User login
For MD-IQ use only
Career pivots: A new perspective on psychiatry
Psychiatrists practice a field of medicine that relies on one’s clinical perspective to interpret observable behaviors originating from the brains of others. In this manner, psychiatry and photography are similar. And digital technology has changed them both.
In photography, there are many technical aspects for one to master when framing and capturing a shot. The length of exposure. The amount of light needed. The speed of the film, which is its sensitivity to light. The aperture that controls how much light falls on the film. The movement of the subject across the film during the exposure. Despite the fact that physical film has mostly yielded to electronic sensors over the past couple decades, these basic aspects of photography remain.
But perspective is the critical ingredient. This is what brings the greatest impact to photography. The composition, or the subject of the photograph and how its elements – foreground, background, shapes, patterns, texture, shadow, motion, leading lines, and focal points – are arranged. The most powerful way to improve the composition – more powerful than fancy camera bells and whistles – is to move. One step to the left or right, one step forward or back. Stand on your toes, or crouch to your knees. Pivot this way or that. A simple change in perspective dramatically changes the nature and the energy of the captured image.
In fact, many physicians are changing what they actually do for a living. Pivoting their clinical perspectives. And applying those perspectives to other areas. The latest catalyst fueling these career pivots, these changes in perspectives, has been the incredible global impact of the tiny little coronavirus known as SARS-CoV-2. The COVID-19 pandemic that began two years ago has disrupted the entire planet. The virus has caused us all to change our perspective, to see our world differently, and our place in it.
The virus has exposed defects in our health care delivery system. And physicians have necessarily reacted, injecting changes in what they do and how they do it. Many of these changes rely on digital technology, building upon the groundwork laid over the past couple of decades to convert our paper processes into electronic processes, and our manual work flows into digital work flows. This groundwork is no small thing, as it relies on conventions and standards, such as DICOM, LOINC, AES, CDA, UMLS, FHIR, ICD, NDC, USCDI, and SNOMED-CT. Establishing, maintaining, and evolving health care standards requires organized groups of people to come together to share their diverse perspectives. This is but one of many places where physicians are using their unique clinical perspective to share what they see with others.
This column will focus on these professional pivots that physicians make when they take a step to the left or right to change their perspective and share their viewpoints in different settings with diverse groups of people. Some of these pivots are small, while others are career changing. But the theme that knits them together is about taking what one has learned while helping others achieve better health, and using that perspective to make a difference.
Dr. Daviss is chief medical officer for Optum Maryland and immediate past president of the Maryland-DC Society of Addiction Medicine, and former medical director and senior medical advisor at SAMHSA. He is coauthor of the 2011 book, Shrink Rap: Three Psychiatrists Explain Their Work. Psychiatrists and other physicians may share their own experience with pivots they have made with Dr. Daviss via email ([email protected]) or Twitter (@HITshrink). The opinions expressed are solely those of the author and do not necessarily reflect those of his employer or organizations with which he is associated.
Psychiatrists practice a field of medicine that relies on one’s clinical perspective to interpret observable behaviors originating from the brains of others. In this manner, psychiatry and photography are similar. And digital technology has changed them both.
In photography, there are many technical aspects for one to master when framing and capturing a shot. The length of exposure. The amount of light needed. The speed of the film, which is its sensitivity to light. The aperture that controls how much light falls on the film. The movement of the subject across the film during the exposure. Despite the fact that physical film has mostly yielded to electronic sensors over the past couple decades, these basic aspects of photography remain.
But perspective is the critical ingredient. This is what brings the greatest impact to photography. The composition, or the subject of the photograph and how its elements – foreground, background, shapes, patterns, texture, shadow, motion, leading lines, and focal points – are arranged. The most powerful way to improve the composition – more powerful than fancy camera bells and whistles – is to move. One step to the left or right, one step forward or back. Stand on your toes, or crouch to your knees. Pivot this way or that. A simple change in perspective dramatically changes the nature and the energy of the captured image.
In fact, many physicians are changing what they actually do for a living. Pivoting their clinical perspectives. And applying those perspectives to other areas. The latest catalyst fueling these career pivots, these changes in perspectives, has been the incredible global impact of the tiny little coronavirus known as SARS-CoV-2. The COVID-19 pandemic that began two years ago has disrupted the entire planet. The virus has caused us all to change our perspective, to see our world differently, and our place in it.
The virus has exposed defects in our health care delivery system. And physicians have necessarily reacted, injecting changes in what they do and how they do it. Many of these changes rely on digital technology, building upon the groundwork laid over the past couple of decades to convert our paper processes into electronic processes, and our manual work flows into digital work flows. This groundwork is no small thing, as it relies on conventions and standards, such as DICOM, LOINC, AES, CDA, UMLS, FHIR, ICD, NDC, USCDI, and SNOMED-CT. Establishing, maintaining, and evolving health care standards requires organized groups of people to come together to share their diverse perspectives. This is but one of many places where physicians are using their unique clinical perspective to share what they see with others.
This column will focus on these professional pivots that physicians make when they take a step to the left or right to change their perspective and share their viewpoints in different settings with diverse groups of people. Some of these pivots are small, while others are career changing. But the theme that knits them together is about taking what one has learned while helping others achieve better health, and using that perspective to make a difference.
Dr. Daviss is chief medical officer for Optum Maryland and immediate past president of the Maryland-DC Society of Addiction Medicine, and former medical director and senior medical advisor at SAMHSA. He is coauthor of the 2011 book, Shrink Rap: Three Psychiatrists Explain Their Work. Psychiatrists and other physicians may share their own experience with pivots they have made with Dr. Daviss via email ([email protected]) or Twitter (@HITshrink). The opinions expressed are solely those of the author and do not necessarily reflect those of his employer or organizations with which he is associated.
Psychiatrists practice a field of medicine that relies on one’s clinical perspective to interpret observable behaviors originating from the brains of others. In this manner, psychiatry and photography are similar. And digital technology has changed them both.
In photography, there are many technical aspects for one to master when framing and capturing a shot. The length of exposure. The amount of light needed. The speed of the film, which is its sensitivity to light. The aperture that controls how much light falls on the film. The movement of the subject across the film during the exposure. Despite the fact that physical film has mostly yielded to electronic sensors over the past couple decades, these basic aspects of photography remain.
But perspective is the critical ingredient. This is what brings the greatest impact to photography. The composition, or the subject of the photograph and how its elements – foreground, background, shapes, patterns, texture, shadow, motion, leading lines, and focal points – are arranged. The most powerful way to improve the composition – more powerful than fancy camera bells and whistles – is to move. One step to the left or right, one step forward or back. Stand on your toes, or crouch to your knees. Pivot this way or that. A simple change in perspective dramatically changes the nature and the energy of the captured image.
In fact, many physicians are changing what they actually do for a living. Pivoting their clinical perspectives. And applying those perspectives to other areas. The latest catalyst fueling these career pivots, these changes in perspectives, has been the incredible global impact of the tiny little coronavirus known as SARS-CoV-2. The COVID-19 pandemic that began two years ago has disrupted the entire planet. The virus has caused us all to change our perspective, to see our world differently, and our place in it.
The virus has exposed defects in our health care delivery system. And physicians have necessarily reacted, injecting changes in what they do and how they do it. Many of these changes rely on digital technology, building upon the groundwork laid over the past couple of decades to convert our paper processes into electronic processes, and our manual work flows into digital work flows. This groundwork is no small thing, as it relies on conventions and standards, such as DICOM, LOINC, AES, CDA, UMLS, FHIR, ICD, NDC, USCDI, and SNOMED-CT. Establishing, maintaining, and evolving health care standards requires organized groups of people to come together to share their diverse perspectives. This is but one of many places where physicians are using their unique clinical perspective to share what they see with others.
This column will focus on these professional pivots that physicians make when they take a step to the left or right to change their perspective and share their viewpoints in different settings with diverse groups of people. Some of these pivots are small, while others are career changing. But the theme that knits them together is about taking what one has learned while helping others achieve better health, and using that perspective to make a difference.
Dr. Daviss is chief medical officer for Optum Maryland and immediate past president of the Maryland-DC Society of Addiction Medicine, and former medical director and senior medical advisor at SAMHSA. He is coauthor of the 2011 book, Shrink Rap: Three Psychiatrists Explain Their Work. Psychiatrists and other physicians may share their own experience with pivots they have made with Dr. Daviss via email ([email protected]) or Twitter (@HITshrink). The opinions expressed are solely those of the author and do not necessarily reflect those of his employer or organizations with which he is associated.
Nap length linked to cognitive changes
No wonder we feel worse after naps
Some of us have hectic schedules that may make a nap feel more necessary. It’s common knowledge that naps shouldn’t be too long – maybe 20 minutes or so – but if you frequently take 3-hour naps and wake up thinking you’re late for school even though you’re 47 and have your PhD, this LOTME is for you.
Studies have shown that there is a link between napping during the day and Alzheimer’s/cognitive decline, but now we’ve got a double whammy for you: Longer and more frequent napping is linked to worse cognition after a year, and in turn, those with cognitive decline and Alzheimer’s are known to nap longer and more frequently during the day.
“We now know that the pathology related to cognitive decline can cause other changes in function,” he said. “It’s really a multisystem disorder, also including difficulty sleeping, changes in movement, changes in body composition, depression symptoms, behavioral changes, etc.,” coauthor Aron Buchman, MD, said in a statement from Rush University Medical Center.
The investigators monitored 1,400 patients over the course of 14 years with wrist bracelets that recorded when a person was not active during the day and considered that a nap.
At the beginning of the study, 75% of the study subjects had no cognitive impairment, 19.5% had some cognitive impairment, and approximately 4% had Alzheimer’s. Napping during the day only increased about 11 minutes a year for those with no signs of cognitive impairment, but those who showed significantly more signs of cognitive decline doubled their nap time and those actually diagnosed with Alzheimer’s tripled theirs.
The investigators did not imply that napping causes Alzheimer’s, but they noted that people who are older and nap more than an hour a day are 40% more likely to be at risk. It is something to consider and monitor.
Sometimes, after all, a nap seems like the best idea ever, but more often than not we wake up feeling 10 times worse. Our bodies may be giving us a heads up.
Pokemon Go away depression
The summer of 2016 was a great time if you happened to be a fan of Pokemon. Which is quite a lot of people. For almost 20 years millions have enjoyed the games and animated series, but Pokemon Go brought the thrill of catching Pokemon to life in a whole new way. For the first time, you could go out into the world and pretend you were a real Pokemon trainer, and everywhere you went, there would be others like you.
The ability to chase after Pikachu and Charizard in real life (well, augmented reality, but close enough) seemed to bring people a lot of joy, but seemed is never good enough for science. Can’t have anecdotes, we need data! So researchers at the London School of Economics and Political Science conducted a study into how Pokemon Go affected local Internet search rates of depression as the game was released slowly around the world.
Through analyzing Google Trend data of words like “depression,” “anxiety,” and “stress,” the researchers found that the release of Pokemon Go was significantly associated with a noticeable, though short-term, drop in depression-related Internet searches. Location-based augmented reality games may alleviate symptoms of mild depression, the researchers said, as they encourage physical activity, face-to-face socialization, and exposure to nature, though they added that simply going outside is likely not enough to combat clinical cases of severe depression.
Still, augmented reality games represent a viable target for public health investment, since they’re easy to use and inexpensive to make. That said, we’re not sure we want the FDA or CDC making a new Pokemon Go game. They’d probably end up filling the streets with Mr. Mime. And no one would leave their house for that.
And now a word from our sponsor
How many times has this happened to you? You need to repair a jet engine, inspect a nuclear reactor cooling system, AND perform bowel surgery, but you can’t carry around all the heavy, old-fashioned tools needed for those jobs.
Well, we’ve got one tool that can do it all! And that tool is a snake. No, it’s a robot.
It’s both! It’s the COntinuum roBot for Remote Applications. COBRA is the robot that looks like a snake! A snake that’s 5 meters long but only as thick as a pencil (about 9 mm in diameter). A robot with “extraordinary manoeuvrability and responsiveness due to … a compliant-joint structure and multiple continuous sections that enable it to bend at around 90 degrees,” according to the team at the University of Nottingham (England) that developed it.
COBRA comes equipped with a stereovision camera and a miniature cutting tool to perform complex industrial repair, but other devices can be interchanged for possible medical use.
COBRA and its joystick-like controller were designed to be easy to use. Dr. Oladejo Olaleye, the ear, nose, and throat and robotic surgeon at University Hospitals of Leicester who is directing its surgical development, was able to use COBRA on a dummy after just 5 minutes of training. He called it “the future of diagnostic endoscopy and therapeutic surgery.”
Don’t be the last aircraft engineer/nuclear technician/surgeon on your block to have this ultraslender, ultramaneuverable reptilian repair robot. Get your COBRA now! Operators are standing by.
Disclaimer: Robot is still under development and not yet on sale.
Rule, (worm) Britannia!
As long as there have been people, there have been parasitic worms living in their guts. Helminth infection is a continuing and largely ignored crisis in poor, tropical nations, though worm-based diseases have been basically eliminated from wealthier countries.
This wasn’t always the case, however, as a study published in PLOS Neglected Tropical Diseases (now there’s a specific topic) has found. The researchers detail the glorious history of helminth infestation in the United Kingdom from the Victorian era all the way back to prehistory, scouring hundreds of skeletons found in 17 sites across the country for eggs, which can remain intact for thousands of years.
The researchers found that two eras in particular had very high rates of infection. Unsurprisingly, the late medieval era was one of them, but the other is less obvious. The Romans were famous for their hygiene, their baths, and their plumbing, but maybe they also should be famous for the abundance of worms in their bellies. That doesn’t make sense at first: Shouldn’t good hygiene lower infection? The benefits of a good sewer system, however, are lessened when the waste containing said infectious organisms is used to fertilize crops. Recycling is generally a good thing, but less so when you’re recycling parasitic worms.
Curiously, of the three sites from the industrial age, only the one in London had high levels of worm infestation. Considering how dirty and cramped 19th-century British cities were, one might expect disease to run rampant (tuberculosis certainly did), but the sites in Oxford and Birmingham were almost devoid of worms. The researchers theorized that this was because of access to clean well water. Or maybe worms just have a thing for London. [Editor’s note: It’s probably not that.]
No wonder we feel worse after naps
Some of us have hectic schedules that may make a nap feel more necessary. It’s common knowledge that naps shouldn’t be too long – maybe 20 minutes or so – but if you frequently take 3-hour naps and wake up thinking you’re late for school even though you’re 47 and have your PhD, this LOTME is for you.
Studies have shown that there is a link between napping during the day and Alzheimer’s/cognitive decline, but now we’ve got a double whammy for you: Longer and more frequent napping is linked to worse cognition after a year, and in turn, those with cognitive decline and Alzheimer’s are known to nap longer and more frequently during the day.
“We now know that the pathology related to cognitive decline can cause other changes in function,” he said. “It’s really a multisystem disorder, also including difficulty sleeping, changes in movement, changes in body composition, depression symptoms, behavioral changes, etc.,” coauthor Aron Buchman, MD, said in a statement from Rush University Medical Center.
The investigators monitored 1,400 patients over the course of 14 years with wrist bracelets that recorded when a person was not active during the day and considered that a nap.
At the beginning of the study, 75% of the study subjects had no cognitive impairment, 19.5% had some cognitive impairment, and approximately 4% had Alzheimer’s. Napping during the day only increased about 11 minutes a year for those with no signs of cognitive impairment, but those who showed significantly more signs of cognitive decline doubled their nap time and those actually diagnosed with Alzheimer’s tripled theirs.
The investigators did not imply that napping causes Alzheimer’s, but they noted that people who are older and nap more than an hour a day are 40% more likely to be at risk. It is something to consider and monitor.
Sometimes, after all, a nap seems like the best idea ever, but more often than not we wake up feeling 10 times worse. Our bodies may be giving us a heads up.
Pokemon Go away depression
The summer of 2016 was a great time if you happened to be a fan of Pokemon. Which is quite a lot of people. For almost 20 years millions have enjoyed the games and animated series, but Pokemon Go brought the thrill of catching Pokemon to life in a whole new way. For the first time, you could go out into the world and pretend you were a real Pokemon trainer, and everywhere you went, there would be others like you.
The ability to chase after Pikachu and Charizard in real life (well, augmented reality, but close enough) seemed to bring people a lot of joy, but seemed is never good enough for science. Can’t have anecdotes, we need data! So researchers at the London School of Economics and Political Science conducted a study into how Pokemon Go affected local Internet search rates of depression as the game was released slowly around the world.
Through analyzing Google Trend data of words like “depression,” “anxiety,” and “stress,” the researchers found that the release of Pokemon Go was significantly associated with a noticeable, though short-term, drop in depression-related Internet searches. Location-based augmented reality games may alleviate symptoms of mild depression, the researchers said, as they encourage physical activity, face-to-face socialization, and exposure to nature, though they added that simply going outside is likely not enough to combat clinical cases of severe depression.
Still, augmented reality games represent a viable target for public health investment, since they’re easy to use and inexpensive to make. That said, we’re not sure we want the FDA or CDC making a new Pokemon Go game. They’d probably end up filling the streets with Mr. Mime. And no one would leave their house for that.
And now a word from our sponsor
How many times has this happened to you? You need to repair a jet engine, inspect a nuclear reactor cooling system, AND perform bowel surgery, but you can’t carry around all the heavy, old-fashioned tools needed for those jobs.
Well, we’ve got one tool that can do it all! And that tool is a snake. No, it’s a robot.
It’s both! It’s the COntinuum roBot for Remote Applications. COBRA is the robot that looks like a snake! A snake that’s 5 meters long but only as thick as a pencil (about 9 mm in diameter). A robot with “extraordinary manoeuvrability and responsiveness due to … a compliant-joint structure and multiple continuous sections that enable it to bend at around 90 degrees,” according to the team at the University of Nottingham (England) that developed it.
COBRA comes equipped with a stereovision camera and a miniature cutting tool to perform complex industrial repair, but other devices can be interchanged for possible medical use.
COBRA and its joystick-like controller were designed to be easy to use. Dr. Oladejo Olaleye, the ear, nose, and throat and robotic surgeon at University Hospitals of Leicester who is directing its surgical development, was able to use COBRA on a dummy after just 5 minutes of training. He called it “the future of diagnostic endoscopy and therapeutic surgery.”
Don’t be the last aircraft engineer/nuclear technician/surgeon on your block to have this ultraslender, ultramaneuverable reptilian repair robot. Get your COBRA now! Operators are standing by.
Disclaimer: Robot is still under development and not yet on sale.
Rule, (worm) Britannia!
As long as there have been people, there have been parasitic worms living in their guts. Helminth infection is a continuing and largely ignored crisis in poor, tropical nations, though worm-based diseases have been basically eliminated from wealthier countries.
This wasn’t always the case, however, as a study published in PLOS Neglected Tropical Diseases (now there’s a specific topic) has found. The researchers detail the glorious history of helminth infestation in the United Kingdom from the Victorian era all the way back to prehistory, scouring hundreds of skeletons found in 17 sites across the country for eggs, which can remain intact for thousands of years.
The researchers found that two eras in particular had very high rates of infection. Unsurprisingly, the late medieval era was one of them, but the other is less obvious. The Romans were famous for their hygiene, their baths, and their plumbing, but maybe they also should be famous for the abundance of worms in their bellies. That doesn’t make sense at first: Shouldn’t good hygiene lower infection? The benefits of a good sewer system, however, are lessened when the waste containing said infectious organisms is used to fertilize crops. Recycling is generally a good thing, but less so when you’re recycling parasitic worms.
Curiously, of the three sites from the industrial age, only the one in London had high levels of worm infestation. Considering how dirty and cramped 19th-century British cities were, one might expect disease to run rampant (tuberculosis certainly did), but the sites in Oxford and Birmingham were almost devoid of worms. The researchers theorized that this was because of access to clean well water. Or maybe worms just have a thing for London. [Editor’s note: It’s probably not that.]
No wonder we feel worse after naps
Some of us have hectic schedules that may make a nap feel more necessary. It’s common knowledge that naps shouldn’t be too long – maybe 20 minutes or so – but if you frequently take 3-hour naps and wake up thinking you’re late for school even though you’re 47 and have your PhD, this LOTME is for you.
Studies have shown that there is a link between napping during the day and Alzheimer’s/cognitive decline, but now we’ve got a double whammy for you: Longer and more frequent napping is linked to worse cognition after a year, and in turn, those with cognitive decline and Alzheimer’s are known to nap longer and more frequently during the day.
“We now know that the pathology related to cognitive decline can cause other changes in function,” he said. “It’s really a multisystem disorder, also including difficulty sleeping, changes in movement, changes in body composition, depression symptoms, behavioral changes, etc.,” coauthor Aron Buchman, MD, said in a statement from Rush University Medical Center.
The investigators monitored 1,400 patients over the course of 14 years with wrist bracelets that recorded when a person was not active during the day and considered that a nap.
At the beginning of the study, 75% of the study subjects had no cognitive impairment, 19.5% had some cognitive impairment, and approximately 4% had Alzheimer’s. Napping during the day only increased about 11 minutes a year for those with no signs of cognitive impairment, but those who showed significantly more signs of cognitive decline doubled their nap time and those actually diagnosed with Alzheimer’s tripled theirs.
The investigators did not imply that napping causes Alzheimer’s, but they noted that people who are older and nap more than an hour a day are 40% more likely to be at risk. It is something to consider and monitor.
Sometimes, after all, a nap seems like the best idea ever, but more often than not we wake up feeling 10 times worse. Our bodies may be giving us a heads up.
Pokemon Go away depression
The summer of 2016 was a great time if you happened to be a fan of Pokemon. Which is quite a lot of people. For almost 20 years millions have enjoyed the games and animated series, but Pokemon Go brought the thrill of catching Pokemon to life in a whole new way. For the first time, you could go out into the world and pretend you were a real Pokemon trainer, and everywhere you went, there would be others like you.
The ability to chase after Pikachu and Charizard in real life (well, augmented reality, but close enough) seemed to bring people a lot of joy, but seemed is never good enough for science. Can’t have anecdotes, we need data! So researchers at the London School of Economics and Political Science conducted a study into how Pokemon Go affected local Internet search rates of depression as the game was released slowly around the world.
Through analyzing Google Trend data of words like “depression,” “anxiety,” and “stress,” the researchers found that the release of Pokemon Go was significantly associated with a noticeable, though short-term, drop in depression-related Internet searches. Location-based augmented reality games may alleviate symptoms of mild depression, the researchers said, as they encourage physical activity, face-to-face socialization, and exposure to nature, though they added that simply going outside is likely not enough to combat clinical cases of severe depression.
Still, augmented reality games represent a viable target for public health investment, since they’re easy to use and inexpensive to make. That said, we’re not sure we want the FDA or CDC making a new Pokemon Go game. They’d probably end up filling the streets with Mr. Mime. And no one would leave their house for that.
And now a word from our sponsor
How many times has this happened to you? You need to repair a jet engine, inspect a nuclear reactor cooling system, AND perform bowel surgery, but you can’t carry around all the heavy, old-fashioned tools needed for those jobs.
Well, we’ve got one tool that can do it all! And that tool is a snake. No, it’s a robot.
It’s both! It’s the COntinuum roBot for Remote Applications. COBRA is the robot that looks like a snake! A snake that’s 5 meters long but only as thick as a pencil (about 9 mm in diameter). A robot with “extraordinary manoeuvrability and responsiveness due to … a compliant-joint structure and multiple continuous sections that enable it to bend at around 90 degrees,” according to the team at the University of Nottingham (England) that developed it.
COBRA comes equipped with a stereovision camera and a miniature cutting tool to perform complex industrial repair, but other devices can be interchanged for possible medical use.
COBRA and its joystick-like controller were designed to be easy to use. Dr. Oladejo Olaleye, the ear, nose, and throat and robotic surgeon at University Hospitals of Leicester who is directing its surgical development, was able to use COBRA on a dummy after just 5 minutes of training. He called it “the future of diagnostic endoscopy and therapeutic surgery.”
Don’t be the last aircraft engineer/nuclear technician/surgeon on your block to have this ultraslender, ultramaneuverable reptilian repair robot. Get your COBRA now! Operators are standing by.
Disclaimer: Robot is still under development and not yet on sale.
Rule, (worm) Britannia!
As long as there have been people, there have been parasitic worms living in their guts. Helminth infection is a continuing and largely ignored crisis in poor, tropical nations, though worm-based diseases have been basically eliminated from wealthier countries.
This wasn’t always the case, however, as a study published in PLOS Neglected Tropical Diseases (now there’s a specific topic) has found. The researchers detail the glorious history of helminth infestation in the United Kingdom from the Victorian era all the way back to prehistory, scouring hundreds of skeletons found in 17 sites across the country for eggs, which can remain intact for thousands of years.
The researchers found that two eras in particular had very high rates of infection. Unsurprisingly, the late medieval era was one of them, but the other is less obvious. The Romans were famous for their hygiene, their baths, and their plumbing, but maybe they also should be famous for the abundance of worms in their bellies. That doesn’t make sense at first: Shouldn’t good hygiene lower infection? The benefits of a good sewer system, however, are lessened when the waste containing said infectious organisms is used to fertilize crops. Recycling is generally a good thing, but less so when you’re recycling parasitic worms.
Curiously, of the three sites from the industrial age, only the one in London had high levels of worm infestation. Considering how dirty and cramped 19th-century British cities were, one might expect disease to run rampant (tuberculosis certainly did), but the sites in Oxford and Birmingham were almost devoid of worms. The researchers theorized that this was because of access to clean well water. Or maybe worms just have a thing for London. [Editor’s note: It’s probably not that.]
Which solid organ transplant recipients face the highest risk of skin cancer?
BOSTON – .
White patients who meet these criteria should be screening within 2 years after transplant, while Black patients should be screened within 5 years after transplant, Ally-Khan Somani, MD, PhD, said at the annual meeting of the American Academy of Dermatology.
Dr. Somani, director of dermatologic surgery and the division of cutaneous oncology at Indiana University, Indianapolis, based his remarks on consensus screening guidelines assembled from three rounds of Delphi method surveys with 47 dermatologists and 37 transplant physicians, with the goal of establishing skin cancer screening recommendations for SOTRs. Among the dermatologists surveyed, 45% were Mohs surgeons and 55% were general dermatologists.
The panel recommended that the transplant team should perform risk assessment for SOTRs to risk stratify patients for skin cancer screening (high risk vs. low risk). They also proposed that dermatologists perform skin cancer screening by full-body skin examinations, and that SOTRs with a history of skin cancer should continue with routine skin cancer surveillance as recommended by their dermatologists.
Those at low risk for skin cancer include abdominal organ recipients, SOTR age of younger than 50 at time of transplant, and female gender. The guidelines recommend that White, Asian, and Hispanic patients who meet those criteria should be screened within 5 years after transplant, while no consensus was reached for Black patients who meet those criteria.
Based on posttransplant skin cancer incidence rates, risk is increased among males, Whites, thoracic organ recipients, and being age 50 or older, Dr. Somani said. “At our institution, we make sure there’s a good connection between our transplant teams and dermatologists. We recommend rapid referral for suspicious lesions and we educate patients and screen them within 1 year of transplant, or sooner for high-risk patients. Surveillance is increased to every 3 or 4 months for patients with a history of multiple or high-risk cancers or sooner, followed by routine surveillance as recommended by the patient’s dermatologist.”
To risk stratify patients on the development of their first skin cancer post transplantation, researchers developed the Skin and Ultraviolet Neoplasia Transplant Risk Assessment Calculator (SUNTRAC), a prediction tool with a freely available app. Data for the tool were drawn from the Transplant Skin Cancer Network study, a 5-year analysis of 6,340 adult recipients of a first solid organ transplant at 26 transplant centers in the United States. It generates a risk score for SOTRs (low, medium, high, or very high), which informs transplant care providers of a patient’s risk of skin cancer.
Dr. Somani disclosed that he has received grants and funding from Castle Biosciences. He is an adviser to Cook Biotech and a consultant to Sanara MedTech.
BOSTON – .
White patients who meet these criteria should be screening within 2 years after transplant, while Black patients should be screened within 5 years after transplant, Ally-Khan Somani, MD, PhD, said at the annual meeting of the American Academy of Dermatology.
Dr. Somani, director of dermatologic surgery and the division of cutaneous oncology at Indiana University, Indianapolis, based his remarks on consensus screening guidelines assembled from three rounds of Delphi method surveys with 47 dermatologists and 37 transplant physicians, with the goal of establishing skin cancer screening recommendations for SOTRs. Among the dermatologists surveyed, 45% were Mohs surgeons and 55% were general dermatologists.
The panel recommended that the transplant team should perform risk assessment for SOTRs to risk stratify patients for skin cancer screening (high risk vs. low risk). They also proposed that dermatologists perform skin cancer screening by full-body skin examinations, and that SOTRs with a history of skin cancer should continue with routine skin cancer surveillance as recommended by their dermatologists.
Those at low risk for skin cancer include abdominal organ recipients, SOTR age of younger than 50 at time of transplant, and female gender. The guidelines recommend that White, Asian, and Hispanic patients who meet those criteria should be screened within 5 years after transplant, while no consensus was reached for Black patients who meet those criteria.
Based on posttransplant skin cancer incidence rates, risk is increased among males, Whites, thoracic organ recipients, and being age 50 or older, Dr. Somani said. “At our institution, we make sure there’s a good connection between our transplant teams and dermatologists. We recommend rapid referral for suspicious lesions and we educate patients and screen them within 1 year of transplant, or sooner for high-risk patients. Surveillance is increased to every 3 or 4 months for patients with a history of multiple or high-risk cancers or sooner, followed by routine surveillance as recommended by the patient’s dermatologist.”
To risk stratify patients on the development of their first skin cancer post transplantation, researchers developed the Skin and Ultraviolet Neoplasia Transplant Risk Assessment Calculator (SUNTRAC), a prediction tool with a freely available app. Data for the tool were drawn from the Transplant Skin Cancer Network study, a 5-year analysis of 6,340 adult recipients of a first solid organ transplant at 26 transplant centers in the United States. It generates a risk score for SOTRs (low, medium, high, or very high), which informs transplant care providers of a patient’s risk of skin cancer.
Dr. Somani disclosed that he has received grants and funding from Castle Biosciences. He is an adviser to Cook Biotech and a consultant to Sanara MedTech.
BOSTON – .
White patients who meet these criteria should be screening within 2 years after transplant, while Black patients should be screened within 5 years after transplant, Ally-Khan Somani, MD, PhD, said at the annual meeting of the American Academy of Dermatology.
Dr. Somani, director of dermatologic surgery and the division of cutaneous oncology at Indiana University, Indianapolis, based his remarks on consensus screening guidelines assembled from three rounds of Delphi method surveys with 47 dermatologists and 37 transplant physicians, with the goal of establishing skin cancer screening recommendations for SOTRs. Among the dermatologists surveyed, 45% were Mohs surgeons and 55% were general dermatologists.
The panel recommended that the transplant team should perform risk assessment for SOTRs to risk stratify patients for skin cancer screening (high risk vs. low risk). They also proposed that dermatologists perform skin cancer screening by full-body skin examinations, and that SOTRs with a history of skin cancer should continue with routine skin cancer surveillance as recommended by their dermatologists.
Those at low risk for skin cancer include abdominal organ recipients, SOTR age of younger than 50 at time of transplant, and female gender. The guidelines recommend that White, Asian, and Hispanic patients who meet those criteria should be screened within 5 years after transplant, while no consensus was reached for Black patients who meet those criteria.
Based on posttransplant skin cancer incidence rates, risk is increased among males, Whites, thoracic organ recipients, and being age 50 or older, Dr. Somani said. “At our institution, we make sure there’s a good connection between our transplant teams and dermatologists. We recommend rapid referral for suspicious lesions and we educate patients and screen them within 1 year of transplant, or sooner for high-risk patients. Surveillance is increased to every 3 or 4 months for patients with a history of multiple or high-risk cancers or sooner, followed by routine surveillance as recommended by the patient’s dermatologist.”
To risk stratify patients on the development of their first skin cancer post transplantation, researchers developed the Skin and Ultraviolet Neoplasia Transplant Risk Assessment Calculator (SUNTRAC), a prediction tool with a freely available app. Data for the tool were drawn from the Transplant Skin Cancer Network study, a 5-year analysis of 6,340 adult recipients of a first solid organ transplant at 26 transplant centers in the United States. It generates a risk score for SOTRs (low, medium, high, or very high), which informs transplant care providers of a patient’s risk of skin cancer.
Dr. Somani disclosed that he has received grants and funding from Castle Biosciences. He is an adviser to Cook Biotech and a consultant to Sanara MedTech.
AT AAD 22
USPSTF final recommendation on aspirin for primary CV prevention
The U.S. Preventive Services Task Force has published a final recommendation statement on aspirin use to prevent cardiovascular disease.
For people aged 40-59 years, the USPSTF suggests that aspirin could be considered in those at increased risk of cardiovascular disease (10-year risk of 10% or greater) but that the decision should be individualized.
It notes that in the 40-59 age group, evidence indicates that the net benefit of aspirin use is small, and that persons who are not at increased risk for bleeding are more likely to benefit.
It adds that these recommendations apply only to people who do not have a history of cardiovascular disease and are not already taking daily aspirin.
The USPSTF statement was published online in the Journal of the American Medical Association. It is accompanied by an evidence review, a modeling study, a patient page, and an editorial.
A draft version of the recommendation statement, evidence review, and modeling report were previously available for public comment. The final recommendation statement is consistent with the draft version.
The task force concludes that there is adequate evidence that low-dose aspirin has a small benefit to reduce risk for cardiovascular events (nonfatal myocardial infarction and stroke) in adults 40 years or older who have no history of cardiovascular disease but are at increased cardiovascular risk.
Evidence shows that the absolute magnitude of benefit increases with increasing 10-year cardiovascular risk and that the magnitude of the lifetime benefits is greater when aspirin is initiated at a younger age.
But it adds that there is also adequate evidence that aspirin use in adults increases the risk for gastrointestinal bleeding, intracranial bleeding, and hemorrhagic stroke. The USPSTF determined that the magnitude of the harms is small overall but increases in older age groups, particularly in adults older than 60 years.
For patients who are eligible and choose to start taking aspirin, the benefits become smaller with advancing age, and data suggest that clinicians and patients should consider stopping aspirin use around age 75 years, the statement advises.
It also says that evidence is unclear whether aspirin use reduces the risk of colorectal cancer incidence or mortality.
USPSTF vice chair Michael Barry, MD, director of the Informed Medical Decisions Program in the Health Decision Sciences Center at Massachusetts General Hospital, Boston, told this news organization that these recommendations apply only to patients not taking aspirin already and who have no evidence of existing cardiovascular disease.
“In adults aged 60 or over we do not recommend starting aspirin for primary prevention. That is because in this age group the risk of bleeding outweighs the cardiovascular benefit,” he said.
“For adults aged 40-59 years with a greater than 10% predicted risk of cardiovascular disease, there appears to be a net benefit from taking aspirin, but this net benefit is relatively small and will vary with other factors such as magnitude of cardiovascular and bleeding risk. People should talk to their physician about these factors and whether to take aspirin or not,” he added.
Dr. Barry noted that these recommendations do not apply to people who are already taking aspirin for primary prevention. “These people need to talk to their physicians about whether they should continue. They need to review the reasons why they started aspirin in the first place, and they need to have their bleeding risk evaluated. Someone who has taken aspirin long term without any bleeding complications has a lower risk of future bleeding complications,” he said.
The task force recommends an aspirin dose of 81 mg daily for those people deciding to take aspirin for primary prevention.
“There is an abundance of evidence that less than 100 mg a day is enough. The lower the dose the lower the bleeding risk. So, the most convenient dose is the widely available 81-mg baby aspirin tablet,” Dr. Barry noted. “While enteric coated products are meant to reduce gastric irritation, the data do not show any difference in bleeding risk between various aspirin formulations,” he added.
Dr. Barry pointed out that aspirin is just one tool for reducing cardiovascular risk.
“People can reduce their risk significantly in many other ways including taking regular exercise, eating a healthy diet, controlling blood pressure and diabetes, and taking statins if they are at increased cardiovascular risk.”
He noted that recent trials have suggested that aspirin has only a marginal value over and above all these other factors. And the risk reduction with aspirin is smaller than with some other interventions.
“For example, aspirin is associated with a 12% reduction in MI whereas statins are associated with a 25%-30% reduction. Statins are a more powerful tool in reducing cardiovascular risk than aspirin, so perhaps people should consider taking statins first. The benefit of aspirin may be smaller in individuals already taking a statin, and clinicians need to think about the big picture,” Dr. Barry said.
He explained that physicians need to evaluate the cardiovascular and bleeding risk in each individual patient. “While there are widely available tools to estimate cardiovascular risk, there are no easy tools yet available to evaluate bleeding risk, so physicians need to consider clinical factors such as history of peptic ulcers.”
He suggests for the many people who have an average bleeding risk, then personal preference may come into play. “In the 40-59 age group, the benefits and harms of aspirin are pretty well-balanced. For the average person we think there may be a small net benefit, but this is small enough for personal preference to be considered as well.”
Pendulum swinging away from aspirin use
In an editorial accompanying publication of the task force statement in JAMA, Allan S. Brett, MD, clinical professor of internal medicine at the University of Colorado at Denver, Aurora, explains that the USPSTF recommendations on aspirin use for primary prevention of cardiovascular disease have changed numerous times over the past 30 years, with the last update in 2016 narrowing the eligible population.
In the new recommendation statement, “the pendulum has swung further away from aspirin prophylaxis for primary prevention: The guideline does not recommend routine preventive aspirin for anyone,” Dr. Brett notes.
He points out that an important development between the 2016 and current version was the publication in 2018 of three large placebo-controlled randomized clinical trials of primary prevention with aspirin – ARRIVE, ASPREE and ASCEND – which taken together “cast doubt about net benefit for aspirin prophylaxis in current practice.”
Asked how physicians should go about “individualizing” the decision on the use of aspirin in the 40-59 age group at increased cardiovascular risk, Dr. Brett suggests that some patents will have a general philosophy of medical care of “don’t prescribe medication for me unless there is strong evidence to support it,” while others may favor preventive interventions even in borderline cases.
But he notes that many patients have no strong general preferences and often ask a trusted clinician to decide for them. “For such patients, the best approach is for clinicians to be knowledgeable about the data on primary prevention with aspirin. Close reading of the new USPSTF guideline and its companion evidence review, and becoming familiar with the three more recent aspirin trials, is a good way to prepare for these clinical encounters,” he concludes.
A cardiologist’s view
Commenting on the task force statement for this news organization, Andrew Freeman, MD, a cardiologist at National Jewish Health, Denver, noted that cardiology societies are already making similar recommendations on aspirin use in primary prevention. “The American College of Cardiology prevention guidelines have been giving similar advice for a couple of years now. It takes a few years for professional societies to catch up with each other,” he said.
“Over the last few years, it has become obvious that the benefit of aspirin is not really very positive until a patient has had a cardiovascular event. In primary prevention, it doesn’t become beneficial unless they are at quite a high risk of having an event,” Dr. Freeman noted.
“In general, most cardiologists are now telling people that, despite what they may have been told in the past, they don’t need to be on aspirin unless they have had a cardiovascular event,” he added. “Our understanding has changed over the years and the weight of evidence has now become clear that the risk of bleeding is not insignificant.”
Dr. Freeman agreed with the shared decision-making advocated for patients in the 40-59 age group. “If a patient is particularly worried about a family history of heart disease, taking aspirin may make some sense, but for most people who have not had a cardiovascular event, the net benefit is very low and gets lower with age as the bleeding risk increases,” he said.
The USPSTF is an independent, voluntary body. The U.S. Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF.
A version of this article first appeared on Medscape.com.
The U.S. Preventive Services Task Force has published a final recommendation statement on aspirin use to prevent cardiovascular disease.
For people aged 40-59 years, the USPSTF suggests that aspirin could be considered in those at increased risk of cardiovascular disease (10-year risk of 10% or greater) but that the decision should be individualized.
It notes that in the 40-59 age group, evidence indicates that the net benefit of aspirin use is small, and that persons who are not at increased risk for bleeding are more likely to benefit.
It adds that these recommendations apply only to people who do not have a history of cardiovascular disease and are not already taking daily aspirin.
The USPSTF statement was published online in the Journal of the American Medical Association. It is accompanied by an evidence review, a modeling study, a patient page, and an editorial.
A draft version of the recommendation statement, evidence review, and modeling report were previously available for public comment. The final recommendation statement is consistent with the draft version.
The task force concludes that there is adequate evidence that low-dose aspirin has a small benefit to reduce risk for cardiovascular events (nonfatal myocardial infarction and stroke) in adults 40 years or older who have no history of cardiovascular disease but are at increased cardiovascular risk.
Evidence shows that the absolute magnitude of benefit increases with increasing 10-year cardiovascular risk and that the magnitude of the lifetime benefits is greater when aspirin is initiated at a younger age.
But it adds that there is also adequate evidence that aspirin use in adults increases the risk for gastrointestinal bleeding, intracranial bleeding, and hemorrhagic stroke. The USPSTF determined that the magnitude of the harms is small overall but increases in older age groups, particularly in adults older than 60 years.
For patients who are eligible and choose to start taking aspirin, the benefits become smaller with advancing age, and data suggest that clinicians and patients should consider stopping aspirin use around age 75 years, the statement advises.
It also says that evidence is unclear whether aspirin use reduces the risk of colorectal cancer incidence or mortality.
USPSTF vice chair Michael Barry, MD, director of the Informed Medical Decisions Program in the Health Decision Sciences Center at Massachusetts General Hospital, Boston, told this news organization that these recommendations apply only to patients not taking aspirin already and who have no evidence of existing cardiovascular disease.
“In adults aged 60 or over we do not recommend starting aspirin for primary prevention. That is because in this age group the risk of bleeding outweighs the cardiovascular benefit,” he said.
“For adults aged 40-59 years with a greater than 10% predicted risk of cardiovascular disease, there appears to be a net benefit from taking aspirin, but this net benefit is relatively small and will vary with other factors such as magnitude of cardiovascular and bleeding risk. People should talk to their physician about these factors and whether to take aspirin or not,” he added.
Dr. Barry noted that these recommendations do not apply to people who are already taking aspirin for primary prevention. “These people need to talk to their physicians about whether they should continue. They need to review the reasons why they started aspirin in the first place, and they need to have their bleeding risk evaluated. Someone who has taken aspirin long term without any bleeding complications has a lower risk of future bleeding complications,” he said.
The task force recommends an aspirin dose of 81 mg daily for those people deciding to take aspirin for primary prevention.
“There is an abundance of evidence that less than 100 mg a day is enough. The lower the dose the lower the bleeding risk. So, the most convenient dose is the widely available 81-mg baby aspirin tablet,” Dr. Barry noted. “While enteric coated products are meant to reduce gastric irritation, the data do not show any difference in bleeding risk between various aspirin formulations,” he added.
Dr. Barry pointed out that aspirin is just one tool for reducing cardiovascular risk.
“People can reduce their risk significantly in many other ways including taking regular exercise, eating a healthy diet, controlling blood pressure and diabetes, and taking statins if they are at increased cardiovascular risk.”
He noted that recent trials have suggested that aspirin has only a marginal value over and above all these other factors. And the risk reduction with aspirin is smaller than with some other interventions.
“For example, aspirin is associated with a 12% reduction in MI whereas statins are associated with a 25%-30% reduction. Statins are a more powerful tool in reducing cardiovascular risk than aspirin, so perhaps people should consider taking statins first. The benefit of aspirin may be smaller in individuals already taking a statin, and clinicians need to think about the big picture,” Dr. Barry said.
He explained that physicians need to evaluate the cardiovascular and bleeding risk in each individual patient. “While there are widely available tools to estimate cardiovascular risk, there are no easy tools yet available to evaluate bleeding risk, so physicians need to consider clinical factors such as history of peptic ulcers.”
He suggests for the many people who have an average bleeding risk, then personal preference may come into play. “In the 40-59 age group, the benefits and harms of aspirin are pretty well-balanced. For the average person we think there may be a small net benefit, but this is small enough for personal preference to be considered as well.”
Pendulum swinging away from aspirin use
In an editorial accompanying publication of the task force statement in JAMA, Allan S. Brett, MD, clinical professor of internal medicine at the University of Colorado at Denver, Aurora, explains that the USPSTF recommendations on aspirin use for primary prevention of cardiovascular disease have changed numerous times over the past 30 years, with the last update in 2016 narrowing the eligible population.
In the new recommendation statement, “the pendulum has swung further away from aspirin prophylaxis for primary prevention: The guideline does not recommend routine preventive aspirin for anyone,” Dr. Brett notes.
He points out that an important development between the 2016 and current version was the publication in 2018 of three large placebo-controlled randomized clinical trials of primary prevention with aspirin – ARRIVE, ASPREE and ASCEND – which taken together “cast doubt about net benefit for aspirin prophylaxis in current practice.”
Asked how physicians should go about “individualizing” the decision on the use of aspirin in the 40-59 age group at increased cardiovascular risk, Dr. Brett suggests that some patents will have a general philosophy of medical care of “don’t prescribe medication for me unless there is strong evidence to support it,” while others may favor preventive interventions even in borderline cases.
But he notes that many patients have no strong general preferences and often ask a trusted clinician to decide for them. “For such patients, the best approach is for clinicians to be knowledgeable about the data on primary prevention with aspirin. Close reading of the new USPSTF guideline and its companion evidence review, and becoming familiar with the three more recent aspirin trials, is a good way to prepare for these clinical encounters,” he concludes.
A cardiologist’s view
Commenting on the task force statement for this news organization, Andrew Freeman, MD, a cardiologist at National Jewish Health, Denver, noted that cardiology societies are already making similar recommendations on aspirin use in primary prevention. “The American College of Cardiology prevention guidelines have been giving similar advice for a couple of years now. It takes a few years for professional societies to catch up with each other,” he said.
“Over the last few years, it has become obvious that the benefit of aspirin is not really very positive until a patient has had a cardiovascular event. In primary prevention, it doesn’t become beneficial unless they are at quite a high risk of having an event,” Dr. Freeman noted.
“In general, most cardiologists are now telling people that, despite what they may have been told in the past, they don’t need to be on aspirin unless they have had a cardiovascular event,” he added. “Our understanding has changed over the years and the weight of evidence has now become clear that the risk of bleeding is not insignificant.”
Dr. Freeman agreed with the shared decision-making advocated for patients in the 40-59 age group. “If a patient is particularly worried about a family history of heart disease, taking aspirin may make some sense, but for most people who have not had a cardiovascular event, the net benefit is very low and gets lower with age as the bleeding risk increases,” he said.
The USPSTF is an independent, voluntary body. The U.S. Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF.
A version of this article first appeared on Medscape.com.
The U.S. Preventive Services Task Force has published a final recommendation statement on aspirin use to prevent cardiovascular disease.
For people aged 40-59 years, the USPSTF suggests that aspirin could be considered in those at increased risk of cardiovascular disease (10-year risk of 10% or greater) but that the decision should be individualized.
It notes that in the 40-59 age group, evidence indicates that the net benefit of aspirin use is small, and that persons who are not at increased risk for bleeding are more likely to benefit.
It adds that these recommendations apply only to people who do not have a history of cardiovascular disease and are not already taking daily aspirin.
The USPSTF statement was published online in the Journal of the American Medical Association. It is accompanied by an evidence review, a modeling study, a patient page, and an editorial.
A draft version of the recommendation statement, evidence review, and modeling report were previously available for public comment. The final recommendation statement is consistent with the draft version.
The task force concludes that there is adequate evidence that low-dose aspirin has a small benefit to reduce risk for cardiovascular events (nonfatal myocardial infarction and stroke) in adults 40 years or older who have no history of cardiovascular disease but are at increased cardiovascular risk.
Evidence shows that the absolute magnitude of benefit increases with increasing 10-year cardiovascular risk and that the magnitude of the lifetime benefits is greater when aspirin is initiated at a younger age.
But it adds that there is also adequate evidence that aspirin use in adults increases the risk for gastrointestinal bleeding, intracranial bleeding, and hemorrhagic stroke. The USPSTF determined that the magnitude of the harms is small overall but increases in older age groups, particularly in adults older than 60 years.
For patients who are eligible and choose to start taking aspirin, the benefits become smaller with advancing age, and data suggest that clinicians and patients should consider stopping aspirin use around age 75 years, the statement advises.
It also says that evidence is unclear whether aspirin use reduces the risk of colorectal cancer incidence or mortality.
USPSTF vice chair Michael Barry, MD, director of the Informed Medical Decisions Program in the Health Decision Sciences Center at Massachusetts General Hospital, Boston, told this news organization that these recommendations apply only to patients not taking aspirin already and who have no evidence of existing cardiovascular disease.
“In adults aged 60 or over we do not recommend starting aspirin for primary prevention. That is because in this age group the risk of bleeding outweighs the cardiovascular benefit,” he said.
“For adults aged 40-59 years with a greater than 10% predicted risk of cardiovascular disease, there appears to be a net benefit from taking aspirin, but this net benefit is relatively small and will vary with other factors such as magnitude of cardiovascular and bleeding risk. People should talk to their physician about these factors and whether to take aspirin or not,” he added.
Dr. Barry noted that these recommendations do not apply to people who are already taking aspirin for primary prevention. “These people need to talk to their physicians about whether they should continue. They need to review the reasons why they started aspirin in the first place, and they need to have their bleeding risk evaluated. Someone who has taken aspirin long term without any bleeding complications has a lower risk of future bleeding complications,” he said.
The task force recommends an aspirin dose of 81 mg daily for those people deciding to take aspirin for primary prevention.
“There is an abundance of evidence that less than 100 mg a day is enough. The lower the dose the lower the bleeding risk. So, the most convenient dose is the widely available 81-mg baby aspirin tablet,” Dr. Barry noted. “While enteric coated products are meant to reduce gastric irritation, the data do not show any difference in bleeding risk between various aspirin formulations,” he added.
Dr. Barry pointed out that aspirin is just one tool for reducing cardiovascular risk.
“People can reduce their risk significantly in many other ways including taking regular exercise, eating a healthy diet, controlling blood pressure and diabetes, and taking statins if they are at increased cardiovascular risk.”
He noted that recent trials have suggested that aspirin has only a marginal value over and above all these other factors. And the risk reduction with aspirin is smaller than with some other interventions.
“For example, aspirin is associated with a 12% reduction in MI whereas statins are associated with a 25%-30% reduction. Statins are a more powerful tool in reducing cardiovascular risk than aspirin, so perhaps people should consider taking statins first. The benefit of aspirin may be smaller in individuals already taking a statin, and clinicians need to think about the big picture,” Dr. Barry said.
He explained that physicians need to evaluate the cardiovascular and bleeding risk in each individual patient. “While there are widely available tools to estimate cardiovascular risk, there are no easy tools yet available to evaluate bleeding risk, so physicians need to consider clinical factors such as history of peptic ulcers.”
He suggests for the many people who have an average bleeding risk, then personal preference may come into play. “In the 40-59 age group, the benefits and harms of aspirin are pretty well-balanced. For the average person we think there may be a small net benefit, but this is small enough for personal preference to be considered as well.”
Pendulum swinging away from aspirin use
In an editorial accompanying publication of the task force statement in JAMA, Allan S. Brett, MD, clinical professor of internal medicine at the University of Colorado at Denver, Aurora, explains that the USPSTF recommendations on aspirin use for primary prevention of cardiovascular disease have changed numerous times over the past 30 years, with the last update in 2016 narrowing the eligible population.
In the new recommendation statement, “the pendulum has swung further away from aspirin prophylaxis for primary prevention: The guideline does not recommend routine preventive aspirin for anyone,” Dr. Brett notes.
He points out that an important development between the 2016 and current version was the publication in 2018 of three large placebo-controlled randomized clinical trials of primary prevention with aspirin – ARRIVE, ASPREE and ASCEND – which taken together “cast doubt about net benefit for aspirin prophylaxis in current practice.”
Asked how physicians should go about “individualizing” the decision on the use of aspirin in the 40-59 age group at increased cardiovascular risk, Dr. Brett suggests that some patents will have a general philosophy of medical care of “don’t prescribe medication for me unless there is strong evidence to support it,” while others may favor preventive interventions even in borderline cases.
But he notes that many patients have no strong general preferences and often ask a trusted clinician to decide for them. “For such patients, the best approach is for clinicians to be knowledgeable about the data on primary prevention with aspirin. Close reading of the new USPSTF guideline and its companion evidence review, and becoming familiar with the three more recent aspirin trials, is a good way to prepare for these clinical encounters,” he concludes.
A cardiologist’s view
Commenting on the task force statement for this news organization, Andrew Freeman, MD, a cardiologist at National Jewish Health, Denver, noted that cardiology societies are already making similar recommendations on aspirin use in primary prevention. “The American College of Cardiology prevention guidelines have been giving similar advice for a couple of years now. It takes a few years for professional societies to catch up with each other,” he said.
“Over the last few years, it has become obvious that the benefit of aspirin is not really very positive until a patient has had a cardiovascular event. In primary prevention, it doesn’t become beneficial unless they are at quite a high risk of having an event,” Dr. Freeman noted.
“In general, most cardiologists are now telling people that, despite what they may have been told in the past, they don’t need to be on aspirin unless they have had a cardiovascular event,” he added. “Our understanding has changed over the years and the weight of evidence has now become clear that the risk of bleeding is not insignificant.”
Dr. Freeman agreed with the shared decision-making advocated for patients in the 40-59 age group. “If a patient is particularly worried about a family history of heart disease, taking aspirin may make some sense, but for most people who have not had a cardiovascular event, the net benefit is very low and gets lower with age as the bleeding risk increases,” he said.
The USPSTF is an independent, voluntary body. The U.S. Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF.
A version of this article first appeared on Medscape.com.
FROM JAMA
Complicated appendicitis during pregnancy: Immediate surgery may be best
Pregnant women who underwent immediate surgery to treat a ruptured or abscessed appendix had lower risk of infectious complications, compared with those whose complicated appendicitis was managed without surgery, according to new research.
Most cases that began with nonoperative management eventually required surgery, and the operative delay was associated with an increased risk of preterm labor, preterm delivery, and abortion.
“Our study findings may help to define the preferred management strategy in complicated appendicitis during pregnancy to be immediate operation,” Kazuhide Matsushima, MD, an assistant professor of clinical surgery at the University of Southern California, Los Angeles, and colleagues wrote.
The retrospective study was published in JAMA Network Open.
While acute appendicitis is relatively rare during pregnancy, it is the most common nonobstetric emergency in pregnant women, Dr. Matsushima said. This condition occurs in an estimated 1 in 700 to 1 in 1,500 pregnancies, and some data suggest that pregnant women are at higher risk for perforation and other forms of complicated appendicitis.
National guidelines support appendectomy as the first-line treatment for pregnant women with acute uncomplicated appendicitis, but there is no clear guidance on the best treatment approach for managing complicated appendicitis in this population, the authors note.
To better understand how surgical and nonoperational interventions affected outcomes, investigators analyzed data from the National Inpatient Sample from January 2003 to September 2015 to identify pregnant women with complicated appendicitis. The condition was defined as “acute appendicitis with generalized peritonitis” and “acute appendicitis with peritoneal abscess.” Patients were excluded if they had complications such as ectopic pregnancy and hydatidiform mole.
Investigators split the patients into three groups: those who underwent immediate operation for complicated appendicitis, those whose appendicitis was successfully managed without surgery, and those in whom nonoperative management of their condition failed, resulting in delayed surgery. Failed nonoperative management was defined as at least 1 day of nonoperative management followed by a laparoscopic or open appendectomy.
Of the 8,087 pregnant women identified during the study with complicated appendicitis, 55.5% underwent immediate appendectomy, 11.8% were successfully treated without surgical intervention, and 32.7% had delayed operations after initial failed nonoperative management. There was no significant difference in preterm delivery, preterm labor, or abortion between the immediate operative and successful nonoperative groups; however, the successful nonoperative group was more than twice as likely to experience premature rupture of membranes (odds ratio, 2.77; P = .03). Patients successfully treated without surgery also were at higher risk for infections such as amniotic infection (OR, 4.35; P < .001), pneumonia (OR, 2.52; P < .001), and sepsis (OR, 1.52; P = .01), compared with patients who underwent immediate operation.
Patients who had delayed surgery were 45% more likely to experience preterm delivery, preterm labor, or abortion (OR, 1.45; P < .001), compared with the immediate surgery group. The delayed surgery group was also at higher risk for antepartum hemorrhage (OR, 1.56; P = .03) and premature rupture of membranes (OR, 3.44; P = .002). They were more than four times as likely to have amniotic infection (OR, 4.74; P < .001), twice as likely to contract pneumonia (OR, 2.01; P < .001), and 58% more likely to develop sepsis (OR, 1.58; P < .001), compared with the immediate surgery group. The researchers calculated that every day surgery was delayed, the risk of preterm delivery, preterm labor, and abortion rose by 23% (OR, 1.23; P < .001).
Delayed surgery and successful nonoperative management were also associated with higher hospital charges and longer hospital stays.
Because this was a retrospective study, there are some limitations to the findings, Dr. Matsushima said, and therefore it should not be used to justify changing standards of care; however, it does give more information on the risks associated with different interventions. “It’s very important to have a discussion with the patient and make a shared decision,” he told this news organization, “because each option has significant risks and benefits.”
Because the data were from a database, he added, the research team was not able to see if outcomes from immediate surgery, nonoperative management, and delayed surgery differed in each trimester.
Kenneth W. Sharp, MD, a professor of surgery at Vanderbilt University Medical Center in Nashville, Tenn., agreed that the study does have limitations, such as lack of information on how complicated appendicitis was identified and diagnosed; however, the study does provide guidance to surgeons in a surgical area with “very sparse literature,” he told this news organization. Dr. Sharp is also a regent from the American College of Surgeons, which arranged the interview.
“Especially with these very complicated patients, it was never clear what to do,” he said. “With the recent studies showing that treatment of appendicitis with antibiotics works for a large number of people, people start extrapolating [those findings] to complicated appendicitis and they start extrapolating it to pregnant women, none of which the studies were meant to show anything about,” he said.
This analysis gives additional information to inform treatment decisions in pregnant women who may be hesitant to undergo this abdominal surgery because of possible complications, like pregnancy loss, he added. “Now, I can say to them that the data would suggest that with your particular complicated appendicitis, we should operate sooner, not later.”
Dr. Matsushima and Dr. Sharp have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Pregnant women who underwent immediate surgery to treat a ruptured or abscessed appendix had lower risk of infectious complications, compared with those whose complicated appendicitis was managed without surgery, according to new research.
Most cases that began with nonoperative management eventually required surgery, and the operative delay was associated with an increased risk of preterm labor, preterm delivery, and abortion.
“Our study findings may help to define the preferred management strategy in complicated appendicitis during pregnancy to be immediate operation,” Kazuhide Matsushima, MD, an assistant professor of clinical surgery at the University of Southern California, Los Angeles, and colleagues wrote.
The retrospective study was published in JAMA Network Open.
While acute appendicitis is relatively rare during pregnancy, it is the most common nonobstetric emergency in pregnant women, Dr. Matsushima said. This condition occurs in an estimated 1 in 700 to 1 in 1,500 pregnancies, and some data suggest that pregnant women are at higher risk for perforation and other forms of complicated appendicitis.
National guidelines support appendectomy as the first-line treatment for pregnant women with acute uncomplicated appendicitis, but there is no clear guidance on the best treatment approach for managing complicated appendicitis in this population, the authors note.
To better understand how surgical and nonoperational interventions affected outcomes, investigators analyzed data from the National Inpatient Sample from January 2003 to September 2015 to identify pregnant women with complicated appendicitis. The condition was defined as “acute appendicitis with generalized peritonitis” and “acute appendicitis with peritoneal abscess.” Patients were excluded if they had complications such as ectopic pregnancy and hydatidiform mole.
Investigators split the patients into three groups: those who underwent immediate operation for complicated appendicitis, those whose appendicitis was successfully managed without surgery, and those in whom nonoperative management of their condition failed, resulting in delayed surgery. Failed nonoperative management was defined as at least 1 day of nonoperative management followed by a laparoscopic or open appendectomy.
Of the 8,087 pregnant women identified during the study with complicated appendicitis, 55.5% underwent immediate appendectomy, 11.8% were successfully treated without surgical intervention, and 32.7% had delayed operations after initial failed nonoperative management. There was no significant difference in preterm delivery, preterm labor, or abortion between the immediate operative and successful nonoperative groups; however, the successful nonoperative group was more than twice as likely to experience premature rupture of membranes (odds ratio, 2.77; P = .03). Patients successfully treated without surgery also were at higher risk for infections such as amniotic infection (OR, 4.35; P < .001), pneumonia (OR, 2.52; P < .001), and sepsis (OR, 1.52; P = .01), compared with patients who underwent immediate operation.
Patients who had delayed surgery were 45% more likely to experience preterm delivery, preterm labor, or abortion (OR, 1.45; P < .001), compared with the immediate surgery group. The delayed surgery group was also at higher risk for antepartum hemorrhage (OR, 1.56; P = .03) and premature rupture of membranes (OR, 3.44; P = .002). They were more than four times as likely to have amniotic infection (OR, 4.74; P < .001), twice as likely to contract pneumonia (OR, 2.01; P < .001), and 58% more likely to develop sepsis (OR, 1.58; P < .001), compared with the immediate surgery group. The researchers calculated that every day surgery was delayed, the risk of preterm delivery, preterm labor, and abortion rose by 23% (OR, 1.23; P < .001).
Delayed surgery and successful nonoperative management were also associated with higher hospital charges and longer hospital stays.
Because this was a retrospective study, there are some limitations to the findings, Dr. Matsushima said, and therefore it should not be used to justify changing standards of care; however, it does give more information on the risks associated with different interventions. “It’s very important to have a discussion with the patient and make a shared decision,” he told this news organization, “because each option has significant risks and benefits.”
Because the data were from a database, he added, the research team was not able to see if outcomes from immediate surgery, nonoperative management, and delayed surgery differed in each trimester.
Kenneth W. Sharp, MD, a professor of surgery at Vanderbilt University Medical Center in Nashville, Tenn., agreed that the study does have limitations, such as lack of information on how complicated appendicitis was identified and diagnosed; however, the study does provide guidance to surgeons in a surgical area with “very sparse literature,” he told this news organization. Dr. Sharp is also a regent from the American College of Surgeons, which arranged the interview.
“Especially with these very complicated patients, it was never clear what to do,” he said. “With the recent studies showing that treatment of appendicitis with antibiotics works for a large number of people, people start extrapolating [those findings] to complicated appendicitis and they start extrapolating it to pregnant women, none of which the studies were meant to show anything about,” he said.
This analysis gives additional information to inform treatment decisions in pregnant women who may be hesitant to undergo this abdominal surgery because of possible complications, like pregnancy loss, he added. “Now, I can say to them that the data would suggest that with your particular complicated appendicitis, we should operate sooner, not later.”
Dr. Matsushima and Dr. Sharp have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Pregnant women who underwent immediate surgery to treat a ruptured or abscessed appendix had lower risk of infectious complications, compared with those whose complicated appendicitis was managed without surgery, according to new research.
Most cases that began with nonoperative management eventually required surgery, and the operative delay was associated with an increased risk of preterm labor, preterm delivery, and abortion.
“Our study findings may help to define the preferred management strategy in complicated appendicitis during pregnancy to be immediate operation,” Kazuhide Matsushima, MD, an assistant professor of clinical surgery at the University of Southern California, Los Angeles, and colleagues wrote.
The retrospective study was published in JAMA Network Open.
While acute appendicitis is relatively rare during pregnancy, it is the most common nonobstetric emergency in pregnant women, Dr. Matsushima said. This condition occurs in an estimated 1 in 700 to 1 in 1,500 pregnancies, and some data suggest that pregnant women are at higher risk for perforation and other forms of complicated appendicitis.
National guidelines support appendectomy as the first-line treatment for pregnant women with acute uncomplicated appendicitis, but there is no clear guidance on the best treatment approach for managing complicated appendicitis in this population, the authors note.
To better understand how surgical and nonoperational interventions affected outcomes, investigators analyzed data from the National Inpatient Sample from January 2003 to September 2015 to identify pregnant women with complicated appendicitis. The condition was defined as “acute appendicitis with generalized peritonitis” and “acute appendicitis with peritoneal abscess.” Patients were excluded if they had complications such as ectopic pregnancy and hydatidiform mole.
Investigators split the patients into three groups: those who underwent immediate operation for complicated appendicitis, those whose appendicitis was successfully managed without surgery, and those in whom nonoperative management of their condition failed, resulting in delayed surgery. Failed nonoperative management was defined as at least 1 day of nonoperative management followed by a laparoscopic or open appendectomy.
Of the 8,087 pregnant women identified during the study with complicated appendicitis, 55.5% underwent immediate appendectomy, 11.8% were successfully treated without surgical intervention, and 32.7% had delayed operations after initial failed nonoperative management. There was no significant difference in preterm delivery, preterm labor, or abortion between the immediate operative and successful nonoperative groups; however, the successful nonoperative group was more than twice as likely to experience premature rupture of membranes (odds ratio, 2.77; P = .03). Patients successfully treated without surgery also were at higher risk for infections such as amniotic infection (OR, 4.35; P < .001), pneumonia (OR, 2.52; P < .001), and sepsis (OR, 1.52; P = .01), compared with patients who underwent immediate operation.
Patients who had delayed surgery were 45% more likely to experience preterm delivery, preterm labor, or abortion (OR, 1.45; P < .001), compared with the immediate surgery group. The delayed surgery group was also at higher risk for antepartum hemorrhage (OR, 1.56; P = .03) and premature rupture of membranes (OR, 3.44; P = .002). They were more than four times as likely to have amniotic infection (OR, 4.74; P < .001), twice as likely to contract pneumonia (OR, 2.01; P < .001), and 58% more likely to develop sepsis (OR, 1.58; P < .001), compared with the immediate surgery group. The researchers calculated that every day surgery was delayed, the risk of preterm delivery, preterm labor, and abortion rose by 23% (OR, 1.23; P < .001).
Delayed surgery and successful nonoperative management were also associated with higher hospital charges and longer hospital stays.
Because this was a retrospective study, there are some limitations to the findings, Dr. Matsushima said, and therefore it should not be used to justify changing standards of care; however, it does give more information on the risks associated with different interventions. “It’s very important to have a discussion with the patient and make a shared decision,” he told this news organization, “because each option has significant risks and benefits.”
Because the data were from a database, he added, the research team was not able to see if outcomes from immediate surgery, nonoperative management, and delayed surgery differed in each trimester.
Kenneth W. Sharp, MD, a professor of surgery at Vanderbilt University Medical Center in Nashville, Tenn., agreed that the study does have limitations, such as lack of information on how complicated appendicitis was identified and diagnosed; however, the study does provide guidance to surgeons in a surgical area with “very sparse literature,” he told this news organization. Dr. Sharp is also a regent from the American College of Surgeons, which arranged the interview.
“Especially with these very complicated patients, it was never clear what to do,” he said. “With the recent studies showing that treatment of appendicitis with antibiotics works for a large number of people, people start extrapolating [those findings] to complicated appendicitis and they start extrapolating it to pregnant women, none of which the studies were meant to show anything about,” he said.
This analysis gives additional information to inform treatment decisions in pregnant women who may be hesitant to undergo this abdominal surgery because of possible complications, like pregnancy loss, he added. “Now, I can say to them that the data would suggest that with your particular complicated appendicitis, we should operate sooner, not later.”
Dr. Matsushima and Dr. Sharp have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN
Cautious optimism
Dear colleagues,
Welcome to the May edition of The New Gastroenterologist! Digestive Disease Week® (DDW) is approaching quickly, which is our first since 2019 with an option to attend in person. This will give many an opportunity to reconnect in a way we have not been able to in so long – a welcome reprieve from the virtual platforms we have become so accustomed to. Cautious optimism is pervasive throughout the country that the acuity of the pandemic may be receding, and that we are perhaps better equipped for future surges should they occur.
I’m excited to introduce this quarter’s content – beginning with our feature clinical “In Focus” piece. Gastroparesis often poses a therapeutic challenge to gastroenterologists; Dr. Thomas Abell and Dr. Prateek Mathur (University of Louisville) provide an excellent, comprehensive discussion of the utility and efficacy of dietary modifications, pharmacotherapy, pylorus-directed therapies, bioelectric therapy, and other novel approaches to the treatment of gastroparesis.
The role of a gastrointestinal psychologist within a gastroenterology practice is invaluable. The gut-brain axis is a key feature of any gastroenterological disorder and one of the hallmarks of therapy is behavioral symptom management. Dr. Alyse Bedell (University of Chicago) educates us on how to effectively integrate psychogastroenterology into our treatment plans and discusses which patients are poised to benefit the most from referral.
In just 2 short months, gastroenterology fellowship programs across the country will welcome their newest trainees. Dr. Rashmi Advani (Stony Brook University), Dr. Naba Saeed (University of Kentucky) and Dr. Aline Charabaty (Johns Hopkins University) offer detailed, practical advice to incoming fellows on how to make the most of (and survive!) the first year of gastroenterology fellowship, which can be one of the most challenging years of medical training.
In our Postfellowship Pathways section, we are fortunate to have Dr. Barbara Jung, chair of the department of medicine at the University of Washington and future AGA president, share her story. Her journey is inspirational as she discusses her path to success: How her roots in basic science led to building clinical programs and her transition from chief of a gastroenterology division to chair of a large department at one of the most prolific academic centers in the country.
One of the hallmarks of any heavily procedural field such as gastroenterology is innovation, namely the continuous evolution of procedural technique and utilization of novel technology. It can be difficult, however, to reconcile this innovation in the informed consent process when there are limited data on safety and efficacy. Dr. Peter Angelos and Dr. Jelani Williams (University of Chicago) share a riveting perspective on how to approach these scenarios in a wonderful addition to our medical ethics case series.
Finally, the DHPA Private Practice Perspectives article this quarter, written by Dr. Paul Feuerstadt (PACT-Gastroenterology Center, Hamden, Conn.) and Dr. Louis Korman (Capital Digestive Care, Maryland), reviews the benefits of performing clinical research in private practice and what early career physicians who would like to explore clinical research should look for when evaluating job opportunities.
If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Ryan Farrell ([email protected]), managing editor of TNG.
Stay well,
Vijaya L. Rao, MD
Editor-in-Chief
Assistant Professor of Medicine, University of Chicago, Section of Gastroenterology, Hepatology & Nutrition
Dear colleagues,
Welcome to the May edition of The New Gastroenterologist! Digestive Disease Week® (DDW) is approaching quickly, which is our first since 2019 with an option to attend in person. This will give many an opportunity to reconnect in a way we have not been able to in so long – a welcome reprieve from the virtual platforms we have become so accustomed to. Cautious optimism is pervasive throughout the country that the acuity of the pandemic may be receding, and that we are perhaps better equipped for future surges should they occur.
I’m excited to introduce this quarter’s content – beginning with our feature clinical “In Focus” piece. Gastroparesis often poses a therapeutic challenge to gastroenterologists; Dr. Thomas Abell and Dr. Prateek Mathur (University of Louisville) provide an excellent, comprehensive discussion of the utility and efficacy of dietary modifications, pharmacotherapy, pylorus-directed therapies, bioelectric therapy, and other novel approaches to the treatment of gastroparesis.
The role of a gastrointestinal psychologist within a gastroenterology practice is invaluable. The gut-brain axis is a key feature of any gastroenterological disorder and one of the hallmarks of therapy is behavioral symptom management. Dr. Alyse Bedell (University of Chicago) educates us on how to effectively integrate psychogastroenterology into our treatment plans and discusses which patients are poised to benefit the most from referral.
In just 2 short months, gastroenterology fellowship programs across the country will welcome their newest trainees. Dr. Rashmi Advani (Stony Brook University), Dr. Naba Saeed (University of Kentucky) and Dr. Aline Charabaty (Johns Hopkins University) offer detailed, practical advice to incoming fellows on how to make the most of (and survive!) the first year of gastroenterology fellowship, which can be one of the most challenging years of medical training.
In our Postfellowship Pathways section, we are fortunate to have Dr. Barbara Jung, chair of the department of medicine at the University of Washington and future AGA president, share her story. Her journey is inspirational as she discusses her path to success: How her roots in basic science led to building clinical programs and her transition from chief of a gastroenterology division to chair of a large department at one of the most prolific academic centers in the country.
One of the hallmarks of any heavily procedural field such as gastroenterology is innovation, namely the continuous evolution of procedural technique and utilization of novel technology. It can be difficult, however, to reconcile this innovation in the informed consent process when there are limited data on safety and efficacy. Dr. Peter Angelos and Dr. Jelani Williams (University of Chicago) share a riveting perspective on how to approach these scenarios in a wonderful addition to our medical ethics case series.
Finally, the DHPA Private Practice Perspectives article this quarter, written by Dr. Paul Feuerstadt (PACT-Gastroenterology Center, Hamden, Conn.) and Dr. Louis Korman (Capital Digestive Care, Maryland), reviews the benefits of performing clinical research in private practice and what early career physicians who would like to explore clinical research should look for when evaluating job opportunities.
If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Ryan Farrell ([email protected]), managing editor of TNG.
Stay well,
Vijaya L. Rao, MD
Editor-in-Chief
Assistant Professor of Medicine, University of Chicago, Section of Gastroenterology, Hepatology & Nutrition
Dear colleagues,
Welcome to the May edition of The New Gastroenterologist! Digestive Disease Week® (DDW) is approaching quickly, which is our first since 2019 with an option to attend in person. This will give many an opportunity to reconnect in a way we have not been able to in so long – a welcome reprieve from the virtual platforms we have become so accustomed to. Cautious optimism is pervasive throughout the country that the acuity of the pandemic may be receding, and that we are perhaps better equipped for future surges should they occur.
I’m excited to introduce this quarter’s content – beginning with our feature clinical “In Focus” piece. Gastroparesis often poses a therapeutic challenge to gastroenterologists; Dr. Thomas Abell and Dr. Prateek Mathur (University of Louisville) provide an excellent, comprehensive discussion of the utility and efficacy of dietary modifications, pharmacotherapy, pylorus-directed therapies, bioelectric therapy, and other novel approaches to the treatment of gastroparesis.
The role of a gastrointestinal psychologist within a gastroenterology practice is invaluable. The gut-brain axis is a key feature of any gastroenterological disorder and one of the hallmarks of therapy is behavioral symptom management. Dr. Alyse Bedell (University of Chicago) educates us on how to effectively integrate psychogastroenterology into our treatment plans and discusses which patients are poised to benefit the most from referral.
In just 2 short months, gastroenterology fellowship programs across the country will welcome their newest trainees. Dr. Rashmi Advani (Stony Brook University), Dr. Naba Saeed (University of Kentucky) and Dr. Aline Charabaty (Johns Hopkins University) offer detailed, practical advice to incoming fellows on how to make the most of (and survive!) the first year of gastroenterology fellowship, which can be one of the most challenging years of medical training.
In our Postfellowship Pathways section, we are fortunate to have Dr. Barbara Jung, chair of the department of medicine at the University of Washington and future AGA president, share her story. Her journey is inspirational as she discusses her path to success: How her roots in basic science led to building clinical programs and her transition from chief of a gastroenterology division to chair of a large department at one of the most prolific academic centers in the country.
One of the hallmarks of any heavily procedural field such as gastroenterology is innovation, namely the continuous evolution of procedural technique and utilization of novel technology. It can be difficult, however, to reconcile this innovation in the informed consent process when there are limited data on safety and efficacy. Dr. Peter Angelos and Dr. Jelani Williams (University of Chicago) share a riveting perspective on how to approach these scenarios in a wonderful addition to our medical ethics case series.
Finally, the DHPA Private Practice Perspectives article this quarter, written by Dr. Paul Feuerstadt (PACT-Gastroenterology Center, Hamden, Conn.) and Dr. Louis Korman (Capital Digestive Care, Maryland), reviews the benefits of performing clinical research in private practice and what early career physicians who would like to explore clinical research should look for when evaluating job opportunities.
If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Ryan Farrell ([email protected]), managing editor of TNG.
Stay well,
Vijaya L. Rao, MD
Editor-in-Chief
Assistant Professor of Medicine, University of Chicago, Section of Gastroenterology, Hepatology & Nutrition
The benefits of conducting clinical research in private practice
Most people believe that, if you want to conduct clinical research, the best path is going into academic medicine. However, for physicians who want both the benefits of practicing in the community setting and a career in research,
Our practices, Capital Digestive Care in Silver Spring, Md., and the PACT-Gastroenterology Center in Hamden, Conn, have been conducting clinical trials for many years on serious diseases such as inflammatory bowel disease, gastroparesis, and most recently, recurrent infection of Clostridioides difficile. We both also worked on the National Institutes of Health–sponsored Anal Cancer/HSIL Outcomes Research (ANCHOR) study.
Academic setting vs. private practice
Research in our practices is similar to the academic setting with regards to how studies are conducted and structured since everyone involved in the study follows the same protocol. The benefit of being in a community setting is that you have a wide range of patients that you are seeing every day.
Getting involved in research is not for everyone, but for those who do get involved, the decision is a rewarding one that can make a significant difference in patients’ lives. Offering new therapeutics for disease states is a powerful tool for a provider, and it is exciting and rewarding to engage in the research considering new mechanisms of action and new approaches to treating diseases.
Finding a better treatment for C. difficile
For example, C. difficile is common in older people who’ve received antibiotics for other infections, especially residents of long-term care facilities. These residents have frequent antibiotic exposure and are already vulnerable to infection because of advanced age, multiple comorbid conditions, and communal living conditions. Once a case of C. difficile is diagnosed in a nursing home, it can spread through contaminated equipment, environments, or hands.
The treatment for C. difficile is to control the bacteria with antibiotics, but spores remain, so after a few days in certain people the spores germinate, and the C. difficile returns: a recurrence. It used to be that, after a second reoccurrence, you would send the patient for a fecal transplant, which was a scarce resource and a challenging process.
To perform a fecal transplant, you would need a spouse or a family member to provide a stool sample. After their stool was tested, the family member would need to process their stool in a blender with saline and draw it up in syringes. Once you had the material, the patient would need to go through a full colonoscopy to infuse the material into the colon. Of course, increased restrictions and safety precautions from the COVID-19 pandemic have made fecal transplants even more complex.
Given all these challenges, conducting research considering microbiota-based live biotherapeutics, the term the Food and Drug Administration uses for pharmaceutically produced forms of fecal microbiota transplantation, is very appealing. There are several different formulations that have come through clinical trials recently including RBX-2660, SER-109, and CP101.
SER-109 is an orally taken treatment produced by Seres Therapeutics. Once patients with acute recurrence of C. difficile are treated with standard antibiotics, they are given a course of four SER-109 capsules for 3 days. The results of the SER-109 study were published recently in the New England Journal of Medicine. This is the first phase 3 clinical trial published on a microbiota-based live biotherapeutic treatment, and the results were exciting, showing a clear efficacy benefit for SER-109.
In the case of C. difficile, we understand the deficiency that SER-109 replaces. SER-109 changes the microbiome within the colon so that the environment becomes less hospitable to C. difficile, which helps to better resist recurrence. With this therapy, we are replenishing the good bacteria, which helps to keep C. difficile from regerminating.
The therapy showed excellent results through the significant difference in rates of recurrence seen in patients with recurrent C. difficile infection following 8 weeks of follow-up. This is exciting because we believe the future of therapeutics for many diseases might involve this type of manipulation of the microbiota, and this is the first to show such an impact with this class of therapeutic.
Joining a practice that conducts clinical research
Within private practice settings, the opportunity to participate in clinical trials usually involves somewhat less bureaucracy and a more patient-centric approach. Private practitioners can also be selective in their research, and we only participate in a handful of selected trials that fit with the expertise of the providers in our practice.
We find the people best suited for involvement in pharmaceutical trials are those providers who want to participate in the scientific process and who see specialized patient populations with the diseases treated by the therapies being studied. In our experience, the young practitioner who enjoyed conducting research in fellowship, who attends national conferences, who keeps track of cutting-edge therapeutics within gastroenterology, and who is highly motivated will be successful in providing this service to their patients.
If you’re an early-career physician who would like to explore clinical research in private practice, there are a several things to look for when considering joining a practice.
Make sure the group has a support infrastructure and a clear compensation model for physicians who want to conduct research. Another important consideration is the kind of support staff the practice provides to manage clinical trials. Does the practice have physician and physician assistant subinvestigators and certified clinical research coordinators? It would be smart to research what kind of capabilities the practice has and inquire about what kind of commitment they have in terms of supporting research efforts.
If the practice you’re thinking of joining has a well-supported research program, you’ll soon be on the way to studying innovative treatments for a wide range of diseases affecting our communities, such as Crohn’s disease, ulcerative colitis, eosinophilic esophagitis, celiac disease, and many others. Many practices also participate in trials assessing new technologies in endoscopy, such as capsule endoscopy of the colon.
It’s incredibly important for community practices to engage in studies and actively recruit younger physicians to participate in their research programs. It changes the character of the practice by bringing a certain level of scholarly activity that benefits the patients we serve, the field of gastroenterology, and medicine as a whole.
Dr. Feuerstadt is a practicing gastroenterologist at the PACT-Gastroenterology Center and is affiliated with Yale New Haven Hospital. Dr. Korman is codirector of Chevy Chase Clinical Research at Capital Digestive Care and a principal investigator in the Seres Therapeutics phase 3 ECOSPOR III study evaluating SER-109. Dr. Feuerstadt disclosed relationships with SERES Therapeutics, Ferring Rebiotix, Finch Therapeutics, and Merck. Dr. Korman disclosed a relationship with SERES Therapeutics.
Most people believe that, if you want to conduct clinical research, the best path is going into academic medicine. However, for physicians who want both the benefits of practicing in the community setting and a career in research,
Our practices, Capital Digestive Care in Silver Spring, Md., and the PACT-Gastroenterology Center in Hamden, Conn, have been conducting clinical trials for many years on serious diseases such as inflammatory bowel disease, gastroparesis, and most recently, recurrent infection of Clostridioides difficile. We both also worked on the National Institutes of Health–sponsored Anal Cancer/HSIL Outcomes Research (ANCHOR) study.
Academic setting vs. private practice
Research in our practices is similar to the academic setting with regards to how studies are conducted and structured since everyone involved in the study follows the same protocol. The benefit of being in a community setting is that you have a wide range of patients that you are seeing every day.
Getting involved in research is not for everyone, but for those who do get involved, the decision is a rewarding one that can make a significant difference in patients’ lives. Offering new therapeutics for disease states is a powerful tool for a provider, and it is exciting and rewarding to engage in the research considering new mechanisms of action and new approaches to treating diseases.
Finding a better treatment for C. difficile
For example, C. difficile is common in older people who’ve received antibiotics for other infections, especially residents of long-term care facilities. These residents have frequent antibiotic exposure and are already vulnerable to infection because of advanced age, multiple comorbid conditions, and communal living conditions. Once a case of C. difficile is diagnosed in a nursing home, it can spread through contaminated equipment, environments, or hands.
The treatment for C. difficile is to control the bacteria with antibiotics, but spores remain, so after a few days in certain people the spores germinate, and the C. difficile returns: a recurrence. It used to be that, after a second reoccurrence, you would send the patient for a fecal transplant, which was a scarce resource and a challenging process.
To perform a fecal transplant, you would need a spouse or a family member to provide a stool sample. After their stool was tested, the family member would need to process their stool in a blender with saline and draw it up in syringes. Once you had the material, the patient would need to go through a full colonoscopy to infuse the material into the colon. Of course, increased restrictions and safety precautions from the COVID-19 pandemic have made fecal transplants even more complex.
Given all these challenges, conducting research considering microbiota-based live biotherapeutics, the term the Food and Drug Administration uses for pharmaceutically produced forms of fecal microbiota transplantation, is very appealing. There are several different formulations that have come through clinical trials recently including RBX-2660, SER-109, and CP101.
SER-109 is an orally taken treatment produced by Seres Therapeutics. Once patients with acute recurrence of C. difficile are treated with standard antibiotics, they are given a course of four SER-109 capsules for 3 days. The results of the SER-109 study were published recently in the New England Journal of Medicine. This is the first phase 3 clinical trial published on a microbiota-based live biotherapeutic treatment, and the results were exciting, showing a clear efficacy benefit for SER-109.
In the case of C. difficile, we understand the deficiency that SER-109 replaces. SER-109 changes the microbiome within the colon so that the environment becomes less hospitable to C. difficile, which helps to better resist recurrence. With this therapy, we are replenishing the good bacteria, which helps to keep C. difficile from regerminating.
The therapy showed excellent results through the significant difference in rates of recurrence seen in patients with recurrent C. difficile infection following 8 weeks of follow-up. This is exciting because we believe the future of therapeutics for many diseases might involve this type of manipulation of the microbiota, and this is the first to show such an impact with this class of therapeutic.
Joining a practice that conducts clinical research
Within private practice settings, the opportunity to participate in clinical trials usually involves somewhat less bureaucracy and a more patient-centric approach. Private practitioners can also be selective in their research, and we only participate in a handful of selected trials that fit with the expertise of the providers in our practice.
We find the people best suited for involvement in pharmaceutical trials are those providers who want to participate in the scientific process and who see specialized patient populations with the diseases treated by the therapies being studied. In our experience, the young practitioner who enjoyed conducting research in fellowship, who attends national conferences, who keeps track of cutting-edge therapeutics within gastroenterology, and who is highly motivated will be successful in providing this service to their patients.
If you’re an early-career physician who would like to explore clinical research in private practice, there are a several things to look for when considering joining a practice.
Make sure the group has a support infrastructure and a clear compensation model for physicians who want to conduct research. Another important consideration is the kind of support staff the practice provides to manage clinical trials. Does the practice have physician and physician assistant subinvestigators and certified clinical research coordinators? It would be smart to research what kind of capabilities the practice has and inquire about what kind of commitment they have in terms of supporting research efforts.
If the practice you’re thinking of joining has a well-supported research program, you’ll soon be on the way to studying innovative treatments for a wide range of diseases affecting our communities, such as Crohn’s disease, ulcerative colitis, eosinophilic esophagitis, celiac disease, and many others. Many practices also participate in trials assessing new technologies in endoscopy, such as capsule endoscopy of the colon.
It’s incredibly important for community practices to engage in studies and actively recruit younger physicians to participate in their research programs. It changes the character of the practice by bringing a certain level of scholarly activity that benefits the patients we serve, the field of gastroenterology, and medicine as a whole.
Dr. Feuerstadt is a practicing gastroenterologist at the PACT-Gastroenterology Center and is affiliated with Yale New Haven Hospital. Dr. Korman is codirector of Chevy Chase Clinical Research at Capital Digestive Care and a principal investigator in the Seres Therapeutics phase 3 ECOSPOR III study evaluating SER-109. Dr. Feuerstadt disclosed relationships with SERES Therapeutics, Ferring Rebiotix, Finch Therapeutics, and Merck. Dr. Korman disclosed a relationship with SERES Therapeutics.
Most people believe that, if you want to conduct clinical research, the best path is going into academic medicine. However, for physicians who want both the benefits of practicing in the community setting and a career in research,
Our practices, Capital Digestive Care in Silver Spring, Md., and the PACT-Gastroenterology Center in Hamden, Conn, have been conducting clinical trials for many years on serious diseases such as inflammatory bowel disease, gastroparesis, and most recently, recurrent infection of Clostridioides difficile. We both also worked on the National Institutes of Health–sponsored Anal Cancer/HSIL Outcomes Research (ANCHOR) study.
Academic setting vs. private practice
Research in our practices is similar to the academic setting with regards to how studies are conducted and structured since everyone involved in the study follows the same protocol. The benefit of being in a community setting is that you have a wide range of patients that you are seeing every day.
Getting involved in research is not for everyone, but for those who do get involved, the decision is a rewarding one that can make a significant difference in patients’ lives. Offering new therapeutics for disease states is a powerful tool for a provider, and it is exciting and rewarding to engage in the research considering new mechanisms of action and new approaches to treating diseases.
Finding a better treatment for C. difficile
For example, C. difficile is common in older people who’ve received antibiotics for other infections, especially residents of long-term care facilities. These residents have frequent antibiotic exposure and are already vulnerable to infection because of advanced age, multiple comorbid conditions, and communal living conditions. Once a case of C. difficile is diagnosed in a nursing home, it can spread through contaminated equipment, environments, or hands.
The treatment for C. difficile is to control the bacteria with antibiotics, but spores remain, so after a few days in certain people the spores germinate, and the C. difficile returns: a recurrence. It used to be that, after a second reoccurrence, you would send the patient for a fecal transplant, which was a scarce resource and a challenging process.
To perform a fecal transplant, you would need a spouse or a family member to provide a stool sample. After their stool was tested, the family member would need to process their stool in a blender with saline and draw it up in syringes. Once you had the material, the patient would need to go through a full colonoscopy to infuse the material into the colon. Of course, increased restrictions and safety precautions from the COVID-19 pandemic have made fecal transplants even more complex.
Given all these challenges, conducting research considering microbiota-based live biotherapeutics, the term the Food and Drug Administration uses for pharmaceutically produced forms of fecal microbiota transplantation, is very appealing. There are several different formulations that have come through clinical trials recently including RBX-2660, SER-109, and CP101.
SER-109 is an orally taken treatment produced by Seres Therapeutics. Once patients with acute recurrence of C. difficile are treated with standard antibiotics, they are given a course of four SER-109 capsules for 3 days. The results of the SER-109 study were published recently in the New England Journal of Medicine. This is the first phase 3 clinical trial published on a microbiota-based live biotherapeutic treatment, and the results were exciting, showing a clear efficacy benefit for SER-109.
In the case of C. difficile, we understand the deficiency that SER-109 replaces. SER-109 changes the microbiome within the colon so that the environment becomes less hospitable to C. difficile, which helps to better resist recurrence. With this therapy, we are replenishing the good bacteria, which helps to keep C. difficile from regerminating.
The therapy showed excellent results through the significant difference in rates of recurrence seen in patients with recurrent C. difficile infection following 8 weeks of follow-up. This is exciting because we believe the future of therapeutics for many diseases might involve this type of manipulation of the microbiota, and this is the first to show such an impact with this class of therapeutic.
Joining a practice that conducts clinical research
Within private practice settings, the opportunity to participate in clinical trials usually involves somewhat less bureaucracy and a more patient-centric approach. Private practitioners can also be selective in their research, and we only participate in a handful of selected trials that fit with the expertise of the providers in our practice.
We find the people best suited for involvement in pharmaceutical trials are those providers who want to participate in the scientific process and who see specialized patient populations with the diseases treated by the therapies being studied. In our experience, the young practitioner who enjoyed conducting research in fellowship, who attends national conferences, who keeps track of cutting-edge therapeutics within gastroenterology, and who is highly motivated will be successful in providing this service to their patients.
If you’re an early-career physician who would like to explore clinical research in private practice, there are a several things to look for when considering joining a practice.
Make sure the group has a support infrastructure and a clear compensation model for physicians who want to conduct research. Another important consideration is the kind of support staff the practice provides to manage clinical trials. Does the practice have physician and physician assistant subinvestigators and certified clinical research coordinators? It would be smart to research what kind of capabilities the practice has and inquire about what kind of commitment they have in terms of supporting research efforts.
If the practice you’re thinking of joining has a well-supported research program, you’ll soon be on the way to studying innovative treatments for a wide range of diseases affecting our communities, such as Crohn’s disease, ulcerative colitis, eosinophilic esophagitis, celiac disease, and many others. Many practices also participate in trials assessing new technologies in endoscopy, such as capsule endoscopy of the colon.
It’s incredibly important for community practices to engage in studies and actively recruit younger physicians to participate in their research programs. It changes the character of the practice by bringing a certain level of scholarly activity that benefits the patients we serve, the field of gastroenterology, and medicine as a whole.
Dr. Feuerstadt is a practicing gastroenterologist at the PACT-Gastroenterology Center and is affiliated with Yale New Haven Hospital. Dr. Korman is codirector of Chevy Chase Clinical Research at Capital Digestive Care and a principal investigator in the Seres Therapeutics phase 3 ECOSPOR III study evaluating SER-109. Dr. Feuerstadt disclosed relationships with SERES Therapeutics, Ferring Rebiotix, Finch Therapeutics, and Merck. Dr. Korman disclosed a relationship with SERES Therapeutics.
My path: Challenges and decisions along the way
It took me a little while to get started on this assignment. What would be most useful to young gastroenterologists embarking on their careers? When I asked around, I heard that many of you wanted me to describe challenges and decision points. The following list is vaguely chronological, surely noncomprehensive, and meant to serve as a starting point.
1. To stay in basic science or return to patient care
My start in science was rocky. I had come to the United States for a post-doc after medical school in Germany. I had never pipetted before. It was the early days of array technologies, and the lab was very technical and basic. We made our own arrays and our own analytics, and none of my experiments worked. So, I spent 1 year feeling like I made no progress – but in hindsight I appreciate the tremendous growth in these formative years honing inquiry and persistence, as well as building resilience. I added a third year as some results were finally emerging; however, the bedside started to feel very far away. I could not ignore the tug back to the patient care, and after contemplating a PhD program, I decided to apply for residency in a physician-scientist pathway. Given the streamlined training that allowed for science and clinical education in an organized fashion, I also decided to stay in the U.S. This of course had vast personal consequences, which I did not fully appreciate at the time.
Residency was another time of immense growth, I was the only “foreign medical graduate” and had a lot to catch up on, but I enjoyed my amazing peers and the hands-on learning.
Pearl: Follow your passion. Not what makes most sense or what someone wants for you or what you could achieve given your past work. Do what will get you up in the morning and add a bounce to your step.
2. To go for big impact or climate
At UCSD at the time, there was a culture of impactful mega-labs, up 30 post-docs, often with many working on the same project with the ones finishing first garnering the publication. This created a “go big or go home” (literally) atmosphere. As part of the PSTP program, I was supported by the GI T32 and, being “free labor,” had a pretty wide array of labs to choose from. To the program director’s surprise, I settled on a fairly junior investigator, who was a fellow gastroenterologist and took a personal interest in my career. When making that decision, I prioritized climate over outcome. I remember thinking to myself that how I spent my time was just as important as the potential outcome of the time spent. Through my years in Dr. John Carethers’ lab, I gained insight into his administrative and leadership roles which added another dimension to our mentorship relationship. These years were fun and productive, and our mentorship grew into a friendship.
Pearl: Look for the right people to work with. Particularly who you work for. Everything else is secondary as the right people will set the tone and most influence your day-to-day experience, which is the foundation of your success.
3. To cultivate a life outside of academia
When I turned 30, I remember driving down Interstate 5 in San Diego and taking stock. Yes, I loved clinical work, I felt valued, and was in a stimulating supportive environment. Yet, I was so immersed that everything else seemed to take a back seat. I made the conscious decision on that drive to prioritize life outside of academia. It is not like I did not have one, I just decided to set an intention so it would not get away from me. I continue to make a conscious effort to be present for my husband, my kids, my family – to take time and spend it together without work bleeding into it. And since this is a goal in and of itself, there is no conflict! Through less travel and no more late nights or weekends, your nonacademic life will flourish.
Pearl: Deliberately prioritize your family and hobbies in the long run. Make key decisions with that in mind.
4. To grow your own program or lead others
When we moved to Chicago for my husband’s residency (he went to medical school as his third career at age 35), I was very excited to build my own comprehensive GI cancer genetics program at Northwestern. It was a little scary but also fun to now run my own lab and try to connect the clinical community around hereditary GI cancers. The program was moving along nicely when I received a generic letter asking for applications to become division chief at the neighboring University of Illinois. The letter concluded with an enticing “Chicago is a vibrant city,” so clearly it was meant for a broad audience. I was not sure what to do and again took stock. Did I want to continue to increase the impact of my own work – clearly there was a lot more ground to cover. Or, did I want to be part of making further-reaching decisions? I had been approached by fellows who wanted to be recruited, and I had ideas for programs and thoughts around processes. While my input was valued, I was not the ultimate decision maker. I decided that I either focus on one or the other and so applied for the position and then took the leap.
Pearl: There are many forks and they will present when you do not expect them. Assess and consider. Also know yourself – not everything that is attainable is desirable.
5. To have greater influence or stay with what you know
Becoming a division chief was transformative. Learning to integrate the needs of various and sometimes conflicting stakeholders, running an operation but also thinking strategically and mission-based – I was drinking from a firehose. How to measure success as a leader? I was fortunate to enter the division at a turbulent time where much rebuilding was needed and it was easy to implement and see change.
Pearl: Again know yourself – not everything that is attainable is desirable. But also – take risks. What is the worst that can happen? Growth may not be attained by waiting.
6. To be spread too thin or close doors
As you develop your focus and expertise while implementing No. 3, you will run out of hours in the day. This means you will need to become more and more efficient, as in delegating (and letting go) where you can and doing fewer nonessential tasks. However, you want to think hard about closing doors completely. I have been careful to hone and keep my endoscopy skills as well as my scientific output. To leave the doors ajar, I have tried to find ways to be very deliberate with my involvement and also understand that at some point it may make sense to close a door.
Pearl: Do not try to do everything well, you will risk doing everything poorly. Work on “good enough” for tasks that can be very involved. Think hard before permanently leaving something behind as you may lose flexibility down the road.
7. To enjoy fruits of labor or continue to grow
A question I get asked often is regarding the ideal time to move. In my mind, there is no perfect time. It depends on your satisfaction with your current position (see No. 2), your personal situation (see No. 3), and what you want at that juncture (see No. 5). At some point, one may want to stay awhile and enjoy. Or continue to change and grow – both have their merits and there is no right or wrong.
Pearl: When contemplating next steps, go back to your passion and priorities. Has anything shifted? Are your goals being met? Are you enjoying yourself? Advice can be helpful but also confusing. Remember, no one knows you like you do.
8. To show tangible results or build out relationships
Over time, as you become more and more efficient, you simultaneously need to spend more time fostering relationships. This feels strange at first as it is the opposite of a fast-paced to-do list and the “results” appear elusive. Build in time for relating – with peers, superiors, fellows, members of your lab.
Pearl: Form relationships early and often. Take care of them (No. 3) and include relationship building into your workstream – I promise it will make your path more successful and satisfying.
I hope this list shows that there are many forks and no one right way. Advice is helpful and subjective. No path is the same, and it truly is yours to shape. Be thoughtful and enjoy – your journey will be amazing and full of surprises.
Dr. Jung is professor and chair, and the Robert G. Petersdorf Endowed Chair in Medicine, in the department of medicine at the University of Washington, Seattle. She is on Twitter @barbarahjung. She has no conflicts of interest.
It took me a little while to get started on this assignment. What would be most useful to young gastroenterologists embarking on their careers? When I asked around, I heard that many of you wanted me to describe challenges and decision points. The following list is vaguely chronological, surely noncomprehensive, and meant to serve as a starting point.
1. To stay in basic science or return to patient care
My start in science was rocky. I had come to the United States for a post-doc after medical school in Germany. I had never pipetted before. It was the early days of array technologies, and the lab was very technical and basic. We made our own arrays and our own analytics, and none of my experiments worked. So, I spent 1 year feeling like I made no progress – but in hindsight I appreciate the tremendous growth in these formative years honing inquiry and persistence, as well as building resilience. I added a third year as some results were finally emerging; however, the bedside started to feel very far away. I could not ignore the tug back to the patient care, and after contemplating a PhD program, I decided to apply for residency in a physician-scientist pathway. Given the streamlined training that allowed for science and clinical education in an organized fashion, I also decided to stay in the U.S. This of course had vast personal consequences, which I did not fully appreciate at the time.
Residency was another time of immense growth, I was the only “foreign medical graduate” and had a lot to catch up on, but I enjoyed my amazing peers and the hands-on learning.
Pearl: Follow your passion. Not what makes most sense or what someone wants for you or what you could achieve given your past work. Do what will get you up in the morning and add a bounce to your step.
2. To go for big impact or climate
At UCSD at the time, there was a culture of impactful mega-labs, up 30 post-docs, often with many working on the same project with the ones finishing first garnering the publication. This created a “go big or go home” (literally) atmosphere. As part of the PSTP program, I was supported by the GI T32 and, being “free labor,” had a pretty wide array of labs to choose from. To the program director’s surprise, I settled on a fairly junior investigator, who was a fellow gastroenterologist and took a personal interest in my career. When making that decision, I prioritized climate over outcome. I remember thinking to myself that how I spent my time was just as important as the potential outcome of the time spent. Through my years in Dr. John Carethers’ lab, I gained insight into his administrative and leadership roles which added another dimension to our mentorship relationship. These years were fun and productive, and our mentorship grew into a friendship.
Pearl: Look for the right people to work with. Particularly who you work for. Everything else is secondary as the right people will set the tone and most influence your day-to-day experience, which is the foundation of your success.
3. To cultivate a life outside of academia
When I turned 30, I remember driving down Interstate 5 in San Diego and taking stock. Yes, I loved clinical work, I felt valued, and was in a stimulating supportive environment. Yet, I was so immersed that everything else seemed to take a back seat. I made the conscious decision on that drive to prioritize life outside of academia. It is not like I did not have one, I just decided to set an intention so it would not get away from me. I continue to make a conscious effort to be present for my husband, my kids, my family – to take time and spend it together without work bleeding into it. And since this is a goal in and of itself, there is no conflict! Through less travel and no more late nights or weekends, your nonacademic life will flourish.
Pearl: Deliberately prioritize your family and hobbies in the long run. Make key decisions with that in mind.
4. To grow your own program or lead others
When we moved to Chicago for my husband’s residency (he went to medical school as his third career at age 35), I was very excited to build my own comprehensive GI cancer genetics program at Northwestern. It was a little scary but also fun to now run my own lab and try to connect the clinical community around hereditary GI cancers. The program was moving along nicely when I received a generic letter asking for applications to become division chief at the neighboring University of Illinois. The letter concluded with an enticing “Chicago is a vibrant city,” so clearly it was meant for a broad audience. I was not sure what to do and again took stock. Did I want to continue to increase the impact of my own work – clearly there was a lot more ground to cover. Or, did I want to be part of making further-reaching decisions? I had been approached by fellows who wanted to be recruited, and I had ideas for programs and thoughts around processes. While my input was valued, I was not the ultimate decision maker. I decided that I either focus on one or the other and so applied for the position and then took the leap.
Pearl: There are many forks and they will present when you do not expect them. Assess and consider. Also know yourself – not everything that is attainable is desirable.
5. To have greater influence or stay with what you know
Becoming a division chief was transformative. Learning to integrate the needs of various and sometimes conflicting stakeholders, running an operation but also thinking strategically and mission-based – I was drinking from a firehose. How to measure success as a leader? I was fortunate to enter the division at a turbulent time where much rebuilding was needed and it was easy to implement and see change.
Pearl: Again know yourself – not everything that is attainable is desirable. But also – take risks. What is the worst that can happen? Growth may not be attained by waiting.
6. To be spread too thin or close doors
As you develop your focus and expertise while implementing No. 3, you will run out of hours in the day. This means you will need to become more and more efficient, as in delegating (and letting go) where you can and doing fewer nonessential tasks. However, you want to think hard about closing doors completely. I have been careful to hone and keep my endoscopy skills as well as my scientific output. To leave the doors ajar, I have tried to find ways to be very deliberate with my involvement and also understand that at some point it may make sense to close a door.
Pearl: Do not try to do everything well, you will risk doing everything poorly. Work on “good enough” for tasks that can be very involved. Think hard before permanently leaving something behind as you may lose flexibility down the road.
7. To enjoy fruits of labor or continue to grow
A question I get asked often is regarding the ideal time to move. In my mind, there is no perfect time. It depends on your satisfaction with your current position (see No. 2), your personal situation (see No. 3), and what you want at that juncture (see No. 5). At some point, one may want to stay awhile and enjoy. Or continue to change and grow – both have their merits and there is no right or wrong.
Pearl: When contemplating next steps, go back to your passion and priorities. Has anything shifted? Are your goals being met? Are you enjoying yourself? Advice can be helpful but also confusing. Remember, no one knows you like you do.
8. To show tangible results or build out relationships
Over time, as you become more and more efficient, you simultaneously need to spend more time fostering relationships. This feels strange at first as it is the opposite of a fast-paced to-do list and the “results” appear elusive. Build in time for relating – with peers, superiors, fellows, members of your lab.
Pearl: Form relationships early and often. Take care of them (No. 3) and include relationship building into your workstream – I promise it will make your path more successful and satisfying.
I hope this list shows that there are many forks and no one right way. Advice is helpful and subjective. No path is the same, and it truly is yours to shape. Be thoughtful and enjoy – your journey will be amazing and full of surprises.
Dr. Jung is professor and chair, and the Robert G. Petersdorf Endowed Chair in Medicine, in the department of medicine at the University of Washington, Seattle. She is on Twitter @barbarahjung. She has no conflicts of interest.
It took me a little while to get started on this assignment. What would be most useful to young gastroenterologists embarking on their careers? When I asked around, I heard that many of you wanted me to describe challenges and decision points. The following list is vaguely chronological, surely noncomprehensive, and meant to serve as a starting point.
1. To stay in basic science or return to patient care
My start in science was rocky. I had come to the United States for a post-doc after medical school in Germany. I had never pipetted before. It was the early days of array technologies, and the lab was very technical and basic. We made our own arrays and our own analytics, and none of my experiments worked. So, I spent 1 year feeling like I made no progress – but in hindsight I appreciate the tremendous growth in these formative years honing inquiry and persistence, as well as building resilience. I added a third year as some results were finally emerging; however, the bedside started to feel very far away. I could not ignore the tug back to the patient care, and after contemplating a PhD program, I decided to apply for residency in a physician-scientist pathway. Given the streamlined training that allowed for science and clinical education in an organized fashion, I also decided to stay in the U.S. This of course had vast personal consequences, which I did not fully appreciate at the time.
Residency was another time of immense growth, I was the only “foreign medical graduate” and had a lot to catch up on, but I enjoyed my amazing peers and the hands-on learning.
Pearl: Follow your passion. Not what makes most sense or what someone wants for you or what you could achieve given your past work. Do what will get you up in the morning and add a bounce to your step.
2. To go for big impact or climate
At UCSD at the time, there was a culture of impactful mega-labs, up 30 post-docs, often with many working on the same project with the ones finishing first garnering the publication. This created a “go big or go home” (literally) atmosphere. As part of the PSTP program, I was supported by the GI T32 and, being “free labor,” had a pretty wide array of labs to choose from. To the program director’s surprise, I settled on a fairly junior investigator, who was a fellow gastroenterologist and took a personal interest in my career. When making that decision, I prioritized climate over outcome. I remember thinking to myself that how I spent my time was just as important as the potential outcome of the time spent. Through my years in Dr. John Carethers’ lab, I gained insight into his administrative and leadership roles which added another dimension to our mentorship relationship. These years were fun and productive, and our mentorship grew into a friendship.
Pearl: Look for the right people to work with. Particularly who you work for. Everything else is secondary as the right people will set the tone and most influence your day-to-day experience, which is the foundation of your success.
3. To cultivate a life outside of academia
When I turned 30, I remember driving down Interstate 5 in San Diego and taking stock. Yes, I loved clinical work, I felt valued, and was in a stimulating supportive environment. Yet, I was so immersed that everything else seemed to take a back seat. I made the conscious decision on that drive to prioritize life outside of academia. It is not like I did not have one, I just decided to set an intention so it would not get away from me. I continue to make a conscious effort to be present for my husband, my kids, my family – to take time and spend it together without work bleeding into it. And since this is a goal in and of itself, there is no conflict! Through less travel and no more late nights or weekends, your nonacademic life will flourish.
Pearl: Deliberately prioritize your family and hobbies in the long run. Make key decisions with that in mind.
4. To grow your own program or lead others
When we moved to Chicago for my husband’s residency (he went to medical school as his third career at age 35), I was very excited to build my own comprehensive GI cancer genetics program at Northwestern. It was a little scary but also fun to now run my own lab and try to connect the clinical community around hereditary GI cancers. The program was moving along nicely when I received a generic letter asking for applications to become division chief at the neighboring University of Illinois. The letter concluded with an enticing “Chicago is a vibrant city,” so clearly it was meant for a broad audience. I was not sure what to do and again took stock. Did I want to continue to increase the impact of my own work – clearly there was a lot more ground to cover. Or, did I want to be part of making further-reaching decisions? I had been approached by fellows who wanted to be recruited, and I had ideas for programs and thoughts around processes. While my input was valued, I was not the ultimate decision maker. I decided that I either focus on one or the other and so applied for the position and then took the leap.
Pearl: There are many forks and they will present when you do not expect them. Assess and consider. Also know yourself – not everything that is attainable is desirable.
5. To have greater influence or stay with what you know
Becoming a division chief was transformative. Learning to integrate the needs of various and sometimes conflicting stakeholders, running an operation but also thinking strategically and mission-based – I was drinking from a firehose. How to measure success as a leader? I was fortunate to enter the division at a turbulent time where much rebuilding was needed and it was easy to implement and see change.
Pearl: Again know yourself – not everything that is attainable is desirable. But also – take risks. What is the worst that can happen? Growth may not be attained by waiting.
6. To be spread too thin or close doors
As you develop your focus and expertise while implementing No. 3, you will run out of hours in the day. This means you will need to become more and more efficient, as in delegating (and letting go) where you can and doing fewer nonessential tasks. However, you want to think hard about closing doors completely. I have been careful to hone and keep my endoscopy skills as well as my scientific output. To leave the doors ajar, I have tried to find ways to be very deliberate with my involvement and also understand that at some point it may make sense to close a door.
Pearl: Do not try to do everything well, you will risk doing everything poorly. Work on “good enough” for tasks that can be very involved. Think hard before permanently leaving something behind as you may lose flexibility down the road.
7. To enjoy fruits of labor or continue to grow
A question I get asked often is regarding the ideal time to move. In my mind, there is no perfect time. It depends on your satisfaction with your current position (see No. 2), your personal situation (see No. 3), and what you want at that juncture (see No. 5). At some point, one may want to stay awhile and enjoy. Or continue to change and grow – both have their merits and there is no right or wrong.
Pearl: When contemplating next steps, go back to your passion and priorities. Has anything shifted? Are your goals being met? Are you enjoying yourself? Advice can be helpful but also confusing. Remember, no one knows you like you do.
8. To show tangible results or build out relationships
Over time, as you become more and more efficient, you simultaneously need to spend more time fostering relationships. This feels strange at first as it is the opposite of a fast-paced to-do list and the “results” appear elusive. Build in time for relating – with peers, superiors, fellows, members of your lab.
Pearl: Form relationships early and often. Take care of them (No. 3) and include relationship building into your workstream – I promise it will make your path more successful and satisfying.
I hope this list shows that there are many forks and no one right way. Advice is helpful and subjective. No path is the same, and it truly is yours to shape. Be thoughtful and enjoy – your journey will be amazing and full of surprises.
Dr. Jung is professor and chair, and the Robert G. Petersdorf Endowed Chair in Medicine, in the department of medicine at the University of Washington, Seattle. She is on Twitter @barbarahjung. She has no conflicts of interest.
Infectious disease pop quiz: Clinical challenge #24 for the ObGyn
What are the 2 most likely causes for persistent fever in a patient who is being treated with antibiotics for postcesarean endometritis?
Continue to the answer...
The 2 most likely causes of a poor response to treatment for postcesarean endometritis are a resistant microorganism and wound infection. Less common causes of persistent postoperative fever include septic pelvic vein thrombophlebitis, pelvic abscess, retained products of conception, reactivation of a connective tissue disorder, and drug fever.
- Duff P. Maternal and perinatal infections: bacterial. In: Landon MB, Galan HL, Jauniaux ERM, et al. Gabbe’s Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021:1124-1146.
- Duff P. Maternal and fetal infections. In: Resnik R, Lockwood CJ, Moore TJ, et al. Creasy & Resnik’s Maternal-Fetal Medicine: Principles and Practice. 8th ed. Elsevier; 2019:862-919.
Dr. Edwards is a Resident in the Department of Medicine, University of Florida College of Medicine, Gainesville.
Dr. Duff is Professor of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville.
The authors report no financial relationships relevant to this article.
Dr. Edwards is a Resident in the Department of Medicine, University of Florida College of Medicine, Gainesville.
Dr. Duff is Professor of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville.
The authors report no financial relationships relevant to this article.
Dr. Edwards is a Resident in the Department of Medicine, University of Florida College of Medicine, Gainesville.
Dr. Duff is Professor of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville.
The authors report no financial relationships relevant to this article.
What are the 2 most likely causes for persistent fever in a patient who is being treated with antibiotics for postcesarean endometritis?
Continue to the answer...
The 2 most likely causes of a poor response to treatment for postcesarean endometritis are a resistant microorganism and wound infection. Less common causes of persistent postoperative fever include septic pelvic vein thrombophlebitis, pelvic abscess, retained products of conception, reactivation of a connective tissue disorder, and drug fever.
What are the 2 most likely causes for persistent fever in a patient who is being treated with antibiotics for postcesarean endometritis?
Continue to the answer...
The 2 most likely causes of a poor response to treatment for postcesarean endometritis are a resistant microorganism and wound infection. Less common causes of persistent postoperative fever include septic pelvic vein thrombophlebitis, pelvic abscess, retained products of conception, reactivation of a connective tissue disorder, and drug fever.
- Duff P. Maternal and perinatal infections: bacterial. In: Landon MB, Galan HL, Jauniaux ERM, et al. Gabbe’s Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021:1124-1146.
- Duff P. Maternal and fetal infections. In: Resnik R, Lockwood CJ, Moore TJ, et al. Creasy & Resnik’s Maternal-Fetal Medicine: Principles and Practice. 8th ed. Elsevier; 2019:862-919.
- Duff P. Maternal and perinatal infections: bacterial. In: Landon MB, Galan HL, Jauniaux ERM, et al. Gabbe’s Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021:1124-1146.
- Duff P. Maternal and fetal infections. In: Resnik R, Lockwood CJ, Moore TJ, et al. Creasy & Resnik’s Maternal-Fetal Medicine: Principles and Practice. 8th ed. Elsevier; 2019:862-919.
Physician assistant pleads not guilty to murdering fellow PA
Jacob L. Klein, 40, of Wirtz, Va., was charged with second-degree murder at the Town of New Scotland Court in New York following the discovery the previous week of 35-year-old Philip Rabadi, another PA. Mr. Rabadi was discovered on the garage floor of his New Scotland home, the Albany County Sheriff’s Office said in a press release.
Mr. Rabadi’s arms were bound and he suffered multiple stab wounds and body mutilation, authorities reported. Mr. Klein allegedly had been stalking Mr. Rabadi and his wife, Elana Z. Radin, for 3 days prior to the homicide after driving the 600 miles from Virginia to New Scotland. Ms. Radin had once been Mr. Klein’s girlfriend, according to a report in the Times Union in Albany, N.Y.
Mr. Klein was being held without bail in the Albany County Correctional Facility and a preliminary hearing was set for April 25. Mr. Klein had been extradited from Virginia April 20, the press release stated. He had been apprehended there April 15 as a fugitive on an arrest warrant, according to authorities.
Ms. Radin and Mr. Rabadi were married last September and worked as surgical PAs together at St. Peter’s Hospital in Albany, and “sincerely loved working with one another,” according to Mr. Rabadi’s obituary. They missed each other if they weren’t working together, the obituary stated.
“I know an endless amount of love and strength is being sent my way,” Ms. Radin said in a Facebook post. “These words do not come close to completely encompassing Phil, but they are mine and I’d like to share them.” The obituary she created, reposted on Facebook, was accompanied by photos of the happy couple at their recent wedding.
“Philip was a shining bright light in this world. He was kind, endlessly charismatic, funny, intelligent, patient, and an immediate friend to all. His smile was breathtaking, and his laugh was infectious. Philip was simply a magnetic person. To have known him was a genuine gift in this lifetime.”
The Albany County Sheriff’s Office received a call to check the welfare of Mr. Rabadi after he failed to show up for work last week, according to the press release. Deputies and family members found Mr. Rabadi dead, the release stated.
Ms. Radin reportedly called 911 and arrived at the home with her father-in-law about the same time as the deputies, according to People magazine.
A St. Peter’s Health Partners spokesperson, in an email to this news organization, shared the health system’s reaction to the incident: “The news of Philip Rabadi’s passing leaves us with a deep sadness and heavy hearts...In a memo to colleagues, our senior leaders offered their condolences to Philip’s family and loved ones, mourning the tragic passing of our colleague and friend.”
The response continued, “As a healthcare organization, it is our mission to care for those in need. Right now, many of our own are struggling. Grief counseling services are being made available to colleagues should they need additional support.”
A scholarship was established for PA students in Mr. Rabadi’s name at his alma mater, Albany Medical College.
Meanwhile a search of Mr. Klein’s professional history shows he held a PA license in Syracuse, N.Y., until 2018 and his current license in Virginia was renewed in February.
A version of this article first appeared on Medscape.com.
Jacob L. Klein, 40, of Wirtz, Va., was charged with second-degree murder at the Town of New Scotland Court in New York following the discovery the previous week of 35-year-old Philip Rabadi, another PA. Mr. Rabadi was discovered on the garage floor of his New Scotland home, the Albany County Sheriff’s Office said in a press release.
Mr. Rabadi’s arms were bound and he suffered multiple stab wounds and body mutilation, authorities reported. Mr. Klein allegedly had been stalking Mr. Rabadi and his wife, Elana Z. Radin, for 3 days prior to the homicide after driving the 600 miles from Virginia to New Scotland. Ms. Radin had once been Mr. Klein’s girlfriend, according to a report in the Times Union in Albany, N.Y.
Mr. Klein was being held without bail in the Albany County Correctional Facility and a preliminary hearing was set for April 25. Mr. Klein had been extradited from Virginia April 20, the press release stated. He had been apprehended there April 15 as a fugitive on an arrest warrant, according to authorities.
Ms. Radin and Mr. Rabadi were married last September and worked as surgical PAs together at St. Peter’s Hospital in Albany, and “sincerely loved working with one another,” according to Mr. Rabadi’s obituary. They missed each other if they weren’t working together, the obituary stated.
“I know an endless amount of love and strength is being sent my way,” Ms. Radin said in a Facebook post. “These words do not come close to completely encompassing Phil, but they are mine and I’d like to share them.” The obituary she created, reposted on Facebook, was accompanied by photos of the happy couple at their recent wedding.
“Philip was a shining bright light in this world. He was kind, endlessly charismatic, funny, intelligent, patient, and an immediate friend to all. His smile was breathtaking, and his laugh was infectious. Philip was simply a magnetic person. To have known him was a genuine gift in this lifetime.”
The Albany County Sheriff’s Office received a call to check the welfare of Mr. Rabadi after he failed to show up for work last week, according to the press release. Deputies and family members found Mr. Rabadi dead, the release stated.
Ms. Radin reportedly called 911 and arrived at the home with her father-in-law about the same time as the deputies, according to People magazine.
A St. Peter’s Health Partners spokesperson, in an email to this news organization, shared the health system’s reaction to the incident: “The news of Philip Rabadi’s passing leaves us with a deep sadness and heavy hearts...In a memo to colleagues, our senior leaders offered their condolences to Philip’s family and loved ones, mourning the tragic passing of our colleague and friend.”
The response continued, “As a healthcare organization, it is our mission to care for those in need. Right now, many of our own are struggling. Grief counseling services are being made available to colleagues should they need additional support.”
A scholarship was established for PA students in Mr. Rabadi’s name at his alma mater, Albany Medical College.
Meanwhile a search of Mr. Klein’s professional history shows he held a PA license in Syracuse, N.Y., until 2018 and his current license in Virginia was renewed in February.
A version of this article first appeared on Medscape.com.
Jacob L. Klein, 40, of Wirtz, Va., was charged with second-degree murder at the Town of New Scotland Court in New York following the discovery the previous week of 35-year-old Philip Rabadi, another PA. Mr. Rabadi was discovered on the garage floor of his New Scotland home, the Albany County Sheriff’s Office said in a press release.
Mr. Rabadi’s arms were bound and he suffered multiple stab wounds and body mutilation, authorities reported. Mr. Klein allegedly had been stalking Mr. Rabadi and his wife, Elana Z. Radin, for 3 days prior to the homicide after driving the 600 miles from Virginia to New Scotland. Ms. Radin had once been Mr. Klein’s girlfriend, according to a report in the Times Union in Albany, N.Y.
Mr. Klein was being held without bail in the Albany County Correctional Facility and a preliminary hearing was set for April 25. Mr. Klein had been extradited from Virginia April 20, the press release stated. He had been apprehended there April 15 as a fugitive on an arrest warrant, according to authorities.
Ms. Radin and Mr. Rabadi were married last September and worked as surgical PAs together at St. Peter’s Hospital in Albany, and “sincerely loved working with one another,” according to Mr. Rabadi’s obituary. They missed each other if they weren’t working together, the obituary stated.
“I know an endless amount of love and strength is being sent my way,” Ms. Radin said in a Facebook post. “These words do not come close to completely encompassing Phil, but they are mine and I’d like to share them.” The obituary she created, reposted on Facebook, was accompanied by photos of the happy couple at their recent wedding.
“Philip was a shining bright light in this world. He was kind, endlessly charismatic, funny, intelligent, patient, and an immediate friend to all. His smile was breathtaking, and his laugh was infectious. Philip was simply a magnetic person. To have known him was a genuine gift in this lifetime.”
The Albany County Sheriff’s Office received a call to check the welfare of Mr. Rabadi after he failed to show up for work last week, according to the press release. Deputies and family members found Mr. Rabadi dead, the release stated.
Ms. Radin reportedly called 911 and arrived at the home with her father-in-law about the same time as the deputies, according to People magazine.
A St. Peter’s Health Partners spokesperson, in an email to this news organization, shared the health system’s reaction to the incident: “The news of Philip Rabadi’s passing leaves us with a deep sadness and heavy hearts...In a memo to colleagues, our senior leaders offered their condolences to Philip’s family and loved ones, mourning the tragic passing of our colleague and friend.”
The response continued, “As a healthcare organization, it is our mission to care for those in need. Right now, many of our own are struggling. Grief counseling services are being made available to colleagues should they need additional support.”
A scholarship was established for PA students in Mr. Rabadi’s name at his alma mater, Albany Medical College.
Meanwhile a search of Mr. Klein’s professional history shows he held a PA license in Syracuse, N.Y., until 2018 and his current license in Virginia was renewed in February.
A version of this article first appeared on Medscape.com.