Background: Current guidelines for ischemic stroke recommend the time to thrombolysis be within 4.5 hours after onset of stroke. Guidelines are based on noncontrasted CT, but CT perfusion and perfusion-diffusion MRI may show salvageable brain tissue beyond the 4.5 hours. Studies have shown better outcomes in patients who were chosen for reperfusion based on tissue viability rather than time from onset of stroke. This has resulted in a disparity between the time windows used for thrombolysis.

Not all centers may have access to perfusion imaging, so the study’s findings may not be applicable to multiple sites.

Bottom line: Diffusion-perfusion imaging may be useful in determining salvageable brain tissue in acute ischemic stroke that may benefit from thrombolysis after the standard 4.5-hour window, but further studies need to be conducted before guidelines are changed.

Citation: Ma H et al. Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke. N Engl J Med. 2019;380(19):1795-803.

Dr. Rogers is a hospitalist at Ochsner Health System, New Orleans.

Background: Current guidelines for ischemic stroke recommend the time to thrombolysis be within 4.5 hours after onset of stroke. Guidelines are based on noncontrasted CT, but CT perfusion and perfusion-diffusion MRI may show salvageable brain tissue beyond the 4.5 hours. Studies have shown better outcomes in patients who were chosen for reperfusion based on tissue viability rather than time from onset of stroke. This has resulted in a disparity between the time windows used for thrombolysis.

Not all centers may have access to perfusion imaging, so the study’s findings may not be applicable to multiple sites.

Bottom line: Diffusion-perfusion imaging may be useful in determining salvageable brain tissue in acute ischemic stroke that may benefit from thrombolysis after the standard 4.5-hour window, but further studies need to be conducted before guidelines are changed.

Citation: Ma H et al. Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke. N Engl J Med. 2019;380(19):1795-803.

Dr. Rogers is a hospitalist at Ochsner Health System, New Orleans.

Background: Current guidelines for ischemic stroke recommend the time to thrombolysis be within 4.5 hours after onset of stroke. Guidelines are based on noncontrasted CT, but CT perfusion and perfusion-diffusion MRI may show salvageable brain tissue beyond the 4.5 hours. Studies have shown better outcomes in patients who were chosen for reperfusion based on tissue viability rather than time from onset of stroke. This has resulted in a disparity between the time windows used for thrombolysis.

Not all centers may have access to perfusion imaging, so the study’s findings may not be applicable to multiple sites.

Bottom line: Diffusion-perfusion imaging may be useful in determining salvageable brain tissue in acute ischemic stroke that may benefit from thrombolysis after the standard 4.5-hour window, but further studies need to be conducted before guidelines are changed.

Citation: Ma H et al. Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke. N Engl J Med. 2019;380(19):1795-803.

Dr. Rogers is a hospitalist at Ochsner Health System, New Orleans.

Amanda Calhoun, MD, recalls noticing a distinct empathy gap while she trained at a youth psychiatric unit.

Courtesy Dr. Amanda Calhoun

A White male patient hurled the N-word at a Black patient, and the majority White staff did nothing. “And then [they] told me the White patient was struggling and that’s why they allowed it, even though he was aggressive,” said Dr. Calhoun, psychiatry resident at Yale University in New Haven, Conn. But Dr. Calhoun noticed less restraint on the part of her colleagues while she was treating an angry female Black Latinx patient.

“I remember staff saying she was a nightmare; they called her the B-word; she was ‘a terror.’ How is that this patient isn’t viewed as struggling, where the other patient is? I don’t understand the difference here.”

And, Dr. Calhoun said, “when a patient can complain that they feel they were treated differently based on skin color, [the White majority staff] would just say they have borderline personality disorder or they’re depressed.

“When the staff is not diverse, I really see differential treatment in who gets the benefit of the doubt and their empathy.”

Psychiatrists such as Dr. Calhoun can list countless other examples of institutional racism, interpersonal racism, and prejudice in psychiatry. They see signs of institutional racism in clinical care, academia, and in research. Some are questioning the American Psychiatric Association decision to put on hiatus the Institute on Psychiatric Services, its fall annual meeting that has traditionally served as a vehicle for examining the treatment of underserved communities.

Against that backdrop – and after the killing of George Floyd and amid the disproportionate impact of COVID-19 on communities of color – the APA launched an effort the group says is aimed at reforming itself and psychiatry as a whole. In June, the APA announced the formation of the Presidential Task Force to Address Structural Racism Throughout Psychiatry, and the panel – focused on anti-Black racism – has begun its yearlong work.

A specialty with inherent contradictions

Jeffrey Geller, MD, MPH, the APA’s president, acknowledged in an interview that racism in psychiatry is older than the APA – which celebrated its 175th anniversary as an association last year.

As Dr. Geller pointed out recently, Benjamin Rush, MD, a founding father of the United States and the father of American psychiatry, was an abolitionist who owned one enslaved man – and thought the intelligence and morality of Black people were equal to that of their White counterparts.¹ Dr. Rush also thought the skin color of Black people was a manifestation of a type of leprosy that he called “Negritude.”² “Rush was a remarkable mix of contradictions,” Dr. Geller wrote.

Many of the kinds of contradictions that animated Dr. Rush can be found within psychiatry.

Altha J. Stewart, MD, the first and only Black president of the APA, declined to be interviewed for this article.

But as Dr. Stewart was wrapping up her term as president, she reportedly³ said that a 1970 paper titled “Dimensions of Institutional Racism in Psychiatry” by the late Melvin Sabshin, MD, and associates was essentially a blueprint for moving the specialty forward.

That paper, published in the American Journal of Psychiatry, took psychiatry to task on many levels. One of the barriers that Black psychiatric patients must overcome, according to Dr. Sabshin and associates, is the “biases of the White therapist, who must overcome his cultural blind spots, reactive guilt, and unconscious prejudice.” They called community psychiatry paternalistic. Furthermore, Dr. Sabshin, who would later serve as medical director of the APA for almost 25 years, criticized White mental health professionals for viewing Black communities as “seething cauldrons of psychopathology”:

“They create stereotypes of absent fathers, primitive rage, psychopathy, self-depreciation, promiscuity, deficits in intellectual capacity, and lack of psychological sensitivity,” Dr. Sabshin and his associates wrote. “Gross pathological caricaturization ignores the enormous variation of behavior in black communities. ... The obsession with black psychopathology has been so great that it has retarded serious consideration of racism as it pertains to white psychopathology.”⁴

In other words, White American psychiatrists adopted the prevailing views of society at large toward Black people. More recently, “there was a period in this country where Black people were thought to be at higher risk of developing issues like schizophrenia⁵ instead of depression,” said Gregory Scott Brown, MD, of the Center for Green Psychiatry and the University of Texas in Austin.

Courtesy Dr. Gregory Scott Brown

“Pharmaceutical companies developed ads for antipsychotic medications that portrayed angry Black men or women. This got into the heads of who may have been conditioned without knowing it,” he said.

In addition, psychiatry has failed to diversify its ranks. To this day, Dr. Geller said, “Black psychiatrists are underrepresented in academic settings, leadership positions, hospitals, and clinics. Black patients are suffering because of inequities in access to care in treatment, and even those who receive treatment are often misdiagnosed since we don’t account for the extended community’s trauma.” About 2% of U.S. psychiatrists are Black, and Black people make up 13% of the U.S. population.⁶

The low percentage of Black psychiatrists hurts the field for many reasons, said task force member Steven Starks, MD, clinical assistant professor of psychiatry at the University of Houston, and not solely because the gap forces many Black patients to be treated by non-Black psychiatrists. “The association has a large, broad impact on our field and profession through the DSM, and work in areas like government relations and access to care and insurance,” Dr. Starks said.
 

Task force gets mixed reviews

After the announcement, Dr. Geller named the psychiatrists who will serve, and the task force, chaired by Cheryl D. Wills, MD, assistant professor of psychiatry at Case Western Reserve University in Cleveland, got to work quickly.

The task force has conducted an online town hall and will conduct another one on Aug. 24. It also released the results of a survey of nearly 500 members about the top three areas that the task force should address.

“Access to Healthcare/Mental Healthcare” received the most votes (97) as the recommended top priority, followed by “Socio-Economic Conditions and Factors” (49). These two areas also received the most first-, second- and third-priority votes overall (173 and 166, respectively).

The other areas with high numbers of first priority votes were “Lack of Minority Psychiatrists, Faculty and Leaders” and “Education for Psychiatrists,” both tied at 46. Those areas received 142 and 122 total votes supporting them as first, second, and third priorities.

Thirty-seven members said “Racism within the APA/APA Actions” should be the top priority. A small number of respondents appeared to doubt the need for such a task force: Nineteen thought the top priority should be “Questioning the Concept of Structural Racism/Task Force.”

Meanwhile, some psychiatrists are raising questions about the task force’s makeup.

Ruth S. Shim, MD, MPH, the Luke & Grace Kim Professor of Cultural Psychiatry at the University of California, Davis, said that she was disappointed by the task force’s membership. Specifically, Dr. Shim said, the task force does not include enough APA members she sees as qualified to address structural racism.

“While many of the Black psychiatrists who are members of the task force are experts in issues of diversity, inclusion, and equity, other members of the board of trustees who were appointed to this task force do not have any expertise in this area,” said Dr. Shim, who wrote a scathing commentary⁷ in July about the APA’s failures regarding structural racism. “I believe the selection of members could have been more thoughtful and more inclusive of diverse perspectives and voices.”

Dr. Geller countered that the task force includes a mix of APA board members and non–board members with various types of expertise. “Certain board members were chosen because their colleagues on the board “were already involved in task forces and other projects,” he said.

How the task force is envisioned

Dr. Geller’s goals for the task force, which will operate at least through his 1-year term as president, are ambitious.

“I hope the task force will identify structural racism wherever it’s taking place – where psychiatrists practice, within the APA itself,” Dr. Geller said. “It will be an educational process so we can inform members and ourselves about clear and subtle structural racism. Then we’re going to proffer solutions in several areas that can rectify some of what we’ve been doing and the negative outcomes that have resulted in areas of leadership such as access to care, treatment, hospital and clinic administration, health insurance, and academia. It’s clear that this is a massive undertaking.”

For her part, Dr. Shim thinks the task force might chip around the edges of the structural problems in the specialty – rather than focusing on the roots. “The task force is set up to fail,” she said. “To truly dismantle structural racism in the APA, the leadership of the organization – the CEO, the executive committee, and the board of trustees – must do the hard work of deep self-reflection and self-study to recognize the role that they have played in perpetuating and upholding White supremacy in the organization.

“I do not believe the task force will be capable of doing this, as this is not what they have been tasked to do,” Dr. Shim said.

Task force member Dr. Starks said he believes there is potential for progress within the APA. While Black members have been frustrated by an APA power structure that seems both harmful and unchangeable, he said, “this is an opportunity for us to re-root and achieve equity in mental health.”

He added that the priorities of the task force are not set in stone. “Those things that are listed on the website may change and evolve over time as we report back to the board and develop our functions internally,” said Dr. Starks, who praised Dr. Shim’s commentary as “courageous.”

The website lists these initial charges for the task force:

• Providing education and resources on APA’s and psychiatry’s history regarding structural racism.
• Explaining the current impact of structural racism on the mental health of our patients and colleagues.
• Developing achievable and actionable recommendations for change to eliminate structural racism in the APA and psychiatry now and in the future.
• Providing reports with specific recommendations for achievable actions to the APA board of trustees at each of its meetings through May 2021.
• Monitoring the implementation of tasks.

Meanwhile, the task force is reporting to the APA board of directors each month. The entity is tied to the 1-year presidential term of Dr. Geller, which ends in spring 2021, but Dr. Starks said he hopes it will continue in another form – such as a formal committee.
 

Importance of cultural competence

Dr. Brown highlighted the importance of cultural competence – “making sure that we are looking at patients in the context of their cultural background, their religion, their race, so we can make informed decisions without jumping to conclusions too soon.”

For example, if an African American man or woman talks about hearing God’s voice, “we shouldn’t necessarily brush it off or diminish it as psychiatric illness if it’s in the context of that person’s religious background,” Dr. Brown said.

Francis G. Lu, MD, agreed. He said the task force should explore cultural competency on both clinical and systems levels.

“An antidote to structural racism would be systems cultural competence involving organizations, clinics, and teams looking beyond patient care issues,” said Dr. Lu, the Luke & Grace Kim Professor in Cultural Psychiatry Emeritus at the University of California, Davis. A good starting point, he said, is the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, also known as the National CLAS Standards.

Looking forward, Olusola Ajilore, MD, PhD, called for a focus on targeted efforts aimed at encouraging more minority medical students to become psychiatrists.

“We have a field with a lot of crucial questions that have yet to be answered,” said Dr. Ajilore, associate director of residency training and education at the University of Illinois at Chicago. “With more Black psychiatrists, we might be more aware of some of the research questions that affect our community, such as the mental health consequences of exposure to racism and prejudice.”

However, the role of White psychiatrists cannot be overemphasized, said Constance E. Dunlap, MD, clinical professor of psychiatry and behavioral sciences at George Washington University in Washington.

“Whites can make a difference by acknowledging the racial hierarchy that ‘unfairly disadvantages some ... and unfairly advantages others’ – to use the language⁸ offered by Dr. Camara Phyllis Jones, said Dr. Dunlap.

“As psychiatrists – as physicians – we are obligated to help patients see themselves and the world more clearly. This starts with our own self-appraisal and extends to our work, whether it is in a psychodynamic space or a community psychiatry setting,” Dr. Dunlap said. “Bottom line, instead of focusing on guilt, I tell my White colleagues and patients: You have privilege, use it constructively to benefit the world.”

Dr. Calhoun said she hopes to see mandated integration of training about racism into psychiatric education. “Rather than a special racism lecture, I’d like to see instruction implemented throughout. It should be essential for psychiatrists to learn about the historical racism of psychiatry and the current racial inequities that exist among psychiatric patients.”

The practice of community psychiatry,⁹ almost by definition, is uniquely positioned to break through some of those structural issues. “The community psychiatry approach to treatment is not specific to any race or cultural group – because each person is treated as an individual,” said Stephanie Le Melle, MD, MS, director of public psychiatry education at Columbia University and the New York Psychiatric Institute. “The social determinants of health, culture, and social justice experience of each person is taken into consideration,” said Dr. Le Melle.

“Community psychiatry steps outside of the traditional medical model of symptoms and illness, and focuses on understanding the person’s strengths and goals – and helps them to live their best lives.”

Dr. Le Melle also views diversifying the psychiatric workforce as imperative.

“For many African American, Latinx, and other marginalized populations that have had to deal with systemic and structural racism, discrimination, and historical abuse at the hands of psychiatry, it can be difficult to establish trust,” said Dr. Le Melle. “Therefore, diversity of our workforce and cultural humility are also crucial for engagement.”

The APA’s decision to not go forward with this year’s Institute on Psychiatric Services: The Mental Health Services Conference undermines the group’s credibility on these issues, according to some psychiatrists.

The IPS meeting, founded in 1948, is “where we traditionally teach and present about the social determinants of health and racism,” said Dr. Le Melle. “If the APA is serious about addressing the social determinants of health, bias, and discrimination against marginalized people and cultural humility, it needs to embrace and grow community psychiatry, not cut it.”

When asked about the IPS conference, Dr. Geller said that it has been scheduled for October 2021 in New York City. He also said the decision to skip the 2020 conference was made 2 years ago. The conference’s organizing committee decided to cancel the event when hotel space in the preferred city could not be arranged, Dr. Geller said.

Meanwhile, in a widely circulated letter that was sent to the APA board of trustees on Aug. 7, numerous leaders in psychiatry from across the country are citing steps they say the APA must take from “continuing impacts of structural racism that will greatly harm underserved patients, [minority and underrepresented] (M/UR) psychiatrists, and the APA as a whole.”

One step the leaders asked the APA to take was to hire an independent entity to investigate the organization’s “workplace culture, staff morale, and experiences of staff members and M/UR psychiatrists who support and/or work at the organization or have previously been dismissed or departed.”

Dr. Calhoun said she agrees that an internal examination would be productive.

“I’d like to see multiple people in positions of power (in the APA) in order to forward agendas,” Dr. Calhoun said. “Unless we do, we’ll have no way to achieve the goal of getting rid of structural racism.”
 

Dr. Calhoun, Dr. Geller, Dr. Brown, Dr. Starks, Dr. Lu, Dr. Ajilore, Dr. Dunlap, and Dr. Le Melle reported no relevant disclosures. Dr. Shim disclosed receiving royalties from American Psychiatric Association Publishing. Dr. Stewart is a coeditor of “Black Mental Health: Patients, Providers, and Systems” (American Psychiatric Association Publishing, 2018).

References

1. Geller J. Psychiatric News. 2020 Jun 23.

2. Washington HA. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans From Colonial Times to the Present. (New York: Doubleday), 2006.

3. ”Stewart brings a robust and eventful presidential year to a close.” Psychiatric News Daily. 2019 May 18.

4. Sabshin M et al. Am J Psychiatry. 1970 Dec;127:6.

5. Metzl JM. The Protest Psychosis: How Schizophrenia Became a Black Disease. (Boston: Beacon Press), 2009.

6. U.S. Census Bureau. Population estimates. 2019 Jul 1.

7. Shim RS. “Structural racism is why I’m leaving organized psychiatry. statnews.com. 2020 Jul 1.

8. Jones CP. Ethn Dis;28(Suppl):231-4.

9. Ewalt JR and Ewalt PA. Am J Psychiatry. 2006 Apr 1. doi: 10.1176/ajp.126.1.43.

Amanda Calhoun, MD, recalls noticing a distinct empathy gap while she trained at a youth psychiatric unit.

Courtesy Dr. Amanda Calhoun

A White male patient hurled the N-word at a Black patient, and the majority White staff did nothing. “And then [they] told me the White patient was struggling and that’s why they allowed it, even though he was aggressive,” said Dr. Calhoun, psychiatry resident at Yale University in New Haven, Conn. But Dr. Calhoun noticed less restraint on the part of her colleagues while she was treating an angry female Black Latinx patient.

“I remember staff saying she was a nightmare; they called her the B-word; she was ‘a terror.’ How is that this patient isn’t viewed as struggling, where the other patient is? I don’t understand the difference here.”

And, Dr. Calhoun said, “when a patient can complain that they feel they were treated differently based on skin color, [the White majority staff] would just say they have borderline personality disorder or they’re depressed.

“When the staff is not diverse, I really see differential treatment in who gets the benefit of the doubt and their empathy.”

Psychiatrists such as Dr. Calhoun can list countless other examples of institutional racism, interpersonal racism, and prejudice in psychiatry. They see signs of institutional racism in clinical care, academia, and in research. Some are questioning the American Psychiatric Association decision to put on hiatus the Institute on Psychiatric Services, its fall annual meeting that has traditionally served as a vehicle for examining the treatment of underserved communities.

Against that backdrop – and after the killing of George Floyd and amid the disproportionate impact of COVID-19 on communities of color – the APA launched an effort the group says is aimed at reforming itself and psychiatry as a whole. In June, the APA announced the formation of the Presidential Task Force to Address Structural Racism Throughout Psychiatry, and the panel – focused on anti-Black racism – has begun its yearlong work.

A specialty with inherent contradictions

Jeffrey Geller, MD, MPH, the APA’s president, acknowledged in an interview that racism in psychiatry is older than the APA – which celebrated its 175th anniversary as an association last year.

As Dr. Geller pointed out recently, Benjamin Rush, MD, a founding father of the United States and the father of American psychiatry, was an abolitionist who owned one enslaved man – and thought the intelligence and morality of Black people were equal to that of their White counterparts.¹ Dr. Rush also thought the skin color of Black people was a manifestation of a type of leprosy that he called “Negritude.”² “Rush was a remarkable mix of contradictions,” Dr. Geller wrote.

Many of the kinds of contradictions that animated Dr. Rush can be found within psychiatry.

Altha J. Stewart, MD, the first and only Black president of the APA, declined to be interviewed for this article.

But as Dr. Stewart was wrapping up her term as president, she reportedly³ said that a 1970 paper titled “Dimensions of Institutional Racism in Psychiatry” by the late Melvin Sabshin, MD, and associates was essentially a blueprint for moving the specialty forward.

That paper, published in the American Journal of Psychiatry, took psychiatry to task on many levels. One of the barriers that Black psychiatric patients must overcome, according to Dr. Sabshin and associates, is the “biases of the White therapist, who must overcome his cultural blind spots, reactive guilt, and unconscious prejudice.” They called community psychiatry paternalistic. Furthermore, Dr. Sabshin, who would later serve as medical director of the APA for almost 25 years, criticized White mental health professionals for viewing Black communities as “seething cauldrons of psychopathology”:

“They create stereotypes of absent fathers, primitive rage, psychopathy, self-depreciation, promiscuity, deficits in intellectual capacity, and lack of psychological sensitivity,” Dr. Sabshin and his associates wrote. “Gross pathological caricaturization ignores the enormous variation of behavior in black communities. ... The obsession with black psychopathology has been so great that it has retarded serious consideration of racism as it pertains to white psychopathology.”⁴

In other words, White American psychiatrists adopted the prevailing views of society at large toward Black people. More recently, “there was a period in this country where Black people were thought to be at higher risk of developing issues like schizophrenia⁵ instead of depression,” said Gregory Scott Brown, MD, of the Center for Green Psychiatry and the University of Texas in Austin.

Courtesy Dr. Gregory Scott Brown

“Pharmaceutical companies developed ads for antipsychotic medications that portrayed angry Black men or women. This got into the heads of who may have been conditioned without knowing it,” he said.

In addition, psychiatry has failed to diversify its ranks. To this day, Dr. Geller said, “Black psychiatrists are underrepresented in academic settings, leadership positions, hospitals, and clinics. Black patients are suffering because of inequities in access to care in treatment, and even those who receive treatment are often misdiagnosed since we don’t account for the extended community’s trauma.” About 2% of U.S. psychiatrists are Black, and Black people make up 13% of the U.S. population.⁶

The low percentage of Black psychiatrists hurts the field for many reasons, said task force member Steven Starks, MD, clinical assistant professor of psychiatry at the University of Houston, and not solely because the gap forces many Black patients to be treated by non-Black psychiatrists. “The association has a large, broad impact on our field and profession through the DSM, and work in areas like government relations and access to care and insurance,” Dr. Starks said.
 

Task force gets mixed reviews

After the announcement, Dr. Geller named the psychiatrists who will serve, and the task force, chaired by Cheryl D. Wills, MD, assistant professor of psychiatry at Case Western Reserve University in Cleveland, got to work quickly.

The task force has conducted an online town hall and will conduct another one on Aug. 24. It also released the results of a survey of nearly 500 members about the top three areas that the task force should address.

“Access to Healthcare/Mental Healthcare” received the most votes (97) as the recommended top priority, followed by “Socio-Economic Conditions and Factors” (49). These two areas also received the most first-, second- and third-priority votes overall (173 and 166, respectively).

The other areas with high numbers of first priority votes were “Lack of Minority Psychiatrists, Faculty and Leaders” and “Education for Psychiatrists,” both tied at 46. Those areas received 142 and 122 total votes supporting them as first, second, and third priorities.

Thirty-seven members said “Racism within the APA/APA Actions” should be the top priority. A small number of respondents appeared to doubt the need for such a task force: Nineteen thought the top priority should be “Questioning the Concept of Structural Racism/Task Force.”

Meanwhile, some psychiatrists are raising questions about the task force’s makeup.

Ruth S. Shim, MD, MPH, the Luke & Grace Kim Professor of Cultural Psychiatry at the University of California, Davis, said that she was disappointed by the task force’s membership. Specifically, Dr. Shim said, the task force does not include enough APA members she sees as qualified to address structural racism.

“While many of the Black psychiatrists who are members of the task force are experts in issues of diversity, inclusion, and equity, other members of the board of trustees who were appointed to this task force do not have any expertise in this area,” said Dr. Shim, who wrote a scathing commentary⁷ in July about the APA’s failures regarding structural racism. “I believe the selection of members could have been more thoughtful and more inclusive of diverse perspectives and voices.”

Dr. Geller countered that the task force includes a mix of APA board members and non–board members with various types of expertise. “Certain board members were chosen because their colleagues on the board “were already involved in task forces and other projects,” he said.

How the task force is envisioned

Dr. Geller’s goals for the task force, which will operate at least through his 1-year term as president, are ambitious.

“I hope the task force will identify structural racism wherever it’s taking place – where psychiatrists practice, within the APA itself,” Dr. Geller said. “It will be an educational process so we can inform members and ourselves about clear and subtle structural racism. Then we’re going to proffer solutions in several areas that can rectify some of what we’ve been doing and the negative outcomes that have resulted in areas of leadership such as access to care, treatment, hospital and clinic administration, health insurance, and academia. It’s clear that this is a massive undertaking.”

For her part, Dr. Shim thinks the task force might chip around the edges of the structural problems in the specialty – rather than focusing on the roots. “The task force is set up to fail,” she said. “To truly dismantle structural racism in the APA, the leadership of the organization – the CEO, the executive committee, and the board of trustees – must do the hard work of deep self-reflection and self-study to recognize the role that they have played in perpetuating and upholding White supremacy in the organization.

“I do not believe the task force will be capable of doing this, as this is not what they have been tasked to do,” Dr. Shim said.

Task force member Dr. Starks said he believes there is potential for progress within the APA. While Black members have been frustrated by an APA power structure that seems both harmful and unchangeable, he said, “this is an opportunity for us to re-root and achieve equity in mental health.”

He added that the priorities of the task force are not set in stone. “Those things that are listed on the website may change and evolve over time as we report back to the board and develop our functions internally,” said Dr. Starks, who praised Dr. Shim’s commentary as “courageous.”

The website lists these initial charges for the task force:

• Providing education and resources on APA’s and psychiatry’s history regarding structural racism.
• Explaining the current impact of structural racism on the mental health of our patients and colleagues.
• Developing achievable and actionable recommendations for change to eliminate structural racism in the APA and psychiatry now and in the future.
• Providing reports with specific recommendations for achievable actions to the APA board of trustees at each of its meetings through May 2021.
• Monitoring the implementation of tasks.

Meanwhile, the task force is reporting to the APA board of directors each month. The entity is tied to the 1-year presidential term of Dr. Geller, which ends in spring 2021, but Dr. Starks said he hopes it will continue in another form – such as a formal committee.
 

Importance of cultural competence

Dr. Brown highlighted the importance of cultural competence – “making sure that we are looking at patients in the context of their cultural background, their religion, their race, so we can make informed decisions without jumping to conclusions too soon.”

For example, if an African American man or woman talks about hearing God’s voice, “we shouldn’t necessarily brush it off or diminish it as psychiatric illness if it’s in the context of that person’s religious background,” Dr. Brown said.

Francis G. Lu, MD, agreed. He said the task force should explore cultural competency on both clinical and systems levels.

“An antidote to structural racism would be systems cultural competence involving organizations, clinics, and teams looking beyond patient care issues,” said Dr. Lu, the Luke & Grace Kim Professor in Cultural Psychiatry Emeritus at the University of California, Davis. A good starting point, he said, is the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, also known as the National CLAS Standards.

Looking forward, Olusola Ajilore, MD, PhD, called for a focus on targeted efforts aimed at encouraging more minority medical students to become psychiatrists.

“We have a field with a lot of crucial questions that have yet to be answered,” said Dr. Ajilore, associate director of residency training and education at the University of Illinois at Chicago. “With more Black psychiatrists, we might be more aware of some of the research questions that affect our community, such as the mental health consequences of exposure to racism and prejudice.”

However, the role of White psychiatrists cannot be overemphasized, said Constance E. Dunlap, MD, clinical professor of psychiatry and behavioral sciences at George Washington University in Washington.

“Whites can make a difference by acknowledging the racial hierarchy that ‘unfairly disadvantages some ... and unfairly advantages others’ – to use the language⁸ offered by Dr. Camara Phyllis Jones, said Dr. Dunlap.

“As psychiatrists – as physicians – we are obligated to help patients see themselves and the world more clearly. This starts with our own self-appraisal and extends to our work, whether it is in a psychodynamic space or a community psychiatry setting,” Dr. Dunlap said. “Bottom line, instead of focusing on guilt, I tell my White colleagues and patients: You have privilege, use it constructively to benefit the world.”

Dr. Calhoun said she hopes to see mandated integration of training about racism into psychiatric education. “Rather than a special racism lecture, I’d like to see instruction implemented throughout. It should be essential for psychiatrists to learn about the historical racism of psychiatry and the current racial inequities that exist among psychiatric patients.”

The practice of community psychiatry,⁹ almost by definition, is uniquely positioned to break through some of those structural issues. “The community psychiatry approach to treatment is not specific to any race or cultural group – because each person is treated as an individual,” said Stephanie Le Melle, MD, MS, director of public psychiatry education at Columbia University and the New York Psychiatric Institute. “The social determinants of health, culture, and social justice experience of each person is taken into consideration,” said Dr. Le Melle.

“Community psychiatry steps outside of the traditional medical model of symptoms and illness, and focuses on understanding the person’s strengths and goals – and helps them to live their best lives.”

Dr. Le Melle also views diversifying the psychiatric workforce as imperative.

“For many African American, Latinx, and other marginalized populations that have had to deal with systemic and structural racism, discrimination, and historical abuse at the hands of psychiatry, it can be difficult to establish trust,” said Dr. Le Melle. “Therefore, diversity of our workforce and cultural humility are also crucial for engagement.”

The APA’s decision to not go forward with this year’s Institute on Psychiatric Services: The Mental Health Services Conference undermines the group’s credibility on these issues, according to some psychiatrists.

The IPS meeting, founded in 1948, is “where we traditionally teach and present about the social determinants of health and racism,” said Dr. Le Melle. “If the APA is serious about addressing the social determinants of health, bias, and discrimination against marginalized people and cultural humility, it needs to embrace and grow community psychiatry, not cut it.”

When asked about the IPS conference, Dr. Geller said that it has been scheduled for October 2021 in New York City. He also said the decision to skip the 2020 conference was made 2 years ago. The conference’s organizing committee decided to cancel the event when hotel space in the preferred city could not be arranged, Dr. Geller said.

Meanwhile, in a widely circulated letter that was sent to the APA board of trustees on Aug. 7, numerous leaders in psychiatry from across the country are citing steps they say the APA must take from “continuing impacts of structural racism that will greatly harm underserved patients, [minority and underrepresented] (M/UR) psychiatrists, and the APA as a whole.”

One step the leaders asked the APA to take was to hire an independent entity to investigate the organization’s “workplace culture, staff morale, and experiences of staff members and M/UR psychiatrists who support and/or work at the organization or have previously been dismissed or departed.”

Dr. Calhoun said she agrees that an internal examination would be productive.

“I’d like to see multiple people in positions of power (in the APA) in order to forward agendas,” Dr. Calhoun said. “Unless we do, we’ll have no way to achieve the goal of getting rid of structural racism.”
 

Dr. Calhoun, Dr. Geller, Dr. Brown, Dr. Starks, Dr. Lu, Dr. Ajilore, Dr. Dunlap, and Dr. Le Melle reported no relevant disclosures. Dr. Shim disclosed receiving royalties from American Psychiatric Association Publishing. Dr. Stewart is a coeditor of “Black Mental Health: Patients, Providers, and Systems” (American Psychiatric Association Publishing, 2018).

References

1. Geller J. Psychiatric News. 2020 Jun 23.

2. Washington HA. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans From Colonial Times to the Present. (New York: Doubleday), 2006.

3. ”Stewart brings a robust and eventful presidential year to a close.” Psychiatric News Daily. 2019 May 18.

4. Sabshin M et al. Am J Psychiatry. 1970 Dec;127:6.

5. Metzl JM. The Protest Psychosis: How Schizophrenia Became a Black Disease. (Boston: Beacon Press), 2009.

6. U.S. Census Bureau. Population estimates. 2019 Jul 1.

7. Shim RS. “Structural racism is why I’m leaving organized psychiatry. statnews.com. 2020 Jul 1.

8. Jones CP. Ethn Dis;28(Suppl):231-4.

9. Ewalt JR and Ewalt PA. Am J Psychiatry. 2006 Apr 1. doi: 10.1176/ajp.126.1.43.

Amanda Calhoun, MD, recalls noticing a distinct empathy gap while she trained at a youth psychiatric unit.

Courtesy Dr. Amanda Calhoun

A White male patient hurled the N-word at a Black patient, and the majority White staff did nothing. “And then [they] told me the White patient was struggling and that’s why they allowed it, even though he was aggressive,” said Dr. Calhoun, psychiatry resident at Yale University in New Haven, Conn. But Dr. Calhoun noticed less restraint on the part of her colleagues while she was treating an angry female Black Latinx patient.

“I remember staff saying she was a nightmare; they called her the B-word; she was ‘a terror.’ How is that this patient isn’t viewed as struggling, where the other patient is? I don’t understand the difference here.”

And, Dr. Calhoun said, “when a patient can complain that they feel they were treated differently based on skin color, [the White majority staff] would just say they have borderline personality disorder or they’re depressed.

“When the staff is not diverse, I really see differential treatment in who gets the benefit of the doubt and their empathy.”

Psychiatrists such as Dr. Calhoun can list countless other examples of institutional racism, interpersonal racism, and prejudice in psychiatry. They see signs of institutional racism in clinical care, academia, and in research. Some are questioning the American Psychiatric Association decision to put on hiatus the Institute on Psychiatric Services, its fall annual meeting that has traditionally served as a vehicle for examining the treatment of underserved communities.

Against that backdrop – and after the killing of George Floyd and amid the disproportionate impact of COVID-19 on communities of color – the APA launched an effort the group says is aimed at reforming itself and psychiatry as a whole. In June, the APA announced the formation of the Presidential Task Force to Address Structural Racism Throughout Psychiatry, and the panel – focused on anti-Black racism – has begun its yearlong work.

A specialty with inherent contradictions

Jeffrey Geller, MD, MPH, the APA’s president, acknowledged in an interview that racism in psychiatry is older than the APA – which celebrated its 175th anniversary as an association last year.

As Dr. Geller pointed out recently, Benjamin Rush, MD, a founding father of the United States and the father of American psychiatry, was an abolitionist who owned one enslaved man – and thought the intelligence and morality of Black people were equal to that of their White counterparts.¹ Dr. Rush also thought the skin color of Black people was a manifestation of a type of leprosy that he called “Negritude.”² “Rush was a remarkable mix of contradictions,” Dr. Geller wrote.

Many of the kinds of contradictions that animated Dr. Rush can be found within psychiatry.

Altha J. Stewart, MD, the first and only Black president of the APA, declined to be interviewed for this article.

But as Dr. Stewart was wrapping up her term as president, she reportedly³ said that a 1970 paper titled “Dimensions of Institutional Racism in Psychiatry” by the late Melvin Sabshin, MD, and associates was essentially a blueprint for moving the specialty forward.

That paper, published in the American Journal of Psychiatry, took psychiatry to task on many levels. One of the barriers that Black psychiatric patients must overcome, according to Dr. Sabshin and associates, is the “biases of the White therapist, who must overcome his cultural blind spots, reactive guilt, and unconscious prejudice.” They called community psychiatry paternalistic. Furthermore, Dr. Sabshin, who would later serve as medical director of the APA for almost 25 years, criticized White mental health professionals for viewing Black communities as “seething cauldrons of psychopathology”:

“They create stereotypes of absent fathers, primitive rage, psychopathy, self-depreciation, promiscuity, deficits in intellectual capacity, and lack of psychological sensitivity,” Dr. Sabshin and his associates wrote. “Gross pathological caricaturization ignores the enormous variation of behavior in black communities. ... The obsession with black psychopathology has been so great that it has retarded serious consideration of racism as it pertains to white psychopathology.”⁴

In other words, White American psychiatrists adopted the prevailing views of society at large toward Black people. More recently, “there was a period in this country where Black people were thought to be at higher risk of developing issues like schizophrenia⁵ instead of depression,” said Gregory Scott Brown, MD, of the Center for Green Psychiatry and the University of Texas in Austin.

Courtesy Dr. Gregory Scott Brown

“Pharmaceutical companies developed ads for antipsychotic medications that portrayed angry Black men or women. This got into the heads of who may have been conditioned without knowing it,” he said.

In addition, psychiatry has failed to diversify its ranks. To this day, Dr. Geller said, “Black psychiatrists are underrepresented in academic settings, leadership positions, hospitals, and clinics. Black patients are suffering because of inequities in access to care in treatment, and even those who receive treatment are often misdiagnosed since we don’t account for the extended community’s trauma.” About 2% of U.S. psychiatrists are Black, and Black people make up 13% of the U.S. population.⁶

The low percentage of Black psychiatrists hurts the field for many reasons, said task force member Steven Starks, MD, clinical assistant professor of psychiatry at the University of Houston, and not solely because the gap forces many Black patients to be treated by non-Black psychiatrists. “The association has a large, broad impact on our field and profession through the DSM, and work in areas like government relations and access to care and insurance,” Dr. Starks said.
 

Task force gets mixed reviews

After the announcement, Dr. Geller named the psychiatrists who will serve, and the task force, chaired by Cheryl D. Wills, MD, assistant professor of psychiatry at Case Western Reserve University in Cleveland, got to work quickly.

The task force has conducted an online town hall and will conduct another one on Aug. 24. It also released the results of a survey of nearly 500 members about the top three areas that the task force should address.

“Access to Healthcare/Mental Healthcare” received the most votes (97) as the recommended top priority, followed by “Socio-Economic Conditions and Factors” (49). These two areas also received the most first-, second- and third-priority votes overall (173 and 166, respectively).

The other areas with high numbers of first priority votes were “Lack of Minority Psychiatrists, Faculty and Leaders” and “Education for Psychiatrists,” both tied at 46. Those areas received 142 and 122 total votes supporting them as first, second, and third priorities.

Thirty-seven members said “Racism within the APA/APA Actions” should be the top priority. A small number of respondents appeared to doubt the need for such a task force: Nineteen thought the top priority should be “Questioning the Concept of Structural Racism/Task Force.”

Meanwhile, some psychiatrists are raising questions about the task force’s makeup.

Ruth S. Shim, MD, MPH, the Luke & Grace Kim Professor of Cultural Psychiatry at the University of California, Davis, said that she was disappointed by the task force’s membership. Specifically, Dr. Shim said, the task force does not include enough APA members she sees as qualified to address structural racism.

“While many of the Black psychiatrists who are members of the task force are experts in issues of diversity, inclusion, and equity, other members of the board of trustees who were appointed to this task force do not have any expertise in this area,” said Dr. Shim, who wrote a scathing commentary⁷ in July about the APA’s failures regarding structural racism. “I believe the selection of members could have been more thoughtful and more inclusive of diverse perspectives and voices.”

Dr. Geller countered that the task force includes a mix of APA board members and non–board members with various types of expertise. “Certain board members were chosen because their colleagues on the board “were already involved in task forces and other projects,” he said.

How the task force is envisioned

Dr. Geller’s goals for the task force, which will operate at least through his 1-year term as president, are ambitious.

“I hope the task force will identify structural racism wherever it’s taking place – where psychiatrists practice, within the APA itself,” Dr. Geller said. “It will be an educational process so we can inform members and ourselves about clear and subtle structural racism. Then we’re going to proffer solutions in several areas that can rectify some of what we’ve been doing and the negative outcomes that have resulted in areas of leadership such as access to care, treatment, hospital and clinic administration, health insurance, and academia. It’s clear that this is a massive undertaking.”

For her part, Dr. Shim thinks the task force might chip around the edges of the structural problems in the specialty – rather than focusing on the roots. “The task force is set up to fail,” she said. “To truly dismantle structural racism in the APA, the leadership of the organization – the CEO, the executive committee, and the board of trustees – must do the hard work of deep self-reflection and self-study to recognize the role that they have played in perpetuating and upholding White supremacy in the organization.

“I do not believe the task force will be capable of doing this, as this is not what they have been tasked to do,” Dr. Shim said.

Task force member Dr. Starks said he believes there is potential for progress within the APA. While Black members have been frustrated by an APA power structure that seems both harmful and unchangeable, he said, “this is an opportunity for us to re-root and achieve equity in mental health.”

He added that the priorities of the task force are not set in stone. “Those things that are listed on the website may change and evolve over time as we report back to the board and develop our functions internally,” said Dr. Starks, who praised Dr. Shim’s commentary as “courageous.”

The website lists these initial charges for the task force:

• Providing education and resources on APA’s and psychiatry’s history regarding structural racism.
• Explaining the current impact of structural racism on the mental health of our patients and colleagues.
• Developing achievable and actionable recommendations for change to eliminate structural racism in the APA and psychiatry now and in the future.
• Providing reports with specific recommendations for achievable actions to the APA board of trustees at each of its meetings through May 2021.
• Monitoring the implementation of tasks.

Meanwhile, the task force is reporting to the APA board of directors each month. The entity is tied to the 1-year presidential term of Dr. Geller, which ends in spring 2021, but Dr. Starks said he hopes it will continue in another form – such as a formal committee.
 

Importance of cultural competence

Dr. Brown highlighted the importance of cultural competence – “making sure that we are looking at patients in the context of their cultural background, their religion, their race, so we can make informed decisions without jumping to conclusions too soon.”

For example, if an African American man or woman talks about hearing God’s voice, “we shouldn’t necessarily brush it off or diminish it as psychiatric illness if it’s in the context of that person’s religious background,” Dr. Brown said.

Francis G. Lu, MD, agreed. He said the task force should explore cultural competency on both clinical and systems levels.

“An antidote to structural racism would be systems cultural competence involving organizations, clinics, and teams looking beyond patient care issues,” said Dr. Lu, the Luke & Grace Kim Professor in Cultural Psychiatry Emeritus at the University of California, Davis. A good starting point, he said, is the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, also known as the National CLAS Standards.

Looking forward, Olusola Ajilore, MD, PhD, called for a focus on targeted efforts aimed at encouraging more minority medical students to become psychiatrists.

“We have a field with a lot of crucial questions that have yet to be answered,” said Dr. Ajilore, associate director of residency training and education at the University of Illinois at Chicago. “With more Black psychiatrists, we might be more aware of some of the research questions that affect our community, such as the mental health consequences of exposure to racism and prejudice.”

However, the role of White psychiatrists cannot be overemphasized, said Constance E. Dunlap, MD, clinical professor of psychiatry and behavioral sciences at George Washington University in Washington.

“Whites can make a difference by acknowledging the racial hierarchy that ‘unfairly disadvantages some ... and unfairly advantages others’ – to use the language⁸ offered by Dr. Camara Phyllis Jones, said Dr. Dunlap.

“As psychiatrists – as physicians – we are obligated to help patients see themselves and the world more clearly. This starts with our own self-appraisal and extends to our work, whether it is in a psychodynamic space or a community psychiatry setting,” Dr. Dunlap said. “Bottom line, instead of focusing on guilt, I tell my White colleagues and patients: You have privilege, use it constructively to benefit the world.”

Dr. Calhoun said she hopes to see mandated integration of training about racism into psychiatric education. “Rather than a special racism lecture, I’d like to see instruction implemented throughout. It should be essential for psychiatrists to learn about the historical racism of psychiatry and the current racial inequities that exist among psychiatric patients.”

The practice of community psychiatry,⁹ almost by definition, is uniquely positioned to break through some of those structural issues. “The community psychiatry approach to treatment is not specific to any race or cultural group – because each person is treated as an individual,” said Stephanie Le Melle, MD, MS, director of public psychiatry education at Columbia University and the New York Psychiatric Institute. “The social determinants of health, culture, and social justice experience of each person is taken into consideration,” said Dr. Le Melle.

“Community psychiatry steps outside of the traditional medical model of symptoms and illness, and focuses on understanding the person’s strengths and goals – and helps them to live their best lives.”

Dr. Le Melle also views diversifying the psychiatric workforce as imperative.

“For many African American, Latinx, and other marginalized populations that have had to deal with systemic and structural racism, discrimination, and historical abuse at the hands of psychiatry, it can be difficult to establish trust,” said Dr. Le Melle. “Therefore, diversity of our workforce and cultural humility are also crucial for engagement.”

The APA’s decision to not go forward with this year’s Institute on Psychiatric Services: The Mental Health Services Conference undermines the group’s credibility on these issues, according to some psychiatrists.

The IPS meeting, founded in 1948, is “where we traditionally teach and present about the social determinants of health and racism,” said Dr. Le Melle. “If the APA is serious about addressing the social determinants of health, bias, and discrimination against marginalized people and cultural humility, it needs to embrace and grow community psychiatry, not cut it.”

When asked about the IPS conference, Dr. Geller said that it has been scheduled for October 2021 in New York City. He also said the decision to skip the 2020 conference was made 2 years ago. The conference’s organizing committee decided to cancel the event when hotel space in the preferred city could not be arranged, Dr. Geller said.

Meanwhile, in a widely circulated letter that was sent to the APA board of trustees on Aug. 7, numerous leaders in psychiatry from across the country are citing steps they say the APA must take from “continuing impacts of structural racism that will greatly harm underserved patients, [minority and underrepresented] (M/UR) psychiatrists, and the APA as a whole.”

One step the leaders asked the APA to take was to hire an independent entity to investigate the organization’s “workplace culture, staff morale, and experiences of staff members and M/UR psychiatrists who support and/or work at the organization or have previously been dismissed or departed.”

Dr. Calhoun said she agrees that an internal examination would be productive.

“I’d like to see multiple people in positions of power (in the APA) in order to forward agendas,” Dr. Calhoun said. “Unless we do, we’ll have no way to achieve the goal of getting rid of structural racism.”
 

Dr. Calhoun, Dr. Geller, Dr. Brown, Dr. Starks, Dr. Lu, Dr. Ajilore, Dr. Dunlap, and Dr. Le Melle reported no relevant disclosures. Dr. Shim disclosed receiving royalties from American Psychiatric Association Publishing. Dr. Stewart is a coeditor of “Black Mental Health: Patients, Providers, and Systems” (American Psychiatric Association Publishing, 2018).

References

1. Geller J. Psychiatric News. 2020 Jun 23.

2. Washington HA. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans From Colonial Times to the Present. (New York: Doubleday), 2006.

3. ”Stewart brings a robust and eventful presidential year to a close.” Psychiatric News Daily. 2019 May 18.

4. Sabshin M et al. Am J Psychiatry. 1970 Dec;127:6.

5. Metzl JM. The Protest Psychosis: How Schizophrenia Became a Black Disease. (Boston: Beacon Press), 2009.

6. U.S. Census Bureau. Population estimates. 2019 Jul 1.

7. Shim RS. “Structural racism is why I’m leaving organized psychiatry. statnews.com. 2020 Jul 1.

8. Jones CP. Ethn Dis;28(Suppl):231-4.

9. Ewalt JR and Ewalt PA. Am J Psychiatry. 2006 Apr 1. doi: 10.1176/ajp.126.1.43.

One of the most significant shifts in hospital practice over recent decades has been the widespread adoption of electronic medical records as a replacement for conventional paper records.

While EMRs show a lot of promise – having the potential to centralize and simplify clinician notes, make information more accessible and reduce paper waste – there is strong evidence that they are not working as well as they could.

Some research suggests that these systems may decrease the working efficiency of clinicians. Now, major health care institutions are looking to understand why these systems are not working — as well as how they may be improved.

A recent white paper from the Society of Hospital Medicine’s Healthcare Information Technology Special Interest Group – titled “More Caring, Less Clicking” – reviews the current shortcomings of EMRs from a hospitalist perspective and provides recommendations for how these systems can be made more workable and efficient.

The current state of EMRs

“Numerous previous papers – including SHM’s 2017 white paper ‘Hospitalist Perspectives on Electronic Medical Records’ – have linked EMRs to decreased provider satisfaction and increased burnout related to multiple issues, including an increase in ‘screen time’ as opposed to patient ‘face-to-face’ time, and limitations in usability and interoperability,” said Rupesh Prasad, MD, SFHM, medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. “Studies have shown that most of a provider’s time spent is in areas like clinical documentation, entry of orders, and accessing patient information.”

The 2017 SHM white paper referenced by Dr. Prasad reported that 74% of hospitalists surveyed were dissatisfied with their EMR. A full one-quarter of surveyed physicians went so far as saying they would prefer switching to paper record keeping.

Other research has also found a possible link between EMRs and physician burnout and dissatisfaction. It is also not uncommon for hospitalists to spend up to 25% of their time at work using their EMR – time that should, ideally, be spent with patients.

The 2017 paper also showed that clinician notes in the United States are four times longer, on average, than notes in other countries. There are a few reasons for this – including technology design and billing requirements encouraging longer notes. Whatever the cause, however, longer notes linked to physician burnout may be partially responsible for the large amounts of time physicians spend looking at EMRs.

While EMRs may hold significant potential for hospitalists, as they are designed currently, they are simply not delivering the value many expected. The new white paper from the Healthcare Information Technology Special Interest Group outlines practical changes that could be made to EMRs to improve their use in hospitals.

The paper breaks down current issues with EMRs into five broad categories – documentation, clinical decision support, order entry, communication, and data review – to discuss how EMRs are currently failing in these areas as well as how they might be improved.

Improving EMR documentation

One of the most significant hurdles clinicians currently face lies in how EMRs currently store and display documentation. Combined with physician note-taking habits, this makes these systems much less usable than they could be. Longer notes, when displayed in current EMR UIs, mostly lead to clutter, making them harder to navigate and difficult to scan quickly for important information.

The authors identify a few different ways that future EMRs may be able to help with this problem.

EMR documentation tools will likely need to be redesigned to optimize documentation entry, standardize note formatting, and improve readability. Many electronic notes contain vestigial formatting and data left over from the design of paper notes. As a result, many of these electronic notes include information that is stored elsewhere and does not need to be explicitly included in every note. Cutting down on repetitive information storage will make important information more visible and help make patient notes easier to scan.

The paper also recommends a few other features that would make documentation more readable – like allowing clinicians to write documentation in SOAP format (subjective, objective, assessment, and plan), to facilitate critical thinking during the note-taking process, and having the EMR display that documentation in APSO format (assessment, plan, subjective, objective).

Doctors have long called for APSO or another note-taking format to replace SOAP in EMRs. Designing EMRs to rearrange SOAP notes to APSO could be a compromise that improves note readability while not requiring that clinicians learn new note-taking strategies.

The paper’s authors also recommended more extensive clinician training on writing notes. While clinicians are often taught how to write certain notes – like progress notes, histories, and physical and discharge summaries – more specific guidance is not always provided. Better training provided by institutions could help improve the quality and readability of clinician notes.

These changes, however, may not be as beneficial as possible without better institutional support for clinicians. Implementing some of the biggest changes recommended by the SHM will require some level of standardization across platforms and institution commitment to training clinicians on best use practices for EMRs. Improved responsiveness to clinician needs will require a coordinated effort with backing from both administrative and governance groups.

Expanding EMR usability

“Our white paper presents evidence-based recommendations that can be implemented at the ground level in collaboration with other stakeholders, including IT, informatics, and administration, to help improve on the current state,” Dr. Prasad said.

“We believe that hospitalists as key stakeholders in health care, have both the responsibility and are uniquely positioned to directly impact EMR functionality,” he noted. “For example, hospitalists can participate in designing appropriate, actionable alerts that would help with patient safety while also improving provider efficiency. Simple steps like limiting hard stops in order entry to would help speed up the process, and free up time for direct patient care. Availability of tools like secure text messaging would help with effective patient care team communication to improve safety and care delivery.”

EMRs often lack features like voice control and speech-to-text transcription, along with other basic accessibility features like compatibility with screen readers. Implementing these features could improve the efficiency of clinicians’ note-taking while also providing wider software usability.

EMRs are not typically designed to work with mobile devices, meaning clinicians cannot enter notes or order medications until they’ve returned to their desk or workstation.

This lack of functionality creates issues in several ways. When clinicians are unable to enter notes on the move, they will need to either keep mental notes or quickly jot down paper notes. This can effectively double the amount of note-taking that clinicians must do or introduce greater room for error. In cases where progress notes are taken throughout the day, this also means the EMR’s documentation timeline may not be accurate or usable.

Requiring clinicians to return to workstations before entering order information can also increase the risk of medication errors, which remains high despite hopes that EMRs could reduce error rates.

Adding support for cross-device and mobile EMR use could help improve the efficiency of note-taking and help cut down on error. Implementing mobile access could have a few different benefits for clinicians – like improving note-taking efficiency in hospitals, where doctors often see patients far away from their workstations.

EMRs also often lack support for certain hardware, like mobile stations and widescreen monitors, which can improve a clinician’s ability to document in real-time and are a better fit in certain work flows.

The SHM paper also recommends a few other tweaks to usability – like reducing the amount of password entry and reentry – that could make these systems easier to use and more efficient.

New features – like the use of natural language processing technology to analyze and organize information contained in clinicians’ notes – could provide further benefits and take full advantage of the advanced technologies that EMRs can integrate.

Dr. Prasad noted, however, that some of these upgrades – especially EMR compatibility with mobile devices – will require some institutional support. Bring-your-own-device policies or system-provided mobile devices will be necessary if institutions want their clinicians to be able to take advantage of mobile EMR access.

These policies will also likely require some kind of mobile device management solution to manage the security of sensitive patient data as it is accessed from personal devices. This may increase the level of necessary institutional buy-in for this support to work.

Designing EMRs with clinician needs in mind

Dr. Prasad said he and his coauthors recommend that EMR developers base more of their design on the needs of clinicians.

Currently, EMR interfaces can make important data unavailable, depending on what a clinician is trying to do. As a result, clinicians often need to rely on mental recall of important information as they navigate EMR systems.

These interfaces also typically do not support any level of user customization or process-specific interfaces, meaning every clinician is working with the same interface regardless of the tasks they need to perform or the information they need access to. Allowing for customization or implementing new process- or disease-specific interfaces could help avoid some of the problems caused by one-size-fits-all interfaces, which are not necessarily compatible with every clinician work flow.

EMR interfaces should also be designed, wherever possible, with familiar or standardized formats and the use of color coding and other techniques that can make interfaces easier to navigate quickly. Right now, many EMR systems utilize inconsistent layout design that can be cluttered with irrelevant information, slowing down interface navigation and sometimes requiring backtracking from clinicians.

Ideally, this will improve the speed of information gathering and data review, reducing the amount of time clinicians need to spend working with their EMR.

The white paper also recommends that EMR designers improve alert systems so that they are more actionable and interrupt clinicians less often – and that, when they do, they ensure that clinicians can respond to them. Designers should also reduce hard-stops or in-line alerts that halt clinicians’ work flows and require immediate responses where possible.

Increased EMR support for clinical decision support systems is one of the biggest health care trends expected to be seen throughout this decade. However, many clinicians are disappointed with the lack of flexibility and optimization of the current alerts that CDS provides. Updating and improving these knowledge-based systems will likely become essential for delivering better alerts and improving decision-making and efficiency.

Overall, EMR design should be informed by the needs of the people these products are designed to support, Dr. Prasad said. The people that work with EMRs – especially frontline staff like providers, nurses, and pharmacists that regularly interact with EMRs to provide care – should be involved early on in the EMR design process. Right now, their needs are not reflected in current EMR design. EMR companies, by working with these hospital staff members, could help improve ease of use and, ideally, prevent some of the errors associated with the current implementation of these systems.

“System designers should be able to avoid some of the most common problems of EMRs – and predict potential problems – by consistently soliciting and integrating clinician feedback during the design process and over the lifespan of a product,” Dr. Prasad said.

How EMRs can be improved

Over the past few years, EMRs have become quickly adopted by health care professionals and institutions. However, despite hopes that EMRs could significantly improve record keeping and note-taking, these systems continue to pose serious challenges for the clinicians who use them. Evidence from recent research suggests that these systems are inefficient and may contribute to physician burnout.

As a result, organizations like SHM are looking for ways that these systems can be improved.

“The growth of health IT has led to availability of large amounts of data and opportunities for applications in [artificial intelligence and machine learning,” Dr. Prasad noted. “While this has opened many avenues to help positively impact patient care and outcomes, it also poses multiple challenges like validation, customization, and governance. Hospitalists can partner with other health professions and IT leaders to work toward the common goal of improving the health of the population while also providing a positive experience to the end user.”

Another problem with current EMRs is their lack of flexibility. These systems are often not compatible with mobile devices and certain types of hardware and may be difficult or impossible to customize. They also frequently require unnecessary information during the note-taking process that results in cluttered and difficult-to-scan documentation. Improving EMR flexibility – and inviting clinicians to consult during the design process – could solve many of these problems.

New technological developments may also soon help developers improve their EMRs. In the future, as technology like natural language processing becomes more advanced and more commonly used, they may be able to make EMRs even more efficient and user friendly.

One of the most significant shifts in hospital practice over recent decades has been the widespread adoption of electronic medical records as a replacement for conventional paper records.

While EMRs show a lot of promise – having the potential to centralize and simplify clinician notes, make information more accessible and reduce paper waste – there is strong evidence that they are not working as well as they could.

Some research suggests that these systems may decrease the working efficiency of clinicians. Now, major health care institutions are looking to understand why these systems are not working — as well as how they may be improved.

A recent white paper from the Society of Hospital Medicine’s Healthcare Information Technology Special Interest Group – titled “More Caring, Less Clicking” – reviews the current shortcomings of EMRs from a hospitalist perspective and provides recommendations for how these systems can be made more workable and efficient.

The current state of EMRs

“Numerous previous papers – including SHM’s 2017 white paper ‘Hospitalist Perspectives on Electronic Medical Records’ – have linked EMRs to decreased provider satisfaction and increased burnout related to multiple issues, including an increase in ‘screen time’ as opposed to patient ‘face-to-face’ time, and limitations in usability and interoperability,” said Rupesh Prasad, MD, SFHM, medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. “Studies have shown that most of a provider’s time spent is in areas like clinical documentation, entry of orders, and accessing patient information.”

The 2017 SHM white paper referenced by Dr. Prasad reported that 74% of hospitalists surveyed were dissatisfied with their EMR. A full one-quarter of surveyed physicians went so far as saying they would prefer switching to paper record keeping.

Other research has also found a possible link between EMRs and physician burnout and dissatisfaction. It is also not uncommon for hospitalists to spend up to 25% of their time at work using their EMR – time that should, ideally, be spent with patients.

The 2017 paper also showed that clinician notes in the United States are four times longer, on average, than notes in other countries. There are a few reasons for this – including technology design and billing requirements encouraging longer notes. Whatever the cause, however, longer notes linked to physician burnout may be partially responsible for the large amounts of time physicians spend looking at EMRs.

While EMRs may hold significant potential for hospitalists, as they are designed currently, they are simply not delivering the value many expected. The new white paper from the Healthcare Information Technology Special Interest Group outlines practical changes that could be made to EMRs to improve their use in hospitals.

The paper breaks down current issues with EMRs into five broad categories – documentation, clinical decision support, order entry, communication, and data review – to discuss how EMRs are currently failing in these areas as well as how they might be improved.

Improving EMR documentation

One of the most significant hurdles clinicians currently face lies in how EMRs currently store and display documentation. Combined with physician note-taking habits, this makes these systems much less usable than they could be. Longer notes, when displayed in current EMR UIs, mostly lead to clutter, making them harder to navigate and difficult to scan quickly for important information.

The authors identify a few different ways that future EMRs may be able to help with this problem.

EMR documentation tools will likely need to be redesigned to optimize documentation entry, standardize note formatting, and improve readability. Many electronic notes contain vestigial formatting and data left over from the design of paper notes. As a result, many of these electronic notes include information that is stored elsewhere and does not need to be explicitly included in every note. Cutting down on repetitive information storage will make important information more visible and help make patient notes easier to scan.

The paper also recommends a few other features that would make documentation more readable – like allowing clinicians to write documentation in SOAP format (subjective, objective, assessment, and plan), to facilitate critical thinking during the note-taking process, and having the EMR display that documentation in APSO format (assessment, plan, subjective, objective).

Doctors have long called for APSO or another note-taking format to replace SOAP in EMRs. Designing EMRs to rearrange SOAP notes to APSO could be a compromise that improves note readability while not requiring that clinicians learn new note-taking strategies.

The paper’s authors also recommended more extensive clinician training on writing notes. While clinicians are often taught how to write certain notes – like progress notes, histories, and physical and discharge summaries – more specific guidance is not always provided. Better training provided by institutions could help improve the quality and readability of clinician notes.

These changes, however, may not be as beneficial as possible without better institutional support for clinicians. Implementing some of the biggest changes recommended by the SHM will require some level of standardization across platforms and institution commitment to training clinicians on best use practices for EMRs. Improved responsiveness to clinician needs will require a coordinated effort with backing from both administrative and governance groups.

Expanding EMR usability

“Our white paper presents evidence-based recommendations that can be implemented at the ground level in collaboration with other stakeholders, including IT, informatics, and administration, to help improve on the current state,” Dr. Prasad said.

“We believe that hospitalists as key stakeholders in health care, have both the responsibility and are uniquely positioned to directly impact EMR functionality,” he noted. “For example, hospitalists can participate in designing appropriate, actionable alerts that would help with patient safety while also improving provider efficiency. Simple steps like limiting hard stops in order entry to would help speed up the process, and free up time for direct patient care. Availability of tools like secure text messaging would help with effective patient care team communication to improve safety and care delivery.”

EMRs often lack features like voice control and speech-to-text transcription, along with other basic accessibility features like compatibility with screen readers. Implementing these features could improve the efficiency of clinicians’ note-taking while also providing wider software usability.

EMRs are not typically designed to work with mobile devices, meaning clinicians cannot enter notes or order medications until they’ve returned to their desk or workstation.

This lack of functionality creates issues in several ways. When clinicians are unable to enter notes on the move, they will need to either keep mental notes or quickly jot down paper notes. This can effectively double the amount of note-taking that clinicians must do or introduce greater room for error. In cases where progress notes are taken throughout the day, this also means the EMR’s documentation timeline may not be accurate or usable.

Requiring clinicians to return to workstations before entering order information can also increase the risk of medication errors, which remains high despite hopes that EMRs could reduce error rates.

Adding support for cross-device and mobile EMR use could help improve the efficiency of note-taking and help cut down on error. Implementing mobile access could have a few different benefits for clinicians – like improving note-taking efficiency in hospitals, where doctors often see patients far away from their workstations.

EMRs also often lack support for certain hardware, like mobile stations and widescreen monitors, which can improve a clinician’s ability to document in real-time and are a better fit in certain work flows.

The SHM paper also recommends a few other tweaks to usability – like reducing the amount of password entry and reentry – that could make these systems easier to use and more efficient.

New features – like the use of natural language processing technology to analyze and organize information contained in clinicians’ notes – could provide further benefits and take full advantage of the advanced technologies that EMRs can integrate.

Dr. Prasad noted, however, that some of these upgrades – especially EMR compatibility with mobile devices – will require some institutional support. Bring-your-own-device policies or system-provided mobile devices will be necessary if institutions want their clinicians to be able to take advantage of mobile EMR access.

These policies will also likely require some kind of mobile device management solution to manage the security of sensitive patient data as it is accessed from personal devices. This may increase the level of necessary institutional buy-in for this support to work.

Designing EMRs with clinician needs in mind

Dr. Prasad said he and his coauthors recommend that EMR developers base more of their design on the needs of clinicians.

Currently, EMR interfaces can make important data unavailable, depending on what a clinician is trying to do. As a result, clinicians often need to rely on mental recall of important information as they navigate EMR systems.

These interfaces also typically do not support any level of user customization or process-specific interfaces, meaning every clinician is working with the same interface regardless of the tasks they need to perform or the information they need access to. Allowing for customization or implementing new process- or disease-specific interfaces could help avoid some of the problems caused by one-size-fits-all interfaces, which are not necessarily compatible with every clinician work flow.

EMR interfaces should also be designed, wherever possible, with familiar or standardized formats and the use of color coding and other techniques that can make interfaces easier to navigate quickly. Right now, many EMR systems utilize inconsistent layout design that can be cluttered with irrelevant information, slowing down interface navigation and sometimes requiring backtracking from clinicians.

Ideally, this will improve the speed of information gathering and data review, reducing the amount of time clinicians need to spend working with their EMR.

The white paper also recommends that EMR designers improve alert systems so that they are more actionable and interrupt clinicians less often – and that, when they do, they ensure that clinicians can respond to them. Designers should also reduce hard-stops or in-line alerts that halt clinicians’ work flows and require immediate responses where possible.

Increased EMR support for clinical decision support systems is one of the biggest health care trends expected to be seen throughout this decade. However, many clinicians are disappointed with the lack of flexibility and optimization of the current alerts that CDS provides. Updating and improving these knowledge-based systems will likely become essential for delivering better alerts and improving decision-making and efficiency.

Overall, EMR design should be informed by the needs of the people these products are designed to support, Dr. Prasad said. The people that work with EMRs – especially frontline staff like providers, nurses, and pharmacists that regularly interact with EMRs to provide care – should be involved early on in the EMR design process. Right now, their needs are not reflected in current EMR design. EMR companies, by working with these hospital staff members, could help improve ease of use and, ideally, prevent some of the errors associated with the current implementation of these systems.

“System designers should be able to avoid some of the most common problems of EMRs – and predict potential problems – by consistently soliciting and integrating clinician feedback during the design process and over the lifespan of a product,” Dr. Prasad said.

How EMRs can be improved

Over the past few years, EMRs have become quickly adopted by health care professionals and institutions. However, despite hopes that EMRs could significantly improve record keeping and note-taking, these systems continue to pose serious challenges for the clinicians who use them. Evidence from recent research suggests that these systems are inefficient and may contribute to physician burnout.

As a result, organizations like SHM are looking for ways that these systems can be improved.

“The growth of health IT has led to availability of large amounts of data and opportunities for applications in [artificial intelligence and machine learning,” Dr. Prasad noted. “While this has opened many avenues to help positively impact patient care and outcomes, it also poses multiple challenges like validation, customization, and governance. Hospitalists can partner with other health professions and IT leaders to work toward the common goal of improving the health of the population while also providing a positive experience to the end user.”

Another problem with current EMRs is their lack of flexibility. These systems are often not compatible with mobile devices and certain types of hardware and may be difficult or impossible to customize. They also frequently require unnecessary information during the note-taking process that results in cluttered and difficult-to-scan documentation. Improving EMR flexibility – and inviting clinicians to consult during the design process – could solve many of these problems.

New technological developments may also soon help developers improve their EMRs. In the future, as technology like natural language processing becomes more advanced and more commonly used, they may be able to make EMRs even more efficient and user friendly.

One of the most significant shifts in hospital practice over recent decades has been the widespread adoption of electronic medical records as a replacement for conventional paper records.

While EMRs show a lot of promise – having the potential to centralize and simplify clinician notes, make information more accessible and reduce paper waste – there is strong evidence that they are not working as well as they could.

Some research suggests that these systems may decrease the working efficiency of clinicians. Now, major health care institutions are looking to understand why these systems are not working — as well as how they may be improved.

A recent white paper from the Society of Hospital Medicine’s Healthcare Information Technology Special Interest Group – titled “More Caring, Less Clicking” – reviews the current shortcomings of EMRs from a hospitalist perspective and provides recommendations for how these systems can be made more workable and efficient.

The current state of EMRs

“Numerous previous papers – including SHM’s 2017 white paper ‘Hospitalist Perspectives on Electronic Medical Records’ – have linked EMRs to decreased provider satisfaction and increased burnout related to multiple issues, including an increase in ‘screen time’ as opposed to patient ‘face-to-face’ time, and limitations in usability and interoperability,” said Rupesh Prasad, MD, SFHM, medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. “Studies have shown that most of a provider’s time spent is in areas like clinical documentation, entry of orders, and accessing patient information.”

The 2017 SHM white paper referenced by Dr. Prasad reported that 74% of hospitalists surveyed were dissatisfied with their EMR. A full one-quarter of surveyed physicians went so far as saying they would prefer switching to paper record keeping.

Other research has also found a possible link between EMRs and physician burnout and dissatisfaction. It is also not uncommon for hospitalists to spend up to 25% of their time at work using their EMR – time that should, ideally, be spent with patients.

The 2017 paper also showed that clinician notes in the United States are four times longer, on average, than notes in other countries. There are a few reasons for this – including technology design and billing requirements encouraging longer notes. Whatever the cause, however, longer notes linked to physician burnout may be partially responsible for the large amounts of time physicians spend looking at EMRs.

While EMRs may hold significant potential for hospitalists, as they are designed currently, they are simply not delivering the value many expected. The new white paper from the Healthcare Information Technology Special Interest Group outlines practical changes that could be made to EMRs to improve their use in hospitals.

The paper breaks down current issues with EMRs into five broad categories – documentation, clinical decision support, order entry, communication, and data review – to discuss how EMRs are currently failing in these areas as well as how they might be improved.

Improving EMR documentation

One of the most significant hurdles clinicians currently face lies in how EMRs currently store and display documentation. Combined with physician note-taking habits, this makes these systems much less usable than they could be. Longer notes, when displayed in current EMR UIs, mostly lead to clutter, making them harder to navigate and difficult to scan quickly for important information.

The authors identify a few different ways that future EMRs may be able to help with this problem.

EMR documentation tools will likely need to be redesigned to optimize documentation entry, standardize note formatting, and improve readability. Many electronic notes contain vestigial formatting and data left over from the design of paper notes. As a result, many of these electronic notes include information that is stored elsewhere and does not need to be explicitly included in every note. Cutting down on repetitive information storage will make important information more visible and help make patient notes easier to scan.

The paper also recommends a few other features that would make documentation more readable – like allowing clinicians to write documentation in SOAP format (subjective, objective, assessment, and plan), to facilitate critical thinking during the note-taking process, and having the EMR display that documentation in APSO format (assessment, plan, subjective, objective).

Doctors have long called for APSO or another note-taking format to replace SOAP in EMRs. Designing EMRs to rearrange SOAP notes to APSO could be a compromise that improves note readability while not requiring that clinicians learn new note-taking strategies.

The paper’s authors also recommended more extensive clinician training on writing notes. While clinicians are often taught how to write certain notes – like progress notes, histories, and physical and discharge summaries – more specific guidance is not always provided. Better training provided by institutions could help improve the quality and readability of clinician notes.

These changes, however, may not be as beneficial as possible without better institutional support for clinicians. Implementing some of the biggest changes recommended by the SHM will require some level of standardization across platforms and institution commitment to training clinicians on best use practices for EMRs. Improved responsiveness to clinician needs will require a coordinated effort with backing from both administrative and governance groups.

Expanding EMR usability

“Our white paper presents evidence-based recommendations that can be implemented at the ground level in collaboration with other stakeholders, including IT, informatics, and administration, to help improve on the current state,” Dr. Prasad said.

“We believe that hospitalists as key stakeholders in health care, have both the responsibility and are uniquely positioned to directly impact EMR functionality,” he noted. “For example, hospitalists can participate in designing appropriate, actionable alerts that would help with patient safety while also improving provider efficiency. Simple steps like limiting hard stops in order entry to would help speed up the process, and free up time for direct patient care. Availability of tools like secure text messaging would help with effective patient care team communication to improve safety and care delivery.”

EMRs often lack features like voice control and speech-to-text transcription, along with other basic accessibility features like compatibility with screen readers. Implementing these features could improve the efficiency of clinicians’ note-taking while also providing wider software usability.

EMRs are not typically designed to work with mobile devices, meaning clinicians cannot enter notes or order medications until they’ve returned to their desk or workstation.

This lack of functionality creates issues in several ways. When clinicians are unable to enter notes on the move, they will need to either keep mental notes or quickly jot down paper notes. This can effectively double the amount of note-taking that clinicians must do or introduce greater room for error. In cases where progress notes are taken throughout the day, this also means the EMR’s documentation timeline may not be accurate or usable.

Requiring clinicians to return to workstations before entering order information can also increase the risk of medication errors, which remains high despite hopes that EMRs could reduce error rates.

Adding support for cross-device and mobile EMR use could help improve the efficiency of note-taking and help cut down on error. Implementing mobile access could have a few different benefits for clinicians – like improving note-taking efficiency in hospitals, where doctors often see patients far away from their workstations.

EMRs also often lack support for certain hardware, like mobile stations and widescreen monitors, which can improve a clinician’s ability to document in real-time and are a better fit in certain work flows.

The SHM paper also recommends a few other tweaks to usability – like reducing the amount of password entry and reentry – that could make these systems easier to use and more efficient.

New features – like the use of natural language processing technology to analyze and organize information contained in clinicians’ notes – could provide further benefits and take full advantage of the advanced technologies that EMRs can integrate.

Dr. Prasad noted, however, that some of these upgrades – especially EMR compatibility with mobile devices – will require some institutional support. Bring-your-own-device policies or system-provided mobile devices will be necessary if institutions want their clinicians to be able to take advantage of mobile EMR access.

These policies will also likely require some kind of mobile device management solution to manage the security of sensitive patient data as it is accessed from personal devices. This may increase the level of necessary institutional buy-in for this support to work.

Designing EMRs with clinician needs in mind

Dr. Prasad said he and his coauthors recommend that EMR developers base more of their design on the needs of clinicians.

Currently, EMR interfaces can make important data unavailable, depending on what a clinician is trying to do. As a result, clinicians often need to rely on mental recall of important information as they navigate EMR systems.

These interfaces also typically do not support any level of user customization or process-specific interfaces, meaning every clinician is working with the same interface regardless of the tasks they need to perform or the information they need access to. Allowing for customization or implementing new process- or disease-specific interfaces could help avoid some of the problems caused by one-size-fits-all interfaces, which are not necessarily compatible with every clinician work flow.

EMR interfaces should also be designed, wherever possible, with familiar or standardized formats and the use of color coding and other techniques that can make interfaces easier to navigate quickly. Right now, many EMR systems utilize inconsistent layout design that can be cluttered with irrelevant information, slowing down interface navigation and sometimes requiring backtracking from clinicians.

Ideally, this will improve the speed of information gathering and data review, reducing the amount of time clinicians need to spend working with their EMR.

The white paper also recommends that EMR designers improve alert systems so that they are more actionable and interrupt clinicians less often – and that, when they do, they ensure that clinicians can respond to them. Designers should also reduce hard-stops or in-line alerts that halt clinicians’ work flows and require immediate responses where possible.

Increased EMR support for clinical decision support systems is one of the biggest health care trends expected to be seen throughout this decade. However, many clinicians are disappointed with the lack of flexibility and optimization of the current alerts that CDS provides. Updating and improving these knowledge-based systems will likely become essential for delivering better alerts and improving decision-making and efficiency.

Overall, EMR design should be informed by the needs of the people these products are designed to support, Dr. Prasad said. The people that work with EMRs – especially frontline staff like providers, nurses, and pharmacists that regularly interact with EMRs to provide care – should be involved early on in the EMR design process. Right now, their needs are not reflected in current EMR design. EMR companies, by working with these hospital staff members, could help improve ease of use and, ideally, prevent some of the errors associated with the current implementation of these systems.

“System designers should be able to avoid some of the most common problems of EMRs – and predict potential problems – by consistently soliciting and integrating clinician feedback during the design process and over the lifespan of a product,” Dr. Prasad said.

How EMRs can be improved

Over the past few years, EMRs have become quickly adopted by health care professionals and institutions. However, despite hopes that EMRs could significantly improve record keeping and note-taking, these systems continue to pose serious challenges for the clinicians who use them. Evidence from recent research suggests that these systems are inefficient and may contribute to physician burnout.

As a result, organizations like SHM are looking for ways that these systems can be improved.

“The growth of health IT has led to availability of large amounts of data and opportunities for applications in [artificial intelligence and machine learning,” Dr. Prasad noted. “While this has opened many avenues to help positively impact patient care and outcomes, it also poses multiple challenges like validation, customization, and governance. Hospitalists can partner with other health professions and IT leaders to work toward the common goal of improving the health of the population while also providing a positive experience to the end user.”

Another problem with current EMRs is their lack of flexibility. These systems are often not compatible with mobile devices and certain types of hardware and may be difficult or impossible to customize. They also frequently require unnecessary information during the note-taking process that results in cluttered and difficult-to-scan documentation. Improving EMR flexibility – and inviting clinicians to consult during the design process – could solve many of these problems.

New technological developments may also soon help developers improve their EMRs. In the future, as technology like natural language processing becomes more advanced and more commonly used, they may be able to make EMRs even more efficient and user friendly.

Concussion is associated with increased risk for subsequent development of attention-deficit/hyperactivity disorder (ADHD), as well as dementia and Parkinson’s disease, new research suggests. Results from a retrospective, population-based cohort study showed that controlling for socioeconomic status and overall health did not significantly affect this association.

The link between concussion and risk for ADHD and for mood and anxiety disorder was stronger in the women than in the men. In addition, having a history of multiple concussions strengthened the association between concussion and subsequent mood and anxiety disorder, dementia, and Parkinson’s disease compared with experiencing just one concussion.

The findings are similar to those of previous studies, noted lead author Marc P. Morissette, PhD, research assistant at the Pan Am Clinic Foundation in Winnipeg, Manitoba, Canada. “The main methodological differences separating our study from previous studies in this area is a focus on concussion-specific injuries identified from medical records and the potential for study participants to have up to 25 years of follow-up data,” said Dr. Morissette.

The findings were published online July 27 in Family Medicine and Community Health, a BMJ journal.
 

Almost 190,000 participants

Several studies have shown associations between head injury and increased risk for ADHD, depression, anxiety, Alzheimer’s disease, and Parkinson’s disease. However, many of these studies relied on self-reported medical history, included all forms of traumatic brain injury, and failed to adjust for preexisting health conditions.

An improved understanding of concussion and the risks associated with it could help physicians manage their patients’ long-term needs, the investigators noted.

In the current study, the researchers examined anonymized administrative health data collected between the periods of 1990–1991 and 2014–2015 in the Manitoba Population Research Data Repository at the Manitoba Center for Health Policy.

Eligible patients had been diagnosed with concussion in accordance with standard criteria. Participants were excluded if they had been diagnosed with dementia or Parkinson’s disease before the incident concussion during the study period. The investigators matched three control participants to each included patient on the basis of age, sex, and location.

Study outcome was time from index date (date of first concussion) to diagnosis of ADHD, mood and anxiety disorder, dementia, or Parkinson’s disease. The researchers controlled for socioeconomic status using the Socioeconomic Factor Index, version 2 (SEFI2), and for preexisting medical conditions using the Charlson Comorbidity Index (CCI).

The study included 28,021 men (mean age, 25 years) and 19,462 women (mean age, 30 years) in the concussion group and 81,871 men (mean age, 25 years) and 57,159 women (mean age, 30 years) in the control group. Mean SEFI2 score was approximately −0.05, and mean CCI score was approximately 0.2.
 

Dose effect?

Results showed that concussion was associated with an increased risk for ADHD (hazard ratio [HR], 1.39), mood and anxiety disorder (HR, 1.72), dementia (HR, 1.72), and Parkinson’s disease (HR, 1.57).

After a concussion, the risk of developing ADHD was 28% higher and the risk of developing mood and anxiety disorder was 7% higher among women than among men. Gender was not associated with risk for dementia or Parkinson’s disease after concussion.

Sustaining a second concussion increased the strength of the association with risk for dementia compared with sustaining a single concussion (HR, 1.62). Similarly, sustaining more than three concussions increased the strength of the association with the risk for mood and anxiety disorders (HR for more than three vs one concussion, 1.22) and Parkinson›s disease (HR, 3.27).

A sensitivity analysis found similar associations between concussion and risk for mood and anxiety disorder among all age groups. Younger participants were at greater risk for ADHD, however, and older participants were at greater risk for dementia and Parkinson’s disease.

Increased awareness of concussion and the outcomes of interest, along with improved diagnostic tools, may have influenced the study’s findings, Dr. Morissette noted. “The sex-based differences may be due to either pathophysiological differences in response to concussive injuries or potentially a difference in willingness to seek medical care or share symptoms, concussion-related or otherwise, with a medical professional,” he said.

“We are hopeful that our findings will encourage practitioners to be cognizant of various conditions that may present in individuals who have previously experienced a concussion,” Dr. Morissette added. “If physicians are aware of the various associations identified following a concussion, it may lead to more thorough clinical examination at initial presentation, along with more dedicated care throughout the patient’s life.”
 

Association versus causation

Commenting on the research, Steven Erickson, MD, sports medicine specialist at Banner–University Medicine Neuroscience Institute, Phoenix, Ariz., noted that although the study showed an association between concussion and subsequent diagnosis of ADHD, anxiety, and Parkinson’s disease, “this association should not be misconstrued as causation.” He added that the study’s conclusions “are just as likely to be due to labeling theory” or a self-fulfilling prophecy.

“Patients diagnosed with ADHD, anxiety, or Parkinson’s disease may recall concussion and associate the two diagnoses; but patients who have not previously been diagnosed with a concussion cannot draw that conclusion,” said Dr. Erickson, who was not involved with the research.

Citing the apparent gender difference in the strength of the association between concussion and the outcomes of interest, Dr. Erickson noted that women are more likely to report symptoms in general “and therefore are more likely to be diagnosed with ADHD and anxiety disorders” because of differences in reporting rather than incidence of disease.

“Further research needs to be done to definitively determine a causal relationship between concussion and any psychiatric or neurologic diagnosis,” Dr. Erickson concluded.

The study was funded by the Pan Am Clinic Foundation. Dr. Morissette and Dr. Erickson have disclosed no relevant financial relationships.

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

Concussion is associated with increased risk for subsequent development of attention-deficit/hyperactivity disorder (ADHD), as well as dementia and Parkinson’s disease, new research suggests. Results from a retrospective, population-based cohort study showed that controlling for socioeconomic status and overall health did not significantly affect this association.

The link between concussion and risk for ADHD and for mood and anxiety disorder was stronger in the women than in the men. In addition, having a history of multiple concussions strengthened the association between concussion and subsequent mood and anxiety disorder, dementia, and Parkinson’s disease compared with experiencing just one concussion.

The findings are similar to those of previous studies, noted lead author Marc P. Morissette, PhD, research assistant at the Pan Am Clinic Foundation in Winnipeg, Manitoba, Canada. “The main methodological differences separating our study from previous studies in this area is a focus on concussion-specific injuries identified from medical records and the potential for study participants to have up to 25 years of follow-up data,” said Dr. Morissette.

The findings were published online July 27 in Family Medicine and Community Health, a BMJ journal.
 

Almost 190,000 participants

Several studies have shown associations between head injury and increased risk for ADHD, depression, anxiety, Alzheimer’s disease, and Parkinson’s disease. However, many of these studies relied on self-reported medical history, included all forms of traumatic brain injury, and failed to adjust for preexisting health conditions.

An improved understanding of concussion and the risks associated with it could help physicians manage their patients’ long-term needs, the investigators noted.

In the current study, the researchers examined anonymized administrative health data collected between the periods of 1990–1991 and 2014–2015 in the Manitoba Population Research Data Repository at the Manitoba Center for Health Policy.

Eligible patients had been diagnosed with concussion in accordance with standard criteria. Participants were excluded if they had been diagnosed with dementia or Parkinson’s disease before the incident concussion during the study period. The investigators matched three control participants to each included patient on the basis of age, sex, and location.

Study outcome was time from index date (date of first concussion) to diagnosis of ADHD, mood and anxiety disorder, dementia, or Parkinson’s disease. The researchers controlled for socioeconomic status using the Socioeconomic Factor Index, version 2 (SEFI2), and for preexisting medical conditions using the Charlson Comorbidity Index (CCI).

The study included 28,021 men (mean age, 25 years) and 19,462 women (mean age, 30 years) in the concussion group and 81,871 men (mean age, 25 years) and 57,159 women (mean age, 30 years) in the control group. Mean SEFI2 score was approximately −0.05, and mean CCI score was approximately 0.2.
 

Dose effect?

Results showed that concussion was associated with an increased risk for ADHD (hazard ratio [HR], 1.39), mood and anxiety disorder (HR, 1.72), dementia (HR, 1.72), and Parkinson’s disease (HR, 1.57).

After a concussion, the risk of developing ADHD was 28% higher and the risk of developing mood and anxiety disorder was 7% higher among women than among men. Gender was not associated with risk for dementia or Parkinson’s disease after concussion.

Sustaining a second concussion increased the strength of the association with risk for dementia compared with sustaining a single concussion (HR, 1.62). Similarly, sustaining more than three concussions increased the strength of the association with the risk for mood and anxiety disorders (HR for more than three vs one concussion, 1.22) and Parkinson›s disease (HR, 3.27).

A sensitivity analysis found similar associations between concussion and risk for mood and anxiety disorder among all age groups. Younger participants were at greater risk for ADHD, however, and older participants were at greater risk for dementia and Parkinson’s disease.

Increased awareness of concussion and the outcomes of interest, along with improved diagnostic tools, may have influenced the study’s findings, Dr. Morissette noted. “The sex-based differences may be due to either pathophysiological differences in response to concussive injuries or potentially a difference in willingness to seek medical care or share symptoms, concussion-related or otherwise, with a medical professional,” he said.

“We are hopeful that our findings will encourage practitioners to be cognizant of various conditions that may present in individuals who have previously experienced a concussion,” Dr. Morissette added. “If physicians are aware of the various associations identified following a concussion, it may lead to more thorough clinical examination at initial presentation, along with more dedicated care throughout the patient’s life.”
 

Association versus causation

Commenting on the research, Steven Erickson, MD, sports medicine specialist at Banner–University Medicine Neuroscience Institute, Phoenix, Ariz., noted that although the study showed an association between concussion and subsequent diagnosis of ADHD, anxiety, and Parkinson’s disease, “this association should not be misconstrued as causation.” He added that the study’s conclusions “are just as likely to be due to labeling theory” or a self-fulfilling prophecy.

“Patients diagnosed with ADHD, anxiety, or Parkinson’s disease may recall concussion and associate the two diagnoses; but patients who have not previously been diagnosed with a concussion cannot draw that conclusion,” said Dr. Erickson, who was not involved with the research.

Citing the apparent gender difference in the strength of the association between concussion and the outcomes of interest, Dr. Erickson noted that women are more likely to report symptoms in general “and therefore are more likely to be diagnosed with ADHD and anxiety disorders” because of differences in reporting rather than incidence of disease.

“Further research needs to be done to definitively determine a causal relationship between concussion and any psychiatric or neurologic diagnosis,” Dr. Erickson concluded.

The study was funded by the Pan Am Clinic Foundation. Dr. Morissette and Dr. Erickson have disclosed no relevant financial relationships.

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

Concussion is associated with increased risk for subsequent development of attention-deficit/hyperactivity disorder (ADHD), as well as dementia and Parkinson’s disease, new research suggests. Results from a retrospective, population-based cohort study showed that controlling for socioeconomic status and overall health did not significantly affect this association.

The link between concussion and risk for ADHD and for mood and anxiety disorder was stronger in the women than in the men. In addition, having a history of multiple concussions strengthened the association between concussion and subsequent mood and anxiety disorder, dementia, and Parkinson’s disease compared with experiencing just one concussion.

The findings are similar to those of previous studies, noted lead author Marc P. Morissette, PhD, research assistant at the Pan Am Clinic Foundation in Winnipeg, Manitoba, Canada. “The main methodological differences separating our study from previous studies in this area is a focus on concussion-specific injuries identified from medical records and the potential for study participants to have up to 25 years of follow-up data,” said Dr. Morissette.

The findings were published online July 27 in Family Medicine and Community Health, a BMJ journal.
 

Almost 190,000 participants

Several studies have shown associations between head injury and increased risk for ADHD, depression, anxiety, Alzheimer’s disease, and Parkinson’s disease. However, many of these studies relied on self-reported medical history, included all forms of traumatic brain injury, and failed to adjust for preexisting health conditions.

An improved understanding of concussion and the risks associated with it could help physicians manage their patients’ long-term needs, the investigators noted.

In the current study, the researchers examined anonymized administrative health data collected between the periods of 1990–1991 and 2014–2015 in the Manitoba Population Research Data Repository at the Manitoba Center for Health Policy.

Eligible patients had been diagnosed with concussion in accordance with standard criteria. Participants were excluded if they had been diagnosed with dementia or Parkinson’s disease before the incident concussion during the study period. The investigators matched three control participants to each included patient on the basis of age, sex, and location.

Study outcome was time from index date (date of first concussion) to diagnosis of ADHD, mood and anxiety disorder, dementia, or Parkinson’s disease. The researchers controlled for socioeconomic status using the Socioeconomic Factor Index, version 2 (SEFI2), and for preexisting medical conditions using the Charlson Comorbidity Index (CCI).

The study included 28,021 men (mean age, 25 years) and 19,462 women (mean age, 30 years) in the concussion group and 81,871 men (mean age, 25 years) and 57,159 women (mean age, 30 years) in the control group. Mean SEFI2 score was approximately −0.05, and mean CCI score was approximately 0.2.
 

Dose effect?

Results showed that concussion was associated with an increased risk for ADHD (hazard ratio [HR], 1.39), mood and anxiety disorder (HR, 1.72), dementia (HR, 1.72), and Parkinson’s disease (HR, 1.57).

After a concussion, the risk of developing ADHD was 28% higher and the risk of developing mood and anxiety disorder was 7% higher among women than among men. Gender was not associated with risk for dementia or Parkinson’s disease after concussion.

Sustaining a second concussion increased the strength of the association with risk for dementia compared with sustaining a single concussion (HR, 1.62). Similarly, sustaining more than three concussions increased the strength of the association with the risk for mood and anxiety disorders (HR for more than three vs one concussion, 1.22) and Parkinson›s disease (HR, 3.27).

A sensitivity analysis found similar associations between concussion and risk for mood and anxiety disorder among all age groups. Younger participants were at greater risk for ADHD, however, and older participants were at greater risk for dementia and Parkinson’s disease.

Increased awareness of concussion and the outcomes of interest, along with improved diagnostic tools, may have influenced the study’s findings, Dr. Morissette noted. “The sex-based differences may be due to either pathophysiological differences in response to concussive injuries or potentially a difference in willingness to seek medical care or share symptoms, concussion-related or otherwise, with a medical professional,” he said.

“We are hopeful that our findings will encourage practitioners to be cognizant of various conditions that may present in individuals who have previously experienced a concussion,” Dr. Morissette added. “If physicians are aware of the various associations identified following a concussion, it may lead to more thorough clinical examination at initial presentation, along with more dedicated care throughout the patient’s life.”
 

Association versus causation

Commenting on the research, Steven Erickson, MD, sports medicine specialist at Banner–University Medicine Neuroscience Institute, Phoenix, Ariz., noted that although the study showed an association between concussion and subsequent diagnosis of ADHD, anxiety, and Parkinson’s disease, “this association should not be misconstrued as causation.” He added that the study’s conclusions “are just as likely to be due to labeling theory” or a self-fulfilling prophecy.

“Patients diagnosed with ADHD, anxiety, or Parkinson’s disease may recall concussion and associate the two diagnoses; but patients who have not previously been diagnosed with a concussion cannot draw that conclusion,” said Dr. Erickson, who was not involved with the research.

Citing the apparent gender difference in the strength of the association between concussion and the outcomes of interest, Dr. Erickson noted that women are more likely to report symptoms in general “and therefore are more likely to be diagnosed with ADHD and anxiety disorders” because of differences in reporting rather than incidence of disease.

“Further research needs to be done to definitively determine a causal relationship between concussion and any psychiatric or neurologic diagnosis,” Dr. Erickson concluded.

The study was funded by the Pan Am Clinic Foundation. Dr. Morissette and Dr. Erickson have disclosed no relevant financial relationships.

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

Monogenic disorders with heart and vascular effects are each pretty rare in clinical practice but collectively can make up a fair proportion of the patients cardiologists see. Still, the diagnosis is missed more often than not, even when the clinical signs are there, suggests an observational study, supporting broader genetic testing in cardiovascular patients.

In a cohort of more than 8,000 patients referred for cardiac catheterization, diagnosis of such a monogenic cardiovascular disease (MCVD) was made in only 35% of those with one related gene variant and signs of phenotypic expression in the electronic health record.

The findings are novel for measuring the field’s “burden of missed diagnoses” in patients with MCVD, which “represent a missed opportunity that could be addressed by genetic screening,” contended the study report, published in the Aug. 18 issue of the Journal of the American College of Cardiology.

“The underrecognition of these diseases underscores the importance of including monogenic diseases in the treating physician’s differential diagnosis,” say the authors, led by Jawan W. Abdulrahim, MD, Duke University, Durham, N.C.

Diagnosis of MCVDs can be important, the group wrote, because many, including familial transthyretin amyloidosis (TTR) and other disorders that pose an increased risk for sudden death, have evidence-based treatment modalities available or are clinically actionable. “Identification of patients with MCVD variants” is also “important for cascade screening of family members who are at risk of inheriting the pathogenic mutations.”

“We tend to ignore these monogenic diseases because they are so rare individually but, in aggregate, monogenic diseases are actually quite common,” senior author Svati H. Shah, MD, MHS, also of Duke University, said in an interview.

The results “support that the cardiology community over time adopt a genotype-forward approach,” one in which every patient presenting to a cardiovascular clinic is genotyped, she said.

One implication of such an approach, Dr. Shah agreed, is that “we would be able to pick these people up earlier in their disease, especially in the context of therapies that could improve certainly their progression, but even their survival.”

For now, she said, the study suggests that “these disorders are more frequent than perhaps all cardiologists are aware of, and we just need to keep our eyes open and know when to refer patients to a cardiovascular genetics clinic, which maybe has more time and can deal with all the nuances that go along with genetic testing.”

In the total cohort, 4.5% were found to carry a gene variant known or believed to cause such diseases. The most frequently represented conditions were familial TTR, hereditary hemochromatosis, heterozygous familial hypercholesterolemia, and various cardiomyopathies.

Of those patients, 52 received a clinical diagnosis of the monogenic disorder after an EHR review. Of the 290 without such a diagnosis, two-thirds showed no evidence in their EHR of the variant’s phenotypic signs. But the records of the other third featured at least some signs that the disease had manifested clinically.

“These data serve as a reminder that monogenic Mendelian disease, including heart and vascular disease, varies in penetrance from individual to individual and may not always present with clinically detectable phenotypes,” noted an editorial accompanying the report.

They also “provide a compelling basis for expanding the role of targeted genetic testing in patients with more traditional forms of heart and vascular disease,” wrote Scott M. Damrauer, MD, University of Pennsylvania, Philadelphia, and William S. Weintraub, MD, Medstar Washington Hospital Center and Georgetown University, Washington.

“Based on the current report, the number needed to screen in a complex cardiovascular patient population to detect 1 case of undiagnosed monogenic cardiovascular disease is 85,” they wrote. “This places targeted genetic testing well within what is considered to be efficacious for most screening programs and in the range of that of other common cardiovascular diseases and cancers.”

Among the 342 patients with a variant predicting a single MCVD – in addition to the 52 who received a diagnosis – 193 had records with no indication of phenotypic expression and so did not receive a diagnosis.

But the 97 patients without a diagnosis who nevertheless had documented signs of some phenotypic expression were deemed, on the basis of extent of expression, to represent a possibly, probably, or definitely missed diagnosis.

Familial TTR made up about 45% of such potentially missed diagnoses, the report noted.

Broader screening of patients with cardiovascular disease, Dr. Shah speculated, “might actually be not only a clinically useful endeavor, but – when we think about the aggregate burden of these monogenic disorders – potentially even cost-effective.”

As the price of genetic sequencing drops, she said, “I think we’ll start to see even more health systems wanting to incorporate the genotype-forward approach.”

Dr. Shah reports serving as primary investigator for research sponsored by Verily Life Sciences and AstraZeneca. Dr. Abdulrahim reports no relevant relationships. Disclosures for the other authors are in the report. Dr. Damrauer discloses receiving research support from RenalytixAI and consulting fees from Calico Labs. Dr. Weintraub had no relevant disclosures.

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

Monogenic disorders with heart and vascular effects are each pretty rare in clinical practice but collectively can make up a fair proportion of the patients cardiologists see. Still, the diagnosis is missed more often than not, even when the clinical signs are there, suggests an observational study, supporting broader genetic testing in cardiovascular patients.

In a cohort of more than 8,000 patients referred for cardiac catheterization, diagnosis of such a monogenic cardiovascular disease (MCVD) was made in only 35% of those with one related gene variant and signs of phenotypic expression in the electronic health record.

The findings are novel for measuring the field’s “burden of missed diagnoses” in patients with MCVD, which “represent a missed opportunity that could be addressed by genetic screening,” contended the study report, published in the Aug. 18 issue of the Journal of the American College of Cardiology.

“The underrecognition of these diseases underscores the importance of including monogenic diseases in the treating physician’s differential diagnosis,” say the authors, led by Jawan W. Abdulrahim, MD, Duke University, Durham, N.C.

Diagnosis of MCVDs can be important, the group wrote, because many, including familial transthyretin amyloidosis (TTR) and other disorders that pose an increased risk for sudden death, have evidence-based treatment modalities available or are clinically actionable. “Identification of patients with MCVD variants” is also “important for cascade screening of family members who are at risk of inheriting the pathogenic mutations.”

“We tend to ignore these monogenic diseases because they are so rare individually but, in aggregate, monogenic diseases are actually quite common,” senior author Svati H. Shah, MD, MHS, also of Duke University, said in an interview.

The results “support that the cardiology community over time adopt a genotype-forward approach,” one in which every patient presenting to a cardiovascular clinic is genotyped, she said.

One implication of such an approach, Dr. Shah agreed, is that “we would be able to pick these people up earlier in their disease, especially in the context of therapies that could improve certainly their progression, but even their survival.”

For now, she said, the study suggests that “these disorders are more frequent than perhaps all cardiologists are aware of, and we just need to keep our eyes open and know when to refer patients to a cardiovascular genetics clinic, which maybe has more time and can deal with all the nuances that go along with genetic testing.”

In the total cohort, 4.5% were found to carry a gene variant known or believed to cause such diseases. The most frequently represented conditions were familial TTR, hereditary hemochromatosis, heterozygous familial hypercholesterolemia, and various cardiomyopathies.

Of those patients, 52 received a clinical diagnosis of the monogenic disorder after an EHR review. Of the 290 without such a diagnosis, two-thirds showed no evidence in their EHR of the variant’s phenotypic signs. But the records of the other third featured at least some signs that the disease had manifested clinically.

“These data serve as a reminder that monogenic Mendelian disease, including heart and vascular disease, varies in penetrance from individual to individual and may not always present with clinically detectable phenotypes,” noted an editorial accompanying the report.

They also “provide a compelling basis for expanding the role of targeted genetic testing in patients with more traditional forms of heart and vascular disease,” wrote Scott M. Damrauer, MD, University of Pennsylvania, Philadelphia, and William S. Weintraub, MD, Medstar Washington Hospital Center and Georgetown University, Washington.

“Based on the current report, the number needed to screen in a complex cardiovascular patient population to detect 1 case of undiagnosed monogenic cardiovascular disease is 85,” they wrote. “This places targeted genetic testing well within what is considered to be efficacious for most screening programs and in the range of that of other common cardiovascular diseases and cancers.”

Among the 342 patients with a variant predicting a single MCVD – in addition to the 52 who received a diagnosis – 193 had records with no indication of phenotypic expression and so did not receive a diagnosis.

But the 97 patients without a diagnosis who nevertheless had documented signs of some phenotypic expression were deemed, on the basis of extent of expression, to represent a possibly, probably, or definitely missed diagnosis.

Familial TTR made up about 45% of such potentially missed diagnoses, the report noted.

Broader screening of patients with cardiovascular disease, Dr. Shah speculated, “might actually be not only a clinically useful endeavor, but – when we think about the aggregate burden of these monogenic disorders – potentially even cost-effective.”

As the price of genetic sequencing drops, she said, “I think we’ll start to see even more health systems wanting to incorporate the genotype-forward approach.”

Dr. Shah reports serving as primary investigator for research sponsored by Verily Life Sciences and AstraZeneca. Dr. Abdulrahim reports no relevant relationships. Disclosures for the other authors are in the report. Dr. Damrauer discloses receiving research support from RenalytixAI and consulting fees from Calico Labs. Dr. Weintraub had no relevant disclosures.

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

Monogenic disorders with heart and vascular effects are each pretty rare in clinical practice but collectively can make up a fair proportion of the patients cardiologists see. Still, the diagnosis is missed more often than not, even when the clinical signs are there, suggests an observational study, supporting broader genetic testing in cardiovascular patients.

In a cohort of more than 8,000 patients referred for cardiac catheterization, diagnosis of such a monogenic cardiovascular disease (MCVD) was made in only 35% of those with one related gene variant and signs of phenotypic expression in the electronic health record.

The findings are novel for measuring the field’s “burden of missed diagnoses” in patients with MCVD, which “represent a missed opportunity that could be addressed by genetic screening,” contended the study report, published in the Aug. 18 issue of the Journal of the American College of Cardiology.

“The underrecognition of these diseases underscores the importance of including monogenic diseases in the treating physician’s differential diagnosis,” say the authors, led by Jawan W. Abdulrahim, MD, Duke University, Durham, N.C.

Diagnosis of MCVDs can be important, the group wrote, because many, including familial transthyretin amyloidosis (TTR) and other disorders that pose an increased risk for sudden death, have evidence-based treatment modalities available or are clinically actionable. “Identification of patients with MCVD variants” is also “important for cascade screening of family members who are at risk of inheriting the pathogenic mutations.”

“We tend to ignore these monogenic diseases because they are so rare individually but, in aggregate, monogenic diseases are actually quite common,” senior author Svati H. Shah, MD, MHS, also of Duke University, said in an interview.

The results “support that the cardiology community over time adopt a genotype-forward approach,” one in which every patient presenting to a cardiovascular clinic is genotyped, she said.

One implication of such an approach, Dr. Shah agreed, is that “we would be able to pick these people up earlier in their disease, especially in the context of therapies that could improve certainly their progression, but even their survival.”

For now, she said, the study suggests that “these disorders are more frequent than perhaps all cardiologists are aware of, and we just need to keep our eyes open and know when to refer patients to a cardiovascular genetics clinic, which maybe has more time and can deal with all the nuances that go along with genetic testing.”

In the total cohort, 4.5% were found to carry a gene variant known or believed to cause such diseases. The most frequently represented conditions were familial TTR, hereditary hemochromatosis, heterozygous familial hypercholesterolemia, and various cardiomyopathies.

Of those patients, 52 received a clinical diagnosis of the monogenic disorder after an EHR review. Of the 290 without such a diagnosis, two-thirds showed no evidence in their EHR of the variant’s phenotypic signs. But the records of the other third featured at least some signs that the disease had manifested clinically.

“These data serve as a reminder that monogenic Mendelian disease, including heart and vascular disease, varies in penetrance from individual to individual and may not always present with clinically detectable phenotypes,” noted an editorial accompanying the report.

They also “provide a compelling basis for expanding the role of targeted genetic testing in patients with more traditional forms of heart and vascular disease,” wrote Scott M. Damrauer, MD, University of Pennsylvania, Philadelphia, and William S. Weintraub, MD, Medstar Washington Hospital Center and Georgetown University, Washington.

“Based on the current report, the number needed to screen in a complex cardiovascular patient population to detect 1 case of undiagnosed monogenic cardiovascular disease is 85,” they wrote. “This places targeted genetic testing well within what is considered to be efficacious for most screening programs and in the range of that of other common cardiovascular diseases and cancers.”

Among the 342 patients with a variant predicting a single MCVD – in addition to the 52 who received a diagnosis – 193 had records with no indication of phenotypic expression and so did not receive a diagnosis.

But the 97 patients without a diagnosis who nevertheless had documented signs of some phenotypic expression were deemed, on the basis of extent of expression, to represent a possibly, probably, or definitely missed diagnosis.

Familial TTR made up about 45% of such potentially missed diagnoses, the report noted.

Broader screening of patients with cardiovascular disease, Dr. Shah speculated, “might actually be not only a clinically useful endeavor, but – when we think about the aggregate burden of these monogenic disorders – potentially even cost-effective.”

As the price of genetic sequencing drops, she said, “I think we’ll start to see even more health systems wanting to incorporate the genotype-forward approach.”

Dr. Shah reports serving as primary investigator for research sponsored by Verily Life Sciences and AstraZeneca. Dr. Abdulrahim reports no relevant relationships. Disclosures for the other authors are in the report. Dr. Damrauer discloses receiving research support from RenalytixAI and consulting fees from Calico Labs. Dr. Weintraub had no relevant disclosures.

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

A group of experts representing various international professional societies has drafted a consensus statement on the determination of brain death or death by neurologic criteria (BD/DNC). The document, a result of the World Brain Death Project, surveys the clinical aspects of this determination, such as clinical testing, apnea testing, and the number of examinations required, as well as its social and legal aspects, including documentation, qualifications for making the determination, and religious attitudes toward BD/DNC.

The recommendations are the minimum criteria for BD/DNC, and countries and professional societies may choose to adopt stricter criteria, the authors noted. Seventeen supplements to the consensus statement contain detailed reports on topics the statement examines, including focuses on both adults and children.

“Perhaps the most important points of this project are, first, to show the worldwide acceptance of the concept of BD/DNC and what the minimum requirements are for BD/DNC,” said corresponding author Gene Sung, MD, MPH, director of the neurocritical care and stroke division at the University of Southern California, Los Angeles. Second, “this standard is centered around a clinical determination without the need for other testing.”

The consensus document and supplements were published online Aug. 3 in JAMA.

Comprehensive review

A lack of rigor has led to many differences in the determination of BD/DNC, said Dr. Sung. “Some of the variance that is common are the numbers of exams and examiners that are required and whether ancillary tests are required for determination of BD/DNC. In addition, a lot of guidelines and protocols that are in use are not thorough in detailing how to do the examinations and what to do in different circumstances.”

Professional societies such as the World Federation of Intensive and Critical Care recruited experts in BD/DNC to develop recommendations, which were based on relevant articles that they identified during a literature search. “We wanted to develop a fairly comprehensive document that, along with the 17 supplements, builds a foundation to show how to determine BD/DNC – what the minimum clinical criteria needed are and what to do in special circumstances,” Dr. Sung said.

Major sections of the statement include recommendations for the minimum clinical standards for the determination of BD/DNC in adults and children.

Determination must begin by establishing that the patient has sustained an irreversible brain injury that resulted in the loss of all brain function, according to the authors. Confounders such as pharmacologic paralysis and the effect of CNS depressant medications should be ruled out.

In addition, clinical evaluation must include an assessment for coma and an evaluation for brain stem areflexia. Among other criteria, the pupils should be fixed and nonresponsive to light, the face should not move in response to noxious cranial stimulation, and the gag and cough reflexes should be absent. Apnea testing is recommended to evaluate the responsiveness of respiratory centers in the medulla.

Although the definition of BD/DNC is the same in children as in adults, less evidence is available for the determination of BD/DNC in the very young. The authors thus advised a cautious approach to the evaluation of infants and younger children.

Recommendations vary by age and often require serial examinations, including apnea testing, they noted.

Ancillary testing

The consensus statement also reviews ancillary testing, which the authors recommend be required when the minimum clinical examination, including the apnea test, cannot be completed and when it is in the presence of confounding conditions that cannot be resolved.

The authors recommended digital subtraction angiography, radionuclide studies, and transcranial Doppler ultrasonography as ancillary tests based on blood flow in the brain. However, CT angiography and magnetic resonance angiography not be used.

A lack of guidance makes performing an apnea test in patients receiving extracorporeal membrane oxygenation (ECMO) challenging, according to the authors. Nevertheless, they recommended that the same principles of BD/DNC be applied to adults and children receiving ECMO.

They further recommended a period of preoxygenation before the apnea test, and the document describes in detail the method for administering this test to people receiving ECMO.

Another potentially challenging situation pointed out in the consensus document is the determination of BD/DNC in patients who have been treated with targeted temperature management. Therapeutic hypothermia, particularly if it is preceded or accompanied by sedation, can temporarily impair brain stem reflexes, thus mimicking BD/DNC.

The new document includes a flowchart and step-by-step recommendations as well as suggestions for determining BD/DNC under these circumstances.

Among document limitations acknowledged by the authors is the lack of high-quality data from randomized, controlled trials on which to base their recommendations.

In addition, economic, technological, or personnel limitations may reduce the available options for ancillary testing, they added. Also, the recommendations do not incorporate contributions from patients or social or religious groups, although the authors were mindful of their concerns.

To promote the national and international harmonization of BD/DNC criteria, “medical societies and countries can evaluate their own policies in relation to this document and fix any deficiencies,” Dr. Sung said.

“Many countries do not have any BD/DNC policies and can use the documents from this project to create their own. There may need to be discussions with legal, governmental, religious, and societal leaders to help understand and accept BD/DNC and to help enact policies in different communities,” he added.

Divergent definitions

The determination of death is not simply a scientific question, but also a philosophical, religious, and cultural question, wrote Robert D. Truog, MD, director of the Harvard Center for Bioethics, Boston, and colleagues in an accompanying editorial. Future research should consider cultural differences over these questions.

“Most important is that there be a clear and logical consistency between the definition of death and the tests that are used to diagnose it,” Dr. Truog said.

The concept of whole brain death was advanced as an equivalent to biological death, “such that, when the brain dies, the body literally disintegrates, just as it does after cardiac arrest,” but evidence indicates that this claim is untrue, Dr. Truog said. Current tests also do not diagnose the death of the whole brain.

Another hypothesis is that brain stem death represents the irreversible loss of consciousness and the capacity for spontaneous respiration.

“Instead of focusing on biology, [this definition] focuses on values and is based on the claim that when a person is in a state of irreversible apneic unconsciousness, we may consider them to be dead,” said Dr. Truog. He and his coeditorialists argued that the concept of whole brain death should be replaced with that of brain stem death.

“This report should be a call for our profession, as well as for federal and state lawmakers, to reform our laws so that they are consistent with our diagnostic criteria,” Dr. Truog said.

“The most straightforward way of doing this would be to change U.S. law and adopt the British standard of brain stem death, and then refine our testing to make the diagnosis of irreversible apneic unconsciousness as reliable and safe as possible,” he concluded.

The drafting of the consensus statement was not supported by outside funding. Dr. Sung reported no relevant financial relationships. Dr. Truog reported receiving compensation from Sanofi and Covance for participating in data and safety monitoring boards unrelated to the consensus document.

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

A group of experts representing various international professional societies has drafted a consensus statement on the determination of brain death or death by neurologic criteria (BD/DNC). The document, a result of the World Brain Death Project, surveys the clinical aspects of this determination, such as clinical testing, apnea testing, and the number of examinations required, as well as its social and legal aspects, including documentation, qualifications for making the determination, and religious attitudes toward BD/DNC.

The recommendations are the minimum criteria for BD/DNC, and countries and professional societies may choose to adopt stricter criteria, the authors noted. Seventeen supplements to the consensus statement contain detailed reports on topics the statement examines, including focuses on both adults and children.

“Perhaps the most important points of this project are, first, to show the worldwide acceptance of the concept of BD/DNC and what the minimum requirements are for BD/DNC,” said corresponding author Gene Sung, MD, MPH, director of the neurocritical care and stroke division at the University of Southern California, Los Angeles. Second, “this standard is centered around a clinical determination without the need for other testing.”

The consensus document and supplements were published online Aug. 3 in JAMA.

Comprehensive review

A lack of rigor has led to many differences in the determination of BD/DNC, said Dr. Sung. “Some of the variance that is common are the numbers of exams and examiners that are required and whether ancillary tests are required for determination of BD/DNC. In addition, a lot of guidelines and protocols that are in use are not thorough in detailing how to do the examinations and what to do in different circumstances.”

Professional societies such as the World Federation of Intensive and Critical Care recruited experts in BD/DNC to develop recommendations, which were based on relevant articles that they identified during a literature search. “We wanted to develop a fairly comprehensive document that, along with the 17 supplements, builds a foundation to show how to determine BD/DNC – what the minimum clinical criteria needed are and what to do in special circumstances,” Dr. Sung said.

Major sections of the statement include recommendations for the minimum clinical standards for the determination of BD/DNC in adults and children.

Determination must begin by establishing that the patient has sustained an irreversible brain injury that resulted in the loss of all brain function, according to the authors. Confounders such as pharmacologic paralysis and the effect of CNS depressant medications should be ruled out.

In addition, clinical evaluation must include an assessment for coma and an evaluation for brain stem areflexia. Among other criteria, the pupils should be fixed and nonresponsive to light, the face should not move in response to noxious cranial stimulation, and the gag and cough reflexes should be absent. Apnea testing is recommended to evaluate the responsiveness of respiratory centers in the medulla.

Although the definition of BD/DNC is the same in children as in adults, less evidence is available for the determination of BD/DNC in the very young. The authors thus advised a cautious approach to the evaluation of infants and younger children.

Recommendations vary by age and often require serial examinations, including apnea testing, they noted.

Ancillary testing

The consensus statement also reviews ancillary testing, which the authors recommend be required when the minimum clinical examination, including the apnea test, cannot be completed and when it is in the presence of confounding conditions that cannot be resolved.

The authors recommended digital subtraction angiography, radionuclide studies, and transcranial Doppler ultrasonography as ancillary tests based on blood flow in the brain. However, CT angiography and magnetic resonance angiography not be used.

A lack of guidance makes performing an apnea test in patients receiving extracorporeal membrane oxygenation (ECMO) challenging, according to the authors. Nevertheless, they recommended that the same principles of BD/DNC be applied to adults and children receiving ECMO.

They further recommended a period of preoxygenation before the apnea test, and the document describes in detail the method for administering this test to people receiving ECMO.

Another potentially challenging situation pointed out in the consensus document is the determination of BD/DNC in patients who have been treated with targeted temperature management. Therapeutic hypothermia, particularly if it is preceded or accompanied by sedation, can temporarily impair brain stem reflexes, thus mimicking BD/DNC.

The new document includes a flowchart and step-by-step recommendations as well as suggestions for determining BD/DNC under these circumstances.

Among document limitations acknowledged by the authors is the lack of high-quality data from randomized, controlled trials on which to base their recommendations.

In addition, economic, technological, or personnel limitations may reduce the available options for ancillary testing, they added. Also, the recommendations do not incorporate contributions from patients or social or religious groups, although the authors were mindful of their concerns.

To promote the national and international harmonization of BD/DNC criteria, “medical societies and countries can evaluate their own policies in relation to this document and fix any deficiencies,” Dr. Sung said.

“Many countries do not have any BD/DNC policies and can use the documents from this project to create their own. There may need to be discussions with legal, governmental, religious, and societal leaders to help understand and accept BD/DNC and to help enact policies in different communities,” he added.

Divergent definitions

The determination of death is not simply a scientific question, but also a philosophical, religious, and cultural question, wrote Robert D. Truog, MD, director of the Harvard Center for Bioethics, Boston, and colleagues in an accompanying editorial. Future research should consider cultural differences over these questions.

“Most important is that there be a clear and logical consistency between the definition of death and the tests that are used to diagnose it,” Dr. Truog said.

The concept of whole brain death was advanced as an equivalent to biological death, “such that, when the brain dies, the body literally disintegrates, just as it does after cardiac arrest,” but evidence indicates that this claim is untrue, Dr. Truog said. Current tests also do not diagnose the death of the whole brain.

Another hypothesis is that brain stem death represents the irreversible loss of consciousness and the capacity for spontaneous respiration.

“Instead of focusing on biology, [this definition] focuses on values and is based on the claim that when a person is in a state of irreversible apneic unconsciousness, we may consider them to be dead,” said Dr. Truog. He and his coeditorialists argued that the concept of whole brain death should be replaced with that of brain stem death.

“This report should be a call for our profession, as well as for federal and state lawmakers, to reform our laws so that they are consistent with our diagnostic criteria,” Dr. Truog said.

“The most straightforward way of doing this would be to change U.S. law and adopt the British standard of brain stem death, and then refine our testing to make the diagnosis of irreversible apneic unconsciousness as reliable and safe as possible,” he concluded.

The drafting of the consensus statement was not supported by outside funding. Dr. Sung reported no relevant financial relationships. Dr. Truog reported receiving compensation from Sanofi and Covance for participating in data and safety monitoring boards unrelated to the consensus document.

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

A group of experts representing various international professional societies has drafted a consensus statement on the determination of brain death or death by neurologic criteria (BD/DNC). The document, a result of the World Brain Death Project, surveys the clinical aspects of this determination, such as clinical testing, apnea testing, and the number of examinations required, as well as its social and legal aspects, including documentation, qualifications for making the determination, and religious attitudes toward BD/DNC.

The recommendations are the minimum criteria for BD/DNC, and countries and professional societies may choose to adopt stricter criteria, the authors noted. Seventeen supplements to the consensus statement contain detailed reports on topics the statement examines, including focuses on both adults and children.

“Perhaps the most important points of this project are, first, to show the worldwide acceptance of the concept of BD/DNC and what the minimum requirements are for BD/DNC,” said corresponding author Gene Sung, MD, MPH, director of the neurocritical care and stroke division at the University of Southern California, Los Angeles. Second, “this standard is centered around a clinical determination without the need for other testing.”

The consensus document and supplements were published online Aug. 3 in JAMA.

Comprehensive review

A lack of rigor has led to many differences in the determination of BD/DNC, said Dr. Sung. “Some of the variance that is common are the numbers of exams and examiners that are required and whether ancillary tests are required for determination of BD/DNC. In addition, a lot of guidelines and protocols that are in use are not thorough in detailing how to do the examinations and what to do in different circumstances.”

Professional societies such as the World Federation of Intensive and Critical Care recruited experts in BD/DNC to develop recommendations, which were based on relevant articles that they identified during a literature search. “We wanted to develop a fairly comprehensive document that, along with the 17 supplements, builds a foundation to show how to determine BD/DNC – what the minimum clinical criteria needed are and what to do in special circumstances,” Dr. Sung said.

Major sections of the statement include recommendations for the minimum clinical standards for the determination of BD/DNC in adults and children.

Determination must begin by establishing that the patient has sustained an irreversible brain injury that resulted in the loss of all brain function, according to the authors. Confounders such as pharmacologic paralysis and the effect of CNS depressant medications should be ruled out.

In addition, clinical evaluation must include an assessment for coma and an evaluation for brain stem areflexia. Among other criteria, the pupils should be fixed and nonresponsive to light, the face should not move in response to noxious cranial stimulation, and the gag and cough reflexes should be absent. Apnea testing is recommended to evaluate the responsiveness of respiratory centers in the medulla.

Although the definition of BD/DNC is the same in children as in adults, less evidence is available for the determination of BD/DNC in the very young. The authors thus advised a cautious approach to the evaluation of infants and younger children.

Recommendations vary by age and often require serial examinations, including apnea testing, they noted.

Ancillary testing

The consensus statement also reviews ancillary testing, which the authors recommend be required when the minimum clinical examination, including the apnea test, cannot be completed and when it is in the presence of confounding conditions that cannot be resolved.

The authors recommended digital subtraction angiography, radionuclide studies, and transcranial Doppler ultrasonography as ancillary tests based on blood flow in the brain. However, CT angiography and magnetic resonance angiography not be used.

A lack of guidance makes performing an apnea test in patients receiving extracorporeal membrane oxygenation (ECMO) challenging, according to the authors. Nevertheless, they recommended that the same principles of BD/DNC be applied to adults and children receiving ECMO.

They further recommended a period of preoxygenation before the apnea test, and the document describes in detail the method for administering this test to people receiving ECMO.

Another potentially challenging situation pointed out in the consensus document is the determination of BD/DNC in patients who have been treated with targeted temperature management. Therapeutic hypothermia, particularly if it is preceded or accompanied by sedation, can temporarily impair brain stem reflexes, thus mimicking BD/DNC.

The new document includes a flowchart and step-by-step recommendations as well as suggestions for determining BD/DNC under these circumstances.

Among document limitations acknowledged by the authors is the lack of high-quality data from randomized, controlled trials on which to base their recommendations.

In addition, economic, technological, or personnel limitations may reduce the available options for ancillary testing, they added. Also, the recommendations do not incorporate contributions from patients or social or religious groups, although the authors were mindful of their concerns.

To promote the national and international harmonization of BD/DNC criteria, “medical societies and countries can evaluate their own policies in relation to this document and fix any deficiencies,” Dr. Sung said.

“Many countries do not have any BD/DNC policies and can use the documents from this project to create their own. There may need to be discussions with legal, governmental, religious, and societal leaders to help understand and accept BD/DNC and to help enact policies in different communities,” he added.

Divergent definitions

The determination of death is not simply a scientific question, but also a philosophical, religious, and cultural question, wrote Robert D. Truog, MD, director of the Harvard Center for Bioethics, Boston, and colleagues in an accompanying editorial. Future research should consider cultural differences over these questions.

“Most important is that there be a clear and logical consistency between the definition of death and the tests that are used to diagnose it,” Dr. Truog said.

The concept of whole brain death was advanced as an equivalent to biological death, “such that, when the brain dies, the body literally disintegrates, just as it does after cardiac arrest,” but evidence indicates that this claim is untrue, Dr. Truog said. Current tests also do not diagnose the death of the whole brain.

Another hypothesis is that brain stem death represents the irreversible loss of consciousness and the capacity for spontaneous respiration.

“Instead of focusing on biology, [this definition] focuses on values and is based on the claim that when a person is in a state of irreversible apneic unconsciousness, we may consider them to be dead,” said Dr. Truog. He and his coeditorialists argued that the concept of whole brain death should be replaced with that of brain stem death.

“This report should be a call for our profession, as well as for federal and state lawmakers, to reform our laws so that they are consistent with our diagnostic criteria,” Dr. Truog said.

“The most straightforward way of doing this would be to change U.S. law and adopt the British standard of brain stem death, and then refine our testing to make the diagnosis of irreversible apneic unconsciousness as reliable and safe as possible,” he concluded.

The drafting of the consensus statement was not supported by outside funding. Dr. Sung reported no relevant financial relationships. Dr. Truog reported receiving compensation from Sanofi and Covance for participating in data and safety monitoring boards unrelated to the consensus document.

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

Resident wellness is a topic that has become increasingly important in recent years due to physician burnout. A prior Cutis Resident Corner column discussed the prevalence of physician burnout and how it can affect dermatologists.¹ When discussing resident burnout, dermatology may not be a specialty that immediately comes to mind, considering that dermatology is mostly outpatient based, with few emergencies and critically ill patients. In a JAMA study assessing levels of burnout by specialty, dermatology residents were the lowest at approximately 30%.² However, this still means that 3 out of every 10 dermatology residents feel burnt out.

Burnout in Dermatology

In 2017, results from a survey of 112 dermatology residents in Canada about burnout was published in the British Journal of Dermatology.³ The numbers were staggering; the results showed that more than 50% of dermatology residents experienced high levels of emotional exhaustion and depersonalization, and 40% had low levels of personal accomplishment. Additionally, 52% experienced low or depressed mood, 20% reported feelings of hurting themselves within the last year, and more than 25% had high anxiety levels.³

Dermatology requires a high level of daily studying, which is a major source of stress for many dermatology residents. The survey of dermatology residents in Canada showed that the top stressor for 61% of survey respondents was studying, specifically for the board examination.³ Dermatology is an academically rigorous specialty. We are responsible for recognizing every disease process affecting the skin, including hundreds that are extremely uncommon. We must understand these disease processes at a molecular level from a basic science standpoint and at a microscopic level through our knowledge of dermatopathology. Much of what we see in clinic are bread-and-butter dermatologic conditions that do not necessarily correlate with the rare diseases that we study. This differs from other specialties in which residents learn much of their specialty knowledge through their clinical work.

Current Challenges

We are training in a uniquely challenging time, providing care for our patients amid the coronavirus disease 2019 pandemic. Many of us are dealing with constant levels of stress and worry about the health and safety of ourselves, along with our friends, families, and patients. Some residents have been redeployed to work in unfamiliar roles in the emergency department or hospital wards, while others adjust to new roles in teledermatology. I also cannot talk about resident wellness without recognizing the challenges faced by physicians who are racial and religious minorities. This is especially true for black physicians, as they face unconscious biases and microaggressions daily derived from implicit racism; this leads to discrimination in every area of life and ultimately harms their emotional and psychological well-being.⁴ Additionally, black physicians are underrepresented in dermatology, making up only 4.3% of dermatology residents in the 2013-2014 academic year.^5,6 Underrepresentation can serve as a major stressor for racial and religious minorities and should be considered when addressing resident wellness to ensure their voices are heard and validated.

Focusing on Wellness

What can we do to improve wellness? A viewpoint published in JAMA Surgery in 2015 by Salles et al⁷ from the Stanford University Department of Surgery (Stanford, California) discussed their Balance in Life (BIL) program, which was established after one of their residency graduates tragically died by suicide shortly after graduating from residency. The BIL program addresses 4 different facets of well-being—professional, physical, psychological, and social—and lists the specific actions taken to improve these areas of well-being.⁷

I completed my transitional year residency at St. Vincent Hospital (Indianapolis, Indiana). The program emphasizes the importance of resident wellness. They established a department-sponsored well-being program to improve resident wellness,⁸ with its objectives aligning with the 4 areas of well-being that were outlined in the Stanford viewpoint.⁷ A short Q&A with me was published in the supplemental material as a way of highlighting their residents.⁹ I will outline the 4 areas of well-being, with suggestions based on the Stanford BIL program, the well-being innovation program at St. Vincent, and initiatives at my current dermatology residency program at the University of Wisconsin (UW) in Madison.

The 4 Areas of Well-being

Professional Well-being

Stanford BIL Program
One of the changes implemented was starting a resident mentorship program. Each junior resident selects a senior resident as a mentor with department-sponsored quarterly lunch meetings.⁷ Another initiative is a leadership training program, which includes an outdoor rope course each year focusing on leadership and team building.⁷

UW Dermatology
Monthly meetings are held with our program director and coordinator so that we can address any concerns or issues as they arise and brainstorm solutions together. During the coronavirus disease 2019 pandemic, we had weekly resident town halls with department leadership with transparency about our institution’s current status.

Physical Well-being

Stanford BIL Program
One method of improving physical well-being included stocking healthy snacks for residents and providing incoming residents with a guide of physicians, dentists, and fitness venues to promote regular health care. We have adopted the same at UW with healthy snacks available in our resident workroom.

St. Vincent Internal Medicine Wellness
There are monthly fitness challenges for a variety of physical wellness activities such as sleep, mindfulness minutes, nutrition, and step challenges.⁸

UW Dermatology
In addition to healthy snacks in our workroom, we also have various discounted fitness classes available for employees, along with discounts on gym memberships, kayak rentals, and city bike-share programs.

Psychological Well-Being

Stanford BIL Program
They enlisted a clinical psychologist available for residents to talk to regularly about any issues they face and to help manage stress in their lives.⁷

St. Vincent Internal Medicine Wellness
Faculty and coordinators provide S.A.F.E.—secure, affirming, friendly, and empathetic—zones to provide confidential and judgment-free support for residents.⁸ They also host photography competitions; residents submit photographs of nature, and the winning photographs are printed and displayed throughout the work area.

UW Dermatology
We have made changes to beautify our resident workroom with photograph collages of residents and other assorted décor to make it a more work-friendly space.

Social Well-being

Common themes highlighted by all 3 programs include the importance of socializing outside of the workplace, team-building activities, and resident retreats. Social media accounts on Instagram at St. Vincent (@stvimresidency) and at UW (@uwderm) highlight resident accomplishments and promote interconnectedness when residents are not together in clinics or hospitals.

Final Thoughts

Resident wellness will continue to be an important topic for discussion in the future, especially given the uncertain times right now during our training. Focusing on the 4 areas of well-being can help to prevent burnout and improve resident wellness.

Resident wellness is a topic that has become increasingly important in recent years due to physician burnout. A prior Cutis Resident Corner column discussed the prevalence of physician burnout and how it can affect dermatologists.¹ When discussing resident burnout, dermatology may not be a specialty that immediately comes to mind, considering that dermatology is mostly outpatient based, with few emergencies and critically ill patients. In a JAMA study assessing levels of burnout by specialty, dermatology residents were the lowest at approximately 30%.² However, this still means that 3 out of every 10 dermatology residents feel burnt out.

Burnout in Dermatology

In 2017, results from a survey of 112 dermatology residents in Canada about burnout was published in the British Journal of Dermatology.³ The numbers were staggering; the results showed that more than 50% of dermatology residents experienced high levels of emotional exhaustion and depersonalization, and 40% had low levels of personal accomplishment. Additionally, 52% experienced low or depressed mood, 20% reported feelings of hurting themselves within the last year, and more than 25% had high anxiety levels.³

Dermatology requires a high level of daily studying, which is a major source of stress for many dermatology residents. The survey of dermatology residents in Canada showed that the top stressor for 61% of survey respondents was studying, specifically for the board examination.³ Dermatology is an academically rigorous specialty. We are responsible for recognizing every disease process affecting the skin, including hundreds that are extremely uncommon. We must understand these disease processes at a molecular level from a basic science standpoint and at a microscopic level through our knowledge of dermatopathology. Much of what we see in clinic are bread-and-butter dermatologic conditions that do not necessarily correlate with the rare diseases that we study. This differs from other specialties in which residents learn much of their specialty knowledge through their clinical work.

Current Challenges

We are training in a uniquely challenging time, providing care for our patients amid the coronavirus disease 2019 pandemic. Many of us are dealing with constant levels of stress and worry about the health and safety of ourselves, along with our friends, families, and patients. Some residents have been redeployed to work in unfamiliar roles in the emergency department or hospital wards, while others adjust to new roles in teledermatology. I also cannot talk about resident wellness without recognizing the challenges faced by physicians who are racial and religious minorities. This is especially true for black physicians, as they face unconscious biases and microaggressions daily derived from implicit racism; this leads to discrimination in every area of life and ultimately harms their emotional and psychological well-being.⁴ Additionally, black physicians are underrepresented in dermatology, making up only 4.3% of dermatology residents in the 2013-2014 academic year.^5,6 Underrepresentation can serve as a major stressor for racial and religious minorities and should be considered when addressing resident wellness to ensure their voices are heard and validated.

Focusing on Wellness

What can we do to improve wellness? A viewpoint published in JAMA Surgery in 2015 by Salles et al⁷ from the Stanford University Department of Surgery (Stanford, California) discussed their Balance in Life (BIL) program, which was established after one of their residency graduates tragically died by suicide shortly after graduating from residency. The BIL program addresses 4 different facets of well-being—professional, physical, psychological, and social—and lists the specific actions taken to improve these areas of well-being.⁷

I completed my transitional year residency at St. Vincent Hospital (Indianapolis, Indiana). The program emphasizes the importance of resident wellness. They established a department-sponsored well-being program to improve resident wellness,⁸ with its objectives aligning with the 4 areas of well-being that were outlined in the Stanford viewpoint.⁷ A short Q&A with me was published in the supplemental material as a way of highlighting their residents.⁹ I will outline the 4 areas of well-being, with suggestions based on the Stanford BIL program, the well-being innovation program at St. Vincent, and initiatives at my current dermatology residency program at the University of Wisconsin (UW) in Madison.

The 4 Areas of Well-being

Professional Well-being

Stanford BIL Program
One of the changes implemented was starting a resident mentorship program. Each junior resident selects a senior resident as a mentor with department-sponsored quarterly lunch meetings.⁷ Another initiative is a leadership training program, which includes an outdoor rope course each year focusing on leadership and team building.⁷

UW Dermatology
Monthly meetings are held with our program director and coordinator so that we can address any concerns or issues as they arise and brainstorm solutions together. During the coronavirus disease 2019 pandemic, we had weekly resident town halls with department leadership with transparency about our institution’s current status.

Physical Well-being

Stanford BIL Program
One method of improving physical well-being included stocking healthy snacks for residents and providing incoming residents with a guide of physicians, dentists, and fitness venues to promote regular health care. We have adopted the same at UW with healthy snacks available in our resident workroom.

St. Vincent Internal Medicine Wellness
There are monthly fitness challenges for a variety of physical wellness activities such as sleep, mindfulness minutes, nutrition, and step challenges.⁸

UW Dermatology
In addition to healthy snacks in our workroom, we also have various discounted fitness classes available for employees, along with discounts on gym memberships, kayak rentals, and city bike-share programs.

Psychological Well-Being

Stanford BIL Program
They enlisted a clinical psychologist available for residents to talk to regularly about any issues they face and to help manage stress in their lives.⁷

St. Vincent Internal Medicine Wellness
Faculty and coordinators provide S.A.F.E.—secure, affirming, friendly, and empathetic—zones to provide confidential and judgment-free support for residents.⁸ They also host photography competitions; residents submit photographs of nature, and the winning photographs are printed and displayed throughout the work area.

UW Dermatology
We have made changes to beautify our resident workroom with photograph collages of residents and other assorted décor to make it a more work-friendly space.

Social Well-being

Common themes highlighted by all 3 programs include the importance of socializing outside of the workplace, team-building activities, and resident retreats. Social media accounts on Instagram at St. Vincent (@stvimresidency) and at UW (@uwderm) highlight resident accomplishments and promote interconnectedness when residents are not together in clinics or hospitals.

Final Thoughts

Resident wellness will continue to be an important topic for discussion in the future, especially given the uncertain times right now during our training. Focusing on the 4 areas of well-being can help to prevent burnout and improve resident wellness.

Resident wellness is a topic that has become increasingly important in recent years due to physician burnout. A prior Cutis Resident Corner column discussed the prevalence of physician burnout and how it can affect dermatologists.¹ When discussing resident burnout, dermatology may not be a specialty that immediately comes to mind, considering that dermatology is mostly outpatient based, with few emergencies and critically ill patients. In a JAMA study assessing levels of burnout by specialty, dermatology residents were the lowest at approximately 30%.² However, this still means that 3 out of every 10 dermatology residents feel burnt out.

Burnout in Dermatology

In 2017, results from a survey of 112 dermatology residents in Canada about burnout was published in the British Journal of Dermatology.³ The numbers were staggering; the results showed that more than 50% of dermatology residents experienced high levels of emotional exhaustion and depersonalization, and 40% had low levels of personal accomplishment. Additionally, 52% experienced low or depressed mood, 20% reported feelings of hurting themselves within the last year, and more than 25% had high anxiety levels.³

Dermatology requires a high level of daily studying, which is a major source of stress for many dermatology residents. The survey of dermatology residents in Canada showed that the top stressor for 61% of survey respondents was studying, specifically for the board examination.³ Dermatology is an academically rigorous specialty. We are responsible for recognizing every disease process affecting the skin, including hundreds that are extremely uncommon. We must understand these disease processes at a molecular level from a basic science standpoint and at a microscopic level through our knowledge of dermatopathology. Much of what we see in clinic are bread-and-butter dermatologic conditions that do not necessarily correlate with the rare diseases that we study. This differs from other specialties in which residents learn much of their specialty knowledge through their clinical work.

Current Challenges

We are training in a uniquely challenging time, providing care for our patients amid the coronavirus disease 2019 pandemic. Many of us are dealing with constant levels of stress and worry about the health and safety of ourselves, along with our friends, families, and patients. Some residents have been redeployed to work in unfamiliar roles in the emergency department or hospital wards, while others adjust to new roles in teledermatology. I also cannot talk about resident wellness without recognizing the challenges faced by physicians who are racial and religious minorities. This is especially true for black physicians, as they face unconscious biases and microaggressions daily derived from implicit racism; this leads to discrimination in every area of life and ultimately harms their emotional and psychological well-being.⁴ Additionally, black physicians are underrepresented in dermatology, making up only 4.3% of dermatology residents in the 2013-2014 academic year.^5,6 Underrepresentation can serve as a major stressor for racial and religious minorities and should be considered when addressing resident wellness to ensure their voices are heard and validated.

Focusing on Wellness

What can we do to improve wellness? A viewpoint published in JAMA Surgery in 2015 by Salles et al⁷ from the Stanford University Department of Surgery (Stanford, California) discussed their Balance in Life (BIL) program, which was established after one of their residency graduates tragically died by suicide shortly after graduating from residency. The BIL program addresses 4 different facets of well-being—professional, physical, psychological, and social—and lists the specific actions taken to improve these areas of well-being.⁷

I completed my transitional year residency at St. Vincent Hospital (Indianapolis, Indiana). The program emphasizes the importance of resident wellness. They established a department-sponsored well-being program to improve resident wellness,⁸ with its objectives aligning with the 4 areas of well-being that were outlined in the Stanford viewpoint.⁷ A short Q&A with me was published in the supplemental material as a way of highlighting their residents.⁹ I will outline the 4 areas of well-being, with suggestions based on the Stanford BIL program, the well-being innovation program at St. Vincent, and initiatives at my current dermatology residency program at the University of Wisconsin (UW) in Madison.

The 4 Areas of Well-being

Professional Well-being

Stanford BIL Program
One of the changes implemented was starting a resident mentorship program. Each junior resident selects a senior resident as a mentor with department-sponsored quarterly lunch meetings.⁷ Another initiative is a leadership training program, which includes an outdoor rope course each year focusing on leadership and team building.⁷

UW Dermatology
Monthly meetings are held with our program director and coordinator so that we can address any concerns or issues as they arise and brainstorm solutions together. During the coronavirus disease 2019 pandemic, we had weekly resident town halls with department leadership with transparency about our institution’s current status.

Physical Well-being

Stanford BIL Program
One method of improving physical well-being included stocking healthy snacks for residents and providing incoming residents with a guide of physicians, dentists, and fitness venues to promote regular health care. We have adopted the same at UW with healthy snacks available in our resident workroom.

St. Vincent Internal Medicine Wellness
There are monthly fitness challenges for a variety of physical wellness activities such as sleep, mindfulness minutes, nutrition, and step challenges.⁸

UW Dermatology
In addition to healthy snacks in our workroom, we also have various discounted fitness classes available for employees, along with discounts on gym memberships, kayak rentals, and city bike-share programs.

Psychological Well-Being

Stanford BIL Program
They enlisted a clinical psychologist available for residents to talk to regularly about any issues they face and to help manage stress in their lives.⁷

St. Vincent Internal Medicine Wellness
Faculty and coordinators provide S.A.F.E.—secure, affirming, friendly, and empathetic—zones to provide confidential and judgment-free support for residents.⁸ They also host photography competitions; residents submit photographs of nature, and the winning photographs are printed and displayed throughout the work area.

UW Dermatology
We have made changes to beautify our resident workroom with photograph collages of residents and other assorted décor to make it a more work-friendly space.

Social Well-being

Common themes highlighted by all 3 programs include the importance of socializing outside of the workplace, team-building activities, and resident retreats. Social media accounts on Instagram at St. Vincent (@stvimresidency) and at UW (@uwderm) highlight resident accomplishments and promote interconnectedness when residents are not together in clinics or hospitals.

Final Thoughts

Resident wellness will continue to be an important topic for discussion in the future, especially given the uncertain times right now during our training. Focusing on the 4 areas of well-being can help to prevent burnout and improve resident wellness.

Patients with sarcoidosis have an increased risk of heart failure and other adverse outcomes, including all-cause mortality, according to a decade-long nationwide study of Danish patients with the inflammatory disease.

“Although these findings are suggestive of the need for regular monitoring of cardiac manifestations in patients with sarcoidosis, it is important to emphasize that no causal relationships can be established from an observational study. Further studies are therefore needed to confirm our findings,” said first author Adelina Yafasova, MB, of Copenhagen University Hospital in Denmark, in an interview. The study was published in the Journal of the American College of Cardiology.

To determine the long-term risk of cardiac outcomes, and beyond – including incident heart failure; a composite of implantable cardioverter-defibrillator (ICD) implantation, ventricular arrhythmias or cardiac arrest; and all-cause mortality – Dr. Yafasova and her colleagues analyzed data from all Danish residents 18 years or older who were diagnosed with sarcoidosis from 1996 to 2016. Patients with any history of cardiac events were excluded. Of the 12,883 diagnosed patients, 11,834 were matched with subjects from a nationwide background population of more than 47,000 based on age, sex, and comorbidity. The median age of both populations was 42.8 (33.1-55.8) and 54.3% were men.

Median follow-up was 8.2 years for the sarcoidosis population and 8.4 years for the background population. The absolute 10-year risk of heart failure was 3.18% (95% confidence interval, 2.83%-3.57%) for sarcoidosis patients and 1.72% (95% CI, 1.58%-1.86%) for their matched controls. The 10-year risk for the composite of ICD implantation, ventricular arrhythmias and cardiac arrest was 0.96% (95% CI, 0.77%-1.18%) for sarcoidosis patients and 0.45% (95% CI, 0.38%-0.53%) for the background population.

For all-cause mortality, the 10-year risk was 10.88% (95% CI, 10.23%-11.55%) for sarcoidosis patients and 7.43% (95% CI, 7.15%-7.72%) for the background population. In a secondary analysis that compared all-cause mortality between the 364 sarcoidosis patients who developed heart failure and the 1,456 patients with heart failure without a history of sarcoidosis, the sarcoidosis group had a 35% higher rate than the nonsarcoidosis group (adjusted hazard ratio 1.35; 95% CI, 1.10-1.64).

“It’s not necessarily surprising that sarcoidosis patients would have a higher rate of heart failure,” said Melissa A. Lyle, MD, of the Mayo Clinic in Jacksonville, Fla., in an interview. “But the key takeaway is that sarcoidosis was associated with a higher rate of all-cause mortality compared to patients with heart failure and no sarcoidosis. That was more of a surprise.”

“There’s been some discrepancy in previous studies describing the cardiovascular outcomes in sarcoidosis,” Dr. Lyle added, “so I think this study provides excellent information while also highlighting the need for additional large-scale studies. We need to have further data on cardiovascular outcomes, which will allow us to refine the consensus statements and guidelines for management and the diagnosis of cardiac sarcoidosis.”

Dr. Lyle and Leslie T. Cooper Jr., MD, also of the Mayo Clinic, extrapolated on those thoughts in an editorial that accompanied the study. In it, the two authors praised the size and lengthy follow-up of the study, while noting its limitations. Specifically, they stressed that the study’s Danish population “may not be representative of other general populations” because of notable differences in ethnicity, age, and comorbidities.

That said, they reinforced that the study did feature “important takeaways” and that its findings emphasize the “need for monitoring for cardiac manifestations in patients with systemic sarcoidosis.”

In addition to the limitations noted in the editorial, the study’s authors acknowledged that the observational nature limited its “assessment of cause-effect relationships” and that the diagnosis codes for sarcoidosis had not been validated in the Danish National Patient Registry.

The authors of both the study and the editorial reported no conflicts of interest.

SOURCE: Yafasova A et al. J Am Coll Cardiol. 2020 Aug 10. doi: 10.1016/j.jacc.2020.06.038.

Patients with sarcoidosis have an increased risk of heart failure and other adverse outcomes, including all-cause mortality, according to a decade-long nationwide study of Danish patients with the inflammatory disease.

“Although these findings are suggestive of the need for regular monitoring of cardiac manifestations in patients with sarcoidosis, it is important to emphasize that no causal relationships can be established from an observational study. Further studies are therefore needed to confirm our findings,” said first author Adelina Yafasova, MB, of Copenhagen University Hospital in Denmark, in an interview. The study was published in the Journal of the American College of Cardiology.

To determine the long-term risk of cardiac outcomes, and beyond – including incident heart failure; a composite of implantable cardioverter-defibrillator (ICD) implantation, ventricular arrhythmias or cardiac arrest; and all-cause mortality – Dr. Yafasova and her colleagues analyzed data from all Danish residents 18 years or older who were diagnosed with sarcoidosis from 1996 to 2016. Patients with any history of cardiac events were excluded. Of the 12,883 diagnosed patients, 11,834 were matched with subjects from a nationwide background population of more than 47,000 based on age, sex, and comorbidity. The median age of both populations was 42.8 (33.1-55.8) and 54.3% were men.

Median follow-up was 8.2 years for the sarcoidosis population and 8.4 years for the background population. The absolute 10-year risk of heart failure was 3.18% (95% confidence interval, 2.83%-3.57%) for sarcoidosis patients and 1.72% (95% CI, 1.58%-1.86%) for their matched controls. The 10-year risk for the composite of ICD implantation, ventricular arrhythmias and cardiac arrest was 0.96% (95% CI, 0.77%-1.18%) for sarcoidosis patients and 0.45% (95% CI, 0.38%-0.53%) for the background population.

For all-cause mortality, the 10-year risk was 10.88% (95% CI, 10.23%-11.55%) for sarcoidosis patients and 7.43% (95% CI, 7.15%-7.72%) for the background population. In a secondary analysis that compared all-cause mortality between the 364 sarcoidosis patients who developed heart failure and the 1,456 patients with heart failure without a history of sarcoidosis, the sarcoidosis group had a 35% higher rate than the nonsarcoidosis group (adjusted hazard ratio 1.35; 95% CI, 1.10-1.64).

“It’s not necessarily surprising that sarcoidosis patients would have a higher rate of heart failure,” said Melissa A. Lyle, MD, of the Mayo Clinic in Jacksonville, Fla., in an interview. “But the key takeaway is that sarcoidosis was associated with a higher rate of all-cause mortality compared to patients with heart failure and no sarcoidosis. That was more of a surprise.”

“There’s been some discrepancy in previous studies describing the cardiovascular outcomes in sarcoidosis,” Dr. Lyle added, “so I think this study provides excellent information while also highlighting the need for additional large-scale studies. We need to have further data on cardiovascular outcomes, which will allow us to refine the consensus statements and guidelines for management and the diagnosis of cardiac sarcoidosis.”

Dr. Lyle and Leslie T. Cooper Jr., MD, also of the Mayo Clinic, extrapolated on those thoughts in an editorial that accompanied the study. In it, the two authors praised the size and lengthy follow-up of the study, while noting its limitations. Specifically, they stressed that the study’s Danish population “may not be representative of other general populations” because of notable differences in ethnicity, age, and comorbidities.

That said, they reinforced that the study did feature “important takeaways” and that its findings emphasize the “need for monitoring for cardiac manifestations in patients with systemic sarcoidosis.”

In addition to the limitations noted in the editorial, the study’s authors acknowledged that the observational nature limited its “assessment of cause-effect relationships” and that the diagnosis codes for sarcoidosis had not been validated in the Danish National Patient Registry.

The authors of both the study and the editorial reported no conflicts of interest.

SOURCE: Yafasova A et al. J Am Coll Cardiol. 2020 Aug 10. doi: 10.1016/j.jacc.2020.06.038.

Patients with sarcoidosis have an increased risk of heart failure and other adverse outcomes, including all-cause mortality, according to a decade-long nationwide study of Danish patients with the inflammatory disease.

“Although these findings are suggestive of the need for regular monitoring of cardiac manifestations in patients with sarcoidosis, it is important to emphasize that no causal relationships can be established from an observational study. Further studies are therefore needed to confirm our findings,” said first author Adelina Yafasova, MB, of Copenhagen University Hospital in Denmark, in an interview. The study was published in the Journal of the American College of Cardiology.

To determine the long-term risk of cardiac outcomes, and beyond – including incident heart failure; a composite of implantable cardioverter-defibrillator (ICD) implantation, ventricular arrhythmias or cardiac arrest; and all-cause mortality – Dr. Yafasova and her colleagues analyzed data from all Danish residents 18 years or older who were diagnosed with sarcoidosis from 1996 to 2016. Patients with any history of cardiac events were excluded. Of the 12,883 diagnosed patients, 11,834 were matched with subjects from a nationwide background population of more than 47,000 based on age, sex, and comorbidity. The median age of both populations was 42.8 (33.1-55.8) and 54.3% were men.

Median follow-up was 8.2 years for the sarcoidosis population and 8.4 years for the background population. The absolute 10-year risk of heart failure was 3.18% (95% confidence interval, 2.83%-3.57%) for sarcoidosis patients and 1.72% (95% CI, 1.58%-1.86%) for their matched controls. The 10-year risk for the composite of ICD implantation, ventricular arrhythmias and cardiac arrest was 0.96% (95% CI, 0.77%-1.18%) for sarcoidosis patients and 0.45% (95% CI, 0.38%-0.53%) for the background population.

For all-cause mortality, the 10-year risk was 10.88% (95% CI, 10.23%-11.55%) for sarcoidosis patients and 7.43% (95% CI, 7.15%-7.72%) for the background population. In a secondary analysis that compared all-cause mortality between the 364 sarcoidosis patients who developed heart failure and the 1,456 patients with heart failure without a history of sarcoidosis, the sarcoidosis group had a 35% higher rate than the nonsarcoidosis group (adjusted hazard ratio 1.35; 95% CI, 1.10-1.64).

“It’s not necessarily surprising that sarcoidosis patients would have a higher rate of heart failure,” said Melissa A. Lyle, MD, of the Mayo Clinic in Jacksonville, Fla., in an interview. “But the key takeaway is that sarcoidosis was associated with a higher rate of all-cause mortality compared to patients with heart failure and no sarcoidosis. That was more of a surprise.”

“There’s been some discrepancy in previous studies describing the cardiovascular outcomes in sarcoidosis,” Dr. Lyle added, “so I think this study provides excellent information while also highlighting the need for additional large-scale studies. We need to have further data on cardiovascular outcomes, which will allow us to refine the consensus statements and guidelines for management and the diagnosis of cardiac sarcoidosis.”

Dr. Lyle and Leslie T. Cooper Jr., MD, also of the Mayo Clinic, extrapolated on those thoughts in an editorial that accompanied the study. In it, the two authors praised the size and lengthy follow-up of the study, while noting its limitations. Specifically, they stressed that the study’s Danish population “may not be representative of other general populations” because of notable differences in ethnicity, age, and comorbidities.

That said, they reinforced that the study did feature “important takeaways” and that its findings emphasize the “need for monitoring for cardiac manifestations in patients with systemic sarcoidosis.”

In addition to the limitations noted in the editorial, the study’s authors acknowledged that the observational nature limited its “assessment of cause-effect relationships” and that the diagnosis codes for sarcoidosis had not been validated in the Danish National Patient Registry.

The authors of both the study and the editorial reported no conflicts of interest.

SOURCE: Yafasova A et al. J Am Coll Cardiol. 2020 Aug 10. doi: 10.1016/j.jacc.2020.06.038.

The BALL score was able to identify a subset of patients with chronic lymphocytic leukemia (CLL) who particularly benefit from single-agent ibrutinib therapy, according to the results of a study of 111 patients followed from two different institutions.

The BALL model consists of four factors: serum beta₂-microglobulin at 5 mg/dL or greater, hemoglobin < 110 g/L for women or < 120 g/L for men, lactate dehydrogenase [LDH] > upper limit of normal [UNL], and time elapsed from last therapy less than 24 months. Each parameter was alloted 1 point, leading to a stratification of patients into three different prognostic groups: low risk (score 0-1), intermediate risk (2-3), and high risk (score 4), according to a report published online in Leukemia Research.

According to Stefano Molica, MD, of the Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy, and his colleagues, the majority of patients (82%) were clinical Rai stage II-IV. The median patient age was 63 years and nearly 68% were men.

The researchers assessed four models for predicting overall survival. The modified version of CLL-International Prognostic Index (CLL-IPI) failed to provide prognostic information in relapsed/refractory (R/R) CLL (P = .77) as did the Ahn et al. model (P = .95) and a simplified BALL model (P = .09). In contrast, the full BALL score captured two groups of patients with significant differences in survival (hazard ratio, 0.240; 95 % confidence interval, 0.10-0.54; P = .0005); however, because of the low number of patients in the high-risk category, these cases were combined with the intermediate-risk group.

The BALL score identified a subset of patients, accounting for about 50% of the whole population, who particularly benefit from single-agent ibrutinib, according to Dr. Molica and his colleagues. These patients had a survival rate of 85% at 3 years.

“In contrast, the outcome of subjects with intermediate-high risk is disappointing. These patients should be considered for a combination of targeted drugs or cellular-based therapies,” the researchers concluded.

The authors reported that they had no conflicts.

[email protected]

SOURCE: Molica S et al. Leuk Res. 2020 Jun 10. https://doi.org/10.1016/j.leukres.2020.

The BALL score was able to identify a subset of patients with chronic lymphocytic leukemia (CLL) who particularly benefit from single-agent ibrutinib therapy, according to the results of a study of 111 patients followed from two different institutions.

The BALL model consists of four factors: serum beta₂-microglobulin at 5 mg/dL or greater, hemoglobin < 110 g/L for women or < 120 g/L for men, lactate dehydrogenase [LDH] > upper limit of normal [UNL], and time elapsed from last therapy less than 24 months. Each parameter was alloted 1 point, leading to a stratification of patients into three different prognostic groups: low risk (score 0-1), intermediate risk (2-3), and high risk (score 4), according to a report published online in Leukemia Research.

According to Stefano Molica, MD, of the Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy, and his colleagues, the majority of patients (82%) were clinical Rai stage II-IV. The median patient age was 63 years and nearly 68% were men.

The researchers assessed four models for predicting overall survival. The modified version of CLL-International Prognostic Index (CLL-IPI) failed to provide prognostic information in relapsed/refractory (R/R) CLL (P = .77) as did the Ahn et al. model (P = .95) and a simplified BALL model (P = .09). In contrast, the full BALL score captured two groups of patients with significant differences in survival (hazard ratio, 0.240; 95 % confidence interval, 0.10-0.54; P = .0005); however, because of the low number of patients in the high-risk category, these cases were combined with the intermediate-risk group.

The BALL score identified a subset of patients, accounting for about 50% of the whole population, who particularly benefit from single-agent ibrutinib, according to Dr. Molica and his colleagues. These patients had a survival rate of 85% at 3 years.

“In contrast, the outcome of subjects with intermediate-high risk is disappointing. These patients should be considered for a combination of targeted drugs or cellular-based therapies,” the researchers concluded.

The authors reported that they had no conflicts.

[email protected]

SOURCE: Molica S et al. Leuk Res. 2020 Jun 10. https://doi.org/10.1016/j.leukres.2020.

The BALL score was able to identify a subset of patients with chronic lymphocytic leukemia (CLL) who particularly benefit from single-agent ibrutinib therapy, according to the results of a study of 111 patients followed from two different institutions.

The BALL model consists of four factors: serum beta₂-microglobulin at 5 mg/dL or greater, hemoglobin < 110 g/L for women or < 120 g/L for men, lactate dehydrogenase [LDH] > upper limit of normal [UNL], and time elapsed from last therapy less than 24 months. Each parameter was alloted 1 point, leading to a stratification of patients into three different prognostic groups: low risk (score 0-1), intermediate risk (2-3), and high risk (score 4), according to a report published online in Leukemia Research.

According to Stefano Molica, MD, of the Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy, and his colleagues, the majority of patients (82%) were clinical Rai stage II-IV. The median patient age was 63 years and nearly 68% were men.

The researchers assessed four models for predicting overall survival. The modified version of CLL-International Prognostic Index (CLL-IPI) failed to provide prognostic information in relapsed/refractory (R/R) CLL (P = .77) as did the Ahn et al. model (P = .95) and a simplified BALL model (P = .09). In contrast, the full BALL score captured two groups of patients with significant differences in survival (hazard ratio, 0.240; 95 % confidence interval, 0.10-0.54; P = .0005); however, because of the low number of patients in the high-risk category, these cases were combined with the intermediate-risk group.

The BALL score identified a subset of patients, accounting for about 50% of the whole population, who particularly benefit from single-agent ibrutinib, according to Dr. Molica and his colleagues. These patients had a survival rate of 85% at 3 years.

“In contrast, the outcome of subjects with intermediate-high risk is disappointing. These patients should be considered for a combination of targeted drugs or cellular-based therapies,” the researchers concluded.

The authors reported that they had no conflicts.

[email protected]

SOURCE: Molica S et al. Leuk Res. 2020 Jun 10. https://doi.org/10.1016/j.leukres.2020.

September every year means one thing to students across the country: Summer break is over, and it is time to go back to school. For LGBTQ youth, this can be both a blessing and a curse. Schools can be a refuge from being stuck at home with unsupportive family, but it also can mean returning to hallways full of harassment from other students and/or staff. Groups such as a gender-sexuality alliance (GSA) or a chapter of the Gay, Lesbian, and Straight Education Network (GLSEN) can provide a safe space for these students at school. Pediatricians can play an important role in ensuring that their patients know about access to these resources.

SolStock/E+

Gender-sexuality alliances, or gay-straight alliances as they have been more commonly known, have been around since the late 1980s. The first one was founded at Concord Academy in Massachusetts in 1988 by a straight student who was upset at how her gay classmates were being treated. Today’s GSAs continue this mission to create a welcoming environment for students of all gender identities and sexual orientations to gather, increase awareness on their campus of LGBTQ issues, and make the school environment safer for all students. According to the GSA network, there are over 4,000 active GSAs today in the United States located in 40 states.¹

GLSEN was founded in 1990 initially as a network of gay and lesbian educators who wanted to create safer spaces in schools for LGBTQ students. Over the last 30 years, GLSEN continues to support this mission but has expanded into research and advocacy as well. There are currently 43 chapters of GLSEN in 30 states.² GLSEN sponsors a number of national events throughout the year to raise awareness of LGBTQ issues in schools, including No Name Calling Week and the Day of Silence. Many chapters provide mentoring to local GSAs and volunteering as a mentor can be a great way for pediatricians to become involved in their local schools.

You may be asking yourself, why are GSAs important? According to GLSEN’s 2017 National School Climate Survey, nearly 35% of LGBTQ students missed at least 1 day of school in the previous month because of feeling unsafe, and nearly 57% of students reported hearing homophobic remarks from teachers and staff at their school.³ Around 10% of LGBTQ students reported being physically assaulted based on their sexual orientation and/or gender identity. Those LGBTQ students who experienced discrimination based on their sexual orientation and/or gender identity were more likely to have lower grade point averages and were more likely to be disciplined than those students who had not experienced discrimination.³ The cumulative effect of these negative experiences at school lead a sizable portion of affected students to drop out of school and possibly not pursue postsecondary education. This then leads to decreased job opportunities or career advancement, which could then lead to unemployment or low-wage jobs. Creating safe spaces for education to take place can have a lasting effect on the lives of LGBTQ students.

The 53% of students who reported having a GSA at their school in the National School Climate survey were less likely to report hearing negative comments about LGBTQ students, were less likely to miss school, experienced lower levels of victimization, and reported higher levels of supportive teachers and staff. All of these factors taken together ensure that LGBTQ students are more likely to complete their high school education. Russell B. Toomey, PhD, and colleagues were able to show that LGBTQ students with a perceived effective GSA were two times more likely than those without an effective GSA to attain a college education.⁴ Research also has shown that the presence of a GSA can have a beneficial impact on reducing bullying in general for all students, whether they identify as LGBTQ or not.⁵

What active steps can a pediatrician take to support their LGBTQ students? First, encourage your patients and families to talk to their schools about starting a GSA at their campus. If the families run into trouble from the school, have your social workers help them connect with legal resources, as many court cases have established precedent that public schools cannot have a blanket ban on GSAs solely because they focus on LGBTQ issues. Second, if your patient has a GSA at their school and seems to be struggling with his/her sexual orientation and/or gender identity, encourage that student to consider attending their GSA so that they are able to spend time with other students like themselves. Third, as many schools will be starting virtually this year, you can provide your LGBTQ patients with a list of local online groups that students can participate in virtually if their school’s GSA is not meeting (see my LGBTQ Youth Consult column entitled, “Resources for LGBTQ youth during challenging times” at mdedge.com/pediatrics for a few ideas).* Lastly, be an active advocate in your own local school district for the inclusion of comprehensive nondiscrimination policies and the presence of GSAs for students. These small steps can go a long way to helping your LGBTQ patients thrive and succeed in school.

Dr. Cooper is assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas. Dr. Cooper has no relevant financial disclosures. Email him at [email protected].

References

1. gsanetwork.org/mission-vision-history/.

2. www.glsen.org/find_chapter?field_chapter_state_target_id=All.

3. live-glsen-website.pantheonsite.io/sites/default/files/2019-10/GLSEN-2017-National-School-Climate-Survey-NSCS-Full-Report.pdf.

4. Appl Dev Sci. 2011 Nov 7;15(4):175-85.

5.www.usnews.com/news/articles/2016-08-04/gay-straight-alliances-in-schools-pay-off-for-all-students-study-finds.

*This article was updated 8/17/2020.

September every year means one thing to students across the country: Summer break is over, and it is time to go back to school. For LGBTQ youth, this can be both a blessing and a curse. Schools can be a refuge from being stuck at home with unsupportive family, but it also can mean returning to hallways full of harassment from other students and/or staff. Groups such as a gender-sexuality alliance (GSA) or a chapter of the Gay, Lesbian, and Straight Education Network (GLSEN) can provide a safe space for these students at school. Pediatricians can play an important role in ensuring that their patients know about access to these resources.

SolStock/E+

Gender-sexuality alliances, or gay-straight alliances as they have been more commonly known, have been around since the late 1980s. The first one was founded at Concord Academy in Massachusetts in 1988 by a straight student who was upset at how her gay classmates were being treated. Today’s GSAs continue this mission to create a welcoming environment for students of all gender identities and sexual orientations to gather, increase awareness on their campus of LGBTQ issues, and make the school environment safer for all students. According to the GSA network, there are over 4,000 active GSAs today in the United States located in 40 states.¹

GLSEN was founded in 1990 initially as a network of gay and lesbian educators who wanted to create safer spaces in schools for LGBTQ students. Over the last 30 years, GLSEN continues to support this mission but has expanded into research and advocacy as well. There are currently 43 chapters of GLSEN in 30 states.² GLSEN sponsors a number of national events throughout the year to raise awareness of LGBTQ issues in schools, including No Name Calling Week and the Day of Silence. Many chapters provide mentoring to local GSAs and volunteering as a mentor can be a great way for pediatricians to become involved in their local schools.

You may be asking yourself, why are GSAs important? According to GLSEN’s 2017 National School Climate Survey, nearly 35% of LGBTQ students missed at least 1 day of school in the previous month because of feeling unsafe, and nearly 57% of students reported hearing homophobic remarks from teachers and staff at their school.³ Around 10% of LGBTQ students reported being physically assaulted based on their sexual orientation and/or gender identity. Those LGBTQ students who experienced discrimination based on their sexual orientation and/or gender identity were more likely to have lower grade point averages and were more likely to be disciplined than those students who had not experienced discrimination.³ The cumulative effect of these negative experiences at school lead a sizable portion of affected students to drop out of school and possibly not pursue postsecondary education. This then leads to decreased job opportunities or career advancement, which could then lead to unemployment or low-wage jobs. Creating safe spaces for education to take place can have a lasting effect on the lives of LGBTQ students.

The 53% of students who reported having a GSA at their school in the National School Climate survey were less likely to report hearing negative comments about LGBTQ students, were less likely to miss school, experienced lower levels of victimization, and reported higher levels of supportive teachers and staff. All of these factors taken together ensure that LGBTQ students are more likely to complete their high school education. Russell B. Toomey, PhD, and colleagues were able to show that LGBTQ students with a perceived effective GSA were two times more likely than those without an effective GSA to attain a college education.⁴ Research also has shown that the presence of a GSA can have a beneficial impact on reducing bullying in general for all students, whether they identify as LGBTQ or not.⁵

What active steps can a pediatrician take to support their LGBTQ students? First, encourage your patients and families to talk to their schools about starting a GSA at their campus. If the families run into trouble from the school, have your social workers help them connect with legal resources, as many court cases have established precedent that public schools cannot have a blanket ban on GSAs solely because they focus on LGBTQ issues. Second, if your patient has a GSA at their school and seems to be struggling with his/her sexual orientation and/or gender identity, encourage that student to consider attending their GSA so that they are able to spend time with other students like themselves. Third, as many schools will be starting virtually this year, you can provide your LGBTQ patients with a list of local online groups that students can participate in virtually if their school’s GSA is not meeting (see my LGBTQ Youth Consult column entitled, “Resources for LGBTQ youth during challenging times” at mdedge.com/pediatrics for a few ideas).* Lastly, be an active advocate in your own local school district for the inclusion of comprehensive nondiscrimination policies and the presence of GSAs for students. These small steps can go a long way to helping your LGBTQ patients thrive and succeed in school.

Dr. Cooper is assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas. Dr. Cooper has no relevant financial disclosures. Email him at [email protected].

References

1. gsanetwork.org/mission-vision-history/.

2. www.glsen.org/find_chapter?field_chapter_state_target_id=All.

3. live-glsen-website.pantheonsite.io/sites/default/files/2019-10/GLSEN-2017-National-School-Climate-Survey-NSCS-Full-Report.pdf.

4. Appl Dev Sci. 2011 Nov 7;15(4):175-85.

5.www.usnews.com/news/articles/2016-08-04/gay-straight-alliances-in-schools-pay-off-for-all-students-study-finds.

*This article was updated 8/17/2020.

September every year means one thing to students across the country: Summer break is over, and it is time to go back to school. For LGBTQ youth, this can be both a blessing and a curse. Schools can be a refuge from being stuck at home with unsupportive family, but it also can mean returning to hallways full of harassment from other students and/or staff. Groups such as a gender-sexuality alliance (GSA) or a chapter of the Gay, Lesbian, and Straight Education Network (GLSEN) can provide a safe space for these students at school. Pediatricians can play an important role in ensuring that their patients know about access to these resources.

SolStock/E+

Gender-sexuality alliances, or gay-straight alliances as they have been more commonly known, have been around since the late 1980s. The first one was founded at Concord Academy in Massachusetts in 1988 by a straight student who was upset at how her gay classmates were being treated. Today’s GSAs continue this mission to create a welcoming environment for students of all gender identities and sexual orientations to gather, increase awareness on their campus of LGBTQ issues, and make the school environment safer for all students. According to the GSA network, there are over 4,000 active GSAs today in the United States located in 40 states.¹

GLSEN was founded in 1990 initially as a network of gay and lesbian educators who wanted to create safer spaces in schools for LGBTQ students. Over the last 30 years, GLSEN continues to support this mission but has expanded into research and advocacy as well. There are currently 43 chapters of GLSEN in 30 states.² GLSEN sponsors a number of national events throughout the year to raise awareness of LGBTQ issues in schools, including No Name Calling Week and the Day of Silence. Many chapters provide mentoring to local GSAs and volunteering as a mentor can be a great way for pediatricians to become involved in their local schools.

You may be asking yourself, why are GSAs important? According to GLSEN’s 2017 National School Climate Survey, nearly 35% of LGBTQ students missed at least 1 day of school in the previous month because of feeling unsafe, and nearly 57% of students reported hearing homophobic remarks from teachers and staff at their school.³ Around 10% of LGBTQ students reported being physically assaulted based on their sexual orientation and/or gender identity. Those LGBTQ students who experienced discrimination based on their sexual orientation and/or gender identity were more likely to have lower grade point averages and were more likely to be disciplined than those students who had not experienced discrimination.³ The cumulative effect of these negative experiences at school lead a sizable portion of affected students to drop out of school and possibly not pursue postsecondary education. This then leads to decreased job opportunities or career advancement, which could then lead to unemployment or low-wage jobs. Creating safe spaces for education to take place can have a lasting effect on the lives of LGBTQ students.

The 53% of students who reported having a GSA at their school in the National School Climate survey were less likely to report hearing negative comments about LGBTQ students, were less likely to miss school, experienced lower levels of victimization, and reported higher levels of supportive teachers and staff. All of these factors taken together ensure that LGBTQ students are more likely to complete their high school education. Russell B. Toomey, PhD, and colleagues were able to show that LGBTQ students with a perceived effective GSA were two times more likely than those without an effective GSA to attain a college education.⁴ Research also has shown that the presence of a GSA can have a beneficial impact on reducing bullying in general for all students, whether they identify as LGBTQ or not.⁵

What active steps can a pediatrician take to support their LGBTQ students? First, encourage your patients and families to talk to their schools about starting a GSA at their campus. If the families run into trouble from the school, have your social workers help them connect with legal resources, as many court cases have established precedent that public schools cannot have a blanket ban on GSAs solely because they focus on LGBTQ issues. Second, if your patient has a GSA at their school and seems to be struggling with his/her sexual orientation and/or gender identity, encourage that student to consider attending their GSA so that they are able to spend time with other students like themselves. Third, as many schools will be starting virtually this year, you can provide your LGBTQ patients with a list of local online groups that students can participate in virtually if their school’s GSA is not meeting (see my LGBTQ Youth Consult column entitled, “Resources for LGBTQ youth during challenging times” at mdedge.com/pediatrics for a few ideas).* Lastly, be an active advocate in your own local school district for the inclusion of comprehensive nondiscrimination policies and the presence of GSAs for students. These small steps can go a long way to helping your LGBTQ patients thrive and succeed in school.

Dr. Cooper is assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas. Dr. Cooper has no relevant financial disclosures. Email him at [email protected].

References

1. gsanetwork.org/mission-vision-history/.

2. www.glsen.org/find_chapter?field_chapter_state_target_id=All.

3. live-glsen-website.pantheonsite.io/sites/default/files/2019-10/GLSEN-2017-National-School-Climate-Survey-NSCS-Full-Report.pdf.

4. Appl Dev Sci. 2011 Nov 7;15(4):175-85.

5.www.usnews.com/news/articles/2016-08-04/gay-straight-alliances-in-schools-pay-off-for-all-students-study-finds.

*This article was updated 8/17/2020.