Mixed Topics

BARCELONA, SPAIN — Migraine is widely considered a predominantly female disorder. Its frequency, duration, and severity tend to be higher in women, and women are also more likely than men to receive a migraine diagnosis. However, gender expectations, differences in the likelihood of self-reporting, and problems with how migraine is classified make it difficult to estimate its true prevalence in men and women. 

Epidemiologists and migraine specialists discussed these apparent sex differences and the difficulties in obtaining accurate estimates of migraine prevalence in a debate session at the 17th European Headache Congress in Barcelona. 

Different Symptoms

Headache disorders are estimated to affect 50% of the general population ; tension-type headache and migraine are the two most common. According to epidemiologic studies, migraine is more prevalent in women, with a female-to-male ratio of 3:1. There are numerous studies of why this might be, most of which focus largely on female-related factors, such as hormones and the menstrual cycle. 

“Despite many years of research, there isn’t one clear factor explaining this substantial difference between women and men,” said Tobias Kurth of Charité – Universitätsmedizin Berlin, Germany. “So the question is: Are we missing something else?”

One factor in these perceived sex differences in migraine is that women seem to report their migraines differently from men, and they also have different symptoms. For example, women are more likely than men to report severe pain, and their migraine attacks are more often accompanied by photophobia, phonophobia, and nausea, whereas men’s migraines are more often accompanied by aura. 

“By favoring female symptoms, the classification system may not be picking up male symptoms because they’re not being classified in the right way,” Dr. Kurth said, with one consequence being that migraine is underdiagnosed in men. “Before trying to understand the biological and behavioral reasons for these sex differences, we first need to consider these methodological challenges that we all apply knowingly or unknowingly.” 

Christian Lampl, professor of neurology at Konventhospital der Barmherzigen Brüder Linz, Austria, and president of the European Headache Federation, said in an interview, “I’m convinced that this 3:1 ratio which has been stated for decades is wrong, but we still don’t have the data. The criteria we have [for classifying migraine] are useful for clinical trials, but they are useless for determining the male-to-female ratio. 

“We need a new definition of migraine,” he added. “Migraine is an episode, not an attack. Attacks have a sudden onset, and migraine onset is not sudden — it is an episode with a headache attack.” 

Inadequate Menopause Services

Professor Anne MacGregor of St. Bartholomew’s Hospital in London, United Kingdom, specializes in migraine and women’s health. She presented data showing that migraine is underdiagnosed in women; one reason being that the disorder receives inadequate attention from healthcare professionals at specialist menopause services. 

Menopause is associated with an increased prevalence of migraine, but women do not discuss headache symptoms at specialist menopause services, Dr. MacGregor said. 

She then described unpublished results from a survey of 117 women attending the specialist menopause service at St. Bartholomew’s Hospital. Among the respondents, 34% reported experiencing episodic migraine and an additional 8% reported having chronic migraine. 

“Within this population of women who were not reporting headache as a symptom [to the menopause service until asked in the survey], 42% of them were positive for a diagnosis of migraine,” said Dr. MacGregor. “They were mostly relying on prescribed paracetamol and codeine, or buying it over the counter, and only 22% of them were receiving triptans. 

“They are clearly being undertreated,” she added. “Part of this issue is that they didn’t spontaneously report headache as a menopause symptom, so they weren’t consulting for headache to their primary care physicians.” 

Correct diagnosis by a consultant is a prerequisite for receiving appropriate migraine treatment. Yet, according to a US study published in 2012, only 45.5% of women with episodic migraine consulted a prescribing healthcare professional. Of those who consulted, 89% were diagnosed correctly, and only 68% of those received the appropriate treatment.

A larger, more recent study confirmed that there is a massive unmet need for improving care in this patient population. The Chronic Migraine Epidemiology and Outcomes (CaMEO) Study, which analyzed data from nearly 90,000 participants, showed that just 4.8% of people with chronic migraine received consultation, correct diagnosis, and treatment, with 89% of women with chronic migraine left undiagnosed. 

The OVERCOME Study further revealed that although many people with migraine were repeat consulters, they were consulting their physicians for other health problems. 

“This makes it very clear that people in other specialties need to be more aware about picking up and diagnosing headache,” said MacGregor. “That’s where the real need is in managing headache. We have the treatments, but if the patients can’t access them, they’re not much good to them.”

A version of this article appeared on Medscape.com.

BARCELONA, SPAIN — Migraine is widely considered a predominantly female disorder. Its frequency, duration, and severity tend to be higher in women, and women are also more likely than men to receive a migraine diagnosis. However, gender expectations, differences in the likelihood of self-reporting, and problems with how migraine is classified make it difficult to estimate its true prevalence in men and women. 

Epidemiologists and migraine specialists discussed these apparent sex differences and the difficulties in obtaining accurate estimates of migraine prevalence in a debate session at the 17th European Headache Congress in Barcelona. 

Different Symptoms

Headache disorders are estimated to affect 50% of the general population ; tension-type headache and migraine are the two most common. According to epidemiologic studies, migraine is more prevalent in women, with a female-to-male ratio of 3:1. There are numerous studies of why this might be, most of which focus largely on female-related factors, such as hormones and the menstrual cycle. 

“Despite many years of research, there isn’t one clear factor explaining this substantial difference between women and men,” said Tobias Kurth of Charité – Universitätsmedizin Berlin, Germany. “So the question is: Are we missing something else?”

One factor in these perceived sex differences in migraine is that women seem to report their migraines differently from men, and they also have different symptoms. For example, women are more likely than men to report severe pain, and their migraine attacks are more often accompanied by photophobia, phonophobia, and nausea, whereas men’s migraines are more often accompanied by aura. 

“By favoring female symptoms, the classification system may not be picking up male symptoms because they’re not being classified in the right way,” Dr. Kurth said, with one consequence being that migraine is underdiagnosed in men. “Before trying to understand the biological and behavioral reasons for these sex differences, we first need to consider these methodological challenges that we all apply knowingly or unknowingly.” 

Christian Lampl, professor of neurology at Konventhospital der Barmherzigen Brüder Linz, Austria, and president of the European Headache Federation, said in an interview, “I’m convinced that this 3:1 ratio which has been stated for decades is wrong, but we still don’t have the data. The criteria we have [for classifying migraine] are useful for clinical trials, but they are useless for determining the male-to-female ratio. 

“We need a new definition of migraine,” he added. “Migraine is an episode, not an attack. Attacks have a sudden onset, and migraine onset is not sudden — it is an episode with a headache attack.” 

Inadequate Menopause Services

Professor Anne MacGregor of St. Bartholomew’s Hospital in London, United Kingdom, specializes in migraine and women’s health. She presented data showing that migraine is underdiagnosed in women; one reason being that the disorder receives inadequate attention from healthcare professionals at specialist menopause services. 

Menopause is associated with an increased prevalence of migraine, but women do not discuss headache symptoms at specialist menopause services, Dr. MacGregor said. 

She then described unpublished results from a survey of 117 women attending the specialist menopause service at St. Bartholomew’s Hospital. Among the respondents, 34% reported experiencing episodic migraine and an additional 8% reported having chronic migraine. 

“Within this population of women who were not reporting headache as a symptom [to the menopause service until asked in the survey], 42% of them were positive for a diagnosis of migraine,” said Dr. MacGregor. “They were mostly relying on prescribed paracetamol and codeine, or buying it over the counter, and only 22% of them were receiving triptans. 

“They are clearly being undertreated,” she added. “Part of this issue is that they didn’t spontaneously report headache as a menopause symptom, so they weren’t consulting for headache to their primary care physicians.” 

Correct diagnosis by a consultant is a prerequisite for receiving appropriate migraine treatment. Yet, according to a US study published in 2012, only 45.5% of women with episodic migraine consulted a prescribing healthcare professional. Of those who consulted, 89% were diagnosed correctly, and only 68% of those received the appropriate treatment.

A larger, more recent study confirmed that there is a massive unmet need for improving care in this patient population. The Chronic Migraine Epidemiology and Outcomes (CaMEO) Study, which analyzed data from nearly 90,000 participants, showed that just 4.8% of people with chronic migraine received consultation, correct diagnosis, and treatment, with 89% of women with chronic migraine left undiagnosed. 

The OVERCOME Study further revealed that although many people with migraine were repeat consulters, they were consulting their physicians for other health problems. 

“This makes it very clear that people in other specialties need to be more aware about picking up and diagnosing headache,” said MacGregor. “That’s where the real need is in managing headache. We have the treatments, but if the patients can’t access them, they’re not much good to them.”

A version of this article appeared on Medscape.com.

BARCELONA, SPAIN — Migraine is widely considered a predominantly female disorder. Its frequency, duration, and severity tend to be higher in women, and women are also more likely than men to receive a migraine diagnosis. However, gender expectations, differences in the likelihood of self-reporting, and problems with how migraine is classified make it difficult to estimate its true prevalence in men and women. 

Epidemiologists and migraine specialists discussed these apparent sex differences and the difficulties in obtaining accurate estimates of migraine prevalence in a debate session at the 17th European Headache Congress in Barcelona. 

Different Symptoms

Headache disorders are estimated to affect 50% of the general population ; tension-type headache and migraine are the two most common. According to epidemiologic studies, migraine is more prevalent in women, with a female-to-male ratio of 3:1. There are numerous studies of why this might be, most of which focus largely on female-related factors, such as hormones and the menstrual cycle. 

“Despite many years of research, there isn’t one clear factor explaining this substantial difference between women and men,” said Tobias Kurth of Charité – Universitätsmedizin Berlin, Germany. “So the question is: Are we missing something else?”

One factor in these perceived sex differences in migraine is that women seem to report their migraines differently from men, and they also have different symptoms. For example, women are more likely than men to report severe pain, and their migraine attacks are more often accompanied by photophobia, phonophobia, and nausea, whereas men’s migraines are more often accompanied by aura. 

“By favoring female symptoms, the classification system may not be picking up male symptoms because they’re not being classified in the right way,” Dr. Kurth said, with one consequence being that migraine is underdiagnosed in men. “Before trying to understand the biological and behavioral reasons for these sex differences, we first need to consider these methodological challenges that we all apply knowingly or unknowingly.” 

Christian Lampl, professor of neurology at Konventhospital der Barmherzigen Brüder Linz, Austria, and president of the European Headache Federation, said in an interview, “I’m convinced that this 3:1 ratio which has been stated for decades is wrong, but we still don’t have the data. The criteria we have [for classifying migraine] are useful for clinical trials, but they are useless for determining the male-to-female ratio. 

“We need a new definition of migraine,” he added. “Migraine is an episode, not an attack. Attacks have a sudden onset, and migraine onset is not sudden — it is an episode with a headache attack.” 

Inadequate Menopause Services

Professor Anne MacGregor of St. Bartholomew’s Hospital in London, United Kingdom, specializes in migraine and women’s health. She presented data showing that migraine is underdiagnosed in women; one reason being that the disorder receives inadequate attention from healthcare professionals at specialist menopause services. 

Menopause is associated with an increased prevalence of migraine, but women do not discuss headache symptoms at specialist menopause services, Dr. MacGregor said. 

She then described unpublished results from a survey of 117 women attending the specialist menopause service at St. Bartholomew’s Hospital. Among the respondents, 34% reported experiencing episodic migraine and an additional 8% reported having chronic migraine. 

“Within this population of women who were not reporting headache as a symptom [to the menopause service until asked in the survey], 42% of them were positive for a diagnosis of migraine,” said Dr. MacGregor. “They were mostly relying on prescribed paracetamol and codeine, or buying it over the counter, and only 22% of them were receiving triptans. 

“They are clearly being undertreated,” she added. “Part of this issue is that they didn’t spontaneously report headache as a menopause symptom, so they weren’t consulting for headache to their primary care physicians.” 

Correct diagnosis by a consultant is a prerequisite for receiving appropriate migraine treatment. Yet, according to a US study published in 2012, only 45.5% of women with episodic migraine consulted a prescribing healthcare professional. Of those who consulted, 89% were diagnosed correctly, and only 68% of those received the appropriate treatment.

A larger, more recent study confirmed that there is a massive unmet need for improving care in this patient population. The Chronic Migraine Epidemiology and Outcomes (CaMEO) Study, which analyzed data from nearly 90,000 participants, showed that just 4.8% of people with chronic migraine received consultation, correct diagnosis, and treatment, with 89% of women with chronic migraine left undiagnosed. 

The OVERCOME Study further revealed that although many people with migraine were repeat consulters, they were consulting their physicians for other health problems. 

“This makes it very clear that people in other specialties need to be more aware about picking up and diagnosing headache,” said MacGregor. “That’s where the real need is in managing headache. We have the treatments, but if the patients can’t access them, they’re not much good to them.”

A version of this article appeared on Medscape.com.

New recommendations to screen for heart failure, peripheral arterial disease (PAD), and type 1 diabetes risk, along with new obesity management guidance, are among many updates to the American Diabetes Association’s (ADA’s) Standards of Care for 2024.

“The Standards of Care are essentially the global guidelines for the care of individuals with diabetes and those at risk,” ADA chief scientific and medical officer Robert Gabbay, MD, PhD, said during a briefing announcing the new Standards.

The document was developed via a scientific literature review by the ADA’s Professional Practice Committee. The panel comprises 21 professionals, including physicians from many specialties, nurse practitioners, certified diabetes care and education specialists, dietitians, and pharmacists. The chair is Nuha A. El Sayed, MD, ADA’s senior vice president of healthcare improvement.

Specific sections of the 2024 document have been endorsed by the American College of Cardiology, the American Society of Bone and Mineral Research, and the Obesity Society. It was published on December 11, 2023, as a supplement in Diabetes Care.

An introductory section summarizing the changes for 2024 spans six pages. Those addressed during the briefing included the following:

Heart Failure Screening: Two new recommendations have been added to include screening of adults with diabetes for asymptomatic heart failure by measuring natriuretic peptide levels to facilitate the prevention or progression to symptomatic stages of heart failure.

“This is a really important and exciting area. We know that people with type 2 diabetes in particular are at high risk for heart failure,” Dr. Gabbay said, adding that these recommendations “are to really more aggressively screen those at high risk for heart failure with a simple blood test and, based on those values, then be able to move on to further evaluation and echocardiography, for example. The recommendations are really to screen a broad number of individuals with type 2 diabetes because many are at risk, [particularly] those without symptoms.”

PAD Screening: A new strong recommendation is to screen for PAD with ankle-brachial index testing in asymptomatic people with diabetes who are aged ≥ 50 years and have microvascular disease in any location, foot complications, or any end-organ damage from diabetes. The document also advises consideration of PAD screening for all individuals who have had diabetes for ≥ 10 years.

Dr. Gabbay commented, “We know that amputation rates are rising, unlike many other complications. We know that there are incredible health disparities. Blacks are two to four times more likely than Whites to have an amputation.”

Dr. El Sayed added, “Many patients don’t show the common symptoms of peripheral arterial disease. Screening is the most important way to find out if they have it or not because it can be a very devastating disease.”

Type 1 Diabetes Screening: This involves several new recommendations, including a framework for investigating suspected type 1 diabetes in newly diagnosed adults using islet autoantibody tests and diagnostic criteria for preclinical stages based on the recent approval of teplizumab for delaying the onset of type 1 diabetes.

“Screening and capturing disease earlier so that we can intervene is really an important consideration here. That includes screening for type 1 diabetes and thinking about therapeutic options to delay the development of frank type 1 diabetes,” Dr. Gabbay said.

Screening first-degree relatives of people with type 1 diabetes is a high priority because they’re at an elevated risk, he added.

Obesity Management: New recommendations here include the use of anthropomorphic measurements beyond body mass index to include waist circumference and waist:hip ratio and individual assessment of body fat mass and distribution.

Individualization of obesity management including behavioral, pharmacologic, and surgical approaches is encouraged. The use of a glucagon-like peptide-1 (GLP-1) receptor agonist or a dual glucose-dependent insulinotropic polypeptide and GLP-1 receptor agonist with greater weight loss efficacy is preferred for obesity management in people with diabetes.

“Obesity management is one of the biggest changes over this last year,” Dr. Gabbay commented.

Other New Recommendations: Among the many other revisions in the 2024 document are new recommendations about regular evaluation and treatment for bone health, assessment of disability and guidance for referral, and alignment of guidance for liver disease screening and management with those of other professional societies. Regarding the last item, Dr. Gabbay noted, “I don’t think it’s gotten the attention it deserves. Diabetes and obesity are becoming the leading causes of liver disease.”

Clinicians can also download the Standards of Care app on their smartphones. “That can be really helpful when questions come up since you can’t remember everything in there. Here you can look it up in a matter of seconds,” Dr. Gabbay said.

Dr. El Sayed added that asking patients about their priorities is also important. “If they aren’t brought up during the visit, it’s unlikely to be as fruitful as it should be.”

Dr. El Sayed has no disclosures. Dr. Gabbay serves as a consultant and/or advisor for HealthReveal, Lark Technologies, Onduo, StartUp Health, Sweetech, and Vida Health.

A version of this article appeared on Medscape.com.

New recommendations to screen for heart failure, peripheral arterial disease (PAD), and type 1 diabetes risk, along with new obesity management guidance, are among many updates to the American Diabetes Association’s (ADA’s) Standards of Care for 2024.

“The Standards of Care are essentially the global guidelines for the care of individuals with diabetes and those at risk,” ADA chief scientific and medical officer Robert Gabbay, MD, PhD, said during a briefing announcing the new Standards.

The document was developed via a scientific literature review by the ADA’s Professional Practice Committee. The panel comprises 21 professionals, including physicians from many specialties, nurse practitioners, certified diabetes care and education specialists, dietitians, and pharmacists. The chair is Nuha A. El Sayed, MD, ADA’s senior vice president of healthcare improvement.

Specific sections of the 2024 document have been endorsed by the American College of Cardiology, the American Society of Bone and Mineral Research, and the Obesity Society. It was published on December 11, 2023, as a supplement in Diabetes Care.

An introductory section summarizing the changes for 2024 spans six pages. Those addressed during the briefing included the following:

Heart Failure Screening: Two new recommendations have been added to include screening of adults with diabetes for asymptomatic heart failure by measuring natriuretic peptide levels to facilitate the prevention or progression to symptomatic stages of heart failure.

“This is a really important and exciting area. We know that people with type 2 diabetes in particular are at high risk for heart failure,” Dr. Gabbay said, adding that these recommendations “are to really more aggressively screen those at high risk for heart failure with a simple blood test and, based on those values, then be able to move on to further evaluation and echocardiography, for example. The recommendations are really to screen a broad number of individuals with type 2 diabetes because many are at risk, [particularly] those without symptoms.”

PAD Screening: A new strong recommendation is to screen for PAD with ankle-brachial index testing in asymptomatic people with diabetes who are aged ≥ 50 years and have microvascular disease in any location, foot complications, or any end-organ damage from diabetes. The document also advises consideration of PAD screening for all individuals who have had diabetes for ≥ 10 years.

Dr. Gabbay commented, “We know that amputation rates are rising, unlike many other complications. We know that there are incredible health disparities. Blacks are two to four times more likely than Whites to have an amputation.”

Dr. El Sayed added, “Many patients don’t show the common symptoms of peripheral arterial disease. Screening is the most important way to find out if they have it or not because it can be a very devastating disease.”

Type 1 Diabetes Screening: This involves several new recommendations, including a framework for investigating suspected type 1 diabetes in newly diagnosed adults using islet autoantibody tests and diagnostic criteria for preclinical stages based on the recent approval of teplizumab for delaying the onset of type 1 diabetes.

“Screening and capturing disease earlier so that we can intervene is really an important consideration here. That includes screening for type 1 diabetes and thinking about therapeutic options to delay the development of frank type 1 diabetes,” Dr. Gabbay said.

Screening first-degree relatives of people with type 1 diabetes is a high priority because they’re at an elevated risk, he added.

Obesity Management: New recommendations here include the use of anthropomorphic measurements beyond body mass index to include waist circumference and waist:hip ratio and individual assessment of body fat mass and distribution.

Individualization of obesity management including behavioral, pharmacologic, and surgical approaches is encouraged. The use of a glucagon-like peptide-1 (GLP-1) receptor agonist or a dual glucose-dependent insulinotropic polypeptide and GLP-1 receptor agonist with greater weight loss efficacy is preferred for obesity management in people with diabetes.

“Obesity management is one of the biggest changes over this last year,” Dr. Gabbay commented.

Other New Recommendations: Among the many other revisions in the 2024 document are new recommendations about regular evaluation and treatment for bone health, assessment of disability and guidance for referral, and alignment of guidance for liver disease screening and management with those of other professional societies. Regarding the last item, Dr. Gabbay noted, “I don’t think it’s gotten the attention it deserves. Diabetes and obesity are becoming the leading causes of liver disease.”

Clinicians can also download the Standards of Care app on their smartphones. “That can be really helpful when questions come up since you can’t remember everything in there. Here you can look it up in a matter of seconds,” Dr. Gabbay said.

Dr. El Sayed added that asking patients about their priorities is also important. “If they aren’t brought up during the visit, it’s unlikely to be as fruitful as it should be.”

Dr. El Sayed has no disclosures. Dr. Gabbay serves as a consultant and/or advisor for HealthReveal, Lark Technologies, Onduo, StartUp Health, Sweetech, and Vida Health.

A version of this article appeared on Medscape.com.

New recommendations to screen for heart failure, peripheral arterial disease (PAD), and type 1 diabetes risk, along with new obesity management guidance, are among many updates to the American Diabetes Association’s (ADA’s) Standards of Care for 2024.

“The Standards of Care are essentially the global guidelines for the care of individuals with diabetes and those at risk,” ADA chief scientific and medical officer Robert Gabbay, MD, PhD, said during a briefing announcing the new Standards.

The document was developed via a scientific literature review by the ADA’s Professional Practice Committee. The panel comprises 21 professionals, including physicians from many specialties, nurse practitioners, certified diabetes care and education specialists, dietitians, and pharmacists. The chair is Nuha A. El Sayed, MD, ADA’s senior vice president of healthcare improvement.

Specific sections of the 2024 document have been endorsed by the American College of Cardiology, the American Society of Bone and Mineral Research, and the Obesity Society. It was published on December 11, 2023, as a supplement in Diabetes Care.

An introductory section summarizing the changes for 2024 spans six pages. Those addressed during the briefing included the following:

Heart Failure Screening: Two new recommendations have been added to include screening of adults with diabetes for asymptomatic heart failure by measuring natriuretic peptide levels to facilitate the prevention or progression to symptomatic stages of heart failure.

“This is a really important and exciting area. We know that people with type 2 diabetes in particular are at high risk for heart failure,” Dr. Gabbay said, adding that these recommendations “are to really more aggressively screen those at high risk for heart failure with a simple blood test and, based on those values, then be able to move on to further evaluation and echocardiography, for example. The recommendations are really to screen a broad number of individuals with type 2 diabetes because many are at risk, [particularly] those without symptoms.”

PAD Screening: A new strong recommendation is to screen for PAD with ankle-brachial index testing in asymptomatic people with diabetes who are aged ≥ 50 years and have microvascular disease in any location, foot complications, or any end-organ damage from diabetes. The document also advises consideration of PAD screening for all individuals who have had diabetes for ≥ 10 years.

Dr. Gabbay commented, “We know that amputation rates are rising, unlike many other complications. We know that there are incredible health disparities. Blacks are two to four times more likely than Whites to have an amputation.”

Dr. El Sayed added, “Many patients don’t show the common symptoms of peripheral arterial disease. Screening is the most important way to find out if they have it or not because it can be a very devastating disease.”

Type 1 Diabetes Screening: This involves several new recommendations, including a framework for investigating suspected type 1 diabetes in newly diagnosed adults using islet autoantibody tests and diagnostic criteria for preclinical stages based on the recent approval of teplizumab for delaying the onset of type 1 diabetes.

“Screening and capturing disease earlier so that we can intervene is really an important consideration here. That includes screening for type 1 diabetes and thinking about therapeutic options to delay the development of frank type 1 diabetes,” Dr. Gabbay said.

Screening first-degree relatives of people with type 1 diabetes is a high priority because they’re at an elevated risk, he added.

Obesity Management: New recommendations here include the use of anthropomorphic measurements beyond body mass index to include waist circumference and waist:hip ratio and individual assessment of body fat mass and distribution.

Individualization of obesity management including behavioral, pharmacologic, and surgical approaches is encouraged. The use of a glucagon-like peptide-1 (GLP-1) receptor agonist or a dual glucose-dependent insulinotropic polypeptide and GLP-1 receptor agonist with greater weight loss efficacy is preferred for obesity management in people with diabetes.

“Obesity management is one of the biggest changes over this last year,” Dr. Gabbay commented.

Other New Recommendations: Among the many other revisions in the 2024 document are new recommendations about regular evaluation and treatment for bone health, assessment of disability and guidance for referral, and alignment of guidance for liver disease screening and management with those of other professional societies. Regarding the last item, Dr. Gabbay noted, “I don’t think it’s gotten the attention it deserves. Diabetes and obesity are becoming the leading causes of liver disease.”

Clinicians can also download the Standards of Care app on their smartphones. “That can be really helpful when questions come up since you can’t remember everything in there. Here you can look it up in a matter of seconds,” Dr. Gabbay said.

Dr. El Sayed added that asking patients about their priorities is also important. “If they aren’t brought up during the visit, it’s unlikely to be as fruitful as it should be.”

Dr. El Sayed has no disclosures. Dr. Gabbay serves as a consultant and/or advisor for HealthReveal, Lark Technologies, Onduo, StartUp Health, Sweetech, and Vida Health.

A version of this article appeared on Medscape.com.

Evidence continues to show that the number of practicing ObGyns lags the growing and diverse US population of women.¹ Furthermore, approximately 1 in every 3 ObGyns will move usually once or twice every 10 years.² Knowing what to expect in being recruited requires a better understanding of your needs and capabilities and what they may be worth in real time. Some ObGyns elect to use a recruitment firm to begin their search to more objectively assess what is fair and equitable.

Understanding physician compensation involves many factors, such as patient composition, sources of reimbursement, impact of health care systems, and geography.³ Several sources report trends in annual physician compensation, most notably the American Medical Association, medical specialty organizations, and recruitment firms. Sources such as the Medical Group Management Association (MGMA), the American Medical Group Association (AMGA), and Medscape report total compensation.

Determining salaries for new positions

A standard and comprehensive benchmarking resource for salaries in new positions has been the annual review of physician and advanced practitioner recruiting incentives by AMN Healthcare (formerly Merritt Hawkins) Physician Solutions.⁴ This resource is used by hospitals, medical groups, academics, other health care systems, and others who track trends in physician supply, demand, and compensation. Their 2023 report considered starting salaries for more than 20 medical or surgical specialties.

Specialists’ revenue-generating potential is tracked by annual billings to commercial payers. The average annual billing by a full-time ObGyn ($3.8 million) is about the same as that of other specialties combined.⁵ As in the past, ObGyns are among the most consistently requested specialists in searches. In 2023, ObGyns were ranked the third most common physician specialists being recruited and tenth as the percentage of physicians per specialty (TABLE).⁴

Full-time salaries for ObGyns have remained within the middle third of all specialties. They consistently have been higher than primary care physicians’ salaries but remain among the lowest of the surgical specialties. This impression is reinforced by 2023 data shown in FIGURE 1.⁴ In the past, salaries remained flat compared with other surgical specialties. As with other specialties, starting salaries decreased during the peak 2020 and 2021 COVID-19 years. It is encouraging that averaged full-time salaries for recruiting ObGyns increased by 14.1% from 2020–2021 to 2021–2022 and by 10.5% from 2021–2022 to 2022–2023 (FIGURE 2).⁴

Special considerations

Incomes tended to be highest for ObGyns practicing in metropolitan areas with population sizes less than 1 million rather than in larger metropolitan areas.³ However, differences in reported incomes do not control for cost of living and other determinants of income (for example, surgeries, deliveries, patient care hours worked). Averaged salaries can vary regionally in the following order from highest to lowest: Midwest/Great Plains, West, Southwest, and Northeast and Southeast.⁴

Differences in starting salaries between male and female ObGyns are often not reported, although they are a very important consideration.^6,7 Both men and women desire “controllable lifestyles” with more flexibility and working in shifts. Sex-based differences in physician salary and compensation can be complex. Explanations may deal with the number of patients seen, number of procedures and surgeries performed, and frequency of after-hours duties. Women constitute most ObGyns, and their salary being at any lower end of the income spectrum may be partially explained by fewer desired work hours or less seniority.

Annual earnings can vary and are positively related to the number of working hours, being in the middle of one’s career (aged 42–51 years), working in a moderately large practice rather than in a solo or self-employed practice, and being board certified.³ A lower starting salary would be anticipated for a recent graduate. However, the resident going into a hard-to-fill position may be offered a higher salary than an experienced ObGyn who takes a relatively easy-to-fill position in a popular location. Practices would be more desirable in which patient volume is sufficient to invest in nonphysician clinicians and revenue-generating ancillary services that do not require costly layers of administration.

Information on physician salaries for new positions from individual recruiting or research firms can serve as a starting point for negotiation, although it may not entirely be representative. Sample sizes can be small, and information in some specialties may not separate salaries of physicians in academic versus nonacademic positions and generalists versus subspecialists. The information in this article reflects the average salaries offered to attract physicians to new practice settings rather than what they might earn and report on their tax return.

Continue to: Incentives...

Incentives

Negotiations involve incentives along with a starting salary. Signing bonuses, movingallowances, continuing education time and allowances, and medical education loan repayments are important incentives. Recent signing bonuses (average, $37,472) likely reflect efforts to bring physicians back to health care facilities post-COVID-19 or, more commonly, when candidates are considering multiple opportunities.⁴ It is important to clarify at the beginning any coverage for health insurance and professional liability insurance.

Relocation allowances are for those being recruited outside their current area of residence. The average continuing medical education allowance was $3,840 in 2023.⁴ Medical school debt is common, being approximately $200,000 at graduation for many. An educational loan repayment (average, $98,665) is typically an exchange for a commitment to stay in the community for a given period.

Starting employment contracts with hospitals or large medical groups often feature a production bonus to reward additional clinical work performed or an adherence to quality protocol or guidelines, rather than income guarantees alone. Metrics are usually volume driven (for example, relative value units, net collections, gross billings, patients seen). Initiatives by payers and health care organizations have included quality metrics, such as high patient satisfaction scores, low morbidity rates, and low readmission rates. Production-based formulas are straightforward, while use of quality-based formulas (up to 14% of total compensation) can be less clear to define.⁴ ●

Evidence continues to show that the number of practicing ObGyns lags the growing and diverse US population of women.¹ Furthermore, approximately 1 in every 3 ObGyns will move usually once or twice every 10 years.² Knowing what to expect in being recruited requires a better understanding of your needs and capabilities and what they may be worth in real time. Some ObGyns elect to use a recruitment firm to begin their search to more objectively assess what is fair and equitable.

Understanding physician compensation involves many factors, such as patient composition, sources of reimbursement, impact of health care systems, and geography.³ Several sources report trends in annual physician compensation, most notably the American Medical Association, medical specialty organizations, and recruitment firms. Sources such as the Medical Group Management Association (MGMA), the American Medical Group Association (AMGA), and Medscape report total compensation.

Determining salaries for new positions

A standard and comprehensive benchmarking resource for salaries in new positions has been the annual review of physician and advanced practitioner recruiting incentives by AMN Healthcare (formerly Merritt Hawkins) Physician Solutions.⁴ This resource is used by hospitals, medical groups, academics, other health care systems, and others who track trends in physician supply, demand, and compensation. Their 2023 report considered starting salaries for more than 20 medical or surgical specialties.

Specialists’ revenue-generating potential is tracked by annual billings to commercial payers. The average annual billing by a full-time ObGyn ($3.8 million) is about the same as that of other specialties combined.⁵ As in the past, ObGyns are among the most consistently requested specialists in searches. In 2023, ObGyns were ranked the third most common physician specialists being recruited and tenth as the percentage of physicians per specialty (TABLE).⁴

Full-time salaries for ObGyns have remained within the middle third of all specialties. They consistently have been higher than primary care physicians’ salaries but remain among the lowest of the surgical specialties. This impression is reinforced by 2023 data shown in FIGURE 1.⁴ In the past, salaries remained flat compared with other surgical specialties. As with other specialties, starting salaries decreased during the peak 2020 and 2021 COVID-19 years. It is encouraging that averaged full-time salaries for recruiting ObGyns increased by 14.1% from 2020–2021 to 2021–2022 and by 10.5% from 2021–2022 to 2022–2023 (FIGURE 2).⁴

Special considerations

Incomes tended to be highest for ObGyns practicing in metropolitan areas with population sizes less than 1 million rather than in larger metropolitan areas.³ However, differences in reported incomes do not control for cost of living and other determinants of income (for example, surgeries, deliveries, patient care hours worked). Averaged salaries can vary regionally in the following order from highest to lowest: Midwest/Great Plains, West, Southwest, and Northeast and Southeast.⁴

Differences in starting salaries between male and female ObGyns are often not reported, although they are a very important consideration.^6,7 Both men and women desire “controllable lifestyles” with more flexibility and working in shifts. Sex-based differences in physician salary and compensation can be complex. Explanations may deal with the number of patients seen, number of procedures and surgeries performed, and frequency of after-hours duties. Women constitute most ObGyns, and their salary being at any lower end of the income spectrum may be partially explained by fewer desired work hours or less seniority.

Annual earnings can vary and are positively related to the number of working hours, being in the middle of one’s career (aged 42–51 years), working in a moderately large practice rather than in a solo or self-employed practice, and being board certified.³ A lower starting salary would be anticipated for a recent graduate. However, the resident going into a hard-to-fill position may be offered a higher salary than an experienced ObGyn who takes a relatively easy-to-fill position in a popular location. Practices would be more desirable in which patient volume is sufficient to invest in nonphysician clinicians and revenue-generating ancillary services that do not require costly layers of administration.

Information on physician salaries for new positions from individual recruiting or research firms can serve as a starting point for negotiation, although it may not entirely be representative. Sample sizes can be small, and information in some specialties may not separate salaries of physicians in academic versus nonacademic positions and generalists versus subspecialists. The information in this article reflects the average salaries offered to attract physicians to new practice settings rather than what they might earn and report on their tax return.

Continue to: Incentives...

Incentives

Negotiations involve incentives along with a starting salary. Signing bonuses, movingallowances, continuing education time and allowances, and medical education loan repayments are important incentives. Recent signing bonuses (average, $37,472) likely reflect efforts to bring physicians back to health care facilities post-COVID-19 or, more commonly, when candidates are considering multiple opportunities.⁴ It is important to clarify at the beginning any coverage for health insurance and professional liability insurance.

Relocation allowances are for those being recruited outside their current area of residence. The average continuing medical education allowance was $3,840 in 2023.⁴ Medical school debt is common, being approximately $200,000 at graduation for many. An educational loan repayment (average, $98,665) is typically an exchange for a commitment to stay in the community for a given period.

Starting employment contracts with hospitals or large medical groups often feature a production bonus to reward additional clinical work performed or an adherence to quality protocol or guidelines, rather than income guarantees alone. Metrics are usually volume driven (for example, relative value units, net collections, gross billings, patients seen). Initiatives by payers and health care organizations have included quality metrics, such as high patient satisfaction scores, low morbidity rates, and low readmission rates. Production-based formulas are straightforward, while use of quality-based formulas (up to 14% of total compensation) can be less clear to define.⁴ ●

Evidence continues to show that the number of practicing ObGyns lags the growing and diverse US population of women.¹ Furthermore, approximately 1 in every 3 ObGyns will move usually once or twice every 10 years.² Knowing what to expect in being recruited requires a better understanding of your needs and capabilities and what they may be worth in real time. Some ObGyns elect to use a recruitment firm to begin their search to more objectively assess what is fair and equitable.

Understanding physician compensation involves many factors, such as patient composition, sources of reimbursement, impact of health care systems, and geography.³ Several sources report trends in annual physician compensation, most notably the American Medical Association, medical specialty organizations, and recruitment firms. Sources such as the Medical Group Management Association (MGMA), the American Medical Group Association (AMGA), and Medscape report total compensation.

Determining salaries for new positions

A standard and comprehensive benchmarking resource for salaries in new positions has been the annual review of physician and advanced practitioner recruiting incentives by AMN Healthcare (formerly Merritt Hawkins) Physician Solutions.⁴ This resource is used by hospitals, medical groups, academics, other health care systems, and others who track trends in physician supply, demand, and compensation. Their 2023 report considered starting salaries for more than 20 medical or surgical specialties.

Specialists’ revenue-generating potential is tracked by annual billings to commercial payers. The average annual billing by a full-time ObGyn ($3.8 million) is about the same as that of other specialties combined.⁵ As in the past, ObGyns are among the most consistently requested specialists in searches. In 2023, ObGyns were ranked the third most common physician specialists being recruited and tenth as the percentage of physicians per specialty (TABLE).⁴

Full-time salaries for ObGyns have remained within the middle third of all specialties. They consistently have been higher than primary care physicians’ salaries but remain among the lowest of the surgical specialties. This impression is reinforced by 2023 data shown in FIGURE 1.⁴ In the past, salaries remained flat compared with other surgical specialties. As with other specialties, starting salaries decreased during the peak 2020 and 2021 COVID-19 years. It is encouraging that averaged full-time salaries for recruiting ObGyns increased by 14.1% from 2020–2021 to 2021–2022 and by 10.5% from 2021–2022 to 2022–2023 (FIGURE 2).⁴

Special considerations

Incomes tended to be highest for ObGyns practicing in metropolitan areas with population sizes less than 1 million rather than in larger metropolitan areas.³ However, differences in reported incomes do not control for cost of living and other determinants of income (for example, surgeries, deliveries, patient care hours worked). Averaged salaries can vary regionally in the following order from highest to lowest: Midwest/Great Plains, West, Southwest, and Northeast and Southeast.⁴

Differences in starting salaries between male and female ObGyns are often not reported, although they are a very important consideration.^6,7 Both men and women desire “controllable lifestyles” with more flexibility and working in shifts. Sex-based differences in physician salary and compensation can be complex. Explanations may deal with the number of patients seen, number of procedures and surgeries performed, and frequency of after-hours duties. Women constitute most ObGyns, and their salary being at any lower end of the income spectrum may be partially explained by fewer desired work hours or less seniority.

Annual earnings can vary and are positively related to the number of working hours, being in the middle of one’s career (aged 42–51 years), working in a moderately large practice rather than in a solo or self-employed practice, and being board certified.³ A lower starting salary would be anticipated for a recent graduate. However, the resident going into a hard-to-fill position may be offered a higher salary than an experienced ObGyn who takes a relatively easy-to-fill position in a popular location. Practices would be more desirable in which patient volume is sufficient to invest in nonphysician clinicians and revenue-generating ancillary services that do not require costly layers of administration.

Information on physician salaries for new positions from individual recruiting or research firms can serve as a starting point for negotiation, although it may not entirely be representative. Sample sizes can be small, and information in some specialties may not separate salaries of physicians in academic versus nonacademic positions and generalists versus subspecialists. The information in this article reflects the average salaries offered to attract physicians to new practice settings rather than what they might earn and report on their tax return.

Continue to: Incentives...

Incentives

Negotiations involve incentives along with a starting salary. Signing bonuses, movingallowances, continuing education time and allowances, and medical education loan repayments are important incentives. Recent signing bonuses (average, $37,472) likely reflect efforts to bring physicians back to health care facilities post-COVID-19 or, more commonly, when candidates are considering multiple opportunities.⁴ It is important to clarify at the beginning any coverage for health insurance and professional liability insurance.

Relocation allowances are for those being recruited outside their current area of residence. The average continuing medical education allowance was $3,840 in 2023.⁴ Medical school debt is common, being approximately $200,000 at graduation for many. An educational loan repayment (average, $98,665) is typically an exchange for a commitment to stay in the community for a given period.

Starting employment contracts with hospitals or large medical groups often feature a production bonus to reward additional clinical work performed or an adherence to quality protocol or guidelines, rather than income guarantees alone. Metrics are usually volume driven (for example, relative value units, net collections, gross billings, patients seen). Initiatives by payers and health care organizations have included quality metrics, such as high patient satisfaction scores, low morbidity rates, and low readmission rates. Production-based formulas are straightforward, while use of quality-based formulas (up to 14% of total compensation) can be less clear to define.⁴ ●

CASE A new patient office visit

A new patient is waiting for you in the exam room. You review the chart and see the sex demographic field is blank, and the patient’s name is Alex. As an ObGyn, most of your patients are female, but you have treated your patients’ partners for sexually transmitted infections. As you enter the room, you see 2 androgynously dressed individuals; you introduce yourself and ask,

“What brings you in today, and who is your friend?”

“This is my partner Charlie, and we are worried I have an STD.”
 

Estimates suggest that between 7% to 12% of the US population identifies as lesbian, gay, bisexual, transgender/non-binary, queer/questioning, intersex, or asexual (LGBTQI+).¹ If you practice in an urban area, the odds are quite high that you have encountered an LGBTQI+ person who openly identified as such; if you are in a rural area, you also likely have had an LGBTQI+ patient, but they may not have disclosed this about themselves.² Maybe you have had training in cultural relevance or are a member of this community and you feel confident in providing quality care to LGBTQI+ patients. Or maybe you think that, as a responsibly practicing health care clinician, you treat all patients the same, so whether or not you know their sexual orientation or gender identity does not impact the care you provide. As the proportion of US adults who identify as LGBTQI+ increases,¹ it becomes more important for health care clinicians to understand the challenges these patients face when trying to access health care. To start, let’s review the meaning of LGBTQI+, the history of the community, what it means to be culturally relevant or humble, and how to create a welcoming and safe practice environment.

LGBTQI+ terms and definitions

The first step in providing quality care to LGBTQI+ patients is to understand the terminology associated with sexual orientation, gender identity, and gender expression.^3–5

Sexual orientation refers to whom a person is sexually attracted. The term straight/heterosexual suggests a person is sexually attracted to a person of the opposite gender. Lesbian or gay refers to those who are attracted to their same gender. Some people use bisexual (attracted to both the same and opposite gender) and pansexual (attracted to all humans regardless of gender). Still others refer to themselves as queer—people who identify as someone who is not heterosexual or cisgender. A variety of other terms exist to describe one’s sexual attraction. There are also some people who identify as asexual, which suggests they are not sexually attracted to anyone.

Gender identity relates to how one views their own gender. If you were assigned female at birth and identify as a woman, you are cisgender. If you were assigned male at birth and identify as a woman, you may identify as transgender whether or not you have had gender transitioning surgery or have taken hormones. Some people do not identify with the terms male or female and may view themselves as nonbinary. The terms gender queer, gender fluid, gender diverse, and gender non-conforming also may be used to describe various ways that an individual may not identify as male or female. We also can refer to people as “assigned female at birth” or “assigned male at birth”. People with intersex conditions may require taking a unique medical history that includes asking about genetic testing (eg, 46,XX congenital adrenal hyperplasia or 46,XY complete gonadal dysgenesis).

Gender expression refers to how one pre-sents themselves to others through appearance, dress, and behavior. A person may be assigned female at birth, dress in a conventional male fashion, and still identify as a woman. Still others may choose to express their gender in a variety of ways that may not have anything to do with their sexual orientation or gender identity, such as dressing in ways that represent their culture.

People may be fluid in their sexual orientation or gender identity; it may change from day to day, month to month, or even year to year.^6,7

*The term LGBTQI+ is not used consistently in the literature. Throughout this article, the terminology used matches that used in the cited reference(s).

Continue to: Health care and the LGBTQI+ community...

Health care and the LGBTQI+ community

The LGBTQI+ community has a history of experiencing societal discrimination and stigma, which stems from medical mistrust often due to a lack of understanding of their medical and psychosocial needs.^8,9 A 2019 survey of US LGBTQ adults, found that about 50% of people who identified as transgender reported having negative or discriminatory experiences with a health care clinician.¹⁰ About 18% of transgender people anticipated being refused medical care due to their gender identity.¹⁰ About 18% of LGBTQ individuals avoid any type of medical care, fearing discrimination.¹⁰ Lesbian women are 3 times more likely to have not seen an ObGyn than women who identify as straight.¹¹ Sixty-two percent of lesbian women have biological children and received prenatal care; however, of those, 47% do not receive routine cancer screenings.^10,11 Only 45% of age-eligible lesbian women have received at least 1 dose of the HPV vaccine, compared with 60% of straight women.^10,11

Due to societal stigma, more than 40% of transgender people have attempted suicide.¹² Felt or perceived stigma is also associated with risky health behaviors that contribute to health disparities. LGBTQI+ people are more likely to use substances,¹³ lesbian women are more likely to be obese,¹⁴ and 19% of transgender men are living with HIV/AIDS.¹⁵ Rates of unintended pregnancy among lesbian women and transgender men are 28%, compared with 6% in straight women, and 12% in heterosexual teens.^15,16

In addition to real or perceived discrimination, there are medical misperceptions among the LGBTQI+ community. For instance, sexual minority women (SMW) are less likely to receive regular screening for cervical cancer. In one survey of more than 400 SMW, about 25% reported not receiving regular screening. SMW may mistakenly believe they do not need Pap testing and pelvic exams because they do not have penile-vaginal intercourse.^17,18 Transgender men may not identify with having a cervix, or may perceive ObGyns to be “gendered” toward people who identify as women.¹⁸

Embracing cultural humility

Cultural humility expands upon the term cultural competence, with the idea that one can never be fully competent in the culture of another person.^19,20 The National Institutes of Health defines cultural humility as “a lifelong process of self-reflection and self-critique whereby the individual not only learns about another’s culture, but one starts with an examination of his/her own beliefs and cultural identities.”²¹

Having cultural humility is the recognition that, in order to treat your ObGyn patient as a whole person and engage in shared medical decision making in the office setting, you need to know their sexual orientation and gender identity. Treating each patient the same is not providing equitable care (equality does not equal equity) because each patient has different medical and psychosocial needs. Embracing cultural humility is the first step in creating safe and welcoming spaces in the ObGyn office.²⁰

CASE Ways to better introduce yourself

To revisit the case, what options does the clinician have to start off on a best foot to create a safe space for Alex?

• Open with your own preferred pronouns. For instance, for an introduction, consider: “I’m Dr. X, my pronouns are she/her.”
• Don’t assume. Do not make assumptions about the relationship between Alex and the person accompanying them.

4 ways for creating welcoming and affirming spaces in ObGyn

1. Make sure your intake form is inclusive. Include a space for pronouns and the patient’s preferred name (which may differ from their legal name). Also allow patients to choose more than 1 sexual orientation and gender identity.²⁰ (An example form is available from the LGBT National Health Education Center: https://www.lgbtqiahealtheducation.org/publication/focus-forms-policy-creating-inclusive-environment-lgbt-patients/.)
2. Create a safe environment in the waiting area. Try to ensure that at least 1 bathroom is labeled “All Gender” or “Family.” Gendered bathrooms (eg, Ladies’ or Men’s rooms) are not welcoming. Make sure your non-discrimination policy is displayed and includes sexual orientation and gender identity. Review the patient education and reading materials in your waiting room to ensure they are inclusive. Do they show people with varied gender expression? Do they show same-sex couples or interracial couples?
3. Use a trauma-informed approach when taking a sexual history and while conducting a physical exam. Determine if a pelvic exam is necessary at this visit or can it be postponed for another visit, when trust has been established with the patient. Explain each part of the pelvic/vaginal exam prior to conducting and again while performing the exam. Before taking a sexual history, explain why you are asking the questions and be sure to remain neutral with your questioning. For instance, you can say, “It’s important for me to understand your medical history in detail to provide you with the best health care possible.” Instead of asking, “Do you have sex with men, women, or both?” ask, “Do you have sex with people with a penis, vagina, or both? Do you have anal sex?” Recognize that some patients may be in a polyamorous relationship and may have more than 1 committed partner. For sexually active patients consider asking if they have ever exchanged sex for money or other goods, making sure to avoid judgmental body language or wording. Patients who do engage in “survival sex” may benefit from a discussion on pre-exposure prophylaxis to reduce HIV transmission.²²
4. Provide appropriate counsel based on their feedback.

• Explain their risk for HPV infection and vaccination options.
• Respectfully ask if there is a need for contraception and review options appropriate for their situation.
• Ask about the use of “toys” and provide guidance on sanitation and risk of infection with shared toys.
• Determine current or past hormone use for patients who identify as transgender and nonbinary (although many do not take hormones and have not had gender-affirming procedures, some may be considering these procedures). Be sure to ask these patients if they have had any surgeries or other procedures.

The receipt of gynecologic care can be traumatic for some LGBTQI+ people. Explain to the patient why you are doing everything during your examination and how it might feel. If a pelvic exam is not absolutely necessary that day, perhaps the patient can return another time. For transgender men who have been taking testosterone,vaginal atrophy may be a concern, and you could consider a pediatric speculum.

Personal introspection may be necessary

In summary, the number of people who identify as lesbian, gay, bisexual, transgender/nonbinary, queer/questioning, intersex, or asexual is not insignificant. Many of these patients or their partners may present for ObGyn care at your office. Clinicians need to understand that there is a new language relative to sexual orientation and gender identity. Incorporating cultural humility into one’s practice requires personal introspection and is a first step to creating safe and welcoming spaces in the ObGyn office. ●

CASE A new patient office visit

A new patient is waiting for you in the exam room. You review the chart and see the sex demographic field is blank, and the patient’s name is Alex. As an ObGyn, most of your patients are female, but you have treated your patients’ partners for sexually transmitted infections. As you enter the room, you see 2 androgynously dressed individuals; you introduce yourself and ask,

“What brings you in today, and who is your friend?”

“This is my partner Charlie, and we are worried I have an STD.”
 

Estimates suggest that between 7% to 12% of the US population identifies as lesbian, gay, bisexual, transgender/non-binary, queer/questioning, intersex, or asexual (LGBTQI+).¹ If you practice in an urban area, the odds are quite high that you have encountered an LGBTQI+ person who openly identified as such; if you are in a rural area, you also likely have had an LGBTQI+ patient, but they may not have disclosed this about themselves.² Maybe you have had training in cultural relevance or are a member of this community and you feel confident in providing quality care to LGBTQI+ patients. Or maybe you think that, as a responsibly practicing health care clinician, you treat all patients the same, so whether or not you know their sexual orientation or gender identity does not impact the care you provide. As the proportion of US adults who identify as LGBTQI+ increases,¹ it becomes more important for health care clinicians to understand the challenges these patients face when trying to access health care. To start, let’s review the meaning of LGBTQI+, the history of the community, what it means to be culturally relevant or humble, and how to create a welcoming and safe practice environment.

LGBTQI+ terms and definitions

The first step in providing quality care to LGBTQI+ patients is to understand the terminology associated with sexual orientation, gender identity, and gender expression.^3–5

Sexual orientation refers to whom a person is sexually attracted. The term straight/heterosexual suggests a person is sexually attracted to a person of the opposite gender. Lesbian or gay refers to those who are attracted to their same gender. Some people use bisexual (attracted to both the same and opposite gender) and pansexual (attracted to all humans regardless of gender). Still others refer to themselves as queer—people who identify as someone who is not heterosexual or cisgender. A variety of other terms exist to describe one’s sexual attraction. There are also some people who identify as asexual, which suggests they are not sexually attracted to anyone.

Gender identity relates to how one views their own gender. If you were assigned female at birth and identify as a woman, you are cisgender. If you were assigned male at birth and identify as a woman, you may identify as transgender whether or not you have had gender transitioning surgery or have taken hormones. Some people do not identify with the terms male or female and may view themselves as nonbinary. The terms gender queer, gender fluid, gender diverse, and gender non-conforming also may be used to describe various ways that an individual may not identify as male or female. We also can refer to people as “assigned female at birth” or “assigned male at birth”. People with intersex conditions may require taking a unique medical history that includes asking about genetic testing (eg, 46,XX congenital adrenal hyperplasia or 46,XY complete gonadal dysgenesis).

Gender expression refers to how one pre-sents themselves to others through appearance, dress, and behavior. A person may be assigned female at birth, dress in a conventional male fashion, and still identify as a woman. Still others may choose to express their gender in a variety of ways that may not have anything to do with their sexual orientation or gender identity, such as dressing in ways that represent their culture.

People may be fluid in their sexual orientation or gender identity; it may change from day to day, month to month, or even year to year.^6,7

*The term LGBTQI+ is not used consistently in the literature. Throughout this article, the terminology used matches that used in the cited reference(s).

Continue to: Health care and the LGBTQI+ community...

Health care and the LGBTQI+ community

The LGBTQI+ community has a history of experiencing societal discrimination and stigma, which stems from medical mistrust often due to a lack of understanding of their medical and psychosocial needs.^8,9 A 2019 survey of US LGBTQ adults, found that about 50% of people who identified as transgender reported having negative or discriminatory experiences with a health care clinician.¹⁰ About 18% of transgender people anticipated being refused medical care due to their gender identity.¹⁰ About 18% of LGBTQ individuals avoid any type of medical care, fearing discrimination.¹⁰ Lesbian women are 3 times more likely to have not seen an ObGyn than women who identify as straight.¹¹ Sixty-two percent of lesbian women have biological children and received prenatal care; however, of those, 47% do not receive routine cancer screenings.^10,11 Only 45% of age-eligible lesbian women have received at least 1 dose of the HPV vaccine, compared with 60% of straight women.^10,11

Due to societal stigma, more than 40% of transgender people have attempted suicide.¹² Felt or perceived stigma is also associated with risky health behaviors that contribute to health disparities. LGBTQI+ people are more likely to use substances,¹³ lesbian women are more likely to be obese,¹⁴ and 19% of transgender men are living with HIV/AIDS.¹⁵ Rates of unintended pregnancy among lesbian women and transgender men are 28%, compared with 6% in straight women, and 12% in heterosexual teens.^15,16

In addition to real or perceived discrimination, there are medical misperceptions among the LGBTQI+ community. For instance, sexual minority women (SMW) are less likely to receive regular screening for cervical cancer. In one survey of more than 400 SMW, about 25% reported not receiving regular screening. SMW may mistakenly believe they do not need Pap testing and pelvic exams because they do not have penile-vaginal intercourse.^17,18 Transgender men may not identify with having a cervix, or may perceive ObGyns to be “gendered” toward people who identify as women.¹⁸

Embracing cultural humility

Cultural humility expands upon the term cultural competence, with the idea that one can never be fully competent in the culture of another person.^19,20 The National Institutes of Health defines cultural humility as “a lifelong process of self-reflection and self-critique whereby the individual not only learns about another’s culture, but one starts with an examination of his/her own beliefs and cultural identities.”²¹

Having cultural humility is the recognition that, in order to treat your ObGyn patient as a whole person and engage in shared medical decision making in the office setting, you need to know their sexual orientation and gender identity. Treating each patient the same is not providing equitable care (equality does not equal equity) because each patient has different medical and psychosocial needs. Embracing cultural humility is the first step in creating safe and welcoming spaces in the ObGyn office.²⁰

CASE Ways to better introduce yourself

To revisit the case, what options does the clinician have to start off on a best foot to create a safe space for Alex?

• Open with your own preferred pronouns. For instance, for an introduction, consider: “I’m Dr. X, my pronouns are she/her.”
• Don’t assume. Do not make assumptions about the relationship between Alex and the person accompanying them.

4 ways for creating welcoming and affirming spaces in ObGyn

1. Make sure your intake form is inclusive. Include a space for pronouns and the patient’s preferred name (which may differ from their legal name). Also allow patients to choose more than 1 sexual orientation and gender identity.²⁰ (An example form is available from the LGBT National Health Education Center: https://www.lgbtqiahealtheducation.org/publication/focus-forms-policy-creating-inclusive-environment-lgbt-patients/.)
2. Create a safe environment in the waiting area. Try to ensure that at least 1 bathroom is labeled “All Gender” or “Family.” Gendered bathrooms (eg, Ladies’ or Men’s rooms) are not welcoming. Make sure your non-discrimination policy is displayed and includes sexual orientation and gender identity. Review the patient education and reading materials in your waiting room to ensure they are inclusive. Do they show people with varied gender expression? Do they show same-sex couples or interracial couples?
3. Use a trauma-informed approach when taking a sexual history and while conducting a physical exam. Determine if a pelvic exam is necessary at this visit or can it be postponed for another visit, when trust has been established with the patient. Explain each part of the pelvic/vaginal exam prior to conducting and again while performing the exam. Before taking a sexual history, explain why you are asking the questions and be sure to remain neutral with your questioning. For instance, you can say, “It’s important for me to understand your medical history in detail to provide you with the best health care possible.” Instead of asking, “Do you have sex with men, women, or both?” ask, “Do you have sex with people with a penis, vagina, or both? Do you have anal sex?” Recognize that some patients may be in a polyamorous relationship and may have more than 1 committed partner. For sexually active patients consider asking if they have ever exchanged sex for money or other goods, making sure to avoid judgmental body language or wording. Patients who do engage in “survival sex” may benefit from a discussion on pre-exposure prophylaxis to reduce HIV transmission.²²
4. Provide appropriate counsel based on their feedback.

• Explain their risk for HPV infection and vaccination options.
• Respectfully ask if there is a need for contraception and review options appropriate for their situation.
• Ask about the use of “toys” and provide guidance on sanitation and risk of infection with shared toys.
• Determine current or past hormone use for patients who identify as transgender and nonbinary (although many do not take hormones and have not had gender-affirming procedures, some may be considering these procedures). Be sure to ask these patients if they have had any surgeries or other procedures.

The receipt of gynecologic care can be traumatic for some LGBTQI+ people. Explain to the patient why you are doing everything during your examination and how it might feel. If a pelvic exam is not absolutely necessary that day, perhaps the patient can return another time. For transgender men who have been taking testosterone,vaginal atrophy may be a concern, and you could consider a pediatric speculum.

Personal introspection may be necessary

In summary, the number of people who identify as lesbian, gay, bisexual, transgender/nonbinary, queer/questioning, intersex, or asexual is not insignificant. Many of these patients or their partners may present for ObGyn care at your office. Clinicians need to understand that there is a new language relative to sexual orientation and gender identity. Incorporating cultural humility into one’s practice requires personal introspection and is a first step to creating safe and welcoming spaces in the ObGyn office. ●

CASE A new patient office visit

A new patient is waiting for you in the exam room. You review the chart and see the sex demographic field is blank, and the patient’s name is Alex. As an ObGyn, most of your patients are female, but you have treated your patients’ partners for sexually transmitted infections. As you enter the room, you see 2 androgynously dressed individuals; you introduce yourself and ask,

“What brings you in today, and who is your friend?”

“This is my partner Charlie, and we are worried I have an STD.”
 

Estimates suggest that between 7% to 12% of the US population identifies as lesbian, gay, bisexual, transgender/non-binary, queer/questioning, intersex, or asexual (LGBTQI+).¹ If you practice in an urban area, the odds are quite high that you have encountered an LGBTQI+ person who openly identified as such; if you are in a rural area, you also likely have had an LGBTQI+ patient, but they may not have disclosed this about themselves.² Maybe you have had training in cultural relevance or are a member of this community and you feel confident in providing quality care to LGBTQI+ patients. Or maybe you think that, as a responsibly practicing health care clinician, you treat all patients the same, so whether or not you know their sexual orientation or gender identity does not impact the care you provide. As the proportion of US adults who identify as LGBTQI+ increases,¹ it becomes more important for health care clinicians to understand the challenges these patients face when trying to access health care. To start, let’s review the meaning of LGBTQI+, the history of the community, what it means to be culturally relevant or humble, and how to create a welcoming and safe practice environment.

LGBTQI+ terms and definitions

The first step in providing quality care to LGBTQI+ patients is to understand the terminology associated with sexual orientation, gender identity, and gender expression.^3–5

Sexual orientation refers to whom a person is sexually attracted. The term straight/heterosexual suggests a person is sexually attracted to a person of the opposite gender. Lesbian or gay refers to those who are attracted to their same gender. Some people use bisexual (attracted to both the same and opposite gender) and pansexual (attracted to all humans regardless of gender). Still others refer to themselves as queer—people who identify as someone who is not heterosexual or cisgender. A variety of other terms exist to describe one’s sexual attraction. There are also some people who identify as asexual, which suggests they are not sexually attracted to anyone.

Gender identity relates to how one views their own gender. If you were assigned female at birth and identify as a woman, you are cisgender. If you were assigned male at birth and identify as a woman, you may identify as transgender whether or not you have had gender transitioning surgery or have taken hormones. Some people do not identify with the terms male or female and may view themselves as nonbinary. The terms gender queer, gender fluid, gender diverse, and gender non-conforming also may be used to describe various ways that an individual may not identify as male or female. We also can refer to people as “assigned female at birth” or “assigned male at birth”. People with intersex conditions may require taking a unique medical history that includes asking about genetic testing (eg, 46,XX congenital adrenal hyperplasia or 46,XY complete gonadal dysgenesis).

Gender expression refers to how one pre-sents themselves to others through appearance, dress, and behavior. A person may be assigned female at birth, dress in a conventional male fashion, and still identify as a woman. Still others may choose to express their gender in a variety of ways that may not have anything to do with their sexual orientation or gender identity, such as dressing in ways that represent their culture.

People may be fluid in their sexual orientation or gender identity; it may change from day to day, month to month, or even year to year.^6,7

*The term LGBTQI+ is not used consistently in the literature. Throughout this article, the terminology used matches that used in the cited reference(s).

Continue to: Health care and the LGBTQI+ community...

Health care and the LGBTQI+ community

The LGBTQI+ community has a history of experiencing societal discrimination and stigma, which stems from medical mistrust often due to a lack of understanding of their medical and psychosocial needs.^8,9 A 2019 survey of US LGBTQ adults, found that about 50% of people who identified as transgender reported having negative or discriminatory experiences with a health care clinician.¹⁰ About 18% of transgender people anticipated being refused medical care due to their gender identity.¹⁰ About 18% of LGBTQ individuals avoid any type of medical care, fearing discrimination.¹⁰ Lesbian women are 3 times more likely to have not seen an ObGyn than women who identify as straight.¹¹ Sixty-two percent of lesbian women have biological children and received prenatal care; however, of those, 47% do not receive routine cancer screenings.^10,11 Only 45% of age-eligible lesbian women have received at least 1 dose of the HPV vaccine, compared with 60% of straight women.^10,11

Due to societal stigma, more than 40% of transgender people have attempted suicide.¹² Felt or perceived stigma is also associated with risky health behaviors that contribute to health disparities. LGBTQI+ people are more likely to use substances,¹³ lesbian women are more likely to be obese,¹⁴ and 19% of transgender men are living with HIV/AIDS.¹⁵ Rates of unintended pregnancy among lesbian women and transgender men are 28%, compared with 6% in straight women, and 12% in heterosexual teens.^15,16

In addition to real or perceived discrimination, there are medical misperceptions among the LGBTQI+ community. For instance, sexual minority women (SMW) are less likely to receive regular screening for cervical cancer. In one survey of more than 400 SMW, about 25% reported not receiving regular screening. SMW may mistakenly believe they do not need Pap testing and pelvic exams because they do not have penile-vaginal intercourse.^17,18 Transgender men may not identify with having a cervix, or may perceive ObGyns to be “gendered” toward people who identify as women.¹⁸

Embracing cultural humility

Cultural humility expands upon the term cultural competence, with the idea that one can never be fully competent in the culture of another person.^19,20 The National Institutes of Health defines cultural humility as “a lifelong process of self-reflection and self-critique whereby the individual not only learns about another’s culture, but one starts with an examination of his/her own beliefs and cultural identities.”²¹

Having cultural humility is the recognition that, in order to treat your ObGyn patient as a whole person and engage in shared medical decision making in the office setting, you need to know their sexual orientation and gender identity. Treating each patient the same is not providing equitable care (equality does not equal equity) because each patient has different medical and psychosocial needs. Embracing cultural humility is the first step in creating safe and welcoming spaces in the ObGyn office.²⁰

CASE Ways to better introduce yourself

To revisit the case, what options does the clinician have to start off on a best foot to create a safe space for Alex?

• Open with your own preferred pronouns. For instance, for an introduction, consider: “I’m Dr. X, my pronouns are she/her.”
• Don’t assume. Do not make assumptions about the relationship between Alex and the person accompanying them.

4 ways for creating welcoming and affirming spaces in ObGyn

1. Make sure your intake form is inclusive. Include a space for pronouns and the patient’s preferred name (which may differ from their legal name). Also allow patients to choose more than 1 sexual orientation and gender identity.²⁰ (An example form is available from the LGBT National Health Education Center: https://www.lgbtqiahealtheducation.org/publication/focus-forms-policy-creating-inclusive-environment-lgbt-patients/.)
2. Create a safe environment in the waiting area. Try to ensure that at least 1 bathroom is labeled “All Gender” or “Family.” Gendered bathrooms (eg, Ladies’ or Men’s rooms) are not welcoming. Make sure your non-discrimination policy is displayed and includes sexual orientation and gender identity. Review the patient education and reading materials in your waiting room to ensure they are inclusive. Do they show people with varied gender expression? Do they show same-sex couples or interracial couples?
3. Use a trauma-informed approach when taking a sexual history and while conducting a physical exam. Determine if a pelvic exam is necessary at this visit or can it be postponed for another visit, when trust has been established with the patient. Explain each part of the pelvic/vaginal exam prior to conducting and again while performing the exam. Before taking a sexual history, explain why you are asking the questions and be sure to remain neutral with your questioning. For instance, you can say, “It’s important for me to understand your medical history in detail to provide you with the best health care possible.” Instead of asking, “Do you have sex with men, women, or both?” ask, “Do you have sex with people with a penis, vagina, or both? Do you have anal sex?” Recognize that some patients may be in a polyamorous relationship and may have more than 1 committed partner. For sexually active patients consider asking if they have ever exchanged sex for money or other goods, making sure to avoid judgmental body language or wording. Patients who do engage in “survival sex” may benefit from a discussion on pre-exposure prophylaxis to reduce HIV transmission.²²
4. Provide appropriate counsel based on their feedback.

• Explain their risk for HPV infection and vaccination options.
• Respectfully ask if there is a need for contraception and review options appropriate for their situation.
• Ask about the use of “toys” and provide guidance on sanitation and risk of infection with shared toys.
• Determine current or past hormone use for patients who identify as transgender and nonbinary (although many do not take hormones and have not had gender-affirming procedures, some may be considering these procedures). Be sure to ask these patients if they have had any surgeries or other procedures.

The receipt of gynecologic care can be traumatic for some LGBTQI+ people. Explain to the patient why you are doing everything during your examination and how it might feel. If a pelvic exam is not absolutely necessary that day, perhaps the patient can return another time. For transgender men who have been taking testosterone,vaginal atrophy may be a concern, and you could consider a pediatric speculum.

Personal introspection may be necessary

In summary, the number of people who identify as lesbian, gay, bisexual, transgender/nonbinary, queer/questioning, intersex, or asexual is not insignificant. Many of these patients or their partners may present for ObGyn care at your office. Clinicians need to understand that there is a new language relative to sexual orientation and gender identity. Incorporating cultural humility into one’s practice requires personal introspection and is a first step to creating safe and welcoming spaces in the ObGyn office. ●

Dear OBG Management Reader:

Frontline Medical Communications Inc has made the difficult decision to discontinue publication of OBG Management, effective with this issue. We thank OBG Management’s esteemed Editorial Board, loyal readers, and dedicated authors for their support. It has been our privilege to publish OBG Management for 35 years. 

The online archive of clinical content for OBG Management (2002–2023) remains accessible on MDedge ObGyn. Reprint requests can be directed to Wright’s Media via email frontline@wrightsmedia.com or telephone (877-652-5295). 

For the latest news and information on obstetrics and gynecology, continue to turn to MDedge ObGyn. 

Goodbye to OBG Management

Robert L. Barbieri, MD

OBG Management was founded in 1988 by Carroll Dowden, a giant in the field of medical publishing. During his career he served as the editor or publisher of Medical Economics, Physician’s Desk Reference, and Mayo Clinic Proceedings. In creating OBG Management, Mr. Dowden’s vision was to edit and publish a monthly magazine focused on issues that impact the practice of obstetrics and gynecology, including patient care and practice management. Dr. Jeffrey Phelan was the founding editor-in-chief of OBG Management, serving from 1988 through 2000, when I became the editor-in-chief. It is with the greatest sadness that we announce that publication of OBG Management will cease with the December 2023 issue, 35 years after its inception.

Over 4 decades, the work of the OBG Management editorial team and authors has been guided by our mission to “enhance the quality of women’s health care and the professional development of ObGyns and all women’s health care clinicians.” The teamwork of our editorial board is the primary reason for the success of OBG Management, ensuring that we consistently provided practical clinical guidance on the most important topics in our field with the goal of improving the health care of our patients. We are proud that OBG Management has been recognized as #1 in readership among obstetrics and gynecology publications.

Our editorial board members are nationally recognized experts in our field and innovators in clinical care. Our editorial members include: Arnold P. Advincula, MD; Linda D. Bradley, MD; Amy L. Garcia, MD; Steven R. Goldstein, MD, MSCP, CCD; Andrew M. Kaunitz, MD, MSCP; Barbara Levy, MD; David G. Mutch, MD; Errol R. Norwitz, MD, PhD, MBA; Jaimey Pauli, MD; JoAnn V. Pinkerton, MD, MSCP; Joseph S. Sanfilippo, MD; and James A. Simon, MD, CCD, IF, MSCP. Prior to his retirement, Dr. John Repke was an important member of our editorial board. Over the past decade our editorial team—Lila O’Connor, Editorial Manager, and Kathy Christie, Senior Medical Content Editor—have ensured that the articles written by our authors are expertly prepared for publication and presentation to our readers.

In clinical practice, we sometimes do not achieve the optimal patient outcomes we desire. Over the past 4 decades, the OBG Management team has strived to identify opportunities to improve patient outcomes and offer practical approaches to optimize practice. We will miss the opportunity to work with you, our community of clinical experts in women’s health care. ●

Dear OBG Management Reader:

Frontline Medical Communications Inc has made the difficult decision to discontinue publication of OBG Management, effective with this issue. We thank OBG Management’s esteemed Editorial Board, loyal readers, and dedicated authors for their support. It has been our privilege to publish OBG Management for 35 years. 

The online archive of clinical content for OBG Management (2002–2023) remains accessible on MDedge ObGyn. Reprint requests can be directed to Wright’s Media via email frontline@wrightsmedia.com or telephone (877-652-5295). 

For the latest news and information on obstetrics and gynecology, continue to turn to MDedge ObGyn. 

Goodbye to OBG Management

Robert L. Barbieri, MD

OBG Management was founded in 1988 by Carroll Dowden, a giant in the field of medical publishing. During his career he served as the editor or publisher of Medical Economics, Physician’s Desk Reference, and Mayo Clinic Proceedings. In creating OBG Management, Mr. Dowden’s vision was to edit and publish a monthly magazine focused on issues that impact the practice of obstetrics and gynecology, including patient care and practice management. Dr. Jeffrey Phelan was the founding editor-in-chief of OBG Management, serving from 1988 through 2000, when I became the editor-in-chief. It is with the greatest sadness that we announce that publication of OBG Management will cease with the December 2023 issue, 35 years after its inception.

Over 4 decades, the work of the OBG Management editorial team and authors has been guided by our mission to “enhance the quality of women’s health care and the professional development of ObGyns and all women’s health care clinicians.” The teamwork of our editorial board is the primary reason for the success of OBG Management, ensuring that we consistently provided practical clinical guidance on the most important topics in our field with the goal of improving the health care of our patients. We are proud that OBG Management has been recognized as #1 in readership among obstetrics and gynecology publications.

Our editorial board members are nationally recognized experts in our field and innovators in clinical care. Our editorial members include: Arnold P. Advincula, MD; Linda D. Bradley, MD; Amy L. Garcia, MD; Steven R. Goldstein, MD, MSCP, CCD; Andrew M. Kaunitz, MD, MSCP; Barbara Levy, MD; David G. Mutch, MD; Errol R. Norwitz, MD, PhD, MBA; Jaimey Pauli, MD; JoAnn V. Pinkerton, MD, MSCP; Joseph S. Sanfilippo, MD; and James A. Simon, MD, CCD, IF, MSCP. Prior to his retirement, Dr. John Repke was an important member of our editorial board. Over the past decade our editorial team—Lila O’Connor, Editorial Manager, and Kathy Christie, Senior Medical Content Editor—have ensured that the articles written by our authors are expertly prepared for publication and presentation to our readers.

In clinical practice, we sometimes do not achieve the optimal patient outcomes we desire. Over the past 4 decades, the OBG Management team has strived to identify opportunities to improve patient outcomes and offer practical approaches to optimize practice. We will miss the opportunity to work with you, our community of clinical experts in women’s health care. ●

Dear OBG Management Reader:

Frontline Medical Communications Inc has made the difficult decision to discontinue publication of OBG Management, effective with this issue. We thank OBG Management’s esteemed Editorial Board, loyal readers, and dedicated authors for their support. It has been our privilege to publish OBG Management for 35 years. 

The online archive of clinical content for OBG Management (2002–2023) remains accessible on MDedge ObGyn. Reprint requests can be directed to Wright’s Media via email frontline@wrightsmedia.com or telephone (877-652-5295). 

For the latest news and information on obstetrics and gynecology, continue to turn to MDedge ObGyn. 

Goodbye to OBG Management

Robert L. Barbieri, MD

OBG Management was founded in 1988 by Carroll Dowden, a giant in the field of medical publishing. During his career he served as the editor or publisher of Medical Economics, Physician’s Desk Reference, and Mayo Clinic Proceedings. In creating OBG Management, Mr. Dowden’s vision was to edit and publish a monthly magazine focused on issues that impact the practice of obstetrics and gynecology, including patient care and practice management. Dr. Jeffrey Phelan was the founding editor-in-chief of OBG Management, serving from 1988 through 2000, when I became the editor-in-chief. It is with the greatest sadness that we announce that publication of OBG Management will cease with the December 2023 issue, 35 years after its inception.

Over 4 decades, the work of the OBG Management editorial team and authors has been guided by our mission to “enhance the quality of women’s health care and the professional development of ObGyns and all women’s health care clinicians.” The teamwork of our editorial board is the primary reason for the success of OBG Management, ensuring that we consistently provided practical clinical guidance on the most important topics in our field with the goal of improving the health care of our patients. We are proud that OBG Management has been recognized as #1 in readership among obstetrics and gynecology publications.

Our editorial board members are nationally recognized experts in our field and innovators in clinical care. Our editorial members include: Arnold P. Advincula, MD; Linda D. Bradley, MD; Amy L. Garcia, MD; Steven R. Goldstein, MD, MSCP, CCD; Andrew M. Kaunitz, MD, MSCP; Barbara Levy, MD; David G. Mutch, MD; Errol R. Norwitz, MD, PhD, MBA; Jaimey Pauli, MD; JoAnn V. Pinkerton, MD, MSCP; Joseph S. Sanfilippo, MD; and James A. Simon, MD, CCD, IF, MSCP. Prior to his retirement, Dr. John Repke was an important member of our editorial board. Over the past decade our editorial team—Lila O’Connor, Editorial Manager, and Kathy Christie, Senior Medical Content Editor—have ensured that the articles written by our authors are expertly prepared for publication and presentation to our readers.

In clinical practice, we sometimes do not achieve the optimal patient outcomes we desire. Over the past 4 decades, the OBG Management team has strived to identify opportunities to improve patient outcomes and offer practical approaches to optimize practice. We will miss the opportunity to work with you, our community of clinical experts in women’s health care. ●

San Antonio – Taxane exposure during pregnancy appears to be safe for mothers and offspring, according to a new retrospective cohort analysis. The findings shed light on a relatively unstudied topic. “Our cohort with 103 patients represents the most extensive study to date, and our main goal was to have homogeneous reporting of adverse events,” Ana Ferrigno Guajardo, MD, said in an interview. She presented the results at the San Antonio Breast Cancer Symposium.

“Breast cancer during pregnancy is a very challenging clinical situation as the expected antineoplastic effects of treatment must be carefully balanced against potential detrimental consequences on the developing fetus,” said Dr. Guajardo. She is a resident physician at Yale University School of Medicine.

Anthracycline-based chemotherapy agents are generally used during pregnancy because there is more safety data available for them, but some studies have shown that taxanes may have better efficacy in some clinical situations. “Cohort studies that have been done in the past [show] that taxane use is mostly deferred to the postpartum period, and we are not really sure of the impact that can have on survival in patients postponing treatment,” said Dr. Guajardo.

There are potential safety concerns with taxanes because neonates lack the cytochrome enzymes to metabolize the drugs, which creates a theoretical risk of adverse effects due to prolonged activity. On the other hand, pregnant women metabolize taxanes faster, and there are placental barriers that can inhibit high molecular weight molecules like taxanes from reaching the fetus, according to Dr. Guajardo.

In addition to pregnancy outcomes, the researchers followed 28 infants, and found that 87% were found to be completely healthy, “so we were relatively reassured. But of course we think that there’s a need for prospective studies that validate our findings regarding the safety taxanes,” said Dr. Guajardo.

Although there is no direct comparison group, the findings correlate well with studies of the general population and other chemotherapy agents. “We have large cohorts with mostly anthracycline-based chemotherapy agents during pregnancy that we can compare our results to, and overall, we were reassured that the prevalence of complications that we found in our cohort was very similar or even lower to those reported in the literature with patients treated with anthracycline-based therapy,” said Dr. Guajardo.

Compared with the general population, the team found higher rates of preterm births, neonatal ICU admissions, and premature membrane rupture, and infants that are small for gestational age. However, with the exception of the latter, all of these risks have been seen in pregnant women treated with other types of chemotherapy. “Perhaps it would be interesting to see if the incidence of small for gestational age neonates might be a bit higher in this population when compared to anthracycline-based therapy agents, but that does require a study that has a comparator group,” said Dr. Guajardo.

The researchers recruited 103 women with an average age of 34 years from 10 centers in 6 countries: United States, France, Spain, Mexico, Italy, and Costa Rica. The great majority were also treated with anthracyclines during gestation, and nearly all (97%) were treated with paclitaxel. The live birth rate was 98%, and 43.4% were preterm, 24% were small for gestational age, 16% were admitted to the neonate ICU, and 12.5% had hyperbilirubinemia.

Obstetric complications included intrauterine growth restriction (9%), preterm premature rupture of membranes (5%), gestational diabetes mellitus (5%), hypertensive disorders (4%), and pregnancy loss (2%).

After the presentation, Virginia Borges, MD, professor of medical oncology at University of Colorado Anschutz Medical Center, served as a discussant.

“Highlights of this study [include] that it is an international cohort from over six countries with over 100 cases of women included specifically focusing on the use of paclitaxel. They demonstrated safe outcomes for the pregnancies and the mothers,” Dr. Borges said during her presentation.

She went on to highlight several key points that physicians should consider when treating pregnancy-related breast cancer. “We want to achieve prepartum treatment wherever feasible to tackle that cancer before delivery of the child to prevent a pregnancy-related breast cancer from potentially turning into a postpartum breast cancer,” she said.

“If the tumor is ER+/HER2-, we now see we can safely give anthracyclines and taxanes from 12 to about 35 weeks of gestation. We don’t want to get too close to the delivery with chemotherapy. If a patient is HER2+, I prefer to give the anthracycline portion while the person is pregnant and then after delivery incorporate the taxane with the HER2 targeted therapies as there’s some older data showing concurrent therapy looks a bit better than sequential. In triple negative breast cancer, again I prefer to give the anthracycline and delay the taxane and carboplatin to overlap with immunotherapy so we are getting the necessary synergy there as well,” Dr. Borges added.

Dr. Guajardo has no relevant financial disclosures. Dr. Borges has consulted for SeaGen, Gilead, and AstraZeneca, and has received research funding from AstraZeneca, Gilead, Olema, and SeaGen.

San Antonio – Taxane exposure during pregnancy appears to be safe for mothers and offspring, according to a new retrospective cohort analysis. The findings shed light on a relatively unstudied topic. “Our cohort with 103 patients represents the most extensive study to date, and our main goal was to have homogeneous reporting of adverse events,” Ana Ferrigno Guajardo, MD, said in an interview. She presented the results at the San Antonio Breast Cancer Symposium.

“Breast cancer during pregnancy is a very challenging clinical situation as the expected antineoplastic effects of treatment must be carefully balanced against potential detrimental consequences on the developing fetus,” said Dr. Guajardo. She is a resident physician at Yale University School of Medicine.

Anthracycline-based chemotherapy agents are generally used during pregnancy because there is more safety data available for them, but some studies have shown that taxanes may have better efficacy in some clinical situations. “Cohort studies that have been done in the past [show] that taxane use is mostly deferred to the postpartum period, and we are not really sure of the impact that can have on survival in patients postponing treatment,” said Dr. Guajardo.

There are potential safety concerns with taxanes because neonates lack the cytochrome enzymes to metabolize the drugs, which creates a theoretical risk of adverse effects due to prolonged activity. On the other hand, pregnant women metabolize taxanes faster, and there are placental barriers that can inhibit high molecular weight molecules like taxanes from reaching the fetus, according to Dr. Guajardo.

In addition to pregnancy outcomes, the researchers followed 28 infants, and found that 87% were found to be completely healthy, “so we were relatively reassured. But of course we think that there’s a need for prospective studies that validate our findings regarding the safety taxanes,” said Dr. Guajardo.

Although there is no direct comparison group, the findings correlate well with studies of the general population and other chemotherapy agents. “We have large cohorts with mostly anthracycline-based chemotherapy agents during pregnancy that we can compare our results to, and overall, we were reassured that the prevalence of complications that we found in our cohort was very similar or even lower to those reported in the literature with patients treated with anthracycline-based therapy,” said Dr. Guajardo.

Compared with the general population, the team found higher rates of preterm births, neonatal ICU admissions, and premature membrane rupture, and infants that are small for gestational age. However, with the exception of the latter, all of these risks have been seen in pregnant women treated with other types of chemotherapy. “Perhaps it would be interesting to see if the incidence of small for gestational age neonates might be a bit higher in this population when compared to anthracycline-based therapy agents, but that does require a study that has a comparator group,” said Dr. Guajardo.

The researchers recruited 103 women with an average age of 34 years from 10 centers in 6 countries: United States, France, Spain, Mexico, Italy, and Costa Rica. The great majority were also treated with anthracyclines during gestation, and nearly all (97%) were treated with paclitaxel. The live birth rate was 98%, and 43.4% were preterm, 24% were small for gestational age, 16% were admitted to the neonate ICU, and 12.5% had hyperbilirubinemia.

Obstetric complications included intrauterine growth restriction (9%), preterm premature rupture of membranes (5%), gestational diabetes mellitus (5%), hypertensive disorders (4%), and pregnancy loss (2%).

After the presentation, Virginia Borges, MD, professor of medical oncology at University of Colorado Anschutz Medical Center, served as a discussant.

“Highlights of this study [include] that it is an international cohort from over six countries with over 100 cases of women included specifically focusing on the use of paclitaxel. They demonstrated safe outcomes for the pregnancies and the mothers,” Dr. Borges said during her presentation.

She went on to highlight several key points that physicians should consider when treating pregnancy-related breast cancer. “We want to achieve prepartum treatment wherever feasible to tackle that cancer before delivery of the child to prevent a pregnancy-related breast cancer from potentially turning into a postpartum breast cancer,” she said.

“If the tumor is ER+/HER2-, we now see we can safely give anthracyclines and taxanes from 12 to about 35 weeks of gestation. We don’t want to get too close to the delivery with chemotherapy. If a patient is HER2+, I prefer to give the anthracycline portion while the person is pregnant and then after delivery incorporate the taxane with the HER2 targeted therapies as there’s some older data showing concurrent therapy looks a bit better than sequential. In triple negative breast cancer, again I prefer to give the anthracycline and delay the taxane and carboplatin to overlap with immunotherapy so we are getting the necessary synergy there as well,” Dr. Borges added.

Dr. Guajardo has no relevant financial disclosures. Dr. Borges has consulted for SeaGen, Gilead, and AstraZeneca, and has received research funding from AstraZeneca, Gilead, Olema, and SeaGen.

San Antonio – Taxane exposure during pregnancy appears to be safe for mothers and offspring, according to a new retrospective cohort analysis. The findings shed light on a relatively unstudied topic. “Our cohort with 103 patients represents the most extensive study to date, and our main goal was to have homogeneous reporting of adverse events,” Ana Ferrigno Guajardo, MD, said in an interview. She presented the results at the San Antonio Breast Cancer Symposium.

“Breast cancer during pregnancy is a very challenging clinical situation as the expected antineoplastic effects of treatment must be carefully balanced against potential detrimental consequences on the developing fetus,” said Dr. Guajardo. She is a resident physician at Yale University School of Medicine.

Anthracycline-based chemotherapy agents are generally used during pregnancy because there is more safety data available for them, but some studies have shown that taxanes may have better efficacy in some clinical situations. “Cohort studies that have been done in the past [show] that taxane use is mostly deferred to the postpartum period, and we are not really sure of the impact that can have on survival in patients postponing treatment,” said Dr. Guajardo.

There are potential safety concerns with taxanes because neonates lack the cytochrome enzymes to metabolize the drugs, which creates a theoretical risk of adverse effects due to prolonged activity. On the other hand, pregnant women metabolize taxanes faster, and there are placental barriers that can inhibit high molecular weight molecules like taxanes from reaching the fetus, according to Dr. Guajardo.

In addition to pregnancy outcomes, the researchers followed 28 infants, and found that 87% were found to be completely healthy, “so we were relatively reassured. But of course we think that there’s a need for prospective studies that validate our findings regarding the safety taxanes,” said Dr. Guajardo.

Although there is no direct comparison group, the findings correlate well with studies of the general population and other chemotherapy agents. “We have large cohorts with mostly anthracycline-based chemotherapy agents during pregnancy that we can compare our results to, and overall, we were reassured that the prevalence of complications that we found in our cohort was very similar or even lower to those reported in the literature with patients treated with anthracycline-based therapy,” said Dr. Guajardo.

Compared with the general population, the team found higher rates of preterm births, neonatal ICU admissions, and premature membrane rupture, and infants that are small for gestational age. However, with the exception of the latter, all of these risks have been seen in pregnant women treated with other types of chemotherapy. “Perhaps it would be interesting to see if the incidence of small for gestational age neonates might be a bit higher in this population when compared to anthracycline-based therapy agents, but that does require a study that has a comparator group,” said Dr. Guajardo.

The researchers recruited 103 women with an average age of 34 years from 10 centers in 6 countries: United States, France, Spain, Mexico, Italy, and Costa Rica. The great majority were also treated with anthracyclines during gestation, and nearly all (97%) were treated with paclitaxel. The live birth rate was 98%, and 43.4% were preterm, 24% were small for gestational age, 16% were admitted to the neonate ICU, and 12.5% had hyperbilirubinemia.

Obstetric complications included intrauterine growth restriction (9%), preterm premature rupture of membranes (5%), gestational diabetes mellitus (5%), hypertensive disorders (4%), and pregnancy loss (2%).

After the presentation, Virginia Borges, MD, professor of medical oncology at University of Colorado Anschutz Medical Center, served as a discussant.

“Highlights of this study [include] that it is an international cohort from over six countries with over 100 cases of women included specifically focusing on the use of paclitaxel. They demonstrated safe outcomes for the pregnancies and the mothers,” Dr. Borges said during her presentation.

She went on to highlight several key points that physicians should consider when treating pregnancy-related breast cancer. “We want to achieve prepartum treatment wherever feasible to tackle that cancer before delivery of the child to prevent a pregnancy-related breast cancer from potentially turning into a postpartum breast cancer,” she said.

“If the tumor is ER+/HER2-, we now see we can safely give anthracyclines and taxanes from 12 to about 35 weeks of gestation. We don’t want to get too close to the delivery with chemotherapy. If a patient is HER2+, I prefer to give the anthracycline portion while the person is pregnant and then after delivery incorporate the taxane with the HER2 targeted therapies as there’s some older data showing concurrent therapy looks a bit better than sequential. In triple negative breast cancer, again I prefer to give the anthracycline and delay the taxane and carboplatin to overlap with immunotherapy so we are getting the necessary synergy there as well,” Dr. Borges added.

Dr. Guajardo has no relevant financial disclosures. Dr. Borges has consulted for SeaGen, Gilead, and AstraZeneca, and has received research funding from AstraZeneca, Gilead, Olema, and SeaGen.

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.