Mixed Topics

In the first 2 years of medical school, the most common reasons for unsuccessful performance are a deficiency in cognitive knowledge, inefficient time management, and poor study skills. Thereafter, however, the principal reasons for poor performance in training or practice are personality issues and/or unprofessional behavior.

In this article, I review the attributes expected of a physician and the factors that undermine professionalism. I then offer suggestions for smoothing the pathway for personal and professional success. I crafted these suggestions with the “help” of some unlikely medical philosophers. (Note: Some variations of the cited quotations may exist.) I have tempered their guidance with my own personal experiences as a spouse, parent, and grandparent and my professional experiences over almost 50 years, during which I served as a career military officer, student clerkship director, residency program director, fellowship program director, and associate dean for student affairs. I readily acknowledge that, as major league baseball player Yogi Berra reputedly said, “I made too many wrong mistakes,” and that bad experiences are a tough way to ultimately learn good judgment. I hope these suggestions will help you avoid many of my “wrong mistakes.”

High expectations for the medical professional

“To whom much is given, much shall be required.”

—Luke 12:48

Medicine is a higher calling. It is not the usual type of business, and our patients certainly are not just customers or clients. In the unique moment of personal contact, we are asked to put the interest and well-being of our patient above all else. Our patients rightly have high expectations for what type of person their physician should be. The personal strengths expected of a physician include:

• humility
• honesty—personal and fiscal
• integrity
• strong moral compass
• fairness
• responsible
• diligent
• accountable
• insightful
• wise
• technically competent
• perseverant
• sympathetic
• empathetic
• inspiring.

To exhibit all these characteristics consistently is a herculean task and one that is impossible to fulfill. Many factors conspire to undermine our ability to steadfastly be all that we can be. Among these factors are:

• time constraints
• financial pressures
• physical illness
• emotional illness
• the explosion of information technology and scientific knowledge
• bureaucratic inefficiencies.

Therefore, we need to acknowledge with the philosopher Voltaire that “Perfect is the enemy of good.” We need to set our performance bar at excellence, not perfection. If we expect perfection of ourselves, we are destined to be consistently disappointed.

What follows is a series of well-intentioned and good-natured suggestions for keeping ourselves on an even keel, personally and professionally, and maintaining our compass setting on true north.

Continue to: Practical suggestions...

Practical suggestions

“It may not be that the race always goes to the swift nor the battle to the strong, but that is the way to bet.”

—Damon Runyon, journalist

The message is to study hard, work hard, practice our technical skills, and stay on top of our game. We must commit ourselves to a lifetime of learning.

“Chance favors the prepared mind.”

—Louis Pasteur, scientist

One of the best examples of this adage is Alexander Fleming’s “chance” discovery of the bactericidal effect of a mold growing on a culture plate in his laboratory. This observation led to the development of penicillin, an amazing antibiotic that, over the course of the past century, has saved the lives of literally hundreds of thousands of patients. We need to sustain our scientific curiosity throughout our careers and always remain open to new discoveries. Moreover, we need to maintain our capacity for awe and wonder as we consider the exquisite beauty of the scientific world.

“I have a dream.”

—Martin Luther King Jr, civil rights leader

Like Reverend King, we must aspire to a world where civility, peace, and social justice prevail, a world where we embrace diversity and inclusiveness and eschew prejudice, mean-spiritedness, and narrow-mindedness. We must acknowledge that some truths and moral principles are absolute, not relative.

“Once you learn to quit, it becomes a habit.”

—Vince Lombardi, professional football coach

Our lesson: Never quit. We must be fiercely determined to do the right thing, even in troubled and confusing times.

“A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty.”

—Winston Churchill, British prime minister

Until proven wrong, always think the best of everyone. The bright side is far superior to the dark side. We must strive to consistently have a positive attitude and to be part of the solution to a problem, not the problem itself.

“It’s all such a delicate balance.”

—From “It’s a Delicate Balance” by Tom Dundee, folk singer and songwriter

Our top 3 priorities should always be our own emotional and physical well-being, the well-being and security of our loved ones, and the well-being of our patients. The order of these priorities may change, depending upon circumstances. When urgent patient care demands our presence and we miss a birthday celebration, anniversary dinner, soccer game, or dance recital, we need to make certain that, the next time a conflict arises, we arrange to have a colleague cover our clinical or administrative responsibilities.

We must learn to say no when our plate is too full. Failure to say no inevitably leads to life-work imbalance. It is always flattering to be asked to make a presentation, serve on a committee, or prepare a textbook chapter, and it is natural to be concerned that, if we decline, we will not be invited again. However, that concern is unwarranted. Rather, others will respect us for acknowledging when we are too busy and will be grateful that we did not accept an invitation and then miss important deadlines. Conversely, when we do say yes, we need to honor that commitment in a timely manner.

Continue to: The importance of time...

The importance of time

Perhaps the most common complaints that patients have with respect to their interactions with physicians are that they were forced to wait too long and then felt rushed through their appointment. Therefore:

• We must respect our patients’ time and recognize that their time is as valuable as ours.
• We must schedule our patient appointments appropriately and allow different amounts of time depending upon the complexity of a patient’s condition. We should not consistently overschedule. We need to offer a genuine apology when we keep a patient waiting for more than 15 minutes in the absence of an outright emergency that requires our attention elsewhere.
• When we interact with patients, we should sit down, establish eye-to-eye contact, and never appear hurried.

“You don’t make your character in a crisis; you exhibit it.”

—Oren Arnold, journalist and novelist

In the often-chaotic environment of the operating room or the labor and delivery suite, we must be the calm voice of reason at the center of the storm. We should not yell and make demands of others. We must strive to be unflappable. The other members of the team will be appreciative if they recognize that we have a steady hand on the tiller.

“To do good is noble. To teach others to do good is nobler—and less trouble.”

—Mark Twain, humorist

We need to teach our patients about their condition(s) so that they can assume more responsibility for their own care. We also need to teach our students and colleagues so that they can help us provide the best possible care for our patients. Being a good teacher is inherent in being a good physician. As the famous scientist Albert Einstein said, “If you cannot explain it simply, you do not understand it well enough.”

“It ain’t the things you don’t know that get you. It’s the things you think you know that ain’t so.”

—Artemus Ward, humorist

We must constantly strive to practice evidence-based medicine. We should not be the first to embrace the new or the last to give up the old. In medicine, as opposed to the highway, the best place to be is usually in the middle of the road. However, our commitment to evidence-based medicine cannot be absolute. In fact, no more than half of all our present treatment guidelines are based on level 1 evidence. At times, good old-fashioned common sense tempered by years of sobering experience should carry the day.

“We may be lost, but we’re making good time.”

—Yogi Berra, major league baseball player

In my experience, only the minority of mistakes in medicine result from lack of fundamental knowledge or a deficiency in technical skill. Rather, most result from imprudent haste and/or attempts to multitask. Therefore, our lesson is to slow down, concentrate on one task at a time, complete that task, and then refocus on the next challenge.

“The single greatest problem in communication is the illusion that it has taken place.”

—George Bernard Shaw, playwright

We must be sure that we always “close the loop” in our written and verbal communication so that we can avoid misunderstandings that threaten personal relationships and/or patient safety.

“You raise me up so I can stand on mountains.”

—From “You Raise Me Up” as sung by Josh Groban

All of us need a mentor to raise us up. We must choose our mentors carefully and recognize that we may need different mentors at different stages of our career. As we benefit from effective mentoring, we must pay it forward and be a good mentor to others.

“Worrying is a total waste of time. It accomplishes nothing, changes nothing, and robs you of joy. It is like paying a debt that you don’t owe.”

—Mark Twain, humorist

We have to assiduously cultivate the strength of resilience. We must accept that mistakes inevitably will occur and that perfection in practice is simply not possible, despite our best intentions. We then have to learn from these errors and ensure that they never occur again. We need to apologize for our mistakes and move on. If we carry our last strikeout into our next at bat, we are likely doomed to more misfortune.

“Feeling gratitude and not expressing it is like wrapping a present and not giving it.”

—William Arthur Ward, motivational writer

Our lesson is to be keenly aware of the importance of showing gratitude to those around us. The height of our success will depend directly on the depth of our gratitude. The higher we rise in the hierarchy of the medical profession, the more gracious and kind we need to be.

“Kindness is the language which the deaf can hear and the blind can see.”

—Mark Twain, humorist

“Kindness is the only service that will stand the storm of life and not wash out.”

—Abraham Lincoln, American president

There is never an excuse for rudeness or hubris. We should never teach or conduct business by intimidation. The words please, thank you, and I’m sorry should be front and center in our vocabulary. We must learn not to take ourselves too seriously, to remember that the best part of life is the laughter, and to always strive for grace and humility.

“The secret of the care of the patient is in caring for the patient.”

—Francis Peabody, physician

Patients may quickly forget what we say to them or even what we do for them, but they will never forget how we made them feel. Observe intently, listen carefully, talk less. Most people do not listen with the intent to understand. Rather, they listen with the intent to reply. We need to break this pattern by learning to listen with our heart. In fact, the quieter we become, the more we can hear. There is great symbolism in the fact that we have two ears and only one mouth.

“You got to know when to hold ‘em, know when to fold ‘em.”

—From “The Gambler” as sung by Kenny Rogers

Sometimes the best medicine is no medicine at all, but rather a soft shoulder, an open ear, a kind heart, and a compassionate soul.

“Do small things with great love.”

—Mother Teresa, Catholic missionary

The vast majority of us will not rise to lofty political or administrative positions or ever achieve celebrity status. We are unlikely to win the Nobel Prize and unlikely to find the cure for cancer or preeclampsia. However, we can work diligently to complete each small task with precision so that, like a great artist views his or her work, we, too, will want to sign our name to the patient care plan we have created and implemented.

“Earn this.”

—From Saving Private Ryan, a Steven Spielberg movie

At the end of this movie, the mortally wounded infantry captain (played by Tom Hanks) looks up at Private Ryan (played by Matt Damon) and says, “Earn this,” meaning make sure that you live your life in a way to justify the sacrifices so many made to save you. Like Private Ryan, we have to recognize that our MD degree does not constitute a lifetime entitlement to respect and honor. Rather, we have to practice each day so we continue to earn the respect of our patients, students, and colleagues and, so that, with confidence, we can then say to our patients, “How can I be of help to you?” ●

In the first 2 years of medical school, the most common reasons for unsuccessful performance are a deficiency in cognitive knowledge, inefficient time management, and poor study skills. Thereafter, however, the principal reasons for poor performance in training or practice are personality issues and/or unprofessional behavior.

In this article, I review the attributes expected of a physician and the factors that undermine professionalism. I then offer suggestions for smoothing the pathway for personal and professional success. I crafted these suggestions with the “help” of some unlikely medical philosophers. (Note: Some variations of the cited quotations may exist.) I have tempered their guidance with my own personal experiences as a spouse, parent, and grandparent and my professional experiences over almost 50 years, during which I served as a career military officer, student clerkship director, residency program director, fellowship program director, and associate dean for student affairs. I readily acknowledge that, as major league baseball player Yogi Berra reputedly said, “I made too many wrong mistakes,” and that bad experiences are a tough way to ultimately learn good judgment. I hope these suggestions will help you avoid many of my “wrong mistakes.”

High expectations for the medical professional

“To whom much is given, much shall be required.”

—Luke 12:48

Medicine is a higher calling. It is not the usual type of business, and our patients certainly are not just customers or clients. In the unique moment of personal contact, we are asked to put the interest and well-being of our patient above all else. Our patients rightly have high expectations for what type of person their physician should be. The personal strengths expected of a physician include:

• humility
• honesty—personal and fiscal
• integrity
• strong moral compass
• fairness
• responsible
• diligent
• accountable
• insightful
• wise
• technically competent
• perseverant
• sympathetic
• empathetic
• inspiring.

To exhibit all these characteristics consistently is a herculean task and one that is impossible to fulfill. Many factors conspire to undermine our ability to steadfastly be all that we can be. Among these factors are:

• time constraints
• financial pressures
• physical illness
• emotional illness
• the explosion of information technology and scientific knowledge
• bureaucratic inefficiencies.

Therefore, we need to acknowledge with the philosopher Voltaire that “Perfect is the enemy of good.” We need to set our performance bar at excellence, not perfection. If we expect perfection of ourselves, we are destined to be consistently disappointed.

What follows is a series of well-intentioned and good-natured suggestions for keeping ourselves on an even keel, personally and professionally, and maintaining our compass setting on true north.

Continue to: Practical suggestions...

Practical suggestions

“It may not be that the race always goes to the swift nor the battle to the strong, but that is the way to bet.”

—Damon Runyon, journalist

The message is to study hard, work hard, practice our technical skills, and stay on top of our game. We must commit ourselves to a lifetime of learning.

“Chance favors the prepared mind.”

—Louis Pasteur, scientist

One of the best examples of this adage is Alexander Fleming’s “chance” discovery of the bactericidal effect of a mold growing on a culture plate in his laboratory. This observation led to the development of penicillin, an amazing antibiotic that, over the course of the past century, has saved the lives of literally hundreds of thousands of patients. We need to sustain our scientific curiosity throughout our careers and always remain open to new discoveries. Moreover, we need to maintain our capacity for awe and wonder as we consider the exquisite beauty of the scientific world.

“I have a dream.”

—Martin Luther King Jr, civil rights leader

Like Reverend King, we must aspire to a world where civility, peace, and social justice prevail, a world where we embrace diversity and inclusiveness and eschew prejudice, mean-spiritedness, and narrow-mindedness. We must acknowledge that some truths and moral principles are absolute, not relative.

“Once you learn to quit, it becomes a habit.”

—Vince Lombardi, professional football coach

Our lesson: Never quit. We must be fiercely determined to do the right thing, even in troubled and confusing times.

“A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty.”

—Winston Churchill, British prime minister

Until proven wrong, always think the best of everyone. The bright side is far superior to the dark side. We must strive to consistently have a positive attitude and to be part of the solution to a problem, not the problem itself.

“It’s all such a delicate balance.”

—From “It’s a Delicate Balance” by Tom Dundee, folk singer and songwriter

Our top 3 priorities should always be our own emotional and physical well-being, the well-being and security of our loved ones, and the well-being of our patients. The order of these priorities may change, depending upon circumstances. When urgent patient care demands our presence and we miss a birthday celebration, anniversary dinner, soccer game, or dance recital, we need to make certain that, the next time a conflict arises, we arrange to have a colleague cover our clinical or administrative responsibilities.

We must learn to say no when our plate is too full. Failure to say no inevitably leads to life-work imbalance. It is always flattering to be asked to make a presentation, serve on a committee, or prepare a textbook chapter, and it is natural to be concerned that, if we decline, we will not be invited again. However, that concern is unwarranted. Rather, others will respect us for acknowledging when we are too busy and will be grateful that we did not accept an invitation and then miss important deadlines. Conversely, when we do say yes, we need to honor that commitment in a timely manner.

Continue to: The importance of time...

The importance of time

Perhaps the most common complaints that patients have with respect to their interactions with physicians are that they were forced to wait too long and then felt rushed through their appointment. Therefore:

• We must respect our patients’ time and recognize that their time is as valuable as ours.
• We must schedule our patient appointments appropriately and allow different amounts of time depending upon the complexity of a patient’s condition. We should not consistently overschedule. We need to offer a genuine apology when we keep a patient waiting for more than 15 minutes in the absence of an outright emergency that requires our attention elsewhere.
• When we interact with patients, we should sit down, establish eye-to-eye contact, and never appear hurried.

“You don’t make your character in a crisis; you exhibit it.”

—Oren Arnold, journalist and novelist

In the often-chaotic environment of the operating room or the labor and delivery suite, we must be the calm voice of reason at the center of the storm. We should not yell and make demands of others. We must strive to be unflappable. The other members of the team will be appreciative if they recognize that we have a steady hand on the tiller.

“To do good is noble. To teach others to do good is nobler—and less trouble.”

—Mark Twain, humorist

We need to teach our patients about their condition(s) so that they can assume more responsibility for their own care. We also need to teach our students and colleagues so that they can help us provide the best possible care for our patients. Being a good teacher is inherent in being a good physician. As the famous scientist Albert Einstein said, “If you cannot explain it simply, you do not understand it well enough.”

“It ain’t the things you don’t know that get you. It’s the things you think you know that ain’t so.”

—Artemus Ward, humorist

We must constantly strive to practice evidence-based medicine. We should not be the first to embrace the new or the last to give up the old. In medicine, as opposed to the highway, the best place to be is usually in the middle of the road. However, our commitment to evidence-based medicine cannot be absolute. In fact, no more than half of all our present treatment guidelines are based on level 1 evidence. At times, good old-fashioned common sense tempered by years of sobering experience should carry the day.

“We may be lost, but we’re making good time.”

—Yogi Berra, major league baseball player

In my experience, only the minority of mistakes in medicine result from lack of fundamental knowledge or a deficiency in technical skill. Rather, most result from imprudent haste and/or attempts to multitask. Therefore, our lesson is to slow down, concentrate on one task at a time, complete that task, and then refocus on the next challenge.

“The single greatest problem in communication is the illusion that it has taken place.”

—George Bernard Shaw, playwright

We must be sure that we always “close the loop” in our written and verbal communication so that we can avoid misunderstandings that threaten personal relationships and/or patient safety.

“You raise me up so I can stand on mountains.”

—From “You Raise Me Up” as sung by Josh Groban

All of us need a mentor to raise us up. We must choose our mentors carefully and recognize that we may need different mentors at different stages of our career. As we benefit from effective mentoring, we must pay it forward and be a good mentor to others.

“Worrying is a total waste of time. It accomplishes nothing, changes nothing, and robs you of joy. It is like paying a debt that you don’t owe.”

—Mark Twain, humorist

We have to assiduously cultivate the strength of resilience. We must accept that mistakes inevitably will occur and that perfection in practice is simply not possible, despite our best intentions. We then have to learn from these errors and ensure that they never occur again. We need to apologize for our mistakes and move on. If we carry our last strikeout into our next at bat, we are likely doomed to more misfortune.

“Feeling gratitude and not expressing it is like wrapping a present and not giving it.”

—William Arthur Ward, motivational writer

Our lesson is to be keenly aware of the importance of showing gratitude to those around us. The height of our success will depend directly on the depth of our gratitude. The higher we rise in the hierarchy of the medical profession, the more gracious and kind we need to be.

“Kindness is the language which the deaf can hear and the blind can see.”

—Mark Twain, humorist

“Kindness is the only service that will stand the storm of life and not wash out.”

—Abraham Lincoln, American president

There is never an excuse for rudeness or hubris. We should never teach or conduct business by intimidation. The words please, thank you, and I’m sorry should be front and center in our vocabulary. We must learn not to take ourselves too seriously, to remember that the best part of life is the laughter, and to always strive for grace and humility.

“The secret of the care of the patient is in caring for the patient.”

—Francis Peabody, physician

Patients may quickly forget what we say to them or even what we do for them, but they will never forget how we made them feel. Observe intently, listen carefully, talk less. Most people do not listen with the intent to understand. Rather, they listen with the intent to reply. We need to break this pattern by learning to listen with our heart. In fact, the quieter we become, the more we can hear. There is great symbolism in the fact that we have two ears and only one mouth.

“You got to know when to hold ‘em, know when to fold ‘em.”

—From “The Gambler” as sung by Kenny Rogers

Sometimes the best medicine is no medicine at all, but rather a soft shoulder, an open ear, a kind heart, and a compassionate soul.

“Do small things with great love.”

—Mother Teresa, Catholic missionary

The vast majority of us will not rise to lofty political or administrative positions or ever achieve celebrity status. We are unlikely to win the Nobel Prize and unlikely to find the cure for cancer or preeclampsia. However, we can work diligently to complete each small task with precision so that, like a great artist views his or her work, we, too, will want to sign our name to the patient care plan we have created and implemented.

“Earn this.”

—From Saving Private Ryan, a Steven Spielberg movie

At the end of this movie, the mortally wounded infantry captain (played by Tom Hanks) looks up at Private Ryan (played by Matt Damon) and says, “Earn this,” meaning make sure that you live your life in a way to justify the sacrifices so many made to save you. Like Private Ryan, we have to recognize that our MD degree does not constitute a lifetime entitlement to respect and honor. Rather, we have to practice each day so we continue to earn the respect of our patients, students, and colleagues and, so that, with confidence, we can then say to our patients, “How can I be of help to you?” ●

In the first 2 years of medical school, the most common reasons for unsuccessful performance are a deficiency in cognitive knowledge, inefficient time management, and poor study skills. Thereafter, however, the principal reasons for poor performance in training or practice are personality issues and/or unprofessional behavior.

In this article, I review the attributes expected of a physician and the factors that undermine professionalism. I then offer suggestions for smoothing the pathway for personal and professional success. I crafted these suggestions with the “help” of some unlikely medical philosophers. (Note: Some variations of the cited quotations may exist.) I have tempered their guidance with my own personal experiences as a spouse, parent, and grandparent and my professional experiences over almost 50 years, during which I served as a career military officer, student clerkship director, residency program director, fellowship program director, and associate dean for student affairs. I readily acknowledge that, as major league baseball player Yogi Berra reputedly said, “I made too many wrong mistakes,” and that bad experiences are a tough way to ultimately learn good judgment. I hope these suggestions will help you avoid many of my “wrong mistakes.”

High expectations for the medical professional

“To whom much is given, much shall be required.”

—Luke 12:48

Medicine is a higher calling. It is not the usual type of business, and our patients certainly are not just customers or clients. In the unique moment of personal contact, we are asked to put the interest and well-being of our patient above all else. Our patients rightly have high expectations for what type of person their physician should be. The personal strengths expected of a physician include:

• humility
• honesty—personal and fiscal
• integrity
• strong moral compass
• fairness
• responsible
• diligent
• accountable
• insightful
• wise
• technically competent
• perseverant
• sympathetic
• empathetic
• inspiring.

To exhibit all these characteristics consistently is a herculean task and one that is impossible to fulfill. Many factors conspire to undermine our ability to steadfastly be all that we can be. Among these factors are:

• time constraints
• financial pressures
• physical illness
• emotional illness
• the explosion of information technology and scientific knowledge
• bureaucratic inefficiencies.

Therefore, we need to acknowledge with the philosopher Voltaire that “Perfect is the enemy of good.” We need to set our performance bar at excellence, not perfection. If we expect perfection of ourselves, we are destined to be consistently disappointed.

What follows is a series of well-intentioned and good-natured suggestions for keeping ourselves on an even keel, personally and professionally, and maintaining our compass setting on true north.

Continue to: Practical suggestions...

Practical suggestions

“It may not be that the race always goes to the swift nor the battle to the strong, but that is the way to bet.”

—Damon Runyon, journalist

The message is to study hard, work hard, practice our technical skills, and stay on top of our game. We must commit ourselves to a lifetime of learning.

“Chance favors the prepared mind.”

—Louis Pasteur, scientist

One of the best examples of this adage is Alexander Fleming’s “chance” discovery of the bactericidal effect of a mold growing on a culture plate in his laboratory. This observation led to the development of penicillin, an amazing antibiotic that, over the course of the past century, has saved the lives of literally hundreds of thousands of patients. We need to sustain our scientific curiosity throughout our careers and always remain open to new discoveries. Moreover, we need to maintain our capacity for awe and wonder as we consider the exquisite beauty of the scientific world.

“I have a dream.”

—Martin Luther King Jr, civil rights leader

Like Reverend King, we must aspire to a world where civility, peace, and social justice prevail, a world where we embrace diversity and inclusiveness and eschew prejudice, mean-spiritedness, and narrow-mindedness. We must acknowledge that some truths and moral principles are absolute, not relative.

“Once you learn to quit, it becomes a habit.”

—Vince Lombardi, professional football coach

Our lesson: Never quit. We must be fiercely determined to do the right thing, even in troubled and confusing times.

“A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty.”

—Winston Churchill, British prime minister

Until proven wrong, always think the best of everyone. The bright side is far superior to the dark side. We must strive to consistently have a positive attitude and to be part of the solution to a problem, not the problem itself.

“It’s all such a delicate balance.”

—From “It’s a Delicate Balance” by Tom Dundee, folk singer and songwriter

Our top 3 priorities should always be our own emotional and physical well-being, the well-being and security of our loved ones, and the well-being of our patients. The order of these priorities may change, depending upon circumstances. When urgent patient care demands our presence and we miss a birthday celebration, anniversary dinner, soccer game, or dance recital, we need to make certain that, the next time a conflict arises, we arrange to have a colleague cover our clinical or administrative responsibilities.

We must learn to say no when our plate is too full. Failure to say no inevitably leads to life-work imbalance. It is always flattering to be asked to make a presentation, serve on a committee, or prepare a textbook chapter, and it is natural to be concerned that, if we decline, we will not be invited again. However, that concern is unwarranted. Rather, others will respect us for acknowledging when we are too busy and will be grateful that we did not accept an invitation and then miss important deadlines. Conversely, when we do say yes, we need to honor that commitment in a timely manner.

Continue to: The importance of time...

The importance of time

Perhaps the most common complaints that patients have with respect to their interactions with physicians are that they were forced to wait too long and then felt rushed through their appointment. Therefore:

• We must respect our patients’ time and recognize that their time is as valuable as ours.
• We must schedule our patient appointments appropriately and allow different amounts of time depending upon the complexity of a patient’s condition. We should not consistently overschedule. We need to offer a genuine apology when we keep a patient waiting for more than 15 minutes in the absence of an outright emergency that requires our attention elsewhere.
• When we interact with patients, we should sit down, establish eye-to-eye contact, and never appear hurried.

“You don’t make your character in a crisis; you exhibit it.”

—Oren Arnold, journalist and novelist

In the often-chaotic environment of the operating room or the labor and delivery suite, we must be the calm voice of reason at the center of the storm. We should not yell and make demands of others. We must strive to be unflappable. The other members of the team will be appreciative if they recognize that we have a steady hand on the tiller.

“To do good is noble. To teach others to do good is nobler—and less trouble.”

—Mark Twain, humorist

We need to teach our patients about their condition(s) so that they can assume more responsibility for their own care. We also need to teach our students and colleagues so that they can help us provide the best possible care for our patients. Being a good teacher is inherent in being a good physician. As the famous scientist Albert Einstein said, “If you cannot explain it simply, you do not understand it well enough.”

“It ain’t the things you don’t know that get you. It’s the things you think you know that ain’t so.”

—Artemus Ward, humorist

We must constantly strive to practice evidence-based medicine. We should not be the first to embrace the new or the last to give up the old. In medicine, as opposed to the highway, the best place to be is usually in the middle of the road. However, our commitment to evidence-based medicine cannot be absolute. In fact, no more than half of all our present treatment guidelines are based on level 1 evidence. At times, good old-fashioned common sense tempered by years of sobering experience should carry the day.

“We may be lost, but we’re making good time.”

—Yogi Berra, major league baseball player

In my experience, only the minority of mistakes in medicine result from lack of fundamental knowledge or a deficiency in technical skill. Rather, most result from imprudent haste and/or attempts to multitask. Therefore, our lesson is to slow down, concentrate on one task at a time, complete that task, and then refocus on the next challenge.

“The single greatest problem in communication is the illusion that it has taken place.”

—George Bernard Shaw, playwright

We must be sure that we always “close the loop” in our written and verbal communication so that we can avoid misunderstandings that threaten personal relationships and/or patient safety.

“You raise me up so I can stand on mountains.”

—From “You Raise Me Up” as sung by Josh Groban

All of us need a mentor to raise us up. We must choose our mentors carefully and recognize that we may need different mentors at different stages of our career. As we benefit from effective mentoring, we must pay it forward and be a good mentor to others.

“Worrying is a total waste of time. It accomplishes nothing, changes nothing, and robs you of joy. It is like paying a debt that you don’t owe.”

—Mark Twain, humorist

We have to assiduously cultivate the strength of resilience. We must accept that mistakes inevitably will occur and that perfection in practice is simply not possible, despite our best intentions. We then have to learn from these errors and ensure that they never occur again. We need to apologize for our mistakes and move on. If we carry our last strikeout into our next at bat, we are likely doomed to more misfortune.

“Feeling gratitude and not expressing it is like wrapping a present and not giving it.”

—William Arthur Ward, motivational writer

Our lesson is to be keenly aware of the importance of showing gratitude to those around us. The height of our success will depend directly on the depth of our gratitude. The higher we rise in the hierarchy of the medical profession, the more gracious and kind we need to be.

“Kindness is the language which the deaf can hear and the blind can see.”

—Mark Twain, humorist

“Kindness is the only service that will stand the storm of life and not wash out.”

—Abraham Lincoln, American president

There is never an excuse for rudeness or hubris. We should never teach or conduct business by intimidation. The words please, thank you, and I’m sorry should be front and center in our vocabulary. We must learn not to take ourselves too seriously, to remember that the best part of life is the laughter, and to always strive for grace and humility.

“The secret of the care of the patient is in caring for the patient.”

—Francis Peabody, physician

Patients may quickly forget what we say to them or even what we do for them, but they will never forget how we made them feel. Observe intently, listen carefully, talk less. Most people do not listen with the intent to understand. Rather, they listen with the intent to reply. We need to break this pattern by learning to listen with our heart. In fact, the quieter we become, the more we can hear. There is great symbolism in the fact that we have two ears and only one mouth.

“You got to know when to hold ‘em, know when to fold ‘em.”

—From “The Gambler” as sung by Kenny Rogers

Sometimes the best medicine is no medicine at all, but rather a soft shoulder, an open ear, a kind heart, and a compassionate soul.

“Do small things with great love.”

—Mother Teresa, Catholic missionary

The vast majority of us will not rise to lofty political or administrative positions or ever achieve celebrity status. We are unlikely to win the Nobel Prize and unlikely to find the cure for cancer or preeclampsia. However, we can work diligently to complete each small task with precision so that, like a great artist views his or her work, we, too, will want to sign our name to the patient care plan we have created and implemented.

“Earn this.”

—From Saving Private Ryan, a Steven Spielberg movie

At the end of this movie, the mortally wounded infantry captain (played by Tom Hanks) looks up at Private Ryan (played by Matt Damon) and says, “Earn this,” meaning make sure that you live your life in a way to justify the sacrifices so many made to save you. Like Private Ryan, we have to recognize that our MD degree does not constitute a lifetime entitlement to respect and honor. Rather, we have to practice each day so we continue to earn the respect of our patients, students, and colleagues and, so that, with confidence, we can then say to our patients, “How can I be of help to you?” ●

SAN DIEGO — CD19-directed chimeric antigen receptor (CAR) T-cell therapy, which has transformed the treatment landscape for B-cell malignancies, is now showing great promise in at least three distinct autoantibody-dependent autoimmune diseases.

A single infusion of autologous CD19-directed CAR T-cell therapy led to persistent, drug-free remission in 15 patients with life-threatening systemic lupus erythematosus, idiopathic inflammatory myositis, or systemic sclerosis, according to research presented at the American Society of Hematology annual meeting.

The responses persisted at 15 months median follow-up, with all patients achieving complete remission, reported Fabian Mueller, MD, of the Bavarian Cancer Research Center and Friedrich-Alexander University of Erlangen-Nuremberg, Bavaria, Germany.

The CAR T-cell treatment appears to provide an “entire reset of B cells,” possibly even a cure, for these 15 patients who had run out of treatment options and had short life expectancies, Dr. Mueller said. “It’s impressive that we have treated these patients.”

Some of the cases have been described previously — including in Annals of the Rheumatic Diseases earlier this year, Nature Medicine in 2022, and the New England Journal of Medicine in 2021. 

Now with substantially longer follow-up, the investigators have gained a greater understanding of “the B-cell biology behind our treatment,” Dr. Mueller said. However, “we need longer follow-up to establish how effective the treatment is going to be in the long run.” 

All 15 patients included in the analysis were heavily pretreated and had multi-organ involvement. Prior to CAR T-cell therapy, patients had a median disease duration of 3 years, ranging from 1 to as many as 20 years, and had failed a median of five previous treatments. Patients were young — a median age of 36 years — which is much younger than most oncology patients who undergo CAR T-cell therapy, Dr. Mueller said. 

The 15 patients underwent typical lymphodepletion and were apheresed and treated with a single infusion of 1 x 10⁶ CD19 CAR T cells per kg of body weight — an established safe dose used in a phase 1 trial of B cell malignancies. 

The CAR T cells, manufactured in-house, expanded rapidly, peaking around day 9. B cells disappeared within 7 days and began to reoccur in peripheral blood in all patients between 60 and 180 days. However, no disease flares occurred, Dr. Mueller said.

After 3 months, eight patients with systemic lupus erythematosus showed no sign of disease activity and dramatic improvement in symptoms. Three patients with idiopathic inflammatory myositis experienced major improvements in symptoms and normalization of creatinine kinase levels, the most clinically relevant marker for muscle inflammation. And three of four patients with systemic sclerosis demonstrated major improvements in symptoms and no new disease activity. These responses lasted for a median of 15 months, and all patients stopped taking immunosuppressive drugs. 

Patients also tolerated the CAR T-cell treatment well, especially compared with the adverse event profile in oncology patients. Only low-grade inflammatory CAR T-related side effects occurred, and few patients required support for B-cell-derived immune deficiency. 

However, infectious complications occurred in 14 patients, including urinary tract and respiratory infections, over the 12-month follow-up. One patient was hospitalized for severe pneumonia a few weeks after CAR T therapy, and two patients experienced herpes zoster reactivations, including one at 6 months and one at 12 months following treatment. 

During a press briefing at the ASH conference, Dr. Mueller addressed the “critical question” of patient selection for CAR T-cell therapy, especially in light of the recently announced US Food and Drug Administration investigation exploring whether CAR T cells can cause secondary blood cancers. 

Although the T-cell malignancy risk complicates matters, CAR T cells appear to behave differently in patients with autoimmune diseases than those with cancer, he said.

“We don’t understand the biology” related to the malignancy risk yet, Dr. Mueller said, but the benefit for end-of-life patients with no other treatment option likely outweighs the risk. That risk-benefit assessment, however, is more uncertain for those with less severe autoimmune diseases.

For now, it’s important to conduct individual assessments and inform patients about the risk, Dr. Mueller said.

Dr. Mueller disclosed relationships with BMS, AstraZeneca, Gilead, Janssen, Miltenyi Biomedicine, Novartis, Incyte, Abbvie, Sobi, and BeiGene.
 

A version of this article appeared on Medscape.com.

SAN DIEGO — CD19-directed chimeric antigen receptor (CAR) T-cell therapy, which has transformed the treatment landscape for B-cell malignancies, is now showing great promise in at least three distinct autoantibody-dependent autoimmune diseases.

A single infusion of autologous CD19-directed CAR T-cell therapy led to persistent, drug-free remission in 15 patients with life-threatening systemic lupus erythematosus, idiopathic inflammatory myositis, or systemic sclerosis, according to research presented at the American Society of Hematology annual meeting.

The responses persisted at 15 months median follow-up, with all patients achieving complete remission, reported Fabian Mueller, MD, of the Bavarian Cancer Research Center and Friedrich-Alexander University of Erlangen-Nuremberg, Bavaria, Germany.

The CAR T-cell treatment appears to provide an “entire reset of B cells,” possibly even a cure, for these 15 patients who had run out of treatment options and had short life expectancies, Dr. Mueller said. “It’s impressive that we have treated these patients.”

Some of the cases have been described previously — including in Annals of the Rheumatic Diseases earlier this year, Nature Medicine in 2022, and the New England Journal of Medicine in 2021. 

Now with substantially longer follow-up, the investigators have gained a greater understanding of “the B-cell biology behind our treatment,” Dr. Mueller said. However, “we need longer follow-up to establish how effective the treatment is going to be in the long run.” 

All 15 patients included in the analysis were heavily pretreated and had multi-organ involvement. Prior to CAR T-cell therapy, patients had a median disease duration of 3 years, ranging from 1 to as many as 20 years, and had failed a median of five previous treatments. Patients were young — a median age of 36 years — which is much younger than most oncology patients who undergo CAR T-cell therapy, Dr. Mueller said. 

The 15 patients underwent typical lymphodepletion and were apheresed and treated with a single infusion of 1 x 10⁶ CD19 CAR T cells per kg of body weight — an established safe dose used in a phase 1 trial of B cell malignancies. 

The CAR T cells, manufactured in-house, expanded rapidly, peaking around day 9. B cells disappeared within 7 days and began to reoccur in peripheral blood in all patients between 60 and 180 days. However, no disease flares occurred, Dr. Mueller said.

After 3 months, eight patients with systemic lupus erythematosus showed no sign of disease activity and dramatic improvement in symptoms. Three patients with idiopathic inflammatory myositis experienced major improvements in symptoms and normalization of creatinine kinase levels, the most clinically relevant marker for muscle inflammation. And three of four patients with systemic sclerosis demonstrated major improvements in symptoms and no new disease activity. These responses lasted for a median of 15 months, and all patients stopped taking immunosuppressive drugs. 

Patients also tolerated the CAR T-cell treatment well, especially compared with the adverse event profile in oncology patients. Only low-grade inflammatory CAR T-related side effects occurred, and few patients required support for B-cell-derived immune deficiency. 

However, infectious complications occurred in 14 patients, including urinary tract and respiratory infections, over the 12-month follow-up. One patient was hospitalized for severe pneumonia a few weeks after CAR T therapy, and two patients experienced herpes zoster reactivations, including one at 6 months and one at 12 months following treatment. 

During a press briefing at the ASH conference, Dr. Mueller addressed the “critical question” of patient selection for CAR T-cell therapy, especially in light of the recently announced US Food and Drug Administration investigation exploring whether CAR T cells can cause secondary blood cancers. 

Although the T-cell malignancy risk complicates matters, CAR T cells appear to behave differently in patients with autoimmune diseases than those with cancer, he said.

“We don’t understand the biology” related to the malignancy risk yet, Dr. Mueller said, but the benefit for end-of-life patients with no other treatment option likely outweighs the risk. That risk-benefit assessment, however, is more uncertain for those with less severe autoimmune diseases.

For now, it’s important to conduct individual assessments and inform patients about the risk, Dr. Mueller said.

Dr. Mueller disclosed relationships with BMS, AstraZeneca, Gilead, Janssen, Miltenyi Biomedicine, Novartis, Incyte, Abbvie, Sobi, and BeiGene.
 

A version of this article appeared on Medscape.com.

SAN DIEGO — CD19-directed chimeric antigen receptor (CAR) T-cell therapy, which has transformed the treatment landscape for B-cell malignancies, is now showing great promise in at least three distinct autoantibody-dependent autoimmune diseases.

A single infusion of autologous CD19-directed CAR T-cell therapy led to persistent, drug-free remission in 15 patients with life-threatening systemic lupus erythematosus, idiopathic inflammatory myositis, or systemic sclerosis, according to research presented at the American Society of Hematology annual meeting.

The responses persisted at 15 months median follow-up, with all patients achieving complete remission, reported Fabian Mueller, MD, of the Bavarian Cancer Research Center and Friedrich-Alexander University of Erlangen-Nuremberg, Bavaria, Germany.

The CAR T-cell treatment appears to provide an “entire reset of B cells,” possibly even a cure, for these 15 patients who had run out of treatment options and had short life expectancies, Dr. Mueller said. “It’s impressive that we have treated these patients.”

Some of the cases have been described previously — including in Annals of the Rheumatic Diseases earlier this year, Nature Medicine in 2022, and the New England Journal of Medicine in 2021. 

Now with substantially longer follow-up, the investigators have gained a greater understanding of “the B-cell biology behind our treatment,” Dr. Mueller said. However, “we need longer follow-up to establish how effective the treatment is going to be in the long run.” 

All 15 patients included in the analysis were heavily pretreated and had multi-organ involvement. Prior to CAR T-cell therapy, patients had a median disease duration of 3 years, ranging from 1 to as many as 20 years, and had failed a median of five previous treatments. Patients were young — a median age of 36 years — which is much younger than most oncology patients who undergo CAR T-cell therapy, Dr. Mueller said. 

The 15 patients underwent typical lymphodepletion and were apheresed and treated with a single infusion of 1 x 10⁶ CD19 CAR T cells per kg of body weight — an established safe dose used in a phase 1 trial of B cell malignancies. 

The CAR T cells, manufactured in-house, expanded rapidly, peaking around day 9. B cells disappeared within 7 days and began to reoccur in peripheral blood in all patients between 60 and 180 days. However, no disease flares occurred, Dr. Mueller said.

After 3 months, eight patients with systemic lupus erythematosus showed no sign of disease activity and dramatic improvement in symptoms. Three patients with idiopathic inflammatory myositis experienced major improvements in symptoms and normalization of creatinine kinase levels, the most clinically relevant marker for muscle inflammation. And three of four patients with systemic sclerosis demonstrated major improvements in symptoms and no new disease activity. These responses lasted for a median of 15 months, and all patients stopped taking immunosuppressive drugs. 

Patients also tolerated the CAR T-cell treatment well, especially compared with the adverse event profile in oncology patients. Only low-grade inflammatory CAR T-related side effects occurred, and few patients required support for B-cell-derived immune deficiency. 

However, infectious complications occurred in 14 patients, including urinary tract and respiratory infections, over the 12-month follow-up. One patient was hospitalized for severe pneumonia a few weeks after CAR T therapy, and two patients experienced herpes zoster reactivations, including one at 6 months and one at 12 months following treatment. 

During a press briefing at the ASH conference, Dr. Mueller addressed the “critical question” of patient selection for CAR T-cell therapy, especially in light of the recently announced US Food and Drug Administration investigation exploring whether CAR T cells can cause secondary blood cancers. 

Although the T-cell malignancy risk complicates matters, CAR T cells appear to behave differently in patients with autoimmune diseases than those with cancer, he said.

“We don’t understand the biology” related to the malignancy risk yet, Dr. Mueller said, but the benefit for end-of-life patients with no other treatment option likely outweighs the risk. That risk-benefit assessment, however, is more uncertain for those with less severe autoimmune diseases.

For now, it’s important to conduct individual assessments and inform patients about the risk, Dr. Mueller said.

Dr. Mueller disclosed relationships with BMS, AstraZeneca, Gilead, Janssen, Miltenyi Biomedicine, Novartis, Incyte, Abbvie, Sobi, and BeiGene.
 

A version of this article appeared on Medscape.com.

Patients with relapsed diffuse large B cell lymphoma (DLBCL) who achieve a complete remission from interim chemotherapy while awaiting secondary chimeric antigen receptor (CAR) T cell therapy show significantly better outcomes if they then receive conventional autologous stem cell transplantation (auto-HCT), compared with CAR T therapy.

“In patients with relapsed DLBCL in a complete remission, treatment with auto-HCT is associated with a lower rate of relapse/progression, and a longer progression-free survival [versus CAR T therapy],” said first author Mazyar Shadman, MD, MPH, of the Division of Medical Oncology, University of Washington, Seattle.

“The data support utilization of auto-HCT in patients with relapsed LBCL achieving a complete response,” he said.

The findings were presented at the annual meeting of the American Society of Hematology in San Diego.

While approximately 60% of patients with DLBCL are successfully treated after an initial anthracycline-based and rituximab-containing chemotherapy regimen, those who do not improve have poorer outcomes, and CAR T-cell therapy has emerged as the standard of care for those patients, based on results from the ZUMA-7 and TRANSFORM clinical trials.

But with delays in accessing CAR T quite common, patients will often receive interim chemotherapy while awaiting referral to a CAR T center, and occasionally, usually unexpectedly, some will achieve a partial or complete response.

In previous research involving patients who achieved a partial remission in such interim cases, Dr. Shadman and colleagues demonstrated that auto-HCT had favorable outcomes, compared with those who received CAR T therapy.

For the new retrospective, real-world analysis, the authors compared outcomes with the treatment options among 360 patients between the ages of 18 and 75 who were enrolled in the Center for International Blood & Marrow Transplant Research registry and had received auto-HCT or CAR T therapy after achieving a complete remission following salvage chemotherapy.

Of those receiving CAR-T cell therapy, most (53.2%) received tisagenlecleucel (tisa-cel), followed by axicabtagene ciloleucel (axi-cel, 45.6%) and lisocabtagene maraleucel (liso-cel, 1.3%), between 2018 and 2021, while 281 patients were treated with auto-HCT between 2015 and 2021.

With a median follow-up of 49.7 months (range 3.0-94.4) for auto-HCT and 24.7 months (range 3.3-49.4) for CAR-T, a univariate analysis showed the rate of 2-year progression free survival was 66.2% in the auto-HCT group and 47.8% in the CAR T group (P < .001).

The results also favored auto-HCT for 2-year progression/relapse, with a cumulative incidence of 27.8% with auto-HCT versus 48% with CAR T (P < .001), and the 2-year overall survival was higher with auto-HCT (78.9% vs. 65.6%; P = .037).

After adjustment in multivariable analysis adjusting for relevant clinical variables, auto-HCT versus CAR T remained associated with a lower risk of relapse or progression (HR 2.18; P < .0001) and an improved progression-free survival (HR 1.83; P = .0011), with no significant differences in the risk of treatment-related mortality (HR 0.59; P = .36) or overall survival (HR 1.44; P = .12).

Deaths occurred among 85 patients in the auto-HCT group and 25 in the CAR T cohort, with lymphoma being the main cause of death in both groups (60% and 68%, respectively).

While 37 (13.2%) of auto-HCT patients later received subsequent CAR-T therapy, no patients receiving CAR-T had subsequent auto-HCT.

There were no differences between the CAR-T and auto-HST groups in rates of 2-year treatment-related mortality (4.1% vs. 5.9%; P = .673).

A subanalysis of those who had treatment failure at 12 months, (CAR-T = 57 and auto-HCT = 163) showed that those receiving CAR-T therapy had a higher 2-year relapse rate (46.3% vs. 25%; P < .001); an inferior 2-year progression-free survival rate (48.4% vs. 68.2%; P = .001) compared with auto-HCT, while there were no significant differences between the groups in terms of 2-year overall survival or treatment-related mortality.

After a multivariable analysis adjusting for relevant clinical factors, CAR-T therapy remained associated with higher risk of relapse (HR 2.18; P < .0001) and an inferior progression-free survival (HR 1.83; P = .0011) compared with auto-HCT, with no differences in the risk of treatment-related mortality (HR 0.59; P = .36) or overall survival (HR 1.44; P = .12).

“These results are consistent with our previously reported findings, indicating higher efficacy of auto-HCT compared with CAR T in patients with partial remission,” Dr. Shadman said.

In addition to the study’s being a retrospective analysis, limitations include that more than half of patients in the CAR T cohort received tisa-cel, which could have lower efficacy compared with other approved CAR T therapies, Dr. Shadman noted.

“A repeat analysis by including more patients treated with axi-cel or liso-cel may address this issue in the future,” he said.

Discussing the results in a press briefing, Dr. Shadman underscored that “there is no question the choice of therapy for these DLBCL patients with primary refractory disease should be second-line CAR T therapy — we are not suggesting that those patients should be sent for auto-HCT,” he said.

“What we are saying is, in real-world practice ... patients may need chemotherapy treatment in the interim (awaiting CAR T treatment), and we don’t expect these patients to respond to those cycles because they have already shown us that they don’t do well with chemotherapy — however some do respond and can go into complete remission.”

The question then becomes whether patients at that point will fare better with CAR T or auto-HCT, and the results indicate that “auto-HCT gives those patients a pretty solid remission that looks better than [that with] CAR T therapy.”

Dr. Shadman noted that the results serve to inform or confirm key clinical practices, including “in patients with late relapses, after 12 months, auto-HCT should remain the standard of care.

“In patients with primary refractory disease or early relapse, CAR T should be the goal of therapy and improving access to CAR T should remain a priority.

“In the subset of patients who achieve a CR with interim treatment, a discussion about the possibility of utilizing auto-HCT seems reasonable and can provide another curative option for some patients while keeping CAR-T as a backup treatment plan in case of auto-HCT failure.”

Commenting on the study, Jonathan W. Friedberg, MD, the Samuel Durand Professor of Medicine and director of the Wilmot Cancer Institute, University of Rochester, New York, said, “these findings confirm utility of auto-HCT in patients who achieve a CR.”

However, “the problem is that only a small fraction of patients achieve CR in this situation, and we do not know who they are going to be at time of relapse,” he told this news organization.

He agreed that “given robust randomized trials showing overall survival benefit of CAR-T compared to auto-HCT in patients with high risk relapsed DLBCL, CAR-T treatment should remain the current standard.

“However, these current results help to confirm the strategy for management of low- risk (late) relapses and indicate that auto-HCT still has a place for these patients if they achieve CR with salvage therapy.”

Dr. Shadman reported relationships with ADC therapeutics, Bristol Myers Squibb, Genmab, Lilly, Vincerx, Kite (Gilead), Janssen, Fate Therapeutics, MorphoSys/Incyte, AstraZeneca, BeiGene, Pharmacyclics, Mustang Bio, AbbVie, Genentech, MEI Pharma, Regeneron, and TG Therapeutics. Dr. Friedberg had no disclosures to report.

Patients with relapsed diffuse large B cell lymphoma (DLBCL) who achieve a complete remission from interim chemotherapy while awaiting secondary chimeric antigen receptor (CAR) T cell therapy show significantly better outcomes if they then receive conventional autologous stem cell transplantation (auto-HCT), compared with CAR T therapy.

“In patients with relapsed DLBCL in a complete remission, treatment with auto-HCT is associated with a lower rate of relapse/progression, and a longer progression-free survival [versus CAR T therapy],” said first author Mazyar Shadman, MD, MPH, of the Division of Medical Oncology, University of Washington, Seattle.

“The data support utilization of auto-HCT in patients with relapsed LBCL achieving a complete response,” he said.

The findings were presented at the annual meeting of the American Society of Hematology in San Diego.

While approximately 60% of patients with DLBCL are successfully treated after an initial anthracycline-based and rituximab-containing chemotherapy regimen, those who do not improve have poorer outcomes, and CAR T-cell therapy has emerged as the standard of care for those patients, based on results from the ZUMA-7 and TRANSFORM clinical trials.

But with delays in accessing CAR T quite common, patients will often receive interim chemotherapy while awaiting referral to a CAR T center, and occasionally, usually unexpectedly, some will achieve a partial or complete response.

In previous research involving patients who achieved a partial remission in such interim cases, Dr. Shadman and colleagues demonstrated that auto-HCT had favorable outcomes, compared with those who received CAR T therapy.

For the new retrospective, real-world analysis, the authors compared outcomes with the treatment options among 360 patients between the ages of 18 and 75 who were enrolled in the Center for International Blood & Marrow Transplant Research registry and had received auto-HCT or CAR T therapy after achieving a complete remission following salvage chemotherapy.

Of those receiving CAR-T cell therapy, most (53.2%) received tisagenlecleucel (tisa-cel), followed by axicabtagene ciloleucel (axi-cel, 45.6%) and lisocabtagene maraleucel (liso-cel, 1.3%), between 2018 and 2021, while 281 patients were treated with auto-HCT between 2015 and 2021.

With a median follow-up of 49.7 months (range 3.0-94.4) for auto-HCT and 24.7 months (range 3.3-49.4) for CAR-T, a univariate analysis showed the rate of 2-year progression free survival was 66.2% in the auto-HCT group and 47.8% in the CAR T group (P < .001).

The results also favored auto-HCT for 2-year progression/relapse, with a cumulative incidence of 27.8% with auto-HCT versus 48% with CAR T (P < .001), and the 2-year overall survival was higher with auto-HCT (78.9% vs. 65.6%; P = .037).

After adjustment in multivariable analysis adjusting for relevant clinical variables, auto-HCT versus CAR T remained associated with a lower risk of relapse or progression (HR 2.18; P < .0001) and an improved progression-free survival (HR 1.83; P = .0011), with no significant differences in the risk of treatment-related mortality (HR 0.59; P = .36) or overall survival (HR 1.44; P = .12).

Deaths occurred among 85 patients in the auto-HCT group and 25 in the CAR T cohort, with lymphoma being the main cause of death in both groups (60% and 68%, respectively).

While 37 (13.2%) of auto-HCT patients later received subsequent CAR-T therapy, no patients receiving CAR-T had subsequent auto-HCT.

There were no differences between the CAR-T and auto-HST groups in rates of 2-year treatment-related mortality (4.1% vs. 5.9%; P = .673).

A subanalysis of those who had treatment failure at 12 months, (CAR-T = 57 and auto-HCT = 163) showed that those receiving CAR-T therapy had a higher 2-year relapse rate (46.3% vs. 25%; P < .001); an inferior 2-year progression-free survival rate (48.4% vs. 68.2%; P = .001) compared with auto-HCT, while there were no significant differences between the groups in terms of 2-year overall survival or treatment-related mortality.

After a multivariable analysis adjusting for relevant clinical factors, CAR-T therapy remained associated with higher risk of relapse (HR 2.18; P < .0001) and an inferior progression-free survival (HR 1.83; P = .0011) compared with auto-HCT, with no differences in the risk of treatment-related mortality (HR 0.59; P = .36) or overall survival (HR 1.44; P = .12).

“These results are consistent with our previously reported findings, indicating higher efficacy of auto-HCT compared with CAR T in patients with partial remission,” Dr. Shadman said.

In addition to the study’s being a retrospective analysis, limitations include that more than half of patients in the CAR T cohort received tisa-cel, which could have lower efficacy compared with other approved CAR T therapies, Dr. Shadman noted.

“A repeat analysis by including more patients treated with axi-cel or liso-cel may address this issue in the future,” he said.

Discussing the results in a press briefing, Dr. Shadman underscored that “there is no question the choice of therapy for these DLBCL patients with primary refractory disease should be second-line CAR T therapy — we are not suggesting that those patients should be sent for auto-HCT,” he said.

“What we are saying is, in real-world practice ... patients may need chemotherapy treatment in the interim (awaiting CAR T treatment), and we don’t expect these patients to respond to those cycles because they have already shown us that they don’t do well with chemotherapy — however some do respond and can go into complete remission.”

The question then becomes whether patients at that point will fare better with CAR T or auto-HCT, and the results indicate that “auto-HCT gives those patients a pretty solid remission that looks better than [that with] CAR T therapy.”

Dr. Shadman noted that the results serve to inform or confirm key clinical practices, including “in patients with late relapses, after 12 months, auto-HCT should remain the standard of care.

“In patients with primary refractory disease or early relapse, CAR T should be the goal of therapy and improving access to CAR T should remain a priority.

“In the subset of patients who achieve a CR with interim treatment, a discussion about the possibility of utilizing auto-HCT seems reasonable and can provide another curative option for some patients while keeping CAR-T as a backup treatment plan in case of auto-HCT failure.”

Commenting on the study, Jonathan W. Friedberg, MD, the Samuel Durand Professor of Medicine and director of the Wilmot Cancer Institute, University of Rochester, New York, said, “these findings confirm utility of auto-HCT in patients who achieve a CR.”

However, “the problem is that only a small fraction of patients achieve CR in this situation, and we do not know who they are going to be at time of relapse,” he told this news organization.

He agreed that “given robust randomized trials showing overall survival benefit of CAR-T compared to auto-HCT in patients with high risk relapsed DLBCL, CAR-T treatment should remain the current standard.

“However, these current results help to confirm the strategy for management of low- risk (late) relapses and indicate that auto-HCT still has a place for these patients if they achieve CR with salvage therapy.”

Dr. Shadman reported relationships with ADC therapeutics, Bristol Myers Squibb, Genmab, Lilly, Vincerx, Kite (Gilead), Janssen, Fate Therapeutics, MorphoSys/Incyte, AstraZeneca, BeiGene, Pharmacyclics, Mustang Bio, AbbVie, Genentech, MEI Pharma, Regeneron, and TG Therapeutics. Dr. Friedberg had no disclosures to report.

Patients with relapsed diffuse large B cell lymphoma (DLBCL) who achieve a complete remission from interim chemotherapy while awaiting secondary chimeric antigen receptor (CAR) T cell therapy show significantly better outcomes if they then receive conventional autologous stem cell transplantation (auto-HCT), compared with CAR T therapy.

“In patients with relapsed DLBCL in a complete remission, treatment with auto-HCT is associated with a lower rate of relapse/progression, and a longer progression-free survival [versus CAR T therapy],” said first author Mazyar Shadman, MD, MPH, of the Division of Medical Oncology, University of Washington, Seattle.

“The data support utilization of auto-HCT in patients with relapsed LBCL achieving a complete response,” he said.

The findings were presented at the annual meeting of the American Society of Hematology in San Diego.

While approximately 60% of patients with DLBCL are successfully treated after an initial anthracycline-based and rituximab-containing chemotherapy regimen, those who do not improve have poorer outcomes, and CAR T-cell therapy has emerged as the standard of care for those patients, based on results from the ZUMA-7 and TRANSFORM clinical trials.

But with delays in accessing CAR T quite common, patients will often receive interim chemotherapy while awaiting referral to a CAR T center, and occasionally, usually unexpectedly, some will achieve a partial or complete response.

In previous research involving patients who achieved a partial remission in such interim cases, Dr. Shadman and colleagues demonstrated that auto-HCT had favorable outcomes, compared with those who received CAR T therapy.

For the new retrospective, real-world analysis, the authors compared outcomes with the treatment options among 360 patients between the ages of 18 and 75 who were enrolled in the Center for International Blood & Marrow Transplant Research registry and had received auto-HCT or CAR T therapy after achieving a complete remission following salvage chemotherapy.

Of those receiving CAR-T cell therapy, most (53.2%) received tisagenlecleucel (tisa-cel), followed by axicabtagene ciloleucel (axi-cel, 45.6%) and lisocabtagene maraleucel (liso-cel, 1.3%), between 2018 and 2021, while 281 patients were treated with auto-HCT between 2015 and 2021.

With a median follow-up of 49.7 months (range 3.0-94.4) for auto-HCT and 24.7 months (range 3.3-49.4) for CAR-T, a univariate analysis showed the rate of 2-year progression free survival was 66.2% in the auto-HCT group and 47.8% in the CAR T group (P < .001).

The results also favored auto-HCT for 2-year progression/relapse, with a cumulative incidence of 27.8% with auto-HCT versus 48% with CAR T (P < .001), and the 2-year overall survival was higher with auto-HCT (78.9% vs. 65.6%; P = .037).

After adjustment in multivariable analysis adjusting for relevant clinical variables, auto-HCT versus CAR T remained associated with a lower risk of relapse or progression (HR 2.18; P < .0001) and an improved progression-free survival (HR 1.83; P = .0011), with no significant differences in the risk of treatment-related mortality (HR 0.59; P = .36) or overall survival (HR 1.44; P = .12).

Deaths occurred among 85 patients in the auto-HCT group and 25 in the CAR T cohort, with lymphoma being the main cause of death in both groups (60% and 68%, respectively).

While 37 (13.2%) of auto-HCT patients later received subsequent CAR-T therapy, no patients receiving CAR-T had subsequent auto-HCT.

There were no differences between the CAR-T and auto-HST groups in rates of 2-year treatment-related mortality (4.1% vs. 5.9%; P = .673).

A subanalysis of those who had treatment failure at 12 months, (CAR-T = 57 and auto-HCT = 163) showed that those receiving CAR-T therapy had a higher 2-year relapse rate (46.3% vs. 25%; P < .001); an inferior 2-year progression-free survival rate (48.4% vs. 68.2%; P = .001) compared with auto-HCT, while there were no significant differences between the groups in terms of 2-year overall survival or treatment-related mortality.

After a multivariable analysis adjusting for relevant clinical factors, CAR-T therapy remained associated with higher risk of relapse (HR 2.18; P < .0001) and an inferior progression-free survival (HR 1.83; P = .0011) compared with auto-HCT, with no differences in the risk of treatment-related mortality (HR 0.59; P = .36) or overall survival (HR 1.44; P = .12).

“These results are consistent with our previously reported findings, indicating higher efficacy of auto-HCT compared with CAR T in patients with partial remission,” Dr. Shadman said.

In addition to the study’s being a retrospective analysis, limitations include that more than half of patients in the CAR T cohort received tisa-cel, which could have lower efficacy compared with other approved CAR T therapies, Dr. Shadman noted.

“A repeat analysis by including more patients treated with axi-cel or liso-cel may address this issue in the future,” he said.

Discussing the results in a press briefing, Dr. Shadman underscored that “there is no question the choice of therapy for these DLBCL patients with primary refractory disease should be second-line CAR T therapy — we are not suggesting that those patients should be sent for auto-HCT,” he said.

“What we are saying is, in real-world practice ... patients may need chemotherapy treatment in the interim (awaiting CAR T treatment), and we don’t expect these patients to respond to those cycles because they have already shown us that they don’t do well with chemotherapy — however some do respond and can go into complete remission.”

The question then becomes whether patients at that point will fare better with CAR T or auto-HCT, and the results indicate that “auto-HCT gives those patients a pretty solid remission that looks better than [that with] CAR T therapy.”

Dr. Shadman noted that the results serve to inform or confirm key clinical practices, including “in patients with late relapses, after 12 months, auto-HCT should remain the standard of care.

“In patients with primary refractory disease or early relapse, CAR T should be the goal of therapy and improving access to CAR T should remain a priority.

“In the subset of patients who achieve a CR with interim treatment, a discussion about the possibility of utilizing auto-HCT seems reasonable and can provide another curative option for some patients while keeping CAR-T as a backup treatment plan in case of auto-HCT failure.”

Commenting on the study, Jonathan W. Friedberg, MD, the Samuel Durand Professor of Medicine and director of the Wilmot Cancer Institute, University of Rochester, New York, said, “these findings confirm utility of auto-HCT in patients who achieve a CR.”

However, “the problem is that only a small fraction of patients achieve CR in this situation, and we do not know who they are going to be at time of relapse,” he told this news organization.

He agreed that “given robust randomized trials showing overall survival benefit of CAR-T compared to auto-HCT in patients with high risk relapsed DLBCL, CAR-T treatment should remain the current standard.

“However, these current results help to confirm the strategy for management of low- risk (late) relapses and indicate that auto-HCT still has a place for these patients if they achieve CR with salvage therapy.”

Dr. Shadman reported relationships with ADC therapeutics, Bristol Myers Squibb, Genmab, Lilly, Vincerx, Kite (Gilead), Janssen, Fate Therapeutics, MorphoSys/Incyte, AstraZeneca, BeiGene, Pharmacyclics, Mustang Bio, AbbVie, Genentech, MEI Pharma, Regeneron, and TG Therapeutics. Dr. Friedberg had no disclosures to report.

The current conflict in Israel and Gaza has evoked more questions than answers, existentially and professionally, for mental health professionals.

In the realm of clinical psychology and psychiatry, our primary duty and commitment is (and should be) to the well-being of our patients. Yet, as we find ourselves in an era marked by escalating geopolitical conflict, such as the Israel-Hamas war, probably more aptly titled the Israeli-Hamas-Hezbollah-Houthi war (a clarification that elucidates a later point), clinicians are increasingly confronted with ethical dilemmas that extend far beyond what is outlined in our code of ethics.

Dr. Feldman

These challenges are not only impacting us on a personal level but are also spilling over into our professional lives, creating a divisive and non-collegial environment within the healthcare community. We commit to “do no harm” when delivering care and yet we are doing harm to one another as colleagues.

We are no strangers to the complexities of human behavior and the intricate tapestry of emotions that are involved with our professional work. However, the current geopolitical landscape has added an extra layer of difficulty to our already taxing professional lives. We are, after all, human first with unconscious drives that govern how we negotiate cognitive dissonance and our need for the illusion of absolute justice as Yuval Noah Harari explains in a recent podcast.

Humans are notoriously bad at holding the multiplicity of experience in mind and various (often competing narratives) that impede the capacity for nuanced thinking. We would like to believe we are better and more capable than the average person in doing so, but divisiveness in our profession has become disturbingly pronounced, making it essential for us to carve out reflective space, more than ever.
 

The personal and professional divide

Geopolitical conflicts like the current war have a unique capacity to ignite strong emotions and deeply held convictions. It’s not hard to quickly become embroiled in passionate and engaged debate.

While discussion and discourse are healthy, these are bleeding into professional spheres, creating rifts within our clinical communities and contributing to a culture where not everyone feels safe. Look at any professional listserv in medicine or psychology and you will find the evidence. It should be an immediate call to action that we need to be fostering a different type of environment.

The impact of divisiveness is profound, hindering opportunities for collaboration, mentorship, and the free exchange of ideas among clinicians. It may lead to misunderstandings, mistrust, and an erosion of the support systems we rely on, ultimately diverting energy away from the pursuit of providing quality patient-care.
 

Balancing obligations and limits

Because of the inherent power differential that accompanies being in a provider role (physician and psychologist alike), we have a social and moral responsibility to be mindful of what we share – for the sake of humanity. There is an implicit assumption that a provider’s guidance should be adhered to and respected. In other words, words carry tremendous weight and deeply matter, and people in the general public ascribe significant meaning to messages put out by professionals.

When providers steer from their lanes of professional expertise to provide the general public with opinions or recommendations on nonmedical topics, problematic precedents can be set. We may be doing people a disservice.

Unfortunately, I have heard several anecdotes about clinicians who spend their patient’s time in session pushing their own ideological agendas. The patient-provider relationship is founded on principles of trust, empathy, and collaboration, with the primary goal of improving overall well-being and addressing a specific presenting problem. Of course, issues emerge that need to be addressed outside of the initial scope of treatment, an inherent part of the process. However, a grave concern emerges when clinicians initiate dialogue that is not meaningful to a patient, disclose and discuss their personal ideologies, or put pressure on patients to explain their beliefs in an attempt to change the patients’ minds.

Clinicians pushing their own agenda during patient sessions is antithetical to the objectives of psychotherapy and compromises the therapeutic alliance by diverting the focus of care in a way that serves the clinician rather than the client. It is quite the opposite of the patient-centered care that we strive for in training and practice.

Even within one’s theoretical professional scope of competence, I have seen the impact of emotions running high during this conflict, and have witnessed trained professionals making light of, or even mocking, hostages and their behavior upon release. These are care providers who could elucidate the complexities of captor-captive dynamics and the impact of trauma for the general public, yet they are contributing to dangerous perceptions and divisiveness.

I have also seen providers justify sexual violence, diminishing survivor and witness testimony due to ideological differences and strong personal beliefs. This is harmful to those impacted and does a disservice to our profession at large. In a helping profession we should strive to support and advocate for anyone who has been maltreated or experienced any form of victimization, violence, or abuse. This should be a professional standard.

As clinicians, we have an ethical obligation to uphold the well-being, autonomy, and dignity of our patients — and humanity. It is crucial to recognize the limits of our expertise and the ethical concerns that can arise in light of geopolitical conflict. How can we balance our duty to provide psychological support while also being cautious about delving into the realms of political analysis, foreign policy, or international relations?

The pitfalls of well-intentioned speaking out

In the age of social media and instant communication, a critical aspect to consider is the role of speaking out. The point I made above, in naming all partaking in the current conflict, speaks to this issue.

As providers and programs, we must be mindful of the inadvertent harm that can arise from making brief, underdeveloped, uninformed, or emotionally charged statements. Expressing opinions without a solid understanding of the historical, cultural, and political nuances of a conflict can contribute to misinformation and further polarization.

Anecdotally, there appears to be some significant degree of bias emerging within professional fields (e.g., psychology, medicine) and an innate calling for providers to “weigh in” as the war continues. Obviously, physicians and psychologists are trained to provide care and to be humanistic and empathic, but the majority do not have expertise in geopolitics or a nuanced awareness of the complexities of the conflict in the Middle East.

While hearts may be in the right place, issuing statements on complicated humanitarian/political situations can inadvertently have unintended and harmful consequences (in terms of antisemitism and islamophobia, increased incidence of hate crimes, and colleagues not feeling safe within professional societies or member organizations).

Unsophisticated, overly simplistic, and reductionistic statements that do not adequately convey nuance will not reflect the range of experience reflected by providers in the field (or the patients we treat). It is essential for clinicians and institutions putting out public statements to engage in deep reflection and utilize discernment. We must recognize that our words carry weight, given our position of influence as treatment providers. To minimize harm, we should seek to provide information that is fair, vetted, and balanced, and encourage open, respectful dialogue rather than asserting definitive positions.

Ultimately, as providers we must strive to seek unity and inclusivity amidst the current challenges. It is important for us to embody a spirit of collaboration during a time demarcated by deep fragmentation.

By acknowledging our limitations, promoting informed discussion, and avoiding the pitfalls of uninformed advocacy, we can contribute to a more compassionate and understanding world, even in the face of the most divisive geopolitical conflicts. We have an obligation to uphold when it comes to ourselves as professionals, and we need to foster healthy, respectful dialogue while maintaining an awareness of our blind spots.

Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She is an affiliate of Baptist West Kendall Hospital/FIU Family Medicine Residency Program and serves as president on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. The opinions expressed by Dr. Feldman are her own and do not represent the institutions with which she is affiliated. She has no disclosures.

The current conflict in Israel and Gaza has evoked more questions than answers, existentially and professionally, for mental health professionals.

In the realm of clinical psychology and psychiatry, our primary duty and commitment is (and should be) to the well-being of our patients. Yet, as we find ourselves in an era marked by escalating geopolitical conflict, such as the Israel-Hamas war, probably more aptly titled the Israeli-Hamas-Hezbollah-Houthi war (a clarification that elucidates a later point), clinicians are increasingly confronted with ethical dilemmas that extend far beyond what is outlined in our code of ethics.

Dr. Feldman

These challenges are not only impacting us on a personal level but are also spilling over into our professional lives, creating a divisive and non-collegial environment within the healthcare community. We commit to “do no harm” when delivering care and yet we are doing harm to one another as colleagues.

We are no strangers to the complexities of human behavior and the intricate tapestry of emotions that are involved with our professional work. However, the current geopolitical landscape has added an extra layer of difficulty to our already taxing professional lives. We are, after all, human first with unconscious drives that govern how we negotiate cognitive dissonance and our need for the illusion of absolute justice as Yuval Noah Harari explains in a recent podcast.

Humans are notoriously bad at holding the multiplicity of experience in mind and various (often competing narratives) that impede the capacity for nuanced thinking. We would like to believe we are better and more capable than the average person in doing so, but divisiveness in our profession has become disturbingly pronounced, making it essential for us to carve out reflective space, more than ever.
 

The personal and professional divide

Geopolitical conflicts like the current war have a unique capacity to ignite strong emotions and deeply held convictions. It’s not hard to quickly become embroiled in passionate and engaged debate.

While discussion and discourse are healthy, these are bleeding into professional spheres, creating rifts within our clinical communities and contributing to a culture where not everyone feels safe. Look at any professional listserv in medicine or psychology and you will find the evidence. It should be an immediate call to action that we need to be fostering a different type of environment.

The impact of divisiveness is profound, hindering opportunities for collaboration, mentorship, and the free exchange of ideas among clinicians. It may lead to misunderstandings, mistrust, and an erosion of the support systems we rely on, ultimately diverting energy away from the pursuit of providing quality patient-care.
 

Balancing obligations and limits

Because of the inherent power differential that accompanies being in a provider role (physician and psychologist alike), we have a social and moral responsibility to be mindful of what we share – for the sake of humanity. There is an implicit assumption that a provider’s guidance should be adhered to and respected. In other words, words carry tremendous weight and deeply matter, and people in the general public ascribe significant meaning to messages put out by professionals.

When providers steer from their lanes of professional expertise to provide the general public with opinions or recommendations on nonmedical topics, problematic precedents can be set. We may be doing people a disservice.

Unfortunately, I have heard several anecdotes about clinicians who spend their patient’s time in session pushing their own ideological agendas. The patient-provider relationship is founded on principles of trust, empathy, and collaboration, with the primary goal of improving overall well-being and addressing a specific presenting problem. Of course, issues emerge that need to be addressed outside of the initial scope of treatment, an inherent part of the process. However, a grave concern emerges when clinicians initiate dialogue that is not meaningful to a patient, disclose and discuss their personal ideologies, or put pressure on patients to explain their beliefs in an attempt to change the patients’ minds.

Clinicians pushing their own agenda during patient sessions is antithetical to the objectives of psychotherapy and compromises the therapeutic alliance by diverting the focus of care in a way that serves the clinician rather than the client. It is quite the opposite of the patient-centered care that we strive for in training and practice.

Even within one’s theoretical professional scope of competence, I have seen the impact of emotions running high during this conflict, and have witnessed trained professionals making light of, or even mocking, hostages and their behavior upon release. These are care providers who could elucidate the complexities of captor-captive dynamics and the impact of trauma for the general public, yet they are contributing to dangerous perceptions and divisiveness.

I have also seen providers justify sexual violence, diminishing survivor and witness testimony due to ideological differences and strong personal beliefs. This is harmful to those impacted and does a disservice to our profession at large. In a helping profession we should strive to support and advocate for anyone who has been maltreated or experienced any form of victimization, violence, or abuse. This should be a professional standard.

As clinicians, we have an ethical obligation to uphold the well-being, autonomy, and dignity of our patients — and humanity. It is crucial to recognize the limits of our expertise and the ethical concerns that can arise in light of geopolitical conflict. How can we balance our duty to provide psychological support while also being cautious about delving into the realms of political analysis, foreign policy, or international relations?

The pitfalls of well-intentioned speaking out

In the age of social media and instant communication, a critical aspect to consider is the role of speaking out. The point I made above, in naming all partaking in the current conflict, speaks to this issue.

As providers and programs, we must be mindful of the inadvertent harm that can arise from making brief, underdeveloped, uninformed, or emotionally charged statements. Expressing opinions without a solid understanding of the historical, cultural, and political nuances of a conflict can contribute to misinformation and further polarization.

Anecdotally, there appears to be some significant degree of bias emerging within professional fields (e.g., psychology, medicine) and an innate calling for providers to “weigh in” as the war continues. Obviously, physicians and psychologists are trained to provide care and to be humanistic and empathic, but the majority do not have expertise in geopolitics or a nuanced awareness of the complexities of the conflict in the Middle East.

While hearts may be in the right place, issuing statements on complicated humanitarian/political situations can inadvertently have unintended and harmful consequences (in terms of antisemitism and islamophobia, increased incidence of hate crimes, and colleagues not feeling safe within professional societies or member organizations).

Unsophisticated, overly simplistic, and reductionistic statements that do not adequately convey nuance will not reflect the range of experience reflected by providers in the field (or the patients we treat). It is essential for clinicians and institutions putting out public statements to engage in deep reflection and utilize discernment. We must recognize that our words carry weight, given our position of influence as treatment providers. To minimize harm, we should seek to provide information that is fair, vetted, and balanced, and encourage open, respectful dialogue rather than asserting definitive positions.

Ultimately, as providers we must strive to seek unity and inclusivity amidst the current challenges. It is important for us to embody a spirit of collaboration during a time demarcated by deep fragmentation.

By acknowledging our limitations, promoting informed discussion, and avoiding the pitfalls of uninformed advocacy, we can contribute to a more compassionate and understanding world, even in the face of the most divisive geopolitical conflicts. We have an obligation to uphold when it comes to ourselves as professionals, and we need to foster healthy, respectful dialogue while maintaining an awareness of our blind spots.

Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She is an affiliate of Baptist West Kendall Hospital/FIU Family Medicine Residency Program and serves as president on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. The opinions expressed by Dr. Feldman are her own and do not represent the institutions with which she is affiliated. She has no disclosures.

The current conflict in Israel and Gaza has evoked more questions than answers, existentially and professionally, for mental health professionals.

In the realm of clinical psychology and psychiatry, our primary duty and commitment is (and should be) to the well-being of our patients. Yet, as we find ourselves in an era marked by escalating geopolitical conflict, such as the Israel-Hamas war, probably more aptly titled the Israeli-Hamas-Hezbollah-Houthi war (a clarification that elucidates a later point), clinicians are increasingly confronted with ethical dilemmas that extend far beyond what is outlined in our code of ethics.

Dr. Feldman

These challenges are not only impacting us on a personal level but are also spilling over into our professional lives, creating a divisive and non-collegial environment within the healthcare community. We commit to “do no harm” when delivering care and yet we are doing harm to one another as colleagues.

We are no strangers to the complexities of human behavior and the intricate tapestry of emotions that are involved with our professional work. However, the current geopolitical landscape has added an extra layer of difficulty to our already taxing professional lives. We are, after all, human first with unconscious drives that govern how we negotiate cognitive dissonance and our need for the illusion of absolute justice as Yuval Noah Harari explains in a recent podcast.

Humans are notoriously bad at holding the multiplicity of experience in mind and various (often competing narratives) that impede the capacity for nuanced thinking. We would like to believe we are better and more capable than the average person in doing so, but divisiveness in our profession has become disturbingly pronounced, making it essential for us to carve out reflective space, more than ever.
 

The personal and professional divide

Geopolitical conflicts like the current war have a unique capacity to ignite strong emotions and deeply held convictions. It’s not hard to quickly become embroiled in passionate and engaged debate.

While discussion and discourse are healthy, these are bleeding into professional spheres, creating rifts within our clinical communities and contributing to a culture where not everyone feels safe. Look at any professional listserv in medicine or psychology and you will find the evidence. It should be an immediate call to action that we need to be fostering a different type of environment.

The impact of divisiveness is profound, hindering opportunities for collaboration, mentorship, and the free exchange of ideas among clinicians. It may lead to misunderstandings, mistrust, and an erosion of the support systems we rely on, ultimately diverting energy away from the pursuit of providing quality patient-care.
 

Balancing obligations and limits

Because of the inherent power differential that accompanies being in a provider role (physician and psychologist alike), we have a social and moral responsibility to be mindful of what we share – for the sake of humanity. There is an implicit assumption that a provider’s guidance should be adhered to and respected. In other words, words carry tremendous weight and deeply matter, and people in the general public ascribe significant meaning to messages put out by professionals.

When providers steer from their lanes of professional expertise to provide the general public with opinions or recommendations on nonmedical topics, problematic precedents can be set. We may be doing people a disservice.

Unfortunately, I have heard several anecdotes about clinicians who spend their patient’s time in session pushing their own ideological agendas. The patient-provider relationship is founded on principles of trust, empathy, and collaboration, with the primary goal of improving overall well-being and addressing a specific presenting problem. Of course, issues emerge that need to be addressed outside of the initial scope of treatment, an inherent part of the process. However, a grave concern emerges when clinicians initiate dialogue that is not meaningful to a patient, disclose and discuss their personal ideologies, or put pressure on patients to explain their beliefs in an attempt to change the patients’ minds.

Clinicians pushing their own agenda during patient sessions is antithetical to the objectives of psychotherapy and compromises the therapeutic alliance by diverting the focus of care in a way that serves the clinician rather than the client. It is quite the opposite of the patient-centered care that we strive for in training and practice.

Even within one’s theoretical professional scope of competence, I have seen the impact of emotions running high during this conflict, and have witnessed trained professionals making light of, or even mocking, hostages and their behavior upon release. These are care providers who could elucidate the complexities of captor-captive dynamics and the impact of trauma for the general public, yet they are contributing to dangerous perceptions and divisiveness.

I have also seen providers justify sexual violence, diminishing survivor and witness testimony due to ideological differences and strong personal beliefs. This is harmful to those impacted and does a disservice to our profession at large. In a helping profession we should strive to support and advocate for anyone who has been maltreated or experienced any form of victimization, violence, or abuse. This should be a professional standard.

As clinicians, we have an ethical obligation to uphold the well-being, autonomy, and dignity of our patients — and humanity. It is crucial to recognize the limits of our expertise and the ethical concerns that can arise in light of geopolitical conflict. How can we balance our duty to provide psychological support while also being cautious about delving into the realms of political analysis, foreign policy, or international relations?

The pitfalls of well-intentioned speaking out

In the age of social media and instant communication, a critical aspect to consider is the role of speaking out. The point I made above, in naming all partaking in the current conflict, speaks to this issue.

As providers and programs, we must be mindful of the inadvertent harm that can arise from making brief, underdeveloped, uninformed, or emotionally charged statements. Expressing opinions without a solid understanding of the historical, cultural, and political nuances of a conflict can contribute to misinformation and further polarization.

Anecdotally, there appears to be some significant degree of bias emerging within professional fields (e.g., psychology, medicine) and an innate calling for providers to “weigh in” as the war continues. Obviously, physicians and psychologists are trained to provide care and to be humanistic and empathic, but the majority do not have expertise in geopolitics or a nuanced awareness of the complexities of the conflict in the Middle East.

While hearts may be in the right place, issuing statements on complicated humanitarian/political situations can inadvertently have unintended and harmful consequences (in terms of antisemitism and islamophobia, increased incidence of hate crimes, and colleagues not feeling safe within professional societies or member organizations).

Unsophisticated, overly simplistic, and reductionistic statements that do not adequately convey nuance will not reflect the range of experience reflected by providers in the field (or the patients we treat). It is essential for clinicians and institutions putting out public statements to engage in deep reflection and utilize discernment. We must recognize that our words carry weight, given our position of influence as treatment providers. To minimize harm, we should seek to provide information that is fair, vetted, and balanced, and encourage open, respectful dialogue rather than asserting definitive positions.

Ultimately, as providers we must strive to seek unity and inclusivity amidst the current challenges. It is important for us to embody a spirit of collaboration during a time demarcated by deep fragmentation.

By acknowledging our limitations, promoting informed discussion, and avoiding the pitfalls of uninformed advocacy, we can contribute to a more compassionate and understanding world, even in the face of the most divisive geopolitical conflicts. We have an obligation to uphold when it comes to ourselves as professionals, and we need to foster healthy, respectful dialogue while maintaining an awareness of our blind spots.

Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She is an affiliate of Baptist West Kendall Hospital/FIU Family Medicine Residency Program and serves as president on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. The opinions expressed by Dr. Feldman are her own and do not represent the institutions with which she is affiliated. She has no disclosures.

In a letter dated Nov. 30, 2023, the Food and Drug Administration informed isotretinoin manufacturers that they have 6 months to make five changes to existing iPLEDGE Risk Evaluation and Mitigation Strategy (REMS) requirements for the acne drug isotretinoin.

The development follows a March 2023 joint meeting of the FDA’s Drug Safety and Risk Management Advisory Committee and the Dermatologic and Ophthalmic Drugs Advisory Committee about iPLEDGE REMS requirements, which included feedback from patients and dermatologists and recommendations for changes to the REMS program, aimed at minimizing the burden of the program on patients, pharmacies, and prescribers while continuing to maintain safe use of the highly teratogenic drug for patients.

The five changes include the following:

• Remove the requirement that pregnancy tests must be performed in a specially certified (i.e., Clinical Laboratory Improvement Amendments [CLIA]) laboratory. In the opinion of John S. Barbieri, MD, MBA, director of the Advanced Acne Therapeutics Clinic at Brigham and Women’s Hospital, Boston, this change “may make it easier to perform pregnancy tests in a clinic setting without needing to send the patient to a separate lab,” he said in an interview.
• Allow prescribers the option of using home pregnancy testing for their patients during and after isotretinoin treatment. Prescribers who rely on the patient to perform a home pregnancy test need to take steps to minimize patients falsifying the results of these tests. According to Dr. Barbieri, this means that two pregnancy tests prior to starting isotretinoin must be done in a lab or office setting. “However, all the pregnancy tests on therapy can be either in a medical setting or using a home pregnancy test,” he told this news organization. “This option facilitates the use of telemedicine so that patients would not need to come in; they can just share a pregnancy test with their name and date with their dermatologist.”
• Remove the waiting period requirement — also known as the “19-day lockout” — for patients if they do not obtain isotretinoin within the first 7-day prescription window. According to Dr. Barbieri, this change helps to ensure that patients can begin isotretinoin in a timely manner. “Insurance and pharmacy delays that are no fault of the patient can commonly cause missed initial window periods,” he said. “Allowing for immediate repeat of a pregnancy test to start a new window period, rather than requiring the patient to wait 19 more days, can ensure patient safety and pregnancy prevention without negatively impacting access.”
• Revise the pregnancy registry requirement to remove the objective to document the pregnancy and fetal outcomes for each pregnancy.
• Revise the requirement for prescribers to document patient counseling in patients who cannot become pregnant from monthly to only at enrollment. Dr. Barbieri characterized this change as “major” and said that it could eliminate the need for monthly visits for persons of non–childbearing potential. “This could substantially reduce logistical burdens for patients and reduce wait times to see a dermatologist,” he said.

Future changes to iPLEDGE that Dr. Barbieri would like to see include allowing for home pregnancy tests prior to starting therapy — particularly the test after the 30-day window period. “In addition, it would be good to be able to reduce the 30-day waiting period prior to therapy to something shorter,” such as 14 days, which would still “reliably exclude pregnancy, particularly for those on stable long-acting reversible contraception,” he said. There are also opportunities to improve the iPLEDGE website functionality and to ensure that the website is accessible to patients with limited English proficiency, he added.

He also recommended greater transparency by the Isotretinoin Products Manufacturers Group and inclusion of input from diverse stakeholders such as dermatologists, patients, and pharmacists.

Dr. Barbieri reported personal fees from Dexcel Pharma.

In a letter dated Nov. 30, 2023, the Food and Drug Administration informed isotretinoin manufacturers that they have 6 months to make five changes to existing iPLEDGE Risk Evaluation and Mitigation Strategy (REMS) requirements for the acne drug isotretinoin.

The development follows a March 2023 joint meeting of the FDA’s Drug Safety and Risk Management Advisory Committee and the Dermatologic and Ophthalmic Drugs Advisory Committee about iPLEDGE REMS requirements, which included feedback from patients and dermatologists and recommendations for changes to the REMS program, aimed at minimizing the burden of the program on patients, pharmacies, and prescribers while continuing to maintain safe use of the highly teratogenic drug for patients.

The five changes include the following:

• Remove the requirement that pregnancy tests must be performed in a specially certified (i.e., Clinical Laboratory Improvement Amendments [CLIA]) laboratory. In the opinion of John S. Barbieri, MD, MBA, director of the Advanced Acne Therapeutics Clinic at Brigham and Women’s Hospital, Boston, this change “may make it easier to perform pregnancy tests in a clinic setting without needing to send the patient to a separate lab,” he said in an interview.
• Allow prescribers the option of using home pregnancy testing for their patients during and after isotretinoin treatment. Prescribers who rely on the patient to perform a home pregnancy test need to take steps to minimize patients falsifying the results of these tests. According to Dr. Barbieri, this means that two pregnancy tests prior to starting isotretinoin must be done in a lab or office setting. “However, all the pregnancy tests on therapy can be either in a medical setting or using a home pregnancy test,” he told this news organization. “This option facilitates the use of telemedicine so that patients would not need to come in; they can just share a pregnancy test with their name and date with their dermatologist.”
• Remove the waiting period requirement — also known as the “19-day lockout” — for patients if they do not obtain isotretinoin within the first 7-day prescription window. According to Dr. Barbieri, this change helps to ensure that patients can begin isotretinoin in a timely manner. “Insurance and pharmacy delays that are no fault of the patient can commonly cause missed initial window periods,” he said. “Allowing for immediate repeat of a pregnancy test to start a new window period, rather than requiring the patient to wait 19 more days, can ensure patient safety and pregnancy prevention without negatively impacting access.”
• Revise the pregnancy registry requirement to remove the objective to document the pregnancy and fetal outcomes for each pregnancy.
• Revise the requirement for prescribers to document patient counseling in patients who cannot become pregnant from monthly to only at enrollment. Dr. Barbieri characterized this change as “major” and said that it could eliminate the need for monthly visits for persons of non–childbearing potential. “This could substantially reduce logistical burdens for patients and reduce wait times to see a dermatologist,” he said.

Future changes to iPLEDGE that Dr. Barbieri would like to see include allowing for home pregnancy tests prior to starting therapy — particularly the test after the 30-day window period. “In addition, it would be good to be able to reduce the 30-day waiting period prior to therapy to something shorter,” such as 14 days, which would still “reliably exclude pregnancy, particularly for those on stable long-acting reversible contraception,” he said. There are also opportunities to improve the iPLEDGE website functionality and to ensure that the website is accessible to patients with limited English proficiency, he added.

He also recommended greater transparency by the Isotretinoin Products Manufacturers Group and inclusion of input from diverse stakeholders such as dermatologists, patients, and pharmacists.

Dr. Barbieri reported personal fees from Dexcel Pharma.

In a letter dated Nov. 30, 2023, the Food and Drug Administration informed isotretinoin manufacturers that they have 6 months to make five changes to existing iPLEDGE Risk Evaluation and Mitigation Strategy (REMS) requirements for the acne drug isotretinoin.

The development follows a March 2023 joint meeting of the FDA’s Drug Safety and Risk Management Advisory Committee and the Dermatologic and Ophthalmic Drugs Advisory Committee about iPLEDGE REMS requirements, which included feedback from patients and dermatologists and recommendations for changes to the REMS program, aimed at minimizing the burden of the program on patients, pharmacies, and prescribers while continuing to maintain safe use of the highly teratogenic drug for patients.

The five changes include the following:

• Remove the requirement that pregnancy tests must be performed in a specially certified (i.e., Clinical Laboratory Improvement Amendments [CLIA]) laboratory. In the opinion of John S. Barbieri, MD, MBA, director of the Advanced Acne Therapeutics Clinic at Brigham and Women’s Hospital, Boston, this change “may make it easier to perform pregnancy tests in a clinic setting without needing to send the patient to a separate lab,” he said in an interview.
• Allow prescribers the option of using home pregnancy testing for their patients during and after isotretinoin treatment. Prescribers who rely on the patient to perform a home pregnancy test need to take steps to minimize patients falsifying the results of these tests. According to Dr. Barbieri, this means that two pregnancy tests prior to starting isotretinoin must be done in a lab or office setting. “However, all the pregnancy tests on therapy can be either in a medical setting or using a home pregnancy test,” he told this news organization. “This option facilitates the use of telemedicine so that patients would not need to come in; they can just share a pregnancy test with their name and date with their dermatologist.”
• Remove the waiting period requirement — also known as the “19-day lockout” — for patients if they do not obtain isotretinoin within the first 7-day prescription window. According to Dr. Barbieri, this change helps to ensure that patients can begin isotretinoin in a timely manner. “Insurance and pharmacy delays that are no fault of the patient can commonly cause missed initial window periods,” he said. “Allowing for immediate repeat of a pregnancy test to start a new window period, rather than requiring the patient to wait 19 more days, can ensure patient safety and pregnancy prevention without negatively impacting access.”
• Revise the pregnancy registry requirement to remove the objective to document the pregnancy and fetal outcomes for each pregnancy.
• Revise the requirement for prescribers to document patient counseling in patients who cannot become pregnant from monthly to only at enrollment. Dr. Barbieri characterized this change as “major” and said that it could eliminate the need for monthly visits for persons of non–childbearing potential. “This could substantially reduce logistical burdens for patients and reduce wait times to see a dermatologist,” he said.

Future changes to iPLEDGE that Dr. Barbieri would like to see include allowing for home pregnancy tests prior to starting therapy — particularly the test after the 30-day window period. “In addition, it would be good to be able to reduce the 30-day waiting period prior to therapy to something shorter,” such as 14 days, which would still “reliably exclude pregnancy, particularly for those on stable long-acting reversible contraception,” he said. There are also opportunities to improve the iPLEDGE website functionality and to ensure that the website is accessible to patients with limited English proficiency, he added.

He also recommended greater transparency by the Isotretinoin Products Manufacturers Group and inclusion of input from diverse stakeholders such as dermatologists, patients, and pharmacists.

Dr. Barbieri reported personal fees from Dexcel Pharma.

Talk about bloodlines: In the Brodsky family, the field of hematology tied father to son. Now a grandson is heading into the “family business.” This extraordinary legacy ties the late Isadore Brodsky, a pioneering hematologist, to his son Robert A. Brodsky, current president of the American Society of Hematology (ASH), and grandson Max Brodsky, now a second-year hematology fellow.

In interviews, Robert and Max Brodsky spoke about the appeal of hematology and the threads that unite them with family members who came before. The elder Brodsky also talked about the work that’s made him the proudest during his year-long presidency at ASH.

Courtesy Dr. Robert A. Brodsky

Robert A. Brodsky is professor of medicine and director of hematology at Johns Hopkins University, Baltimore. He is stepping down as ASH president at its annual meeting in San Diego, December 9-12. Here are excerpts from our conversation:

Q: What drew your dad into medicine?

Dr. Robert A. Brodsky: He was going through his medical training at the University of Pennsylvania, then the Vietnam War came, and he served at the National Institutes of Health in what they referred to as the Yellow Berets. He got very interested in retroviruses and viruses that lead to cancer, which was a foreign idea at the time. This led him into hematology, stem cells, and myeloproliferative disorders.

He had a very successful career in hematology and just loved it. He performed the first bone marrow transplant in the tristate area of Pennsylvania, Delaware, and New Jersey.

Q: What did he like about hematology specifically?

Dr. Robert A. Brodsky: It’s a fascinating field, probably the most scientific area of medicine. It’s so easy to access blood and bone marrow. You can grow it, you can look at it, you can see it. It’s hard to do that with a lung, heart, kidney, or brain. Even back then, they could translate some of the science. What really drew him to hematology — and me, for that matter — was looking at a blood smear or bone marrow and being able to make a diagnosis. The other thing is the personal aspect. Hematologists tend to like the long-term relationships that they develop with their patients over the years.

Q: What were the biggest transformations in hematology during his career?

Dr. Robert A. Brodsky: Bone marrow transplant had the biggest impact, and it’s an area he really pioneered. He was very much involved in some of the early bone marrow transplants and was very close with Dr. George W. Santos, who was at Johns Hopkins and one of the big pioneers in that area as well. To be able to take marrow from related donors, get it to grow without the patient rejecting it, and cure a disease, was really huge. When he started doing this, patients had no other option. To see patients be cured was incredibly satisfying to him.

Q: How did you end up following your father into hematology?

Dr. Robert A. Brodsky: My brother Jeff, who’s a surgeon and older than me, knew he was going into medicine — probably about 3 hours after he was born. I came to it late. I was a political science major as an undergrad and really trying to figure out what I wanted to do. In my sophomore year, I decided I wanted to give this a shot. My dad worked very hard, long hours, but you could tell he loved what he did. And he was never absent, always involved in our lives and still made time for everyone. At some level, that must have had an influence on me.

Q: What has changed in hematology over your 30-plus years in medicine?

A: When I look back at when I was a fellow, it’s just mind-boggling how many lethal or life-threatening diseases are now pretty easy to treat. I studied disorders like aplastic anemia, which was very fatal. Without treatment, patients would die within a year. Now, over 95% are cured. Another classic examples is chronic myeloid leukemia disorder. Back when I was a fellow, the median survival for CML was maybe 4 to 6 years. Now, Kareem Abdul Jabbar has had this[for about 15 years]. Also a lot of hematologic malignancies are being cured with immunotherapy approaches. We’ve figured out the pathophysiology of a lot of diseases, and there are incredible genetic diagnostic assays.

Q: What was your father’s relationship with ASH?

Dr. Robert A. Brodsky: The first ASH meeting was 1958 in Atlantic City, New Jersey. There were 300 hematologists there, and my dad was one of them. We’re going to have over 30,000 people in San Diego, which is a record, and another 5,000 or 6,000 virtually.

Q: As ASH president, what are your biggest accomplishments when it comes to addressing the shortage of hematologists and other issues?

Dr. Robert A. Brodsky: ASH is investing $19 million to develop fellowships with a focus on hematology.* This is going to put lots of new hematologists into the workforce over the next 5 to 10 years. We’ve also been working on the Maintenance of Certification [MOC] process to make it less onerous on physicians. It’s really a bad process, and it’s not just ASH [that’s complaining], it’s all of medicine. We’re hearing this from GI, endocrine, renal and the general internists.

[In a September 2023 letter to the American Board of Internal Medicine’s president and chief officer, Dr. Brodsky wrote that “ASH continues to support the importance of lifelong learning for hematologists via a program that is evidence-based, relevant to one’s practice, and transparent; however, these three basic requirements are not met by the current ABIM MOC program.” ASH is calling for a new and reformed MOC program.]

Q: What convinced ASH to expand its journals by adding Blood Neoplasia and Blood Vessels, Thrombosis & Hemostasis?

Dr. Robert A. Brodsky: ASH has two flagship journals right now, Blood and Blood Advances, and they’re both very competitive, high-impact journals. It turns out there’s not enough room to publish all the new science, and they end up rejecting the majority of the submissions that come to them. We decided to keep these journals in the ASH family because there’s some fantastic clinical trials and science that would be going elsewhere.

Dr. Brodsky’s sons both have medical degrees: Brett Brodsky, DO, is a resident at Virginia Commonwealth University who plans to become a sports medicine specialist, and Max Brodsky, MD, is a second-year fellow in hematology at Johns Hopkins University.

In an interview, Max Brodsky, MD, talked about the roots of his family’s dedication to caring for others.

Q: What drew you to hematology?

Dr. Max Brodsky: I’ve watched both my dad and my grandfather be leaders in the field as both physicians and scientists, and that was very inspirational for me to see. And I went to a medical school [Drexel University College of Medicine] that my dad went to and where my grandfather was on faculty. That was like walking in their footsteps in a major way.

Q: What do you hope to focus on as a hematologist?

Dr. Max Brodsky: I’m still working through that, but I am really interested in thrombotic thrombocytopenic purpura. Patients used to not be able to survive their initial episodes, but now we have good treatments and are able to follow them as outpatients. With this whole cohort of patients that are surviving, we’re seeing that they have more health problems — more heart disease, more strokes and kidney disease. There’s a whole growing field exploring how to treat these patients for their lifespan.

Q: How do you deal with the reality that more of your patients will die than in some other medical fields?

Dr. Max Brodsky: It is challenging, but I also see those moments as opportunities to support patients and families. I’m good at connecting to patients and families who are in scary situations. I’ve always had that skill of putting people at ease, making people feel calm, knowing that they can trust me, and I have their best interests in mind.

Q: Why do you think your family is so committed to medicine?

Dr. Max Brodsky: We’re Jewish, and looking to help the world is one of the main core values of Judaism. The Torah expects us to make this world better.  Actually, my great-grandfather Max, whom I’m named after, used to dig tunnels to help people escape Ukraine and get to freedom. He was always looking to help others as well. My great-grandmother was shot crossing the border escaping from Ukraine, and he carried her the whole way to the boat. They lived in very poor West Philadelphia and poured everything into my grandfather. He became a great doctor, and his sons and his grandchildren are in medicine today.

*Correction, 12/11: A previous version of this story misstated the amount of ASH’s $19 million investment in developing fellowships with a focus on hematology.

Talk about bloodlines: In the Brodsky family, the field of hematology tied father to son. Now a grandson is heading into the “family business.” This extraordinary legacy ties the late Isadore Brodsky, a pioneering hematologist, to his son Robert A. Brodsky, current president of the American Society of Hematology (ASH), and grandson Max Brodsky, now a second-year hematology fellow.

In interviews, Robert and Max Brodsky spoke about the appeal of hematology and the threads that unite them with family members who came before. The elder Brodsky also talked about the work that’s made him the proudest during his year-long presidency at ASH.

Courtesy Dr. Robert A. Brodsky

Robert A. Brodsky is professor of medicine and director of hematology at Johns Hopkins University, Baltimore. He is stepping down as ASH president at its annual meeting in San Diego, December 9-12. Here are excerpts from our conversation:

Q: What drew your dad into medicine?

Dr. Robert A. Brodsky: He was going through his medical training at the University of Pennsylvania, then the Vietnam War came, and he served at the National Institutes of Health in what they referred to as the Yellow Berets. He got very interested in retroviruses and viruses that lead to cancer, which was a foreign idea at the time. This led him into hematology, stem cells, and myeloproliferative disorders.

He had a very successful career in hematology and just loved it. He performed the first bone marrow transplant in the tristate area of Pennsylvania, Delaware, and New Jersey.

Q: What did he like about hematology specifically?

Dr. Robert A. Brodsky: It’s a fascinating field, probably the most scientific area of medicine. It’s so easy to access blood and bone marrow. You can grow it, you can look at it, you can see it. It’s hard to do that with a lung, heart, kidney, or brain. Even back then, they could translate some of the science. What really drew him to hematology — and me, for that matter — was looking at a blood smear or bone marrow and being able to make a diagnosis. The other thing is the personal aspect. Hematologists tend to like the long-term relationships that they develop with their patients over the years.

Q: What were the biggest transformations in hematology during his career?

Dr. Robert A. Brodsky: Bone marrow transplant had the biggest impact, and it’s an area he really pioneered. He was very much involved in some of the early bone marrow transplants and was very close with Dr. George W. Santos, who was at Johns Hopkins and one of the big pioneers in that area as well. To be able to take marrow from related donors, get it to grow without the patient rejecting it, and cure a disease, was really huge. When he started doing this, patients had no other option. To see patients be cured was incredibly satisfying to him.

Q: How did you end up following your father into hematology?

Dr. Robert A. Brodsky: My brother Jeff, who’s a surgeon and older than me, knew he was going into medicine — probably about 3 hours after he was born. I came to it late. I was a political science major as an undergrad and really trying to figure out what I wanted to do. In my sophomore year, I decided I wanted to give this a shot. My dad worked very hard, long hours, but you could tell he loved what he did. And he was never absent, always involved in our lives and still made time for everyone. At some level, that must have had an influence on me.

Q: What has changed in hematology over your 30-plus years in medicine?

A: When I look back at when I was a fellow, it’s just mind-boggling how many lethal or life-threatening diseases are now pretty easy to treat. I studied disorders like aplastic anemia, which was very fatal. Without treatment, patients would die within a year. Now, over 95% are cured. Another classic examples is chronic myeloid leukemia disorder. Back when I was a fellow, the median survival for CML was maybe 4 to 6 years. Now, Kareem Abdul Jabbar has had this[for about 15 years]. Also a lot of hematologic malignancies are being cured with immunotherapy approaches. We’ve figured out the pathophysiology of a lot of diseases, and there are incredible genetic diagnostic assays.

Q: What was your father’s relationship with ASH?

Dr. Robert A. Brodsky: The first ASH meeting was 1958 in Atlantic City, New Jersey. There were 300 hematologists there, and my dad was one of them. We’re going to have over 30,000 people in San Diego, which is a record, and another 5,000 or 6,000 virtually.

Q: As ASH president, what are your biggest accomplishments when it comes to addressing the shortage of hematologists and other issues?

Dr. Robert A. Brodsky: ASH is investing $19 million to develop fellowships with a focus on hematology.* This is going to put lots of new hematologists into the workforce over the next 5 to 10 years. We’ve also been working on the Maintenance of Certification [MOC] process to make it less onerous on physicians. It’s really a bad process, and it’s not just ASH [that’s complaining], it’s all of medicine. We’re hearing this from GI, endocrine, renal and the general internists.

[In a September 2023 letter to the American Board of Internal Medicine’s president and chief officer, Dr. Brodsky wrote that “ASH continues to support the importance of lifelong learning for hematologists via a program that is evidence-based, relevant to one’s practice, and transparent; however, these three basic requirements are not met by the current ABIM MOC program.” ASH is calling for a new and reformed MOC program.]

Q: What convinced ASH to expand its journals by adding Blood Neoplasia and Blood Vessels, Thrombosis & Hemostasis?

Dr. Robert A. Brodsky: ASH has two flagship journals right now, Blood and Blood Advances, and they’re both very competitive, high-impact journals. It turns out there’s not enough room to publish all the new science, and they end up rejecting the majority of the submissions that come to them. We decided to keep these journals in the ASH family because there’s some fantastic clinical trials and science that would be going elsewhere.

Dr. Brodsky’s sons both have medical degrees: Brett Brodsky, DO, is a resident at Virginia Commonwealth University who plans to become a sports medicine specialist, and Max Brodsky, MD, is a second-year fellow in hematology at Johns Hopkins University.

In an interview, Max Brodsky, MD, talked about the roots of his family’s dedication to caring for others.

Q: What drew you to hematology?

Dr. Max Brodsky: I’ve watched both my dad and my grandfather be leaders in the field as both physicians and scientists, and that was very inspirational for me to see. And I went to a medical school [Drexel University College of Medicine] that my dad went to and where my grandfather was on faculty. That was like walking in their footsteps in a major way.

Q: What do you hope to focus on as a hematologist?

Dr. Max Brodsky: I’m still working through that, but I am really interested in thrombotic thrombocytopenic purpura. Patients used to not be able to survive their initial episodes, but now we have good treatments and are able to follow them as outpatients. With this whole cohort of patients that are surviving, we’re seeing that they have more health problems — more heart disease, more strokes and kidney disease. There’s a whole growing field exploring how to treat these patients for their lifespan.

Q: How do you deal with the reality that more of your patients will die than in some other medical fields?

Dr. Max Brodsky: It is challenging, but I also see those moments as opportunities to support patients and families. I’m good at connecting to patients and families who are in scary situations. I’ve always had that skill of putting people at ease, making people feel calm, knowing that they can trust me, and I have their best interests in mind.

Q: Why do you think your family is so committed to medicine?

Dr. Max Brodsky: We’re Jewish, and looking to help the world is one of the main core values of Judaism. The Torah expects us to make this world better.  Actually, my great-grandfather Max, whom I’m named after, used to dig tunnels to help people escape Ukraine and get to freedom. He was always looking to help others as well. My great-grandmother was shot crossing the border escaping from Ukraine, and he carried her the whole way to the boat. They lived in very poor West Philadelphia and poured everything into my grandfather. He became a great doctor, and his sons and his grandchildren are in medicine today.

*Correction, 12/11: A previous version of this story misstated the amount of ASH’s $19 million investment in developing fellowships with a focus on hematology.

Talk about bloodlines: In the Brodsky family, the field of hematology tied father to son. Now a grandson is heading into the “family business.” This extraordinary legacy ties the late Isadore Brodsky, a pioneering hematologist, to his son Robert A. Brodsky, current president of the American Society of Hematology (ASH), and grandson Max Brodsky, now a second-year hematology fellow.

In interviews, Robert and Max Brodsky spoke about the appeal of hematology and the threads that unite them with family members who came before. The elder Brodsky also talked about the work that’s made him the proudest during his year-long presidency at ASH.

Courtesy Dr. Robert A. Brodsky

Robert A. Brodsky is professor of medicine and director of hematology at Johns Hopkins University, Baltimore. He is stepping down as ASH president at its annual meeting in San Diego, December 9-12. Here are excerpts from our conversation:

Q: What drew your dad into medicine?

Dr. Robert A. Brodsky: He was going through his medical training at the University of Pennsylvania, then the Vietnam War came, and he served at the National Institutes of Health in what they referred to as the Yellow Berets. He got very interested in retroviruses and viruses that lead to cancer, which was a foreign idea at the time. This led him into hematology, stem cells, and myeloproliferative disorders.

He had a very successful career in hematology and just loved it. He performed the first bone marrow transplant in the tristate area of Pennsylvania, Delaware, and New Jersey.

Q: What did he like about hematology specifically?

Dr. Robert A. Brodsky: It’s a fascinating field, probably the most scientific area of medicine. It’s so easy to access blood and bone marrow. You can grow it, you can look at it, you can see it. It’s hard to do that with a lung, heart, kidney, or brain. Even back then, they could translate some of the science. What really drew him to hematology — and me, for that matter — was looking at a blood smear or bone marrow and being able to make a diagnosis. The other thing is the personal aspect. Hematologists tend to like the long-term relationships that they develop with their patients over the years.

Q: What were the biggest transformations in hematology during his career?

Dr. Robert A. Brodsky: Bone marrow transplant had the biggest impact, and it’s an area he really pioneered. He was very much involved in some of the early bone marrow transplants and was very close with Dr. George W. Santos, who was at Johns Hopkins and one of the big pioneers in that area as well. To be able to take marrow from related donors, get it to grow without the patient rejecting it, and cure a disease, was really huge. When he started doing this, patients had no other option. To see patients be cured was incredibly satisfying to him.

Q: How did you end up following your father into hematology?

Dr. Robert A. Brodsky: My brother Jeff, who’s a surgeon and older than me, knew he was going into medicine — probably about 3 hours after he was born. I came to it late. I was a political science major as an undergrad and really trying to figure out what I wanted to do. In my sophomore year, I decided I wanted to give this a shot. My dad worked very hard, long hours, but you could tell he loved what he did. And he was never absent, always involved in our lives and still made time for everyone. At some level, that must have had an influence on me.

Q: What has changed in hematology over your 30-plus years in medicine?

A: When I look back at when I was a fellow, it’s just mind-boggling how many lethal or life-threatening diseases are now pretty easy to treat. I studied disorders like aplastic anemia, which was very fatal. Without treatment, patients would die within a year. Now, over 95% are cured. Another classic examples is chronic myeloid leukemia disorder. Back when I was a fellow, the median survival for CML was maybe 4 to 6 years. Now, Kareem Abdul Jabbar has had this[for about 15 years]. Also a lot of hematologic malignancies are being cured with immunotherapy approaches. We’ve figured out the pathophysiology of a lot of diseases, and there are incredible genetic diagnostic assays.

Q: What was your father’s relationship with ASH?

Dr. Robert A. Brodsky: The first ASH meeting was 1958 in Atlantic City, New Jersey. There were 300 hematologists there, and my dad was one of them. We’re going to have over 30,000 people in San Diego, which is a record, and another 5,000 or 6,000 virtually.

Q: As ASH president, what are your biggest accomplishments when it comes to addressing the shortage of hematologists and other issues?

Dr. Robert A. Brodsky: ASH is investing $19 million to develop fellowships with a focus on hematology.* This is going to put lots of new hematologists into the workforce over the next 5 to 10 years. We’ve also been working on the Maintenance of Certification [MOC] process to make it less onerous on physicians. It’s really a bad process, and it’s not just ASH [that’s complaining], it’s all of medicine. We’re hearing this from GI, endocrine, renal and the general internists.

[In a September 2023 letter to the American Board of Internal Medicine’s president and chief officer, Dr. Brodsky wrote that “ASH continues to support the importance of lifelong learning for hematologists via a program that is evidence-based, relevant to one’s practice, and transparent; however, these three basic requirements are not met by the current ABIM MOC program.” ASH is calling for a new and reformed MOC program.]

Q: What convinced ASH to expand its journals by adding Blood Neoplasia and Blood Vessels, Thrombosis & Hemostasis?

Dr. Robert A. Brodsky: ASH has two flagship journals right now, Blood and Blood Advances, and they’re both very competitive, high-impact journals. It turns out there’s not enough room to publish all the new science, and they end up rejecting the majority of the submissions that come to them. We decided to keep these journals in the ASH family because there’s some fantastic clinical trials and science that would be going elsewhere.

Dr. Brodsky’s sons both have medical degrees: Brett Brodsky, DO, is a resident at Virginia Commonwealth University who plans to become a sports medicine specialist, and Max Brodsky, MD, is a second-year fellow in hematology at Johns Hopkins University.

In an interview, Max Brodsky, MD, talked about the roots of his family’s dedication to caring for others.

Q: What drew you to hematology?

Dr. Max Brodsky: I’ve watched both my dad and my grandfather be leaders in the field as both physicians and scientists, and that was very inspirational for me to see. And I went to a medical school [Drexel University College of Medicine] that my dad went to and where my grandfather was on faculty. That was like walking in their footsteps in a major way.

Q: What do you hope to focus on as a hematologist?

Dr. Max Brodsky: I’m still working through that, but I am really interested in thrombotic thrombocytopenic purpura. Patients used to not be able to survive their initial episodes, but now we have good treatments and are able to follow them as outpatients. With this whole cohort of patients that are surviving, we’re seeing that they have more health problems — more heart disease, more strokes and kidney disease. There’s a whole growing field exploring how to treat these patients for their lifespan.

Q: How do you deal with the reality that more of your patients will die than in some other medical fields?

Dr. Max Brodsky: It is challenging, but I also see those moments as opportunities to support patients and families. I’m good at connecting to patients and families who are in scary situations. I’ve always had that skill of putting people at ease, making people feel calm, knowing that they can trust me, and I have their best interests in mind.

Q: Why do you think your family is so committed to medicine?

Dr. Max Brodsky: We’re Jewish, and looking to help the world is one of the main core values of Judaism. The Torah expects us to make this world better.  Actually, my great-grandfather Max, whom I’m named after, used to dig tunnels to help people escape Ukraine and get to freedom. He was always looking to help others as well. My great-grandmother was shot crossing the border escaping from Ukraine, and he carried her the whole way to the boat. They lived in very poor West Philadelphia and poured everything into my grandfather. He became a great doctor, and his sons and his grandchildren are in medicine today.

*Correction, 12/11: A previous version of this story misstated the amount of ASH’s $19 million investment in developing fellowships with a focus on hematology.

Scientists know that tinnitus, or ringing in the ears, affects 10% of adults worldwide. But they’re not exactly sure what causes the condition.

The traditional belief is that tinnitus happens in people who had already lost hearing. But some people who have tinnitus are still able to perform well on standard hearing tests, according to researchers at the Massachusetts Eye and Ear Infirmary. That happens because the tests don’t pick up auditory nerve loss, sometimes called “hidden hearing loss.” 

“Our work reconciles the idea that tinnitus may be triggered by a loss of auditory nerve, including in people with normal hearing,” Stéphane F. Maison, PhD, the lead author of a new study on tinnitus, said in a news release about the study.

Tinnitus is sometimes compared to phantom limb syndrome, in which people feel pain in limbs they no longer have. While the study published in Scientific Reports doesn’t refer to phantom limb syndrome, it does talk about “phantom sound.”

“In other words, the brain tries to compensate for the loss of hearing by increasing its activity, resulting in the perception of a phantom sound, tinnitus. Until recently though, this idea was disputed as some tinnitus sufferers have normal hearing tests,” the researchers explained in the news release. 

Annoyed by the ringing in your ears? What causes tinnitus, and how can you get the sound to buzz off?

The study included 294 adults — 201 who had never reported having tinnitus, 64 who had reported having temporary tinnitus, and 29 who had reported having constant tinnitus for 6 months or more. 

All 294 had performed normally on a pure tone test, in which subjects raise their hands when they hear beeps to measure the quietest sounds they can detect.

In a different kind of test, electrodes measured responses to clicking sounds in the inner ear, the auditory nerve, and the brain. The second test found reduced response in the auditory nerves and increased activity in the brainstem activity among those who had tinnitus.

Dr Maison, a principal investigator at Eaton-Peabody Laboratories at Mass Eye and Ear/Harvard Medical School, called the study “a first step toward our ultimate goal of silencing tinnitus.”

“Beyond the nuisance of having persistent ringing or other sounds in the ears, tinnitus symptoms are debilitating in many patients, causing sleep deprivation, social isolation, anxiety and depression, adversely affecting work performance, and reducing significantly their quality of life,” he said in the news release. “We won’t be able to cure tinnitus until we fully understand the mechanisms underlying its genesis.”

A version of this article appeared on WebMD.com.

Scientists know that tinnitus, or ringing in the ears, affects 10% of adults worldwide. But they’re not exactly sure what causes the condition.

The traditional belief is that tinnitus happens in people who had already lost hearing. But some people who have tinnitus are still able to perform well on standard hearing tests, according to researchers at the Massachusetts Eye and Ear Infirmary. That happens because the tests don’t pick up auditory nerve loss, sometimes called “hidden hearing loss.” 

“Our work reconciles the idea that tinnitus may be triggered by a loss of auditory nerve, including in people with normal hearing,” Stéphane F. Maison, PhD, the lead author of a new study on tinnitus, said in a news release about the study.

Tinnitus is sometimes compared to phantom limb syndrome, in which people feel pain in limbs they no longer have. While the study published in Scientific Reports doesn’t refer to phantom limb syndrome, it does talk about “phantom sound.”

“In other words, the brain tries to compensate for the loss of hearing by increasing its activity, resulting in the perception of a phantom sound, tinnitus. Until recently though, this idea was disputed as some tinnitus sufferers have normal hearing tests,” the researchers explained in the news release. 

Annoyed by the ringing in your ears? What causes tinnitus, and how can you get the sound to buzz off?

The study included 294 adults — 201 who had never reported having tinnitus, 64 who had reported having temporary tinnitus, and 29 who had reported having constant tinnitus for 6 months or more. 

All 294 had performed normally on a pure tone test, in which subjects raise their hands when they hear beeps to measure the quietest sounds they can detect.

In a different kind of test, electrodes measured responses to clicking sounds in the inner ear, the auditory nerve, and the brain. The second test found reduced response in the auditory nerves and increased activity in the brainstem activity among those who had tinnitus.

Dr Maison, a principal investigator at Eaton-Peabody Laboratories at Mass Eye and Ear/Harvard Medical School, called the study “a first step toward our ultimate goal of silencing tinnitus.”

“Beyond the nuisance of having persistent ringing or other sounds in the ears, tinnitus symptoms are debilitating in many patients, causing sleep deprivation, social isolation, anxiety and depression, adversely affecting work performance, and reducing significantly their quality of life,” he said in the news release. “We won’t be able to cure tinnitus until we fully understand the mechanisms underlying its genesis.”

A version of this article appeared on WebMD.com.

Scientists know that tinnitus, or ringing in the ears, affects 10% of adults worldwide. But they’re not exactly sure what causes the condition.

The traditional belief is that tinnitus happens in people who had already lost hearing. But some people who have tinnitus are still able to perform well on standard hearing tests, according to researchers at the Massachusetts Eye and Ear Infirmary. That happens because the tests don’t pick up auditory nerve loss, sometimes called “hidden hearing loss.” 

“Our work reconciles the idea that tinnitus may be triggered by a loss of auditory nerve, including in people with normal hearing,” Stéphane F. Maison, PhD, the lead author of a new study on tinnitus, said in a news release about the study.

Tinnitus is sometimes compared to phantom limb syndrome, in which people feel pain in limbs they no longer have. While the study published in Scientific Reports doesn’t refer to phantom limb syndrome, it does talk about “phantom sound.”

“In other words, the brain tries to compensate for the loss of hearing by increasing its activity, resulting in the perception of a phantom sound, tinnitus. Until recently though, this idea was disputed as some tinnitus sufferers have normal hearing tests,” the researchers explained in the news release. 

Annoyed by the ringing in your ears? What causes tinnitus, and how can you get the sound to buzz off?

The study included 294 adults — 201 who had never reported having tinnitus, 64 who had reported having temporary tinnitus, and 29 who had reported having constant tinnitus for 6 months or more. 

All 294 had performed normally on a pure tone test, in which subjects raise their hands when they hear beeps to measure the quietest sounds they can detect.

In a different kind of test, electrodes measured responses to clicking sounds in the inner ear, the auditory nerve, and the brain. The second test found reduced response in the auditory nerves and increased activity in the brainstem activity among those who had tinnitus.

Dr Maison, a principal investigator at Eaton-Peabody Laboratories at Mass Eye and Ear/Harvard Medical School, called the study “a first step toward our ultimate goal of silencing tinnitus.”

“Beyond the nuisance of having persistent ringing or other sounds in the ears, tinnitus symptoms are debilitating in many patients, causing sleep deprivation, social isolation, anxiety and depression, adversely affecting work performance, and reducing significantly their quality of life,” he said in the news release. “We won’t be able to cure tinnitus until we fully understand the mechanisms underlying its genesis.”

A version of this article appeared on WebMD.com.

WASHINGTON, DC — The American Gastroenterological Association Center for GI Innovation and Technology recently held its fifth annual Innovation Conference (formerly Consensus Conference) on the Advances in Endosurgery, November 10 – 11. It was organized and chaired by Amrita Sethi, MD, Columbia University Irving Medical Center—NYP and Sri Komanduri, MD, MS, Feinberg School of Medicine, Northwestern University, Chicago.

The conference brought together gastroenterologists (GIs), surgeons, and industry partners to explore what further collaboration and clinical adoption is needed to advance endosurgical applications. Both GIs and surgeons welcomed potential collaboration especially in developing strategies to promote education and training initiatives, including defining what procedures and techniques are to be included in the endosurgery arena. Jeffrey Potkul, Medtronic Endoscopy, noted that this was a “great forum, format, and discussions — it will take novel approaches such as this conference and new collaboration models to ensure technology innovation in the endoluminal space can reach patients and empower improved outcomes in Gastroenterology.”

Dana Johnston

Topics discussed included third space endoscopy, endobariatric and metabolic endoscopy, and endoscopy related to transluminal access. Exciting new developments in robotic endoscopy were also highlighted with an attempt to understand the value proposition of this innovation in the endoscopy space, as well as successes and failures of past efforts to help guide success going forward. Other issues raised were methods for device development including initiating research studies, how to navigate regulatory processes for Food and Drug Administration approval of new devices, and ongoing issues related to billing and reimbursement. There was consensus around the need for collaboration between all stakeholders to drive innovation and its adoption in the field of endosurgery. This meeting is one of the first of its kind to bring innovators across multiple disciplines together with the intention of moving the entire field of endosurgery forward and encouraging creative solutions.

We would like to thank the members of the AGA Center for GI Innovation and Technology Committee and attendees who made this year’s conference a success. The conference was supported by independent grants from Boston Scientific Corporation, Cook Medical Inc., Endo Tools Therapeutics, Fujifilm Healthcare Americas Corporation, Intuitive Surgical, Olympus Corporation, and Medtronic.

WASHINGTON, DC — The American Gastroenterological Association Center for GI Innovation and Technology recently held its fifth annual Innovation Conference (formerly Consensus Conference) on the Advances in Endosurgery, November 10 – 11. It was organized and chaired by Amrita Sethi, MD, Columbia University Irving Medical Center—NYP and Sri Komanduri, MD, MS, Feinberg School of Medicine, Northwestern University, Chicago.

The conference brought together gastroenterologists (GIs), surgeons, and industry partners to explore what further collaboration and clinical adoption is needed to advance endosurgical applications. Both GIs and surgeons welcomed potential collaboration especially in developing strategies to promote education and training initiatives, including defining what procedures and techniques are to be included in the endosurgery arena. Jeffrey Potkul, Medtronic Endoscopy, noted that this was a “great forum, format, and discussions — it will take novel approaches such as this conference and new collaboration models to ensure technology innovation in the endoluminal space can reach patients and empower improved outcomes in Gastroenterology.”

Dana Johnston

Topics discussed included third space endoscopy, endobariatric and metabolic endoscopy, and endoscopy related to transluminal access. Exciting new developments in robotic endoscopy were also highlighted with an attempt to understand the value proposition of this innovation in the endoscopy space, as well as successes and failures of past efforts to help guide success going forward. Other issues raised were methods for device development including initiating research studies, how to navigate regulatory processes for Food and Drug Administration approval of new devices, and ongoing issues related to billing and reimbursement. There was consensus around the need for collaboration between all stakeholders to drive innovation and its adoption in the field of endosurgery. This meeting is one of the first of its kind to bring innovators across multiple disciplines together with the intention of moving the entire field of endosurgery forward and encouraging creative solutions.

We would like to thank the members of the AGA Center for GI Innovation and Technology Committee and attendees who made this year’s conference a success. The conference was supported by independent grants from Boston Scientific Corporation, Cook Medical Inc., Endo Tools Therapeutics, Fujifilm Healthcare Americas Corporation, Intuitive Surgical, Olympus Corporation, and Medtronic.

WASHINGTON, DC — The American Gastroenterological Association Center for GI Innovation and Technology recently held its fifth annual Innovation Conference (formerly Consensus Conference) on the Advances in Endosurgery, November 10 – 11. It was organized and chaired by Amrita Sethi, MD, Columbia University Irving Medical Center—NYP and Sri Komanduri, MD, MS, Feinberg School of Medicine, Northwestern University, Chicago.

The conference brought together gastroenterologists (GIs), surgeons, and industry partners to explore what further collaboration and clinical adoption is needed to advance endosurgical applications. Both GIs and surgeons welcomed potential collaboration especially in developing strategies to promote education and training initiatives, including defining what procedures and techniques are to be included in the endosurgery arena. Jeffrey Potkul, Medtronic Endoscopy, noted that this was a “great forum, format, and discussions — it will take novel approaches such as this conference and new collaboration models to ensure technology innovation in the endoluminal space can reach patients and empower improved outcomes in Gastroenterology.”

Dana Johnston

Topics discussed included third space endoscopy, endobariatric and metabolic endoscopy, and endoscopy related to transluminal access. Exciting new developments in robotic endoscopy were also highlighted with an attempt to understand the value proposition of this innovation in the endoscopy space, as well as successes and failures of past efforts to help guide success going forward. Other issues raised were methods for device development including initiating research studies, how to navigate regulatory processes for Food and Drug Administration approval of new devices, and ongoing issues related to billing and reimbursement. There was consensus around the need for collaboration between all stakeholders to drive innovation and its adoption in the field of endosurgery. This meeting is one of the first of its kind to bring innovators across multiple disciplines together with the intention of moving the entire field of endosurgery forward and encouraging creative solutions.

We would like to thank the members of the AGA Center for GI Innovation and Technology Committee and attendees who made this year’s conference a success. The conference was supported by independent grants from Boston Scientific Corporation, Cook Medical Inc., Endo Tools Therapeutics, Fujifilm Healthcare Americas Corporation, Intuitive Surgical, Olympus Corporation, and Medtronic.

The 2024 updates to the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) final rules represent a mixed bag for gastroenterologists.

Medicare Physician Fee Schedule (MPFS) Final Rule

Cuts to physician payments continue: The final calendar year (CY) 2024 MPFS conversion factor will be $32.7442, a cut of approximately 3.4% from CY 2023, unless Congress acts. The reduction is the result of several factors, including the statutory base payment update of 0 percent, the reduction in assistance provided by the Consolidated Appropriations Act, 2023 (from 2.5% for 2023 to 1.25% for 2024), and budget neutrality adjustments of –2.18 percent resulting from CMS’ finalized policies.

New add-on code for complex care: CMS is finalizing complexity add-on code, G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition), that it originally proposed in 2018 rulemaking. CMS noted that G2211 cannot be used with an office and outpatient E/M procedure reported with modifier –25. CMS further clarified that the add-on code “is not intended for use by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature ...” CMS further stated, “The inherent complexity that this code (G2211) captures is not in the clinical condition itself ... but rather the cognitive load of the continued responsibility of being the focal point for all needed services for this patient.” For gastroenterologists, it is reasonable to assume G2211 could be reported for care of patients with complex, chronic conditions such as inflammatory bowel disease (IBD), celiac disease, and/or chronic liver disease.

CMS to align split (or shared) visit policy with CPT rules: Originally, CMS proposed to again delay “through at least December 31, 2024” its planned implementation of defining the “substantive portion” of a split/shared visit as more than half of the total time. However, after the American Medical Association’s CPT Editorial Panel, the body responsible for maintaining the CPT code set, issued new guidelines for split (or shared) services CMS decided to finalize the following policy to align with those guidelines: “Substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making except as otherwise provided in this paragraph. For critical care visits, substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit.”

While the CPT guidance states, “If code selection is based on total time on the date of the encounter, the service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service,” this direction does not appear in the finalized CMS language.

CMS has extended Telehealth flexibility provisions through Dec. 31, 2024:

• Reporting of Home Address — CMS will continue to permit distant site practitioners to use their currently enrolled practice location instead of their home address when providing telehealth services from their home through CY 2024.
• Place of Service (POS) for Medicare Telehealth Services — Beginning in CY 2024, claims billed with POS 10 (Telehealth Provided in Patient’s Home) will be paid at the non-facility rate, and claims billed with POS 02 (Telehealth Provided Other than in Patient’s Home) will be paid at the facility rate. CMS also clarified that modifier –95 should be used when the clinician is in the hospital and the patient is at home.
• Direct Supervision with Virtual Presence — CMS will continue to define direct supervision to permit the presence and “immediate availability” of the supervising practitioner through real-time audio and visual interactive telecommunications through CY 2024.
• Supervision of Residents in Teaching Settings — CMS will allow teaching physicians to have a virtual presence (to continue to include real-time audio and video observation by the teaching physician) in all teaching settings, but only in clinical instances when the service is furnished virtually, through CY 2024.
• Telephone E/M Services — CMS will continue to pay for CPT codes for telephone assessment and management services (99441-99443) through CY 2024.

Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) Final Rule

Hospital and ASC payments will increase: Conversion factors will increase 3.1% to $87.38 for hospitals and $53.51 for ASCs that meet applicable quality reporting requirements.

Hospital payments for Peroral Endoscopic Myotomy (POEM) increase: The GI societies successfully advocated for a 67% increase to the facility payment for POEM. To better align with the procedure’s cost, CMS will place CPT code 43497 for POEM into a higher-level Ambulatory Payment Classification (APC) (5331 — Complex GI procedures) with a facility payment of $5,435.83.

Cuts to hospital payments for some Level 3 upper GI procedures: CMS has finalized moving the following GI CPT codes that had previously been assigned to APC 5303 (Level 3 Upper GI Procedures — $3,260.69) to APC 5302 (Level 2 Upper GI Procedures — $1,814.88) without explanation and against advice from AGA and the GI societies. This will result in payment cuts of 44% to hospitals.

• 43252 (EGD, flexible transoral with optical microscopy)
• 43263 (ERCP with pressure measurement, sphincter of Oddi)
• 43275 (ERCP, remove foreign body/stent biliary/pancreatic duct)

GI Comprehensive APC complexity adjustments: Based on a cost and volume threshold, CMS sometimes makes payment adjustments for Comprehensive APCs when two procedures are performed together. In response to comments received, CMS is adding the following procedures to the list of code combinations eligible for an increased payment via the Complexity Adjustment.

• CPT 43270 (EGD, ablate tumor polyp/lesion with dilation and wire)
• CPT 43252 (EGD, flexible transoral with optical microscopy)

For more information, see 2024 the payment rules summary and payment tables at https://gastro.org/practice-resources/reimbursement.

The Coverage and Reimbursement Subcommittee members have no conflicts of interest.

The 2024 updates to the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) final rules represent a mixed bag for gastroenterologists.

Medicare Physician Fee Schedule (MPFS) Final Rule

Cuts to physician payments continue: The final calendar year (CY) 2024 MPFS conversion factor will be $32.7442, a cut of approximately 3.4% from CY 2023, unless Congress acts. The reduction is the result of several factors, including the statutory base payment update of 0 percent, the reduction in assistance provided by the Consolidated Appropriations Act, 2023 (from 2.5% for 2023 to 1.25% for 2024), and budget neutrality adjustments of –2.18 percent resulting from CMS’ finalized policies.

New add-on code for complex care: CMS is finalizing complexity add-on code, G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition), that it originally proposed in 2018 rulemaking. CMS noted that G2211 cannot be used with an office and outpatient E/M procedure reported with modifier –25. CMS further clarified that the add-on code “is not intended for use by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature ...” CMS further stated, “The inherent complexity that this code (G2211) captures is not in the clinical condition itself ... but rather the cognitive load of the continued responsibility of being the focal point for all needed services for this patient.” For gastroenterologists, it is reasonable to assume G2211 could be reported for care of patients with complex, chronic conditions such as inflammatory bowel disease (IBD), celiac disease, and/or chronic liver disease.

CMS to align split (or shared) visit policy with CPT rules: Originally, CMS proposed to again delay “through at least December 31, 2024” its planned implementation of defining the “substantive portion” of a split/shared visit as more than half of the total time. However, after the American Medical Association’s CPT Editorial Panel, the body responsible for maintaining the CPT code set, issued new guidelines for split (or shared) services CMS decided to finalize the following policy to align with those guidelines: “Substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making except as otherwise provided in this paragraph. For critical care visits, substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit.”

While the CPT guidance states, “If code selection is based on total time on the date of the encounter, the service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service,” this direction does not appear in the finalized CMS language.

CMS has extended Telehealth flexibility provisions through Dec. 31, 2024:

• Reporting of Home Address — CMS will continue to permit distant site practitioners to use their currently enrolled practice location instead of their home address when providing telehealth services from their home through CY 2024.
• Place of Service (POS) for Medicare Telehealth Services — Beginning in CY 2024, claims billed with POS 10 (Telehealth Provided in Patient’s Home) will be paid at the non-facility rate, and claims billed with POS 02 (Telehealth Provided Other than in Patient’s Home) will be paid at the facility rate. CMS also clarified that modifier –95 should be used when the clinician is in the hospital and the patient is at home.
• Direct Supervision with Virtual Presence — CMS will continue to define direct supervision to permit the presence and “immediate availability” of the supervising practitioner through real-time audio and visual interactive telecommunications through CY 2024.
• Supervision of Residents in Teaching Settings — CMS will allow teaching physicians to have a virtual presence (to continue to include real-time audio and video observation by the teaching physician) in all teaching settings, but only in clinical instances when the service is furnished virtually, through CY 2024.
• Telephone E/M Services — CMS will continue to pay for CPT codes for telephone assessment and management services (99441-99443) through CY 2024.

Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) Final Rule

Hospital and ASC payments will increase: Conversion factors will increase 3.1% to $87.38 for hospitals and $53.51 for ASCs that meet applicable quality reporting requirements.

Hospital payments for Peroral Endoscopic Myotomy (POEM) increase: The GI societies successfully advocated for a 67% increase to the facility payment for POEM. To better align with the procedure’s cost, CMS will place CPT code 43497 for POEM into a higher-level Ambulatory Payment Classification (APC) (5331 — Complex GI procedures) with a facility payment of $5,435.83.

Cuts to hospital payments for some Level 3 upper GI procedures: CMS has finalized moving the following GI CPT codes that had previously been assigned to APC 5303 (Level 3 Upper GI Procedures — $3,260.69) to APC 5302 (Level 2 Upper GI Procedures — $1,814.88) without explanation and against advice from AGA and the GI societies. This will result in payment cuts of 44% to hospitals.

• 43252 (EGD, flexible transoral with optical microscopy)
• 43263 (ERCP with pressure measurement, sphincter of Oddi)
• 43275 (ERCP, remove foreign body/stent biliary/pancreatic duct)

GI Comprehensive APC complexity adjustments: Based on a cost and volume threshold, CMS sometimes makes payment adjustments for Comprehensive APCs when two procedures are performed together. In response to comments received, CMS is adding the following procedures to the list of code combinations eligible for an increased payment via the Complexity Adjustment.

• CPT 43270 (EGD, ablate tumor polyp/lesion with dilation and wire)
• CPT 43252 (EGD, flexible transoral with optical microscopy)

For more information, see 2024 the payment rules summary and payment tables at https://gastro.org/practice-resources/reimbursement.

The Coverage and Reimbursement Subcommittee members have no conflicts of interest.

The 2024 updates to the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) final rules represent a mixed bag for gastroenterologists.

Medicare Physician Fee Schedule (MPFS) Final Rule

Cuts to physician payments continue: The final calendar year (CY) 2024 MPFS conversion factor will be $32.7442, a cut of approximately 3.4% from CY 2023, unless Congress acts. The reduction is the result of several factors, including the statutory base payment update of 0 percent, the reduction in assistance provided by the Consolidated Appropriations Act, 2023 (from 2.5% for 2023 to 1.25% for 2024), and budget neutrality adjustments of –2.18 percent resulting from CMS’ finalized policies.

New add-on code for complex care: CMS is finalizing complexity add-on code, G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition), that it originally proposed in 2018 rulemaking. CMS noted that G2211 cannot be used with an office and outpatient E/M procedure reported with modifier –25. CMS further clarified that the add-on code “is not intended for use by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature ...” CMS further stated, “The inherent complexity that this code (G2211) captures is not in the clinical condition itself ... but rather the cognitive load of the continued responsibility of being the focal point for all needed services for this patient.” For gastroenterologists, it is reasonable to assume G2211 could be reported for care of patients with complex, chronic conditions such as inflammatory bowel disease (IBD), celiac disease, and/or chronic liver disease.

CMS to align split (or shared) visit policy with CPT rules: Originally, CMS proposed to again delay “through at least December 31, 2024” its planned implementation of defining the “substantive portion” of a split/shared visit as more than half of the total time. However, after the American Medical Association’s CPT Editorial Panel, the body responsible for maintaining the CPT code set, issued new guidelines for split (or shared) services CMS decided to finalize the following policy to align with those guidelines: “Substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making except as otherwise provided in this paragraph. For critical care visits, substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit.”

While the CPT guidance states, “If code selection is based on total time on the date of the encounter, the service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service,” this direction does not appear in the finalized CMS language.

CMS has extended Telehealth flexibility provisions through Dec. 31, 2024:

• Reporting of Home Address — CMS will continue to permit distant site practitioners to use their currently enrolled practice location instead of their home address when providing telehealth services from their home through CY 2024.
• Place of Service (POS) for Medicare Telehealth Services — Beginning in CY 2024, claims billed with POS 10 (Telehealth Provided in Patient’s Home) will be paid at the non-facility rate, and claims billed with POS 02 (Telehealth Provided Other than in Patient’s Home) will be paid at the facility rate. CMS also clarified that modifier –95 should be used when the clinician is in the hospital and the patient is at home.
• Direct Supervision with Virtual Presence — CMS will continue to define direct supervision to permit the presence and “immediate availability” of the supervising practitioner through real-time audio and visual interactive telecommunications through CY 2024.
• Supervision of Residents in Teaching Settings — CMS will allow teaching physicians to have a virtual presence (to continue to include real-time audio and video observation by the teaching physician) in all teaching settings, but only in clinical instances when the service is furnished virtually, through CY 2024.
• Telephone E/M Services — CMS will continue to pay for CPT codes for telephone assessment and management services (99441-99443) through CY 2024.

Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) Final Rule

Hospital and ASC payments will increase: Conversion factors will increase 3.1% to $87.38 for hospitals and $53.51 for ASCs that meet applicable quality reporting requirements.

Hospital payments for Peroral Endoscopic Myotomy (POEM) increase: The GI societies successfully advocated for a 67% increase to the facility payment for POEM. To better align with the procedure’s cost, CMS will place CPT code 43497 for POEM into a higher-level Ambulatory Payment Classification (APC) (5331 — Complex GI procedures) with a facility payment of $5,435.83.

Cuts to hospital payments for some Level 3 upper GI procedures: CMS has finalized moving the following GI CPT codes that had previously been assigned to APC 5303 (Level 3 Upper GI Procedures — $3,260.69) to APC 5302 (Level 2 Upper GI Procedures — $1,814.88) without explanation and against advice from AGA and the GI societies. This will result in payment cuts of 44% to hospitals.

• 43252 (EGD, flexible transoral with optical microscopy)
• 43263 (ERCP with pressure measurement, sphincter of Oddi)
• 43275 (ERCP, remove foreign body/stent biliary/pancreatic duct)

GI Comprehensive APC complexity adjustments: Based on a cost and volume threshold, CMS sometimes makes payment adjustments for Comprehensive APCs when two procedures are performed together. In response to comments received, CMS is adding the following procedures to the list of code combinations eligible for an increased payment via the Complexity Adjustment.

• CPT 43270 (EGD, ablate tumor polyp/lesion with dilation and wire)
• CPT 43252 (EGD, flexible transoral with optical microscopy)

For more information, see 2024 the payment rules summary and payment tables at https://gastro.org/practice-resources/reimbursement.

The Coverage and Reimbursement Subcommittee members have no conflicts of interest.

Health equity, sickle cell disease (SCD), and the thoughtful use of artificial intelligence (AI) and social media are among the key themes to be presented at the Dec. 9-12 annual meeting of the American Society of Hematology (ASH) in San Diego, association leaders told reporters in a media preview session.

Cynthia E. Dunbar, MD, chief of the Translational Stem Cell Biology Branch at the National Heart, Lung, and Blood Institute and secretary of ASH, added that insight into actual patient experiences also will be a major theme at ASH 2023.

“There is a huge growth in research on outcomes and focusing on using real-world data and how important that is,” Dr. Dunbar said. “Academic research and hematology is really focusing on patient-reported outcomes and how care is delivered in a real-world setting – actually looking at what matters to patients. Are they alive in a certain number of years? And how are they feeling?”

As an example, Dr. Dunbar pointed to an abstract that examined clinical databases in Canada and found that real-world outcomes in multiple myeloma treatments were much worse than those in the original clinical trials for the therapies. Patients reached relapse 44% faster and their overall survival was 75% worse.

In the media briefing, ASH chair of communications Mikkael A. Sekeres, MD, MS, of the Sylvester Comprehensive Cancer Center at the University of Miami, noted that patients in these types of clinical trials “are just these pristine specimens of human beings except for the cancer that’s being treated.”

Dr. Dunbar agreed, noting that “patients who are able to enroll in clinical trials are more likely to be able to show up at the treatment center at the right time and for every dose, have transportation, and afford drugs to prevent side effects. They might stay on the drug for longer, or they have nurses who are always encouraging them of how to make it through a toxicity.”

Hematologists and patients should consider randomized controlled trials to be “the best possible outcome, and perhaps adjust their thinking if an individual patient is older, sicker, or less able to follow a regimen exactly,” she said.

Another highlighted study linked worse outcomes in African-Americans with pediatric acute myeloid leukemia to genetic traits that are more common in that population. The traits “likely explain at least in part the worst outcomes in Black patients in prior studies and on some regimens,” Dr. Dunbar said.

She added that the findings emphasize how testing for genetic variants and biomarkers that impact outcomes should be performed “instead of assuming that a certain dose should be given simply based on perceived or reported race or ethnicity.”

ASH President Robert A. Brodsky, MD, of Johns Hopkins University School of Medicine, Baltimore, highlighted an abstract that reported on the use of AI as a clinical decision support tool to differentiate two easily confused conditions — prefibrotic primary myelofibrosis and essential thrombocythemia.

AI “is a tool that’s going to help pathologists make more accurate and faster diagnoses,” he said. He also spotlighted an abstract about the use of “social media listening” to understand the experiences of patients with SCD and their caregivers. “There can be a lot of misuse and waste of time with social media, but they used this in a way to try and gain insight as to what’s really important to the patients and the caregiver.”

Also, in regard to SCD, Dr. Dunbar pointed to a study that reports on outcomes in patients who received lovotibeglogene autotemcel (lovo-cel) gene therapy for up to 60 months. Both this treatment and a CRISPR-based therapy called exa-cel  “appear to result in comparable very impressive efficacy in terms of pain crises and organ dysfunction,” she said. “The hurdle is going to be figuring out how to deliver what will be very expensive and complicated therapies — but likely curative — therapies to patients.”

Another study to be presented at ASH — coauthored by Dr. Brodsky — shows promising results from reduced-intensity haploidentical bone marrow transplantation in adults with severe SCD. Results were similar to those seen with bone marrow from matched siblings, Dr. Sekeres said.

He added that more clarity is needed about new treatment options for SCD, perhaps through a “randomized trial where patients upfront get a haploidentical bone marrow transplant or fully matched bone marrow transplant. Then other patients are randomized to some of these other, newer technology therapies, and we follow them over time. We’re looking not only for overall survival but complications of the therapy itself and how many patients relapse from the treatment.”

Health equity, sickle cell disease (SCD), and the thoughtful use of artificial intelligence (AI) and social media are among the key themes to be presented at the Dec. 9-12 annual meeting of the American Society of Hematology (ASH) in San Diego, association leaders told reporters in a media preview session.

Cynthia E. Dunbar, MD, chief of the Translational Stem Cell Biology Branch at the National Heart, Lung, and Blood Institute and secretary of ASH, added that insight into actual patient experiences also will be a major theme at ASH 2023.

“There is a huge growth in research on outcomes and focusing on using real-world data and how important that is,” Dr. Dunbar said. “Academic research and hematology is really focusing on patient-reported outcomes and how care is delivered in a real-world setting – actually looking at what matters to patients. Are they alive in a certain number of years? And how are they feeling?”

As an example, Dr. Dunbar pointed to an abstract that examined clinical databases in Canada and found that real-world outcomes in multiple myeloma treatments were much worse than those in the original clinical trials for the therapies. Patients reached relapse 44% faster and their overall survival was 75% worse.

In the media briefing, ASH chair of communications Mikkael A. Sekeres, MD, MS, of the Sylvester Comprehensive Cancer Center at the University of Miami, noted that patients in these types of clinical trials “are just these pristine specimens of human beings except for the cancer that’s being treated.”

Dr. Dunbar agreed, noting that “patients who are able to enroll in clinical trials are more likely to be able to show up at the treatment center at the right time and for every dose, have transportation, and afford drugs to prevent side effects. They might stay on the drug for longer, or they have nurses who are always encouraging them of how to make it through a toxicity.”

Hematologists and patients should consider randomized controlled trials to be “the best possible outcome, and perhaps adjust their thinking if an individual patient is older, sicker, or less able to follow a regimen exactly,” she said.

Another highlighted study linked worse outcomes in African-Americans with pediatric acute myeloid leukemia to genetic traits that are more common in that population. The traits “likely explain at least in part the worst outcomes in Black patients in prior studies and on some regimens,” Dr. Dunbar said.

She added that the findings emphasize how testing for genetic variants and biomarkers that impact outcomes should be performed “instead of assuming that a certain dose should be given simply based on perceived or reported race or ethnicity.”

ASH President Robert A. Brodsky, MD, of Johns Hopkins University School of Medicine, Baltimore, highlighted an abstract that reported on the use of AI as a clinical decision support tool to differentiate two easily confused conditions — prefibrotic primary myelofibrosis and essential thrombocythemia.

AI “is a tool that’s going to help pathologists make more accurate and faster diagnoses,” he said. He also spotlighted an abstract about the use of “social media listening” to understand the experiences of patients with SCD and their caregivers. “There can be a lot of misuse and waste of time with social media, but they used this in a way to try and gain insight as to what’s really important to the patients and the caregiver.”

Also, in regard to SCD, Dr. Dunbar pointed to a study that reports on outcomes in patients who received lovotibeglogene autotemcel (lovo-cel) gene therapy for up to 60 months. Both this treatment and a CRISPR-based therapy called exa-cel  “appear to result in comparable very impressive efficacy in terms of pain crises and organ dysfunction,” she said. “The hurdle is going to be figuring out how to deliver what will be very expensive and complicated therapies — but likely curative — therapies to patients.”

Another study to be presented at ASH — coauthored by Dr. Brodsky — shows promising results from reduced-intensity haploidentical bone marrow transplantation in adults with severe SCD. Results were similar to those seen with bone marrow from matched siblings, Dr. Sekeres said.

He added that more clarity is needed about new treatment options for SCD, perhaps through a “randomized trial where patients upfront get a haploidentical bone marrow transplant or fully matched bone marrow transplant. Then other patients are randomized to some of these other, newer technology therapies, and we follow them over time. We’re looking not only for overall survival but complications of the therapy itself and how many patients relapse from the treatment.”

Health equity, sickle cell disease (SCD), and the thoughtful use of artificial intelligence (AI) and social media are among the key themes to be presented at the Dec. 9-12 annual meeting of the American Society of Hematology (ASH) in San Diego, association leaders told reporters in a media preview session.

Cynthia E. Dunbar, MD, chief of the Translational Stem Cell Biology Branch at the National Heart, Lung, and Blood Institute and secretary of ASH, added that insight into actual patient experiences also will be a major theme at ASH 2023.

“There is a huge growth in research on outcomes and focusing on using real-world data and how important that is,” Dr. Dunbar said. “Academic research and hematology is really focusing on patient-reported outcomes and how care is delivered in a real-world setting – actually looking at what matters to patients. Are they alive in a certain number of years? And how are they feeling?”

As an example, Dr. Dunbar pointed to an abstract that examined clinical databases in Canada and found that real-world outcomes in multiple myeloma treatments were much worse than those in the original clinical trials for the therapies. Patients reached relapse 44% faster and their overall survival was 75% worse.

In the media briefing, ASH chair of communications Mikkael A. Sekeres, MD, MS, of the Sylvester Comprehensive Cancer Center at the University of Miami, noted that patients in these types of clinical trials “are just these pristine specimens of human beings except for the cancer that’s being treated.”

Dr. Dunbar agreed, noting that “patients who are able to enroll in clinical trials are more likely to be able to show up at the treatment center at the right time and for every dose, have transportation, and afford drugs to prevent side effects. They might stay on the drug for longer, or they have nurses who are always encouraging them of how to make it through a toxicity.”

Hematologists and patients should consider randomized controlled trials to be “the best possible outcome, and perhaps adjust their thinking if an individual patient is older, sicker, or less able to follow a regimen exactly,” she said.

Another highlighted study linked worse outcomes in African-Americans with pediatric acute myeloid leukemia to genetic traits that are more common in that population. The traits “likely explain at least in part the worst outcomes in Black patients in prior studies and on some regimens,” Dr. Dunbar said.

She added that the findings emphasize how testing for genetic variants and biomarkers that impact outcomes should be performed “instead of assuming that a certain dose should be given simply based on perceived or reported race or ethnicity.”

ASH President Robert A. Brodsky, MD, of Johns Hopkins University School of Medicine, Baltimore, highlighted an abstract that reported on the use of AI as a clinical decision support tool to differentiate two easily confused conditions — prefibrotic primary myelofibrosis and essential thrombocythemia.

AI “is a tool that’s going to help pathologists make more accurate and faster diagnoses,” he said. He also spotlighted an abstract about the use of “social media listening” to understand the experiences of patients with SCD and their caregivers. “There can be a lot of misuse and waste of time with social media, but they used this in a way to try and gain insight as to what’s really important to the patients and the caregiver.”

Also, in regard to SCD, Dr. Dunbar pointed to a study that reports on outcomes in patients who received lovotibeglogene autotemcel (lovo-cel) gene therapy for up to 60 months. Both this treatment and a CRISPR-based therapy called exa-cel  “appear to result in comparable very impressive efficacy in terms of pain crises and organ dysfunction,” she said. “The hurdle is going to be figuring out how to deliver what will be very expensive and complicated therapies — but likely curative — therapies to patients.”

Another study to be presented at ASH — coauthored by Dr. Brodsky — shows promising results from reduced-intensity haploidentical bone marrow transplantation in adults with severe SCD. Results were similar to those seen with bone marrow from matched siblings, Dr. Sekeres said.

He added that more clarity is needed about new treatment options for SCD, perhaps through a “randomized trial where patients upfront get a haploidentical bone marrow transplant or fully matched bone marrow transplant. Then other patients are randomized to some of these other, newer technology therapies, and we follow them over time. We’re looking not only for overall survival but complications of the therapy itself and how many patients relapse from the treatment.”