Clinical Psychiatry News

SYNLAB and ALCEDIAG recently launched the first blood test to assist in mental health diagnosis in France. The test is aimed at differentiating bipolar disorders from depression. The news may be surprising, given the challenges in diagnosing psychiatric conditions, especially when they share common symptoms such as recurrent depression and bipolar disorder.

Psychiatrists’ reactions to the new test are cautious. Many have echoed the sentiments of the French Association of Biological Psychiatry and Neuropsychopharmacology (AFPBN) and Stéphane Jamain, PhD, director of translational neuropsychiatry research (Inserm U955, Mondor Institute of Biomedical Research), who spoke with this news organization.

Early Diagnosis

Depression and bipolar disorders are two distinct psychiatric illnesses requiring different treatments. Early and accurate diagnosis and appropriate treatment are major challenges for clinicians, especially since untreated or inadequately treated bipolar disorder can lead to significant mental and physical health consequences for patients and their families.

Published studies indicate that it takes an average of 8-10 years, and sometimes even longer, to diagnose bipolar disorder. The diagnosis is based on a psychiatric clinical examination, which is conducted by a specialist using validated questionnaires and evaluation scales.

Early and accurate diagnosis of bipolar disorders that allows for appropriate treatment would be a significant advance for patients and their families. This is what the French laboratories SYNLAB, in partnership with ALCEDIAG, propose through myEDIT-B, a blood test described as “the first validated diagnostic aid test to differentiate depression and bipolar disorders.”

Whether this test, the availability of which has somewhat surprised the psychiatric medical and scientific community, will attract psychiatrists remains to be seen.

The AFPBN stated in a press release that “to date, no test meets conditions for clinical use.” For a diagnostic test to be scientifically valid, ethical, and usable in clinical practice, its development must meet strict criteria, as highlighted by the AFPBN. The approximately 10 criteria include the validation of the scientific results in at least two independent clinical studies or cohorts, satisfactory sensitivity (detection of true positives) and specificity (detection of false negatives), and cost that is ethically responsible and allows patient access, independent of commercial interests.

ALCEDIAG has reported two clinical studies, but only one has been published so far (in Translational Psychiatry) involving 400 patients. In this case, “these patients already had a well-established psychiatric condition, did not quite present the same symptoms between patients with recurrent depression and those with bipolar disorder and were not taking the same treatments,” noted Dr. Jamain.

Differentiating between bipolar disorder and depression is crucial, especially regarding treatments, because antidepressants given to a patient with bipolar disorder can induce a manic shift if they are not accompanied by mood stabilizers, Dr. Jamain acknowledged. Nevertheless, he believes that based on what the laboratory has published, it is difficult to comment on the test at this time.

RNA Editing 

Moreover, myEDIT-B is based on a technique that measures RNA editing modifications of specific markers in patients’ blood, which could lead to differences in amino acids within proteins. The technique is unique to the ALCEDIAG laboratory, which coupled it with an artificial intelligence tool that specifically selected 8 RNA sequences for analysis from thousands of edited sequences to obtain a differential signature for unipolar and bipolar depressions. “This method is niche, the trademark of ALCEDIAG,” said Dr. Jamain, who questions the significance of this “editing” on the periphery of the CNS.

“This technique differs from that adopted by most international consortia, which are very active in this research field. The latter technique compares differences in genome [DNA] nucleotides between individuals in large cohorts involving tens of thousands of people and identifies the most frequently occurring patterns associated with a pathology to deduce a risk of developing a psychiatric illness,” said Jamain. “However, the information provided by these large-scale studies does not allow us to define who is at risk for developing the disease any more than the simple observation of the familial recurrence [heritability] of it does.” 

Scientific Validation 

While ALCEDIAG boasts a sensitivity and specificity of more than 80% for its test, the psychiatric world remains cautious. Interviewed by France Info TV, Marion Leboyer, PhD, general director of the FondaMental Foundation, psychiatrist, and researcher (at AP-HP, Inserm in Créteil, France), highlighted the importance of encouraging research on psychiatric illnesses, especially that which will contribute to the understanding and treatment of patients with bipolar disorders. But she expressed caution regarding the test because of the absence of rigorous scientific validation through clinical trials.

Regarding “ALCEDIAG’s test and its commercial aspect, caution is warranted,” said Dr. Jamain. Only time will tell if psychiatrists will prescribe this €899 test, which currently is not reimbursed by social security (see box below). ALCEDIAG plans to submit a validation dossier to the US Food and Drug Administration.

Test Not Reimbursed by Social Security

The ALCEDIAG test will be available beginning in April 2024, by prescription, in SYNLAB France network laboratories. It is intended for patients aged 18 years and older who are being treated for a moderate or severe depressive episode. Test results are transmitted within 4 weeks to the prescribing psychiatrist, who will confirm the diagnosis to the patient during a consultation. Already available in Italy, this in vitro medical device has a CE-IVD marking. In France, however, it costs €899 and is not reimbursed by social security because of insufficient clinical evidence.

This story was translated from the Medscape French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

SYNLAB and ALCEDIAG recently launched the first blood test to assist in mental health diagnosis in France. The test is aimed at differentiating bipolar disorders from depression. The news may be surprising, given the challenges in diagnosing psychiatric conditions, especially when they share common symptoms such as recurrent depression and bipolar disorder.

Psychiatrists’ reactions to the new test are cautious. Many have echoed the sentiments of the French Association of Biological Psychiatry and Neuropsychopharmacology (AFPBN) and Stéphane Jamain, PhD, director of translational neuropsychiatry research (Inserm U955, Mondor Institute of Biomedical Research), who spoke with this news organization.

Early Diagnosis

Depression and bipolar disorders are two distinct psychiatric illnesses requiring different treatments. Early and accurate diagnosis and appropriate treatment are major challenges for clinicians, especially since untreated or inadequately treated bipolar disorder can lead to significant mental and physical health consequences for patients and their families.

Published studies indicate that it takes an average of 8-10 years, and sometimes even longer, to diagnose bipolar disorder. The diagnosis is based on a psychiatric clinical examination, which is conducted by a specialist using validated questionnaires and evaluation scales.

Early and accurate diagnosis of bipolar disorders that allows for appropriate treatment would be a significant advance for patients and their families. This is what the French laboratories SYNLAB, in partnership with ALCEDIAG, propose through myEDIT-B, a blood test described as “the first validated diagnostic aid test to differentiate depression and bipolar disorders.”

Whether this test, the availability of which has somewhat surprised the psychiatric medical and scientific community, will attract psychiatrists remains to be seen.

The AFPBN stated in a press release that “to date, no test meets conditions for clinical use.” For a diagnostic test to be scientifically valid, ethical, and usable in clinical practice, its development must meet strict criteria, as highlighted by the AFPBN. The approximately 10 criteria include the validation of the scientific results in at least two independent clinical studies or cohorts, satisfactory sensitivity (detection of true positives) and specificity (detection of false negatives), and cost that is ethically responsible and allows patient access, independent of commercial interests.

ALCEDIAG has reported two clinical studies, but only one has been published so far (in Translational Psychiatry) involving 400 patients. In this case, “these patients already had a well-established psychiatric condition, did not quite present the same symptoms between patients with recurrent depression and those with bipolar disorder and were not taking the same treatments,” noted Dr. Jamain.

Differentiating between bipolar disorder and depression is crucial, especially regarding treatments, because antidepressants given to a patient with bipolar disorder can induce a manic shift if they are not accompanied by mood stabilizers, Dr. Jamain acknowledged. Nevertheless, he believes that based on what the laboratory has published, it is difficult to comment on the test at this time.

RNA Editing 

Moreover, myEDIT-B is based on a technique that measures RNA editing modifications of specific markers in patients’ blood, which could lead to differences in amino acids within proteins. The technique is unique to the ALCEDIAG laboratory, which coupled it with an artificial intelligence tool that specifically selected 8 RNA sequences for analysis from thousands of edited sequences to obtain a differential signature for unipolar and bipolar depressions. “This method is niche, the trademark of ALCEDIAG,” said Dr. Jamain, who questions the significance of this “editing” on the periphery of the CNS.

“This technique differs from that adopted by most international consortia, which are very active in this research field. The latter technique compares differences in genome [DNA] nucleotides between individuals in large cohorts involving tens of thousands of people and identifies the most frequently occurring patterns associated with a pathology to deduce a risk of developing a psychiatric illness,” said Jamain. “However, the information provided by these large-scale studies does not allow us to define who is at risk for developing the disease any more than the simple observation of the familial recurrence [heritability] of it does.” 

Scientific Validation 

While ALCEDIAG boasts a sensitivity and specificity of more than 80% for its test, the psychiatric world remains cautious. Interviewed by France Info TV, Marion Leboyer, PhD, general director of the FondaMental Foundation, psychiatrist, and researcher (at AP-HP, Inserm in Créteil, France), highlighted the importance of encouraging research on psychiatric illnesses, especially that which will contribute to the understanding and treatment of patients with bipolar disorders. But she expressed caution regarding the test because of the absence of rigorous scientific validation through clinical trials.

Regarding “ALCEDIAG’s test and its commercial aspect, caution is warranted,” said Dr. Jamain. Only time will tell if psychiatrists will prescribe this €899 test, which currently is not reimbursed by social security (see box below). ALCEDIAG plans to submit a validation dossier to the US Food and Drug Administration.

Test Not Reimbursed by Social Security

The ALCEDIAG test will be available beginning in April 2024, by prescription, in SYNLAB France network laboratories. It is intended for patients aged 18 years and older who are being treated for a moderate or severe depressive episode. Test results are transmitted within 4 weeks to the prescribing psychiatrist, who will confirm the diagnosis to the patient during a consultation. Already available in Italy, this in vitro medical device has a CE-IVD marking. In France, however, it costs €899 and is not reimbursed by social security because of insufficient clinical evidence.

This story was translated from the Medscape French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

SYNLAB and ALCEDIAG recently launched the first blood test to assist in mental health diagnosis in France. The test is aimed at differentiating bipolar disorders from depression. The news may be surprising, given the challenges in diagnosing psychiatric conditions, especially when they share common symptoms such as recurrent depression and bipolar disorder.

Psychiatrists’ reactions to the new test are cautious. Many have echoed the sentiments of the French Association of Biological Psychiatry and Neuropsychopharmacology (AFPBN) and Stéphane Jamain, PhD, director of translational neuropsychiatry research (Inserm U955, Mondor Institute of Biomedical Research), who spoke with this news organization.

Early Diagnosis

Depression and bipolar disorders are two distinct psychiatric illnesses requiring different treatments. Early and accurate diagnosis and appropriate treatment are major challenges for clinicians, especially since untreated or inadequately treated bipolar disorder can lead to significant mental and physical health consequences for patients and their families.

Published studies indicate that it takes an average of 8-10 years, and sometimes even longer, to diagnose bipolar disorder. The diagnosis is based on a psychiatric clinical examination, which is conducted by a specialist using validated questionnaires and evaluation scales.

Early and accurate diagnosis of bipolar disorders that allows for appropriate treatment would be a significant advance for patients and their families. This is what the French laboratories SYNLAB, in partnership with ALCEDIAG, propose through myEDIT-B, a blood test described as “the first validated diagnostic aid test to differentiate depression and bipolar disorders.”

Whether this test, the availability of which has somewhat surprised the psychiatric medical and scientific community, will attract psychiatrists remains to be seen.

The AFPBN stated in a press release that “to date, no test meets conditions for clinical use.” For a diagnostic test to be scientifically valid, ethical, and usable in clinical practice, its development must meet strict criteria, as highlighted by the AFPBN. The approximately 10 criteria include the validation of the scientific results in at least two independent clinical studies or cohorts, satisfactory sensitivity (detection of true positives) and specificity (detection of false negatives), and cost that is ethically responsible and allows patient access, independent of commercial interests.

ALCEDIAG has reported two clinical studies, but only one has been published so far (in Translational Psychiatry) involving 400 patients. In this case, “these patients already had a well-established psychiatric condition, did not quite present the same symptoms between patients with recurrent depression and those with bipolar disorder and were not taking the same treatments,” noted Dr. Jamain.

Differentiating between bipolar disorder and depression is crucial, especially regarding treatments, because antidepressants given to a patient with bipolar disorder can induce a manic shift if they are not accompanied by mood stabilizers, Dr. Jamain acknowledged. Nevertheless, he believes that based on what the laboratory has published, it is difficult to comment on the test at this time.

RNA Editing 

Moreover, myEDIT-B is based on a technique that measures RNA editing modifications of specific markers in patients’ blood, which could lead to differences in amino acids within proteins. The technique is unique to the ALCEDIAG laboratory, which coupled it with an artificial intelligence tool that specifically selected 8 RNA sequences for analysis from thousands of edited sequences to obtain a differential signature for unipolar and bipolar depressions. “This method is niche, the trademark of ALCEDIAG,” said Dr. Jamain, who questions the significance of this “editing” on the periphery of the CNS.

“This technique differs from that adopted by most international consortia, which are very active in this research field. The latter technique compares differences in genome [DNA] nucleotides between individuals in large cohorts involving tens of thousands of people and identifies the most frequently occurring patterns associated with a pathology to deduce a risk of developing a psychiatric illness,” said Jamain. “However, the information provided by these large-scale studies does not allow us to define who is at risk for developing the disease any more than the simple observation of the familial recurrence [heritability] of it does.” 

Scientific Validation 

While ALCEDIAG boasts a sensitivity and specificity of more than 80% for its test, the psychiatric world remains cautious. Interviewed by France Info TV, Marion Leboyer, PhD, general director of the FondaMental Foundation, psychiatrist, and researcher (at AP-HP, Inserm in Créteil, France), highlighted the importance of encouraging research on psychiatric illnesses, especially that which will contribute to the understanding and treatment of patients with bipolar disorders. But she expressed caution regarding the test because of the absence of rigorous scientific validation through clinical trials.

Regarding “ALCEDIAG’s test and its commercial aspect, caution is warranted,” said Dr. Jamain. Only time will tell if psychiatrists will prescribe this €899 test, which currently is not reimbursed by social security (see box below). ALCEDIAG plans to submit a validation dossier to the US Food and Drug Administration.

Test Not Reimbursed by Social Security

The ALCEDIAG test will be available beginning in April 2024, by prescription, in SYNLAB France network laboratories. It is intended for patients aged 18 years and older who are being treated for a moderate or severe depressive episode. Test results are transmitted within 4 weeks to the prescribing psychiatrist, who will confirm the diagnosis to the patient during a consultation. Already available in Italy, this in vitro medical device has a CE-IVD marking. In France, however, it costs €899 and is not reimbursed by social security because of insufficient clinical evidence.

This story was translated from the Medscape French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

In a 2023 study published in the Annals of Emergency Medicine, European researchers fed the AI system ChatGPT information on 30 ER patients. Details included physician notes on the patients’ symptoms, physical exams, and lab results. ChatGPT made the correct diagnosis in 97% of patients compared to 87% for human doctors.

AI 1, Physicians 0

JAMA Cardiology reported in 2021 that an AI trained on nearly a million ECGs performed comparably to or exceeded cardiologist clinical diagnoses and the MUSE (GE Healthcare) system›s automated ECG analysis for most diagnostic classes.

AI 2, Physicians 0

Google’s medically focused AI model (Med-PaLM2) scored 85%+ when answering US Medical Licensing Examination–style questions. That›s an «expert» physician level and far beyond the accuracy threshold needed to pass the actual exam.

AI 3, Physicians 0

A new AI tool that uses an online finger-tapping test outperformed primary care physicians when assessing the severity of Parkinson’s disease.

AI 4, Physicians 0

JAMA Ophthalmology reported in 2024 that a chatbot outperformed glaucoma specialists and matched retina specialists in diagnostic and treatment accuracy.

AI 5, Physicians 0

Should we stop? Because we could go on. In the last few years, these AI vs Physician studies have proliferated, and guess who’s winning?

65% of Doctors are Concerned

Now, the standard answer with anything AI-and-Medicine goes something like this: AI is coming, and it will be a transformative tool for physicians and improve patient care.

But the underlying unanswered question is: Physicians spend many years and a lot of money to become really good at what they do. How, exactly, should a doctor feel about a machine that can suddenly do the job better and faster?

The Medscape 2023 Physician and AI Report surveyed 1043 US physicians about their views on AI. In total, 65% are concerned about AI making diagnosis and treatment decisions, but 56% are enthusiastic about having it as an adjunct.

Cardiologists, anesthesiologists, and radiologists are most enthusiastic about AI, whereas family physicians and pediatricians are the least enthusiastic.

To get a more personal view of how physicians and other healthcare professionals are feeling about this transformative tech, I spoke with a variety of practicing doctors, a psychotherapist, and a third-year Harvard Medical School student.

‘Abysmally Poor Understanding’

Alfredo A. Sadun, MD, PhD, has been a neuro-ophthalmologist for nearly 50 years. A graduate of MIT and vice-chair of ophthalmology at UCLA, he’s long been fascinated by AI’s march into medicine. He’s watched it accomplish things that no ophthalmologist can do, such as identify gender, age, and risk for heart attack and stroke from retinal scans. But he doesn›t see the same level of interest and comprehension among the medical community.

“There’s still an abysmally poor understanding of AI among physicians in general,” he said. “It’s striking because these are intelligent, well-educated people. But we tend to draw conclusions based on what we’re familiar with, and most doctors’ experience with computers involves EHRs [electronic health records] and administrative garbage. It’s the reason they’re burning out.”

Easing the Burden

Anthony Philippakis, MD, PhD, left his cardiology practice in 2015 to become the chief data officer at the Broad Institute of MIT and Harvard. While there, he helped develop an AI-based method for identifying patients at risk for atrial fibrillation. Now, he’s a general partner at Google Ventures with the goal of bridging the gap between data sciences and medicine. His perspective on AI is unique, given that he’s seen the issue from both sides.

“I am not a bitter physician, but to be honest, when I was practicing, way too much of my time was spent staring at screens and not enough laying hands on patients,” he said. “Can you imagine what it would be like to speak to the EHR naturally and say, ‘Please order the following labs for this patient and notify me when the results come in.’ Boy, would that improve healthcare and physician satisfaction. Every physician I know is excited and optimistic about that. Almost everyone I’ve talked to feels like AI could take a lot of the stuff they don’t like doing off their plates.”

Indeed, the dividing line between physician support for AI and physician suspicion or skepticism of AI is just that. In our survey, more than three quarters of physicians said they would consider using AI for office administrative tasks, scheduling, EHRs, researching medical conditions, and even summarizing a patient’s record before a visit. But far fewer are supportive of it delivering diagnoses and treatments. This, despite an estimated 800,000 Americans dying or becoming permanently disabled each year because of diagnostic error.

Could AI Have Diagnosed This?

John D. Nuschke, MD, has been a primary care physician in Allentown, Pennsylvania, for 40 years. He’s a jovial general physician who insists his patients call him Jack. He’s recently started using an AI medical scribe called Freed. With the patient’s permission, it listens in on the visit and generates notes, saving Dr. Nuschke time and helping him focus on the person. He likes that type of assistance, but when it comes to AI replacing him, he’s skeptical.

“I had this patient I diagnosed with prostate cancer,” he explained. “He got treated and was fine for 5 years. Then, he started losing weight and feeling awful — got weak as a kitten. He went back to his urologist and oncologist who thought he had metastatic prostate cancer. He went through PET scans and blood work, but there was no sign his cancer had returned. So the specialists sent him back to me, and the second he walked in, I saw he was floridly hyperthyroid. I could tell across the room just by looking at him. Would AI have been able to make that diagnosis? Does AI do physical exams?”

Dr. Nuschke said he’s also had several instances where patients received their cancer diagnosis from the lab through an automated patient-portal system rather than from him. “That’s an AI of sorts, and I found it distressing,” he said.

Empathy From a Robot

All the doctors I spoke to were hopeful that by freeing them from the burden of administrative work, they would be able to return to the reason they got into this business in the first place — to spend more time with patients in need and support them with grace and compassion.

But suppose AI could do that too?

In a 2023 study conducted at the University of California San Diego and published in JAMA Internal Medicine, three licensed healthcare professionals compared the responses of ChatGPT and physicians to real-world health questions. The panel rated the AI’s answers nearly four times higher in quality and almost 10 times more empathetic than physicians’ replies.

A similar 2024 study in Nature found that Google’s large-language model AI matched or surpassed physician diagnostic accuracy in all six of the medical specialties considered. Plus, it outperformed doctors in 24 of 26 criteria for conversation quality, including politeness, explanation, honesty, and expressing care and commitment.

Nathaniel Chin, MD, is a gerontologist at the University of Wisconsin and advisory board member for the Alzheimer’s Foundation of America. Although he admits that studies like these “sadden me,” he’s also a realist. “There was hesitation among physicians at the beginning of the pandemic to virtual care because we missed the human connection,” he explained, “but we worked our way around that. We need to remember that what makes a chatbot strong is that it’s nothuman. It doesn’t burn out, it doesn’t get tired, it can look at data very quickly, and it doesn’t have to go home to a family and try to balance work with other aspects of life. A human being is very complex, whereas a chatbot has one single purpose.”

“Even if you don’t have AI in your space now or don’t like the idea of it, that doesn’t matter,” he added. “It’s coming. But it needs to be done right. If AI is implemented by clinicians for clinicians, it has great potential. But if it’s implemented by businesspeople for business reasons, perhaps not.”

‘The Ones Who Use the Tools the Best Will Be the Best’

One branch of medicine that stands to be dramatically affected by AI is mental health. Because bots are natural data-crunchers, they are becoming adept at analyzing the many subtle clues (phrasing in social media posts and text messages, smartwatch biometrics, therapy session videos…) that could indicate depression or other psychological disorders. In fact, its availability via smartphone apps could help democratize and destigmatize the practice.

“There is a day ahead — probably within 5 years — when a patient won’t be able to tell the difference between a real therapist and an AI therapist,” said Ken Mallon, MS, LMFT, a clinical psychotherapist and data scientist in San Jose, California. “That doesn’t worry me, though. It’s hard on therapists’ egos, but new technologies get developed. Things change. People who embrace these tools will benefit from them. The ones who use the tools the best will be the best.”

Time to Restructure Med School

Aditya Jain is in his third year at Harvard Medical School. At age 24, he’s heading into this brave new medical world with excitement and anxiety. Excitement because he sees AI revolutionizing healthcare on every level. Although the current generations of physicians and patients may grumble about its onset, he believes younger ones will feel comfortable with “DocGPT.” He’s excited that his generation of physicians will be the “translators and managers of this transition” and redefine “what it means to be a doctor.”

His anxiety, however, stems from the fact that AI has come on so fast that “it has not yet crossed the threshold of medical education,” he said. “Medical schools still largely prepare students to work as solo clinical decision makers. Most of my first 2 years were spent on pattern recognition and rote memorization, skills that AI can and will master.”

Indeed, Mr. Jain said AI was not a part of his first- or second-year curriculum. “I talk to students who are a year older than me, graduating, heading to residency, and they tell me they wish they had gotten a better grasp of how to use these technologies in medicine and in their practice. They were surprised to hear that people in my year hadn’t started using ChatGPT. We need to expend a lot more effort within the field, within academia, within practicing physicians, to figure out what our role will be in a world where AI is matching or even exceeding human intelligence. And then we need to restructure the medical education to better accomplish these goals.”

So Are You Ready for AI to Be a Better Doctor Than You?

“Yes, I am,” said Dr. Philippakis without hesitation. “When I was going through my medical training, I was continually confronted with the reality that I personally was not smart enough to keep all the information in my head that could be used to make a good decision for a patient. We have now reached a point where the amount of information that is important and useful in the practice of medicine outstrips what a human being can know. The opportunity to enable physicians with AI to remedy that situation is a good thing for doctors and, most importantly, a good thing for patients. I believe the future of medicine belongs not so much to the AI practitioner but to the AI-enabled practitioner.”

“Quick story,” added Dr. Chin. “I asked ChatGPT two questions. The first was ‘Explain the difference between Alzheimer’s and dementia’ because that’s the most common misconception in my field. And it gave me a pretty darn good answer — one I would use in a presentation with some tweaking. Then I asked it, ‘Are you a better doctor than me?’ And it replied, ‘My purpose is not to replace you, my purpose is to be supportive of you and enhance your ability.’ ”

A version of this article appeared on Medscape.com.

In a 2023 study published in the Annals of Emergency Medicine, European researchers fed the AI system ChatGPT information on 30 ER patients. Details included physician notes on the patients’ symptoms, physical exams, and lab results. ChatGPT made the correct diagnosis in 97% of patients compared to 87% for human doctors.

AI 1, Physicians 0

JAMA Cardiology reported in 2021 that an AI trained on nearly a million ECGs performed comparably to or exceeded cardiologist clinical diagnoses and the MUSE (GE Healthcare) system›s automated ECG analysis for most diagnostic classes.

AI 2, Physicians 0

Google’s medically focused AI model (Med-PaLM2) scored 85%+ when answering US Medical Licensing Examination–style questions. That›s an «expert» physician level and far beyond the accuracy threshold needed to pass the actual exam.

AI 3, Physicians 0

A new AI tool that uses an online finger-tapping test outperformed primary care physicians when assessing the severity of Parkinson’s disease.

AI 4, Physicians 0

JAMA Ophthalmology reported in 2024 that a chatbot outperformed glaucoma specialists and matched retina specialists in diagnostic and treatment accuracy.

AI 5, Physicians 0

Should we stop? Because we could go on. In the last few years, these AI vs Physician studies have proliferated, and guess who’s winning?

65% of Doctors are Concerned

Now, the standard answer with anything AI-and-Medicine goes something like this: AI is coming, and it will be a transformative tool for physicians and improve patient care.

But the underlying unanswered question is: Physicians spend many years and a lot of money to become really good at what they do. How, exactly, should a doctor feel about a machine that can suddenly do the job better and faster?

The Medscape 2023 Physician and AI Report surveyed 1043 US physicians about their views on AI. In total, 65% are concerned about AI making diagnosis and treatment decisions, but 56% are enthusiastic about having it as an adjunct.

Cardiologists, anesthesiologists, and radiologists are most enthusiastic about AI, whereas family physicians and pediatricians are the least enthusiastic.

To get a more personal view of how physicians and other healthcare professionals are feeling about this transformative tech, I spoke with a variety of practicing doctors, a psychotherapist, and a third-year Harvard Medical School student.

‘Abysmally Poor Understanding’

Alfredo A. Sadun, MD, PhD, has been a neuro-ophthalmologist for nearly 50 years. A graduate of MIT and vice-chair of ophthalmology at UCLA, he’s long been fascinated by AI’s march into medicine. He’s watched it accomplish things that no ophthalmologist can do, such as identify gender, age, and risk for heart attack and stroke from retinal scans. But he doesn›t see the same level of interest and comprehension among the medical community.

“There’s still an abysmally poor understanding of AI among physicians in general,” he said. “It’s striking because these are intelligent, well-educated people. But we tend to draw conclusions based on what we’re familiar with, and most doctors’ experience with computers involves EHRs [electronic health records] and administrative garbage. It’s the reason they’re burning out.”

Easing the Burden

Anthony Philippakis, MD, PhD, left his cardiology practice in 2015 to become the chief data officer at the Broad Institute of MIT and Harvard. While there, he helped develop an AI-based method for identifying patients at risk for atrial fibrillation. Now, he’s a general partner at Google Ventures with the goal of bridging the gap between data sciences and medicine. His perspective on AI is unique, given that he’s seen the issue from both sides.

“I am not a bitter physician, but to be honest, when I was practicing, way too much of my time was spent staring at screens and not enough laying hands on patients,” he said. “Can you imagine what it would be like to speak to the EHR naturally and say, ‘Please order the following labs for this patient and notify me when the results come in.’ Boy, would that improve healthcare and physician satisfaction. Every physician I know is excited and optimistic about that. Almost everyone I’ve talked to feels like AI could take a lot of the stuff they don’t like doing off their plates.”

Indeed, the dividing line between physician support for AI and physician suspicion or skepticism of AI is just that. In our survey, more than three quarters of physicians said they would consider using AI for office administrative tasks, scheduling, EHRs, researching medical conditions, and even summarizing a patient’s record before a visit. But far fewer are supportive of it delivering diagnoses and treatments. This, despite an estimated 800,000 Americans dying or becoming permanently disabled each year because of diagnostic error.

Could AI Have Diagnosed This?

John D. Nuschke, MD, has been a primary care physician in Allentown, Pennsylvania, for 40 years. He’s a jovial general physician who insists his patients call him Jack. He’s recently started using an AI medical scribe called Freed. With the patient’s permission, it listens in on the visit and generates notes, saving Dr. Nuschke time and helping him focus on the person. He likes that type of assistance, but when it comes to AI replacing him, he’s skeptical.

“I had this patient I diagnosed with prostate cancer,” he explained. “He got treated and was fine for 5 years. Then, he started losing weight and feeling awful — got weak as a kitten. He went back to his urologist and oncologist who thought he had metastatic prostate cancer. He went through PET scans and blood work, but there was no sign his cancer had returned. So the specialists sent him back to me, and the second he walked in, I saw he was floridly hyperthyroid. I could tell across the room just by looking at him. Would AI have been able to make that diagnosis? Does AI do physical exams?”

Dr. Nuschke said he’s also had several instances where patients received their cancer diagnosis from the lab through an automated patient-portal system rather than from him. “That’s an AI of sorts, and I found it distressing,” he said.

Empathy From a Robot

All the doctors I spoke to were hopeful that by freeing them from the burden of administrative work, they would be able to return to the reason they got into this business in the first place — to spend more time with patients in need and support them with grace and compassion.

But suppose AI could do that too?

In a 2023 study conducted at the University of California San Diego and published in JAMA Internal Medicine, three licensed healthcare professionals compared the responses of ChatGPT and physicians to real-world health questions. The panel rated the AI’s answers nearly four times higher in quality and almost 10 times more empathetic than physicians’ replies.

A similar 2024 study in Nature found that Google’s large-language model AI matched or surpassed physician diagnostic accuracy in all six of the medical specialties considered. Plus, it outperformed doctors in 24 of 26 criteria for conversation quality, including politeness, explanation, honesty, and expressing care and commitment.

Nathaniel Chin, MD, is a gerontologist at the University of Wisconsin and advisory board member for the Alzheimer’s Foundation of America. Although he admits that studies like these “sadden me,” he’s also a realist. “There was hesitation among physicians at the beginning of the pandemic to virtual care because we missed the human connection,” he explained, “but we worked our way around that. We need to remember that what makes a chatbot strong is that it’s nothuman. It doesn’t burn out, it doesn’t get tired, it can look at data very quickly, and it doesn’t have to go home to a family and try to balance work with other aspects of life. A human being is very complex, whereas a chatbot has one single purpose.”

“Even if you don’t have AI in your space now or don’t like the idea of it, that doesn’t matter,” he added. “It’s coming. But it needs to be done right. If AI is implemented by clinicians for clinicians, it has great potential. But if it’s implemented by businesspeople for business reasons, perhaps not.”

‘The Ones Who Use the Tools the Best Will Be the Best’

One branch of medicine that stands to be dramatically affected by AI is mental health. Because bots are natural data-crunchers, they are becoming adept at analyzing the many subtle clues (phrasing in social media posts and text messages, smartwatch biometrics, therapy session videos…) that could indicate depression or other psychological disorders. In fact, its availability via smartphone apps could help democratize and destigmatize the practice.

“There is a day ahead — probably within 5 years — when a patient won’t be able to tell the difference between a real therapist and an AI therapist,” said Ken Mallon, MS, LMFT, a clinical psychotherapist and data scientist in San Jose, California. “That doesn’t worry me, though. It’s hard on therapists’ egos, but new technologies get developed. Things change. People who embrace these tools will benefit from them. The ones who use the tools the best will be the best.”

Time to Restructure Med School

Aditya Jain is in his third year at Harvard Medical School. At age 24, he’s heading into this brave new medical world with excitement and anxiety. Excitement because he sees AI revolutionizing healthcare on every level. Although the current generations of physicians and patients may grumble about its onset, he believes younger ones will feel comfortable with “DocGPT.” He’s excited that his generation of physicians will be the “translators and managers of this transition” and redefine “what it means to be a doctor.”

His anxiety, however, stems from the fact that AI has come on so fast that “it has not yet crossed the threshold of medical education,” he said. “Medical schools still largely prepare students to work as solo clinical decision makers. Most of my first 2 years were spent on pattern recognition and rote memorization, skills that AI can and will master.”

Indeed, Mr. Jain said AI was not a part of his first- or second-year curriculum. “I talk to students who are a year older than me, graduating, heading to residency, and they tell me they wish they had gotten a better grasp of how to use these technologies in medicine and in their practice. They were surprised to hear that people in my year hadn’t started using ChatGPT. We need to expend a lot more effort within the field, within academia, within practicing physicians, to figure out what our role will be in a world where AI is matching or even exceeding human intelligence. And then we need to restructure the medical education to better accomplish these goals.”

So Are You Ready for AI to Be a Better Doctor Than You?

“Yes, I am,” said Dr. Philippakis without hesitation. “When I was going through my medical training, I was continually confronted with the reality that I personally was not smart enough to keep all the information in my head that could be used to make a good decision for a patient. We have now reached a point where the amount of information that is important and useful in the practice of medicine outstrips what a human being can know. The opportunity to enable physicians with AI to remedy that situation is a good thing for doctors and, most importantly, a good thing for patients. I believe the future of medicine belongs not so much to the AI practitioner but to the AI-enabled practitioner.”

“Quick story,” added Dr. Chin. “I asked ChatGPT two questions. The first was ‘Explain the difference between Alzheimer’s and dementia’ because that’s the most common misconception in my field. And it gave me a pretty darn good answer — one I would use in a presentation with some tweaking. Then I asked it, ‘Are you a better doctor than me?’ And it replied, ‘My purpose is not to replace you, my purpose is to be supportive of you and enhance your ability.’ ”

A version of this article appeared on Medscape.com.

In a 2023 study published in the Annals of Emergency Medicine, European researchers fed the AI system ChatGPT information on 30 ER patients. Details included physician notes on the patients’ symptoms, physical exams, and lab results. ChatGPT made the correct diagnosis in 97% of patients compared to 87% for human doctors.

AI 1, Physicians 0

JAMA Cardiology reported in 2021 that an AI trained on nearly a million ECGs performed comparably to or exceeded cardiologist clinical diagnoses and the MUSE (GE Healthcare) system›s automated ECG analysis for most diagnostic classes.

AI 2, Physicians 0

Google’s medically focused AI model (Med-PaLM2) scored 85%+ when answering US Medical Licensing Examination–style questions. That›s an «expert» physician level and far beyond the accuracy threshold needed to pass the actual exam.

AI 3, Physicians 0

A new AI tool that uses an online finger-tapping test outperformed primary care physicians when assessing the severity of Parkinson’s disease.

AI 4, Physicians 0

JAMA Ophthalmology reported in 2024 that a chatbot outperformed glaucoma specialists and matched retina specialists in diagnostic and treatment accuracy.

AI 5, Physicians 0

Should we stop? Because we could go on. In the last few years, these AI vs Physician studies have proliferated, and guess who’s winning?

65% of Doctors are Concerned

Now, the standard answer with anything AI-and-Medicine goes something like this: AI is coming, and it will be a transformative tool for physicians and improve patient care.

But the underlying unanswered question is: Physicians spend many years and a lot of money to become really good at what they do. How, exactly, should a doctor feel about a machine that can suddenly do the job better and faster?

The Medscape 2023 Physician and AI Report surveyed 1043 US physicians about their views on AI. In total, 65% are concerned about AI making diagnosis and treatment decisions, but 56% are enthusiastic about having it as an adjunct.

Cardiologists, anesthesiologists, and radiologists are most enthusiastic about AI, whereas family physicians and pediatricians are the least enthusiastic.

To get a more personal view of how physicians and other healthcare professionals are feeling about this transformative tech, I spoke with a variety of practicing doctors, a psychotherapist, and a third-year Harvard Medical School student.

‘Abysmally Poor Understanding’

Alfredo A. Sadun, MD, PhD, has been a neuro-ophthalmologist for nearly 50 years. A graduate of MIT and vice-chair of ophthalmology at UCLA, he’s long been fascinated by AI’s march into medicine. He’s watched it accomplish things that no ophthalmologist can do, such as identify gender, age, and risk for heart attack and stroke from retinal scans. But he doesn›t see the same level of interest and comprehension among the medical community.

“There’s still an abysmally poor understanding of AI among physicians in general,” he said. “It’s striking because these are intelligent, well-educated people. But we tend to draw conclusions based on what we’re familiar with, and most doctors’ experience with computers involves EHRs [electronic health records] and administrative garbage. It’s the reason they’re burning out.”

Easing the Burden

Anthony Philippakis, MD, PhD, left his cardiology practice in 2015 to become the chief data officer at the Broad Institute of MIT and Harvard. While there, he helped develop an AI-based method for identifying patients at risk for atrial fibrillation. Now, he’s a general partner at Google Ventures with the goal of bridging the gap between data sciences and medicine. His perspective on AI is unique, given that he’s seen the issue from both sides.

“I am not a bitter physician, but to be honest, when I was practicing, way too much of my time was spent staring at screens and not enough laying hands on patients,” he said. “Can you imagine what it would be like to speak to the EHR naturally and say, ‘Please order the following labs for this patient and notify me when the results come in.’ Boy, would that improve healthcare and physician satisfaction. Every physician I know is excited and optimistic about that. Almost everyone I’ve talked to feels like AI could take a lot of the stuff they don’t like doing off their plates.”

Indeed, the dividing line between physician support for AI and physician suspicion or skepticism of AI is just that. In our survey, more than three quarters of physicians said they would consider using AI for office administrative tasks, scheduling, EHRs, researching medical conditions, and even summarizing a patient’s record before a visit. But far fewer are supportive of it delivering diagnoses and treatments. This, despite an estimated 800,000 Americans dying or becoming permanently disabled each year because of diagnostic error.

Could AI Have Diagnosed This?

John D. Nuschke, MD, has been a primary care physician in Allentown, Pennsylvania, for 40 years. He’s a jovial general physician who insists his patients call him Jack. He’s recently started using an AI medical scribe called Freed. With the patient’s permission, it listens in on the visit and generates notes, saving Dr. Nuschke time and helping him focus on the person. He likes that type of assistance, but when it comes to AI replacing him, he’s skeptical.

“I had this patient I diagnosed with prostate cancer,” he explained. “He got treated and was fine for 5 years. Then, he started losing weight and feeling awful — got weak as a kitten. He went back to his urologist and oncologist who thought he had metastatic prostate cancer. He went through PET scans and blood work, but there was no sign his cancer had returned. So the specialists sent him back to me, and the second he walked in, I saw he was floridly hyperthyroid. I could tell across the room just by looking at him. Would AI have been able to make that diagnosis? Does AI do physical exams?”

Dr. Nuschke said he’s also had several instances where patients received their cancer diagnosis from the lab through an automated patient-portal system rather than from him. “That’s an AI of sorts, and I found it distressing,” he said.

Empathy From a Robot

All the doctors I spoke to were hopeful that by freeing them from the burden of administrative work, they would be able to return to the reason they got into this business in the first place — to spend more time with patients in need and support them with grace and compassion.

But suppose AI could do that too?

In a 2023 study conducted at the University of California San Diego and published in JAMA Internal Medicine, three licensed healthcare professionals compared the responses of ChatGPT and physicians to real-world health questions. The panel rated the AI’s answers nearly four times higher in quality and almost 10 times more empathetic than physicians’ replies.

A similar 2024 study in Nature found that Google’s large-language model AI matched or surpassed physician diagnostic accuracy in all six of the medical specialties considered. Plus, it outperformed doctors in 24 of 26 criteria for conversation quality, including politeness, explanation, honesty, and expressing care and commitment.

Nathaniel Chin, MD, is a gerontologist at the University of Wisconsin and advisory board member for the Alzheimer’s Foundation of America. Although he admits that studies like these “sadden me,” he’s also a realist. “There was hesitation among physicians at the beginning of the pandemic to virtual care because we missed the human connection,” he explained, “but we worked our way around that. We need to remember that what makes a chatbot strong is that it’s nothuman. It doesn’t burn out, it doesn’t get tired, it can look at data very quickly, and it doesn’t have to go home to a family and try to balance work with other aspects of life. A human being is very complex, whereas a chatbot has one single purpose.”

“Even if you don’t have AI in your space now or don’t like the idea of it, that doesn’t matter,” he added. “It’s coming. But it needs to be done right. If AI is implemented by clinicians for clinicians, it has great potential. But if it’s implemented by businesspeople for business reasons, perhaps not.”

‘The Ones Who Use the Tools the Best Will Be the Best’

One branch of medicine that stands to be dramatically affected by AI is mental health. Because bots are natural data-crunchers, they are becoming adept at analyzing the many subtle clues (phrasing in social media posts and text messages, smartwatch biometrics, therapy session videos…) that could indicate depression or other psychological disorders. In fact, its availability via smartphone apps could help democratize and destigmatize the practice.

“There is a day ahead — probably within 5 years — when a patient won’t be able to tell the difference between a real therapist and an AI therapist,” said Ken Mallon, MS, LMFT, a clinical psychotherapist and data scientist in San Jose, California. “That doesn’t worry me, though. It’s hard on therapists’ egos, but new technologies get developed. Things change. People who embrace these tools will benefit from them. The ones who use the tools the best will be the best.”

Time to Restructure Med School

Aditya Jain is in his third year at Harvard Medical School. At age 24, he’s heading into this brave new medical world with excitement and anxiety. Excitement because he sees AI revolutionizing healthcare on every level. Although the current generations of physicians and patients may grumble about its onset, he believes younger ones will feel comfortable with “DocGPT.” He’s excited that his generation of physicians will be the “translators and managers of this transition” and redefine “what it means to be a doctor.”

His anxiety, however, stems from the fact that AI has come on so fast that “it has not yet crossed the threshold of medical education,” he said. “Medical schools still largely prepare students to work as solo clinical decision makers. Most of my first 2 years were spent on pattern recognition and rote memorization, skills that AI can and will master.”

Indeed, Mr. Jain said AI was not a part of his first- or second-year curriculum. “I talk to students who are a year older than me, graduating, heading to residency, and they tell me they wish they had gotten a better grasp of how to use these technologies in medicine and in their practice. They were surprised to hear that people in my year hadn’t started using ChatGPT. We need to expend a lot more effort within the field, within academia, within practicing physicians, to figure out what our role will be in a world where AI is matching or even exceeding human intelligence. And then we need to restructure the medical education to better accomplish these goals.”

So Are You Ready for AI to Be a Better Doctor Than You?

“Yes, I am,” said Dr. Philippakis without hesitation. “When I was going through my medical training, I was continually confronted with the reality that I personally was not smart enough to keep all the information in my head that could be used to make a good decision for a patient. We have now reached a point where the amount of information that is important and useful in the practice of medicine outstrips what a human being can know. The opportunity to enable physicians with AI to remedy that situation is a good thing for doctors and, most importantly, a good thing for patients. I believe the future of medicine belongs not so much to the AI practitioner but to the AI-enabled practitioner.”

“Quick story,” added Dr. Chin. “I asked ChatGPT two questions. The first was ‘Explain the difference between Alzheimer’s and dementia’ because that’s the most common misconception in my field. And it gave me a pretty darn good answer — one I would use in a presentation with some tweaking. Then I asked it, ‘Are you a better doctor than me?’ And it replied, ‘My purpose is not to replace you, my purpose is to be supportive of you and enhance your ability.’ ”

A version of this article appeared on Medscape.com.

A smartphone-based tool that tracks mental health status by detecting changes in voice may complement traditional psychiatric assessments and improve an individual’s ability to self-monitor depressive and other mental health symptoms, new research suggested.

Investigators used the Mental Fitness Vocal Biomarker (MFVB) scoring algorithm, which is incorporated into a smartphone voice journaling application, to detect increased or decreased risk for elevated mental health symptom severity by analyzing 30-second free speech voice recordings for specific vocal patterns previously linked to mental health.

A comparison between MFVB scores and commonly used clinical mental health assessments revealed a statistically significant correlation, researchers noted.

“While the MFVB tool is not intended to diagnose or treat mental health conditions, these findings provide a robust initial foundation upon which to further explore its potential in personalized wellness tracking, which has so far not yet been able to extend measurement of physical health to mental wellbeing,” reported the researchers, led by Erik Larsen, PhD, with Boston-based Sonde Health, which developed the tool.

The study was published online in Frontiers in Psychiatry.
 

Eight Vocal Features

The potential value of vocal biomarkers for mental health assessment has gained increasing attention.

“Somebody that is depressed often sounds more monotone; they may have less inflection in their voice and speak slower with less energy, which can be recognized in voice recordings,” Dr. Larsen told this news organization.

“This is an area which has received quite a bit of research in the last few decades to find out what specific aspects of acoustics and rhythm of speech could point to conditions like depression,” Dr. Larsen said.

In the current study, the researchers set out to validate the ability of the MFVB platform to detect mental health symptoms.

With the tool, users record their thoughts and feelings as a 30-second voice journal. The tool analyzes the recordings for eight vocal features previously shown to be relevant to mental health. These include jitter, shimmer, pitch variability, energy variability, vowel space, phonation duration, speech rate, and pause duration.

The tool calculates a real-time MFVB score ranging from 0 to 100. A score of 80-100 is defined as “excellent” and 70-79 as “good,” while a score of 0-69 is categorized as “pay attention.” It was trained on more than 1 million voice samples to optimize performance across a diverse range of cultures, languages, and socioeconomic groups.

The current study included 104 outpatient psychiatric patients (73% women) with anxiety-related diagnoses, trauma, and stress-related disorders or depressive disorders. The cohort was mostly made up of White, non-Hispanic young adults. Patients with a history of substance abuse or who were taking psychiatric medications that may affect voice and speech were excluded.

During the 4-week study period, participants conducted 1336 app sessions with voice recordings, resulting in an average of 12.8 sessions per participant, or 3.2 per week.

MFVB scores were cross-referenced against the results of participants’ M3 Checklist, a clinically validated mental health assessment tool.

Over a period of 2 weeks, participants were twice as likely to report elevated mental health symptoms if their MFVB scores remained in the “pay attention” range vs in the “excellent” range, the researchers found.

The effect was more pronounced in those who used the app more frequently, with frequent users 8.5 times more likely to show elevated symptoms.

The correlation between MFVB scores and established mental health assessments was “not only statistically significant but also meaningful for participants,” researchers wrote. Subgroup analyses suggest the app works best for depression and stress- and trauma-related disorders.

The tool provides psychiatric outpatients with “immediate quantitative feedback on their mental health symptom severity,” the researchers noted.

In their paper, the investigators caution that the results highlight the “general ability” of MFVB score categories to differentiate mental health symptom severity levels but do not distinguish what type of symptoms these may be, such as depression, anxiety, or posttraumatic stress disorder.

In a statement, study investigator Lindsey Venesky, PhD, psychologist and clinical director at the Cognitive Behavior Institute in Pittsburgh, noted that the ability to collect mental health data from patients between clinic visits “could transform how we monitor symptoms and optimize treatment plans.”

“Voice-based health tracking technology can provide accurate insights into a client’s mental health status over time and can do so seamlessly and unobtrusively, with little added effort for clients,” Dr. Venesky said.

Need for Replication, Validation

Commenting on the findings, John Torous, MD, director of the division of digital psychiatry at Beth Israel Deaconess Medical Center, Boston, noted that “over the last 20 years, there has been a lot of interest in voice biomarkers, yet somehow that research has never been translated into mainstream clinical care.”

Voice biomarkers are “relevant and have potential” in mental health, he noted. The findings in this study are “interesting, but they need to be thoroughly externally replicated and validated to show that these biomarkers are valid and reliable,” Dr. Torous added.

Changes in voice are part of the mental status exam, Dr. Torous said, “but it’s only one piece of information that we collect in a clinical assessment of many pieces of information.”

Dr. Torous also cautioned that “as a practicing psychiatrist, it can be tricky to be given new data if you don’t know how to interpret it or what it means. An important step would be education, outreach, and resources for physicians to learn about potential voice biomarkers.”

The authors received internal financial support for the research, authorship, and/or publication of this article. The pilot phase of the study at St. Joseph’s Healthcare Hamilton was partially supported through Mitacs Accelerate International, Canada. Dr. Larsen and three coauthors are employed by Sonde Health. Dr. Torous had no relevant conflicts of interest.

A version of this article appeared on Medscape.com.

A smartphone-based tool that tracks mental health status by detecting changes in voice may complement traditional psychiatric assessments and improve an individual’s ability to self-monitor depressive and other mental health symptoms, new research suggested.

Investigators used the Mental Fitness Vocal Biomarker (MFVB) scoring algorithm, which is incorporated into a smartphone voice journaling application, to detect increased or decreased risk for elevated mental health symptom severity by analyzing 30-second free speech voice recordings for specific vocal patterns previously linked to mental health.

A comparison between MFVB scores and commonly used clinical mental health assessments revealed a statistically significant correlation, researchers noted.

“While the MFVB tool is not intended to diagnose or treat mental health conditions, these findings provide a robust initial foundation upon which to further explore its potential in personalized wellness tracking, which has so far not yet been able to extend measurement of physical health to mental wellbeing,” reported the researchers, led by Erik Larsen, PhD, with Boston-based Sonde Health, which developed the tool.

The study was published online in Frontiers in Psychiatry.
 

Eight Vocal Features

The potential value of vocal biomarkers for mental health assessment has gained increasing attention.

“Somebody that is depressed often sounds more monotone; they may have less inflection in their voice and speak slower with less energy, which can be recognized in voice recordings,” Dr. Larsen told this news organization.

“This is an area which has received quite a bit of research in the last few decades to find out what specific aspects of acoustics and rhythm of speech could point to conditions like depression,” Dr. Larsen said.

In the current study, the researchers set out to validate the ability of the MFVB platform to detect mental health symptoms.

With the tool, users record their thoughts and feelings as a 30-second voice journal. The tool analyzes the recordings for eight vocal features previously shown to be relevant to mental health. These include jitter, shimmer, pitch variability, energy variability, vowel space, phonation duration, speech rate, and pause duration.

The tool calculates a real-time MFVB score ranging from 0 to 100. A score of 80-100 is defined as “excellent” and 70-79 as “good,” while a score of 0-69 is categorized as “pay attention.” It was trained on more than 1 million voice samples to optimize performance across a diverse range of cultures, languages, and socioeconomic groups.

The current study included 104 outpatient psychiatric patients (73% women) with anxiety-related diagnoses, trauma, and stress-related disorders or depressive disorders. The cohort was mostly made up of White, non-Hispanic young adults. Patients with a history of substance abuse or who were taking psychiatric medications that may affect voice and speech were excluded.

During the 4-week study period, participants conducted 1336 app sessions with voice recordings, resulting in an average of 12.8 sessions per participant, or 3.2 per week.

MFVB scores were cross-referenced against the results of participants’ M3 Checklist, a clinically validated mental health assessment tool.

Over a period of 2 weeks, participants were twice as likely to report elevated mental health symptoms if their MFVB scores remained in the “pay attention” range vs in the “excellent” range, the researchers found.

The effect was more pronounced in those who used the app more frequently, with frequent users 8.5 times more likely to show elevated symptoms.

The correlation between MFVB scores and established mental health assessments was “not only statistically significant but also meaningful for participants,” researchers wrote. Subgroup analyses suggest the app works best for depression and stress- and trauma-related disorders.

The tool provides psychiatric outpatients with “immediate quantitative feedback on their mental health symptom severity,” the researchers noted.

In their paper, the investigators caution that the results highlight the “general ability” of MFVB score categories to differentiate mental health symptom severity levels but do not distinguish what type of symptoms these may be, such as depression, anxiety, or posttraumatic stress disorder.

In a statement, study investigator Lindsey Venesky, PhD, psychologist and clinical director at the Cognitive Behavior Institute in Pittsburgh, noted that the ability to collect mental health data from patients between clinic visits “could transform how we monitor symptoms and optimize treatment plans.”

“Voice-based health tracking technology can provide accurate insights into a client’s mental health status over time and can do so seamlessly and unobtrusively, with little added effort for clients,” Dr. Venesky said.

Need for Replication, Validation

Commenting on the findings, John Torous, MD, director of the division of digital psychiatry at Beth Israel Deaconess Medical Center, Boston, noted that “over the last 20 years, there has been a lot of interest in voice biomarkers, yet somehow that research has never been translated into mainstream clinical care.”

Voice biomarkers are “relevant and have potential” in mental health, he noted. The findings in this study are “interesting, but they need to be thoroughly externally replicated and validated to show that these biomarkers are valid and reliable,” Dr. Torous added.

Changes in voice are part of the mental status exam, Dr. Torous said, “but it’s only one piece of information that we collect in a clinical assessment of many pieces of information.”

Dr. Torous also cautioned that “as a practicing psychiatrist, it can be tricky to be given new data if you don’t know how to interpret it or what it means. An important step would be education, outreach, and resources for physicians to learn about potential voice biomarkers.”

The authors received internal financial support for the research, authorship, and/or publication of this article. The pilot phase of the study at St. Joseph’s Healthcare Hamilton was partially supported through Mitacs Accelerate International, Canada. Dr. Larsen and three coauthors are employed by Sonde Health. Dr. Torous had no relevant conflicts of interest.

A version of this article appeared on Medscape.com.

A smartphone-based tool that tracks mental health status by detecting changes in voice may complement traditional psychiatric assessments and improve an individual’s ability to self-monitor depressive and other mental health symptoms, new research suggested.

Investigators used the Mental Fitness Vocal Biomarker (MFVB) scoring algorithm, which is incorporated into a smartphone voice journaling application, to detect increased or decreased risk for elevated mental health symptom severity by analyzing 30-second free speech voice recordings for specific vocal patterns previously linked to mental health.

A comparison between MFVB scores and commonly used clinical mental health assessments revealed a statistically significant correlation, researchers noted.

“While the MFVB tool is not intended to diagnose or treat mental health conditions, these findings provide a robust initial foundation upon which to further explore its potential in personalized wellness tracking, which has so far not yet been able to extend measurement of physical health to mental wellbeing,” reported the researchers, led by Erik Larsen, PhD, with Boston-based Sonde Health, which developed the tool.

The study was published online in Frontiers in Psychiatry.
 

Eight Vocal Features

The potential value of vocal biomarkers for mental health assessment has gained increasing attention.

“Somebody that is depressed often sounds more monotone; they may have less inflection in their voice and speak slower with less energy, which can be recognized in voice recordings,” Dr. Larsen told this news organization.

“This is an area which has received quite a bit of research in the last few decades to find out what specific aspects of acoustics and rhythm of speech could point to conditions like depression,” Dr. Larsen said.

In the current study, the researchers set out to validate the ability of the MFVB platform to detect mental health symptoms.

With the tool, users record their thoughts and feelings as a 30-second voice journal. The tool analyzes the recordings for eight vocal features previously shown to be relevant to mental health. These include jitter, shimmer, pitch variability, energy variability, vowel space, phonation duration, speech rate, and pause duration.

The tool calculates a real-time MFVB score ranging from 0 to 100. A score of 80-100 is defined as “excellent” and 70-79 as “good,” while a score of 0-69 is categorized as “pay attention.” It was trained on more than 1 million voice samples to optimize performance across a diverse range of cultures, languages, and socioeconomic groups.

The current study included 104 outpatient psychiatric patients (73% women) with anxiety-related diagnoses, trauma, and stress-related disorders or depressive disorders. The cohort was mostly made up of White, non-Hispanic young adults. Patients with a history of substance abuse or who were taking psychiatric medications that may affect voice and speech were excluded.

During the 4-week study period, participants conducted 1336 app sessions with voice recordings, resulting in an average of 12.8 sessions per participant, or 3.2 per week.

MFVB scores were cross-referenced against the results of participants’ M3 Checklist, a clinically validated mental health assessment tool.

Over a period of 2 weeks, participants were twice as likely to report elevated mental health symptoms if their MFVB scores remained in the “pay attention” range vs in the “excellent” range, the researchers found.

The effect was more pronounced in those who used the app more frequently, with frequent users 8.5 times more likely to show elevated symptoms.

The correlation between MFVB scores and established mental health assessments was “not only statistically significant but also meaningful for participants,” researchers wrote. Subgroup analyses suggest the app works best for depression and stress- and trauma-related disorders.

The tool provides psychiatric outpatients with “immediate quantitative feedback on their mental health symptom severity,” the researchers noted.

In their paper, the investigators caution that the results highlight the “general ability” of MFVB score categories to differentiate mental health symptom severity levels but do not distinguish what type of symptoms these may be, such as depression, anxiety, or posttraumatic stress disorder.

In a statement, study investigator Lindsey Venesky, PhD, psychologist and clinical director at the Cognitive Behavior Institute in Pittsburgh, noted that the ability to collect mental health data from patients between clinic visits “could transform how we monitor symptoms and optimize treatment plans.”

“Voice-based health tracking technology can provide accurate insights into a client’s mental health status over time and can do so seamlessly and unobtrusively, with little added effort for clients,” Dr. Venesky said.

Need for Replication, Validation

Commenting on the findings, John Torous, MD, director of the division of digital psychiatry at Beth Israel Deaconess Medical Center, Boston, noted that “over the last 20 years, there has been a lot of interest in voice biomarkers, yet somehow that research has never been translated into mainstream clinical care.”

Voice biomarkers are “relevant and have potential” in mental health, he noted. The findings in this study are “interesting, but they need to be thoroughly externally replicated and validated to show that these biomarkers are valid and reliable,” Dr. Torous added.

Changes in voice are part of the mental status exam, Dr. Torous said, “but it’s only one piece of information that we collect in a clinical assessment of many pieces of information.”

Dr. Torous also cautioned that “as a practicing psychiatrist, it can be tricky to be given new data if you don’t know how to interpret it or what it means. An important step would be education, outreach, and resources for physicians to learn about potential voice biomarkers.”

The authors received internal financial support for the research, authorship, and/or publication of this article. The pilot phase of the study at St. Joseph’s Healthcare Hamilton was partially supported through Mitacs Accelerate International, Canada. Dr. Larsen and three coauthors are employed by Sonde Health. Dr. Torous had no relevant conflicts of interest.

A version of this article appeared on Medscape.com.

TOPLINE:

Black patients with schizophrenia are less likely to receive a clozapine prescription compared with White patients, a new study shows. The findings held even after the researchers controlled for demographic variables, social determinants of health, and care access patterns.

METHODOLOGY:

• The study drew on structured electronic health record data on 3160 adult patients with schizophrenia.
• The mean age at first recorded diagnosis was 39.5 years; 70% of participants were male, 53% Black, and 91% resided in an urban setting.
• The researchers used the social vulnerability index (SVI) to quantify social determinants of health.
• Descriptive data analysis, logistic regression, and sensitivity analysis were used to identify differences between those who received a clozapine prescription and those who were prescribed antipsychotic medications other than clozapine.

TAKEAWAY:

• Overall, 401 patients received a clozapine prescription, 51% of whom were White and 40% were Black.
• Moreover, 19% of all White patients in the study received clozapine vs 10% of Black patients.
• After the researchers controlled for demographic variables, SVI scores, and care patterns, White patients were significantly more likely to receive a clozapine prescription than Black patients (adjusted odds ratio [aOR], 1.71; P < .001).
• Factors that had a statistically significant influence on the likelihood of receiving a clozapine prescription were minority status and language (OR, 2.97; P < .007), treatment duration (OR, 1.36; P < .001), and socioeconomic status (OR, 0.27; P = .001).

IN PRACTICE:

“The reasons for the underprescription of clozapine among Black patients with schizophrenia are multifactorial and may include concerns about benign ethnic neutropenia, prescriber bias, prescribers’ anticipation of patients’ nonadherence to the treatment, and the notion that the medication is less effective for Black patients,” the authors wrote.

SOURCE:

Xiaoming Zeng, MD, PhD, professor of psychiatry, University of North Carolina, Chapel Hill, North Carolina, was the senior and corresponding on the study. It was published online on March 19 in Psychiatric Services.

LIMITATIONS:

Due to the study’s cross-sectional and single-site design, the findings may not be generalizable to other geographic areas or institutions. The study lacked information on substance use disorders, common health conditions, or other patient-level data. A question remains whether all patients who received clozapine actually had treatment-resistant schizophrenia because other research has shown that there is an overdiagnosis of schizophrenia among Black patients.

DISCLOSURES:

The study was supported by a grant from the Foundation of Hope. Dr. Zeng reported no relevant financial relationships. The other authors’ disclosures are listed on the original paper.

A version of this article appeared on Medscape.com.

TOPLINE:

Black patients with schizophrenia are less likely to receive a clozapine prescription compared with White patients, a new study shows. The findings held even after the researchers controlled for demographic variables, social determinants of health, and care access patterns.

METHODOLOGY:

• The study drew on structured electronic health record data on 3160 adult patients with schizophrenia.
• The mean age at first recorded diagnosis was 39.5 years; 70% of participants were male, 53% Black, and 91% resided in an urban setting.
• The researchers used the social vulnerability index (SVI) to quantify social determinants of health.
• Descriptive data analysis, logistic regression, and sensitivity analysis were used to identify differences between those who received a clozapine prescription and those who were prescribed antipsychotic medications other than clozapine.

TAKEAWAY:

• Overall, 401 patients received a clozapine prescription, 51% of whom were White and 40% were Black.
• Moreover, 19% of all White patients in the study received clozapine vs 10% of Black patients.
• After the researchers controlled for demographic variables, SVI scores, and care patterns, White patients were significantly more likely to receive a clozapine prescription than Black patients (adjusted odds ratio [aOR], 1.71; P < .001).
• Factors that had a statistically significant influence on the likelihood of receiving a clozapine prescription were minority status and language (OR, 2.97; P < .007), treatment duration (OR, 1.36; P < .001), and socioeconomic status (OR, 0.27; P = .001).

IN PRACTICE:

“The reasons for the underprescription of clozapine among Black patients with schizophrenia are multifactorial and may include concerns about benign ethnic neutropenia, prescriber bias, prescribers’ anticipation of patients’ nonadherence to the treatment, and the notion that the medication is less effective for Black patients,” the authors wrote.

SOURCE:

Xiaoming Zeng, MD, PhD, professor of psychiatry, University of North Carolina, Chapel Hill, North Carolina, was the senior and corresponding on the study. It was published online on March 19 in Psychiatric Services.

LIMITATIONS:

Due to the study’s cross-sectional and single-site design, the findings may not be generalizable to other geographic areas or institutions. The study lacked information on substance use disorders, common health conditions, or other patient-level data. A question remains whether all patients who received clozapine actually had treatment-resistant schizophrenia because other research has shown that there is an overdiagnosis of schizophrenia among Black patients.

DISCLOSURES:

The study was supported by a grant from the Foundation of Hope. Dr. Zeng reported no relevant financial relationships. The other authors’ disclosures are listed on the original paper.

A version of this article appeared on Medscape.com.

TOPLINE:

Black patients with schizophrenia are less likely to receive a clozapine prescription compared with White patients, a new study shows. The findings held even after the researchers controlled for demographic variables, social determinants of health, and care access patterns.

METHODOLOGY:

• The study drew on structured electronic health record data on 3160 adult patients with schizophrenia.
• The mean age at first recorded diagnosis was 39.5 years; 70% of participants were male, 53% Black, and 91% resided in an urban setting.
• The researchers used the social vulnerability index (SVI) to quantify social determinants of health.
• Descriptive data analysis, logistic regression, and sensitivity analysis were used to identify differences between those who received a clozapine prescription and those who were prescribed antipsychotic medications other than clozapine.

TAKEAWAY:

• Overall, 401 patients received a clozapine prescription, 51% of whom were White and 40% were Black.
• Moreover, 19% of all White patients in the study received clozapine vs 10% of Black patients.
• After the researchers controlled for demographic variables, SVI scores, and care patterns, White patients were significantly more likely to receive a clozapine prescription than Black patients (adjusted odds ratio [aOR], 1.71; P < .001).
• Factors that had a statistically significant influence on the likelihood of receiving a clozapine prescription were minority status and language (OR, 2.97; P < .007), treatment duration (OR, 1.36; P < .001), and socioeconomic status (OR, 0.27; P = .001).

IN PRACTICE:

“The reasons for the underprescription of clozapine among Black patients with schizophrenia are multifactorial and may include concerns about benign ethnic neutropenia, prescriber bias, prescribers’ anticipation of patients’ nonadherence to the treatment, and the notion that the medication is less effective for Black patients,” the authors wrote.

SOURCE:

Xiaoming Zeng, MD, PhD, professor of psychiatry, University of North Carolina, Chapel Hill, North Carolina, was the senior and corresponding on the study. It was published online on March 19 in Psychiatric Services.

LIMITATIONS:

Due to the study’s cross-sectional and single-site design, the findings may not be generalizable to other geographic areas or institutions. The study lacked information on substance use disorders, common health conditions, or other patient-level data. A question remains whether all patients who received clozapine actually had treatment-resistant schizophrenia because other research has shown that there is an overdiagnosis of schizophrenia among Black patients.

DISCLOSURES:

The study was supported by a grant from the Foundation of Hope. Dr. Zeng reported no relevant financial relationships. The other authors’ disclosures are listed on the original paper.

A version of this article appeared on Medscape.com.

The first US clinical guidelines to diagnose and treat attention-deficit/hyperactivity disorder (ADHD) in adults are expected to be released this fall, providing patients, clinicians, insurers, and policymakers with a long overdue and much-needed standardized framework.

The initiative comes under the auspices of the American Professional Society of ADHD and Related Disorders (APSARD). David Goodman, MD, a member of the APSARD guidelines executive committee and assistant professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine in Baltimore, Maryland, noted that the US lags behind several other nations, including Canada, the United Kingdom, Australia, and New Zealand who already have guidelines in place.

Dr. Goodman would not go into any detail as to why the country has been so slow off the mark but told this news organization that in part it has been due to a lack of specific funding. In addition, he said, “adult psychiatry abdicated responsibility for ADHD in adults.”

The American Psychiatric Association (APA) would not comment, although a spokesperson said two of its members are working with APSARD on the guidelines.

Estimates show that there are 10-11 million American adults (4.4%) with ADHD, making it the second most common psychiatric disorder in adults.

Surveys show that mental health professionals, including psychiatrists, report a lack of familiarity with ADHD in adults, said Margaret Sibley, PhD, professor of psychiatry and behavioral sciences at the University of Washington School of Medicine in Seattle and chair of the APSARD guidelines diagnostic and screening committee.

Many don’t consider an ADHD diagnosis in adults “because they were always trained to conceptualize it as something that’s relevant only in childhood,” Dr. Sibley told this new organization. However, research shows that people with ADHD do not outgrow the disorder.

“ADHD itself is still present and has unique problems associated with it in adults,” Dr. Sibley said.
 

Filling the Leadership Gap

Laurie Kulikosky, CEO of the advocacy group CHADD, said that the organization views the development of guidelines “as a huge step forward in the ability for more people to understand ADHD, particularly on the adult side.”

Oren Mason, MD, a primary care physician who specializes in ADHD at his Grand Rapids, Michigan-based practice, said “there hasn’t been a single specialty that has taken lead responsibility in adult ADHD,” which has contributed to the lag in guideline development.

In addition, Dr. Mason said, “trying to come up with adult guidelines even 5 or 10 years ago wouldn’t have yielded nearly as robust a set of guidelines because it’s taken awhile to have the evidence base to be able to make a few pronouncements really confidently.”

Not only has the evidence base grown but so has telehealth, especially during the height of the COVID-19 pandemic. That led to concerns that ADHD was not rigorously evaluated and that stimulants were prescribed too easily, said Dr. Goodman.

Several telehealth providers came under federal scrutiny, with the DEA accusing Cerebral’s pharmacy of dispensing stimulants for nonmedical reasons. The agency said that some 72,000 prescriptions for controlled substances, mostly stimulants, were written between 2020 and 2022.

APSARD felt it was time to act, said Dr. Goodman.

“We could not allow entrepreneurs who felt there was a business opportunity here to, under the auspices of advocating for mental health, increase the distribution of potentially addictive medications in the community,” he said
 

Ensuring Psychiatrist Buy-In

Development of the APSARD guidelines is led by Thomas Spencer, MD, a retired associate professor of psychiatry at Harvard Medical School, and Frances Rudnick Levin, MD, the Kennedy-Leavy Professor of Psychiatry at Columbia University, both of whom have decades of experience and clinical work in adults with ADHD.

Dr. Goodman is joined on the executive committee by Lenard Adler, MD (NYU Grossman School of Medicine), and Stephen Faraone, PhD (SUNY Upstate Medical University), along with 30 others who have expertise in psychiatry, psychology, primary care, and other health professions.

To participate in the development of the guidelines, experts had to agree to disengage from any potential conflicts and devote themselves — unpaid — to the process, said Dr. Goodman. The goal is to head off any charges of conflicts or biases, he said.

Three subcommittees — diagnosis and assessment, medical treatment, and nonmedical treatment — will review the literature, grade the evidence base, and use the Delphi consensus method to write the draft guidelines.

The draft will go out to the public and to medical specialties for comment, which will be considered for inclusion in the final publication, said Dr. Goodman.

The guidelines panel has been working closely with the APA and following the APA guideline development process in an effort to get buy-in from psychiatrists, he said.
 

Critical Educational Tool

“Doctors are often surprised to hear that there are no guidelines for adult ADHD in the US,” said Ann Childress, MD, APSARD president, when the group announced its effort in 2023. “Whether diagnosis and treatment are provided in office or online, the standard of care should be the same throughout the country,” she said.

Guidelines will “reduce mythology and error or at least when we run into mythology and error we can say no, there’s a giant consensus with hundreds of experts that disagree with that and so if you want to counter that you better bring some heavy machinery, you can’t just throw out an opinion and leave it unsupported,” said Dr. Mason.

Dr. Sibley said that, although there are no good data, anecdotally it appears many clinicians rely on the Diagnostic and Statistical Manual of Mental Disorders (DSM) when treating adults with ADHD.

The DSM “tells people what they should do but it doesn’t exactly tell them what’s the best way to do it,” she said, adding that often physicians follow what they learned from whoever they were trained by.

“Some people have been trained by people who are well versed in best practices and so they might be doing things that we would say have a research support to them, and other people might be doing things based on people who developed their own opinions about the best way to diagnose ADHD based on lived experience which may or may not be best practices,” Dr. Sibley said.

Her subcommittee aims to offer guidance on screening “that will be helpful in primary care, in terms of what are the most efficient ways to do it” and to help with accuracy, she said. Currently, there are likely some clinicians who are making too liberal a diagnosis and others who are making too conservative a diagnosis, she said.

With so many clinicians — especially in primary care — having a lack of experience, the guidelines could increase “the ability for more different kinds of providers to help,” said Dr. Kulikosky.

Guidelines should also provide a template for ongoing education, especially for clinicians who have never received any training in ADHD.

Dr. Goodman said it is increasingly likely that primary care physicians will be writing more prescriptions for ADHD medications than psychiatrists. “If that is the trajectory, the education of those providers seeing these patients is critical,” he said.
 

Offering Standards, Dispelling Myths

Guidelines can also help “shorten the learning curve,” said Dr. Mason, who said that he’s had to piece together evidence over the last few decades. Once published, the standards can be used in residency, for board exams, and continuing medical education, he said.

Not only do they offer a “kind of a shortcut to what we all know and agree on,” they also specify where the edges of knowledge are, he said.

Guidelines can also dissuade clinicians from practices that have no evidence to support them, such as “medication holidays,” said Dr. Mason. That has been employed to give children, especially, a break from side effects, but studies have shown that it actually increases side effects, he said.

Dr. Goodman and Dr. Sibley expect the guidelines to help with the challenge of diagnosis. Approximately 38% of adults with ADHD have a mood disorder and 48% have anxiety, said Dr. Goodman. Many others have coexisting posttraumatic stress disorder, substance use disorders, or medical illnesses that compound cognitive problems.

If an individual has several psychiatric conditions, “the question is how do you diagnostically prioritize which you treat first, second, and third, with the goal of treating one without making the others worse,” said Dr. Goodman.

“ADHD takes more detective work than other disorders,” said Dr. Sibley, adding that without an objective diagnostic and with overlaps with other comorbid disorders, “there are very complex issues that all of us wrestle with.”

While the guidelines will not provide algorithms, they will provide information that “will help guide them in the tougher diagnostic context,” she said.

Dr. Mason agreed. “It’s a complicated disorder to diagnose and treat. It’s hard for somebody to jump into it. [The guidelines] are going to give us — here’s what you really have to know, here’s what you have to do,” he said.

And it won’t just be clinicians who look to the guidelines. Calls to National Resource Center on ADHD — which CHADD runs for the federal government — from adults wanting to know more about their own condition “have increased exponentially” in the last few years, said Dr. Kulikosky. “We know adults are seeking out information, they are seeking out diagnosis and treatment,” she said.

Dr. Goodman and Dr. Sibley reported no relevant financial relationships. Dr. Mason reported that he consults for Otsuka and is a speaker for Iron Shore.

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

The first US clinical guidelines to diagnose and treat attention-deficit/hyperactivity disorder (ADHD) in adults are expected to be released this fall, providing patients, clinicians, insurers, and policymakers with a long overdue and much-needed standardized framework.

The initiative comes under the auspices of the American Professional Society of ADHD and Related Disorders (APSARD). David Goodman, MD, a member of the APSARD guidelines executive committee and assistant professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine in Baltimore, Maryland, noted that the US lags behind several other nations, including Canada, the United Kingdom, Australia, and New Zealand who already have guidelines in place.

Dr. Goodman would not go into any detail as to why the country has been so slow off the mark but told this news organization that in part it has been due to a lack of specific funding. In addition, he said, “adult psychiatry abdicated responsibility for ADHD in adults.”

The American Psychiatric Association (APA) would not comment, although a spokesperson said two of its members are working with APSARD on the guidelines.

Estimates show that there are 10-11 million American adults (4.4%) with ADHD, making it the second most common psychiatric disorder in adults.

Surveys show that mental health professionals, including psychiatrists, report a lack of familiarity with ADHD in adults, said Margaret Sibley, PhD, professor of psychiatry and behavioral sciences at the University of Washington School of Medicine in Seattle and chair of the APSARD guidelines diagnostic and screening committee.

Many don’t consider an ADHD diagnosis in adults “because they were always trained to conceptualize it as something that’s relevant only in childhood,” Dr. Sibley told this new organization. However, research shows that people with ADHD do not outgrow the disorder.

“ADHD itself is still present and has unique problems associated with it in adults,” Dr. Sibley said.
 

Filling the Leadership Gap

Laurie Kulikosky, CEO of the advocacy group CHADD, said that the organization views the development of guidelines “as a huge step forward in the ability for more people to understand ADHD, particularly on the adult side.”

Oren Mason, MD, a primary care physician who specializes in ADHD at his Grand Rapids, Michigan-based practice, said “there hasn’t been a single specialty that has taken lead responsibility in adult ADHD,” which has contributed to the lag in guideline development.

In addition, Dr. Mason said, “trying to come up with adult guidelines even 5 or 10 years ago wouldn’t have yielded nearly as robust a set of guidelines because it’s taken awhile to have the evidence base to be able to make a few pronouncements really confidently.”

Not only has the evidence base grown but so has telehealth, especially during the height of the COVID-19 pandemic. That led to concerns that ADHD was not rigorously evaluated and that stimulants were prescribed too easily, said Dr. Goodman.

Several telehealth providers came under federal scrutiny, with the DEA accusing Cerebral’s pharmacy of dispensing stimulants for nonmedical reasons. The agency said that some 72,000 prescriptions for controlled substances, mostly stimulants, were written between 2020 and 2022.

APSARD felt it was time to act, said Dr. Goodman.

“We could not allow entrepreneurs who felt there was a business opportunity here to, under the auspices of advocating for mental health, increase the distribution of potentially addictive medications in the community,” he said
 

Ensuring Psychiatrist Buy-In

Development of the APSARD guidelines is led by Thomas Spencer, MD, a retired associate professor of psychiatry at Harvard Medical School, and Frances Rudnick Levin, MD, the Kennedy-Leavy Professor of Psychiatry at Columbia University, both of whom have decades of experience and clinical work in adults with ADHD.

Dr. Goodman is joined on the executive committee by Lenard Adler, MD (NYU Grossman School of Medicine), and Stephen Faraone, PhD (SUNY Upstate Medical University), along with 30 others who have expertise in psychiatry, psychology, primary care, and other health professions.

To participate in the development of the guidelines, experts had to agree to disengage from any potential conflicts and devote themselves — unpaid — to the process, said Dr. Goodman. The goal is to head off any charges of conflicts or biases, he said.

Three subcommittees — diagnosis and assessment, medical treatment, and nonmedical treatment — will review the literature, grade the evidence base, and use the Delphi consensus method to write the draft guidelines.

The draft will go out to the public and to medical specialties for comment, which will be considered for inclusion in the final publication, said Dr. Goodman.

The guidelines panel has been working closely with the APA and following the APA guideline development process in an effort to get buy-in from psychiatrists, he said.
 

Critical Educational Tool

“Doctors are often surprised to hear that there are no guidelines for adult ADHD in the US,” said Ann Childress, MD, APSARD president, when the group announced its effort in 2023. “Whether diagnosis and treatment are provided in office or online, the standard of care should be the same throughout the country,” she said.

Guidelines will “reduce mythology and error or at least when we run into mythology and error we can say no, there’s a giant consensus with hundreds of experts that disagree with that and so if you want to counter that you better bring some heavy machinery, you can’t just throw out an opinion and leave it unsupported,” said Dr. Mason.

Dr. Sibley said that, although there are no good data, anecdotally it appears many clinicians rely on the Diagnostic and Statistical Manual of Mental Disorders (DSM) when treating adults with ADHD.

The DSM “tells people what they should do but it doesn’t exactly tell them what’s the best way to do it,” she said, adding that often physicians follow what they learned from whoever they were trained by.

“Some people have been trained by people who are well versed in best practices and so they might be doing things that we would say have a research support to them, and other people might be doing things based on people who developed their own opinions about the best way to diagnose ADHD based on lived experience which may or may not be best practices,” Dr. Sibley said.

Her subcommittee aims to offer guidance on screening “that will be helpful in primary care, in terms of what are the most efficient ways to do it” and to help with accuracy, she said. Currently, there are likely some clinicians who are making too liberal a diagnosis and others who are making too conservative a diagnosis, she said.

With so many clinicians — especially in primary care — having a lack of experience, the guidelines could increase “the ability for more different kinds of providers to help,” said Dr. Kulikosky.

Guidelines should also provide a template for ongoing education, especially for clinicians who have never received any training in ADHD.

Dr. Goodman said it is increasingly likely that primary care physicians will be writing more prescriptions for ADHD medications than psychiatrists. “If that is the trajectory, the education of those providers seeing these patients is critical,” he said.
 

Offering Standards, Dispelling Myths

Guidelines can also help “shorten the learning curve,” said Dr. Mason, who said that he’s had to piece together evidence over the last few decades. Once published, the standards can be used in residency, for board exams, and continuing medical education, he said.

Not only do they offer a “kind of a shortcut to what we all know and agree on,” they also specify where the edges of knowledge are, he said.

Guidelines can also dissuade clinicians from practices that have no evidence to support them, such as “medication holidays,” said Dr. Mason. That has been employed to give children, especially, a break from side effects, but studies have shown that it actually increases side effects, he said.

Dr. Goodman and Dr. Sibley expect the guidelines to help with the challenge of diagnosis. Approximately 38% of adults with ADHD have a mood disorder and 48% have anxiety, said Dr. Goodman. Many others have coexisting posttraumatic stress disorder, substance use disorders, or medical illnesses that compound cognitive problems.

If an individual has several psychiatric conditions, “the question is how do you diagnostically prioritize which you treat first, second, and third, with the goal of treating one without making the others worse,” said Dr. Goodman.

“ADHD takes more detective work than other disorders,” said Dr. Sibley, adding that without an objective diagnostic and with overlaps with other comorbid disorders, “there are very complex issues that all of us wrestle with.”

While the guidelines will not provide algorithms, they will provide information that “will help guide them in the tougher diagnostic context,” she said.

Dr. Mason agreed. “It’s a complicated disorder to diagnose and treat. It’s hard for somebody to jump into it. [The guidelines] are going to give us — here’s what you really have to know, here’s what you have to do,” he said.

And it won’t just be clinicians who look to the guidelines. Calls to National Resource Center on ADHD — which CHADD runs for the federal government — from adults wanting to know more about their own condition “have increased exponentially” in the last few years, said Dr. Kulikosky. “We know adults are seeking out information, they are seeking out diagnosis and treatment,” she said.

Dr. Goodman and Dr. Sibley reported no relevant financial relationships. Dr. Mason reported that he consults for Otsuka and is a speaker for Iron Shore.

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

The first US clinical guidelines to diagnose and treat attention-deficit/hyperactivity disorder (ADHD) in adults are expected to be released this fall, providing patients, clinicians, insurers, and policymakers with a long overdue and much-needed standardized framework.

The initiative comes under the auspices of the American Professional Society of ADHD and Related Disorders (APSARD). David Goodman, MD, a member of the APSARD guidelines executive committee and assistant professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine in Baltimore, Maryland, noted that the US lags behind several other nations, including Canada, the United Kingdom, Australia, and New Zealand who already have guidelines in place.

Dr. Goodman would not go into any detail as to why the country has been so slow off the mark but told this news organization that in part it has been due to a lack of specific funding. In addition, he said, “adult psychiatry abdicated responsibility for ADHD in adults.”

The American Psychiatric Association (APA) would not comment, although a spokesperson said two of its members are working with APSARD on the guidelines.

Estimates show that there are 10-11 million American adults (4.4%) with ADHD, making it the second most common psychiatric disorder in adults.

Surveys show that mental health professionals, including psychiatrists, report a lack of familiarity with ADHD in adults, said Margaret Sibley, PhD, professor of psychiatry and behavioral sciences at the University of Washington School of Medicine in Seattle and chair of the APSARD guidelines diagnostic and screening committee.

Many don’t consider an ADHD diagnosis in adults “because they were always trained to conceptualize it as something that’s relevant only in childhood,” Dr. Sibley told this new organization. However, research shows that people with ADHD do not outgrow the disorder.

“ADHD itself is still present and has unique problems associated with it in adults,” Dr. Sibley said.
 

Filling the Leadership Gap

Laurie Kulikosky, CEO of the advocacy group CHADD, said that the organization views the development of guidelines “as a huge step forward in the ability for more people to understand ADHD, particularly on the adult side.”

Oren Mason, MD, a primary care physician who specializes in ADHD at his Grand Rapids, Michigan-based practice, said “there hasn’t been a single specialty that has taken lead responsibility in adult ADHD,” which has contributed to the lag in guideline development.

In addition, Dr. Mason said, “trying to come up with adult guidelines even 5 or 10 years ago wouldn’t have yielded nearly as robust a set of guidelines because it’s taken awhile to have the evidence base to be able to make a few pronouncements really confidently.”

Not only has the evidence base grown but so has telehealth, especially during the height of the COVID-19 pandemic. That led to concerns that ADHD was not rigorously evaluated and that stimulants were prescribed too easily, said Dr. Goodman.

Several telehealth providers came under federal scrutiny, with the DEA accusing Cerebral’s pharmacy of dispensing stimulants for nonmedical reasons. The agency said that some 72,000 prescriptions for controlled substances, mostly stimulants, were written between 2020 and 2022.

APSARD felt it was time to act, said Dr. Goodman.

“We could not allow entrepreneurs who felt there was a business opportunity here to, under the auspices of advocating for mental health, increase the distribution of potentially addictive medications in the community,” he said
 

Ensuring Psychiatrist Buy-In

Development of the APSARD guidelines is led by Thomas Spencer, MD, a retired associate professor of psychiatry at Harvard Medical School, and Frances Rudnick Levin, MD, the Kennedy-Leavy Professor of Psychiatry at Columbia University, both of whom have decades of experience and clinical work in adults with ADHD.

Dr. Goodman is joined on the executive committee by Lenard Adler, MD (NYU Grossman School of Medicine), and Stephen Faraone, PhD (SUNY Upstate Medical University), along with 30 others who have expertise in psychiatry, psychology, primary care, and other health professions.

To participate in the development of the guidelines, experts had to agree to disengage from any potential conflicts and devote themselves — unpaid — to the process, said Dr. Goodman. The goal is to head off any charges of conflicts or biases, he said.

Three subcommittees — diagnosis and assessment, medical treatment, and nonmedical treatment — will review the literature, grade the evidence base, and use the Delphi consensus method to write the draft guidelines.

The draft will go out to the public and to medical specialties for comment, which will be considered for inclusion in the final publication, said Dr. Goodman.

The guidelines panel has been working closely with the APA and following the APA guideline development process in an effort to get buy-in from psychiatrists, he said.
 

Critical Educational Tool

“Doctors are often surprised to hear that there are no guidelines for adult ADHD in the US,” said Ann Childress, MD, APSARD president, when the group announced its effort in 2023. “Whether diagnosis and treatment are provided in office or online, the standard of care should be the same throughout the country,” she said.

Guidelines will “reduce mythology and error or at least when we run into mythology and error we can say no, there’s a giant consensus with hundreds of experts that disagree with that and so if you want to counter that you better bring some heavy machinery, you can’t just throw out an opinion and leave it unsupported,” said Dr. Mason.

Dr. Sibley said that, although there are no good data, anecdotally it appears many clinicians rely on the Diagnostic and Statistical Manual of Mental Disorders (DSM) when treating adults with ADHD.

The DSM “tells people what they should do but it doesn’t exactly tell them what’s the best way to do it,” she said, adding that often physicians follow what they learned from whoever they were trained by.

“Some people have been trained by people who are well versed in best practices and so they might be doing things that we would say have a research support to them, and other people might be doing things based on people who developed their own opinions about the best way to diagnose ADHD based on lived experience which may or may not be best practices,” Dr. Sibley said.

Her subcommittee aims to offer guidance on screening “that will be helpful in primary care, in terms of what are the most efficient ways to do it” and to help with accuracy, she said. Currently, there are likely some clinicians who are making too liberal a diagnosis and others who are making too conservative a diagnosis, she said.

With so many clinicians — especially in primary care — having a lack of experience, the guidelines could increase “the ability for more different kinds of providers to help,” said Dr. Kulikosky.

Guidelines should also provide a template for ongoing education, especially for clinicians who have never received any training in ADHD.

Dr. Goodman said it is increasingly likely that primary care physicians will be writing more prescriptions for ADHD medications than psychiatrists. “If that is the trajectory, the education of those providers seeing these patients is critical,” he said.
 

Offering Standards, Dispelling Myths

Guidelines can also help “shorten the learning curve,” said Dr. Mason, who said that he’s had to piece together evidence over the last few decades. Once published, the standards can be used in residency, for board exams, and continuing medical education, he said.

Not only do they offer a “kind of a shortcut to what we all know and agree on,” they also specify where the edges of knowledge are, he said.

Guidelines can also dissuade clinicians from practices that have no evidence to support them, such as “medication holidays,” said Dr. Mason. That has been employed to give children, especially, a break from side effects, but studies have shown that it actually increases side effects, he said.

Dr. Goodman and Dr. Sibley expect the guidelines to help with the challenge of diagnosis. Approximately 38% of adults with ADHD have a mood disorder and 48% have anxiety, said Dr. Goodman. Many others have coexisting posttraumatic stress disorder, substance use disorders, or medical illnesses that compound cognitive problems.

If an individual has several psychiatric conditions, “the question is how do you diagnostically prioritize which you treat first, second, and third, with the goal of treating one without making the others worse,” said Dr. Goodman.

“ADHD takes more detective work than other disorders,” said Dr. Sibley, adding that without an objective diagnostic and with overlaps with other comorbid disorders, “there are very complex issues that all of us wrestle with.”

While the guidelines will not provide algorithms, they will provide information that “will help guide them in the tougher diagnostic context,” she said.

Dr. Mason agreed. “It’s a complicated disorder to diagnose and treat. It’s hard for somebody to jump into it. [The guidelines] are going to give us — here’s what you really have to know, here’s what you have to do,” he said.

And it won’t just be clinicians who look to the guidelines. Calls to National Resource Center on ADHD — which CHADD runs for the federal government — from adults wanting to know more about their own condition “have increased exponentially” in the last few years, said Dr. Kulikosky. “We know adults are seeking out information, they are seeking out diagnosis and treatment,” she said.

Dr. Goodman and Dr. Sibley reported no relevant financial relationships. Dr. Mason reported that he consults for Otsuka and is a speaker for Iron Shore.

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

Physicians who misuse the “copy-and-paste” feature in patients’ electronic health records (EHRs) can face serious consequences, including lost hospital privileges, fines, and malpractice lawsuits.

In California, a locum tenens physician lost her hospital privileges after repeatedly violating the copy-and-paste policy developed at Santa Rosa Memorial Hospital, Santa Rosa, California.

“Her use of copy and paste impaired continuity of care,” said Alvin Gore, MD, who was involved in the case as the hospital’s director of utilization management.

Dr. Gore said the hospital warned the doctor, but she did not change her behavior. He did not identify the physician, citing confidentiality. The case occurred more than 5 years ago. Since then, several physicians have been called onto the carpet for violations of the policy, but no one else has lost privileges, Dr. Gore said.

Copy-paste practices can save doctors’ time when dealing with cumbersome EHR systems, but they also can lead to redundant, outdated, or inconsistent information that can compromise patient care, experts said.

“EHRs are imperfect, time consuming, and somewhat rigid,” said Robert A. Dowling, MD, a practice management consultant for large medical groups. “If physicians can’t easily figure out a complex system, they’re likely to use a workaround like copy and paste.”

Copy-and-paste abuse has also led to fines. A six-member cardiology group in Somerville, New Jersey, paid a $422,000 fine to the federal government to settle copy-and-paste charges, following an investigation by the Office of the Inspector General of the Department of Health and Human Services, according to the Report on Medicare Compliance.

This big settlement, announced in 2016, is a rare case in which physicians were charged with copy-and-paste fraud — intentionally using it to enhance reimbursement.

More commonly, Medicare contractors identify physicians who unintentionally received overpayments through sloppy copy-and-paste practices, according to a coding and documentation auditor who worked for 10 years at a Medicare contractor in Pennsylvania.

Such cases are frequent and are handled confidentially, said the auditor, who asked not to be identified. Practices must return the overpayment, and the physicians involved are “contacted and educated,” she said.

Copy and paste can also show up in malpractice lawsuits. In a 2012 survey, 53% of professional liability carriers said they had handled an EHR-related malpractice claim, and 71% of those claims included copy-and-paste use.

One such case, described by CRICO, a malpractice carrier based in Massachusetts, took place in 2012-2013. “A patient developed amiodarone toxicity because the patient›s history and medications were copied from a previous note that did not document that the patient was already on the medication,» CRICO stated.

“If you do face a malpractice claim, copying and pasting the same note repeatedly makes you look clinically inattentive, even if the copy/pasted material is unrelated to the adverse event,” CRICO officials noted in a report.
 

The Push to Use Copy and Paste

Copy and paste is a great time-saver. One study linked its use to lower burnout rates. However, it can easily introduce errors into the medical record. “This can be a huge problem,” Dr. Dowling said. “If, for example, you copy forward a previous note that said the patient had blood in their urine ‘6 days ago,’ it is immediately inaccurate.”

Practices can control use of copy and paste through coding clerks who read the medical records and then educate doctors when problems crop up.

The Pennsylvania auditor, who now works for a large group practice, said the group has very few copy-and-paste problems because of her role. “Not charting responsibly rarely happens because I work very closely with the doctors,” she said.

Dr. Dowling, however, reports that many physicians continue to overuse copy and paste. He points to a 2022 study which found that, on average, half the clinical note at one health system had been copied and pasted.

One solution might be to sanction physicians for overusing copy and paste, just as they’re sometimes penalized for not completing their notes on time with a reduction in income or possible termination.

Practices could periodically audit medical records for excessive copy-paste use. EHR systems like Epic’s can indicate how much of a doctor’s note has been copied. But Dr. Dowling doesn’t know of any practices that do this.

“There is little appetite to introduce a new enforcement activity for physicians,” he said. “Physicians would see it just as a way to make their lives more difficult than they already are.”
 

Monitoring in Hospitals and Health Systems

Some hospitals and health systems have gone as far as disabling copy-and-paste function in their EHR systems. However, enterprising physicians have found ways around these blocks.

Some institutions have also introduced formal policies, directing doctors on how they can copy and paste, including Banner Health in Arizona, Northwell Health in New York, UConn Health in Connecticut, University of Maryland Medical System, and University of Toledo in Ohio.

Definitions of what is not acceptable vary, but most of these policies oppose copying someone else’s notes and direct physicians to indicate the origin of pasted material.

Santa Rosa Memorial’s policy is quite specific. It still allows some copy and paste but stipulates that it cannot be used for the chief complaint, the review of systems, the physical examination, and the assessment and plan in the medical record, except when the information can’t be obtained directly from the patient. Also, physicians must summarize test results and provide references to other providers’ notes.

Dr. Gore said he and a physician educator who works with physicians on clinical documentation proposed the policy about a decade ago. When physicians on staff were asked to comment, some said they would be opposed to a complete ban, but they generally agreed that copy and paste was a serious problem that needed to be addressed, he said.

The hospital could have simply adopted guidelines, as opposed to rules with consequences, but “we wanted our policy to have teeth,” Dr. Gore said.

When violators are identified, Dr. Gore says he meets with them confidentially and educates them on proper use of copy and paste. Sometimes, the department head is brought in. Some physicians go on to violate the policy again and have to attend another meeting, he said, but aside from the one case, no one else has been disciplined.

It’s unclear how many physicians have faced consequences for misusing copy-paste features — such data aren’t tracked, and sanctions are likely to be handled confidentially, as a personnel matter.

Geisinger Health in Pennsylvania regularly monitors copy-and-paste usage and makes it part of physicians’ professional evaluations, according to a 2022 presentation by a Geisinger official.

Meanwhile, even when systems don’t have specific policies, they may still discipline physicians when copy and paste leads to errors. Scott MacDonald, MD, chief medical information officer at UC Davis Health in Sacramento, California, told this news organization that copy-and-paste abuse has come up a few times over the years in investigations of clinical errors.
 

Holding Physicians Accountable

Physicians can be held accountable for copy and paste by Medicare contractors and in malpractice lawsuits, but the most obvious way is at their place of work: A practice, hospital, or health system.

One physician has lost staff privileges, but more typically, coding clerks or colleagues talk to offending physicians and try to educate them on proper use of copy and paste.

Educational outreach, however, is often ineffective, said Robert Hirschtick, MD, a retired teaching physician at Northwestern University Feinberg School of Medicine, Chicago, Illinois. “The physician may be directed to take an online course,” he said. “When they take the course, the goal is to get it done with, rather than to learn something new.”

Dr. Hirschtick’s articles on copy and paste, including one titled, “Sloppy and Paste,” have put him at the front lines of the debate. “This is an ethical issue,” he said in an interview. He agrees that some forms of copy and paste are permissible, but in many cases, “it is intellectually dishonest and potentially even plagiarism,” he said.

Dr. Hirschtick argues that copy-and-paste policies need more teeth. “Tying violations to compensation would be quite effective,” he said. “Even if physicians were rarely penalized, just knowing that it could happen to you might be enough. But I haven’t heard of anyone doing this.”

A version of this article appeared on Medscape.com.

Physicians who misuse the “copy-and-paste” feature in patients’ electronic health records (EHRs) can face serious consequences, including lost hospital privileges, fines, and malpractice lawsuits.

In California, a locum tenens physician lost her hospital privileges after repeatedly violating the copy-and-paste policy developed at Santa Rosa Memorial Hospital, Santa Rosa, California.

“Her use of copy and paste impaired continuity of care,” said Alvin Gore, MD, who was involved in the case as the hospital’s director of utilization management.

Dr. Gore said the hospital warned the doctor, but she did not change her behavior. He did not identify the physician, citing confidentiality. The case occurred more than 5 years ago. Since then, several physicians have been called onto the carpet for violations of the policy, but no one else has lost privileges, Dr. Gore said.

Copy-paste practices can save doctors’ time when dealing with cumbersome EHR systems, but they also can lead to redundant, outdated, or inconsistent information that can compromise patient care, experts said.

“EHRs are imperfect, time consuming, and somewhat rigid,” said Robert A. Dowling, MD, a practice management consultant for large medical groups. “If physicians can’t easily figure out a complex system, they’re likely to use a workaround like copy and paste.”

Copy-and-paste abuse has also led to fines. A six-member cardiology group in Somerville, New Jersey, paid a $422,000 fine to the federal government to settle copy-and-paste charges, following an investigation by the Office of the Inspector General of the Department of Health and Human Services, according to the Report on Medicare Compliance.

This big settlement, announced in 2016, is a rare case in which physicians were charged with copy-and-paste fraud — intentionally using it to enhance reimbursement.

More commonly, Medicare contractors identify physicians who unintentionally received overpayments through sloppy copy-and-paste practices, according to a coding and documentation auditor who worked for 10 years at a Medicare contractor in Pennsylvania.

Such cases are frequent and are handled confidentially, said the auditor, who asked not to be identified. Practices must return the overpayment, and the physicians involved are “contacted and educated,” she said.

Copy and paste can also show up in malpractice lawsuits. In a 2012 survey, 53% of professional liability carriers said they had handled an EHR-related malpractice claim, and 71% of those claims included copy-and-paste use.

One such case, described by CRICO, a malpractice carrier based in Massachusetts, took place in 2012-2013. “A patient developed amiodarone toxicity because the patient›s history and medications were copied from a previous note that did not document that the patient was already on the medication,» CRICO stated.

“If you do face a malpractice claim, copying and pasting the same note repeatedly makes you look clinically inattentive, even if the copy/pasted material is unrelated to the adverse event,” CRICO officials noted in a report.
 

The Push to Use Copy and Paste

Copy and paste is a great time-saver. One study linked its use to lower burnout rates. However, it can easily introduce errors into the medical record. “This can be a huge problem,” Dr. Dowling said. “If, for example, you copy forward a previous note that said the patient had blood in their urine ‘6 days ago,’ it is immediately inaccurate.”

Practices can control use of copy and paste through coding clerks who read the medical records and then educate doctors when problems crop up.

The Pennsylvania auditor, who now works for a large group practice, said the group has very few copy-and-paste problems because of her role. “Not charting responsibly rarely happens because I work very closely with the doctors,” she said.

Dr. Dowling, however, reports that many physicians continue to overuse copy and paste. He points to a 2022 study which found that, on average, half the clinical note at one health system had been copied and pasted.

One solution might be to sanction physicians for overusing copy and paste, just as they’re sometimes penalized for not completing their notes on time with a reduction in income or possible termination.

Practices could periodically audit medical records for excessive copy-paste use. EHR systems like Epic’s can indicate how much of a doctor’s note has been copied. But Dr. Dowling doesn’t know of any practices that do this.

“There is little appetite to introduce a new enforcement activity for physicians,” he said. “Physicians would see it just as a way to make their lives more difficult than they already are.”
 

Monitoring in Hospitals and Health Systems

Some hospitals and health systems have gone as far as disabling copy-and-paste function in their EHR systems. However, enterprising physicians have found ways around these blocks.

Some institutions have also introduced formal policies, directing doctors on how they can copy and paste, including Banner Health in Arizona, Northwell Health in New York, UConn Health in Connecticut, University of Maryland Medical System, and University of Toledo in Ohio.

Definitions of what is not acceptable vary, but most of these policies oppose copying someone else’s notes and direct physicians to indicate the origin of pasted material.

Santa Rosa Memorial’s policy is quite specific. It still allows some copy and paste but stipulates that it cannot be used for the chief complaint, the review of systems, the physical examination, and the assessment and plan in the medical record, except when the information can’t be obtained directly from the patient. Also, physicians must summarize test results and provide references to other providers’ notes.

Dr. Gore said he and a physician educator who works with physicians on clinical documentation proposed the policy about a decade ago. When physicians on staff were asked to comment, some said they would be opposed to a complete ban, but they generally agreed that copy and paste was a serious problem that needed to be addressed, he said.

The hospital could have simply adopted guidelines, as opposed to rules with consequences, but “we wanted our policy to have teeth,” Dr. Gore said.

When violators are identified, Dr. Gore says he meets with them confidentially and educates them on proper use of copy and paste. Sometimes, the department head is brought in. Some physicians go on to violate the policy again and have to attend another meeting, he said, but aside from the one case, no one else has been disciplined.

It’s unclear how many physicians have faced consequences for misusing copy-paste features — such data aren’t tracked, and sanctions are likely to be handled confidentially, as a personnel matter.

Geisinger Health in Pennsylvania regularly monitors copy-and-paste usage and makes it part of physicians’ professional evaluations, according to a 2022 presentation by a Geisinger official.

Meanwhile, even when systems don’t have specific policies, they may still discipline physicians when copy and paste leads to errors. Scott MacDonald, MD, chief medical information officer at UC Davis Health in Sacramento, California, told this news organization that copy-and-paste abuse has come up a few times over the years in investigations of clinical errors.
 

Holding Physicians Accountable

Physicians can be held accountable for copy and paste by Medicare contractors and in malpractice lawsuits, but the most obvious way is at their place of work: A practice, hospital, or health system.

One physician has lost staff privileges, but more typically, coding clerks or colleagues talk to offending physicians and try to educate them on proper use of copy and paste.

Educational outreach, however, is often ineffective, said Robert Hirschtick, MD, a retired teaching physician at Northwestern University Feinberg School of Medicine, Chicago, Illinois. “The physician may be directed to take an online course,” he said. “When they take the course, the goal is to get it done with, rather than to learn something new.”

Dr. Hirschtick’s articles on copy and paste, including one titled, “Sloppy and Paste,” have put him at the front lines of the debate. “This is an ethical issue,” he said in an interview. He agrees that some forms of copy and paste are permissible, but in many cases, “it is intellectually dishonest and potentially even plagiarism,” he said.

Dr. Hirschtick argues that copy-and-paste policies need more teeth. “Tying violations to compensation would be quite effective,” he said. “Even if physicians were rarely penalized, just knowing that it could happen to you might be enough. But I haven’t heard of anyone doing this.”

A version of this article appeared on Medscape.com.

Physicians who misuse the “copy-and-paste” feature in patients’ electronic health records (EHRs) can face serious consequences, including lost hospital privileges, fines, and malpractice lawsuits.

In California, a locum tenens physician lost her hospital privileges after repeatedly violating the copy-and-paste policy developed at Santa Rosa Memorial Hospital, Santa Rosa, California.

“Her use of copy and paste impaired continuity of care,” said Alvin Gore, MD, who was involved in the case as the hospital’s director of utilization management.

Dr. Gore said the hospital warned the doctor, but she did not change her behavior. He did not identify the physician, citing confidentiality. The case occurred more than 5 years ago. Since then, several physicians have been called onto the carpet for violations of the policy, but no one else has lost privileges, Dr. Gore said.

Copy-paste practices can save doctors’ time when dealing with cumbersome EHR systems, but they also can lead to redundant, outdated, or inconsistent information that can compromise patient care, experts said.

“EHRs are imperfect, time consuming, and somewhat rigid,” said Robert A. Dowling, MD, a practice management consultant for large medical groups. “If physicians can’t easily figure out a complex system, they’re likely to use a workaround like copy and paste.”

Copy-and-paste abuse has also led to fines. A six-member cardiology group in Somerville, New Jersey, paid a $422,000 fine to the federal government to settle copy-and-paste charges, following an investigation by the Office of the Inspector General of the Department of Health and Human Services, according to the Report on Medicare Compliance.

This big settlement, announced in 2016, is a rare case in which physicians were charged with copy-and-paste fraud — intentionally using it to enhance reimbursement.

More commonly, Medicare contractors identify physicians who unintentionally received overpayments through sloppy copy-and-paste practices, according to a coding and documentation auditor who worked for 10 years at a Medicare contractor in Pennsylvania.

Such cases are frequent and are handled confidentially, said the auditor, who asked not to be identified. Practices must return the overpayment, and the physicians involved are “contacted and educated,” she said.

Copy and paste can also show up in malpractice lawsuits. In a 2012 survey, 53% of professional liability carriers said they had handled an EHR-related malpractice claim, and 71% of those claims included copy-and-paste use.

One such case, described by CRICO, a malpractice carrier based in Massachusetts, took place in 2012-2013. “A patient developed amiodarone toxicity because the patient›s history and medications were copied from a previous note that did not document that the patient was already on the medication,» CRICO stated.

“If you do face a malpractice claim, copying and pasting the same note repeatedly makes you look clinically inattentive, even if the copy/pasted material is unrelated to the adverse event,” CRICO officials noted in a report.
 

The Push to Use Copy and Paste

Copy and paste is a great time-saver. One study linked its use to lower burnout rates. However, it can easily introduce errors into the medical record. “This can be a huge problem,” Dr. Dowling said. “If, for example, you copy forward a previous note that said the patient had blood in their urine ‘6 days ago,’ it is immediately inaccurate.”

Practices can control use of copy and paste through coding clerks who read the medical records and then educate doctors when problems crop up.

The Pennsylvania auditor, who now works for a large group practice, said the group has very few copy-and-paste problems because of her role. “Not charting responsibly rarely happens because I work very closely with the doctors,” she said.

Dr. Dowling, however, reports that many physicians continue to overuse copy and paste. He points to a 2022 study which found that, on average, half the clinical note at one health system had been copied and pasted.

One solution might be to sanction physicians for overusing copy and paste, just as they’re sometimes penalized for not completing their notes on time with a reduction in income or possible termination.

Practices could periodically audit medical records for excessive copy-paste use. EHR systems like Epic’s can indicate how much of a doctor’s note has been copied. But Dr. Dowling doesn’t know of any practices that do this.

“There is little appetite to introduce a new enforcement activity for physicians,” he said. “Physicians would see it just as a way to make their lives more difficult than they already are.”
 

Monitoring in Hospitals and Health Systems

Some hospitals and health systems have gone as far as disabling copy-and-paste function in their EHR systems. However, enterprising physicians have found ways around these blocks.

Some institutions have also introduced formal policies, directing doctors on how they can copy and paste, including Banner Health in Arizona, Northwell Health in New York, UConn Health in Connecticut, University of Maryland Medical System, and University of Toledo in Ohio.

Definitions of what is not acceptable vary, but most of these policies oppose copying someone else’s notes and direct physicians to indicate the origin of pasted material.

Santa Rosa Memorial’s policy is quite specific. It still allows some copy and paste but stipulates that it cannot be used for the chief complaint, the review of systems, the physical examination, and the assessment and plan in the medical record, except when the information can’t be obtained directly from the patient. Also, physicians must summarize test results and provide references to other providers’ notes.

Dr. Gore said he and a physician educator who works with physicians on clinical documentation proposed the policy about a decade ago. When physicians on staff were asked to comment, some said they would be opposed to a complete ban, but they generally agreed that copy and paste was a serious problem that needed to be addressed, he said.

The hospital could have simply adopted guidelines, as opposed to rules with consequences, but “we wanted our policy to have teeth,” Dr. Gore said.

When violators are identified, Dr. Gore says he meets with them confidentially and educates them on proper use of copy and paste. Sometimes, the department head is brought in. Some physicians go on to violate the policy again and have to attend another meeting, he said, but aside from the one case, no one else has been disciplined.

It’s unclear how many physicians have faced consequences for misusing copy-paste features — such data aren’t tracked, and sanctions are likely to be handled confidentially, as a personnel matter.

Geisinger Health in Pennsylvania regularly monitors copy-and-paste usage and makes it part of physicians’ professional evaluations, according to a 2022 presentation by a Geisinger official.

Meanwhile, even when systems don’t have specific policies, they may still discipline physicians when copy and paste leads to errors. Scott MacDonald, MD, chief medical information officer at UC Davis Health in Sacramento, California, told this news organization that copy-and-paste abuse has come up a few times over the years in investigations of clinical errors.
 

Holding Physicians Accountable

Physicians can be held accountable for copy and paste by Medicare contractors and in malpractice lawsuits, but the most obvious way is at their place of work: A practice, hospital, or health system.

One physician has lost staff privileges, but more typically, coding clerks or colleagues talk to offending physicians and try to educate them on proper use of copy and paste.

Educational outreach, however, is often ineffective, said Robert Hirschtick, MD, a retired teaching physician at Northwestern University Feinberg School of Medicine, Chicago, Illinois. “The physician may be directed to take an online course,” he said. “When they take the course, the goal is to get it done with, rather than to learn something new.”

Dr. Hirschtick’s articles on copy and paste, including one titled, “Sloppy and Paste,” have put him at the front lines of the debate. “This is an ethical issue,” he said in an interview. He agrees that some forms of copy and paste are permissible, but in many cases, “it is intellectually dishonest and potentially even plagiarism,” he said.

Dr. Hirschtick argues that copy-and-paste policies need more teeth. “Tying violations to compensation would be quite effective,” he said. “Even if physicians were rarely penalized, just knowing that it could happen to you might be enough. But I haven’t heard of anyone doing this.”

A version of this article appeared on Medscape.com.

Delirium is tied to a significantly increased risk for dementia and death in older adults, with men at particular risk, new research showed.

Incident dementia risk was more than three times higher in those who experienced just one episode of delirium, with each additional episode linked to a further 20% increase in dementia risk. The association was strongest in men.

Patients with delirium also had a 39% higher mortality risk than those with no history of delirium.

“We have known for a long time that delirium is dangerous, and this provides evidence that it’s even more dangerous than perhaps we had appreciated,” said study investigator Emily H. Gordon, PhD, MBBS, a geriatrician and senior lecturer at the University of Queensland, Brisbane, Australia.

“But we also know delirium is preventable. There are no excuses anymore; we really need to work together to improve the hospital system, to implement what are known to be effective interventions,” she added.

The findings were published online in The BMJ.
 

Close Matching

Prior studies that suggested an association between delirium and dementia were relatively small with short follow-up and varied in their adjustment for confounders. They also didn’t account for the competing risk for death, researchers noted.

Investigators used a linked New South Wales (NSW) statewide dataset that includes records of care episodes from all NSW hospitals as well as personal, administrative, clinical, and death information.

The study included an eligible sample of 626,467 older adults without dementia at baseline with at least one hospital admission between 2009 and 2014. For these patients, researchers calculated a hospital frailty risk score and collected other information including primary diagnosis and mean length of hospital stay and stay in the intensive care unit. From diagnostic codes, they categorized patients into no delirium and delirium groups and determined the number of delirium episodes.

Investigators matched patients in the delirium group to patients with no delirium according to characteristics with potential to confound the association between delirium and risk for dementia, including age, gender, frailty, reason for hospitalization, and length of stay in hospital and intensive care.

The matched study sample included 55,211 (mean age, 83 years) each in the delirium and the no delirium groups. Despite matching, the length of hospital stay for the index episode was longer for the delirium group than the no delirium group (mean, 9 days vs 6 days).

The primary outcomes were death and incident dementia, determined via diagnostic codes. During a follow-up of 5.25 years, 58% of patients died, and 17% had a new dementia diagnosis.

Among patients with at least one episode of delirium, the rate of incident dementia was 3.4 times higher than in those without delirium. After accounting for the competing risk for death, incident dementia risk remained three times higher among the delirium group (hazard ratio [HR], 3.00; 95% CI, 2.91-3.10).

This association was stronger for men than women (HR, 3.17 and 2.88, respectively; P = .004).
 

Sex Differences

The study is thought to be the first to identify a difference between sexes in dementia risk and delirium, Dr. Gordon said. It’s possible delirium in men is more severe in intensity or lasts longer than in women, or the male brain is, for whatever reason, more vulnerable to the effects of delirium, said Dr. Gordon. But she stressed these are only theories.

Investigators also found a mortality rate 1.4 times higher in the delirium group versus those without delirium, equating to a 39% increased risk for death (HR, 1.39; 95% CI, 1.37-1.41). The risk was similar for men and women (interaction P = .62).

When researchers categorized delirium by number of episodes, they found each additional episode was associated with a 10% increased risk for death (HR, 1.10; 95% CI, 1.09-1.12).

In addition to its large size, long follow-up, and close matching, what sets this new study apart from previous research is it accounted for the competing risk for death, said Dr. Gordon.

“This is really important because you’re not going to get dementia if you die, and in this population, the rate of death is incredibly high,” she said. “If we just assume people who died didn’t get dementia, then that screws the results.”
 

Causal Link?

For those who experienced at least one episode of delirium within the first 12 months, each additional episode of delirium was associated with a 20% increased risk for dementia (HR, 1.20; 95% CI, 1.18-1.23).

That dose-response association suggests a causal link between the two, Dr. Gordon said.

“The number one way to prove causality is to do a randomized controlled trial,” which isn’t feasible with delirium, she said. “By demonstrating a dose-response relationship suggests that it could be a causal pathway.”

Exact mechanisms linking delirium with dementia are unclear. Delirium might uncover preexisting or preclinical dementia, or it might cause dementia by accelerating underlying neuropathologic processes or de novo mechanisms, the authors noted.

Study limitations included the potential for residual confounding from unmeasured variables in the matching criteria. Delirium and dementia diagnoses depended on clinical coding of medical information recorded in the administrative dataset, and under-coding of dementia during hospitalization is well-recognized.

Although the study controlled for length of stay in hospital and in intensive care, this may not have fully captured differences in severity of medical conditions. Data about the duration and severity of delirium episodes were also unavailable, which limited the dose-response analysis.

Commenting on the findings, Christopher Weber, PhD, Alzheimer’s Association as director of Global Science Initiatives, said the results are consistent with other research on the association between delirium and incidents of dementia.

The increased risk for dementia following delirium in males is “an interesting finding,” said Dr. Weber. “This suggests a need for more research to understand the impact of sex differences in delirium, as well as research to see if preventing incidents of delirium could ultimately reduce rates of dementia.”

The study received support from the National Health and Medical Research Council: Partnership Centre for Health System Sustainability. Dr. Gordon and Dr. Weber reported no relevant conflicts of interest.

A version of this article appeared on Medscape.com.

Delirium is tied to a significantly increased risk for dementia and death in older adults, with men at particular risk, new research showed.

Incident dementia risk was more than three times higher in those who experienced just one episode of delirium, with each additional episode linked to a further 20% increase in dementia risk. The association was strongest in men.

Patients with delirium also had a 39% higher mortality risk than those with no history of delirium.

“We have known for a long time that delirium is dangerous, and this provides evidence that it’s even more dangerous than perhaps we had appreciated,” said study investigator Emily H. Gordon, PhD, MBBS, a geriatrician and senior lecturer at the University of Queensland, Brisbane, Australia.

“But we also know delirium is preventable. There are no excuses anymore; we really need to work together to improve the hospital system, to implement what are known to be effective interventions,” she added.

The findings were published online in The BMJ.
 

Close Matching

Prior studies that suggested an association between delirium and dementia were relatively small with short follow-up and varied in their adjustment for confounders. They also didn’t account for the competing risk for death, researchers noted.

Investigators used a linked New South Wales (NSW) statewide dataset that includes records of care episodes from all NSW hospitals as well as personal, administrative, clinical, and death information.

The study included an eligible sample of 626,467 older adults without dementia at baseline with at least one hospital admission between 2009 and 2014. For these patients, researchers calculated a hospital frailty risk score and collected other information including primary diagnosis and mean length of hospital stay and stay in the intensive care unit. From diagnostic codes, they categorized patients into no delirium and delirium groups and determined the number of delirium episodes.

Investigators matched patients in the delirium group to patients with no delirium according to characteristics with potential to confound the association between delirium and risk for dementia, including age, gender, frailty, reason for hospitalization, and length of stay in hospital and intensive care.

The matched study sample included 55,211 (mean age, 83 years) each in the delirium and the no delirium groups. Despite matching, the length of hospital stay for the index episode was longer for the delirium group than the no delirium group (mean, 9 days vs 6 days).

The primary outcomes were death and incident dementia, determined via diagnostic codes. During a follow-up of 5.25 years, 58% of patients died, and 17% had a new dementia diagnosis.

Among patients with at least one episode of delirium, the rate of incident dementia was 3.4 times higher than in those without delirium. After accounting for the competing risk for death, incident dementia risk remained three times higher among the delirium group (hazard ratio [HR], 3.00; 95% CI, 2.91-3.10).

This association was stronger for men than women (HR, 3.17 and 2.88, respectively; P = .004).
 

Sex Differences

The study is thought to be the first to identify a difference between sexes in dementia risk and delirium, Dr. Gordon said. It’s possible delirium in men is more severe in intensity or lasts longer than in women, or the male brain is, for whatever reason, more vulnerable to the effects of delirium, said Dr. Gordon. But she stressed these are only theories.

Investigators also found a mortality rate 1.4 times higher in the delirium group versus those without delirium, equating to a 39% increased risk for death (HR, 1.39; 95% CI, 1.37-1.41). The risk was similar for men and women (interaction P = .62).

When researchers categorized delirium by number of episodes, they found each additional episode was associated with a 10% increased risk for death (HR, 1.10; 95% CI, 1.09-1.12).

In addition to its large size, long follow-up, and close matching, what sets this new study apart from previous research is it accounted for the competing risk for death, said Dr. Gordon.

“This is really important because you’re not going to get dementia if you die, and in this population, the rate of death is incredibly high,” she said. “If we just assume people who died didn’t get dementia, then that screws the results.”
 

Causal Link?

For those who experienced at least one episode of delirium within the first 12 months, each additional episode of delirium was associated with a 20% increased risk for dementia (HR, 1.20; 95% CI, 1.18-1.23).

That dose-response association suggests a causal link between the two, Dr. Gordon said.

“The number one way to prove causality is to do a randomized controlled trial,” which isn’t feasible with delirium, she said. “By demonstrating a dose-response relationship suggests that it could be a causal pathway.”

Exact mechanisms linking delirium with dementia are unclear. Delirium might uncover preexisting or preclinical dementia, or it might cause dementia by accelerating underlying neuropathologic processes or de novo mechanisms, the authors noted.

Study limitations included the potential for residual confounding from unmeasured variables in the matching criteria. Delirium and dementia diagnoses depended on clinical coding of medical information recorded in the administrative dataset, and under-coding of dementia during hospitalization is well-recognized.

Although the study controlled for length of stay in hospital and in intensive care, this may not have fully captured differences in severity of medical conditions. Data about the duration and severity of delirium episodes were also unavailable, which limited the dose-response analysis.

Commenting on the findings, Christopher Weber, PhD, Alzheimer’s Association as director of Global Science Initiatives, said the results are consistent with other research on the association between delirium and incidents of dementia.

The increased risk for dementia following delirium in males is “an interesting finding,” said Dr. Weber. “This suggests a need for more research to understand the impact of sex differences in delirium, as well as research to see if preventing incidents of delirium could ultimately reduce rates of dementia.”

The study received support from the National Health and Medical Research Council: Partnership Centre for Health System Sustainability. Dr. Gordon and Dr. Weber reported no relevant conflicts of interest.

A version of this article appeared on Medscape.com.

Delirium is tied to a significantly increased risk for dementia and death in older adults, with men at particular risk, new research showed.

Incident dementia risk was more than three times higher in those who experienced just one episode of delirium, with each additional episode linked to a further 20% increase in dementia risk. The association was strongest in men.

Patients with delirium also had a 39% higher mortality risk than those with no history of delirium.

“We have known for a long time that delirium is dangerous, and this provides evidence that it’s even more dangerous than perhaps we had appreciated,” said study investigator Emily H. Gordon, PhD, MBBS, a geriatrician and senior lecturer at the University of Queensland, Brisbane, Australia.

“But we also know delirium is preventable. There are no excuses anymore; we really need to work together to improve the hospital system, to implement what are known to be effective interventions,” she added.

The findings were published online in The BMJ.
 

Close Matching

Prior studies that suggested an association between delirium and dementia were relatively small with short follow-up and varied in their adjustment for confounders. They also didn’t account for the competing risk for death, researchers noted.

Investigators used a linked New South Wales (NSW) statewide dataset that includes records of care episodes from all NSW hospitals as well as personal, administrative, clinical, and death information.

The study included an eligible sample of 626,467 older adults without dementia at baseline with at least one hospital admission between 2009 and 2014. For these patients, researchers calculated a hospital frailty risk score and collected other information including primary diagnosis and mean length of hospital stay and stay in the intensive care unit. From diagnostic codes, they categorized patients into no delirium and delirium groups and determined the number of delirium episodes.

Investigators matched patients in the delirium group to patients with no delirium according to characteristics with potential to confound the association between delirium and risk for dementia, including age, gender, frailty, reason for hospitalization, and length of stay in hospital and intensive care.

The matched study sample included 55,211 (mean age, 83 years) each in the delirium and the no delirium groups. Despite matching, the length of hospital stay for the index episode was longer for the delirium group than the no delirium group (mean, 9 days vs 6 days).

The primary outcomes were death and incident dementia, determined via diagnostic codes. During a follow-up of 5.25 years, 58% of patients died, and 17% had a new dementia diagnosis.

Among patients with at least one episode of delirium, the rate of incident dementia was 3.4 times higher than in those without delirium. After accounting for the competing risk for death, incident dementia risk remained three times higher among the delirium group (hazard ratio [HR], 3.00; 95% CI, 2.91-3.10).

This association was stronger for men than women (HR, 3.17 and 2.88, respectively; P = .004).
 

Sex Differences

The study is thought to be the first to identify a difference between sexes in dementia risk and delirium, Dr. Gordon said. It’s possible delirium in men is more severe in intensity or lasts longer than in women, or the male brain is, for whatever reason, more vulnerable to the effects of delirium, said Dr. Gordon. But she stressed these are only theories.

Investigators also found a mortality rate 1.4 times higher in the delirium group versus those without delirium, equating to a 39% increased risk for death (HR, 1.39; 95% CI, 1.37-1.41). The risk was similar for men and women (interaction P = .62).

When researchers categorized delirium by number of episodes, they found each additional episode was associated with a 10% increased risk for death (HR, 1.10; 95% CI, 1.09-1.12).

In addition to its large size, long follow-up, and close matching, what sets this new study apart from previous research is it accounted for the competing risk for death, said Dr. Gordon.

“This is really important because you’re not going to get dementia if you die, and in this population, the rate of death is incredibly high,” she said. “If we just assume people who died didn’t get dementia, then that screws the results.”
 

Causal Link?

For those who experienced at least one episode of delirium within the first 12 months, each additional episode of delirium was associated with a 20% increased risk for dementia (HR, 1.20; 95% CI, 1.18-1.23).

That dose-response association suggests a causal link between the two, Dr. Gordon said.

“The number one way to prove causality is to do a randomized controlled trial,” which isn’t feasible with delirium, she said. “By demonstrating a dose-response relationship suggests that it could be a causal pathway.”

Exact mechanisms linking delirium with dementia are unclear. Delirium might uncover preexisting or preclinical dementia, or it might cause dementia by accelerating underlying neuropathologic processes or de novo mechanisms, the authors noted.

Study limitations included the potential for residual confounding from unmeasured variables in the matching criteria. Delirium and dementia diagnoses depended on clinical coding of medical information recorded in the administrative dataset, and under-coding of dementia during hospitalization is well-recognized.

Although the study controlled for length of stay in hospital and in intensive care, this may not have fully captured differences in severity of medical conditions. Data about the duration and severity of delirium episodes were also unavailable, which limited the dose-response analysis.

Commenting on the findings, Christopher Weber, PhD, Alzheimer’s Association as director of Global Science Initiatives, said the results are consistent with other research on the association between delirium and incidents of dementia.

The increased risk for dementia following delirium in males is “an interesting finding,” said Dr. Weber. “This suggests a need for more research to understand the impact of sex differences in delirium, as well as research to see if preventing incidents of delirium could ultimately reduce rates of dementia.”

The study received support from the National Health and Medical Research Council: Partnership Centre for Health System Sustainability. Dr. Gordon and Dr. Weber reported no relevant conflicts of interest.

A version of this article appeared on Medscape.com.

The consequences of chronic musculoskeletal pain (CMP) may extend well beyond physical discomfort, potentially leading to faster aging of the brain, new research showed.

Using structural MRI data from more than 9000 adults with knee osteoarthritis (KOA) from the UK Biobank, investigators developed a brain age model to compare an individual’s brain age with their chronological age. Those with KOA showed a much faster rate of brain aging than healthy individuals.

The acceleration in brain aging was largely driven by the hippocampus and predicted memory decline and incident dementia during follow-up. Researchers identified a gene highly expressed in glial cells as a possible genetic factor for accelerated brain aging.

“We demonstrate the accelerated brain aging and cognitive decline in chronic musculoskeletal pain, in particular knee osteoarthritis, and provide a neural marker for early detection and intervention,” said co-first author Jiao Liu, PhD candidate, Chinese Academy of Sciences, Beijing.

“We are interested to know how to slow down the aging brain in chronic musculoskeletal pain patients. Proper exercise and lifestyle may reduce the risk,” Dr. Liu said.

The study was published online in Nature Mental Health.
 

Common Condition

CMP affects more than 40% of the world’s population and has been shown to have a harmful impact on cognitive function, although the exact mechanisms remain unclear. Prior research suggests that inflammatory markers associated with brain aging are higher in patients with CMP, suggesting a link between brain aging and CMP.

To investigate further, researchers explored patterns of brain aging in healthy cohorts and cohorts with four common types of CMP — chronic knee pain, chronic back pain, chronic neck pain, and chronic hip pain.

Using their brain age model, investigators observed significantly increased brain aging, or “predicted age difference,” only in individuals with KOA (P < .001). The observation was validated in an independent dataset (P = .020), suggesting a pattern of brain aging acceleration specific to KOA.

This acceleration was primarily driven by key brain regions involved in cognitive processing, including hippocampus and orbitofrontal cortex, and was correlated with longitudinal memory decline and dementia risk.

These data also suggest that the SLC39A8 gene, which is highly expressed in glial cells, might be a key genetic factor underpinning this acceleration.

“We not only revealed the specificity of accelerated brain aging in knee osteoarthritis patients, but importantly, we also provided longitudinal evidence suggesting the ability of our brain aging marker to predict future memory decline and increased dementia risk,” corresponding author Yiheng Tu, PhD, also with Chinese Academy of Sciences, Beijing, said in a news release.
 

A Future Treatment Target?

Commenting on this research, Shaheen Lakhan, MD, PhD, a neurologist and researcher based in Miami, noted that in this study, people with KOA showed signs of “faster brain aging on scans. Think of it as your brain wearing a disguise, appearing older than its actual years,” Dr. Lakhan said.

“Inflammation, a key player in osteoarthritis, might be playing a double agent, wreaking havoc not just on your joints but potentially on your memory too. Researchers even identified a specific gene linked to both knee pain and faster brain aging, hinting at a potential target for future treatments,” he added.

“Importantly, the increased risk of cognitive decline and dementia associated with chronic pain is likely one of many factors, and probably not a very high one on its own,” Dr. Lakhan noted.

The “good news,” he said, is that there are many “well-established ways to keep your brain sharp. Regular exercise, a healthy diet, and staying mentally stimulated are all proven strategies to reduce dementia risk. Think of chronic pain management as another tool you can add to your brain health toolbox.”

Support for the study was provided by the STI-2030 Major Project, the National Natural Science Foundation of China, the Scientific Foundation of the Institute of Psychology, Chinese Academy of Sciences, and the Young Elite Scientist Sponsorship Program by the China Association for Science and Technology. Dr. Liu and Dr. Lakhan had no relevant disclosures.

A version of this article appeared on Medscape.com.

The consequences of chronic musculoskeletal pain (CMP) may extend well beyond physical discomfort, potentially leading to faster aging of the brain, new research showed.

Using structural MRI data from more than 9000 adults with knee osteoarthritis (KOA) from the UK Biobank, investigators developed a brain age model to compare an individual’s brain age with their chronological age. Those with KOA showed a much faster rate of brain aging than healthy individuals.

The acceleration in brain aging was largely driven by the hippocampus and predicted memory decline and incident dementia during follow-up. Researchers identified a gene highly expressed in glial cells as a possible genetic factor for accelerated brain aging.

“We demonstrate the accelerated brain aging and cognitive decline in chronic musculoskeletal pain, in particular knee osteoarthritis, and provide a neural marker for early detection and intervention,” said co-first author Jiao Liu, PhD candidate, Chinese Academy of Sciences, Beijing.

“We are interested to know how to slow down the aging brain in chronic musculoskeletal pain patients. Proper exercise and lifestyle may reduce the risk,” Dr. Liu said.

The study was published online in Nature Mental Health.
 

Common Condition

CMP affects more than 40% of the world’s population and has been shown to have a harmful impact on cognitive function, although the exact mechanisms remain unclear. Prior research suggests that inflammatory markers associated with brain aging are higher in patients with CMP, suggesting a link between brain aging and CMP.

To investigate further, researchers explored patterns of brain aging in healthy cohorts and cohorts with four common types of CMP — chronic knee pain, chronic back pain, chronic neck pain, and chronic hip pain.

Using their brain age model, investigators observed significantly increased brain aging, or “predicted age difference,” only in individuals with KOA (P < .001). The observation was validated in an independent dataset (P = .020), suggesting a pattern of brain aging acceleration specific to KOA.

This acceleration was primarily driven by key brain regions involved in cognitive processing, including hippocampus and orbitofrontal cortex, and was correlated with longitudinal memory decline and dementia risk.

These data also suggest that the SLC39A8 gene, which is highly expressed in glial cells, might be a key genetic factor underpinning this acceleration.

“We not only revealed the specificity of accelerated brain aging in knee osteoarthritis patients, but importantly, we also provided longitudinal evidence suggesting the ability of our brain aging marker to predict future memory decline and increased dementia risk,” corresponding author Yiheng Tu, PhD, also with Chinese Academy of Sciences, Beijing, said in a news release.
 

A Future Treatment Target?

Commenting on this research, Shaheen Lakhan, MD, PhD, a neurologist and researcher based in Miami, noted that in this study, people with KOA showed signs of “faster brain aging on scans. Think of it as your brain wearing a disguise, appearing older than its actual years,” Dr. Lakhan said.

“Inflammation, a key player in osteoarthritis, might be playing a double agent, wreaking havoc not just on your joints but potentially on your memory too. Researchers even identified a specific gene linked to both knee pain and faster brain aging, hinting at a potential target for future treatments,” he added.

“Importantly, the increased risk of cognitive decline and dementia associated with chronic pain is likely one of many factors, and probably not a very high one on its own,” Dr. Lakhan noted.

The “good news,” he said, is that there are many “well-established ways to keep your brain sharp. Regular exercise, a healthy diet, and staying mentally stimulated are all proven strategies to reduce dementia risk. Think of chronic pain management as another tool you can add to your brain health toolbox.”

Support for the study was provided by the STI-2030 Major Project, the National Natural Science Foundation of China, the Scientific Foundation of the Institute of Psychology, Chinese Academy of Sciences, and the Young Elite Scientist Sponsorship Program by the China Association for Science and Technology. Dr. Liu and Dr. Lakhan had no relevant disclosures.

A version of this article appeared on Medscape.com.

The consequences of chronic musculoskeletal pain (CMP) may extend well beyond physical discomfort, potentially leading to faster aging of the brain, new research showed.

Using structural MRI data from more than 9000 adults with knee osteoarthritis (KOA) from the UK Biobank, investigators developed a brain age model to compare an individual’s brain age with their chronological age. Those with KOA showed a much faster rate of brain aging than healthy individuals.

The acceleration in brain aging was largely driven by the hippocampus and predicted memory decline and incident dementia during follow-up. Researchers identified a gene highly expressed in glial cells as a possible genetic factor for accelerated brain aging.

“We demonstrate the accelerated brain aging and cognitive decline in chronic musculoskeletal pain, in particular knee osteoarthritis, and provide a neural marker for early detection and intervention,” said co-first author Jiao Liu, PhD candidate, Chinese Academy of Sciences, Beijing.

“We are interested to know how to slow down the aging brain in chronic musculoskeletal pain patients. Proper exercise and lifestyle may reduce the risk,” Dr. Liu said.

The study was published online in Nature Mental Health.
 

Common Condition

CMP affects more than 40% of the world’s population and has been shown to have a harmful impact on cognitive function, although the exact mechanisms remain unclear. Prior research suggests that inflammatory markers associated with brain aging are higher in patients with CMP, suggesting a link between brain aging and CMP.

To investigate further, researchers explored patterns of brain aging in healthy cohorts and cohorts with four common types of CMP — chronic knee pain, chronic back pain, chronic neck pain, and chronic hip pain.

Using their brain age model, investigators observed significantly increased brain aging, or “predicted age difference,” only in individuals with KOA (P < .001). The observation was validated in an independent dataset (P = .020), suggesting a pattern of brain aging acceleration specific to KOA.

This acceleration was primarily driven by key brain regions involved in cognitive processing, including hippocampus and orbitofrontal cortex, and was correlated with longitudinal memory decline and dementia risk.

These data also suggest that the SLC39A8 gene, which is highly expressed in glial cells, might be a key genetic factor underpinning this acceleration.

“We not only revealed the specificity of accelerated brain aging in knee osteoarthritis patients, but importantly, we also provided longitudinal evidence suggesting the ability of our brain aging marker to predict future memory decline and increased dementia risk,” corresponding author Yiheng Tu, PhD, also with Chinese Academy of Sciences, Beijing, said in a news release.
 

A Future Treatment Target?

Commenting on this research, Shaheen Lakhan, MD, PhD, a neurologist and researcher based in Miami, noted that in this study, people with KOA showed signs of “faster brain aging on scans. Think of it as your brain wearing a disguise, appearing older than its actual years,” Dr. Lakhan said.

“Inflammation, a key player in osteoarthritis, might be playing a double agent, wreaking havoc not just on your joints but potentially on your memory too. Researchers even identified a specific gene linked to both knee pain and faster brain aging, hinting at a potential target for future treatments,” he added.

“Importantly, the increased risk of cognitive decline and dementia associated with chronic pain is likely one of many factors, and probably not a very high one on its own,” Dr. Lakhan noted.

The “good news,” he said, is that there are many “well-established ways to keep your brain sharp. Regular exercise, a healthy diet, and staying mentally stimulated are all proven strategies to reduce dementia risk. Think of chronic pain management as another tool you can add to your brain health toolbox.”

Support for the study was provided by the STI-2030 Major Project, the National Natural Science Foundation of China, the Scientific Foundation of the Institute of Psychology, Chinese Academy of Sciences, and the Young Elite Scientist Sponsorship Program by the China Association for Science and Technology. Dr. Liu and Dr. Lakhan had no relevant disclosures.

A version of this article appeared on Medscape.com.

BUDAPEST, Hungary — A single dose of intravenous esketamine during delivery or cesarean section appears to reduce the risk for postpartum depression (PPD) by more than 50% in the first 6 weeks, a new meta-analysis suggested. However, the long-term safety and efficacy of the drug are still unclear.

Study investigator Angelina Kozhokar, MD, Department of Medicine, Universitat Internacional de Catalunya, Barcelona, Sant Cugat del Valles, Spain, told this news organization she was “surprised” by the size of the PPD risk reduction associated with the drug.

However, she added, “it’s important to consider that preliminary studies on a lot of medications used for postpartum depression have also shown very big effect sizes.”

Dr. Kozhokar believes that as more studies examining esketamine for PPD are conducted, “we will see more definitive effect sizes, and the safety profile for this new treatment” will become clearer.

The findings were presented at the European Psychiatric Association (EPA) Congress.
 

Significant Reduction

As previously reported by this news organization, intranasal esketamine (Spravato, Janssen) was shown to be superior to extended-release quetiapine (Seroquel, AstraZeneca), an atypical antipsychotic, for treatment-resistant depression.

With up to 13% of women experiencing PPD in the perinatal period, the researchers sought to examine the impact of esketamine administered prophylactically during labor or cesarean section on the incidence of the disorder.

They searched the PubMed, Scopus, and Google Scholar databases for randomized controlled trials examining the efficacy of esketamine and screened for PPD using the Edinburgh Postpartum Depression Scale (EPDS).

While the intranasal spray is the only form of esketamine approved by the US Food and Drug Administration, an injectable solution is also available. The researchers identified seven eligible trials that included a total of 1287 women. Of these participants, 635 (49.3%) received esketamine. Esketamine was delivered as either patient-controlled intravenous analgesia or a single intravenous dose during delivery or cesarean section.

Across the seven trials, esketamine was associated with a significant reduction in PPD at 1 week after delivery at a risk ratio vs placebo of 0.459 (P < .05). At 6 weeks, the reduction in PPD incidence was maintained, at a risk ratio of 0.470 (P < .01).

However, Dr. Kozhokar pointed out that the EPDS is a subjective measure of PPD, and the studies used different cutoff scores for depression, ranging from 9 to 13 points.
 

Unanswered Questions

She also cautioned that the adverse effects of esketamine on maternal and neonatal health need to be assessed, as well as the long-term cost/benefit ratio of prophylactic treatment.

All seven studies included in the meta-analysis were conducted in China, which limits the generalizability of the findings.

“I suppose they were quicker to get to the topic than the rest of the world,” Dr. Kozhokar said, while also suggesting that, potentially, “we are more regulated here in Europe.”

She pointed out that there is “an important safety concern about the use of medications such as ketamine and esketamine” in terms of the potential for addiction and the effect on babies over the long term, which is currently unknown.

Session chair Linda Rubene, MD, a psychiatrist in the Department of Psychiatry and Narcology at Riga Stradinš University, Riga, Latvia, welcomed the study.

“If we had more options to treat postpartum depression and to treat depression during pregnancy, it would be a great improvement,” she said.

However, she noted, because there are no long-term outcome data for esketamine in PPD, more study is needed. It is possible, said Dr. Rubene, that esketamine may not work for all women.

The investigators and Dr. Rubene reported no relevant financial disclosures.

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

BUDAPEST, Hungary — A single dose of intravenous esketamine during delivery or cesarean section appears to reduce the risk for postpartum depression (PPD) by more than 50% in the first 6 weeks, a new meta-analysis suggested. However, the long-term safety and efficacy of the drug are still unclear.

Study investigator Angelina Kozhokar, MD, Department of Medicine, Universitat Internacional de Catalunya, Barcelona, Sant Cugat del Valles, Spain, told this news organization she was “surprised” by the size of the PPD risk reduction associated with the drug.

However, she added, “it’s important to consider that preliminary studies on a lot of medications used for postpartum depression have also shown very big effect sizes.”

Dr. Kozhokar believes that as more studies examining esketamine for PPD are conducted, “we will see more definitive effect sizes, and the safety profile for this new treatment” will become clearer.

The findings were presented at the European Psychiatric Association (EPA) Congress.
 

Significant Reduction

As previously reported by this news organization, intranasal esketamine (Spravato, Janssen) was shown to be superior to extended-release quetiapine (Seroquel, AstraZeneca), an atypical antipsychotic, for treatment-resistant depression.

With up to 13% of women experiencing PPD in the perinatal period, the researchers sought to examine the impact of esketamine administered prophylactically during labor or cesarean section on the incidence of the disorder.

They searched the PubMed, Scopus, and Google Scholar databases for randomized controlled trials examining the efficacy of esketamine and screened for PPD using the Edinburgh Postpartum Depression Scale (EPDS).

While the intranasal spray is the only form of esketamine approved by the US Food and Drug Administration, an injectable solution is also available. The researchers identified seven eligible trials that included a total of 1287 women. Of these participants, 635 (49.3%) received esketamine. Esketamine was delivered as either patient-controlled intravenous analgesia or a single intravenous dose during delivery or cesarean section.

Across the seven trials, esketamine was associated with a significant reduction in PPD at 1 week after delivery at a risk ratio vs placebo of 0.459 (P < .05). At 6 weeks, the reduction in PPD incidence was maintained, at a risk ratio of 0.470 (P < .01).

However, Dr. Kozhokar pointed out that the EPDS is a subjective measure of PPD, and the studies used different cutoff scores for depression, ranging from 9 to 13 points.
 

Unanswered Questions

She also cautioned that the adverse effects of esketamine on maternal and neonatal health need to be assessed, as well as the long-term cost/benefit ratio of prophylactic treatment.

All seven studies included in the meta-analysis were conducted in China, which limits the generalizability of the findings.

“I suppose they were quicker to get to the topic than the rest of the world,” Dr. Kozhokar said, while also suggesting that, potentially, “we are more regulated here in Europe.”

She pointed out that there is “an important safety concern about the use of medications such as ketamine and esketamine” in terms of the potential for addiction and the effect on babies over the long term, which is currently unknown.

Session chair Linda Rubene, MD, a psychiatrist in the Department of Psychiatry and Narcology at Riga Stradinš University, Riga, Latvia, welcomed the study.

“If we had more options to treat postpartum depression and to treat depression during pregnancy, it would be a great improvement,” she said.

However, she noted, because there are no long-term outcome data for esketamine in PPD, more study is needed. It is possible, said Dr. Rubene, that esketamine may not work for all women.

The investigators and Dr. Rubene reported no relevant financial disclosures.

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

BUDAPEST, Hungary — A single dose of intravenous esketamine during delivery or cesarean section appears to reduce the risk for postpartum depression (PPD) by more than 50% in the first 6 weeks, a new meta-analysis suggested. However, the long-term safety and efficacy of the drug are still unclear.

Study investigator Angelina Kozhokar, MD, Department of Medicine, Universitat Internacional de Catalunya, Barcelona, Sant Cugat del Valles, Spain, told this news organization she was “surprised” by the size of the PPD risk reduction associated with the drug.

However, she added, “it’s important to consider that preliminary studies on a lot of medications used for postpartum depression have also shown very big effect sizes.”

Dr. Kozhokar believes that as more studies examining esketamine for PPD are conducted, “we will see more definitive effect sizes, and the safety profile for this new treatment” will become clearer.

The findings were presented at the European Psychiatric Association (EPA) Congress.
 

Significant Reduction

As previously reported by this news organization, intranasal esketamine (Spravato, Janssen) was shown to be superior to extended-release quetiapine (Seroquel, AstraZeneca), an atypical antipsychotic, for treatment-resistant depression.

With up to 13% of women experiencing PPD in the perinatal period, the researchers sought to examine the impact of esketamine administered prophylactically during labor or cesarean section on the incidence of the disorder.

They searched the PubMed, Scopus, and Google Scholar databases for randomized controlled trials examining the efficacy of esketamine and screened for PPD using the Edinburgh Postpartum Depression Scale (EPDS).

While the intranasal spray is the only form of esketamine approved by the US Food and Drug Administration, an injectable solution is also available. The researchers identified seven eligible trials that included a total of 1287 women. Of these participants, 635 (49.3%) received esketamine. Esketamine was delivered as either patient-controlled intravenous analgesia or a single intravenous dose during delivery or cesarean section.

Across the seven trials, esketamine was associated with a significant reduction in PPD at 1 week after delivery at a risk ratio vs placebo of 0.459 (P < .05). At 6 weeks, the reduction in PPD incidence was maintained, at a risk ratio of 0.470 (P < .01).

However, Dr. Kozhokar pointed out that the EPDS is a subjective measure of PPD, and the studies used different cutoff scores for depression, ranging from 9 to 13 points.
 

Unanswered Questions

She also cautioned that the adverse effects of esketamine on maternal and neonatal health need to be assessed, as well as the long-term cost/benefit ratio of prophylactic treatment.

All seven studies included in the meta-analysis were conducted in China, which limits the generalizability of the findings.

“I suppose they were quicker to get to the topic than the rest of the world,” Dr. Kozhokar said, while also suggesting that, potentially, “we are more regulated here in Europe.”

She pointed out that there is “an important safety concern about the use of medications such as ketamine and esketamine” in terms of the potential for addiction and the effect on babies over the long term, which is currently unknown.

Session chair Linda Rubene, MD, a psychiatrist in the Department of Psychiatry and Narcology at Riga Stradinš University, Riga, Latvia, welcomed the study.

“If we had more options to treat postpartum depression and to treat depression during pregnancy, it would be a great improvement,” she said.

However, she noted, because there are no long-term outcome data for esketamine in PPD, more study is needed. It is possible, said Dr. Rubene, that esketamine may not work for all women.

The investigators and Dr. Rubene reported no relevant financial disclosures.

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

It should come as no surprise that when physicians speak out on social and political issues, there is sometimes a backlash. This can range from the typical trolling that occurs online to rarer cases of professional penalties. Two doctors were fired by NYU Langone Health late last year after they posted social media messages about the Israel-Hamas war. Still, many physicians are not only willing to stand up for what they believe in, but they see it as an essential part of their profession. 
"We're now at a place where doctors need to engage in public advocacy as an urgent part of our job," wrote Rob Davidson, MD, an emergency department physician, at the onslaught of the COVID-19 pandemic. In an Op-Ed piece for The Guardian, Dr. Davidson noted how the virus forced many physicians into becoming "activist doctors," calling for adequate personal protective equipment and correcting misinformation. "What we want above all is for the administration to listen to doctors, nurses, and frontline health workers - and stop playing politics," he wrote. 

'It's Not About Being Political' 

The intersection of medicine and politics is hardly new. Doctors frequently testify before Congress, sharing their expertise on issues concerning public health. This, however, isn't the same as "playing politics." 
"I'm not taking political stances," said Megan Ranney, MD, Dean of the Yale School of Public Health. "Rather, I'm using science to inform best practices, and I'm vocal around the area where I have expertise where we could do collectively better." 
Dr. Ranney's work to end firearm injury and death garnered particular attention when she co-authored an open letter to the National Rifle Association (NRA) in 2018. She wrote the letter in response to a tweet by the organization, admonishing physicians to "stay in their lane" when it comes to gun control.  
Dr. Ranney's letter discussed gun violence as a public health crisis and urged the NRA to "be part of the solution" by joining the collective effort to reduce firearm injury and death through research, education, and advocacy. "We are not anti-gun," she stated. "We are anti-bullet hole," adding that "almost half of doctors own guns." 
The NRA disagreed. When Dr. Ranney testified before Congress during a hearing on gun violence in 2023, NRA spokesperson Billy McLaughlin condemned her testimony as an effort to "dismantle the Second Amendment," calling Dr. Ranney "a known gun control extremist." 
"If you actually read what I write, or if you actually listen to what I say, I'm not saying things on behalf of one political party or another," said Dr. Ranney. "It's not about being political. It's about recognizing our role in describing what's happening and making it clear for the world to see. Showing where, based off of data, there may be a better path to improve health and wellbeing." 
In spite of the backlash, Dr. Ranney has no regrets about being an activist. "In the current media landscape, folks love to slap labels on people that may or may not be accurate. To me, what matters isn't where I land with a particular politician or political party, but how the work that I do improves health for populations." 

When the Need to Act Outweighs the Fear 

Laura Andreson, DO, an ob.gyn, took activism a step further when she joined a group of women in Tennessee to file a suit against the state, the attorney general, and the state board of medical examiners. The issue was the Tennessee's abortion ban, which the suit claimed prevented women from getting "necessary and potentially life-saving medical care."  
Dr. Andreson, who says she was "not at all" politically active in the past, began to realize how the abortion ban could drastically affect her profession and her patients. "I don't know what flipped in me, but I just felt like I could do this," she said. 
Like Dr. Ranney, Dr. Andreson has been as visible as she has been vocal, giving press conferences and interviews, but she acknowledges she has some fears about safety. In fact, after filing the lawsuit, the Center for Reproductive Rights recommended that she go to a website, DeleteMe, that removes personal data from the internet, making it more difficult for people to find her information. "But my need to do this and my desire to do this is stronger than my fears," she added. 
Dr. Andreson, who is part of a small practice, did check with both her coworkers and the hospital administration before moving forward with the lawsuit. She was relieved to find that she had the support of her practice and that there wasn't anything in the hospital bylaws to prevent her from filing the lawsuit. "But the people in the bigger institutions who probably have an even better expert base than I do, they are handcuffed," she said. 
It has been, in Dr. Andreson's words, "a little uncomfortable" being on the board of the Tennessee Medical Association when the Tennessee Board of Medical Examiners is part of the lawsuit. "We're all members of the same group," she said. "But I'm not suing them as individuals; I'm suing them as an entity that is under our government." 
Dr. Andreson said most people have been supportive of her activist work, though she admitted to feeling frustrated when she encounters apathy from fellow ob.gyns. She got little response when she circulated information explaining the abortion laws and trying to get others involved. But she still sees education as being a key part of making change happen.  
"I think advocacy, as someone who is considered a responsible, trustworthy person by your community, is important, because you can sway some people just by educating them," she said. 

Fighting Inequities in Medicine and Beyond 

Christina Chen, MD, says she felt very supported by her medical community at the Mayo Clinic in Rochester, Minnesota, when she and 16 other Asian American physicians posted a video on Instagram in 2020 highlighting increased violence and harassment of Asian Americans during COVID-19. It soon went viral, and the Mayo Clinic distributed it across their social media channels. The only negative repercussions Mayo faced were a few posts on social media saying that politics should not be brought into the healthcare space. Dr. Chen disagrees. 
"Social issues and political decisions have direct impact on the health of our communities," Dr. Chen said. "We know that we still have a long way to go to solve health inequities, which is a public health problem, and we all play a huge role in voicing our concerns." 
Activism, however, seems to be more complicated when it involves physicians being critical of inequities within the medical field. Nephrologist, Vanessa Grubbs, MD, MPH, founded the nonprofit Black Doc Village in 2022 to raise awareness about the wrongful dismissal of Black residents and expand the Black physician workforce. 
Dr. Grubbs said that the medical community has not been supportive of her activism. "The reason why I'm no longer in academia is in part because they got very upset with me tweeting about how some trainees are biased in their treatment of attendings," she said. "Senior White men attendings are often treated very differently than junior women of color faculty." 
Dr. Grubbs also expressed her views in 2020 essay in the New England Journal of Medicine where she criticized academic medical institutions for ignoring systemic racism, paying lip service to diversity, equity, and inclusion, and staying "deafeningly silent" when issues of racism are raised. 
Today, Black Doc Village is focused on conducting research that can be used to change policy. And Dr. Grubbs now has the full support of her colleagues at West Oakland Health, in Oakland, California, which aspires to advance the Bay Area Black community's health and dignity. "So, no one here has a problem with me speaking out," she added. 
The emphasis on data-driven activism as opposed to "playing politics," is a recurring theme for many physicians who publicly engage with social issues. 
"It's not partisan," Dr. Ranney said. "Rather, it's a commitment to translating science into actionable steps that can be used regardless of what political party you are in. My job is not to be on one side or the other, but to advance human health." These doctors challenge their critics to explain how such a goal is outside their purview. 
A version of this article first appeared on Medscape.com.

It should come as no surprise that when physicians speak out on social and political issues, there is sometimes a backlash. This can range from the typical trolling that occurs online to rarer cases of professional penalties. Two doctors were fired by NYU Langone Health late last year after they posted social media messages about the Israel-Hamas war. Still, many physicians are not only willing to stand up for what they believe in, but they see it as an essential part of their profession. 
"We're now at a place where doctors need to engage in public advocacy as an urgent part of our job," wrote Rob Davidson, MD, an emergency department physician, at the onslaught of the COVID-19 pandemic. In an Op-Ed piece for The Guardian, Dr. Davidson noted how the virus forced many physicians into becoming "activist doctors," calling for adequate personal protective equipment and correcting misinformation. "What we want above all is for the administration to listen to doctors, nurses, and frontline health workers - and stop playing politics," he wrote. 

'It's Not About Being Political' 

The intersection of medicine and politics is hardly new. Doctors frequently testify before Congress, sharing their expertise on issues concerning public health. This, however, isn't the same as "playing politics." 
"I'm not taking political stances," said Megan Ranney, MD, Dean of the Yale School of Public Health. "Rather, I'm using science to inform best practices, and I'm vocal around the area where I have expertise where we could do collectively better." 
Dr. Ranney's work to end firearm injury and death garnered particular attention when she co-authored an open letter to the National Rifle Association (NRA) in 2018. She wrote the letter in response to a tweet by the organization, admonishing physicians to "stay in their lane" when it comes to gun control.  
Dr. Ranney's letter discussed gun violence as a public health crisis and urged the NRA to "be part of the solution" by joining the collective effort to reduce firearm injury and death through research, education, and advocacy. "We are not anti-gun," she stated. "We are anti-bullet hole," adding that "almost half of doctors own guns." 
The NRA disagreed. When Dr. Ranney testified before Congress during a hearing on gun violence in 2023, NRA spokesperson Billy McLaughlin condemned her testimony as an effort to "dismantle the Second Amendment," calling Dr. Ranney "a known gun control extremist." 
"If you actually read what I write, or if you actually listen to what I say, I'm not saying things on behalf of one political party or another," said Dr. Ranney. "It's not about being political. It's about recognizing our role in describing what's happening and making it clear for the world to see. Showing where, based off of data, there may be a better path to improve health and wellbeing." 
In spite of the backlash, Dr. Ranney has no regrets about being an activist. "In the current media landscape, folks love to slap labels on people that may or may not be accurate. To me, what matters isn't where I land with a particular politician or political party, but how the work that I do improves health for populations." 

When the Need to Act Outweighs the Fear 

Laura Andreson, DO, an ob.gyn, took activism a step further when she joined a group of women in Tennessee to file a suit against the state, the attorney general, and the state board of medical examiners. The issue was the Tennessee's abortion ban, which the suit claimed prevented women from getting "necessary and potentially life-saving medical care."  
Dr. Andreson, who says she was "not at all" politically active in the past, began to realize how the abortion ban could drastically affect her profession and her patients. "I don't know what flipped in me, but I just felt like I could do this," she said. 
Like Dr. Ranney, Dr. Andreson has been as visible as she has been vocal, giving press conferences and interviews, but she acknowledges she has some fears about safety. In fact, after filing the lawsuit, the Center for Reproductive Rights recommended that she go to a website, DeleteMe, that removes personal data from the internet, making it more difficult for people to find her information. "But my need to do this and my desire to do this is stronger than my fears," she added. 
Dr. Andreson, who is part of a small practice, did check with both her coworkers and the hospital administration before moving forward with the lawsuit. She was relieved to find that she had the support of her practice and that there wasn't anything in the hospital bylaws to prevent her from filing the lawsuit. "But the people in the bigger institutions who probably have an even better expert base than I do, they are handcuffed," she said. 
It has been, in Dr. Andreson's words, "a little uncomfortable" being on the board of the Tennessee Medical Association when the Tennessee Board of Medical Examiners is part of the lawsuit. "We're all members of the same group," she said. "But I'm not suing them as individuals; I'm suing them as an entity that is under our government." 
Dr. Andreson said most people have been supportive of her activist work, though she admitted to feeling frustrated when she encounters apathy from fellow ob.gyns. She got little response when she circulated information explaining the abortion laws and trying to get others involved. But she still sees education as being a key part of making change happen.  
"I think advocacy, as someone who is considered a responsible, trustworthy person by your community, is important, because you can sway some people just by educating them," she said. 

Fighting Inequities in Medicine and Beyond 

Christina Chen, MD, says she felt very supported by her medical community at the Mayo Clinic in Rochester, Minnesota, when she and 16 other Asian American physicians posted a video on Instagram in 2020 highlighting increased violence and harassment of Asian Americans during COVID-19. It soon went viral, and the Mayo Clinic distributed it across their social media channels. The only negative repercussions Mayo faced were a few posts on social media saying that politics should not be brought into the healthcare space. Dr. Chen disagrees. 
"Social issues and political decisions have direct impact on the health of our communities," Dr. Chen said. "We know that we still have a long way to go to solve health inequities, which is a public health problem, and we all play a huge role in voicing our concerns." 
Activism, however, seems to be more complicated when it involves physicians being critical of inequities within the medical field. Nephrologist, Vanessa Grubbs, MD, MPH, founded the nonprofit Black Doc Village in 2022 to raise awareness about the wrongful dismissal of Black residents and expand the Black physician workforce. 
Dr. Grubbs said that the medical community has not been supportive of her activism. "The reason why I'm no longer in academia is in part because they got very upset with me tweeting about how some trainees are biased in their treatment of attendings," she said. "Senior White men attendings are often treated very differently than junior women of color faculty." 
Dr. Grubbs also expressed her views in 2020 essay in the New England Journal of Medicine where she criticized academic medical institutions for ignoring systemic racism, paying lip service to diversity, equity, and inclusion, and staying "deafeningly silent" when issues of racism are raised. 
Today, Black Doc Village is focused on conducting research that can be used to change policy. And Dr. Grubbs now has the full support of her colleagues at West Oakland Health, in Oakland, California, which aspires to advance the Bay Area Black community's health and dignity. "So, no one here has a problem with me speaking out," she added. 
The emphasis on data-driven activism as opposed to "playing politics," is a recurring theme for many physicians who publicly engage with social issues. 
"It's not partisan," Dr. Ranney said. "Rather, it's a commitment to translating science into actionable steps that can be used regardless of what political party you are in. My job is not to be on one side or the other, but to advance human health." These doctors challenge their critics to explain how such a goal is outside their purview. 
A version of this article first appeared on Medscape.com.

It should come as no surprise that when physicians speak out on social and political issues, there is sometimes a backlash. This can range from the typical trolling that occurs online to rarer cases of professional penalties. Two doctors were fired by NYU Langone Health late last year after they posted social media messages about the Israel-Hamas war. Still, many physicians are not only willing to stand up for what they believe in, but they see it as an essential part of their profession. 
"We're now at a place where doctors need to engage in public advocacy as an urgent part of our job," wrote Rob Davidson, MD, an emergency department physician, at the onslaught of the COVID-19 pandemic. In an Op-Ed piece for The Guardian, Dr. Davidson noted how the virus forced many physicians into becoming "activist doctors," calling for adequate personal protective equipment and correcting misinformation. "What we want above all is for the administration to listen to doctors, nurses, and frontline health workers - and stop playing politics," he wrote. 

'It's Not About Being Political' 

The intersection of medicine and politics is hardly new. Doctors frequently testify before Congress, sharing their expertise on issues concerning public health. This, however, isn't the same as "playing politics." 
"I'm not taking political stances," said Megan Ranney, MD, Dean of the Yale School of Public Health. "Rather, I'm using science to inform best practices, and I'm vocal around the area where I have expertise where we could do collectively better." 
Dr. Ranney's work to end firearm injury and death garnered particular attention when she co-authored an open letter to the National Rifle Association (NRA) in 2018. She wrote the letter in response to a tweet by the organization, admonishing physicians to "stay in their lane" when it comes to gun control.  
Dr. Ranney's letter discussed gun violence as a public health crisis and urged the NRA to "be part of the solution" by joining the collective effort to reduce firearm injury and death through research, education, and advocacy. "We are not anti-gun," she stated. "We are anti-bullet hole," adding that "almost half of doctors own guns." 
The NRA disagreed. When Dr. Ranney testified before Congress during a hearing on gun violence in 2023, NRA spokesperson Billy McLaughlin condemned her testimony as an effort to "dismantle the Second Amendment," calling Dr. Ranney "a known gun control extremist." 
"If you actually read what I write, or if you actually listen to what I say, I'm not saying things on behalf of one political party or another," said Dr. Ranney. "It's not about being political. It's about recognizing our role in describing what's happening and making it clear for the world to see. Showing where, based off of data, there may be a better path to improve health and wellbeing." 
In spite of the backlash, Dr. Ranney has no regrets about being an activist. "In the current media landscape, folks love to slap labels on people that may or may not be accurate. To me, what matters isn't where I land with a particular politician or political party, but how the work that I do improves health for populations." 

When the Need to Act Outweighs the Fear 

Laura Andreson, DO, an ob.gyn, took activism a step further when she joined a group of women in Tennessee to file a suit against the state, the attorney general, and the state board of medical examiners. The issue was the Tennessee's abortion ban, which the suit claimed prevented women from getting "necessary and potentially life-saving medical care."  
Dr. Andreson, who says she was "not at all" politically active in the past, began to realize how the abortion ban could drastically affect her profession and her patients. "I don't know what flipped in me, but I just felt like I could do this," she said. 
Like Dr. Ranney, Dr. Andreson has been as visible as she has been vocal, giving press conferences and interviews, but she acknowledges she has some fears about safety. In fact, after filing the lawsuit, the Center for Reproductive Rights recommended that she go to a website, DeleteMe, that removes personal data from the internet, making it more difficult for people to find her information. "But my need to do this and my desire to do this is stronger than my fears," she added. 
Dr. Andreson, who is part of a small practice, did check with both her coworkers and the hospital administration before moving forward with the lawsuit. She was relieved to find that she had the support of her practice and that there wasn't anything in the hospital bylaws to prevent her from filing the lawsuit. "But the people in the bigger institutions who probably have an even better expert base than I do, they are handcuffed," she said. 
It has been, in Dr. Andreson's words, "a little uncomfortable" being on the board of the Tennessee Medical Association when the Tennessee Board of Medical Examiners is part of the lawsuit. "We're all members of the same group," she said. "But I'm not suing them as individuals; I'm suing them as an entity that is under our government." 
Dr. Andreson said most people have been supportive of her activist work, though she admitted to feeling frustrated when she encounters apathy from fellow ob.gyns. She got little response when she circulated information explaining the abortion laws and trying to get others involved. But she still sees education as being a key part of making change happen.  
"I think advocacy, as someone who is considered a responsible, trustworthy person by your community, is important, because you can sway some people just by educating them," she said. 

Fighting Inequities in Medicine and Beyond 

Christina Chen, MD, says she felt very supported by her medical community at the Mayo Clinic in Rochester, Minnesota, when she and 16 other Asian American physicians posted a video on Instagram in 2020 highlighting increased violence and harassment of Asian Americans during COVID-19. It soon went viral, and the Mayo Clinic distributed it across their social media channels. The only negative repercussions Mayo faced were a few posts on social media saying that politics should not be brought into the healthcare space. Dr. Chen disagrees. 
"Social issues and political decisions have direct impact on the health of our communities," Dr. Chen said. "We know that we still have a long way to go to solve health inequities, which is a public health problem, and we all play a huge role in voicing our concerns." 
Activism, however, seems to be more complicated when it involves physicians being critical of inequities within the medical field. Nephrologist, Vanessa Grubbs, MD, MPH, founded the nonprofit Black Doc Village in 2022 to raise awareness about the wrongful dismissal of Black residents and expand the Black physician workforce. 
Dr. Grubbs said that the medical community has not been supportive of her activism. "The reason why I'm no longer in academia is in part because they got very upset with me tweeting about how some trainees are biased in their treatment of attendings," she said. "Senior White men attendings are often treated very differently than junior women of color faculty." 
Dr. Grubbs also expressed her views in 2020 essay in the New England Journal of Medicine where she criticized academic medical institutions for ignoring systemic racism, paying lip service to diversity, equity, and inclusion, and staying "deafeningly silent" when issues of racism are raised. 
Today, Black Doc Village is focused on conducting research that can be used to change policy. And Dr. Grubbs now has the full support of her colleagues at West Oakland Health, in Oakland, California, which aspires to advance the Bay Area Black community's health and dignity. "So, no one here has a problem with me speaking out," she added. 
The emphasis on data-driven activism as opposed to "playing politics," is a recurring theme for many physicians who publicly engage with social issues. 
"It's not partisan," Dr. Ranney said. "Rather, it's a commitment to translating science into actionable steps that can be used regardless of what political party you are in. My job is not to be on one side or the other, but to advance human health." These doctors challenge their critics to explain how such a goal is outside their purview. 
A version of this article first appeared on Medscape.com.