Practice Management

Insurance companies pay National Cancer Institute–designated cancer centers more for common cancer surgeries, but there’s no improvement in length of stay, subsequent ED use, or 90-day hospital readmission, compared with community hospitals, according to a recent report in JAMA Network Open.

“While acceptable to pay higher prices for care that is expected to be of higher quality, we found no differences in short-term postsurgical outcomes,” said authors led by Samuel Takvorian, MD, a medical oncologist at the University of Pennsylvania, Philadelphia.

The team looked at what insurance companies paid for incident breast, colon, and lung cancer surgeries, which together account for most cancer surgeries, among 66,878 patients treated from 2011 to 2014 at almost 3,000 U.S. hospitals.

Three-quarters had surgery at a community hospital, and 8.3% were treated at one of the nation’s 71 NCI centers, which are recognized by the NCI as meeting rigorous standards in cancer care. The remaining patients were treated at non-NCI academic hospitals.

The mean surgery-specific insurer prices paid at NCI centers was $18,526 versus $14,772 at community hospitals, a difference of $3,755 (P < .001) that was driven primarily by higher facility payments at NCI centers, a mean of $17,704 versus $14,120 at community hospitals.

Mean 90-day postdischarge payments were also $5,744 higher at NCI centers, $47,035 versus $41,291 at community hospitals (P = .006).

The team used postsurgical acute care utilization as a marker of quality but found no differences between the two settings. Mean length of stay was 5.1 days and the probability of ED utilization just over 13% in both, and both had a 90-day readmission rate of just over 10%.
 

Who should be treated at an NCI center?

The data didn’t allow for direct comparison of surgical quality, such as margin status, number of lymph nodes assessed, or postoperative complications, but the postsurgery utilization outcomes “suggest that quality may have been similar,” said Nancy Keating, MD, a health care policy and medicine professor at Harvard Medical School, Boston, in an invited commentary.

The price differences are probably because NCI centers, with their comprehensive offerings, market share, and prestige, can negotiate higher reimbursement rates from insurers, the researchers said.

There is also evidence of better outcomes at NCI centers, particularly for more advanced and complex cases. However, “this study focused on common cancer surgical procedures ... revealing that there is a premium associated with receipt of surgical cancer care at NCI centers.” Further research “is necessary to judge whether and under what circumstances the premium price of NCI centers is justified,” the investigators said.

Dr. Keating noted that “it is likely that some patients benefit from the highly specialized care available at NCI-designated cancer centers ... but it is also likely that many other patients will do equally well regardless of where they receive their care.”

Amid ever-increasing cancer care costs and the need to strategically allocate financial resources, more research is needed to “identify subgroups of patients for whom highly specialized care is particularly necessary to achieve better outcomes. Such data could also be used by payers considering tiered networks and by physician organizations participating in risk contracts for decisions about where to refer patients with cancer for treatment,” she said.
 

Rectifying a ‘misalignment’

The researchers also said the findings reveal competing incentives, with commercial payers wanting to steer patients away from high-cost hospitals but health systems hoping to maximize surgical volume at lucrative referral centers.

“Value-based or bundled payment reimbursement for surgical episodes, particularly when paired with mandatory reporting on surgical outcomes, could help to rectify this misalignment,” they said.

Out-of-pocket spending wasn’t analyzed in the study, so it’s unknown how the higher prices at NCI centers hit patients in the pocketbook.

Meanwhile, non-NCI academic hospitals also had higher insurer prices paid than community hospitals, but the differences were not statistically significant, nor were differences in the study’s utilization outcomes.

Over half the patients had breast cancer, about one-third had colon cancer, and the rest had lung tumors. Patients treated at NCI centers tended to be younger than those treated at community hospitals and more likely to be women, but comorbidity scores were similar between the groups.

NCI centers, compared with community hospitals, were larger with higher surgical volumes and in more populated areas. They also had higher rates of laparoscopic partial colectomies and pneumonectomies.

Data came from the Health Care Cost Institute’s national commercial claims data set, which includes claims from three of the country’s five largest commercial insurers: Aetna, Humana, and UnitedHealthcare.

The work was funded by the Commonwealth of Pennsylvania and the National Cancer Institute. Dr. Takvorian and Dr. Keating didn’t have any disclosures. One of Dr. Takvorian’s coauthors reported grants and/or personal fees from several sources, including Pfizer, UnitedHealthcare, and Blue Cross Blue Shield of North Carolina.

[email protected]

Insurance companies pay National Cancer Institute–designated cancer centers more for common cancer surgeries, but there’s no improvement in length of stay, subsequent ED use, or 90-day hospital readmission, compared with community hospitals, according to a recent report in JAMA Network Open.

“While acceptable to pay higher prices for care that is expected to be of higher quality, we found no differences in short-term postsurgical outcomes,” said authors led by Samuel Takvorian, MD, a medical oncologist at the University of Pennsylvania, Philadelphia.

The team looked at what insurance companies paid for incident breast, colon, and lung cancer surgeries, which together account for most cancer surgeries, among 66,878 patients treated from 2011 to 2014 at almost 3,000 U.S. hospitals.

Three-quarters had surgery at a community hospital, and 8.3% were treated at one of the nation’s 71 NCI centers, which are recognized by the NCI as meeting rigorous standards in cancer care. The remaining patients were treated at non-NCI academic hospitals.

The mean surgery-specific insurer prices paid at NCI centers was $18,526 versus $14,772 at community hospitals, a difference of $3,755 (P < .001) that was driven primarily by higher facility payments at NCI centers, a mean of $17,704 versus $14,120 at community hospitals.

Mean 90-day postdischarge payments were also $5,744 higher at NCI centers, $47,035 versus $41,291 at community hospitals (P = .006).

The team used postsurgical acute care utilization as a marker of quality but found no differences between the two settings. Mean length of stay was 5.1 days and the probability of ED utilization just over 13% in both, and both had a 90-day readmission rate of just over 10%.
 

Who should be treated at an NCI center?

The data didn’t allow for direct comparison of surgical quality, such as margin status, number of lymph nodes assessed, or postoperative complications, but the postsurgery utilization outcomes “suggest that quality may have been similar,” said Nancy Keating, MD, a health care policy and medicine professor at Harvard Medical School, Boston, in an invited commentary.

The price differences are probably because NCI centers, with their comprehensive offerings, market share, and prestige, can negotiate higher reimbursement rates from insurers, the researchers said.

There is also evidence of better outcomes at NCI centers, particularly for more advanced and complex cases. However, “this study focused on common cancer surgical procedures ... revealing that there is a premium associated with receipt of surgical cancer care at NCI centers.” Further research “is necessary to judge whether and under what circumstances the premium price of NCI centers is justified,” the investigators said.

Dr. Keating noted that “it is likely that some patients benefit from the highly specialized care available at NCI-designated cancer centers ... but it is also likely that many other patients will do equally well regardless of where they receive their care.”

Amid ever-increasing cancer care costs and the need to strategically allocate financial resources, more research is needed to “identify subgroups of patients for whom highly specialized care is particularly necessary to achieve better outcomes. Such data could also be used by payers considering tiered networks and by physician organizations participating in risk contracts for decisions about where to refer patients with cancer for treatment,” she said.
 

Rectifying a ‘misalignment’

The researchers also said the findings reveal competing incentives, with commercial payers wanting to steer patients away from high-cost hospitals but health systems hoping to maximize surgical volume at lucrative referral centers.

“Value-based or bundled payment reimbursement for surgical episodes, particularly when paired with mandatory reporting on surgical outcomes, could help to rectify this misalignment,” they said.

Out-of-pocket spending wasn’t analyzed in the study, so it’s unknown how the higher prices at NCI centers hit patients in the pocketbook.

Meanwhile, non-NCI academic hospitals also had higher insurer prices paid than community hospitals, but the differences were not statistically significant, nor were differences in the study’s utilization outcomes.

Over half the patients had breast cancer, about one-third had colon cancer, and the rest had lung tumors. Patients treated at NCI centers tended to be younger than those treated at community hospitals and more likely to be women, but comorbidity scores were similar between the groups.

NCI centers, compared with community hospitals, were larger with higher surgical volumes and in more populated areas. They also had higher rates of laparoscopic partial colectomies and pneumonectomies.

Data came from the Health Care Cost Institute’s national commercial claims data set, which includes claims from three of the country’s five largest commercial insurers: Aetna, Humana, and UnitedHealthcare.

The work was funded by the Commonwealth of Pennsylvania and the National Cancer Institute. Dr. Takvorian and Dr. Keating didn’t have any disclosures. One of Dr. Takvorian’s coauthors reported grants and/or personal fees from several sources, including Pfizer, UnitedHealthcare, and Blue Cross Blue Shield of North Carolina.

[email protected]

Insurance companies pay National Cancer Institute–designated cancer centers more for common cancer surgeries, but there’s no improvement in length of stay, subsequent ED use, or 90-day hospital readmission, compared with community hospitals, according to a recent report in JAMA Network Open.

“While acceptable to pay higher prices for care that is expected to be of higher quality, we found no differences in short-term postsurgical outcomes,” said authors led by Samuel Takvorian, MD, a medical oncologist at the University of Pennsylvania, Philadelphia.

The team looked at what insurance companies paid for incident breast, colon, and lung cancer surgeries, which together account for most cancer surgeries, among 66,878 patients treated from 2011 to 2014 at almost 3,000 U.S. hospitals.

Three-quarters had surgery at a community hospital, and 8.3% were treated at one of the nation’s 71 NCI centers, which are recognized by the NCI as meeting rigorous standards in cancer care. The remaining patients were treated at non-NCI academic hospitals.

The mean surgery-specific insurer prices paid at NCI centers was $18,526 versus $14,772 at community hospitals, a difference of $3,755 (P < .001) that was driven primarily by higher facility payments at NCI centers, a mean of $17,704 versus $14,120 at community hospitals.

Mean 90-day postdischarge payments were also $5,744 higher at NCI centers, $47,035 versus $41,291 at community hospitals (P = .006).

The team used postsurgical acute care utilization as a marker of quality but found no differences between the two settings. Mean length of stay was 5.1 days and the probability of ED utilization just over 13% in both, and both had a 90-day readmission rate of just over 10%.
 

Who should be treated at an NCI center?

The data didn’t allow for direct comparison of surgical quality, such as margin status, number of lymph nodes assessed, or postoperative complications, but the postsurgery utilization outcomes “suggest that quality may have been similar,” said Nancy Keating, MD, a health care policy and medicine professor at Harvard Medical School, Boston, in an invited commentary.

The price differences are probably because NCI centers, with their comprehensive offerings, market share, and prestige, can negotiate higher reimbursement rates from insurers, the researchers said.

There is also evidence of better outcomes at NCI centers, particularly for more advanced and complex cases. However, “this study focused on common cancer surgical procedures ... revealing that there is a premium associated with receipt of surgical cancer care at NCI centers.” Further research “is necessary to judge whether and under what circumstances the premium price of NCI centers is justified,” the investigators said.

Dr. Keating noted that “it is likely that some patients benefit from the highly specialized care available at NCI-designated cancer centers ... but it is also likely that many other patients will do equally well regardless of where they receive their care.”

Amid ever-increasing cancer care costs and the need to strategically allocate financial resources, more research is needed to “identify subgroups of patients for whom highly specialized care is particularly necessary to achieve better outcomes. Such data could also be used by payers considering tiered networks and by physician organizations participating in risk contracts for decisions about where to refer patients with cancer for treatment,” she said.
 

Rectifying a ‘misalignment’

The researchers also said the findings reveal competing incentives, with commercial payers wanting to steer patients away from high-cost hospitals but health systems hoping to maximize surgical volume at lucrative referral centers.

“Value-based or bundled payment reimbursement for surgical episodes, particularly when paired with mandatory reporting on surgical outcomes, could help to rectify this misalignment,” they said.

Out-of-pocket spending wasn’t analyzed in the study, so it’s unknown how the higher prices at NCI centers hit patients in the pocketbook.

Meanwhile, non-NCI academic hospitals also had higher insurer prices paid than community hospitals, but the differences were not statistically significant, nor were differences in the study’s utilization outcomes.

Over half the patients had breast cancer, about one-third had colon cancer, and the rest had lung tumors. Patients treated at NCI centers tended to be younger than those treated at community hospitals and more likely to be women, but comorbidity scores were similar between the groups.

NCI centers, compared with community hospitals, were larger with higher surgical volumes and in more populated areas. They also had higher rates of laparoscopic partial colectomies and pneumonectomies.

Data came from the Health Care Cost Institute’s national commercial claims data set, which includes claims from three of the country’s five largest commercial insurers: Aetna, Humana, and UnitedHealthcare.

The work was funded by the Commonwealth of Pennsylvania and the National Cancer Institute. Dr. Takvorian and Dr. Keating didn’t have any disclosures. One of Dr. Takvorian’s coauthors reported grants and/or personal fees from several sources, including Pfizer, UnitedHealthcare, and Blue Cross Blue Shield of North Carolina.

[email protected]

The adage “so much to do, so little time” aptly describes the daily challenges facing dermatologists and dermatology residents. The time and attention required by direct patient care, writing notes, navigating electronic health records, and engaging in education and research as well as family commitments can drain even the most tireless clinician. In addition, dermatologists are expected to play a critical role in clinic and practice management to successfully curate an online presence and adapt their skills to successfully manage a teledermatology practice. Coupled with the time spent socializing with friends or colleagues and time for personal hobbies or exercise, it’s easy to see how sleep deprivation is common in many of our colleagues.

What’s being left out of these jam-packed schedules? Increasingly, it is the time and expertise dedicated to volunteering in our local communities. Two recent research letters highlighted how a dramatic increase in the number of research projects and publications is not mirrored by a similar increase in volunteer experiences as dermatology residency selection becomes more competitive.^1,2

Although the rate of volunteerism among practicing dermatologists has yet to be studied, a brief review suggests a component of unmet dermatology need within our communities. It’s estimated that approximately 5% to 10% of all emergency department visits are for dermatologic concerns.^3-5 In many cases, the reason for the visit is nonurgent and instead reflects a lack of other options for care. However, the need for dermatologists extends beyond the emergency department setting. A review of the prevalence of patients presenting for care to a group of regional free clinics found that 8% (N=5553) of all visitors sought care for dermatologic concerns.⁶ The benefit is not just for those seated on the examination table; research has shown that while many of the underlying factors resulting in physician burnout stem from systemic issues, participating in volunteer opportunities helps combat burnout in ourselves and our colleagues.^7-9 Herein, opportunities that exist for dermatologists to reconnect with their communities, advocate for causes distinctive to the specialty, and care for neighbors most in need are highlighted.

Camp Wonder

Every year, children from across the United States living with chronic and debilitating skin conditions get the opportunity to join fellow campers and spend a week just being kids without the constant focus on being a patient. Camp Wonder’s founder and director, Francesca Tenconi, describes the camp as a place where kids “can form a community and can feel free to be themselves, without judgment, without stares. They get the chance to forget about their skin disease and be themselves” (oral communication, June 18, 2021). Tenconi and the camp’s cofounders and medical directors, Drs. Jenny Kim and Stefani Takahashi, envisioned the camp as a place for all campers regardless of their skin condition to feel safe and welcome. This overall mission guides camp leadership and staff every year over the course of the camp week where campers participate in a mix of traditional and nontraditional summer activities that are safe and accessible for all, from spending time in the pool to arts and crafts and a ropes course.

Camp Wonder is in its 21st year of hosting children and adolescents from across North America at its camp in Livermore, California. This year, Tenconi expects about 100 campers during the last week in July. Camp Wonder relies on medical staff volunteers to make the camp setting safe, inclusive, and fun. “Our dermatology residents and dermatology volunteers are a huge part of why we’re able to have camp,” said Tenconi. “A lot of our kids require very specific medical care throughout the week. We are able to provide this camp experience for them because we have this medical support system available, this specialized dermatology knowledge.” She also noted the benefit to the volunteers themselves, saying,“The feedback we get a lot from residents and dermatologists is that camp gave them a chance to understand the true-life impact of some of the skin diseases these kids and families are living with. Kids will open up to them and tell them how their disease has impacted them personally” (oral communication, June 18, 2021).

Volunteer medical providers help manage the medical needs of the campers beginning at check-in and work shifts in the infirmary as well as help with dispensing and administering medications, changing dressings, and applying ointments or other topical medications. When not assisting with medical care, medical staff can get to know the campers; help out with arts and crafts, games, sports, and other camp activities; and put on skits and plays for campers at nightly camp hangouts (Figure 1).

Native American Health Services Rotation

Located in the southwestern United States, the Navajo Nation is North America’s largest Native American tribe by enrollment and resides on the largest reservation in the United States.¹⁰ Comprised of 27,000 square miles within portions of Arizona, New Mexico, and Utah, the reservation’s total area is greater than that of Massachusetts, Vermont, and New Hampshire combined.¹¹ The reservation is home to an estimated 180,000 Navajo people, a population roughly the size of Salt Lake City, Utah. Yet, many homes on the reservation are without electricity, running water, telephones, or broadband access, and many roads on the reservation remain unpaved. Prior to the COVID-19 pandemic, 4 dermatology residents were selected each year to travel to this unique and remote location to work with the staff of the Chinle Comprehensive Health Care Facility (Chinle, Arizona), an Indian Health Service facility, as part of the American Academy of Dermatology (AAD)–sponsored Native American Health Services Resident Rotation (NAHSRR).

Dr. Lucinda Kohn, Assistant Professor of Dermatology at the University of Colorado and the director of the NAHSRR program discovered the value of this rotation firsthand as a dermatology resident. In 2017, she traveled to the area to spend 2 weeks serving within the community. “I went because of a personal connection. My husband is Native American, although not Navajo. I wanted to experience what it was like to provide dermatologic care for Native Americans. I found the Navajo people to be so friendly and so grateful for our care. The clinicians we worked with at Chinle were excited to have us share our expertise and to pass on their knowledge to us,” said Dr. Kohn (personal communication, June 24, 2021).

Rotating residents provide dermatologic care for the Navajo people and share their unique medical skill set to local primary care clinicians serving as preceptors. They also may have an opportunity to learn from Native healers about traditional Navajo beliefs and ceremonies used as part of a holistic approach to healing.

The program, similar to volunteer programs across the country, was put on hold during the height of the COVID-19 pandemic. “The Navajo nation witnessed a really tragic surge of COVID cases that required that limited medical resources be diverted to help cope with the pandemic,” says Dr. Kohn. “It really wasn’t safe for residents to travel to the reservation either, so the rotation had to be put on hold.” However, in April 2021, the health care staff of the Chinle Comprehensive Care Facility reached out to revive the program, which is now pending the green light from the AAD. It is unclear if or when AAD leadership will allow this rotation to restart. Dr. Kohn hopes to be able to start accepting new applications soon. “This rotation provides a wealth of benefits to all those involved, from the residents who get the chance to work with a unique population in need to the clinicians who gain a diverse understanding of dermatology treatment techniques. And of course, for the patients, who are so appreciative of the care they receive from our volunteers” (personal communication, June 25, 2021).

How to Get Involved
Dr. Kohn is happy to field questions regarding the rotation and requests for more information via email ([email protected]). Residents interested in this program also may reach out to the AAD’s Education and Volunteers Abroad Committee to express interest in the NAHSRR program’s reinstatement.

Destination Healthy Skin

Since 2017, the Skin Cancer Foundation’s Destination Healthy Skin (DHS) RV has been the setting for more than 3800 free skin cancer screenings provided by volunteers within underserved populations across the United States (Figure 2). After a year hiatus due to the pandemic, DHS hit the road again, starting in New York City on August 1 to 3, 2021. From there, the DHS RV will traverse the country in one large loop, starting with visits to large and small cities in the Midwest and the West Coast. Following a visit to San Diego, California, in early October, the RV will turn east, with stops in Arizona, Texas, and several southern states before ending in Philadelphia, Pennsylvania. Dr. Elizabeth Hale, Senior Vice President of the Skin Cancer Foundation, feels that increasing awareness of the importance of regular skin cancer screening for those at risk is more important than ever. “We know that many people in the past year put routine cancer screening on the back burner, but we’re beginning to appreciate that this has led to significant delays in skin cancer diagnosis and potentially more significant disease when cases are diagnosed.” Dr. Hale noted that as the country continues to return to a degree of normalcy, the backlog of patients now seeking their routine screening has led to longer wait times. She expects DHS may offer some relief. “There are no appointments necessary. If the RV is close to their hometown, patients have an advantage in being able to be seen first come, first served, without having to wait for an appointment or make sure their insurance is accepted. It’s a free screening that can increase access to dermatologists” (personal communication, June 21, 2021).

The program’s organizers acknowledge that DHS is not a long-term solution for improving dermatology access in the United States and recognize that more needs to be done to raise awareness, both of the value that screenings can provide and the importance of sun-protective behavior. “This is an important first step,” says Dr. Hale. “It’s important that we disseminate that no one is immune to skin cancer. It’s about education, and this is a tool to educate patients that everyone should have a skin check once a year, regardless of where you live or what your skin type is” (personal communication, June 21, 2021).

Volunteer dermatologists are needed to assist with screenings when the DHS RV arrives in their community. Providers complete a screening form identifying any concerning lesions and can document specific lesions using the patient’s cell phone. Following the screenings, participating dermatologists are welcome to invite participants to make appointments at their practices or suggest local clinics for follow-up care.

How to Get Involved
The schedule for this year’s screening events can be found online (https://www.skincancer.org/early-detection/destination-healthy-skin/). Consider volunteering (https://www.skincancer.org/early-detection/destination-healthy-skin/physician-volunteers/) or helping to raise awareness by reaching out to local dermatology societies or free clinics in your area. Residents and physician’s assistants are welcome to volunteer as well, as long as they are under the on-site supervision of a board-certified dermatologist.

Final Thoughts

As medical professionals, we all recognize there are valuable contributions we can make to groups and organizations that need our help. The stresses and pressure of work and everyday life can make finding the time to offer that help seem impossible. Although it may seem counterintuitive, volunteering our time to help others can help us better navigate the professional burnout that many medical professionals experience today.

The adage “so much to do, so little time” aptly describes the daily challenges facing dermatologists and dermatology residents. The time and attention required by direct patient care, writing notes, navigating electronic health records, and engaging in education and research as well as family commitments can drain even the most tireless clinician. In addition, dermatologists are expected to play a critical role in clinic and practice management to successfully curate an online presence and adapt their skills to successfully manage a teledermatology practice. Coupled with the time spent socializing with friends or colleagues and time for personal hobbies or exercise, it’s easy to see how sleep deprivation is common in many of our colleagues.

What’s being left out of these jam-packed schedules? Increasingly, it is the time and expertise dedicated to volunteering in our local communities. Two recent research letters highlighted how a dramatic increase in the number of research projects and publications is not mirrored by a similar increase in volunteer experiences as dermatology residency selection becomes more competitive.^1,2

Although the rate of volunteerism among practicing dermatologists has yet to be studied, a brief review suggests a component of unmet dermatology need within our communities. It’s estimated that approximately 5% to 10% of all emergency department visits are for dermatologic concerns.^3-5 In many cases, the reason for the visit is nonurgent and instead reflects a lack of other options for care. However, the need for dermatologists extends beyond the emergency department setting. A review of the prevalence of patients presenting for care to a group of regional free clinics found that 8% (N=5553) of all visitors sought care for dermatologic concerns.⁶ The benefit is not just for those seated on the examination table; research has shown that while many of the underlying factors resulting in physician burnout stem from systemic issues, participating in volunteer opportunities helps combat burnout in ourselves and our colleagues.^7-9 Herein, opportunities that exist for dermatologists to reconnect with their communities, advocate for causes distinctive to the specialty, and care for neighbors most in need are highlighted.

Camp Wonder

Every year, children from across the United States living with chronic and debilitating skin conditions get the opportunity to join fellow campers and spend a week just being kids without the constant focus on being a patient. Camp Wonder’s founder and director, Francesca Tenconi, describes the camp as a place where kids “can form a community and can feel free to be themselves, without judgment, without stares. They get the chance to forget about their skin disease and be themselves” (oral communication, June 18, 2021). Tenconi and the camp’s cofounders and medical directors, Drs. Jenny Kim and Stefani Takahashi, envisioned the camp as a place for all campers regardless of their skin condition to feel safe and welcome. This overall mission guides camp leadership and staff every year over the course of the camp week where campers participate in a mix of traditional and nontraditional summer activities that are safe and accessible for all, from spending time in the pool to arts and crafts and a ropes course.

Camp Wonder is in its 21st year of hosting children and adolescents from across North America at its camp in Livermore, California. This year, Tenconi expects about 100 campers during the last week in July. Camp Wonder relies on medical staff volunteers to make the camp setting safe, inclusive, and fun. “Our dermatology residents and dermatology volunteers are a huge part of why we’re able to have camp,” said Tenconi. “A lot of our kids require very specific medical care throughout the week. We are able to provide this camp experience for them because we have this medical support system available, this specialized dermatology knowledge.” She also noted the benefit to the volunteers themselves, saying,“The feedback we get a lot from residents and dermatologists is that camp gave them a chance to understand the true-life impact of some of the skin diseases these kids and families are living with. Kids will open up to them and tell them how their disease has impacted them personally” (oral communication, June 18, 2021).

Volunteer medical providers help manage the medical needs of the campers beginning at check-in and work shifts in the infirmary as well as help with dispensing and administering medications, changing dressings, and applying ointments or other topical medications. When not assisting with medical care, medical staff can get to know the campers; help out with arts and crafts, games, sports, and other camp activities; and put on skits and plays for campers at nightly camp hangouts (Figure 1).

Native American Health Services Rotation

Located in the southwestern United States, the Navajo Nation is North America’s largest Native American tribe by enrollment and resides on the largest reservation in the United States.¹⁰ Comprised of 27,000 square miles within portions of Arizona, New Mexico, and Utah, the reservation’s total area is greater than that of Massachusetts, Vermont, and New Hampshire combined.¹¹ The reservation is home to an estimated 180,000 Navajo people, a population roughly the size of Salt Lake City, Utah. Yet, many homes on the reservation are without electricity, running water, telephones, or broadband access, and many roads on the reservation remain unpaved. Prior to the COVID-19 pandemic, 4 dermatology residents were selected each year to travel to this unique and remote location to work with the staff of the Chinle Comprehensive Health Care Facility (Chinle, Arizona), an Indian Health Service facility, as part of the American Academy of Dermatology (AAD)–sponsored Native American Health Services Resident Rotation (NAHSRR).

Dr. Lucinda Kohn, Assistant Professor of Dermatology at the University of Colorado and the director of the NAHSRR program discovered the value of this rotation firsthand as a dermatology resident. In 2017, she traveled to the area to spend 2 weeks serving within the community. “I went because of a personal connection. My husband is Native American, although not Navajo. I wanted to experience what it was like to provide dermatologic care for Native Americans. I found the Navajo people to be so friendly and so grateful for our care. The clinicians we worked with at Chinle were excited to have us share our expertise and to pass on their knowledge to us,” said Dr. Kohn (personal communication, June 24, 2021).

Rotating residents provide dermatologic care for the Navajo people and share their unique medical skill set to local primary care clinicians serving as preceptors. They also may have an opportunity to learn from Native healers about traditional Navajo beliefs and ceremonies used as part of a holistic approach to healing.

The program, similar to volunteer programs across the country, was put on hold during the height of the COVID-19 pandemic. “The Navajo nation witnessed a really tragic surge of COVID cases that required that limited medical resources be diverted to help cope with the pandemic,” says Dr. Kohn. “It really wasn’t safe for residents to travel to the reservation either, so the rotation had to be put on hold.” However, in April 2021, the health care staff of the Chinle Comprehensive Care Facility reached out to revive the program, which is now pending the green light from the AAD. It is unclear if or when AAD leadership will allow this rotation to restart. Dr. Kohn hopes to be able to start accepting new applications soon. “This rotation provides a wealth of benefits to all those involved, from the residents who get the chance to work with a unique population in need to the clinicians who gain a diverse understanding of dermatology treatment techniques. And of course, for the patients, who are so appreciative of the care they receive from our volunteers” (personal communication, June 25, 2021).

How to Get Involved
Dr. Kohn is happy to field questions regarding the rotation and requests for more information via email ([email protected]). Residents interested in this program also may reach out to the AAD’s Education and Volunteers Abroad Committee to express interest in the NAHSRR program’s reinstatement.

Destination Healthy Skin

Since 2017, the Skin Cancer Foundation’s Destination Healthy Skin (DHS) RV has been the setting for more than 3800 free skin cancer screenings provided by volunteers within underserved populations across the United States (Figure 2). After a year hiatus due to the pandemic, DHS hit the road again, starting in New York City on August 1 to 3, 2021. From there, the DHS RV will traverse the country in one large loop, starting with visits to large and small cities in the Midwest and the West Coast. Following a visit to San Diego, California, in early October, the RV will turn east, with stops in Arizona, Texas, and several southern states before ending in Philadelphia, Pennsylvania. Dr. Elizabeth Hale, Senior Vice President of the Skin Cancer Foundation, feels that increasing awareness of the importance of regular skin cancer screening for those at risk is more important than ever. “We know that many people in the past year put routine cancer screening on the back burner, but we’re beginning to appreciate that this has led to significant delays in skin cancer diagnosis and potentially more significant disease when cases are diagnosed.” Dr. Hale noted that as the country continues to return to a degree of normalcy, the backlog of patients now seeking their routine screening has led to longer wait times. She expects DHS may offer some relief. “There are no appointments necessary. If the RV is close to their hometown, patients have an advantage in being able to be seen first come, first served, without having to wait for an appointment or make sure their insurance is accepted. It’s a free screening that can increase access to dermatologists” (personal communication, June 21, 2021).

The program’s organizers acknowledge that DHS is not a long-term solution for improving dermatology access in the United States and recognize that more needs to be done to raise awareness, both of the value that screenings can provide and the importance of sun-protective behavior. “This is an important first step,” says Dr. Hale. “It’s important that we disseminate that no one is immune to skin cancer. It’s about education, and this is a tool to educate patients that everyone should have a skin check once a year, regardless of where you live or what your skin type is” (personal communication, June 21, 2021).

Volunteer dermatologists are needed to assist with screenings when the DHS RV arrives in their community. Providers complete a screening form identifying any concerning lesions and can document specific lesions using the patient’s cell phone. Following the screenings, participating dermatologists are welcome to invite participants to make appointments at their practices or suggest local clinics for follow-up care.

How to Get Involved
The schedule for this year’s screening events can be found online (https://www.skincancer.org/early-detection/destination-healthy-skin/). Consider volunteering (https://www.skincancer.org/early-detection/destination-healthy-skin/physician-volunteers/) or helping to raise awareness by reaching out to local dermatology societies or free clinics in your area. Residents and physician’s assistants are welcome to volunteer as well, as long as they are under the on-site supervision of a board-certified dermatologist.

Final Thoughts

As medical professionals, we all recognize there are valuable contributions we can make to groups and organizations that need our help. The stresses and pressure of work and everyday life can make finding the time to offer that help seem impossible. Although it may seem counterintuitive, volunteering our time to help others can help us better navigate the professional burnout that many medical professionals experience today.

The adage “so much to do, so little time” aptly describes the daily challenges facing dermatologists and dermatology residents. The time and attention required by direct patient care, writing notes, navigating electronic health records, and engaging in education and research as well as family commitments can drain even the most tireless clinician. In addition, dermatologists are expected to play a critical role in clinic and practice management to successfully curate an online presence and adapt their skills to successfully manage a teledermatology practice. Coupled with the time spent socializing with friends or colleagues and time for personal hobbies or exercise, it’s easy to see how sleep deprivation is common in many of our colleagues.

What’s being left out of these jam-packed schedules? Increasingly, it is the time and expertise dedicated to volunteering in our local communities. Two recent research letters highlighted how a dramatic increase in the number of research projects and publications is not mirrored by a similar increase in volunteer experiences as dermatology residency selection becomes more competitive.^1,2

Although the rate of volunteerism among practicing dermatologists has yet to be studied, a brief review suggests a component of unmet dermatology need within our communities. It’s estimated that approximately 5% to 10% of all emergency department visits are for dermatologic concerns.^3-5 In many cases, the reason for the visit is nonurgent and instead reflects a lack of other options for care. However, the need for dermatologists extends beyond the emergency department setting. A review of the prevalence of patients presenting for care to a group of regional free clinics found that 8% (N=5553) of all visitors sought care for dermatologic concerns.⁶ The benefit is not just for those seated on the examination table; research has shown that while many of the underlying factors resulting in physician burnout stem from systemic issues, participating in volunteer opportunities helps combat burnout in ourselves and our colleagues.^7-9 Herein, opportunities that exist for dermatologists to reconnect with their communities, advocate for causes distinctive to the specialty, and care for neighbors most in need are highlighted.

Camp Wonder

Every year, children from across the United States living with chronic and debilitating skin conditions get the opportunity to join fellow campers and spend a week just being kids without the constant focus on being a patient. Camp Wonder’s founder and director, Francesca Tenconi, describes the camp as a place where kids “can form a community and can feel free to be themselves, without judgment, without stares. They get the chance to forget about their skin disease and be themselves” (oral communication, June 18, 2021). Tenconi and the camp’s cofounders and medical directors, Drs. Jenny Kim and Stefani Takahashi, envisioned the camp as a place for all campers regardless of their skin condition to feel safe and welcome. This overall mission guides camp leadership and staff every year over the course of the camp week where campers participate in a mix of traditional and nontraditional summer activities that are safe and accessible for all, from spending time in the pool to arts and crafts and a ropes course.

Camp Wonder is in its 21st year of hosting children and adolescents from across North America at its camp in Livermore, California. This year, Tenconi expects about 100 campers during the last week in July. Camp Wonder relies on medical staff volunteers to make the camp setting safe, inclusive, and fun. “Our dermatology residents and dermatology volunteers are a huge part of why we’re able to have camp,” said Tenconi. “A lot of our kids require very specific medical care throughout the week. We are able to provide this camp experience for them because we have this medical support system available, this specialized dermatology knowledge.” She also noted the benefit to the volunteers themselves, saying,“The feedback we get a lot from residents and dermatologists is that camp gave them a chance to understand the true-life impact of some of the skin diseases these kids and families are living with. Kids will open up to them and tell them how their disease has impacted them personally” (oral communication, June 18, 2021).

Volunteer medical providers help manage the medical needs of the campers beginning at check-in and work shifts in the infirmary as well as help with dispensing and administering medications, changing dressings, and applying ointments or other topical medications. When not assisting with medical care, medical staff can get to know the campers; help out with arts and crafts, games, sports, and other camp activities; and put on skits and plays for campers at nightly camp hangouts (Figure 1).

Native American Health Services Rotation

Located in the southwestern United States, the Navajo Nation is North America’s largest Native American tribe by enrollment and resides on the largest reservation in the United States.¹⁰ Comprised of 27,000 square miles within portions of Arizona, New Mexico, and Utah, the reservation’s total area is greater than that of Massachusetts, Vermont, and New Hampshire combined.¹¹ The reservation is home to an estimated 180,000 Navajo people, a population roughly the size of Salt Lake City, Utah. Yet, many homes on the reservation are without electricity, running water, telephones, or broadband access, and many roads on the reservation remain unpaved. Prior to the COVID-19 pandemic, 4 dermatology residents were selected each year to travel to this unique and remote location to work with the staff of the Chinle Comprehensive Health Care Facility (Chinle, Arizona), an Indian Health Service facility, as part of the American Academy of Dermatology (AAD)–sponsored Native American Health Services Resident Rotation (NAHSRR).

Dr. Lucinda Kohn, Assistant Professor of Dermatology at the University of Colorado and the director of the NAHSRR program discovered the value of this rotation firsthand as a dermatology resident. In 2017, she traveled to the area to spend 2 weeks serving within the community. “I went because of a personal connection. My husband is Native American, although not Navajo. I wanted to experience what it was like to provide dermatologic care for Native Americans. I found the Navajo people to be so friendly and so grateful for our care. The clinicians we worked with at Chinle were excited to have us share our expertise and to pass on their knowledge to us,” said Dr. Kohn (personal communication, June 24, 2021).

Rotating residents provide dermatologic care for the Navajo people and share their unique medical skill set to local primary care clinicians serving as preceptors. They also may have an opportunity to learn from Native healers about traditional Navajo beliefs and ceremonies used as part of a holistic approach to healing.

The program, similar to volunteer programs across the country, was put on hold during the height of the COVID-19 pandemic. “The Navajo nation witnessed a really tragic surge of COVID cases that required that limited medical resources be diverted to help cope with the pandemic,” says Dr. Kohn. “It really wasn’t safe for residents to travel to the reservation either, so the rotation had to be put on hold.” However, in April 2021, the health care staff of the Chinle Comprehensive Care Facility reached out to revive the program, which is now pending the green light from the AAD. It is unclear if or when AAD leadership will allow this rotation to restart. Dr. Kohn hopes to be able to start accepting new applications soon. “This rotation provides a wealth of benefits to all those involved, from the residents who get the chance to work with a unique population in need to the clinicians who gain a diverse understanding of dermatology treatment techniques. And of course, for the patients, who are so appreciative of the care they receive from our volunteers” (personal communication, June 25, 2021).

How to Get Involved
Dr. Kohn is happy to field questions regarding the rotation and requests for more information via email ([email protected]). Residents interested in this program also may reach out to the AAD’s Education and Volunteers Abroad Committee to express interest in the NAHSRR program’s reinstatement.

Destination Healthy Skin

Since 2017, the Skin Cancer Foundation’s Destination Healthy Skin (DHS) RV has been the setting for more than 3800 free skin cancer screenings provided by volunteers within underserved populations across the United States (Figure 2). After a year hiatus due to the pandemic, DHS hit the road again, starting in New York City on August 1 to 3, 2021. From there, the DHS RV will traverse the country in one large loop, starting with visits to large and small cities in the Midwest and the West Coast. Following a visit to San Diego, California, in early October, the RV will turn east, with stops in Arizona, Texas, and several southern states before ending in Philadelphia, Pennsylvania. Dr. Elizabeth Hale, Senior Vice President of the Skin Cancer Foundation, feels that increasing awareness of the importance of regular skin cancer screening for those at risk is more important than ever. “We know that many people in the past year put routine cancer screening on the back burner, but we’re beginning to appreciate that this has led to significant delays in skin cancer diagnosis and potentially more significant disease when cases are diagnosed.” Dr. Hale noted that as the country continues to return to a degree of normalcy, the backlog of patients now seeking their routine screening has led to longer wait times. She expects DHS may offer some relief. “There are no appointments necessary. If the RV is close to their hometown, patients have an advantage in being able to be seen first come, first served, without having to wait for an appointment or make sure their insurance is accepted. It’s a free screening that can increase access to dermatologists” (personal communication, June 21, 2021).

The program’s organizers acknowledge that DHS is not a long-term solution for improving dermatology access in the United States and recognize that more needs to be done to raise awareness, both of the value that screenings can provide and the importance of sun-protective behavior. “This is an important first step,” says Dr. Hale. “It’s important that we disseminate that no one is immune to skin cancer. It’s about education, and this is a tool to educate patients that everyone should have a skin check once a year, regardless of where you live or what your skin type is” (personal communication, June 21, 2021).

Volunteer dermatologists are needed to assist with screenings when the DHS RV arrives in their community. Providers complete a screening form identifying any concerning lesions and can document specific lesions using the patient’s cell phone. Following the screenings, participating dermatologists are welcome to invite participants to make appointments at their practices or suggest local clinics for follow-up care.

How to Get Involved
The schedule for this year’s screening events can be found online (https://www.skincancer.org/early-detection/destination-healthy-skin/). Consider volunteering (https://www.skincancer.org/early-detection/destination-healthy-skin/physician-volunteers/) or helping to raise awareness by reaching out to local dermatology societies or free clinics in your area. Residents and physician’s assistants are welcome to volunteer as well, as long as they are under the on-site supervision of a board-certified dermatologist.

Final Thoughts

As medical professionals, we all recognize there are valuable contributions we can make to groups and organizations that need our help. The stresses and pressure of work and everyday life can make finding the time to offer that help seem impossible. Although it may seem counterintuitive, volunteering our time to help others can help us better navigate the professional burnout that many medical professionals experience today.

The transition from undergraduate medical education (UME) to graduate medical education in the United States needs comprehensive reform, says a new report from the Graduate Medical Education Review Committee (UGRC) of the Coalition for Physician Accountability.

The 275-page report presents preliminary findings that were released in April 2021 and a long list of stakeholder comments. According to the report, the coalition will meet soon to discuss the final recommendations and consider next steps toward implementation.

The UGRC includes representatives of national medical organizations, medical schools, and residency programs. Among the organizations that participated in the report’s creation are the American Medical Association, the National Board of Medical Examiners, the American Osteopathic Association, the National Board of Osteopathic Medical Examiners, the Educational Commission for Foreign Medical Graduates, and the Association of American Medical Colleges.

The report identifies a list of challenges that affect the transition of medical students into residency programs and beyond. They include:

• Too much focus on finding and filling residency positions instead of “assuring learner competence and readiness for residency training”
• Inattention to assuring congruence between applicant goals and program missions
• Overreliance on licensure exam scores rather than “valid, trustworthy measures of students’ competence and clinical abilities”
• Increasing financial costs to students
• Individual and systemic biases in the UME-GME transition, as well as inequities related to international medical graduates

Seeking a common framework for competence

Overall, the report calls for increased standardization of how students are evaluated in medical school and how residency programs evaluate students. Less reliance should be placed on the numerical scores of the U.S. Medical Licensing Examination (USMLE), the report says, and more attention should be paid to the direct observation of student performance in clinical situations. In addition, the various organizations involved in the UME-GME transition process are asked to work better together.

To develop better methods of evaluating medical students and residents, UME and GME educators should jointly define and implement a common framework and set of competencies to apply to learners across the UME-GME transition, the report suggests.

While emphasizing the need for a broader student assessment framework, the report says, USMLE scores should also continue to be used in judging residency applicants. “Assessment information should be shared in residency applications and a postmatch learner handover. Licensing examinations should be used for their intended purpose to ensure requisite competence.”

Among the committee’s three dozen recommendations are the following:

• The Centers for Medicare & Medicaid Services should change the GME funding structure so that the initial residency period is calculated starting with the second year of postgraduate training. This change would allow residents to reconsider their career choices. Currently, if a resident decides to switch to another program or specialty after beginning training, the hospital may not receive full GME funding, so may be less likely to approve the change.
• Residency programs should improve recruitment practices to increase specialty-specific diversity of residents. Medical educators should also receive additional training regarding antiracism, avoiding bias, and ensuring equity.
• The self-reported demographic information of applicants to residency programs should be measured and shared with stakeholders, including the programs and medical schools, to promote equity. “A residency program that finds bias in its selection process could go back in real time to find qualified applicants who may have been missed, potentially improving outcomes,” the report notes.
• An interactive database of GME program and specialty track information should be created and made available to all applicants, medical schools, and residency programs at no cost to applicants. “Applicants and their advisors should be able to sort the information according to demographic and educational features that may significantly impact the likelihood of matching at a program.”

Less than half of applicants get in-depth reviews

The 2020 National Resident Matching Program Program Director Survey found that only 49% of applications received in-depth review. In light of this, the report suggests that the application system be updated to use modern information technology, including discrete fields for key data to expedite application reviews.

Many applications have been discarded because of various filters used to block consideration of certain applications. The report suggests that new filters be designed to ensure that each detects meaningful differences among applicants and promotes review based on mission alignment and likelihood of success in a program. Filters should be improved to decrease the likelihood of random exclusions of qualified applicants.

Specialty-specific, just-in-time training for all incoming first-year residents is also suggested to support the transition from the role of student to a physician ready to assume increased responsibility for patient care. In addition, the report urges adequate time be allowed between medical school graduation and residency to enable new residents to relocate and find homes.

The report also calls for a standardized process in the United States for initial licensing of doctors at entrance to residency in order to streamline the process of credentialing for both residency training and continuing practice.
 

Osteopathic students’ dilemma

To promote equitable treatment of applicants regardless of licensure examination requirements, comparable exams with different scales (COMLEX-USA and USMLE) should be reported within the electronic application system in a single field, the report said.

Osteopathic students, who make up 25% of U.S. medical students, must take the COMLEX-USA exam, but residency programs may filter them out if they don’t also take the USMLE exam. Thus, many osteopathic students take both exams, incurring extra time, cost, and stress.

The UGRC recommends creating a combined field in the electronic residency application service that normalizes the scores between the two exams. Residency programs could then filter applications based only on the single normalized score.

This approach makes sense from the viewpoint that it would reduce the pressure on osteopathic students to take the USMLE, Bryan Carmody, MD, an outspoken critic of various current training policies, said in an interview. But it could also have serious disadvantages.

For one thing, only osteopathic students can take the COMLEX-USA exam, he noted. If they don’t like their score, they can then take the USMLE test to get a higher score – an option that allopathic students don’t have. It’s not clear that they’d be prevented from doing this under the UGRC recommendation.

Second, he said, osteopathic students, on average, don’t do as well as allopathic students on the UMSLE exam. If they only take the COMLEX-USA test, they’re competing against other students who don’t do as well on tests as allopathic students do. If their scores were normalized with those of the USMLE test takers, they’d gain an unfair advantage against students who can only take the USMLE, including international medical graduates.

Although Dr. Carmody admitted that osteopathic students face a harder challenge than allopathic students in matching to residency programs, he said that the UGRC approach to the licensing exams might actually penalize them further. As a result of the scores of the two exams being averaged, residency program directors might discount the scores of all osteopathic students.

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

The transition from undergraduate medical education (UME) to graduate medical education in the United States needs comprehensive reform, says a new report from the Graduate Medical Education Review Committee (UGRC) of the Coalition for Physician Accountability.

The 275-page report presents preliminary findings that were released in April 2021 and a long list of stakeholder comments. According to the report, the coalition will meet soon to discuss the final recommendations and consider next steps toward implementation.

The UGRC includes representatives of national medical organizations, medical schools, and residency programs. Among the organizations that participated in the report’s creation are the American Medical Association, the National Board of Medical Examiners, the American Osteopathic Association, the National Board of Osteopathic Medical Examiners, the Educational Commission for Foreign Medical Graduates, and the Association of American Medical Colleges.

The report identifies a list of challenges that affect the transition of medical students into residency programs and beyond. They include:

• Too much focus on finding and filling residency positions instead of “assuring learner competence and readiness for residency training”
• Inattention to assuring congruence between applicant goals and program missions
• Overreliance on licensure exam scores rather than “valid, trustworthy measures of students’ competence and clinical abilities”
• Increasing financial costs to students
• Individual and systemic biases in the UME-GME transition, as well as inequities related to international medical graduates

Seeking a common framework for competence

Overall, the report calls for increased standardization of how students are evaluated in medical school and how residency programs evaluate students. Less reliance should be placed on the numerical scores of the U.S. Medical Licensing Examination (USMLE), the report says, and more attention should be paid to the direct observation of student performance in clinical situations. In addition, the various organizations involved in the UME-GME transition process are asked to work better together.

To develop better methods of evaluating medical students and residents, UME and GME educators should jointly define and implement a common framework and set of competencies to apply to learners across the UME-GME transition, the report suggests.

While emphasizing the need for a broader student assessment framework, the report says, USMLE scores should also continue to be used in judging residency applicants. “Assessment information should be shared in residency applications and a postmatch learner handover. Licensing examinations should be used for their intended purpose to ensure requisite competence.”

Among the committee’s three dozen recommendations are the following:

• The Centers for Medicare & Medicaid Services should change the GME funding structure so that the initial residency period is calculated starting with the second year of postgraduate training. This change would allow residents to reconsider their career choices. Currently, if a resident decides to switch to another program or specialty after beginning training, the hospital may not receive full GME funding, so may be less likely to approve the change.
• Residency programs should improve recruitment practices to increase specialty-specific diversity of residents. Medical educators should also receive additional training regarding antiracism, avoiding bias, and ensuring equity.
• The self-reported demographic information of applicants to residency programs should be measured and shared with stakeholders, including the programs and medical schools, to promote equity. “A residency program that finds bias in its selection process could go back in real time to find qualified applicants who may have been missed, potentially improving outcomes,” the report notes.
• An interactive database of GME program and specialty track information should be created and made available to all applicants, medical schools, and residency programs at no cost to applicants. “Applicants and their advisors should be able to sort the information according to demographic and educational features that may significantly impact the likelihood of matching at a program.”

Less than half of applicants get in-depth reviews

The 2020 National Resident Matching Program Program Director Survey found that only 49% of applications received in-depth review. In light of this, the report suggests that the application system be updated to use modern information technology, including discrete fields for key data to expedite application reviews.

Many applications have been discarded because of various filters used to block consideration of certain applications. The report suggests that new filters be designed to ensure that each detects meaningful differences among applicants and promotes review based on mission alignment and likelihood of success in a program. Filters should be improved to decrease the likelihood of random exclusions of qualified applicants.

Specialty-specific, just-in-time training for all incoming first-year residents is also suggested to support the transition from the role of student to a physician ready to assume increased responsibility for patient care. In addition, the report urges adequate time be allowed between medical school graduation and residency to enable new residents to relocate and find homes.

The report also calls for a standardized process in the United States for initial licensing of doctors at entrance to residency in order to streamline the process of credentialing for both residency training and continuing practice.
 

Osteopathic students’ dilemma

To promote equitable treatment of applicants regardless of licensure examination requirements, comparable exams with different scales (COMLEX-USA and USMLE) should be reported within the electronic application system in a single field, the report said.

Osteopathic students, who make up 25% of U.S. medical students, must take the COMLEX-USA exam, but residency programs may filter them out if they don’t also take the USMLE exam. Thus, many osteopathic students take both exams, incurring extra time, cost, and stress.

The UGRC recommends creating a combined field in the electronic residency application service that normalizes the scores between the two exams. Residency programs could then filter applications based only on the single normalized score.

This approach makes sense from the viewpoint that it would reduce the pressure on osteopathic students to take the USMLE, Bryan Carmody, MD, an outspoken critic of various current training policies, said in an interview. But it could also have serious disadvantages.

For one thing, only osteopathic students can take the COMLEX-USA exam, he noted. If they don’t like their score, they can then take the USMLE test to get a higher score – an option that allopathic students don’t have. It’s not clear that they’d be prevented from doing this under the UGRC recommendation.

Second, he said, osteopathic students, on average, don’t do as well as allopathic students on the UMSLE exam. If they only take the COMLEX-USA test, they’re competing against other students who don’t do as well on tests as allopathic students do. If their scores were normalized with those of the USMLE test takers, they’d gain an unfair advantage against students who can only take the USMLE, including international medical graduates.

Although Dr. Carmody admitted that osteopathic students face a harder challenge than allopathic students in matching to residency programs, he said that the UGRC approach to the licensing exams might actually penalize them further. As a result of the scores of the two exams being averaged, residency program directors might discount the scores of all osteopathic students.

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

The transition from undergraduate medical education (UME) to graduate medical education in the United States needs comprehensive reform, says a new report from the Graduate Medical Education Review Committee (UGRC) of the Coalition for Physician Accountability.

The 275-page report presents preliminary findings that were released in April 2021 and a long list of stakeholder comments. According to the report, the coalition will meet soon to discuss the final recommendations and consider next steps toward implementation.

The UGRC includes representatives of national medical organizations, medical schools, and residency programs. Among the organizations that participated in the report’s creation are the American Medical Association, the National Board of Medical Examiners, the American Osteopathic Association, the National Board of Osteopathic Medical Examiners, the Educational Commission for Foreign Medical Graduates, and the Association of American Medical Colleges.

The report identifies a list of challenges that affect the transition of medical students into residency programs and beyond. They include:

• Too much focus on finding and filling residency positions instead of “assuring learner competence and readiness for residency training”
• Inattention to assuring congruence between applicant goals and program missions
• Overreliance on licensure exam scores rather than “valid, trustworthy measures of students’ competence and clinical abilities”
• Increasing financial costs to students
• Individual and systemic biases in the UME-GME transition, as well as inequities related to international medical graduates

Seeking a common framework for competence

Overall, the report calls for increased standardization of how students are evaluated in medical school and how residency programs evaluate students. Less reliance should be placed on the numerical scores of the U.S. Medical Licensing Examination (USMLE), the report says, and more attention should be paid to the direct observation of student performance in clinical situations. In addition, the various organizations involved in the UME-GME transition process are asked to work better together.

To develop better methods of evaluating medical students and residents, UME and GME educators should jointly define and implement a common framework and set of competencies to apply to learners across the UME-GME transition, the report suggests.

While emphasizing the need for a broader student assessment framework, the report says, USMLE scores should also continue to be used in judging residency applicants. “Assessment information should be shared in residency applications and a postmatch learner handover. Licensing examinations should be used for their intended purpose to ensure requisite competence.”

Among the committee’s three dozen recommendations are the following:

• The Centers for Medicare & Medicaid Services should change the GME funding structure so that the initial residency period is calculated starting with the second year of postgraduate training. This change would allow residents to reconsider their career choices. Currently, if a resident decides to switch to another program or specialty after beginning training, the hospital may not receive full GME funding, so may be less likely to approve the change.
• Residency programs should improve recruitment practices to increase specialty-specific diversity of residents. Medical educators should also receive additional training regarding antiracism, avoiding bias, and ensuring equity.
• The self-reported demographic information of applicants to residency programs should be measured and shared with stakeholders, including the programs and medical schools, to promote equity. “A residency program that finds bias in its selection process could go back in real time to find qualified applicants who may have been missed, potentially improving outcomes,” the report notes.
• An interactive database of GME program and specialty track information should be created and made available to all applicants, medical schools, and residency programs at no cost to applicants. “Applicants and their advisors should be able to sort the information according to demographic and educational features that may significantly impact the likelihood of matching at a program.”

Less than half of applicants get in-depth reviews

The 2020 National Resident Matching Program Program Director Survey found that only 49% of applications received in-depth review. In light of this, the report suggests that the application system be updated to use modern information technology, including discrete fields for key data to expedite application reviews.

Many applications have been discarded because of various filters used to block consideration of certain applications. The report suggests that new filters be designed to ensure that each detects meaningful differences among applicants and promotes review based on mission alignment and likelihood of success in a program. Filters should be improved to decrease the likelihood of random exclusions of qualified applicants.

Specialty-specific, just-in-time training for all incoming first-year residents is also suggested to support the transition from the role of student to a physician ready to assume increased responsibility for patient care. In addition, the report urges adequate time be allowed between medical school graduation and residency to enable new residents to relocate and find homes.

The report also calls for a standardized process in the United States for initial licensing of doctors at entrance to residency in order to streamline the process of credentialing for both residency training and continuing practice.
 

Osteopathic students’ dilemma

To promote equitable treatment of applicants regardless of licensure examination requirements, comparable exams with different scales (COMLEX-USA and USMLE) should be reported within the electronic application system in a single field, the report said.

Osteopathic students, who make up 25% of U.S. medical students, must take the COMLEX-USA exam, but residency programs may filter them out if they don’t also take the USMLE exam. Thus, many osteopathic students take both exams, incurring extra time, cost, and stress.

The UGRC recommends creating a combined field in the electronic residency application service that normalizes the scores between the two exams. Residency programs could then filter applications based only on the single normalized score.

This approach makes sense from the viewpoint that it would reduce the pressure on osteopathic students to take the USMLE, Bryan Carmody, MD, an outspoken critic of various current training policies, said in an interview. But it could also have serious disadvantages.

For one thing, only osteopathic students can take the COMLEX-USA exam, he noted. If they don’t like their score, they can then take the USMLE test to get a higher score – an option that allopathic students don’t have. It’s not clear that they’d be prevented from doing this under the UGRC recommendation.

Second, he said, osteopathic students, on average, don’t do as well as allopathic students on the UMSLE exam. If they only take the COMLEX-USA test, they’re competing against other students who don’t do as well on tests as allopathic students do. If their scores were normalized with those of the USMLE test takers, they’d gain an unfair advantage against students who can only take the USMLE, including international medical graduates.

Although Dr. Carmody admitted that osteopathic students face a harder challenge than allopathic students in matching to residency programs, he said that the UGRC approach to the licensing exams might actually penalize them further. As a result of the scores of the two exams being averaged, residency program directors might discount the scores of all osteopathic students.

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

A Louisiana physician, who refers to himself as a “former assassin,” was indicted by a federal grand jury for his role in distributing more than 1.2 million doses of schedule II controlled substances outside the scope of professional practice and not for a legitimate medical purpose, according to the U.S. Department of Justice. The substances include oxycodone and morphine.

Adrian Dexter Talbot, MD, 55, of Slidell, La., is also charged with maintaining a medical clinic for the purpose of illegally distributing controlled substances, per the indictment.

Because the opioid prescriptions were filled using beneficiaries’ health insurance, Dr. Talbot is also charged with defrauding Medicare, Medicaid, and Blue Cross and Blue Shield of Louisiana of more than $5.1 million.

When contacted by this news organization for comment on the case via Twitter, Dr. Talbot or a representative responded with a link to his self-published book on Amazon. In his author bio, Dr. Talbot refers to himself as “a former assassin,” “retired military commander,” and “leader of the Medellin Cartel’s New York operations at the age of 16.” The Medellin Cartel is a notorious drug distribution empire.

Dr. Talbot is listed as the author of another book on Google Books detailing his time as a “former teenage assassin” and leader of the cartel, told as he struggles with early onset Alzheimer’s.
 

Dr. Talbot could spend decades in prison

According to the National Institute on Drug Abuse, 444 residents of the Bayou State lost their lives because of an opioid-related drug overdose in 2018. During that year, the state’s health care providers wrote more than 79.4 opioid prescriptions for every 100 persons, which puts the state in the top five in the United States in 2018, when the average U.S. rate was 51.4 prescriptions per 100 persons.

Charged with one count each of conspiracy to unlawfully distribute and dispense controlled substances and maintaining drug-involved premises and conspiracy to commit health care fraud, Dr. Talbot is also charged with four counts of unlawfully distributing and dispensing controlled substances. He is scheduled for a federal court appearance on September 10.

In addition to presigning prescriptions for individuals he didn’t meet or examine, federal officials allege Dr. Talbot hired another health care provider to similarly presign prescriptions for people who weren’t examined at a medical practice in Slidell, where Dr. Talbot was employed. The DOJ says Dr. Talbot took a full-time job in Pineville, La., and presigned prescriptions while no longer physically present at the Slidell clinic.

A speaker’s bio for Dr. Talbot indicates he worked as chief of medical services for the Alexandria Veterans Affairs Health Care System in Pineville.

According to the DOJ’s indictment, Dr. Talbot was aware that patients were filling the prescriptions that were provided outside the scope of professional practice and not for a legitimate medical purpose. This is what triggered the DOJ’s fraudulent billing claim. 

Dr. Talbot faces a maximum penalty of 10 years for conspiracy to commit health care fraud and 20 years each for the other counts, if convicted.
 

Dr. Talbot was candidate for local coroner

In February 2015, Dr. Talbot announced his candidacy for coroner for St. Tammany Parish, about an hour’s drive south of New Orleans, reported the Times Picayune. The seat was open because the previous coroner had resigned and ultimately pleaded guilty to a federal corruption charge.

The Times Picayune reported at the time that Dr. Talbot was a U.S. Navy veteran, in addition to serving as medical director and a primary care physician at the Medical Care Center in Slidell. Among the services provided to his patients were evaluations and treatment for substance use and mental health disorders, according to a press release issued by Dr. Talbot’s campaign.

Dr. Talbot’s medical license was issued in 1999 and inactive as of 2017, per the Louisiana State Board of Medical Examiners.
 

Louisiana expects $325M in multistate settlement with opioid companies

Louisiana is a party to a multistate and multijurisdictional lawsuit where the state is expected to receive more than $325 million in a settlement reached with drug distributors Cardinal, McKesson, and AmerisourceBergen, and drug manufacturer Johnson & Johnson, reported the Louisiana Illuminator in July. The total settlement may reach $26 billion dollars.

The Associated Press reported in July that there have been at least $40 billion in completed or proposed settlements, penalties, and fines between governments as a result of the opioid epidemic since 2007.

That total doesn’t include a proposed settlement involving members of the Sackler family, who own Purdue Pharmaceuticals, which manufactured and marketed the opioid painkiller OxyContin. The Sackler family have agreed to pay approximately $4.3 billion and surrender ownership of their bankrupt company, reported NPR. The family’s proposed settlement is part of a deal involving Purdue Pharmaceuticals worth more than $10 billion, reported Reuters.

In 2020, there were more than 81,000 drug overdose deaths, the highest number recorded in a 12-month period, per the U.S. Centers for Disease Control and Prevention. Fentanyl, an illicitly manufactured synthetic opioid, was the lead driver of those deaths.

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

A Louisiana physician, who refers to himself as a “former assassin,” was indicted by a federal grand jury for his role in distributing more than 1.2 million doses of schedule II controlled substances outside the scope of professional practice and not for a legitimate medical purpose, according to the U.S. Department of Justice. The substances include oxycodone and morphine.

Adrian Dexter Talbot, MD, 55, of Slidell, La., is also charged with maintaining a medical clinic for the purpose of illegally distributing controlled substances, per the indictment.

Because the opioid prescriptions were filled using beneficiaries’ health insurance, Dr. Talbot is also charged with defrauding Medicare, Medicaid, and Blue Cross and Blue Shield of Louisiana of more than $5.1 million.

When contacted by this news organization for comment on the case via Twitter, Dr. Talbot or a representative responded with a link to his self-published book on Amazon. In his author bio, Dr. Talbot refers to himself as “a former assassin,” “retired military commander,” and “leader of the Medellin Cartel’s New York operations at the age of 16.” The Medellin Cartel is a notorious drug distribution empire.

Dr. Talbot is listed as the author of another book on Google Books detailing his time as a “former teenage assassin” and leader of the cartel, told as he struggles with early onset Alzheimer’s.
 

Dr. Talbot could spend decades in prison

According to the National Institute on Drug Abuse, 444 residents of the Bayou State lost their lives because of an opioid-related drug overdose in 2018. During that year, the state’s health care providers wrote more than 79.4 opioid prescriptions for every 100 persons, which puts the state in the top five in the United States in 2018, when the average U.S. rate was 51.4 prescriptions per 100 persons.

Charged with one count each of conspiracy to unlawfully distribute and dispense controlled substances and maintaining drug-involved premises and conspiracy to commit health care fraud, Dr. Talbot is also charged with four counts of unlawfully distributing and dispensing controlled substances. He is scheduled for a federal court appearance on September 10.

In addition to presigning prescriptions for individuals he didn’t meet or examine, federal officials allege Dr. Talbot hired another health care provider to similarly presign prescriptions for people who weren’t examined at a medical practice in Slidell, where Dr. Talbot was employed. The DOJ says Dr. Talbot took a full-time job in Pineville, La., and presigned prescriptions while no longer physically present at the Slidell clinic.

A speaker’s bio for Dr. Talbot indicates he worked as chief of medical services for the Alexandria Veterans Affairs Health Care System in Pineville.

According to the DOJ’s indictment, Dr. Talbot was aware that patients were filling the prescriptions that were provided outside the scope of professional practice and not for a legitimate medical purpose. This is what triggered the DOJ’s fraudulent billing claim. 

Dr. Talbot faces a maximum penalty of 10 years for conspiracy to commit health care fraud and 20 years each for the other counts, if convicted.
 

Dr. Talbot was candidate for local coroner

In February 2015, Dr. Talbot announced his candidacy for coroner for St. Tammany Parish, about an hour’s drive south of New Orleans, reported the Times Picayune. The seat was open because the previous coroner had resigned and ultimately pleaded guilty to a federal corruption charge.

The Times Picayune reported at the time that Dr. Talbot was a U.S. Navy veteran, in addition to serving as medical director and a primary care physician at the Medical Care Center in Slidell. Among the services provided to his patients were evaluations and treatment for substance use and mental health disorders, according to a press release issued by Dr. Talbot’s campaign.

Dr. Talbot’s medical license was issued in 1999 and inactive as of 2017, per the Louisiana State Board of Medical Examiners.
 

Louisiana expects $325M in multistate settlement with opioid companies

Louisiana is a party to a multistate and multijurisdictional lawsuit where the state is expected to receive more than $325 million in a settlement reached with drug distributors Cardinal, McKesson, and AmerisourceBergen, and drug manufacturer Johnson & Johnson, reported the Louisiana Illuminator in July. The total settlement may reach $26 billion dollars.

The Associated Press reported in July that there have been at least $40 billion in completed or proposed settlements, penalties, and fines between governments as a result of the opioid epidemic since 2007.

That total doesn’t include a proposed settlement involving members of the Sackler family, who own Purdue Pharmaceuticals, which manufactured and marketed the opioid painkiller OxyContin. The Sackler family have agreed to pay approximately $4.3 billion and surrender ownership of their bankrupt company, reported NPR. The family’s proposed settlement is part of a deal involving Purdue Pharmaceuticals worth more than $10 billion, reported Reuters.

In 2020, there were more than 81,000 drug overdose deaths, the highest number recorded in a 12-month period, per the U.S. Centers for Disease Control and Prevention. Fentanyl, an illicitly manufactured synthetic opioid, was the lead driver of those deaths.

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

A Louisiana physician, who refers to himself as a “former assassin,” was indicted by a federal grand jury for his role in distributing more than 1.2 million doses of schedule II controlled substances outside the scope of professional practice and not for a legitimate medical purpose, according to the U.S. Department of Justice. The substances include oxycodone and morphine.

Adrian Dexter Talbot, MD, 55, of Slidell, La., is also charged with maintaining a medical clinic for the purpose of illegally distributing controlled substances, per the indictment.

Because the opioid prescriptions were filled using beneficiaries’ health insurance, Dr. Talbot is also charged with defrauding Medicare, Medicaid, and Blue Cross and Blue Shield of Louisiana of more than $5.1 million.

When contacted by this news organization for comment on the case via Twitter, Dr. Talbot or a representative responded with a link to his self-published book on Amazon. In his author bio, Dr. Talbot refers to himself as “a former assassin,” “retired military commander,” and “leader of the Medellin Cartel’s New York operations at the age of 16.” The Medellin Cartel is a notorious drug distribution empire.

Dr. Talbot is listed as the author of another book on Google Books detailing his time as a “former teenage assassin” and leader of the cartel, told as he struggles with early onset Alzheimer’s.
 

Dr. Talbot could spend decades in prison

According to the National Institute on Drug Abuse, 444 residents of the Bayou State lost their lives because of an opioid-related drug overdose in 2018. During that year, the state’s health care providers wrote more than 79.4 opioid prescriptions for every 100 persons, which puts the state in the top five in the United States in 2018, when the average U.S. rate was 51.4 prescriptions per 100 persons.

Charged with one count each of conspiracy to unlawfully distribute and dispense controlled substances and maintaining drug-involved premises and conspiracy to commit health care fraud, Dr. Talbot is also charged with four counts of unlawfully distributing and dispensing controlled substances. He is scheduled for a federal court appearance on September 10.

In addition to presigning prescriptions for individuals he didn’t meet or examine, federal officials allege Dr. Talbot hired another health care provider to similarly presign prescriptions for people who weren’t examined at a medical practice in Slidell, where Dr. Talbot was employed. The DOJ says Dr. Talbot took a full-time job in Pineville, La., and presigned prescriptions while no longer physically present at the Slidell clinic.

A speaker’s bio for Dr. Talbot indicates he worked as chief of medical services for the Alexandria Veterans Affairs Health Care System in Pineville.

According to the DOJ’s indictment, Dr. Talbot was aware that patients were filling the prescriptions that were provided outside the scope of professional practice and not for a legitimate medical purpose. This is what triggered the DOJ’s fraudulent billing claim. 

Dr. Talbot faces a maximum penalty of 10 years for conspiracy to commit health care fraud and 20 years each for the other counts, if convicted.
 

Dr. Talbot was candidate for local coroner

In February 2015, Dr. Talbot announced his candidacy for coroner for St. Tammany Parish, about an hour’s drive south of New Orleans, reported the Times Picayune. The seat was open because the previous coroner had resigned and ultimately pleaded guilty to a federal corruption charge.

The Times Picayune reported at the time that Dr. Talbot was a U.S. Navy veteran, in addition to serving as medical director and a primary care physician at the Medical Care Center in Slidell. Among the services provided to his patients were evaluations and treatment for substance use and mental health disorders, according to a press release issued by Dr. Talbot’s campaign.

Dr. Talbot’s medical license was issued in 1999 and inactive as of 2017, per the Louisiana State Board of Medical Examiners.
 

Louisiana expects $325M in multistate settlement with opioid companies

Louisiana is a party to a multistate and multijurisdictional lawsuit where the state is expected to receive more than $325 million in a settlement reached with drug distributors Cardinal, McKesson, and AmerisourceBergen, and drug manufacturer Johnson & Johnson, reported the Louisiana Illuminator in July. The total settlement may reach $26 billion dollars.

The Associated Press reported in July that there have been at least $40 billion in completed or proposed settlements, penalties, and fines between governments as a result of the opioid epidemic since 2007.

That total doesn’t include a proposed settlement involving members of the Sackler family, who own Purdue Pharmaceuticals, which manufactured and marketed the opioid painkiller OxyContin. The Sackler family have agreed to pay approximately $4.3 billion and surrender ownership of their bankrupt company, reported NPR. The family’s proposed settlement is part of a deal involving Purdue Pharmaceuticals worth more than $10 billion, reported Reuters.

In 2020, there were more than 81,000 drug overdose deaths, the highest number recorded in a 12-month period, per the U.S. Centers for Disease Control and Prevention. Fentanyl, an illicitly manufactured synthetic opioid, was the lead driver of those deaths.

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

Despite the COVID-19 pandemic, oncologists still enjoyed an increase in their income as well as an increase in their overall wealth, according to the Medscape Oncologist Debt and Net Worth Report 2021.

Overall, oncologists’ average annual income rose from $377,000 in 2020 to $403,000 this year.

Although many offices closed for periods during 2020, some physicians used the Paycheck Protection Program. Others found other methods to keep their earnings relatively stable, such as switching to telehealth, cutting staff, and renegotiating leases.

The overall net worth of oncologists also increased. This year, 55% reported a net worth of $1.5 million, compared to 42% last year. A contributing factor is the rise in home prices, suggested Joel Greenwald, MD, CFP, a wealth management advisor for physicians.

The rise in the stock market also played a role, he noted. “And I’ve seen clients accumulate cash, which has added to their net worth. They cut back on spending because they were worried about big declines in income and also because there was simply less to spend money on.”

The percentage of oncologists (16%) with a net worth of more than $5 million stayed pretty much the same. Oncology remained in the upper half of the list of wealthy specialties. Topping that list are dermatology (28%), orthopedics and orthopedic surgery (25%), and plastic surgery (24%).

On the flip side, the percentage of oncologists on the lower end of the net worth scale declined from last year. Oncology was the specialty with the lowest percentage of practitioners (16%) reporting a net worth of under $500,000.
 

Expenses and debts

Similar to reports from previous years, this latest survey found that more than half of oncologists (56%) said they are paying off a mortgage on a primary residence. About a third (32%) are paying off a car loan. Credit card debt (19%), college or medical school loans (17%), childcare (14%), and medical expenses for themselves or a loved one (12%) were also reported.

When it comes to paying off school loans, oncology was near the bottom of the list of 29 medical specialties, along with nephrology, gastroenterology, and diabetes and endocrinology. Emergency medicine topped that list, followed by family medicine, pediatrics, physical medicine, and rehabilitation (all 31%).

Although the vast majority of oncologists (94%) were able to keep up with their bills, the pandemic did take a toll on some. Six percent said that they were unable to keep up with their bills, and 3% could not meet their mortgage. This is far superior to the American population at large – a quarter of adults missed a mortgage payment or rent payment because of challenges associated with the pandemic.
 

Saving and losses

Most oncologists did not take any extra steps to curtail spending – 77% reported that they had not done anything to reduce major expenses. About a quarter of respondents took significant steps to lower their expenses, such as deferring or refinancing loans (11%), switching to a different type of car (6%), or moving to a different home (5%).

Savings for tax deferred accounts this year was a mixed bag. More than half (56%) of oncologists said that they put aside the same amount every month, give or take; 11% do not regularly put money into a 401(k) retirement account or tax-deferred savings account. Compared to last year, 32% put less money into their savings accounts. Having fewer patients or working fewer hours during the pandemic may have resulted in oncologists needing more of their income, or even their full income, to pay their bills.

Similar results were seen with taxable savings. Half of oncologists were putting the same amount into bank accounts; 20% reported that they do not regularly put money into this type of account. Compared to last year, 29% put less money into taxable savings.

Most oncologists (75%) reported that they did not experience any significant financial losses during the past year. This was similar to last year (77%). The percentage of those who had losses related to their practice rose from 3% to 8%. Much of this increase was due to COVID-19.
 

Living within their means

The vast majority of oncologists live within or below their means (94%). “There are certainly folks who believe that as long as they pay their credit card every month and contribute to their 401(k) enough to get their employer match, they’re doing okay,” said Dr. Greenwald. “I would say living within one’s means is having a 3 to 6 months’ emergency fund and saving at least 20% of gross income toward retirement.”

Although most oncologists live within their means, they also have a higher than average number of credit cards. More than half (54%) have at least five; the average American has four. Nineteen percent of oncologists reported having seven or more credit cards, and none said they had no credit cards.

Mortgage payments varied considerably among respondents, from less than $100,000 (16%) to more than half a million (21%). More than a third (37%) reported having no mortgage at all. According to the Mortgage Bankers Association, the overall average size of a home mortgage loan was $344,556 in March 2020.

For household finances, 57% reported that they pool incomes to pay the bills, regardless of how much each person earns. A quarter said that they do not have joint finances with a spouse or partner, and for 13%, the person with the higher income paid a larger share.

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

Despite the COVID-19 pandemic, oncologists still enjoyed an increase in their income as well as an increase in their overall wealth, according to the Medscape Oncologist Debt and Net Worth Report 2021.

Overall, oncologists’ average annual income rose from $377,000 in 2020 to $403,000 this year.

Although many offices closed for periods during 2020, some physicians used the Paycheck Protection Program. Others found other methods to keep their earnings relatively stable, such as switching to telehealth, cutting staff, and renegotiating leases.

The overall net worth of oncologists also increased. This year, 55% reported a net worth of $1.5 million, compared to 42% last year. A contributing factor is the rise in home prices, suggested Joel Greenwald, MD, CFP, a wealth management advisor for physicians.

The rise in the stock market also played a role, he noted. “And I’ve seen clients accumulate cash, which has added to their net worth. They cut back on spending because they were worried about big declines in income and also because there was simply less to spend money on.”

The percentage of oncologists (16%) with a net worth of more than $5 million stayed pretty much the same. Oncology remained in the upper half of the list of wealthy specialties. Topping that list are dermatology (28%), orthopedics and orthopedic surgery (25%), and plastic surgery (24%).

On the flip side, the percentage of oncologists on the lower end of the net worth scale declined from last year. Oncology was the specialty with the lowest percentage of practitioners (16%) reporting a net worth of under $500,000.
 

Expenses and debts

Similar to reports from previous years, this latest survey found that more than half of oncologists (56%) said they are paying off a mortgage on a primary residence. About a third (32%) are paying off a car loan. Credit card debt (19%), college or medical school loans (17%), childcare (14%), and medical expenses for themselves or a loved one (12%) were also reported.

When it comes to paying off school loans, oncology was near the bottom of the list of 29 medical specialties, along with nephrology, gastroenterology, and diabetes and endocrinology. Emergency medicine topped that list, followed by family medicine, pediatrics, physical medicine, and rehabilitation (all 31%).

Although the vast majority of oncologists (94%) were able to keep up with their bills, the pandemic did take a toll on some. Six percent said that they were unable to keep up with their bills, and 3% could not meet their mortgage. This is far superior to the American population at large – a quarter of adults missed a mortgage payment or rent payment because of challenges associated with the pandemic.
 

Saving and losses

Most oncologists did not take any extra steps to curtail spending – 77% reported that they had not done anything to reduce major expenses. About a quarter of respondents took significant steps to lower their expenses, such as deferring or refinancing loans (11%), switching to a different type of car (6%), or moving to a different home (5%).

Savings for tax deferred accounts this year was a mixed bag. More than half (56%) of oncologists said that they put aside the same amount every month, give or take; 11% do not regularly put money into a 401(k) retirement account or tax-deferred savings account. Compared to last year, 32% put less money into their savings accounts. Having fewer patients or working fewer hours during the pandemic may have resulted in oncologists needing more of their income, or even their full income, to pay their bills.

Similar results were seen with taxable savings. Half of oncologists were putting the same amount into bank accounts; 20% reported that they do not regularly put money into this type of account. Compared to last year, 29% put less money into taxable savings.

Most oncologists (75%) reported that they did not experience any significant financial losses during the past year. This was similar to last year (77%). The percentage of those who had losses related to their practice rose from 3% to 8%. Much of this increase was due to COVID-19.
 

Living within their means

The vast majority of oncologists live within or below their means (94%). “There are certainly folks who believe that as long as they pay their credit card every month and contribute to their 401(k) enough to get their employer match, they’re doing okay,” said Dr. Greenwald. “I would say living within one’s means is having a 3 to 6 months’ emergency fund and saving at least 20% of gross income toward retirement.”

Although most oncologists live within their means, they also have a higher than average number of credit cards. More than half (54%) have at least five; the average American has four. Nineteen percent of oncologists reported having seven or more credit cards, and none said they had no credit cards.

Mortgage payments varied considerably among respondents, from less than $100,000 (16%) to more than half a million (21%). More than a third (37%) reported having no mortgage at all. According to the Mortgage Bankers Association, the overall average size of a home mortgage loan was $344,556 in March 2020.

For household finances, 57% reported that they pool incomes to pay the bills, regardless of how much each person earns. A quarter said that they do not have joint finances with a spouse or partner, and for 13%, the person with the higher income paid a larger share.

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

Despite the COVID-19 pandemic, oncologists still enjoyed an increase in their income as well as an increase in their overall wealth, according to the Medscape Oncologist Debt and Net Worth Report 2021.

Overall, oncologists’ average annual income rose from $377,000 in 2020 to $403,000 this year.

Although many offices closed for periods during 2020, some physicians used the Paycheck Protection Program. Others found other methods to keep their earnings relatively stable, such as switching to telehealth, cutting staff, and renegotiating leases.

The overall net worth of oncologists also increased. This year, 55% reported a net worth of $1.5 million, compared to 42% last year. A contributing factor is the rise in home prices, suggested Joel Greenwald, MD, CFP, a wealth management advisor for physicians.

The rise in the stock market also played a role, he noted. “And I’ve seen clients accumulate cash, which has added to their net worth. They cut back on spending because they were worried about big declines in income and also because there was simply less to spend money on.”

The percentage of oncologists (16%) with a net worth of more than $5 million stayed pretty much the same. Oncology remained in the upper half of the list of wealthy specialties. Topping that list are dermatology (28%), orthopedics and orthopedic surgery (25%), and plastic surgery (24%).

On the flip side, the percentage of oncologists on the lower end of the net worth scale declined from last year. Oncology was the specialty with the lowest percentage of practitioners (16%) reporting a net worth of under $500,000.
 

Expenses and debts

Similar to reports from previous years, this latest survey found that more than half of oncologists (56%) said they are paying off a mortgage on a primary residence. About a third (32%) are paying off a car loan. Credit card debt (19%), college or medical school loans (17%), childcare (14%), and medical expenses for themselves or a loved one (12%) were also reported.

When it comes to paying off school loans, oncology was near the bottom of the list of 29 medical specialties, along with nephrology, gastroenterology, and diabetes and endocrinology. Emergency medicine topped that list, followed by family medicine, pediatrics, physical medicine, and rehabilitation (all 31%).

Although the vast majority of oncologists (94%) were able to keep up with their bills, the pandemic did take a toll on some. Six percent said that they were unable to keep up with their bills, and 3% could not meet their mortgage. This is far superior to the American population at large – a quarter of adults missed a mortgage payment or rent payment because of challenges associated with the pandemic.
 

Saving and losses

Most oncologists did not take any extra steps to curtail spending – 77% reported that they had not done anything to reduce major expenses. About a quarter of respondents took significant steps to lower their expenses, such as deferring or refinancing loans (11%), switching to a different type of car (6%), or moving to a different home (5%).

Savings for tax deferred accounts this year was a mixed bag. More than half (56%) of oncologists said that they put aside the same amount every month, give or take; 11% do not regularly put money into a 401(k) retirement account or tax-deferred savings account. Compared to last year, 32% put less money into their savings accounts. Having fewer patients or working fewer hours during the pandemic may have resulted in oncologists needing more of their income, or even their full income, to pay their bills.

Similar results were seen with taxable savings. Half of oncologists were putting the same amount into bank accounts; 20% reported that they do not regularly put money into this type of account. Compared to last year, 29% put less money into taxable savings.

Most oncologists (75%) reported that they did not experience any significant financial losses during the past year. This was similar to last year (77%). The percentage of those who had losses related to their practice rose from 3% to 8%. Much of this increase was due to COVID-19.
 

Living within their means

The vast majority of oncologists live within or below their means (94%). “There are certainly folks who believe that as long as they pay their credit card every month and contribute to their 401(k) enough to get their employer match, they’re doing okay,” said Dr. Greenwald. “I would say living within one’s means is having a 3 to 6 months’ emergency fund and saving at least 20% of gross income toward retirement.”

Although most oncologists live within their means, they also have a higher than average number of credit cards. More than half (54%) have at least five; the average American has four. Nineteen percent of oncologists reported having seven or more credit cards, and none said they had no credit cards.

Mortgage payments varied considerably among respondents, from less than $100,000 (16%) to more than half a million (21%). More than a third (37%) reported having no mortgage at all. According to the Mortgage Bankers Association, the overall average size of a home mortgage loan was $344,556 in March 2020.

For household finances, 57% reported that they pool incomes to pay the bills, regardless of how much each person earns. A quarter said that they do not have joint finances with a spouse or partner, and for 13%, the person with the higher income paid a larger share.

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

As COVID vaccine boosters move closer to reality, most physicians and nurses are ready and willing to get another shot in the arm, according to a new Medscape survey.

Altogether, 93% of physicians and 87% of nurses/advanced practice nurses (APNs) said they wanted to get a booster, although the timing of when they wanted the shots differed somewhat between the two groups surveyed Aug. 4-15.

Among the 732 physicians polled, 50% wanted to get their shot immediately, compared with 38% of the 1,193 nurses/APNs who responded, while 44% of physicians and 50% of nurses/APNs said that they would wait until the vaccine booster was authorized and recommended.

At this point in time, almost all of the health care workers surveyed – 98% of physicians and 94% of nurses/APNs – have been fully vaccinated against COVID-19. A small proportion of each group, however, received the Johnson & Johnson vaccine (1% of physicians and 3% of nurses) and are not included in the current plan for booster shots.

The Medscape survey sample did include one group that is already eligible for a third dose: About 20% of physicians and 26% of nurses/ANPs said they have a condition or take a medication that compromises their immune system.

Respondents’ experiences with patient requests for boosters suggest a somewhat lower level of interest. About two-thirds of the health care workers (69% of physicians and 63% of nurses) said that patients frequently or sometimes asked about COVID boosters, compared with 13% (physicians) and 19% (nurses) who said their patients had never asked.
 

Interest lower among general population

In a separate survey conducted by WebMD, 82% of those who have been at least partially vaccinated said they want to get a COVID vaccine booster (14% immediately and 68% after authorization and recommendation). Of the remaining vaccinees, 7% said they do not want to get a booster and 11% were unsure.

The full sample of 592 respondents surveyed Aug. 5-10, however, included 19% who do not plan to get vaccinated and 6% who are planning to be vaccinated but have not yet done so.

The proportion of immunocompromised individuals in the two survey groups was similar, with about 25% of those in the WebMD survey reporting they have a condition or take a medication that compromises their immune system. Those respondents were more than twice as likely to want to get a booster immediately, compared to those with an uncompromised immune system (24% vs. 11%).

The distribution of vaccines received by brand was also comparable between the two groups surveyed. Of health care workers and readers, over half of each group received the Pfizer/BioNTech vaccine (59% vs. 54%), followed by Moderna (38% vs. 40%) and Johnson & Johnson (3% vs. 5%).

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

As COVID vaccine boosters move closer to reality, most physicians and nurses are ready and willing to get another shot in the arm, according to a new Medscape survey.

Altogether, 93% of physicians and 87% of nurses/advanced practice nurses (APNs) said they wanted to get a booster, although the timing of when they wanted the shots differed somewhat between the two groups surveyed Aug. 4-15.

Among the 732 physicians polled, 50% wanted to get their shot immediately, compared with 38% of the 1,193 nurses/APNs who responded, while 44% of physicians and 50% of nurses/APNs said that they would wait until the vaccine booster was authorized and recommended.

At this point in time, almost all of the health care workers surveyed – 98% of physicians and 94% of nurses/APNs – have been fully vaccinated against COVID-19. A small proportion of each group, however, received the Johnson & Johnson vaccine (1% of physicians and 3% of nurses) and are not included in the current plan for booster shots.

The Medscape survey sample did include one group that is already eligible for a third dose: About 20% of physicians and 26% of nurses/ANPs said they have a condition or take a medication that compromises their immune system.

Respondents’ experiences with patient requests for boosters suggest a somewhat lower level of interest. About two-thirds of the health care workers (69% of physicians and 63% of nurses) said that patients frequently or sometimes asked about COVID boosters, compared with 13% (physicians) and 19% (nurses) who said their patients had never asked.
 

Interest lower among general population

In a separate survey conducted by WebMD, 82% of those who have been at least partially vaccinated said they want to get a COVID vaccine booster (14% immediately and 68% after authorization and recommendation). Of the remaining vaccinees, 7% said they do not want to get a booster and 11% were unsure.

The full sample of 592 respondents surveyed Aug. 5-10, however, included 19% who do not plan to get vaccinated and 6% who are planning to be vaccinated but have not yet done so.

The proportion of immunocompromised individuals in the two survey groups was similar, with about 25% of those in the WebMD survey reporting they have a condition or take a medication that compromises their immune system. Those respondents were more than twice as likely to want to get a booster immediately, compared to those with an uncompromised immune system (24% vs. 11%).

The distribution of vaccines received by brand was also comparable between the two groups surveyed. Of health care workers and readers, over half of each group received the Pfizer/BioNTech vaccine (59% vs. 54%), followed by Moderna (38% vs. 40%) and Johnson & Johnson (3% vs. 5%).

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

As COVID vaccine boosters move closer to reality, most physicians and nurses are ready and willing to get another shot in the arm, according to a new Medscape survey.

Altogether, 93% of physicians and 87% of nurses/advanced practice nurses (APNs) said they wanted to get a booster, although the timing of when they wanted the shots differed somewhat between the two groups surveyed Aug. 4-15.

Among the 732 physicians polled, 50% wanted to get their shot immediately, compared with 38% of the 1,193 nurses/APNs who responded, while 44% of physicians and 50% of nurses/APNs said that they would wait until the vaccine booster was authorized and recommended.

At this point in time, almost all of the health care workers surveyed – 98% of physicians and 94% of nurses/APNs – have been fully vaccinated against COVID-19. A small proportion of each group, however, received the Johnson & Johnson vaccine (1% of physicians and 3% of nurses) and are not included in the current plan for booster shots.

The Medscape survey sample did include one group that is already eligible for a third dose: About 20% of physicians and 26% of nurses/ANPs said they have a condition or take a medication that compromises their immune system.

Respondents’ experiences with patient requests for boosters suggest a somewhat lower level of interest. About two-thirds of the health care workers (69% of physicians and 63% of nurses) said that patients frequently or sometimes asked about COVID boosters, compared with 13% (physicians) and 19% (nurses) who said their patients had never asked.
 

Interest lower among general population

In a separate survey conducted by WebMD, 82% of those who have been at least partially vaccinated said they want to get a COVID vaccine booster (14% immediately and 68% after authorization and recommendation). Of the remaining vaccinees, 7% said they do not want to get a booster and 11% were unsure.

The full sample of 592 respondents surveyed Aug. 5-10, however, included 19% who do not plan to get vaccinated and 6% who are planning to be vaccinated but have not yet done so.

The proportion of immunocompromised individuals in the two survey groups was similar, with about 25% of those in the WebMD survey reporting they have a condition or take a medication that compromises their immune system. Those respondents were more than twice as likely to want to get a booster immediately, compared to those with an uncompromised immune system (24% vs. 11%).

The distribution of vaccines received by brand was also comparable between the two groups surveyed. Of health care workers and readers, over half of each group received the Pfizer/BioNTech vaccine (59% vs. 54%), followed by Moderna (38% vs. 40%) and Johnson & Johnson (3% vs. 5%).

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

Globally, the United States has the highest per-capita cost of health care; total costs are expected to account for approximately 20% of the nation’s gross domestic product by 2025.¹ These rising costs have prompted residency programs and medical schools to incorporate business education into their curricula.^2-5 Although medical training is demanding—with little room to add curricular components—these business-focused curricula have consistently received positive feedback from residents.^5,6

In dermatology, more than 50% of residents opt to join a private practice upon graduation.⁷ In the United States, there also is an upward trend of practice acquisition and consolidation by private equity firms. Therefore, dermatology trainees are uniquely positioned to benefit from business education to make well-informed decisions about joining or starting a practice.Furthermore, whether in a private or academic setting, knowledge of foundational economics, business strategy, finance, marketing, and health care policy can equip dermatologists to more effectively advocate for local and national policies that benefit their patient population.⁷

We conducted a survey of dermatology program directors (PDs) to determine the availability of and perceptions regarding business education during residency training.

Materials and Methods

Institutional review board (Vanderbilt University Medical Center, Nashville, Tennessee) approval was obtained. The survey was distributed weekly during a 5-week period from July 2020 to August 2020 through the Research Electronic Data Capture survey application (www.project-redcap.org). Program director email addresses were obtained through the Accreditation Council for Graduate Medical Education (ACGME) program list. A PD was included in the survey if they were employed by an accredited US osteopathic or allopathic program and their email address was provided in the ACGME program list or on their program’s faculty web page; a PD was excluded if an email address was not provided in the ACGME program list or on their program’s faculty web page.

The 8-part questionnaire was designed to assess the following characteristics: details about the respondent’s residency program (institutional affiliation, number of residents), the respondent’s professional background (number of years as a PD, business training experience), resources for business education provided by the program, the respondent’s opinion about business education for residents, and the respondent’s perception of the most important topics to include in a dermatology curriculum’s business education component, which included economics/finance, health care policy/government, management, marketing, negotiation, private equity involvement in health care, business strategy, supply chain/operations, and technology/product development. Responses were kept anonymous. Categorical and continuous variables were analyzed with medians and proportions.

Results

Of the 139 surveys distributed, 35 were completed and returned (response rate, 25.2%). Most programs were university-affiliated (71.4%) or community-affiliated (22.9%). The median number of residents was 12. The respondents had a median of 5 years’ experience in their role. Most respondents (65.7%) had no business training, although 20.0% had completed undergraduate business coursework, and 8.6% had attended formal seminars on business topics; 5.7% were self-taught on business topics.

Business Education Availability
Approximately half (51.4%) of programs offered business training to residents, primarily through seminars or lectures (94.4%) and take-home modules (16.7%). None of the programs offered a formal gap year during which residents could pursue a professional business degree. Most respondents thought business education during residency was important (82.8%) and that programs should implement more training (57.1%). When asked whether residents were competent to handle business aspects of dermatology upon graduation, most respondents disagreed somewhat (22.9%) or were neutral (40.0%).

Topics for Business Education
The most important topics identified for inclusion in a business curriculum were economics or finance (68.6%), management (68.6%), and health care policy or government (57.1%). Other identified topics included negotiation (40.0%), private equity involvement in health care (40.0%), strategy (11.4%), supply chain or operations (11.4%), marketing (2.9%), and technology (2.9%).

Comment

Residency programs and medical schools in the United States have started to integrate formal business training into their curricula; however, the state of business training in dermatology has not been characterized. Overall, this survey revealed largely positive perceptions about business education and identified a demand for more resources.

Whereas most PDs identified business education as important, only one half (51.4%) of the representative programs offered structured training. Notably, most PDs did not agree that graduating residents were competent to handle the business demands of dermatology practice. These responses highlight a gap in the demand and resources available for business training.

Identifying Curricular Resources
During an already demanding residency, additional curricular components need to be beneficial and worthwhile. To avoid significant disruption, business training could take place in the form of online lectures or take-home modules. Most programs represented in the survey responses had an academic affiliation and therefore commonly have access to an affiliated graduate business school and/or hospital administrators who have clinical and business training.

Community dermatologists who own or run their own practice also are uniquely positioned to provide residents with practical, dermatology-specific business education. Programs can utilize their institutional and local colleagues to aid in curricular design and implementation. In addition, a potential long-term solution to obtaining resources for business education is to coordinate with a national dermatology organization to create standardized modules that are available to all residency programs.

Key Curriculum Topics
Our survey identified the most important topics to include in a business curriculum for dermatology residents. Economics and finance, management, and health care policy would be valuable to a trainee regardless of whether they ultimately choose a career in academia or private practice. A thorough understanding of complex health care policy reinforces knowledge about insurance and regional and national regulations, which could ultimately benefit patient care. As an example, the American Academy of Dermatology outlines several advocacy priorities such as Medicare reimbursement policies, access to dermatologic care through public and private insurance, medication access and pricing, and preservation of private practice in the setting of market consolidation. Having a better understanding of health care policy and business could better equip dermatologists to lead these often business-driven advocacy efforts to ultimately improve patient care and advance the specialty.⁸

Limitations
There were notable limitations to this survey, primarily related to its design. With a 25% response rate, there was the potential for response and selection biases; therefore, these results might not be generalizable to all programs. In addition, views held by PDs might not be consistent with those of other members of the dermatology community; for example, surveying residents, other faculty members, and dermatologists in private practice would have provided a more comprehensive characterization of the topic.

Conclusion

This study assessed residency program directors’ perceptions of business education in dermatology training. There appears to be an imbalance between the perceived importance of such education and the resources that are available to provide it. More attention is needed to address this gap to ensure that dermatologists are prepared to manage a rapidly changing health care environment. Results of this survey should encourage efforts to establish (1) a standardized, dermatology-specific business curriculum and (2) a plan to make that curriculum accessible to trainees and other members of the dermatology community.

Globally, the United States has the highest per-capita cost of health care; total costs are expected to account for approximately 20% of the nation’s gross domestic product by 2025.¹ These rising costs have prompted residency programs and medical schools to incorporate business education into their curricula.^2-5 Although medical training is demanding—with little room to add curricular components—these business-focused curricula have consistently received positive feedback from residents.^5,6

In dermatology, more than 50% of residents opt to join a private practice upon graduation.⁷ In the United States, there also is an upward trend of practice acquisition and consolidation by private equity firms. Therefore, dermatology trainees are uniquely positioned to benefit from business education to make well-informed decisions about joining or starting a practice.Furthermore, whether in a private or academic setting, knowledge of foundational economics, business strategy, finance, marketing, and health care policy can equip dermatologists to more effectively advocate for local and national policies that benefit their patient population.⁷

We conducted a survey of dermatology program directors (PDs) to determine the availability of and perceptions regarding business education during residency training.

Materials and Methods

Institutional review board (Vanderbilt University Medical Center, Nashville, Tennessee) approval was obtained. The survey was distributed weekly during a 5-week period from July 2020 to August 2020 through the Research Electronic Data Capture survey application (www.project-redcap.org). Program director email addresses were obtained through the Accreditation Council for Graduate Medical Education (ACGME) program list. A PD was included in the survey if they were employed by an accredited US osteopathic or allopathic program and their email address was provided in the ACGME program list or on their program’s faculty web page; a PD was excluded if an email address was not provided in the ACGME program list or on their program’s faculty web page.

The 8-part questionnaire was designed to assess the following characteristics: details about the respondent’s residency program (institutional affiliation, number of residents), the respondent’s professional background (number of years as a PD, business training experience), resources for business education provided by the program, the respondent’s opinion about business education for residents, and the respondent’s perception of the most important topics to include in a dermatology curriculum’s business education component, which included economics/finance, health care policy/government, management, marketing, negotiation, private equity involvement in health care, business strategy, supply chain/operations, and technology/product development. Responses were kept anonymous. Categorical and continuous variables were analyzed with medians and proportions.

Results

Of the 139 surveys distributed, 35 were completed and returned (response rate, 25.2%). Most programs were university-affiliated (71.4%) or community-affiliated (22.9%). The median number of residents was 12. The respondents had a median of 5 years’ experience in their role. Most respondents (65.7%) had no business training, although 20.0% had completed undergraduate business coursework, and 8.6% had attended formal seminars on business topics; 5.7% were self-taught on business topics.

Business Education Availability
Approximately half (51.4%) of programs offered business training to residents, primarily through seminars or lectures (94.4%) and take-home modules (16.7%). None of the programs offered a formal gap year during which residents could pursue a professional business degree. Most respondents thought business education during residency was important (82.8%) and that programs should implement more training (57.1%). When asked whether residents were competent to handle business aspects of dermatology upon graduation, most respondents disagreed somewhat (22.9%) or were neutral (40.0%).

Topics for Business Education
The most important topics identified for inclusion in a business curriculum were economics or finance (68.6%), management (68.6%), and health care policy or government (57.1%). Other identified topics included negotiation (40.0%), private equity involvement in health care (40.0%), strategy (11.4%), supply chain or operations (11.4%), marketing (2.9%), and technology (2.9%).

Comment

Residency programs and medical schools in the United States have started to integrate formal business training into their curricula; however, the state of business training in dermatology has not been characterized. Overall, this survey revealed largely positive perceptions about business education and identified a demand for more resources.

Whereas most PDs identified business education as important, only one half (51.4%) of the representative programs offered structured training. Notably, most PDs did not agree that graduating residents were competent to handle the business demands of dermatology practice. These responses highlight a gap in the demand and resources available for business training.

Identifying Curricular Resources
During an already demanding residency, additional curricular components need to be beneficial and worthwhile. To avoid significant disruption, business training could take place in the form of online lectures or take-home modules. Most programs represented in the survey responses had an academic affiliation and therefore commonly have access to an affiliated graduate business school and/or hospital administrators who have clinical and business training.

Community dermatologists who own or run their own practice also are uniquely positioned to provide residents with practical, dermatology-specific business education. Programs can utilize their institutional and local colleagues to aid in curricular design and implementation. In addition, a potential long-term solution to obtaining resources for business education is to coordinate with a national dermatology organization to create standardized modules that are available to all residency programs.

Key Curriculum Topics
Our survey identified the most important topics to include in a business curriculum for dermatology residents. Economics and finance, management, and health care policy would be valuable to a trainee regardless of whether they ultimately choose a career in academia or private practice. A thorough understanding of complex health care policy reinforces knowledge about insurance and regional and national regulations, which could ultimately benefit patient care. As an example, the American Academy of Dermatology outlines several advocacy priorities such as Medicare reimbursement policies, access to dermatologic care through public and private insurance, medication access and pricing, and preservation of private practice in the setting of market consolidation. Having a better understanding of health care policy and business could better equip dermatologists to lead these often business-driven advocacy efforts to ultimately improve patient care and advance the specialty.⁸

Limitations
There were notable limitations to this survey, primarily related to its design. With a 25% response rate, there was the potential for response and selection biases; therefore, these results might not be generalizable to all programs. In addition, views held by PDs might not be consistent with those of other members of the dermatology community; for example, surveying residents, other faculty members, and dermatologists in private practice would have provided a more comprehensive characterization of the topic.

Conclusion

This study assessed residency program directors’ perceptions of business education in dermatology training. There appears to be an imbalance between the perceived importance of such education and the resources that are available to provide it. More attention is needed to address this gap to ensure that dermatologists are prepared to manage a rapidly changing health care environment. Results of this survey should encourage efforts to establish (1) a standardized, dermatology-specific business curriculum and (2) a plan to make that curriculum accessible to trainees and other members of the dermatology community.

Globally, the United States has the highest per-capita cost of health care; total costs are expected to account for approximately 20% of the nation’s gross domestic product by 2025.¹ These rising costs have prompted residency programs and medical schools to incorporate business education into their curricula.^2-5 Although medical training is demanding—with little room to add curricular components—these business-focused curricula have consistently received positive feedback from residents.^5,6

In dermatology, more than 50% of residents opt to join a private practice upon graduation.⁷ In the United States, there also is an upward trend of practice acquisition and consolidation by private equity firms. Therefore, dermatology trainees are uniquely positioned to benefit from business education to make well-informed decisions about joining or starting a practice.Furthermore, whether in a private or academic setting, knowledge of foundational economics, business strategy, finance, marketing, and health care policy can equip dermatologists to more effectively advocate for local and national policies that benefit their patient population.⁷

We conducted a survey of dermatology program directors (PDs) to determine the availability of and perceptions regarding business education during residency training.

Materials and Methods

Institutional review board (Vanderbilt University Medical Center, Nashville, Tennessee) approval was obtained. The survey was distributed weekly during a 5-week period from July 2020 to August 2020 through the Research Electronic Data Capture survey application (www.project-redcap.org). Program director email addresses were obtained through the Accreditation Council for Graduate Medical Education (ACGME) program list. A PD was included in the survey if they were employed by an accredited US osteopathic or allopathic program and their email address was provided in the ACGME program list or on their program’s faculty web page; a PD was excluded if an email address was not provided in the ACGME program list or on their program’s faculty web page.

The 8-part questionnaire was designed to assess the following characteristics: details about the respondent’s residency program (institutional affiliation, number of residents), the respondent’s professional background (number of years as a PD, business training experience), resources for business education provided by the program, the respondent’s opinion about business education for residents, and the respondent’s perception of the most important topics to include in a dermatology curriculum’s business education component, which included economics/finance, health care policy/government, management, marketing, negotiation, private equity involvement in health care, business strategy, supply chain/operations, and technology/product development. Responses were kept anonymous. Categorical and continuous variables were analyzed with medians and proportions.

Results

Of the 139 surveys distributed, 35 were completed and returned (response rate, 25.2%). Most programs were university-affiliated (71.4%) or community-affiliated (22.9%). The median number of residents was 12. The respondents had a median of 5 years’ experience in their role. Most respondents (65.7%) had no business training, although 20.0% had completed undergraduate business coursework, and 8.6% had attended formal seminars on business topics; 5.7% were self-taught on business topics.

Business Education Availability
Approximately half (51.4%) of programs offered business training to residents, primarily through seminars or lectures (94.4%) and take-home modules (16.7%). None of the programs offered a formal gap year during which residents could pursue a professional business degree. Most respondents thought business education during residency was important (82.8%) and that programs should implement more training (57.1%). When asked whether residents were competent to handle business aspects of dermatology upon graduation, most respondents disagreed somewhat (22.9%) or were neutral (40.0%).

Topics for Business Education
The most important topics identified for inclusion in a business curriculum were economics or finance (68.6%), management (68.6%), and health care policy or government (57.1%). Other identified topics included negotiation (40.0%), private equity involvement in health care (40.0%), strategy (11.4%), supply chain or operations (11.4%), marketing (2.9%), and technology (2.9%).

Comment

Residency programs and medical schools in the United States have started to integrate formal business training into their curricula; however, the state of business training in dermatology has not been characterized. Overall, this survey revealed largely positive perceptions about business education and identified a demand for more resources.

Whereas most PDs identified business education as important, only one half (51.4%) of the representative programs offered structured training. Notably, most PDs did not agree that graduating residents were competent to handle the business demands of dermatology practice. These responses highlight a gap in the demand and resources available for business training.

Identifying Curricular Resources
During an already demanding residency, additional curricular components need to be beneficial and worthwhile. To avoid significant disruption, business training could take place in the form of online lectures or take-home modules. Most programs represented in the survey responses had an academic affiliation and therefore commonly have access to an affiliated graduate business school and/or hospital administrators who have clinical and business training.

Community dermatologists who own or run their own practice also are uniquely positioned to provide residents with practical, dermatology-specific business education. Programs can utilize their institutional and local colleagues to aid in curricular design and implementation. In addition, a potential long-term solution to obtaining resources for business education is to coordinate with a national dermatology organization to create standardized modules that are available to all residency programs.

Key Curriculum Topics
Our survey identified the most important topics to include in a business curriculum for dermatology residents. Economics and finance, management, and health care policy would be valuable to a trainee regardless of whether they ultimately choose a career in academia or private practice. A thorough understanding of complex health care policy reinforces knowledge about insurance and regional and national regulations, which could ultimately benefit patient care. As an example, the American Academy of Dermatology outlines several advocacy priorities such as Medicare reimbursement policies, access to dermatologic care through public and private insurance, medication access and pricing, and preservation of private practice in the setting of market consolidation. Having a better understanding of health care policy and business could better equip dermatologists to lead these often business-driven advocacy efforts to ultimately improve patient care and advance the specialty.⁸

Limitations
There were notable limitations to this survey, primarily related to its design. With a 25% response rate, there was the potential for response and selection biases; therefore, these results might not be generalizable to all programs. In addition, views held by PDs might not be consistent with those of other members of the dermatology community; for example, surveying residents, other faculty members, and dermatologists in private practice would have provided a more comprehensive characterization of the topic.

Conclusion

This study assessed residency program directors’ perceptions of business education in dermatology training. There appears to be an imbalance between the perceived importance of such education and the resources that are available to provide it. More attention is needed to address this gap to ensure that dermatologists are prepared to manage a rapidly changing health care environment. Results of this survey should encourage efforts to establish (1) a standardized, dermatology-specific business curriculum and (2) a plan to make that curriculum accessible to trainees and other members of the dermatology community.

The COVID-19 pandemic has fueled a growing demand for nurse practitioners (NPs), while demand for primary care physicians has cooled, according to Merritt Hawkins’ annual review of physician and advanced practitioner recruiting trends.

This marks the first time in the review’s 28-year history that NPs have topped the list of the most recruited practitioners, according to the medical search firm. In the 27 prior years, physicians held the top spot. For the previous 14 years, the No. 1 position was held by family physicians.

“COVID-19 and other market forces are changing the dynamics of physician and advanced practitioner recruiting. NPs are coming into their own in a market that puts a premium on easy access to care and cost containment,” Tom Florence, president of Merritt Hawkins, said in a statement.
 

Primary care ‘recruiting frenzy’ over

Mr. Florence said primary care physicians remain a “vital part of team-based care and will be increasingly responsible for coordinating the care of older patients with multiple chronic conditions. But the recruiting frenzy in primary care is over.”

Merritt Hawkins says that overall COVID-19 has had a “severely inhibiting” effect on demand for physicians. The number of searches the company conducted dropped 25%, compared with 2020, and many hospitals and medical groups shut down or lost money during the pandemic.

But the drop-off in demand for physicians is likely to be temporary because the underlying dynamics driving physician supply and demand remain in place, according to the report. These include a growing and aging population, a limited supply of newly trained physicians, and an aging physician workforce.

COVID-19 will not permanently change these market conditions, and demand for physicians already is rebounding, the company said.

The 2021 review of physician and advanced practitioner recruiting is based on a representative sample of 2,458 permanent search engagements that Merritt Hawkins/AMN Healthcare’s physician staffing companies conducted or were in the process of conducting during the 12-month period from April 1, 2020, to March 31, 2021.

Among the key findings:

• 18% of Merritt Hawkins’ recruiting searches were for advanced practitioners, including NPs, physician assistants (PAs), and certified registered nurse anesthetists, up from 13% in the 2020 review. This represents the highest percentage in the 28 years the review has been conducted.
• About two-thirds (64%) of Merritt Hawkins’ search engagements were for physician specialists, including radiologists, psychiatrists, gastroenterologists, and others, “highlighting the robust demand for specialty physicians.”
• In 2021, 18% of Merritt Hawkins’ search engagements were for primary care physicians, down from 20% in 2020 and 22% in 2019, “signaling a relative decline in demand for primary care doctors.”
• Psychiatrists placed fourth on the list of most requested search engagements, a sign of continued strong demand for mental health professionals that is likely to accelerate because of COVID-19.

Starting salaries take a pandemic hit

Owing to the reduced demand for practitioners, starting salaries decreased for many types of health care professions, with the exception of NPs and PAs.

Average starting salaries for NPs showed strong growth, increasing 12% year over year, from $125,000 to $140,000. The average starting salaries for PAs also showed strong growth, increasing by 14% year over year, from $112,000 to $128,000.

Among physicians, interventional cardiologists were offered the highest average starting salaries, at $611,000, followed by orthopedic surgeons, at $546,000. Pediatricians were offered the lowest average starting salaries, at $236,000.

Merritt Hawkins said only 3% of their search engagements were for solo practice or partnership settings, “underscoring the decline of physician private practice.”

Roughly two-thirds (67%) of Merritt Hawkins’ search engagements were in communities of 100,000 people or more, indicating that demand for physicians and advanced practitioners is not limited to small or rural communities.

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

The COVID-19 pandemic has fueled a growing demand for nurse practitioners (NPs), while demand for primary care physicians has cooled, according to Merritt Hawkins’ annual review of physician and advanced practitioner recruiting trends.

This marks the first time in the review’s 28-year history that NPs have topped the list of the most recruited practitioners, according to the medical search firm. In the 27 prior years, physicians held the top spot. For the previous 14 years, the No. 1 position was held by family physicians.

“COVID-19 and other market forces are changing the dynamics of physician and advanced practitioner recruiting. NPs are coming into their own in a market that puts a premium on easy access to care and cost containment,” Tom Florence, president of Merritt Hawkins, said in a statement.
 

Primary care ‘recruiting frenzy’ over

Mr. Florence said primary care physicians remain a “vital part of team-based care and will be increasingly responsible for coordinating the care of older patients with multiple chronic conditions. But the recruiting frenzy in primary care is over.”

Merritt Hawkins says that overall COVID-19 has had a “severely inhibiting” effect on demand for physicians. The number of searches the company conducted dropped 25%, compared with 2020, and many hospitals and medical groups shut down or lost money during the pandemic.

But the drop-off in demand for physicians is likely to be temporary because the underlying dynamics driving physician supply and demand remain in place, according to the report. These include a growing and aging population, a limited supply of newly trained physicians, and an aging physician workforce.

COVID-19 will not permanently change these market conditions, and demand for physicians already is rebounding, the company said.

The 2021 review of physician and advanced practitioner recruiting is based on a representative sample of 2,458 permanent search engagements that Merritt Hawkins/AMN Healthcare’s physician staffing companies conducted or were in the process of conducting during the 12-month period from April 1, 2020, to March 31, 2021.

Among the key findings:

• 18% of Merritt Hawkins’ recruiting searches were for advanced practitioners, including NPs, physician assistants (PAs), and certified registered nurse anesthetists, up from 13% in the 2020 review. This represents the highest percentage in the 28 years the review has been conducted.
• About two-thirds (64%) of Merritt Hawkins’ search engagements were for physician specialists, including radiologists, psychiatrists, gastroenterologists, and others, “highlighting the robust demand for specialty physicians.”
• In 2021, 18% of Merritt Hawkins’ search engagements were for primary care physicians, down from 20% in 2020 and 22% in 2019, “signaling a relative decline in demand for primary care doctors.”
• Psychiatrists placed fourth on the list of most requested search engagements, a sign of continued strong demand for mental health professionals that is likely to accelerate because of COVID-19.

Starting salaries take a pandemic hit

Owing to the reduced demand for practitioners, starting salaries decreased for many types of health care professions, with the exception of NPs and PAs.

Average starting salaries for NPs showed strong growth, increasing 12% year over year, from $125,000 to $140,000. The average starting salaries for PAs also showed strong growth, increasing by 14% year over year, from $112,000 to $128,000.

Among physicians, interventional cardiologists were offered the highest average starting salaries, at $611,000, followed by orthopedic surgeons, at $546,000. Pediatricians were offered the lowest average starting salaries, at $236,000.

Merritt Hawkins said only 3% of their search engagements were for solo practice or partnership settings, “underscoring the decline of physician private practice.”

Roughly two-thirds (67%) of Merritt Hawkins’ search engagements were in communities of 100,000 people or more, indicating that demand for physicians and advanced practitioners is not limited to small or rural communities.

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

The COVID-19 pandemic has fueled a growing demand for nurse practitioners (NPs), while demand for primary care physicians has cooled, according to Merritt Hawkins’ annual review of physician and advanced practitioner recruiting trends.

This marks the first time in the review’s 28-year history that NPs have topped the list of the most recruited practitioners, according to the medical search firm. In the 27 prior years, physicians held the top spot. For the previous 14 years, the No. 1 position was held by family physicians.

“COVID-19 and other market forces are changing the dynamics of physician and advanced practitioner recruiting. NPs are coming into their own in a market that puts a premium on easy access to care and cost containment,” Tom Florence, president of Merritt Hawkins, said in a statement.
 

Primary care ‘recruiting frenzy’ over

Mr. Florence said primary care physicians remain a “vital part of team-based care and will be increasingly responsible for coordinating the care of older patients with multiple chronic conditions. But the recruiting frenzy in primary care is over.”

Merritt Hawkins says that overall COVID-19 has had a “severely inhibiting” effect on demand for physicians. The number of searches the company conducted dropped 25%, compared with 2020, and many hospitals and medical groups shut down or lost money during the pandemic.

But the drop-off in demand for physicians is likely to be temporary because the underlying dynamics driving physician supply and demand remain in place, according to the report. These include a growing and aging population, a limited supply of newly trained physicians, and an aging physician workforce.

COVID-19 will not permanently change these market conditions, and demand for physicians already is rebounding, the company said.

The 2021 review of physician and advanced practitioner recruiting is based on a representative sample of 2,458 permanent search engagements that Merritt Hawkins/AMN Healthcare’s physician staffing companies conducted or were in the process of conducting during the 12-month period from April 1, 2020, to March 31, 2021.

Among the key findings:

• 18% of Merritt Hawkins’ recruiting searches were for advanced practitioners, including NPs, physician assistants (PAs), and certified registered nurse anesthetists, up from 13% in the 2020 review. This represents the highest percentage in the 28 years the review has been conducted.
• About two-thirds (64%) of Merritt Hawkins’ search engagements were for physician specialists, including radiologists, psychiatrists, gastroenterologists, and others, “highlighting the robust demand for specialty physicians.”
• In 2021, 18% of Merritt Hawkins’ search engagements were for primary care physicians, down from 20% in 2020 and 22% in 2019, “signaling a relative decline in demand for primary care doctors.”
• Psychiatrists placed fourth on the list of most requested search engagements, a sign of continued strong demand for mental health professionals that is likely to accelerate because of COVID-19.

Starting salaries take a pandemic hit

Owing to the reduced demand for practitioners, starting salaries decreased for many types of health care professions, with the exception of NPs and PAs.

Average starting salaries for NPs showed strong growth, increasing 12% year over year, from $125,000 to $140,000. The average starting salaries for PAs also showed strong growth, increasing by 14% year over year, from $112,000 to $128,000.

Among physicians, interventional cardiologists were offered the highest average starting salaries, at $611,000, followed by orthopedic surgeons, at $546,000. Pediatricians were offered the lowest average starting salaries, at $236,000.

Merritt Hawkins said only 3% of their search engagements were for solo practice or partnership settings, “underscoring the decline of physician private practice.”

Roughly two-thirds (67%) of Merritt Hawkins’ search engagements were in communities of 100,000 people or more, indicating that demand for physicians and advanced practitioners is not limited to small or rural communities.

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

Study Overview

Objective. To update national trends in the treatment and risk factor control of diabetic patients from 1999 through 2018 in the US using data from the National Health and Nutrition Examination Survey (NHANES) with the goal of identifying population subgroups with the highest probability of having untreated risk factors.

Design. The authors conducted a cross-sectional analysis of data from NHANES focusing on adults with diabetes. They examined patient characteristics and medication use over time and estimated the prevalence of risk factor control and medication use. To minimize the effects of a small sample size, the survey years were pooled into 4-year intervals. The variables studied included glycated hemoglobin (HbA_1c), blood pressure, serum cholesterol, medication use, sociodemographic characteristics, and weight status. For statistical analysis, logistic and multinomial logistic regression models were used to examine factors associated with treatment in participants who did not achieve targets for glycemic, blood pressure, and lipid control. Temporal trends were estimated using 2-piece linear spline models with 1 knot at inflection points.

Setting and participants. The NHANES program began in the early 1960s to monitor the health of the US population. In 1999, the survey became a continuous program combining interviews and physical examinations. The survey examines a nationally representative sample of about 5000 persons each year. This study included 6653 participants who were nonpregnant, aged older than 20 years, reported a diagnosis of diabetes from a physician, and participated in NHANES from 1999 through 2018.

Main outcome measures. The main outcome measures were temporal trends in risk factor control (glycemic, blood pressure, or lipid levels) and medication use (glucose lowering, blood pressure lowering, or lipid lowering medications), and number as well as class of drug used, from 1999 through 2018 in diabetic adults from the US participating in NHANES.

Results. Sociodemographic characteristics of the studied diabetes population—The age and racial or ethnic distribution of participants with diabetes were stable from 1999 through 2018, whereas participants with a college degree, higher income, health insurance, obesity, or long-standing diabetes increased during the same period.

Trends in diabetes risk factor control—The trends for glycemic, blood pressure, and lipid control were nonlinear, with an inflection point around 2010. Glycemic control was defined as HbA_1c less than 7%, blood pressure was considered controlled if less than 140/90 mmHg, and lipid was controlled if non-HDL cholesterol level was less than 130 mg/dL. Although these chosen targets were based on the most recent clinical guidelines, the authors declared that they observed similar trends when alternative targets were used. The level of risk factor control improved in all diabetic patients from 1999 through 2010. However, the percentage of adult diabetic participants for whom glycemic control was achieved declined from 57.4% (95% CI, 52.9-61.8) in 2007-2010 to 50.5% (95% CI, 45.8-55.3) in 2015-2018. Blood pressure control was achieved in 74.2% of participants (95% CI, 70.7-77.4) in 2011-2014 but declined to 70.4% (95% CI, 66.7-73.8) in 2015-2018. Control in lipid levels improved during the entire study period; however, the rate of improvement heavily declined after 2007 with lipid target levels attained in 52.3% of participants (95% CI, 49.2-55.3) in 2007-2014 and 55.7% (95% CI, 50.8-60.5) in 2015-2018. Finally, the percentage of participants in whom targets for all 3 risk factors were simultaneously achieved plateaued after 2010 and was 22.2% (95% CI, 17.9-27.3) in 2015-2018.

Trends in diabetes treatment—The use of glucose lowering drugs increased from 74.1% in 1999-2002 to 82.7% in 2007-2010 and then stabilized. A shift toward a safer glucose lowering treatment choice was observed with a decline in the use of older glucose lowering medications such as sulfonylureas, which increases the risk of hypoglycemia, and an increase in the use of metformin, insulin, and newer agents such as sodium-glucose cotransporter 2 inhibitors.

Similarly, blood pressure lowering medication use rose from 1999-2002 to 2007-2010 and then stabilized, with increased use of first-line recommended treatments including angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. Likewise, statin use rose from 28.4% in 1999-2002 to 56% in 2011-2014 and then stabilized. The total number of drugs used culminated in 2011-2014 with 60% of participants using more than 5 drugs and then leveled off to 57.2% in 2015-2018. Lastly, health insurance status and race or ethnicity impacted the likelihood of receiving monotherapy or combination drug therapy when targets for glycemic, blood pressure, or lipid control were not achieved.

Conclusion. Despite great progress in the control of diabetes and its associated risk factors between 1999 and 2010, this trend declined for glycemic and blood pressure control and leveled off for lipid control in adult NHANES participants with diabetes after 2010. First-line treatments for diabetes and associated risk factors remain underused, and treatment intensification may not be sufficiently considered in patients with uncontrolled risk factors despite clinical guideline recommendations. The findings of this study may portend a possible population-level increase in diabetes-related illnesses in the years to come.

Commentary

The thorough understanding of trends in management of diseases is critical to inform public health policies and planning. Well designed clinical studies heavily influence the development of public health policies and clinical guidelines, which in turn drive real-world clinical practice. In a recent analysis utilizing data from NHANES, Fang et al¹ showed evidence of a general shift toward less intensive treatment of diabetes, hypertension, and hypercholesterolemia in adults living in the US during the last decade.

Similarly, in a separate study using NHANES data collected between 1999 and 2018 published in JAMA just 2 weeks after the current report, Wang et al² confirms this declining trend in diabetes management with only 21.2% of diabetic adults simultaneously attaining glycemic, blood pressure, and lipid level targets during the same period. What led to the decline in more stringent risk factor and diabetes management since 2010 observed in these studies? One possible explanation, as suggested by Fang et al, is that major clinical trials from the late 2000s­—including Action to Control Cardiovascular Risk in Diabetes, UK Prospective Diabetes Study, Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation, and Veterans Affairs Diabetes Trial—that assessed the effects of intensive glycemic control (with target HbA_1c < 6.5%) found that intensive treatment of diabetes compared to standard care had no cardiovascular benefit albeit increasing the risk of hypoglycemia. Thus, these trial findings may have translated into suboptimal diabetes treatment observed in some NHANES participants. Wang et al propose that effective tailored approaches are needed to improve risk factor control in diabetic patients, such as enhance and maintain adherence to medications and healthy lifestyle behaviors, as well as better access to health care and therapeutic education.

The changes in recent trends in diabetes management have immense clinical implications. The authors of this study suggest a link between the recent relaxation of glycemic targets, as well as risk factor control, and a resurgence of diabetic complications such as lower limb amputation or stroke. Indeed, several recent studies indicate an upward trend or plateau in diabetic complications which had been decreasing in prevalence prior to 2010.³ For example, lower extremity amputation has surged by more than 25% between 2010 and 2015, especially in young and middle-aged adults.⁴ Among the arguments brought forward that this recent resurgence in amputations is directly linked to worsening glycemic control is the fact that between 2007 and 2010, when glucose levels were best controlled within the previous 30-year period, amputations were also at the lowest levels. Moreover, data from the Centers for Disease Control and Prevention also show a 55% increase in mortality (from 15.7 to 24.2 per 1000) among diabetic patients between 2010 and 2015.¹⁴ On the other hand, a growing number of studies show that an increase of inappropriate treatment intensification—reaching HbA_1c levels that are way below the recommended targets—is associated with adverse consequences in diabetic patients particularly in those aged more than 65 years.^5-7 These seemingly contradictory findings highlight the importance of a personalized and thoughtful approach to the management of diabetes and its risk factors. As an example, an increase in the use of newer and safer glucose lowering drugs (eg, sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and dipeptidyl peptidase 4 inhibitors) can help achieve better HbA_1c goals with a reduced risk of hypoglycemic episodes as recently shown by a Danish study.⁸ In this study, the authors concluded that the reduction of the rate of hypoglycemic episodes leading to hospitalization in Denmark was directly linked to the use of these safer and newer glucose lowering drugs.

A discussion on the specifics of trends in diabetes treatment and control must include considerations in older adults aged more than 65 years who constitute more than 40% of the diabetic population. Despite the high prevalence of diabetes in this vulnerable population, such data are still insufficient in the literature and are critically needed to inform public health policies and clinical guidelines. In epidemiological studies focusing on diabetic complications from the last 10 years, concerning increases have been observed in younger⁹ and middle-aged adults while remaining stable in older adults. However, the risk of hypoglycemia or severe hypoglycemia remains high in older adults living in nursing facilities, even in those with an elevated HbA_1c of greater than 8%.⁷ Moreover, in light of more relaxed HbA_1c treatment goals for older frail adults as recommended by international guidelines since 2010,^10,11 recent findings from the French GERODIAB cohort show an increased mortality (hazard ratio, 1.76) in type 2 diabetics aged 70 years and older with HbA_1c greater than or equal to 8.6%.¹² Similarly, a 5-year retrospective British study from 2018 which included patients aged 70 years and older, shows an increased overall mortality in those with HbA_1c greater than 8.5%.¹³ Taken together, further age-stratified analysis utilizing data from large cohort studies including NHANES may help to clarify national trends in diabetes treatment and risk factor control as well as diabetic complications specific to the geriatric population. By being better informed of such trends, clinicians could then develop treatment strategies that minimize complications (eg, hypoglycemia, falls) while achieving favorable outcomes (eg, reduce hyperglycemic emergencies, improve survival) in frail older patients.

Applications for Clinical Practice

The understanding of population-wide trends in diabetes control is critical to planning public health approaches for the prevention and treatment of this disease and its complications. In older adults, the high risk of hypoglycemic events and insufficient epidemiological data on trends of diabetes control hinder diabetes management. Personalized treatment targets taking into account geriatric syndromes and general health status, as well as multidisciplinary management involving endocrinologists, geriatricians, and clinical pharmacists, are necessary to optimize care in older adults with diabetes.

Study Overview

Objective. To update national trends in the treatment and risk factor control of diabetic patients from 1999 through 2018 in the US using data from the National Health and Nutrition Examination Survey (NHANES) with the goal of identifying population subgroups with the highest probability of having untreated risk factors.

Design. The authors conducted a cross-sectional analysis of data from NHANES focusing on adults with diabetes. They examined patient characteristics and medication use over time and estimated the prevalence of risk factor control and medication use. To minimize the effects of a small sample size, the survey years were pooled into 4-year intervals. The variables studied included glycated hemoglobin (HbA_1c), blood pressure, serum cholesterol, medication use, sociodemographic characteristics, and weight status. For statistical analysis, logistic and multinomial logistic regression models were used to examine factors associated with treatment in participants who did not achieve targets for glycemic, blood pressure, and lipid control. Temporal trends were estimated using 2-piece linear spline models with 1 knot at inflection points.

Setting and participants. The NHANES program began in the early 1960s to monitor the health of the US population. In 1999, the survey became a continuous program combining interviews and physical examinations. The survey examines a nationally representative sample of about 5000 persons each year. This study included 6653 participants who were nonpregnant, aged older than 20 years, reported a diagnosis of diabetes from a physician, and participated in NHANES from 1999 through 2018.

Main outcome measures. The main outcome measures were temporal trends in risk factor control (glycemic, blood pressure, or lipid levels) and medication use (glucose lowering, blood pressure lowering, or lipid lowering medications), and number as well as class of drug used, from 1999 through 2018 in diabetic adults from the US participating in NHANES.

Results. Sociodemographic characteristics of the studied diabetes population—The age and racial or ethnic distribution of participants with diabetes were stable from 1999 through 2018, whereas participants with a college degree, higher income, health insurance, obesity, or long-standing diabetes increased during the same period.

Trends in diabetes risk factor control—The trends for glycemic, blood pressure, and lipid control were nonlinear, with an inflection point around 2010. Glycemic control was defined as HbA_1c less than 7%, blood pressure was considered controlled if less than 140/90 mmHg, and lipid was controlled if non-HDL cholesterol level was less than 130 mg/dL. Although these chosen targets were based on the most recent clinical guidelines, the authors declared that they observed similar trends when alternative targets were used. The level of risk factor control improved in all diabetic patients from 1999 through 2010. However, the percentage of adult diabetic participants for whom glycemic control was achieved declined from 57.4% (95% CI, 52.9-61.8) in 2007-2010 to 50.5% (95% CI, 45.8-55.3) in 2015-2018. Blood pressure control was achieved in 74.2% of participants (95% CI, 70.7-77.4) in 2011-2014 but declined to 70.4% (95% CI, 66.7-73.8) in 2015-2018. Control in lipid levels improved during the entire study period; however, the rate of improvement heavily declined after 2007 with lipid target levels attained in 52.3% of participants (95% CI, 49.2-55.3) in 2007-2014 and 55.7% (95% CI, 50.8-60.5) in 2015-2018. Finally, the percentage of participants in whom targets for all 3 risk factors were simultaneously achieved plateaued after 2010 and was 22.2% (95% CI, 17.9-27.3) in 2015-2018.

Trends in diabetes treatment—The use of glucose lowering drugs increased from 74.1% in 1999-2002 to 82.7% in 2007-2010 and then stabilized. A shift toward a safer glucose lowering treatment choice was observed with a decline in the use of older glucose lowering medications such as sulfonylureas, which increases the risk of hypoglycemia, and an increase in the use of metformin, insulin, and newer agents such as sodium-glucose cotransporter 2 inhibitors.

Similarly, blood pressure lowering medication use rose from 1999-2002 to 2007-2010 and then stabilized, with increased use of first-line recommended treatments including angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. Likewise, statin use rose from 28.4% in 1999-2002 to 56% in 2011-2014 and then stabilized. The total number of drugs used culminated in 2011-2014 with 60% of participants using more than 5 drugs and then leveled off to 57.2% in 2015-2018. Lastly, health insurance status and race or ethnicity impacted the likelihood of receiving monotherapy or combination drug therapy when targets for glycemic, blood pressure, or lipid control were not achieved.

Conclusion. Despite great progress in the control of diabetes and its associated risk factors between 1999 and 2010, this trend declined for glycemic and blood pressure control and leveled off for lipid control in adult NHANES participants with diabetes after 2010. First-line treatments for diabetes and associated risk factors remain underused, and treatment intensification may not be sufficiently considered in patients with uncontrolled risk factors despite clinical guideline recommendations. The findings of this study may portend a possible population-level increase in diabetes-related illnesses in the years to come.

Commentary

The thorough understanding of trends in management of diseases is critical to inform public health policies and planning. Well designed clinical studies heavily influence the development of public health policies and clinical guidelines, which in turn drive real-world clinical practice. In a recent analysis utilizing data from NHANES, Fang et al¹ showed evidence of a general shift toward less intensive treatment of diabetes, hypertension, and hypercholesterolemia in adults living in the US during the last decade.

Similarly, in a separate study using NHANES data collected between 1999 and 2018 published in JAMA just 2 weeks after the current report, Wang et al² confirms this declining trend in diabetes management with only 21.2% of diabetic adults simultaneously attaining glycemic, blood pressure, and lipid level targets during the same period. What led to the decline in more stringent risk factor and diabetes management since 2010 observed in these studies? One possible explanation, as suggested by Fang et al, is that major clinical trials from the late 2000s­—including Action to Control Cardiovascular Risk in Diabetes, UK Prospective Diabetes Study, Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation, and Veterans Affairs Diabetes Trial—that assessed the effects of intensive glycemic control (with target HbA_1c < 6.5%) found that intensive treatment of diabetes compared to standard care had no cardiovascular benefit albeit increasing the risk of hypoglycemia. Thus, these trial findings may have translated into suboptimal diabetes treatment observed in some NHANES participants. Wang et al propose that effective tailored approaches are needed to improve risk factor control in diabetic patients, such as enhance and maintain adherence to medications and healthy lifestyle behaviors, as well as better access to health care and therapeutic education.

The changes in recent trends in diabetes management have immense clinical implications. The authors of this study suggest a link between the recent relaxation of glycemic targets, as well as risk factor control, and a resurgence of diabetic complications such as lower limb amputation or stroke. Indeed, several recent studies indicate an upward trend or plateau in diabetic complications which had been decreasing in prevalence prior to 2010.³ For example, lower extremity amputation has surged by more than 25% between 2010 and 2015, especially in young and middle-aged adults.⁴ Among the arguments brought forward that this recent resurgence in amputations is directly linked to worsening glycemic control is the fact that between 2007 and 2010, when glucose levels were best controlled within the previous 30-year period, amputations were also at the lowest levels. Moreover, data from the Centers for Disease Control and Prevention also show a 55% increase in mortality (from 15.7 to 24.2 per 1000) among diabetic patients between 2010 and 2015.¹⁴ On the other hand, a growing number of studies show that an increase of inappropriate treatment intensification—reaching HbA_1c levels that are way below the recommended targets—is associated with adverse consequences in diabetic patients particularly in those aged more than 65 years.^5-7 These seemingly contradictory findings highlight the importance of a personalized and thoughtful approach to the management of diabetes and its risk factors. As an example, an increase in the use of newer and safer glucose lowering drugs (eg, sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and dipeptidyl peptidase 4 inhibitors) can help achieve better HbA_1c goals with a reduced risk of hypoglycemic episodes as recently shown by a Danish study.⁸ In this study, the authors concluded that the reduction of the rate of hypoglycemic episodes leading to hospitalization in Denmark was directly linked to the use of these safer and newer glucose lowering drugs.

A discussion on the specifics of trends in diabetes treatment and control must include considerations in older adults aged more than 65 years who constitute more than 40% of the diabetic population. Despite the high prevalence of diabetes in this vulnerable population, such data are still insufficient in the literature and are critically needed to inform public health policies and clinical guidelines. In epidemiological studies focusing on diabetic complications from the last 10 years, concerning increases have been observed in younger⁹ and middle-aged adults while remaining stable in older adults. However, the risk of hypoglycemia or severe hypoglycemia remains high in older adults living in nursing facilities, even in those with an elevated HbA_1c of greater than 8%.⁷ Moreover, in light of more relaxed HbA_1c treatment goals for older frail adults as recommended by international guidelines since 2010,^10,11 recent findings from the French GERODIAB cohort show an increased mortality (hazard ratio, 1.76) in type 2 diabetics aged 70 years and older with HbA_1c greater than or equal to 8.6%.¹² Similarly, a 5-year retrospective British study from 2018 which included patients aged 70 years and older, shows an increased overall mortality in those with HbA_1c greater than 8.5%.¹³ Taken together, further age-stratified analysis utilizing data from large cohort studies including NHANES may help to clarify national trends in diabetes treatment and risk factor control as well as diabetic complications specific to the geriatric population. By being better informed of such trends, clinicians could then develop treatment strategies that minimize complications (eg, hypoglycemia, falls) while achieving favorable outcomes (eg, reduce hyperglycemic emergencies, improve survival) in frail older patients.

Applications for Clinical Practice

The understanding of population-wide trends in diabetes control is critical to planning public health approaches for the prevention and treatment of this disease and its complications. In older adults, the high risk of hypoglycemic events and insufficient epidemiological data on trends of diabetes control hinder diabetes management. Personalized treatment targets taking into account geriatric syndromes and general health status, as well as multidisciplinary management involving endocrinologists, geriatricians, and clinical pharmacists, are necessary to optimize care in older adults with diabetes.

Study Overview

Objective. To update national trends in the treatment and risk factor control of diabetic patients from 1999 through 2018 in the US using data from the National Health and Nutrition Examination Survey (NHANES) with the goal of identifying population subgroups with the highest probability of having untreated risk factors.

Design. The authors conducted a cross-sectional analysis of data from NHANES focusing on adults with diabetes. They examined patient characteristics and medication use over time and estimated the prevalence of risk factor control and medication use. To minimize the effects of a small sample size, the survey years were pooled into 4-year intervals. The variables studied included glycated hemoglobin (HbA_1c), blood pressure, serum cholesterol, medication use, sociodemographic characteristics, and weight status. For statistical analysis, logistic and multinomial logistic regression models were used to examine factors associated with treatment in participants who did not achieve targets for glycemic, blood pressure, and lipid control. Temporal trends were estimated using 2-piece linear spline models with 1 knot at inflection points.

Setting and participants. The NHANES program began in the early 1960s to monitor the health of the US population. In 1999, the survey became a continuous program combining interviews and physical examinations. The survey examines a nationally representative sample of about 5000 persons each year. This study included 6653 participants who were nonpregnant, aged older than 20 years, reported a diagnosis of diabetes from a physician, and participated in NHANES from 1999 through 2018.

Main outcome measures. The main outcome measures were temporal trends in risk factor control (glycemic, blood pressure, or lipid levels) and medication use (glucose lowering, blood pressure lowering, or lipid lowering medications), and number as well as class of drug used, from 1999 through 2018 in diabetic adults from the US participating in NHANES.

Results. Sociodemographic characteristics of the studied diabetes population—The age and racial or ethnic distribution of participants with diabetes were stable from 1999 through 2018, whereas participants with a college degree, higher income, health insurance, obesity, or long-standing diabetes increased during the same period.

Trends in diabetes risk factor control—The trends for glycemic, blood pressure, and lipid control were nonlinear, with an inflection point around 2010. Glycemic control was defined as HbA_1c less than 7%, blood pressure was considered controlled if less than 140/90 mmHg, and lipid was controlled if non-HDL cholesterol level was less than 130 mg/dL. Although these chosen targets were based on the most recent clinical guidelines, the authors declared that they observed similar trends when alternative targets were used. The level of risk factor control improved in all diabetic patients from 1999 through 2010. However, the percentage of adult diabetic participants for whom glycemic control was achieved declined from 57.4% (95% CI, 52.9-61.8) in 2007-2010 to 50.5% (95% CI, 45.8-55.3) in 2015-2018. Blood pressure control was achieved in 74.2% of participants (95% CI, 70.7-77.4) in 2011-2014 but declined to 70.4% (95% CI, 66.7-73.8) in 2015-2018. Control in lipid levels improved during the entire study period; however, the rate of improvement heavily declined after 2007 with lipid target levels attained in 52.3% of participants (95% CI, 49.2-55.3) in 2007-2014 and 55.7% (95% CI, 50.8-60.5) in 2015-2018. Finally, the percentage of participants in whom targets for all 3 risk factors were simultaneously achieved plateaued after 2010 and was 22.2% (95% CI, 17.9-27.3) in 2015-2018.

Trends in diabetes treatment—The use of glucose lowering drugs increased from 74.1% in 1999-2002 to 82.7% in 2007-2010 and then stabilized. A shift toward a safer glucose lowering treatment choice was observed with a decline in the use of older glucose lowering medications such as sulfonylureas, which increases the risk of hypoglycemia, and an increase in the use of metformin, insulin, and newer agents such as sodium-glucose cotransporter 2 inhibitors.

Similarly, blood pressure lowering medication use rose from 1999-2002 to 2007-2010 and then stabilized, with increased use of first-line recommended treatments including angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. Likewise, statin use rose from 28.4% in 1999-2002 to 56% in 2011-2014 and then stabilized. The total number of drugs used culminated in 2011-2014 with 60% of participants using more than 5 drugs and then leveled off to 57.2% in 2015-2018. Lastly, health insurance status and race or ethnicity impacted the likelihood of receiving monotherapy or combination drug therapy when targets for glycemic, blood pressure, or lipid control were not achieved.

Conclusion. Despite great progress in the control of diabetes and its associated risk factors between 1999 and 2010, this trend declined for glycemic and blood pressure control and leveled off for lipid control in adult NHANES participants with diabetes after 2010. First-line treatments for diabetes and associated risk factors remain underused, and treatment intensification may not be sufficiently considered in patients with uncontrolled risk factors despite clinical guideline recommendations. The findings of this study may portend a possible population-level increase in diabetes-related illnesses in the years to come.

Commentary

The thorough understanding of trends in management of diseases is critical to inform public health policies and planning. Well designed clinical studies heavily influence the development of public health policies and clinical guidelines, which in turn drive real-world clinical practice. In a recent analysis utilizing data from NHANES, Fang et al¹ showed evidence of a general shift toward less intensive treatment of diabetes, hypertension, and hypercholesterolemia in adults living in the US during the last decade.

Similarly, in a separate study using NHANES data collected between 1999 and 2018 published in JAMA just 2 weeks after the current report, Wang et al² confirms this declining trend in diabetes management with only 21.2% of diabetic adults simultaneously attaining glycemic, blood pressure, and lipid level targets during the same period. What led to the decline in more stringent risk factor and diabetes management since 2010 observed in these studies? One possible explanation, as suggested by Fang et al, is that major clinical trials from the late 2000s­—including Action to Control Cardiovascular Risk in Diabetes, UK Prospective Diabetes Study, Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation, and Veterans Affairs Diabetes Trial—that assessed the effects of intensive glycemic control (with target HbA_1c < 6.5%) found that intensive treatment of diabetes compared to standard care had no cardiovascular benefit albeit increasing the risk of hypoglycemia. Thus, these trial findings may have translated into suboptimal diabetes treatment observed in some NHANES participants. Wang et al propose that effective tailored approaches are needed to improve risk factor control in diabetic patients, such as enhance and maintain adherence to medications and healthy lifestyle behaviors, as well as better access to health care and therapeutic education.

The changes in recent trends in diabetes management have immense clinical implications. The authors of this study suggest a link between the recent relaxation of glycemic targets, as well as risk factor control, and a resurgence of diabetic complications such as lower limb amputation or stroke. Indeed, several recent studies indicate an upward trend or plateau in diabetic complications which had been decreasing in prevalence prior to 2010.³ For example, lower extremity amputation has surged by more than 25% between 2010 and 2015, especially in young and middle-aged adults.⁴ Among the arguments brought forward that this recent resurgence in amputations is directly linked to worsening glycemic control is the fact that between 2007 and 2010, when glucose levels were best controlled within the previous 30-year period, amputations were also at the lowest levels. Moreover, data from the Centers for Disease Control and Prevention also show a 55% increase in mortality (from 15.7 to 24.2 per 1000) among diabetic patients between 2010 and 2015.¹⁴ On the other hand, a growing number of studies show that an increase of inappropriate treatment intensification—reaching HbA_1c levels that are way below the recommended targets—is associated with adverse consequences in diabetic patients particularly in those aged more than 65 years.^5-7 These seemingly contradictory findings highlight the importance of a personalized and thoughtful approach to the management of diabetes and its risk factors. As an example, an increase in the use of newer and safer glucose lowering drugs (eg, sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and dipeptidyl peptidase 4 inhibitors) can help achieve better HbA_1c goals with a reduced risk of hypoglycemic episodes as recently shown by a Danish study.⁸ In this study, the authors concluded that the reduction of the rate of hypoglycemic episodes leading to hospitalization in Denmark was directly linked to the use of these safer and newer glucose lowering drugs.

A discussion on the specifics of trends in diabetes treatment and control must include considerations in older adults aged more than 65 years who constitute more than 40% of the diabetic population. Despite the high prevalence of diabetes in this vulnerable population, such data are still insufficient in the literature and are critically needed to inform public health policies and clinical guidelines. In epidemiological studies focusing on diabetic complications from the last 10 years, concerning increases have been observed in younger⁹ and middle-aged adults while remaining stable in older adults. However, the risk of hypoglycemia or severe hypoglycemia remains high in older adults living in nursing facilities, even in those with an elevated HbA_1c of greater than 8%.⁷ Moreover, in light of more relaxed HbA_1c treatment goals for older frail adults as recommended by international guidelines since 2010,^10,11 recent findings from the French GERODIAB cohort show an increased mortality (hazard ratio, 1.76) in type 2 diabetics aged 70 years and older with HbA_1c greater than or equal to 8.6%.¹² Similarly, a 5-year retrospective British study from 2018 which included patients aged 70 years and older, shows an increased overall mortality in those with HbA_1c greater than 8.5%.¹³ Taken together, further age-stratified analysis utilizing data from large cohort studies including NHANES may help to clarify national trends in diabetes treatment and risk factor control as well as diabetic complications specific to the geriatric population. By being better informed of such trends, clinicians could then develop treatment strategies that minimize complications (eg, hypoglycemia, falls) while achieving favorable outcomes (eg, reduce hyperglycemic emergencies, improve survival) in frail older patients.

Applications for Clinical Practice

The understanding of population-wide trends in diabetes control is critical to planning public health approaches for the prevention and treatment of this disease and its complications. In older adults, the high risk of hypoglycemic events and insufficient epidemiological data on trends of diabetes control hinder diabetes management. Personalized treatment targets taking into account geriatric syndromes and general health status, as well as multidisciplinary management involving endocrinologists, geriatricians, and clinical pharmacists, are necessary to optimize care in older adults with diabetes.

Less than one in five women physicians are practicing in the top five high-paying specialties. Women compose only 6% of orthopedic surgeons, 8% of interventional cardiologists, 10% of urologists, 17% of plastic surgeons, and 18% of otolaryngologists, according to the 2020 Association of American Medical Colleges Physician Specialty Data Report.

Plastic surgeons earn an average of $526,000 annually, which is the highest-paying specialty. Otolaryngologists earn an average of $417,000 annually, and urologists earn $427,000, according to the Medscape Physician Compensation Report 2021: The Recovery Begins.

Yet, far more women are practicing in specialties that pay less. Women are the majority in pediatrics (64%), ob.gyn. (59%), internal medicine (53%), and endocrinology (51%), the AAMC data show. The exception is dermatology, which pays well and in which 51% are women. The annual average pay is $394,000.

Why are so many women avoiding the top-paying specialties?

Several physician researchers and leaders in the top-paying specialties point to four main factors: Women are attracted to specialties that have more women in faculty and leadership positions, women prioritize work-life balance over pay, women residents may be deterred from the high-paying specialties because of gender discrimination and sexual harassment, and the longer training periods for surgical specialties may be a deterrent for women who want to have children.
 

Lack of women leaders

The specialties with the most women tend to have the highest proportion of women in leadership positions. For example, obstetrics and gynecology had the highest proportion of women department chairs (24.1%) and vice chairs (38.8). Pediatrics had the highest proportion of women division directors (31.5%) and residency program directors (64.6%), a study shows.

Surgical specialties, on the other hand, may have a harder time attracting female residents, possibly because of a lack of women in leadership positions. A recent study that examined gender differences in attitudes toward surgery training found that women would be more likely to go into surgery if there were more surgical faculty and residents of their same gender.

An analysis of orthopedic residency programs shows that more trainees were drawn to programs that had more female faculty members, including associate professors and women in leadership positions.

Terri Malcolm, MD, a board-certified ob.gyn. and CEO/founder of Master Physician Leaders, said women need to consider whether they want to be a trailblazer in a specialty that has fewer women. “What support systems are in place to accommodate your goals, whether it’s career advancement, having a family, or mentorship? Where can you show up as your whole self and be supported in that?”

Being the only woman in a residency program can be a challenge, said Dr. Malcolm. If the residents and attendings are predominantly men, for example, they may not think about creating a call schedule that takes into account maternity leave or the fact that women tend to be caretakers for their children and parents.

The study of gender differences toward surgery training shows that 75% of women, in comparison with 46% of men, would be more willing to enter surgery if maternity leave and childcare were made available to female residents and attending physicians.
 

Women want work-life balance

Although both men and women want families, women still shoulder more family and childcare responsibilities. That may explain why women physicians ranked work-life balance first and compensation second in the Medscape Women Physicians 2020 Report: The Issues They Care About.

“My physician colleagues have been and are supportive of intellectual abilities, but I feel they don’t fully understand the uneven distribution of childcare issues on women,” a woman dermatologist commented.

Women may want to work fewer hours or have a more flexible schedule to take care of children. “I can count on one hand the number of women who have a part-time job in orthopedics. It’s very rare, and working part time absolutely is a barrier for someone who wants to be a surgeon,” said Julie Samora, MD, PhD, a researcher and pediatric hand surgeon at Nationwide Children’s Hospital, in Columbus, Ohio. She is also a spokesperson for the American Association of Orthopedic Surgeons.

Preeti Malani, MD, a professor of medicine who specializes in infectious diseases at the University of Michigan, chose to work full-time in academia while raising two children with her husband. In a decade, she rose through the ranks to full professor. “I took the advice of a woman who wanted to recruit me to have a full-time position with maximum flexibility rather than work part time, often for more hours and less pay. I also have tried to build my career so I was not doing all clinical work.”

Her husband is a surgeon at the University of Michigan. His schedule was not flexible, and he was unable to take on family responsibilities, said Dr. Malani. “I knew someone had to be able to grab the kids from daycare or pick them up at school if they were sick.” She also took work home and worked weekends.

Young women physicians in particular are thinking about combining parenting with work – in the Medscape report, that issue ranked third among the issues women care about. Seeing other women doctors navigate that in their particular specialty can have a positive impact.

“When I chose adolescent medicine, I remember working with a doctor in this field who talked about how much she enjoyed raising her kids even as teenagers and how much she was enjoying them as young adults. She seemed so balanced and happy in her family, and it gave me a nice feeling about the field,” said Nancy Dodson, MD, MPH, a pediatrician specializing in adolescent medicine at Pediatrics on Hudson in New York.

Rachel Zhuk, MD, a reproductive psychiatrist in New York, took a break after medical school to spend time with her newborn son. She met a woman who was also a young parent and a psychiatrist. “We were both figuring out parenting together – it was like looking into my future.” That friendship and her desire to have more time with patients influenced her decision to pursue psychiatry instead of internal medicine.
 

Discrimination and harassment influence specialty choice

Women doctors in the top-paying surgical and other specialties have reported experiencing more discrimination and harassment than men.

Of 927 orthopedic surgeons who responded to an AAOS survey, 66% said they experienced gender discrimination, bullying, sexual harassment, or harassment in the health care workplace. More than twice as many women (81%) experienced these behaviors as men (35%).

“This study shows that women in orthopedic surgery disproportionately experience these negative behaviors, and only a handful of institutions in the United States provide any type of training to prevent them,” said Dr. Samora, the lead author of the AAOS report.

Radiology is another male-dominated field – women represent 26% of all radiologists, the 2020 AAMC specialty report shows. A systematic review shows that 40% of women radiologists experienced gender discrimination at work, compared with 1% of men, and that 47% of women experienced sexual harassment.

Female trainees in surgery have also reported disproportionate rates of discrimination and harassment. Female general surgical residents have experienced more gender discrimination than male residents (65.1% vs. 10.0%) and more sexual harassment than male residents (19.9% vs. 3.9), a national survey indicates.

When medical students are exposed to these behaviors through personal experience, witnessing, or hearing about them, it can affect which specialty they choose. A survey of fourth-year medical students shows that far more women than men reported that exposure to gender discrimination and sexual harassment influenced their specialty choices (45.3% vs. 16.4%) and residency rankings (25.3% vs. 10.9%). Women who chose general surgery were the most likely to experience gender discrimination and sexual harassment during residency selection; women who chose psychiatry were the least likely to experience such behaviors, the report shows.

“If young trainees witness such behaviors in a specific field, they would naturally migrate toward a different specialty,” said Dr. Samora.

Trainees can also be put off by residency directors asking them inappropriate questions. Of nearly 500 female orthopedic surgeons surveyed, 62% reported that they were asked inappropriate questions during their residency interviews. “Inappropriate questions and comments directed toward women during residency interviews are clearly not conducive to women entering the field,” the authors stated. They found that little changed during the study period from 1971 to 2015.

The most frequent inappropriate questions concerned whether the prospective residents would be getting pregnant or raising children during residency and their marital status. One female orthopedic surgeon reported: “I was asked if I have children and was told that it would be too difficult to complete an orthopedic residency with children.”

The interviewers also made frequent comments about the inferiority of women to men. For example, “I was told by one program interviewer that ‘I don’t have a bias about women in medicine, I have a bias about women in orthopedic surgery,’ ” another female orthopedic surgeon commented.
 

Longer training

Residency training for the top-paying surgical specialties, including orthopedic surgery, plastic surgery, and otolaryngology, lasts 5-6 years. This compares with 3-4 years for the lower-paying specialties, such as pediatrics, internal medicine, and ob.gyn., according to data from the American Medical Association.

Women doctors are in their prime childbearing years during residency. Women who want to start a family will consider whether they want to get pregnant during residency or wait until they finish their training, said Dr. Malcolm.

The vast majority (84%) of 190 female orthopedic surgery trainees who responded to a survey indicated that they did not have children or were pregnant during residency. Nearly half (48%) reported that they had postponed having children because they were in training.

“The longer training is definitely a concerning issue for women of childbearing age. Many professional women are waiting to have children, for multiple reasons, but one major fear is the stigma due to taking time off from work obligations. There is a risk of irritating your peers because they may have to take on more work and cover more calls for you during your absence,” said Dr. Samora.

That fear is not unfounded. At least half of the 190 female orthopedic residents reported that they encountered bias against becoming pregnant during training from both coresidents (60%) and attendings (50%), according to the study.

Another recent survey suggests that pregnant surgical residents face several barriers during their training, including a lack of salary for extended family leave, resentment from fellow residents who need to cover for them during maternity leave, and a lack of formal lactation policies.

A few policy changes by national board organizations, including those in the surgical specialties, may make life a little easier for female trainees to have children, suggested Dr. Samora.

Residents and fellows are now allowed a minimum of 6 weeks away for medical leave or caregiving once during training, without having to use vacation or sick leave and without having to extend their training, the American Board of Medical Specialties has announced.

In addition, the American Board of Orthopaedic Surgery and the American Board of Surgery have enacted policies that allow lactating women to take a break to pump during their board exams.

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

Less than one in five women physicians are practicing in the top five high-paying specialties. Women compose only 6% of orthopedic surgeons, 8% of interventional cardiologists, 10% of urologists, 17% of plastic surgeons, and 18% of otolaryngologists, according to the 2020 Association of American Medical Colleges Physician Specialty Data Report.

Plastic surgeons earn an average of $526,000 annually, which is the highest-paying specialty. Otolaryngologists earn an average of $417,000 annually, and urologists earn $427,000, according to the Medscape Physician Compensation Report 2021: The Recovery Begins.

Yet, far more women are practicing in specialties that pay less. Women are the majority in pediatrics (64%), ob.gyn. (59%), internal medicine (53%), and endocrinology (51%), the AAMC data show. The exception is dermatology, which pays well and in which 51% are women. The annual average pay is $394,000.

Why are so many women avoiding the top-paying specialties?

Several physician researchers and leaders in the top-paying specialties point to four main factors: Women are attracted to specialties that have more women in faculty and leadership positions, women prioritize work-life balance over pay, women residents may be deterred from the high-paying specialties because of gender discrimination and sexual harassment, and the longer training periods for surgical specialties may be a deterrent for women who want to have children.
 

Lack of women leaders

The specialties with the most women tend to have the highest proportion of women in leadership positions. For example, obstetrics and gynecology had the highest proportion of women department chairs (24.1%) and vice chairs (38.8). Pediatrics had the highest proportion of women division directors (31.5%) and residency program directors (64.6%), a study shows.

Surgical specialties, on the other hand, may have a harder time attracting female residents, possibly because of a lack of women in leadership positions. A recent study that examined gender differences in attitudes toward surgery training found that women would be more likely to go into surgery if there were more surgical faculty and residents of their same gender.

An analysis of orthopedic residency programs shows that more trainees were drawn to programs that had more female faculty members, including associate professors and women in leadership positions.

Terri Malcolm, MD, a board-certified ob.gyn. and CEO/founder of Master Physician Leaders, said women need to consider whether they want to be a trailblazer in a specialty that has fewer women. “What support systems are in place to accommodate your goals, whether it’s career advancement, having a family, or mentorship? Where can you show up as your whole self and be supported in that?”

Being the only woman in a residency program can be a challenge, said Dr. Malcolm. If the residents and attendings are predominantly men, for example, they may not think about creating a call schedule that takes into account maternity leave or the fact that women tend to be caretakers for their children and parents.

The study of gender differences toward surgery training shows that 75% of women, in comparison with 46% of men, would be more willing to enter surgery if maternity leave and childcare were made available to female residents and attending physicians.
 

Women want work-life balance

Although both men and women want families, women still shoulder more family and childcare responsibilities. That may explain why women physicians ranked work-life balance first and compensation second in the Medscape Women Physicians 2020 Report: The Issues They Care About.

“My physician colleagues have been and are supportive of intellectual abilities, but I feel they don’t fully understand the uneven distribution of childcare issues on women,” a woman dermatologist commented.

Women may want to work fewer hours or have a more flexible schedule to take care of children. “I can count on one hand the number of women who have a part-time job in orthopedics. It’s very rare, and working part time absolutely is a barrier for someone who wants to be a surgeon,” said Julie Samora, MD, PhD, a researcher and pediatric hand surgeon at Nationwide Children’s Hospital, in Columbus, Ohio. She is also a spokesperson for the American Association of Orthopedic Surgeons.

Preeti Malani, MD, a professor of medicine who specializes in infectious diseases at the University of Michigan, chose to work full-time in academia while raising two children with her husband. In a decade, she rose through the ranks to full professor. “I took the advice of a woman who wanted to recruit me to have a full-time position with maximum flexibility rather than work part time, often for more hours and less pay. I also have tried to build my career so I was not doing all clinical work.”

Her husband is a surgeon at the University of Michigan. His schedule was not flexible, and he was unable to take on family responsibilities, said Dr. Malani. “I knew someone had to be able to grab the kids from daycare or pick them up at school if they were sick.” She also took work home and worked weekends.

Young women physicians in particular are thinking about combining parenting with work – in the Medscape report, that issue ranked third among the issues women care about. Seeing other women doctors navigate that in their particular specialty can have a positive impact.

“When I chose adolescent medicine, I remember working with a doctor in this field who talked about how much she enjoyed raising her kids even as teenagers and how much she was enjoying them as young adults. She seemed so balanced and happy in her family, and it gave me a nice feeling about the field,” said Nancy Dodson, MD, MPH, a pediatrician specializing in adolescent medicine at Pediatrics on Hudson in New York.

Rachel Zhuk, MD, a reproductive psychiatrist in New York, took a break after medical school to spend time with her newborn son. She met a woman who was also a young parent and a psychiatrist. “We were both figuring out parenting together – it was like looking into my future.” That friendship and her desire to have more time with patients influenced her decision to pursue psychiatry instead of internal medicine.
 

Discrimination and harassment influence specialty choice

Women doctors in the top-paying surgical and other specialties have reported experiencing more discrimination and harassment than men.

Of 927 orthopedic surgeons who responded to an AAOS survey, 66% said they experienced gender discrimination, bullying, sexual harassment, or harassment in the health care workplace. More than twice as many women (81%) experienced these behaviors as men (35%).

“This study shows that women in orthopedic surgery disproportionately experience these negative behaviors, and only a handful of institutions in the United States provide any type of training to prevent them,” said Dr. Samora, the lead author of the AAOS report.

Radiology is another male-dominated field – women represent 26% of all radiologists, the 2020 AAMC specialty report shows. A systematic review shows that 40% of women radiologists experienced gender discrimination at work, compared with 1% of men, and that 47% of women experienced sexual harassment.

Female trainees in surgery have also reported disproportionate rates of discrimination and harassment. Female general surgical residents have experienced more gender discrimination than male residents (65.1% vs. 10.0%) and more sexual harassment than male residents (19.9% vs. 3.9), a national survey indicates.

When medical students are exposed to these behaviors through personal experience, witnessing, or hearing about them, it can affect which specialty they choose. A survey of fourth-year medical students shows that far more women than men reported that exposure to gender discrimination and sexual harassment influenced their specialty choices (45.3% vs. 16.4%) and residency rankings (25.3% vs. 10.9%). Women who chose general surgery were the most likely to experience gender discrimination and sexual harassment during residency selection; women who chose psychiatry were the least likely to experience such behaviors, the report shows.

“If young trainees witness such behaviors in a specific field, they would naturally migrate toward a different specialty,” said Dr. Samora.

Trainees can also be put off by residency directors asking them inappropriate questions. Of nearly 500 female orthopedic surgeons surveyed, 62% reported that they were asked inappropriate questions during their residency interviews. “Inappropriate questions and comments directed toward women during residency interviews are clearly not conducive to women entering the field,” the authors stated. They found that little changed during the study period from 1971 to 2015.

The most frequent inappropriate questions concerned whether the prospective residents would be getting pregnant or raising children during residency and their marital status. One female orthopedic surgeon reported: “I was asked if I have children and was told that it would be too difficult to complete an orthopedic residency with children.”

The interviewers also made frequent comments about the inferiority of women to men. For example, “I was told by one program interviewer that ‘I don’t have a bias about women in medicine, I have a bias about women in orthopedic surgery,’ ” another female orthopedic surgeon commented.
 

Longer training

Residency training for the top-paying surgical specialties, including orthopedic surgery, plastic surgery, and otolaryngology, lasts 5-6 years. This compares with 3-4 years for the lower-paying specialties, such as pediatrics, internal medicine, and ob.gyn., according to data from the American Medical Association.

Women doctors are in their prime childbearing years during residency. Women who want to start a family will consider whether they want to get pregnant during residency or wait until they finish their training, said Dr. Malcolm.

The vast majority (84%) of 190 female orthopedic surgery trainees who responded to a survey indicated that they did not have children or were pregnant during residency. Nearly half (48%) reported that they had postponed having children because they were in training.

“The longer training is definitely a concerning issue for women of childbearing age. Many professional women are waiting to have children, for multiple reasons, but one major fear is the stigma due to taking time off from work obligations. There is a risk of irritating your peers because they may have to take on more work and cover more calls for you during your absence,” said Dr. Samora.

That fear is not unfounded. At least half of the 190 female orthopedic residents reported that they encountered bias against becoming pregnant during training from both coresidents (60%) and attendings (50%), according to the study.

Another recent survey suggests that pregnant surgical residents face several barriers during their training, including a lack of salary for extended family leave, resentment from fellow residents who need to cover for them during maternity leave, and a lack of formal lactation policies.

A few policy changes by national board organizations, including those in the surgical specialties, may make life a little easier for female trainees to have children, suggested Dr. Samora.

Residents and fellows are now allowed a minimum of 6 weeks away for medical leave or caregiving once during training, without having to use vacation or sick leave and without having to extend their training, the American Board of Medical Specialties has announced.

In addition, the American Board of Orthopaedic Surgery and the American Board of Surgery have enacted policies that allow lactating women to take a break to pump during their board exams.

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

Less than one in five women physicians are practicing in the top five high-paying specialties. Women compose only 6% of orthopedic surgeons, 8% of interventional cardiologists, 10% of urologists, 17% of plastic surgeons, and 18% of otolaryngologists, according to the 2020 Association of American Medical Colleges Physician Specialty Data Report.

Plastic surgeons earn an average of $526,000 annually, which is the highest-paying specialty. Otolaryngologists earn an average of $417,000 annually, and urologists earn $427,000, according to the Medscape Physician Compensation Report 2021: The Recovery Begins.

Yet, far more women are practicing in specialties that pay less. Women are the majority in pediatrics (64%), ob.gyn. (59%), internal medicine (53%), and endocrinology (51%), the AAMC data show. The exception is dermatology, which pays well and in which 51% are women. The annual average pay is $394,000.

Why are so many women avoiding the top-paying specialties?

Several physician researchers and leaders in the top-paying specialties point to four main factors: Women are attracted to specialties that have more women in faculty and leadership positions, women prioritize work-life balance over pay, women residents may be deterred from the high-paying specialties because of gender discrimination and sexual harassment, and the longer training periods for surgical specialties may be a deterrent for women who want to have children.
 

Lack of women leaders

The specialties with the most women tend to have the highest proportion of women in leadership positions. For example, obstetrics and gynecology had the highest proportion of women department chairs (24.1%) and vice chairs (38.8). Pediatrics had the highest proportion of women division directors (31.5%) and residency program directors (64.6%), a study shows.

Surgical specialties, on the other hand, may have a harder time attracting female residents, possibly because of a lack of women in leadership positions. A recent study that examined gender differences in attitudes toward surgery training found that women would be more likely to go into surgery if there were more surgical faculty and residents of their same gender.

An analysis of orthopedic residency programs shows that more trainees were drawn to programs that had more female faculty members, including associate professors and women in leadership positions.

Terri Malcolm, MD, a board-certified ob.gyn. and CEO/founder of Master Physician Leaders, said women need to consider whether they want to be a trailblazer in a specialty that has fewer women. “What support systems are in place to accommodate your goals, whether it’s career advancement, having a family, or mentorship? Where can you show up as your whole self and be supported in that?”

Being the only woman in a residency program can be a challenge, said Dr. Malcolm. If the residents and attendings are predominantly men, for example, they may not think about creating a call schedule that takes into account maternity leave or the fact that women tend to be caretakers for their children and parents.

The study of gender differences toward surgery training shows that 75% of women, in comparison with 46% of men, would be more willing to enter surgery if maternity leave and childcare were made available to female residents and attending physicians.
 

Women want work-life balance

Although both men and women want families, women still shoulder more family and childcare responsibilities. That may explain why women physicians ranked work-life balance first and compensation second in the Medscape Women Physicians 2020 Report: The Issues They Care About.

“My physician colleagues have been and are supportive of intellectual abilities, but I feel they don’t fully understand the uneven distribution of childcare issues on women,” a woman dermatologist commented.

Women may want to work fewer hours or have a more flexible schedule to take care of children. “I can count on one hand the number of women who have a part-time job in orthopedics. It’s very rare, and working part time absolutely is a barrier for someone who wants to be a surgeon,” said Julie Samora, MD, PhD, a researcher and pediatric hand surgeon at Nationwide Children’s Hospital, in Columbus, Ohio. She is also a spokesperson for the American Association of Orthopedic Surgeons.

Preeti Malani, MD, a professor of medicine who specializes in infectious diseases at the University of Michigan, chose to work full-time in academia while raising two children with her husband. In a decade, she rose through the ranks to full professor. “I took the advice of a woman who wanted to recruit me to have a full-time position with maximum flexibility rather than work part time, often for more hours and less pay. I also have tried to build my career so I was not doing all clinical work.”

Her husband is a surgeon at the University of Michigan. His schedule was not flexible, and he was unable to take on family responsibilities, said Dr. Malani. “I knew someone had to be able to grab the kids from daycare or pick them up at school if they were sick.” She also took work home and worked weekends.

Young women physicians in particular are thinking about combining parenting with work – in the Medscape report, that issue ranked third among the issues women care about. Seeing other women doctors navigate that in their particular specialty can have a positive impact.

“When I chose adolescent medicine, I remember working with a doctor in this field who talked about how much she enjoyed raising her kids even as teenagers and how much she was enjoying them as young adults. She seemed so balanced and happy in her family, and it gave me a nice feeling about the field,” said Nancy Dodson, MD, MPH, a pediatrician specializing in adolescent medicine at Pediatrics on Hudson in New York.

Rachel Zhuk, MD, a reproductive psychiatrist in New York, took a break after medical school to spend time with her newborn son. She met a woman who was also a young parent and a psychiatrist. “We were both figuring out parenting together – it was like looking into my future.” That friendship and her desire to have more time with patients influenced her decision to pursue psychiatry instead of internal medicine.
 

Discrimination and harassment influence specialty choice

Women doctors in the top-paying surgical and other specialties have reported experiencing more discrimination and harassment than men.

Of 927 orthopedic surgeons who responded to an AAOS survey, 66% said they experienced gender discrimination, bullying, sexual harassment, or harassment in the health care workplace. More than twice as many women (81%) experienced these behaviors as men (35%).

“This study shows that women in orthopedic surgery disproportionately experience these negative behaviors, and only a handful of institutions in the United States provide any type of training to prevent them,” said Dr. Samora, the lead author of the AAOS report.

Radiology is another male-dominated field – women represent 26% of all radiologists, the 2020 AAMC specialty report shows. A systematic review shows that 40% of women radiologists experienced gender discrimination at work, compared with 1% of men, and that 47% of women experienced sexual harassment.

Female trainees in surgery have also reported disproportionate rates of discrimination and harassment. Female general surgical residents have experienced more gender discrimination than male residents (65.1% vs. 10.0%) and more sexual harassment than male residents (19.9% vs. 3.9), a national survey indicates.

When medical students are exposed to these behaviors through personal experience, witnessing, or hearing about them, it can affect which specialty they choose. A survey of fourth-year medical students shows that far more women than men reported that exposure to gender discrimination and sexual harassment influenced their specialty choices (45.3% vs. 16.4%) and residency rankings (25.3% vs. 10.9%). Women who chose general surgery were the most likely to experience gender discrimination and sexual harassment during residency selection; women who chose psychiatry were the least likely to experience such behaviors, the report shows.

“If young trainees witness such behaviors in a specific field, they would naturally migrate toward a different specialty,” said Dr. Samora.

Trainees can also be put off by residency directors asking them inappropriate questions. Of nearly 500 female orthopedic surgeons surveyed, 62% reported that they were asked inappropriate questions during their residency interviews. “Inappropriate questions and comments directed toward women during residency interviews are clearly not conducive to women entering the field,” the authors stated. They found that little changed during the study period from 1971 to 2015.

The most frequent inappropriate questions concerned whether the prospective residents would be getting pregnant or raising children during residency and their marital status. One female orthopedic surgeon reported: “I was asked if I have children and was told that it would be too difficult to complete an orthopedic residency with children.”

The interviewers also made frequent comments about the inferiority of women to men. For example, “I was told by one program interviewer that ‘I don’t have a bias about women in medicine, I have a bias about women in orthopedic surgery,’ ” another female orthopedic surgeon commented.
 

Longer training

Residency training for the top-paying surgical specialties, including orthopedic surgery, plastic surgery, and otolaryngology, lasts 5-6 years. This compares with 3-4 years for the lower-paying specialties, such as pediatrics, internal medicine, and ob.gyn., according to data from the American Medical Association.

Women doctors are in their prime childbearing years during residency. Women who want to start a family will consider whether they want to get pregnant during residency or wait until they finish their training, said Dr. Malcolm.

The vast majority (84%) of 190 female orthopedic surgery trainees who responded to a survey indicated that they did not have children or were pregnant during residency. Nearly half (48%) reported that they had postponed having children because they were in training.

“The longer training is definitely a concerning issue for women of childbearing age. Many professional women are waiting to have children, for multiple reasons, but one major fear is the stigma due to taking time off from work obligations. There is a risk of irritating your peers because they may have to take on more work and cover more calls for you during your absence,” said Dr. Samora.

That fear is not unfounded. At least half of the 190 female orthopedic residents reported that they encountered bias against becoming pregnant during training from both coresidents (60%) and attendings (50%), according to the study.

Another recent survey suggests that pregnant surgical residents face several barriers during their training, including a lack of salary for extended family leave, resentment from fellow residents who need to cover for them during maternity leave, and a lack of formal lactation policies.

A few policy changes by national board organizations, including those in the surgical specialties, may make life a little easier for female trainees to have children, suggested Dr. Samora.

Residents and fellows are now allowed a minimum of 6 weeks away for medical leave or caregiving once during training, without having to use vacation or sick leave and without having to extend their training, the American Board of Medical Specialties has announced.

In addition, the American Board of Orthopaedic Surgery and the American Board of Surgery have enacted policies that allow lactating women to take a break to pump during their board exams.

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