Opinion

I have received lots of notes from readers about other pet peeves they have about practicing primary care in our current environment and wanted to share some of them. I appreciate all the emails I received on this topic.

• The rapid increase in the number of hospital administrators in the last 50 years

This has increased health system costs without providing any relief for practicing physicians, and often has led to policies that have been harmful and detrimental. This would be a great place to start cutting back to get true savings without affecting quality of care.

• Emergency physicians and specialists who refer my patient elsewhere for a service we provide in our office

It is expensive for patients to go to a specialty provider for a simple procedure that can be easily done in a primary care practice, or to be referred to see a specialist for a problem that does not need specialty care. This creates further problems accessing specialists.

• Online reviews of practices, including reviews from people who have never been patients

I am concerned about the accuracy and intent of online reviews. If a patient is upset because they did not receive an antibiotic or narcotic, they can vent their frustration in a review, when what the medical professional was actually doing was good medicine. More concerning to me is that some organizations use these reviews to determine compensation, promotion, and support. These reviews are not evidence based or accurately collected.

• Offices and organizations being dropped by insurance carriers

Insurance companies are running amok. They make their own rules, which can devastate practices and patients. They can change fees paid unilaterally, and drop practices without explanation or valid reasons. Patients suffer terribly because they now cannot see their long-time physicians or they have to pay much more to see them as they are suddenly “out of network.”

• The lack of appreciation by organizations as well as the general public of the enormous cost savings primary care professionals contribute to the healthcare system

There are many studies showing that patients who see a primary care physician save the system money and have better health outcomes. US adults who regularly see a primary care physician have 33% lower healthcare costs and 19% lower odds of dying prematurely than those who see only a specialist.¹

In one study, for every $1 invested in primary care, there was $13 in savings in healthcare costs.² I had a patient a few years ago complain about the “enormous” bill she received for a visit where I had done an annual exam, cryotherapy for three actinic keratoses, and a steroid injection for her ailing knee. The cost savings was well over $700 (the new patient cost for two specialty visits). There is no doubt that patients who have stable primary care save money themselves and for the whole medical system.
 

• The stress of being witness to a dysfunctional system

It is really hard to see the hurt and difficulty our patients go through on a daily basis while trying to navigate a broken system. We bear witness to them and listen to all the stories when things have gone wrong. This also takes its toll on us, as we are part of the system, and our patients’ frustrations sometimes boil over. We are also the ones who care for the whole patient, so every bad experience with a specialty clinic is shared with us.

Many thanks extended to those who wrote to share their ideas (Drs. Sylvia Androne, Bhawna Bahethi, Pierre Ghassibi, Richard Katz, Louis Kasunic, Rebecca Keenan, David Kosnosky, Gregory Miller, and James Wilkens).

Dr. Paauw is professor of medicine in the Division of General Internal Medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington, Seattle. Contact Dr. Paauw at [email protected].
 

References

1. Forbes.com. Why Primary Care Matters, and What We Can Do To Increase It. 2023 Nov 27.

2. Washingtonpost.com. A Health Care Solution We Can’t Afford to Ignore: Primary Care.

I have received lots of notes from readers about other pet peeves they have about practicing primary care in our current environment and wanted to share some of them. I appreciate all the emails I received on this topic.

• The rapid increase in the number of hospital administrators in the last 50 years

This has increased health system costs without providing any relief for practicing physicians, and often has led to policies that have been harmful and detrimental. This would be a great place to start cutting back to get true savings without affecting quality of care.

• Emergency physicians and specialists who refer my patient elsewhere for a service we provide in our office

It is expensive for patients to go to a specialty provider for a simple procedure that can be easily done in a primary care practice, or to be referred to see a specialist for a problem that does not need specialty care. This creates further problems accessing specialists.

• Online reviews of practices, including reviews from people who have never been patients

I am concerned about the accuracy and intent of online reviews. If a patient is upset because they did not receive an antibiotic or narcotic, they can vent their frustration in a review, when what the medical professional was actually doing was good medicine. More concerning to me is that some organizations use these reviews to determine compensation, promotion, and support. These reviews are not evidence based or accurately collected.

• Offices and organizations being dropped by insurance carriers

Insurance companies are running amok. They make their own rules, which can devastate practices and patients. They can change fees paid unilaterally, and drop practices without explanation or valid reasons. Patients suffer terribly because they now cannot see their long-time physicians or they have to pay much more to see them as they are suddenly “out of network.”

• The lack of appreciation by organizations as well as the general public of the enormous cost savings primary care professionals contribute to the healthcare system

There are many studies showing that patients who see a primary care physician save the system money and have better health outcomes. US adults who regularly see a primary care physician have 33% lower healthcare costs and 19% lower odds of dying prematurely than those who see only a specialist.¹

In one study, for every $1 invested in primary care, there was $13 in savings in healthcare costs.² I had a patient a few years ago complain about the “enormous” bill she received for a visit where I had done an annual exam, cryotherapy for three actinic keratoses, and a steroid injection for her ailing knee. The cost savings was well over $700 (the new patient cost for two specialty visits). There is no doubt that patients who have stable primary care save money themselves and for the whole medical system.
 

• The stress of being witness to a dysfunctional system

It is really hard to see the hurt and difficulty our patients go through on a daily basis while trying to navigate a broken system. We bear witness to them and listen to all the stories when things have gone wrong. This also takes its toll on us, as we are part of the system, and our patients’ frustrations sometimes boil over. We are also the ones who care for the whole patient, so every bad experience with a specialty clinic is shared with us.

Many thanks extended to those who wrote to share their ideas (Drs. Sylvia Androne, Bhawna Bahethi, Pierre Ghassibi, Richard Katz, Louis Kasunic, Rebecca Keenan, David Kosnosky, Gregory Miller, and James Wilkens).

Dr. Paauw is professor of medicine in the Division of General Internal Medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington, Seattle. Contact Dr. Paauw at [email protected].
 

References

1. Forbes.com. Why Primary Care Matters, and What We Can Do To Increase It. 2023 Nov 27.

2. Washingtonpost.com. A Health Care Solution We Can’t Afford to Ignore: Primary Care.

I have received lots of notes from readers about other pet peeves they have about practicing primary care in our current environment and wanted to share some of them. I appreciate all the emails I received on this topic.

• The rapid increase in the number of hospital administrators in the last 50 years

This has increased health system costs without providing any relief for practicing physicians, and often has led to policies that have been harmful and detrimental. This would be a great place to start cutting back to get true savings without affecting quality of care.

• Emergency physicians and specialists who refer my patient elsewhere for a service we provide in our office

It is expensive for patients to go to a specialty provider for a simple procedure that can be easily done in a primary care practice, or to be referred to see a specialist for a problem that does not need specialty care. This creates further problems accessing specialists.

• Online reviews of practices, including reviews from people who have never been patients

I am concerned about the accuracy and intent of online reviews. If a patient is upset because they did not receive an antibiotic or narcotic, they can vent their frustration in a review, when what the medical professional was actually doing was good medicine. More concerning to me is that some organizations use these reviews to determine compensation, promotion, and support. These reviews are not evidence based or accurately collected.

• Offices and organizations being dropped by insurance carriers

Insurance companies are running amok. They make their own rules, which can devastate practices and patients. They can change fees paid unilaterally, and drop practices without explanation or valid reasons. Patients suffer terribly because they now cannot see their long-time physicians or they have to pay much more to see them as they are suddenly “out of network.”

• The lack of appreciation by organizations as well as the general public of the enormous cost savings primary care professionals contribute to the healthcare system

There are many studies showing that patients who see a primary care physician save the system money and have better health outcomes. US adults who regularly see a primary care physician have 33% lower healthcare costs and 19% lower odds of dying prematurely than those who see only a specialist.¹

In one study, for every $1 invested in primary care, there was $13 in savings in healthcare costs.² I had a patient a few years ago complain about the “enormous” bill she received for a visit where I had done an annual exam, cryotherapy for three actinic keratoses, and a steroid injection for her ailing knee. The cost savings was well over $700 (the new patient cost for two specialty visits). There is no doubt that patients who have stable primary care save money themselves and for the whole medical system.
 

• The stress of being witness to a dysfunctional system

It is really hard to see the hurt and difficulty our patients go through on a daily basis while trying to navigate a broken system. We bear witness to them and listen to all the stories when things have gone wrong. This also takes its toll on us, as we are part of the system, and our patients’ frustrations sometimes boil over. We are also the ones who care for the whole patient, so every bad experience with a specialty clinic is shared with us.

Many thanks extended to those who wrote to share their ideas (Drs. Sylvia Androne, Bhawna Bahethi, Pierre Ghassibi, Richard Katz, Louis Kasunic, Rebecca Keenan, David Kosnosky, Gregory Miller, and James Wilkens).

Dr. Paauw is professor of medicine in the Division of General Internal Medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington, Seattle. Contact Dr. Paauw at [email protected].
 

References

1. Forbes.com. Why Primary Care Matters, and What We Can Do To Increase It. 2023 Nov 27.

2. Washingtonpost.com. A Health Care Solution We Can’t Afford to Ignore: Primary Care.

Making eye contact is important in human interactions. It shows attention and comprehension. It also helps us read the nuances of another’s facial expressions when interacting.

Although the idea of video phone calls isn’t new — I remember it from my childhood in “house of the future” TV shows — it certainly didn’t take off until the advent of high-speed Internet, computers, and phones with cameras. Then Facetime, Skype, Zoom, Teams, and others.

Of course, it all still took a back seat to actually seeing people and having meetings in person. Until the pandemic made that the least attractive option. Then the adoption of such things went into hyperdrive and has stayed there ever since.

And ya know, I don’t have too many complaints. Between clinical trials and legal cases, both of which involve A LOT of meetings, it’s made my life easier. I no longer have to leave the office, allow time to drive somewhere and back, fight traffic, burn gas, and find parking. I move from a patient to the meeting and back to a patient from the cozy confines of my office, all without my tea getting cold.

But you can’t really make eye contact on Zoom. Instinctively, we generally look directly at the eyes of the person we’re speaking to, but in the virtual world we really don’t do that. On their end you’re on a screen, your gaze fixed somewhere below the level of your camera.

Try talking directly to the camera on Zoom — or any video platform. It doesn’t work. You feel like Dave addressing HAL’s red light in 2001. Inevitably your eyes are drawn back to the other person’s face, which is what you’re programmed to do. If they’re speaking you look at them, even though the sound is really coming from your speakers.

Interestingly, though, it seems something is lost in there. A recent perspective noted that Zoom meetings seemed to stifle creativity and produced fewer ideas than in person.

An interesting study compared neural response signals of people seeing a presentation on Zoom versus the same talk in person. When looking at a “real” speaker, there was synchronized neural activity, a higher level of engagement, and increased activation of the dorsal-parietal cortex.

Without actual eye contact it’s harder to read subtle facial expressions. Hand gestures and other body language may be out of the camera frame, or absent altogether. The nuances of voice pitch, timbre, and tone may not be the same over the speaker.

Our brains have spent several million of years developing facial recognition and reading, knowing friend from foe, and understanding what’s meant not just in what sounds are used but how they’re conveyed.

I’m not saying we should stop using Zoom altogether — it makes meetings more convenient for most people, including myself. But we also need to keep in mind that what it doesn’t convey is as important as what it does, and that virtual is never a perfect substitute for reality.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Making eye contact is important in human interactions. It shows attention and comprehension. It also helps us read the nuances of another’s facial expressions when interacting.

Although the idea of video phone calls isn’t new — I remember it from my childhood in “house of the future” TV shows — it certainly didn’t take off until the advent of high-speed Internet, computers, and phones with cameras. Then Facetime, Skype, Zoom, Teams, and others.

Of course, it all still took a back seat to actually seeing people and having meetings in person. Until the pandemic made that the least attractive option. Then the adoption of such things went into hyperdrive and has stayed there ever since.

And ya know, I don’t have too many complaints. Between clinical trials and legal cases, both of which involve A LOT of meetings, it’s made my life easier. I no longer have to leave the office, allow time to drive somewhere and back, fight traffic, burn gas, and find parking. I move from a patient to the meeting and back to a patient from the cozy confines of my office, all without my tea getting cold.

But you can’t really make eye contact on Zoom. Instinctively, we generally look directly at the eyes of the person we’re speaking to, but in the virtual world we really don’t do that. On their end you’re on a screen, your gaze fixed somewhere below the level of your camera.

Try talking directly to the camera on Zoom — or any video platform. It doesn’t work. You feel like Dave addressing HAL’s red light in 2001. Inevitably your eyes are drawn back to the other person’s face, which is what you’re programmed to do. If they’re speaking you look at them, even though the sound is really coming from your speakers.

Interestingly, though, it seems something is lost in there. A recent perspective noted that Zoom meetings seemed to stifle creativity and produced fewer ideas than in person.

An interesting study compared neural response signals of people seeing a presentation on Zoom versus the same talk in person. When looking at a “real” speaker, there was synchronized neural activity, a higher level of engagement, and increased activation of the dorsal-parietal cortex.

Without actual eye contact it’s harder to read subtle facial expressions. Hand gestures and other body language may be out of the camera frame, or absent altogether. The nuances of voice pitch, timbre, and tone may not be the same over the speaker.

Our brains have spent several million of years developing facial recognition and reading, knowing friend from foe, and understanding what’s meant not just in what sounds are used but how they’re conveyed.

I’m not saying we should stop using Zoom altogether — it makes meetings more convenient for most people, including myself. But we also need to keep in mind that what it doesn’t convey is as important as what it does, and that virtual is never a perfect substitute for reality.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Making eye contact is important in human interactions. It shows attention and comprehension. It also helps us read the nuances of another’s facial expressions when interacting.

Although the idea of video phone calls isn’t new — I remember it from my childhood in “house of the future” TV shows — it certainly didn’t take off until the advent of high-speed Internet, computers, and phones with cameras. Then Facetime, Skype, Zoom, Teams, and others.

Of course, it all still took a back seat to actually seeing people and having meetings in person. Until the pandemic made that the least attractive option. Then the adoption of such things went into hyperdrive and has stayed there ever since.

And ya know, I don’t have too many complaints. Between clinical trials and legal cases, both of which involve A LOT of meetings, it’s made my life easier. I no longer have to leave the office, allow time to drive somewhere and back, fight traffic, burn gas, and find parking. I move from a patient to the meeting and back to a patient from the cozy confines of my office, all without my tea getting cold.

But you can’t really make eye contact on Zoom. Instinctively, we generally look directly at the eyes of the person we’re speaking to, but in the virtual world we really don’t do that. On their end you’re on a screen, your gaze fixed somewhere below the level of your camera.

Try talking directly to the camera on Zoom — or any video platform. It doesn’t work. You feel like Dave addressing HAL’s red light in 2001. Inevitably your eyes are drawn back to the other person’s face, which is what you’re programmed to do. If they’re speaking you look at them, even though the sound is really coming from your speakers.

Interestingly, though, it seems something is lost in there. A recent perspective noted that Zoom meetings seemed to stifle creativity and produced fewer ideas than in person.

An interesting study compared neural response signals of people seeing a presentation on Zoom versus the same talk in person. When looking at a “real” speaker, there was synchronized neural activity, a higher level of engagement, and increased activation of the dorsal-parietal cortex.

Without actual eye contact it’s harder to read subtle facial expressions. Hand gestures and other body language may be out of the camera frame, or absent altogether. The nuances of voice pitch, timbre, and tone may not be the same over the speaker.

Our brains have spent several million of years developing facial recognition and reading, knowing friend from foe, and understanding what’s meant not just in what sounds are used but how they’re conveyed.

I’m not saying we should stop using Zoom altogether — it makes meetings more convenient for most people, including myself. But we also need to keep in mind that what it doesn’t convey is as important as what it does, and that virtual is never a perfect substitute for reality.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

With the flip of the calendar a few short weeks ago, gyms and fitness centers began ramping up their advertising campaigns in hopes of attracting the horde of resolution makers searching for a place where they can inject some exercise into their sedentary lives. A recent survey by C.S. Mott’s Children’s Hospital found that even young people are setting health-related goals with more than half of the parents of 11- to 18-year-olds reporting their children were setting personal goals for themselves. More than 40% of the young people listed more exercise as a target.

However, our personal and professional experiences have taught us that achieving goals, particularly when it comes to exercise, is far more difficult than setting the target. Finding an exercise buddy can be an important motivator on the days when just lacing up one’s sneakers is a stumbling block. Investing in a gym membership and sweating with a peer group can help. However, it is an investment that rarely pays a dividend. Exercise isn’t fun for everyone. For adults, showing up at a gym may be just one more reminder of how they have already lost their competitive edge over their leaner and fitter peers. If they aren’t lucky enough to find a sport or activity that they enjoy, the loneliness of the long-distance runner has little appeal.

A recent study on children in the United Kingdom suggests that at least when it comes to teens and young adults we as physicians may actually have been making things worse for our obese patients by urging them to accept unrealistic activity goals. While it is already known that sedentary time is responsible for 70% of the total increase in cholesterol as children advance to young adulthood an unqualified recommendation for more exercise may not be the best advice.

In an interview with the study author, Andre O. Agbaje MD, MPH, said that in his large study population “light physical activity outperforms moderate to vigorous physical activity by five to eight times in lowering lipids”. While we may be surprised by this counterintuitive finding, Dr. Agbaje points out that an increase in sedentariness from 6 to 9 hours per day translates into a loss of 3 hours of light physical activity. In other words if you’re not sedentary you must be standing at attention or engaged in some light activity.

In my experience, and I suspect yours, it is difficult to get adults to do something, particularly if that something involves exerting energy, even a small amount of energy. The general admonishment of “be more active” is often met with a blank stare and the sometimes unspoken question “Like what?”

You could fall into a bottomless trap with them by suggesting a long list of activities, many of which are probably ones you do or would enjoy but don’t happen to fit with any of their interests or capabilities. Your chances of hitting on a perfect activity that the patient will attempt, let alone adopt, is very slim. Those of you with more patience than I have may choose to persist with this strategy. You could argue that even if the patient only dabbles briefly in one of your recommended activities, this is a minor victory worth celebrating. Who knows? The brief jolt of energy they received from this activity may prompt them to seek and find something else that works.

My interpretation of Dr. Agbaje’s findings is this: If we are going to suggest more activity, aim low. Don’t even mention the heavily weighted words “sport” or “exercise,” which are likely to dredge up bad memories. For adults, “Go shopping” or “Visit a friend” may be sufficient to at least get the person off the couch and on their feet and moving, even if very briefly.

The second message from this study applies more to children and adolescents and is one of those unusual instances in which a negative intervention may be more effective than a positive approach. Acknowledging that we are likely to have difficulty finding even a light activity that the child enjoys, why not pivot to the other side of the equation? Make a list of the child’s primary sedentary “activities.” Then suggest the parents put the child on a couch potato diet by immediately cutting in half the time he or she spends being sedentary. By definition, this will automatically increase his or her light physical activity by 50%. According to Dr. Agbaje’s data, this should be more effective in lowering lipids than in the unlikely event of finding a moderate activity the child accepts.

You can argue that the child will hound his or her parents unmercifully asking to be entertained. This may be true and this persistent complaining will be more likely to come from the older the child and the longer that the child has been allowed to be sedentary. Although the child may appear to have lost the ability to self amuse, I contend this isn’t a permanent loss and, with parental help, self-generated activity is a skill that can be regained if sedentary behavior is curtailed. This is another example of how saying “No!” in the right circumstances is often the most effective remedy for an unhealthy situation. I would never claim saying “No” is easy and helping parents to learn how to say “No” is one of our most difficult challenges. But, nothing else seems to be working.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

With the flip of the calendar a few short weeks ago, gyms and fitness centers began ramping up their advertising campaigns in hopes of attracting the horde of resolution makers searching for a place where they can inject some exercise into their sedentary lives. A recent survey by C.S. Mott’s Children’s Hospital found that even young people are setting health-related goals with more than half of the parents of 11- to 18-year-olds reporting their children were setting personal goals for themselves. More than 40% of the young people listed more exercise as a target.

However, our personal and professional experiences have taught us that achieving goals, particularly when it comes to exercise, is far more difficult than setting the target. Finding an exercise buddy can be an important motivator on the days when just lacing up one’s sneakers is a stumbling block. Investing in a gym membership and sweating with a peer group can help. However, it is an investment that rarely pays a dividend. Exercise isn’t fun for everyone. For adults, showing up at a gym may be just one more reminder of how they have already lost their competitive edge over their leaner and fitter peers. If they aren’t lucky enough to find a sport or activity that they enjoy, the loneliness of the long-distance runner has little appeal.

A recent study on children in the United Kingdom suggests that at least when it comes to teens and young adults we as physicians may actually have been making things worse for our obese patients by urging them to accept unrealistic activity goals. While it is already known that sedentary time is responsible for 70% of the total increase in cholesterol as children advance to young adulthood an unqualified recommendation for more exercise may not be the best advice.

In an interview with the study author, Andre O. Agbaje MD, MPH, said that in his large study population “light physical activity outperforms moderate to vigorous physical activity by five to eight times in lowering lipids”. While we may be surprised by this counterintuitive finding, Dr. Agbaje points out that an increase in sedentariness from 6 to 9 hours per day translates into a loss of 3 hours of light physical activity. In other words if you’re not sedentary you must be standing at attention or engaged in some light activity.

In my experience, and I suspect yours, it is difficult to get adults to do something, particularly if that something involves exerting energy, even a small amount of energy. The general admonishment of “be more active” is often met with a blank stare and the sometimes unspoken question “Like what?”

You could fall into a bottomless trap with them by suggesting a long list of activities, many of which are probably ones you do or would enjoy but don’t happen to fit with any of their interests or capabilities. Your chances of hitting on a perfect activity that the patient will attempt, let alone adopt, is very slim. Those of you with more patience than I have may choose to persist with this strategy. You could argue that even if the patient only dabbles briefly in one of your recommended activities, this is a minor victory worth celebrating. Who knows? The brief jolt of energy they received from this activity may prompt them to seek and find something else that works.

My interpretation of Dr. Agbaje’s findings is this: If we are going to suggest more activity, aim low. Don’t even mention the heavily weighted words “sport” or “exercise,” which are likely to dredge up bad memories. For adults, “Go shopping” or “Visit a friend” may be sufficient to at least get the person off the couch and on their feet and moving, even if very briefly.

The second message from this study applies more to children and adolescents and is one of those unusual instances in which a negative intervention may be more effective than a positive approach. Acknowledging that we are likely to have difficulty finding even a light activity that the child enjoys, why not pivot to the other side of the equation? Make a list of the child’s primary sedentary “activities.” Then suggest the parents put the child on a couch potato diet by immediately cutting in half the time he or she spends being sedentary. By definition, this will automatically increase his or her light physical activity by 50%. According to Dr. Agbaje’s data, this should be more effective in lowering lipids than in the unlikely event of finding a moderate activity the child accepts.

You can argue that the child will hound his or her parents unmercifully asking to be entertained. This may be true and this persistent complaining will be more likely to come from the older the child and the longer that the child has been allowed to be sedentary. Although the child may appear to have lost the ability to self amuse, I contend this isn’t a permanent loss and, with parental help, self-generated activity is a skill that can be regained if sedentary behavior is curtailed. This is another example of how saying “No!” in the right circumstances is often the most effective remedy for an unhealthy situation. I would never claim saying “No” is easy and helping parents to learn how to say “No” is one of our most difficult challenges. But, nothing else seems to be working.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

With the flip of the calendar a few short weeks ago, gyms and fitness centers began ramping up their advertising campaigns in hopes of attracting the horde of resolution makers searching for a place where they can inject some exercise into their sedentary lives. A recent survey by C.S. Mott’s Children’s Hospital found that even young people are setting health-related goals with more than half of the parents of 11- to 18-year-olds reporting their children were setting personal goals for themselves. More than 40% of the young people listed more exercise as a target.

However, our personal and professional experiences have taught us that achieving goals, particularly when it comes to exercise, is far more difficult than setting the target. Finding an exercise buddy can be an important motivator on the days when just lacing up one’s sneakers is a stumbling block. Investing in a gym membership and sweating with a peer group can help. However, it is an investment that rarely pays a dividend. Exercise isn’t fun for everyone. For adults, showing up at a gym may be just one more reminder of how they have already lost their competitive edge over their leaner and fitter peers. If they aren’t lucky enough to find a sport or activity that they enjoy, the loneliness of the long-distance runner has little appeal.

A recent study on children in the United Kingdom suggests that at least when it comes to teens and young adults we as physicians may actually have been making things worse for our obese patients by urging them to accept unrealistic activity goals. While it is already known that sedentary time is responsible for 70% of the total increase in cholesterol as children advance to young adulthood an unqualified recommendation for more exercise may not be the best advice.

In an interview with the study author, Andre O. Agbaje MD, MPH, said that in his large study population “light physical activity outperforms moderate to vigorous physical activity by five to eight times in lowering lipids”. While we may be surprised by this counterintuitive finding, Dr. Agbaje points out that an increase in sedentariness from 6 to 9 hours per day translates into a loss of 3 hours of light physical activity. In other words if you’re not sedentary you must be standing at attention or engaged in some light activity.

In my experience, and I suspect yours, it is difficult to get adults to do something, particularly if that something involves exerting energy, even a small amount of energy. The general admonishment of “be more active” is often met with a blank stare and the sometimes unspoken question “Like what?”

You could fall into a bottomless trap with them by suggesting a long list of activities, many of which are probably ones you do or would enjoy but don’t happen to fit with any of their interests or capabilities. Your chances of hitting on a perfect activity that the patient will attempt, let alone adopt, is very slim. Those of you with more patience than I have may choose to persist with this strategy. You could argue that even if the patient only dabbles briefly in one of your recommended activities, this is a minor victory worth celebrating. Who knows? The brief jolt of energy they received from this activity may prompt them to seek and find something else that works.

My interpretation of Dr. Agbaje’s findings is this: If we are going to suggest more activity, aim low. Don’t even mention the heavily weighted words “sport” or “exercise,” which are likely to dredge up bad memories. For adults, “Go shopping” or “Visit a friend” may be sufficient to at least get the person off the couch and on their feet and moving, even if very briefly.

The second message from this study applies more to children and adolescents and is one of those unusual instances in which a negative intervention may be more effective than a positive approach. Acknowledging that we are likely to have difficulty finding even a light activity that the child enjoys, why not pivot to the other side of the equation? Make a list of the child’s primary sedentary “activities.” Then suggest the parents put the child on a couch potato diet by immediately cutting in half the time he or she spends being sedentary. By definition, this will automatically increase his or her light physical activity by 50%. According to Dr. Agbaje’s data, this should be more effective in lowering lipids than in the unlikely event of finding a moderate activity the child accepts.

You can argue that the child will hound his or her parents unmercifully asking to be entertained. This may be true and this persistent complaining will be more likely to come from the older the child and the longer that the child has been allowed to be sedentary. Although the child may appear to have lost the ability to self amuse, I contend this isn’t a permanent loss and, with parental help, self-generated activity is a skill that can be regained if sedentary behavior is curtailed. This is another example of how saying “No!” in the right circumstances is often the most effective remedy for an unhealthy situation. I would never claim saying “No” is easy and helping parents to learn how to say “No” is one of our most difficult challenges. But, nothing else seems to be working.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

The past year has been a challenging time for many, both at the local level and globally, with divisive undercurrents across many communities. Many times, the end of the year is an opportunity for reflection. As I reflect on the state of perinatal psychiatry in the new year, I see several evolving issues that I’d like to share in this first column of 2024.

In 2023, the American College of Obstetricians and Gynecologists published new recommendations meant to enhance the well-being of pregnant and postpartum women and families. A main message from discussion papers borne out of these recommendations was that as a field, we should be doing more than identifying perinatal illness. We should be screening women at risk for postpartum psychiatric illness and see that those suffering from posttraumatic stress disorder (PTSD) have access to care and “wrap-around services” from clinicians with varying expertise.

Screening is a primary way we identify patients at risk for psychiatric illness and also those who are suffering at the time of a screen. One problem I see in the near future is our disparate collection and management of data. When we look closely across health care systems, it’s not clear how screening data are captured, let alone managed. What is being done in one hospital system may be very different from what is being done elsewhere. Some clinicians are adopting digital platforms to identify those with postpartum depression, while others are practicing as they always have, either through a paper screening process or with queries as part of a clinical encounter.

Given this amalgam of methods for collecting and storing information, there does not appear to be a systematic way clinicians and researchers are recording whether women are meeting criteria for significant depressive symptoms or frank postpartum psychiatric illness. It is clear a more cohesive method for collection and management is needed to optimize the likelihood that next steps can be taken to get patients the care they need.

However, screening is only one part of the story. Certainly, in our own center, one of our greatest interests, both clinically and on the research side, is what happens after screening. Through our center’s initiation of the Screening and Treatment Enhancement for Postpartum Depression (STEPS for PPD) project funded by the Marriott Foundation, we are evaluating the outcomes of women who are screened at 6 weeks postpartum with significant depressive symptoms, and who are then given an opportunity to engage with a perinatal social worker who can assist with direct psychotherapy, arranging for referrals, and navigating care for a new mother.

What we are learning as we enroll women through the initial stages of STEPS for PPD is that screening and identifying women who likely suffer from PPD simply is not enough. In fact, once identified with a depression screening tool, women who are suffering from postpartum depression can be very challenging to engage clinically. What I am learning decades after starting to work with perinatal patients is that even with a screening system and effective tools for treatment of PPD, optimizing engagement with these depressed women seems a critical and understudied step on the road to optimizing positive clinical outcomes.

A recent study published in the Journal of Women’s Health explored gaps in care for perinatal depression and found that patients without a history of psychiatric illness prior to pregnancy were less likely to be screened for depression and 80% less likely to receive care if they developed depression compared with women with a previous history of psychiatric illness (J Womens Health (Larchmt). 2023 Oct;32[10]:1111-9).

That history may help women navigate to care, while women for whom psychiatric illness is a new experience may be less likely to engage, be referred for care, and receive appropriate treatment. The study indicates that, as a field, we must strive to ensure universal screening for depression in perinatal populations.

While we have always been particularly interested in populations of patients at highest risk for PPD, helping women at risk for PPD in the general population without a history of psychiatric illness is a large public health issue and will be an even larger undertaking. As women’s mental health is gaining more appropriate focus, both at the local level and even in the recent White House Initiative on Women’s Health Research, the focus has been on screening and developing new treatments.

We are not lacking in pharmacologic agents nor nonpharmacologic options as treatments for women experiencing PPD. Newer alternative treatments are being explored, such as transcranial magnetic stimulation (TMS) and even psychedelics as a potential therapy for PPD. But perhaps what we’ve learned in 2023 and as we move into a new year, is that the problem of tackling PPD is not only about having the right tools, but is about helping women navigate to the care that they need.

The COVID-19 pandemic brought with it an explosion of telehealth options that have enhanced the odds women can find support during such a challenging time; as society has returned to some semblance of normal, nearly all support groups for postpartum women have remained online.

When we set up Virtual Rounds at the Center for Women’s Mental Health at the beginning of the pandemic, I was struck by the community of colleagues at various stages of their careers dedicated to mitigating the suffering associated with perinatal psychiatric illness. As I’ve often said, it takes a village to care for these patients. We need help from colleagues with varying expertise — from lactation consultants, psychiatrists, psychologists, obstetricians, nurse practitioners, support group leaders, and a host of others — who can help reach these women.

At the end of the day, helping depressed women find resources is a challenge that we have not met in this country. We should be excited that we have so many treatment options to offer patients — whether it be a new first-in-class medication, TMS, or digital apps to ensure patients are receiving effective treatment. But there should also be a focus on reaching women who still need treatment, particularly in underserved communities where resources are sparse or nonexistent. Identifying the path to reaching these women where they are and getting them well should be a top priority in 2024.
 

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital (MGH) in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. STEPS for PPD is funded by the Marriott Foundation. Full disclosure information for Dr. Cohen is available at womensmentalhealth.org. Email Dr. Cohen at [email protected].

The past year has been a challenging time for many, both at the local level and globally, with divisive undercurrents across many communities. Many times, the end of the year is an opportunity for reflection. As I reflect on the state of perinatal psychiatry in the new year, I see several evolving issues that I’d like to share in this first column of 2024.

In 2023, the American College of Obstetricians and Gynecologists published new recommendations meant to enhance the well-being of pregnant and postpartum women and families. A main message from discussion papers borne out of these recommendations was that as a field, we should be doing more than identifying perinatal illness. We should be screening women at risk for postpartum psychiatric illness and see that those suffering from posttraumatic stress disorder (PTSD) have access to care and “wrap-around services” from clinicians with varying expertise.

Screening is a primary way we identify patients at risk for psychiatric illness and also those who are suffering at the time of a screen. One problem I see in the near future is our disparate collection and management of data. When we look closely across health care systems, it’s not clear how screening data are captured, let alone managed. What is being done in one hospital system may be very different from what is being done elsewhere. Some clinicians are adopting digital platforms to identify those with postpartum depression, while others are practicing as they always have, either through a paper screening process or with queries as part of a clinical encounter.

Given this amalgam of methods for collecting and storing information, there does not appear to be a systematic way clinicians and researchers are recording whether women are meeting criteria for significant depressive symptoms or frank postpartum psychiatric illness. It is clear a more cohesive method for collection and management is needed to optimize the likelihood that next steps can be taken to get patients the care they need.

However, screening is only one part of the story. Certainly, in our own center, one of our greatest interests, both clinically and on the research side, is what happens after screening. Through our center’s initiation of the Screening and Treatment Enhancement for Postpartum Depression (STEPS for PPD) project funded by the Marriott Foundation, we are evaluating the outcomes of women who are screened at 6 weeks postpartum with significant depressive symptoms, and who are then given an opportunity to engage with a perinatal social worker who can assist with direct psychotherapy, arranging for referrals, and navigating care for a new mother.

What we are learning as we enroll women through the initial stages of STEPS for PPD is that screening and identifying women who likely suffer from PPD simply is not enough. In fact, once identified with a depression screening tool, women who are suffering from postpartum depression can be very challenging to engage clinically. What I am learning decades after starting to work with perinatal patients is that even with a screening system and effective tools for treatment of PPD, optimizing engagement with these depressed women seems a critical and understudied step on the road to optimizing positive clinical outcomes.

A recent study published in the Journal of Women’s Health explored gaps in care for perinatal depression and found that patients without a history of psychiatric illness prior to pregnancy were less likely to be screened for depression and 80% less likely to receive care if they developed depression compared with women with a previous history of psychiatric illness (J Womens Health (Larchmt). 2023 Oct;32[10]:1111-9).

That history may help women navigate to care, while women for whom psychiatric illness is a new experience may be less likely to engage, be referred for care, and receive appropriate treatment. The study indicates that, as a field, we must strive to ensure universal screening for depression in perinatal populations.

While we have always been particularly interested in populations of patients at highest risk for PPD, helping women at risk for PPD in the general population without a history of psychiatric illness is a large public health issue and will be an even larger undertaking. As women’s mental health is gaining more appropriate focus, both at the local level and even in the recent White House Initiative on Women’s Health Research, the focus has been on screening and developing new treatments.

We are not lacking in pharmacologic agents nor nonpharmacologic options as treatments for women experiencing PPD. Newer alternative treatments are being explored, such as transcranial magnetic stimulation (TMS) and even psychedelics as a potential therapy for PPD. But perhaps what we’ve learned in 2023 and as we move into a new year, is that the problem of tackling PPD is not only about having the right tools, but is about helping women navigate to the care that they need.

The COVID-19 pandemic brought with it an explosion of telehealth options that have enhanced the odds women can find support during such a challenging time; as society has returned to some semblance of normal, nearly all support groups for postpartum women have remained online.

When we set up Virtual Rounds at the Center for Women’s Mental Health at the beginning of the pandemic, I was struck by the community of colleagues at various stages of their careers dedicated to mitigating the suffering associated with perinatal psychiatric illness. As I’ve often said, it takes a village to care for these patients. We need help from colleagues with varying expertise — from lactation consultants, psychiatrists, psychologists, obstetricians, nurse practitioners, support group leaders, and a host of others — who can help reach these women.

At the end of the day, helping depressed women find resources is a challenge that we have not met in this country. We should be excited that we have so many treatment options to offer patients — whether it be a new first-in-class medication, TMS, or digital apps to ensure patients are receiving effective treatment. But there should also be a focus on reaching women who still need treatment, particularly in underserved communities where resources are sparse or nonexistent. Identifying the path to reaching these women where they are and getting them well should be a top priority in 2024.
 

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital (MGH) in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. STEPS for PPD is funded by the Marriott Foundation. Full disclosure information for Dr. Cohen is available at womensmentalhealth.org. Email Dr. Cohen at [email protected].

The past year has been a challenging time for many, both at the local level and globally, with divisive undercurrents across many communities. Many times, the end of the year is an opportunity for reflection. As I reflect on the state of perinatal psychiatry in the new year, I see several evolving issues that I’d like to share in this first column of 2024.

In 2023, the American College of Obstetricians and Gynecologists published new recommendations meant to enhance the well-being of pregnant and postpartum women and families. A main message from discussion papers borne out of these recommendations was that as a field, we should be doing more than identifying perinatal illness. We should be screening women at risk for postpartum psychiatric illness and see that those suffering from posttraumatic stress disorder (PTSD) have access to care and “wrap-around services” from clinicians with varying expertise.

Screening is a primary way we identify patients at risk for psychiatric illness and also those who are suffering at the time of a screen. One problem I see in the near future is our disparate collection and management of data. When we look closely across health care systems, it’s not clear how screening data are captured, let alone managed. What is being done in one hospital system may be very different from what is being done elsewhere. Some clinicians are adopting digital platforms to identify those with postpartum depression, while others are practicing as they always have, either through a paper screening process or with queries as part of a clinical encounter.

Given this amalgam of methods for collecting and storing information, there does not appear to be a systematic way clinicians and researchers are recording whether women are meeting criteria for significant depressive symptoms or frank postpartum psychiatric illness. It is clear a more cohesive method for collection and management is needed to optimize the likelihood that next steps can be taken to get patients the care they need.

However, screening is only one part of the story. Certainly, in our own center, one of our greatest interests, both clinically and on the research side, is what happens after screening. Through our center’s initiation of the Screening and Treatment Enhancement for Postpartum Depression (STEPS for PPD) project funded by the Marriott Foundation, we are evaluating the outcomes of women who are screened at 6 weeks postpartum with significant depressive symptoms, and who are then given an opportunity to engage with a perinatal social worker who can assist with direct psychotherapy, arranging for referrals, and navigating care for a new mother.

What we are learning as we enroll women through the initial stages of STEPS for PPD is that screening and identifying women who likely suffer from PPD simply is not enough. In fact, once identified with a depression screening tool, women who are suffering from postpartum depression can be very challenging to engage clinically. What I am learning decades after starting to work with perinatal patients is that even with a screening system and effective tools for treatment of PPD, optimizing engagement with these depressed women seems a critical and understudied step on the road to optimizing positive clinical outcomes.

A recent study published in the Journal of Women’s Health explored gaps in care for perinatal depression and found that patients without a history of psychiatric illness prior to pregnancy were less likely to be screened for depression and 80% less likely to receive care if they developed depression compared with women with a previous history of psychiatric illness (J Womens Health (Larchmt). 2023 Oct;32[10]:1111-9).

That history may help women navigate to care, while women for whom psychiatric illness is a new experience may be less likely to engage, be referred for care, and receive appropriate treatment. The study indicates that, as a field, we must strive to ensure universal screening for depression in perinatal populations.

While we have always been particularly interested in populations of patients at highest risk for PPD, helping women at risk for PPD in the general population without a history of psychiatric illness is a large public health issue and will be an even larger undertaking. As women’s mental health is gaining more appropriate focus, both at the local level and even in the recent White House Initiative on Women’s Health Research, the focus has been on screening and developing new treatments.

We are not lacking in pharmacologic agents nor nonpharmacologic options as treatments for women experiencing PPD. Newer alternative treatments are being explored, such as transcranial magnetic stimulation (TMS) and even psychedelics as a potential therapy for PPD. But perhaps what we’ve learned in 2023 and as we move into a new year, is that the problem of tackling PPD is not only about having the right tools, but is about helping women navigate to the care that they need.

The COVID-19 pandemic brought with it an explosion of telehealth options that have enhanced the odds women can find support during such a challenging time; as society has returned to some semblance of normal, nearly all support groups for postpartum women have remained online.

When we set up Virtual Rounds at the Center for Women’s Mental Health at the beginning of the pandemic, I was struck by the community of colleagues at various stages of their careers dedicated to mitigating the suffering associated with perinatal psychiatric illness. As I’ve often said, it takes a village to care for these patients. We need help from colleagues with varying expertise — from lactation consultants, psychiatrists, psychologists, obstetricians, nurse practitioners, support group leaders, and a host of others — who can help reach these women.

At the end of the day, helping depressed women find resources is a challenge that we have not met in this country. We should be excited that we have so many treatment options to offer patients — whether it be a new first-in-class medication, TMS, or digital apps to ensure patients are receiving effective treatment. But there should also be a focus on reaching women who still need treatment, particularly in underserved communities where resources are sparse or nonexistent. Identifying the path to reaching these women where they are and getting them well should be a top priority in 2024.
 

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital (MGH) in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. STEPS for PPD is funded by the Marriott Foundation. Full disclosure information for Dr. Cohen is available at womensmentalhealth.org. Email Dr. Cohen at [email protected].

Harvard Medical School’s Sharon K. Inouye, MD, MPH, is editor in chief of JAMA Internal Medicine and a leading voice in American gerontology. We asked her to choose five of the influential journal’s most impactful studies from 2023 and highlight important take-home messages for internists and their colleagues.
 

Q: One of the studies you chose suggests that the antiviral nirmatrelvir (Paxlovid) can ward off long COVID. Could you recap the findings?

A: Researchers followed a group of more than 280,000 Department of Veterans Affairs patients who were seen in 2022, had a positive COVID test, and had at least one risk factor for severe COVID. They focused on those who survived to 30 days after their COVID infection and compared those who received the drug within the first 5 days of a positive test with an equivalent control group.

They found that 13 long COVID symptoms were all significantly less common (relative risk = 0.74) in those who received nirmatrelvir. This was true no matter whether they’d ever had a COVID vaccination.
 

Q: How should this research affect clinical practice?

A: You can’t generalize from this to everyone because, of course, not everyone was included in this study. But it is highly suggestive that this drug is very effective for preventing long COVID.

Nirmatrelvir was touted as being able to shorten duration of illness and prevent hospitalization. But if you were low risk or you were already well into your COVID course, it wasn’t like rush, rush, rush to the doctor to get it.

This changes that equation because we know long COVID is such a huge issue. The vast majority of doctors who work with COVID patients and know this are now being more aggressive about prescribing it.
 

Q: What about patients whom the CDC considers to be at less risk — people with up-to-date vaccinations who are under 50 with mild-to-moderate COVID and no higher-risk medical conditions? Should they take nirmatrelvir?

A: The evidence is not 100% in yet. A study like this one needs to be repeated and include younger people without any risk factors to see if we see the same thing. So it’s a personal choice, and a personal calculus needs to be done. A lot of people are making that choice [to take the drug], and it can be a rational decision.

Q: You also chose a study that links high thyroid hormone levels to higher rates of dementia. What did it reveal?

A: This study looks at patients who had thyrotoxicosis — a thyroid level that’s too high — from hormone produced endogenously, and exogenously. Researchers tracked almost 66,000 patients aged 65 and older and found that thyrotoxicosis from all causes, whether it was endogenous or exogenous, was linked to an increased risk of dementia in a dose-response relationship (adjusted hazard ratio = 1.39).

Q: Is there a clinical take-home message here?

A: When we start patients on thyroid medication, they don’t always get reassessed on a regular basis. Given this finding, a TSH [thyroid-stimulating hormone] level is indicated during the annual wellness check that patients on Medicare can get every year.

Q: Is TSH measured as part of routine blood tests?

A: No it’s not. It has to be ordered. I think that’s why we’re seeing this problem to begin with — because it’s not something we all have awareness about. I wasn’t aware myself that mildly high levels of thyroid could increase the risk of cognitive impairment. Certainly, I’m going to be much more aware in my practice.

Q: You also picked a study about silicosis in workers who are exposed to dust when they make engineered stone countertops, also known as quartz countertops. What were the findings?

A: Silicosis is a very serious lung condition that develops from exposure to crystalline silica. Essentially, sand gets inhaled into the lungs. Workers can be exposed when they’re making engineered stone countertops, the most popular countertops now in the United States.

This study is based on statewide surveys from 2019 to 2022 that the California Department of Public Health does routinely. They gathered cases of silicosis and found 52 — all men with an average age of 45. All but one were Latino immigrants, and most either had no insurance or very poor insurance.
 

Q: The study found that “diagnosis was delayed in 58%, with 38% presenting with advanced disease (progressive massive fibrosis), and 19% died.” What does that tell you?

A: It’s a very serious condition. Once it gets to the advanced stage, it will just continue to progress, and the person will die. That’s why it’s so important to know that it’s absolutely preventable.

Q: Is there a message here for internists?

A: If you treat a lot of immigrants or work in an area where there are a lot of industrial workers, you’re going to want to have a very high suspicion about it. If you see an atypical pattern on the chest x-ray or via diffusion scoring, have a low threshold for getting a pulmonary function test.

Doctors need to be aware and diagnose this very quickly. When patients present, you can pull them out of that work environment or put mitigation systems into place.
 

Q: California regulators were expected to put emergency rules into place in late December to protect workers. Did this study play a role in focusing attention on the problem?

A: This article, along with a commentary and podcast that we put out, really helped with advocacy to improve health and safety for workers at stone-cutting and fabrication shops.

Q: You were impressed by another study about airborne dangers, this one linking air pollution to dementia. What did researchers discover?

A: [This analysis] of more than 27,000 people in the Health and Retirement Study, a respected and rich database, found that exposure to air pollution was associated with greater rates of dementia — an increase of about 8% a year. Exposure to agricultural emissions and wildfire smoke were most robustly associated with a greater risk of dementia.

Q: How are these findings important, especially in light of the unhealthy air spawned by recent wildfires in the United States and Canada?

A: Studies like this will make it even more compelling that we are better prepared for air quality issues.

I grew up in Los Angeles, where smog and pollution were very big issues. I was constantly hearing about various mitigation strategies that were going into place. But after I moved to the East Coast, I almost never heard about prevention.

Now, I’m hoping we can keep this topic in the national conversation.
 

Q: You also highlighted a systematic review of the use of restraints in the emergency department. Why did you choose this research?

A: At JAMA Internal Medicine, we’re really focused on ways we can address health disparities and raise awareness of potential unconscious bias.

This review looked at 10 studies that included more than 2.5 million patient encounters, including 24,000 incidents of physical restraint use. They found that the overall rate of use of restraints was low at below 1%.

But when they are used, Black patients were 1.3 times more likely to be restrained than White patients.
 

Q: What’s the message here?

A: This is an important start to recognizing these differences and then changing our behavior. Perhaps restraints don’t need to be used as often in light of evidence, for example, of increased rates of misdiagnosis of psychosis in the Black population.

Q: How should physicians change their approach to restraints?

A: Restraints are not to be used to control disruption — wild behavior or verbal outbursts. They’re for when someone is a danger to themselves or others.

Dr. Inouye has no conflicts of interest.

Harvard Medical School’s Sharon K. Inouye, MD, MPH, is editor in chief of JAMA Internal Medicine and a leading voice in American gerontology. We asked her to choose five of the influential journal’s most impactful studies from 2023 and highlight important take-home messages for internists and their colleagues.
 

Q: One of the studies you chose suggests that the antiviral nirmatrelvir (Paxlovid) can ward off long COVID. Could you recap the findings?

A: Researchers followed a group of more than 280,000 Department of Veterans Affairs patients who were seen in 2022, had a positive COVID test, and had at least one risk factor for severe COVID. They focused on those who survived to 30 days after their COVID infection and compared those who received the drug within the first 5 days of a positive test with an equivalent control group.

They found that 13 long COVID symptoms were all significantly less common (relative risk = 0.74) in those who received nirmatrelvir. This was true no matter whether they’d ever had a COVID vaccination.
 

Q: How should this research affect clinical practice?

A: You can’t generalize from this to everyone because, of course, not everyone was included in this study. But it is highly suggestive that this drug is very effective for preventing long COVID.

Nirmatrelvir was touted as being able to shorten duration of illness and prevent hospitalization. But if you were low risk or you were already well into your COVID course, it wasn’t like rush, rush, rush to the doctor to get it.

This changes that equation because we know long COVID is such a huge issue. The vast majority of doctors who work with COVID patients and know this are now being more aggressive about prescribing it.
 

Q: What about patients whom the CDC considers to be at less risk — people with up-to-date vaccinations who are under 50 with mild-to-moderate COVID and no higher-risk medical conditions? Should they take nirmatrelvir?

A: The evidence is not 100% in yet. A study like this one needs to be repeated and include younger people without any risk factors to see if we see the same thing. So it’s a personal choice, and a personal calculus needs to be done. A lot of people are making that choice [to take the drug], and it can be a rational decision.

Q: You also chose a study that links high thyroid hormone levels to higher rates of dementia. What did it reveal?

A: This study looks at patients who had thyrotoxicosis — a thyroid level that’s too high — from hormone produced endogenously, and exogenously. Researchers tracked almost 66,000 patients aged 65 and older and found that thyrotoxicosis from all causes, whether it was endogenous or exogenous, was linked to an increased risk of dementia in a dose-response relationship (adjusted hazard ratio = 1.39).

Q: Is there a clinical take-home message here?

A: When we start patients on thyroid medication, they don’t always get reassessed on a regular basis. Given this finding, a TSH [thyroid-stimulating hormone] level is indicated during the annual wellness check that patients on Medicare can get every year.

Q: Is TSH measured as part of routine blood tests?

A: No it’s not. It has to be ordered. I think that’s why we’re seeing this problem to begin with — because it’s not something we all have awareness about. I wasn’t aware myself that mildly high levels of thyroid could increase the risk of cognitive impairment. Certainly, I’m going to be much more aware in my practice.

Q: You also picked a study about silicosis in workers who are exposed to dust when they make engineered stone countertops, also known as quartz countertops. What were the findings?

A: Silicosis is a very serious lung condition that develops from exposure to crystalline silica. Essentially, sand gets inhaled into the lungs. Workers can be exposed when they’re making engineered stone countertops, the most popular countertops now in the United States.

This study is based on statewide surveys from 2019 to 2022 that the California Department of Public Health does routinely. They gathered cases of silicosis and found 52 — all men with an average age of 45. All but one were Latino immigrants, and most either had no insurance or very poor insurance.
 

Q: The study found that “diagnosis was delayed in 58%, with 38% presenting with advanced disease (progressive massive fibrosis), and 19% died.” What does that tell you?

A: It’s a very serious condition. Once it gets to the advanced stage, it will just continue to progress, and the person will die. That’s why it’s so important to know that it’s absolutely preventable.

Q: Is there a message here for internists?

A: If you treat a lot of immigrants or work in an area where there are a lot of industrial workers, you’re going to want to have a very high suspicion about it. If you see an atypical pattern on the chest x-ray or via diffusion scoring, have a low threshold for getting a pulmonary function test.

Doctors need to be aware and diagnose this very quickly. When patients present, you can pull them out of that work environment or put mitigation systems into place.
 

Q: California regulators were expected to put emergency rules into place in late December to protect workers. Did this study play a role in focusing attention on the problem?

A: This article, along with a commentary and podcast that we put out, really helped with advocacy to improve health and safety for workers at stone-cutting and fabrication shops.

Q: You were impressed by another study about airborne dangers, this one linking air pollution to dementia. What did researchers discover?

A: [This analysis] of more than 27,000 people in the Health and Retirement Study, a respected and rich database, found that exposure to air pollution was associated with greater rates of dementia — an increase of about 8% a year. Exposure to agricultural emissions and wildfire smoke were most robustly associated with a greater risk of dementia.

Q: How are these findings important, especially in light of the unhealthy air spawned by recent wildfires in the United States and Canada?

A: Studies like this will make it even more compelling that we are better prepared for air quality issues.

I grew up in Los Angeles, where smog and pollution were very big issues. I was constantly hearing about various mitigation strategies that were going into place. But after I moved to the East Coast, I almost never heard about prevention.

Now, I’m hoping we can keep this topic in the national conversation.
 

Q: You also highlighted a systematic review of the use of restraints in the emergency department. Why did you choose this research?

A: At JAMA Internal Medicine, we’re really focused on ways we can address health disparities and raise awareness of potential unconscious bias.

This review looked at 10 studies that included more than 2.5 million patient encounters, including 24,000 incidents of physical restraint use. They found that the overall rate of use of restraints was low at below 1%.

But when they are used, Black patients were 1.3 times more likely to be restrained than White patients.
 

Q: What’s the message here?

A: This is an important start to recognizing these differences and then changing our behavior. Perhaps restraints don’t need to be used as often in light of evidence, for example, of increased rates of misdiagnosis of psychosis in the Black population.

Q: How should physicians change their approach to restraints?

A: Restraints are not to be used to control disruption — wild behavior or verbal outbursts. They’re for when someone is a danger to themselves or others.

Dr. Inouye has no conflicts of interest.

Harvard Medical School’s Sharon K. Inouye, MD, MPH, is editor in chief of JAMA Internal Medicine and a leading voice in American gerontology. We asked her to choose five of the influential journal’s most impactful studies from 2023 and highlight important take-home messages for internists and their colleagues.
 

Q: One of the studies you chose suggests that the antiviral nirmatrelvir (Paxlovid) can ward off long COVID. Could you recap the findings?

A: Researchers followed a group of more than 280,000 Department of Veterans Affairs patients who were seen in 2022, had a positive COVID test, and had at least one risk factor for severe COVID. They focused on those who survived to 30 days after their COVID infection and compared those who received the drug within the first 5 days of a positive test with an equivalent control group.

They found that 13 long COVID symptoms were all significantly less common (relative risk = 0.74) in those who received nirmatrelvir. This was true no matter whether they’d ever had a COVID vaccination.
 

Q: How should this research affect clinical practice?

A: You can’t generalize from this to everyone because, of course, not everyone was included in this study. But it is highly suggestive that this drug is very effective for preventing long COVID.

Nirmatrelvir was touted as being able to shorten duration of illness and prevent hospitalization. But if you were low risk or you were already well into your COVID course, it wasn’t like rush, rush, rush to the doctor to get it.

This changes that equation because we know long COVID is such a huge issue. The vast majority of doctors who work with COVID patients and know this are now being more aggressive about prescribing it.
 

Q: What about patients whom the CDC considers to be at less risk — people with up-to-date vaccinations who are under 50 with mild-to-moderate COVID and no higher-risk medical conditions? Should they take nirmatrelvir?

A: The evidence is not 100% in yet. A study like this one needs to be repeated and include younger people without any risk factors to see if we see the same thing. So it’s a personal choice, and a personal calculus needs to be done. A lot of people are making that choice [to take the drug], and it can be a rational decision.

Q: You also chose a study that links high thyroid hormone levels to higher rates of dementia. What did it reveal?

A: This study looks at patients who had thyrotoxicosis — a thyroid level that’s too high — from hormone produced endogenously, and exogenously. Researchers tracked almost 66,000 patients aged 65 and older and found that thyrotoxicosis from all causes, whether it was endogenous or exogenous, was linked to an increased risk of dementia in a dose-response relationship (adjusted hazard ratio = 1.39).

Q: Is there a clinical take-home message here?

A: When we start patients on thyroid medication, they don’t always get reassessed on a regular basis. Given this finding, a TSH [thyroid-stimulating hormone] level is indicated during the annual wellness check that patients on Medicare can get every year.

Q: Is TSH measured as part of routine blood tests?

A: No it’s not. It has to be ordered. I think that’s why we’re seeing this problem to begin with — because it’s not something we all have awareness about. I wasn’t aware myself that mildly high levels of thyroid could increase the risk of cognitive impairment. Certainly, I’m going to be much more aware in my practice.

Q: You also picked a study about silicosis in workers who are exposed to dust when they make engineered stone countertops, also known as quartz countertops. What were the findings?

A: Silicosis is a very serious lung condition that develops from exposure to crystalline silica. Essentially, sand gets inhaled into the lungs. Workers can be exposed when they’re making engineered stone countertops, the most popular countertops now in the United States.

This study is based on statewide surveys from 2019 to 2022 that the California Department of Public Health does routinely. They gathered cases of silicosis and found 52 — all men with an average age of 45. All but one were Latino immigrants, and most either had no insurance or very poor insurance.
 

Q: The study found that “diagnosis was delayed in 58%, with 38% presenting with advanced disease (progressive massive fibrosis), and 19% died.” What does that tell you?

A: It’s a very serious condition. Once it gets to the advanced stage, it will just continue to progress, and the person will die. That’s why it’s so important to know that it’s absolutely preventable.

Q: Is there a message here for internists?

A: If you treat a lot of immigrants or work in an area where there are a lot of industrial workers, you’re going to want to have a very high suspicion about it. If you see an atypical pattern on the chest x-ray or via diffusion scoring, have a low threshold for getting a pulmonary function test.

Doctors need to be aware and diagnose this very quickly. When patients present, you can pull them out of that work environment or put mitigation systems into place.
 

Q: California regulators were expected to put emergency rules into place in late December to protect workers. Did this study play a role in focusing attention on the problem?

A: This article, along with a commentary and podcast that we put out, really helped with advocacy to improve health and safety for workers at stone-cutting and fabrication shops.

Q: You were impressed by another study about airborne dangers, this one linking air pollution to dementia. What did researchers discover?

A: [This analysis] of more than 27,000 people in the Health and Retirement Study, a respected and rich database, found that exposure to air pollution was associated with greater rates of dementia — an increase of about 8% a year. Exposure to agricultural emissions and wildfire smoke were most robustly associated with a greater risk of dementia.

Q: How are these findings important, especially in light of the unhealthy air spawned by recent wildfires in the United States and Canada?

A: Studies like this will make it even more compelling that we are better prepared for air quality issues.

I grew up in Los Angeles, where smog and pollution were very big issues. I was constantly hearing about various mitigation strategies that were going into place. But after I moved to the East Coast, I almost never heard about prevention.

Now, I’m hoping we can keep this topic in the national conversation.
 

Q: You also highlighted a systematic review of the use of restraints in the emergency department. Why did you choose this research?

A: At JAMA Internal Medicine, we’re really focused on ways we can address health disparities and raise awareness of potential unconscious bias.

This review looked at 10 studies that included more than 2.5 million patient encounters, including 24,000 incidents of physical restraint use. They found that the overall rate of use of restraints was low at below 1%.

But when they are used, Black patients were 1.3 times more likely to be restrained than White patients.
 

Q: What’s the message here?

A: This is an important start to recognizing these differences and then changing our behavior. Perhaps restraints don’t need to be used as often in light of evidence, for example, of increased rates of misdiagnosis of psychosis in the Black population.

Q: How should physicians change their approach to restraints?

A: Restraints are not to be used to control disruption — wild behavior or verbal outbursts. They’re for when someone is a danger to themselves or others.

Dr. Inouye has no conflicts of interest.

Christmas, like New Year’s Day, Thanksgiving, birthdays, and anniversaries, is one of those times that we use to mark where we were and how far we’ve come.

I’m in a mixed marriage, so we celebrate both Hanukkah and Christmas. Twenty-five years ago I was a newly minted attending neurologist, not even 6 months out of fellowship.

My wife was pregnant with our first child and had invited my Jewish family over for Christmas dinner. This was our first December in our first house and she wanted to do something special for them.

Being the low person on the totem pole, it was my first Christmas on call, covering for myself and two other neurologists.

So I was driving. A lot. My wife was on her own to get things ready, and I was hoping to be home for dinner.

It was, as always seems to be the case with holidays, quite busy. I was up long before dawn to start, driving a circular route to cover four hospitals scattered around Phoenix. At least the roads were empty.

At some point the planned pattern breaks down as new consults and urgent patient status changes happen. You try to start by going from A to B to C to D for rounds, but within a few hours I was going from A to B to C, then back to A, then D, then B, then A again, and so on. All the while I was returning patient calls. Wash, rinse, repeat.

At some point I dialed my wife to see how she was doing and she gave me a list of last-minute things she needed picked up (which included some dairy products and more Christmas lights for her tree). I found a small store that was still open. For the rest of my day on call a grocery bag full of dairy products was carried from hospital to hospital with me, being put in the doctor’s lounge refrigerator with my name on it (this is Phoenix, even in winter you can’t leave it in the car). This added another trip from C back to A when I realized I’d left the groceries there.

I got home a few minutes before my family came over, after 14-15 hours of driving between hospitals. I was putting up the new lights when they came in. Fortunately I wasn’t called back in that night, and turned things over to my call partners in the morning.

Now? Since early 2020 my hospital days are behind me. My kids have their own lives, jobs, and school, but still all came over to see us.

I didn’t have to leave the house. I spent most of the day in a robe and pajamas, working at my desk on this and that, sometimes wandering to another table to futz with my current jigsaw puzzle or chat with my kids or go soak in my hot tub.

In 1998 I weighed 50 pounds less (still working on losing it), had no kids, or dogs. Now I’m in another house, have three grown kids, and in the interim have enjoyed seven awesome dogs (currently only one). My wife still invited my family over for Christmas dinner, but now it’s my mom and uncle. My dad and aunt are gone.

The changes are mostly good, though, as with all passages of time there is sadness and loss. When all is said and done I wouldn’t have done much differently even if I could.

I’m lucky, and I know it. Regardless of what you celebrate, it’s a good time to take stock of your blessings. To quote Sheryl Crow, “It’s not having what you want, it’s wanting what you’ve got.”

Happy New Year to all.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Christmas, like New Year’s Day, Thanksgiving, birthdays, and anniversaries, is one of those times that we use to mark where we were and how far we’ve come.

I’m in a mixed marriage, so we celebrate both Hanukkah and Christmas. Twenty-five years ago I was a newly minted attending neurologist, not even 6 months out of fellowship.

My wife was pregnant with our first child and had invited my Jewish family over for Christmas dinner. This was our first December in our first house and she wanted to do something special for them.

Being the low person on the totem pole, it was my first Christmas on call, covering for myself and two other neurologists.

So I was driving. A lot. My wife was on her own to get things ready, and I was hoping to be home for dinner.

It was, as always seems to be the case with holidays, quite busy. I was up long before dawn to start, driving a circular route to cover four hospitals scattered around Phoenix. At least the roads were empty.

At some point the planned pattern breaks down as new consults and urgent patient status changes happen. You try to start by going from A to B to C to D for rounds, but within a few hours I was going from A to B to C, then back to A, then D, then B, then A again, and so on. All the while I was returning patient calls. Wash, rinse, repeat.

At some point I dialed my wife to see how she was doing and she gave me a list of last-minute things she needed picked up (which included some dairy products and more Christmas lights for her tree). I found a small store that was still open. For the rest of my day on call a grocery bag full of dairy products was carried from hospital to hospital with me, being put in the doctor’s lounge refrigerator with my name on it (this is Phoenix, even in winter you can’t leave it in the car). This added another trip from C back to A when I realized I’d left the groceries there.

I got home a few minutes before my family came over, after 14-15 hours of driving between hospitals. I was putting up the new lights when they came in. Fortunately I wasn’t called back in that night, and turned things over to my call partners in the morning.

Now? Since early 2020 my hospital days are behind me. My kids have their own lives, jobs, and school, but still all came over to see us.

I didn’t have to leave the house. I spent most of the day in a robe and pajamas, working at my desk on this and that, sometimes wandering to another table to futz with my current jigsaw puzzle or chat with my kids or go soak in my hot tub.

In 1998 I weighed 50 pounds less (still working on losing it), had no kids, or dogs. Now I’m in another house, have three grown kids, and in the interim have enjoyed seven awesome dogs (currently only one). My wife still invited my family over for Christmas dinner, but now it’s my mom and uncle. My dad and aunt are gone.

The changes are mostly good, though, as with all passages of time there is sadness and loss. When all is said and done I wouldn’t have done much differently even if I could.

I’m lucky, and I know it. Regardless of what you celebrate, it’s a good time to take stock of your blessings. To quote Sheryl Crow, “It’s not having what you want, it’s wanting what you’ve got.”

Happy New Year to all.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Christmas, like New Year’s Day, Thanksgiving, birthdays, and anniversaries, is one of those times that we use to mark where we were and how far we’ve come.

I’m in a mixed marriage, so we celebrate both Hanukkah and Christmas. Twenty-five years ago I was a newly minted attending neurologist, not even 6 months out of fellowship.

My wife was pregnant with our first child and had invited my Jewish family over for Christmas dinner. This was our first December in our first house and she wanted to do something special for them.

Being the low person on the totem pole, it was my first Christmas on call, covering for myself and two other neurologists.

So I was driving. A lot. My wife was on her own to get things ready, and I was hoping to be home for dinner.

It was, as always seems to be the case with holidays, quite busy. I was up long before dawn to start, driving a circular route to cover four hospitals scattered around Phoenix. At least the roads were empty.

At some point the planned pattern breaks down as new consults and urgent patient status changes happen. You try to start by going from A to B to C to D for rounds, but within a few hours I was going from A to B to C, then back to A, then D, then B, then A again, and so on. All the while I was returning patient calls. Wash, rinse, repeat.

At some point I dialed my wife to see how she was doing and she gave me a list of last-minute things she needed picked up (which included some dairy products and more Christmas lights for her tree). I found a small store that was still open. For the rest of my day on call a grocery bag full of dairy products was carried from hospital to hospital with me, being put in the doctor’s lounge refrigerator with my name on it (this is Phoenix, even in winter you can’t leave it in the car). This added another trip from C back to A when I realized I’d left the groceries there.

I got home a few minutes before my family came over, after 14-15 hours of driving between hospitals. I was putting up the new lights when they came in. Fortunately I wasn’t called back in that night, and turned things over to my call partners in the morning.

Now? Since early 2020 my hospital days are behind me. My kids have their own lives, jobs, and school, but still all came over to see us.

I didn’t have to leave the house. I spent most of the day in a robe and pajamas, working at my desk on this and that, sometimes wandering to another table to futz with my current jigsaw puzzle or chat with my kids or go soak in my hot tub.

In 1998 I weighed 50 pounds less (still working on losing it), had no kids, or dogs. Now I’m in another house, have three grown kids, and in the interim have enjoyed seven awesome dogs (currently only one). My wife still invited my family over for Christmas dinner, but now it’s my mom and uncle. My dad and aunt are gone.

The changes are mostly good, though, as with all passages of time there is sadness and loss. When all is said and done I wouldn’t have done much differently even if I could.

I’m lucky, and I know it. Regardless of what you celebrate, it’s a good time to take stock of your blessings. To quote Sheryl Crow, “It’s not having what you want, it’s wanting what you’ve got.”

Happy New Year to all.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

People are surprised when they learn I was an art history major in college. Most folks assume I had majored in biology or chemistry. Their assumption was based on strong odds. The U.S. Bureau of Labor Statistics reports that nearly half of all physicians practicing in this country were biology majors.

I headed off to college clueless about my future. I was hoping to succeed as a walk-on to the football team and beyond that I figured someone or something would guide me toward a career. Had you asked me, “physician” it would have been a definite “Never.”

I flirted with a psychology major, but after a semester I realized that the department was more interested in the behavior of rats rather than humans. I got an “easy A” in the intro to art history and that was the open door I was looking for.

By my senior year I was applying for fellowships to study in faraway places. However, the world situation in 1965 was unsettling for a young man in this country. I had had a strong high school science education and had continued to take a some science courses. Fortunately, I had banked just enough credits so that I could apply to medical school, again without really planning to become a physician.

Even during the sharpest turns in my circuitous path to becoming a small town pediatrician, including a year doing research in exercise physiology in Denmark, I never once regretted my years spent studying art history. I credit them with making me a more sensitive observer.

You can probably understand why I was intrigued by an article I recently read that described a program in which the radiology residents that the Brigham and Women’s Hospital in Boston take a year-long course in art history using the Art Museum at Harvard University as a resource. Titled “Seeing in Art and Medical Imaging,” the program is now 6 years old. Hyewon Hyun, MD, a radiologist and one of its cofounders, observes that “art is the starting point for in-depth conversations about medicine, humanity, and different ways of seeing the world.”

Radiology and dermatology are obviously the two specialties in which the physician relies most heavily on his or her powers of observation. However, every doctor can benefit from learning to really “see” what they are looking at. Looking and seeing are two very different activities. There is obviously the forest-from the-trees phenomenon. Can the physician in a hurried clinical situation muster up the discipline to shift focus back and forth from the lesion or painful body part to the entire patient and beyond? How is the parent responding to the child’s discomfort? How are they dressed? Does this wider view suggest some additional questions to ask that may help you understand how this patient or family will be able to cope with diagnosis or follow up with your treatment plan?

The art historian sees every object in its historical context. What has come before? How have the societal conditions influenced the artist choice of subject and use of materials? How has his or her emotions at the time of creation influenced his or her style? The astute physician must likewise see the patients and their complaints in the broader context of their emotional health and socioeconomic situation. This requires sensitive listening and careful observation.

One doesn’t have to major in art history or spend years roaming through the sometimes dark and dusty halls of the world’s museums to progress from being one who simply looks to a person who really sees the environment and its inhabitants. It is really a state of mind and a commitment to improvement.

As physicians, we often complain or sometimes brag about how many patients we “see” in a day. I fear that too often we mean “looked at.” How frequently did we make the effort to really see the patient?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

People are surprised when they learn I was an art history major in college. Most folks assume I had majored in biology or chemistry. Their assumption was based on strong odds. The U.S. Bureau of Labor Statistics reports that nearly half of all physicians practicing in this country were biology majors.

I headed off to college clueless about my future. I was hoping to succeed as a walk-on to the football team and beyond that I figured someone or something would guide me toward a career. Had you asked me, “physician” it would have been a definite “Never.”

I flirted with a psychology major, but after a semester I realized that the department was more interested in the behavior of rats rather than humans. I got an “easy A” in the intro to art history and that was the open door I was looking for.

By my senior year I was applying for fellowships to study in faraway places. However, the world situation in 1965 was unsettling for a young man in this country. I had had a strong high school science education and had continued to take a some science courses. Fortunately, I had banked just enough credits so that I could apply to medical school, again without really planning to become a physician.

Even during the sharpest turns in my circuitous path to becoming a small town pediatrician, including a year doing research in exercise physiology in Denmark, I never once regretted my years spent studying art history. I credit them with making me a more sensitive observer.

You can probably understand why I was intrigued by an article I recently read that described a program in which the radiology residents that the Brigham and Women’s Hospital in Boston take a year-long course in art history using the Art Museum at Harvard University as a resource. Titled “Seeing in Art and Medical Imaging,” the program is now 6 years old. Hyewon Hyun, MD, a radiologist and one of its cofounders, observes that “art is the starting point for in-depth conversations about medicine, humanity, and different ways of seeing the world.”

Radiology and dermatology are obviously the two specialties in which the physician relies most heavily on his or her powers of observation. However, every doctor can benefit from learning to really “see” what they are looking at. Looking and seeing are two very different activities. There is obviously the forest-from the-trees phenomenon. Can the physician in a hurried clinical situation muster up the discipline to shift focus back and forth from the lesion or painful body part to the entire patient and beyond? How is the parent responding to the child’s discomfort? How are they dressed? Does this wider view suggest some additional questions to ask that may help you understand how this patient or family will be able to cope with diagnosis or follow up with your treatment plan?

The art historian sees every object in its historical context. What has come before? How have the societal conditions influenced the artist choice of subject and use of materials? How has his or her emotions at the time of creation influenced his or her style? The astute physician must likewise see the patients and their complaints in the broader context of their emotional health and socioeconomic situation. This requires sensitive listening and careful observation.

One doesn’t have to major in art history or spend years roaming through the sometimes dark and dusty halls of the world’s museums to progress from being one who simply looks to a person who really sees the environment and its inhabitants. It is really a state of mind and a commitment to improvement.

As physicians, we often complain or sometimes brag about how many patients we “see” in a day. I fear that too often we mean “looked at.” How frequently did we make the effort to really see the patient?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

People are surprised when they learn I was an art history major in college. Most folks assume I had majored in biology or chemistry. Their assumption was based on strong odds. The U.S. Bureau of Labor Statistics reports that nearly half of all physicians practicing in this country were biology majors.

I headed off to college clueless about my future. I was hoping to succeed as a walk-on to the football team and beyond that I figured someone or something would guide me toward a career. Had you asked me, “physician” it would have been a definite “Never.”

I flirted with a psychology major, but after a semester I realized that the department was more interested in the behavior of rats rather than humans. I got an “easy A” in the intro to art history and that was the open door I was looking for.

By my senior year I was applying for fellowships to study in faraway places. However, the world situation in 1965 was unsettling for a young man in this country. I had had a strong high school science education and had continued to take a some science courses. Fortunately, I had banked just enough credits so that I could apply to medical school, again without really planning to become a physician.

Even during the sharpest turns in my circuitous path to becoming a small town pediatrician, including a year doing research in exercise physiology in Denmark, I never once regretted my years spent studying art history. I credit them with making me a more sensitive observer.

You can probably understand why I was intrigued by an article I recently read that described a program in which the radiology residents that the Brigham and Women’s Hospital in Boston take a year-long course in art history using the Art Museum at Harvard University as a resource. Titled “Seeing in Art and Medical Imaging,” the program is now 6 years old. Hyewon Hyun, MD, a radiologist and one of its cofounders, observes that “art is the starting point for in-depth conversations about medicine, humanity, and different ways of seeing the world.”

Radiology and dermatology are obviously the two specialties in which the physician relies most heavily on his or her powers of observation. However, every doctor can benefit from learning to really “see” what they are looking at. Looking and seeing are two very different activities. There is obviously the forest-from the-trees phenomenon. Can the physician in a hurried clinical situation muster up the discipline to shift focus back and forth from the lesion or painful body part to the entire patient and beyond? How is the parent responding to the child’s discomfort? How are they dressed? Does this wider view suggest some additional questions to ask that may help you understand how this patient or family will be able to cope with diagnosis or follow up with your treatment plan?

The art historian sees every object in its historical context. What has come before? How have the societal conditions influenced the artist choice of subject and use of materials? How has his or her emotions at the time of creation influenced his or her style? The astute physician must likewise see the patients and their complaints in the broader context of their emotional health and socioeconomic situation. This requires sensitive listening and careful observation.

One doesn’t have to major in art history or spend years roaming through the sometimes dark and dusty halls of the world’s museums to progress from being one who simply looks to a person who really sees the environment and its inhabitants. It is really a state of mind and a commitment to improvement.

As physicians, we often complain or sometimes brag about how many patients we “see” in a day. I fear that too often we mean “looked at.” How frequently did we make the effort to really see the patient?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

The past year brought major changes in preventive standards for anxiety, HIV, and RSV along with new guidelines for the treatment of atrial fibrillation. For insight into the effect on internal medicine, we turned to Sarah Candler, MD, MPH, a Houston internist who specializes in the care of high-risk older adults.


Q: Which new prevention guidelines had the most impact on you over the past year?

A: I’m a primary care doctor, and most of the internal medicine updates that are interesting to me focus on how we can keep people from getting sick in the first place. That’s especially important in light of the fact that we had a decrease in life expectancy of 2 years [it finally rose slightly in 2022] and widening of the gender gap in life expectancy for men and women.

I’m excited to see new recommendations from the U.S. Preventive Services Task Force, including a new one about using PREP [pre-exposure prophylaxis] to preventively treat anyone who’s at risk for getting HIV. That’s a big one because it’s one of the first times that we’ve identified at-risk groups for screening based on social risk factors, not gender, age, or genetics.

The new recommendation is PREP for anyone who’s at risk for getting HIV because they have a partner with HIV, had an sexually transmitted infection in the last 6 months, or a history of inconsistent or no condom use with partners with unknown HIV status.

PREP therapy is something that most primary care physicians can either do or learn how to do pretty easily. But the treatment does require maintenance and monitoring.
 

Q: How firm is this recommendation?

A: The task force gives different grades for their recommendations based on how strong the evidence is. For the guidelines about PREP, they give a grade of A. That means this is top of the class: You should definitely do this.


Q: What are the best strategies to ask patients personal questions about their sex lives in order to evaluate their risk?

A: A lot of internal medicine physicians are getting pretty good at this. We see it as part of our job just the same way as we asked things like, “How often are you walking?” and “Have you been feeling down?”

There’s no one right way to have a conversation like that. But it’s key to say, as I do to my patients, that “I’m not here to judge anything. I am truly here to gather information and make recommendations to you as a partner in your care.”  
 

Q: What other guidelines made an impact in 2023?

A: The U.S. Preventive Services Task Force made a recommendation to screen adults aged 18-64 for anxiety, and this guidance got a B grade. [The task force said there’s not enough evidence to support routine anxiety screening in adults 65 and older.]

The new recommendations is a sign that we’re doing a better job at making treatment of those diseases more acceptable. This is also another example of the medical community recognizing that internal medicine physicians are pretty good at identifying and treating mental health.
 

Q: How do you figure out whether to treat depression/anxiety yourself or refer patients to specialists?

A: As a primary care physician, I feel comfortable diagnosing and managing some mental health disease in my own practice. There are FDA-approved medications for both anxiety and depression that are easily managed by a primary care physician.

And there’s something to the therapeutic relationship, to naming and identifying these conditions with your patients. Some patients feel a bit of relief just knowing that they have a diagnosis.
 

Q: What should internists know about the new CDC guidelines that promote discussing RSV vaccines with patients who are over 60?

A: The vaccines are recommended for folks who have underlying conditions like lung disease or heart disease. Those are the ones who end up getting really, really sick. There are two adult vaccines that are available, and there’s not a preference for one over the other.

The vaccines are both protein-based, like the old-school versions of vaccines, not the mRNA vaccines that we’ve all been hearing more about through COVID. Anybody who’s reluctant to take an mRNA vaccine can rest assured that the RSV is not protein-based. And they are single-dose vaccines, which is helpful.  
 

Q: What else should internists know about that was new in 2023?

A: I’m super excited about how cardiologists are thinking about atrial fibrillation. In 2023, the American College of Cardiology and the American Heart Association came up with a giant overhaul of how they look at atrial fibrillation. They classify it in stages and allows us to think about stopping it before it starts.

They’re talking about something they’re calling preclinical or subclinical atrial fibrillation, which you may detect on wearables like somebody’s watch or another tool used to monitor heart rate or exercise. It might be the first harbinger that there’s something wrong with the heart rate, and they may not even have symptoms of it. [A 2023 study in The New England Journal of Medicine linked the anticoagulant apixaban, or Eliquis, to a 37% lower risk of stroke and systemic embolism rates in older patients with subclinical atrial fibrillation but an 80% higher risk of major bleeding vs. aspirin therapy.]

And they’re now recommending early rhythm control.
 

Q: What does early rhythm control mean for patients and physicians?

A: For the longest time, we have thought about atrial fibrillation treatment in terms of rate control and not worrying too much about the rhythm. But now we recognize that it’s actually really important that we get the rhythm under control because physical changes to the heart can lead to permanent damage.

So now they’re recommending catheter ablation as first-line therapy in some patients as a class 1 recommendation because heart function is already decreased. Improving the ability of the heart to beat with a regular rhythm can lead to improvement of function. This was unheard of even 5 years ago.
 

Q: Should internists be more willing to refer patients with atrial fibrillation to cardiologists?

A: Yes, I think so. One of the biggest changes for me is that I am going to refer new diagnoses of atrial fibrillation to a cardiologist. And I’m going to ask patients if they have wearable devices because sometimes those things might tell me about something like subclinical atrial fibrillation.

Q: There’s also detailed data about atrial fibrillation risk factors, which include older age, smoking, sedentary lifestyle, alcohol use, diabetes, height, obesity, diabetes, and others. Is this information useful?

A: It’s a really great tool to have in the arsenal because it helps me have shared decision-making conversations with my patients in a way that’s much more convincing. A patient might say, “Why do you care if I drink so much? My liver levels are fine.” And I can say, “It’s going to be a risk factor for having problems with your heart.”

For better or worse, people really take the heart very seriously, I am an internal medicine physician, so I love all the organs equally. But man, people get pretty scared when you tell them something can affect their heart. So when I talk to patients about their risk factors, it’s going to really be helpful that I can remind them of the impact that some of these lifestyle behaviors can have on their heart health.
 

Dr. Candler has no disclosures.

The past year brought major changes in preventive standards for anxiety, HIV, and RSV along with new guidelines for the treatment of atrial fibrillation. For insight into the effect on internal medicine, we turned to Sarah Candler, MD, MPH, a Houston internist who specializes in the care of high-risk older adults.


Q: Which new prevention guidelines had the most impact on you over the past year?

A: I’m a primary care doctor, and most of the internal medicine updates that are interesting to me focus on how we can keep people from getting sick in the first place. That’s especially important in light of the fact that we had a decrease in life expectancy of 2 years [it finally rose slightly in 2022] and widening of the gender gap in life expectancy for men and women.

I’m excited to see new recommendations from the U.S. Preventive Services Task Force, including a new one about using PREP [pre-exposure prophylaxis] to preventively treat anyone who’s at risk for getting HIV. That’s a big one because it’s one of the first times that we’ve identified at-risk groups for screening based on social risk factors, not gender, age, or genetics.

The new recommendation is PREP for anyone who’s at risk for getting HIV because they have a partner with HIV, had an sexually transmitted infection in the last 6 months, or a history of inconsistent or no condom use with partners with unknown HIV status.

PREP therapy is something that most primary care physicians can either do or learn how to do pretty easily. But the treatment does require maintenance and monitoring.
 

Q: How firm is this recommendation?

A: The task force gives different grades for their recommendations based on how strong the evidence is. For the guidelines about PREP, they give a grade of A. That means this is top of the class: You should definitely do this.


Q: What are the best strategies to ask patients personal questions about their sex lives in order to evaluate their risk?

A: A lot of internal medicine physicians are getting pretty good at this. We see it as part of our job just the same way as we asked things like, “How often are you walking?” and “Have you been feeling down?”

There’s no one right way to have a conversation like that. But it’s key to say, as I do to my patients, that “I’m not here to judge anything. I am truly here to gather information and make recommendations to you as a partner in your care.”  
 

Q: What other guidelines made an impact in 2023?

A: The U.S. Preventive Services Task Force made a recommendation to screen adults aged 18-64 for anxiety, and this guidance got a B grade. [The task force said there’s not enough evidence to support routine anxiety screening in adults 65 and older.]

The new recommendations is a sign that we’re doing a better job at making treatment of those diseases more acceptable. This is also another example of the medical community recognizing that internal medicine physicians are pretty good at identifying and treating mental health.
 

Q: How do you figure out whether to treat depression/anxiety yourself or refer patients to specialists?

A: As a primary care physician, I feel comfortable diagnosing and managing some mental health disease in my own practice. There are FDA-approved medications for both anxiety and depression that are easily managed by a primary care physician.

And there’s something to the therapeutic relationship, to naming and identifying these conditions with your patients. Some patients feel a bit of relief just knowing that they have a diagnosis.
 

Q: What should internists know about the new CDC guidelines that promote discussing RSV vaccines with patients who are over 60?

A: The vaccines are recommended for folks who have underlying conditions like lung disease or heart disease. Those are the ones who end up getting really, really sick. There are two adult vaccines that are available, and there’s not a preference for one over the other.

The vaccines are both protein-based, like the old-school versions of vaccines, not the mRNA vaccines that we’ve all been hearing more about through COVID. Anybody who’s reluctant to take an mRNA vaccine can rest assured that the RSV is not protein-based. And they are single-dose vaccines, which is helpful.  
 

Q: What else should internists know about that was new in 2023?

A: I’m super excited about how cardiologists are thinking about atrial fibrillation. In 2023, the American College of Cardiology and the American Heart Association came up with a giant overhaul of how they look at atrial fibrillation. They classify it in stages and allows us to think about stopping it before it starts.

They’re talking about something they’re calling preclinical or subclinical atrial fibrillation, which you may detect on wearables like somebody’s watch or another tool used to monitor heart rate or exercise. It might be the first harbinger that there’s something wrong with the heart rate, and they may not even have symptoms of it. [A 2023 study in The New England Journal of Medicine linked the anticoagulant apixaban, or Eliquis, to a 37% lower risk of stroke and systemic embolism rates in older patients with subclinical atrial fibrillation but an 80% higher risk of major bleeding vs. aspirin therapy.]

And they’re now recommending early rhythm control.
 

Q: What does early rhythm control mean for patients and physicians?

A: For the longest time, we have thought about atrial fibrillation treatment in terms of rate control and not worrying too much about the rhythm. But now we recognize that it’s actually really important that we get the rhythm under control because physical changes to the heart can lead to permanent damage.

So now they’re recommending catheter ablation as first-line therapy in some patients as a class 1 recommendation because heart function is already decreased. Improving the ability of the heart to beat with a regular rhythm can lead to improvement of function. This was unheard of even 5 years ago.
 

Q: Should internists be more willing to refer patients with atrial fibrillation to cardiologists?

A: Yes, I think so. One of the biggest changes for me is that I am going to refer new diagnoses of atrial fibrillation to a cardiologist. And I’m going to ask patients if they have wearable devices because sometimes those things might tell me about something like subclinical atrial fibrillation.

Q: There’s also detailed data about atrial fibrillation risk factors, which include older age, smoking, sedentary lifestyle, alcohol use, diabetes, height, obesity, diabetes, and others. Is this information useful?

A: It’s a really great tool to have in the arsenal because it helps me have shared decision-making conversations with my patients in a way that’s much more convincing. A patient might say, “Why do you care if I drink so much? My liver levels are fine.” And I can say, “It’s going to be a risk factor for having problems with your heart.”

For better or worse, people really take the heart very seriously, I am an internal medicine physician, so I love all the organs equally. But man, people get pretty scared when you tell them something can affect their heart. So when I talk to patients about their risk factors, it’s going to really be helpful that I can remind them of the impact that some of these lifestyle behaviors can have on their heart health.
 

Dr. Candler has no disclosures.

The past year brought major changes in preventive standards for anxiety, HIV, and RSV along with new guidelines for the treatment of atrial fibrillation. For insight into the effect on internal medicine, we turned to Sarah Candler, MD, MPH, a Houston internist who specializes in the care of high-risk older adults.


Q: Which new prevention guidelines had the most impact on you over the past year?

A: I’m a primary care doctor, and most of the internal medicine updates that are interesting to me focus on how we can keep people from getting sick in the first place. That’s especially important in light of the fact that we had a decrease in life expectancy of 2 years [it finally rose slightly in 2022] and widening of the gender gap in life expectancy for men and women.

I’m excited to see new recommendations from the U.S. Preventive Services Task Force, including a new one about using PREP [pre-exposure prophylaxis] to preventively treat anyone who’s at risk for getting HIV. That’s a big one because it’s one of the first times that we’ve identified at-risk groups for screening based on social risk factors, not gender, age, or genetics.

The new recommendation is PREP for anyone who’s at risk for getting HIV because they have a partner with HIV, had an sexually transmitted infection in the last 6 months, or a history of inconsistent or no condom use with partners with unknown HIV status.

PREP therapy is something that most primary care physicians can either do or learn how to do pretty easily. But the treatment does require maintenance and monitoring.
 

Q: How firm is this recommendation?

A: The task force gives different grades for their recommendations based on how strong the evidence is. For the guidelines about PREP, they give a grade of A. That means this is top of the class: You should definitely do this.


Q: What are the best strategies to ask patients personal questions about their sex lives in order to evaluate their risk?

A: A lot of internal medicine physicians are getting pretty good at this. We see it as part of our job just the same way as we asked things like, “How often are you walking?” and “Have you been feeling down?”

There’s no one right way to have a conversation like that. But it’s key to say, as I do to my patients, that “I’m not here to judge anything. I am truly here to gather information and make recommendations to you as a partner in your care.”  
 

Q: What other guidelines made an impact in 2023?

A: The U.S. Preventive Services Task Force made a recommendation to screen adults aged 18-64 for anxiety, and this guidance got a B grade. [The task force said there’s not enough evidence to support routine anxiety screening in adults 65 and older.]

The new recommendations is a sign that we’re doing a better job at making treatment of those diseases more acceptable. This is also another example of the medical community recognizing that internal medicine physicians are pretty good at identifying and treating mental health.
 

Q: How do you figure out whether to treat depression/anxiety yourself or refer patients to specialists?

A: As a primary care physician, I feel comfortable diagnosing and managing some mental health disease in my own practice. There are FDA-approved medications for both anxiety and depression that are easily managed by a primary care physician.

And there’s something to the therapeutic relationship, to naming and identifying these conditions with your patients. Some patients feel a bit of relief just knowing that they have a diagnosis.
 

Q: What should internists know about the new CDC guidelines that promote discussing RSV vaccines with patients who are over 60?

A: The vaccines are recommended for folks who have underlying conditions like lung disease or heart disease. Those are the ones who end up getting really, really sick. There are two adult vaccines that are available, and there’s not a preference for one over the other.

The vaccines are both protein-based, like the old-school versions of vaccines, not the mRNA vaccines that we’ve all been hearing more about through COVID. Anybody who’s reluctant to take an mRNA vaccine can rest assured that the RSV is not protein-based. And they are single-dose vaccines, which is helpful.  
 

Q: What else should internists know about that was new in 2023?

A: I’m super excited about how cardiologists are thinking about atrial fibrillation. In 2023, the American College of Cardiology and the American Heart Association came up with a giant overhaul of how they look at atrial fibrillation. They classify it in stages and allows us to think about stopping it before it starts.

They’re talking about something they’re calling preclinical or subclinical atrial fibrillation, which you may detect on wearables like somebody’s watch or another tool used to monitor heart rate or exercise. It might be the first harbinger that there’s something wrong with the heart rate, and they may not even have symptoms of it. [A 2023 study in The New England Journal of Medicine linked the anticoagulant apixaban, or Eliquis, to a 37% lower risk of stroke and systemic embolism rates in older patients with subclinical atrial fibrillation but an 80% higher risk of major bleeding vs. aspirin therapy.]

And they’re now recommending early rhythm control.
 

Q: What does early rhythm control mean for patients and physicians?

A: For the longest time, we have thought about atrial fibrillation treatment in terms of rate control and not worrying too much about the rhythm. But now we recognize that it’s actually really important that we get the rhythm under control because physical changes to the heart can lead to permanent damage.

So now they’re recommending catheter ablation as first-line therapy in some patients as a class 1 recommendation because heart function is already decreased. Improving the ability of the heart to beat with a regular rhythm can lead to improvement of function. This was unheard of even 5 years ago.
 

Q: Should internists be more willing to refer patients with atrial fibrillation to cardiologists?

A: Yes, I think so. One of the biggest changes for me is that I am going to refer new diagnoses of atrial fibrillation to a cardiologist. And I’m going to ask patients if they have wearable devices because sometimes those things might tell me about something like subclinical atrial fibrillation.

Q: There’s also detailed data about atrial fibrillation risk factors, which include older age, smoking, sedentary lifestyle, alcohol use, diabetes, height, obesity, diabetes, and others. Is this information useful?

A: It’s a really great tool to have in the arsenal because it helps me have shared decision-making conversations with my patients in a way that’s much more convincing. A patient might say, “Why do you care if I drink so much? My liver levels are fine.” And I can say, “It’s going to be a risk factor for having problems with your heart.”

For better or worse, people really take the heart very seriously, I am an internal medicine physician, so I love all the organs equally. But man, people get pretty scared when you tell them something can affect their heart. So when I talk to patients about their risk factors, it’s going to really be helpful that I can remind them of the impact that some of these lifestyle behaviors can have on their heart health.
 

Dr. Candler has no disclosures.

Dear colleagues,

In this issue of Perspectives, we explore the impact of substance use on liver transplantation (LT). With recent dramatic improvements in treating hepatitis C, alcoholic liver disease has now become the leading indication for LT. Determining candidacy for a transplanted liver is a rigorous process and there has always been concern for relapse to alcohol use and its effect on the implanted graft. But, have we been too strict in restricting access in such patients?

Drs. Mitchell Mah’moud and John Aita explore this topic with a concise review of the current literature through an ethical lens. After alcohol, the most commonly used psychotropic drug is marijuana. Marijuana has traditionally been a barrier to candidacy for LT but, as with alcohol, should transplant centers relax this restriction, especially with ongoing legalization across the United States? Dr. Mohamed Shoreibah and colleagues explore this topic though a cogent review of the literature assessing the impact of marijuana use on liver transplant outcomes. We hope these essays will help your medical practice and ongoing advocacy for your patients.

We welcome your thoughts on X at @AGA_GIHN.

Yale University

Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven VA Medical Center in Connecticut. He is an associate editor for GI & Hepatology News.

Liver transplantation in the setting of alcohol-related liver disease

BY MITCHELL MAH’MOUD, MD, FACG, AGAF, FAASLD, AND JOHN AITA, MD

Alcohol-related liver disease (ALD), with its subset of severe alcohol-associated hepatitis (SAH), currently accounts for most liver transplantation (LT) recipients in the United States. Patients with SAH, particularly those with a MELD-NA of at least 35, have a 70%-75% mortality rate within 6 months. The ethics of liver transplantation in the setting of SAH are complex and still controversial. With liver transplantation in general, there are more patients with various disorders listed for transplant than available organs. There may also be concern regarding a posttransplant return to harmful alcohol use leading to graft dysfunction or loss. Ultimately, in ethics terms, there is an inherent conflict between the values of beneficence (the obligation to act for an individual patient’s benefit) and justice (fair and equitable treatment of a society).

Duke University

The past decade has yielded supportive data depicting adequate posttransplant (LT) survival in select SAH patients. Previously, 6 months of alcohol sobriety was typically mandated by LT centers. Reasons for this requirement included (a) documentation of sobriety (including enrollment in an alcohol rehabilitation program) and (b) determination of maximal recovery (such that transplant may not be indicated). Present day information shows poor correlation between the 6-month alcohol sobriety period and reduced posttransplant alcohol use. In particular, the ACCELERATE-AH study, in which patients with severe alcoholic hepatitis underwent LT before 6 months of abstinence, demonstrated post-LT survival rates of 94% at 1 year and 84% at 3 years, similar to post-LT survival rates of other LT recipients. Although other factors may play into a transplant committee’s decision to require a period of sobriety before liver transplant evaluation, these data suggest that a “one size fits all” mandatory sobriety period prior to LT evaluation is now incongruent with normative medical practice.

Cleveland Clinic

One overarching principle of LT is that society provides organs to those patients with the greatest need. An inherent effect of listing select patients with SAH for liver transplant is that it potentially increases the wait time (and therefore the mortality risk) for other liver disease patients. Unfortunately, alcohol use disorder (AUD) has increased significantly in recent years among younger patients (from 2001 to 2013), and some patients may even be at greater risk of ALD (e.g., PNPLA3, TM6SF2, polymorphisms or post gastric bypass) with even mild/moderate use compared to other individuals . LT should not be considered a cure for AUD but rather a treatment for SAH that carries a high mortality rate but comparable post-LT survival to other indications for LT. Data from the ACCELERATE-AH trial revealed a cumulative incidence of any alcohol use at 1 year of approximately 25% and at 3 years of 34% for post-LT patients with SAH. This is roughly equivalent to reported disease recurrence rates of 10%-40% over 1-10 years post-LT for AIH, PBC and PSC and 7%-33% for MASLD. Despite these data, concern for reemergence of metabolic syndrome has never been an impediment when evaluating patients for LT due to end-stage liver disease from MASLD. LT centers may have a selection pathway that permits judicious transplant evaluation for SAH patients who, in the context of beneficence, are felt to greatly benefit from liver transplant in the near term (and are felt unlikely to recover without transplant) while, in the spirit of the ethical tenet of justice, also yield the best suitability for the donated organ (meaning the organ was put to good use with adequate graft survival). In this setting, a liver transplant program may utilize tools such as S-DAT, the PACT scoring system and TERS in identifying candidates with SAH for LT and those who are likely to relapse post-LT.

The optimal role of liver transplant in SAH patients is still emerging, but recent evidence suggests that the post-LT survival rate and alcohol-relapse rate appear to be acceptable. Nonetheless, the need to prevent harmful and sustained alcohol use post LT is vital since it is considered the strongest predictor of graft loss and death. Recent observations have also highlighted younger age and consumption of >10 drinks/day within 6 months of LT as predictors of sustained alcohol use post-LT. Hence, early identification of sustained alcohol use post-LT coupled with timely interventions based on abstinence-promoting behavioral and pharmacologic therapy should remain the goal of all transplant centers to avoid relapse and alcohol related deaths. In addition, incorporating addiction treatment centers into post-LT management should be considered standard of care to provide continued therapy for AUD in all patients post-LT. As in the DAA era of hepatitis C therapies, the role of LT in the setting of SAH may dwindle as emerging SAH-specific therapies evolve resulting in adequate transplant-free survival. Until then, it is beneficial to refine the guidelines periodically across all the UNOS regions on patient selection for LT in SAH, consistent with ethical principles of beneficence and justice. Finally, despite the concern about return to harmful drinking post LT, the need to destigmatize AUD and explain the purpose of LT for SAH through public education is vital.
 

Dr. Mah’moud is professor of medicine in the division of gastroenterology at Duke University School of Medicine, Durham, N.C., and a gastroenterologist with RMG Gastroenterology in North Carolina. Dr. Aita is gastroenterologist with Cleveland Clinic Indian River Hospital in Vero Beach, Fla. Dr. Mah’moud disclosed serving on the advisory board of CLDF, and receiving research support from Intercept Pharma and Gilead Scientific, but not in a capacity related to this article.

References

Tapper E. BMJ. 2018;362: k2817

Louvet A. Lancet Gastro Hep. 2022;7(5):416-25

Lee B. Gastroenterology. 2018;155:422-30

Shroff H. Hot Topics in Hepatology: Chicago ALF Debate. Clinical Liver Disease (2020 vol 16, No.5: 178-85)

High Stakes: Navigating the Hazy Intersection of Marijuana and Liver Transplants

BY JOVEN TRISTEZA, MD, THOMAS RULI, MD, AND MOHAMED SHOREIBAH, MD

Marijuana remains a topic of controversy even amidst the ever-changing sociopolitical landscape, particularly in the United States.

Marijuana is currently illegal at the federal level and is listed as a schedule I substance. However, marijuana for medical and recreational use has been legalized by several states, leading to an increase in its use. This unclear and disparate status of marijuana has created a smoky situation for patients being evaluated for liver transplant. Multiple studies have shown marijuana to provide medical benefits, while other studies in liver transplant patients have shown that it does not affect posttransplant outcomes. Those studies have helped inform decision-making for liver transplant selection committees across the country, where marijuana use is evaluated in the context of the patient’s medical and social history, as well as the history of other substance use. Though we do not encourage its use, we do not believe that marijuana use should be the singular reason to deny a patient listing for liver transplant.

University of Alabama at Birmingham

Marijuana has been studied extensively regarding its effects on the human body. The main compounds in marijuana are tetrahydrocannabinol, or THC, and cannabidiol, or CBD. These compounds exhibit many effects that we observe clinically through the endocannabinoid system. Beneficial effects related to the gastrointestinal tract include relief from nausea and vomiting and stimulation of appetite in patients with anorexia. Other benefits outside the GI tract include alleviation of chronic pain and management of some forms of drug-resistant epilepsy. Ongoing studies are investigating the role of marijuana in other medical conditions.^1,2 At least equally notable are marijuana’s potential adverse effects, which include tachycardia, hypertension, agitation, nausea, psychosis, and hallucinations.² Marijuana may also increase the risk of heart failure, acute myocardial infarction, and stroke.³

University of Alabama at Birmingham

The exact effect of marijuana on the liver remains inconclusive. Receptors for endocannabinoids have been associated with steatosis and fibrosis in some studies. However, some evidence also suggests that marijuana may reduce inflammation in the liver.² Small, prospective studies have not been able to link marijuana use with hepatic laboratory abnormalities, and there is currently no significant association between marijuana and liver disease, injury, or cirrhosis. Of particular relevance to liver transplant recipients is marijuana’s effect on cytochrome P450 enzyme function, especially CYP3A4 which is the CYP class that metabolizes tacrolimus, a common immunosuppressant used in liver transplant patients. Marijuana inhibits CYP3A4 which could increase tacrolimus levels, potentially leading to morbidity. One strategy to mitigate this process is closer monitoring of tacrolimus levels for patients using marijuana.

The once-presumed increased risk of fungal infection — particularly Aspergillus — for liver transplant patients who use marijuana has been refuted. Furthermore, there have been concerns by liver transplant selection committees that marijuana use may be related to a greater risk of post–liver transplant noncompliance, infections, or even death. However, marijuana use on its own has not been associated with these concerns in the liver transplant population.⁴ 

The practice of excluding marijuana users from being listed for liver transplant does not appear to be evidence based. In a 2018 study focusing on US transplant centers, 40% of centers would not accept any marijuana use, and only 28% would list those who were taking medical marijuana for transplant. Interestingly, eight states have passed legislation prohibiting withholding transplant evaluation for marijuana users if it is solely based on their marijuana use.⁵ In the 5 years since that study was published, there have been major changes in the legality of marijuana. A future study of interest could assess how these changes have affected the position of transplant centers.

University of Alabama at Birmingham

The sociopolitical and transplant medicine worlds alike continue to adapt to the legalization of marijuana. While marijuana use is associated with adverse effects, its potential for benefit for a variety of medical conditions is an evolving area that has shown promise. It is therefore logical to view marijuana as a pharmacologic agent with potential for risks and benefits, but not necessarily a sole reason to exclude patients from listing for liver transplant. The current data are reassuring in that those who use marijuana and receive liver transplantation are not at higher risk of posttransplant complications, infections, or death when compared to those who do not use it. Should marijuana use exist in the context of substance use disorder or other behavioral and mental health issues, then the case warrants careful multidisciplinary evaluation prior to consideration for liver transplant. The aim of our discourse is not to encourage the use of marijuana in patients being considered for liver transplant but rather to discourage their exclusion from listing solely on the basis of marijuana use. In the pursuit of an equitable organ allocation system, our hope is that this work facilitates a more informed discussion and a change in policy in liver transplant programs that may still consider marijuana use an exclusion criterion.

Joven Tristeza, MD, and Thomas Ruli, MD, are residents in internal medicine at the University of Alabama at Birmingham; Mohamed Shoreibah, MD, is a specialist in gastroenterology and hepatology at the University of Alabama at Birmingham where he also serves on the faculty of the internal medicine residency program. The authors have no conflicts of interest.

REFERENCES

1. Cox, EJ. Pharmacology & Therapeutics. 2019;201:25-38.

2. Maselli, DB. Clinical Gastroenterology and Hepatology. 2021;19(9):1748-1758.e2.

3. Page, RL. Circulation. 2020;142(10):e131-e152.

4. Panchani, N. The American Journal of the Medical Sciences. 2023;365(2):115-120.

5. Zhu, J. Transplantation. 2018;102(3):433-439.

Dear colleagues,

In this issue of Perspectives, we explore the impact of substance use on liver transplantation (LT). With recent dramatic improvements in treating hepatitis C, alcoholic liver disease has now become the leading indication for LT. Determining candidacy for a transplanted liver is a rigorous process and there has always been concern for relapse to alcohol use and its effect on the implanted graft. But, have we been too strict in restricting access in such patients?

Drs. Mitchell Mah’moud and John Aita explore this topic with a concise review of the current literature through an ethical lens. After alcohol, the most commonly used psychotropic drug is marijuana. Marijuana has traditionally been a barrier to candidacy for LT but, as with alcohol, should transplant centers relax this restriction, especially with ongoing legalization across the United States? Dr. Mohamed Shoreibah and colleagues explore this topic though a cogent review of the literature assessing the impact of marijuana use on liver transplant outcomes. We hope these essays will help your medical practice and ongoing advocacy for your patients.

We welcome your thoughts on X at @AGA_GIHN.

Yale University

Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven VA Medical Center in Connecticut. He is an associate editor for GI & Hepatology News.

Liver transplantation in the setting of alcohol-related liver disease

BY MITCHELL MAH’MOUD, MD, FACG, AGAF, FAASLD, AND JOHN AITA, MD

Alcohol-related liver disease (ALD), with its subset of severe alcohol-associated hepatitis (SAH), currently accounts for most liver transplantation (LT) recipients in the United States. Patients with SAH, particularly those with a MELD-NA of at least 35, have a 70%-75% mortality rate within 6 months. The ethics of liver transplantation in the setting of SAH are complex and still controversial. With liver transplantation in general, there are more patients with various disorders listed for transplant than available organs. There may also be concern regarding a posttransplant return to harmful alcohol use leading to graft dysfunction or loss. Ultimately, in ethics terms, there is an inherent conflict between the values of beneficence (the obligation to act for an individual patient’s benefit) and justice (fair and equitable treatment of a society).

Duke University

The past decade has yielded supportive data depicting adequate posttransplant (LT) survival in select SAH patients. Previously, 6 months of alcohol sobriety was typically mandated by LT centers. Reasons for this requirement included (a) documentation of sobriety (including enrollment in an alcohol rehabilitation program) and (b) determination of maximal recovery (such that transplant may not be indicated). Present day information shows poor correlation between the 6-month alcohol sobriety period and reduced posttransplant alcohol use. In particular, the ACCELERATE-AH study, in which patients with severe alcoholic hepatitis underwent LT before 6 months of abstinence, demonstrated post-LT survival rates of 94% at 1 year and 84% at 3 years, similar to post-LT survival rates of other LT recipients. Although other factors may play into a transplant committee’s decision to require a period of sobriety before liver transplant evaluation, these data suggest that a “one size fits all” mandatory sobriety period prior to LT evaluation is now incongruent with normative medical practice.

Cleveland Clinic

One overarching principle of LT is that society provides organs to those patients with the greatest need. An inherent effect of listing select patients with SAH for liver transplant is that it potentially increases the wait time (and therefore the mortality risk) for other liver disease patients. Unfortunately, alcohol use disorder (AUD) has increased significantly in recent years among younger patients (from 2001 to 2013), and some patients may even be at greater risk of ALD (e.g., PNPLA3, TM6SF2, polymorphisms or post gastric bypass) with even mild/moderate use compared to other individuals . LT should not be considered a cure for AUD but rather a treatment for SAH that carries a high mortality rate but comparable post-LT survival to other indications for LT. Data from the ACCELERATE-AH trial revealed a cumulative incidence of any alcohol use at 1 year of approximately 25% and at 3 years of 34% for post-LT patients with SAH. This is roughly equivalent to reported disease recurrence rates of 10%-40% over 1-10 years post-LT for AIH, PBC and PSC and 7%-33% for MASLD. Despite these data, concern for reemergence of metabolic syndrome has never been an impediment when evaluating patients for LT due to end-stage liver disease from MASLD. LT centers may have a selection pathway that permits judicious transplant evaluation for SAH patients who, in the context of beneficence, are felt to greatly benefit from liver transplant in the near term (and are felt unlikely to recover without transplant) while, in the spirit of the ethical tenet of justice, also yield the best suitability for the donated organ (meaning the organ was put to good use with adequate graft survival). In this setting, a liver transplant program may utilize tools such as S-DAT, the PACT scoring system and TERS in identifying candidates with SAH for LT and those who are likely to relapse post-LT.

The optimal role of liver transplant in SAH patients is still emerging, but recent evidence suggests that the post-LT survival rate and alcohol-relapse rate appear to be acceptable. Nonetheless, the need to prevent harmful and sustained alcohol use post LT is vital since it is considered the strongest predictor of graft loss and death. Recent observations have also highlighted younger age and consumption of >10 drinks/day within 6 months of LT as predictors of sustained alcohol use post-LT. Hence, early identification of sustained alcohol use post-LT coupled with timely interventions based on abstinence-promoting behavioral and pharmacologic therapy should remain the goal of all transplant centers to avoid relapse and alcohol related deaths. In addition, incorporating addiction treatment centers into post-LT management should be considered standard of care to provide continued therapy for AUD in all patients post-LT. As in the DAA era of hepatitis C therapies, the role of LT in the setting of SAH may dwindle as emerging SAH-specific therapies evolve resulting in adequate transplant-free survival. Until then, it is beneficial to refine the guidelines periodically across all the UNOS regions on patient selection for LT in SAH, consistent with ethical principles of beneficence and justice. Finally, despite the concern about return to harmful drinking post LT, the need to destigmatize AUD and explain the purpose of LT for SAH through public education is vital.
 

Dr. Mah’moud is professor of medicine in the division of gastroenterology at Duke University School of Medicine, Durham, N.C., and a gastroenterologist with RMG Gastroenterology in North Carolina. Dr. Aita is gastroenterologist with Cleveland Clinic Indian River Hospital in Vero Beach, Fla. Dr. Mah’moud disclosed serving on the advisory board of CLDF, and receiving research support from Intercept Pharma and Gilead Scientific, but not in a capacity related to this article.

References

Tapper E. BMJ. 2018;362: k2817

Louvet A. Lancet Gastro Hep. 2022;7(5):416-25

Lee B. Gastroenterology. 2018;155:422-30

Shroff H. Hot Topics in Hepatology: Chicago ALF Debate. Clinical Liver Disease (2020 vol 16, No.5: 178-85)

High Stakes: Navigating the Hazy Intersection of Marijuana and Liver Transplants

BY JOVEN TRISTEZA, MD, THOMAS RULI, MD, AND MOHAMED SHOREIBAH, MD

Marijuana remains a topic of controversy even amidst the ever-changing sociopolitical landscape, particularly in the United States.

Marijuana is currently illegal at the federal level and is listed as a schedule I substance. However, marijuana for medical and recreational use has been legalized by several states, leading to an increase in its use. This unclear and disparate status of marijuana has created a smoky situation for patients being evaluated for liver transplant. Multiple studies have shown marijuana to provide medical benefits, while other studies in liver transplant patients have shown that it does not affect posttransplant outcomes. Those studies have helped inform decision-making for liver transplant selection committees across the country, where marijuana use is evaluated in the context of the patient’s medical and social history, as well as the history of other substance use. Though we do not encourage its use, we do not believe that marijuana use should be the singular reason to deny a patient listing for liver transplant.

University of Alabama at Birmingham

Marijuana has been studied extensively regarding its effects on the human body. The main compounds in marijuana are tetrahydrocannabinol, or THC, and cannabidiol, or CBD. These compounds exhibit many effects that we observe clinically through the endocannabinoid system. Beneficial effects related to the gastrointestinal tract include relief from nausea and vomiting and stimulation of appetite in patients with anorexia. Other benefits outside the GI tract include alleviation of chronic pain and management of some forms of drug-resistant epilepsy. Ongoing studies are investigating the role of marijuana in other medical conditions.^1,2 At least equally notable are marijuana’s potential adverse effects, which include tachycardia, hypertension, agitation, nausea, psychosis, and hallucinations.² Marijuana may also increase the risk of heart failure, acute myocardial infarction, and stroke.³

University of Alabama at Birmingham

The exact effect of marijuana on the liver remains inconclusive. Receptors for endocannabinoids have been associated with steatosis and fibrosis in some studies. However, some evidence also suggests that marijuana may reduce inflammation in the liver.² Small, prospective studies have not been able to link marijuana use with hepatic laboratory abnormalities, and there is currently no significant association between marijuana and liver disease, injury, or cirrhosis. Of particular relevance to liver transplant recipients is marijuana’s effect on cytochrome P450 enzyme function, especially CYP3A4 which is the CYP class that metabolizes tacrolimus, a common immunosuppressant used in liver transplant patients. Marijuana inhibits CYP3A4 which could increase tacrolimus levels, potentially leading to morbidity. One strategy to mitigate this process is closer monitoring of tacrolimus levels for patients using marijuana.

The once-presumed increased risk of fungal infection — particularly Aspergillus — for liver transplant patients who use marijuana has been refuted. Furthermore, there have been concerns by liver transplant selection committees that marijuana use may be related to a greater risk of post–liver transplant noncompliance, infections, or even death. However, marijuana use on its own has not been associated with these concerns in the liver transplant population.⁴ 

The practice of excluding marijuana users from being listed for liver transplant does not appear to be evidence based. In a 2018 study focusing on US transplant centers, 40% of centers would not accept any marijuana use, and only 28% would list those who were taking medical marijuana for transplant. Interestingly, eight states have passed legislation prohibiting withholding transplant evaluation for marijuana users if it is solely based on their marijuana use.⁵ In the 5 years since that study was published, there have been major changes in the legality of marijuana. A future study of interest could assess how these changes have affected the position of transplant centers.

University of Alabama at Birmingham

The sociopolitical and transplant medicine worlds alike continue to adapt to the legalization of marijuana. While marijuana use is associated with adverse effects, its potential for benefit for a variety of medical conditions is an evolving area that has shown promise. It is therefore logical to view marijuana as a pharmacologic agent with potential for risks and benefits, but not necessarily a sole reason to exclude patients from listing for liver transplant. The current data are reassuring in that those who use marijuana and receive liver transplantation are not at higher risk of posttransplant complications, infections, or death when compared to those who do not use it. Should marijuana use exist in the context of substance use disorder or other behavioral and mental health issues, then the case warrants careful multidisciplinary evaluation prior to consideration for liver transplant. The aim of our discourse is not to encourage the use of marijuana in patients being considered for liver transplant but rather to discourage their exclusion from listing solely on the basis of marijuana use. In the pursuit of an equitable organ allocation system, our hope is that this work facilitates a more informed discussion and a change in policy in liver transplant programs that may still consider marijuana use an exclusion criterion.

Joven Tristeza, MD, and Thomas Ruli, MD, are residents in internal medicine at the University of Alabama at Birmingham; Mohamed Shoreibah, MD, is a specialist in gastroenterology and hepatology at the University of Alabama at Birmingham where he also serves on the faculty of the internal medicine residency program. The authors have no conflicts of interest.

REFERENCES

1. Cox, EJ. Pharmacology & Therapeutics. 2019;201:25-38.

2. Maselli, DB. Clinical Gastroenterology and Hepatology. 2021;19(9):1748-1758.e2.

3. Page, RL. Circulation. 2020;142(10):e131-e152.

4. Panchani, N. The American Journal of the Medical Sciences. 2023;365(2):115-120.

5. Zhu, J. Transplantation. 2018;102(3):433-439.

Dear colleagues,

In this issue of Perspectives, we explore the impact of substance use on liver transplantation (LT). With recent dramatic improvements in treating hepatitis C, alcoholic liver disease has now become the leading indication for LT. Determining candidacy for a transplanted liver is a rigorous process and there has always been concern for relapse to alcohol use and its effect on the implanted graft. But, have we been too strict in restricting access in such patients?

Drs. Mitchell Mah’moud and John Aita explore this topic with a concise review of the current literature through an ethical lens. After alcohol, the most commonly used psychotropic drug is marijuana. Marijuana has traditionally been a barrier to candidacy for LT but, as with alcohol, should transplant centers relax this restriction, especially with ongoing legalization across the United States? Dr. Mohamed Shoreibah and colleagues explore this topic though a cogent review of the literature assessing the impact of marijuana use on liver transplant outcomes. We hope these essays will help your medical practice and ongoing advocacy for your patients.

We welcome your thoughts on X at @AGA_GIHN.

Yale University

Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven VA Medical Center in Connecticut. He is an associate editor for GI & Hepatology News.

Liver transplantation in the setting of alcohol-related liver disease

BY MITCHELL MAH’MOUD, MD, FACG, AGAF, FAASLD, AND JOHN AITA, MD

Alcohol-related liver disease (ALD), with its subset of severe alcohol-associated hepatitis (SAH), currently accounts for most liver transplantation (LT) recipients in the United States. Patients with SAH, particularly those with a MELD-NA of at least 35, have a 70%-75% mortality rate within 6 months. The ethics of liver transplantation in the setting of SAH are complex and still controversial. With liver transplantation in general, there are more patients with various disorders listed for transplant than available organs. There may also be concern regarding a posttransplant return to harmful alcohol use leading to graft dysfunction or loss. Ultimately, in ethics terms, there is an inherent conflict between the values of beneficence (the obligation to act for an individual patient’s benefit) and justice (fair and equitable treatment of a society).

Duke University

The past decade has yielded supportive data depicting adequate posttransplant (LT) survival in select SAH patients. Previously, 6 months of alcohol sobriety was typically mandated by LT centers. Reasons for this requirement included (a) documentation of sobriety (including enrollment in an alcohol rehabilitation program) and (b) determination of maximal recovery (such that transplant may not be indicated). Present day information shows poor correlation between the 6-month alcohol sobriety period and reduced posttransplant alcohol use. In particular, the ACCELERATE-AH study, in which patients with severe alcoholic hepatitis underwent LT before 6 months of abstinence, demonstrated post-LT survival rates of 94% at 1 year and 84% at 3 years, similar to post-LT survival rates of other LT recipients. Although other factors may play into a transplant committee’s decision to require a period of sobriety before liver transplant evaluation, these data suggest that a “one size fits all” mandatory sobriety period prior to LT evaluation is now incongruent with normative medical practice.

Cleveland Clinic

One overarching principle of LT is that society provides organs to those patients with the greatest need. An inherent effect of listing select patients with SAH for liver transplant is that it potentially increases the wait time (and therefore the mortality risk) for other liver disease patients. Unfortunately, alcohol use disorder (AUD) has increased significantly in recent years among younger patients (from 2001 to 2013), and some patients may even be at greater risk of ALD (e.g., PNPLA3, TM6SF2, polymorphisms or post gastric bypass) with even mild/moderate use compared to other individuals . LT should not be considered a cure for AUD but rather a treatment for SAH that carries a high mortality rate but comparable post-LT survival to other indications for LT. Data from the ACCELERATE-AH trial revealed a cumulative incidence of any alcohol use at 1 year of approximately 25% and at 3 years of 34% for post-LT patients with SAH. This is roughly equivalent to reported disease recurrence rates of 10%-40% over 1-10 years post-LT for AIH, PBC and PSC and 7%-33% for MASLD. Despite these data, concern for reemergence of metabolic syndrome has never been an impediment when evaluating patients for LT due to end-stage liver disease from MASLD. LT centers may have a selection pathway that permits judicious transplant evaluation for SAH patients who, in the context of beneficence, are felt to greatly benefit from liver transplant in the near term (and are felt unlikely to recover without transplant) while, in the spirit of the ethical tenet of justice, also yield the best suitability for the donated organ (meaning the organ was put to good use with adequate graft survival). In this setting, a liver transplant program may utilize tools such as S-DAT, the PACT scoring system and TERS in identifying candidates with SAH for LT and those who are likely to relapse post-LT.

The optimal role of liver transplant in SAH patients is still emerging, but recent evidence suggests that the post-LT survival rate and alcohol-relapse rate appear to be acceptable. Nonetheless, the need to prevent harmful and sustained alcohol use post LT is vital since it is considered the strongest predictor of graft loss and death. Recent observations have also highlighted younger age and consumption of >10 drinks/day within 6 months of LT as predictors of sustained alcohol use post-LT. Hence, early identification of sustained alcohol use post-LT coupled with timely interventions based on abstinence-promoting behavioral and pharmacologic therapy should remain the goal of all transplant centers to avoid relapse and alcohol related deaths. In addition, incorporating addiction treatment centers into post-LT management should be considered standard of care to provide continued therapy for AUD in all patients post-LT. As in the DAA era of hepatitis C therapies, the role of LT in the setting of SAH may dwindle as emerging SAH-specific therapies evolve resulting in adequate transplant-free survival. Until then, it is beneficial to refine the guidelines periodically across all the UNOS regions on patient selection for LT in SAH, consistent with ethical principles of beneficence and justice. Finally, despite the concern about return to harmful drinking post LT, the need to destigmatize AUD and explain the purpose of LT for SAH through public education is vital.
 

Dr. Mah’moud is professor of medicine in the division of gastroenterology at Duke University School of Medicine, Durham, N.C., and a gastroenterologist with RMG Gastroenterology in North Carolina. Dr. Aita is gastroenterologist with Cleveland Clinic Indian River Hospital in Vero Beach, Fla. Dr. Mah’moud disclosed serving on the advisory board of CLDF, and receiving research support from Intercept Pharma and Gilead Scientific, but not in a capacity related to this article.

References

Tapper E. BMJ. 2018;362: k2817

Louvet A. Lancet Gastro Hep. 2022;7(5):416-25

Lee B. Gastroenterology. 2018;155:422-30

Shroff H. Hot Topics in Hepatology: Chicago ALF Debate. Clinical Liver Disease (2020 vol 16, No.5: 178-85)

High Stakes: Navigating the Hazy Intersection of Marijuana and Liver Transplants

BY JOVEN TRISTEZA, MD, THOMAS RULI, MD, AND MOHAMED SHOREIBAH, MD

Marijuana remains a topic of controversy even amidst the ever-changing sociopolitical landscape, particularly in the United States.

Marijuana is currently illegal at the federal level and is listed as a schedule I substance. However, marijuana for medical and recreational use has been legalized by several states, leading to an increase in its use. This unclear and disparate status of marijuana has created a smoky situation for patients being evaluated for liver transplant. Multiple studies have shown marijuana to provide medical benefits, while other studies in liver transplant patients have shown that it does not affect posttransplant outcomes. Those studies have helped inform decision-making for liver transplant selection committees across the country, where marijuana use is evaluated in the context of the patient’s medical and social history, as well as the history of other substance use. Though we do not encourage its use, we do not believe that marijuana use should be the singular reason to deny a patient listing for liver transplant.

University of Alabama at Birmingham

Marijuana has been studied extensively regarding its effects on the human body. The main compounds in marijuana are tetrahydrocannabinol, or THC, and cannabidiol, or CBD. These compounds exhibit many effects that we observe clinically through the endocannabinoid system. Beneficial effects related to the gastrointestinal tract include relief from nausea and vomiting and stimulation of appetite in patients with anorexia. Other benefits outside the GI tract include alleviation of chronic pain and management of some forms of drug-resistant epilepsy. Ongoing studies are investigating the role of marijuana in other medical conditions.^1,2 At least equally notable are marijuana’s potential adverse effects, which include tachycardia, hypertension, agitation, nausea, psychosis, and hallucinations.² Marijuana may also increase the risk of heart failure, acute myocardial infarction, and stroke.³

University of Alabama at Birmingham

The exact effect of marijuana on the liver remains inconclusive. Receptors for endocannabinoids have been associated with steatosis and fibrosis in some studies. However, some evidence also suggests that marijuana may reduce inflammation in the liver.² Small, prospective studies have not been able to link marijuana use with hepatic laboratory abnormalities, and there is currently no significant association between marijuana and liver disease, injury, or cirrhosis. Of particular relevance to liver transplant recipients is marijuana’s effect on cytochrome P450 enzyme function, especially CYP3A4 which is the CYP class that metabolizes tacrolimus, a common immunosuppressant used in liver transplant patients. Marijuana inhibits CYP3A4 which could increase tacrolimus levels, potentially leading to morbidity. One strategy to mitigate this process is closer monitoring of tacrolimus levels for patients using marijuana.

The once-presumed increased risk of fungal infection — particularly Aspergillus — for liver transplant patients who use marijuana has been refuted. Furthermore, there have been concerns by liver transplant selection committees that marijuana use may be related to a greater risk of post–liver transplant noncompliance, infections, or even death. However, marijuana use on its own has not been associated with these concerns in the liver transplant population.⁴ 

The practice of excluding marijuana users from being listed for liver transplant does not appear to be evidence based. In a 2018 study focusing on US transplant centers, 40% of centers would not accept any marijuana use, and only 28% would list those who were taking medical marijuana for transplant. Interestingly, eight states have passed legislation prohibiting withholding transplant evaluation for marijuana users if it is solely based on their marijuana use.⁵ In the 5 years since that study was published, there have been major changes in the legality of marijuana. A future study of interest could assess how these changes have affected the position of transplant centers.

University of Alabama at Birmingham

The sociopolitical and transplant medicine worlds alike continue to adapt to the legalization of marijuana. While marijuana use is associated with adverse effects, its potential for benefit for a variety of medical conditions is an evolving area that has shown promise. It is therefore logical to view marijuana as a pharmacologic agent with potential for risks and benefits, but not necessarily a sole reason to exclude patients from listing for liver transplant. The current data are reassuring in that those who use marijuana and receive liver transplantation are not at higher risk of posttransplant complications, infections, or death when compared to those who do not use it. Should marijuana use exist in the context of substance use disorder or other behavioral and mental health issues, then the case warrants careful multidisciplinary evaluation prior to consideration for liver transplant. The aim of our discourse is not to encourage the use of marijuana in patients being considered for liver transplant but rather to discourage their exclusion from listing solely on the basis of marijuana use. In the pursuit of an equitable organ allocation system, our hope is that this work facilitates a more informed discussion and a change in policy in liver transplant programs that may still consider marijuana use an exclusion criterion.

Joven Tristeza, MD, and Thomas Ruli, MD, are residents in internal medicine at the University of Alabama at Birmingham; Mohamed Shoreibah, MD, is a specialist in gastroenterology and hepatology at the University of Alabama at Birmingham where he also serves on the faculty of the internal medicine residency program. The authors have no conflicts of interest.

REFERENCES

1. Cox, EJ. Pharmacology & Therapeutics. 2019;201:25-38.

2. Maselli, DB. Clinical Gastroenterology and Hepatology. 2021;19(9):1748-1758.e2.

3. Page, RL. Circulation. 2020;142(10):e131-e152.

4. Panchani, N. The American Journal of the Medical Sciences. 2023;365(2):115-120.

5. Zhu, J. Transplantation. 2018;102(3):433-439.

Happy New Year, everyone. It’s hard to believe, but we are nearing the mid-point of our five-year term on the GI & Hepatology News (GIHN) board of editors. Our central goal over the past two-and-a-half years has been to curate thought-provoking content for GIHN that helps to inform clinical practice and keeps you up-to-date on emerging scientific innovations and policy changes impacting patients with digestive and liver diseases.

As we usher in 2024, we want to hear from you—our readers—to ensure we are appropriately tailoring our coverage to your needs. Your feedback is critical to ensuring the continued success of the newspaper as your go-to source for cutting edge news relevant to our field.

To start, we welcome your thoughts on the following questions:

• What do you want to see more of in the newspaper (e.g., a particular column, topic)?
• How can we continue to serve you best as a reader? 

Please email your feedback to us at [email protected]. Your input is greatly appreciated by both the board and our larger editorial team and will help inform future coverage.

In this month’s issue of GIHN, we update you on the proceedings of AGA’s 2023 Innovation Conference, highlight a new Clinical Practice Guideline focused on the role of biomarkers in Crohn’s disease management, and summarize key AGA journal content.

The AGA Government Affairs Committee also details 2024 updates to Medicare payment rules, including a new add-on code for complex care, increased facility payment for POEM procedures, and continuation of expanded telehealth coverage through the end of 2024.

GIHN associate editor Dr. Avi Ketwaroo introduces this month’s Perspectives column focused on the impact of substance use (specifically alcohol and marijuana) on liver transplant candidacy.

In our January Member Spotlight, we feature Dr. Sonali Paul, a hepatologist and co-founder of Rainbows in Gastro. She shares her passion for promoting health equity in sexual and gender minority populations.

We hope you enjoy this, and all the exciting content included in our January issue.

Megan A. Adams, MD, JD, MSc

Editor-in-Chief

Happy New Year, everyone. It’s hard to believe, but we are nearing the mid-point of our five-year term on the GI & Hepatology News (GIHN) board of editors. Our central goal over the past two-and-a-half years has been to curate thought-provoking content for GIHN that helps to inform clinical practice and keeps you up-to-date on emerging scientific innovations and policy changes impacting patients with digestive and liver diseases.

As we usher in 2024, we want to hear from you—our readers—to ensure we are appropriately tailoring our coverage to your needs. Your feedback is critical to ensuring the continued success of the newspaper as your go-to source for cutting edge news relevant to our field.

To start, we welcome your thoughts on the following questions:

• What do you want to see more of in the newspaper (e.g., a particular column, topic)?
• How can we continue to serve you best as a reader? 

Please email your feedback to us at [email protected]. Your input is greatly appreciated by both the board and our larger editorial team and will help inform future coverage.

In this month’s issue of GIHN, we update you on the proceedings of AGA’s 2023 Innovation Conference, highlight a new Clinical Practice Guideline focused on the role of biomarkers in Crohn’s disease management, and summarize key AGA journal content.

The AGA Government Affairs Committee also details 2024 updates to Medicare payment rules, including a new add-on code for complex care, increased facility payment for POEM procedures, and continuation of expanded telehealth coverage through the end of 2024.

GIHN associate editor Dr. Avi Ketwaroo introduces this month’s Perspectives column focused on the impact of substance use (specifically alcohol and marijuana) on liver transplant candidacy.

In our January Member Spotlight, we feature Dr. Sonali Paul, a hepatologist and co-founder of Rainbows in Gastro. She shares her passion for promoting health equity in sexual and gender minority populations.

We hope you enjoy this, and all the exciting content included in our January issue.

Megan A. Adams, MD, JD, MSc

Editor-in-Chief

Happy New Year, everyone. It’s hard to believe, but we are nearing the mid-point of our five-year term on the GI & Hepatology News (GIHN) board of editors. Our central goal over the past two-and-a-half years has been to curate thought-provoking content for GIHN that helps to inform clinical practice and keeps you up-to-date on emerging scientific innovations and policy changes impacting patients with digestive and liver diseases.

As we usher in 2024, we want to hear from you—our readers—to ensure we are appropriately tailoring our coverage to your needs. Your feedback is critical to ensuring the continued success of the newspaper as your go-to source for cutting edge news relevant to our field.

To start, we welcome your thoughts on the following questions:

• What do you want to see more of in the newspaper (e.g., a particular column, topic)?
• How can we continue to serve you best as a reader? 

Please email your feedback to us at [email protected]. Your input is greatly appreciated by both the board and our larger editorial team and will help inform future coverage.

In this month’s issue of GIHN, we update you on the proceedings of AGA’s 2023 Innovation Conference, highlight a new Clinical Practice Guideline focused on the role of biomarkers in Crohn’s disease management, and summarize key AGA journal content.

The AGA Government Affairs Committee also details 2024 updates to Medicare payment rules, including a new add-on code for complex care, increased facility payment for POEM procedures, and continuation of expanded telehealth coverage through the end of 2024.

GIHN associate editor Dr. Avi Ketwaroo introduces this month’s Perspectives column focused on the impact of substance use (specifically alcohol and marijuana) on liver transplant candidacy.

In our January Member Spotlight, we feature Dr. Sonali Paul, a hepatologist and co-founder of Rainbows in Gastro. She shares her passion for promoting health equity in sexual and gender minority populations.

We hope you enjoy this, and all the exciting content included in our January issue.

Megan A. Adams, MD, JD, MSc

Editor-in-Chief