity rates were significantly higher with combination therapy (70.3% vs 39.7%; P < .0001), primarily affecting skin and mucosa, though late toxicity rates were similar (33.2% vs 29.0%; P = .3101).
• The benefit of RT plus C was only observed in those patients who were human papillomavirus–negative, which comprised 80.2% of trial participants.

IN PRACTICE:

RT plus C “significantly improved DFS, but not OS, with no increase in long-term toxicity, compared with RT alone for resected, intermediate-risk SCCHN. RT plus C is an appropriate option for carefully selected patients with HPV-negative disease,” the authors of the study wrote.

SOURCE:

This study was led by Mitchell Machtay, MD, Penn State Health Milton S. Hershey Medical Center in Hershey, Pennsylvania. It was published online  in Journal of Clinical Oncology.

LIMITATIONS:

According to the researchers, the OS in the control group was higher than predicted, resulting in the trial being underpowered to detect the initial targeted HR. The authors noted that the better-than-expected survival rates could be attributed to improvements in surgical and radiotherapeutic techniques, including mandatory intensity-modulated RT for all patients. Additionally, the researchers pointed out that patient selection may have influenced outcomes, as only 30% of study participants had more than two risk factors.

DISCLOSURES:

This study was supported by grants from the US National Cancer Institute and Eli Lilly Inc. Machtay received grants from Lilly/ImClone, AstraZeneca, and Merck Sharp & Dohme. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

Heavy menstrual bleeding is more than an inconvenience in adolescents: It often leads to significant medical complications, in addition to disruptions in quality of life. While measuring the true level of bleeding can be a challenge, hematologists say treatments are helpful and can be as simple — and surprising — as doses of aspirin.

About 90% of adolescents with heavy menstrual bleeding will have low ferritin, and 70% will develop anemia, said benign hematologist Juliana Perez Botero, MD, of the Mayo Clinic in Rochester, Minnesota, in a presentation at the American Society of Hematology (ASH) 2024 Annual Meeting. “This is an issue of big magnitude that has public health implications, but it’s also an issue of gender equality and social justice.”

 

Measuring Menstruation: What Counts as Heavy Bleeding?

According to hematologist Allison Wheeler, MD, of the University of Washington in Seattle, normal menstrual bleeding is defined as lasting for about 5 days with 30-50 mL of blood loss.

“Historically, heavy menstrual bleeding was defined as bleeding as > 7 days or > 80 mL of blood loss,” Wheeler said. “It’s pretty hard to measure those mL. So a more modern definition is increased menstrual blood loss that interferes with a female’s physical, social, emotional, or material quality of life.”

Measuring blood loss during menstruation isn’t simple. The alkaline hematin method, which measures blood in feminine hygiene products, is the “gold standard, but that’s all I’m going to say about that,” Wheeler said.

An alternative is the Pictorial Blood Loss Assessment Chart, a visual tool that patients can use to estimate blood loss, she said, although there have been questions about its accuracy. In addition, it only covers pads and tampons even though other products are now available.

Another option is the Adolescent Menstrual Bleeding Questionnaire. “It captures both how much patients are bleeding and a lot of quality-of-life aspects,” she said.

 

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Surprisingly, Can Be Effective Treatments

It seems counterintuitive that NSAIDs can be helpful in patients with heavy bleeding. “We don’t think about them because Cox inhibition ends up leading to decreases in thromboxane A2, which is going to increase bleeding,” Wheeler said. However, she said, the drugs also decrease prostaglandin within the endometrium, which can improve menstrual bleeding.

“In a meta-analysis, when NSAIDs were compared to placebo, there was decreased menstrual bleeding,” she said. “It was pretty similar to estrogen-progesterone formulations together. And when compared to antifibrinolytics, there was a little more menstrual bleeding with the NSAID use.”

Wheeler cautioned that “it’s important to optimize NSAID dosage. You really can’t use lower doses, and you can’t use sporadic doses.”

 

Other Options: Tranexamic Acid, Hormone Management

Tranexamic acid is the most common antifibrinolytic treatment for heavy bleeding, Wheeler said. “This is a lysine analog that’s going to inhibit the conversion from plasminogen to plasmin,” she said. “This is going to strengthen and stabilize blood clots that are already formed.”

Multiple clinical trials have studied the treatment in heavy menstrual bleeding, she said. “There’s no increased risk of venous or arterial thrombosis among participants in these clinical trials, but patients with a history of thrombosis were excluded from the majority of them. So we do need to keep that in mind.”

As for adverse effects, they’re mild and sporadic and include headaches and stomach upset, she said.

Another treatment option is estrogen and progesterone therapy using pill, patch, or vaginal ring, Wheeler said. The treatment leads to a “stable and thin very endometrium,” and typically takes 3-6 months to fully kick in. Studies have suggested the therapy can lead to 35%-80% reduction in menstrual blood loss, she said.

Keep in mind, Wheeler noted, “that there are many contraindications associated with estrogen use. Please take note of this, especially in consideration of discussions with patients shifting over to progesterone-only hormonal therapy” — another option to treat excess bleeding.

In most patients, she added, progesterone-only therapy “is going to result in irregular bleeding when you first start taking it. That irregular bleeding can last from up to 3-6 months. It’s something that’s really important to discuss with patients.”

She also noted that this therapy can be given to patients in forms that do not prevent pregnancy.

Botero had no disclosures. Wheeler reported relationships with Novo Nordisk, Bayer, BioMarin, Bioverativ, CSL Behring, Genentech, HEMA, Octapharma, Pfizer, Sanofi-Aventis, Shire North America, Spark, and Takeda.

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

Heavy menstrual bleeding is more than an inconvenience in adolescents: It often leads to significant medical complications, in addition to disruptions in quality of life. While measuring the true level of bleeding can be a challenge, hematologists say treatments are helpful and can be as simple — and surprising — as doses of aspirin.

About 90% of adolescents with heavy menstrual bleeding will have low ferritin, and 70% will develop anemia, said benign hematologist Juliana Perez Botero, MD, of the Mayo Clinic in Rochester, Minnesota, in a presentation at the American Society of Hematology (ASH) 2024 Annual Meeting. “This is an issue of big magnitude that has public health implications, but it’s also an issue of gender equality and social justice.”

 

Measuring Menstruation: What Counts as Heavy Bleeding?

According to hematologist Allison Wheeler, MD, of the University of Washington in Seattle, normal menstrual bleeding is defined as lasting for about 5 days with 30-50 mL of blood loss.

“Historically, heavy menstrual bleeding was defined as bleeding as > 7 days or > 80 mL of blood loss,” Wheeler said. “It’s pretty hard to measure those mL. So a more modern definition is increased menstrual blood loss that interferes with a female’s physical, social, emotional, or material quality of life.”

Measuring blood loss during menstruation isn’t simple. The alkaline hematin method, which measures blood in feminine hygiene products, is the “gold standard, but that’s all I’m going to say about that,” Wheeler said.

An alternative is the Pictorial Blood Loss Assessment Chart, a visual tool that patients can use to estimate blood loss, she said, although there have been questions about its accuracy. In addition, it only covers pads and tampons even though other products are now available.

Another option is the Adolescent Menstrual Bleeding Questionnaire. “It captures both how much patients are bleeding and a lot of quality-of-life aspects,” she said.

 

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Surprisingly, Can Be Effective Treatments

It seems counterintuitive that NSAIDs can be helpful in patients with heavy bleeding. “We don’t think about them because Cox inhibition ends up leading to decreases in thromboxane A2, which is going to increase bleeding,” Wheeler said. However, she said, the drugs also decrease prostaglandin within the endometrium, which can improve menstrual bleeding.

“In a meta-analysis, when NSAIDs were compared to placebo, there was decreased menstrual bleeding,” she said. “It was pretty similar to estrogen-progesterone formulations together. And when compared to antifibrinolytics, there was a little more menstrual bleeding with the NSAID use.”

Wheeler cautioned that “it’s important to optimize NSAID dosage. You really can’t use lower doses, and you can’t use sporadic doses.”

 

Other Options: Tranexamic Acid, Hormone Management

Tranexamic acid is the most common antifibrinolytic treatment for heavy bleeding, Wheeler said. “This is a lysine analog that’s going to inhibit the conversion from plasminogen to plasmin,” she said. “This is going to strengthen and stabilize blood clots that are already formed.”

Multiple clinical trials have studied the treatment in heavy menstrual bleeding, she said. “There’s no increased risk of venous or arterial thrombosis among participants in these clinical trials, but patients with a history of thrombosis were excluded from the majority of them. So we do need to keep that in mind.”

As for adverse effects, they’re mild and sporadic and include headaches and stomach upset, she said.

Another treatment option is estrogen and progesterone therapy using pill, patch, or vaginal ring, Wheeler said. The treatment leads to a “stable and thin very endometrium,” and typically takes 3-6 months to fully kick in. Studies have suggested the therapy can lead to 35%-80% reduction in menstrual blood loss, she said.

Keep in mind, Wheeler noted, “that there are many contraindications associated with estrogen use. Please take note of this, especially in consideration of discussions with patients shifting over to progesterone-only hormonal therapy” — another option to treat excess bleeding.

In most patients, she added, progesterone-only therapy “is going to result in irregular bleeding when you first start taking it. That irregular bleeding can last from up to 3-6 months. It’s something that’s really important to discuss with patients.”

She also noted that this therapy can be given to patients in forms that do not prevent pregnancy.

Botero had no disclosures. Wheeler reported relationships with Novo Nordisk, Bayer, BioMarin, Bioverativ, CSL Behring, Genentech, HEMA, Octapharma, Pfizer, Sanofi-Aventis, Shire North America, Spark, and Takeda.

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

Heavy menstrual bleeding is more than an inconvenience in adolescents: It often leads to significant medical complications, in addition to disruptions in quality of life. While measuring the true level of bleeding can be a challenge, hematologists say treatments are helpful and can be as simple — and surprising — as doses of aspirin.

About 90% of adolescents with heavy menstrual bleeding will have low ferritin, and 70% will develop anemia, said benign hematologist Juliana Perez Botero, MD, of the Mayo Clinic in Rochester, Minnesota, in a presentation at the American Society of Hematology (ASH) 2024 Annual Meeting. “This is an issue of big magnitude that has public health implications, but it’s also an issue of gender equality and social justice.”

 

Measuring Menstruation: What Counts as Heavy Bleeding?

According to hematologist Allison Wheeler, MD, of the University of Washington in Seattle, normal menstrual bleeding is defined as lasting for about 5 days with 30-50 mL of blood loss.

“Historically, heavy menstrual bleeding was defined as bleeding as > 7 days or > 80 mL of blood loss,” Wheeler said. “It’s pretty hard to measure those mL. So a more modern definition is increased menstrual blood loss that interferes with a female’s physical, social, emotional, or material quality of life.”

Measuring blood loss during menstruation isn’t simple. The alkaline hematin method, which measures blood in feminine hygiene products, is the “gold standard, but that’s all I’m going to say about that,” Wheeler said.

An alternative is the Pictorial Blood Loss Assessment Chart, a visual tool that patients can use to estimate blood loss, she said, although there have been questions about its accuracy. In addition, it only covers pads and tampons even though other products are now available.

Another option is the Adolescent Menstrual Bleeding Questionnaire. “It captures both how much patients are bleeding and a lot of quality-of-life aspects,” she said.

 

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Surprisingly, Can Be Effective Treatments

It seems counterintuitive that NSAIDs can be helpful in patients with heavy bleeding. “We don’t think about them because Cox inhibition ends up leading to decreases in thromboxane A2, which is going to increase bleeding,” Wheeler said. However, she said, the drugs also decrease prostaglandin within the endometrium, which can improve menstrual bleeding.

“In a meta-analysis, when NSAIDs were compared to placebo, there was decreased menstrual bleeding,” she said. “It was pretty similar to estrogen-progesterone formulations together. And when compared to antifibrinolytics, there was a little more menstrual bleeding with the NSAID use.”

Wheeler cautioned that “it’s important to optimize NSAID dosage. You really can’t use lower doses, and you can’t use sporadic doses.”

 

Other Options: Tranexamic Acid, Hormone Management

Tranexamic acid is the most common antifibrinolytic treatment for heavy bleeding, Wheeler said. “This is a lysine analog that’s going to inhibit the conversion from plasminogen to plasmin,” she said. “This is going to strengthen and stabilize blood clots that are already formed.”

Multiple clinical trials have studied the treatment in heavy menstrual bleeding, she said. “There’s no increased risk of venous or arterial thrombosis among participants in these clinical trials, but patients with a history of thrombosis were excluded from the majority of them. So we do need to keep that in mind.”

As for adverse effects, they’re mild and sporadic and include headaches and stomach upset, she said.

Another treatment option is estrogen and progesterone therapy using pill, patch, or vaginal ring, Wheeler said. The treatment leads to a “stable and thin very endometrium,” and typically takes 3-6 months to fully kick in. Studies have suggested the therapy can lead to 35%-80% reduction in menstrual blood loss, she said.

Keep in mind, Wheeler noted, “that there are many contraindications associated with estrogen use. Please take note of this, especially in consideration of discussions with patients shifting over to progesterone-only hormonal therapy” — another option to treat excess bleeding.

In most patients, she added, progesterone-only therapy “is going to result in irregular bleeding when you first start taking it. That irregular bleeding can last from up to 3-6 months. It’s something that’s really important to discuss with patients.”

She also noted that this therapy can be given to patients in forms that do not prevent pregnancy.

Botero had no disclosures. Wheeler reported relationships with Novo Nordisk, Bayer, BioMarin, Bioverativ, CSL Behring, Genentech, HEMA, Octapharma, Pfizer, Sanofi-Aventis, Shire North America, Spark, and Takeda.

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

TOPLINE:

A cross-sectional survey of patients preparing for their first radiation therapy consultation found that many patients worried about the physical effects of radiation therapy, including pain, memory loss, and nausea, and more than 60% said they were concerned about their ability to perform daily activities. Respondents reported a range of other worries, including the financial cost of treatment, transportation to treatment sessions, and the ability to continue working, as well as misconceptions about radiation therapy, such as concerns about emitting radiation to others.

METHODOLOGY:

• Toxicities from cancer therapies can significantly affect patients’ quality of life and may contribute to their apprehensions before starting a new treatment. Some studies have indicated that patients may have misconceptions about chemotherapy, but less is known about patients’ perceptions of radiation therapy.
• Researchers conducted a cross-sectional survey of patients presenting for initial radiation therapy consultation at a single academic institution and analyzed responses from 214 patients (52% men; 51% White individuals) with no prior radiation therapy experience.
• The patients completed a 30-question electronic survey about radiation therapy perceptions and fears or concerns prior to their initial radiation consultation.
• Cancer diagnoses spanned 18 disease sites, with hematologic malignancies (21%), breast cancer (18%), and lung cancer (15%) being the most common.

TAKEAWAY:

• Physical adverse effects were the top concern for patients. These included radiation-induced pain (67%), memory loss (62%), nausea/vomiting (60%), and skin reactions (58%).
• Patients expressed concerns about the impact radiation therapy would have on daily activities, with 62% reporting being moderately or very concerned about their ability to perform daily activities and 37% worried about their ability to continue working. Other concerns included the ability to exercise (over half of respondents), financial cost (36%), and transportation to treatment sessions (26%).
• Misconceptions among patients were also common, with 48% expressing concerns about emitting radiation to others and 45% worrying about excreting radioactive urine or stool.
• Patients had varied levels of prior understanding of radiation therapy. Half of patients reported a complete lack of knowledge about radiation therapy, and 35% said they had read or heard stories about bad adverse effects.

IN PRACTICE:

“Our study suggests that a survey administered prior to radiation oncology consultation can reveal patients’ primary concerns which could promote a more patient-centered discussion that addresses specific concerns and involves appropriate services to help the patient,” the authors wrote.

SOURCE:

This study, led by Jennifer Novak, MD, MS, Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California, was published online in Advances in Radiation Oncology.

LIMITATIONS:

Limitations included response bias and time constraints, which prevented many eligible patients from completing the survey. The single-institution design limits the generalizability of the findings. The survey results also showed a disproportionate focus on physical effects over the social impacts of radiation therapy, which could have limited the comprehensiveness of the findings.

DISCLOSURES:

The authors reported no specific funding for this work and no relevant competing financial interests or personal relationships that could have influenced the work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

A cross-sectional survey of patients preparing for their first radiation therapy consultation found that many patients worried about the physical effects of radiation therapy, including pain, memory loss, and nausea, and more than 60% said they were concerned about their ability to perform daily activities. Respondents reported a range of other worries, including the financial cost of treatment, transportation to treatment sessions, and the ability to continue working, as well as misconceptions about radiation therapy, such as concerns about emitting radiation to others.

METHODOLOGY:

• Toxicities from cancer therapies can significantly affect patients’ quality of life and may contribute to their apprehensions before starting a new treatment. Some studies have indicated that patients may have misconceptions about chemotherapy, but less is known about patients’ perceptions of radiation therapy.
• Researchers conducted a cross-sectional survey of patients presenting for initial radiation therapy consultation at a single academic institution and analyzed responses from 214 patients (52% men; 51% White individuals) with no prior radiation therapy experience.
• The patients completed a 30-question electronic survey about radiation therapy perceptions and fears or concerns prior to their initial radiation consultation.
• Cancer diagnoses spanned 18 disease sites, with hematologic malignancies (21%), breast cancer (18%), and lung cancer (15%) being the most common.

TAKEAWAY:

• Physical adverse effects were the top concern for patients. These included radiation-induced pain (67%), memory loss (62%), nausea/vomiting (60%), and skin reactions (58%).
• Patients expressed concerns about the impact radiation therapy would have on daily activities, with 62% reporting being moderately or very concerned about their ability to perform daily activities and 37% worried about their ability to continue working. Other concerns included the ability to exercise (over half of respondents), financial cost (36%), and transportation to treatment sessions (26%).
• Misconceptions among patients were also common, with 48% expressing concerns about emitting radiation to others and 45% worrying about excreting radioactive urine or stool.
• Patients had varied levels of prior understanding of radiation therapy. Half of patients reported a complete lack of knowledge about radiation therapy, and 35% said they had read or heard stories about bad adverse effects.

IN PRACTICE:

“Our study suggests that a survey administered prior to radiation oncology consultation can reveal patients’ primary concerns which could promote a more patient-centered discussion that addresses specific concerns and involves appropriate services to help the patient,” the authors wrote.

SOURCE:

This study, led by Jennifer Novak, MD, MS, Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California, was published online in Advances in Radiation Oncology.

LIMITATIONS:

Limitations included response bias and time constraints, which prevented many eligible patients from completing the survey. The single-institution design limits the generalizability of the findings. The survey results also showed a disproportionate focus on physical effects over the social impacts of radiation therapy, which could have limited the comprehensiveness of the findings.

DISCLOSURES:

The authors reported no specific funding for this work and no relevant competing financial interests or personal relationships that could have influenced the work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

A cross-sectional survey of patients preparing for their first radiation therapy consultation found that many patients worried about the physical effects of radiation therapy, including pain, memory loss, and nausea, and more than 60% said they were concerned about their ability to perform daily activities. Respondents reported a range of other worries, including the financial cost of treatment, transportation to treatment sessions, and the ability to continue working, as well as misconceptions about radiation therapy, such as concerns about emitting radiation to others.

METHODOLOGY:

• Toxicities from cancer therapies can significantly affect patients’ quality of life and may contribute to their apprehensions before starting a new treatment. Some studies have indicated that patients may have misconceptions about chemotherapy, but less is known about patients’ perceptions of radiation therapy.
• Researchers conducted a cross-sectional survey of patients presenting for initial radiation therapy consultation at a single academic institution and analyzed responses from 214 patients (52% men; 51% White individuals) with no prior radiation therapy experience.
• The patients completed a 30-question electronic survey about radiation therapy perceptions and fears or concerns prior to their initial radiation consultation.
• Cancer diagnoses spanned 18 disease sites, with hematologic malignancies (21%), breast cancer (18%), and lung cancer (15%) being the most common.

TAKEAWAY:

• Physical adverse effects were the top concern for patients. These included radiation-induced pain (67%), memory loss (62%), nausea/vomiting (60%), and skin reactions (58%).
• Patients expressed concerns about the impact radiation therapy would have on daily activities, with 62% reporting being moderately or very concerned about their ability to perform daily activities and 37% worried about their ability to continue working. Other concerns included the ability to exercise (over half of respondents), financial cost (36%), and transportation to treatment sessions (26%).
• Misconceptions among patients were also common, with 48% expressing concerns about emitting radiation to others and 45% worrying about excreting radioactive urine or stool.
• Patients had varied levels of prior understanding of radiation therapy. Half of patients reported a complete lack of knowledge about radiation therapy, and 35% said they had read or heard stories about bad adverse effects.

IN PRACTICE:

“Our study suggests that a survey administered prior to radiation oncology consultation can reveal patients’ primary concerns which could promote a more patient-centered discussion that addresses specific concerns and involves appropriate services to help the patient,” the authors wrote.

SOURCE:

This study, led by Jennifer Novak, MD, MS, Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California, was published online in Advances in Radiation Oncology.

LIMITATIONS:

Limitations included response bias and time constraints, which prevented many eligible patients from completing the survey. The single-institution design limits the generalizability of the findings. The survey results also showed a disproportionate focus on physical effects over the social impacts of radiation therapy, which could have limited the comprehensiveness of the findings.

DISCLOSURES:

The authors reported no specific funding for this work and no relevant competing financial interests or personal relationships that could have influenced the work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

Last year, Eric Singhi, MD, a thoracic medical oncologist at MD Anderson Cancer Center in Houston, noticed a shift in his team. The small band of four clinicians, once motivated and enthusiastic, were now withdrawn and distant.

“We had to take a break from clinic one day. We went out, got food and…acknowledged something was off,” Singhi recalled.

That something: Intense emotional exhaustion.

No thoracic oncology team has it easy. Lung cancer remains the leading cause of cancer deaths. But over the last 12 months Singhi’s team had taken on more and more cases in younger patients. Watching patients so close to their own age struggle and ultimately be consumed by this disease took its toll, Singhi said. And the toll was showing up in the lives of his colleagues.

Singhi’s team was suffering from compassion fatigue — the mental, physical, or emotional exhaustion brought on by prolonged exposure to the trauma of people in one’s care. Also referred to secondary trauma, compassion fatigue “leaves someone feeling numb, detached, or like they don’t have emotional resources to keep on giving,” Singhi said.

This fatigue is common among people who work in high-stress caretaking professions. Those involved in cancer care, who frequently find themselves navigating life and death conversations and experiences with patients, are particularly at risk, experts told this news organization.

“I think anyone in medical oncology or hematology who has practiced long enough will feel this,” said Alfred Lee, MD, PhD, burnout researcher and director of the hematology/oncology fellowship at Yale School of Medicine in New Haven, Connecticut. “It’s par for the course, even in training.”

Still, compassion fatigue can be hard to detect without help. Left unaddressed, compassion fatigue can undermine good patient care, even lead to burnout.

“I’ve absolutely treated people leaving the field who think they shouldn’t be a doctor anymore,” said Jennifer Bickel, MD, recently named MD Anderson’s inaugural vice president and chief wellness officer. Those are preventable losses the field can’t afford in a provider shortage, she said.

 

Recognizing the Signs

Compassion is an essential part of patient care as is empathy. Expressing compassion or feeling empathy toward patients can foster the doctor-patient bond and help both navigate challenging conversations and decisions.

“Compassion and being able to empathize are so important — it’s how you gain trust,” Singhi said. This is especially true for patients who may be underrepresented. “That’s how they become a partner in their care, how they agree to listen about a clinical trial or agree to adhere to their treatment plan,” Singhi noted.

But there’s a risk when clinicians start to give too much.

Overtime, repeated exposure to patients’ trauma can create a sense of heaviness and fatigue, and ultimately cause caregivers to detach, Lee said.

A case study of compassion fatigue, based on the experience of one oncologist, highlighted that the condition parallels posttraumatic stress disorder, aligning on three main symptoms: Feeling hyperarousal, notably hypervigilance or irritability, avoiding stressful situations, and reliving traumatic events.

The initial phases of compassion fatigue, however, can be subtle and easily dismissed. An oncologist may begin to feel a creeping sense of detachment — a divide slowly growing with their patients, a buzz of dissatisfaction on the job, unusual mood changes.

While it’s normal for healthcare workers to experience moments of irritability, dissatisfaction, exhaustion or avoidance, when these experiences become pervasive, compassion fatigue could be the culprit, according to Marra Ackerman, MD, a psychiatrist at NYU Langone Health in New York City.

Compassion fatigue is “a form of coping more than anything,” Ackerman explained. Most of the time, it’s not a conscious choice, she said. When a brain experiences repeated distressing inputs it can shift into self-protection mode. The tipping point is different for everyone, but eventually the brain tries to detach and distance itself from the stressor, Ackerman said. And, in oncology, that stressor is often very sick patients.

If not addressed, the emotional exhaustion can limit a doctor’s efficacy at work. Clinicians suffering from compassion fatigue may find themselves calling in sick more often, making more mistakes, avoiding very sick patients, or having panic attacks at work, said Ackerman.

Clinicians also might use food, drugs, or alcohol to feel better, or detach from their patients, Lee added. “We find if you detach, you can’t provide the care patients need,” he said.

When trying to identify the issue, it’s important to understand that compassion fatigue is not burnout. The two issues can look similar, sharing symptoms like emotional detachment or disillusionment, and may co-exist, but the phenomena stem from different root causes.

While compassion fatigue is rooted in emotions and isn’t necessarily tied to work, burnout is a product of work-related stress. It’s often caused by system-level problems that leave clinicians feeling their work has lost its meaning. Inefficient technology or excessive data entry, for instance, could be drivers of burnout for oncologists because these tasks can pull the doctor away from the meaningful work of treating patients.

 

What Can Be Done

Oncology comes with its own set of risks and traumas, but for a long time, doctors weren’t equipped or encouraged to see the constant life-or-death tension of the job as a risk factor to their well-being, said Bickel.

“It’s not something we are inherently taught to identify and it’s not something we can identify without time for self-reflection,” Bickel told this news organization. In fact, many people don’t see their own compassion fatigue until a colleague points it out or they’re already past it and have some distance.

Although common among oncology clinicians, compassion fatigue is not inevitable. Oncologists can learn strategies to help manage their exposures to suffering and stave off reverting to coping mechanisms that only perpetuate the problem.

The key, Bickel said, is creating environments where people can feel safe and share their vulnerabilities. Formal peer support check-ins are a good example because they normalize regular communication about day-to-day difficulties as they happen and create space to experience grief. In these groups, no one has to worry that they’re complaining, she said.

Formalized groups also serve as a training ground where staff can learn to be better listeners. Healthcare providers are more likely to reach out to peers because so few people outside their field can relate to the challenges, Bickel explained. That’s why Moffitt Cancer Center, where Bickel recently worked before moving to MD Anderson, offers trainings to help staff learn to listen more effectively. Thirty doctors, nurses and health professionals have received the training so far and serve as a point of contact for colleagues who might be struggling, Bickel said. They can offer their peers an empathic ear, without providing unsolicited advice or commentary.

NYU Langone has a similar offering, Ackerman said. Providers can reach out to fellow nurses or doctors who have more mental health training. The conversation isn’t recorded like an appointment with a therapist may be. It’s more like mentorship where doctors can be open about what they are facing and find some comradery from someone who understands, without fear of stigma.

Talking to colleagues or having debriefs with your care team is critical because it eliminates the isolation that allows compassion fatigue to fester, Lee said. “Reflecting on positive encounters can help inspire us to keep going. Reflecting on the negative can be therapeutic and help find that sense of balance that everyone needs to find.”

As for Singhi’s team, “lots has changed since we’ve become more open,” he said. The team talks about hard patients early and often. These discussions have helped team members keep the challenges at work from seeping into their home life.

Experts agree that the threshold for seeking out help and guidance should be low. Waiting for depression or more severe symptoms to set in is not the best point of intervention, Bickel said. As soon as an oncologist begins to acknowledge a shift in how they connect with patients and the job, that’s enough to reach out.

“It’s not about what you can handle, it’s about how can you thrive and find joy,” she said.

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

Last year, Eric Singhi, MD, a thoracic medical oncologist at MD Anderson Cancer Center in Houston, noticed a shift in his team. The small band of four clinicians, once motivated and enthusiastic, were now withdrawn and distant.

“We had to take a break from clinic one day. We went out, got food and…acknowledged something was off,” Singhi recalled.

That something: Intense emotional exhaustion.

No thoracic oncology team has it easy. Lung cancer remains the leading cause of cancer deaths. But over the last 12 months Singhi’s team had taken on more and more cases in younger patients. Watching patients so close to their own age struggle and ultimately be consumed by this disease took its toll, Singhi said. And the toll was showing up in the lives of his colleagues.

Singhi’s team was suffering from compassion fatigue — the mental, physical, or emotional exhaustion brought on by prolonged exposure to the trauma of people in one’s care. Also referred to secondary trauma, compassion fatigue “leaves someone feeling numb, detached, or like they don’t have emotional resources to keep on giving,” Singhi said.

This fatigue is common among people who work in high-stress caretaking professions. Those involved in cancer care, who frequently find themselves navigating life and death conversations and experiences with patients, are particularly at risk, experts told this news organization.

“I think anyone in medical oncology or hematology who has practiced long enough will feel this,” said Alfred Lee, MD, PhD, burnout researcher and director of the hematology/oncology fellowship at Yale School of Medicine in New Haven, Connecticut. “It’s par for the course, even in training.”

Still, compassion fatigue can be hard to detect without help. Left unaddressed, compassion fatigue can undermine good patient care, even lead to burnout.

“I’ve absolutely treated people leaving the field who think they shouldn’t be a doctor anymore,” said Jennifer Bickel, MD, recently named MD Anderson’s inaugural vice president and chief wellness officer. Those are preventable losses the field can’t afford in a provider shortage, she said.

 

Recognizing the Signs

Compassion is an essential part of patient care as is empathy. Expressing compassion or feeling empathy toward patients can foster the doctor-patient bond and help both navigate challenging conversations and decisions.

“Compassion and being able to empathize are so important — it’s how you gain trust,” Singhi said. This is especially true for patients who may be underrepresented. “That’s how they become a partner in their care, how they agree to listen about a clinical trial or agree to adhere to their treatment plan,” Singhi noted.

But there’s a risk when clinicians start to give too much.

Overtime, repeated exposure to patients’ trauma can create a sense of heaviness and fatigue, and ultimately cause caregivers to detach, Lee said.

A case study of compassion fatigue, based on the experience of one oncologist, highlighted that the condition parallels posttraumatic stress disorder, aligning on three main symptoms: Feeling hyperarousal, notably hypervigilance or irritability, avoiding stressful situations, and reliving traumatic events.

The initial phases of compassion fatigue, however, can be subtle and easily dismissed. An oncologist may begin to feel a creeping sense of detachment — a divide slowly growing with their patients, a buzz of dissatisfaction on the job, unusual mood changes.

While it’s normal for healthcare workers to experience moments of irritability, dissatisfaction, exhaustion or avoidance, when these experiences become pervasive, compassion fatigue could be the culprit, according to Marra Ackerman, MD, a psychiatrist at NYU Langone Health in New York City.

Compassion fatigue is “a form of coping more than anything,” Ackerman explained. Most of the time, it’s not a conscious choice, she said. When a brain experiences repeated distressing inputs it can shift into self-protection mode. The tipping point is different for everyone, but eventually the brain tries to detach and distance itself from the stressor, Ackerman said. And, in oncology, that stressor is often very sick patients.

If not addressed, the emotional exhaustion can limit a doctor’s efficacy at work. Clinicians suffering from compassion fatigue may find themselves calling in sick more often, making more mistakes, avoiding very sick patients, or having panic attacks at work, said Ackerman.

Clinicians also might use food, drugs, or alcohol to feel better, or detach from their patients, Lee added. “We find if you detach, you can’t provide the care patients need,” he said.

When trying to identify the issue, it’s important to understand that compassion fatigue is not burnout. The two issues can look similar, sharing symptoms like emotional detachment or disillusionment, and may co-exist, but the phenomena stem from different root causes.

While compassion fatigue is rooted in emotions and isn’t necessarily tied to work, burnout is a product of work-related stress. It’s often caused by system-level problems that leave clinicians feeling their work has lost its meaning. Inefficient technology or excessive data entry, for instance, could be drivers of burnout for oncologists because these tasks can pull the doctor away from the meaningful work of treating patients.

 

What Can Be Done

Oncology comes with its own set of risks and traumas, but for a long time, doctors weren’t equipped or encouraged to see the constant life-or-death tension of the job as a risk factor to their well-being, said Bickel.

“It’s not something we are inherently taught to identify and it’s not something we can identify without time for self-reflection,” Bickel told this news organization. In fact, many people don’t see their own compassion fatigue until a colleague points it out or they’re already past it and have some distance.

Although common among oncology clinicians, compassion fatigue is not inevitable. Oncologists can learn strategies to help manage their exposures to suffering and stave off reverting to coping mechanisms that only perpetuate the problem.

The key, Bickel said, is creating environments where people can feel safe and share their vulnerabilities. Formal peer support check-ins are a good example because they normalize regular communication about day-to-day difficulties as they happen and create space to experience grief. In these groups, no one has to worry that they’re complaining, she said.

Formalized groups also serve as a training ground where staff can learn to be better listeners. Healthcare providers are more likely to reach out to peers because so few people outside their field can relate to the challenges, Bickel explained. That’s why Moffitt Cancer Center, where Bickel recently worked before moving to MD Anderson, offers trainings to help staff learn to listen more effectively. Thirty doctors, nurses and health professionals have received the training so far and serve as a point of contact for colleagues who might be struggling, Bickel said. They can offer their peers an empathic ear, without providing unsolicited advice or commentary.

NYU Langone has a similar offering, Ackerman said. Providers can reach out to fellow nurses or doctors who have more mental health training. The conversation isn’t recorded like an appointment with a therapist may be. It’s more like mentorship where doctors can be open about what they are facing and find some comradery from someone who understands, without fear of stigma.

Talking to colleagues or having debriefs with your care team is critical because it eliminates the isolation that allows compassion fatigue to fester, Lee said. “Reflecting on positive encounters can help inspire us to keep going. Reflecting on the negative can be therapeutic and help find that sense of balance that everyone needs to find.”

As for Singhi’s team, “lots has changed since we’ve become more open,” he said. The team talks about hard patients early and often. These discussions have helped team members keep the challenges at work from seeping into their home life.

Experts agree that the threshold for seeking out help and guidance should be low. Waiting for depression or more severe symptoms to set in is not the best point of intervention, Bickel said. As soon as an oncologist begins to acknowledge a shift in how they connect with patients and the job, that’s enough to reach out.

“It’s not about what you can handle, it’s about how can you thrive and find joy,” she said.

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

Last year, Eric Singhi, MD, a thoracic medical oncologist at MD Anderson Cancer Center in Houston, noticed a shift in his team. The small band of four clinicians, once motivated and enthusiastic, were now withdrawn and distant.

“We had to take a break from clinic one day. We went out, got food and…acknowledged something was off,” Singhi recalled.

That something: Intense emotional exhaustion.

No thoracic oncology team has it easy. Lung cancer remains the leading cause of cancer deaths. But over the last 12 months Singhi’s team had taken on more and more cases in younger patients. Watching patients so close to their own age struggle and ultimately be consumed by this disease took its toll, Singhi said. And the toll was showing up in the lives of his colleagues.

Singhi’s team was suffering from compassion fatigue — the mental, physical, or emotional exhaustion brought on by prolonged exposure to the trauma of people in one’s care. Also referred to secondary trauma, compassion fatigue “leaves someone feeling numb, detached, or like they don’t have emotional resources to keep on giving,” Singhi said.

This fatigue is common among people who work in high-stress caretaking professions. Those involved in cancer care, who frequently find themselves navigating life and death conversations and experiences with patients, are particularly at risk, experts told this news organization.

“I think anyone in medical oncology or hematology who has practiced long enough will feel this,” said Alfred Lee, MD, PhD, burnout researcher and director of the hematology/oncology fellowship at Yale School of Medicine in New Haven, Connecticut. “It’s par for the course, even in training.”

Still, compassion fatigue can be hard to detect without help. Left unaddressed, compassion fatigue can undermine good patient care, even lead to burnout.

“I’ve absolutely treated people leaving the field who think they shouldn’t be a doctor anymore,” said Jennifer Bickel, MD, recently named MD Anderson’s inaugural vice president and chief wellness officer. Those are preventable losses the field can’t afford in a provider shortage, she said.

 

Recognizing the Signs

Compassion is an essential part of patient care as is empathy. Expressing compassion or feeling empathy toward patients can foster the doctor-patient bond and help both navigate challenging conversations and decisions.

“Compassion and being able to empathize are so important — it’s how you gain trust,” Singhi said. This is especially true for patients who may be underrepresented. “That’s how they become a partner in their care, how they agree to listen about a clinical trial or agree to adhere to their treatment plan,” Singhi noted.

But there’s a risk when clinicians start to give too much.

Overtime, repeated exposure to patients’ trauma can create a sense of heaviness and fatigue, and ultimately cause caregivers to detach, Lee said.

A case study of compassion fatigue, based on the experience of one oncologist, highlighted that the condition parallels posttraumatic stress disorder, aligning on three main symptoms: Feeling hyperarousal, notably hypervigilance or irritability, avoiding stressful situations, and reliving traumatic events.

The initial phases of compassion fatigue, however, can be subtle and easily dismissed. An oncologist may begin to feel a creeping sense of detachment — a divide slowly growing with their patients, a buzz of dissatisfaction on the job, unusual mood changes.

While it’s normal for healthcare workers to experience moments of irritability, dissatisfaction, exhaustion or avoidance, when these experiences become pervasive, compassion fatigue could be the culprit, according to Marra Ackerman, MD, a psychiatrist at NYU Langone Health in New York City.

Compassion fatigue is “a form of coping more than anything,” Ackerman explained. Most of the time, it’s not a conscious choice, she said. When a brain experiences repeated distressing inputs it can shift into self-protection mode. The tipping point is different for everyone, but eventually the brain tries to detach and distance itself from the stressor, Ackerman said. And, in oncology, that stressor is often very sick patients.

If not addressed, the emotional exhaustion can limit a doctor’s efficacy at work. Clinicians suffering from compassion fatigue may find themselves calling in sick more often, making more mistakes, avoiding very sick patients, or having panic attacks at work, said Ackerman.

Clinicians also might use food, drugs, or alcohol to feel better, or detach from their patients, Lee added. “We find if you detach, you can’t provide the care patients need,” he said.

When trying to identify the issue, it’s important to understand that compassion fatigue is not burnout. The two issues can look similar, sharing symptoms like emotional detachment or disillusionment, and may co-exist, but the phenomena stem from different root causes.

While compassion fatigue is rooted in emotions and isn’t necessarily tied to work, burnout is a product of work-related stress. It’s often caused by system-level problems that leave clinicians feeling their work has lost its meaning. Inefficient technology or excessive data entry, for instance, could be drivers of burnout for oncologists because these tasks can pull the doctor away from the meaningful work of treating patients.

 

What Can Be Done

Oncology comes with its own set of risks and traumas, but for a long time, doctors weren’t equipped or encouraged to see the constant life-or-death tension of the job as a risk factor to their well-being, said Bickel.

“It’s not something we are inherently taught to identify and it’s not something we can identify without time for self-reflection,” Bickel told this news organization. In fact, many people don’t see their own compassion fatigue until a colleague points it out or they’re already past it and have some distance.

Although common among oncology clinicians, compassion fatigue is not inevitable. Oncologists can learn strategies to help manage their exposures to suffering and stave off reverting to coping mechanisms that only perpetuate the problem.

The key, Bickel said, is creating environments where people can feel safe and share their vulnerabilities. Formal peer support check-ins are a good example because they normalize regular communication about day-to-day difficulties as they happen and create space to experience grief. In these groups, no one has to worry that they’re complaining, she said.

Formalized groups also serve as a training ground where staff can learn to be better listeners. Healthcare providers are more likely to reach out to peers because so few people outside their field can relate to the challenges, Bickel explained. That’s why Moffitt Cancer Center, where Bickel recently worked before moving to MD Anderson, offers trainings to help staff learn to listen more effectively. Thirty doctors, nurses and health professionals have received the training so far and serve as a point of contact for colleagues who might be struggling, Bickel said. They can offer their peers an empathic ear, without providing unsolicited advice or commentary.

NYU Langone has a similar offering, Ackerman said. Providers can reach out to fellow nurses or doctors who have more mental health training. The conversation isn’t recorded like an appointment with a therapist may be. It’s more like mentorship where doctors can be open about what they are facing and find some comradery from someone who understands, without fear of stigma.

Talking to colleagues or having debriefs with your care team is critical because it eliminates the isolation that allows compassion fatigue to fester, Lee said. “Reflecting on positive encounters can help inspire us to keep going. Reflecting on the negative can be therapeutic and help find that sense of balance that everyone needs to find.”

As for Singhi’s team, “lots has changed since we’ve become more open,” he said. The team talks about hard patients early and often. These discussions have helped team members keep the challenges at work from seeping into their home life.

Experts agree that the threshold for seeking out help and guidance should be low. Waiting for depression or more severe symptoms to set in is not the best point of intervention, Bickel said. As soon as an oncologist begins to acknowledge a shift in how they connect with patients and the job, that’s enough to reach out.

“It’s not about what you can handle, it’s about how can you thrive and find joy,” she said.

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

In 2016, Brady Scott was in his parents’ home in Garrett, Kentucky, scrolling his Facebook feed when a post from a local newspaper caught his attention. “The article said that if you grew up in the region I grew up in, compared to the richer Central Kentucky region, the life expectancy differed by about 9 years,” he recalled.

The respiratory therapist, then a PhD student at Rush University, Chicago, was struck and began “Googling” to find out why this was the case. Initially, he thought diabetes, smoking, and economic distress — all prevalent problems in the area — were the culprits. However, he soon found that respiratory disease was particularly common in his region.

Now a professor and program director of the Respiratory Care Program at Rush University, Scott has spent several years trying to understand why people in certain regions experience respiratory illness at higher rates than in other places.

The Environment as a Determinant of Health

When Scott began his PhD, the prevalence of asthma in Southeast Kentucky, part of the Appalachian region, was already well-documented. He focused his research on uncontrolled asthma and the triggers that drove asthma exacerbations.

Housing quality emerged as an important factor. He found that exposure to mold, mildew, dust mites, pests, and rodents increased the risk for asthma and exacerbated existing cases. Lower-income families, more likely to live in poor-quality housing, were significantly affected, even in single-family homes.

Wanda Phipatanakul, MD, MS, director of the Division of Immunology Research Center at Boston Children’s Hospital and S. Jean Emans professor of Pediatrics at Harvard Medical School, Boston, has found similar results in urban environments. She said cockroach and mouse allergen exposure is disproportionately prevalent in urban, low-income neighborhoods. These exposures, closely tied to housing conditions, contribute to worse asthma and respiratory problems, particularly in children.

Scott and Phipatanakul agreed that the environment surrounding people’s homes can also exacerbate respiratory disease.

Rural areas present unique risks, such as agricultural activities that release pesticides and other particulates into the air, said Scott. In mountainous areas like Appalachia, mining operations are another significant contributor. For example, blasting mountains with dynamite creates large clouds of dust and pollutants that settle in valleys. Coal-hauling roads contribute to air quality issues, too. And houses near these roads may be exposed to increased levels of particulate matter, he said.

In the city, Phipatanakul has found that historical practices like redlining have systematically denied certain neighborhoods access to resources and investment, leaving a legacy of poor infrastructure, limited resources, and higher exposure to environmental risks. Today, these areas have more highways and fewer green spaces and are disproportionately linked with a higher incidence of respiratory illnesses.

The findings of both Scott and Phipatanakul underscore a critical bottom line: Health disparities are deeply influenced by environmental factors, which are themselves shaped by socioeconomic conditions and historical inequities. Poor housing quality, exposure to allergens, and proximity to environmental hazards disproportionately affect underserved and minority communities, whether in rural or urban settings.

The Role of Green Spaces in Improving Respiratory Health

Restoring and increasing tree cover and green spaces in urban areas can significantly improve respiratory health by addressing environmental challenges and reducing triggers for respiratory issues. Areas with greater greenness tend to have lower levels of pollutants and fewer environmental infestations, such as mice and cockroaches, explained Phipatanakul. Her research highlights that schools in greener areas have fewer airborne pollutants and particles than those in more urbanized, less green areas, which are usually in poorer suburbs.

Trees absorb pollutants such as particulate matter and sulfur dioxide through dry deposition and stomatal uptake, improving air quality. “The question is whether we can use trees as a public health tool, and this is being done in many cities,” said Alessandro Marcon, PhD, a professor of epidemiology and medical statistics at the University of Verona, Verona, Italy, while speaking at the European Respiratory Society conference held in Vienna last September.

A US analysis showed that existing natural vegetation, such as forests and grasslands, absorbs a large portion of emissions. By restoring land cover, pollution from harmful substances like sulfur dioxide and particulate matter could be reduced by about 30%. This approach is often more cost-effective than technological solutions for managing emissions.

Moreover, tree cover contributes to a healthier air microbiome. Research indicates that urban forest areas have lower pathogenic bacteria and fungi concentrations than nearby urban zones.

Another major advantage is the mitigation of the urban heat island effect. A study conducted in Paris found that municipalities with higher tree coverage experienced 20%-30% lower heat-related mortality than those with less greenery. Increasing tree coverage to 30% could reduce up to 40% of excess mortality associated with urban heat islands. Trees achieve this by providing shade and facilitating evapotranspiration, which cools the surrounding air.

Urban environments, unsurprisingly, often have higher levels of air pollution due to increased traffic and industrial activity. However, despite appearing greener, rural environments may harbor less obvious but significant sources of air pollution. “I live in an urban environment now, but I grew up in a rural environment,” Scott said. “Each has its own issues that affect air quality and health.”

Scott, Phipatanakul, and Marcon reported no relevant financial relationships.■

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

In 2016, Brady Scott was in his parents’ home in Garrett, Kentucky, scrolling his Facebook feed when a post from a local newspaper caught his attention. “The article said that if you grew up in the region I grew up in, compared to the richer Central Kentucky region, the life expectancy differed by about 9 years,” he recalled.

The respiratory therapist, then a PhD student at Rush University, Chicago, was struck and began “Googling” to find out why this was the case. Initially, he thought diabetes, smoking, and economic distress — all prevalent problems in the area — were the culprits. However, he soon found that respiratory disease was particularly common in his region.

Now a professor and program director of the Respiratory Care Program at Rush University, Scott has spent several years trying to understand why people in certain regions experience respiratory illness at higher rates than in other places.

The Environment as a Determinant of Health

When Scott began his PhD, the prevalence of asthma in Southeast Kentucky, part of the Appalachian region, was already well-documented. He focused his research on uncontrolled asthma and the triggers that drove asthma exacerbations.

Housing quality emerged as an important factor. He found that exposure to mold, mildew, dust mites, pests, and rodents increased the risk for asthma and exacerbated existing cases. Lower-income families, more likely to live in poor-quality housing, were significantly affected, even in single-family homes.

Wanda Phipatanakul, MD, MS, director of the Division of Immunology Research Center at Boston Children’s Hospital and S. Jean Emans professor of Pediatrics at Harvard Medical School, Boston, has found similar results in urban environments. She said cockroach and mouse allergen exposure is disproportionately prevalent in urban, low-income neighborhoods. These exposures, closely tied to housing conditions, contribute to worse asthma and respiratory problems, particularly in children.

Scott and Phipatanakul agreed that the environment surrounding people’s homes can also exacerbate respiratory disease.

Rural areas present unique risks, such as agricultural activities that release pesticides and other particulates into the air, said Scott. In mountainous areas like Appalachia, mining operations are another significant contributor. For example, blasting mountains with dynamite creates large clouds of dust and pollutants that settle in valleys. Coal-hauling roads contribute to air quality issues, too. And houses near these roads may be exposed to increased levels of particulate matter, he said.

In the city, Phipatanakul has found that historical practices like redlining have systematically denied certain neighborhoods access to resources and investment, leaving a legacy of poor infrastructure, limited resources, and higher exposure to environmental risks. Today, these areas have more highways and fewer green spaces and are disproportionately linked with a higher incidence of respiratory illnesses.

The findings of both Scott and Phipatanakul underscore a critical bottom line: Health disparities are deeply influenced by environmental factors, which are themselves shaped by socioeconomic conditions and historical inequities. Poor housing quality, exposure to allergens, and proximity to environmental hazards disproportionately affect underserved and minority communities, whether in rural or urban settings.

The Role of Green Spaces in Improving Respiratory Health

Restoring and increasing tree cover and green spaces in urban areas can significantly improve respiratory health by addressing environmental challenges and reducing triggers for respiratory issues. Areas with greater greenness tend to have lower levels of pollutants and fewer environmental infestations, such as mice and cockroaches, explained Phipatanakul. Her research highlights that schools in greener areas have fewer airborne pollutants and particles than those in more urbanized, less green areas, which are usually in poorer suburbs.

Trees absorb pollutants such as particulate matter and sulfur dioxide through dry deposition and stomatal uptake, improving air quality. “The question is whether we can use trees as a public health tool, and this is being done in many cities,” said Alessandro Marcon, PhD, a professor of epidemiology and medical statistics at the University of Verona, Verona, Italy, while speaking at the European Respiratory Society conference held in Vienna last September.

A US analysis showed that existing natural vegetation, such as forests and grasslands, absorbs a large portion of emissions. By restoring land cover, pollution from harmful substances like sulfur dioxide and particulate matter could be reduced by about 30%. This approach is often more cost-effective than technological solutions for managing emissions.

Moreover, tree cover contributes to a healthier air microbiome. Research indicates that urban forest areas have lower pathogenic bacteria and fungi concentrations than nearby urban zones.

Another major advantage is the mitigation of the urban heat island effect. A study conducted in Paris found that municipalities with higher tree coverage experienced 20%-30% lower heat-related mortality than those with less greenery. Increasing tree coverage to 30% could reduce up to 40% of excess mortality associated with urban heat islands. Trees achieve this by providing shade and facilitating evapotranspiration, which cools the surrounding air.

Urban environments, unsurprisingly, often have higher levels of air pollution due to increased traffic and industrial activity. However, despite appearing greener, rural environments may harbor less obvious but significant sources of air pollution. “I live in an urban environment now, but I grew up in a rural environment,” Scott said. “Each has its own issues that affect air quality and health.”

Scott, Phipatanakul, and Marcon reported no relevant financial relationships.■

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

In 2016, Brady Scott was in his parents’ home in Garrett, Kentucky, scrolling his Facebook feed when a post from a local newspaper caught his attention. “The article said that if you grew up in the region I grew up in, compared to the richer Central Kentucky region, the life expectancy differed by about 9 years,” he recalled.

The respiratory therapist, then a PhD student at Rush University, Chicago, was struck and began “Googling” to find out why this was the case. Initially, he thought diabetes, smoking, and economic distress — all prevalent problems in the area — were the culprits. However, he soon found that respiratory disease was particularly common in his region.

Now a professor and program director of the Respiratory Care Program at Rush University, Scott has spent several years trying to understand why people in certain regions experience respiratory illness at higher rates than in other places.

The Environment as a Determinant of Health

When Scott began his PhD, the prevalence of asthma in Southeast Kentucky, part of the Appalachian region, was already well-documented. He focused his research on uncontrolled asthma and the triggers that drove asthma exacerbations.

Housing quality emerged as an important factor. He found that exposure to mold, mildew, dust mites, pests, and rodents increased the risk for asthma and exacerbated existing cases. Lower-income families, more likely to live in poor-quality housing, were significantly affected, even in single-family homes.

Wanda Phipatanakul, MD, MS, director of the Division of Immunology Research Center at Boston Children’s Hospital and S. Jean Emans professor of Pediatrics at Harvard Medical School, Boston, has found similar results in urban environments. She said cockroach and mouse allergen exposure is disproportionately prevalent in urban, low-income neighborhoods. These exposures, closely tied to housing conditions, contribute to worse asthma and respiratory problems, particularly in children.

Scott and Phipatanakul agreed that the environment surrounding people’s homes can also exacerbate respiratory disease.

Rural areas present unique risks, such as agricultural activities that release pesticides and other particulates into the air, said Scott. In mountainous areas like Appalachia, mining operations are another significant contributor. For example, blasting mountains with dynamite creates large clouds of dust and pollutants that settle in valleys. Coal-hauling roads contribute to air quality issues, too. And houses near these roads may be exposed to increased levels of particulate matter, he said.

In the city, Phipatanakul has found that historical practices like redlining have systematically denied certain neighborhoods access to resources and investment, leaving a legacy of poor infrastructure, limited resources, and higher exposure to environmental risks. Today, these areas have more highways and fewer green spaces and are disproportionately linked with a higher incidence of respiratory illnesses.

The findings of both Scott and Phipatanakul underscore a critical bottom line: Health disparities are deeply influenced by environmental factors, which are themselves shaped by socioeconomic conditions and historical inequities. Poor housing quality, exposure to allergens, and proximity to environmental hazards disproportionately affect underserved and minority communities, whether in rural or urban settings.

The Role of Green Spaces in Improving Respiratory Health

Restoring and increasing tree cover and green spaces in urban areas can significantly improve respiratory health by addressing environmental challenges and reducing triggers for respiratory issues. Areas with greater greenness tend to have lower levels of pollutants and fewer environmental infestations, such as mice and cockroaches, explained Phipatanakul. Her research highlights that schools in greener areas have fewer airborne pollutants and particles than those in more urbanized, less green areas, which are usually in poorer suburbs.

Trees absorb pollutants such as particulate matter and sulfur dioxide through dry deposition and stomatal uptake, improving air quality. “The question is whether we can use trees as a public health tool, and this is being done in many cities,” said Alessandro Marcon, PhD, a professor of epidemiology and medical statistics at the University of Verona, Verona, Italy, while speaking at the European Respiratory Society conference held in Vienna last September.

A US analysis showed that existing natural vegetation, such as forests and grasslands, absorbs a large portion of emissions. By restoring land cover, pollution from harmful substances like sulfur dioxide and particulate matter could be reduced by about 30%. This approach is often more cost-effective than technological solutions for managing emissions.

Moreover, tree cover contributes to a healthier air microbiome. Research indicates that urban forest areas have lower pathogenic bacteria and fungi concentrations than nearby urban zones.

Another major advantage is the mitigation of the urban heat island effect. A study conducted in Paris found that municipalities with higher tree coverage experienced 20%-30% lower heat-related mortality than those with less greenery. Increasing tree coverage to 30% could reduce up to 40% of excess mortality associated with urban heat islands. Trees achieve this by providing shade and facilitating evapotranspiration, which cools the surrounding air.

Urban environments, unsurprisingly, often have higher levels of air pollution due to increased traffic and industrial activity. However, despite appearing greener, rural environments may harbor less obvious but significant sources of air pollution. “I live in an urban environment now, but I grew up in a rural environment,” Scott said. “Each has its own issues that affect air quality and health.”

Scott, Phipatanakul, and Marcon reported no relevant financial relationships.■

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