MDedge Emergency Medicine

The combination of heat waves and poor air quality is associated with double the risk of fatal myocardial infarction (MI), with women and older adults at greatest risk, a study from China suggests.

rottadana/Thinkstock

The researchers estimate that up to 3% of all deaths due to MI could be attributed to the combination of extreme temperatures and high levels of ambient fine particulate matter (PM2.5).

“Our findings provide evidence that reducing exposure to both extreme temperatures and fine particulate pollution may be useful to prevent premature deaths from heart attack,” senior author Yuewei Liu, MD, PhD, with Sun Yat-sen University in Guangzhou, China, said in a statement.

There is “long-standing evidence” of the harmful cardiovascular effects of air pollution, Jonathan Newman, MD, MPH, cardiologist at NYU Langone Heart in New York, who wasn’t involved in the study, said in an interview.

The added value of this study was finding an interaction between extreme hot temperatures and air pollution, “which is worrisome with global warming,” said Dr. Newman, assistant professor, department of medicine, the Leon H. Charney Division of Cardiology at NYU Langone Health.

The study was published online in Circulation.
 

Intensity and duration matter

The researchers analyzed data on 202,678 adults (mean age, 77.6 years; 52% male) who suffered fatal MI between 2015 and 2020 in Jiangsu province, a region with four distinct seasons and a wide range of temperatures and ambient PM2.5.

They evaluated the association of exposure to extreme temperature events, including both hot and cold spells, and PM2.5 with MI mortality, and their interactive effects.

Among the key findings:

• The risk of fatal MI was 18% higher during 2-day heat waves with heat indexes at or above the 90th percentile (ranging from 82.6° to 97.9° F) and 74% higher during 4-day heat waves with heat indexes at or above the 97.5th percentile (ranging from 94.8° to 109.4° F), compared with control days.
• The risk of fatal MI was 4% higher during 2-day cold snaps with temperatures at or below the 10th percentile (ranging from 33.3° to 40.5° F) and 12% higher during 3-day cold snaps with temperatures at or below the 2.5th percentile (ranging from 27.0° to 37.2° F).
• The risk of fatal MI was twice as high during 4-day heat waves that had PM2.5 above 37.5 mcg/m³. Days with high levels of PM2.5 during cold snaps did not have an equivalent increase in the risk of fatal MI.
• Up to 2.8% of MI deaths during the 5-year study period may be attributable to the combination of extreme temperature exposure and PM2.5 at levels exceeding World Health Organization air quality guidelines (37.5 mcg/m³).
• The risk of fatal MI was generally higher among women than men during heat waves and was higher among adults 80 years old and older than in younger adults during heat waves, cold snaps, or days with high levels of PM2.5.

The finding that adults over age 80 are particularly susceptible to the effects of heat and air pollution and the interaction of the two is “notable and particularly relevant given the aging of the population,” Dr. Newman told this news organization.

Mitigating both extreme temperature events and PM2.5 exposures “may bring health cobenefits in preventing premature deaths from MI,” the researchers write.

“To improve public health, it is important to take fine particulate pollution into consideration when providing extreme temperature warnings to the public,” Dr. Liu adds in the statement.

In an earlier study, Dr. Liu and colleagues showed that exposure to both large and small particulate matter, as well as nitrogen dioxide, was significantly associated with increased odds of death from MI.

This study was funded by China’s Ministry of Science and Technology. The authors and Dr. Newman have disclosed no relevant financial relationships.

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

The combination of heat waves and poor air quality is associated with double the risk of fatal myocardial infarction (MI), with women and older adults at greatest risk, a study from China suggests.

rottadana/Thinkstock

The researchers estimate that up to 3% of all deaths due to MI could be attributed to the combination of extreme temperatures and high levels of ambient fine particulate matter (PM2.5).

“Our findings provide evidence that reducing exposure to both extreme temperatures and fine particulate pollution may be useful to prevent premature deaths from heart attack,” senior author Yuewei Liu, MD, PhD, with Sun Yat-sen University in Guangzhou, China, said in a statement.

There is “long-standing evidence” of the harmful cardiovascular effects of air pollution, Jonathan Newman, MD, MPH, cardiologist at NYU Langone Heart in New York, who wasn’t involved in the study, said in an interview.

The added value of this study was finding an interaction between extreme hot temperatures and air pollution, “which is worrisome with global warming,” said Dr. Newman, assistant professor, department of medicine, the Leon H. Charney Division of Cardiology at NYU Langone Health.

The study was published online in Circulation.
 

Intensity and duration matter

The researchers analyzed data on 202,678 adults (mean age, 77.6 years; 52% male) who suffered fatal MI between 2015 and 2020 in Jiangsu province, a region with four distinct seasons and a wide range of temperatures and ambient PM2.5.

They evaluated the association of exposure to extreme temperature events, including both hot and cold spells, and PM2.5 with MI mortality, and their interactive effects.

Among the key findings:

• The risk of fatal MI was 18% higher during 2-day heat waves with heat indexes at or above the 90th percentile (ranging from 82.6° to 97.9° F) and 74% higher during 4-day heat waves with heat indexes at or above the 97.5th percentile (ranging from 94.8° to 109.4° F), compared with control days.
• The risk of fatal MI was 4% higher during 2-day cold snaps with temperatures at or below the 10th percentile (ranging from 33.3° to 40.5° F) and 12% higher during 3-day cold snaps with temperatures at or below the 2.5th percentile (ranging from 27.0° to 37.2° F).
• The risk of fatal MI was twice as high during 4-day heat waves that had PM2.5 above 37.5 mcg/m³. Days with high levels of PM2.5 during cold snaps did not have an equivalent increase in the risk of fatal MI.
• Up to 2.8% of MI deaths during the 5-year study period may be attributable to the combination of extreme temperature exposure and PM2.5 at levels exceeding World Health Organization air quality guidelines (37.5 mcg/m³).
• The risk of fatal MI was generally higher among women than men during heat waves and was higher among adults 80 years old and older than in younger adults during heat waves, cold snaps, or days with high levels of PM2.5.

The finding that adults over age 80 are particularly susceptible to the effects of heat and air pollution and the interaction of the two is “notable and particularly relevant given the aging of the population,” Dr. Newman told this news organization.

Mitigating both extreme temperature events and PM2.5 exposures “may bring health cobenefits in preventing premature deaths from MI,” the researchers write.

“To improve public health, it is important to take fine particulate pollution into consideration when providing extreme temperature warnings to the public,” Dr. Liu adds in the statement.

In an earlier study, Dr. Liu and colleagues showed that exposure to both large and small particulate matter, as well as nitrogen dioxide, was significantly associated with increased odds of death from MI.

This study was funded by China’s Ministry of Science and Technology. The authors and Dr. Newman have disclosed no relevant financial relationships.

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

The combination of heat waves and poor air quality is associated with double the risk of fatal myocardial infarction (MI), with women and older adults at greatest risk, a study from China suggests.

rottadana/Thinkstock

The researchers estimate that up to 3% of all deaths due to MI could be attributed to the combination of extreme temperatures and high levels of ambient fine particulate matter (PM2.5).

“Our findings provide evidence that reducing exposure to both extreme temperatures and fine particulate pollution may be useful to prevent premature deaths from heart attack,” senior author Yuewei Liu, MD, PhD, with Sun Yat-sen University in Guangzhou, China, said in a statement.

There is “long-standing evidence” of the harmful cardiovascular effects of air pollution, Jonathan Newman, MD, MPH, cardiologist at NYU Langone Heart in New York, who wasn’t involved in the study, said in an interview.

The added value of this study was finding an interaction between extreme hot temperatures and air pollution, “which is worrisome with global warming,” said Dr. Newman, assistant professor, department of medicine, the Leon H. Charney Division of Cardiology at NYU Langone Health.

The study was published online in Circulation.
 

Intensity and duration matter

The researchers analyzed data on 202,678 adults (mean age, 77.6 years; 52% male) who suffered fatal MI between 2015 and 2020 in Jiangsu province, a region with four distinct seasons and a wide range of temperatures and ambient PM2.5.

They evaluated the association of exposure to extreme temperature events, including both hot and cold spells, and PM2.5 with MI mortality, and their interactive effects.

Among the key findings:

• The risk of fatal MI was 18% higher during 2-day heat waves with heat indexes at or above the 90th percentile (ranging from 82.6° to 97.9° F) and 74% higher during 4-day heat waves with heat indexes at or above the 97.5th percentile (ranging from 94.8° to 109.4° F), compared with control days.
• The risk of fatal MI was 4% higher during 2-day cold snaps with temperatures at or below the 10th percentile (ranging from 33.3° to 40.5° F) and 12% higher during 3-day cold snaps with temperatures at or below the 2.5th percentile (ranging from 27.0° to 37.2° F).
• The risk of fatal MI was twice as high during 4-day heat waves that had PM2.5 above 37.5 mcg/m³. Days with high levels of PM2.5 during cold snaps did not have an equivalent increase in the risk of fatal MI.
• Up to 2.8% of MI deaths during the 5-year study period may be attributable to the combination of extreme temperature exposure and PM2.5 at levels exceeding World Health Organization air quality guidelines (37.5 mcg/m³).
• The risk of fatal MI was generally higher among women than men during heat waves and was higher among adults 80 years old and older than in younger adults during heat waves, cold snaps, or days with high levels of PM2.5.

The finding that adults over age 80 are particularly susceptible to the effects of heat and air pollution and the interaction of the two is “notable and particularly relevant given the aging of the population,” Dr. Newman told this news organization.

Mitigating both extreme temperature events and PM2.5 exposures “may bring health cobenefits in preventing premature deaths from MI,” the researchers write.

“To improve public health, it is important to take fine particulate pollution into consideration when providing extreme temperature warnings to the public,” Dr. Liu adds in the statement.

In an earlier study, Dr. Liu and colleagues showed that exposure to both large and small particulate matter, as well as nitrogen dioxide, was significantly associated with increased odds of death from MI.

This study was funded by China’s Ministry of Science and Technology. The authors and Dr. Newman have disclosed no relevant financial relationships.

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

GE HealthCare is recalling 7,559 TruSignal arterial oxygen saturation (SpO₂) sensors because of problems that may reduce defibrillation energy, expose patients to unintended voltage, or give inaccurate readings.

The Food and Drug Administration has identified this as a class I recall, the most serious type. The company has not received any reports of patient injury or deaths as a result of these issues.*

The recall includes the TruSignal Adult Pediatric Sensor, TruSignal AllFit Sensor, TruSignal Sensitive Skin Sensor, TruSignal Wrap Sensor, TruSignal Ear Sensor, TruSignal Integrated Ear Sensor with GE Connector, TruSignal Integrated Ear Sensor With Datex Connector, TruSignal Integrated Ear Sensor With Datex Connector, and TruSignal Integrated Ear Sensor With Ohmeda Connector.

The sensors were distributed in the United States from Jan. 1, 2021, to March 4, 2023.

According to the recall notice, the malfunctioning sensors “may reduce the amount of energy sent to the heart during defibrillation without any notification to the care provider, which could prevent delivery of lifesaving therapy in a critical situation.

“This issue is most hazardous to hospitalized patients who may need defibrillation for cardiac arrest. Affected sensors may also unintentionally expose patients to electrical currents from other sources or may provide inaccurate measurements of SpO₂, which can impact treatment decisions,” the notice warns.

In an urgent device correction letter sent to health care professionals in May, GE HealthCare recommends that health care professionals do the following:

• Use an alternate method for SpO₂ monitoring, including TruSignal sensors not impacted or an alternate SpO₂ device.
• If alternate methods are not available, use affected TruSignal SpO₂ sensors as long as they have not been saturated with fluids.
• If defibrillation is necessary when affected TruSignal SpO₂ sensors are being used, remove the affected TruSignal SpO₂ sensor, defibrillate per hospital protocol, and reattach the affected TruSignal SpO₂ sensor after defibrillation is no longer needed.
• For Adult/Pediatric SpO₂ sensors, confirm that material does not cover the emitter or detector before using.
• Discard the sensor and use another sensor if any additional material is present.
• Make sure all potential users are made aware of this safety notification and the recommended actions, and retain this notice.

Customers are also asked to complete and return the acknowledgment form attached to the notice to [email protected].

For questions or concerns about this recall, contact GE HealthCare Service at 1-800-437-1171 or a local service representative.

Health care professionals can report adverse reactions or quality problems they experience using these devices to the FDA’s MedWatch program.

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

*Correction, 8/3/23: An earlier version of this article mischaracterized the reports received by the company.

GE HealthCare is recalling 7,559 TruSignal arterial oxygen saturation (SpO₂) sensors because of problems that may reduce defibrillation energy, expose patients to unintended voltage, or give inaccurate readings.

The Food and Drug Administration has identified this as a class I recall, the most serious type. The company has not received any reports of patient injury or deaths as a result of these issues.*

The recall includes the TruSignal Adult Pediatric Sensor, TruSignal AllFit Sensor, TruSignal Sensitive Skin Sensor, TruSignal Wrap Sensor, TruSignal Ear Sensor, TruSignal Integrated Ear Sensor with GE Connector, TruSignal Integrated Ear Sensor With Datex Connector, TruSignal Integrated Ear Sensor With Datex Connector, and TruSignal Integrated Ear Sensor With Ohmeda Connector.

The sensors were distributed in the United States from Jan. 1, 2021, to March 4, 2023.

According to the recall notice, the malfunctioning sensors “may reduce the amount of energy sent to the heart during defibrillation without any notification to the care provider, which could prevent delivery of lifesaving therapy in a critical situation.

“This issue is most hazardous to hospitalized patients who may need defibrillation for cardiac arrest. Affected sensors may also unintentionally expose patients to electrical currents from other sources or may provide inaccurate measurements of SpO₂, which can impact treatment decisions,” the notice warns.

In an urgent device correction letter sent to health care professionals in May, GE HealthCare recommends that health care professionals do the following:

• Use an alternate method for SpO₂ monitoring, including TruSignal sensors not impacted or an alternate SpO₂ device.
• If alternate methods are not available, use affected TruSignal SpO₂ sensors as long as they have not been saturated with fluids.
• If defibrillation is necessary when affected TruSignal SpO₂ sensors are being used, remove the affected TruSignal SpO₂ sensor, defibrillate per hospital protocol, and reattach the affected TruSignal SpO₂ sensor after defibrillation is no longer needed.
• For Adult/Pediatric SpO₂ sensors, confirm that material does not cover the emitter or detector before using.
• Discard the sensor and use another sensor if any additional material is present.
• Make sure all potential users are made aware of this safety notification and the recommended actions, and retain this notice.

Customers are also asked to complete and return the acknowledgment form attached to the notice to [email protected].

For questions or concerns about this recall, contact GE HealthCare Service at 1-800-437-1171 or a local service representative.

Health care professionals can report adverse reactions or quality problems they experience using these devices to the FDA’s MedWatch program.

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

*Correction, 8/3/23: An earlier version of this article mischaracterized the reports received by the company.

GE HealthCare is recalling 7,559 TruSignal arterial oxygen saturation (SpO₂) sensors because of problems that may reduce defibrillation energy, expose patients to unintended voltage, or give inaccurate readings.

The Food and Drug Administration has identified this as a class I recall, the most serious type. The company has not received any reports of patient injury or deaths as a result of these issues.*

The recall includes the TruSignal Adult Pediatric Sensor, TruSignal AllFit Sensor, TruSignal Sensitive Skin Sensor, TruSignal Wrap Sensor, TruSignal Ear Sensor, TruSignal Integrated Ear Sensor with GE Connector, TruSignal Integrated Ear Sensor With Datex Connector, TruSignal Integrated Ear Sensor With Datex Connector, and TruSignal Integrated Ear Sensor With Ohmeda Connector.

The sensors were distributed in the United States from Jan. 1, 2021, to March 4, 2023.

According to the recall notice, the malfunctioning sensors “may reduce the amount of energy sent to the heart during defibrillation without any notification to the care provider, which could prevent delivery of lifesaving therapy in a critical situation.

“This issue is most hazardous to hospitalized patients who may need defibrillation for cardiac arrest. Affected sensors may also unintentionally expose patients to electrical currents from other sources or may provide inaccurate measurements of SpO₂, which can impact treatment decisions,” the notice warns.

In an urgent device correction letter sent to health care professionals in May, GE HealthCare recommends that health care professionals do the following:

• Use an alternate method for SpO₂ monitoring, including TruSignal sensors not impacted or an alternate SpO₂ device.
• If alternate methods are not available, use affected TruSignal SpO₂ sensors as long as they have not been saturated with fluids.
• If defibrillation is necessary when affected TruSignal SpO₂ sensors are being used, remove the affected TruSignal SpO₂ sensor, defibrillate per hospital protocol, and reattach the affected TruSignal SpO₂ sensor after defibrillation is no longer needed.
• For Adult/Pediatric SpO₂ sensors, confirm that material does not cover the emitter or detector before using.
• Discard the sensor and use another sensor if any additional material is present.
• Make sure all potential users are made aware of this safety notification and the recommended actions, and retain this notice.

Customers are also asked to complete and return the acknowledgment form attached to the notice to [email protected].

For questions or concerns about this recall, contact GE HealthCare Service at 1-800-437-1171 or a local service representative.

Health care professionals can report adverse reactions or quality problems they experience using these devices to the FDA’s MedWatch program.

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

*Correction, 8/3/23: An earlier version of this article mischaracterized the reports received by the company.

A Georgia doctor was cleared in June of having failed to diagnose and treat a child whose acute pancreatitis developed life-threatening complications, according to a report posted on the website of Courtroom View Network.

In 2018, the parents of the then 9-year-old child brought him to Wellstar Paulding Hospital in Hiram, Ga., because of his severe abdominal pain and distention, among other symptoms. Following their examination, medical personnel at the hospital suspected the child’s symptoms were the result of severe constipation.

That evening, he was transferred to Children’s Healthcare of Atlanta, where a pediatric gastroenterologist oversaw his care. (Neither the Atlanta hospital nor Wellstar Paulding were defendants in the subsequent lawsuit.)

Late the following day, the child went into hypovolemic shock, a condition that interrupted the blood supply to his body. Admitted to the pediatric ICU, he was diagnosed with a dangerous complication of acute pancreatitis, necrotizing pancreatitis.

Further complications of his original disease led to a 4-month hospital stay, multiple surgeries, and other interventions. To this point, his medical expenses totaled more than $2.5 million.

His parents then sued the pediatric gastroenterologist who had overseen their child’s care. At issue during the 4-day trial was whether the doctor had properly monitored and treated his patient before his hypovolemic shock set in.

Their attorney sketched the “timeline” of the child’s decline, including his rapid heart rate and repeated vomiting. Given these symptoms, he argued, the standard of care required that steps be taken – including the proper tests and other interventions – to prevent the child’s acute pancreatitis from progressing even further.

“We are not asking you to say, ‘Should [the doctor] have immediately diagnosed pancreatitis,’ “ the attorney told the jury. “But the totality here requires you to think, ‘This might be more than just a backed-up kid.’ ”

The defense pushed back strenuously, however. It argued that the pediatric gastroenterologist had acted appropriately given the prevailing consensus, namely that the child was suffering from extreme constipation. Doctors at Wellstar Paulding, the first hospital where he was seen, suspected this diagnosis – and so, based on his exam and the child’s “non-specific” symptoms, did their client, the pediatric gastroenterologist, who saw him subsequently. “The only clinicians who actually laid hands on [the child] all thought constipation,” the attorney said during his closing argument.

The jury agreed, finding that the pediatric gastroenterologist had acted appropriately, based on the available evidence. Following the jury verdict, the defense attorney noted: Absent the “classic” symptoms of pancreatitis, the jury saw that his client “was working with a reasonable diagnosis until [the child’s] clinical picture deteriorated.”
 

ED doctors can reduce system errors, study says

Emergency physicians are often blamed for system errors beyond their control, asserts a study in the June issue of Emergency Medicine News.

The study – conducted by Tom Belanger, MD, an emergency physician in Texas and chair-elect of the American College of Emergency Physicians Workforce Section – sought to understand to what extent doctors themselves were aware of systemic problems affecting their job. Dr. Belanger surveyed 99 doctors who were asked to comment on a series of ED–related adverse outcomes.

To mitigate response bias, he randomly manipulated the degree to which system error was a perceived factor in each of the adverse cases. In other words, in some cases, the system was represented as a major factor leading to error, while, in other cases, its role was diminished.

Dr. Belanger also divided his doctor/respondents into two groups: The first was asked about his or her personal experience with systemic issues before being presented with the adverse cases; the second group was queried about this experience after being presented with the cases.

The result confirmed Dr. Belanger’s suspicions: Physicians in the first group – that is, those asked about “system factors” before reading about the cases – “were 1.7 times more likely ... to attribute the adverse outcomes in the cases to system factors. (Other significant variables – including whether their shift was busy – also contributed to doctors’ perceptions of adverse outcomes.)

Concluded Dr. Belanger: Since doctors “can identify factors that increase their chances of making mistakes,” system designers should take heed and make efforts to reduce “the probability of error.” If they drag their heels or continue to point to individual doctor error, “they should be held medically and legally liable.”
 

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

A Georgia doctor was cleared in June of having failed to diagnose and treat a child whose acute pancreatitis developed life-threatening complications, according to a report posted on the website of Courtroom View Network.

In 2018, the parents of the then 9-year-old child brought him to Wellstar Paulding Hospital in Hiram, Ga., because of his severe abdominal pain and distention, among other symptoms. Following their examination, medical personnel at the hospital suspected the child’s symptoms were the result of severe constipation.

That evening, he was transferred to Children’s Healthcare of Atlanta, where a pediatric gastroenterologist oversaw his care. (Neither the Atlanta hospital nor Wellstar Paulding were defendants in the subsequent lawsuit.)

Late the following day, the child went into hypovolemic shock, a condition that interrupted the blood supply to his body. Admitted to the pediatric ICU, he was diagnosed with a dangerous complication of acute pancreatitis, necrotizing pancreatitis.

Further complications of his original disease led to a 4-month hospital stay, multiple surgeries, and other interventions. To this point, his medical expenses totaled more than $2.5 million.

His parents then sued the pediatric gastroenterologist who had overseen their child’s care. At issue during the 4-day trial was whether the doctor had properly monitored and treated his patient before his hypovolemic shock set in.

Their attorney sketched the “timeline” of the child’s decline, including his rapid heart rate and repeated vomiting. Given these symptoms, he argued, the standard of care required that steps be taken – including the proper tests and other interventions – to prevent the child’s acute pancreatitis from progressing even further.

“We are not asking you to say, ‘Should [the doctor] have immediately diagnosed pancreatitis,’ “ the attorney told the jury. “But the totality here requires you to think, ‘This might be more than just a backed-up kid.’ ”

The defense pushed back strenuously, however. It argued that the pediatric gastroenterologist had acted appropriately given the prevailing consensus, namely that the child was suffering from extreme constipation. Doctors at Wellstar Paulding, the first hospital where he was seen, suspected this diagnosis – and so, based on his exam and the child’s “non-specific” symptoms, did their client, the pediatric gastroenterologist, who saw him subsequently. “The only clinicians who actually laid hands on [the child] all thought constipation,” the attorney said during his closing argument.

The jury agreed, finding that the pediatric gastroenterologist had acted appropriately, based on the available evidence. Following the jury verdict, the defense attorney noted: Absent the “classic” symptoms of pancreatitis, the jury saw that his client “was working with a reasonable diagnosis until [the child’s] clinical picture deteriorated.”
 

ED doctors can reduce system errors, study says

Emergency physicians are often blamed for system errors beyond their control, asserts a study in the June issue of Emergency Medicine News.

The study – conducted by Tom Belanger, MD, an emergency physician in Texas and chair-elect of the American College of Emergency Physicians Workforce Section – sought to understand to what extent doctors themselves were aware of systemic problems affecting their job. Dr. Belanger surveyed 99 doctors who were asked to comment on a series of ED–related adverse outcomes.

To mitigate response bias, he randomly manipulated the degree to which system error was a perceived factor in each of the adverse cases. In other words, in some cases, the system was represented as a major factor leading to error, while, in other cases, its role was diminished.

Dr. Belanger also divided his doctor/respondents into two groups: The first was asked about his or her personal experience with systemic issues before being presented with the adverse cases; the second group was queried about this experience after being presented with the cases.

The result confirmed Dr. Belanger’s suspicions: Physicians in the first group – that is, those asked about “system factors” before reading about the cases – “were 1.7 times more likely ... to attribute the adverse outcomes in the cases to system factors. (Other significant variables – including whether their shift was busy – also contributed to doctors’ perceptions of adverse outcomes.)

Concluded Dr. Belanger: Since doctors “can identify factors that increase their chances of making mistakes,” system designers should take heed and make efforts to reduce “the probability of error.” If they drag their heels or continue to point to individual doctor error, “they should be held medically and legally liable.”
 

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

A Georgia doctor was cleared in June of having failed to diagnose and treat a child whose acute pancreatitis developed life-threatening complications, according to a report posted on the website of Courtroom View Network.

In 2018, the parents of the then 9-year-old child brought him to Wellstar Paulding Hospital in Hiram, Ga., because of his severe abdominal pain and distention, among other symptoms. Following their examination, medical personnel at the hospital suspected the child’s symptoms were the result of severe constipation.

That evening, he was transferred to Children’s Healthcare of Atlanta, where a pediatric gastroenterologist oversaw his care. (Neither the Atlanta hospital nor Wellstar Paulding were defendants in the subsequent lawsuit.)

Late the following day, the child went into hypovolemic shock, a condition that interrupted the blood supply to his body. Admitted to the pediatric ICU, he was diagnosed with a dangerous complication of acute pancreatitis, necrotizing pancreatitis.

Further complications of his original disease led to a 4-month hospital stay, multiple surgeries, and other interventions. To this point, his medical expenses totaled more than $2.5 million.

His parents then sued the pediatric gastroenterologist who had overseen their child’s care. At issue during the 4-day trial was whether the doctor had properly monitored and treated his patient before his hypovolemic shock set in.

Their attorney sketched the “timeline” of the child’s decline, including his rapid heart rate and repeated vomiting. Given these symptoms, he argued, the standard of care required that steps be taken – including the proper tests and other interventions – to prevent the child’s acute pancreatitis from progressing even further.

“We are not asking you to say, ‘Should [the doctor] have immediately diagnosed pancreatitis,’ “ the attorney told the jury. “But the totality here requires you to think, ‘This might be more than just a backed-up kid.’ ”

The defense pushed back strenuously, however. It argued that the pediatric gastroenterologist had acted appropriately given the prevailing consensus, namely that the child was suffering from extreme constipation. Doctors at Wellstar Paulding, the first hospital where he was seen, suspected this diagnosis – and so, based on his exam and the child’s “non-specific” symptoms, did their client, the pediatric gastroenterologist, who saw him subsequently. “The only clinicians who actually laid hands on [the child] all thought constipation,” the attorney said during his closing argument.

The jury agreed, finding that the pediatric gastroenterologist had acted appropriately, based on the available evidence. Following the jury verdict, the defense attorney noted: Absent the “classic” symptoms of pancreatitis, the jury saw that his client “was working with a reasonable diagnosis until [the child’s] clinical picture deteriorated.”
 

ED doctors can reduce system errors, study says

Emergency physicians are often blamed for system errors beyond their control, asserts a study in the June issue of Emergency Medicine News.

The study – conducted by Tom Belanger, MD, an emergency physician in Texas and chair-elect of the American College of Emergency Physicians Workforce Section – sought to understand to what extent doctors themselves were aware of systemic problems affecting their job. Dr. Belanger surveyed 99 doctors who were asked to comment on a series of ED–related adverse outcomes.

To mitigate response bias, he randomly manipulated the degree to which system error was a perceived factor in each of the adverse cases. In other words, in some cases, the system was represented as a major factor leading to error, while, in other cases, its role was diminished.

Dr. Belanger also divided his doctor/respondents into two groups: The first was asked about his or her personal experience with systemic issues before being presented with the adverse cases; the second group was queried about this experience after being presented with the cases.

The result confirmed Dr. Belanger’s suspicions: Physicians in the first group – that is, those asked about “system factors” before reading about the cases – “were 1.7 times more likely ... to attribute the adverse outcomes in the cases to system factors. (Other significant variables – including whether their shift was busy – also contributed to doctors’ perceptions of adverse outcomes.)

Concluded Dr. Belanger: Since doctors “can identify factors that increase their chances of making mistakes,” system designers should take heed and make efforts to reduce “the probability of error.” If they drag their heels or continue to point to individual doctor error, “they should be held medically and legally liable.”
 

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

In March 2023, four “medical tourists” from South Carolina who were seeking health care in Mexico were kidnapped by a drug cartel. Two were killed when they were trapped in a shootout. One of them was scheduled for tummy-tuck surgery, and others were seeking cheaper prescription drugs.

The news reached Bruce Hermann, MD, a plastic surgeon in Denton, Tex., who brought up the incident in a segment of his podcast, “Nip Talk,” in which he talked about the risks of medical tourism. But violence in foreign countries isn’t Dr. Hermann’s primary concern.

“Being the victim of a crime is lower down the risk strata,” Dr. Hermann said in an interview. “A bigger concern is the lack of regulations of doctors and facilities in countries like Mexico.”

The savings from medical tourism may be tempting, but the unpredictable clinical risks are daunting. Some employers pay for treatment at certain foreign clinics, and Blue Shield of California’s HMO plan, Access Baja, covers care in certain clinics in Mexico’s Baja peninsula. But U.S. health insurance generally does not cover medical tourism.

Despite its popularity, medical tourism is not siphoning off a significant number of patients from U.S. doctors, with the possible exception of plastic surgery. One study found that medical tourism accounts for less than 2% of U.S. spending on noncosmetic health care.

Still, as many as 1.2 million Americans travel to Mexico each year seeking health care at lower costs, particularly dental care, bariatric surgery, and cosmetic procedures.

Physicians such as Dr. Hermann see the results when things go awry. Dr. Hermann said when he takes calls at a nearby level II trauma center, he sees, on average, one patient a month with complications from plastic surgeries performed abroad.

Patients tell Dr. Hermann they often had little preoperative time with the surgeons, and some may not even see their surgeon. They have to fly back home just days after their procedures, so complications that typically arise later are missed, he said.
 

Who opts for medical tourism?

There are few statistics on the number of medical tourists or the clinical problems they have. Josef Woodman, CEO of Patients Beyond Borders, a medical tourism consultancy in Chapel Hill, N.C., has developed a profile of medical tourism that is based on his close contacts within the industry.

Mr. Woodman said the vast majority of U.S. medical tourists go to Mexico, which accounts for an estimated 1 million to 1.2 million medical visitors a year. He said Costa Rica is another popular destination, followed by other Latin American countries and some in the Far East, the Middle East, and Eastern Europe.

Mr. Woodman estimates that dental treatments make up 65% of all medical tourism. Cosmetic procedures come in a distant second, at 15%. Cosmetic procedures can be expensive and are rarely covered by insurance. They can be performed at half the price abroad, he said.

According to Mr. Woodman, other significant fields for medical tourism are orthopedics, which accounts for 5% of all visits, and bariatrics, with 3%-5%. Hip and knee replacements are expensive, and in the case of bariatrics, U.S. insurers often deny coverage, he said.

People also go abroad for fertility care and organ transplants, and one Jamaica company even offered dialysis vacations for U.S. tourists.

On the other hand, medical tourism does not work well for cancer treatments, because cancer care involves long periods of treatment and cannot be completed in a trip or two, Mr. Woodman said. “The media also plays up major procedures like open heart surgery, but they are in fact very rare,” he added.
 

What patients are looking for

Medical tourists typically pay 50%-70% of what they would pay in the United States for the same procedure, Mr. Woodman said. Prices are lower because patients pay in cash, foreign wages are lower, and expenses such as malpractice insurance are much lower.

“Many medical tourists don’t have a choice,” Mr. Woodman said. “They cannot afford the U.S. price for the procedure, even if they have health insurance, because they often have a high deductible.” In one study, the majority of medical tourists to Mexico reported an income of $25,000-$50,000 a year.

That same study also found that the average age of medical tourists was just under 65. These older patients often come for a vacation. “A sizable number of medical tourists are looking for surgery plus a vacation, a tummy-tuck and a stay at an all-inclusive resort,” said Steven P. Davison, MD, DDS, a plastic surgeon in Washington, who has written on the phenomenon.

Another large group of medical tourists are immigrants to the United States who want surgery in their country of origin, such as Brazil or Iran, Dr. Davison said, perhaps because they feel more comfortable or have family members who can act as caregivers. He said some go to places that have expertise in a certain procedure.

“For instance, they get their hair transplantation done in Turkey because surgeons there have the expertise and it’s cheaper than in the United States,” Dr. Davison said.
 

Arranging the trip

Patients often find foreign providers through online brokers who can arrange the flight, hotel, clinic, and physician. Brokers are not unbiased because they are usually paid by the clinic. Mr. Woodman said this arrangement works when the broker can offer a wide variety of options but not when the broker represents just a few clinics.

Mr. Woodman said patients could conceivably make their own arrangements without a broker, and some do so. “All the tools are on the Internet,” he said. “However, many people don’t trust themselves to do this work.”

Even for patients who depend on brokers, Mr. Woodman advises verifying the quality of the clinic and its doctors before signing on. Most countries have online lists of registered doctors, and patients seeking health care can research complaints against a doctor.

There is no insurance that patients can have to guard against the risks of medical tourism, Mr. Woodman said. “When you could get it, it was prohibitively expensive,” he said. “You can get travel insurance, but that just covers peripheral problems, such as flight cancellations, accidental injury, and emergency care. It has nothing to do with problems stemming from planned procedures.

“Some clinics and hospitals serving medical tourists provide warranties on their work,” he added. “However, plastic surgery clinics are less likely to offer warranties, because patients are so frequently dissatisfied.”
 

How things can go wrong

Mr. Woodman said medical tourists may often receive substandard care when they select a provider who offers unusually large savings, such as 80% off the U.S. price. “Those providers are likely cutting corners to get that kind of savings, and you should stay away from them,” he said.

Even when receiving care at an excellent clinic, patients can get infections if postoperative requirements are not followed, according to Darrick E. Antell, MD, a plastic surgeon in New York, who has treated medical tourists upon their return to the United States.

Typically, patients are told to stay in their rooms for several days after the operation, but friends may push them to go out and have fun, he said. Sometimes patients choose exotic arrangements that place them at risk for infection. As an example, Dr. Antell mentioned a broker who offered a safari in combination with plastic surgery.

Dr. Hermann said tummy tucks are riskier because they involve large incisions, and many such patients are overweight, which impairs healing. “Tummy-tuck patients need a longer recovery, and they often have more discomfort than other plastic surgery,” he said.

When things go wrong, medical tourists have few legal protections. “They usually don’t go to an accredited facility, there is no credentialing of physicians, and their ability to sue is extremely limited,” Dr. Davison said. Patients would have to return to the foreign country and hire a lawyer there, and even then, it is harder to win a case and to receive an award as high as in the United States, he added.
 

Dealing with follow-ups

An inherent flaw with medical tourism, Dr. Antell said, is that patients typically go back home before postoperative care is fully completed. “They may stay just a few days after surgery, and then fly back home,” he said.

“Patients who have complex operations abroad should stay for 8-10 days to have a proper follow-up,” he said. “But they fly back early, which can also lead to getting pulmonary embolisms on the flight.

“A checkup right after surgery doesn’t uncover many complications, because these tend to occur 7-12 days after surgery,” Dr. Hermann said.

“If they come to me within 3 months after surgery, I charge an upfront fee just to see them, because it takes an hour of my time,” Dr. Davison said. “Then I will take care of acute emergency, such as taking out an infected implant.”

Hermann said many patients wait too long to have their complications treated in the United States. “They may first try calling their doctor in Mexico, who tells them to take some antibiotics or something,” he said. “So when they finally do seek care, the infection is pretty far along.”
 

What U.S. doctors can do

Patients rarely tell their U.S. doctors that they are planning a trip to a foreign country to undergo medical treatment, even though they have to request a copy of their medical records for the foreign doctor, Mr. Woodman said.

Dr. Hermann said only one of his patients told him she was planning to go aboard for plastic surgery. “She was a young mom, and I tried to talk her out of it,” he said. “I don’t know what happened because she didn’t come back.”

Dr. Hermann said doctors should assume that they won’t be able to change their patients’ minds, and they should try to help their patients make the best of it.

“They should insist on seeing the doctor ahead of time and make sure they get along with them,” he said. “Ask for credentialing of the doctor and the facility, and stay there several weeks post op. But they’re probably not going to do all of this.”

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

In March 2023, four “medical tourists” from South Carolina who were seeking health care in Mexico were kidnapped by a drug cartel. Two were killed when they were trapped in a shootout. One of them was scheduled for tummy-tuck surgery, and others were seeking cheaper prescription drugs.

The news reached Bruce Hermann, MD, a plastic surgeon in Denton, Tex., who brought up the incident in a segment of his podcast, “Nip Talk,” in which he talked about the risks of medical tourism. But violence in foreign countries isn’t Dr. Hermann’s primary concern.

“Being the victim of a crime is lower down the risk strata,” Dr. Hermann said in an interview. “A bigger concern is the lack of regulations of doctors and facilities in countries like Mexico.”

The savings from medical tourism may be tempting, but the unpredictable clinical risks are daunting. Some employers pay for treatment at certain foreign clinics, and Blue Shield of California’s HMO plan, Access Baja, covers care in certain clinics in Mexico’s Baja peninsula. But U.S. health insurance generally does not cover medical tourism.

Despite its popularity, medical tourism is not siphoning off a significant number of patients from U.S. doctors, with the possible exception of plastic surgery. One study found that medical tourism accounts for less than 2% of U.S. spending on noncosmetic health care.

Still, as many as 1.2 million Americans travel to Mexico each year seeking health care at lower costs, particularly dental care, bariatric surgery, and cosmetic procedures.

Physicians such as Dr. Hermann see the results when things go awry. Dr. Hermann said when he takes calls at a nearby level II trauma center, he sees, on average, one patient a month with complications from plastic surgeries performed abroad.

Patients tell Dr. Hermann they often had little preoperative time with the surgeons, and some may not even see their surgeon. They have to fly back home just days after their procedures, so complications that typically arise later are missed, he said.
 

Who opts for medical tourism?

There are few statistics on the number of medical tourists or the clinical problems they have. Josef Woodman, CEO of Patients Beyond Borders, a medical tourism consultancy in Chapel Hill, N.C., has developed a profile of medical tourism that is based on his close contacts within the industry.

Mr. Woodman said the vast majority of U.S. medical tourists go to Mexico, which accounts for an estimated 1 million to 1.2 million medical visitors a year. He said Costa Rica is another popular destination, followed by other Latin American countries and some in the Far East, the Middle East, and Eastern Europe.

Mr. Woodman estimates that dental treatments make up 65% of all medical tourism. Cosmetic procedures come in a distant second, at 15%. Cosmetic procedures can be expensive and are rarely covered by insurance. They can be performed at half the price abroad, he said.

According to Mr. Woodman, other significant fields for medical tourism are orthopedics, which accounts for 5% of all visits, and bariatrics, with 3%-5%. Hip and knee replacements are expensive, and in the case of bariatrics, U.S. insurers often deny coverage, he said.

People also go abroad for fertility care and organ transplants, and one Jamaica company even offered dialysis vacations for U.S. tourists.

On the other hand, medical tourism does not work well for cancer treatments, because cancer care involves long periods of treatment and cannot be completed in a trip or two, Mr. Woodman said. “The media also plays up major procedures like open heart surgery, but they are in fact very rare,” he added.
 

What patients are looking for

Medical tourists typically pay 50%-70% of what they would pay in the United States for the same procedure, Mr. Woodman said. Prices are lower because patients pay in cash, foreign wages are lower, and expenses such as malpractice insurance are much lower.

“Many medical tourists don’t have a choice,” Mr. Woodman said. “They cannot afford the U.S. price for the procedure, even if they have health insurance, because they often have a high deductible.” In one study, the majority of medical tourists to Mexico reported an income of $25,000-$50,000 a year.

That same study also found that the average age of medical tourists was just under 65. These older patients often come for a vacation. “A sizable number of medical tourists are looking for surgery plus a vacation, a tummy-tuck and a stay at an all-inclusive resort,” said Steven P. Davison, MD, DDS, a plastic surgeon in Washington, who has written on the phenomenon.

Another large group of medical tourists are immigrants to the United States who want surgery in their country of origin, such as Brazil or Iran, Dr. Davison said, perhaps because they feel more comfortable or have family members who can act as caregivers. He said some go to places that have expertise in a certain procedure.

“For instance, they get their hair transplantation done in Turkey because surgeons there have the expertise and it’s cheaper than in the United States,” Dr. Davison said.
 

Arranging the trip

Patients often find foreign providers through online brokers who can arrange the flight, hotel, clinic, and physician. Brokers are not unbiased because they are usually paid by the clinic. Mr. Woodman said this arrangement works when the broker can offer a wide variety of options but not when the broker represents just a few clinics.

Mr. Woodman said patients could conceivably make their own arrangements without a broker, and some do so. “All the tools are on the Internet,” he said. “However, many people don’t trust themselves to do this work.”

Even for patients who depend on brokers, Mr. Woodman advises verifying the quality of the clinic and its doctors before signing on. Most countries have online lists of registered doctors, and patients seeking health care can research complaints against a doctor.

There is no insurance that patients can have to guard against the risks of medical tourism, Mr. Woodman said. “When you could get it, it was prohibitively expensive,” he said. “You can get travel insurance, but that just covers peripheral problems, such as flight cancellations, accidental injury, and emergency care. It has nothing to do with problems stemming from planned procedures.

“Some clinics and hospitals serving medical tourists provide warranties on their work,” he added. “However, plastic surgery clinics are less likely to offer warranties, because patients are so frequently dissatisfied.”
 

How things can go wrong

Mr. Woodman said medical tourists may often receive substandard care when they select a provider who offers unusually large savings, such as 80% off the U.S. price. “Those providers are likely cutting corners to get that kind of savings, and you should stay away from them,” he said.

Even when receiving care at an excellent clinic, patients can get infections if postoperative requirements are not followed, according to Darrick E. Antell, MD, a plastic surgeon in New York, who has treated medical tourists upon their return to the United States.

Typically, patients are told to stay in their rooms for several days after the operation, but friends may push them to go out and have fun, he said. Sometimes patients choose exotic arrangements that place them at risk for infection. As an example, Dr. Antell mentioned a broker who offered a safari in combination with plastic surgery.

Dr. Hermann said tummy tucks are riskier because they involve large incisions, and many such patients are overweight, which impairs healing. “Tummy-tuck patients need a longer recovery, and they often have more discomfort than other plastic surgery,” he said.

When things go wrong, medical tourists have few legal protections. “They usually don’t go to an accredited facility, there is no credentialing of physicians, and their ability to sue is extremely limited,” Dr. Davison said. Patients would have to return to the foreign country and hire a lawyer there, and even then, it is harder to win a case and to receive an award as high as in the United States, he added.
 

Dealing with follow-ups

An inherent flaw with medical tourism, Dr. Antell said, is that patients typically go back home before postoperative care is fully completed. “They may stay just a few days after surgery, and then fly back home,” he said.

“Patients who have complex operations abroad should stay for 8-10 days to have a proper follow-up,” he said. “But they fly back early, which can also lead to getting pulmonary embolisms on the flight.

“A checkup right after surgery doesn’t uncover many complications, because these tend to occur 7-12 days after surgery,” Dr. Hermann said.

“If they come to me within 3 months after surgery, I charge an upfront fee just to see them, because it takes an hour of my time,” Dr. Davison said. “Then I will take care of acute emergency, such as taking out an infected implant.”

Hermann said many patients wait too long to have their complications treated in the United States. “They may first try calling their doctor in Mexico, who tells them to take some antibiotics or something,” he said. “So when they finally do seek care, the infection is pretty far along.”
 

What U.S. doctors can do

Patients rarely tell their U.S. doctors that they are planning a trip to a foreign country to undergo medical treatment, even though they have to request a copy of their medical records for the foreign doctor, Mr. Woodman said.

Dr. Hermann said only one of his patients told him she was planning to go aboard for plastic surgery. “She was a young mom, and I tried to talk her out of it,” he said. “I don’t know what happened because she didn’t come back.”

Dr. Hermann said doctors should assume that they won’t be able to change their patients’ minds, and they should try to help their patients make the best of it.

“They should insist on seeing the doctor ahead of time and make sure they get along with them,” he said. “Ask for credentialing of the doctor and the facility, and stay there several weeks post op. But they’re probably not going to do all of this.”

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

In March 2023, four “medical tourists” from South Carolina who were seeking health care in Mexico were kidnapped by a drug cartel. Two were killed when they were trapped in a shootout. One of them was scheduled for tummy-tuck surgery, and others were seeking cheaper prescription drugs.

The news reached Bruce Hermann, MD, a plastic surgeon in Denton, Tex., who brought up the incident in a segment of his podcast, “Nip Talk,” in which he talked about the risks of medical tourism. But violence in foreign countries isn’t Dr. Hermann’s primary concern.

“Being the victim of a crime is lower down the risk strata,” Dr. Hermann said in an interview. “A bigger concern is the lack of regulations of doctors and facilities in countries like Mexico.”

The savings from medical tourism may be tempting, but the unpredictable clinical risks are daunting. Some employers pay for treatment at certain foreign clinics, and Blue Shield of California’s HMO plan, Access Baja, covers care in certain clinics in Mexico’s Baja peninsula. But U.S. health insurance generally does not cover medical tourism.

Despite its popularity, medical tourism is not siphoning off a significant number of patients from U.S. doctors, with the possible exception of plastic surgery. One study found that medical tourism accounts for less than 2% of U.S. spending on noncosmetic health care.

Still, as many as 1.2 million Americans travel to Mexico each year seeking health care at lower costs, particularly dental care, bariatric surgery, and cosmetic procedures.

Physicians such as Dr. Hermann see the results when things go awry. Dr. Hermann said when he takes calls at a nearby level II trauma center, he sees, on average, one patient a month with complications from plastic surgeries performed abroad.

Patients tell Dr. Hermann they often had little preoperative time with the surgeons, and some may not even see their surgeon. They have to fly back home just days after their procedures, so complications that typically arise later are missed, he said.
 

Who opts for medical tourism?

There are few statistics on the number of medical tourists or the clinical problems they have. Josef Woodman, CEO of Patients Beyond Borders, a medical tourism consultancy in Chapel Hill, N.C., has developed a profile of medical tourism that is based on his close contacts within the industry.

Mr. Woodman said the vast majority of U.S. medical tourists go to Mexico, which accounts for an estimated 1 million to 1.2 million medical visitors a year. He said Costa Rica is another popular destination, followed by other Latin American countries and some in the Far East, the Middle East, and Eastern Europe.

Mr. Woodman estimates that dental treatments make up 65% of all medical tourism. Cosmetic procedures come in a distant second, at 15%. Cosmetic procedures can be expensive and are rarely covered by insurance. They can be performed at half the price abroad, he said.

According to Mr. Woodman, other significant fields for medical tourism are orthopedics, which accounts for 5% of all visits, and bariatrics, with 3%-5%. Hip and knee replacements are expensive, and in the case of bariatrics, U.S. insurers often deny coverage, he said.

People also go abroad for fertility care and organ transplants, and one Jamaica company even offered dialysis vacations for U.S. tourists.

On the other hand, medical tourism does not work well for cancer treatments, because cancer care involves long periods of treatment and cannot be completed in a trip or two, Mr. Woodman said. “The media also plays up major procedures like open heart surgery, but they are in fact very rare,” he added.
 

What patients are looking for

Medical tourists typically pay 50%-70% of what they would pay in the United States for the same procedure, Mr. Woodman said. Prices are lower because patients pay in cash, foreign wages are lower, and expenses such as malpractice insurance are much lower.

“Many medical tourists don’t have a choice,” Mr. Woodman said. “They cannot afford the U.S. price for the procedure, even if they have health insurance, because they often have a high deductible.” In one study, the majority of medical tourists to Mexico reported an income of $25,000-$50,000 a year.

That same study also found that the average age of medical tourists was just under 65. These older patients often come for a vacation. “A sizable number of medical tourists are looking for surgery plus a vacation, a tummy-tuck and a stay at an all-inclusive resort,” said Steven P. Davison, MD, DDS, a plastic surgeon in Washington, who has written on the phenomenon.

Another large group of medical tourists are immigrants to the United States who want surgery in their country of origin, such as Brazil or Iran, Dr. Davison said, perhaps because they feel more comfortable or have family members who can act as caregivers. He said some go to places that have expertise in a certain procedure.

“For instance, they get their hair transplantation done in Turkey because surgeons there have the expertise and it’s cheaper than in the United States,” Dr. Davison said.
 

Arranging the trip

Patients often find foreign providers through online brokers who can arrange the flight, hotel, clinic, and physician. Brokers are not unbiased because they are usually paid by the clinic. Mr. Woodman said this arrangement works when the broker can offer a wide variety of options but not when the broker represents just a few clinics.

Mr. Woodman said patients could conceivably make their own arrangements without a broker, and some do so. “All the tools are on the Internet,” he said. “However, many people don’t trust themselves to do this work.”

Even for patients who depend on brokers, Mr. Woodman advises verifying the quality of the clinic and its doctors before signing on. Most countries have online lists of registered doctors, and patients seeking health care can research complaints against a doctor.

There is no insurance that patients can have to guard against the risks of medical tourism, Mr. Woodman said. “When you could get it, it was prohibitively expensive,” he said. “You can get travel insurance, but that just covers peripheral problems, such as flight cancellations, accidental injury, and emergency care. It has nothing to do with problems stemming from planned procedures.

“Some clinics and hospitals serving medical tourists provide warranties on their work,” he added. “However, plastic surgery clinics are less likely to offer warranties, because patients are so frequently dissatisfied.”
 

How things can go wrong

Mr. Woodman said medical tourists may often receive substandard care when they select a provider who offers unusually large savings, such as 80% off the U.S. price. “Those providers are likely cutting corners to get that kind of savings, and you should stay away from them,” he said.

Even when receiving care at an excellent clinic, patients can get infections if postoperative requirements are not followed, according to Darrick E. Antell, MD, a plastic surgeon in New York, who has treated medical tourists upon their return to the United States.

Typically, patients are told to stay in their rooms for several days after the operation, but friends may push them to go out and have fun, he said. Sometimes patients choose exotic arrangements that place them at risk for infection. As an example, Dr. Antell mentioned a broker who offered a safari in combination with plastic surgery.

Dr. Hermann said tummy tucks are riskier because they involve large incisions, and many such patients are overweight, which impairs healing. “Tummy-tuck patients need a longer recovery, and they often have more discomfort than other plastic surgery,” he said.

When things go wrong, medical tourists have few legal protections. “They usually don’t go to an accredited facility, there is no credentialing of physicians, and their ability to sue is extremely limited,” Dr. Davison said. Patients would have to return to the foreign country and hire a lawyer there, and even then, it is harder to win a case and to receive an award as high as in the United States, he added.
 

Dealing with follow-ups

An inherent flaw with medical tourism, Dr. Antell said, is that patients typically go back home before postoperative care is fully completed. “They may stay just a few days after surgery, and then fly back home,” he said.

“Patients who have complex operations abroad should stay for 8-10 days to have a proper follow-up,” he said. “But they fly back early, which can also lead to getting pulmonary embolisms on the flight.

“A checkup right after surgery doesn’t uncover many complications, because these tend to occur 7-12 days after surgery,” Dr. Hermann said.

“If they come to me within 3 months after surgery, I charge an upfront fee just to see them, because it takes an hour of my time,” Dr. Davison said. “Then I will take care of acute emergency, such as taking out an infected implant.”

Hermann said many patients wait too long to have their complications treated in the United States. “They may first try calling their doctor in Mexico, who tells them to take some antibiotics or something,” he said. “So when they finally do seek care, the infection is pretty far along.”
 

What U.S. doctors can do

Patients rarely tell their U.S. doctors that they are planning a trip to a foreign country to undergo medical treatment, even though they have to request a copy of their medical records for the foreign doctor, Mr. Woodman said.

Dr. Hermann said only one of his patients told him she was planning to go aboard for plastic surgery. “She was a young mom, and I tried to talk her out of it,” he said. “I don’t know what happened because she didn’t come back.”

Dr. Hermann said doctors should assume that they won’t be able to change their patients’ minds, and they should try to help their patients make the best of it.

“They should insist on seeing the doctor ahead of time and make sure they get along with them,” he said. “Ask for credentialing of the doctor and the facility, and stay there several weeks post op. But they’re probably not going to do all of this.”

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

Like hundreds of other medical experts, Leana Wen, MD, an emergency physician and former Baltimore health commissioner, was an early and avid supporter of COVID vaccines and their ability to prevent severe disease, hospitalization, and death from SARS-CoV-2 infections.

When 51-year-old Scott Eli Harris, of Aubrey, Tex., heard of Dr. Wen’s stance in July 2021, the self-described “fifth-generation U.S. Army veteran and a sniper” sent Dr. Wen an electronic invective laden with racist language and very specific threats to shoot her.

Mr. Harris pled guilty to transmitting threats via interstate commerce last February and began serving 6 months in federal prison in the fall of 2022, but his threats wouldn’t be the last for Dr. Wen. Just 2 days after Mr. Harris was sentenced, charges were unsealed against another man in Massachusetts, who threatened that Dr. Wen would “end up in pieces” if she continued “pushing” her thoughts publicly.’

Dr. Wen has plenty of company. In an August 2022 survey of emergency doctors conducted by the American College of Emergency Physicians, 85% of respondents said violence against them is increasing. One in four doctors said they’re being assaulted by patients and their family and friends multiple times a week, compared with just 8% of doctors who said as much in 2018. About 64% of emergency physicians reported receiving verbal assaults and threats of violence; 40% reported being hit or slapped, and 26% were kicked.

This uptick of violence and threats against physicians didn’t come out of nowhere; violence against health care workers has been gradually increasing over the past decade. Health care providers can attest to the hostility that particular topics have sparked for years: vaccines in pediatrics, abortion in ob.gyn., and gender-affirming care in endocrinology.

But the pandemic fueled the fire. While there have always been hot-button issues in medicine, the ire they arouse today is more intense than ever before. The proliferation of misinformation (often via social media) and the politicization of public health and medicine are at the center of the problem.
 

‘The people attacking are themselves victims’

The misinformation problem first came to a head in one area of public health: vaccines. The pandemic accelerated antagonism in medicine – thanks, in part, to decades of antivaccine activism.

The antivaccine movement, which has ebbed and flowed in the United States and across the globe since the first vaccine, experienced a new wave in the early 2000s with the combination of concerns about thimerosal in vaccines and a now disproven link between autism and the MMR vaccine. But that movement grew. It picked up steam when activists gained political clout after a 2014 measles outbreak at Disneyland led California schools to tighten up policies regarding vaccinations for kids who enrolled. These stronger public school vaccination laws ran up against religious freedom arguments from antivaccine advocates.

Use of social media continues to grow, and with it, the spread of misinformation. A recent study found that Facebook “users’ social media habits doubled, and in some cases, tripled the amount of fake news they shared.”

In the face of growing confusion, health care providers and public health experts have often struggled to treat their patients – and communicate to the public – without appearing political.

“The people that are doing the attacking are in some ways themselves victims,” said Peter Hotez, MD, PhD, dean of the National School of Tropical Medicine at Baylor College of Medicine, Houston. “They’re victims of the antiscience, antihealth ecosystem coming out of Fox News, the House Freedom Caucus, the CPAC conference, coming out of contrarian intellectuals.”

Many of Dr. Hotez’s colleagues don’t want to talk about the political right as an enabler of scientific disinformation, he said, but that doesn’t change what the evidence shows. The vast majority of state and national bills opposing vaccination, gender-affirming care, comprehensive reproductive care, and other evidence-based medical care often come from Republican legislators.
 

When politics and health care collide

“We’re in an incredible status quo,” said William Schaffner, MD, the previous director of the Infectious Diseases Society of America and a professor of infectious diseases and preventive medicine at Vanderbilt University, Nashville, Tenn. “You can’t get away from the politics, because you have [political] candidates espousing certain concepts that are antithetical to good public health.”

In March 2023, Florida Gov. Ron DeSantis’s surgeon general, Joseph Ladapo, MD, PhD, warned that COVID vaccines are harmful to young men, prompting rebukes from federal health authorities. It later came out that Dr. Ladapo had changed some of the results of the study before issuing his warning. But long before 2023, there emerged an increasing gap in COVID deaths between red states and blue states, mirroring the vaccination rates in those states. The redder the state, the higher the death toll.

It’s not just Republican Party culture warriors; medical misinformation is also finding increasing purchase on the far left. Robert F. Kennedy Jr. and Marianne Williamson, both of whom have launched long-shot challenges to President Biden for the 2024 Democratic nomination, had promoted antivaccine ideas long before the COVID pandemic. Mr. Kennedy continues to spread misinformation.

In June 2023, Joe Rogan hosted Mr. Kennedy, on his podcast. During the episode, Mr. Rogan listened uncritically as Mr. Kennedy told his millions of listeners that vaccines cause autism and that 5G causes cancer, among other fringe, often-debunked theories.

Dr. Hotez, a prominent misinformation debunker who was also part of a team that designed a low-cost COVID-19 vaccine, wrote on Twitter that the episode was “just awful.”

The backlash began almost immediately. Mr. Rogan, who has over 11 million followers on Twitter, responded with a public challenge for Dr. Hotez to debate Mr. Kennedy on Mr. Rogan’s show, with a reward of $100,000 to the charity of Dr. Hotez’s choice. More offers streamed in, including from Elon Musk, who tweeted that Dr. Hotez was “afraid of a public debate, because he knows he’s wrong.” More supporters of Mr. Kennedy and Mr. Rogan piled on.

Vaccine skeptics even showed up at Dr. Hotez’s house, filming him as he was returning from buying a Father’s Day cake and taunting him to debate Mr. Kennedy.
 

A turn in the pandemic

For a precious few weeks at the start of the pandemic, it felt as though the country was all in this together. There were arguments against closing schools and shutting down businesses, but for the most part, the nation had about 4 solid weeks of solidarity.

As masking mandates changed and the public health establishment lost the confidence of Americans, the veneer of solidarity began to chip away.

“Things were changing so rapidly during the pandemic that it was very hard for staff and patients to understand the changing guidelines, whether it was visitor constraints or masking,” said Carrie Nelson, the chief medical officer at the telehealth company AmWell, who worked as a supervisor at a large health care system in the Midwest until 2021.

In the midst of the public health crisis, former President Trump was downplaying the severity of the disease and was silencing officials from the Centers for Disease Control and Prevention, such as Nancy Messonier, who warned from the very beginning of the pandemic’s potential.

When the vaccines came out, the latent antivaccine movement flared up once again. And this time – unlike in decades past – the debate over vaccines had become partisan.

“Before the pandemic,” said Christopher Thomas, an emergency physician on the West Coast who requested that a pseudonym be used because of personal threats he has received, “patients wouldn’t really challenge me or throw out weird questions.” It’s not that he never encountered pushback, but the stakes felt lower, and people largely deferred to his medical expertise. “If we got a parent who had not vaccinated their child, I would totally engage back then,” Dr. Thomas said.

But the pandemic – and America’s response to it – changed the conversation. “The rhetoric ... switched from downplaying the virus to demonizing the vaccines,” Dr. Thomas said.
 

The toll on health care professionals

By the time vaccines were available, the public had begun to conflate doctors with public health experts, since both were “pushing” the vaccine.

“Most people probably don’t really know the difference between clinical medicine and public health,” said Richard Pan, MD, MPH, a pediatrician and California legislator who sponsored two bills – now laws – that strengthened state childhood vaccination requirements.

At first, it was clearly public health officials, such as Anthony Fauci, MD, who were the face of measures to mitigate the virus. But as doctors became the enforcers of those measures, the line between physicians and public health officials blurred.

A lot of the anger then shifted toward doctors, nurses, and other health care professionals, Dr. Pan said, “because we were, of course, the ones who would be administering the vaccines. They don’t really think of their doctor as a government person until your doctor is carrying a [government] message.”

Given the pressures and struggles of the past few years, it’s no surprise that burnout among health care professionals is high. According to an April 2023 study by the National Council of State Boards of Nursing and the National Forum of State Nursing Workforce Centers, an estimated 800,000 nurses expect to leave the profession by 2027, driven first and foremost by “stress and burnout.”

All of these departures in medicine’s “great resignation” have left hospitals and health care organizations even more short staffed, thereby increasing even more the pressure and burnout on those left.

The pandemic had already badly exacerbated the already widespread problem of burnout in the medical field, which Ms. Nelson said has contributed to the tension.

“The burnout problem that we have in health care is not a good basis for the development of a good therapeutic relationship,” Ms. Nelson said. “Burnout is fraught with apathy and desensitization to human emotions. It takes away the empathy that we once had for people that we see.”
 

What comes next?

Almost exactly 3 years after the world learned about SARS-CoV-2, Biden declared an end to the coronavirus public health emergency in April 2023. Yet, Americans continue to die from COVID, and the anger that bloomed and spread has not abated.

“I think we’re in a new steady state of violence in health care settings,” Ms. Nelson said. “It’s not gone down, because people are still very distressed.” That’s evident from the high prevalence of mental health conditions, the financial strain of first the pandemic and then inflation, and the overall traumatic impact the pandemic had on people, whether they recognize it or not.

The first step to solving any problem is, as the saying goes, to admit that there is a problem.

“I think people need to start stepping out of their comfort bubbles and start to look at things that make them uncomfortable,” Dr. Thomas said, but he doesn’t see that happening any time soon. “I’ve been very let down by physicians and embarrassed by the American physician organizations.”

The medical board in his state, he said, has stood by as some doctors continue misrepresenting medical evidence. “That’s been really, really hard on me. I didn’t think that the medical boards would go so far as to look the other way for something that was this tremendously bad.”

There are others who can take the lead – if they’re willing.

“There are some things the medical societies and academic health centers can do,” Dr. Hotez said, “starting with building up a culture of physicians and health care providers feeling comfortable in the public domain.” He said the messaging when he was getting his degrees was not to engage the public and not to talk to journalists because that was “self-promotion” or “grandstanding.” But the world is different now. Health care professionals need training in public engagement and communication, he said, and the culture needs to change so that health care providers feel comfortable speaking out without feeling “the sword of Damocles over their heads” every time they talk to a reporter, Dr. Hotez said.

There may be no silver bullet to solve the big-picture trust problem in medicine and public health. No TV appearance or quote in an article can solve it. But on an individual level — through careful relationship building with patients – doctors can strengthen that trust.

Telehealth may help with that, but there’s a fine balance there, Ms. Nelson cautioned. On the one hand, with the doctor and the patient each in their own private spaces, where they feel safe and comfortable, the overall experience can be more therapeutic and less stressful. At the same time, telehealth can pile on change-management tasks that can exacerbate burnout, “so it’s a delicate thing we have to approach.”

One very thin silver lining that could emerge from the way in which patients have begun to try to take charge of their care.

“They should fully understand the reasoning behind the recommendations that physicians are making,” Ms. Nelson said. “I’d like to see us get to a happy medium where it’s a partnership. We can’t go back to the old school where the doctor knows best and you don’t ever question him.

“What we need is the partnership, and I would love to see that as the silver lining, but the anger has got to settle down in order for that kind of productive thing to happen.”

As for the big picture? There’s a limit to what even society’s “miracle workers” can do. “The biggest priority right now for the health system is to protect their staff whatever way they can and do some training in deescalation,” Ms. Nelson said. “But I don’t think health care can solve the societal issues that seem to be creating this.”

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

Like hundreds of other medical experts, Leana Wen, MD, an emergency physician and former Baltimore health commissioner, was an early and avid supporter of COVID vaccines and their ability to prevent severe disease, hospitalization, and death from SARS-CoV-2 infections.

When 51-year-old Scott Eli Harris, of Aubrey, Tex., heard of Dr. Wen’s stance in July 2021, the self-described “fifth-generation U.S. Army veteran and a sniper” sent Dr. Wen an electronic invective laden with racist language and very specific threats to shoot her.

Mr. Harris pled guilty to transmitting threats via interstate commerce last February and began serving 6 months in federal prison in the fall of 2022, but his threats wouldn’t be the last for Dr. Wen. Just 2 days after Mr. Harris was sentenced, charges were unsealed against another man in Massachusetts, who threatened that Dr. Wen would “end up in pieces” if she continued “pushing” her thoughts publicly.’

Dr. Wen has plenty of company. In an August 2022 survey of emergency doctors conducted by the American College of Emergency Physicians, 85% of respondents said violence against them is increasing. One in four doctors said they’re being assaulted by patients and their family and friends multiple times a week, compared with just 8% of doctors who said as much in 2018. About 64% of emergency physicians reported receiving verbal assaults and threats of violence; 40% reported being hit or slapped, and 26% were kicked.

This uptick of violence and threats against physicians didn’t come out of nowhere; violence against health care workers has been gradually increasing over the past decade. Health care providers can attest to the hostility that particular topics have sparked for years: vaccines in pediatrics, abortion in ob.gyn., and gender-affirming care in endocrinology.

But the pandemic fueled the fire. While there have always been hot-button issues in medicine, the ire they arouse today is more intense than ever before. The proliferation of misinformation (often via social media) and the politicization of public health and medicine are at the center of the problem.
 

‘The people attacking are themselves victims’

The misinformation problem first came to a head in one area of public health: vaccines. The pandemic accelerated antagonism in medicine – thanks, in part, to decades of antivaccine activism.

The antivaccine movement, which has ebbed and flowed in the United States and across the globe since the first vaccine, experienced a new wave in the early 2000s with the combination of concerns about thimerosal in vaccines and a now disproven link between autism and the MMR vaccine. But that movement grew. It picked up steam when activists gained political clout after a 2014 measles outbreak at Disneyland led California schools to tighten up policies regarding vaccinations for kids who enrolled. These stronger public school vaccination laws ran up against religious freedom arguments from antivaccine advocates.

Use of social media continues to grow, and with it, the spread of misinformation. A recent study found that Facebook “users’ social media habits doubled, and in some cases, tripled the amount of fake news they shared.”

In the face of growing confusion, health care providers and public health experts have often struggled to treat their patients – and communicate to the public – without appearing political.

“The people that are doing the attacking are in some ways themselves victims,” said Peter Hotez, MD, PhD, dean of the National School of Tropical Medicine at Baylor College of Medicine, Houston. “They’re victims of the antiscience, antihealth ecosystem coming out of Fox News, the House Freedom Caucus, the CPAC conference, coming out of contrarian intellectuals.”

Many of Dr. Hotez’s colleagues don’t want to talk about the political right as an enabler of scientific disinformation, he said, but that doesn’t change what the evidence shows. The vast majority of state and national bills opposing vaccination, gender-affirming care, comprehensive reproductive care, and other evidence-based medical care often come from Republican legislators.
 

When politics and health care collide

“We’re in an incredible status quo,” said William Schaffner, MD, the previous director of the Infectious Diseases Society of America and a professor of infectious diseases and preventive medicine at Vanderbilt University, Nashville, Tenn. “You can’t get away from the politics, because you have [political] candidates espousing certain concepts that are antithetical to good public health.”

In March 2023, Florida Gov. Ron DeSantis’s surgeon general, Joseph Ladapo, MD, PhD, warned that COVID vaccines are harmful to young men, prompting rebukes from federal health authorities. It later came out that Dr. Ladapo had changed some of the results of the study before issuing his warning. But long before 2023, there emerged an increasing gap in COVID deaths between red states and blue states, mirroring the vaccination rates in those states. The redder the state, the higher the death toll.

It’s not just Republican Party culture warriors; medical misinformation is also finding increasing purchase on the far left. Robert F. Kennedy Jr. and Marianne Williamson, both of whom have launched long-shot challenges to President Biden for the 2024 Democratic nomination, had promoted antivaccine ideas long before the COVID pandemic. Mr. Kennedy continues to spread misinformation.

In June 2023, Joe Rogan hosted Mr. Kennedy, on his podcast. During the episode, Mr. Rogan listened uncritically as Mr. Kennedy told his millions of listeners that vaccines cause autism and that 5G causes cancer, among other fringe, often-debunked theories.

Dr. Hotez, a prominent misinformation debunker who was also part of a team that designed a low-cost COVID-19 vaccine, wrote on Twitter that the episode was “just awful.”

The backlash began almost immediately. Mr. Rogan, who has over 11 million followers on Twitter, responded with a public challenge for Dr. Hotez to debate Mr. Kennedy on Mr. Rogan’s show, with a reward of $100,000 to the charity of Dr. Hotez’s choice. More offers streamed in, including from Elon Musk, who tweeted that Dr. Hotez was “afraid of a public debate, because he knows he’s wrong.” More supporters of Mr. Kennedy and Mr. Rogan piled on.

Vaccine skeptics even showed up at Dr. Hotez’s house, filming him as he was returning from buying a Father’s Day cake and taunting him to debate Mr. Kennedy.
 

A turn in the pandemic

For a precious few weeks at the start of the pandemic, it felt as though the country was all in this together. There were arguments against closing schools and shutting down businesses, but for the most part, the nation had about 4 solid weeks of solidarity.

As masking mandates changed and the public health establishment lost the confidence of Americans, the veneer of solidarity began to chip away.

“Things were changing so rapidly during the pandemic that it was very hard for staff and patients to understand the changing guidelines, whether it was visitor constraints or masking,” said Carrie Nelson, the chief medical officer at the telehealth company AmWell, who worked as a supervisor at a large health care system in the Midwest until 2021.

In the midst of the public health crisis, former President Trump was downplaying the severity of the disease and was silencing officials from the Centers for Disease Control and Prevention, such as Nancy Messonier, who warned from the very beginning of the pandemic’s potential.

When the vaccines came out, the latent antivaccine movement flared up once again. And this time – unlike in decades past – the debate over vaccines had become partisan.

“Before the pandemic,” said Christopher Thomas, an emergency physician on the West Coast who requested that a pseudonym be used because of personal threats he has received, “patients wouldn’t really challenge me or throw out weird questions.” It’s not that he never encountered pushback, but the stakes felt lower, and people largely deferred to his medical expertise. “If we got a parent who had not vaccinated their child, I would totally engage back then,” Dr. Thomas said.

But the pandemic – and America’s response to it – changed the conversation. “The rhetoric ... switched from downplaying the virus to demonizing the vaccines,” Dr. Thomas said.
 

The toll on health care professionals

By the time vaccines were available, the public had begun to conflate doctors with public health experts, since both were “pushing” the vaccine.

“Most people probably don’t really know the difference between clinical medicine and public health,” said Richard Pan, MD, MPH, a pediatrician and California legislator who sponsored two bills – now laws – that strengthened state childhood vaccination requirements.

At first, it was clearly public health officials, such as Anthony Fauci, MD, who were the face of measures to mitigate the virus. But as doctors became the enforcers of those measures, the line between physicians and public health officials blurred.

A lot of the anger then shifted toward doctors, nurses, and other health care professionals, Dr. Pan said, “because we were, of course, the ones who would be administering the vaccines. They don’t really think of their doctor as a government person until your doctor is carrying a [government] message.”

Given the pressures and struggles of the past few years, it’s no surprise that burnout among health care professionals is high. According to an April 2023 study by the National Council of State Boards of Nursing and the National Forum of State Nursing Workforce Centers, an estimated 800,000 nurses expect to leave the profession by 2027, driven first and foremost by “stress and burnout.”

All of these departures in medicine’s “great resignation” have left hospitals and health care organizations even more short staffed, thereby increasing even more the pressure and burnout on those left.

The pandemic had already badly exacerbated the already widespread problem of burnout in the medical field, which Ms. Nelson said has contributed to the tension.

“The burnout problem that we have in health care is not a good basis for the development of a good therapeutic relationship,” Ms. Nelson said. “Burnout is fraught with apathy and desensitization to human emotions. It takes away the empathy that we once had for people that we see.”
 

What comes next?

Almost exactly 3 years after the world learned about SARS-CoV-2, Biden declared an end to the coronavirus public health emergency in April 2023. Yet, Americans continue to die from COVID, and the anger that bloomed and spread has not abated.

“I think we’re in a new steady state of violence in health care settings,” Ms. Nelson said. “It’s not gone down, because people are still very distressed.” That’s evident from the high prevalence of mental health conditions, the financial strain of first the pandemic and then inflation, and the overall traumatic impact the pandemic had on people, whether they recognize it or not.

The first step to solving any problem is, as the saying goes, to admit that there is a problem.

“I think people need to start stepping out of their comfort bubbles and start to look at things that make them uncomfortable,” Dr. Thomas said, but he doesn’t see that happening any time soon. “I’ve been very let down by physicians and embarrassed by the American physician organizations.”

The medical board in his state, he said, has stood by as some doctors continue misrepresenting medical evidence. “That’s been really, really hard on me. I didn’t think that the medical boards would go so far as to look the other way for something that was this tremendously bad.”

There are others who can take the lead – if they’re willing.

“There are some things the medical societies and academic health centers can do,” Dr. Hotez said, “starting with building up a culture of physicians and health care providers feeling comfortable in the public domain.” He said the messaging when he was getting his degrees was not to engage the public and not to talk to journalists because that was “self-promotion” or “grandstanding.” But the world is different now. Health care professionals need training in public engagement and communication, he said, and the culture needs to change so that health care providers feel comfortable speaking out without feeling “the sword of Damocles over their heads” every time they talk to a reporter, Dr. Hotez said.

There may be no silver bullet to solve the big-picture trust problem in medicine and public health. No TV appearance or quote in an article can solve it. But on an individual level — through careful relationship building with patients – doctors can strengthen that trust.

Telehealth may help with that, but there’s a fine balance there, Ms. Nelson cautioned. On the one hand, with the doctor and the patient each in their own private spaces, where they feel safe and comfortable, the overall experience can be more therapeutic and less stressful. At the same time, telehealth can pile on change-management tasks that can exacerbate burnout, “so it’s a delicate thing we have to approach.”

One very thin silver lining that could emerge from the way in which patients have begun to try to take charge of their care.

“They should fully understand the reasoning behind the recommendations that physicians are making,” Ms. Nelson said. “I’d like to see us get to a happy medium where it’s a partnership. We can’t go back to the old school where the doctor knows best and you don’t ever question him.

“What we need is the partnership, and I would love to see that as the silver lining, but the anger has got to settle down in order for that kind of productive thing to happen.”

As for the big picture? There’s a limit to what even society’s “miracle workers” can do. “The biggest priority right now for the health system is to protect their staff whatever way they can and do some training in deescalation,” Ms. Nelson said. “But I don’t think health care can solve the societal issues that seem to be creating this.”

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

Like hundreds of other medical experts, Leana Wen, MD, an emergency physician and former Baltimore health commissioner, was an early and avid supporter of COVID vaccines and their ability to prevent severe disease, hospitalization, and death from SARS-CoV-2 infections.

When 51-year-old Scott Eli Harris, of Aubrey, Tex., heard of Dr. Wen’s stance in July 2021, the self-described “fifth-generation U.S. Army veteran and a sniper” sent Dr. Wen an electronic invective laden with racist language and very specific threats to shoot her.

Mr. Harris pled guilty to transmitting threats via interstate commerce last February and began serving 6 months in federal prison in the fall of 2022, but his threats wouldn’t be the last for Dr. Wen. Just 2 days after Mr. Harris was sentenced, charges were unsealed against another man in Massachusetts, who threatened that Dr. Wen would “end up in pieces” if she continued “pushing” her thoughts publicly.’

Dr. Wen has plenty of company. In an August 2022 survey of emergency doctors conducted by the American College of Emergency Physicians, 85% of respondents said violence against them is increasing. One in four doctors said they’re being assaulted by patients and their family and friends multiple times a week, compared with just 8% of doctors who said as much in 2018. About 64% of emergency physicians reported receiving verbal assaults and threats of violence; 40% reported being hit or slapped, and 26% were kicked.

This uptick of violence and threats against physicians didn’t come out of nowhere; violence against health care workers has been gradually increasing over the past decade. Health care providers can attest to the hostility that particular topics have sparked for years: vaccines in pediatrics, abortion in ob.gyn., and gender-affirming care in endocrinology.

But the pandemic fueled the fire. While there have always been hot-button issues in medicine, the ire they arouse today is more intense than ever before. The proliferation of misinformation (often via social media) and the politicization of public health and medicine are at the center of the problem.
 

‘The people attacking are themselves victims’

The misinformation problem first came to a head in one area of public health: vaccines. The pandemic accelerated antagonism in medicine – thanks, in part, to decades of antivaccine activism.

The antivaccine movement, which has ebbed and flowed in the United States and across the globe since the first vaccine, experienced a new wave in the early 2000s with the combination of concerns about thimerosal in vaccines and a now disproven link between autism and the MMR vaccine. But that movement grew. It picked up steam when activists gained political clout after a 2014 measles outbreak at Disneyland led California schools to tighten up policies regarding vaccinations for kids who enrolled. These stronger public school vaccination laws ran up against religious freedom arguments from antivaccine advocates.

Use of social media continues to grow, and with it, the spread of misinformation. A recent study found that Facebook “users’ social media habits doubled, and in some cases, tripled the amount of fake news they shared.”

In the face of growing confusion, health care providers and public health experts have often struggled to treat their patients – and communicate to the public – without appearing political.

“The people that are doing the attacking are in some ways themselves victims,” said Peter Hotez, MD, PhD, dean of the National School of Tropical Medicine at Baylor College of Medicine, Houston. “They’re victims of the antiscience, antihealth ecosystem coming out of Fox News, the House Freedom Caucus, the CPAC conference, coming out of contrarian intellectuals.”

Many of Dr. Hotez’s colleagues don’t want to talk about the political right as an enabler of scientific disinformation, he said, but that doesn’t change what the evidence shows. The vast majority of state and national bills opposing vaccination, gender-affirming care, comprehensive reproductive care, and other evidence-based medical care often come from Republican legislators.
 

When politics and health care collide

“We’re in an incredible status quo,” said William Schaffner, MD, the previous director of the Infectious Diseases Society of America and a professor of infectious diseases and preventive medicine at Vanderbilt University, Nashville, Tenn. “You can’t get away from the politics, because you have [political] candidates espousing certain concepts that are antithetical to good public health.”

In March 2023, Florida Gov. Ron DeSantis’s surgeon general, Joseph Ladapo, MD, PhD, warned that COVID vaccines are harmful to young men, prompting rebukes from federal health authorities. It later came out that Dr. Ladapo had changed some of the results of the study before issuing his warning. But long before 2023, there emerged an increasing gap in COVID deaths between red states and blue states, mirroring the vaccination rates in those states. The redder the state, the higher the death toll.

It’s not just Republican Party culture warriors; medical misinformation is also finding increasing purchase on the far left. Robert F. Kennedy Jr. and Marianne Williamson, both of whom have launched long-shot challenges to President Biden for the 2024 Democratic nomination, had promoted antivaccine ideas long before the COVID pandemic. Mr. Kennedy continues to spread misinformation.

In June 2023, Joe Rogan hosted Mr. Kennedy, on his podcast. During the episode, Mr. Rogan listened uncritically as Mr. Kennedy told his millions of listeners that vaccines cause autism and that 5G causes cancer, among other fringe, often-debunked theories.

Dr. Hotez, a prominent misinformation debunker who was also part of a team that designed a low-cost COVID-19 vaccine, wrote on Twitter that the episode was “just awful.”

The backlash began almost immediately. Mr. Rogan, who has over 11 million followers on Twitter, responded with a public challenge for Dr. Hotez to debate Mr. Kennedy on Mr. Rogan’s show, with a reward of $100,000 to the charity of Dr. Hotez’s choice. More offers streamed in, including from Elon Musk, who tweeted that Dr. Hotez was “afraid of a public debate, because he knows he’s wrong.” More supporters of Mr. Kennedy and Mr. Rogan piled on.

Vaccine skeptics even showed up at Dr. Hotez’s house, filming him as he was returning from buying a Father’s Day cake and taunting him to debate Mr. Kennedy.
 

A turn in the pandemic

For a precious few weeks at the start of the pandemic, it felt as though the country was all in this together. There were arguments against closing schools and shutting down businesses, but for the most part, the nation had about 4 solid weeks of solidarity.

As masking mandates changed and the public health establishment lost the confidence of Americans, the veneer of solidarity began to chip away.

“Things were changing so rapidly during the pandemic that it was very hard for staff and patients to understand the changing guidelines, whether it was visitor constraints or masking,” said Carrie Nelson, the chief medical officer at the telehealth company AmWell, who worked as a supervisor at a large health care system in the Midwest until 2021.

In the midst of the public health crisis, former President Trump was downplaying the severity of the disease and was silencing officials from the Centers for Disease Control and Prevention, such as Nancy Messonier, who warned from the very beginning of the pandemic’s potential.

When the vaccines came out, the latent antivaccine movement flared up once again. And this time – unlike in decades past – the debate over vaccines had become partisan.

“Before the pandemic,” said Christopher Thomas, an emergency physician on the West Coast who requested that a pseudonym be used because of personal threats he has received, “patients wouldn’t really challenge me or throw out weird questions.” It’s not that he never encountered pushback, but the stakes felt lower, and people largely deferred to his medical expertise. “If we got a parent who had not vaccinated their child, I would totally engage back then,” Dr. Thomas said.

But the pandemic – and America’s response to it – changed the conversation. “The rhetoric ... switched from downplaying the virus to demonizing the vaccines,” Dr. Thomas said.
 

The toll on health care professionals

By the time vaccines were available, the public had begun to conflate doctors with public health experts, since both were “pushing” the vaccine.

“Most people probably don’t really know the difference between clinical medicine and public health,” said Richard Pan, MD, MPH, a pediatrician and California legislator who sponsored two bills – now laws – that strengthened state childhood vaccination requirements.

At first, it was clearly public health officials, such as Anthony Fauci, MD, who were the face of measures to mitigate the virus. But as doctors became the enforcers of those measures, the line between physicians and public health officials blurred.

A lot of the anger then shifted toward doctors, nurses, and other health care professionals, Dr. Pan said, “because we were, of course, the ones who would be administering the vaccines. They don’t really think of their doctor as a government person until your doctor is carrying a [government] message.”

Given the pressures and struggles of the past few years, it’s no surprise that burnout among health care professionals is high. According to an April 2023 study by the National Council of State Boards of Nursing and the National Forum of State Nursing Workforce Centers, an estimated 800,000 nurses expect to leave the profession by 2027, driven first and foremost by “stress and burnout.”

All of these departures in medicine’s “great resignation” have left hospitals and health care organizations even more short staffed, thereby increasing even more the pressure and burnout on those left.

The pandemic had already badly exacerbated the already widespread problem of burnout in the medical field, which Ms. Nelson said has contributed to the tension.

“The burnout problem that we have in health care is not a good basis for the development of a good therapeutic relationship,” Ms. Nelson said. “Burnout is fraught with apathy and desensitization to human emotions. It takes away the empathy that we once had for people that we see.”
 

What comes next?

Almost exactly 3 years after the world learned about SARS-CoV-2, Biden declared an end to the coronavirus public health emergency in April 2023. Yet, Americans continue to die from COVID, and the anger that bloomed and spread has not abated.

“I think we’re in a new steady state of violence in health care settings,” Ms. Nelson said. “It’s not gone down, because people are still very distressed.” That’s evident from the high prevalence of mental health conditions, the financial strain of first the pandemic and then inflation, and the overall traumatic impact the pandemic had on people, whether they recognize it or not.

The first step to solving any problem is, as the saying goes, to admit that there is a problem.

“I think people need to start stepping out of their comfort bubbles and start to look at things that make them uncomfortable,” Dr. Thomas said, but he doesn’t see that happening any time soon. “I’ve been very let down by physicians and embarrassed by the American physician organizations.”

The medical board in his state, he said, has stood by as some doctors continue misrepresenting medical evidence. “That’s been really, really hard on me. I didn’t think that the medical boards would go so far as to look the other way for something that was this tremendously bad.”

There are others who can take the lead – if they’re willing.

“There are some things the medical societies and academic health centers can do,” Dr. Hotez said, “starting with building up a culture of physicians and health care providers feeling comfortable in the public domain.” He said the messaging when he was getting his degrees was not to engage the public and not to talk to journalists because that was “self-promotion” or “grandstanding.” But the world is different now. Health care professionals need training in public engagement and communication, he said, and the culture needs to change so that health care providers feel comfortable speaking out without feeling “the sword of Damocles over their heads” every time they talk to a reporter, Dr. Hotez said.

There may be no silver bullet to solve the big-picture trust problem in medicine and public health. No TV appearance or quote in an article can solve it. But on an individual level — through careful relationship building with patients – doctors can strengthen that trust.

Telehealth may help with that, but there’s a fine balance there, Ms. Nelson cautioned. On the one hand, with the doctor and the patient each in their own private spaces, where they feel safe and comfortable, the overall experience can be more therapeutic and less stressful. At the same time, telehealth can pile on change-management tasks that can exacerbate burnout, “so it’s a delicate thing we have to approach.”

One very thin silver lining that could emerge from the way in which patients have begun to try to take charge of their care.

“They should fully understand the reasoning behind the recommendations that physicians are making,” Ms. Nelson said. “I’d like to see us get to a happy medium where it’s a partnership. We can’t go back to the old school where the doctor knows best and you don’t ever question him.

“What we need is the partnership, and I would love to see that as the silver lining, but the anger has got to settle down in order for that kind of productive thing to happen.”

As for the big picture? There’s a limit to what even society’s “miracle workers” can do. “The biggest priority right now for the health system is to protect their staff whatever way they can and do some training in deescalation,” Ms. Nelson said. “But I don’t think health care can solve the societal issues that seem to be creating this.”

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

A new guide offers recommendations for the nonsurgical management of major hemorrhage, which is a challenging clinical problem.

Major hemorrhage is a significant cause of death and can occur in a myriad of clinical settings.

“In Ontario, we’ve been collecting quality metrics on major hemorrhages to try and make sure that a higher percentage of patients gets the best possible care when they are experiencing significant bleeding,” author Jeannie Callum, MD, professor and director of transfusion medicine at Kingston (Ont.) Health Sciences Centre and Queen’s University, also in Kingston, said in an interview. “There were some gaps, so this is our effort to get open, clear information out to the emergency doctors, intensive care unit doctors, the surgeons, and everyone else involved in managing major hemorrhage, to help close these gaps.”

The guide was published in the Canadian Medical Association Journal.
 

Fast care essential

The guide aims to provide answers, based on the latest research, to questions such as when to activate a massive hemorrhage protocol (MHP), which patients should receive tranexamic acid (TXA), which blood products should be transfused before laboratory results are available, how to monitor the effects of blood transfusion, and when fibrinogen concentrate or prothrombin complex concentrate should be given.

Not all recommendations will be followed, Dr. Callum said, especially in rural hospitals with limited resources. But the guide is adaptable, and rural hospitals can create protocols that are customized to their unique circumstances.

Care must be “perfect and fast” in the first hour of major injury, said Dr. Callum. “You need to get a proclotting drug in that first hour if you have a traumatic or postpartum bleed. You have to make sure your clotting factors never fail you throughout your resuscitation. You have to be fast with the transfusion. You have to monitor for the complications of the transfusion, electrolyte disturbances, and the patient’s temperature dropping. It’s a complicated situation that needs a multidisciplinary team.”

Bleeding affects everybody in medicine, from family doctors in smaller institutions who work in emergency departments to obstetricians and surgeons, she added.

“For people under the age of 45, trauma is the most common cause of death. When people die of trauma, they die of bleeding. So many people experience these extreme bleeds. We believe that some of them might be preventable with faster, more standardized, more aggressive care. That’s why we wrote this review,” said Dr. Callum.
 

Administer TXA quickly  

The first recommendation is to ensure that every hospital has a massive hemorrhage protocol. Such a protocol is vital for the emergency department, operating room, and obstetric unit. “Making sure you’ve got a protocol that is updated every 3 years and adjusted to the local hospital context is essential,” said Dr. Callum.

Smaller hospitals will have to adjust their protocols according to the capabilities of their sites. “Some smaller hospitals do not have platelets in stock and get their platelets from another hospital, so you need to adjust your protocol to what you are able to do. Not every hospital can control bleeding in a trauma patient, so your protocol would be to stabilize and call a helicopter. Make sure all of this is detailed so that implementing it becomes automatic,” said Dr. Callum.

An MHP should be activated for patients with uncontrolled hemorrhage who meet the clinical criteria of the local hospital and are expected to need blood product support and red blood cells.

“Lots of people bleed, but not everybody is bleeding enough that they need a code transfusion,” said Dr. Callum. Most patients with gastrointestinal bleeds caused by NSAID use can be managed with uncrossed matched blood from the local blood bank. “But in patients who need the full code transfusion because they are going to need plasma, clotting factor replacement, and many other drugs, that is when the MHP should be activated. Don’t activate it when you don’t need it, because doing so activates the whole hospital and diverts care away from other patients.”

TXA should be administered as soon as possible after onset of hemorrhage in most patients, with the exception of gastrointestinal hemorrhage, where a benefit has not been shown.

TXA has been a major advance in treating massive bleeding, Dr. Callum said. “TXA was invented by a Japanese husband-and-wife research team. We know that it reduces the death rate in trauma and in postpartum hemorrhage, and it reduces the chance of major bleeding with major surgical procedures. We give it routinely in surgical procedures. If a patient gets TXA within 60 minutes of injury, it dramatically reduces the death rate. And it costs $10 per patient. It’s cheap, it’s easy, it has no side effects. It’s just amazing.”

Future research must address several unanswered questions, said Dr. Callum. These questions include whether prehospital transfusion improves patient outcomes, whether whole blood has a role in the early management of major hemorrhage, and what role factor concentrates play in patients with major bleeding.
 

‘Optimal recommendations’

Commenting on the document, Bourke Tillmann, MD, PhD, trauma team leader at Sunnybrook Health Sciences Centre and the Ross Tilley Burn Center in Toronto, said: “Overall, I think it is a good overview of MHPs as an approach to major hemorrhage.”

The review also is timely, since Ontario released its MHP guidelines in 2021, he added. “I would have liked to see more about the treatment aspects than just an overview of an MHP. But if you are the person overseeing the emergency department or running the blood bank, these protocols are incredibly useful and incredibly important.”

“This report is a nice and thoughtful overview of best practices in many areas, especially trauma, and makes recommendations that are optimal, although they are not necessarily practical in all centers,” Eric L. Legome, MD, professor and chair of emergency medicine at Mount Sinai West and Mount Sinai Morningside, New York, said in an interview.

“If you’re in a small rural hospital with one lab technician, trying to do all of these things, it will not be possible. These are optimal recommendations that people can use to the best of their ability, but they are not standard of care, because some places will not be able to provide this level of care,” he added. “This paper provides practical, reasonable advice that should be looked at as you are trying to implement transfusion policies and processes, with the understanding that it is not necessarily applicable or practical for very small hospitals in very rural centers that might not have access to these types of products and tools, but it’s a reasonable and nicely written paper.”

No outside funding for the guideline was reported. Dr. Callum has received research funding from Canadian Blood Services and Octapharma. She sits on the nominating committee with the Association for the Advancement of Blood & Biotherapies and on the data safety monitoring boards for the Tranexamic Acid for Subdural Hematoma trial and the Fibrinogen Replacement in Trauma trial. Dr. Tillmann and Dr. Legome reported no relevant financial relationships.

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

A new guide offers recommendations for the nonsurgical management of major hemorrhage, which is a challenging clinical problem.

Major hemorrhage is a significant cause of death and can occur in a myriad of clinical settings.

“In Ontario, we’ve been collecting quality metrics on major hemorrhages to try and make sure that a higher percentage of patients gets the best possible care when they are experiencing significant bleeding,” author Jeannie Callum, MD, professor and director of transfusion medicine at Kingston (Ont.) Health Sciences Centre and Queen’s University, also in Kingston, said in an interview. “There were some gaps, so this is our effort to get open, clear information out to the emergency doctors, intensive care unit doctors, the surgeons, and everyone else involved in managing major hemorrhage, to help close these gaps.”

The guide was published in the Canadian Medical Association Journal.
 

Fast care essential

The guide aims to provide answers, based on the latest research, to questions such as when to activate a massive hemorrhage protocol (MHP), which patients should receive tranexamic acid (TXA), which blood products should be transfused before laboratory results are available, how to monitor the effects of blood transfusion, and when fibrinogen concentrate or prothrombin complex concentrate should be given.

Not all recommendations will be followed, Dr. Callum said, especially in rural hospitals with limited resources. But the guide is adaptable, and rural hospitals can create protocols that are customized to their unique circumstances.

Care must be “perfect and fast” in the first hour of major injury, said Dr. Callum. “You need to get a proclotting drug in that first hour if you have a traumatic or postpartum bleed. You have to make sure your clotting factors never fail you throughout your resuscitation. You have to be fast with the transfusion. You have to monitor for the complications of the transfusion, electrolyte disturbances, and the patient’s temperature dropping. It’s a complicated situation that needs a multidisciplinary team.”

Bleeding affects everybody in medicine, from family doctors in smaller institutions who work in emergency departments to obstetricians and surgeons, she added.

“For people under the age of 45, trauma is the most common cause of death. When people die of trauma, they die of bleeding. So many people experience these extreme bleeds. We believe that some of them might be preventable with faster, more standardized, more aggressive care. That’s why we wrote this review,” said Dr. Callum.
 

Administer TXA quickly  

The first recommendation is to ensure that every hospital has a massive hemorrhage protocol. Such a protocol is vital for the emergency department, operating room, and obstetric unit. “Making sure you’ve got a protocol that is updated every 3 years and adjusted to the local hospital context is essential,” said Dr. Callum.

Smaller hospitals will have to adjust their protocols according to the capabilities of their sites. “Some smaller hospitals do not have platelets in stock and get their platelets from another hospital, so you need to adjust your protocol to what you are able to do. Not every hospital can control bleeding in a trauma patient, so your protocol would be to stabilize and call a helicopter. Make sure all of this is detailed so that implementing it becomes automatic,” said Dr. Callum.

An MHP should be activated for patients with uncontrolled hemorrhage who meet the clinical criteria of the local hospital and are expected to need blood product support and red blood cells.

“Lots of people bleed, but not everybody is bleeding enough that they need a code transfusion,” said Dr. Callum. Most patients with gastrointestinal bleeds caused by NSAID use can be managed with uncrossed matched blood from the local blood bank. “But in patients who need the full code transfusion because they are going to need plasma, clotting factor replacement, and many other drugs, that is when the MHP should be activated. Don’t activate it when you don’t need it, because doing so activates the whole hospital and diverts care away from other patients.”

TXA should be administered as soon as possible after onset of hemorrhage in most patients, with the exception of gastrointestinal hemorrhage, where a benefit has not been shown.

TXA has been a major advance in treating massive bleeding, Dr. Callum said. “TXA was invented by a Japanese husband-and-wife research team. We know that it reduces the death rate in trauma and in postpartum hemorrhage, and it reduces the chance of major bleeding with major surgical procedures. We give it routinely in surgical procedures. If a patient gets TXA within 60 minutes of injury, it dramatically reduces the death rate. And it costs $10 per patient. It’s cheap, it’s easy, it has no side effects. It’s just amazing.”

Future research must address several unanswered questions, said Dr. Callum. These questions include whether prehospital transfusion improves patient outcomes, whether whole blood has a role in the early management of major hemorrhage, and what role factor concentrates play in patients with major bleeding.
 

‘Optimal recommendations’

Commenting on the document, Bourke Tillmann, MD, PhD, trauma team leader at Sunnybrook Health Sciences Centre and the Ross Tilley Burn Center in Toronto, said: “Overall, I think it is a good overview of MHPs as an approach to major hemorrhage.”

The review also is timely, since Ontario released its MHP guidelines in 2021, he added. “I would have liked to see more about the treatment aspects than just an overview of an MHP. But if you are the person overseeing the emergency department or running the blood bank, these protocols are incredibly useful and incredibly important.”

“This report is a nice and thoughtful overview of best practices in many areas, especially trauma, and makes recommendations that are optimal, although they are not necessarily practical in all centers,” Eric L. Legome, MD, professor and chair of emergency medicine at Mount Sinai West and Mount Sinai Morningside, New York, said in an interview.

“If you’re in a small rural hospital with one lab technician, trying to do all of these things, it will not be possible. These are optimal recommendations that people can use to the best of their ability, but they are not standard of care, because some places will not be able to provide this level of care,” he added. “This paper provides practical, reasonable advice that should be looked at as you are trying to implement transfusion policies and processes, with the understanding that it is not necessarily applicable or practical for very small hospitals in very rural centers that might not have access to these types of products and tools, but it’s a reasonable and nicely written paper.”

No outside funding for the guideline was reported. Dr. Callum has received research funding from Canadian Blood Services and Octapharma. She sits on the nominating committee with the Association for the Advancement of Blood & Biotherapies and on the data safety monitoring boards for the Tranexamic Acid for Subdural Hematoma trial and the Fibrinogen Replacement in Trauma trial. Dr. Tillmann and Dr. Legome reported no relevant financial relationships.

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

A new guide offers recommendations for the nonsurgical management of major hemorrhage, which is a challenging clinical problem.

Major hemorrhage is a significant cause of death and can occur in a myriad of clinical settings.

“In Ontario, we’ve been collecting quality metrics on major hemorrhages to try and make sure that a higher percentage of patients gets the best possible care when they are experiencing significant bleeding,” author Jeannie Callum, MD, professor and director of transfusion medicine at Kingston (Ont.) Health Sciences Centre and Queen’s University, also in Kingston, said in an interview. “There were some gaps, so this is our effort to get open, clear information out to the emergency doctors, intensive care unit doctors, the surgeons, and everyone else involved in managing major hemorrhage, to help close these gaps.”

The guide was published in the Canadian Medical Association Journal.
 

Fast care essential

The guide aims to provide answers, based on the latest research, to questions such as when to activate a massive hemorrhage protocol (MHP), which patients should receive tranexamic acid (TXA), which blood products should be transfused before laboratory results are available, how to monitor the effects of blood transfusion, and when fibrinogen concentrate or prothrombin complex concentrate should be given.

Not all recommendations will be followed, Dr. Callum said, especially in rural hospitals with limited resources. But the guide is adaptable, and rural hospitals can create protocols that are customized to their unique circumstances.

Care must be “perfect and fast” in the first hour of major injury, said Dr. Callum. “You need to get a proclotting drug in that first hour if you have a traumatic or postpartum bleed. You have to make sure your clotting factors never fail you throughout your resuscitation. You have to be fast with the transfusion. You have to monitor for the complications of the transfusion, electrolyte disturbances, and the patient’s temperature dropping. It’s a complicated situation that needs a multidisciplinary team.”

Bleeding affects everybody in medicine, from family doctors in smaller institutions who work in emergency departments to obstetricians and surgeons, she added.

“For people under the age of 45, trauma is the most common cause of death. When people die of trauma, they die of bleeding. So many people experience these extreme bleeds. We believe that some of them might be preventable with faster, more standardized, more aggressive care. That’s why we wrote this review,” said Dr. Callum.
 

Administer TXA quickly  

The first recommendation is to ensure that every hospital has a massive hemorrhage protocol. Such a protocol is vital for the emergency department, operating room, and obstetric unit. “Making sure you’ve got a protocol that is updated every 3 years and adjusted to the local hospital context is essential,” said Dr. Callum.

Smaller hospitals will have to adjust their protocols according to the capabilities of their sites. “Some smaller hospitals do not have platelets in stock and get their platelets from another hospital, so you need to adjust your protocol to what you are able to do. Not every hospital can control bleeding in a trauma patient, so your protocol would be to stabilize and call a helicopter. Make sure all of this is detailed so that implementing it becomes automatic,” said Dr. Callum.

An MHP should be activated for patients with uncontrolled hemorrhage who meet the clinical criteria of the local hospital and are expected to need blood product support and red blood cells.

“Lots of people bleed, but not everybody is bleeding enough that they need a code transfusion,” said Dr. Callum. Most patients with gastrointestinal bleeds caused by NSAID use can be managed with uncrossed matched blood from the local blood bank. “But in patients who need the full code transfusion because they are going to need plasma, clotting factor replacement, and many other drugs, that is when the MHP should be activated. Don’t activate it when you don’t need it, because doing so activates the whole hospital and diverts care away from other patients.”

TXA should be administered as soon as possible after onset of hemorrhage in most patients, with the exception of gastrointestinal hemorrhage, where a benefit has not been shown.

TXA has been a major advance in treating massive bleeding, Dr. Callum said. “TXA was invented by a Japanese husband-and-wife research team. We know that it reduces the death rate in trauma and in postpartum hemorrhage, and it reduces the chance of major bleeding with major surgical procedures. We give it routinely in surgical procedures. If a patient gets TXA within 60 minutes of injury, it dramatically reduces the death rate. And it costs $10 per patient. It’s cheap, it’s easy, it has no side effects. It’s just amazing.”

Future research must address several unanswered questions, said Dr. Callum. These questions include whether prehospital transfusion improves patient outcomes, whether whole blood has a role in the early management of major hemorrhage, and what role factor concentrates play in patients with major bleeding.
 

‘Optimal recommendations’

Commenting on the document, Bourke Tillmann, MD, PhD, trauma team leader at Sunnybrook Health Sciences Centre and the Ross Tilley Burn Center in Toronto, said: “Overall, I think it is a good overview of MHPs as an approach to major hemorrhage.”

The review also is timely, since Ontario released its MHP guidelines in 2021, he added. “I would have liked to see more about the treatment aspects than just an overview of an MHP. But if you are the person overseeing the emergency department or running the blood bank, these protocols are incredibly useful and incredibly important.”

“This report is a nice and thoughtful overview of best practices in many areas, especially trauma, and makes recommendations that are optimal, although they are not necessarily practical in all centers,” Eric L. Legome, MD, professor and chair of emergency medicine at Mount Sinai West and Mount Sinai Morningside, New York, said in an interview.

“If you’re in a small rural hospital with one lab technician, trying to do all of these things, it will not be possible. These are optimal recommendations that people can use to the best of their ability, but they are not standard of care, because some places will not be able to provide this level of care,” he added. “This paper provides practical, reasonable advice that should be looked at as you are trying to implement transfusion policies and processes, with the understanding that it is not necessarily applicable or practical for very small hospitals in very rural centers that might not have access to these types of products and tools, but it’s a reasonable and nicely written paper.”

No outside funding for the guideline was reported. Dr. Callum has received research funding from Canadian Blood Services and Octapharma. She sits on the nominating committee with the Association for the Advancement of Blood & Biotherapies and on the data safety monitoring boards for the Tranexamic Acid for Subdural Hematoma trial and the Fibrinogen Replacement in Trauma trial. Dr. Tillmann and Dr. Legome reported no relevant financial relationships.

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

Overweight boy, infertile man?

When it comes to causes of infertility, history and science have generally focused on women. A lot of the research overlooks men, but some previous studies have suggested that male infertility contributes to about half of the cases of couple infertility. The reason for much of that male infertility, however, has been a mystery. Until now.

A group of Italian investigators looked at the declining trend in sperm counts over the past 40 years and the increase of childhood obesity. Is there a correlation? The researchers think so. Childhood obesity can be linked to multiple causes, but the researchers zeroed in on the effect that obesity has on metabolic rates and, therefore, testicular growth.

Collecting data on testicular volume, body mass index (BMI), and insulin resistance from 268 boys aged 2-18 years, the researchers discovered that those with normal weight and normal insulin levels had testicular volumes 1.5 times higher than their overweight counterparts and 1.5-2 times higher than those with hyperinsulinemia, building a case for obesity being a factor for infertility later in life.

Since low testicular volume is associated with lower sperm count and production as an adult, putting two and two together makes a compelling argument for childhood obesity being a major male infertility culprit. It also creates even more urgency for the health care industry and community decision makers to focus on childhood obesity.

It sure would be nice to be able to take one of the many risk factors for future human survival off the table. Maybe by taking something, like cake, off the table.

Fecal transplantation moves to the kitchen

Fecal microbiota transplantation is an effective way to treat Clostridioides difficile infection, but, in the end, it’s still a transplantation procedure involving a nasogastric or colorectal tube or rather large oral capsules with a demanding (30-40 capsules over 2 days) dosage. Please, Science, tell us there’s a better way.

CC BY-NC-ND 4.0, Adèle Rakotonirina et Nathalie Boulens

Science, in the form of investigators at the University of Geneva and Lausanne University Hospital in Switzerland, has spoken, and there may be a better way. Presenting fecal beads: All the bacterial goodness of donor stool without the tubal insertions or massive quantities of giant capsules.

We know you’re scoffing out there, but it’s true. All you need is a little alginate, which is a “biocompatible polysaccharide isolated from brown algae” of the Phaeophyceae family. The donor feces is microencapsulated by mixing it with the alginate, dropping that mixture into water containing calcium chloride, turning it into a gel, and then freeze-drying the gel into small (just 2 mm), solid beads.

Sounds plausible enough, but what do you do with them? “These brownish beads can be easily dispersed in a liquid or food that is pleasant to eat. They also have no taste,” senior author Eric Allémann, PhD, said in a statement released by the University of Geneva.

Pleasant to eat? No taste? So which is it? If you really want to know, watch fecal beads week on the new season of “The Great British Baking Show,” when Paul and Prue judge poop baked into crumpets, crepes, and crostatas. Yum.
 

We’re on the low-oxygen diet

Nine out of ten doctors agree: Oxygen is more important to your continued well-being than food. After all, a human can go weeks without food, but just minutes without oxygen. However, ten out of ten doctors agree that the United States has an obesity problem. They all also agree that previous research has shown soldiers who train at high altitudes lose more weight than those training at lower altitudes.

PBRC

So, on the one hand, we have a country full of overweight people, and on the other, we have low oxygen levels causing weight loss. The solution, then, is obvious: Stop breathing.

More specifically (and somewhat less facetiously), researchers from Louisiana have launched the Low Oxygen and Weight Status trial and are currently recruiting individuals with BMIs of 30-40 to, uh, suffocate themselves. No, no, it’s okay, it’s just when they’re sleeping.

Fine, straight face. Participants in the LOWS trial will undergo an 8-week period when they will consume a controlled weight-loss diet and spend their nights in a hypoxic sealed tent, where they will sleep in an environment with an oxygen level equivalent to 8,500 feet above sea level (roughly equivalent to Aspen, Colo.). They will be compared with people on the same diet who sleep in a normal, sea-level oxygen environment.

The study’s goal is to determine whether or not spending time in a low-oxygen environment will suppress appetite, increase energy expenditure, and improve weight loss and insulin sensitivity. Excessive weight loss in high-altitude environments isn’t a good thing for soldiers – they kind of need their muscles and body weight to do the whole soldiering thing – but it could be great for people struggling to lose those last few pounds. And it also may prove LOTME’s previous thesis: Air is not good.

Overweight boy, infertile man?

When it comes to causes of infertility, history and science have generally focused on women. A lot of the research overlooks men, but some previous studies have suggested that male infertility contributes to about half of the cases of couple infertility. The reason for much of that male infertility, however, has been a mystery. Until now.

A group of Italian investigators looked at the declining trend in sperm counts over the past 40 years and the increase of childhood obesity. Is there a correlation? The researchers think so. Childhood obesity can be linked to multiple causes, but the researchers zeroed in on the effect that obesity has on metabolic rates and, therefore, testicular growth.

Collecting data on testicular volume, body mass index (BMI), and insulin resistance from 268 boys aged 2-18 years, the researchers discovered that those with normal weight and normal insulin levels had testicular volumes 1.5 times higher than their overweight counterparts and 1.5-2 times higher than those with hyperinsulinemia, building a case for obesity being a factor for infertility later in life.

Since low testicular volume is associated with lower sperm count and production as an adult, putting two and two together makes a compelling argument for childhood obesity being a major male infertility culprit. It also creates even more urgency for the health care industry and community decision makers to focus on childhood obesity.

It sure would be nice to be able to take one of the many risk factors for future human survival off the table. Maybe by taking something, like cake, off the table.

Fecal transplantation moves to the kitchen

Fecal microbiota transplantation is an effective way to treat Clostridioides difficile infection, but, in the end, it’s still a transplantation procedure involving a nasogastric or colorectal tube or rather large oral capsules with a demanding (30-40 capsules over 2 days) dosage. Please, Science, tell us there’s a better way.

CC BY-NC-ND 4.0, Adèle Rakotonirina et Nathalie Boulens

Science, in the form of investigators at the University of Geneva and Lausanne University Hospital in Switzerland, has spoken, and there may be a better way. Presenting fecal beads: All the bacterial goodness of donor stool without the tubal insertions or massive quantities of giant capsules.

We know you’re scoffing out there, but it’s true. All you need is a little alginate, which is a “biocompatible polysaccharide isolated from brown algae” of the Phaeophyceae family. The donor feces is microencapsulated by mixing it with the alginate, dropping that mixture into water containing calcium chloride, turning it into a gel, and then freeze-drying the gel into small (just 2 mm), solid beads.

Sounds plausible enough, but what do you do with them? “These brownish beads can be easily dispersed in a liquid or food that is pleasant to eat. They also have no taste,” senior author Eric Allémann, PhD, said in a statement released by the University of Geneva.

Pleasant to eat? No taste? So which is it? If you really want to know, watch fecal beads week on the new season of “The Great British Baking Show,” when Paul and Prue judge poop baked into crumpets, crepes, and crostatas. Yum.
 

We’re on the low-oxygen diet

Nine out of ten doctors agree: Oxygen is more important to your continued well-being than food. After all, a human can go weeks without food, but just minutes without oxygen. However, ten out of ten doctors agree that the United States has an obesity problem. They all also agree that previous research has shown soldiers who train at high altitudes lose more weight than those training at lower altitudes.

PBRC

So, on the one hand, we have a country full of overweight people, and on the other, we have low oxygen levels causing weight loss. The solution, then, is obvious: Stop breathing.

More specifically (and somewhat less facetiously), researchers from Louisiana have launched the Low Oxygen and Weight Status trial and are currently recruiting individuals with BMIs of 30-40 to, uh, suffocate themselves. No, no, it’s okay, it’s just when they’re sleeping.

Fine, straight face. Participants in the LOWS trial will undergo an 8-week period when they will consume a controlled weight-loss diet and spend their nights in a hypoxic sealed tent, where they will sleep in an environment with an oxygen level equivalent to 8,500 feet above sea level (roughly equivalent to Aspen, Colo.). They will be compared with people on the same diet who sleep in a normal, sea-level oxygen environment.

The study’s goal is to determine whether or not spending time in a low-oxygen environment will suppress appetite, increase energy expenditure, and improve weight loss and insulin sensitivity. Excessive weight loss in high-altitude environments isn’t a good thing for soldiers – they kind of need their muscles and body weight to do the whole soldiering thing – but it could be great for people struggling to lose those last few pounds. And it also may prove LOTME’s previous thesis: Air is not good.

Overweight boy, infertile man?

When it comes to causes of infertility, history and science have generally focused on women. A lot of the research overlooks men, but some previous studies have suggested that male infertility contributes to about half of the cases of couple infertility. The reason for much of that male infertility, however, has been a mystery. Until now.

A group of Italian investigators looked at the declining trend in sperm counts over the past 40 years and the increase of childhood obesity. Is there a correlation? The researchers think so. Childhood obesity can be linked to multiple causes, but the researchers zeroed in on the effect that obesity has on metabolic rates and, therefore, testicular growth.

Collecting data on testicular volume, body mass index (BMI), and insulin resistance from 268 boys aged 2-18 years, the researchers discovered that those with normal weight and normal insulin levels had testicular volumes 1.5 times higher than their overweight counterparts and 1.5-2 times higher than those with hyperinsulinemia, building a case for obesity being a factor for infertility later in life.

Since low testicular volume is associated with lower sperm count and production as an adult, putting two and two together makes a compelling argument for childhood obesity being a major male infertility culprit. It also creates even more urgency for the health care industry and community decision makers to focus on childhood obesity.

It sure would be nice to be able to take one of the many risk factors for future human survival off the table. Maybe by taking something, like cake, off the table.

Fecal transplantation moves to the kitchen

Fecal microbiota transplantation is an effective way to treat Clostridioides difficile infection, but, in the end, it’s still a transplantation procedure involving a nasogastric or colorectal tube or rather large oral capsules with a demanding (30-40 capsules over 2 days) dosage. Please, Science, tell us there’s a better way.

CC BY-NC-ND 4.0, Adèle Rakotonirina et Nathalie Boulens

Science, in the form of investigators at the University of Geneva and Lausanne University Hospital in Switzerland, has spoken, and there may be a better way. Presenting fecal beads: All the bacterial goodness of donor stool without the tubal insertions or massive quantities of giant capsules.

We know you’re scoffing out there, but it’s true. All you need is a little alginate, which is a “biocompatible polysaccharide isolated from brown algae” of the Phaeophyceae family. The donor feces is microencapsulated by mixing it with the alginate, dropping that mixture into water containing calcium chloride, turning it into a gel, and then freeze-drying the gel into small (just 2 mm), solid beads.

Sounds plausible enough, but what do you do with them? “These brownish beads can be easily dispersed in a liquid or food that is pleasant to eat. They also have no taste,” senior author Eric Allémann, PhD, said in a statement released by the University of Geneva.

Pleasant to eat? No taste? So which is it? If you really want to know, watch fecal beads week on the new season of “The Great British Baking Show,” when Paul and Prue judge poop baked into crumpets, crepes, and crostatas. Yum.
 

We’re on the low-oxygen diet

Nine out of ten doctors agree: Oxygen is more important to your continued well-being than food. After all, a human can go weeks without food, but just minutes without oxygen. However, ten out of ten doctors agree that the United States has an obesity problem. They all also agree that previous research has shown soldiers who train at high altitudes lose more weight than those training at lower altitudes.

PBRC

So, on the one hand, we have a country full of overweight people, and on the other, we have low oxygen levels causing weight loss. The solution, then, is obvious: Stop breathing.

More specifically (and somewhat less facetiously), researchers from Louisiana have launched the Low Oxygen and Weight Status trial and are currently recruiting individuals with BMIs of 30-40 to, uh, suffocate themselves. No, no, it’s okay, it’s just when they’re sleeping.

Fine, straight face. Participants in the LOWS trial will undergo an 8-week period when they will consume a controlled weight-loss diet and spend their nights in a hypoxic sealed tent, where they will sleep in an environment with an oxygen level equivalent to 8,500 feet above sea level (roughly equivalent to Aspen, Colo.). They will be compared with people on the same diet who sleep in a normal, sea-level oxygen environment.

The study’s goal is to determine whether or not spending time in a low-oxygen environment will suppress appetite, increase energy expenditure, and improve weight loss and insulin sensitivity. Excessive weight loss in high-altitude environments isn’t a good thing for soldiers – they kind of need their muscles and body weight to do the whole soldiering thing – but it could be great for people struggling to lose those last few pounds. And it also may prove LOTME’s previous thesis: Air is not good.

On average, physicians reported in the Medscape Physician Compensation Report 2023 that they worked 50 hours per week. Five specialties, including critical care, cardiology, and general surgery reported working 55 or more hours weekly.

But there’s a small segment of physicians that has bucked the norm. They’ve scaled back their hours to part time, clocking in only 25-30 hours a week.

In 2011, The New England Journal of Medicine reported that part-time physician careers were rising. At the time, part-time doctors made up 21% of the physician workforce, up from 13% in 2005.

In a more recent survey from the California Health Care Foundation, only 12% of California physicians said they devoted 20-29 hours a week to patient care. 

Amy Knoup, a senior recruitment adviser with Provider Solutions & Development), has been helping doctors find jobs for over a decade, and she’s noticed a trend.

“Not only are more physicians seeking part-time roles than they were 10 years ago, but more large health care systems are also offering part time or per diem as well,” said Ms. Knoup.
 

Who’s working part time, and why?

Ten years ago, the fastest growing segment of part-timers were men nearing retirement and early- to mid-career women.

Pediatricians led the part-time pack in 2002, according to an American Academy of Pediatrics study. At the time, 15% of pediatricians reported their hours as part time. However, the numbers may have increased over the years. For example, a 2021 study by the department of pediatrics, Boston Medical Center, and Boston University found that almost 30% of graduating pediatricians sought part-time work at the end of their training. 

At PS&D, Ms. Knoup said she has noticed a trend toward part-timers among primary care, behavioral health, and outpatient specialties such as endocrinology. “We’re also seeing it with the inpatient side in roles that are more shift based like hospitalists, radiologists, and critical care and ER doctors.”

Another trend Ms. Knoup has noticed is with early-career doctors. “They have a different mindset,” she said. “Younger generations are acutely aware of burnout. They may have experienced it in residency or during the pandemic. They’ve had a taste of that and don’t want to go down that road again, so they’re seeking part-time roles. It’s an intentional choice.” 

Tracey O’Connell, MD, a radiologist, always knew that she wanted to work part time. “I had a baby as a resident, and I was pregnant with my second child as a fellow,” she said. “I was already feeling overwhelmed with medical training and having a family.”

Dr. O’Connell worked in private practice for 16 years on Mondays, Wednesdays, and Fridays, with no nights or weekends. 

“I still found it completely overwhelming,” she said. “Even though I had more days not working than working, I felt like the demands of medical life had advanced faster than human beings could adapt, and I still feel that way.”

Today she runs a part-time teleradiology practice from home but spends more time on her second career as a life coach. “Most of my clients are physicians looking for more fulfillment and sustainable ways of practicing medicine while maintaining their own identity as human beings, not just the all-consuming identity of ‘doctor,’ ” she said. 

On the other end of the career spectrum is Lois Goodman, MD, an ob.gyn. in her late 70s. After 42 years in a group practice, she started her solo practice at 72, seeing patients 3 days per week. “I’m just happy to be working. That’s a tremendous payoff for me. I need to keep working for my mental health.”
 

How does part-time work affect physician shortages and care delivery?

Reducing clinical effort is one of the strategies physicians use to scale down overload. Still, it’s not viable as a long-term solution, said Christine Sinsky, MD, AMA’s vice president of professional satisfaction and a nationally regarded researcher on physician burnout.

“If all the physicians in a community went from working 100% FTE clinical to 50% FTE clinical, then the people in that community would have half the access to care that they had,” said Dr. Sinsky. “There’s less capacity in the system to care for patients.”

Some could argue, then, that part-time physician work may contribute to physician shortage predictions. An Association of American Medical Colleges report estimates there will be a shortage of 37,800 to 124,000 physicians by 2034.

But physicians working part-time express a contrasting point of view. “I don’t believe that part-time workers are responsible for the health care shortage but rather, a great solution,” said Dr. O’Connell. “Because in order to continue working for a long time rather than quitting when the demands exceed human capacity, working part time is a great compromise to offer a life of more sustainable well-being and longevity as a physician, and still live a wholehearted life.”
 

Pros and cons of being a part-time physician

Pros

Less burnout: The American Medical Association has tracked burnout rates for 22 years. By the end of 2021, nearly 63% of physicians reported burnout symptoms, compared with 38% the year before. Going part time appears to reduce burnout, suggests a study published in Mayo Clinic Proceedings.

Better work-life balance: Rachel Miller, MD, an ob.gyn., worked 60-70 hours weekly for 9 years. In 2022, she went to work as an OB hospitalist for a health care system that welcomes part-time clinicians. Since then, she has achieved a better work-life balance, putting in 26-28 hours a week. Dr. Miller now spends more time with her kids and in her additional role as an executive coach to leaders in the medical field. 

More focus: “When I’m at work, I’m 100% mentally in and focused,” said Dr. Miller. “My interactions with patients are different because I’m not burned out. My demeanor and my willingness to connect are stronger.”

Better health: Mehmet Cilingiroglu, MD, with CardioSolution, traded full-time work for part time when health issues and a kidney transplant sidelined his 30-year career in 2018. “Despite my significant health issues, I’ve been able to continue working at a pace that suits me rather than having to retire,” he said. “Part-time physicians can still enjoy patient care, research, innovation, education, and training while balancing that with other areas of life.” 

Errin Weisman, a DO who gave up full-time work in 2016, said cutting back makes her feel healthier, happier, and more energized. “Part-time work helps me to bring my A game each day I work and deliver the best care.” She’s also a life coach encouraging other physicians to find balance in their professional and personal lives.
 

Cons

Cut in pay: Obviously, the No. 1 con is you’ll make less working part time, so adjusting to a salary decrease can be a huge issue, especially if you don’t have other sources of income. Physicians paying off student loans, those caring for children or elderly parents, or those in their prime earning years needing to save for retirement may not be able to go part time.

Diminished career: The chance for promotions or being well known in your field can be diminished, as well as a loss of proficiency if you’re only performing surgery or procedures part time. In some specialties, working part time and not keeping up with (or being able to practice) newer technology developments can harm your career or reputation in the long run.

Missing out: While working part time has many benefits, physicians also experience a wide range of drawbacks. Dr. Goodman, for example, said she misses delivering babies and doing surgeries. Dr. Miller said she gave up some aspects of her specialty, like performing hysterectomies, participating in complex cases, and no longer having an office like she did as a full-time ob.gyn.

Loss of fellowship: Dr. O’Connell said she missed the camaraderie and sense of belonging when she scaled back her hours. “I felt like a fish out of water, that my values didn’t align with the group’s values,” she said. This led to self-doubt, frustrated colleagues, and a reduction in benefits.

Lost esteem: Dr. O’Connell also felt she was expected to work overtime without additional pay and was no longer eligible for bonuses. “I was treated as a team player when I was needed, but not when it came to perks and benefits and insider privilege,” she said. There may be a loss of esteem among colleagues and supervisors.

Overcoming stigma: Because part-time physician work is still not prevalent among colleagues, some may resist the idea, have less respect for it, perceive it as not being serious about your career as a physician, or associate it with being lazy or entitled.

Summing it up

Every physician must weigh the value and drawbacks of part-time work, but the more physicians who go this route, the more part-time medicine gains traction and the more physicians can learn about its values versus its drawbacks.

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

On average, physicians reported in the Medscape Physician Compensation Report 2023 that they worked 50 hours per week. Five specialties, including critical care, cardiology, and general surgery reported working 55 or more hours weekly.

But there’s a small segment of physicians that has bucked the norm. They’ve scaled back their hours to part time, clocking in only 25-30 hours a week.

In 2011, The New England Journal of Medicine reported that part-time physician careers were rising. At the time, part-time doctors made up 21% of the physician workforce, up from 13% in 2005.

In a more recent survey from the California Health Care Foundation, only 12% of California physicians said they devoted 20-29 hours a week to patient care. 

Amy Knoup, a senior recruitment adviser with Provider Solutions & Development), has been helping doctors find jobs for over a decade, and she’s noticed a trend.

“Not only are more physicians seeking part-time roles than they were 10 years ago, but more large health care systems are also offering part time or per diem as well,” said Ms. Knoup.
 

Who’s working part time, and why?

Ten years ago, the fastest growing segment of part-timers were men nearing retirement and early- to mid-career women.

Pediatricians led the part-time pack in 2002, according to an American Academy of Pediatrics study. At the time, 15% of pediatricians reported their hours as part time. However, the numbers may have increased over the years. For example, a 2021 study by the department of pediatrics, Boston Medical Center, and Boston University found that almost 30% of graduating pediatricians sought part-time work at the end of their training. 

At PS&D, Ms. Knoup said she has noticed a trend toward part-timers among primary care, behavioral health, and outpatient specialties such as endocrinology. “We’re also seeing it with the inpatient side in roles that are more shift based like hospitalists, radiologists, and critical care and ER doctors.”

Another trend Ms. Knoup has noticed is with early-career doctors. “They have a different mindset,” she said. “Younger generations are acutely aware of burnout. They may have experienced it in residency or during the pandemic. They’ve had a taste of that and don’t want to go down that road again, so they’re seeking part-time roles. It’s an intentional choice.” 

Tracey O’Connell, MD, a radiologist, always knew that she wanted to work part time. “I had a baby as a resident, and I was pregnant with my second child as a fellow,” she said. “I was already feeling overwhelmed with medical training and having a family.”

Dr. O’Connell worked in private practice for 16 years on Mondays, Wednesdays, and Fridays, with no nights or weekends. 

“I still found it completely overwhelming,” she said. “Even though I had more days not working than working, I felt like the demands of medical life had advanced faster than human beings could adapt, and I still feel that way.”

Today she runs a part-time teleradiology practice from home but spends more time on her second career as a life coach. “Most of my clients are physicians looking for more fulfillment and sustainable ways of practicing medicine while maintaining their own identity as human beings, not just the all-consuming identity of ‘doctor,’ ” she said. 

On the other end of the career spectrum is Lois Goodman, MD, an ob.gyn. in her late 70s. After 42 years in a group practice, she started her solo practice at 72, seeing patients 3 days per week. “I’m just happy to be working. That’s a tremendous payoff for me. I need to keep working for my mental health.”
 

How does part-time work affect physician shortages and care delivery?

Reducing clinical effort is one of the strategies physicians use to scale down overload. Still, it’s not viable as a long-term solution, said Christine Sinsky, MD, AMA’s vice president of professional satisfaction and a nationally regarded researcher on physician burnout.

“If all the physicians in a community went from working 100% FTE clinical to 50% FTE clinical, then the people in that community would have half the access to care that they had,” said Dr. Sinsky. “There’s less capacity in the system to care for patients.”

Some could argue, then, that part-time physician work may contribute to physician shortage predictions. An Association of American Medical Colleges report estimates there will be a shortage of 37,800 to 124,000 physicians by 2034.

But physicians working part-time express a contrasting point of view. “I don’t believe that part-time workers are responsible for the health care shortage but rather, a great solution,” said Dr. O’Connell. “Because in order to continue working for a long time rather than quitting when the demands exceed human capacity, working part time is a great compromise to offer a life of more sustainable well-being and longevity as a physician, and still live a wholehearted life.”
 

Pros and cons of being a part-time physician

Pros

Less burnout: The American Medical Association has tracked burnout rates for 22 years. By the end of 2021, nearly 63% of physicians reported burnout symptoms, compared with 38% the year before. Going part time appears to reduce burnout, suggests a study published in Mayo Clinic Proceedings.

Better work-life balance: Rachel Miller, MD, an ob.gyn., worked 60-70 hours weekly for 9 years. In 2022, she went to work as an OB hospitalist for a health care system that welcomes part-time clinicians. Since then, she has achieved a better work-life balance, putting in 26-28 hours a week. Dr. Miller now spends more time with her kids and in her additional role as an executive coach to leaders in the medical field. 

More focus: “When I’m at work, I’m 100% mentally in and focused,” said Dr. Miller. “My interactions with patients are different because I’m not burned out. My demeanor and my willingness to connect are stronger.”

Better health: Mehmet Cilingiroglu, MD, with CardioSolution, traded full-time work for part time when health issues and a kidney transplant sidelined his 30-year career in 2018. “Despite my significant health issues, I’ve been able to continue working at a pace that suits me rather than having to retire,” he said. “Part-time physicians can still enjoy patient care, research, innovation, education, and training while balancing that with other areas of life.” 

Errin Weisman, a DO who gave up full-time work in 2016, said cutting back makes her feel healthier, happier, and more energized. “Part-time work helps me to bring my A game each day I work and deliver the best care.” She’s also a life coach encouraging other physicians to find balance in their professional and personal lives.
 

Cons

Cut in pay: Obviously, the No. 1 con is you’ll make less working part time, so adjusting to a salary decrease can be a huge issue, especially if you don’t have other sources of income. Physicians paying off student loans, those caring for children or elderly parents, or those in their prime earning years needing to save for retirement may not be able to go part time.

Diminished career: The chance for promotions or being well known in your field can be diminished, as well as a loss of proficiency if you’re only performing surgery or procedures part time. In some specialties, working part time and not keeping up with (or being able to practice) newer technology developments can harm your career or reputation in the long run.

Missing out: While working part time has many benefits, physicians also experience a wide range of drawbacks. Dr. Goodman, for example, said she misses delivering babies and doing surgeries. Dr. Miller said she gave up some aspects of her specialty, like performing hysterectomies, participating in complex cases, and no longer having an office like she did as a full-time ob.gyn.

Loss of fellowship: Dr. O’Connell said she missed the camaraderie and sense of belonging when she scaled back her hours. “I felt like a fish out of water, that my values didn’t align with the group’s values,” she said. This led to self-doubt, frustrated colleagues, and a reduction in benefits.

Lost esteem: Dr. O’Connell also felt she was expected to work overtime without additional pay and was no longer eligible for bonuses. “I was treated as a team player when I was needed, but not when it came to perks and benefits and insider privilege,” she said. There may be a loss of esteem among colleagues and supervisors.

Overcoming stigma: Because part-time physician work is still not prevalent among colleagues, some may resist the idea, have less respect for it, perceive it as not being serious about your career as a physician, or associate it with being lazy or entitled.

Summing it up

Every physician must weigh the value and drawbacks of part-time work, but the more physicians who go this route, the more part-time medicine gains traction and the more physicians can learn about its values versus its drawbacks.

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

On average, physicians reported in the Medscape Physician Compensation Report 2023 that they worked 50 hours per week. Five specialties, including critical care, cardiology, and general surgery reported working 55 or more hours weekly.

But there’s a small segment of physicians that has bucked the norm. They’ve scaled back their hours to part time, clocking in only 25-30 hours a week.

In 2011, The New England Journal of Medicine reported that part-time physician careers were rising. At the time, part-time doctors made up 21% of the physician workforce, up from 13% in 2005.

In a more recent survey from the California Health Care Foundation, only 12% of California physicians said they devoted 20-29 hours a week to patient care. 

Amy Knoup, a senior recruitment adviser with Provider Solutions & Development), has been helping doctors find jobs for over a decade, and she’s noticed a trend.

“Not only are more physicians seeking part-time roles than they were 10 years ago, but more large health care systems are also offering part time or per diem as well,” said Ms. Knoup.
 

Who’s working part time, and why?

Ten years ago, the fastest growing segment of part-timers were men nearing retirement and early- to mid-career women.

Pediatricians led the part-time pack in 2002, according to an American Academy of Pediatrics study. At the time, 15% of pediatricians reported their hours as part time. However, the numbers may have increased over the years. For example, a 2021 study by the department of pediatrics, Boston Medical Center, and Boston University found that almost 30% of graduating pediatricians sought part-time work at the end of their training. 

At PS&D, Ms. Knoup said she has noticed a trend toward part-timers among primary care, behavioral health, and outpatient specialties such as endocrinology. “We’re also seeing it with the inpatient side in roles that are more shift based like hospitalists, radiologists, and critical care and ER doctors.”

Another trend Ms. Knoup has noticed is with early-career doctors. “They have a different mindset,” she said. “Younger generations are acutely aware of burnout. They may have experienced it in residency or during the pandemic. They’ve had a taste of that and don’t want to go down that road again, so they’re seeking part-time roles. It’s an intentional choice.” 

Tracey O’Connell, MD, a radiologist, always knew that she wanted to work part time. “I had a baby as a resident, and I was pregnant with my second child as a fellow,” she said. “I was already feeling overwhelmed with medical training and having a family.”

Dr. O’Connell worked in private practice for 16 years on Mondays, Wednesdays, and Fridays, with no nights or weekends. 

“I still found it completely overwhelming,” she said. “Even though I had more days not working than working, I felt like the demands of medical life had advanced faster than human beings could adapt, and I still feel that way.”

Today she runs a part-time teleradiology practice from home but spends more time on her second career as a life coach. “Most of my clients are physicians looking for more fulfillment and sustainable ways of practicing medicine while maintaining their own identity as human beings, not just the all-consuming identity of ‘doctor,’ ” she said. 

On the other end of the career spectrum is Lois Goodman, MD, an ob.gyn. in her late 70s. After 42 years in a group practice, she started her solo practice at 72, seeing patients 3 days per week. “I’m just happy to be working. That’s a tremendous payoff for me. I need to keep working for my mental health.”
 

How does part-time work affect physician shortages and care delivery?

Reducing clinical effort is one of the strategies physicians use to scale down overload. Still, it’s not viable as a long-term solution, said Christine Sinsky, MD, AMA’s vice president of professional satisfaction and a nationally regarded researcher on physician burnout.

“If all the physicians in a community went from working 100% FTE clinical to 50% FTE clinical, then the people in that community would have half the access to care that they had,” said Dr. Sinsky. “There’s less capacity in the system to care for patients.”

Some could argue, then, that part-time physician work may contribute to physician shortage predictions. An Association of American Medical Colleges report estimates there will be a shortage of 37,800 to 124,000 physicians by 2034.

But physicians working part-time express a contrasting point of view. “I don’t believe that part-time workers are responsible for the health care shortage but rather, a great solution,” said Dr. O’Connell. “Because in order to continue working for a long time rather than quitting when the demands exceed human capacity, working part time is a great compromise to offer a life of more sustainable well-being and longevity as a physician, and still live a wholehearted life.”
 

Pros and cons of being a part-time physician

Pros

Less burnout: The American Medical Association has tracked burnout rates for 22 years. By the end of 2021, nearly 63% of physicians reported burnout symptoms, compared with 38% the year before. Going part time appears to reduce burnout, suggests a study published in Mayo Clinic Proceedings.

Better work-life balance: Rachel Miller, MD, an ob.gyn., worked 60-70 hours weekly for 9 years. In 2022, she went to work as an OB hospitalist for a health care system that welcomes part-time clinicians. Since then, she has achieved a better work-life balance, putting in 26-28 hours a week. Dr. Miller now spends more time with her kids and in her additional role as an executive coach to leaders in the medical field. 

More focus: “When I’m at work, I’m 100% mentally in and focused,” said Dr. Miller. “My interactions with patients are different because I’m not burned out. My demeanor and my willingness to connect are stronger.”

Better health: Mehmet Cilingiroglu, MD, with CardioSolution, traded full-time work for part time when health issues and a kidney transplant sidelined his 30-year career in 2018. “Despite my significant health issues, I’ve been able to continue working at a pace that suits me rather than having to retire,” he said. “Part-time physicians can still enjoy patient care, research, innovation, education, and training while balancing that with other areas of life.” 

Errin Weisman, a DO who gave up full-time work in 2016, said cutting back makes her feel healthier, happier, and more energized. “Part-time work helps me to bring my A game each day I work and deliver the best care.” She’s also a life coach encouraging other physicians to find balance in their professional and personal lives.
 

Cons

Cut in pay: Obviously, the No. 1 con is you’ll make less working part time, so adjusting to a salary decrease can be a huge issue, especially if you don’t have other sources of income. Physicians paying off student loans, those caring for children or elderly parents, or those in their prime earning years needing to save for retirement may not be able to go part time.

Diminished career: The chance for promotions or being well known in your field can be diminished, as well as a loss of proficiency if you’re only performing surgery or procedures part time. In some specialties, working part time and not keeping up with (or being able to practice) newer technology developments can harm your career or reputation in the long run.

Missing out: While working part time has many benefits, physicians also experience a wide range of drawbacks. Dr. Goodman, for example, said she misses delivering babies and doing surgeries. Dr. Miller said she gave up some aspects of her specialty, like performing hysterectomies, participating in complex cases, and no longer having an office like she did as a full-time ob.gyn.

Loss of fellowship: Dr. O’Connell said she missed the camaraderie and sense of belonging when she scaled back her hours. “I felt like a fish out of water, that my values didn’t align with the group’s values,” she said. This led to self-doubt, frustrated colleagues, and a reduction in benefits.

Lost esteem: Dr. O’Connell also felt she was expected to work overtime without additional pay and was no longer eligible for bonuses. “I was treated as a team player when I was needed, but not when it came to perks and benefits and insider privilege,” she said. There may be a loss of esteem among colleagues and supervisors.

Overcoming stigma: Because part-time physician work is still not prevalent among colleagues, some may resist the idea, have less respect for it, perceive it as not being serious about your career as a physician, or associate it with being lazy or entitled.

Summing it up

Every physician must weigh the value and drawbacks of part-time work, but the more physicians who go this route, the more part-time medicine gains traction and the more physicians can learn about its values versus its drawbacks.

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

SEATTLE – Taking sulfonylureas sold as “street Valium” can lead to severe hypoglycemia that may result in emergency department visits, the latest of a handful of case reports suggest.

“Physicians should be aware of this possibility and consider intentional or unintentional sulfonylurea abuse, with or without other drugs,” Amanda McKenna, MD, a first-year endocrinology fellow at the Mayo Clinic, Jacksonville, Fla., and colleagues say in a poster presented at the annual scientific & clinical congress of the American Association of Clinical Endocrinology.

The new case, seen in Florida, involves a 33-year-old man with a history of narcotic dependence and anxiety but not diabetes. At the time of presentation, the patient was unconscious and diaphoretic. The patient’s blood glucose level was 18 mg/dL. He had purchased two unmarked, light blue pills on the street which he thought were Valiums but turned out to be glyburide.

Sulfonylureas have no potential for abuse, but they physically resemble Valiums and are easier for illicit drug dealers to obtain because they’re not a controlled substance, and they can be sold for considerably more money, Dr. McKenna said in an interview.

“He thought he was getting Valium, but what he really purchased was glyburide. ... When he took it, he developed sweating and weakness. He probably thought he was having a bad trip, but it was really low blood sugar,” she said.
 

Similar cases go back nearly two decades

Similar cases have been reported as far back as 2004 in different parts of the United States. A 2004 article reports five cases in which people in San Francisco were “admitted to the hospital for hypoglycemia as a result of a drug purchased on the streets as a presumed benzodiazepine.”

Two more cases of “glyburide poisoning by ingestion of ‘street Valium,’ ” also from San Francisco, were reported in 2012. And in another case presented at the 2022 Endocrine Society meeting, sulfonylurea had been cut with cocaine, presumably to increase the volume.

The lead author of the 2012 article, Craig Smollin, MD, medical director of the California Poison Control System, San Francisco Division, and professor of emergency medicine at the University of California, San Francisco, told this news organization that his team has seen “a handful of cases over the years” but that “it is hard to say how common it is because hypoglycemia is common in this patient population for a variety of reasons.”
 

Persistent hypoglycemia led to the source

In the current case, paramedics treated the patient with D50W, and his blood glucose level increased from 18 mg/dL to 109 mg/dL. He regained consciousness but then developed recurrent hypoglycemia, and his blood glucose level dropped back to 15 mg/dL in the ED. Urine toxicology results were positive for benzodiazepines, cannabis, and cocaine.

Laboratory results showed elevations in levels of insulin (47.4 mIU/mL), C-peptide (5.4 ng/mL), and glucose (44 mg/dL). He was again treated with D50W, and his blood glucose level returned to normal over 20 hours. Once alert and oriented, he reported no personal or family history of diabetes. A 72-hour fast showed no evidence of insulinoma. A sulfonylurea screen was positive for glyburide. He was discharged home in stable condition. How many more cases have been missed?

Dr. McKenna pointed out that a typical urine toxicology screen for drugs wouldn’t detect a sulfonylurea. “The screen for hypoglycemic agents is a blood test, not a urine screen, so it’s completely different in the workup, and you really have to be thinking about that. It typically takes a while to come back,” she said.

She added that if the hypoglycemia resolves and testing isn’t conducted, the cause of the low blood sugar level might be missed. “If the hypoglycemia doesn’t persist, the [ED] physician wouldn’t consult endocrine. ... Is this happening more than we think?”
 

Ocreotide: A ‘unique antidote’

In their article, Dr. Smollin and colleagues describe the use of ocreotide, a long-acting somatostatin agonist that reverses the insulin-releasing effect of sulfonylureas on pancreatic beta cells, resulting in diminished insulin secretion. Unlike glucose supplementation, ocreotide doesn’t stimulate additional insulin release. It is of longer duration than glucagon, the authors say.

“The management of sulfonylurea overdose includes administration of glucose but also may include the use of octreotide, a unique antidote for sulfonylurea induced hypoglycemia,” Dr. Smollin said.

However, he also cautioned, “there is a broad differential diagnosis for hypoglycemia, and clinicians must consider many alternative diagnoses.”

Dr. McKenna and Dr. Smollin have disclosed no relevant financial relationships.

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

SEATTLE – Taking sulfonylureas sold as “street Valium” can lead to severe hypoglycemia that may result in emergency department visits, the latest of a handful of case reports suggest.

“Physicians should be aware of this possibility and consider intentional or unintentional sulfonylurea abuse, with or without other drugs,” Amanda McKenna, MD, a first-year endocrinology fellow at the Mayo Clinic, Jacksonville, Fla., and colleagues say in a poster presented at the annual scientific & clinical congress of the American Association of Clinical Endocrinology.

The new case, seen in Florida, involves a 33-year-old man with a history of narcotic dependence and anxiety but not diabetes. At the time of presentation, the patient was unconscious and diaphoretic. The patient’s blood glucose level was 18 mg/dL. He had purchased two unmarked, light blue pills on the street which he thought were Valiums but turned out to be glyburide.

Sulfonylureas have no potential for abuse, but they physically resemble Valiums and are easier for illicit drug dealers to obtain because they’re not a controlled substance, and they can be sold for considerably more money, Dr. McKenna said in an interview.

“He thought he was getting Valium, but what he really purchased was glyburide. ... When he took it, he developed sweating and weakness. He probably thought he was having a bad trip, but it was really low blood sugar,” she said.
 

Similar cases go back nearly two decades

Similar cases have been reported as far back as 2004 in different parts of the United States. A 2004 article reports five cases in which people in San Francisco were “admitted to the hospital for hypoglycemia as a result of a drug purchased on the streets as a presumed benzodiazepine.”

Two more cases of “glyburide poisoning by ingestion of ‘street Valium,’ ” also from San Francisco, were reported in 2012. And in another case presented at the 2022 Endocrine Society meeting, sulfonylurea had been cut with cocaine, presumably to increase the volume.

The lead author of the 2012 article, Craig Smollin, MD, medical director of the California Poison Control System, San Francisco Division, and professor of emergency medicine at the University of California, San Francisco, told this news organization that his team has seen “a handful of cases over the years” but that “it is hard to say how common it is because hypoglycemia is common in this patient population for a variety of reasons.”
 

Persistent hypoglycemia led to the source

In the current case, paramedics treated the patient with D50W, and his blood glucose level increased from 18 mg/dL to 109 mg/dL. He regained consciousness but then developed recurrent hypoglycemia, and his blood glucose level dropped back to 15 mg/dL in the ED. Urine toxicology results were positive for benzodiazepines, cannabis, and cocaine.

Laboratory results showed elevations in levels of insulin (47.4 mIU/mL), C-peptide (5.4 ng/mL), and glucose (44 mg/dL). He was again treated with D50W, and his blood glucose level returned to normal over 20 hours. Once alert and oriented, he reported no personal or family history of diabetes. A 72-hour fast showed no evidence of insulinoma. A sulfonylurea screen was positive for glyburide. He was discharged home in stable condition. How many more cases have been missed?

Dr. McKenna pointed out that a typical urine toxicology screen for drugs wouldn’t detect a sulfonylurea. “The screen for hypoglycemic agents is a blood test, not a urine screen, so it’s completely different in the workup, and you really have to be thinking about that. It typically takes a while to come back,” she said.

She added that if the hypoglycemia resolves and testing isn’t conducted, the cause of the low blood sugar level might be missed. “If the hypoglycemia doesn’t persist, the [ED] physician wouldn’t consult endocrine. ... Is this happening more than we think?”
 

Ocreotide: A ‘unique antidote’

In their article, Dr. Smollin and colleagues describe the use of ocreotide, a long-acting somatostatin agonist that reverses the insulin-releasing effect of sulfonylureas on pancreatic beta cells, resulting in diminished insulin secretion. Unlike glucose supplementation, ocreotide doesn’t stimulate additional insulin release. It is of longer duration than glucagon, the authors say.

“The management of sulfonylurea overdose includes administration of glucose but also may include the use of octreotide, a unique antidote for sulfonylurea induced hypoglycemia,” Dr. Smollin said.

However, he also cautioned, “there is a broad differential diagnosis for hypoglycemia, and clinicians must consider many alternative diagnoses.”

Dr. McKenna and Dr. Smollin have disclosed no relevant financial relationships.

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

SEATTLE – Taking sulfonylureas sold as “street Valium” can lead to severe hypoglycemia that may result in emergency department visits, the latest of a handful of case reports suggest.

“Physicians should be aware of this possibility and consider intentional or unintentional sulfonylurea abuse, with or without other drugs,” Amanda McKenna, MD, a first-year endocrinology fellow at the Mayo Clinic, Jacksonville, Fla., and colleagues say in a poster presented at the annual scientific & clinical congress of the American Association of Clinical Endocrinology.

The new case, seen in Florida, involves a 33-year-old man with a history of narcotic dependence and anxiety but not diabetes. At the time of presentation, the patient was unconscious and diaphoretic. The patient’s blood glucose level was 18 mg/dL. He had purchased two unmarked, light blue pills on the street which he thought were Valiums but turned out to be glyburide.

Sulfonylureas have no potential for abuse, but they physically resemble Valiums and are easier for illicit drug dealers to obtain because they’re not a controlled substance, and they can be sold for considerably more money, Dr. McKenna said in an interview.

“He thought he was getting Valium, but what he really purchased was glyburide. ... When he took it, he developed sweating and weakness. He probably thought he was having a bad trip, but it was really low blood sugar,” she said.
 

Similar cases go back nearly two decades

Similar cases have been reported as far back as 2004 in different parts of the United States. A 2004 article reports five cases in which people in San Francisco were “admitted to the hospital for hypoglycemia as a result of a drug purchased on the streets as a presumed benzodiazepine.”

Two more cases of “glyburide poisoning by ingestion of ‘street Valium,’ ” also from San Francisco, were reported in 2012. And in another case presented at the 2022 Endocrine Society meeting, sulfonylurea had been cut with cocaine, presumably to increase the volume.

The lead author of the 2012 article, Craig Smollin, MD, medical director of the California Poison Control System, San Francisco Division, and professor of emergency medicine at the University of California, San Francisco, told this news organization that his team has seen “a handful of cases over the years” but that “it is hard to say how common it is because hypoglycemia is common in this patient population for a variety of reasons.”
 

Persistent hypoglycemia led to the source

In the current case, paramedics treated the patient with D50W, and his blood glucose level increased from 18 mg/dL to 109 mg/dL. He regained consciousness but then developed recurrent hypoglycemia, and his blood glucose level dropped back to 15 mg/dL in the ED. Urine toxicology results were positive for benzodiazepines, cannabis, and cocaine.

Laboratory results showed elevations in levels of insulin (47.4 mIU/mL), C-peptide (5.4 ng/mL), and glucose (44 mg/dL). He was again treated with D50W, and his blood glucose level returned to normal over 20 hours. Once alert and oriented, he reported no personal or family history of diabetes. A 72-hour fast showed no evidence of insulinoma. A sulfonylurea screen was positive for glyburide. He was discharged home in stable condition. How many more cases have been missed?

Dr. McKenna pointed out that a typical urine toxicology screen for drugs wouldn’t detect a sulfonylurea. “The screen for hypoglycemic agents is a blood test, not a urine screen, so it’s completely different in the workup, and you really have to be thinking about that. It typically takes a while to come back,” she said.

She added that if the hypoglycemia resolves and testing isn’t conducted, the cause of the low blood sugar level might be missed. “If the hypoglycemia doesn’t persist, the [ED] physician wouldn’t consult endocrine. ... Is this happening more than we think?”
 

Ocreotide: A ‘unique antidote’

In their article, Dr. Smollin and colleagues describe the use of ocreotide, a long-acting somatostatin agonist that reverses the insulin-releasing effect of sulfonylureas on pancreatic beta cells, resulting in diminished insulin secretion. Unlike glucose supplementation, ocreotide doesn’t stimulate additional insulin release. It is of longer duration than glucagon, the authors say.

“The management of sulfonylurea overdose includes administration of glucose but also may include the use of octreotide, a unique antidote for sulfonylurea induced hypoglycemia,” Dr. Smollin said.

However, he also cautioned, “there is a broad differential diagnosis for hypoglycemia, and clinicians must consider many alternative diagnoses.”

Dr. McKenna and Dr. Smollin have disclosed no relevant financial relationships.

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

Canadian family physicians’ increased use of virtual care during the first years of the pandemic was not associated with increased emergency department use among patients, a new analysis of data from Ontario suggests.

In a cross-sectional study that included almost 14,000 family physicians and almost 13 million patients in Ontario, an adjusted analysis indicated that patients with physicians who provided more than 20% of care virtually had lower rates of ED visits, compared with patients whose physicians provided the least virtual care.

“I was surprised to see that ED visit volumes in fall 2021 were below prepandemic levels,” study author Tara Kiran, MD, who practices family medicine at St. Michael’s Hospital of the University of Toronto, told this news organization.

“At that time, there was a lot in the news about how our EDs were overcrowded and an assumption that this related to higher visit volumes. But our data [suggest] there were other factors at play, including strains in staffing in the ED, hospital inpatient units, and in long-term care.” Dr. Kiran is also the Fidani chair in improvement and innovation and vice-chair of quality and innovation at the department of family and community medicine of the University of Toronto.

The study was published online in JAMA Network Open.
 

Embrace of telehealth

The investigators analyzed administrative data from Ontario for 13,820 family physicians (mean age, 50 years; 51.5% men) and 12,951,063 patients (mean age, 42.6 years; 51.8% women) under their care.

The family physicians had at least one primary care visit claim between Feb. 1 and Oct. 31, 2021. The researchers categorized the physicians by the percentage of total visits they delivered virtually (via telephone or video) during the study period, as follows: 0% (100% in person), greater than 0%-20%, greater than 20%-40%, greater than 40%-60%, greater than 60%-80%, greater than 80% to less than 100%, or 100%.

The percentage of virtual primary care visits peaked at 82% in the first 2 weeks of the pandemic and decreased to 49% by October 2021. ED visit rates decreased at the start of the pandemic and remained lower than in 2019 throughout the study period.

Most physicians provided between 40% and 80% of care virtually. A greater percentage of those who provided more than 80% of care virtually were aged 65 years or older, were women, and practiced in large cities.

Patient comorbidity and morbidity were similar across all categories of virtual care use. The mean number of ED visits was highest among patients whose physicians provided only in-person care (470.3 per 1,000 patients) and was lowest among those whose physicians provided greater than 0% to less than 100% of care virtually (242 per 1,000 patients).

After adjustment for patient characteristics, patients of physicians who provided more than 20% of care virtually had lower rates of ED visits, compared with patients of physicians who provided the least virtual care (for example, greater than 80% to less than 100% versus 0%-20% virtual visits in big cities; relative rate, 0.77). This pattern was consistent across all rurality of practice categories and after adjustment for 2019 ED visit rates.

The investigators observed a gradient in urban areas. Patients of physicians who provided the highest level of virtual care had the lowest ED visit rates.
 

Investigating virtual modalities

Some policymakers worried that inappropriate use of virtual care was leading to an increase in ED use. “Findings of this study refute this hypothesis,” the authors write. Increases in ED use seemed to coincide with decreases in COVID-19 cases, not with increases in virtual primary care visits.

Furthermore, at the population level, patients who were cared for by physicians who provided a high percentage of virtual care did not have a higher rate of ED visits, compared with those cared for by physicians who provided the lowest levels of virtual care.

During the pandemic, the switch to virtual care worked well for some of Dr. Kiran’s patients. It was more convenient, because they didn’t have to take time off work, travel to and from the clinic, find and pay for parking, or wait in the clinic before the appointment, she said.

But for others, “virtual care really didn’t work well,” she said. “This was particularly true for people who didn’t have a regular working phone, who didn’t have a private space to take calls, who weren’t fluent in English, and who were hard of hearing or had severe mental illness that resulted in paranoid thoughts.”

Clinicians also may have had different comfort levels and preferences regarding virtual visits, Dr. Kiran hypothesized. Some found it convenient and efficient, whereas others may have found it cumbersome and inefficient. “I personally find it harder to build relationships with patients when I use virtual care,” she said. “I experience more joy in work with in-person visits, but other clinicians may feel differently.”

Dr. Kiran and her colleagues are conducting a public engagement initiative called OurCare to understand public perspectives on the future of primary care. “As part of that work, we want to understand what virtual modalities are most important to the public and how the public thinks these should be integrated into primary care.”

Virtual care can support access, patient-centered care, and equity in primary care, Dr. Kiran added. “Ideally, it should be integrated into an existing relationship with a family physician and be a complement to in-person visits.”
 

The right dose?

In an accompanying editorial, Jesse M. Pines, MD, chief of clinical innovation at U.S. Acute Care Solutions, Canton, Ohio, writes, “There is no convincing mechanism consistent with the data for the observed outcome of lower ED use at higher telehealth use.”

Additional research is needed, he notes, to answer the “Goldilocks question” – that is, what amount of telehealth optimizes its benefits while minimizing potential problems?

“The right dose of telehealth needs to balance (1) concerns by payers and policymakers that it will increase cost and cause unintended consequences (for example, misdiagnosis or duplicative care) and (2) the desire of its proponents who want to allow clinicians to use it as they see fit, with few restrictions,” writes Dr. Pines.

“Future research would ideally use more robust research design,” he suggested. “For example, randomized trials could test different doses of telehealth, or mixed-methods studies could help elucidate how telehealth may be changing clinical management or care-seeking behavior.”
 

Equitable reimbursement needed

Priya Nori, MD, associate professor of infectious diseases at Montefiore Health System and associate professor at the Albert Einstein College of Medicine, both in New York, said, “I agree with their conclusions and am reassured about telehealth as a durable form of health care delivery.”

Large, population-level studies such as this one might persuade legislators to require equitable reimbursement for in-person and virtual visits “so providers have comparable incentives to provide both types of care,” she said. “Although only primary care was addressed in the study, I believe that virtual care is here to stay and can be applied to primary care, subspecialty care, and other services, like antimicrobial stewardship, infection prevention, et cetera. We need to embrace it.”

A similar study should be conducted in the United States, along with additional research “to ensure that visits done by telephone have similar outcomes as those done by video, as not all communities have adequate internet access or video conferencing technology,” said Dr. Nori.

The study was supported by ICES and grants from Ontario Health, the Canadian Institutes of Health Research, and the Health Systems Research Program of Ontario MOH. Dr. Kiran, Dr. Pines, and Dr. Nori have disclosed no relevant financial relationships.

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

Canadian family physicians’ increased use of virtual care during the first years of the pandemic was not associated with increased emergency department use among patients, a new analysis of data from Ontario suggests.

In a cross-sectional study that included almost 14,000 family physicians and almost 13 million patients in Ontario, an adjusted analysis indicated that patients with physicians who provided more than 20% of care virtually had lower rates of ED visits, compared with patients whose physicians provided the least virtual care.

“I was surprised to see that ED visit volumes in fall 2021 were below prepandemic levels,” study author Tara Kiran, MD, who practices family medicine at St. Michael’s Hospital of the University of Toronto, told this news organization.

“At that time, there was a lot in the news about how our EDs were overcrowded and an assumption that this related to higher visit volumes. But our data [suggest] there were other factors at play, including strains in staffing in the ED, hospital inpatient units, and in long-term care.” Dr. Kiran is also the Fidani chair in improvement and innovation and vice-chair of quality and innovation at the department of family and community medicine of the University of Toronto.

The study was published online in JAMA Network Open.
 

Embrace of telehealth

The investigators analyzed administrative data from Ontario for 13,820 family physicians (mean age, 50 years; 51.5% men) and 12,951,063 patients (mean age, 42.6 years; 51.8% women) under their care.

The family physicians had at least one primary care visit claim between Feb. 1 and Oct. 31, 2021. The researchers categorized the physicians by the percentage of total visits they delivered virtually (via telephone or video) during the study period, as follows: 0% (100% in person), greater than 0%-20%, greater than 20%-40%, greater than 40%-60%, greater than 60%-80%, greater than 80% to less than 100%, or 100%.

The percentage of virtual primary care visits peaked at 82% in the first 2 weeks of the pandemic and decreased to 49% by October 2021. ED visit rates decreased at the start of the pandemic and remained lower than in 2019 throughout the study period.

Most physicians provided between 40% and 80% of care virtually. A greater percentage of those who provided more than 80% of care virtually were aged 65 years or older, were women, and practiced in large cities.

Patient comorbidity and morbidity were similar across all categories of virtual care use. The mean number of ED visits was highest among patients whose physicians provided only in-person care (470.3 per 1,000 patients) and was lowest among those whose physicians provided greater than 0% to less than 100% of care virtually (242 per 1,000 patients).

After adjustment for patient characteristics, patients of physicians who provided more than 20% of care virtually had lower rates of ED visits, compared with patients of physicians who provided the least virtual care (for example, greater than 80% to less than 100% versus 0%-20% virtual visits in big cities; relative rate, 0.77). This pattern was consistent across all rurality of practice categories and after adjustment for 2019 ED visit rates.

The investigators observed a gradient in urban areas. Patients of physicians who provided the highest level of virtual care had the lowest ED visit rates.
 

Investigating virtual modalities

Some policymakers worried that inappropriate use of virtual care was leading to an increase in ED use. “Findings of this study refute this hypothesis,” the authors write. Increases in ED use seemed to coincide with decreases in COVID-19 cases, not with increases in virtual primary care visits.

Furthermore, at the population level, patients who were cared for by physicians who provided a high percentage of virtual care did not have a higher rate of ED visits, compared with those cared for by physicians who provided the lowest levels of virtual care.

During the pandemic, the switch to virtual care worked well for some of Dr. Kiran’s patients. It was more convenient, because they didn’t have to take time off work, travel to and from the clinic, find and pay for parking, or wait in the clinic before the appointment, she said.

But for others, “virtual care really didn’t work well,” she said. “This was particularly true for people who didn’t have a regular working phone, who didn’t have a private space to take calls, who weren’t fluent in English, and who were hard of hearing or had severe mental illness that resulted in paranoid thoughts.”

Clinicians also may have had different comfort levels and preferences regarding virtual visits, Dr. Kiran hypothesized. Some found it convenient and efficient, whereas others may have found it cumbersome and inefficient. “I personally find it harder to build relationships with patients when I use virtual care,” she said. “I experience more joy in work with in-person visits, but other clinicians may feel differently.”

Dr. Kiran and her colleagues are conducting a public engagement initiative called OurCare to understand public perspectives on the future of primary care. “As part of that work, we want to understand what virtual modalities are most important to the public and how the public thinks these should be integrated into primary care.”

Virtual care can support access, patient-centered care, and equity in primary care, Dr. Kiran added. “Ideally, it should be integrated into an existing relationship with a family physician and be a complement to in-person visits.”
 

The right dose?

In an accompanying editorial, Jesse M. Pines, MD, chief of clinical innovation at U.S. Acute Care Solutions, Canton, Ohio, writes, “There is no convincing mechanism consistent with the data for the observed outcome of lower ED use at higher telehealth use.”

Additional research is needed, he notes, to answer the “Goldilocks question” – that is, what amount of telehealth optimizes its benefits while minimizing potential problems?

“The right dose of telehealth needs to balance (1) concerns by payers and policymakers that it will increase cost and cause unintended consequences (for example, misdiagnosis or duplicative care) and (2) the desire of its proponents who want to allow clinicians to use it as they see fit, with few restrictions,” writes Dr. Pines.

“Future research would ideally use more robust research design,” he suggested. “For example, randomized trials could test different doses of telehealth, or mixed-methods studies could help elucidate how telehealth may be changing clinical management or care-seeking behavior.”
 

Equitable reimbursement needed

Priya Nori, MD, associate professor of infectious diseases at Montefiore Health System and associate professor at the Albert Einstein College of Medicine, both in New York, said, “I agree with their conclusions and am reassured about telehealth as a durable form of health care delivery.”

Large, population-level studies such as this one might persuade legislators to require equitable reimbursement for in-person and virtual visits “so providers have comparable incentives to provide both types of care,” she said. “Although only primary care was addressed in the study, I believe that virtual care is here to stay and can be applied to primary care, subspecialty care, and other services, like antimicrobial stewardship, infection prevention, et cetera. We need to embrace it.”

A similar study should be conducted in the United States, along with additional research “to ensure that visits done by telephone have similar outcomes as those done by video, as not all communities have adequate internet access or video conferencing technology,” said Dr. Nori.

The study was supported by ICES and grants from Ontario Health, the Canadian Institutes of Health Research, and the Health Systems Research Program of Ontario MOH. Dr. Kiran, Dr. Pines, and Dr. Nori have disclosed no relevant financial relationships.

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

Canadian family physicians’ increased use of virtual care during the first years of the pandemic was not associated with increased emergency department use among patients, a new analysis of data from Ontario suggests.

In a cross-sectional study that included almost 14,000 family physicians and almost 13 million patients in Ontario, an adjusted analysis indicated that patients with physicians who provided more than 20% of care virtually had lower rates of ED visits, compared with patients whose physicians provided the least virtual care.

“I was surprised to see that ED visit volumes in fall 2021 were below prepandemic levels,” study author Tara Kiran, MD, who practices family medicine at St. Michael’s Hospital of the University of Toronto, told this news organization.

“At that time, there was a lot in the news about how our EDs were overcrowded and an assumption that this related to higher visit volumes. But our data [suggest] there were other factors at play, including strains in staffing in the ED, hospital inpatient units, and in long-term care.” Dr. Kiran is also the Fidani chair in improvement and innovation and vice-chair of quality and innovation at the department of family and community medicine of the University of Toronto.

The study was published online in JAMA Network Open.
 

Embrace of telehealth

The investigators analyzed administrative data from Ontario for 13,820 family physicians (mean age, 50 years; 51.5% men) and 12,951,063 patients (mean age, 42.6 years; 51.8% women) under their care.

The family physicians had at least one primary care visit claim between Feb. 1 and Oct. 31, 2021. The researchers categorized the physicians by the percentage of total visits they delivered virtually (via telephone or video) during the study period, as follows: 0% (100% in person), greater than 0%-20%, greater than 20%-40%, greater than 40%-60%, greater than 60%-80%, greater than 80% to less than 100%, or 100%.

The percentage of virtual primary care visits peaked at 82% in the first 2 weeks of the pandemic and decreased to 49% by October 2021. ED visit rates decreased at the start of the pandemic and remained lower than in 2019 throughout the study period.

Most physicians provided between 40% and 80% of care virtually. A greater percentage of those who provided more than 80% of care virtually were aged 65 years or older, were women, and practiced in large cities.

Patient comorbidity and morbidity were similar across all categories of virtual care use. The mean number of ED visits was highest among patients whose physicians provided only in-person care (470.3 per 1,000 patients) and was lowest among those whose physicians provided greater than 0% to less than 100% of care virtually (242 per 1,000 patients).

After adjustment for patient characteristics, patients of physicians who provided more than 20% of care virtually had lower rates of ED visits, compared with patients of physicians who provided the least virtual care (for example, greater than 80% to less than 100% versus 0%-20% virtual visits in big cities; relative rate, 0.77). This pattern was consistent across all rurality of practice categories and after adjustment for 2019 ED visit rates.

The investigators observed a gradient in urban areas. Patients of physicians who provided the highest level of virtual care had the lowest ED visit rates.
 

Investigating virtual modalities

Some policymakers worried that inappropriate use of virtual care was leading to an increase in ED use. “Findings of this study refute this hypothesis,” the authors write. Increases in ED use seemed to coincide with decreases in COVID-19 cases, not with increases in virtual primary care visits.

Furthermore, at the population level, patients who were cared for by physicians who provided a high percentage of virtual care did not have a higher rate of ED visits, compared with those cared for by physicians who provided the lowest levels of virtual care.

During the pandemic, the switch to virtual care worked well for some of Dr. Kiran’s patients. It was more convenient, because they didn’t have to take time off work, travel to and from the clinic, find and pay for parking, or wait in the clinic before the appointment, she said.

But for others, “virtual care really didn’t work well,” she said. “This was particularly true for people who didn’t have a regular working phone, who didn’t have a private space to take calls, who weren’t fluent in English, and who were hard of hearing or had severe mental illness that resulted in paranoid thoughts.”

Clinicians also may have had different comfort levels and preferences regarding virtual visits, Dr. Kiran hypothesized. Some found it convenient and efficient, whereas others may have found it cumbersome and inefficient. “I personally find it harder to build relationships with patients when I use virtual care,” she said. “I experience more joy in work with in-person visits, but other clinicians may feel differently.”

Dr. Kiran and her colleagues are conducting a public engagement initiative called OurCare to understand public perspectives on the future of primary care. “As part of that work, we want to understand what virtual modalities are most important to the public and how the public thinks these should be integrated into primary care.”

Virtual care can support access, patient-centered care, and equity in primary care, Dr. Kiran added. “Ideally, it should be integrated into an existing relationship with a family physician and be a complement to in-person visits.”
 

The right dose?

In an accompanying editorial, Jesse M. Pines, MD, chief of clinical innovation at U.S. Acute Care Solutions, Canton, Ohio, writes, “There is no convincing mechanism consistent with the data for the observed outcome of lower ED use at higher telehealth use.”

Additional research is needed, he notes, to answer the “Goldilocks question” – that is, what amount of telehealth optimizes its benefits while minimizing potential problems?

“The right dose of telehealth needs to balance (1) concerns by payers and policymakers that it will increase cost and cause unintended consequences (for example, misdiagnosis or duplicative care) and (2) the desire of its proponents who want to allow clinicians to use it as they see fit, with few restrictions,” writes Dr. Pines.

“Future research would ideally use more robust research design,” he suggested. “For example, randomized trials could test different doses of telehealth, or mixed-methods studies could help elucidate how telehealth may be changing clinical management or care-seeking behavior.”
 

Equitable reimbursement needed

Priya Nori, MD, associate professor of infectious diseases at Montefiore Health System and associate professor at the Albert Einstein College of Medicine, both in New York, said, “I agree with their conclusions and am reassured about telehealth as a durable form of health care delivery.”

Large, population-level studies such as this one might persuade legislators to require equitable reimbursement for in-person and virtual visits “so providers have comparable incentives to provide both types of care,” she said. “Although only primary care was addressed in the study, I believe that virtual care is here to stay and can be applied to primary care, subspecialty care, and other services, like antimicrobial stewardship, infection prevention, et cetera. We need to embrace it.”

A similar study should be conducted in the United States, along with additional research “to ensure that visits done by telephone have similar outcomes as those done by video, as not all communities have adequate internet access or video conferencing technology,” said Dr. Nori.

The study was supported by ICES and grants from Ontario Health, the Canadian Institutes of Health Research, and the Health Systems Research Program of Ontario MOH. Dr. Kiran, Dr. Pines, and Dr. Nori have disclosed no relevant financial relationships.

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