Mixed Topics

Hospital and physician groups on Dec. 9 announced their plan to sue the federal government over its plan for addressing disputes about surprise medical bills, which tilts toward using prevailing rates paid for services.

The American Hospital Association and American Medical Association said they will ask the U.S. District Court for the District of Columbia to try to prevent implementation of certain provisions of new federal rules on surprise bills. This court is often a venue for fights over federal rules. Also joining the suit are Nevada-based Renown Health, UMass Memorial Health, and two physicians based in North Carolina, AHA and AMA said.

Federal agencies, including the Department of Health & Human Services, in September had unveiled the rule on surprise medical bills that will take effect Jan. 1.

Under this rule, a key benchmark for payment disputes would be the qualifying payment amount (QPA), which is pegged to median contracted rates. In the dispute-resolution process outlined in the rule, there is a presumption that the QPA is the appropriate out-of-network rate.

The rule allows for exceptions in which the independent mediating organization handling the payment dispute resolution has “credible information” as to why the QPA is materially different from the appropriate out-of-network rate.

In the view of the federal agencies that issued the rule, this approach “encourages predictable outcomes,” which likely would reduce the number of disputes that go through the resolution process while also “providing equitable and clear standards” for cases to appropriately deviate from QPA. HHS was joined in issuing the rule by the Treasury and Labor Departments and the Office of Personnel Management.

AMA and AHA disagree with their view, seeing this approach as a boon for insurers at the expense of physicians and hospitals.

In a press release, they said the rule’s approach to surprise billing would “all but ensure that hospitals, physicians, and other providers will routinely be undercompensated by commercial insurers, and patients will have fewer choices for access to in-network services.”

The rule is part of the implementation of a federal law passed in December 2020, known as the No Surprises Act. In their statement, AHA and AMA said their legal challenge would not prevent “core patient protections’’ of that law from moving forward.

“No patient should fear receiving a surprise medical bill,” Rick Pollack, AHA president and chief executive, said in the statement. “That is why hospitals and health systems supported the No Surprises Act to protect patients and keep them out of the middle of disputes between providers and insurers. Congress carefully crafted the law with a balanced, patient-friendly approach and it should be implemented as intended.”

AMA President Gerald E. Harmon, MD, added the approach used in the rule on surprise billing could create “an unsustainable situation for physicians.”

“Our legal challenge urges regulators to ensure there is a fair and meaningful process to resolve disputes between health care providers and insurance companies,” Dr. Harmon said.

AHA and AMA included with their statement a link to a November letter from more than 150 members of Congress, who also objected to the approach taken in designing the independent dispute-resolution (IDR) process.

“This directive establishes a de facto benchmark rate, making the median in-network rate the default factor considered in the IDR process. This approach is contrary to statute and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and jeopardize patient access to care – the exact opposite of the goal of the law,” wrote the members of Congress, including Rep. Raul Ruiz, MD, a California Democrat, and Rep. Larry Bucshon, MD, an Indiana Republican.

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

Hospital and physician groups on Dec. 9 announced their plan to sue the federal government over its plan for addressing disputes about surprise medical bills, which tilts toward using prevailing rates paid for services.

The American Hospital Association and American Medical Association said they will ask the U.S. District Court for the District of Columbia to try to prevent implementation of certain provisions of new federal rules on surprise bills. This court is often a venue for fights over federal rules. Also joining the suit are Nevada-based Renown Health, UMass Memorial Health, and two physicians based in North Carolina, AHA and AMA said.

Federal agencies, including the Department of Health & Human Services, in September had unveiled the rule on surprise medical bills that will take effect Jan. 1.

Under this rule, a key benchmark for payment disputes would be the qualifying payment amount (QPA), which is pegged to median contracted rates. In the dispute-resolution process outlined in the rule, there is a presumption that the QPA is the appropriate out-of-network rate.

The rule allows for exceptions in which the independent mediating organization handling the payment dispute resolution has “credible information” as to why the QPA is materially different from the appropriate out-of-network rate.

In the view of the federal agencies that issued the rule, this approach “encourages predictable outcomes,” which likely would reduce the number of disputes that go through the resolution process while also “providing equitable and clear standards” for cases to appropriately deviate from QPA. HHS was joined in issuing the rule by the Treasury and Labor Departments and the Office of Personnel Management.

AMA and AHA disagree with their view, seeing this approach as a boon for insurers at the expense of physicians and hospitals.

In a press release, they said the rule’s approach to surprise billing would “all but ensure that hospitals, physicians, and other providers will routinely be undercompensated by commercial insurers, and patients will have fewer choices for access to in-network services.”

The rule is part of the implementation of a federal law passed in December 2020, known as the No Surprises Act. In their statement, AHA and AMA said their legal challenge would not prevent “core patient protections’’ of that law from moving forward.

“No patient should fear receiving a surprise medical bill,” Rick Pollack, AHA president and chief executive, said in the statement. “That is why hospitals and health systems supported the No Surprises Act to protect patients and keep them out of the middle of disputes between providers and insurers. Congress carefully crafted the law with a balanced, patient-friendly approach and it should be implemented as intended.”

AMA President Gerald E. Harmon, MD, added the approach used in the rule on surprise billing could create “an unsustainable situation for physicians.”

“Our legal challenge urges regulators to ensure there is a fair and meaningful process to resolve disputes between health care providers and insurance companies,” Dr. Harmon said.

AHA and AMA included with their statement a link to a November letter from more than 150 members of Congress, who also objected to the approach taken in designing the independent dispute-resolution (IDR) process.

“This directive establishes a de facto benchmark rate, making the median in-network rate the default factor considered in the IDR process. This approach is contrary to statute and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and jeopardize patient access to care – the exact opposite of the goal of the law,” wrote the members of Congress, including Rep. Raul Ruiz, MD, a California Democrat, and Rep. Larry Bucshon, MD, an Indiana Republican.

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

Hospital and physician groups on Dec. 9 announced their plan to sue the federal government over its plan for addressing disputes about surprise medical bills, which tilts toward using prevailing rates paid for services.

The American Hospital Association and American Medical Association said they will ask the U.S. District Court for the District of Columbia to try to prevent implementation of certain provisions of new federal rules on surprise bills. This court is often a venue for fights over federal rules. Also joining the suit are Nevada-based Renown Health, UMass Memorial Health, and two physicians based in North Carolina, AHA and AMA said.

Federal agencies, including the Department of Health & Human Services, in September had unveiled the rule on surprise medical bills that will take effect Jan. 1.

Under this rule, a key benchmark for payment disputes would be the qualifying payment amount (QPA), which is pegged to median contracted rates. In the dispute-resolution process outlined in the rule, there is a presumption that the QPA is the appropriate out-of-network rate.

The rule allows for exceptions in which the independent mediating organization handling the payment dispute resolution has “credible information” as to why the QPA is materially different from the appropriate out-of-network rate.

In the view of the federal agencies that issued the rule, this approach “encourages predictable outcomes,” which likely would reduce the number of disputes that go through the resolution process while also “providing equitable and clear standards” for cases to appropriately deviate from QPA. HHS was joined in issuing the rule by the Treasury and Labor Departments and the Office of Personnel Management.

AMA and AHA disagree with their view, seeing this approach as a boon for insurers at the expense of physicians and hospitals.

In a press release, they said the rule’s approach to surprise billing would “all but ensure that hospitals, physicians, and other providers will routinely be undercompensated by commercial insurers, and patients will have fewer choices for access to in-network services.”

The rule is part of the implementation of a federal law passed in December 2020, known as the No Surprises Act. In their statement, AHA and AMA said their legal challenge would not prevent “core patient protections’’ of that law from moving forward.

“No patient should fear receiving a surprise medical bill,” Rick Pollack, AHA president and chief executive, said in the statement. “That is why hospitals and health systems supported the No Surprises Act to protect patients and keep them out of the middle of disputes between providers and insurers. Congress carefully crafted the law with a balanced, patient-friendly approach and it should be implemented as intended.”

AMA President Gerald E. Harmon, MD, added the approach used in the rule on surprise billing could create “an unsustainable situation for physicians.”

“Our legal challenge urges regulators to ensure there is a fair and meaningful process to resolve disputes between health care providers and insurance companies,” Dr. Harmon said.

AHA and AMA included with their statement a link to a November letter from more than 150 members of Congress, who also objected to the approach taken in designing the independent dispute-resolution (IDR) process.

“This directive establishes a de facto benchmark rate, making the median in-network rate the default factor considered in the IDR process. This approach is contrary to statute and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and jeopardize patient access to care – the exact opposite of the goal of the law,” wrote the members of Congress, including Rep. Raul Ruiz, MD, a California Democrat, and Rep. Larry Bucshon, MD, an Indiana Republican.

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

The year is rapidly approaching an end, and with it, we can perhaps look forward to better and brighter days in 2022. With daylight savings, seasonal depression, and cold and flu season making a comeback as temperatures across the Northern Hemisphere drop, some strange remedies have been appearing on TikTok – as they often do.

The good: doctor reveals the truth about dieting

Chisom Ikeji, MD, is a critical care clinical fellow at the University of Pittsburgh Medical Center and on TikTok under the username @drchizmd. In a TikTok with almost 200,000 views and over 18,000 likes, Dr. Ikeji explains to all New Year’s resolution-makers that dieting isn’t all it’s cracked up to be. “Dieting leads to perpetually losing weight and gaining weight on a cycle,” she says, “so that your body never really settles at its set point weight.”

Celebrities and your friends who drink lemon water in the morning may tout all sorts of fad diets and some of them might even work. But Dr. Ikeji explains that diets with gimmicks don’t have lasting power and create cycles of losing and gaining weight. Additionally, associating “points” with foods, or separating them into “good” or “bad” categories, encourages habits that can lead to disordered eating.

The best way to keep weight off is to make actual lifestyle changes that stick. In contrast, going back to dieting every year (the rapid cycle of losing and gaining weight is called  “yo-yo” dieting) can have a bad impact on your health, including increased risk of heart disease and metabolism issues.

“The best thing you can do for your body, and to help you lose weight, is to stop dieting,” Dr. Ikeji says. “Incorporate whole foods into your diet and make sure you move your body. If you don’t, you’ll be chasing that diet into your 80s and feeling guilty over a piece of cake forever. That’s no way to live life.”
 

The bad: vitamin C contraceptive

In this TikTok, user @itsdiosa reveals her contraception hack for anyone with a uterus who may be having unprotected sex. She claims that for those who forget to take the Plan B pill, vitamin C is a worthwhile substitute in preventing unwanted pregnancy. She recommends taking four or five vitamin C tablets a day for a few days for the return of a normal period.

Not surprisingly, Vitamin C isn’t safe or reliable and doesn’t have studies to back up @itsdiosa’s claim. If anything, all you’ll get from taking too much vitamin C is diarrhea and a stomachache.

Karan Rajan, MBBS, from Imperial College London and the University of Sunderland in the United Kingdom, responded to the TikTok to confirm that this claim isn’t backed up by science.

“Vitamin C doesn’t start or stop a period. Period,” he commented on the video.
 

The ugly: garlic sinus decongestant

Now this one went viral one went viral with over 5.2 million likes. In this TikTok, @hwannah5 and her boyfriend try out a trend that involves putting a clove of peeled garlic in each nostril in order to clear up congestion. The bubbles of ooey gooey snot coming out of her boyfriend’s nose certainly make it seem like it’s working, but what’s really going on?

This is hardly new; people have been putting strange things in nasal rinses for some time now and garlic is a tried-and-true favorite. Garlic does have some medically valid uses. These studies have shown that garlic taken orally may improve insulin in people with diabetes, slightly lower cholesterol, and reduce blood pressure in people with hypertension. When it comes to home remedies, people have historically used garlic as an antiseptic, antibacterial, and antifungal agent, though these claims are not widely supported by research. But taking a garlic supplement and sticking raw garlic up your nose are two very different things.

New York-based board-certified dermatologist Whitney Bowe, MD, weighed in on the viral trend.

In her own reaction video, she explained: “Guys, this is actually not safe. What’s happening is the garlic is actually triggering something called contact dermatitis and the mucosa is trying to protect itself by secreting tons of mucus. It’s creating swelling.”

For those tempted by this smelly “remedy,” a few drops of essential oil in a steamy shower is a much more pleasant (and significantly less gross) way to treat congestion.

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

The year is rapidly approaching an end, and with it, we can perhaps look forward to better and brighter days in 2022. With daylight savings, seasonal depression, and cold and flu season making a comeback as temperatures across the Northern Hemisphere drop, some strange remedies have been appearing on TikTok – as they often do.

The good: doctor reveals the truth about dieting

Chisom Ikeji, MD, is a critical care clinical fellow at the University of Pittsburgh Medical Center and on TikTok under the username @drchizmd. In a TikTok with almost 200,000 views and over 18,000 likes, Dr. Ikeji explains to all New Year’s resolution-makers that dieting isn’t all it’s cracked up to be. “Dieting leads to perpetually losing weight and gaining weight on a cycle,” she says, “so that your body never really settles at its set point weight.”

Celebrities and your friends who drink lemon water in the morning may tout all sorts of fad diets and some of them might even work. But Dr. Ikeji explains that diets with gimmicks don’t have lasting power and create cycles of losing and gaining weight. Additionally, associating “points” with foods, or separating them into “good” or “bad” categories, encourages habits that can lead to disordered eating.

The best way to keep weight off is to make actual lifestyle changes that stick. In contrast, going back to dieting every year (the rapid cycle of losing and gaining weight is called  “yo-yo” dieting) can have a bad impact on your health, including increased risk of heart disease and metabolism issues.

“The best thing you can do for your body, and to help you lose weight, is to stop dieting,” Dr. Ikeji says. “Incorporate whole foods into your diet and make sure you move your body. If you don’t, you’ll be chasing that diet into your 80s and feeling guilty over a piece of cake forever. That’s no way to live life.”
 

The bad: vitamin C contraceptive

In this TikTok, user @itsdiosa reveals her contraception hack for anyone with a uterus who may be having unprotected sex. She claims that for those who forget to take the Plan B pill, vitamin C is a worthwhile substitute in preventing unwanted pregnancy. She recommends taking four or five vitamin C tablets a day for a few days for the return of a normal period.

Not surprisingly, Vitamin C isn’t safe or reliable and doesn’t have studies to back up @itsdiosa’s claim. If anything, all you’ll get from taking too much vitamin C is diarrhea and a stomachache.

Karan Rajan, MBBS, from Imperial College London and the University of Sunderland in the United Kingdom, responded to the TikTok to confirm that this claim isn’t backed up by science.

“Vitamin C doesn’t start or stop a period. Period,” he commented on the video.
 

The ugly: garlic sinus decongestant

Now this one went viral one went viral with over 5.2 million likes. In this TikTok, @hwannah5 and her boyfriend try out a trend that involves putting a clove of peeled garlic in each nostril in order to clear up congestion. The bubbles of ooey gooey snot coming out of her boyfriend’s nose certainly make it seem like it’s working, but what’s really going on?

This is hardly new; people have been putting strange things in nasal rinses for some time now and garlic is a tried-and-true favorite. Garlic does have some medically valid uses. These studies have shown that garlic taken orally may improve insulin in people with diabetes, slightly lower cholesterol, and reduce blood pressure in people with hypertension. When it comes to home remedies, people have historically used garlic as an antiseptic, antibacterial, and antifungal agent, though these claims are not widely supported by research. But taking a garlic supplement and sticking raw garlic up your nose are two very different things.

New York-based board-certified dermatologist Whitney Bowe, MD, weighed in on the viral trend.

In her own reaction video, she explained: “Guys, this is actually not safe. What’s happening is the garlic is actually triggering something called contact dermatitis and the mucosa is trying to protect itself by secreting tons of mucus. It’s creating swelling.”

For those tempted by this smelly “remedy,” a few drops of essential oil in a steamy shower is a much more pleasant (and significantly less gross) way to treat congestion.

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

The year is rapidly approaching an end, and with it, we can perhaps look forward to better and brighter days in 2022. With daylight savings, seasonal depression, and cold and flu season making a comeback as temperatures across the Northern Hemisphere drop, some strange remedies have been appearing on TikTok – as they often do.

The good: doctor reveals the truth about dieting

Chisom Ikeji, MD, is a critical care clinical fellow at the University of Pittsburgh Medical Center and on TikTok under the username @drchizmd. In a TikTok with almost 200,000 views and over 18,000 likes, Dr. Ikeji explains to all New Year’s resolution-makers that dieting isn’t all it’s cracked up to be. “Dieting leads to perpetually losing weight and gaining weight on a cycle,” she says, “so that your body never really settles at its set point weight.”

Celebrities and your friends who drink lemon water in the morning may tout all sorts of fad diets and some of them might even work. But Dr. Ikeji explains that diets with gimmicks don’t have lasting power and create cycles of losing and gaining weight. Additionally, associating “points” with foods, or separating them into “good” or “bad” categories, encourages habits that can lead to disordered eating.

The best way to keep weight off is to make actual lifestyle changes that stick. In contrast, going back to dieting every year (the rapid cycle of losing and gaining weight is called  “yo-yo” dieting) can have a bad impact on your health, including increased risk of heart disease and metabolism issues.

“The best thing you can do for your body, and to help you lose weight, is to stop dieting,” Dr. Ikeji says. “Incorporate whole foods into your diet and make sure you move your body. If you don’t, you’ll be chasing that diet into your 80s and feeling guilty over a piece of cake forever. That’s no way to live life.”
 

The bad: vitamin C contraceptive

In this TikTok, user @itsdiosa reveals her contraception hack for anyone with a uterus who may be having unprotected sex. She claims that for those who forget to take the Plan B pill, vitamin C is a worthwhile substitute in preventing unwanted pregnancy. She recommends taking four or five vitamin C tablets a day for a few days for the return of a normal period.

Not surprisingly, Vitamin C isn’t safe or reliable and doesn’t have studies to back up @itsdiosa’s claim. If anything, all you’ll get from taking too much vitamin C is diarrhea and a stomachache.

Karan Rajan, MBBS, from Imperial College London and the University of Sunderland in the United Kingdom, responded to the TikTok to confirm that this claim isn’t backed up by science.

“Vitamin C doesn’t start or stop a period. Period,” he commented on the video.
 

The ugly: garlic sinus decongestant

Now this one went viral one went viral with over 5.2 million likes. In this TikTok, @hwannah5 and her boyfriend try out a trend that involves putting a clove of peeled garlic in each nostril in order to clear up congestion. The bubbles of ooey gooey snot coming out of her boyfriend’s nose certainly make it seem like it’s working, but what’s really going on?

This is hardly new; people have been putting strange things in nasal rinses for some time now and garlic is a tried-and-true favorite. Garlic does have some medically valid uses. These studies have shown that garlic taken orally may improve insulin in people with diabetes, slightly lower cholesterol, and reduce blood pressure in people with hypertension. When it comes to home remedies, people have historically used garlic as an antiseptic, antibacterial, and antifungal agent, though these claims are not widely supported by research. But taking a garlic supplement and sticking raw garlic up your nose are two very different things.

New York-based board-certified dermatologist Whitney Bowe, MD, weighed in on the viral trend.

In her own reaction video, she explained: “Guys, this is actually not safe. What’s happening is the garlic is actually triggering something called contact dermatitis and the mucosa is trying to protect itself by secreting tons of mucus. It’s creating swelling.”

For those tempted by this smelly “remedy,” a few drops of essential oil in a steamy shower is a much more pleasant (and significantly less gross) way to treat congestion.

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

Female patients are more likely to experience adverse outcomes following common surgical procedures when treated by a male rather than a female surgeon, according to a new analysis of over 1.3 million surgery patients. The study found no difference in adverse outcomes in male patients treated by surgeons of either sex.

While the effect of patient and provider sex discordance (female patient/male physician or male patient/female physician) on care has been explored before, “to the best of our knowledge, this is the first study to assess this in patients undergoing surgery,” Christopher Wallis, MD, PhD, an assistant professor in the division of urology at the University of Toronto, said in an email. The study was published online December 8 in JAMA Surgery.

Past studies in primary care settings have found that sex discordance between a physician and patient can result in “worse rapport, lower certainty of diagnosis, lower likelihood of assessing patient’s conditions as being of high severity, concerns of a hidden agenda, and disagreements regarding advice provided,” the authors write in the paper. Gender discordance has also been shown to negatively affect cancer screening rates and survival after heart attack. Given these past findings, Dr. Wallis and colleagues postulated that gender match between patients and surgeons could affect postoperative outcomes.

To find out, researchers analyzed data from over 1,320,100 patients undergoing one of 21 common elective and emergent surgical procedures in Ontario, Canada, from January 1, 2007, through December 31, 2019. Procedures were performed across the following specialties: cardiothoracic surgery, general surgery, neurosurgery, orthopedic surgery, otolaryngology, plastic surgery, thoracic surgery, urology, and vascular surgery. The investigators compared adverse postoperative outcomes — death, readmission, or complications within 30 days after surgery — in patients of both sexes when treated by male or female surgeons.

The study included 2,937 surgeons, and nearly 46% of patients included in the study were the same sex as their surgeon. Of the remaining 717,548 sex-discordant pairings, 93% were female patients with male surgeons, and 7% were male patients with female surgeons.

Among all patients, 14.9% experienced at least one adverse outcome. The researchers found that sex discordance between patient and surgeon was associated with higher odds of complications (adjusted odds ratio [aOR], 1.09; 95% CI, 1.07 – 1.11) and death (aOR, 1.07; 95% CI, 1.02 – 1.13). There was no statistically significant relationship between sex discordance and readmission in the study.

Using multivariable modeling, the researchers then teased out how patient sex affected this association. They found that female patients treated by male surgeons, compared to those treated by female surgeons, were more likely to have worse outcomes (aOR, 1.15; 95% CI, 1.10 – 1.20); however, there was no difference in outcomes in male patients treated by female surgeons compared with those with male surgeons (aOR, 0.99; 95% CI, 0.95 – 1.03).

While the study did not look at the underlying reasons for this disparity, communication differences between surgeons and patients could be one factor, Dr. Wallis noted. “Prior research has suggested differences in communication style between male and female physicians. Further, there is evidence that female physicians, including surgeons, spend more time with patients,” he wrote in an email. “This, coupled with evidence that female patients may have disparities in the management of their pain, suggest that communication differences may underpin the observed disparity.”

The finding “sounds the alarm for urgent action,” write Andrea Riner, MD, MPH, and Amalia Cochran, MD, both from the department of surgery at the University of Florida College of Medicine in Gainesville, in an accompanying commentary. While recruiting more women into surgical specialties is one way to address this disparity, both Dr. Riner and Dr. Cochran note the importance of identifying unconscious biases in patient care. “Surgeons likely believe they provide the same quality of care to patients irrespective of identity,” they write. “However, these data underscore an underappreciated phenomenon and highlight a measurable repercussion of implicit bias.”

Training programs that work with surgeons to improve communication and care with diverse patients may help counter these biases, they suggest, and incorporating patient identity in surgical outcome metrics could help identify biases. “Female patients with surgical disease should not be disadvantaged because there simply are not enough female surgeons or surgeons who are competent in the care of female patients,” they note. “We owe it to patients to provide them with the best outcomes, regardless of how their identities may align with ours.”

Dr. Riner reports grants from the National Human Genome Research Institute and the National Cancer Institute.Dr. Cochran is a section editor for UpToDate. Dr. Wallis reports no relevant financial relationships.

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

Female patients are more likely to experience adverse outcomes following common surgical procedures when treated by a male rather than a female surgeon, according to a new analysis of over 1.3 million surgery patients. The study found no difference in adverse outcomes in male patients treated by surgeons of either sex.

While the effect of patient and provider sex discordance (female patient/male physician or male patient/female physician) on care has been explored before, “to the best of our knowledge, this is the first study to assess this in patients undergoing surgery,” Christopher Wallis, MD, PhD, an assistant professor in the division of urology at the University of Toronto, said in an email. The study was published online December 8 in JAMA Surgery.

Past studies in primary care settings have found that sex discordance between a physician and patient can result in “worse rapport, lower certainty of diagnosis, lower likelihood of assessing patient’s conditions as being of high severity, concerns of a hidden agenda, and disagreements regarding advice provided,” the authors write in the paper. Gender discordance has also been shown to negatively affect cancer screening rates and survival after heart attack. Given these past findings, Dr. Wallis and colleagues postulated that gender match between patients and surgeons could affect postoperative outcomes.

To find out, researchers analyzed data from over 1,320,100 patients undergoing one of 21 common elective and emergent surgical procedures in Ontario, Canada, from January 1, 2007, through December 31, 2019. Procedures were performed across the following specialties: cardiothoracic surgery, general surgery, neurosurgery, orthopedic surgery, otolaryngology, plastic surgery, thoracic surgery, urology, and vascular surgery. The investigators compared adverse postoperative outcomes — death, readmission, or complications within 30 days after surgery — in patients of both sexes when treated by male or female surgeons.

The study included 2,937 surgeons, and nearly 46% of patients included in the study were the same sex as their surgeon. Of the remaining 717,548 sex-discordant pairings, 93% were female patients with male surgeons, and 7% were male patients with female surgeons.

Among all patients, 14.9% experienced at least one adverse outcome. The researchers found that sex discordance between patient and surgeon was associated with higher odds of complications (adjusted odds ratio [aOR], 1.09; 95% CI, 1.07 – 1.11) and death (aOR, 1.07; 95% CI, 1.02 – 1.13). There was no statistically significant relationship between sex discordance and readmission in the study.

Using multivariable modeling, the researchers then teased out how patient sex affected this association. They found that female patients treated by male surgeons, compared to those treated by female surgeons, were more likely to have worse outcomes (aOR, 1.15; 95% CI, 1.10 – 1.20); however, there was no difference in outcomes in male patients treated by female surgeons compared with those with male surgeons (aOR, 0.99; 95% CI, 0.95 – 1.03).

While the study did not look at the underlying reasons for this disparity, communication differences between surgeons and patients could be one factor, Dr. Wallis noted. “Prior research has suggested differences in communication style between male and female physicians. Further, there is evidence that female physicians, including surgeons, spend more time with patients,” he wrote in an email. “This, coupled with evidence that female patients may have disparities in the management of their pain, suggest that communication differences may underpin the observed disparity.”

The finding “sounds the alarm for urgent action,” write Andrea Riner, MD, MPH, and Amalia Cochran, MD, both from the department of surgery at the University of Florida College of Medicine in Gainesville, in an accompanying commentary. While recruiting more women into surgical specialties is one way to address this disparity, both Dr. Riner and Dr. Cochran note the importance of identifying unconscious biases in patient care. “Surgeons likely believe they provide the same quality of care to patients irrespective of identity,” they write. “However, these data underscore an underappreciated phenomenon and highlight a measurable repercussion of implicit bias.”

Training programs that work with surgeons to improve communication and care with diverse patients may help counter these biases, they suggest, and incorporating patient identity in surgical outcome metrics could help identify biases. “Female patients with surgical disease should not be disadvantaged because there simply are not enough female surgeons or surgeons who are competent in the care of female patients,” they note. “We owe it to patients to provide them with the best outcomes, regardless of how their identities may align with ours.”

Dr. Riner reports grants from the National Human Genome Research Institute and the National Cancer Institute.Dr. Cochran is a section editor for UpToDate. Dr. Wallis reports no relevant financial relationships.

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

Female patients are more likely to experience adverse outcomes following common surgical procedures when treated by a male rather than a female surgeon, according to a new analysis of over 1.3 million surgery patients. The study found no difference in adverse outcomes in male patients treated by surgeons of either sex.

While the effect of patient and provider sex discordance (female patient/male physician or male patient/female physician) on care has been explored before, “to the best of our knowledge, this is the first study to assess this in patients undergoing surgery,” Christopher Wallis, MD, PhD, an assistant professor in the division of urology at the University of Toronto, said in an email. The study was published online December 8 in JAMA Surgery.

Past studies in primary care settings have found that sex discordance between a physician and patient can result in “worse rapport, lower certainty of diagnosis, lower likelihood of assessing patient’s conditions as being of high severity, concerns of a hidden agenda, and disagreements regarding advice provided,” the authors write in the paper. Gender discordance has also been shown to negatively affect cancer screening rates and survival after heart attack. Given these past findings, Dr. Wallis and colleagues postulated that gender match between patients and surgeons could affect postoperative outcomes.

To find out, researchers analyzed data from over 1,320,100 patients undergoing one of 21 common elective and emergent surgical procedures in Ontario, Canada, from January 1, 2007, through December 31, 2019. Procedures were performed across the following specialties: cardiothoracic surgery, general surgery, neurosurgery, orthopedic surgery, otolaryngology, plastic surgery, thoracic surgery, urology, and vascular surgery. The investigators compared adverse postoperative outcomes — death, readmission, or complications within 30 days after surgery — in patients of both sexes when treated by male or female surgeons.

The study included 2,937 surgeons, and nearly 46% of patients included in the study were the same sex as their surgeon. Of the remaining 717,548 sex-discordant pairings, 93% were female patients with male surgeons, and 7% were male patients with female surgeons.

Among all patients, 14.9% experienced at least one adverse outcome. The researchers found that sex discordance between patient and surgeon was associated with higher odds of complications (adjusted odds ratio [aOR], 1.09; 95% CI, 1.07 – 1.11) and death (aOR, 1.07; 95% CI, 1.02 – 1.13). There was no statistically significant relationship between sex discordance and readmission in the study.

Using multivariable modeling, the researchers then teased out how patient sex affected this association. They found that female patients treated by male surgeons, compared to those treated by female surgeons, were more likely to have worse outcomes (aOR, 1.15; 95% CI, 1.10 – 1.20); however, there was no difference in outcomes in male patients treated by female surgeons compared with those with male surgeons (aOR, 0.99; 95% CI, 0.95 – 1.03).

While the study did not look at the underlying reasons for this disparity, communication differences between surgeons and patients could be one factor, Dr. Wallis noted. “Prior research has suggested differences in communication style between male and female physicians. Further, there is evidence that female physicians, including surgeons, spend more time with patients,” he wrote in an email. “This, coupled with evidence that female patients may have disparities in the management of their pain, suggest that communication differences may underpin the observed disparity.”

The finding “sounds the alarm for urgent action,” write Andrea Riner, MD, MPH, and Amalia Cochran, MD, both from the department of surgery at the University of Florida College of Medicine in Gainesville, in an accompanying commentary. While recruiting more women into surgical specialties is one way to address this disparity, both Dr. Riner and Dr. Cochran note the importance of identifying unconscious biases in patient care. “Surgeons likely believe they provide the same quality of care to patients irrespective of identity,” they write. “However, these data underscore an underappreciated phenomenon and highlight a measurable repercussion of implicit bias.”

Training programs that work with surgeons to improve communication and care with diverse patients may help counter these biases, they suggest, and incorporating patient identity in surgical outcome metrics could help identify biases. “Female patients with surgical disease should not be disadvantaged because there simply are not enough female surgeons or surgeons who are competent in the care of female patients,” they note. “We owe it to patients to provide them with the best outcomes, regardless of how their identities may align with ours.”

Dr. Riner reports grants from the National Human Genome Research Institute and the National Cancer Institute.Dr. Cochran is a section editor for UpToDate. Dr. Wallis reports no relevant financial relationships.

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

Motivated, calm, and high-functioning. On the surface, you are the epitome of success. You arrive at work early. You are driven, meet all deadlines and, in fact, excel at tasks. Not only are you successful in your work, but also you appear well put-together – not a single hair out of place. You have a busy social life, always smiling, laughing, or generally in an uplifting mood. On the surface, you have everything together. 

Inside, you’re drowning. You’re in constant survival mode – always overthinking, ruminating, and fearful. Your need for self-preservation is in overdrive. You use your anxiety and fear as motivation. You are a people pleaser, need constant reassurance, and are unable to enjoy the present moment. You have an inability to say no regardless of your overloaded schedule. You are mentally and physically fatigued and overworked beyond the brink of exhaustion. You need to take time off but can’t bring yourself to do so. Others wouldn’t see you in this light because you always appear to be doing well.

The portraits I’ve painted here sound like two different people, but in fact are representative of one. High-functioning anxiety, while not a formal health diagnosis, is a term that broadly encapsulates individuals who experience anxiety but also function well in their day-to-day lives. On the surface, individuals with high-functioning anxiety appear to be “perfect” but in actuality are under constant stress and anxiety in fear of disappointing others. They are perceived as overachievers, but this perception fails to recognize and acknowledge the mental health toll required to achieve at such a high level.

I came across this concept when a friend sent me a post on social media. It was a completely new but oddly familiar concept when I first read about high-functioning anxiety. In fact, I related to this concept almost immediately based on interactions with friends and colleagues, and their recollection of stressors over the years in high-stress, high-functioning environments. 

In addition to personal interactions, I’ve seen anxiety and mental health at large become more “normalized” on various platforms (e.g., Instagram, TikTok) over the years. Interestingly, normalizing these concepts could be beneficial. For example, they increase awareness, encourage conversations (e.g., creating communities), and minimize the barriers toward understanding and respecting individuals who experience high-functioning anxiety. However, social media also has the potential to be harmful (e.g., “humorizing” the concept or turning it into memes, diminishing the experience).

However, the question that nagged at my mind even further was: What reasons are there, if any, for why high-functioning anxiety is not recognized as a formal diagnosis? Is this concept too new? Difficult to diagnose? Anecdotal evidence seems to suggest that high-functioning anxiety is debilitating and impairs one’s quality of life. There appears to be a need to formally recognize this subtype of anxiety and invest more time and research. Increasing the sphere of knowledge may bring more good than harm, as a way to let others know that it’s okay.

Ms. Lui is an MSc candidate at the University of Toronto and is with the mood disorders psychopharmacology unit, Toronto Western Hospital, University Health Network, also in Toronto. She reported receiving income from Braxia Scientific.

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

Motivated, calm, and high-functioning. On the surface, you are the epitome of success. You arrive at work early. You are driven, meet all deadlines and, in fact, excel at tasks. Not only are you successful in your work, but also you appear well put-together – not a single hair out of place. You have a busy social life, always smiling, laughing, or generally in an uplifting mood. On the surface, you have everything together. 

Inside, you’re drowning. You’re in constant survival mode – always overthinking, ruminating, and fearful. Your need for self-preservation is in overdrive. You use your anxiety and fear as motivation. You are a people pleaser, need constant reassurance, and are unable to enjoy the present moment. You have an inability to say no regardless of your overloaded schedule. You are mentally and physically fatigued and overworked beyond the brink of exhaustion. You need to take time off but can’t bring yourself to do so. Others wouldn’t see you in this light because you always appear to be doing well.

The portraits I’ve painted here sound like two different people, but in fact are representative of one. High-functioning anxiety, while not a formal health diagnosis, is a term that broadly encapsulates individuals who experience anxiety but also function well in their day-to-day lives. On the surface, individuals with high-functioning anxiety appear to be “perfect” but in actuality are under constant stress and anxiety in fear of disappointing others. They are perceived as overachievers, but this perception fails to recognize and acknowledge the mental health toll required to achieve at such a high level.

I came across this concept when a friend sent me a post on social media. It was a completely new but oddly familiar concept when I first read about high-functioning anxiety. In fact, I related to this concept almost immediately based on interactions with friends and colleagues, and their recollection of stressors over the years in high-stress, high-functioning environments. 

In addition to personal interactions, I’ve seen anxiety and mental health at large become more “normalized” on various platforms (e.g., Instagram, TikTok) over the years. Interestingly, normalizing these concepts could be beneficial. For example, they increase awareness, encourage conversations (e.g., creating communities), and minimize the barriers toward understanding and respecting individuals who experience high-functioning anxiety. However, social media also has the potential to be harmful (e.g., “humorizing” the concept or turning it into memes, diminishing the experience).

However, the question that nagged at my mind even further was: What reasons are there, if any, for why high-functioning anxiety is not recognized as a formal diagnosis? Is this concept too new? Difficult to diagnose? Anecdotal evidence seems to suggest that high-functioning anxiety is debilitating and impairs one’s quality of life. There appears to be a need to formally recognize this subtype of anxiety and invest more time and research. Increasing the sphere of knowledge may bring more good than harm, as a way to let others know that it’s okay.

Ms. Lui is an MSc candidate at the University of Toronto and is with the mood disorders psychopharmacology unit, Toronto Western Hospital, University Health Network, also in Toronto. She reported receiving income from Braxia Scientific.

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

Motivated, calm, and high-functioning. On the surface, you are the epitome of success. You arrive at work early. You are driven, meet all deadlines and, in fact, excel at tasks. Not only are you successful in your work, but also you appear well put-together – not a single hair out of place. You have a busy social life, always smiling, laughing, or generally in an uplifting mood. On the surface, you have everything together. 

Inside, you’re drowning. You’re in constant survival mode – always overthinking, ruminating, and fearful. Your need for self-preservation is in overdrive. You use your anxiety and fear as motivation. You are a people pleaser, need constant reassurance, and are unable to enjoy the present moment. You have an inability to say no regardless of your overloaded schedule. You are mentally and physically fatigued and overworked beyond the brink of exhaustion. You need to take time off but can’t bring yourself to do so. Others wouldn’t see you in this light because you always appear to be doing well.

The portraits I’ve painted here sound like two different people, but in fact are representative of one. High-functioning anxiety, while not a formal health diagnosis, is a term that broadly encapsulates individuals who experience anxiety but also function well in their day-to-day lives. On the surface, individuals with high-functioning anxiety appear to be “perfect” but in actuality are under constant stress and anxiety in fear of disappointing others. They are perceived as overachievers, but this perception fails to recognize and acknowledge the mental health toll required to achieve at such a high level.

I came across this concept when a friend sent me a post on social media. It was a completely new but oddly familiar concept when I first read about high-functioning anxiety. In fact, I related to this concept almost immediately based on interactions with friends and colleagues, and their recollection of stressors over the years in high-stress, high-functioning environments. 

In addition to personal interactions, I’ve seen anxiety and mental health at large become more “normalized” on various platforms (e.g., Instagram, TikTok) over the years. Interestingly, normalizing these concepts could be beneficial. For example, they increase awareness, encourage conversations (e.g., creating communities), and minimize the barriers toward understanding and respecting individuals who experience high-functioning anxiety. However, social media also has the potential to be harmful (e.g., “humorizing” the concept or turning it into memes, diminishing the experience).

However, the question that nagged at my mind even further was: What reasons are there, if any, for why high-functioning anxiety is not recognized as a formal diagnosis? Is this concept too new? Difficult to diagnose? Anecdotal evidence seems to suggest that high-functioning anxiety is debilitating and impairs one’s quality of life. There appears to be a need to formally recognize this subtype of anxiety and invest more time and research. Increasing the sphere of knowledge may bring more good than harm, as a way to let others know that it’s okay.

Ms. Lui is an MSc candidate at the University of Toronto and is with the mood disorders psychopharmacology unit, Toronto Western Hospital, University Health Network, also in Toronto. She reported receiving income from Braxia Scientific.

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

What are the major manifestations of congenital rubella syndrome?

Continue to the answer...

Rubella is one of the most highly teratogenic of all the viral infections, particularly when maternal infection occurs in the first trimester. Manifestations of congenital rubella include hearing deficits, cataracts, glaucoma, microcephaly, mental retardation, cardiac malformations such as patent ductus arteriosus and pulmonic stenosis, and growth restriction.

What are the major manifestations of congenital rubella syndrome?

Continue to the answer...

Rubella is one of the most highly teratogenic of all the viral infections, particularly when maternal infection occurs in the first trimester. Manifestations of congenital rubella include hearing deficits, cataracts, glaucoma, microcephaly, mental retardation, cardiac malformations such as patent ductus arteriosus and pulmonic stenosis, and growth restriction.

What are the major manifestations of congenital rubella syndrome?

Continue to the answer...

Rubella is one of the most highly teratogenic of all the viral infections, particularly when maternal infection occurs in the first trimester. Manifestations of congenital rubella include hearing deficits, cataracts, glaucoma, microcephaly, mental retardation, cardiac malformations such as patent ductus arteriosus and pulmonic stenosis, and growth restriction.

People with thyroid cancer treated with thyroidectomy have as much as a 40% increased risk of developing type 2 diabetes, regardless of their age, with the elevated risk observed with low as well as high doses of postoperative levothyroxine, new research shows.

“This is the first population-based study to demonstrate an elevated risk of type 2 diabetes in postthyroidectomy patients with thyroid cancer, compared with that in matched controls,” wrote the authors of the research, published recently in the Journal of Clinical Endocrinology & Metabolism.

“Notably, there was a U-shaped relationship between postoperative levothyroxine dosage, a surrogate marker of TSH suppression, and the risk of type 2 diabetes,” said Hye Jin Yoo, MD, of the division of endocrinology and metabolism, Korea University College of Medicine, Seoul, and colleagues.

While other studies have linked thyroidectomy for thyroid cancer with an elevated risk for other metabolic conditions, including coronary heart disease and ischemic stroke, the relatively high diabetes risk is unexpected, said Tyler Drake, MD, an endocrinologist with the Minneapolis VA Health Care System.

“A 40% increased risk of diabetes is a big surprise,” he said in an interview.

“Diabetes is very common, with about one in 10 U.S. adults having type 2 diabetes, but a 40% increased risk in thyroid cancer patients is higher than I see in my clinical practice. [However], it is important to note that the [highest] risk was predominantly among the groups on the lowest and highest doses of levothyroxine,” said Dr. Drake, assistant professor of medicine at the University of Minnesota, Minneapolis.
 

U-shaped relationship between levothyroxine dose and diabetes risk

The findings are from a study of 36,377 patients with thyroid cancer in the National Health Insurance Service (NHIS) database in Korea who had undergone a thyroidectomy between 2004 and 2013.

The patients were matched 1:1 with controls who had nonthyroid cancers. Their mean age was 46.6 years, about 30% were male, and their mean body mass index was 23.8 kg/m².

Over a mean follow-up of 6.6 years, the patients with thyroid cancer had a significantly higher risk of developing type 2 diabetes, at a rate of 47.5% (10,812) compared with 36.9% (9414; HR, 1.43; P < .001) in the control group, after adjustment for factors such as age, sex, BMI, smoking, drinking, systolic blood pressure, and fasting glucose.

The risk of type 2 diabetes among those with thyroid cancer was higher among the 83.2% of patients who underwent a total thyroidectomy compared with the 16.8% who had a unilateral lobectomy (HR, 1.06; P < .001).

In addition, those with thyroid cancer who received the lowest as well as highest dosages of levothyroxine had significantly higher risks of type 2 diabetes compared with controls (HR, 1.50 and 1.39, respectively; both P < .001).

A closer look at quartiles of levothyroxine dosing showed the first (lowest) quartile (defined as a mean levothyroxine dosage of < 101 mcg/day) was associated with an increased risk of type 2 diabetes compared with the second quartile group (101-127 mcg/day; HR, 1.45), as was the fourth quartile (≥ 150 mcg/day; HR, 1.37), while a decreased risk of type 2 diabetes was observed in the third quartile group (128-149 mcg/day versus the second quartile group; HR, 0.91).

“This result suggests a U-shaped relationship between the mean levothyroxine dosage and risk of type 2 diabetes in postthyroidectomy patients with thyroid cancer,” the authors said.

However, “consistent with previous studies, the present study showed that the highest risk of type 2 diabetes was observed in patients with thyroid cancer who were treated with the lowest mean dosage of levothyroxine,” they noted.

“This result suggests that inadequate supplementation of thyroid hormones may worsen glucose metabolism and should therefore be avoided.”
 

Potential mechanisms

Abnormal thyroid function, including hypo- and hyperthyroidism, following thyroidectomy and subsequent treatment with levothyroxine, is known to have potentially detrimental effects on glucose regulation among patients with thyroid cancer.

The potential mechanisms linking hypothyroidism with diabetes specifically include the possibility that insulin becomes unable to promote the utilization of glucose by muscles and adipose tissue. However, thyroid hormone replacement has been associated with a normalization of insulin sensitivity, the authors noted.

Meanwhile, glucose intolerance is common among patients with hyperthyroidism, largely due to an increase in hepatic glucose production, and likewise, the normalization of thyroid levels among those treated with methimazole has been linked to normalization of glucose and lipid metabolism alterations.

Dr. Drake noted that an important study limitation is that patients were analyzed based on their levothyroxine dose and not their TSH values, which the authors explain was due to the unavailability of the TSH values. 

“By looking at levothyroxine doses, and not TSH values, it is possible some patients were being improperly treated with either too much or too little levothyroxine,” Dr. Drake noted.
 

Control group should have had hypothyroidism

The findings nevertheless shed light on the risk of diabetes following thyroidectomy for thyroid cancer, Anupam Kotwal, MD, commented on the study.

“This study is significant because it addresses an important topic exploring the link between thyroid dysfunction and metabolic disease, in this case ... hypothyroidism, due to surgery for thyroid cancer and type 2 diabetes,” Dr. Kotwal, assistant professor of medicine in the division of diabetes, endocrinology & metabolism at the University of Nebraska Medical Center, Omaha, said in an interview.

In terms of other limitations, Dr. Kotwal noted that the controls did not have hypothyroidism; therefore, “from this study, it is impossible to confirm whether hypothyroidism from any cause would be associated with higher incidence of diabetes or if it is specific to thyroid surgery for thyroid cancer.

“It would have been useful to have a control group of autoimmune primary hypothyroidism to evaluate the rate of diabetes during a similar follow-up duration,” Dr. Kotwal said.

“Hence, cohort studies with more granular data such as degree of TSH suppression and having a control group of hypothyroid patients due to autoimmune thyroid disease are needed to better understand this risk.”

Dr. Kotwal and Dr. Drake have reported no relevant financial relationships.

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

People with thyroid cancer treated with thyroidectomy have as much as a 40% increased risk of developing type 2 diabetes, regardless of their age, with the elevated risk observed with low as well as high doses of postoperative levothyroxine, new research shows.

“This is the first population-based study to demonstrate an elevated risk of type 2 diabetes in postthyroidectomy patients with thyroid cancer, compared with that in matched controls,” wrote the authors of the research, published recently in the Journal of Clinical Endocrinology & Metabolism.

“Notably, there was a U-shaped relationship between postoperative levothyroxine dosage, a surrogate marker of TSH suppression, and the risk of type 2 diabetes,” said Hye Jin Yoo, MD, of the division of endocrinology and metabolism, Korea University College of Medicine, Seoul, and colleagues.

While other studies have linked thyroidectomy for thyroid cancer with an elevated risk for other metabolic conditions, including coronary heart disease and ischemic stroke, the relatively high diabetes risk is unexpected, said Tyler Drake, MD, an endocrinologist with the Minneapolis VA Health Care System.

“A 40% increased risk of diabetes is a big surprise,” he said in an interview.

“Diabetes is very common, with about one in 10 U.S. adults having type 2 diabetes, but a 40% increased risk in thyroid cancer patients is higher than I see in my clinical practice. [However], it is important to note that the [highest] risk was predominantly among the groups on the lowest and highest doses of levothyroxine,” said Dr. Drake, assistant professor of medicine at the University of Minnesota, Minneapolis.
 

U-shaped relationship between levothyroxine dose and diabetes risk

The findings are from a study of 36,377 patients with thyroid cancer in the National Health Insurance Service (NHIS) database in Korea who had undergone a thyroidectomy between 2004 and 2013.

The patients were matched 1:1 with controls who had nonthyroid cancers. Their mean age was 46.6 years, about 30% were male, and their mean body mass index was 23.8 kg/m².

Over a mean follow-up of 6.6 years, the patients with thyroid cancer had a significantly higher risk of developing type 2 diabetes, at a rate of 47.5% (10,812) compared with 36.9% (9414; HR, 1.43; P < .001) in the control group, after adjustment for factors such as age, sex, BMI, smoking, drinking, systolic blood pressure, and fasting glucose.

The risk of type 2 diabetes among those with thyroid cancer was higher among the 83.2% of patients who underwent a total thyroidectomy compared with the 16.8% who had a unilateral lobectomy (HR, 1.06; P < .001).

In addition, those with thyroid cancer who received the lowest as well as highest dosages of levothyroxine had significantly higher risks of type 2 diabetes compared with controls (HR, 1.50 and 1.39, respectively; both P < .001).

A closer look at quartiles of levothyroxine dosing showed the first (lowest) quartile (defined as a mean levothyroxine dosage of < 101 mcg/day) was associated with an increased risk of type 2 diabetes compared with the second quartile group (101-127 mcg/day; HR, 1.45), as was the fourth quartile (≥ 150 mcg/day; HR, 1.37), while a decreased risk of type 2 diabetes was observed in the third quartile group (128-149 mcg/day versus the second quartile group; HR, 0.91).

“This result suggests a U-shaped relationship between the mean levothyroxine dosage and risk of type 2 diabetes in postthyroidectomy patients with thyroid cancer,” the authors said.

However, “consistent with previous studies, the present study showed that the highest risk of type 2 diabetes was observed in patients with thyroid cancer who were treated with the lowest mean dosage of levothyroxine,” they noted.

“This result suggests that inadequate supplementation of thyroid hormones may worsen glucose metabolism and should therefore be avoided.”
 

Potential mechanisms

Abnormal thyroid function, including hypo- and hyperthyroidism, following thyroidectomy and subsequent treatment with levothyroxine, is known to have potentially detrimental effects on glucose regulation among patients with thyroid cancer.

The potential mechanisms linking hypothyroidism with diabetes specifically include the possibility that insulin becomes unable to promote the utilization of glucose by muscles and adipose tissue. However, thyroid hormone replacement has been associated with a normalization of insulin sensitivity, the authors noted.

Meanwhile, glucose intolerance is common among patients with hyperthyroidism, largely due to an increase in hepatic glucose production, and likewise, the normalization of thyroid levels among those treated with methimazole has been linked to normalization of glucose and lipid metabolism alterations.

Dr. Drake noted that an important study limitation is that patients were analyzed based on their levothyroxine dose and not their TSH values, which the authors explain was due to the unavailability of the TSH values. 

“By looking at levothyroxine doses, and not TSH values, it is possible some patients were being improperly treated with either too much or too little levothyroxine,” Dr. Drake noted.
 

Control group should have had hypothyroidism

The findings nevertheless shed light on the risk of diabetes following thyroidectomy for thyroid cancer, Anupam Kotwal, MD, commented on the study.

“This study is significant because it addresses an important topic exploring the link between thyroid dysfunction and metabolic disease, in this case ... hypothyroidism, due to surgery for thyroid cancer and type 2 diabetes,” Dr. Kotwal, assistant professor of medicine in the division of diabetes, endocrinology & metabolism at the University of Nebraska Medical Center, Omaha, said in an interview.

In terms of other limitations, Dr. Kotwal noted that the controls did not have hypothyroidism; therefore, “from this study, it is impossible to confirm whether hypothyroidism from any cause would be associated with higher incidence of diabetes or if it is specific to thyroid surgery for thyroid cancer.

“It would have been useful to have a control group of autoimmune primary hypothyroidism to evaluate the rate of diabetes during a similar follow-up duration,” Dr. Kotwal said.

“Hence, cohort studies with more granular data such as degree of TSH suppression and having a control group of hypothyroid patients due to autoimmune thyroid disease are needed to better understand this risk.”

Dr. Kotwal and Dr. Drake have reported no relevant financial relationships.

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

People with thyroid cancer treated with thyroidectomy have as much as a 40% increased risk of developing type 2 diabetes, regardless of their age, with the elevated risk observed with low as well as high doses of postoperative levothyroxine, new research shows.

“This is the first population-based study to demonstrate an elevated risk of type 2 diabetes in postthyroidectomy patients with thyroid cancer, compared with that in matched controls,” wrote the authors of the research, published recently in the Journal of Clinical Endocrinology & Metabolism.

“Notably, there was a U-shaped relationship between postoperative levothyroxine dosage, a surrogate marker of TSH suppression, and the risk of type 2 diabetes,” said Hye Jin Yoo, MD, of the division of endocrinology and metabolism, Korea University College of Medicine, Seoul, and colleagues.

While other studies have linked thyroidectomy for thyroid cancer with an elevated risk for other metabolic conditions, including coronary heart disease and ischemic stroke, the relatively high diabetes risk is unexpected, said Tyler Drake, MD, an endocrinologist with the Minneapolis VA Health Care System.

“A 40% increased risk of diabetes is a big surprise,” he said in an interview.

“Diabetes is very common, with about one in 10 U.S. adults having type 2 diabetes, but a 40% increased risk in thyroid cancer patients is higher than I see in my clinical practice. [However], it is important to note that the [highest] risk was predominantly among the groups on the lowest and highest doses of levothyroxine,” said Dr. Drake, assistant professor of medicine at the University of Minnesota, Minneapolis.
 

U-shaped relationship between levothyroxine dose and diabetes risk

The findings are from a study of 36,377 patients with thyroid cancer in the National Health Insurance Service (NHIS) database in Korea who had undergone a thyroidectomy between 2004 and 2013.

The patients were matched 1:1 with controls who had nonthyroid cancers. Their mean age was 46.6 years, about 30% were male, and their mean body mass index was 23.8 kg/m².

Over a mean follow-up of 6.6 years, the patients with thyroid cancer had a significantly higher risk of developing type 2 diabetes, at a rate of 47.5% (10,812) compared with 36.9% (9414; HR, 1.43; P < .001) in the control group, after adjustment for factors such as age, sex, BMI, smoking, drinking, systolic blood pressure, and fasting glucose.

The risk of type 2 diabetes among those with thyroid cancer was higher among the 83.2% of patients who underwent a total thyroidectomy compared with the 16.8% who had a unilateral lobectomy (HR, 1.06; P < .001).

In addition, those with thyroid cancer who received the lowest as well as highest dosages of levothyroxine had significantly higher risks of type 2 diabetes compared with controls (HR, 1.50 and 1.39, respectively; both P < .001).

A closer look at quartiles of levothyroxine dosing showed the first (lowest) quartile (defined as a mean levothyroxine dosage of < 101 mcg/day) was associated with an increased risk of type 2 diabetes compared with the second quartile group (101-127 mcg/day; HR, 1.45), as was the fourth quartile (≥ 150 mcg/day; HR, 1.37), while a decreased risk of type 2 diabetes was observed in the third quartile group (128-149 mcg/day versus the second quartile group; HR, 0.91).

“This result suggests a U-shaped relationship between the mean levothyroxine dosage and risk of type 2 diabetes in postthyroidectomy patients with thyroid cancer,” the authors said.

However, “consistent with previous studies, the present study showed that the highest risk of type 2 diabetes was observed in patients with thyroid cancer who were treated with the lowest mean dosage of levothyroxine,” they noted.

“This result suggests that inadequate supplementation of thyroid hormones may worsen glucose metabolism and should therefore be avoided.”
 

Potential mechanisms

Abnormal thyroid function, including hypo- and hyperthyroidism, following thyroidectomy and subsequent treatment with levothyroxine, is known to have potentially detrimental effects on glucose regulation among patients with thyroid cancer.

The potential mechanisms linking hypothyroidism with diabetes specifically include the possibility that insulin becomes unable to promote the utilization of glucose by muscles and adipose tissue. However, thyroid hormone replacement has been associated with a normalization of insulin sensitivity, the authors noted.

Meanwhile, glucose intolerance is common among patients with hyperthyroidism, largely due to an increase in hepatic glucose production, and likewise, the normalization of thyroid levels among those treated with methimazole has been linked to normalization of glucose and lipid metabolism alterations.

Dr. Drake noted that an important study limitation is that patients were analyzed based on their levothyroxine dose and not their TSH values, which the authors explain was due to the unavailability of the TSH values. 

“By looking at levothyroxine doses, and not TSH values, it is possible some patients were being improperly treated with either too much or too little levothyroxine,” Dr. Drake noted.
 

Control group should have had hypothyroidism

The findings nevertheless shed light on the risk of diabetes following thyroidectomy for thyroid cancer, Anupam Kotwal, MD, commented on the study.

“This study is significant because it addresses an important topic exploring the link between thyroid dysfunction and metabolic disease, in this case ... hypothyroidism, due to surgery for thyroid cancer and type 2 diabetes,” Dr. Kotwal, assistant professor of medicine in the division of diabetes, endocrinology & metabolism at the University of Nebraska Medical Center, Omaha, said in an interview.

In terms of other limitations, Dr. Kotwal noted that the controls did not have hypothyroidism; therefore, “from this study, it is impossible to confirm whether hypothyroidism from any cause would be associated with higher incidence of diabetes or if it is specific to thyroid surgery for thyroid cancer.

“It would have been useful to have a control group of autoimmune primary hypothyroidism to evaluate the rate of diabetes during a similar follow-up duration,” Dr. Kotwal said.

“Hence, cohort studies with more granular data such as degree of TSH suppression and having a control group of hypothyroid patients due to autoimmune thyroid disease are needed to better understand this risk.”

Dr. Kotwal and Dr. Drake have reported no relevant financial relationships.

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

How did you realize medical education was the pathway for you?

Near the end of medical school, I recall my friends and I casting predictions about what each person would be doing in twenty years. The projections offered up about my ultimate landing place were unanimous: a clinical researcher leading a gastroenterology division. I was excited when they said this to me. It made sense, as I had already done over 3 years of clinical research on inflammatory bowel disease at the time. But as I began leading various clinical research projects during my internal medicine residency, I realized that they were not generating a strong sense of fulfillment or passion for me. I greatly enjoyed the process of research and writing, but there still was something missing; I could no longer see the role of a funded clinical researcher sustaining me for the length of my medical and academic career.

Thus, at the end of my 2nd year of residency, I began to self-reflect more on the various aspects of my medical journey to elucidate my path forward. This process was jump-started by a humbling recognition from that year’s graduating class of medical students for my contributions to their education over the past 3 years. I had served as a teaching assistant for their pathophysiology course and then subsequently worked alongside many of them on their medicine rotations. I realized that helping foster their growth as physicians in a longitudinal way was unquestionably the most rewarding experience that I had had to date. With further reflection, I recognized that, amid the chaos of a busy call day, I most looked forward to the moments when I could teach the interns and students about the nuances of the patients being admitted. It never felt like an obligation but rather always left me feeling revitalized. So, by the beginning of my 3rd year of residency, I knew that I wanted to pursue a career within medical education.
 

Once you decided to become a medical educator, what were your next steps?

As I began to vocalize this change in career trajectory, I did not always encounter enthusiastic support. Because the medical educator pathway is more typical amongst the general medicine community, some faculty members advised me to avoid solely focusing on medical education as a specialist because academic success would be difficult to attain. But I had just recognized this could be my vocation within medicine, so I could not turn back now. Thus, I began to seek the mentorship of educators at my institution, and many of them wisely advised me to consider pursuing additional training in medical education to accrue the skill sets needed to lay the groundwork for a lifelong career. So, I participated in a 1-year medical education fellowship in conjunction with my chief residency year. This training was profoundly formative; I learned about the various theories on adult learning, as well as how to create curricula, how to teach effectively in a clinical environment, and how to deliver meaningful feedback to learners. But perhaps most importantly, I learned how to generate tangible evidence of productivity within medical education to allow for advancement in academia. This included rigorously studying the impact of educational interventions. It became clear to me by the end of this year that the pathways of medical education and researcher were not incongruent but could actually be quite complementary. In light of this, I designed and implemented a mandatory inpatient hepatology curriculum for internal medicine residents, for which I studied its immediate and long-term effects throughout my gastroenterology and hepatology fellowships as well as during my time as an attending. Currently, I am also investigating medical students’ exposure to liver disease through a multicenter assessment. Projects such as these would not have been feasible without dedicated mentorship, but as alluded to above, in contrast to the traditional clinical research paradigm, my mentors have often been from outside the fields of gastroenterology and hepatology.

What advice would you offer a junior faculty member interested in a career in medical education within gastroenterology and hepatology?

1. Just before I completed fellowship, I asked Holly Humphrey, MD, the former dean of the Pritzker School of Medicine at the University of Chicago, this same question. Her answer was simple and is worth sharing: “In the beginning, just focus on becoming the best clinician possible. The rest will fall into place with time.” So, I did exactly this. I continually tried to push the limits of my knowledge, always questioning standard clinical practices to understand the evidence behind (or not behind) them. This knowledge then naturally became the content of my teaching for trainees in the clinical environment so that eventually patient care and teaching were seamlessly integrated into the same day-to-day workflow. The more I taught trainees, the more my commitment to education was recognized by my institution.

2. Meet with leadership of your medical school, internal medicine residency program, and gastroenterology and hepatology fellowships early in the course of your career to assert your desire to contribute to their respective educational missions.

3. Create a teaching philosophy that clearly communicates “your fundamental beliefs about teaching and learning, why you hold those values and beliefs, and how you translate these claims into practice.”¹ This document will act as a guiding force in your career by highlighting the themes and principles that you have already incorporated and will continue to incorporate into your teaching practices and educational activities. For example, it can provide clarity when you are in doubt of how to address a difficult learning environment or whether to accept a certain position.

4. Because of No. 1 and No. 2, you will start to be offered opportunities to formally become involved in curricula within undergraduate (UME) and graduate medical education (GME). It will likely begin with requests to lecture or precept small group sessions. Use these smaller opportunities not only to refine your teaching skills but to explore whether your career aspirations better align with UME or GME. With hard work and perseverance, the opportunities can progress to invitations to become a course director, join a curriculum committee, or become an associate program director for a residency or fellowship program (which at this point is why you want to know if you prefer working in UME, GME, or both).

5. Seek feedback often from your learners. It is the only way you will continue to improve your teaching skills and the learning environment you create. Furthermore, formal evaluations can be used in the promotion process.

6. Collaborate with and seek mentorship from fellow medical educators both at your own institution and at others. As previously mentioned, these relationships do not need to be (and are often not) with other gastroenterologists or hepatologists.

7. Seek out national opportunities related to medical education. Most of the gastroenterology and hepatology societies have one or more committees focused on medical training. The AGA Academy of Educators is a fantastic community of education-focused individuals within our specialty that provides opportunities for networking, funding, and career development. Furthermore, other general societies (for example, the Association of American Medical Colleges, American College of Physicians) may be interested in including subspecialty members in their educational committees and activities.

Dr. Mikolajczyk is an assistant professor of medicine and an associate program director for the Internal Medicine Residency Program at the University of Illinois Chicago. He is the lead faculty adviser for the Liver Fellow Network. He has no conflicts of interest to disclose.

How did you realize medical education was the pathway for you?

Near the end of medical school, I recall my friends and I casting predictions about what each person would be doing in twenty years. The projections offered up about my ultimate landing place were unanimous: a clinical researcher leading a gastroenterology division. I was excited when they said this to me. It made sense, as I had already done over 3 years of clinical research on inflammatory bowel disease at the time. But as I began leading various clinical research projects during my internal medicine residency, I realized that they were not generating a strong sense of fulfillment or passion for me. I greatly enjoyed the process of research and writing, but there still was something missing; I could no longer see the role of a funded clinical researcher sustaining me for the length of my medical and academic career.

Thus, at the end of my 2nd year of residency, I began to self-reflect more on the various aspects of my medical journey to elucidate my path forward. This process was jump-started by a humbling recognition from that year’s graduating class of medical students for my contributions to their education over the past 3 years. I had served as a teaching assistant for their pathophysiology course and then subsequently worked alongside many of them on their medicine rotations. I realized that helping foster their growth as physicians in a longitudinal way was unquestionably the most rewarding experience that I had had to date. With further reflection, I recognized that, amid the chaos of a busy call day, I most looked forward to the moments when I could teach the interns and students about the nuances of the patients being admitted. It never felt like an obligation but rather always left me feeling revitalized. So, by the beginning of my 3rd year of residency, I knew that I wanted to pursue a career within medical education.
 

Once you decided to become a medical educator, what were your next steps?

As I began to vocalize this change in career trajectory, I did not always encounter enthusiastic support. Because the medical educator pathway is more typical amongst the general medicine community, some faculty members advised me to avoid solely focusing on medical education as a specialist because academic success would be difficult to attain. But I had just recognized this could be my vocation within medicine, so I could not turn back now. Thus, I began to seek the mentorship of educators at my institution, and many of them wisely advised me to consider pursuing additional training in medical education to accrue the skill sets needed to lay the groundwork for a lifelong career. So, I participated in a 1-year medical education fellowship in conjunction with my chief residency year. This training was profoundly formative; I learned about the various theories on adult learning, as well as how to create curricula, how to teach effectively in a clinical environment, and how to deliver meaningful feedback to learners. But perhaps most importantly, I learned how to generate tangible evidence of productivity within medical education to allow for advancement in academia. This included rigorously studying the impact of educational interventions. It became clear to me by the end of this year that the pathways of medical education and researcher were not incongruent but could actually be quite complementary. In light of this, I designed and implemented a mandatory inpatient hepatology curriculum for internal medicine residents, for which I studied its immediate and long-term effects throughout my gastroenterology and hepatology fellowships as well as during my time as an attending. Currently, I am also investigating medical students’ exposure to liver disease through a multicenter assessment. Projects such as these would not have been feasible without dedicated mentorship, but as alluded to above, in contrast to the traditional clinical research paradigm, my mentors have often been from outside the fields of gastroenterology and hepatology.

What advice would you offer a junior faculty member interested in a career in medical education within gastroenterology and hepatology?

1. Just before I completed fellowship, I asked Holly Humphrey, MD, the former dean of the Pritzker School of Medicine at the University of Chicago, this same question. Her answer was simple and is worth sharing: “In the beginning, just focus on becoming the best clinician possible. The rest will fall into place with time.” So, I did exactly this. I continually tried to push the limits of my knowledge, always questioning standard clinical practices to understand the evidence behind (or not behind) them. This knowledge then naturally became the content of my teaching for trainees in the clinical environment so that eventually patient care and teaching were seamlessly integrated into the same day-to-day workflow. The more I taught trainees, the more my commitment to education was recognized by my institution.

2. Meet with leadership of your medical school, internal medicine residency program, and gastroenterology and hepatology fellowships early in the course of your career to assert your desire to contribute to their respective educational missions.

3. Create a teaching philosophy that clearly communicates “your fundamental beliefs about teaching and learning, why you hold those values and beliefs, and how you translate these claims into practice.”¹ This document will act as a guiding force in your career by highlighting the themes and principles that you have already incorporated and will continue to incorporate into your teaching practices and educational activities. For example, it can provide clarity when you are in doubt of how to address a difficult learning environment or whether to accept a certain position.

4. Because of No. 1 and No. 2, you will start to be offered opportunities to formally become involved in curricula within undergraduate (UME) and graduate medical education (GME). It will likely begin with requests to lecture or precept small group sessions. Use these smaller opportunities not only to refine your teaching skills but to explore whether your career aspirations better align with UME or GME. With hard work and perseverance, the opportunities can progress to invitations to become a course director, join a curriculum committee, or become an associate program director for a residency or fellowship program (which at this point is why you want to know if you prefer working in UME, GME, or both).

5. Seek feedback often from your learners. It is the only way you will continue to improve your teaching skills and the learning environment you create. Furthermore, formal evaluations can be used in the promotion process.

6. Collaborate with and seek mentorship from fellow medical educators both at your own institution and at others. As previously mentioned, these relationships do not need to be (and are often not) with other gastroenterologists or hepatologists.

7. Seek out national opportunities related to medical education. Most of the gastroenterology and hepatology societies have one or more committees focused on medical training. The AGA Academy of Educators is a fantastic community of education-focused individuals within our specialty that provides opportunities for networking, funding, and career development. Furthermore, other general societies (for example, the Association of American Medical Colleges, American College of Physicians) may be interested in including subspecialty members in their educational committees and activities.

Dr. Mikolajczyk is an assistant professor of medicine and an associate program director for the Internal Medicine Residency Program at the University of Illinois Chicago. He is the lead faculty adviser for the Liver Fellow Network. He has no conflicts of interest to disclose.

How did you realize medical education was the pathway for you?

Near the end of medical school, I recall my friends and I casting predictions about what each person would be doing in twenty years. The projections offered up about my ultimate landing place were unanimous: a clinical researcher leading a gastroenterology division. I was excited when they said this to me. It made sense, as I had already done over 3 years of clinical research on inflammatory bowel disease at the time. But as I began leading various clinical research projects during my internal medicine residency, I realized that they were not generating a strong sense of fulfillment or passion for me. I greatly enjoyed the process of research and writing, but there still was something missing; I could no longer see the role of a funded clinical researcher sustaining me for the length of my medical and academic career.

Thus, at the end of my 2nd year of residency, I began to self-reflect more on the various aspects of my medical journey to elucidate my path forward. This process was jump-started by a humbling recognition from that year’s graduating class of medical students for my contributions to their education over the past 3 years. I had served as a teaching assistant for their pathophysiology course and then subsequently worked alongside many of them on their medicine rotations. I realized that helping foster their growth as physicians in a longitudinal way was unquestionably the most rewarding experience that I had had to date. With further reflection, I recognized that, amid the chaos of a busy call day, I most looked forward to the moments when I could teach the interns and students about the nuances of the patients being admitted. It never felt like an obligation but rather always left me feeling revitalized. So, by the beginning of my 3rd year of residency, I knew that I wanted to pursue a career within medical education.
 

Once you decided to become a medical educator, what were your next steps?

As I began to vocalize this change in career trajectory, I did not always encounter enthusiastic support. Because the medical educator pathway is more typical amongst the general medicine community, some faculty members advised me to avoid solely focusing on medical education as a specialist because academic success would be difficult to attain. But I had just recognized this could be my vocation within medicine, so I could not turn back now. Thus, I began to seek the mentorship of educators at my institution, and many of them wisely advised me to consider pursuing additional training in medical education to accrue the skill sets needed to lay the groundwork for a lifelong career. So, I participated in a 1-year medical education fellowship in conjunction with my chief residency year. This training was profoundly formative; I learned about the various theories on adult learning, as well as how to create curricula, how to teach effectively in a clinical environment, and how to deliver meaningful feedback to learners. But perhaps most importantly, I learned how to generate tangible evidence of productivity within medical education to allow for advancement in academia. This included rigorously studying the impact of educational interventions. It became clear to me by the end of this year that the pathways of medical education and researcher were not incongruent but could actually be quite complementary. In light of this, I designed and implemented a mandatory inpatient hepatology curriculum for internal medicine residents, for which I studied its immediate and long-term effects throughout my gastroenterology and hepatology fellowships as well as during my time as an attending. Currently, I am also investigating medical students’ exposure to liver disease through a multicenter assessment. Projects such as these would not have been feasible without dedicated mentorship, but as alluded to above, in contrast to the traditional clinical research paradigm, my mentors have often been from outside the fields of gastroenterology and hepatology.

What advice would you offer a junior faculty member interested in a career in medical education within gastroenterology and hepatology?

1. Just before I completed fellowship, I asked Holly Humphrey, MD, the former dean of the Pritzker School of Medicine at the University of Chicago, this same question. Her answer was simple and is worth sharing: “In the beginning, just focus on becoming the best clinician possible. The rest will fall into place with time.” So, I did exactly this. I continually tried to push the limits of my knowledge, always questioning standard clinical practices to understand the evidence behind (or not behind) them. This knowledge then naturally became the content of my teaching for trainees in the clinical environment so that eventually patient care and teaching were seamlessly integrated into the same day-to-day workflow. The more I taught trainees, the more my commitment to education was recognized by my institution.

2. Meet with leadership of your medical school, internal medicine residency program, and gastroenterology and hepatology fellowships early in the course of your career to assert your desire to contribute to their respective educational missions.

3. Create a teaching philosophy that clearly communicates “your fundamental beliefs about teaching and learning, why you hold those values and beliefs, and how you translate these claims into practice.”¹ This document will act as a guiding force in your career by highlighting the themes and principles that you have already incorporated and will continue to incorporate into your teaching practices and educational activities. For example, it can provide clarity when you are in doubt of how to address a difficult learning environment or whether to accept a certain position.

4. Because of No. 1 and No. 2, you will start to be offered opportunities to formally become involved in curricula within undergraduate (UME) and graduate medical education (GME). It will likely begin with requests to lecture or precept small group sessions. Use these smaller opportunities not only to refine your teaching skills but to explore whether your career aspirations better align with UME or GME. With hard work and perseverance, the opportunities can progress to invitations to become a course director, join a curriculum committee, or become an associate program director for a residency or fellowship program (which at this point is why you want to know if you prefer working in UME, GME, or both).

5. Seek feedback often from your learners. It is the only way you will continue to improve your teaching skills and the learning environment you create. Furthermore, formal evaluations can be used in the promotion process.

6. Collaborate with and seek mentorship from fellow medical educators both at your own institution and at others. As previously mentioned, these relationships do not need to be (and are often not) with other gastroenterologists or hepatologists.

7. Seek out national opportunities related to medical education. Most of the gastroenterology and hepatology societies have one or more committees focused on medical training. The AGA Academy of Educators is a fantastic community of education-focused individuals within our specialty that provides opportunities for networking, funding, and career development. Furthermore, other general societies (for example, the Association of American Medical Colleges, American College of Physicians) may be interested in including subspecialty members in their educational committees and activities.

Dr. Mikolajczyk is an assistant professor of medicine and an associate program director for the Internal Medicine Residency Program at the University of Illinois Chicago. He is the lead faculty adviser for the Liver Fellow Network. He has no conflicts of interest to disclose.

A new survey from the National Foundation for Infectious Diseases shows that, despite the recommendation that patients who have chronic illnesses receive annual flu vaccines, only 45% of these patients do get them. People with chronic diseases are at increased risk for serious flu-related complications, including hospitalization and death.

MarianVejcik/Getty Images

The survey looked at physicians’ practices toward flu vaccination and communication between health care providers (HCP) and their adult patients with chronic health conditions.

Overall, less than a third of HCPs (31%) said they recommend annual flu vaccination to all of their patients with chronic health conditions. There were some surprising differences between subspecialists. For example, 72% of patients with a heart problem who saw a cardiologist said that physician recommended the flu vaccine. The recommendation rate dropped to 32% of lung patients seeing a pulmonary physician and only 10% of people with diabetes who saw an endocrinologist.

There is quite a large gap between what physicians and patients say about their interactions. Fully 77% of HCPs who recommend annual flu vaccination say they tell patients when they are at higher risk of complications from influenza. Yet only 48% of patients say they have been given such information.

Although it is critically important information for patients to learn, their risk of influenza is often missing from the discussion. For example, patients with heart disease are six times more likely to have a heart attack within 7 days of flu infection. People with diabetes are six times more likely to be hospitalized from flu and three times more likely to die. Similarly, those with asthma or chronic obstructive pulmonary disorder are at a much higher risk of complications.

One problem is that more than half of specialist physicians who do not offer flu vaccinations report that it is because they believe that immunizations are the responsibility of the primary care physician. Yet only 65% of patients with one of these chronic illnesses report seeing their primary care physician at least annually.

Much of the disparity between the patient’s perception of what they were told and the physician’s is “how the ‘recommendation’ is actually made,” William Schaffner, MD, NFID’s medical director and professor of medicine at Vanderbilt University, Nashville, Tenn., told this news organization. Dr. Schaffner offered the following example: At the end of the visit, the doctor might say: “It’s that time of the year again – you want to think about getting your flu shot.”

“The doctor thinks they’ve recommended that, but the doctor really has opened the door for you to think about it and leave [yourself] unvaccinated.”

Dr. Schaffner’s alternative? Tell the patient: “‘You’ll get your flu vaccine on the way out. Tom or Sally will give it to you.’ That’s a very different kind of recommendation. And it’s a much greater assurance of providing the vaccine.”

Another major problem, Dr. Schaffner said, is that many specialists “don’t think of vaccination as something that’s included with their routine care” even though they do direct much of the patient’s care. He said that physicians should be more “directive” in their care and that immunizations should be better integrated into routine practice.

Jody Lanard, MD, a retired risk communication consultant who spent many years working with the World Health Organization on disease outbreak communications, said in an interview that this disconnect between physician and patient reports “was really jarring. And it’s actionable!”

She offered several practical suggestions. For one, she said, “the messaging to the specialists has to be very, very empathic. We know you’re already overburdened. And here we’re asking you to do something that you think of as somebody else’s job.” But if your patient gets flu, then your job as the cardiologist or endocrinologist will become more complicated and time-consuming. So getting the patients vaccinated will be a good investment and will make your job easier.

Because of the disparity in patient and physician reports, Dr. Lanard suggested implementing a “feedback mechanism where they [the health care providers] give out the prescription, and then the office calls [the patient] to see if they’ve gotten the shot or not. Because that way it will help correct the mismatch between them thinking that they told the patient and the patient not hearing it.”

Asked about why there might be a big gap between what physicians report they said and what patients heard, Dr. Lanard explained that “physicians often communicate in [a manner] sort of like a checklist. And the patients are focused on one or two things that are high in their minds. And the physician was mentioning some things that are on a separate topic that are not on a patient’s list and it goes right past them.”

Dr. Lanard recommended brief storytelling instead of checklists. For example: “I’ve been treating your diabetes for 10 years. During this last flu season, several of my diabetic patients had a really hard time when they caught the flu. So now I’m trying harder to remember to remind you to get your flu shots.”

She urged HCPs to “make it more personal ... but it can still be scripted in advance as part of something that [you’re] remembering to do during the check.” She added that their professional associations may be able to send them suggested language they can adapt.

Finally, Dr. Lanard cautioned about vaccine myths. “The word myth is so insulting. It’s basically a word that sends the signal that you’re an idiot.”

She advised specialists to avoid the word “myth,” which will make the person defensive. Instead, say something like, “A lot of people, even some of my own family members, think the flu vaccine gives you the flu. ... But it doesn’t. And then you go into the reality.”

Dr. Lanard suggested that specialists implement the follow-up calls and close the feedback loop, saying: “If they did the survey a few years later, I bet that gap would narrow.”

Dr. Schaffner and Dr. Lanard disclosed no relevant financial relationships.

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

A new survey from the National Foundation for Infectious Diseases shows that, despite the recommendation that patients who have chronic illnesses receive annual flu vaccines, only 45% of these patients do get them. People with chronic diseases are at increased risk for serious flu-related complications, including hospitalization and death.

MarianVejcik/Getty Images

The survey looked at physicians’ practices toward flu vaccination and communication between health care providers (HCP) and their adult patients with chronic health conditions.

Overall, less than a third of HCPs (31%) said they recommend annual flu vaccination to all of their patients with chronic health conditions. There were some surprising differences between subspecialists. For example, 72% of patients with a heart problem who saw a cardiologist said that physician recommended the flu vaccine. The recommendation rate dropped to 32% of lung patients seeing a pulmonary physician and only 10% of people with diabetes who saw an endocrinologist.

There is quite a large gap between what physicians and patients say about their interactions. Fully 77% of HCPs who recommend annual flu vaccination say they tell patients when they are at higher risk of complications from influenza. Yet only 48% of patients say they have been given such information.

Although it is critically important information for patients to learn, their risk of influenza is often missing from the discussion. For example, patients with heart disease are six times more likely to have a heart attack within 7 days of flu infection. People with diabetes are six times more likely to be hospitalized from flu and three times more likely to die. Similarly, those with asthma or chronic obstructive pulmonary disorder are at a much higher risk of complications.

One problem is that more than half of specialist physicians who do not offer flu vaccinations report that it is because they believe that immunizations are the responsibility of the primary care physician. Yet only 65% of patients with one of these chronic illnesses report seeing their primary care physician at least annually.

Much of the disparity between the patient’s perception of what they were told and the physician’s is “how the ‘recommendation’ is actually made,” William Schaffner, MD, NFID’s medical director and professor of medicine at Vanderbilt University, Nashville, Tenn., told this news organization. Dr. Schaffner offered the following example: At the end of the visit, the doctor might say: “It’s that time of the year again – you want to think about getting your flu shot.”

“The doctor thinks they’ve recommended that, but the doctor really has opened the door for you to think about it and leave [yourself] unvaccinated.”

Dr. Schaffner’s alternative? Tell the patient: “‘You’ll get your flu vaccine on the way out. Tom or Sally will give it to you.’ That’s a very different kind of recommendation. And it’s a much greater assurance of providing the vaccine.”

Another major problem, Dr. Schaffner said, is that many specialists “don’t think of vaccination as something that’s included with their routine care” even though they do direct much of the patient’s care. He said that physicians should be more “directive” in their care and that immunizations should be better integrated into routine practice.

Jody Lanard, MD, a retired risk communication consultant who spent many years working with the World Health Organization on disease outbreak communications, said in an interview that this disconnect between physician and patient reports “was really jarring. And it’s actionable!”

She offered several practical suggestions. For one, she said, “the messaging to the specialists has to be very, very empathic. We know you’re already overburdened. And here we’re asking you to do something that you think of as somebody else’s job.” But if your patient gets flu, then your job as the cardiologist or endocrinologist will become more complicated and time-consuming. So getting the patients vaccinated will be a good investment and will make your job easier.

Because of the disparity in patient and physician reports, Dr. Lanard suggested implementing a “feedback mechanism where they [the health care providers] give out the prescription, and then the office calls [the patient] to see if they’ve gotten the shot or not. Because that way it will help correct the mismatch between them thinking that they told the patient and the patient not hearing it.”

Asked about why there might be a big gap between what physicians report they said and what patients heard, Dr. Lanard explained that “physicians often communicate in [a manner] sort of like a checklist. And the patients are focused on one or two things that are high in their minds. And the physician was mentioning some things that are on a separate topic that are not on a patient’s list and it goes right past them.”

Dr. Lanard recommended brief storytelling instead of checklists. For example: “I’ve been treating your diabetes for 10 years. During this last flu season, several of my diabetic patients had a really hard time when they caught the flu. So now I’m trying harder to remember to remind you to get your flu shots.”

She urged HCPs to “make it more personal ... but it can still be scripted in advance as part of something that [you’re] remembering to do during the check.” She added that their professional associations may be able to send them suggested language they can adapt.

Finally, Dr. Lanard cautioned about vaccine myths. “The word myth is so insulting. It’s basically a word that sends the signal that you’re an idiot.”

She advised specialists to avoid the word “myth,” which will make the person defensive. Instead, say something like, “A lot of people, even some of my own family members, think the flu vaccine gives you the flu. ... But it doesn’t. And then you go into the reality.”

Dr. Lanard suggested that specialists implement the follow-up calls and close the feedback loop, saying: “If they did the survey a few years later, I bet that gap would narrow.”

Dr. Schaffner and Dr. Lanard disclosed no relevant financial relationships.

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

A new survey from the National Foundation for Infectious Diseases shows that, despite the recommendation that patients who have chronic illnesses receive annual flu vaccines, only 45% of these patients do get them. People with chronic diseases are at increased risk for serious flu-related complications, including hospitalization and death.

MarianVejcik/Getty Images

The survey looked at physicians’ practices toward flu vaccination and communication between health care providers (HCP) and their adult patients with chronic health conditions.

Overall, less than a third of HCPs (31%) said they recommend annual flu vaccination to all of their patients with chronic health conditions. There were some surprising differences between subspecialists. For example, 72% of patients with a heart problem who saw a cardiologist said that physician recommended the flu vaccine. The recommendation rate dropped to 32% of lung patients seeing a pulmonary physician and only 10% of people with diabetes who saw an endocrinologist.

There is quite a large gap between what physicians and patients say about their interactions. Fully 77% of HCPs who recommend annual flu vaccination say they tell patients when they are at higher risk of complications from influenza. Yet only 48% of patients say they have been given such information.

Although it is critically important information for patients to learn, their risk of influenza is often missing from the discussion. For example, patients with heart disease are six times more likely to have a heart attack within 7 days of flu infection. People with diabetes are six times more likely to be hospitalized from flu and three times more likely to die. Similarly, those with asthma or chronic obstructive pulmonary disorder are at a much higher risk of complications.

One problem is that more than half of specialist physicians who do not offer flu vaccinations report that it is because they believe that immunizations are the responsibility of the primary care physician. Yet only 65% of patients with one of these chronic illnesses report seeing their primary care physician at least annually.

Much of the disparity between the patient’s perception of what they were told and the physician’s is “how the ‘recommendation’ is actually made,” William Schaffner, MD, NFID’s medical director and professor of medicine at Vanderbilt University, Nashville, Tenn., told this news organization. Dr. Schaffner offered the following example: At the end of the visit, the doctor might say: “It’s that time of the year again – you want to think about getting your flu shot.”

“The doctor thinks they’ve recommended that, but the doctor really has opened the door for you to think about it and leave [yourself] unvaccinated.”

Dr. Schaffner’s alternative? Tell the patient: “‘You’ll get your flu vaccine on the way out. Tom or Sally will give it to you.’ That’s a very different kind of recommendation. And it’s a much greater assurance of providing the vaccine.”

Another major problem, Dr. Schaffner said, is that many specialists “don’t think of vaccination as something that’s included with their routine care” even though they do direct much of the patient’s care. He said that physicians should be more “directive” in their care and that immunizations should be better integrated into routine practice.

Jody Lanard, MD, a retired risk communication consultant who spent many years working with the World Health Organization on disease outbreak communications, said in an interview that this disconnect between physician and patient reports “was really jarring. And it’s actionable!”

She offered several practical suggestions. For one, she said, “the messaging to the specialists has to be very, very empathic. We know you’re already overburdened. And here we’re asking you to do something that you think of as somebody else’s job.” But if your patient gets flu, then your job as the cardiologist or endocrinologist will become more complicated and time-consuming. So getting the patients vaccinated will be a good investment and will make your job easier.

Because of the disparity in patient and physician reports, Dr. Lanard suggested implementing a “feedback mechanism where they [the health care providers] give out the prescription, and then the office calls [the patient] to see if they’ve gotten the shot or not. Because that way it will help correct the mismatch between them thinking that they told the patient and the patient not hearing it.”

Asked about why there might be a big gap between what physicians report they said and what patients heard, Dr. Lanard explained that “physicians often communicate in [a manner] sort of like a checklist. And the patients are focused on one or two things that are high in their minds. And the physician was mentioning some things that are on a separate topic that are not on a patient’s list and it goes right past them.”

Dr. Lanard recommended brief storytelling instead of checklists. For example: “I’ve been treating your diabetes for 10 years. During this last flu season, several of my diabetic patients had a really hard time when they caught the flu. So now I’m trying harder to remember to remind you to get your flu shots.”

She urged HCPs to “make it more personal ... but it can still be scripted in advance as part of something that [you’re] remembering to do during the check.” She added that their professional associations may be able to send them suggested language they can adapt.

Finally, Dr. Lanard cautioned about vaccine myths. “The word myth is so insulting. It’s basically a word that sends the signal that you’re an idiot.”

She advised specialists to avoid the word “myth,” which will make the person defensive. Instead, say something like, “A lot of people, even some of my own family members, think the flu vaccine gives you the flu. ... But it doesn’t. And then you go into the reality.”

Dr. Lanard suggested that specialists implement the follow-up calls and close the feedback loop, saying: “If they did the survey a few years later, I bet that gap would narrow.”

Dr. Schaffner and Dr. Lanard disclosed no relevant financial relationships.

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

As the pandemic shows no signs of ending, primary care doctors may be reassured that delivering care via video teleconferencing can be as effective as usual in-person consultation for several common health conditions.

This was a finding of a new study published in Annals of Internal Medicine involving a review of literature on video teleconferencing (VTC) visits, which was authored by Jordan Albritton, PhD, MPH and his colleagues.

The authors found generally comparable patient outcomes as well as no differences in health care use, patient satisfaction, and quality of life when visits conducted using VTC were compared with usual care.

While VTC may work best for monitoring patients with chronic conditions, it can also be effective for acute care, said Dr. Albritton, who is a research public health analyst at RTI International in Research Triangle Park, N.C., in an interview.

The investigators analyzed 20 randomized controlled trials of at least 50 patients and acceptable risk of bias in which VTC was used either for main or adjunct care delivery. Published from 2013 to 2019, these studies looked at care for diabetes and pain management, as well as some respiratory, neurologic, and cardiovascular conditions. Studies comparing VTC with usual care that did not involve any added in-person care were more likely to favor the VTC group, the investigators found.

“We excluded conditions such as substance use disorders, maternal care, and weight management for which there was sufficient prior evidence of the benefit of VTC,” Dr. Albritton said in an interview. “But I don’t think our results would have been substantially different if we had included these other diseases. We found general evidence in the literature that VTC is effective for a broader range of conditions.”

In some cases, such as if changes in a patient’s condition triggered an automatic virtual visit, the author said he thinks VTC may lead to even greater effectiveness.

“The doctor and patient could figure out on the spot what’s going on and perhaps change the medication,” Dr. Albritton explained.

In general agreement is Julia L. Frydman, MD, assistant professor in the Brookdale Department of Geriatric and Palliative Medicine at Icahn School of Medicine at Mount Sinai in New York, who was not involved in the RTI research.

“Telemedicine has promise across many medical subspecialties, and what we need now are more studies to understand the perspectives of patients, caregivers, and clinicians as well as the impact of telemedicine on health outcomes and healthcare utilization.”

In acknowledgment of their utility, video visits are on the rise in the United States. A 2020 survey found that 22% of patients and 80% of physicians reported having participated in a video visit, three times the rate of the previous year. The authors noted that policy changes enacted to support telehealth strategies during the pandemic are expected to remain in place, and although patients are returning to in-person care, the virtual visit market will likely continue growing.
 

Increased telemedicine use by older adults

“We’ve seen an exciting expansion of telemedicine use among older adults, and we need to focus on continuing to meet their needs,” Dr. Frydman said.

In a recent study of televisits during the pandemic, Dr. Frydman’s group found a fivefold greater uptake of remote consultations by seniors – from 5% to 25%. Although in-person visits were far more common among older adults.

A specific advantage of video-based over audio-only telehealth, noted Dr. Albritton, is that physicians can directly observe patients in their home environment. Sharing that view is Deepa Iyengar, MBBS/MD,MPH, professor of family medicine at McGovern Medical School at The University of Texas Health Science Center at Houston, where, she said, “the pandemic has put VTC use into overdrive.”

According to Dr. Iyengar, who was not involved in the RTI research, the video component definitely represents value-added over phone calls. “You can pick up visual cues on video that you might not see if the patient came in and you can see what the home environment is like – whether there are a lot of loose rugs on the floor or broken or missing light bulbs,” she said in an interview.
 

‘VTC is here to stay’

In other parts of the country, doctors are finding virtual care useful – and more common. “VTC is here to stay, for sure – the horse is out of the barn,” said Cheryl L. Wilkes, MD, an internist at Northwestern Medicine and assistant professor of medicine at Northwestern University in Chicago. “The RTI study shows no harm from VTC and also shows it may even improve clinical outcomes.”

Video visits can also save patients high parking fees at clinics and spare the sick or elderly from having to hire caregivers to bring them into the office or from having to walk blocks in dangerous weather conditions, she added. “And I can do a virtual visit on the fly or at night when a relative or caregiver is home from work to be there with the patient.”

In addition to being beneficial for following up with patients with chronic diseases such as hypertension or diabetes, VTC may be able to replace some visits that have traditionally required hands-on care, said Dr. Wilkes.

She said she knows a cardiologist who has refined a process whereby a patient – say, one who may have edema – is asked to perform a maneuver via VTC and then display the result to the doctor: The doctor says, “put your leg up and press on it hard for 10 seconds and then show me what it looks like,” according to Dr. Wilkes.

The key now is to identify the best persons across specialties from neurology to rheumatology to videotape ways they’ve created to help their patients participate virtually in consults traditionally done at the office, Dr. Wilkes noted.

But some conditions will always require palpation and the use of a stethoscope, according Dr. Iyengar.

“If someone has an ulcer, I have to be able to feel it,” she said.

And while some maternity care can be given virtually – for instance, if a mother-to be develops a bad cold – hands-on obstetrical care to check the position and health of the baby obviously has to be done in person. “So VTC is definitely going to be a welcome addition but not a replacement,” Dr. Iyengar said.

Gaps in research on VTC visits

Many questions remain regarding the overall usefulness of VTC visits for certain patient groups, according to the authors.

They highlighted, for example, the dearth of data on subgroups or on underserved and vulnerable populations, with no head-to-head studies identified in their review. In addition, they found no studies examining VTC versus usual care for patients with concurrent conditions or on its effect on health equity and disparities.

“It’s now our job to understand the ongoing barriers to telemedicine access, including the digital divide and the usability of telemedicine platforms, and design interventions that overcome them,” Dr. Frydman said. “At the same time, we need to make sure we’re understanding and respecting the preferences of older adults in terms of how they access health care.”

This study was supported by the Patient-Centered Outcomes Research Institute (PCORI). Dr. Albritton is employed by RTI International, the contractor responsible for conducting the research and developing the manuscript. Several coauthors disclosed support from or contracts with PCORI. One coauthor’s spouse holds stock in private health companies. Dr. Frydman, Dr. Iyengar, and Dr. Wilkes disclosed no competing interests relevant to their comments.

As the pandemic shows no signs of ending, primary care doctors may be reassured that delivering care via video teleconferencing can be as effective as usual in-person consultation for several common health conditions.

This was a finding of a new study published in Annals of Internal Medicine involving a review of literature on video teleconferencing (VTC) visits, which was authored by Jordan Albritton, PhD, MPH and his colleagues.

The authors found generally comparable patient outcomes as well as no differences in health care use, patient satisfaction, and quality of life when visits conducted using VTC were compared with usual care.

While VTC may work best for monitoring patients with chronic conditions, it can also be effective for acute care, said Dr. Albritton, who is a research public health analyst at RTI International in Research Triangle Park, N.C., in an interview.

The investigators analyzed 20 randomized controlled trials of at least 50 patients and acceptable risk of bias in which VTC was used either for main or adjunct care delivery. Published from 2013 to 2019, these studies looked at care for diabetes and pain management, as well as some respiratory, neurologic, and cardiovascular conditions. Studies comparing VTC with usual care that did not involve any added in-person care were more likely to favor the VTC group, the investigators found.

“We excluded conditions such as substance use disorders, maternal care, and weight management for which there was sufficient prior evidence of the benefit of VTC,” Dr. Albritton said in an interview. “But I don’t think our results would have been substantially different if we had included these other diseases. We found general evidence in the literature that VTC is effective for a broader range of conditions.”

In some cases, such as if changes in a patient’s condition triggered an automatic virtual visit, the author said he thinks VTC may lead to even greater effectiveness.

“The doctor and patient could figure out on the spot what’s going on and perhaps change the medication,” Dr. Albritton explained.

In general agreement is Julia L. Frydman, MD, assistant professor in the Brookdale Department of Geriatric and Palliative Medicine at Icahn School of Medicine at Mount Sinai in New York, who was not involved in the RTI research.

“Telemedicine has promise across many medical subspecialties, and what we need now are more studies to understand the perspectives of patients, caregivers, and clinicians as well as the impact of telemedicine on health outcomes and healthcare utilization.”

In acknowledgment of their utility, video visits are on the rise in the United States. A 2020 survey found that 22% of patients and 80% of physicians reported having participated in a video visit, three times the rate of the previous year. The authors noted that policy changes enacted to support telehealth strategies during the pandemic are expected to remain in place, and although patients are returning to in-person care, the virtual visit market will likely continue growing.
 

Increased telemedicine use by older adults

“We’ve seen an exciting expansion of telemedicine use among older adults, and we need to focus on continuing to meet their needs,” Dr. Frydman said.

In a recent study of televisits during the pandemic, Dr. Frydman’s group found a fivefold greater uptake of remote consultations by seniors – from 5% to 25%. Although in-person visits were far more common among older adults.

A specific advantage of video-based over audio-only telehealth, noted Dr. Albritton, is that physicians can directly observe patients in their home environment. Sharing that view is Deepa Iyengar, MBBS/MD,MPH, professor of family medicine at McGovern Medical School at The University of Texas Health Science Center at Houston, where, she said, “the pandemic has put VTC use into overdrive.”

According to Dr. Iyengar, who was not involved in the RTI research, the video component definitely represents value-added over phone calls. “You can pick up visual cues on video that you might not see if the patient came in and you can see what the home environment is like – whether there are a lot of loose rugs on the floor or broken or missing light bulbs,” she said in an interview.
 

‘VTC is here to stay’

In other parts of the country, doctors are finding virtual care useful – and more common. “VTC is here to stay, for sure – the horse is out of the barn,” said Cheryl L. Wilkes, MD, an internist at Northwestern Medicine and assistant professor of medicine at Northwestern University in Chicago. “The RTI study shows no harm from VTC and also shows it may even improve clinical outcomes.”

Video visits can also save patients high parking fees at clinics and spare the sick or elderly from having to hire caregivers to bring them into the office or from having to walk blocks in dangerous weather conditions, she added. “And I can do a virtual visit on the fly or at night when a relative or caregiver is home from work to be there with the patient.”

In addition to being beneficial for following up with patients with chronic diseases such as hypertension or diabetes, VTC may be able to replace some visits that have traditionally required hands-on care, said Dr. Wilkes.

She said she knows a cardiologist who has refined a process whereby a patient – say, one who may have edema – is asked to perform a maneuver via VTC and then display the result to the doctor: The doctor says, “put your leg up and press on it hard for 10 seconds and then show me what it looks like,” according to Dr. Wilkes.

The key now is to identify the best persons across specialties from neurology to rheumatology to videotape ways they’ve created to help their patients participate virtually in consults traditionally done at the office, Dr. Wilkes noted.

But some conditions will always require palpation and the use of a stethoscope, according Dr. Iyengar.

“If someone has an ulcer, I have to be able to feel it,” she said.

And while some maternity care can be given virtually – for instance, if a mother-to be develops a bad cold – hands-on obstetrical care to check the position and health of the baby obviously has to be done in person. “So VTC is definitely going to be a welcome addition but not a replacement,” Dr. Iyengar said.

Gaps in research on VTC visits

Many questions remain regarding the overall usefulness of VTC visits for certain patient groups, according to the authors.

They highlighted, for example, the dearth of data on subgroups or on underserved and vulnerable populations, with no head-to-head studies identified in their review. In addition, they found no studies examining VTC versus usual care for patients with concurrent conditions or on its effect on health equity and disparities.

“It’s now our job to understand the ongoing barriers to telemedicine access, including the digital divide and the usability of telemedicine platforms, and design interventions that overcome them,” Dr. Frydman said. “At the same time, we need to make sure we’re understanding and respecting the preferences of older adults in terms of how they access health care.”

This study was supported by the Patient-Centered Outcomes Research Institute (PCORI). Dr. Albritton is employed by RTI International, the contractor responsible for conducting the research and developing the manuscript. Several coauthors disclosed support from or contracts with PCORI. One coauthor’s spouse holds stock in private health companies. Dr. Frydman, Dr. Iyengar, and Dr. Wilkes disclosed no competing interests relevant to their comments.

As the pandemic shows no signs of ending, primary care doctors may be reassured that delivering care via video teleconferencing can be as effective as usual in-person consultation for several common health conditions.

This was a finding of a new study published in Annals of Internal Medicine involving a review of literature on video teleconferencing (VTC) visits, which was authored by Jordan Albritton, PhD, MPH and his colleagues.

The authors found generally comparable patient outcomes as well as no differences in health care use, patient satisfaction, and quality of life when visits conducted using VTC were compared with usual care.

While VTC may work best for monitoring patients with chronic conditions, it can also be effective for acute care, said Dr. Albritton, who is a research public health analyst at RTI International in Research Triangle Park, N.C., in an interview.

The investigators analyzed 20 randomized controlled trials of at least 50 patients and acceptable risk of bias in which VTC was used either for main or adjunct care delivery. Published from 2013 to 2019, these studies looked at care for diabetes and pain management, as well as some respiratory, neurologic, and cardiovascular conditions. Studies comparing VTC with usual care that did not involve any added in-person care were more likely to favor the VTC group, the investigators found.

“We excluded conditions such as substance use disorders, maternal care, and weight management for which there was sufficient prior evidence of the benefit of VTC,” Dr. Albritton said in an interview. “But I don’t think our results would have been substantially different if we had included these other diseases. We found general evidence in the literature that VTC is effective for a broader range of conditions.”

In some cases, such as if changes in a patient’s condition triggered an automatic virtual visit, the author said he thinks VTC may lead to even greater effectiveness.

“The doctor and patient could figure out on the spot what’s going on and perhaps change the medication,” Dr. Albritton explained.

In general agreement is Julia L. Frydman, MD, assistant professor in the Brookdale Department of Geriatric and Palliative Medicine at Icahn School of Medicine at Mount Sinai in New York, who was not involved in the RTI research.

“Telemedicine has promise across many medical subspecialties, and what we need now are more studies to understand the perspectives of patients, caregivers, and clinicians as well as the impact of telemedicine on health outcomes and healthcare utilization.”

In acknowledgment of their utility, video visits are on the rise in the United States. A 2020 survey found that 22% of patients and 80% of physicians reported having participated in a video visit, three times the rate of the previous year. The authors noted that policy changes enacted to support telehealth strategies during the pandemic are expected to remain in place, and although patients are returning to in-person care, the virtual visit market will likely continue growing.
 

Increased telemedicine use by older adults

“We’ve seen an exciting expansion of telemedicine use among older adults, and we need to focus on continuing to meet their needs,” Dr. Frydman said.

In a recent study of televisits during the pandemic, Dr. Frydman’s group found a fivefold greater uptake of remote consultations by seniors – from 5% to 25%. Although in-person visits were far more common among older adults.

A specific advantage of video-based over audio-only telehealth, noted Dr. Albritton, is that physicians can directly observe patients in their home environment. Sharing that view is Deepa Iyengar, MBBS/MD,MPH, professor of family medicine at McGovern Medical School at The University of Texas Health Science Center at Houston, where, she said, “the pandemic has put VTC use into overdrive.”

According to Dr. Iyengar, who was not involved in the RTI research, the video component definitely represents value-added over phone calls. “You can pick up visual cues on video that you might not see if the patient came in and you can see what the home environment is like – whether there are a lot of loose rugs on the floor or broken or missing light bulbs,” she said in an interview.
 

‘VTC is here to stay’

In other parts of the country, doctors are finding virtual care useful – and more common. “VTC is here to stay, for sure – the horse is out of the barn,” said Cheryl L. Wilkes, MD, an internist at Northwestern Medicine and assistant professor of medicine at Northwestern University in Chicago. “The RTI study shows no harm from VTC and also shows it may even improve clinical outcomes.”

Video visits can also save patients high parking fees at clinics and spare the sick or elderly from having to hire caregivers to bring them into the office or from having to walk blocks in dangerous weather conditions, she added. “And I can do a virtual visit on the fly or at night when a relative or caregiver is home from work to be there with the patient.”

In addition to being beneficial for following up with patients with chronic diseases such as hypertension or diabetes, VTC may be able to replace some visits that have traditionally required hands-on care, said Dr. Wilkes.

She said she knows a cardiologist who has refined a process whereby a patient – say, one who may have edema – is asked to perform a maneuver via VTC and then display the result to the doctor: The doctor says, “put your leg up and press on it hard for 10 seconds and then show me what it looks like,” according to Dr. Wilkes.

The key now is to identify the best persons across specialties from neurology to rheumatology to videotape ways they’ve created to help their patients participate virtually in consults traditionally done at the office, Dr. Wilkes noted.

But some conditions will always require palpation and the use of a stethoscope, according Dr. Iyengar.

“If someone has an ulcer, I have to be able to feel it,” she said.

And while some maternity care can be given virtually – for instance, if a mother-to be develops a bad cold – hands-on obstetrical care to check the position and health of the baby obviously has to be done in person. “So VTC is definitely going to be a welcome addition but not a replacement,” Dr. Iyengar said.

Gaps in research on VTC visits

Many questions remain regarding the overall usefulness of VTC visits for certain patient groups, according to the authors.

They highlighted, for example, the dearth of data on subgroups or on underserved and vulnerable populations, with no head-to-head studies identified in their review. In addition, they found no studies examining VTC versus usual care for patients with concurrent conditions or on its effect on health equity and disparities.

“It’s now our job to understand the ongoing barriers to telemedicine access, including the digital divide and the usability of telemedicine platforms, and design interventions that overcome them,” Dr. Frydman said. “At the same time, we need to make sure we’re understanding and respecting the preferences of older adults in terms of how they access health care.”

This study was supported by the Patient-Centered Outcomes Research Institute (PCORI). Dr. Albritton is employed by RTI International, the contractor responsible for conducting the research and developing the manuscript. Several coauthors disclosed support from or contracts with PCORI. One coauthor’s spouse holds stock in private health companies. Dr. Frydman, Dr. Iyengar, and Dr. Wilkes disclosed no competing interests relevant to their comments.

Introduction

The virtual space has created new opportunities for gastroenterology fellows, but direct conversations about education and career development on the national level have been limited. On Oct. 16, 2021, the American Gastroenterological Association and EndoscopyNow hosted an online Fellows Forum titled “Navigating New Frontiers of Training in Gastroenterology.” Close to 100 fellows attended and had the chance to listen to discussions from a national panel of faculty with expertise in medical education, ask candid questions, and share experiences in breakout rooms specific to their year of training. Reading materials were also provided, which are cited throughout this article. What follows is a rundown of the discussion and points of particular interest for fellows.

What do fellows value?

Dr. Laura Raffals kicked off the event by asking fellows to create word clouds related to their challenges (“Balance” was the most common answer) and joys (“Family”). These answers underscore that, when faced with pressures to be 100% at work and home, it is human connection, particularly family, that sustains us. Fellows, however, worried that spending time with family conflicted with spending time on GI training and that they would be perceived as “that person who always leaves early.”¹

Attendees discussed that “there are only 168 hours in a week,” (time is a zero-sum game), and it is important to be self-aware and honest about one’s personal values and commit the commensurate time and energy to those values. Consider personal development exercises.² Faculty have a crucial role in coaching fellows on time management based on personal values.³
 

Has COVID-19 reduced fellows’ endoscopic skills?

One brave attendee asked: Is this generation of fellows “weaker” because of limited scoping during the pandemic? Faculty discussed that, even prepandemic, it was “not all about quantity; the quality of exposure matters just as much.” From their perspective, prepared, goal-directed, and helpful fellows would maximize learning during endoscopy blocks (see below). Lawrence Schiller, MD, providing the long view, reassured fellows that with a proactive attitude it all evens out in the end.

Fellows reflected that, although social isolation and burnout were rampant, some individuals stepped up to do extra work, supported colleagues with personal or family health issues, and scoped COVID-positive patients if others could not. In future years, the pandemic will be seen as a case study for those in leadership positions. The decisions that health systems, administrators, and providers made will be remembered, as well as how algorithms for “practice as usual” changed.⁴

What fellows can do to maximize endoscopic learning (attendings’ perspective):

• Know the patient before the case. Prior endoscopy reports, patient comorbidities, and medical history including details like anticoagulation use or issues with anesthesia.
• Help the work flow (and reduce the attending’s stress level). Consent patients and complete preprocedure paperwork if possible.
• Come into the scope block with a plan. Example: “I want to get to the cecum. The attending can withdraw, and I will take out polyps we find.”
• Ask about decision-making. Example: “Why did you choose to place a clip over that polypectomy site?” or “Why did you choose that instrument and not the other?”
• Give feedback on problematic behavior. Attendings that treat fellows like burdens and undermine fellow scope time should be reported. Fellows may be concerned about being perceived as a “troublemaker,” but discussing these situations with program directors is a civic duty.

How can we improve diversity?

We cannot wait for, and must instead proactively recruit, diverse trainees, as well as create inclusive environments. Mentorship is key. However, recent work showing imbalances in gender of mentor-mentees and extra pressure on women mentors raises concerns about sustainability.^5,6 The panel suggested that interested fellows could engage students earlier in the pipeline, participate in community awareness and exposure programs, and dedicate education time to health equity.⁷ Fellows raised concerns about barriers for international medical graduates, which would require institutional and federal policy changes would to implement change.

How can fellows develop better practice patterns?

Sri Komanduri, MD, focused on complex endoscopic cases.⁸ Having live video, using polls, and listening to other attendings comment on cases was illuminating and sometimes humbling. The panel discussed that simulation labs could strongly enhance endoscopic skill training, but if unavailable, companies are often willing to sponsor events for teaching purposes.⁹ If training on specific topics is not offered at an institution, regional weekend courses are also an option.

Raman Muthusamy, MD, MS, discussed his philosophy towards endoscopic complications: be prepared and follow your instinct if something feels off. He and Dr. Ikuo Hirano emphasized the importance of following up with patients after a complication. The panel also suggested that fellows can build quality improvement experience by contributing to GI morbidity and mortality conferences or start them if not already offered.
 

Where is the future headed?

Amrita Sethi, MD, outlined the trend towards virtual platforms and getting the global GI community involved in education efforts. She pointed out the need for a gold standard on assessing competency in endoscopy. From a practice perspective, implementation of telemedicine in GI merits further study, as so far this technology has been attractive to providers and patients alike. Todd Baron, MD, stressed that newer technologies, including artificial intelligence, will not replace the endoscopist but may reduce the need for screening procedures and instead increase demand for specific diagnostic and therapeutic procedures. He used the examples of therapeutic applications of endoscopic ultrasound and the development of single-use duodenoscopes.

Concerns about transitioning from training to independent practice

During the third-year breakout session, fellows discussed anxieties about starting practice and living up to expectations: “What if it’s my first week and there’s something I can’t do?” Faculty recommended getting to know colleagues at a new institution, being confident in your training, and staying engaged with your own complications.¹⁰ Fellows described the surprising amount of time and energy they dedicated to the job search and got counseling from Dr. Schiller, who recommended defining what “success” and “satisfaction” look like (again, defining one’s values). He recommended that, for fellows looking at private practice positions, one should ask: How much autonomy do I want? How much business risk am I willing to accept? Fellows need more formal education on practice management and the “business side” of gastroenterology.¹¹

Conclusions

The 2021 AGA EndoscopyNow forum was unique in its discussion of issues impacting GI fellows. The forum revealed that worries about personal well-being, training quality, and future career prospects have affected fellows everywhere: you are not alone. Presentations and lively conversation between seasoned faculty who reflected on career development, education, and medical management demonstrate the importance of seeking advice from colleagues and mentorship. Based on this event, future sessions with conversations between faculty and fellows to assess needs and set priorities for directions in training would be welcome.

Dr. Liu is a gastroenterology fellow, Northwestern University, Chicago. The author has no conflicts of interest to disclose.

References 

1. Katzka DA and Proctor DD. Gastroenterology. 2009;136(4):1147-8.

2. Sull D and Houlder D. Do Your Commitments Match Your Convictions? Harv Bus Rev. 2005 Jan 1. https://hbr.org/2005/01/do-your-commitments-match-your-convictions.

3. Keswani RN et al. Gastroenterology. 2020;159(1):26-9.

4. Sethi A et al. Clin Gastroenterol Hepatol. 2020;18(8):1673-81.

5. Rabinowitz LG et al. Gastrointest Endosc. 2021;93(5):1047-56.e5.

6. Rabinowitz LG et al. Gastrointest Endosc. 2020;91(1):155-61.

7. Lee-Allen J, Shah BJ. Gastroenterology. 2021;160(6):1924-8.

8. Richter JM et al. Am J Gastroenterol. 2016;111(3):348-52.

9. Muthusamy VR and Komanduri S. Clin Gastroenterol Hepatol. 2019 Mar;17(4):580-3.

10. Liu H and Boyatzis RE. Front Psychol. 2021. doi: 10.3389/fpsyg.2021.685829.

11. Amann ST et al. “Words” to practice by: A guide to understand the business vernacular of a healthy practice. https://webfiles.gi.org/links/pm/TheHealthOfMyPracticeToolboxPMCommitteeToolbox.pdf.
 

Introduction

The virtual space has created new opportunities for gastroenterology fellows, but direct conversations about education and career development on the national level have been limited. On Oct. 16, 2021, the American Gastroenterological Association and EndoscopyNow hosted an online Fellows Forum titled “Navigating New Frontiers of Training in Gastroenterology.” Close to 100 fellows attended and had the chance to listen to discussions from a national panel of faculty with expertise in medical education, ask candid questions, and share experiences in breakout rooms specific to their year of training. Reading materials were also provided, which are cited throughout this article. What follows is a rundown of the discussion and points of particular interest for fellows.

What do fellows value?

Dr. Laura Raffals kicked off the event by asking fellows to create word clouds related to their challenges (“Balance” was the most common answer) and joys (“Family”). These answers underscore that, when faced with pressures to be 100% at work and home, it is human connection, particularly family, that sustains us. Fellows, however, worried that spending time with family conflicted with spending time on GI training and that they would be perceived as “that person who always leaves early.”¹

Attendees discussed that “there are only 168 hours in a week,” (time is a zero-sum game), and it is important to be self-aware and honest about one’s personal values and commit the commensurate time and energy to those values. Consider personal development exercises.² Faculty have a crucial role in coaching fellows on time management based on personal values.³
 

Has COVID-19 reduced fellows’ endoscopic skills?

One brave attendee asked: Is this generation of fellows “weaker” because of limited scoping during the pandemic? Faculty discussed that, even prepandemic, it was “not all about quantity; the quality of exposure matters just as much.” From their perspective, prepared, goal-directed, and helpful fellows would maximize learning during endoscopy blocks (see below). Lawrence Schiller, MD, providing the long view, reassured fellows that with a proactive attitude it all evens out in the end.

Fellows reflected that, although social isolation and burnout were rampant, some individuals stepped up to do extra work, supported colleagues with personal or family health issues, and scoped COVID-positive patients if others could not. In future years, the pandemic will be seen as a case study for those in leadership positions. The decisions that health systems, administrators, and providers made will be remembered, as well as how algorithms for “practice as usual” changed.⁴

What fellows can do to maximize endoscopic learning (attendings’ perspective):

• Know the patient before the case. Prior endoscopy reports, patient comorbidities, and medical history including details like anticoagulation use or issues with anesthesia.
• Help the work flow (and reduce the attending’s stress level). Consent patients and complete preprocedure paperwork if possible.
• Come into the scope block with a plan. Example: “I want to get to the cecum. The attending can withdraw, and I will take out polyps we find.”
• Ask about decision-making. Example: “Why did you choose to place a clip over that polypectomy site?” or “Why did you choose that instrument and not the other?”
• Give feedback on problematic behavior. Attendings that treat fellows like burdens and undermine fellow scope time should be reported. Fellows may be concerned about being perceived as a “troublemaker,” but discussing these situations with program directors is a civic duty.

How can we improve diversity?

We cannot wait for, and must instead proactively recruit, diverse trainees, as well as create inclusive environments. Mentorship is key. However, recent work showing imbalances in gender of mentor-mentees and extra pressure on women mentors raises concerns about sustainability.^5,6 The panel suggested that interested fellows could engage students earlier in the pipeline, participate in community awareness and exposure programs, and dedicate education time to health equity.⁷ Fellows raised concerns about barriers for international medical graduates, which would require institutional and federal policy changes would to implement change.

How can fellows develop better practice patterns?

Sri Komanduri, MD, focused on complex endoscopic cases.⁸ Having live video, using polls, and listening to other attendings comment on cases was illuminating and sometimes humbling. The panel discussed that simulation labs could strongly enhance endoscopic skill training, but if unavailable, companies are often willing to sponsor events for teaching purposes.⁹ If training on specific topics is not offered at an institution, regional weekend courses are also an option.

Raman Muthusamy, MD, MS, discussed his philosophy towards endoscopic complications: be prepared and follow your instinct if something feels off. He and Dr. Ikuo Hirano emphasized the importance of following up with patients after a complication. The panel also suggested that fellows can build quality improvement experience by contributing to GI morbidity and mortality conferences or start them if not already offered.
 

Where is the future headed?

Amrita Sethi, MD, outlined the trend towards virtual platforms and getting the global GI community involved in education efforts. She pointed out the need for a gold standard on assessing competency in endoscopy. From a practice perspective, implementation of telemedicine in GI merits further study, as so far this technology has been attractive to providers and patients alike. Todd Baron, MD, stressed that newer technologies, including artificial intelligence, will not replace the endoscopist but may reduce the need for screening procedures and instead increase demand for specific diagnostic and therapeutic procedures. He used the examples of therapeutic applications of endoscopic ultrasound and the development of single-use duodenoscopes.

Concerns about transitioning from training to independent practice

During the third-year breakout session, fellows discussed anxieties about starting practice and living up to expectations: “What if it’s my first week and there’s something I can’t do?” Faculty recommended getting to know colleagues at a new institution, being confident in your training, and staying engaged with your own complications.¹⁰ Fellows described the surprising amount of time and energy they dedicated to the job search and got counseling from Dr. Schiller, who recommended defining what “success” and “satisfaction” look like (again, defining one’s values). He recommended that, for fellows looking at private practice positions, one should ask: How much autonomy do I want? How much business risk am I willing to accept? Fellows need more formal education on practice management and the “business side” of gastroenterology.¹¹

Conclusions

The 2021 AGA EndoscopyNow forum was unique in its discussion of issues impacting GI fellows. The forum revealed that worries about personal well-being, training quality, and future career prospects have affected fellows everywhere: you are not alone. Presentations and lively conversation between seasoned faculty who reflected on career development, education, and medical management demonstrate the importance of seeking advice from colleagues and mentorship. Based on this event, future sessions with conversations between faculty and fellows to assess needs and set priorities for directions in training would be welcome.

Dr. Liu is a gastroenterology fellow, Northwestern University, Chicago. The author has no conflicts of interest to disclose.

References 

1. Katzka DA and Proctor DD. Gastroenterology. 2009;136(4):1147-8.

2. Sull D and Houlder D. Do Your Commitments Match Your Convictions? Harv Bus Rev. 2005 Jan 1. https://hbr.org/2005/01/do-your-commitments-match-your-convictions.

3. Keswani RN et al. Gastroenterology. 2020;159(1):26-9.

4. Sethi A et al. Clin Gastroenterol Hepatol. 2020;18(8):1673-81.

5. Rabinowitz LG et al. Gastrointest Endosc. 2021;93(5):1047-56.e5.

6. Rabinowitz LG et al. Gastrointest Endosc. 2020;91(1):155-61.

7. Lee-Allen J, Shah BJ. Gastroenterology. 2021;160(6):1924-8.

8. Richter JM et al. Am J Gastroenterol. 2016;111(3):348-52.

9. Muthusamy VR and Komanduri S. Clin Gastroenterol Hepatol. 2019 Mar;17(4):580-3.

10. Liu H and Boyatzis RE. Front Psychol. 2021. doi: 10.3389/fpsyg.2021.685829.

11. Amann ST et al. “Words” to practice by: A guide to understand the business vernacular of a healthy practice. https://webfiles.gi.org/links/pm/TheHealthOfMyPracticeToolboxPMCommitteeToolbox.pdf.
 

Introduction

The virtual space has created new opportunities for gastroenterology fellows, but direct conversations about education and career development on the national level have been limited. On Oct. 16, 2021, the American Gastroenterological Association and EndoscopyNow hosted an online Fellows Forum titled “Navigating New Frontiers of Training in Gastroenterology.” Close to 100 fellows attended and had the chance to listen to discussions from a national panel of faculty with expertise in medical education, ask candid questions, and share experiences in breakout rooms specific to their year of training. Reading materials were also provided, which are cited throughout this article. What follows is a rundown of the discussion and points of particular interest for fellows.

What do fellows value?

Dr. Laura Raffals kicked off the event by asking fellows to create word clouds related to their challenges (“Balance” was the most common answer) and joys (“Family”). These answers underscore that, when faced with pressures to be 100% at work and home, it is human connection, particularly family, that sustains us. Fellows, however, worried that spending time with family conflicted with spending time on GI training and that they would be perceived as “that person who always leaves early.”¹

Attendees discussed that “there are only 168 hours in a week,” (time is a zero-sum game), and it is important to be self-aware and honest about one’s personal values and commit the commensurate time and energy to those values. Consider personal development exercises.² Faculty have a crucial role in coaching fellows on time management based on personal values.³
 

Has COVID-19 reduced fellows’ endoscopic skills?

One brave attendee asked: Is this generation of fellows “weaker” because of limited scoping during the pandemic? Faculty discussed that, even prepandemic, it was “not all about quantity; the quality of exposure matters just as much.” From their perspective, prepared, goal-directed, and helpful fellows would maximize learning during endoscopy blocks (see below). Lawrence Schiller, MD, providing the long view, reassured fellows that with a proactive attitude it all evens out in the end.

Fellows reflected that, although social isolation and burnout were rampant, some individuals stepped up to do extra work, supported colleagues with personal or family health issues, and scoped COVID-positive patients if others could not. In future years, the pandemic will be seen as a case study for those in leadership positions. The decisions that health systems, administrators, and providers made will be remembered, as well as how algorithms for “practice as usual” changed.⁴

What fellows can do to maximize endoscopic learning (attendings’ perspective):

• Know the patient before the case. Prior endoscopy reports, patient comorbidities, and medical history including details like anticoagulation use or issues with anesthesia.
• Help the work flow (and reduce the attending’s stress level). Consent patients and complete preprocedure paperwork if possible.
• Come into the scope block with a plan. Example: “I want to get to the cecum. The attending can withdraw, and I will take out polyps we find.”
• Ask about decision-making. Example: “Why did you choose to place a clip over that polypectomy site?” or “Why did you choose that instrument and not the other?”
• Give feedback on problematic behavior. Attendings that treat fellows like burdens and undermine fellow scope time should be reported. Fellows may be concerned about being perceived as a “troublemaker,” but discussing these situations with program directors is a civic duty.

How can we improve diversity?

We cannot wait for, and must instead proactively recruit, diverse trainees, as well as create inclusive environments. Mentorship is key. However, recent work showing imbalances in gender of mentor-mentees and extra pressure on women mentors raises concerns about sustainability.^5,6 The panel suggested that interested fellows could engage students earlier in the pipeline, participate in community awareness and exposure programs, and dedicate education time to health equity.⁷ Fellows raised concerns about barriers for international medical graduates, which would require institutional and federal policy changes would to implement change.

How can fellows develop better practice patterns?

Sri Komanduri, MD, focused on complex endoscopic cases.⁸ Having live video, using polls, and listening to other attendings comment on cases was illuminating and sometimes humbling. The panel discussed that simulation labs could strongly enhance endoscopic skill training, but if unavailable, companies are often willing to sponsor events for teaching purposes.⁹ If training on specific topics is not offered at an institution, regional weekend courses are also an option.

Raman Muthusamy, MD, MS, discussed his philosophy towards endoscopic complications: be prepared and follow your instinct if something feels off. He and Dr. Ikuo Hirano emphasized the importance of following up with patients after a complication. The panel also suggested that fellows can build quality improvement experience by contributing to GI morbidity and mortality conferences or start them if not already offered.
 

Where is the future headed?

Amrita Sethi, MD, outlined the trend towards virtual platforms and getting the global GI community involved in education efforts. She pointed out the need for a gold standard on assessing competency in endoscopy. From a practice perspective, implementation of telemedicine in GI merits further study, as so far this technology has been attractive to providers and patients alike. Todd Baron, MD, stressed that newer technologies, including artificial intelligence, will not replace the endoscopist but may reduce the need for screening procedures and instead increase demand for specific diagnostic and therapeutic procedures. He used the examples of therapeutic applications of endoscopic ultrasound and the development of single-use duodenoscopes.

Concerns about transitioning from training to independent practice

During the third-year breakout session, fellows discussed anxieties about starting practice and living up to expectations: “What if it’s my first week and there’s something I can’t do?” Faculty recommended getting to know colleagues at a new institution, being confident in your training, and staying engaged with your own complications.¹⁰ Fellows described the surprising amount of time and energy they dedicated to the job search and got counseling from Dr. Schiller, who recommended defining what “success” and “satisfaction” look like (again, defining one’s values). He recommended that, for fellows looking at private practice positions, one should ask: How much autonomy do I want? How much business risk am I willing to accept? Fellows need more formal education on practice management and the “business side” of gastroenterology.¹¹

Conclusions

The 2021 AGA EndoscopyNow forum was unique in its discussion of issues impacting GI fellows. The forum revealed that worries about personal well-being, training quality, and future career prospects have affected fellows everywhere: you are not alone. Presentations and lively conversation between seasoned faculty who reflected on career development, education, and medical management demonstrate the importance of seeking advice from colleagues and mentorship. Based on this event, future sessions with conversations between faculty and fellows to assess needs and set priorities for directions in training would be welcome.

Dr. Liu is a gastroenterology fellow, Northwestern University, Chicago. The author has no conflicts of interest to disclose.

References 

1. Katzka DA and Proctor DD. Gastroenterology. 2009;136(4):1147-8.

2. Sull D and Houlder D. Do Your Commitments Match Your Convictions? Harv Bus Rev. 2005 Jan 1. https://hbr.org/2005/01/do-your-commitments-match-your-convictions.

3. Keswani RN et al. Gastroenterology. 2020;159(1):26-9.

4. Sethi A et al. Clin Gastroenterol Hepatol. 2020;18(8):1673-81.

5. Rabinowitz LG et al. Gastrointest Endosc. 2021;93(5):1047-56.e5.

6. Rabinowitz LG et al. Gastrointest Endosc. 2020;91(1):155-61.

7. Lee-Allen J, Shah BJ. Gastroenterology. 2021;160(6):1924-8.

8. Richter JM et al. Am J Gastroenterol. 2016;111(3):348-52.

9. Muthusamy VR and Komanduri S. Clin Gastroenterol Hepatol. 2019 Mar;17(4):580-3.

10. Liu H and Boyatzis RE. Front Psychol. 2021. doi: 10.3389/fpsyg.2021.685829.

11. Amann ST et al. “Words” to practice by: A guide to understand the business vernacular of a healthy practice. https://webfiles.gi.org/links/pm/TheHealthOfMyPracticeToolboxPMCommitteeToolbox.pdf.