Perspectives

It is a time of significant change as the Military Health System (MHS) transitions to the purview of the Defense Health Agency (DHA). Additionally, the landscape of combat is ever changing, and military medicine needs to evolve to ensure that the lessons learned are utilized to optimize care of the war fighters. The purpose of this review is to evaluate the available literature on existing operational medicine curriculums and make recommendations to restructure current military medicine training to produce operationally prepared clinicians who are informed in operationally focused research principles.

Operational Medicine

Before diving into the importance of creating a curriculum and investing in training for scholarly activity proficiency, operational medicine needs to be defined. It can be defined as medical care provided in an austere environment with limited resources and possibly under hostile conditions. Another way to look at operational medicine is as the evaluation of normal human physiology and pathology under abnormal conditions. The mission set of each of the services is unique. The Marines and Army may operate forward past the wire vulnerable to the environment, gunfire, and improvised explosive devices, remote from fixed medical facilities. The Navy has divers exposed to the risks of decompression sickness. The Air Force has pilots exposed to altitude changes and strains of G-forces during flight. Locations vary from cold high-altitude mountainous regions to high-temperature desolate deserts. Many times, medical practitioners may be remotely stationed, far from specialty or immediate definitive care. Patient care may consist of low-acuity management of individual patients in sick call to mass casualty events where patient numbers and morbidity may outstrip available resources, making the difficult task of triage necessary.

Despite the challenges of being a uniformed physician, the benefits of being embedded is a better understanding of the roles and capability of the unit. Military physicians need to have the unique knowledge of the type of injuries sustained in that particular theater of war, such as differentiating between the trauma pattern and care required for blast injuries vs high-velocity missiles. There are also chemical, biologic, radiologic, and nuclear threats that military physicians need to recognize. Much of what disables a military fighting force is not a direct relationship to combat-related injuries; however, entire units have been taken down by infectious diarrhea or trench foot. There is also a need for familiarity of the infections and parasitology endemic to the particular theater with the aim of implementation of prevention whenever possible.

Military medicine does not fit in any box. Military physicians need to know the job requirements of various specialties, including elements of occupational medicine, such as aircrew piloting high-performance fighters or ground troops fully loaded with body armor and 80-lb backpacks. There are musculoskeletal injuries from the stressors of various military occupations. Working around weaponry and contact with hostile forces will create scenarios requiring emergent and critical care. In addition to physical injuries, there is the mental strain of combat with the risk of imminent personal injury, the guilt of survivorship, dealing with the scars and permanent physical damage of combat, and prolonged separation from family and other support systems.

The National Defense Authorization Act 2017 mandated the establishment of a standardized process to oversee all military graduate medical education (GME) programs with the goal of ensuring medical operational readiness.¹ This is no small task with > 3000 residents in more than 70 specialties, comprising approximately 12% of US residents.^1,2 Presently, 26 to 32% of the medical corps is enrolled in full-time training compared with 12% of the total force.² With significant time and resources expended during this period, it is vital to maximize the potential of the training.

Literature Review

A literature review was performed, evaluating historical precedence of specialized military medical training and research as well as current operational curriculums. Literature search was conducted in the PubMed and Uniformed Services University (USU) Learning Resource databases using the terms “operational medicine curriculum,” “military medicine curriculum,” “operational medicine training,” “military medicine training,” “operational medicine research,” and “military medicine research,” and included all articles from 1997 to 2020. Inclusion criteria included studies that detailed military medicine training programs and/or outcomes. The source types used in this research project included peer-reviewed journal publications—both review articles and original research—from medical and military journals. The citations of these articles were also reviewed for additional usable publications. Secondary sources included official reports and studies by the RAND Corporation, the US Government Accountability Office, and the Institute for Defense Analysis (IDA). Due to lack of literature on the topic, other sources such as talking papers, letters, and formal presentations from subject matter experts were included to showcase the current state and gaps on this topic. Key findings from peer-reviewed publications are presented in Table 1.

Overall, the literature review showed that longitudinal deliberately mapped out curriculums can be well integrated into the existing medical curriculum.³ The military medicine course topics include environmental medicine, applied field medicine, combat casualty care, medical support planning, mass casualty incident preparation, and military-focused problem solving, decision making, and leadership.⁴

One 1997 study looked at the degree of implementation of military unique curriculum in 18 family medicine residencies. Only 30% of residents stated that their program had a specific operational medicine curriculum.5 Salerno and colleagues surveyed current residents and recently graduated internal medicine physicians at 14 facilities in the Army, Air Force, and Navy to determine confidence level with military medicine. More than half did not feel ready to practice deployment medicine; just 19% felt comfortable treating nuclear, biologic, and chemical warfare injuries; and 32% felt unfamiliar with the command and administrative duties. A subgroup analysis showed that USU graduates felt more prepared in these areas compared with civilian program graduates.6 Additional studies showed perceived smoother transition in the first active-duty tour after participation in an operational curriculum.⁷

In addition to in-program training, other options include operational rotations offsite and military courses conducted outside the GME program.¹² Some of these courses may include just-in-time training such as expeditionary medical support system training prior to scheduled deployments. Examples of experiential training are listed in Table 3.

Critical Analysis 

Current gaps were identified in the military medicine training pipeline’s operational medicine curriculum and research programs. The analysis looked at specific components that make the operational medicine curriculum and research unique as well as current readiness goals, to determine how to best align both to meet the mission requirements. Some factors considered included efficiency, cost, program portability, duplication minimization, retention, and sustainability.

Efficiency

A well-created curriculum that meets objectives will require more than an assigned rotation and a few lectures. The most successful ones in the literature review were the ones that were deliberately planned and longitudinal, such as the ones at USU that combined a mixture of classroom and field exercises over the course of 4 years.^4,8 In that way, the curriculum may not be considered time efficient, but if integrated well into the already existing medical training, the production of military physicians who are mission ready upon graduation—ready to serve as military medical leaders and deploy—will be invaluable.

Cost Comparison

Due to the associated overhead of running a training platform and the additional hours of operational training, military GME is more expensive initially compared with civilian outsourcing. In USU, for example, there is an additional 700 hours of operational curriculum alone. This cost difference more than doubles the cost of a USU education vs a Health Professional Scholarship Program (HPSP) scholarship at a civilian medical school. However, a causal analysis performed by the IDA to determine value basis noted that USU graduates deploy almost 3 times as much and serve 6 years longer on active duty.³

After graduating medical school through either accession source, physicians complete specialization training in a GME program. The IDA study noted an average $12,000 increased cost of military GME compared with civilian programs. The analysis included resident compensation and overhead costs of running the program as well as the net cost, which also accounted for resident productivity and workload by training in a military facility.³ Calculations due to mandated budget cuts estimated cost savings of closing the military medical school at < $100 million while significantly impacting the military physician pipeline and operational research output.³

Duplication of Effort

There are already established training programs such as Tactical Combat Casualty Care (TCCC) that could be incorporated into the curriculum to avoid expending additional resources to recreate the wheel. USU has a validated operational training curriculum and may be able to make opportunities available for outside trainees to participate in some of its military-unique training and leadership exercises. Other ways to decrease duplication of effort and improve cost efficiency include focusing on the creation of an academic health system (AHS) and consolidating similar programs to conserve resources. Increasing existing military program sizes will not only ensure the continuation of the military medicine pipeline, but will spread overhead costs over a larger cohort, decrease costs of civilian outsourcing, and ensure the less tangible benefits of military cultural exposure early in trainees’ careers. For example, increasing the class size of USU by 30 students actually reduces the cost per student to $239,000 per year from $253,000, while decreasing the need for HPSP accessions training in civilian programs, making the endeavor overall cost neutral.³

Program Portability

The operational medicine residency has proved that an operational curriculum can be remotely managed and reproduced at a variety of residency specialties.¹² Remote education could be developed and distributed throughout the MHS, such as the proposed USU course Military Medicine and Leadership course.3 Centralized training programs like Global Medicine and C-STARS could be scheduled TDYs during the medical training calendar.

Retention

The military medical school, USU, is the largest military medicine accession source. An IDA report notes that retention of USU graduates is 15.2 years compared with 9.2 years served by civilian trainees. Due to the longevity in service, USU graduates also make up more than 25% of military medical leadership.4 The long-term outcome study that looked at the past 40 years of USU graduates observed that over 70% of graduates served until retirement eligibility and are overrepresented in special operations units.3,13 While some of this longevity may be attributed to the longer USU service contracts, military GME graduates were still noted to be 4 times more likely to commit to a multiyear service contract.¹⁴ A RAND study on the retention of military physicians in the Army, Air Force, and Navy noted that overall retention increased throughout all the services for physicians who went through the military GME pipeline.¹⁵ Conversely, civilian GME training was associated with a 45% chance in leaving active duty.¹⁶

It is theorized that early military acculturation during training increases the likelihood of instilling a sense of mission. Being involved in military GME on the teaching side also showed increased retention rates for 63% of survey respondents.¹⁷ Reduced burnout and increased work satisfaction for those involved in military GME was noted on another faculty satisfaction survey.¹⁷

Sustainability

Programs like USU, which have been around for decades, and the newer operational residency program evolving since 2013 have shown sustainability.^4,11 Dissemination of proven curriculums as well as centralization of already validated training programs can help standardize operational medical training throughout the MHS. In order to flourish at individual programs, the faculty need to be well versed in a train the trainer model and have institutional support. The ability to engage with the line at individual locations may be a factor as well.¹⁸ In regard to research, once residents are taught the principles of scholarly activity, they will have the tools to continue operational medicine research advancements and mentoring students.

Discussion

The 2020 NDAA recommends the establishment of an AHS.3 This step will create a culture of military medical readiness from the top down as congressional mandates push reorganization of the MHS, including military GME programs. An overall restructuring of military medicine will require prioritization of resources toward operational requirements vs the historic significant division of attention to beneficiary care that has caused a lack of unity of effort and additional strain on an already heavily tasked medical force. The changes in military GME are just one aspect of that. It is vital to look at the restructuring with a comprehension of the unique challenges of combat health rather than only from an in-garrison, hospital-based aspect.¹⁹ Benefits of having a military medicine AHS include opportunities to share resources and successful business models as well as foster interdisciplinary teamwork and partnerships with civilian health care facilities and research institutions as a force multiplier.¹⁹

There has been recent discussion about budget cuts, including shutting down USU and military GME and transitioning all training to civilian programs to be cost-effective.⁴ If this were to happen, it would be a step backward from the goal of operational readiness. Maintaining US Department of Defense (DoD) control of the military medicine pipeline has innumerable benefits, including built-in mentorship from operationally-seasoned faculty, military leadership development, proficiency in MHS systems, open communication between GME programs and DoD, and curriculum control to ensure focus on readiness.²⁰ Military GME programs are also a significant production source of military-related scholarly activity. Over fiscal year 2017/2018, 63% of the publications out of the San Antonio Uniformed Services Health Education Consortium—the largest Air Force GME platform and second largest multiservice GME platform—involved military relevant medical topics.¹⁷ Much of the volume of operational research as well as the relevant skills learned and future innovations secondary to conducting this research would be lost if military GME did not exist.^17,21

Practically speaking, military GME provides the majority of the military medicine accessions. For example, a presentation by the Air Force Chief of Physician Education noted that the total military GME pipeline included 2875 students, but direct physician access averaged only 20 physicians a year.²² Even if the decision was made to defer to civilian education, capacity does not exist in civilian GME programs. This is worsened by the increased competitiveness of the GME match with the proliferation of medical schools without concurrent increase in residency spots. The 2018 National Resident Matching Program noted that there were more than 37,103 US and foreign applicants for only 33,000 residency positions, leaving many US applicants unmatched.¹⁷ It is doubtful that the civilian GME programs would be able to absorb the influx of military residents, affecting both the military and civilian medicine pipelines. As a secondary effect, the military treatment centers that house the military GME programs would have to close, with surrounding civilian medical facilities also likely unable to absorb the sudden influx of patients and residents losing the intangible benefits of caring for a military population.¹⁵ This was even recognized by the civilian president of the Accreditation Council for Graduate Medical Education:

Military physicians must be trained in the systems of care that are operative in military medicine, which is significantly unlike civilian medicine in many ways. It is often practiced in circumstances that are not seen in civilian medicine, within care structures that are not encountered in American medical practice… Military medicine has advanced research into the care of individuals suffering traumatic injury, critical care, rehabilitation medicine, prosthetics, psychiatric care of those traumatized, and closed head injury, to name a just a few. The sacrifices of our active military demand these advances, and the American Public benefit from these advances.²¹

Where deficiencies exist in military GME, it is possible to use the growing military-civilian training institution partnerships. Two prime examples are the just-in-time deployment training done with civilian trauma facilities by the Air Force Center for the Sustainment of Trauma Readiness Skills and the Air Force Special Operations Surgical Team-Special Operations Critical Care Evacuation Team being embedded in civilian facilities to maintain trauma, surgical, and emergency care skills. While military physicians can maintain competencies, at the same time, the civilian sector can benefit from the lessons learned in the military in regard to mass casualty and disaster responses. Fostering military and civilian training agreements can also enhance research opportunities.¹

Just as the realities of operational medicine frequently require the military physician to think outside the box, the most successful methods of instruction of military medicine tend to be nontraditional. Classroom education should be involved beyond lectures and can include other methods, such as case-based, role-playing, small group discussion, and computer-based teaching. Maintaining flexibility in live vs distance learning as well as synchronous vs asynchronous learning can expand the capacity of available instructors and standardize material over several sites.²³ Asking learners to consider operational concerns, such as whether certain medical conditions would be compatible with military duty in addition to the routine investigation is an easy way to incorporate military training in preexisting medical training.¹² The advancement of technology has made simulation one of the best ways to engage in hands-on learning, whether through computer simulations, animal models, standardized or moulaged patients, or mannequins that can realistically mimic medical or trauma-related conditions.²⁴ Many times, simulation can be combined with exercises in the field to create a realistic operational environment.²³

There are 3 pillars of an operational curriculum that should be integrated into the existing residency curriculum—operational medicine, leadership, and research principles (Appendix).

Conclusions

Judging by the continuing operational tempo and evolution of warfare, maintaining enhanced military medical readiness will remain a priority. Operational medicine is a unique field that requires specialized preparation. Studies have shown that longitudinal deliberately mapped out curriculums are able to be integrated well into the existing medical curriculum. The recommendation moving forward is increasing the access of existing operational training structures that have well established programs and modeling individual GME program curriculums after those that have shown proven success with a focus on the 3 pillars of operational training, leadership, and research.

Acknowledgments

Previously submitted in April 2020 in expanded form as part of graduation requirements for the Masters of Military Arts and Science degree program at Air University, Maxwell Air Force Base in Alabama.

It is a time of significant change as the Military Health System (MHS) transitions to the purview of the Defense Health Agency (DHA). Additionally, the landscape of combat is ever changing, and military medicine needs to evolve to ensure that the lessons learned are utilized to optimize care of the war fighters. The purpose of this review is to evaluate the available literature on existing operational medicine curriculums and make recommendations to restructure current military medicine training to produce operationally prepared clinicians who are informed in operationally focused research principles.

Operational Medicine

Before diving into the importance of creating a curriculum and investing in training for scholarly activity proficiency, operational medicine needs to be defined. It can be defined as medical care provided in an austere environment with limited resources and possibly under hostile conditions. Another way to look at operational medicine is as the evaluation of normal human physiology and pathology under abnormal conditions. The mission set of each of the services is unique. The Marines and Army may operate forward past the wire vulnerable to the environment, gunfire, and improvised explosive devices, remote from fixed medical facilities. The Navy has divers exposed to the risks of decompression sickness. The Air Force has pilots exposed to altitude changes and strains of G-forces during flight. Locations vary from cold high-altitude mountainous regions to high-temperature desolate deserts. Many times, medical practitioners may be remotely stationed, far from specialty or immediate definitive care. Patient care may consist of low-acuity management of individual patients in sick call to mass casualty events where patient numbers and morbidity may outstrip available resources, making the difficult task of triage necessary.

Despite the challenges of being a uniformed physician, the benefits of being embedded is a better understanding of the roles and capability of the unit. Military physicians need to have the unique knowledge of the type of injuries sustained in that particular theater of war, such as differentiating between the trauma pattern and care required for blast injuries vs high-velocity missiles. There are also chemical, biologic, radiologic, and nuclear threats that military physicians need to recognize. Much of what disables a military fighting force is not a direct relationship to combat-related injuries; however, entire units have been taken down by infectious diarrhea or trench foot. There is also a need for familiarity of the infections and parasitology endemic to the particular theater with the aim of implementation of prevention whenever possible.

Military medicine does not fit in any box. Military physicians need to know the job requirements of various specialties, including elements of occupational medicine, such as aircrew piloting high-performance fighters or ground troops fully loaded with body armor and 80-lb backpacks. There are musculoskeletal injuries from the stressors of various military occupations. Working around weaponry and contact with hostile forces will create scenarios requiring emergent and critical care. In addition to physical injuries, there is the mental strain of combat with the risk of imminent personal injury, the guilt of survivorship, dealing with the scars and permanent physical damage of combat, and prolonged separation from family and other support systems.

The National Defense Authorization Act 2017 mandated the establishment of a standardized process to oversee all military graduate medical education (GME) programs with the goal of ensuring medical operational readiness.¹ This is no small task with > 3000 residents in more than 70 specialties, comprising approximately 12% of US residents.^1,2 Presently, 26 to 32% of the medical corps is enrolled in full-time training compared with 12% of the total force.² With significant time and resources expended during this period, it is vital to maximize the potential of the training.

Literature Review

A literature review was performed, evaluating historical precedence of specialized military medical training and research as well as current operational curriculums. Literature search was conducted in the PubMed and Uniformed Services University (USU) Learning Resource databases using the terms “operational medicine curriculum,” “military medicine curriculum,” “operational medicine training,” “military medicine training,” “operational medicine research,” and “military medicine research,” and included all articles from 1997 to 2020. Inclusion criteria included studies that detailed military medicine training programs and/or outcomes. The source types used in this research project included peer-reviewed journal publications—both review articles and original research—from medical and military journals. The citations of these articles were also reviewed for additional usable publications. Secondary sources included official reports and studies by the RAND Corporation, the US Government Accountability Office, and the Institute for Defense Analysis (IDA). Due to lack of literature on the topic, other sources such as talking papers, letters, and formal presentations from subject matter experts were included to showcase the current state and gaps on this topic. Key findings from peer-reviewed publications are presented in Table 1.

Overall, the literature review showed that longitudinal deliberately mapped out curriculums can be well integrated into the existing medical curriculum.³ The military medicine course topics include environmental medicine, applied field medicine, combat casualty care, medical support planning, mass casualty incident preparation, and military-focused problem solving, decision making, and leadership.⁴

One 1997 study looked at the degree of implementation of military unique curriculum in 18 family medicine residencies. Only 30% of residents stated that their program had a specific operational medicine curriculum.5 Salerno and colleagues surveyed current residents and recently graduated internal medicine physicians at 14 facilities in the Army, Air Force, and Navy to determine confidence level with military medicine. More than half did not feel ready to practice deployment medicine; just 19% felt comfortable treating nuclear, biologic, and chemical warfare injuries; and 32% felt unfamiliar with the command and administrative duties. A subgroup analysis showed that USU graduates felt more prepared in these areas compared with civilian program graduates.6 Additional studies showed perceived smoother transition in the first active-duty tour after participation in an operational curriculum.⁷

In addition to in-program training, other options include operational rotations offsite and military courses conducted outside the GME program.¹² Some of these courses may include just-in-time training such as expeditionary medical support system training prior to scheduled deployments. Examples of experiential training are listed in Table 3.

Critical Analysis 

Current gaps were identified in the military medicine training pipeline’s operational medicine curriculum and research programs. The analysis looked at specific components that make the operational medicine curriculum and research unique as well as current readiness goals, to determine how to best align both to meet the mission requirements. Some factors considered included efficiency, cost, program portability, duplication minimization, retention, and sustainability.

Efficiency

A well-created curriculum that meets objectives will require more than an assigned rotation and a few lectures. The most successful ones in the literature review were the ones that were deliberately planned and longitudinal, such as the ones at USU that combined a mixture of classroom and field exercises over the course of 4 years.^4,8 In that way, the curriculum may not be considered time efficient, but if integrated well into the already existing medical training, the production of military physicians who are mission ready upon graduation—ready to serve as military medical leaders and deploy—will be invaluable.

Cost Comparison

Due to the associated overhead of running a training platform and the additional hours of operational training, military GME is more expensive initially compared with civilian outsourcing. In USU, for example, there is an additional 700 hours of operational curriculum alone. This cost difference more than doubles the cost of a USU education vs a Health Professional Scholarship Program (HPSP) scholarship at a civilian medical school. However, a causal analysis performed by the IDA to determine value basis noted that USU graduates deploy almost 3 times as much and serve 6 years longer on active duty.³

After graduating medical school through either accession source, physicians complete specialization training in a GME program. The IDA study noted an average $12,000 increased cost of military GME compared with civilian programs. The analysis included resident compensation and overhead costs of running the program as well as the net cost, which also accounted for resident productivity and workload by training in a military facility.³ Calculations due to mandated budget cuts estimated cost savings of closing the military medical school at < $100 million while significantly impacting the military physician pipeline and operational research output.³

Duplication of Effort

There are already established training programs such as Tactical Combat Casualty Care (TCCC) that could be incorporated into the curriculum to avoid expending additional resources to recreate the wheel. USU has a validated operational training curriculum and may be able to make opportunities available for outside trainees to participate in some of its military-unique training and leadership exercises. Other ways to decrease duplication of effort and improve cost efficiency include focusing on the creation of an academic health system (AHS) and consolidating similar programs to conserve resources. Increasing existing military program sizes will not only ensure the continuation of the military medicine pipeline, but will spread overhead costs over a larger cohort, decrease costs of civilian outsourcing, and ensure the less tangible benefits of military cultural exposure early in trainees’ careers. For example, increasing the class size of USU by 30 students actually reduces the cost per student to $239,000 per year from $253,000, while decreasing the need for HPSP accessions training in civilian programs, making the endeavor overall cost neutral.³

Program Portability

The operational medicine residency has proved that an operational curriculum can be remotely managed and reproduced at a variety of residency specialties.¹² Remote education could be developed and distributed throughout the MHS, such as the proposed USU course Military Medicine and Leadership course.3 Centralized training programs like Global Medicine and C-STARS could be scheduled TDYs during the medical training calendar.

Retention

The military medical school, USU, is the largest military medicine accession source. An IDA report notes that retention of USU graduates is 15.2 years compared with 9.2 years served by civilian trainees. Due to the longevity in service, USU graduates also make up more than 25% of military medical leadership.4 The long-term outcome study that looked at the past 40 years of USU graduates observed that over 70% of graduates served until retirement eligibility and are overrepresented in special operations units.3,13 While some of this longevity may be attributed to the longer USU service contracts, military GME graduates were still noted to be 4 times more likely to commit to a multiyear service contract.¹⁴ A RAND study on the retention of military physicians in the Army, Air Force, and Navy noted that overall retention increased throughout all the services for physicians who went through the military GME pipeline.¹⁵ Conversely, civilian GME training was associated with a 45% chance in leaving active duty.¹⁶

It is theorized that early military acculturation during training increases the likelihood of instilling a sense of mission. Being involved in military GME on the teaching side also showed increased retention rates for 63% of survey respondents.¹⁷ Reduced burnout and increased work satisfaction for those involved in military GME was noted on another faculty satisfaction survey.¹⁷

Sustainability

Programs like USU, which have been around for decades, and the newer operational residency program evolving since 2013 have shown sustainability.^4,11 Dissemination of proven curriculums as well as centralization of already validated training programs can help standardize operational medical training throughout the MHS. In order to flourish at individual programs, the faculty need to be well versed in a train the trainer model and have institutional support. The ability to engage with the line at individual locations may be a factor as well.¹⁸ In regard to research, once residents are taught the principles of scholarly activity, they will have the tools to continue operational medicine research advancements and mentoring students.

Discussion

The 2020 NDAA recommends the establishment of an AHS.3 This step will create a culture of military medical readiness from the top down as congressional mandates push reorganization of the MHS, including military GME programs. An overall restructuring of military medicine will require prioritization of resources toward operational requirements vs the historic significant division of attention to beneficiary care that has caused a lack of unity of effort and additional strain on an already heavily tasked medical force. The changes in military GME are just one aspect of that. It is vital to look at the restructuring with a comprehension of the unique challenges of combat health rather than only from an in-garrison, hospital-based aspect.¹⁹ Benefits of having a military medicine AHS include opportunities to share resources and successful business models as well as foster interdisciplinary teamwork and partnerships with civilian health care facilities and research institutions as a force multiplier.¹⁹

There has been recent discussion about budget cuts, including shutting down USU and military GME and transitioning all training to civilian programs to be cost-effective.⁴ If this were to happen, it would be a step backward from the goal of operational readiness. Maintaining US Department of Defense (DoD) control of the military medicine pipeline has innumerable benefits, including built-in mentorship from operationally-seasoned faculty, military leadership development, proficiency in MHS systems, open communication between GME programs and DoD, and curriculum control to ensure focus on readiness.²⁰ Military GME programs are also a significant production source of military-related scholarly activity. Over fiscal year 2017/2018, 63% of the publications out of the San Antonio Uniformed Services Health Education Consortium—the largest Air Force GME platform and second largest multiservice GME platform—involved military relevant medical topics.¹⁷ Much of the volume of operational research as well as the relevant skills learned and future innovations secondary to conducting this research would be lost if military GME did not exist.^17,21

Practically speaking, military GME provides the majority of the military medicine accessions. For example, a presentation by the Air Force Chief of Physician Education noted that the total military GME pipeline included 2875 students, but direct physician access averaged only 20 physicians a year.²² Even if the decision was made to defer to civilian education, capacity does not exist in civilian GME programs. This is worsened by the increased competitiveness of the GME match with the proliferation of medical schools without concurrent increase in residency spots. The 2018 National Resident Matching Program noted that there were more than 37,103 US and foreign applicants for only 33,000 residency positions, leaving many US applicants unmatched.¹⁷ It is doubtful that the civilian GME programs would be able to absorb the influx of military residents, affecting both the military and civilian medicine pipelines. As a secondary effect, the military treatment centers that house the military GME programs would have to close, with surrounding civilian medical facilities also likely unable to absorb the sudden influx of patients and residents losing the intangible benefits of caring for a military population.¹⁵ This was even recognized by the civilian president of the Accreditation Council for Graduate Medical Education:

Military physicians must be trained in the systems of care that are operative in military medicine, which is significantly unlike civilian medicine in many ways. It is often practiced in circumstances that are not seen in civilian medicine, within care structures that are not encountered in American medical practice… Military medicine has advanced research into the care of individuals suffering traumatic injury, critical care, rehabilitation medicine, prosthetics, psychiatric care of those traumatized, and closed head injury, to name a just a few. The sacrifices of our active military demand these advances, and the American Public benefit from these advances.²¹

Where deficiencies exist in military GME, it is possible to use the growing military-civilian training institution partnerships. Two prime examples are the just-in-time deployment training done with civilian trauma facilities by the Air Force Center for the Sustainment of Trauma Readiness Skills and the Air Force Special Operations Surgical Team-Special Operations Critical Care Evacuation Team being embedded in civilian facilities to maintain trauma, surgical, and emergency care skills. While military physicians can maintain competencies, at the same time, the civilian sector can benefit from the lessons learned in the military in regard to mass casualty and disaster responses. Fostering military and civilian training agreements can also enhance research opportunities.¹

Just as the realities of operational medicine frequently require the military physician to think outside the box, the most successful methods of instruction of military medicine tend to be nontraditional. Classroom education should be involved beyond lectures and can include other methods, such as case-based, role-playing, small group discussion, and computer-based teaching. Maintaining flexibility in live vs distance learning as well as synchronous vs asynchronous learning can expand the capacity of available instructors and standardize material over several sites.²³ Asking learners to consider operational concerns, such as whether certain medical conditions would be compatible with military duty in addition to the routine investigation is an easy way to incorporate military training in preexisting medical training.¹² The advancement of technology has made simulation one of the best ways to engage in hands-on learning, whether through computer simulations, animal models, standardized or moulaged patients, or mannequins that can realistically mimic medical or trauma-related conditions.²⁴ Many times, simulation can be combined with exercises in the field to create a realistic operational environment.²³

There are 3 pillars of an operational curriculum that should be integrated into the existing residency curriculum—operational medicine, leadership, and research principles (Appendix).

Conclusions

Judging by the continuing operational tempo and evolution of warfare, maintaining enhanced military medical readiness will remain a priority. Operational medicine is a unique field that requires specialized preparation. Studies have shown that longitudinal deliberately mapped out curriculums are able to be integrated well into the existing medical curriculum. The recommendation moving forward is increasing the access of existing operational training structures that have well established programs and modeling individual GME program curriculums after those that have shown proven success with a focus on the 3 pillars of operational training, leadership, and research.

Acknowledgments

Previously submitted in April 2020 in expanded form as part of graduation requirements for the Masters of Military Arts and Science degree program at Air University, Maxwell Air Force Base in Alabama.

It is a time of significant change as the Military Health System (MHS) transitions to the purview of the Defense Health Agency (DHA). Additionally, the landscape of combat is ever changing, and military medicine needs to evolve to ensure that the lessons learned are utilized to optimize care of the war fighters. The purpose of this review is to evaluate the available literature on existing operational medicine curriculums and make recommendations to restructure current military medicine training to produce operationally prepared clinicians who are informed in operationally focused research principles.

Operational Medicine

Before diving into the importance of creating a curriculum and investing in training for scholarly activity proficiency, operational medicine needs to be defined. It can be defined as medical care provided in an austere environment with limited resources and possibly under hostile conditions. Another way to look at operational medicine is as the evaluation of normal human physiology and pathology under abnormal conditions. The mission set of each of the services is unique. The Marines and Army may operate forward past the wire vulnerable to the environment, gunfire, and improvised explosive devices, remote from fixed medical facilities. The Navy has divers exposed to the risks of decompression sickness. The Air Force has pilots exposed to altitude changes and strains of G-forces during flight. Locations vary from cold high-altitude mountainous regions to high-temperature desolate deserts. Many times, medical practitioners may be remotely stationed, far from specialty or immediate definitive care. Patient care may consist of low-acuity management of individual patients in sick call to mass casualty events where patient numbers and morbidity may outstrip available resources, making the difficult task of triage necessary.

Despite the challenges of being a uniformed physician, the benefits of being embedded is a better understanding of the roles and capability of the unit. Military physicians need to have the unique knowledge of the type of injuries sustained in that particular theater of war, such as differentiating between the trauma pattern and care required for blast injuries vs high-velocity missiles. There are also chemical, biologic, radiologic, and nuclear threats that military physicians need to recognize. Much of what disables a military fighting force is not a direct relationship to combat-related injuries; however, entire units have been taken down by infectious diarrhea or trench foot. There is also a need for familiarity of the infections and parasitology endemic to the particular theater with the aim of implementation of prevention whenever possible.

Military medicine does not fit in any box. Military physicians need to know the job requirements of various specialties, including elements of occupational medicine, such as aircrew piloting high-performance fighters or ground troops fully loaded with body armor and 80-lb backpacks. There are musculoskeletal injuries from the stressors of various military occupations. Working around weaponry and contact with hostile forces will create scenarios requiring emergent and critical care. In addition to physical injuries, there is the mental strain of combat with the risk of imminent personal injury, the guilt of survivorship, dealing with the scars and permanent physical damage of combat, and prolonged separation from family and other support systems.

The National Defense Authorization Act 2017 mandated the establishment of a standardized process to oversee all military graduate medical education (GME) programs with the goal of ensuring medical operational readiness.¹ This is no small task with > 3000 residents in more than 70 specialties, comprising approximately 12% of US residents.^1,2 Presently, 26 to 32% of the medical corps is enrolled in full-time training compared with 12% of the total force.² With significant time and resources expended during this period, it is vital to maximize the potential of the training.

Literature Review

A literature review was performed, evaluating historical precedence of specialized military medical training and research as well as current operational curriculums. Literature search was conducted in the PubMed and Uniformed Services University (USU) Learning Resource databases using the terms “operational medicine curriculum,” “military medicine curriculum,” “operational medicine training,” “military medicine training,” “operational medicine research,” and “military medicine research,” and included all articles from 1997 to 2020. Inclusion criteria included studies that detailed military medicine training programs and/or outcomes. The source types used in this research project included peer-reviewed journal publications—both review articles and original research—from medical and military journals. The citations of these articles were also reviewed for additional usable publications. Secondary sources included official reports and studies by the RAND Corporation, the US Government Accountability Office, and the Institute for Defense Analysis (IDA). Due to lack of literature on the topic, other sources such as talking papers, letters, and formal presentations from subject matter experts were included to showcase the current state and gaps on this topic. Key findings from peer-reviewed publications are presented in Table 1.

Overall, the literature review showed that longitudinal deliberately mapped out curriculums can be well integrated into the existing medical curriculum.³ The military medicine course topics include environmental medicine, applied field medicine, combat casualty care, medical support planning, mass casualty incident preparation, and military-focused problem solving, decision making, and leadership.⁴

One 1997 study looked at the degree of implementation of military unique curriculum in 18 family medicine residencies. Only 30% of residents stated that their program had a specific operational medicine curriculum.5 Salerno and colleagues surveyed current residents and recently graduated internal medicine physicians at 14 facilities in the Army, Air Force, and Navy to determine confidence level with military medicine. More than half did not feel ready to practice deployment medicine; just 19% felt comfortable treating nuclear, biologic, and chemical warfare injuries; and 32% felt unfamiliar with the command and administrative duties. A subgroup analysis showed that USU graduates felt more prepared in these areas compared with civilian program graduates.6 Additional studies showed perceived smoother transition in the first active-duty tour after participation in an operational curriculum.⁷

In addition to in-program training, other options include operational rotations offsite and military courses conducted outside the GME program.¹² Some of these courses may include just-in-time training such as expeditionary medical support system training prior to scheduled deployments. Examples of experiential training are listed in Table 3.

Critical Analysis 

Current gaps were identified in the military medicine training pipeline’s operational medicine curriculum and research programs. The analysis looked at specific components that make the operational medicine curriculum and research unique as well as current readiness goals, to determine how to best align both to meet the mission requirements. Some factors considered included efficiency, cost, program portability, duplication minimization, retention, and sustainability.

Efficiency

A well-created curriculum that meets objectives will require more than an assigned rotation and a few lectures. The most successful ones in the literature review were the ones that were deliberately planned and longitudinal, such as the ones at USU that combined a mixture of classroom and field exercises over the course of 4 years.^4,8 In that way, the curriculum may not be considered time efficient, but if integrated well into the already existing medical training, the production of military physicians who are mission ready upon graduation—ready to serve as military medical leaders and deploy—will be invaluable.

Cost Comparison

Due to the associated overhead of running a training platform and the additional hours of operational training, military GME is more expensive initially compared with civilian outsourcing. In USU, for example, there is an additional 700 hours of operational curriculum alone. This cost difference more than doubles the cost of a USU education vs a Health Professional Scholarship Program (HPSP) scholarship at a civilian medical school. However, a causal analysis performed by the IDA to determine value basis noted that USU graduates deploy almost 3 times as much and serve 6 years longer on active duty.³

After graduating medical school through either accession source, physicians complete specialization training in a GME program. The IDA study noted an average $12,000 increased cost of military GME compared with civilian programs. The analysis included resident compensation and overhead costs of running the program as well as the net cost, which also accounted for resident productivity and workload by training in a military facility.³ Calculations due to mandated budget cuts estimated cost savings of closing the military medical school at < $100 million while significantly impacting the military physician pipeline and operational research output.³

Duplication of Effort

There are already established training programs such as Tactical Combat Casualty Care (TCCC) that could be incorporated into the curriculum to avoid expending additional resources to recreate the wheel. USU has a validated operational training curriculum and may be able to make opportunities available for outside trainees to participate in some of its military-unique training and leadership exercises. Other ways to decrease duplication of effort and improve cost efficiency include focusing on the creation of an academic health system (AHS) and consolidating similar programs to conserve resources. Increasing existing military program sizes will not only ensure the continuation of the military medicine pipeline, but will spread overhead costs over a larger cohort, decrease costs of civilian outsourcing, and ensure the less tangible benefits of military cultural exposure early in trainees’ careers. For example, increasing the class size of USU by 30 students actually reduces the cost per student to $239,000 per year from $253,000, while decreasing the need for HPSP accessions training in civilian programs, making the endeavor overall cost neutral.³

Program Portability

The operational medicine residency has proved that an operational curriculum can be remotely managed and reproduced at a variety of residency specialties.¹² Remote education could be developed and distributed throughout the MHS, such as the proposed USU course Military Medicine and Leadership course.3 Centralized training programs like Global Medicine and C-STARS could be scheduled TDYs during the medical training calendar.

Retention

The military medical school, USU, is the largest military medicine accession source. An IDA report notes that retention of USU graduates is 15.2 years compared with 9.2 years served by civilian trainees. Due to the longevity in service, USU graduates also make up more than 25% of military medical leadership.4 The long-term outcome study that looked at the past 40 years of USU graduates observed that over 70% of graduates served until retirement eligibility and are overrepresented in special operations units.3,13 While some of this longevity may be attributed to the longer USU service contracts, military GME graduates were still noted to be 4 times more likely to commit to a multiyear service contract.¹⁴ A RAND study on the retention of military physicians in the Army, Air Force, and Navy noted that overall retention increased throughout all the services for physicians who went through the military GME pipeline.¹⁵ Conversely, civilian GME training was associated with a 45% chance in leaving active duty.¹⁶

It is theorized that early military acculturation during training increases the likelihood of instilling a sense of mission. Being involved in military GME on the teaching side also showed increased retention rates for 63% of survey respondents.¹⁷ Reduced burnout and increased work satisfaction for those involved in military GME was noted on another faculty satisfaction survey.¹⁷

Sustainability

Programs like USU, which have been around for decades, and the newer operational residency program evolving since 2013 have shown sustainability.^4,11 Dissemination of proven curriculums as well as centralization of already validated training programs can help standardize operational medical training throughout the MHS. In order to flourish at individual programs, the faculty need to be well versed in a train the trainer model and have institutional support. The ability to engage with the line at individual locations may be a factor as well.¹⁸ In regard to research, once residents are taught the principles of scholarly activity, they will have the tools to continue operational medicine research advancements and mentoring students.

Discussion

The 2020 NDAA recommends the establishment of an AHS.3 This step will create a culture of military medical readiness from the top down as congressional mandates push reorganization of the MHS, including military GME programs. An overall restructuring of military medicine will require prioritization of resources toward operational requirements vs the historic significant division of attention to beneficiary care that has caused a lack of unity of effort and additional strain on an already heavily tasked medical force. The changes in military GME are just one aspect of that. It is vital to look at the restructuring with a comprehension of the unique challenges of combat health rather than only from an in-garrison, hospital-based aspect.¹⁹ Benefits of having a military medicine AHS include opportunities to share resources and successful business models as well as foster interdisciplinary teamwork and partnerships with civilian health care facilities and research institutions as a force multiplier.¹⁹

There has been recent discussion about budget cuts, including shutting down USU and military GME and transitioning all training to civilian programs to be cost-effective.⁴ If this were to happen, it would be a step backward from the goal of operational readiness. Maintaining US Department of Defense (DoD) control of the military medicine pipeline has innumerable benefits, including built-in mentorship from operationally-seasoned faculty, military leadership development, proficiency in MHS systems, open communication between GME programs and DoD, and curriculum control to ensure focus on readiness.²⁰ Military GME programs are also a significant production source of military-related scholarly activity. Over fiscal year 2017/2018, 63% of the publications out of the San Antonio Uniformed Services Health Education Consortium—the largest Air Force GME platform and second largest multiservice GME platform—involved military relevant medical topics.¹⁷ Much of the volume of operational research as well as the relevant skills learned and future innovations secondary to conducting this research would be lost if military GME did not exist.^17,21

Practically speaking, military GME provides the majority of the military medicine accessions. For example, a presentation by the Air Force Chief of Physician Education noted that the total military GME pipeline included 2875 students, but direct physician access averaged only 20 physicians a year.²² Even if the decision was made to defer to civilian education, capacity does not exist in civilian GME programs. This is worsened by the increased competitiveness of the GME match with the proliferation of medical schools without concurrent increase in residency spots. The 2018 National Resident Matching Program noted that there were more than 37,103 US and foreign applicants for only 33,000 residency positions, leaving many US applicants unmatched.¹⁷ It is doubtful that the civilian GME programs would be able to absorb the influx of military residents, affecting both the military and civilian medicine pipelines. As a secondary effect, the military treatment centers that house the military GME programs would have to close, with surrounding civilian medical facilities also likely unable to absorb the sudden influx of patients and residents losing the intangible benefits of caring for a military population.¹⁵ This was even recognized by the civilian president of the Accreditation Council for Graduate Medical Education:

Military physicians must be trained in the systems of care that are operative in military medicine, which is significantly unlike civilian medicine in many ways. It is often practiced in circumstances that are not seen in civilian medicine, within care structures that are not encountered in American medical practice… Military medicine has advanced research into the care of individuals suffering traumatic injury, critical care, rehabilitation medicine, prosthetics, psychiatric care of those traumatized, and closed head injury, to name a just a few. The sacrifices of our active military demand these advances, and the American Public benefit from these advances.²¹

Where deficiencies exist in military GME, it is possible to use the growing military-civilian training institution partnerships. Two prime examples are the just-in-time deployment training done with civilian trauma facilities by the Air Force Center for the Sustainment of Trauma Readiness Skills and the Air Force Special Operations Surgical Team-Special Operations Critical Care Evacuation Team being embedded in civilian facilities to maintain trauma, surgical, and emergency care skills. While military physicians can maintain competencies, at the same time, the civilian sector can benefit from the lessons learned in the military in regard to mass casualty and disaster responses. Fostering military and civilian training agreements can also enhance research opportunities.¹

Just as the realities of operational medicine frequently require the military physician to think outside the box, the most successful methods of instruction of military medicine tend to be nontraditional. Classroom education should be involved beyond lectures and can include other methods, such as case-based, role-playing, small group discussion, and computer-based teaching. Maintaining flexibility in live vs distance learning as well as synchronous vs asynchronous learning can expand the capacity of available instructors and standardize material over several sites.²³ Asking learners to consider operational concerns, such as whether certain medical conditions would be compatible with military duty in addition to the routine investigation is an easy way to incorporate military training in preexisting medical training.¹² The advancement of technology has made simulation one of the best ways to engage in hands-on learning, whether through computer simulations, animal models, standardized or moulaged patients, or mannequins that can realistically mimic medical or trauma-related conditions.²⁴ Many times, simulation can be combined with exercises in the field to create a realistic operational environment.²³

There are 3 pillars of an operational curriculum that should be integrated into the existing residency curriculum—operational medicine, leadership, and research principles (Appendix).

Conclusions

Judging by the continuing operational tempo and evolution of warfare, maintaining enhanced military medical readiness will remain a priority. Operational medicine is a unique field that requires specialized preparation. Studies have shown that longitudinal deliberately mapped out curriculums are able to be integrated well into the existing medical curriculum. The recommendation moving forward is increasing the access of existing operational training structures that have well established programs and modeling individual GME program curriculums after those that have shown proven success with a focus on the 3 pillars of operational training, leadership, and research.

Acknowledgments

Previously submitted in April 2020 in expanded form as part of graduation requirements for the Masters of Military Arts and Science degree program at Air University, Maxwell Air Force Base in Alabama.

Exhaustion. Defeat. Hopelessness. Physicians, nurses, physician assistants, and nurse practitioners are overwhelmed with burnout.

The recent round of COVID-19 is more frustrating than the first, with scientific evidence supporting ways we can prevent disease and disease progression. The health care team is no longer viewed as heroes but as the enemy, fraudulently proposing a vaccine and painting a fictional story of death, though it’s all true. The daily educational battle with patients and family members creates a challenging environment that cultivates hopelessness.

Clinicians are physically exhausted from the numerous COVID cases. Gone are the medical patients we trained for, who either remain home and risk their health or lack access to medical providers because of excessive wait times. Empathy for COVID patients is being tested even more with this new surge, and without the two-way bond of trust, clinicians are running out of fuel. Anger and distrust regarding vaccination guidance dominate the interaction when patients present demanding urgent intervention, while clinicians know that more than 95% of hospitalized patients are unvaccinated.

The struggle to find the commitment to medicine and serving patients is made worse by the pandemic fog and loss of trust from patients. Every day, health care teams risk their personal well-being to provide medical care and intervention. Not by choice do we gown up, mask up, and glove up. Each time we enter a COVID patient’s room, we expose ourselves and risk our own lives and the lives of our families for the patients who have elected to ignore medical guidance.

This national wave of resistance to vaccination is spurring an exodus from health care. Physicians are retiring early and physician assistants and nurse practitioners are seeking non–patient-facing positions to improve their own wellness and balance. A national nursing shortage is impacting patients seeking care in every medical discipline. The underlying wave of exhaustion and frustration has not completely destroyed their empathy but has depleted their drive.

How can we regain this drive amid exhausting work hours and angry patients?

As much as we have heard it, we need to protect our time to recharge. The demand to pick up extra shifts and support our colleagues has affected our personal health. Setting boundaries and building time for exercise, meditation, and connecting with family is essential for survival. Mental health is key to retaining empathy and finding hope. Education is one path to reigniting the fires of critical thinking and commitment to patient care – consider precepting students to support the growth of health care teams. Memories of patient care before this pandemic give us the hope that there is light at the end of this tunnel.

Dr. Gadalla is a hospitalist at Treasure Coast Hospitalists in Port St. Lucie, Fla. She is a member of the Hospitalist’s editorial advisory board and also serves as a physician assistant program director at South University in West Palm Beach, Fla. She disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

Exhaustion. Defeat. Hopelessness. Physicians, nurses, physician assistants, and nurse practitioners are overwhelmed with burnout.

The recent round of COVID-19 is more frustrating than the first, with scientific evidence supporting ways we can prevent disease and disease progression. The health care team is no longer viewed as heroes but as the enemy, fraudulently proposing a vaccine and painting a fictional story of death, though it’s all true. The daily educational battle with patients and family members creates a challenging environment that cultivates hopelessness.

Clinicians are physically exhausted from the numerous COVID cases. Gone are the medical patients we trained for, who either remain home and risk their health or lack access to medical providers because of excessive wait times. Empathy for COVID patients is being tested even more with this new surge, and without the two-way bond of trust, clinicians are running out of fuel. Anger and distrust regarding vaccination guidance dominate the interaction when patients present demanding urgent intervention, while clinicians know that more than 95% of hospitalized patients are unvaccinated.

The struggle to find the commitment to medicine and serving patients is made worse by the pandemic fog and loss of trust from patients. Every day, health care teams risk their personal well-being to provide medical care and intervention. Not by choice do we gown up, mask up, and glove up. Each time we enter a COVID patient’s room, we expose ourselves and risk our own lives and the lives of our families for the patients who have elected to ignore medical guidance.

This national wave of resistance to vaccination is spurring an exodus from health care. Physicians are retiring early and physician assistants and nurse practitioners are seeking non–patient-facing positions to improve their own wellness and balance. A national nursing shortage is impacting patients seeking care in every medical discipline. The underlying wave of exhaustion and frustration has not completely destroyed their empathy but has depleted their drive.

How can we regain this drive amid exhausting work hours and angry patients?

As much as we have heard it, we need to protect our time to recharge. The demand to pick up extra shifts and support our colleagues has affected our personal health. Setting boundaries and building time for exercise, meditation, and connecting with family is essential for survival. Mental health is key to retaining empathy and finding hope. Education is one path to reigniting the fires of critical thinking and commitment to patient care – consider precepting students to support the growth of health care teams. Memories of patient care before this pandemic give us the hope that there is light at the end of this tunnel.

Dr. Gadalla is a hospitalist at Treasure Coast Hospitalists in Port St. Lucie, Fla. She is a member of the Hospitalist’s editorial advisory board and also serves as a physician assistant program director at South University in West Palm Beach, Fla. She disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

Exhaustion. Defeat. Hopelessness. Physicians, nurses, physician assistants, and nurse practitioners are overwhelmed with burnout.

The recent round of COVID-19 is more frustrating than the first, with scientific evidence supporting ways we can prevent disease and disease progression. The health care team is no longer viewed as heroes but as the enemy, fraudulently proposing a vaccine and painting a fictional story of death, though it’s all true. The daily educational battle with patients and family members creates a challenging environment that cultivates hopelessness.

Clinicians are physically exhausted from the numerous COVID cases. Gone are the medical patients we trained for, who either remain home and risk their health or lack access to medical providers because of excessive wait times. Empathy for COVID patients is being tested even more with this new surge, and without the two-way bond of trust, clinicians are running out of fuel. Anger and distrust regarding vaccination guidance dominate the interaction when patients present demanding urgent intervention, while clinicians know that more than 95% of hospitalized patients are unvaccinated.

The struggle to find the commitment to medicine and serving patients is made worse by the pandemic fog and loss of trust from patients. Every day, health care teams risk their personal well-being to provide medical care and intervention. Not by choice do we gown up, mask up, and glove up. Each time we enter a COVID patient’s room, we expose ourselves and risk our own lives and the lives of our families for the patients who have elected to ignore medical guidance.

This national wave of resistance to vaccination is spurring an exodus from health care. Physicians are retiring early and physician assistants and nurse practitioners are seeking non–patient-facing positions to improve their own wellness and balance. A national nursing shortage is impacting patients seeking care in every medical discipline. The underlying wave of exhaustion and frustration has not completely destroyed their empathy but has depleted their drive.

How can we regain this drive amid exhausting work hours and angry patients?

As much as we have heard it, we need to protect our time to recharge. The demand to pick up extra shifts and support our colleagues has affected our personal health. Setting boundaries and building time for exercise, meditation, and connecting with family is essential for survival. Mental health is key to retaining empathy and finding hope. Education is one path to reigniting the fires of critical thinking and commitment to patient care – consider precepting students to support the growth of health care teams. Memories of patient care before this pandemic give us the hope that there is light at the end of this tunnel.

Dr. Gadalla is a hospitalist at Treasure Coast Hospitalists in Port St. Lucie, Fla. She is a member of the Hospitalist’s editorial advisory board and also serves as a physician assistant program director at South University in West Palm Beach, Fla. She disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

Dr. Paula Braveman, director of the Center on Social Disparities in Health at the University of California, San Francisco, says her latest research revealed an “astounding” level of evidence that racism is a decisive “upstream” cause of higher rates of preterm birth among Black women.

The tipping point for Dr. Paula Braveman came when a longtime patient of hers at a community clinic in San Francisco’s Mission District slipped past the front desk and knocked on her office door to say goodbye. He wouldn’t be coming to the clinic anymore, he told her, because he could no longer afford it.

It was a decisive moment for Dr. Braveman, who decided she wanted not only to heal ailing patients but also to advocate for policies that would help them be healthier when they arrived at her clinic. In the nearly four decades since, Dr. Braveman has dedicated herself to studying the “social determinants of health” – how the spaces where we live, work, play and learn, and the relationships we have in those places influence how healthy we are.

As director of the Center on Social Disparities in Health at the University of California, San Francisco, Dr. Braveman has studied the link between neighborhood wealth and children’s health, and how access to insurance influences prenatal care. A longtime advocate of translating research into policy, she has collaborated on major health initiatives with the health department in San Francisco, the federal Centers for Disease Control and Prevention, and the World Health Organization.

Dr. Braveman has a particular interest in maternal and infant health. Her latest research reviews what’s known about the persistent gap in preterm birth rates between Black and White women in the United States. Black women are about 1.6 times as likely as White women to give birth more than three weeks before the due date. That statistic bears alarming and costly health consequences, as infants born prematurely are at higher risk for breathing, heart, and brain abnormalities, among other complications.

Dr. Braveman coauthored the review with a group of experts convened by the March of Dimes that included geneticists, clinicians, epidemiologists, biomedical experts, and neurologists. They examined more than two dozen suspected causes of preterm births – including quality of prenatal care, environmental toxics, chronic stress, poverty and obesity – and determined that racism, directly or indirectly, best explained the racial disparities in preterm birth rates.

(Note: In the review, the authors make extensive use of the terms “upstream” and “downstream” to describe what determines people’s health. A downstream risk is the condition or factor most directly responsible for a health outcome, while an upstream factor is what causes or fuels the downstream risk – and often what needs to change to prevent someone from becoming sick. For example, a person living near drinking water polluted with toxic chemicals might get sick from drinking the water. The downstream fix would be telling individuals to use filters. The upstream solution would be to stop the dumping of toxic chemicals.)

KHN spoke with Dr. Braveman about the study and its findings. The excerpts have been edited for length and style.
 

Q: You have been studying the issue of preterm birth and racial disparities for so long. Were there any findings from this review that surprised you?

The process of systematically going through all of the risk factors that are written about in the literature and then seeing how the story of racism was an upstream determinant for virtually all of them. That was kind of astounding.

The other thing that was very impressive: When we looked at the idea that genetic factors could be the cause of the Black-White disparity in preterm birth. The genetics experts in the group, and there were three or four of them, concluded from the evidence that genetic factors might influence the disparity in preterm birth, but at most the effect would be very small, very small indeed. This could not account for the greater rate of preterm birth among Black women compared to White women.
 

Q: You were looking to identify not just what causes preterm birth but also to explain racial differences in rates of preterm birth. Are there examples of factors that can influence preterm birth that don’t explain racial disparities?

It does look like there are genetic components to preterm birth, but they don’t explain the Black-White disparity in preterm birth. Another example is having an early elective C-section. That’s one of the problems contributing to avoidable preterm birth, but it doesn’t look like that’s really contributing to the Black-White disparity in preterm birth.
 

Q: You and your colleagues listed exactly one upstream cause of preterm birth: racism. How would you characterize the certainty that racism is a decisive upstream cause of higher rates of preterm birth among Black women?

It makes me think of this saying: A randomized clinical trial wouldn’t be necessary to give certainty about the importance of having a parachute on if you jump from a plane. To me, at this point, it is close to that.

Going through that paper – and we worked on that paper over a three- or four-year period, so there was a lot of time to think about it – I don’t see how the evidence that we have could be explained otherwise.
 

Q: What did you learn about how a mother’s broader lifetime experience of racism might affect birth outcomes versus what she experienced within the medical establishment during pregnancy?

There were many ways that experiencing racial discrimination would affect a woman’s pregnancy, but one major way would be through pathways and biological mechanisms involved in stress and stress physiology. In neuroscience, what’s been clear is that a chronic stressor seems to be more damaging to health than an acute stressor.

So it doesn’t make much sense to be looking only during pregnancy. But that’s where most of that research has been done: stress during pregnancy and racial discrimination, and its role in birth outcomes. Very few studies have looked at experiences of racial discrimination across the life course.

My colleagues and I have published a paper where we asked African American women about their experiences of racism, and we didn’t even define what we meant. Women did not talk a lot about the experiences of racism during pregnancy from their medical providers; they talked about the lifetime experience and particularly experiences going back to childhood. And they talked about having to worry, and constant vigilance, so that even if they’re not experiencing an incident, their antennae have to be out to be prepared in case an incident does occur.

Putting all of it together with what we know about stress physiology, I would put my money on the lifetime experiences being so much more important than experiences during pregnancy. There isn’t enough known about preterm birth, but from what is known, inflammation is involved, immune dysfunction, and that’s what stress leads to. The neuroscientists have shown us that chronic stress produces inflammation and immune system dysfunction.

Q: What policies do you think are most important at this stage for reducing preterm birth for Black women?

I wish I could just say one policy or two policies, but I think it does get back to the need to dismantle racism in our society. In all of its manifestations. That’s unfortunate, not to be able to say, “Oh, here, I have this magic bullet, and if you just go with that, that will solve the problem.”

If you take the conclusions of this study seriously, you say, well, policies to just go after these downstream factors are not going to work. It’s up to the upstream investment in trying to achieve a more equitable and less racist society. Ultimately, I think that’s the take-home, and it’s a tall, tall order.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Dr. Paula Braveman, director of the Center on Social Disparities in Health at the University of California, San Francisco, says her latest research revealed an “astounding” level of evidence that racism is a decisive “upstream” cause of higher rates of preterm birth among Black women.

The tipping point for Dr. Paula Braveman came when a longtime patient of hers at a community clinic in San Francisco’s Mission District slipped past the front desk and knocked on her office door to say goodbye. He wouldn’t be coming to the clinic anymore, he told her, because he could no longer afford it.

It was a decisive moment for Dr. Braveman, who decided she wanted not only to heal ailing patients but also to advocate for policies that would help them be healthier when they arrived at her clinic. In the nearly four decades since, Dr. Braveman has dedicated herself to studying the “social determinants of health” – how the spaces where we live, work, play and learn, and the relationships we have in those places influence how healthy we are.

As director of the Center on Social Disparities in Health at the University of California, San Francisco, Dr. Braveman has studied the link between neighborhood wealth and children’s health, and how access to insurance influences prenatal care. A longtime advocate of translating research into policy, she has collaborated on major health initiatives with the health department in San Francisco, the federal Centers for Disease Control and Prevention, and the World Health Organization.

Dr. Braveman has a particular interest in maternal and infant health. Her latest research reviews what’s known about the persistent gap in preterm birth rates between Black and White women in the United States. Black women are about 1.6 times as likely as White women to give birth more than three weeks before the due date. That statistic bears alarming and costly health consequences, as infants born prematurely are at higher risk for breathing, heart, and brain abnormalities, among other complications.

Dr. Braveman coauthored the review with a group of experts convened by the March of Dimes that included geneticists, clinicians, epidemiologists, biomedical experts, and neurologists. They examined more than two dozen suspected causes of preterm births – including quality of prenatal care, environmental toxics, chronic stress, poverty and obesity – and determined that racism, directly or indirectly, best explained the racial disparities in preterm birth rates.

(Note: In the review, the authors make extensive use of the terms “upstream” and “downstream” to describe what determines people’s health. A downstream risk is the condition or factor most directly responsible for a health outcome, while an upstream factor is what causes or fuels the downstream risk – and often what needs to change to prevent someone from becoming sick. For example, a person living near drinking water polluted with toxic chemicals might get sick from drinking the water. The downstream fix would be telling individuals to use filters. The upstream solution would be to stop the dumping of toxic chemicals.)

KHN spoke with Dr. Braveman about the study and its findings. The excerpts have been edited for length and style.
 

Q: You have been studying the issue of preterm birth and racial disparities for so long. Were there any findings from this review that surprised you?

The process of systematically going through all of the risk factors that are written about in the literature and then seeing how the story of racism was an upstream determinant for virtually all of them. That was kind of astounding.

The other thing that was very impressive: When we looked at the idea that genetic factors could be the cause of the Black-White disparity in preterm birth. The genetics experts in the group, and there were three or four of them, concluded from the evidence that genetic factors might influence the disparity in preterm birth, but at most the effect would be very small, very small indeed. This could not account for the greater rate of preterm birth among Black women compared to White women.
 

Q: You were looking to identify not just what causes preterm birth but also to explain racial differences in rates of preterm birth. Are there examples of factors that can influence preterm birth that don’t explain racial disparities?

It does look like there are genetic components to preterm birth, but they don’t explain the Black-White disparity in preterm birth. Another example is having an early elective C-section. That’s one of the problems contributing to avoidable preterm birth, but it doesn’t look like that’s really contributing to the Black-White disparity in preterm birth.
 

Q: You and your colleagues listed exactly one upstream cause of preterm birth: racism. How would you characterize the certainty that racism is a decisive upstream cause of higher rates of preterm birth among Black women?

It makes me think of this saying: A randomized clinical trial wouldn’t be necessary to give certainty about the importance of having a parachute on if you jump from a plane. To me, at this point, it is close to that.

Going through that paper – and we worked on that paper over a three- or four-year period, so there was a lot of time to think about it – I don’t see how the evidence that we have could be explained otherwise.
 

Q: What did you learn about how a mother’s broader lifetime experience of racism might affect birth outcomes versus what she experienced within the medical establishment during pregnancy?

There were many ways that experiencing racial discrimination would affect a woman’s pregnancy, but one major way would be through pathways and biological mechanisms involved in stress and stress physiology. In neuroscience, what’s been clear is that a chronic stressor seems to be more damaging to health than an acute stressor.

So it doesn’t make much sense to be looking only during pregnancy. But that’s where most of that research has been done: stress during pregnancy and racial discrimination, and its role in birth outcomes. Very few studies have looked at experiences of racial discrimination across the life course.

My colleagues and I have published a paper where we asked African American women about their experiences of racism, and we didn’t even define what we meant. Women did not talk a lot about the experiences of racism during pregnancy from their medical providers; they talked about the lifetime experience and particularly experiences going back to childhood. And they talked about having to worry, and constant vigilance, so that even if they’re not experiencing an incident, their antennae have to be out to be prepared in case an incident does occur.

Putting all of it together with what we know about stress physiology, I would put my money on the lifetime experiences being so much more important than experiences during pregnancy. There isn’t enough known about preterm birth, but from what is known, inflammation is involved, immune dysfunction, and that’s what stress leads to. The neuroscientists have shown us that chronic stress produces inflammation and immune system dysfunction.

Q: What policies do you think are most important at this stage for reducing preterm birth for Black women?

I wish I could just say one policy or two policies, but I think it does get back to the need to dismantle racism in our society. In all of its manifestations. That’s unfortunate, not to be able to say, “Oh, here, I have this magic bullet, and if you just go with that, that will solve the problem.”

If you take the conclusions of this study seriously, you say, well, policies to just go after these downstream factors are not going to work. It’s up to the upstream investment in trying to achieve a more equitable and less racist society. Ultimately, I think that’s the take-home, and it’s a tall, tall order.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Dr. Paula Braveman, director of the Center on Social Disparities in Health at the University of California, San Francisco, says her latest research revealed an “astounding” level of evidence that racism is a decisive “upstream” cause of higher rates of preterm birth among Black women.

The tipping point for Dr. Paula Braveman came when a longtime patient of hers at a community clinic in San Francisco’s Mission District slipped past the front desk and knocked on her office door to say goodbye. He wouldn’t be coming to the clinic anymore, he told her, because he could no longer afford it.

It was a decisive moment for Dr. Braveman, who decided she wanted not only to heal ailing patients but also to advocate for policies that would help them be healthier when they arrived at her clinic. In the nearly four decades since, Dr. Braveman has dedicated herself to studying the “social determinants of health” – how the spaces where we live, work, play and learn, and the relationships we have in those places influence how healthy we are.

As director of the Center on Social Disparities in Health at the University of California, San Francisco, Dr. Braveman has studied the link between neighborhood wealth and children’s health, and how access to insurance influences prenatal care. A longtime advocate of translating research into policy, she has collaborated on major health initiatives with the health department in San Francisco, the federal Centers for Disease Control and Prevention, and the World Health Organization.

Dr. Braveman has a particular interest in maternal and infant health. Her latest research reviews what’s known about the persistent gap in preterm birth rates between Black and White women in the United States. Black women are about 1.6 times as likely as White women to give birth more than three weeks before the due date. That statistic bears alarming and costly health consequences, as infants born prematurely are at higher risk for breathing, heart, and brain abnormalities, among other complications.

Dr. Braveman coauthored the review with a group of experts convened by the March of Dimes that included geneticists, clinicians, epidemiologists, biomedical experts, and neurologists. They examined more than two dozen suspected causes of preterm births – including quality of prenatal care, environmental toxics, chronic stress, poverty and obesity – and determined that racism, directly or indirectly, best explained the racial disparities in preterm birth rates.

(Note: In the review, the authors make extensive use of the terms “upstream” and “downstream” to describe what determines people’s health. A downstream risk is the condition or factor most directly responsible for a health outcome, while an upstream factor is what causes or fuels the downstream risk – and often what needs to change to prevent someone from becoming sick. For example, a person living near drinking water polluted with toxic chemicals might get sick from drinking the water. The downstream fix would be telling individuals to use filters. The upstream solution would be to stop the dumping of toxic chemicals.)

KHN spoke with Dr. Braveman about the study and its findings. The excerpts have been edited for length and style.
 

Q: You have been studying the issue of preterm birth and racial disparities for so long. Were there any findings from this review that surprised you?

The process of systematically going through all of the risk factors that are written about in the literature and then seeing how the story of racism was an upstream determinant for virtually all of them. That was kind of astounding.

The other thing that was very impressive: When we looked at the idea that genetic factors could be the cause of the Black-White disparity in preterm birth. The genetics experts in the group, and there were three or four of them, concluded from the evidence that genetic factors might influence the disparity in preterm birth, but at most the effect would be very small, very small indeed. This could not account for the greater rate of preterm birth among Black women compared to White women.
 

Q: You were looking to identify not just what causes preterm birth but also to explain racial differences in rates of preterm birth. Are there examples of factors that can influence preterm birth that don’t explain racial disparities?

It does look like there are genetic components to preterm birth, but they don’t explain the Black-White disparity in preterm birth. Another example is having an early elective C-section. That’s one of the problems contributing to avoidable preterm birth, but it doesn’t look like that’s really contributing to the Black-White disparity in preterm birth.
 

Q: You and your colleagues listed exactly one upstream cause of preterm birth: racism. How would you characterize the certainty that racism is a decisive upstream cause of higher rates of preterm birth among Black women?

It makes me think of this saying: A randomized clinical trial wouldn’t be necessary to give certainty about the importance of having a parachute on if you jump from a plane. To me, at this point, it is close to that.

Going through that paper – and we worked on that paper over a three- or four-year period, so there was a lot of time to think about it – I don’t see how the evidence that we have could be explained otherwise.
 

Q: What did you learn about how a mother’s broader lifetime experience of racism might affect birth outcomes versus what she experienced within the medical establishment during pregnancy?

There were many ways that experiencing racial discrimination would affect a woman’s pregnancy, but one major way would be through pathways and biological mechanisms involved in stress and stress physiology. In neuroscience, what’s been clear is that a chronic stressor seems to be more damaging to health than an acute stressor.

So it doesn’t make much sense to be looking only during pregnancy. But that’s where most of that research has been done: stress during pregnancy and racial discrimination, and its role in birth outcomes. Very few studies have looked at experiences of racial discrimination across the life course.

My colleagues and I have published a paper where we asked African American women about their experiences of racism, and we didn’t even define what we meant. Women did not talk a lot about the experiences of racism during pregnancy from their medical providers; they talked about the lifetime experience and particularly experiences going back to childhood. And they talked about having to worry, and constant vigilance, so that even if they’re not experiencing an incident, their antennae have to be out to be prepared in case an incident does occur.

Putting all of it together with what we know about stress physiology, I would put my money on the lifetime experiences being so much more important than experiences during pregnancy. There isn’t enough known about preterm birth, but from what is known, inflammation is involved, immune dysfunction, and that’s what stress leads to. The neuroscientists have shown us that chronic stress produces inflammation and immune system dysfunction.

Q: What policies do you think are most important at this stage for reducing preterm birth for Black women?

I wish I could just say one policy or two policies, but I think it does get back to the need to dismantle racism in our society. In all of its manifestations. That’s unfortunate, not to be able to say, “Oh, here, I have this magic bullet, and if you just go with that, that will solve the problem.”

If you take the conclusions of this study seriously, you say, well, policies to just go after these downstream factors are not going to work. It’s up to the upstream investment in trying to achieve a more equitable and less racist society. Ultimately, I think that’s the take-home, and it’s a tall, tall order.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

There is a narrative being pushed now about health care professionals being “frustrated” and “tired” in the midst of this current delta COVID wave. This stems from the idea that this current wave was potentially preventable if everyone received the COVID vaccines when they were made available.

Courtesy of Sound Physicians

I certainly understand this frustration and am tired of dealing with COVID restrictions and wearing masks. Above all I’m tired of talking about it. But frustration and fatigue are nothing new for those in the health care profession. Part of our training is that we should care for everyone, no matter what. Compassion for the ill should not be restricted to patients with a certain financial status, immigration status, race, gender, sexual orientation, or education level. Socially and politically, we are having a reckoning with how we treat people and how we need to do better to create a more just society. A key virtue in all of this is tolerance.

If we are going to have a free society, tolerance is essential. This is because in a free society people are going to, well, be free. In medicine we tolerate people who are morbidly obese, drink alcohol excessively, smoke, refuse to take their medications, won’t exercise, won’t sleep, and do drugs. The overwhelming majority of these people know that what they are doing is bad for their health. Not only do we tolerate them, we are taught to treat them indiscriminately. When someone who is morbidly obese has a heart attack, we treat them, give them medicine, and tell them the importance of losing weight. We do not tell them, “you shouldn’t have eaten so much and gotten so fat,” or “don’t you wish you didn’t get so fat?”

What I am trying to circle back to here is that if you could force people into doing everything they could for their health and eliminate all “preventable” diseases, then the need for health care in this country – including doctors, nurses, hospitals, and pharmaceuticals, just to name a few – would be cut dramatically. While the frustration for the continued COVID surges is understandable, I urge people to remember that in the business of health care we deal with preventable diseases all the time, every day. We are taught to show compassion for everyone, and for good reason. We have no idea what many people’s backstories are, we just know that they are sick and need help.

I urge everyone to put the unvaccinated under the same umbrella you put other people with preventable diseases, which, sadly, is a lot of patients. Continue to educate those about the vaccine as you should about every other aspect of their health. Education is part of our job as health care professionals but judgment is not.

Dr. Matuszak works for Sound Physicians and is a nocturnist at a hospital in the San Francisco Bay Area.

There is a narrative being pushed now about health care professionals being “frustrated” and “tired” in the midst of this current delta COVID wave. This stems from the idea that this current wave was potentially preventable if everyone received the COVID vaccines when they were made available.

Courtesy of Sound Physicians

I certainly understand this frustration and am tired of dealing with COVID restrictions and wearing masks. Above all I’m tired of talking about it. But frustration and fatigue are nothing new for those in the health care profession. Part of our training is that we should care for everyone, no matter what. Compassion for the ill should not be restricted to patients with a certain financial status, immigration status, race, gender, sexual orientation, or education level. Socially and politically, we are having a reckoning with how we treat people and how we need to do better to create a more just society. A key virtue in all of this is tolerance.

If we are going to have a free society, tolerance is essential. This is because in a free society people are going to, well, be free. In medicine we tolerate people who are morbidly obese, drink alcohol excessively, smoke, refuse to take their medications, won’t exercise, won’t sleep, and do drugs. The overwhelming majority of these people know that what they are doing is bad for their health. Not only do we tolerate them, we are taught to treat them indiscriminately. When someone who is morbidly obese has a heart attack, we treat them, give them medicine, and tell them the importance of losing weight. We do not tell them, “you shouldn’t have eaten so much and gotten so fat,” or “don’t you wish you didn’t get so fat?”

What I am trying to circle back to here is that if you could force people into doing everything they could for their health and eliminate all “preventable” diseases, then the need for health care in this country – including doctors, nurses, hospitals, and pharmaceuticals, just to name a few – would be cut dramatically. While the frustration for the continued COVID surges is understandable, I urge people to remember that in the business of health care we deal with preventable diseases all the time, every day. We are taught to show compassion for everyone, and for good reason. We have no idea what many people’s backstories are, we just know that they are sick and need help.

I urge everyone to put the unvaccinated under the same umbrella you put other people with preventable diseases, which, sadly, is a lot of patients. Continue to educate those about the vaccine as you should about every other aspect of their health. Education is part of our job as health care professionals but judgment is not.

Dr. Matuszak works for Sound Physicians and is a nocturnist at a hospital in the San Francisco Bay Area.

There is a narrative being pushed now about health care professionals being “frustrated” and “tired” in the midst of this current delta COVID wave. This stems from the idea that this current wave was potentially preventable if everyone received the COVID vaccines when they were made available.

Courtesy of Sound Physicians

I certainly understand this frustration and am tired of dealing with COVID restrictions and wearing masks. Above all I’m tired of talking about it. But frustration and fatigue are nothing new for those in the health care profession. Part of our training is that we should care for everyone, no matter what. Compassion for the ill should not be restricted to patients with a certain financial status, immigration status, race, gender, sexual orientation, or education level. Socially and politically, we are having a reckoning with how we treat people and how we need to do better to create a more just society. A key virtue in all of this is tolerance.

If we are going to have a free society, tolerance is essential. This is because in a free society people are going to, well, be free. In medicine we tolerate people who are morbidly obese, drink alcohol excessively, smoke, refuse to take their medications, won’t exercise, won’t sleep, and do drugs. The overwhelming majority of these people know that what they are doing is bad for their health. Not only do we tolerate them, we are taught to treat them indiscriminately. When someone who is morbidly obese has a heart attack, we treat them, give them medicine, and tell them the importance of losing weight. We do not tell them, “you shouldn’t have eaten so much and gotten so fat,” or “don’t you wish you didn’t get so fat?”

What I am trying to circle back to here is that if you could force people into doing everything they could for their health and eliminate all “preventable” diseases, then the need for health care in this country – including doctors, nurses, hospitals, and pharmaceuticals, just to name a few – would be cut dramatically. While the frustration for the continued COVID surges is understandable, I urge people to remember that in the business of health care we deal with preventable diseases all the time, every day. We are taught to show compassion for everyone, and for good reason. We have no idea what many people’s backstories are, we just know that they are sick and need help.

I urge everyone to put the unvaccinated under the same umbrella you put other people with preventable diseases, which, sadly, is a lot of patients. Continue to educate those about the vaccine as you should about every other aspect of their health. Education is part of our job as health care professionals but judgment is not.

Dr. Matuszak works for Sound Physicians and is a nocturnist at a hospital in the San Francisco Bay Area.

It’s an all-too-common news item: The crash and burn of yet another politician, celebrity, or prominent individual. It’s painful to watch someone who spent years to achieve the status of a household name suddenly, and often ignominiously, lose it all. This is the equivalent of a human train wreck.

Some adversaries (who doesn’t have a few?) will rejoice or express schadenfreude, but many people will experience some empathy or sorrow as they witness the implosion of a celebrity. Fans, followers, or voters may grieve as the object of their respect and adulation falls off the high pedestal of fame. What starts as a drip-drip of rumors and innuendos soon eventuates in a denouement. And with time, as additional public figures fall from grace, the previous casualties will become mere footnotes in the annals of human self-destruction. Their loss of face, shame, and wrenching emotional and financial toll will be forgotten from the public’s collective memory, but the embers of bitterness and regret will continue to smolder in the hearts and souls of those who inadvertently contributed to their own social or professional demise due to a mistake, error of judgement, or plain old-fashioned stupidity. For the fallen, forgiveness and redemption are hard to come by.

Oh, how the mighty have fallen over centuries, and they include historical figures such as kings, military leaders, religious leaders, and politicians. The fall from grace in the past often led to executions, excommunication, or persecution. In the contemporary era, the oppressive “cancel culture” will mercilessly discard anyone, regardless of stature, after only 1 “wrong” tweet. In the digital age of mass communication, being “cancelled” is a frequent fall from grace and is the equivalent of being ostracized from millions of denizens on social media, which can spell doom for one’s career and social interactions.

The list of those whose careers ended calamitously include many familiar names, but I will only cite their prominent roles (you can easily guess their names!):

• emperors, kings, presidents, prime ministers, and political demagogues
• congressmen, senators, governors, and mayors
• Nobel Laureates (a Medicine and Physiology winner went to prison for pedophilia, and a Peace Prize winner fell from grace for supporting a military dictatorship)
• Cardinals and bishops in various countries (for sexual or financial crimes)
• billionaires, often for erratic personal lives
• sport legends, including decorated athletes and coaches of college and professional teams
• world chess masters
• Wall Street moguls
• Hollywood celebrities, including actors and directors, some with Oscars and related recognitions
• television news anchors and commentators
• comedians of various stripes
• CEOs of major media companies
• talk show hosts watched by millions
• celebrated musicians (classical, pop, rap, or blues)
• university presidents
• others in esteemed positions (including some psychiatrists).

Why is this so common?

From a psychiatric perspective, the most compelling question is why is the fall from grace so common? What are the transgressions, flaws, and shortcomings of successful individuals whose reputations end up smeared or who lose everything they worked for? Why do high achievers, talented and successful, at the apogee of fame and fortune, lose it all with nary a chance for recovery

The answer is all too obvious: human frailties. Successful persons are by no means immune from poor judgment. They can be as error-prone as the rest of us mortals. Having robust cognitive intelligence can be undermined by stunted emotional intelligence or poor interpersonal or social judgment. In Freudian terms, famous people who crash and burn may have a “Swiss cheese superego” that allows their id to viciously weaken their ego. From a neuroscience perspective, their limbic system conquers their cortical circuitry with relentless innate forces, including:

• fervent sexual appetite, compounded by the cockiness that comes with fame
• felonious paraphilias, such as pedophilia or public indecency
• intense greed that clouds one’s judgment (a trait exhibited by some ultra-rich persons)
• narcissism, either inborn or acquired with unexpected success and power
• impulsivity and recklessness, with injurious words or actions.
• substance use.

Consideration should be given to psychopathology. Some may have a personality disorder. Others may be both blessed and cursed with hypomania that leads to high achievement but also to foolish and impulsive behavior.¹ Some may have maladaptive social skills seen in autism spectrum disorder (recently, a very prominent and innovative billionaire casually announced that he has autistic traits). And others my have limited coping skills to deal with fame and fortune and unwittingly end up shooting themselves in both feet.

Continue to: But perhaps the most common thread...

But perhaps the most common thread across all the tragic cases of self-destruction is hubris. As humans become rich, famous, or powerful, they gradually develop the fallacious belief that they can get away with anything because they have masses of fans and followers who “love them no matter what.” This dangerous “acquired narcissism” is an unfortunate byproduct of success. Humility is rare among celebrities and powerful leaders. Modest celebrities almost never fall from grace and are endowed with an innate antidote to self-aggrandizement. A few years ago, I wrote an editorial in Current Psychiatry titled “Should psychiatry list hubris in DSM-V?”² While hubris is not regarded as a psychiatric disorder, it is certainly an affliction that often ends badly. The mental repercussions can include depression, anxiety, posttraumatic stress disorder, despair, and even falling on one’s sword. Hubris can be a fatal flaw with devastating consequences to one’s career. Perhaps those who aspire to become a celebrity should receive mentorship about hubris as a hazard of fame and fortune, when they are still in the “rising star” stage of their lives.

In contemporary society, with the era of social media and toxic political zeitgeist, there are many inadvertent “opportunities” to stumble and ruin one’s career by uttering an “unacceptable” word or dispatching an “offensive tweet” or posting a politically incorrect photo. And even if one is currently careful, there are now social media detectives and fact-finding “archeologists” who can excavate and disseminate the faux pas, peccadillos, or misdeeds from a prominent person’s immature youth, which will destroy a famous person overnight. That can be a nightmare for anyone who becomes a bona fide celebrity after years of working hard to get there.

High achievers: Beware!

It’s an all-too-common news item: The crash and burn of yet another politician, celebrity, or prominent individual. It’s painful to watch someone who spent years to achieve the status of a household name suddenly, and often ignominiously, lose it all. This is the equivalent of a human train wreck.

Some adversaries (who doesn’t have a few?) will rejoice or express schadenfreude, but many people will experience some empathy or sorrow as they witness the implosion of a celebrity. Fans, followers, or voters may grieve as the object of their respect and adulation falls off the high pedestal of fame. What starts as a drip-drip of rumors and innuendos soon eventuates in a denouement. And with time, as additional public figures fall from grace, the previous casualties will become mere footnotes in the annals of human self-destruction. Their loss of face, shame, and wrenching emotional and financial toll will be forgotten from the public’s collective memory, but the embers of bitterness and regret will continue to smolder in the hearts and souls of those who inadvertently contributed to their own social or professional demise due to a mistake, error of judgement, or plain old-fashioned stupidity. For the fallen, forgiveness and redemption are hard to come by.

Oh, how the mighty have fallen over centuries, and they include historical figures such as kings, military leaders, religious leaders, and politicians. The fall from grace in the past often led to executions, excommunication, or persecution. In the contemporary era, the oppressive “cancel culture” will mercilessly discard anyone, regardless of stature, after only 1 “wrong” tweet. In the digital age of mass communication, being “cancelled” is a frequent fall from grace and is the equivalent of being ostracized from millions of denizens on social media, which can spell doom for one’s career and social interactions.

The list of those whose careers ended calamitously include many familiar names, but I will only cite their prominent roles (you can easily guess their names!):

• emperors, kings, presidents, prime ministers, and political demagogues
• congressmen, senators, governors, and mayors
• Nobel Laureates (a Medicine and Physiology winner went to prison for pedophilia, and a Peace Prize winner fell from grace for supporting a military dictatorship)
• Cardinals and bishops in various countries (for sexual or financial crimes)
• billionaires, often for erratic personal lives
• sport legends, including decorated athletes and coaches of college and professional teams
• world chess masters
• Wall Street moguls
• Hollywood celebrities, including actors and directors, some with Oscars and related recognitions
• television news anchors and commentators
• comedians of various stripes
• CEOs of major media companies
• talk show hosts watched by millions
• celebrated musicians (classical, pop, rap, or blues)
• university presidents
• others in esteemed positions (including some psychiatrists).

Why is this so common?

From a psychiatric perspective, the most compelling question is why is the fall from grace so common? What are the transgressions, flaws, and shortcomings of successful individuals whose reputations end up smeared or who lose everything they worked for? Why do high achievers, talented and successful, at the apogee of fame and fortune, lose it all with nary a chance for recovery

The answer is all too obvious: human frailties. Successful persons are by no means immune from poor judgment. They can be as error-prone as the rest of us mortals. Having robust cognitive intelligence can be undermined by stunted emotional intelligence or poor interpersonal or social judgment. In Freudian terms, famous people who crash and burn may have a “Swiss cheese superego” that allows their id to viciously weaken their ego. From a neuroscience perspective, their limbic system conquers their cortical circuitry with relentless innate forces, including:

• fervent sexual appetite, compounded by the cockiness that comes with fame
• felonious paraphilias, such as pedophilia or public indecency
• intense greed that clouds one’s judgment (a trait exhibited by some ultra-rich persons)
• narcissism, either inborn or acquired with unexpected success and power
• impulsivity and recklessness, with injurious words or actions.
• substance use.

Consideration should be given to psychopathology. Some may have a personality disorder. Others may be both blessed and cursed with hypomania that leads to high achievement but also to foolish and impulsive behavior.¹ Some may have maladaptive social skills seen in autism spectrum disorder (recently, a very prominent and innovative billionaire casually announced that he has autistic traits). And others my have limited coping skills to deal with fame and fortune and unwittingly end up shooting themselves in both feet.

Continue to: But perhaps the most common thread...

But perhaps the most common thread across all the tragic cases of self-destruction is hubris. As humans become rich, famous, or powerful, they gradually develop the fallacious belief that they can get away with anything because they have masses of fans and followers who “love them no matter what.” This dangerous “acquired narcissism” is an unfortunate byproduct of success. Humility is rare among celebrities and powerful leaders. Modest celebrities almost never fall from grace and are endowed with an innate antidote to self-aggrandizement. A few years ago, I wrote an editorial in Current Psychiatry titled “Should psychiatry list hubris in DSM-V?”² While hubris is not regarded as a psychiatric disorder, it is certainly an affliction that often ends badly. The mental repercussions can include depression, anxiety, posttraumatic stress disorder, despair, and even falling on one’s sword. Hubris can be a fatal flaw with devastating consequences to one’s career. Perhaps those who aspire to become a celebrity should receive mentorship about hubris as a hazard of fame and fortune, when they are still in the “rising star” stage of their lives.

In contemporary society, with the era of social media and toxic political zeitgeist, there are many inadvertent “opportunities” to stumble and ruin one’s career by uttering an “unacceptable” word or dispatching an “offensive tweet” or posting a politically incorrect photo. And even if one is currently careful, there are now social media detectives and fact-finding “archeologists” who can excavate and disseminate the faux pas, peccadillos, or misdeeds from a prominent person’s immature youth, which will destroy a famous person overnight. That can be a nightmare for anyone who becomes a bona fide celebrity after years of working hard to get there.

High achievers: Beware!

It’s an all-too-common news item: The crash and burn of yet another politician, celebrity, or prominent individual. It’s painful to watch someone who spent years to achieve the status of a household name suddenly, and often ignominiously, lose it all. This is the equivalent of a human train wreck.

Some adversaries (who doesn’t have a few?) will rejoice or express schadenfreude, but many people will experience some empathy or sorrow as they witness the implosion of a celebrity. Fans, followers, or voters may grieve as the object of their respect and adulation falls off the high pedestal of fame. What starts as a drip-drip of rumors and innuendos soon eventuates in a denouement. And with time, as additional public figures fall from grace, the previous casualties will become mere footnotes in the annals of human self-destruction. Their loss of face, shame, and wrenching emotional and financial toll will be forgotten from the public’s collective memory, but the embers of bitterness and regret will continue to smolder in the hearts and souls of those who inadvertently contributed to their own social or professional demise due to a mistake, error of judgement, or plain old-fashioned stupidity. For the fallen, forgiveness and redemption are hard to come by.

Oh, how the mighty have fallen over centuries, and they include historical figures such as kings, military leaders, religious leaders, and politicians. The fall from grace in the past often led to executions, excommunication, or persecution. In the contemporary era, the oppressive “cancel culture” will mercilessly discard anyone, regardless of stature, after only 1 “wrong” tweet. In the digital age of mass communication, being “cancelled” is a frequent fall from grace and is the equivalent of being ostracized from millions of denizens on social media, which can spell doom for one’s career and social interactions.

The list of those whose careers ended calamitously include many familiar names, but I will only cite their prominent roles (you can easily guess their names!):

• emperors, kings, presidents, prime ministers, and political demagogues
• congressmen, senators, governors, and mayors
• Nobel Laureates (a Medicine and Physiology winner went to prison for pedophilia, and a Peace Prize winner fell from grace for supporting a military dictatorship)
• Cardinals and bishops in various countries (for sexual or financial crimes)
• billionaires, often for erratic personal lives
• sport legends, including decorated athletes and coaches of college and professional teams
• world chess masters
• Wall Street moguls
• Hollywood celebrities, including actors and directors, some with Oscars and related recognitions
• television news anchors and commentators
• comedians of various stripes
• CEOs of major media companies
• talk show hosts watched by millions
• celebrated musicians (classical, pop, rap, or blues)
• university presidents
• others in esteemed positions (including some psychiatrists).

Why is this so common?

From a psychiatric perspective, the most compelling question is why is the fall from grace so common? What are the transgressions, flaws, and shortcomings of successful individuals whose reputations end up smeared or who lose everything they worked for? Why do high achievers, talented and successful, at the apogee of fame and fortune, lose it all with nary a chance for recovery

The answer is all too obvious: human frailties. Successful persons are by no means immune from poor judgment. They can be as error-prone as the rest of us mortals. Having robust cognitive intelligence can be undermined by stunted emotional intelligence or poor interpersonal or social judgment. In Freudian terms, famous people who crash and burn may have a “Swiss cheese superego” that allows their id to viciously weaken their ego. From a neuroscience perspective, their limbic system conquers their cortical circuitry with relentless innate forces, including:

• fervent sexual appetite, compounded by the cockiness that comes with fame
• felonious paraphilias, such as pedophilia or public indecency
• intense greed that clouds one’s judgment (a trait exhibited by some ultra-rich persons)
• narcissism, either inborn or acquired with unexpected success and power
• impulsivity and recklessness, with injurious words or actions.
• substance use.

Consideration should be given to psychopathology. Some may have a personality disorder. Others may be both blessed and cursed with hypomania that leads to high achievement but also to foolish and impulsive behavior.¹ Some may have maladaptive social skills seen in autism spectrum disorder (recently, a very prominent and innovative billionaire casually announced that he has autistic traits). And others my have limited coping skills to deal with fame and fortune and unwittingly end up shooting themselves in both feet.

Continue to: But perhaps the most common thread...

But perhaps the most common thread across all the tragic cases of self-destruction is hubris. As humans become rich, famous, or powerful, they gradually develop the fallacious belief that they can get away with anything because they have masses of fans and followers who “love them no matter what.” This dangerous “acquired narcissism” is an unfortunate byproduct of success. Humility is rare among celebrities and powerful leaders. Modest celebrities almost never fall from grace and are endowed with an innate antidote to self-aggrandizement. A few years ago, I wrote an editorial in Current Psychiatry titled “Should psychiatry list hubris in DSM-V?”² While hubris is not regarded as a psychiatric disorder, it is certainly an affliction that often ends badly. The mental repercussions can include depression, anxiety, posttraumatic stress disorder, despair, and even falling on one’s sword. Hubris can be a fatal flaw with devastating consequences to one’s career. Perhaps those who aspire to become a celebrity should receive mentorship about hubris as a hazard of fame and fortune, when they are still in the “rising star” stage of their lives.

In contemporary society, with the era of social media and toxic political zeitgeist, there are many inadvertent “opportunities” to stumble and ruin one’s career by uttering an “unacceptable” word or dispatching an “offensive tweet” or posting a politically incorrect photo. And even if one is currently careful, there are now social media detectives and fact-finding “archeologists” who can excavate and disseminate the faux pas, peccadillos, or misdeeds from a prominent person’s immature youth, which will destroy a famous person overnight. That can be a nightmare for anyone who becomes a bona fide celebrity after years of working hard to get there.

High achievers: Beware!

The attraction of reproductive endocrinology and infertility (REI), personally, is the hormonal interplay of the hypothalamus and pituitary with the end organs that are intimately involved in female reproduction. While the sex hormone–producing organs, such as the ovaries and adrenal glands, are directly related to reproductive function, the thyroid gland is typically overlooked until dysfunction occurs, resulting in ovulation dysfunction and pregnancy complications, namely miscarriage and preterm labor. This month we address thyroid function, given its vital role for fertility and pregnancy health and the fetus’ reliance on maternal thyroid hormone during the first trimester to ensure normal neurologic development.

Thyroid disease is the second most common endocrine disorder affecting women of reproductive age; the first being polycystic ovary syndrome (PCOS). Thyroid dysfunction can impair ovulation and, consequently, fertility. Hyperthyroidism is found in approximately 2.3% of women presenting with fertility problems, compared with 1.5% of women in the general population. Hypothyroidism affects 0.5% of women of reproductive age and has been shown to result in impaired reproductive outcomes, including miscarriage, along with adverse obstetric and fetal outcomes. Subclinical hypothyroidism (SCH), defined as an elevated thyroid-stimulating hormone (TSH) level with a normal free T4, has an incidence of 4%-8% in the reproductive-age population. While there is fair evidence SCH increases miscarriage, treatment may result in improved outcomes.

The prevalence of thyroid autoimmunity (TAI) among women of reproductive age is 8%-14% worldwide and it is increased in the infertility population. TAI, defined as the presence of thyroid peroxidase and thyroglobulin antibodies, has been shown to be associated with a reduced live birth rate, increase in preterm birth, and a two- to threefold increase in miscarriage.

The endocrinologic “pendulum” of guidance regarding the effect on and management of thyroid function regarding fertility, pregnancy, and baby has conflicting results. Controlled ovarian hyperstimulation for in vitro fertilization appears to alter TSH levels and levothyroxine requirements increase in the first trimester by approximately 50%. The controversy lies in which population of women should be tested for TAI, which TSH level is acceptable, and how to manage, if at all, euthyroid women with TAI or women with SCH who are trying to conceive. Ultimately, which women would benefit from levothyroxine while trying to conceive and during pregnancy?
 

Summary of salient studies

• In a meta-analysis, untreated women with SCH had a higher prevalence of miscarriage, compared with euthyroid women (RR, 1.90). Miscarriage rates were even higher in SCH with TIA, compared with women with SCH. The authors recommend “early treatments to avoid adverse pregnancy outcomes and complications.”
• A randomized controlled trial from China studied women who were euthyroid with TAI undergoing IVF. The authors demonstrated levothyroxine did not reduce miscarriage rates or increase live birth rates. To dive further into their cohort, the authors addressed whether TSH above 2.5 mIU/L or above 4 mIU/L (per the American Society for Reproductive Medicine cutoff values) impaired reproductive outcome and found no benefit of levothyroxine in any subgroup. This is consistent with other studies that showed no detrimental effect on pregnancy outcome with TSH levels above 2.5 mIU/L in the normal range and no reduction in miscarriage with the addition of levothyroxine.
• An observational cohort study of IVF patients that underwent preimplantation genetic testing for aneuploidy did not demonstrate an association between chromosomally normal embryos that miscarried and maternal antithyroid antibodies in recurrent miscarriage patients.
• A double-blind, placebo-controlled trial on the use of levothyroxine in euthyroid women with TAI did not result in a higher rate of live births, lower rate of pregnancy loss, or preterm birth, compared with placebo.

Consensus statements

• The American Society for Reproductive Medicine considers it reasonable to test infertile women trying to conceive and to treat SCH with levothyroxine to maintain a TSH less than 2.5 mIU/L and within the normal range. Women who have TAI and TSH greater than 2.5 mIU/L can be considered for treatment with levothyroxine.
• The Endocrine Society recommends levothyroxine in women with SCH who have TAI.
• The American Thyroid Association guideline recommends women with SCH who are undergoing IVF be treated with levothyroxine to achieve a TSH concentration less than 2.5mIU/L.
• The 2011 guidelines of the American Thyroid Association and the 2012 guidelines of the Endocrine Society recommended the specific reference ranges for TSH in the early, middle, and late stages of pregnancy as 0.1-2.5 mIU/L, 0.2-3.0 mIU/L, and 0.3-3.0 mIU/L, respectively.
• The American College of Obstetricians & Gynecologists recommend avoiding universal thyroid screening in pregnancy since “identification and treatment of maternal subclinical hypothyroidism has not been shown to result in improved pregnancy outcomes and neurocognitive function in offspring.”

Conclusion

The 2019 Cochrane Database states there are no clear conclusions regarding treatment with levothyroxine in euthyroid TAI or SCH because of the low quality of evidence reported. While TAI and SCH have been associated with pregnancy complications, there is no apparent benefit of levothyroxine in women with TAI or TSH levels between 2.5 and 4 mIU/L.

So, the conundrum is which preconception women to test and how to manage nonovert thyroid disease. For now, it is reasonable to obtain a serum TSH on all women desiring fertility, to treat SCH with levothyroxine to maintain TSH less than 2.5 mIU/L in the normal range, and to adjust levothyroxine accordingly throughout pregnancy.

Dr. Trolice is director of fertility at CARE – The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando. He has no disclosures. Email him at [email protected].

The attraction of reproductive endocrinology and infertility (REI), personally, is the hormonal interplay of the hypothalamus and pituitary with the end organs that are intimately involved in female reproduction. While the sex hormone–producing organs, such as the ovaries and adrenal glands, are directly related to reproductive function, the thyroid gland is typically overlooked until dysfunction occurs, resulting in ovulation dysfunction and pregnancy complications, namely miscarriage and preterm labor. This month we address thyroid function, given its vital role for fertility and pregnancy health and the fetus’ reliance on maternal thyroid hormone during the first trimester to ensure normal neurologic development.

Thyroid disease is the second most common endocrine disorder affecting women of reproductive age; the first being polycystic ovary syndrome (PCOS). Thyroid dysfunction can impair ovulation and, consequently, fertility. Hyperthyroidism is found in approximately 2.3% of women presenting with fertility problems, compared with 1.5% of women in the general population. Hypothyroidism affects 0.5% of women of reproductive age and has been shown to result in impaired reproductive outcomes, including miscarriage, along with adverse obstetric and fetal outcomes. Subclinical hypothyroidism (SCH), defined as an elevated thyroid-stimulating hormone (TSH) level with a normal free T4, has an incidence of 4%-8% in the reproductive-age population. While there is fair evidence SCH increases miscarriage, treatment may result in improved outcomes.

The prevalence of thyroid autoimmunity (TAI) among women of reproductive age is 8%-14% worldwide and it is increased in the infertility population. TAI, defined as the presence of thyroid peroxidase and thyroglobulin antibodies, has been shown to be associated with a reduced live birth rate, increase in preterm birth, and a two- to threefold increase in miscarriage.

The endocrinologic “pendulum” of guidance regarding the effect on and management of thyroid function regarding fertility, pregnancy, and baby has conflicting results. Controlled ovarian hyperstimulation for in vitro fertilization appears to alter TSH levels and levothyroxine requirements increase in the first trimester by approximately 50%. The controversy lies in which population of women should be tested for TAI, which TSH level is acceptable, and how to manage, if at all, euthyroid women with TAI or women with SCH who are trying to conceive. Ultimately, which women would benefit from levothyroxine while trying to conceive and during pregnancy?
 

Summary of salient studies

• In a meta-analysis, untreated women with SCH had a higher prevalence of miscarriage, compared with euthyroid women (RR, 1.90). Miscarriage rates were even higher in SCH with TIA, compared with women with SCH. The authors recommend “early treatments to avoid adverse pregnancy outcomes and complications.”
• A randomized controlled trial from China studied women who were euthyroid with TAI undergoing IVF. The authors demonstrated levothyroxine did not reduce miscarriage rates or increase live birth rates. To dive further into their cohort, the authors addressed whether TSH above 2.5 mIU/L or above 4 mIU/L (per the American Society for Reproductive Medicine cutoff values) impaired reproductive outcome and found no benefit of levothyroxine in any subgroup. This is consistent with other studies that showed no detrimental effect on pregnancy outcome with TSH levels above 2.5 mIU/L in the normal range and no reduction in miscarriage with the addition of levothyroxine.
• An observational cohort study of IVF patients that underwent preimplantation genetic testing for aneuploidy did not demonstrate an association between chromosomally normal embryos that miscarried and maternal antithyroid antibodies in recurrent miscarriage patients.
• A double-blind, placebo-controlled trial on the use of levothyroxine in euthyroid women with TAI did not result in a higher rate of live births, lower rate of pregnancy loss, or preterm birth, compared with placebo.

Consensus statements

• The American Society for Reproductive Medicine considers it reasonable to test infertile women trying to conceive and to treat SCH with levothyroxine to maintain a TSH less than 2.5 mIU/L and within the normal range. Women who have TAI and TSH greater than 2.5 mIU/L can be considered for treatment with levothyroxine.
• The Endocrine Society recommends levothyroxine in women with SCH who have TAI.
• The American Thyroid Association guideline recommends women with SCH who are undergoing IVF be treated with levothyroxine to achieve a TSH concentration less than 2.5mIU/L.
• The 2011 guidelines of the American Thyroid Association and the 2012 guidelines of the Endocrine Society recommended the specific reference ranges for TSH in the early, middle, and late stages of pregnancy as 0.1-2.5 mIU/L, 0.2-3.0 mIU/L, and 0.3-3.0 mIU/L, respectively.
• The American College of Obstetricians & Gynecologists recommend avoiding universal thyroid screening in pregnancy since “identification and treatment of maternal subclinical hypothyroidism has not been shown to result in improved pregnancy outcomes and neurocognitive function in offspring.”

Conclusion

The 2019 Cochrane Database states there are no clear conclusions regarding treatment with levothyroxine in euthyroid TAI or SCH because of the low quality of evidence reported. While TAI and SCH have been associated with pregnancy complications, there is no apparent benefit of levothyroxine in women with TAI or TSH levels between 2.5 and 4 mIU/L.

So, the conundrum is which preconception women to test and how to manage nonovert thyroid disease. For now, it is reasonable to obtain a serum TSH on all women desiring fertility, to treat SCH with levothyroxine to maintain TSH less than 2.5 mIU/L in the normal range, and to adjust levothyroxine accordingly throughout pregnancy.

Dr. Trolice is director of fertility at CARE – The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando. He has no disclosures. Email him at [email protected].

The attraction of reproductive endocrinology and infertility (REI), personally, is the hormonal interplay of the hypothalamus and pituitary with the end organs that are intimately involved in female reproduction. While the sex hormone–producing organs, such as the ovaries and adrenal glands, are directly related to reproductive function, the thyroid gland is typically overlooked until dysfunction occurs, resulting in ovulation dysfunction and pregnancy complications, namely miscarriage and preterm labor. This month we address thyroid function, given its vital role for fertility and pregnancy health and the fetus’ reliance on maternal thyroid hormone during the first trimester to ensure normal neurologic development.

Thyroid disease is the second most common endocrine disorder affecting women of reproductive age; the first being polycystic ovary syndrome (PCOS). Thyroid dysfunction can impair ovulation and, consequently, fertility. Hyperthyroidism is found in approximately 2.3% of women presenting with fertility problems, compared with 1.5% of women in the general population. Hypothyroidism affects 0.5% of women of reproductive age and has been shown to result in impaired reproductive outcomes, including miscarriage, along with adverse obstetric and fetal outcomes. Subclinical hypothyroidism (SCH), defined as an elevated thyroid-stimulating hormone (TSH) level with a normal free T4, has an incidence of 4%-8% in the reproductive-age population. While there is fair evidence SCH increases miscarriage, treatment may result in improved outcomes.

The prevalence of thyroid autoimmunity (TAI) among women of reproductive age is 8%-14% worldwide and it is increased in the infertility population. TAI, defined as the presence of thyroid peroxidase and thyroglobulin antibodies, has been shown to be associated with a reduced live birth rate, increase in preterm birth, and a two- to threefold increase in miscarriage.

The endocrinologic “pendulum” of guidance regarding the effect on and management of thyroid function regarding fertility, pregnancy, and baby has conflicting results. Controlled ovarian hyperstimulation for in vitro fertilization appears to alter TSH levels and levothyroxine requirements increase in the first trimester by approximately 50%. The controversy lies in which population of women should be tested for TAI, which TSH level is acceptable, and how to manage, if at all, euthyroid women with TAI or women with SCH who are trying to conceive. Ultimately, which women would benefit from levothyroxine while trying to conceive and during pregnancy?
 

Summary of salient studies

• In a meta-analysis, untreated women with SCH had a higher prevalence of miscarriage, compared with euthyroid women (RR, 1.90). Miscarriage rates were even higher in SCH with TIA, compared with women with SCH. The authors recommend “early treatments to avoid adverse pregnancy outcomes and complications.”
• A randomized controlled trial from China studied women who were euthyroid with TAI undergoing IVF. The authors demonstrated levothyroxine did not reduce miscarriage rates or increase live birth rates. To dive further into their cohort, the authors addressed whether TSH above 2.5 mIU/L or above 4 mIU/L (per the American Society for Reproductive Medicine cutoff values) impaired reproductive outcome and found no benefit of levothyroxine in any subgroup. This is consistent with other studies that showed no detrimental effect on pregnancy outcome with TSH levels above 2.5 mIU/L in the normal range and no reduction in miscarriage with the addition of levothyroxine.
• An observational cohort study of IVF patients that underwent preimplantation genetic testing for aneuploidy did not demonstrate an association between chromosomally normal embryos that miscarried and maternal antithyroid antibodies in recurrent miscarriage patients.
• A double-blind, placebo-controlled trial on the use of levothyroxine in euthyroid women with TAI did not result in a higher rate of live births, lower rate of pregnancy loss, or preterm birth, compared with placebo.

Consensus statements

• The American Society for Reproductive Medicine considers it reasonable to test infertile women trying to conceive and to treat SCH with levothyroxine to maintain a TSH less than 2.5 mIU/L and within the normal range. Women who have TAI and TSH greater than 2.5 mIU/L can be considered for treatment with levothyroxine.
• The Endocrine Society recommends levothyroxine in women with SCH who have TAI.
• The American Thyroid Association guideline recommends women with SCH who are undergoing IVF be treated with levothyroxine to achieve a TSH concentration less than 2.5mIU/L.
• The 2011 guidelines of the American Thyroid Association and the 2012 guidelines of the Endocrine Society recommended the specific reference ranges for TSH in the early, middle, and late stages of pregnancy as 0.1-2.5 mIU/L, 0.2-3.0 mIU/L, and 0.3-3.0 mIU/L, respectively.
• The American College of Obstetricians & Gynecologists recommend avoiding universal thyroid screening in pregnancy since “identification and treatment of maternal subclinical hypothyroidism has not been shown to result in improved pregnancy outcomes and neurocognitive function in offspring.”

Conclusion

The 2019 Cochrane Database states there are no clear conclusions regarding treatment with levothyroxine in euthyroid TAI or SCH because of the low quality of evidence reported. While TAI and SCH have been associated with pregnancy complications, there is no apparent benefit of levothyroxine in women with TAI or TSH levels between 2.5 and 4 mIU/L.

So, the conundrum is which preconception women to test and how to manage nonovert thyroid disease. For now, it is reasonable to obtain a serum TSH on all women desiring fertility, to treat SCH with levothyroxine to maintain TSH less than 2.5 mIU/L in the normal range, and to adjust levothyroxine accordingly throughout pregnancy.

Dr. Trolice is director of fertility at CARE – The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando. He has no disclosures. Email him at [email protected].

On Sept. 1, Texas enacted astonishing legislation that effectively bans abortion after a fetal heartbeat is detected. In addition, it further empowers private citizens to sue anyone “aiding and abetting” patients who seek abortion services. Many organizations, including Planned Parenthood and the American College of Obstetricians and Gynecologists, have issued formalized statements condemning the bill. While we as obstetrician/gynecologists try to remain as nonpartisan as humanly possible in our patient care, unfortunately our specialty is inarguably one of the few in the medical field that is routinely significantly affected by federal and state politics.

It is no secret that Texas Senate Bill 8, otherwise referred to the “Texas Heartbeat Act,” will have devastating consequences for women, particularly women of color, but it will also have potentially catastrophic repercussions for patients who identify as LGBTQ. Overall, the LGBTQ population faces higher rates of poverty, unemployment, insurance coverage barriers, and provider discrimination because of their gender identity or sexual orientation, which can make access to abortion services challenging. Furthermore, they are more susceptible to hate-motivated violence and sexual assault and as a result, may seek to terminate pregnancies that result from these traumatic experiences.

A survey conducted by the Centers for Disease Control and Prevention examining rates of intimate partner violence and sexual violence found that 44% of lesbians and 61% of bisexual women experience rape and physical violence, compared with 35% of straight women.¹ A separate survey revealed that 47% of transgender people are sexually assaulted at some point in their lifetime, with rates reaching as high as 65% among transgender people of color.² Furthermore, many members of the LGBTQ population are misinformed or have misconceptions regarding their need for contraceptives and experience unintended pregnancies. As discussed in a previous column, one-third of pregnancies in transgender men were unplanned, and 20% of those patients were amenorrheic on testosterone at the time of conception.³

Current studies estimate that approximately 25% of all cisgender women will have an abortion. No corresponding data exist to describe the abortion rates of transgender and gender diverse patients.^4,5 Bills such as Texas SB8 make accessing safe abortions for patients virtually impossible and interferes with the ability for physicians to provide patients with much needed health care services. It further delegitimizes rape and incest victims and is almost punitive in requiring such victims to carry the unintended pregnancies resulting from these heinous acts to term.

Regardless of a provider’s feelings toward abortion or even gender-affirming care, it is undeniable that access to these services is necessary and should be readily available to patients seeking them. As we all took an oath in medical school to “do no harm,” we must not only abide by that solemn decree in everyday patient interactions, but also live by those words to advocate for our patients when politics prohibit appropriate care. While discussions surrounding abortion are often limited to cisgender, heterosexual patients, providers must also be aware that abortion access spans across a wider spectrum that includes the LGBTQ community. Our patients, and all patients, deserve equal access to abortion. This harmful law sets a dangerous precedent that could continue to threaten these services with detrimental effects to our patients.
 

Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.

References

1. Black MC et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2011.

2. James SE et al. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016.

3. Abern L, Maguire K. Obstet Gynecol 2018;131:65S.

4. Jones RK et al. Abortion incidence and service availability in the Unites States, 2017. New York, NY: Guttmacher Institute: 2019.

5. Moseson H et al. Am J Obstet Gynecol 2021;224:376.e1-11.

On Sept. 1, Texas enacted astonishing legislation that effectively bans abortion after a fetal heartbeat is detected. In addition, it further empowers private citizens to sue anyone “aiding and abetting” patients who seek abortion services. Many organizations, including Planned Parenthood and the American College of Obstetricians and Gynecologists, have issued formalized statements condemning the bill. While we as obstetrician/gynecologists try to remain as nonpartisan as humanly possible in our patient care, unfortunately our specialty is inarguably one of the few in the medical field that is routinely significantly affected by federal and state politics.

It is no secret that Texas Senate Bill 8, otherwise referred to the “Texas Heartbeat Act,” will have devastating consequences for women, particularly women of color, but it will also have potentially catastrophic repercussions for patients who identify as LGBTQ. Overall, the LGBTQ population faces higher rates of poverty, unemployment, insurance coverage barriers, and provider discrimination because of their gender identity or sexual orientation, which can make access to abortion services challenging. Furthermore, they are more susceptible to hate-motivated violence and sexual assault and as a result, may seek to terminate pregnancies that result from these traumatic experiences.

A survey conducted by the Centers for Disease Control and Prevention examining rates of intimate partner violence and sexual violence found that 44% of lesbians and 61% of bisexual women experience rape and physical violence, compared with 35% of straight women.¹ A separate survey revealed that 47% of transgender people are sexually assaulted at some point in their lifetime, with rates reaching as high as 65% among transgender people of color.² Furthermore, many members of the LGBTQ population are misinformed or have misconceptions regarding their need for contraceptives and experience unintended pregnancies. As discussed in a previous column, one-third of pregnancies in transgender men were unplanned, and 20% of those patients were amenorrheic on testosterone at the time of conception.³

Current studies estimate that approximately 25% of all cisgender women will have an abortion. No corresponding data exist to describe the abortion rates of transgender and gender diverse patients.^4,5 Bills such as Texas SB8 make accessing safe abortions for patients virtually impossible and interferes with the ability for physicians to provide patients with much needed health care services. It further delegitimizes rape and incest victims and is almost punitive in requiring such victims to carry the unintended pregnancies resulting from these heinous acts to term.

Regardless of a provider’s feelings toward abortion or even gender-affirming care, it is undeniable that access to these services is necessary and should be readily available to patients seeking them. As we all took an oath in medical school to “do no harm,” we must not only abide by that solemn decree in everyday patient interactions, but also live by those words to advocate for our patients when politics prohibit appropriate care. While discussions surrounding abortion are often limited to cisgender, heterosexual patients, providers must also be aware that abortion access spans across a wider spectrum that includes the LGBTQ community. Our patients, and all patients, deserve equal access to abortion. This harmful law sets a dangerous precedent that could continue to threaten these services with detrimental effects to our patients.
 

Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.

References

1. Black MC et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2011.

2. James SE et al. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016.

3. Abern L, Maguire K. Obstet Gynecol 2018;131:65S.

4. Jones RK et al. Abortion incidence and service availability in the Unites States, 2017. New York, NY: Guttmacher Institute: 2019.

5. Moseson H et al. Am J Obstet Gynecol 2021;224:376.e1-11.

On Sept. 1, Texas enacted astonishing legislation that effectively bans abortion after a fetal heartbeat is detected. In addition, it further empowers private citizens to sue anyone “aiding and abetting” patients who seek abortion services. Many organizations, including Planned Parenthood and the American College of Obstetricians and Gynecologists, have issued formalized statements condemning the bill. While we as obstetrician/gynecologists try to remain as nonpartisan as humanly possible in our patient care, unfortunately our specialty is inarguably one of the few in the medical field that is routinely significantly affected by federal and state politics.

It is no secret that Texas Senate Bill 8, otherwise referred to the “Texas Heartbeat Act,” will have devastating consequences for women, particularly women of color, but it will also have potentially catastrophic repercussions for patients who identify as LGBTQ. Overall, the LGBTQ population faces higher rates of poverty, unemployment, insurance coverage barriers, and provider discrimination because of their gender identity or sexual orientation, which can make access to abortion services challenging. Furthermore, they are more susceptible to hate-motivated violence and sexual assault and as a result, may seek to terminate pregnancies that result from these traumatic experiences.

A survey conducted by the Centers for Disease Control and Prevention examining rates of intimate partner violence and sexual violence found that 44% of lesbians and 61% of bisexual women experience rape and physical violence, compared with 35% of straight women.¹ A separate survey revealed that 47% of transgender people are sexually assaulted at some point in their lifetime, with rates reaching as high as 65% among transgender people of color.² Furthermore, many members of the LGBTQ population are misinformed or have misconceptions regarding their need for contraceptives and experience unintended pregnancies. As discussed in a previous column, one-third of pregnancies in transgender men were unplanned, and 20% of those patients were amenorrheic on testosterone at the time of conception.³

Current studies estimate that approximately 25% of all cisgender women will have an abortion. No corresponding data exist to describe the abortion rates of transgender and gender diverse patients.^4,5 Bills such as Texas SB8 make accessing safe abortions for patients virtually impossible and interferes with the ability for physicians to provide patients with much needed health care services. It further delegitimizes rape and incest victims and is almost punitive in requiring such victims to carry the unintended pregnancies resulting from these heinous acts to term.

Regardless of a provider’s feelings toward abortion or even gender-affirming care, it is undeniable that access to these services is necessary and should be readily available to patients seeking them. As we all took an oath in medical school to “do no harm,” we must not only abide by that solemn decree in everyday patient interactions, but also live by those words to advocate for our patients when politics prohibit appropriate care. While discussions surrounding abortion are often limited to cisgender, heterosexual patients, providers must also be aware that abortion access spans across a wider spectrum that includes the LGBTQ community. Our patients, and all patients, deserve equal access to abortion. This harmful law sets a dangerous precedent that could continue to threaten these services with detrimental effects to our patients.
 

Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.

References

1. Black MC et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2011.

2. James SE et al. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016.

3. Abern L, Maguire K. Obstet Gynecol 2018;131:65S.

4. Jones RK et al. Abortion incidence and service availability in the Unites States, 2017. New York, NY: Guttmacher Institute: 2019.

5. Moseson H et al. Am J Obstet Gynecol 2021;224:376.e1-11.

Phaeohyphomycosis are caused by dematiaceous (pigmented) mycoses that produce dark colored hyphae due to melanin deposition in their cell walls. There are more than 100 species of dematiaceous fungi that can cause phaeohyphomycosis, including Alternaria, Exophiala, Phialophora, Wangiella, Bipolaris, Curvularia, and Exserohilum.^1,2 The causative fungi are found in plants and soil, so they are commonly seen after activities such as gardening or walking barefoot. Trauma, such as a splinter, typically incites the infection. Infections can present with superficial, cutaneous and subcutaneous involvement.

Donna Bilu Martin, MD

Sporotrichosis, also called Rose gardener’s disease, is a mycosis caused by Sporothrix schenckii. A typical presentation is when a gardener gets pricked by a rose thorn. Classically, a pustule will develop at the site of inoculation, with additional lesions forming along the path of lymphatic drainage (called a “sporotrichoid” pattern) weeks later. Atypical mycobacterial infections, mainly Mycobacterium marinum, may also present in this way. Histopathology and tissue cultures help to differentiate the two.

An incision and drainage with pathology was performed in the office. Upon opening the nodule, a large wood splinter was extracted. Both the foreign body and a punch biopsy of skin were sent in for examination. Pathology revealed polarizable foreign material in association with suppurative inflammation and dematiaceous fungi. PAS (Periodic-acid Schiff) and GMS (Grocott methenamine silver) stain highlighted fungal forms. Cultures were negative.

Local disease may be treated with excision alone. Oral antifungals, such as itraconazole, fluconazole, or ketoconazole may be used, although may require long treatment courses for months. Amphotericin B and flucytosine may be required in systemic cases. Almost all cases of disseminated disease occur in immunocompromised patients. Our patient’s hand resolved after removal of the causative thorn.

This case and these photos were submitted by Dr. Bilu Martin.
 

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

References

1. Kradin R. Diagnostic Pathology of Infectious Disease, 1st edition (Saunders, Feb. 2, 2010).

2. Bolognia J et al. Dermatology (St. Louis: Mosby/Elsevier, 2008).

Phaeohyphomycosis are caused by dematiaceous (pigmented) mycoses that produce dark colored hyphae due to melanin deposition in their cell walls. There are more than 100 species of dematiaceous fungi that can cause phaeohyphomycosis, including Alternaria, Exophiala, Phialophora, Wangiella, Bipolaris, Curvularia, and Exserohilum.^1,2 The causative fungi are found in plants and soil, so they are commonly seen after activities such as gardening or walking barefoot. Trauma, such as a splinter, typically incites the infection. Infections can present with superficial, cutaneous and subcutaneous involvement.

Donna Bilu Martin, MD

Sporotrichosis, also called Rose gardener’s disease, is a mycosis caused by Sporothrix schenckii. A typical presentation is when a gardener gets pricked by a rose thorn. Classically, a pustule will develop at the site of inoculation, with additional lesions forming along the path of lymphatic drainage (called a “sporotrichoid” pattern) weeks later. Atypical mycobacterial infections, mainly Mycobacterium marinum, may also present in this way. Histopathology and tissue cultures help to differentiate the two.

An incision and drainage with pathology was performed in the office. Upon opening the nodule, a large wood splinter was extracted. Both the foreign body and a punch biopsy of skin were sent in for examination. Pathology revealed polarizable foreign material in association with suppurative inflammation and dematiaceous fungi. PAS (Periodic-acid Schiff) and GMS (Grocott methenamine silver) stain highlighted fungal forms. Cultures were negative.

Local disease may be treated with excision alone. Oral antifungals, such as itraconazole, fluconazole, or ketoconazole may be used, although may require long treatment courses for months. Amphotericin B and flucytosine may be required in systemic cases. Almost all cases of disseminated disease occur in immunocompromised patients. Our patient’s hand resolved after removal of the causative thorn.

This case and these photos were submitted by Dr. Bilu Martin.
 

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

References

1. Kradin R. Diagnostic Pathology of Infectious Disease, 1st edition (Saunders, Feb. 2, 2010).

2. Bolognia J et al. Dermatology (St. Louis: Mosby/Elsevier, 2008).

Phaeohyphomycosis are caused by dematiaceous (pigmented) mycoses that produce dark colored hyphae due to melanin deposition in their cell walls. There are more than 100 species of dematiaceous fungi that can cause phaeohyphomycosis, including Alternaria, Exophiala, Phialophora, Wangiella, Bipolaris, Curvularia, and Exserohilum.^1,2 The causative fungi are found in plants and soil, so they are commonly seen after activities such as gardening or walking barefoot. Trauma, such as a splinter, typically incites the infection. Infections can present with superficial, cutaneous and subcutaneous involvement.

Donna Bilu Martin, MD

Sporotrichosis, also called Rose gardener’s disease, is a mycosis caused by Sporothrix schenckii. A typical presentation is when a gardener gets pricked by a rose thorn. Classically, a pustule will develop at the site of inoculation, with additional lesions forming along the path of lymphatic drainage (called a “sporotrichoid” pattern) weeks later. Atypical mycobacterial infections, mainly Mycobacterium marinum, may also present in this way. Histopathology and tissue cultures help to differentiate the two.

An incision and drainage with pathology was performed in the office. Upon opening the nodule, a large wood splinter was extracted. Both the foreign body and a punch biopsy of skin were sent in for examination. Pathology revealed polarizable foreign material in association with suppurative inflammation and dematiaceous fungi. PAS (Periodic-acid Schiff) and GMS (Grocott methenamine silver) stain highlighted fungal forms. Cultures were negative.

Local disease may be treated with excision alone. Oral antifungals, such as itraconazole, fluconazole, or ketoconazole may be used, although may require long treatment courses for months. Amphotericin B and flucytosine may be required in systemic cases. Almost all cases of disseminated disease occur in immunocompromised patients. Our patient’s hand resolved after removal of the causative thorn.

This case and these photos were submitted by Dr. Bilu Martin.
 

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

References

1. Kradin R. Diagnostic Pathology of Infectious Disease, 1st edition (Saunders, Feb. 2, 2010).

2. Bolognia J et al. Dermatology (St. Louis: Mosby/Elsevier, 2008).

While sick at home with a 26-day symptomatic course of COVID-19 in March 2020, I watched the surge unfold in my state and the hospital where I work as an inpatient adult medicine physician. Although the preponderance of my professional life is dedicated to leading teams in implementing delivery system transformation, the hat I wore in that moment involved living through and keeping up with the changes around me. Once I recovered and returned to the arena as a COVID doctor, I adapted to and made changes during constant shifts in how we provided care.

Looking back on those months during the worst of the COVID-19 hospital surge in my region, I reflect on the factors that helped me, as a frontline and shift-work clinician, adapt to and make those changes. In reflecting on the elements that were meaningful to me during the crisis, I recognize a set of change-enabling factors that have broad relevance for those of us who work to improve outcomes for patients and populations.

Confidence engendered by liberating data

In the early days of the surge, there was much uncertainty, and unfortunately, some seriously imperfect messaging. Trust was broken or badly bruised for many frontline clinicians. I share this painful phase not to criticize, but rather reflect on what mattered to me during that crisis of confidence. It was data. Raw, unadjusted, best-available data. Produced and pushed out. Available, trended over time, telling the story of where we are, now. Counts of tests, beds, and ventilators. The consistent, transparent availability of relevant and straightforward data provided an active antidote to a sense of uncertainty during a crisis of confidence.

Personal practice change stimulated by relevance and urgency

For half a decade, I have been encouraging interdisciplinary inpatient teams to identify and actively engage the family and/or care partner as a member of the care team. Despite even the American Association of Retired Persons mobilizing an impressive regulatory approach in 32 states to require that family and/or care partners are included as such, the practice change efforts continued on a slow and steady path. Why? We just didn’t believe it was of urgent, relevant, mission-critical importance to our daily practice to do so. That all changed in March 2020.

Without needing to be told, educated, or incentivized, my first night as a COVID doctor found me calling every single patient’s family upon admission, regardless of what time it was. It was critical to review the diagnosis, transparently discuss the uncertainty regarding the upcoming hours and days, review the potential contingencies, and ask, right there and then, whether intubation is consistent with goals of care. It was that urgent and relevant. Without exception, families were grateful for the effort and candor.

The significance of this practice—undoubtedly adopted by every inpatient provider who has worked a COVID surge—is rooted in decades of academic deliberation on which is the “right” doctor to have these discussions. None of that mattered. Historical opinions changed due to what was urgent and relevant given the situation at hand and the job we had to do. Imagine, for example, what we could do and how we could change if we now consider it urgent and relevant to identify and mobilize enhanced services and supports to patients who experience inequities because we believe it to be mission-critical to the job we show up to do every day.

Change fostered by a creative problem-solving ecosystem

Embracing personal practice change was made easier and implicitly affirmed by the creative problem solving that occurred everywhere. Tents, drive-throughs, and even college field houses were now settings of care. Primary care physicians, cardiologists, and gastrointestinal (GI) and postanesthesia care nurses staffed the COVID floors. Rolling stands held iPads so staff could communicate with patients without entering the room. This creative ecosystem fostered individual practice change. No debates were needed to recognize that standard processes were inadequate. No single role or service of any discipline was singularly asked to change to meet the needs of the moment. Because of this ecosystem of creative, active change, there was a much greater flexibility among individuals, role types, departments, and disciplines to change. This is particularly poignant to me in light of the work I lead to improve care for patients who experience systemic inequities in our health care system. When we ask a single role type or discipline to change, it can be met with resistance; far more success is achieved when we engage an interdisciplinary and interdepartmental approach to change. When surrounded by others making change, it makes us more willing to change, too.

 

 

Change catalyzed teamwork

It is so often invoked that health care is a team sport. In practicality, while we may aspire to work as a team, health care delivery is still all too often comprised of a set of individual actors with individualized responsibilities trying to communicate the best they can with each other.

What I experienced during the surge at my hospital was the very best version of teamwork I have ever been a part of in health care: empathetic, mutually interdependent strangers coming together during daily changes in staffing, processes, and resources. I will never forget nights walking into the pediatric floor or day surgery recovery area—now repurposed as a COVID unit—to entirely new faces comprised of GI suite nurses, outpatient doctors, and moonlighting intensivists.

We were all new to each other, all new to working in this setting, and all new to whatever the newest changes of the day brought. I will never forget how we greeted each other and introduced ourselves. We asked each other where we were “from,” and held a genuine appreciation to each other for being there. Imagine how this impacted how we worked together. Looking back on those night shifts, I remember us as a truly interdependent team. I will endeavor to bring that sense of mutual regard and interdependency into my work to foster effective interdisciplinary and cross-continuum teamwork.

Takeaways

As a student and practitioner of delivery system transformation, I am often in conversations about imperfect data, incomplete evidence, and role-specific and organizational resistance to change. As an acute care provider during the COVID-19 hospital surge in my region, the experiences I had as a participant in the COVID-related delivery system change will stay with me as I lead value-based delivery system change. What worked in an infectious disease crisis holds great relevance to our pressing, urgent, relevant work to create a more person-centered, equitable, and value-based delivery system.

I am confident that if those of us seeking to improve outcomes use visible and accessible data to engender confidence, clearly link practice change to the relevant and urgent issue at hand, promote broadly visible creative problem solving to foster an ecosystem of change, and cultivate empathy and mutual interdependence to promote the teamwork we aspire to have, that we will foster meaningful progress in our efforts to improve care for patients and populations.

Corresponding author: Amy Boutwell, MD, MPP, President, Collaborative Healthcare Strategies, Lexington, MA; [email protected].

Financial disclosures: None.

While sick at home with a 26-day symptomatic course of COVID-19 in March 2020, I watched the surge unfold in my state and the hospital where I work as an inpatient adult medicine physician. Although the preponderance of my professional life is dedicated to leading teams in implementing delivery system transformation, the hat I wore in that moment involved living through and keeping up with the changes around me. Once I recovered and returned to the arena as a COVID doctor, I adapted to and made changes during constant shifts in how we provided care.

Looking back on those months during the worst of the COVID-19 hospital surge in my region, I reflect on the factors that helped me, as a frontline and shift-work clinician, adapt to and make those changes. In reflecting on the elements that were meaningful to me during the crisis, I recognize a set of change-enabling factors that have broad relevance for those of us who work to improve outcomes for patients and populations.

Confidence engendered by liberating data

In the early days of the surge, there was much uncertainty, and unfortunately, some seriously imperfect messaging. Trust was broken or badly bruised for many frontline clinicians. I share this painful phase not to criticize, but rather reflect on what mattered to me during that crisis of confidence. It was data. Raw, unadjusted, best-available data. Produced and pushed out. Available, trended over time, telling the story of where we are, now. Counts of tests, beds, and ventilators. The consistent, transparent availability of relevant and straightforward data provided an active antidote to a sense of uncertainty during a crisis of confidence.

Personal practice change stimulated by relevance and urgency

For half a decade, I have been encouraging interdisciplinary inpatient teams to identify and actively engage the family and/or care partner as a member of the care team. Despite even the American Association of Retired Persons mobilizing an impressive regulatory approach in 32 states to require that family and/or care partners are included as such, the practice change efforts continued on a slow and steady path. Why? We just didn’t believe it was of urgent, relevant, mission-critical importance to our daily practice to do so. That all changed in March 2020.

Without needing to be told, educated, or incentivized, my first night as a COVID doctor found me calling every single patient’s family upon admission, regardless of what time it was. It was critical to review the diagnosis, transparently discuss the uncertainty regarding the upcoming hours and days, review the potential contingencies, and ask, right there and then, whether intubation is consistent with goals of care. It was that urgent and relevant. Without exception, families were grateful for the effort and candor.

The significance of this practice—undoubtedly adopted by every inpatient provider who has worked a COVID surge—is rooted in decades of academic deliberation on which is the “right” doctor to have these discussions. None of that mattered. Historical opinions changed due to what was urgent and relevant given the situation at hand and the job we had to do. Imagine, for example, what we could do and how we could change if we now consider it urgent and relevant to identify and mobilize enhanced services and supports to patients who experience inequities because we believe it to be mission-critical to the job we show up to do every day.

Change fostered by a creative problem-solving ecosystem

Embracing personal practice change was made easier and implicitly affirmed by the creative problem solving that occurred everywhere. Tents, drive-throughs, and even college field houses were now settings of care. Primary care physicians, cardiologists, and gastrointestinal (GI) and postanesthesia care nurses staffed the COVID floors. Rolling stands held iPads so staff could communicate with patients without entering the room. This creative ecosystem fostered individual practice change. No debates were needed to recognize that standard processes were inadequate. No single role or service of any discipline was singularly asked to change to meet the needs of the moment. Because of this ecosystem of creative, active change, there was a much greater flexibility among individuals, role types, departments, and disciplines to change. This is particularly poignant to me in light of the work I lead to improve care for patients who experience systemic inequities in our health care system. When we ask a single role type or discipline to change, it can be met with resistance; far more success is achieved when we engage an interdisciplinary and interdepartmental approach to change. When surrounded by others making change, it makes us more willing to change, too.

 

 

Change catalyzed teamwork

It is so often invoked that health care is a team sport. In practicality, while we may aspire to work as a team, health care delivery is still all too often comprised of a set of individual actors with individualized responsibilities trying to communicate the best they can with each other.

What I experienced during the surge at my hospital was the very best version of teamwork I have ever been a part of in health care: empathetic, mutually interdependent strangers coming together during daily changes in staffing, processes, and resources. I will never forget nights walking into the pediatric floor or day surgery recovery area—now repurposed as a COVID unit—to entirely new faces comprised of GI suite nurses, outpatient doctors, and moonlighting intensivists.

We were all new to each other, all new to working in this setting, and all new to whatever the newest changes of the day brought. I will never forget how we greeted each other and introduced ourselves. We asked each other where we were “from,” and held a genuine appreciation to each other for being there. Imagine how this impacted how we worked together. Looking back on those night shifts, I remember us as a truly interdependent team. I will endeavor to bring that sense of mutual regard and interdependency into my work to foster effective interdisciplinary and cross-continuum teamwork.

Takeaways

As a student and practitioner of delivery system transformation, I am often in conversations about imperfect data, incomplete evidence, and role-specific and organizational resistance to change. As an acute care provider during the COVID-19 hospital surge in my region, the experiences I had as a participant in the COVID-related delivery system change will stay with me as I lead value-based delivery system change. What worked in an infectious disease crisis holds great relevance to our pressing, urgent, relevant work to create a more person-centered, equitable, and value-based delivery system.

I am confident that if those of us seeking to improve outcomes use visible and accessible data to engender confidence, clearly link practice change to the relevant and urgent issue at hand, promote broadly visible creative problem solving to foster an ecosystem of change, and cultivate empathy and mutual interdependence to promote the teamwork we aspire to have, that we will foster meaningful progress in our efforts to improve care for patients and populations.

Corresponding author: Amy Boutwell, MD, MPP, President, Collaborative Healthcare Strategies, Lexington, MA; [email protected].

Financial disclosures: None.

While sick at home with a 26-day symptomatic course of COVID-19 in March 2020, I watched the surge unfold in my state and the hospital where I work as an inpatient adult medicine physician. Although the preponderance of my professional life is dedicated to leading teams in implementing delivery system transformation, the hat I wore in that moment involved living through and keeping up with the changes around me. Once I recovered and returned to the arena as a COVID doctor, I adapted to and made changes during constant shifts in how we provided care.

Looking back on those months during the worst of the COVID-19 hospital surge in my region, I reflect on the factors that helped me, as a frontline and shift-work clinician, adapt to and make those changes. In reflecting on the elements that were meaningful to me during the crisis, I recognize a set of change-enabling factors that have broad relevance for those of us who work to improve outcomes for patients and populations.

Confidence engendered by liberating data

In the early days of the surge, there was much uncertainty, and unfortunately, some seriously imperfect messaging. Trust was broken or badly bruised for many frontline clinicians. I share this painful phase not to criticize, but rather reflect on what mattered to me during that crisis of confidence. It was data. Raw, unadjusted, best-available data. Produced and pushed out. Available, trended over time, telling the story of where we are, now. Counts of tests, beds, and ventilators. The consistent, transparent availability of relevant and straightforward data provided an active antidote to a sense of uncertainty during a crisis of confidence.

Personal practice change stimulated by relevance and urgency

For half a decade, I have been encouraging interdisciplinary inpatient teams to identify and actively engage the family and/or care partner as a member of the care team. Despite even the American Association of Retired Persons mobilizing an impressive regulatory approach in 32 states to require that family and/or care partners are included as such, the practice change efforts continued on a slow and steady path. Why? We just didn’t believe it was of urgent, relevant, mission-critical importance to our daily practice to do so. That all changed in March 2020.

Without needing to be told, educated, or incentivized, my first night as a COVID doctor found me calling every single patient’s family upon admission, regardless of what time it was. It was critical to review the diagnosis, transparently discuss the uncertainty regarding the upcoming hours and days, review the potential contingencies, and ask, right there and then, whether intubation is consistent with goals of care. It was that urgent and relevant. Without exception, families were grateful for the effort and candor.

The significance of this practice—undoubtedly adopted by every inpatient provider who has worked a COVID surge—is rooted in decades of academic deliberation on which is the “right” doctor to have these discussions. None of that mattered. Historical opinions changed due to what was urgent and relevant given the situation at hand and the job we had to do. Imagine, for example, what we could do and how we could change if we now consider it urgent and relevant to identify and mobilize enhanced services and supports to patients who experience inequities because we believe it to be mission-critical to the job we show up to do every day.

Change fostered by a creative problem-solving ecosystem

Embracing personal practice change was made easier and implicitly affirmed by the creative problem solving that occurred everywhere. Tents, drive-throughs, and even college field houses were now settings of care. Primary care physicians, cardiologists, and gastrointestinal (GI) and postanesthesia care nurses staffed the COVID floors. Rolling stands held iPads so staff could communicate with patients without entering the room. This creative ecosystem fostered individual practice change. No debates were needed to recognize that standard processes were inadequate. No single role or service of any discipline was singularly asked to change to meet the needs of the moment. Because of this ecosystem of creative, active change, there was a much greater flexibility among individuals, role types, departments, and disciplines to change. This is particularly poignant to me in light of the work I lead to improve care for patients who experience systemic inequities in our health care system. When we ask a single role type or discipline to change, it can be met with resistance; far more success is achieved when we engage an interdisciplinary and interdepartmental approach to change. When surrounded by others making change, it makes us more willing to change, too.

 

 

Change catalyzed teamwork

It is so often invoked that health care is a team sport. In practicality, while we may aspire to work as a team, health care delivery is still all too often comprised of a set of individual actors with individualized responsibilities trying to communicate the best they can with each other.

What I experienced during the surge at my hospital was the very best version of teamwork I have ever been a part of in health care: empathetic, mutually interdependent strangers coming together during daily changes in staffing, processes, and resources. I will never forget nights walking into the pediatric floor or day surgery recovery area—now repurposed as a COVID unit—to entirely new faces comprised of GI suite nurses, outpatient doctors, and moonlighting intensivists.

We were all new to each other, all new to working in this setting, and all new to whatever the newest changes of the day brought. I will never forget how we greeted each other and introduced ourselves. We asked each other where we were “from,” and held a genuine appreciation to each other for being there. Imagine how this impacted how we worked together. Looking back on those night shifts, I remember us as a truly interdependent team. I will endeavor to bring that sense of mutual regard and interdependency into my work to foster effective interdisciplinary and cross-continuum teamwork.

Takeaways

As a student and practitioner of delivery system transformation, I am often in conversations about imperfect data, incomplete evidence, and role-specific and organizational resistance to change. As an acute care provider during the COVID-19 hospital surge in my region, the experiences I had as a participant in the COVID-related delivery system change will stay with me as I lead value-based delivery system change. What worked in an infectious disease crisis holds great relevance to our pressing, urgent, relevant work to create a more person-centered, equitable, and value-based delivery system.

I am confident that if those of us seeking to improve outcomes use visible and accessible data to engender confidence, clearly link practice change to the relevant and urgent issue at hand, promote broadly visible creative problem solving to foster an ecosystem of change, and cultivate empathy and mutual interdependence to promote the teamwork we aspire to have, that we will foster meaningful progress in our efforts to improve care for patients and populations.

Corresponding author: Amy Boutwell, MD, MPP, President, Collaborative Healthcare Strategies, Lexington, MA; [email protected].

Financial disclosures: None.

In a recent inpatient service block, I was seeing patients alongside a resident I had gotten to know well. We were consulted on a patient with metastatic head and neck cancer who had not sought care for over a year.

When the patient presented, his voice was raspy and he could not swallow. He had lost 40 pounds. In addition to his locally advanced disease, his lungs were riddled with metastatic lesions.

When we left the room, the resident and I went to speak to the patient’s primary team, and he began to relay our recommendations.

The first words out of his mouth were, “Well, it’s pretty clear he’s going to die.”

The statement took me aback. I wasn’t alarmed by the accuracy of what he had said. The patient was obviously not doing well, and he ended up dying soon after this visit.

It was more the abrupt manner in which the resident had spoken about death. The brusque phrasing felt atypical coming from the otherwise gentle-hearted trainee. He wasn’t referring to a faceless person. We had just seen the man a few minutes ago and heard his personal struggles. I tried to see if anyone else on the team was caught off guard, but everyone was taking notes or continuing to listen, seemingly undeterred.
 

Oncologists’ ‘locker room talk’

I’ve noticed that “locker room talk” about death happens often. Phrases like “he’s definitely not going to do well” and “his life expectancy is poor” make their way into oncologists’ daily language. Thinking back on my own interactions, I realize I am also guilty of discussing death in this way.

And now, with the COVID pandemic forcing most of our tumor boards to go virtual, I find this locker room talk comes even more readily; phrases like “this patient is going to die” are often passed around flippantly, as if saying so will help ease the tension. During these interactions, my colleagues and I rarely acknowledge the seriousness of what a patient death will do to their family and loved ones – or what losing a patient whom we’ve known for years may do to our own psyche.

This language can even creep into how we speak with patients. We are often taught to offer prognoses coldly, ensuring that patients have a clear sense of how long they have left and to help inform their treatment choices. And yet, this training does not necessarily align with what patients want and need. For instance, in a recent survey of patients with chronic obstructive pulmonary disease, patients consistently rated physicians poorly at discussing prognosis, what dying might be like, as well as spirituality and religion.

But at the same time, these matter-of-fact statements about death probably help protect us. Death is a routine, inevitable part of an oncologist’s life, and over time, oncology training and practice hardens us to it. During medical school, I remember that a patient dying would trigger immediate reflection, sadness, and conversation with our peers. Now, unless I know a patient well, I find myself rarely reflecting on the patient behind the facts. This evolution is natural for an oncologist: If you don’t develop a tough skin about death, you may become overwhelmed with the frequency of it.

The COVID pandemic has amped our hardness toward death into overdrive. Whether we are in the intensive care unit or simply viewing death rates during the most recent COVID Delta wave, many of us cope by disassociating a face from a name.
 

Making time for reflection

But taking time to reflect can be therapeutic.

I recently referred a patient with metastatic prostate cancer for a phase 1 trial at an outside institution. He was one of the first patients in my genitourinary malignancies clinic when I started as an attending. The patient had progressed through several lines of therapy and was being referred for an investigational phase 1 therapy. We had discussed hospice referral, and the patient was ready for it if this therapy didn’t work out.

I did not see or hear from the man while he was on the trial. A few months later, however, the principal investigator of the trial called me to let me know the patient had progressed through the agent, suffering from significant urinary obstruction, and he was on hospice. “Unfortunately,” the investigator told me, “he’s not going to live much longer.”

When I checked in with the hospice, the patient had died.

I was surprised again at how matter-of-fact the discussion of death had been. But I was even more surprised by my own reaction. Despite the relationship I had formed with the patient, I did not feel much when I heard he had died. I didn’t have time to process the news in the moment. It was time to move on to the next patient.

It was only later, when I called the patient’s family, that I allowed my emotions to flood in. I told his family how grateful I was to know him, how strong he’d been. The patient’s family and I talked about the human, not his passing. It felt good.
 

Abandoning locker room talk

So how do we change how we talk about death? I don’t think the answer is massive educational programs or passing responsibility for advance care planning onto palliative care specialists. The change needs to be driven by individual oncologists. We can call out discussions of death that make us uncomfortable, gently reminding each other that we’re talking about a human life.

We can learn from our palliative care colleagues; their conversations about death routinely include a patient’s support system and personal stories. Palliative care doctors always refer to the patient by name, which helps humanize the person behind the chart.

We can emphasize a feeling of hope, a sentiment that may also be therapeutic to our patients. Even when a patient is dying, there is always something to be done. We can comfort their family, explaining what brought us to this point and how sorry we are that this is happening. We can provide options for symptom control and help patients manage those symptoms.

And we can allow ourselves to talk about how much a death affects us. We can acknowledge how much it sucks that a patient is going to die, how challenging that will be to his/her family, and how we wish it could have ended differently.

Subtle changes like these will improve our own ability to process and discuss death and will ultimately lead to better relationships with our patients. But it starts with eliminating the “locker room talk” of how we discuss death.
 

Ravi B. Parikh, MD, MPP, is a medical oncologist and faculty member at the University of Pennsylvania and the Philadelphia VA Medical Center, an adjunct fellow at the Leonard Davis Institute of Health Economics, and senior clinical advisor at the Coalition to Transform Advanced Care (C-TAC). He has served as a director, officer, partner, employee, adviser, consultant, or trustee for GNS Healthcare, Nanology, and Cancer Study Group, and he has received research grant from Embedded Healthcare, Veterans Administration, PCF, National Palliative Care Research Center, and MUSC. A version of this article first appeared on Medscape.com.

In a recent inpatient service block, I was seeing patients alongside a resident I had gotten to know well. We were consulted on a patient with metastatic head and neck cancer who had not sought care for over a year.

When the patient presented, his voice was raspy and he could not swallow. He had lost 40 pounds. In addition to his locally advanced disease, his lungs were riddled with metastatic lesions.

When we left the room, the resident and I went to speak to the patient’s primary team, and he began to relay our recommendations.

The first words out of his mouth were, “Well, it’s pretty clear he’s going to die.”

The statement took me aback. I wasn’t alarmed by the accuracy of what he had said. The patient was obviously not doing well, and he ended up dying soon after this visit.

It was more the abrupt manner in which the resident had spoken about death. The brusque phrasing felt atypical coming from the otherwise gentle-hearted trainee. He wasn’t referring to a faceless person. We had just seen the man a few minutes ago and heard his personal struggles. I tried to see if anyone else on the team was caught off guard, but everyone was taking notes or continuing to listen, seemingly undeterred.
 

Oncologists’ ‘locker room talk’

I’ve noticed that “locker room talk” about death happens often. Phrases like “he’s definitely not going to do well” and “his life expectancy is poor” make their way into oncologists’ daily language. Thinking back on my own interactions, I realize I am also guilty of discussing death in this way.

And now, with the COVID pandemic forcing most of our tumor boards to go virtual, I find this locker room talk comes even more readily; phrases like “this patient is going to die” are often passed around flippantly, as if saying so will help ease the tension. During these interactions, my colleagues and I rarely acknowledge the seriousness of what a patient death will do to their family and loved ones – or what losing a patient whom we’ve known for years may do to our own psyche.

This language can even creep into how we speak with patients. We are often taught to offer prognoses coldly, ensuring that patients have a clear sense of how long they have left and to help inform their treatment choices. And yet, this training does not necessarily align with what patients want and need. For instance, in a recent survey of patients with chronic obstructive pulmonary disease, patients consistently rated physicians poorly at discussing prognosis, what dying might be like, as well as spirituality and religion.

But at the same time, these matter-of-fact statements about death probably help protect us. Death is a routine, inevitable part of an oncologist’s life, and over time, oncology training and practice hardens us to it. During medical school, I remember that a patient dying would trigger immediate reflection, sadness, and conversation with our peers. Now, unless I know a patient well, I find myself rarely reflecting on the patient behind the facts. This evolution is natural for an oncologist: If you don’t develop a tough skin about death, you may become overwhelmed with the frequency of it.

The COVID pandemic has amped our hardness toward death into overdrive. Whether we are in the intensive care unit or simply viewing death rates during the most recent COVID Delta wave, many of us cope by disassociating a face from a name.
 

Making time for reflection

But taking time to reflect can be therapeutic.

I recently referred a patient with metastatic prostate cancer for a phase 1 trial at an outside institution. He was one of the first patients in my genitourinary malignancies clinic when I started as an attending. The patient had progressed through several lines of therapy and was being referred for an investigational phase 1 therapy. We had discussed hospice referral, and the patient was ready for it if this therapy didn’t work out.

I did not see or hear from the man while he was on the trial. A few months later, however, the principal investigator of the trial called me to let me know the patient had progressed through the agent, suffering from significant urinary obstruction, and he was on hospice. “Unfortunately,” the investigator told me, “he’s not going to live much longer.”

When I checked in with the hospice, the patient had died.

I was surprised again at how matter-of-fact the discussion of death had been. But I was even more surprised by my own reaction. Despite the relationship I had formed with the patient, I did not feel much when I heard he had died. I didn’t have time to process the news in the moment. It was time to move on to the next patient.

It was only later, when I called the patient’s family, that I allowed my emotions to flood in. I told his family how grateful I was to know him, how strong he’d been. The patient’s family and I talked about the human, not his passing. It felt good.
 

Abandoning locker room talk

So how do we change how we talk about death? I don’t think the answer is massive educational programs or passing responsibility for advance care planning onto palliative care specialists. The change needs to be driven by individual oncologists. We can call out discussions of death that make us uncomfortable, gently reminding each other that we’re talking about a human life.

We can learn from our palliative care colleagues; their conversations about death routinely include a patient’s support system and personal stories. Palliative care doctors always refer to the patient by name, which helps humanize the person behind the chart.

We can emphasize a feeling of hope, a sentiment that may also be therapeutic to our patients. Even when a patient is dying, there is always something to be done. We can comfort their family, explaining what brought us to this point and how sorry we are that this is happening. We can provide options for symptom control and help patients manage those symptoms.

And we can allow ourselves to talk about how much a death affects us. We can acknowledge how much it sucks that a patient is going to die, how challenging that will be to his/her family, and how we wish it could have ended differently.

Subtle changes like these will improve our own ability to process and discuss death and will ultimately lead to better relationships with our patients. But it starts with eliminating the “locker room talk” of how we discuss death.
 

Ravi B. Parikh, MD, MPP, is a medical oncologist and faculty member at the University of Pennsylvania and the Philadelphia VA Medical Center, an adjunct fellow at the Leonard Davis Institute of Health Economics, and senior clinical advisor at the Coalition to Transform Advanced Care (C-TAC). He has served as a director, officer, partner, employee, adviser, consultant, or trustee for GNS Healthcare, Nanology, and Cancer Study Group, and he has received research grant from Embedded Healthcare, Veterans Administration, PCF, National Palliative Care Research Center, and MUSC. A version of this article first appeared on Medscape.com.

In a recent inpatient service block, I was seeing patients alongside a resident I had gotten to know well. We were consulted on a patient with metastatic head and neck cancer who had not sought care for over a year.

When the patient presented, his voice was raspy and he could not swallow. He had lost 40 pounds. In addition to his locally advanced disease, his lungs were riddled with metastatic lesions.

When we left the room, the resident and I went to speak to the patient’s primary team, and he began to relay our recommendations.

The first words out of his mouth were, “Well, it’s pretty clear he’s going to die.”

The statement took me aback. I wasn’t alarmed by the accuracy of what he had said. The patient was obviously not doing well, and he ended up dying soon after this visit.

It was more the abrupt manner in which the resident had spoken about death. The brusque phrasing felt atypical coming from the otherwise gentle-hearted trainee. He wasn’t referring to a faceless person. We had just seen the man a few minutes ago and heard his personal struggles. I tried to see if anyone else on the team was caught off guard, but everyone was taking notes or continuing to listen, seemingly undeterred.
 

Oncologists’ ‘locker room talk’

I’ve noticed that “locker room talk” about death happens often. Phrases like “he’s definitely not going to do well” and “his life expectancy is poor” make their way into oncologists’ daily language. Thinking back on my own interactions, I realize I am also guilty of discussing death in this way.

And now, with the COVID pandemic forcing most of our tumor boards to go virtual, I find this locker room talk comes even more readily; phrases like “this patient is going to die” are often passed around flippantly, as if saying so will help ease the tension. During these interactions, my colleagues and I rarely acknowledge the seriousness of what a patient death will do to their family and loved ones – or what losing a patient whom we’ve known for years may do to our own psyche.

This language can even creep into how we speak with patients. We are often taught to offer prognoses coldly, ensuring that patients have a clear sense of how long they have left and to help inform their treatment choices. And yet, this training does not necessarily align with what patients want and need. For instance, in a recent survey of patients with chronic obstructive pulmonary disease, patients consistently rated physicians poorly at discussing prognosis, what dying might be like, as well as spirituality and religion.

But at the same time, these matter-of-fact statements about death probably help protect us. Death is a routine, inevitable part of an oncologist’s life, and over time, oncology training and practice hardens us to it. During medical school, I remember that a patient dying would trigger immediate reflection, sadness, and conversation with our peers. Now, unless I know a patient well, I find myself rarely reflecting on the patient behind the facts. This evolution is natural for an oncologist: If you don’t develop a tough skin about death, you may become overwhelmed with the frequency of it.

The COVID pandemic has amped our hardness toward death into overdrive. Whether we are in the intensive care unit or simply viewing death rates during the most recent COVID Delta wave, many of us cope by disassociating a face from a name.
 

Making time for reflection

But taking time to reflect can be therapeutic.

I recently referred a patient with metastatic prostate cancer for a phase 1 trial at an outside institution. He was one of the first patients in my genitourinary malignancies clinic when I started as an attending. The patient had progressed through several lines of therapy and was being referred for an investigational phase 1 therapy. We had discussed hospice referral, and the patient was ready for it if this therapy didn’t work out.

I did not see or hear from the man while he was on the trial. A few months later, however, the principal investigator of the trial called me to let me know the patient had progressed through the agent, suffering from significant urinary obstruction, and he was on hospice. “Unfortunately,” the investigator told me, “he’s not going to live much longer.”

When I checked in with the hospice, the patient had died.

I was surprised again at how matter-of-fact the discussion of death had been. But I was even more surprised by my own reaction. Despite the relationship I had formed with the patient, I did not feel much when I heard he had died. I didn’t have time to process the news in the moment. It was time to move on to the next patient.

It was only later, when I called the patient’s family, that I allowed my emotions to flood in. I told his family how grateful I was to know him, how strong he’d been. The patient’s family and I talked about the human, not his passing. It felt good.
 

Abandoning locker room talk

So how do we change how we talk about death? I don’t think the answer is massive educational programs or passing responsibility for advance care planning onto palliative care specialists. The change needs to be driven by individual oncologists. We can call out discussions of death that make us uncomfortable, gently reminding each other that we’re talking about a human life.

We can learn from our palliative care colleagues; their conversations about death routinely include a patient’s support system and personal stories. Palliative care doctors always refer to the patient by name, which helps humanize the person behind the chart.

We can emphasize a feeling of hope, a sentiment that may also be therapeutic to our patients. Even when a patient is dying, there is always something to be done. We can comfort their family, explaining what brought us to this point and how sorry we are that this is happening. We can provide options for symptom control and help patients manage those symptoms.

And we can allow ourselves to talk about how much a death affects us. We can acknowledge how much it sucks that a patient is going to die, how challenging that will be to his/her family, and how we wish it could have ended differently.

Subtle changes like these will improve our own ability to process and discuss death and will ultimately lead to better relationships with our patients. But it starts with eliminating the “locker room talk” of how we discuss death.
 

Ravi B. Parikh, MD, MPP, is a medical oncologist and faculty member at the University of Pennsylvania and the Philadelphia VA Medical Center, an adjunct fellow at the Leonard Davis Institute of Health Economics, and senior clinical advisor at the Coalition to Transform Advanced Care (C-TAC). He has served as a director, officer, partner, employee, adviser, consultant, or trustee for GNS Healthcare, Nanology, and Cancer Study Group, and he has received research grant from Embedded Healthcare, Veterans Administration, PCF, National Palliative Care Research Center, and MUSC. A version of this article first appeared on Medscape.com.