Ob.Gyn. News

State laws capping initial opioid prescriptions to 7 days or less have led to a reduction in opioid prescribing, a new analysis of Medicare data shows.

While overall opioid prescribing has decreased, the reduction in states with legislation restricting opioid prescribing was “significantly greater than in states without such legislation,” study investigator Michael Brenner, MD, University of Michigan, Ann Arbor, said in an interview.

The study was published online August 9 in JAMA Internal Medicine.
 

Significant but limited effect

Because of rising concern around the opioid crisis, 23 states representing 43% of the U.S. population passed laws from 2016 through 2018 limiting initial opioid prescription to 7 days or less.

Using Medicare data from 2013 through 2018, Dr. Brenner and colleagues conducted a before-and-after study to assess the effect of these laws.

They found that on average, the number of days an opioid was prescribed for each Medicare beneficiary decreased by 11.6 days (from 44.2 days in 2013 to 32.7 days in 2018) in states that imposed duration limits, compared with 10.1 days in states without these laws (from 43.4 days in 2013 to 33.3 days in 2018).

Prior to the start of duration limits in 2016, days an opioid was prescribed were comparable among states.

After adjusting for state-level differences in race, urbanization, median income, tobacco and alcohol use, serious mental illness, and other factors, state laws limiting opioid prescriptions to 7 days or less were associated with a reduction in prescribing of 1.7 days per enrollee, “suggesting a significant but limited outcome” for these laws, the researchers note.

The largest decrease in opioid prescribing occurred in primary care, but this was not significantly different in states with limit laws versus those without. However, state laws limiting duration led to a significant reduction in days of opioid prescribed among surgeons, dentists, pain specialists, and other specialists.
 

Inadequate pain control?

The researchers note the study was limited to Medicare beneficiaries; however, excess opioid prescribing is prevalent across all patient populations.

In addition, it’s not possible to tell from the data whether acute pain was adequately controlled with fewer pills.

“The question of adequacy of pain control is a crucial one that has been investigated extensively in prior work but was not possible to evaluate in this particular study,” said Dr. Brenner.

However, “ample evidence supports a role for reducing opioid prescribing and that such reduction can be achieved while ensuring that pain is adequately controlled with fewer pills,” he noted.

“A persistent misconception is that opioids are uniquely powerful and effective for controlling pain. Patients may perceive that effective analgesia is being withheld when opioids are not included in a regimen,” Dr. Brenner added.

“Yet, the evidence from meta-analyses derived from large numbers of randomized clinical trials finds that [nonsteroidal anti-inflammatory drugs] NSAIDS combined with acetaminophen provide similar or improved acute pain when compared to commonly prescribed opioid regimens, based on number-needed-to-treat analyses,” he added.

In a related editorial, Deborah Grady, MD, MPH, with University of California, San Francisco, and Mitchell H. Katz, MD, president and CEO of NYC Health + Hospitals, say the decrease in opioid prescribing with duration limits was “small but probably meaningful.” 

Restricting initial prescriptions to seven or fewer days is “reasonable because patients with new onset of pain should be re-evaluated in a week if the pain continues,” they write. 

However, Dr. Grady and Dr. Katz “worry” that restricting initial prescriptions to shorter periods, such as 3 or 5 days, as has occurred in six states, “may result in patients with acute pain going untreated or having to go to extraordinary effort to obtain adequate pain relief.”

In their view, the data from this study suggest that limiting initial prescriptions to seven or fewer days is “helpful, but we would not restrict any further given that we do not know how it affected patients with acute pain.”

The study had no specific funding. Dr. Brenner, Dr. Grady, and Dr. Katz have disclosed no relevant financial relationships.

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

State laws capping initial opioid prescriptions to 7 days or less have led to a reduction in opioid prescribing, a new analysis of Medicare data shows.

While overall opioid prescribing has decreased, the reduction in states with legislation restricting opioid prescribing was “significantly greater than in states without such legislation,” study investigator Michael Brenner, MD, University of Michigan, Ann Arbor, said in an interview.

The study was published online August 9 in JAMA Internal Medicine.
 

Significant but limited effect

Because of rising concern around the opioid crisis, 23 states representing 43% of the U.S. population passed laws from 2016 through 2018 limiting initial opioid prescription to 7 days or less.

Using Medicare data from 2013 through 2018, Dr. Brenner and colleagues conducted a before-and-after study to assess the effect of these laws.

They found that on average, the number of days an opioid was prescribed for each Medicare beneficiary decreased by 11.6 days (from 44.2 days in 2013 to 32.7 days in 2018) in states that imposed duration limits, compared with 10.1 days in states without these laws (from 43.4 days in 2013 to 33.3 days in 2018).

Prior to the start of duration limits in 2016, days an opioid was prescribed were comparable among states.

After adjusting for state-level differences in race, urbanization, median income, tobacco and alcohol use, serious mental illness, and other factors, state laws limiting opioid prescriptions to 7 days or less were associated with a reduction in prescribing of 1.7 days per enrollee, “suggesting a significant but limited outcome” for these laws, the researchers note.

The largest decrease in opioid prescribing occurred in primary care, but this was not significantly different in states with limit laws versus those without. However, state laws limiting duration led to a significant reduction in days of opioid prescribed among surgeons, dentists, pain specialists, and other specialists.
 

Inadequate pain control?

The researchers note the study was limited to Medicare beneficiaries; however, excess opioid prescribing is prevalent across all patient populations.

In addition, it’s not possible to tell from the data whether acute pain was adequately controlled with fewer pills.

“The question of adequacy of pain control is a crucial one that has been investigated extensively in prior work but was not possible to evaluate in this particular study,” said Dr. Brenner.

However, “ample evidence supports a role for reducing opioid prescribing and that such reduction can be achieved while ensuring that pain is adequately controlled with fewer pills,” he noted.

“A persistent misconception is that opioids are uniquely powerful and effective for controlling pain. Patients may perceive that effective analgesia is being withheld when opioids are not included in a regimen,” Dr. Brenner added.

“Yet, the evidence from meta-analyses derived from large numbers of randomized clinical trials finds that [nonsteroidal anti-inflammatory drugs] NSAIDS combined with acetaminophen provide similar or improved acute pain when compared to commonly prescribed opioid regimens, based on number-needed-to-treat analyses,” he added.

In a related editorial, Deborah Grady, MD, MPH, with University of California, San Francisco, and Mitchell H. Katz, MD, president and CEO of NYC Health + Hospitals, say the decrease in opioid prescribing with duration limits was “small but probably meaningful.” 

Restricting initial prescriptions to seven or fewer days is “reasonable because patients with new onset of pain should be re-evaluated in a week if the pain continues,” they write. 

However, Dr. Grady and Dr. Katz “worry” that restricting initial prescriptions to shorter periods, such as 3 or 5 days, as has occurred in six states, “may result in patients with acute pain going untreated or having to go to extraordinary effort to obtain adequate pain relief.”

In their view, the data from this study suggest that limiting initial prescriptions to seven or fewer days is “helpful, but we would not restrict any further given that we do not know how it affected patients with acute pain.”

The study had no specific funding. Dr. Brenner, Dr. Grady, and Dr. Katz have disclosed no relevant financial relationships.

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

State laws capping initial opioid prescriptions to 7 days or less have led to a reduction in opioid prescribing, a new analysis of Medicare data shows.

While overall opioid prescribing has decreased, the reduction in states with legislation restricting opioid prescribing was “significantly greater than in states without such legislation,” study investigator Michael Brenner, MD, University of Michigan, Ann Arbor, said in an interview.

The study was published online August 9 in JAMA Internal Medicine.
 

Significant but limited effect

Because of rising concern around the opioid crisis, 23 states representing 43% of the U.S. population passed laws from 2016 through 2018 limiting initial opioid prescription to 7 days or less.

Using Medicare data from 2013 through 2018, Dr. Brenner and colleagues conducted a before-and-after study to assess the effect of these laws.

They found that on average, the number of days an opioid was prescribed for each Medicare beneficiary decreased by 11.6 days (from 44.2 days in 2013 to 32.7 days in 2018) in states that imposed duration limits, compared with 10.1 days in states without these laws (from 43.4 days in 2013 to 33.3 days in 2018).

Prior to the start of duration limits in 2016, days an opioid was prescribed were comparable among states.

After adjusting for state-level differences in race, urbanization, median income, tobacco and alcohol use, serious mental illness, and other factors, state laws limiting opioid prescriptions to 7 days or less were associated with a reduction in prescribing of 1.7 days per enrollee, “suggesting a significant but limited outcome” for these laws, the researchers note.

The largest decrease in opioid prescribing occurred in primary care, but this was not significantly different in states with limit laws versus those without. However, state laws limiting duration led to a significant reduction in days of opioid prescribed among surgeons, dentists, pain specialists, and other specialists.
 

Inadequate pain control?

The researchers note the study was limited to Medicare beneficiaries; however, excess opioid prescribing is prevalent across all patient populations.

In addition, it’s not possible to tell from the data whether acute pain was adequately controlled with fewer pills.

“The question of adequacy of pain control is a crucial one that has been investigated extensively in prior work but was not possible to evaluate in this particular study,” said Dr. Brenner.

However, “ample evidence supports a role for reducing opioid prescribing and that such reduction can be achieved while ensuring that pain is adequately controlled with fewer pills,” he noted.

“A persistent misconception is that opioids are uniquely powerful and effective for controlling pain. Patients may perceive that effective analgesia is being withheld when opioids are not included in a regimen,” Dr. Brenner added.

“Yet, the evidence from meta-analyses derived from large numbers of randomized clinical trials finds that [nonsteroidal anti-inflammatory drugs] NSAIDS combined with acetaminophen provide similar or improved acute pain when compared to commonly prescribed opioid regimens, based on number-needed-to-treat analyses,” he added.

In a related editorial, Deborah Grady, MD, MPH, with University of California, San Francisco, and Mitchell H. Katz, MD, president and CEO of NYC Health + Hospitals, say the decrease in opioid prescribing with duration limits was “small but probably meaningful.” 

Restricting initial prescriptions to seven or fewer days is “reasonable because patients with new onset of pain should be re-evaluated in a week if the pain continues,” they write. 

However, Dr. Grady and Dr. Katz “worry” that restricting initial prescriptions to shorter periods, such as 3 or 5 days, as has occurred in six states, “may result in patients with acute pain going untreated or having to go to extraordinary effort to obtain adequate pain relief.”

In their view, the data from this study suggest that limiting initial prescriptions to seven or fewer days is “helpful, but we would not restrict any further given that we do not know how it affected patients with acute pain.”

The study had no specific funding. Dr. Brenner, Dr. Grady, and Dr. Katz have disclosed no relevant financial relationships.

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

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

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

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

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

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

Lack of women leaders

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

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

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

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

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

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

Women want work-life balance

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

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

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

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

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

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

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

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

Discrimination and harassment influence specialty choice

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

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

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

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

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

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

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

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

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

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

Longer training

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lack of women leaders

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

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

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

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

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

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

Women want work-life balance

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

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

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

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

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

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

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

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

Discrimination and harassment influence specialty choice

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

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

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

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

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

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

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

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

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

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

Longer training

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lack of women leaders

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

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

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

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

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

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

Women want work-life balance

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

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

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

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

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

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

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

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

Discrimination and harassment influence specialty choice

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

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

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

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

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

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

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

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

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

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

Longer training

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

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

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

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

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

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

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

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

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

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

COVID-19 rates are surging again, and many Americans who’ve been vaccinated are turning their anger toward those who refuse to get the shot.

Outraged at vaccine-hesitant people, some are even calling for mandates requiring all Americans to get inoculated, arguing the holdouts are allowing the Delta coronavirus variant to gain traction and reverse the progress the United States was making against the virus.

“I am angry, I am resentful, and I think it’s a fair and appropriate response,” said Jonathan Hyman, a Berea, Ohio, attorney who blames the unvaccinated for the backslide in pandemic progress.

Mr. Hyman has been following the difficult guidelines health experts have been urging from the beginning. He has been masking up, avoiding large gatherings, postponing travel, and he signed up to receive the vaccine as soon as it was available.

“We have been responsible, I did everything I was supposed to do,” said Mr. Hyman, 48, who didn’t visit his parents for 18 months to keep them safe. “Yet here we are, 16, 17 months later, and it feels like we’re in the exact same place we were last summer, and it’s all because some people refuse to do the responsible things they were told to do.”

James Simmons, a retired South Florida high school finance teacher, is also angered by the vaccine holdouts, citing new spikes in COVID-19 infections, hospitalization rates, and deaths across the country – nearly all of which are among unvaccinated people.

“I can’t fathom the fact that people have seen over 600,000 Americans die from COVID, yet are resistant to a vaccine that provides direct protection for themselves and others,” said Mr. Simmons, 63, who received the shot early. “Their irresponsible decision is an affront to those of us who are vaccinated and still wear masks for the benefit of our society.”

Melissa Martin, an Atlanta resident who contracted a serious case of COVID-19 in September 2020, says it is “perplexing and frustrating” that so many Americans are refusing the vaccine. She believes the anger so many vaccinated people feel is tied to fear.

“I believe at the core of this anger is a fear of losing the ones we love,” said Ms. Martin, 55, who has been vaccinated, as has her fiancé, Shane McGeehin. “I was very angry last year after contracting COVID. The experience of having COVID was negative physically, emotionally, and socially.”

She recalled arguing with friends and relatives who downplayed how severe the virus was and who still refuse vaccination, despite seeing how COVID affected her.

“I am trying to understand why they feel the way they do,” she said, “but I would describe the emotions I have now towards those who do not get the vaccine as frustration, confusion, and disbelief.”

Leana Wen, MD, an emergency medicine doctor and public health policy professor at George Washington University, said such sentiments are common and justified.

“I understand that feeling of frustration and anger, because it is the unvaccinated who are setting back the progress that we’ve made [because of] the many sacrifices that many people have undergone,” said Dr. Wen, author of the newly published book “Lifelines: A Doctor’s Journey in the Fight for Public Health.”

“I think it is appropriate for the vaccinated to feel like they’re being punished right now,” she said. “We as a country had the opportunity to beat this virus – to return to prepandemic normal [life] and have our kids go back to school without worrying about coronavirus and our economy fully recovering. We came so close to achieving this, but we didn’t, and now COVID-19 is surging again. The vaccinated are having to pay the price for the choices that some have made to not end this pandemic.”
 

COVID rising, driving anger

The rising anger among vaccinated Americans comes as health officials are reporting huge spikes in new cases, hospitalizations, and deaths. Meanwhile, only about half of all Americans fully vaccinated, according to the Centers for Disease Control and Prevention.

Per Aug. 6 estimates from the CDC, the nation is averaging more than 100,000 new cases every day – the highest levels seen since February.

Southern states, with the lowest vaccination rates in the country, have been particularly hard-hit. Florida and Louisiana recently set 7-day records for new cases and hospitalizations, beating previous peaks last summer. Those two states, along with Mississippi, North Carolina, South Carolina, Tennessee, Kentucky, and Georgia, account for 41% of all new COVID-19 hospitalizations in the country, according to the CDC.

“It’s time to start blaming the unvaccinated folks, not the regular folks,” an angry Gov. Kay Ivey (R) of Alabama, told reporters. “It’s the unvaccinated folks that are letting us down.”

In response to the resurgence in cases, President Joe Biden has ordered new vaccine mandates for millions of federal workers.

California started requiring health care professionals to be vaccinated in August 2021, removing the option for unvaccinated employees to submit to regular testing.

New York City became the first in the country to require proof of vaccination for all workers and customers to enter restaurants, gyms, concert halls, movie theaters, and Broadway venues.

Nearly 60 major medical organizations, including the American Medical Association and the American Nurses Association, have called for mandatory vaccination of all health care workers.

Meanwhile, many businesses are requiring workers to be vaccinated before returning to offices and other workplaces. Colleges across the country are mandating the shots for students and staff. And some states and cities are also returning to mask mandates, including Hawaii; Louisiana; Washington, D.C.; San Francisco; and Los Angeles.

Experts say the 90 million unvaccinated Americans are most at risk from COVID and have helped the new Delta variant gain a foothold and spread, posing a risk of “breakthrough” cases even in vaccinated people.

Delta is more contagious and causes more severe disease than other known variants of the virus, according to the CDC. It is also more contagious than the viruses that cause Middle East respiratory syndrome, severe acute respiratory syndrome, Ebola, the common cold, flu, and smallpox
 

Calls for mandates grow

With Delta helping to drive new spikes in COVID cases, some vaccinated Americans argue that the federal government should be taking a harder line with holdouts. Others have even advocated withholding government stimulus checks or tax credits from vaccine refusers and cutting federal funding to states that don’t meet vaccine targets.

Eric Jaffe, a creative writer and producer from Florida who is vaccinated, said he would like to see government agencies and private businesses do more to put pressure on unvaccinated Americans to get the shot.

“In the interest of public safety, I believe the government and private businesses need to [make] life difficult for the unvaccinated,” said Mr. Jaffe, 29, whose parents both contracted the virus but recovered. “They should not be allowed to dine at restaurants, ride public transportation, attend concerts, or broadly be in spaces with large concentrations of people without passing a COVID test at the door.

“They’ll stand in long lines and be inconvenienced at every turn, while vaccinated people get to fly through security, TSA PreCheck-style. The holdouts at [this] point are beyond convincing. The vaccinated should be able to return to a level of normalcy, and the unvaccinated should face restrictions. Any other dynamic puts the stress on citizens who did the right thing.”

Elif Akcali, 49, who teaches engineering at the University of Florida, Gainesville, worries that the rights of people who refuse the vaccine are being put ahead of those of vaccinated people. She’s also concerned for people who face greater COVID risks, including health care workers and children too young to be inoculated.

“Each infection is an opportunity for the virus to evolve into a stronger version in itself,” said Ms. Akcali, who felt such a sense of relief when she received her vaccination that she teared up. “Each hospitalization is an unnecessary burden to health care workers and the system. Each death brings heartbreak to someone in their circle.”

Ed Berliner, an Emmy Award–winning broadcast journalist and Florida-based media specialist, blames social media for spreading misinformation that has taken root with unvaccinated Americans.

“When America rallied together to combat polio, there were two things we didn’t have. One was a lack of the sewer-dwelling, troll-infested social media, which has become the main source of news for the less intelligent and arrogant,” said Mr. Berliner, CEO of Entourage Media and host of The Man in the Arena, a talk show. “Second, children were dying across the country, and that made people sit up and take notice.”

Mr. Berliner, who knows two people who’ve died from COVID and who received the vaccine early, also believes too many political leaders are still fueling falsehoods that are giving unvaccinated Americans a license to refuse the shot.

“We are also here because governments and officials spend too little time being brutally honest, choosing instead to dance around issues with soft words,” he said. “The first words out of their mouths should have been: ‘What we are doing is trying to save lives. Help us save your life and that of everyone else.’ Would it have made a difference? We will never know.”

Shon Neyland, senior pastor at the Highland Christian Center church in Portland, Ore., said vaccine tensions have divided his congregation, with about half refusing the shot by his estimation. But he said it’s important to understand why some are making that choice, rather than rage at them and hammer home the benefits of the shot.

Many vaccine holdouts don’t trust the government or medical establishment or have bought into political arguments against the shot, he says. Some conservative evangelicals are also swayed by spiritual beliefs that COVID-19 is a sign of “biblical end-times prophesies” and the vaccine is “the mark of the beast.”

But he has tried to counter those beliefs and biases, arguing they are false and unfounded, urging members of his church to get the vaccine, and partnering with local health officials to run clinics to deliver it.

“I gently try to show them that the vaccine is for our own good and, in fact, is a blessing from God, and it’s up to us to accept the blessing [so] we can get back to somewhat of normalcy,” said Mr. Neyland, author of “The Courage to Stand: A New America.”

“I also believe that to get a vaccine this quick, this was nothing short of a miracle to turn the tide so quickly. Now, for us to resist, it would cause us to continue to suffer and lose lives. And you can’t turn away from the lives that have already been lost.”

Mr. Hyman fears we may not have seen the worst of the pandemic and that the Delta variant won’t be the last or most virulent mutation to emerge.

“The number of unvaccinated people is allowing this virus to continue circulating in the community,” he noted. “And while I have a tremendous amount of confidence that the vaccine protects me now from Delta, I have less confidence that it’s going to protect me from whatever [variant] comes next.

“So, I have a tremendous amount of concern for my own health and safety and welfare, and that of the people that I love. But I’m also concerned about what’s it going to do to businesses [and] the economy. Are we going to have more shutdowns if cases continue trending up? I’m very concerned as to what this could do [to] the country.”

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

COVID-19 rates are surging again, and many Americans who’ve been vaccinated are turning their anger toward those who refuse to get the shot.

Outraged at vaccine-hesitant people, some are even calling for mandates requiring all Americans to get inoculated, arguing the holdouts are allowing the Delta coronavirus variant to gain traction and reverse the progress the United States was making against the virus.

“I am angry, I am resentful, and I think it’s a fair and appropriate response,” said Jonathan Hyman, a Berea, Ohio, attorney who blames the unvaccinated for the backslide in pandemic progress.

Mr. Hyman has been following the difficult guidelines health experts have been urging from the beginning. He has been masking up, avoiding large gatherings, postponing travel, and he signed up to receive the vaccine as soon as it was available.

“We have been responsible, I did everything I was supposed to do,” said Mr. Hyman, 48, who didn’t visit his parents for 18 months to keep them safe. “Yet here we are, 16, 17 months later, and it feels like we’re in the exact same place we were last summer, and it’s all because some people refuse to do the responsible things they were told to do.”

James Simmons, a retired South Florida high school finance teacher, is also angered by the vaccine holdouts, citing new spikes in COVID-19 infections, hospitalization rates, and deaths across the country – nearly all of which are among unvaccinated people.

“I can’t fathom the fact that people have seen over 600,000 Americans die from COVID, yet are resistant to a vaccine that provides direct protection for themselves and others,” said Mr. Simmons, 63, who received the shot early. “Their irresponsible decision is an affront to those of us who are vaccinated and still wear masks for the benefit of our society.”

Melissa Martin, an Atlanta resident who contracted a serious case of COVID-19 in September 2020, says it is “perplexing and frustrating” that so many Americans are refusing the vaccine. She believes the anger so many vaccinated people feel is tied to fear.

“I believe at the core of this anger is a fear of losing the ones we love,” said Ms. Martin, 55, who has been vaccinated, as has her fiancé, Shane McGeehin. “I was very angry last year after contracting COVID. The experience of having COVID was negative physically, emotionally, and socially.”

She recalled arguing with friends and relatives who downplayed how severe the virus was and who still refuse vaccination, despite seeing how COVID affected her.

“I am trying to understand why they feel the way they do,” she said, “but I would describe the emotions I have now towards those who do not get the vaccine as frustration, confusion, and disbelief.”

Leana Wen, MD, an emergency medicine doctor and public health policy professor at George Washington University, said such sentiments are common and justified.

“I understand that feeling of frustration and anger, because it is the unvaccinated who are setting back the progress that we’ve made [because of] the many sacrifices that many people have undergone,” said Dr. Wen, author of the newly published book “Lifelines: A Doctor’s Journey in the Fight for Public Health.”

“I think it is appropriate for the vaccinated to feel like they’re being punished right now,” she said. “We as a country had the opportunity to beat this virus – to return to prepandemic normal [life] and have our kids go back to school without worrying about coronavirus and our economy fully recovering. We came so close to achieving this, but we didn’t, and now COVID-19 is surging again. The vaccinated are having to pay the price for the choices that some have made to not end this pandemic.”
 

COVID rising, driving anger

The rising anger among vaccinated Americans comes as health officials are reporting huge spikes in new cases, hospitalizations, and deaths. Meanwhile, only about half of all Americans fully vaccinated, according to the Centers for Disease Control and Prevention.

Per Aug. 6 estimates from the CDC, the nation is averaging more than 100,000 new cases every day – the highest levels seen since February.

Southern states, with the lowest vaccination rates in the country, have been particularly hard-hit. Florida and Louisiana recently set 7-day records for new cases and hospitalizations, beating previous peaks last summer. Those two states, along with Mississippi, North Carolina, South Carolina, Tennessee, Kentucky, and Georgia, account for 41% of all new COVID-19 hospitalizations in the country, according to the CDC.

“It’s time to start blaming the unvaccinated folks, not the regular folks,” an angry Gov. Kay Ivey (R) of Alabama, told reporters. “It’s the unvaccinated folks that are letting us down.”

In response to the resurgence in cases, President Joe Biden has ordered new vaccine mandates for millions of federal workers.

California started requiring health care professionals to be vaccinated in August 2021, removing the option for unvaccinated employees to submit to regular testing.

New York City became the first in the country to require proof of vaccination for all workers and customers to enter restaurants, gyms, concert halls, movie theaters, and Broadway venues.

Nearly 60 major medical organizations, including the American Medical Association and the American Nurses Association, have called for mandatory vaccination of all health care workers.

Meanwhile, many businesses are requiring workers to be vaccinated before returning to offices and other workplaces. Colleges across the country are mandating the shots for students and staff. And some states and cities are also returning to mask mandates, including Hawaii; Louisiana; Washington, D.C.; San Francisco; and Los Angeles.

Experts say the 90 million unvaccinated Americans are most at risk from COVID and have helped the new Delta variant gain a foothold and spread, posing a risk of “breakthrough” cases even in vaccinated people.

Delta is more contagious and causes more severe disease than other known variants of the virus, according to the CDC. It is also more contagious than the viruses that cause Middle East respiratory syndrome, severe acute respiratory syndrome, Ebola, the common cold, flu, and smallpox
 

Calls for mandates grow

With Delta helping to drive new spikes in COVID cases, some vaccinated Americans argue that the federal government should be taking a harder line with holdouts. Others have even advocated withholding government stimulus checks or tax credits from vaccine refusers and cutting federal funding to states that don’t meet vaccine targets.

Eric Jaffe, a creative writer and producer from Florida who is vaccinated, said he would like to see government agencies and private businesses do more to put pressure on unvaccinated Americans to get the shot.

“In the interest of public safety, I believe the government and private businesses need to [make] life difficult for the unvaccinated,” said Mr. Jaffe, 29, whose parents both contracted the virus but recovered. “They should not be allowed to dine at restaurants, ride public transportation, attend concerts, or broadly be in spaces with large concentrations of people without passing a COVID test at the door.

“They’ll stand in long lines and be inconvenienced at every turn, while vaccinated people get to fly through security, TSA PreCheck-style. The holdouts at [this] point are beyond convincing. The vaccinated should be able to return to a level of normalcy, and the unvaccinated should face restrictions. Any other dynamic puts the stress on citizens who did the right thing.”

Elif Akcali, 49, who teaches engineering at the University of Florida, Gainesville, worries that the rights of people who refuse the vaccine are being put ahead of those of vaccinated people. She’s also concerned for people who face greater COVID risks, including health care workers and children too young to be inoculated.

“Each infection is an opportunity for the virus to evolve into a stronger version in itself,” said Ms. Akcali, who felt such a sense of relief when she received her vaccination that she teared up. “Each hospitalization is an unnecessary burden to health care workers and the system. Each death brings heartbreak to someone in their circle.”

Ed Berliner, an Emmy Award–winning broadcast journalist and Florida-based media specialist, blames social media for spreading misinformation that has taken root with unvaccinated Americans.

“When America rallied together to combat polio, there were two things we didn’t have. One was a lack of the sewer-dwelling, troll-infested social media, which has become the main source of news for the less intelligent and arrogant,” said Mr. Berliner, CEO of Entourage Media and host of The Man in the Arena, a talk show. “Second, children were dying across the country, and that made people sit up and take notice.”

Mr. Berliner, who knows two people who’ve died from COVID and who received the vaccine early, also believes too many political leaders are still fueling falsehoods that are giving unvaccinated Americans a license to refuse the shot.

“We are also here because governments and officials spend too little time being brutally honest, choosing instead to dance around issues with soft words,” he said. “The first words out of their mouths should have been: ‘What we are doing is trying to save lives. Help us save your life and that of everyone else.’ Would it have made a difference? We will never know.”

Shon Neyland, senior pastor at the Highland Christian Center church in Portland, Ore., said vaccine tensions have divided his congregation, with about half refusing the shot by his estimation. But he said it’s important to understand why some are making that choice, rather than rage at them and hammer home the benefits of the shot.

Many vaccine holdouts don’t trust the government or medical establishment or have bought into political arguments against the shot, he says. Some conservative evangelicals are also swayed by spiritual beliefs that COVID-19 is a sign of “biblical end-times prophesies” and the vaccine is “the mark of the beast.”

But he has tried to counter those beliefs and biases, arguing they are false and unfounded, urging members of his church to get the vaccine, and partnering with local health officials to run clinics to deliver it.

“I gently try to show them that the vaccine is for our own good and, in fact, is a blessing from God, and it’s up to us to accept the blessing [so] we can get back to somewhat of normalcy,” said Mr. Neyland, author of “The Courage to Stand: A New America.”

“I also believe that to get a vaccine this quick, this was nothing short of a miracle to turn the tide so quickly. Now, for us to resist, it would cause us to continue to suffer and lose lives. And you can’t turn away from the lives that have already been lost.”

Mr. Hyman fears we may not have seen the worst of the pandemic and that the Delta variant won’t be the last or most virulent mutation to emerge.

“The number of unvaccinated people is allowing this virus to continue circulating in the community,” he noted. “And while I have a tremendous amount of confidence that the vaccine protects me now from Delta, I have less confidence that it’s going to protect me from whatever [variant] comes next.

“So, I have a tremendous amount of concern for my own health and safety and welfare, and that of the people that I love. But I’m also concerned about what’s it going to do to businesses [and] the economy. Are we going to have more shutdowns if cases continue trending up? I’m very concerned as to what this could do [to] the country.”

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

COVID-19 rates are surging again, and many Americans who’ve been vaccinated are turning their anger toward those who refuse to get the shot.

Outraged at vaccine-hesitant people, some are even calling for mandates requiring all Americans to get inoculated, arguing the holdouts are allowing the Delta coronavirus variant to gain traction and reverse the progress the United States was making against the virus.

“I am angry, I am resentful, and I think it’s a fair and appropriate response,” said Jonathan Hyman, a Berea, Ohio, attorney who blames the unvaccinated for the backslide in pandemic progress.

Mr. Hyman has been following the difficult guidelines health experts have been urging from the beginning. He has been masking up, avoiding large gatherings, postponing travel, and he signed up to receive the vaccine as soon as it was available.

“We have been responsible, I did everything I was supposed to do,” said Mr. Hyman, 48, who didn’t visit his parents for 18 months to keep them safe. “Yet here we are, 16, 17 months later, and it feels like we’re in the exact same place we were last summer, and it’s all because some people refuse to do the responsible things they were told to do.”

James Simmons, a retired South Florida high school finance teacher, is also angered by the vaccine holdouts, citing new spikes in COVID-19 infections, hospitalization rates, and deaths across the country – nearly all of which are among unvaccinated people.

“I can’t fathom the fact that people have seen over 600,000 Americans die from COVID, yet are resistant to a vaccine that provides direct protection for themselves and others,” said Mr. Simmons, 63, who received the shot early. “Their irresponsible decision is an affront to those of us who are vaccinated and still wear masks for the benefit of our society.”

Melissa Martin, an Atlanta resident who contracted a serious case of COVID-19 in September 2020, says it is “perplexing and frustrating” that so many Americans are refusing the vaccine. She believes the anger so many vaccinated people feel is tied to fear.

“I believe at the core of this anger is a fear of losing the ones we love,” said Ms. Martin, 55, who has been vaccinated, as has her fiancé, Shane McGeehin. “I was very angry last year after contracting COVID. The experience of having COVID was negative physically, emotionally, and socially.”

She recalled arguing with friends and relatives who downplayed how severe the virus was and who still refuse vaccination, despite seeing how COVID affected her.

“I am trying to understand why they feel the way they do,” she said, “but I would describe the emotions I have now towards those who do not get the vaccine as frustration, confusion, and disbelief.”

Leana Wen, MD, an emergency medicine doctor and public health policy professor at George Washington University, said such sentiments are common and justified.

“I understand that feeling of frustration and anger, because it is the unvaccinated who are setting back the progress that we’ve made [because of] the many sacrifices that many people have undergone,” said Dr. Wen, author of the newly published book “Lifelines: A Doctor’s Journey in the Fight for Public Health.”

“I think it is appropriate for the vaccinated to feel like they’re being punished right now,” she said. “We as a country had the opportunity to beat this virus – to return to prepandemic normal [life] and have our kids go back to school without worrying about coronavirus and our economy fully recovering. We came so close to achieving this, but we didn’t, and now COVID-19 is surging again. The vaccinated are having to pay the price for the choices that some have made to not end this pandemic.”
 

COVID rising, driving anger

The rising anger among vaccinated Americans comes as health officials are reporting huge spikes in new cases, hospitalizations, and deaths. Meanwhile, only about half of all Americans fully vaccinated, according to the Centers for Disease Control and Prevention.

Per Aug. 6 estimates from the CDC, the nation is averaging more than 100,000 new cases every day – the highest levels seen since February.

Southern states, with the lowest vaccination rates in the country, have been particularly hard-hit. Florida and Louisiana recently set 7-day records for new cases and hospitalizations, beating previous peaks last summer. Those two states, along with Mississippi, North Carolina, South Carolina, Tennessee, Kentucky, and Georgia, account for 41% of all new COVID-19 hospitalizations in the country, according to the CDC.

“It’s time to start blaming the unvaccinated folks, not the regular folks,” an angry Gov. Kay Ivey (R) of Alabama, told reporters. “It’s the unvaccinated folks that are letting us down.”

In response to the resurgence in cases, President Joe Biden has ordered new vaccine mandates for millions of federal workers.

California started requiring health care professionals to be vaccinated in August 2021, removing the option for unvaccinated employees to submit to regular testing.

New York City became the first in the country to require proof of vaccination for all workers and customers to enter restaurants, gyms, concert halls, movie theaters, and Broadway venues.

Nearly 60 major medical organizations, including the American Medical Association and the American Nurses Association, have called for mandatory vaccination of all health care workers.

Meanwhile, many businesses are requiring workers to be vaccinated before returning to offices and other workplaces. Colleges across the country are mandating the shots for students and staff. And some states and cities are also returning to mask mandates, including Hawaii; Louisiana; Washington, D.C.; San Francisco; and Los Angeles.

Experts say the 90 million unvaccinated Americans are most at risk from COVID and have helped the new Delta variant gain a foothold and spread, posing a risk of “breakthrough” cases even in vaccinated people.

Delta is more contagious and causes more severe disease than other known variants of the virus, according to the CDC. It is also more contagious than the viruses that cause Middle East respiratory syndrome, severe acute respiratory syndrome, Ebola, the common cold, flu, and smallpox
 

Calls for mandates grow

With Delta helping to drive new spikes in COVID cases, some vaccinated Americans argue that the federal government should be taking a harder line with holdouts. Others have even advocated withholding government stimulus checks or tax credits from vaccine refusers and cutting federal funding to states that don’t meet vaccine targets.

Eric Jaffe, a creative writer and producer from Florida who is vaccinated, said he would like to see government agencies and private businesses do more to put pressure on unvaccinated Americans to get the shot.

“In the interest of public safety, I believe the government and private businesses need to [make] life difficult for the unvaccinated,” said Mr. Jaffe, 29, whose parents both contracted the virus but recovered. “They should not be allowed to dine at restaurants, ride public transportation, attend concerts, or broadly be in spaces with large concentrations of people without passing a COVID test at the door.

“They’ll stand in long lines and be inconvenienced at every turn, while vaccinated people get to fly through security, TSA PreCheck-style. The holdouts at [this] point are beyond convincing. The vaccinated should be able to return to a level of normalcy, and the unvaccinated should face restrictions. Any other dynamic puts the stress on citizens who did the right thing.”

Elif Akcali, 49, who teaches engineering at the University of Florida, Gainesville, worries that the rights of people who refuse the vaccine are being put ahead of those of vaccinated people. She’s also concerned for people who face greater COVID risks, including health care workers and children too young to be inoculated.

“Each infection is an opportunity for the virus to evolve into a stronger version in itself,” said Ms. Akcali, who felt such a sense of relief when she received her vaccination that she teared up. “Each hospitalization is an unnecessary burden to health care workers and the system. Each death brings heartbreak to someone in their circle.”

Ed Berliner, an Emmy Award–winning broadcast journalist and Florida-based media specialist, blames social media for spreading misinformation that has taken root with unvaccinated Americans.

“When America rallied together to combat polio, there were two things we didn’t have. One was a lack of the sewer-dwelling, troll-infested social media, which has become the main source of news for the less intelligent and arrogant,” said Mr. Berliner, CEO of Entourage Media and host of The Man in the Arena, a talk show. “Second, children were dying across the country, and that made people sit up and take notice.”

Mr. Berliner, who knows two people who’ve died from COVID and who received the vaccine early, also believes too many political leaders are still fueling falsehoods that are giving unvaccinated Americans a license to refuse the shot.

“We are also here because governments and officials spend too little time being brutally honest, choosing instead to dance around issues with soft words,” he said. “The first words out of their mouths should have been: ‘What we are doing is trying to save lives. Help us save your life and that of everyone else.’ Would it have made a difference? We will never know.”

Shon Neyland, senior pastor at the Highland Christian Center church in Portland, Ore., said vaccine tensions have divided his congregation, with about half refusing the shot by his estimation. But he said it’s important to understand why some are making that choice, rather than rage at them and hammer home the benefits of the shot.

Many vaccine holdouts don’t trust the government or medical establishment or have bought into political arguments against the shot, he says. Some conservative evangelicals are also swayed by spiritual beliefs that COVID-19 is a sign of “biblical end-times prophesies” and the vaccine is “the mark of the beast.”

But he has tried to counter those beliefs and biases, arguing they are false and unfounded, urging members of his church to get the vaccine, and partnering with local health officials to run clinics to deliver it.

“I gently try to show them that the vaccine is for our own good and, in fact, is a blessing from God, and it’s up to us to accept the blessing [so] we can get back to somewhat of normalcy,” said Mr. Neyland, author of “The Courage to Stand: A New America.”

“I also believe that to get a vaccine this quick, this was nothing short of a miracle to turn the tide so quickly. Now, for us to resist, it would cause us to continue to suffer and lose lives. And you can’t turn away from the lives that have already been lost.”

Mr. Hyman fears we may not have seen the worst of the pandemic and that the Delta variant won’t be the last or most virulent mutation to emerge.

“The number of unvaccinated people is allowing this virus to continue circulating in the community,” he noted. “And while I have a tremendous amount of confidence that the vaccine protects me now from Delta, I have less confidence that it’s going to protect me from whatever [variant] comes next.

“So, I have a tremendous amount of concern for my own health and safety and welfare, and that of the people that I love. But I’m also concerned about what’s it going to do to businesses [and] the economy. Are we going to have more shutdowns if cases continue trending up? I’m very concerned as to what this could do [to] the country.”

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

Asymptomatic pregnant women with no previous diagnosis of type 1 or 2 diabetes should be screened for gestational diabetes at 24 weeks’ gestation or later, according to an updated recommendation from the U.S. Preventive Services Task Force.

Pregnant individuals who develop gestational diabetes are at increased risk for complications including preeclampsia, fetal macrosomia, and neonatal hypoglycemia, as well as negative long-term outcomes for themselves and their children, wrote lead author Karina W. Davidson, PhD, of Feinstein Institute for Medical Research, Manhasset, N.Y., and colleagues. The statement was published online in JAMA.

The B recommendation and I statement reflect “moderate certainty” that current evidence supports the recommendation in terms of harms versus benefits, and is consistent with the 2014 USPSTF recommendation.

The statement calls for a one-time screening using a glucose tolerance test at or after 24 weeks’ gestation. Although most screening in the United States takes place prior to 28 weeks’ gestation, it can be performed later in patients who begin prenatal care after 28 weeks’ gestation, according to the statement. Data on the harms and benefits of gestational diabetes screening prior to 24 weeks’ gestation are limited, the authors noted. Gestational diabetes was defined as diabetes that develops during pregnancy that is not clearly overt diabetes.

To update the 2014 recommendation, the USPSTF commissioned a systematic review. In 45 prospective studies on the accuracy of gestational diabetes screening, several tests, included oral glucose challenge test, oral glucose tolerance test, and fasting plasma glucose using either a one- or two-step approach were accurate detectors of gestational diabetes; therefore, the USPSTF does not recommend a specific test.

In 13 trials on the impact of treating gestational diabetes on intermediate and health outcomes, treatment was associated with a reduced risk of outcomes, including primary cesarean delivery (but not total cesarean delivery) and preterm delivery, but not with a reduced risk of outcomes including preeclampsia, emergency cesarean delivery, induction of labor, or maternal birth trauma.

The task force also reviewed seven studies of harms associated with screening for gestational diabetes, including three on psychosocial harms, three on hospital experiences, and one of the odds of cesarean delivery after a diagnosis of gestational diabetes. No increase in anxiety or depression occurred following a positive diagnosis or false-positive test result, but data suggested that a gestational diabetes diagnosis may be associated with higher rates of cesarean delivery.

A total of 13 trials evaluated the harms associated with treatment of gestational diabetes, and found no association between treatment and increased risk of several outcomes including severe maternal hypoglycemia, low birth weight, and small for gestational age, and no effect was noted on the number of cesarean deliveries.

Evidence gaps that require additional research include randomized, controlled trials on the effects of gestational diabetes screening on health outcomes, as well as benefits versus harms of screening for pregnant individuals prior to 24 weeks, and studies on the effects of screening in subpopulations of race/ethnicity, age, and socioeconomic factors, according to the task force. Additional research also is needed in areas of maternal health outcomes, long-term outcomes, and the effect on outcomes of one-step versus two-step screening, the USPSTF said.

However, “screening for and detecting gestational diabetes provides a potential opportunity to control blood glucose levels (through lifestyle changes, pharmacological interventions, or both) and reduce the risk of macrosomia and LGA [large for gestational age] infants,” the task force wrote. “In turn, this can prevent associated complications such as primary cesarean delivery, shoulder dystocia, and [neonatal] ICU admissions.”
 

Support screening with counseling on risk reduction

The USPSTF recommendation is important at this time because “the prevalence of gestational diabetes is increasing secondary to rising rates of obesity,” Iris Krishna, MD, of Emory University, Atlanta, said in an interview.

“In 2014, based on a systematic review of literature, the USPSTF recommended screening all asymptomatic pregnant women for gestational diabetes mellitus [GDM] starting at 24 weeks’ gestation. The recommended gestational age for screening coincides with increasing insulin resistance during pregnancy with advancing gestational age,” Dr. Krishna said.

“An updated systematic review by the USPSTF concluded that existing literature continues to affirm current recommendations of universal screening for GDM at 24 weeks gestation or later. There continues, however, to be no consensus on the optimal approach to screening,” she noted.

“Screening can be performed as a two-step or one-step approach,” said Dr. Krishna. “The two-step approach is commonly used in the United States, and all pregnant women are first screened with a 50-gram oral glucose solution followed by a diagnostic test if they have a positive initial screening.

“Women with risk factors for diabetes, such as prior GDM, obesity, strong family history of diabetes, or history of fetal macrosomia, should be screened early in pregnancy for GDM and have the GDM screen repeated at 24 weeks’ gestation or later if normal in early pregnancy,” Dr. Krishna said. “Pregnant women should be counseled on the importance of diet and exercise and appropriate weight gain in pregnancy to reduce the risk of GDM. Overall, timely diagnosis of gestational diabetes is crucial to improving maternal and fetal pregnancy outcomes.”

The full recommendation statement is also available on the USPSTF website. The research was supported by the Agency for Healthcare Research and Quality. The researchers had no financial conflicts to disclose. Dr. Krishna had no disclosures, but serves on the editorial advisory board of Ob.Gyn News.

Asymptomatic pregnant women with no previous diagnosis of type 1 or 2 diabetes should be screened for gestational diabetes at 24 weeks’ gestation or later, according to an updated recommendation from the U.S. Preventive Services Task Force.

Pregnant individuals who develop gestational diabetes are at increased risk for complications including preeclampsia, fetal macrosomia, and neonatal hypoglycemia, as well as negative long-term outcomes for themselves and their children, wrote lead author Karina W. Davidson, PhD, of Feinstein Institute for Medical Research, Manhasset, N.Y., and colleagues. The statement was published online in JAMA.

The B recommendation and I statement reflect “moderate certainty” that current evidence supports the recommendation in terms of harms versus benefits, and is consistent with the 2014 USPSTF recommendation.

The statement calls for a one-time screening using a glucose tolerance test at or after 24 weeks’ gestation. Although most screening in the United States takes place prior to 28 weeks’ gestation, it can be performed later in patients who begin prenatal care after 28 weeks’ gestation, according to the statement. Data on the harms and benefits of gestational diabetes screening prior to 24 weeks’ gestation are limited, the authors noted. Gestational diabetes was defined as diabetes that develops during pregnancy that is not clearly overt diabetes.

To update the 2014 recommendation, the USPSTF commissioned a systematic review. In 45 prospective studies on the accuracy of gestational diabetes screening, several tests, included oral glucose challenge test, oral glucose tolerance test, and fasting plasma glucose using either a one- or two-step approach were accurate detectors of gestational diabetes; therefore, the USPSTF does not recommend a specific test.

In 13 trials on the impact of treating gestational diabetes on intermediate and health outcomes, treatment was associated with a reduced risk of outcomes, including primary cesarean delivery (but not total cesarean delivery) and preterm delivery, but not with a reduced risk of outcomes including preeclampsia, emergency cesarean delivery, induction of labor, or maternal birth trauma.

The task force also reviewed seven studies of harms associated with screening for gestational diabetes, including three on psychosocial harms, three on hospital experiences, and one of the odds of cesarean delivery after a diagnosis of gestational diabetes. No increase in anxiety or depression occurred following a positive diagnosis or false-positive test result, but data suggested that a gestational diabetes diagnosis may be associated with higher rates of cesarean delivery.

A total of 13 trials evaluated the harms associated with treatment of gestational diabetes, and found no association between treatment and increased risk of several outcomes including severe maternal hypoglycemia, low birth weight, and small for gestational age, and no effect was noted on the number of cesarean deliveries.

Evidence gaps that require additional research include randomized, controlled trials on the effects of gestational diabetes screening on health outcomes, as well as benefits versus harms of screening for pregnant individuals prior to 24 weeks, and studies on the effects of screening in subpopulations of race/ethnicity, age, and socioeconomic factors, according to the task force. Additional research also is needed in areas of maternal health outcomes, long-term outcomes, and the effect on outcomes of one-step versus two-step screening, the USPSTF said.

However, “screening for and detecting gestational diabetes provides a potential opportunity to control blood glucose levels (through lifestyle changes, pharmacological interventions, or both) and reduce the risk of macrosomia and LGA [large for gestational age] infants,” the task force wrote. “In turn, this can prevent associated complications such as primary cesarean delivery, shoulder dystocia, and [neonatal] ICU admissions.”
 

Support screening with counseling on risk reduction

The USPSTF recommendation is important at this time because “the prevalence of gestational diabetes is increasing secondary to rising rates of obesity,” Iris Krishna, MD, of Emory University, Atlanta, said in an interview.

“In 2014, based on a systematic review of literature, the USPSTF recommended screening all asymptomatic pregnant women for gestational diabetes mellitus [GDM] starting at 24 weeks’ gestation. The recommended gestational age for screening coincides with increasing insulin resistance during pregnancy with advancing gestational age,” Dr. Krishna said.

“An updated systematic review by the USPSTF concluded that existing literature continues to affirm current recommendations of universal screening for GDM at 24 weeks gestation or later. There continues, however, to be no consensus on the optimal approach to screening,” she noted.

“Screening can be performed as a two-step or one-step approach,” said Dr. Krishna. “The two-step approach is commonly used in the United States, and all pregnant women are first screened with a 50-gram oral glucose solution followed by a diagnostic test if they have a positive initial screening.

“Women with risk factors for diabetes, such as prior GDM, obesity, strong family history of diabetes, or history of fetal macrosomia, should be screened early in pregnancy for GDM and have the GDM screen repeated at 24 weeks’ gestation or later if normal in early pregnancy,” Dr. Krishna said. “Pregnant women should be counseled on the importance of diet and exercise and appropriate weight gain in pregnancy to reduce the risk of GDM. Overall, timely diagnosis of gestational diabetes is crucial to improving maternal and fetal pregnancy outcomes.”

The full recommendation statement is also available on the USPSTF website. The research was supported by the Agency for Healthcare Research and Quality. The researchers had no financial conflicts to disclose. Dr. Krishna had no disclosures, but serves on the editorial advisory board of Ob.Gyn News.

Asymptomatic pregnant women with no previous diagnosis of type 1 or 2 diabetes should be screened for gestational diabetes at 24 weeks’ gestation or later, according to an updated recommendation from the U.S. Preventive Services Task Force.

Pregnant individuals who develop gestational diabetes are at increased risk for complications including preeclampsia, fetal macrosomia, and neonatal hypoglycemia, as well as negative long-term outcomes for themselves and their children, wrote lead author Karina W. Davidson, PhD, of Feinstein Institute for Medical Research, Manhasset, N.Y., and colleagues. The statement was published online in JAMA.

The B recommendation and I statement reflect “moderate certainty” that current evidence supports the recommendation in terms of harms versus benefits, and is consistent with the 2014 USPSTF recommendation.

The statement calls for a one-time screening using a glucose tolerance test at or after 24 weeks’ gestation. Although most screening in the United States takes place prior to 28 weeks’ gestation, it can be performed later in patients who begin prenatal care after 28 weeks’ gestation, according to the statement. Data on the harms and benefits of gestational diabetes screening prior to 24 weeks’ gestation are limited, the authors noted. Gestational diabetes was defined as diabetes that develops during pregnancy that is not clearly overt diabetes.

To update the 2014 recommendation, the USPSTF commissioned a systematic review. In 45 prospective studies on the accuracy of gestational diabetes screening, several tests, included oral glucose challenge test, oral glucose tolerance test, and fasting plasma glucose using either a one- or two-step approach were accurate detectors of gestational diabetes; therefore, the USPSTF does not recommend a specific test.

In 13 trials on the impact of treating gestational diabetes on intermediate and health outcomes, treatment was associated with a reduced risk of outcomes, including primary cesarean delivery (but not total cesarean delivery) and preterm delivery, but not with a reduced risk of outcomes including preeclampsia, emergency cesarean delivery, induction of labor, or maternal birth trauma.

The task force also reviewed seven studies of harms associated with screening for gestational diabetes, including three on psychosocial harms, three on hospital experiences, and one of the odds of cesarean delivery after a diagnosis of gestational diabetes. No increase in anxiety or depression occurred following a positive diagnosis or false-positive test result, but data suggested that a gestational diabetes diagnosis may be associated with higher rates of cesarean delivery.

A total of 13 trials evaluated the harms associated with treatment of gestational diabetes, and found no association between treatment and increased risk of several outcomes including severe maternal hypoglycemia, low birth weight, and small for gestational age, and no effect was noted on the number of cesarean deliveries.

Evidence gaps that require additional research include randomized, controlled trials on the effects of gestational diabetes screening on health outcomes, as well as benefits versus harms of screening for pregnant individuals prior to 24 weeks, and studies on the effects of screening in subpopulations of race/ethnicity, age, and socioeconomic factors, according to the task force. Additional research also is needed in areas of maternal health outcomes, long-term outcomes, and the effect on outcomes of one-step versus two-step screening, the USPSTF said.

However, “screening for and detecting gestational diabetes provides a potential opportunity to control blood glucose levels (through lifestyle changes, pharmacological interventions, or both) and reduce the risk of macrosomia and LGA [large for gestational age] infants,” the task force wrote. “In turn, this can prevent associated complications such as primary cesarean delivery, shoulder dystocia, and [neonatal] ICU admissions.”
 

Support screening with counseling on risk reduction

The USPSTF recommendation is important at this time because “the prevalence of gestational diabetes is increasing secondary to rising rates of obesity,” Iris Krishna, MD, of Emory University, Atlanta, said in an interview.

“In 2014, based on a systematic review of literature, the USPSTF recommended screening all asymptomatic pregnant women for gestational diabetes mellitus [GDM] starting at 24 weeks’ gestation. The recommended gestational age for screening coincides with increasing insulin resistance during pregnancy with advancing gestational age,” Dr. Krishna said.

“An updated systematic review by the USPSTF concluded that existing literature continues to affirm current recommendations of universal screening for GDM at 24 weeks gestation or later. There continues, however, to be no consensus on the optimal approach to screening,” she noted.

“Screening can be performed as a two-step or one-step approach,” said Dr. Krishna. “The two-step approach is commonly used in the United States, and all pregnant women are first screened with a 50-gram oral glucose solution followed by a diagnostic test if they have a positive initial screening.

“Women with risk factors for diabetes, such as prior GDM, obesity, strong family history of diabetes, or history of fetal macrosomia, should be screened early in pregnancy for GDM and have the GDM screen repeated at 24 weeks’ gestation or later if normal in early pregnancy,” Dr. Krishna said. “Pregnant women should be counseled on the importance of diet and exercise and appropriate weight gain in pregnancy to reduce the risk of GDM. Overall, timely diagnosis of gestational diabetes is crucial to improving maternal and fetal pregnancy outcomes.”

The full recommendation statement is also available on the USPSTF website. The research was supported by the Agency for Healthcare Research and Quality. The researchers had no financial conflicts to disclose. Dr. Krishna had no disclosures, but serves on the editorial advisory board of Ob.Gyn News.

Cardiologist Samirkumar J. Shah, MD, was sentenced to 78 months in prison after his conviction on two counts of federal health care fraud involving more than $13 million.

Instants/Getty Images

As part of his sentence, Dr. Shah, 58, of Fox Chapel, Pa., must pay $1.7 million in restitution and other penalties and undergo 3 years of supervised release after prison.

“Dr. Shah risked the health of his patients so he could make millions of dollars through unnecessary procedures, and lied and fabricated records for years to perpetuate his fraud scheme,” acting U.S. Attorney Stephen R. Kaufman said in an Aug. 5 statement from the Department of Justice.

As previously reported, Dr. Shah was convicted June 14, 2019, of submitting fraudulent claims to private and federal insurance programs between 2008 and 2013 for external counterpulsation (ECP) therapy, a lower limb compression treatment approved for patients with coronary artery disease and refractory angina.

Dr. Shah, however, advertised ECP as the “fountain of youth,” claimed it made patients “younger and smarter,” and offered the treatment for conditions such as obesity, hypertension, hypotension, diabetes, and erectile dysfunction.

Patients were required to undergo diagnostic ultrasounds as a precautionary measure prior to starting ECP, but witness testimony established that Dr. Shah did not review any of the imaging before approving new patients for ECP, placing his patients at risk for serious injury or even death, the DOJ stated.

The evidence also showed that Dr. Shah double-billed insurers, routinely submitted fabricated patient files, and made false statements concerning his practice, patient population, recording keeping, and compliance with coverage guidelines, the government said.

During the scheme, Dr. Shah submitted ECP-related claims for Medicare Part B, UPMC Health Plan, Highmark Blue Cross Blue Shield, and Gateway Health Plan beneficiaries totalling more than $13 million and received reimbursement payments in excess of $3.5 million.

“Rather than upholding the oath he swore and providing care for patients who trusted him, this defendant misled patients and drained critical Medicaid funds from families who needed it,” said Attorney General Josh Shapiro. “We will not let anyone put their patients’ lives at risk for a profit.”

“Today’s sentence holds Mr. Shah accountable for his appalling actions,” said FBI Pittsburgh Special Agent in Charge Mike Nordwall. “Mr. Shah used his position as a doctor to illegally profit from a health care program paid for by taxpayers. Fraud of this magnitude will not be tolerated.”

Dr. Shah has been in custody since July 15, 2021, after skipping out on his original July 14 sentencing date. The Tribune-Review reported that Dr. Shah filed a last-minute request for a continuance, claiming he had an adverse reaction to the Pfizer COVID-19 vaccination and was advised by his doctor that he needed “strict bedrest for at least 6 weeks.”

Dr. Shah reportedly turned himself after presiding U.S. District Judge David S. Cercone denied the motion and issued an arrest warrant.

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

Cardiologist Samirkumar J. Shah, MD, was sentenced to 78 months in prison after his conviction on two counts of federal health care fraud involving more than $13 million.

Instants/Getty Images

As part of his sentence, Dr. Shah, 58, of Fox Chapel, Pa., must pay $1.7 million in restitution and other penalties and undergo 3 years of supervised release after prison.

“Dr. Shah risked the health of his patients so he could make millions of dollars through unnecessary procedures, and lied and fabricated records for years to perpetuate his fraud scheme,” acting U.S. Attorney Stephen R. Kaufman said in an Aug. 5 statement from the Department of Justice.

As previously reported, Dr. Shah was convicted June 14, 2019, of submitting fraudulent claims to private and federal insurance programs between 2008 and 2013 for external counterpulsation (ECP) therapy, a lower limb compression treatment approved for patients with coronary artery disease and refractory angina.

Dr. Shah, however, advertised ECP as the “fountain of youth,” claimed it made patients “younger and smarter,” and offered the treatment for conditions such as obesity, hypertension, hypotension, diabetes, and erectile dysfunction.

Patients were required to undergo diagnostic ultrasounds as a precautionary measure prior to starting ECP, but witness testimony established that Dr. Shah did not review any of the imaging before approving new patients for ECP, placing his patients at risk for serious injury or even death, the DOJ stated.

The evidence also showed that Dr. Shah double-billed insurers, routinely submitted fabricated patient files, and made false statements concerning his practice, patient population, recording keeping, and compliance with coverage guidelines, the government said.

During the scheme, Dr. Shah submitted ECP-related claims for Medicare Part B, UPMC Health Plan, Highmark Blue Cross Blue Shield, and Gateway Health Plan beneficiaries totalling more than $13 million and received reimbursement payments in excess of $3.5 million.

“Rather than upholding the oath he swore and providing care for patients who trusted him, this defendant misled patients and drained critical Medicaid funds from families who needed it,” said Attorney General Josh Shapiro. “We will not let anyone put their patients’ lives at risk for a profit.”

“Today’s sentence holds Mr. Shah accountable for his appalling actions,” said FBI Pittsburgh Special Agent in Charge Mike Nordwall. “Mr. Shah used his position as a doctor to illegally profit from a health care program paid for by taxpayers. Fraud of this magnitude will not be tolerated.”

Dr. Shah has been in custody since July 15, 2021, after skipping out on his original July 14 sentencing date. The Tribune-Review reported that Dr. Shah filed a last-minute request for a continuance, claiming he had an adverse reaction to the Pfizer COVID-19 vaccination and was advised by his doctor that he needed “strict bedrest for at least 6 weeks.”

Dr. Shah reportedly turned himself after presiding U.S. District Judge David S. Cercone denied the motion and issued an arrest warrant.

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

Cardiologist Samirkumar J. Shah, MD, was sentenced to 78 months in prison after his conviction on two counts of federal health care fraud involving more than $13 million.

Instants/Getty Images

As part of his sentence, Dr. Shah, 58, of Fox Chapel, Pa., must pay $1.7 million in restitution and other penalties and undergo 3 years of supervised release after prison.

“Dr. Shah risked the health of his patients so he could make millions of dollars through unnecessary procedures, and lied and fabricated records for years to perpetuate his fraud scheme,” acting U.S. Attorney Stephen R. Kaufman said in an Aug. 5 statement from the Department of Justice.

As previously reported, Dr. Shah was convicted June 14, 2019, of submitting fraudulent claims to private and federal insurance programs between 2008 and 2013 for external counterpulsation (ECP) therapy, a lower limb compression treatment approved for patients with coronary artery disease and refractory angina.

Dr. Shah, however, advertised ECP as the “fountain of youth,” claimed it made patients “younger and smarter,” and offered the treatment for conditions such as obesity, hypertension, hypotension, diabetes, and erectile dysfunction.

Patients were required to undergo diagnostic ultrasounds as a precautionary measure prior to starting ECP, but witness testimony established that Dr. Shah did not review any of the imaging before approving new patients for ECP, placing his patients at risk for serious injury or even death, the DOJ stated.

The evidence also showed that Dr. Shah double-billed insurers, routinely submitted fabricated patient files, and made false statements concerning his practice, patient population, recording keeping, and compliance with coverage guidelines, the government said.

During the scheme, Dr. Shah submitted ECP-related claims for Medicare Part B, UPMC Health Plan, Highmark Blue Cross Blue Shield, and Gateway Health Plan beneficiaries totalling more than $13 million and received reimbursement payments in excess of $3.5 million.

“Rather than upholding the oath he swore and providing care for patients who trusted him, this defendant misled patients and drained critical Medicaid funds from families who needed it,” said Attorney General Josh Shapiro. “We will not let anyone put their patients’ lives at risk for a profit.”

“Today’s sentence holds Mr. Shah accountable for his appalling actions,” said FBI Pittsburgh Special Agent in Charge Mike Nordwall. “Mr. Shah used his position as a doctor to illegally profit from a health care program paid for by taxpayers. Fraud of this magnitude will not be tolerated.”

Dr. Shah has been in custody since July 15, 2021, after skipping out on his original July 14 sentencing date. The Tribune-Review reported that Dr. Shah filed a last-minute request for a continuance, claiming he had an adverse reaction to the Pfizer COVID-19 vaccination and was advised by his doctor that he needed “strict bedrest for at least 6 weeks.”

Dr. Shah reportedly turned himself after presiding U.S. District Judge David S. Cercone denied the motion and issued an arrest warrant.

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

As working mothers with babies in tow when the COVID-19 crisis struck, countless uncertainties threatened our already precarious work-life balance. We suddenly had many questions:

“If my daycare closes, what will I do for childcare?”

“How do I navigate diaper changes, feedings, and naps with my hectic remote work schedule?”

“If I’m constantly interrupted during the day, should I skip sleep to catch up on work and not let my colleagues down?”

As professionals who work closely with medical trainees, we knew our parenting dilemmas were being experienced even more acutely by our frontline worker colleagues.

Medical training is an increasingly common time to start a family. In a recent study, 34% of trainees in Harvard-affiliated residency programs became parents during training, and another 52% planned to do so. Trainees have higher breastfeeding initiation rates but lower continuation rates than the general population. Early nursing cessation among trainees is well documented nationally and is most often attributed to work-related barriers. These barriers range from insufficient time and limited access to facilities to a lack of support and discrimination by supervisors and peers.

This trend does not discriminate by specialty. Even among training programs known to be “family friendly,” the average duration of nursing is just 4.5 months. Residents of color are disproportionately affected by inadequate support. Studies show that Black parents breastfeed at lower rates than White parents. This has been largely attributed to structural racism and implicit bias, such as Black parents receiving less assistance initiating nursing after delivery. Adequate lactation support and inclusivity are also lacking for transgender parents who choose to breastfeed or chestfeed.

The very nature of residency training, which includes shifts that can span more than 24 hours, conflicts with many health-promoting behaviors like sleeping and eating well. However, its interference with lactation is correlated with gender. Women are disproportionately affected by the negative outcomes of unmet lactation goals. These include work-life imbalance, career dissatisfaction, and negative emotions. In a study of pediatric residents, one in four did not achieve their breastfeeding goals. Respondents reported feeling “sad, devastated, defeated, disappointed, guilty, embarrassed, frustrated, angry, like a failure, and inadequate.” Among physician mothers more broadly, discrimination related to pregnancy, parental leave, and nursing is associated with higher self-reported burnout.

Navigating nursing during residency training has more than just emotional and psychological consequences – it also has professional ones. Pursuing personal lactation goals can delay residency program completion and board certification, influence specialty selection, negatively impact research productivity, impede career advancement, and lead to misgivings about career choice.

Trainees and their families are not the only ones harmed by inadequate support in residency programs. Patients and their families are affected, too. Research suggests that physicians’ personal breastfeeding practices affect the advice they give to patients. Those who receive lactation support are more likely to help patients meet their own goals. In the previously mentioned study of pediatric residents, more than 90% of the 400 respondents said their own or their partner’s nursing experience affected their interaction with lactating patients in their clinic or hospital.

Increased lactation support is a straightforward, low-cost, high-impact intervention. It benefits trainee well-being, satisfaction, workflow, and future patient care. The Accreditation Council for Graduate Medical Education mandated in July 2019 that all residency programs provide adequate lactation facilities – including refrigeration capabilities and proximity for safe patient care. However, to our knowledge, rates of compliance with this new policy and citation for noncompliance have yet to be seen. Regardless, facilities alone are not enough. Residency programs should develop and enforce formal lactation policies.

Several institutions have successfully piloted such policies in recent years. One in particular from the University of Michigan’s surgery residency program inspired the development of a lactation policy within the internal medicine residency at our institution. These policies designate appropriate spaces at each clinical rotation site, clarify that residents are encouraged to take pumping breaks as needed – in coordination with clinical teams so as not to compromise patient care – and communicate support from supervisors.

Our program also established an informal peer mentoring program. Residents with experience pumping at work pair up with newer trainees. The policy benefits residents who wish to chestfeed or breastfeed, normalizes lactation, and empowers trainees by diminishing the need to ask for individual accommodations. It also costs the program nothing.

As more women enter medicine and more trainees become parents during residency, the need for support in this area will only continue to grow. The widespread lack of such resources, and the fact that clean and private facilities are only now being mandated, is symbolic. If even this basic need is rarely acknowledged or met, what other resident needs are being neglected?

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

As working mothers with babies in tow when the COVID-19 crisis struck, countless uncertainties threatened our already precarious work-life balance. We suddenly had many questions:

“If my daycare closes, what will I do for childcare?”

“How do I navigate diaper changes, feedings, and naps with my hectic remote work schedule?”

“If I’m constantly interrupted during the day, should I skip sleep to catch up on work and not let my colleagues down?”

As professionals who work closely with medical trainees, we knew our parenting dilemmas were being experienced even more acutely by our frontline worker colleagues.

Medical training is an increasingly common time to start a family. In a recent study, 34% of trainees in Harvard-affiliated residency programs became parents during training, and another 52% planned to do so. Trainees have higher breastfeeding initiation rates but lower continuation rates than the general population. Early nursing cessation among trainees is well documented nationally and is most often attributed to work-related barriers. These barriers range from insufficient time and limited access to facilities to a lack of support and discrimination by supervisors and peers.

This trend does not discriminate by specialty. Even among training programs known to be “family friendly,” the average duration of nursing is just 4.5 months. Residents of color are disproportionately affected by inadequate support. Studies show that Black parents breastfeed at lower rates than White parents. This has been largely attributed to structural racism and implicit bias, such as Black parents receiving less assistance initiating nursing after delivery. Adequate lactation support and inclusivity are also lacking for transgender parents who choose to breastfeed or chestfeed.

The very nature of residency training, which includes shifts that can span more than 24 hours, conflicts with many health-promoting behaviors like sleeping and eating well. However, its interference with lactation is correlated with gender. Women are disproportionately affected by the negative outcomes of unmet lactation goals. These include work-life imbalance, career dissatisfaction, and negative emotions. In a study of pediatric residents, one in four did not achieve their breastfeeding goals. Respondents reported feeling “sad, devastated, defeated, disappointed, guilty, embarrassed, frustrated, angry, like a failure, and inadequate.” Among physician mothers more broadly, discrimination related to pregnancy, parental leave, and nursing is associated with higher self-reported burnout.

Navigating nursing during residency training has more than just emotional and psychological consequences – it also has professional ones. Pursuing personal lactation goals can delay residency program completion and board certification, influence specialty selection, negatively impact research productivity, impede career advancement, and lead to misgivings about career choice.

Trainees and their families are not the only ones harmed by inadequate support in residency programs. Patients and their families are affected, too. Research suggests that physicians’ personal breastfeeding practices affect the advice they give to patients. Those who receive lactation support are more likely to help patients meet their own goals. In the previously mentioned study of pediatric residents, more than 90% of the 400 respondents said their own or their partner’s nursing experience affected their interaction with lactating patients in their clinic or hospital.

Increased lactation support is a straightforward, low-cost, high-impact intervention. It benefits trainee well-being, satisfaction, workflow, and future patient care. The Accreditation Council for Graduate Medical Education mandated in July 2019 that all residency programs provide adequate lactation facilities – including refrigeration capabilities and proximity for safe patient care. However, to our knowledge, rates of compliance with this new policy and citation for noncompliance have yet to be seen. Regardless, facilities alone are not enough. Residency programs should develop and enforce formal lactation policies.

Several institutions have successfully piloted such policies in recent years. One in particular from the University of Michigan’s surgery residency program inspired the development of a lactation policy within the internal medicine residency at our institution. These policies designate appropriate spaces at each clinical rotation site, clarify that residents are encouraged to take pumping breaks as needed – in coordination with clinical teams so as not to compromise patient care – and communicate support from supervisors.

Our program also established an informal peer mentoring program. Residents with experience pumping at work pair up with newer trainees. The policy benefits residents who wish to chestfeed or breastfeed, normalizes lactation, and empowers trainees by diminishing the need to ask for individual accommodations. It also costs the program nothing.

As more women enter medicine and more trainees become parents during residency, the need for support in this area will only continue to grow. The widespread lack of such resources, and the fact that clean and private facilities are only now being mandated, is symbolic. If even this basic need is rarely acknowledged or met, what other resident needs are being neglected?

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

As working mothers with babies in tow when the COVID-19 crisis struck, countless uncertainties threatened our already precarious work-life balance. We suddenly had many questions:

“If my daycare closes, what will I do for childcare?”

“How do I navigate diaper changes, feedings, and naps with my hectic remote work schedule?”

“If I’m constantly interrupted during the day, should I skip sleep to catch up on work and not let my colleagues down?”

As professionals who work closely with medical trainees, we knew our parenting dilemmas were being experienced even more acutely by our frontline worker colleagues.

Medical training is an increasingly common time to start a family. In a recent study, 34% of trainees in Harvard-affiliated residency programs became parents during training, and another 52% planned to do so. Trainees have higher breastfeeding initiation rates but lower continuation rates than the general population. Early nursing cessation among trainees is well documented nationally and is most often attributed to work-related barriers. These barriers range from insufficient time and limited access to facilities to a lack of support and discrimination by supervisors and peers.

This trend does not discriminate by specialty. Even among training programs known to be “family friendly,” the average duration of nursing is just 4.5 months. Residents of color are disproportionately affected by inadequate support. Studies show that Black parents breastfeed at lower rates than White parents. This has been largely attributed to structural racism and implicit bias, such as Black parents receiving less assistance initiating nursing after delivery. Adequate lactation support and inclusivity are also lacking for transgender parents who choose to breastfeed or chestfeed.

The very nature of residency training, which includes shifts that can span more than 24 hours, conflicts with many health-promoting behaviors like sleeping and eating well. However, its interference with lactation is correlated with gender. Women are disproportionately affected by the negative outcomes of unmet lactation goals. These include work-life imbalance, career dissatisfaction, and negative emotions. In a study of pediatric residents, one in four did not achieve their breastfeeding goals. Respondents reported feeling “sad, devastated, defeated, disappointed, guilty, embarrassed, frustrated, angry, like a failure, and inadequate.” Among physician mothers more broadly, discrimination related to pregnancy, parental leave, and nursing is associated with higher self-reported burnout.

Navigating nursing during residency training has more than just emotional and psychological consequences – it also has professional ones. Pursuing personal lactation goals can delay residency program completion and board certification, influence specialty selection, negatively impact research productivity, impede career advancement, and lead to misgivings about career choice.

Trainees and their families are not the only ones harmed by inadequate support in residency programs. Patients and their families are affected, too. Research suggests that physicians’ personal breastfeeding practices affect the advice they give to patients. Those who receive lactation support are more likely to help patients meet their own goals. In the previously mentioned study of pediatric residents, more than 90% of the 400 respondents said their own or their partner’s nursing experience affected their interaction with lactating patients in their clinic or hospital.

Increased lactation support is a straightforward, low-cost, high-impact intervention. It benefits trainee well-being, satisfaction, workflow, and future patient care. The Accreditation Council for Graduate Medical Education mandated in July 2019 that all residency programs provide adequate lactation facilities – including refrigeration capabilities and proximity for safe patient care. However, to our knowledge, rates of compliance with this new policy and citation for noncompliance have yet to be seen. Regardless, facilities alone are not enough. Residency programs should develop and enforce formal lactation policies.

Several institutions have successfully piloted such policies in recent years. One in particular from the University of Michigan’s surgery residency program inspired the development of a lactation policy within the internal medicine residency at our institution. These policies designate appropriate spaces at each clinical rotation site, clarify that residents are encouraged to take pumping breaks as needed – in coordination with clinical teams so as not to compromise patient care – and communicate support from supervisors.

Our program also established an informal peer mentoring program. Residents with experience pumping at work pair up with newer trainees. The policy benefits residents who wish to chestfeed or breastfeed, normalizes lactation, and empowers trainees by diminishing the need to ask for individual accommodations. It also costs the program nothing.

As more women enter medicine and more trainees become parents during residency, the need for support in this area will only continue to grow. The widespread lack of such resources, and the fact that clean and private facilities are only now being mandated, is symbolic. If even this basic need is rarely acknowledged or met, what other resident needs are being neglected?

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

A vital aspect of expanding access and care for sexually transmitted infections (STIs) in the United States is broadening responsibility for this care across the health care system and other community resources, according to an article published online July 6 in Clinical Infectious Diseases. This expansion and decentralization of care are central to adopting the “new sexual health paradigm” recommended by a National Academies report that was published in March.

“STIs represent a sizable, longstanding, and growing public health challenge,” write Vincent Guilamo-Ramos, PhD, MPH, dean and professor at the Duke University School of Nursing and director of the Center for Latino Adolescent and Family Health (CLAFH) at Duke University, both in Durham, N.C., and his colleagues. Yet the limitations on the current STI workforce and limited federal funding and support for STI prevention and care mean it will take clinicians of all types from across the health care spectrum to meet the challenge, they explain.

“For too long, STI prevention and treatment has been perceived as the sole responsibility of a narrow workforce of specialized STI and HIV service providers,” Dr. Guilamo-Ramos and his coauthor, Marco Thimm-Kaiser, MPH, associate in research at Duke University and epidemiologist at CLAFH, wrote in an email.

“However, the resources allocated to this STI specialty workforce have diminished over time, along with decreasing investments in the broader U.S. public health infrastructure,” they continued. “At the same time – and in part due to this underinvestment – STI rates have soared, reaching a record high for the sixth year in a row in 2019.”

Those factors led to the National Academies report, which recommends moving “away from the traditional, disease-focused perspective on STIs in favor of a holistic perspective of sexual health as an integral component of overall health and well-being,” Dr. Guilamo-Ramos and Mr. Thimm-Kaiser wrote to this news organization.

In their article, the authors review the limitations in the STI workforce, the implications of those limitations for the broader health care industry, and what it will take for STI and HIV specialists as well as regulators to ensure it’s possible to achieve the paradigm shift recommended by the National Academies.

Currently, the biggest limitation is access to care, said Laura Mercer, MD, MBA, of the department of obstetrics and gynecology and the ob.gyn. clerkship director at the University of Arizona, Phoenix. Dr. Mercer, who was not involved with the National Academies report or the analysis of it, said in an interview that it’s essential to emphasize “sexual health as a core element of routine primary and preventative care” to ensure it becomes more accessible to patients without the need to seek out specialty care.

Dr. Guilamo-Ramos and his colleagues drive home the importance of such a shift by noting that more than 200 million Americans live in counties with no practicing infectious disease physicians. The disparities are greatest in Southern states, which account for 40% of all reported STIs. The workforce shortage has continued to worsen alongside the deterioration of the clinical infrastructure supporting STI specialty services, the authors write.

Hence the need to expand accountability for care not only to primary-care physicians but also to nurses, pharmacists, physician assistants, nurse practitioners, and behavioral health practitioners. Doing so also requires normalizing sexual health services across health care professions.

“Prevention is a crucial first step” to this, Dr. Mercer said. “This is particularly important as we recall that almost half of new sexually transmitted infections occur in teenagers. Destigmatizing sexual health and sexual health education will also help encourage patients of all ages to request and accept testing.”

Further, with primary care practitioners managing most STI testing and treatment, subspecialists can focus primarily on complex or refractory cases, she added. Ways to help broaden care include developing point-of-care testing for STIs and improving the accuracy of existing testing, she said.

“The goal is to make routine sexual health services accessible in a wide range of settings, such as in primary care, at pharmacies, and in community-based settings, and to draw on a broader workforce for delivery of sexual health services,” Dr. Guilamo-Ramos and Mr. Thimm-Kaiser said in an interview.

Kevin Ault, MD, professor of obstetrics and gynecology and director of clinical and translational research at the University of Kansas Medical Center in Kansas City, said that many medical organizations, such as the American College of Obstetricians and Gynecologists, have long advocated incorporating sexual health into routine preventive care. He also noted that pharmacists have already become proactive in preventing STIs and could continue to do so.

“Vaccines for hepatitis and human papillomavirus are commonly available at pharmacies,” Dr. Ault said. He was not involved in the article by Dr. Guilamo-Ramos and colleagues or the original report. “Pharmacists could also fill a gap by administering injectable medications such as penicillin. States would have to approve changes in policy, but many states have already done this for expedited partner therapy.”

Dr. Guilamo-Ramos and Mr. Thimm-Kaiser noted similar barriers that must be removed to broaden delivery of STI services.

“Unfortunately, too many highly trained health care providers who are well-positioned for the delivery of sexual health services face regulatory or administrative barriers to practice to the full scope of their training,” they wrote. “These barriers can have a particularly negative impact in medically underserved communities, where physician shortages are common and where novel, decentralized health care service delivery models that draw on nonphysician providers may hold the greatest promise.”

As more diverse health care practitioners take on these roles, ID and HIV specialists can provide their expertise in developing training and technical assistance to support generalists, Dr. Guilamo-Ramos and Mr. Thimm-Kaiser wrote. They can also aid in aligning “clinical training curricula, licensing criteria, and practice guidelines with routine delivery of sexual health services.”

Dr. Guilamo-Ramos and his coauthors offer specific recommendations for professional training, licensing, and practice guidelines to help overcome the “insufficient knowledge, inadequate training, and absence of explicit protocols” that currently impede delivery of STI services in general practice settings.

Although the paradigm shift recommended by the National Academies is ambitious, it’s also necessary, and “none of the recommendations are out of reach,” Dr. Guilamo-Ramos and Mr. Thimm-Kaiser said in an interview. They pointed out how the COVID-19 pandemic has highlighted how underresourced the health care workforce and infrastructure are and how great health care disparities are.

“There is momentum toward rebuilding the nation’s health and public health system in a more effective and efficient way,” they said, and many of the STI report’s recommendations “overlap with priorities for the broader health and public health system moving forward.”

Dr. Mercer also believes the recommendations are realistic, “but only the beginning,” she told this news organization. “Comprehensive sexual education to expand knowledge about STI prevention and public health campaigns to help destigmatize sexual health care in general will remain crucial,” she said.

Sexual education, expanded access, and destigmatizing sexual care are particularly important for reaching the populations most in need of care, such as adolescents and young adults, as well as ethnic, racial, sexual, and gender-minority youth.

“It cannot be overstated how important of a priority population adolescents and young adults are,” Dr. Guilamo-Ramos and Mr. Thimm-Kaiser wrote. They noted that those aged 15-24 account for half of all STIs each year but represent only a quarter of the sexually active population. “Targeted efforts for STI prevention and treatment among adolescents and young adults are therefore essential for an overall successful strategy to address STIs and sexual health in the United States.”

The National Academies report was supported by the Centers for Disease Control and Prevention and the National Association of County and City Health Officials. Dr. Mercer, Dr. Ault, and Mr. Thimm-Kaiser have disclosed no relevant financial relationships. Dr. Guilamo-Ramos has received grants and personal fees from ViiV Health care.

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

A vital aspect of expanding access and care for sexually transmitted infections (STIs) in the United States is broadening responsibility for this care across the health care system and other community resources, according to an article published online July 6 in Clinical Infectious Diseases. This expansion and decentralization of care are central to adopting the “new sexual health paradigm” recommended by a National Academies report that was published in March.

“STIs represent a sizable, longstanding, and growing public health challenge,” write Vincent Guilamo-Ramos, PhD, MPH, dean and professor at the Duke University School of Nursing and director of the Center for Latino Adolescent and Family Health (CLAFH) at Duke University, both in Durham, N.C., and his colleagues. Yet the limitations on the current STI workforce and limited federal funding and support for STI prevention and care mean it will take clinicians of all types from across the health care spectrum to meet the challenge, they explain.

“For too long, STI prevention and treatment has been perceived as the sole responsibility of a narrow workforce of specialized STI and HIV service providers,” Dr. Guilamo-Ramos and his coauthor, Marco Thimm-Kaiser, MPH, associate in research at Duke University and epidemiologist at CLAFH, wrote in an email.

“However, the resources allocated to this STI specialty workforce have diminished over time, along with decreasing investments in the broader U.S. public health infrastructure,” they continued. “At the same time – and in part due to this underinvestment – STI rates have soared, reaching a record high for the sixth year in a row in 2019.”

Those factors led to the National Academies report, which recommends moving “away from the traditional, disease-focused perspective on STIs in favor of a holistic perspective of sexual health as an integral component of overall health and well-being,” Dr. Guilamo-Ramos and Mr. Thimm-Kaiser wrote to this news organization.

In their article, the authors review the limitations in the STI workforce, the implications of those limitations for the broader health care industry, and what it will take for STI and HIV specialists as well as regulators to ensure it’s possible to achieve the paradigm shift recommended by the National Academies.

Currently, the biggest limitation is access to care, said Laura Mercer, MD, MBA, of the department of obstetrics and gynecology and the ob.gyn. clerkship director at the University of Arizona, Phoenix. Dr. Mercer, who was not involved with the National Academies report or the analysis of it, said in an interview that it’s essential to emphasize “sexual health as a core element of routine primary and preventative care” to ensure it becomes more accessible to patients without the need to seek out specialty care.

Dr. Guilamo-Ramos and his colleagues drive home the importance of such a shift by noting that more than 200 million Americans live in counties with no practicing infectious disease physicians. The disparities are greatest in Southern states, which account for 40% of all reported STIs. The workforce shortage has continued to worsen alongside the deterioration of the clinical infrastructure supporting STI specialty services, the authors write.

Hence the need to expand accountability for care not only to primary-care physicians but also to nurses, pharmacists, physician assistants, nurse practitioners, and behavioral health practitioners. Doing so also requires normalizing sexual health services across health care professions.

“Prevention is a crucial first step” to this, Dr. Mercer said. “This is particularly important as we recall that almost half of new sexually transmitted infections occur in teenagers. Destigmatizing sexual health and sexual health education will also help encourage patients of all ages to request and accept testing.”

Further, with primary care practitioners managing most STI testing and treatment, subspecialists can focus primarily on complex or refractory cases, she added. Ways to help broaden care include developing point-of-care testing for STIs and improving the accuracy of existing testing, she said.

“The goal is to make routine sexual health services accessible in a wide range of settings, such as in primary care, at pharmacies, and in community-based settings, and to draw on a broader workforce for delivery of sexual health services,” Dr. Guilamo-Ramos and Mr. Thimm-Kaiser said in an interview.

Kevin Ault, MD, professor of obstetrics and gynecology and director of clinical and translational research at the University of Kansas Medical Center in Kansas City, said that many medical organizations, such as the American College of Obstetricians and Gynecologists, have long advocated incorporating sexual health into routine preventive care. He also noted that pharmacists have already become proactive in preventing STIs and could continue to do so.

“Vaccines for hepatitis and human papillomavirus are commonly available at pharmacies,” Dr. Ault said. He was not involved in the article by Dr. Guilamo-Ramos and colleagues or the original report. “Pharmacists could also fill a gap by administering injectable medications such as penicillin. States would have to approve changes in policy, but many states have already done this for expedited partner therapy.”

Dr. Guilamo-Ramos and Mr. Thimm-Kaiser noted similar barriers that must be removed to broaden delivery of STI services.

“Unfortunately, too many highly trained health care providers who are well-positioned for the delivery of sexual health services face regulatory or administrative barriers to practice to the full scope of their training,” they wrote. “These barriers can have a particularly negative impact in medically underserved communities, where physician shortages are common and where novel, decentralized health care service delivery models that draw on nonphysician providers may hold the greatest promise.”

As more diverse health care practitioners take on these roles, ID and HIV specialists can provide their expertise in developing training and technical assistance to support generalists, Dr. Guilamo-Ramos and Mr. Thimm-Kaiser wrote. They can also aid in aligning “clinical training curricula, licensing criteria, and practice guidelines with routine delivery of sexual health services.”

Dr. Guilamo-Ramos and his coauthors offer specific recommendations for professional training, licensing, and practice guidelines to help overcome the “insufficient knowledge, inadequate training, and absence of explicit protocols” that currently impede delivery of STI services in general practice settings.

Although the paradigm shift recommended by the National Academies is ambitious, it’s also necessary, and “none of the recommendations are out of reach,” Dr. Guilamo-Ramos and Mr. Thimm-Kaiser said in an interview. They pointed out how the COVID-19 pandemic has highlighted how underresourced the health care workforce and infrastructure are and how great health care disparities are.

“There is momentum toward rebuilding the nation’s health and public health system in a more effective and efficient way,” they said, and many of the STI report’s recommendations “overlap with priorities for the broader health and public health system moving forward.”

Dr. Mercer also believes the recommendations are realistic, “but only the beginning,” she told this news organization. “Comprehensive sexual education to expand knowledge about STI prevention and public health campaigns to help destigmatize sexual health care in general will remain crucial,” she said.

Sexual education, expanded access, and destigmatizing sexual care are particularly important for reaching the populations most in need of care, such as adolescents and young adults, as well as ethnic, racial, sexual, and gender-minority youth.

“It cannot be overstated how important of a priority population adolescents and young adults are,” Dr. Guilamo-Ramos and Mr. Thimm-Kaiser wrote. They noted that those aged 15-24 account for half of all STIs each year but represent only a quarter of the sexually active population. “Targeted efforts for STI prevention and treatment among adolescents and young adults are therefore essential for an overall successful strategy to address STIs and sexual health in the United States.”

The National Academies report was supported by the Centers for Disease Control and Prevention and the National Association of County and City Health Officials. Dr. Mercer, Dr. Ault, and Mr. Thimm-Kaiser have disclosed no relevant financial relationships. Dr. Guilamo-Ramos has received grants and personal fees from ViiV Health care.

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

A vital aspect of expanding access and care for sexually transmitted infections (STIs) in the United States is broadening responsibility for this care across the health care system and other community resources, according to an article published online July 6 in Clinical Infectious Diseases. This expansion and decentralization of care are central to adopting the “new sexual health paradigm” recommended by a National Academies report that was published in March.

“STIs represent a sizable, longstanding, and growing public health challenge,” write Vincent Guilamo-Ramos, PhD, MPH, dean and professor at the Duke University School of Nursing and director of the Center for Latino Adolescent and Family Health (CLAFH) at Duke University, both in Durham, N.C., and his colleagues. Yet the limitations on the current STI workforce and limited federal funding and support for STI prevention and care mean it will take clinicians of all types from across the health care spectrum to meet the challenge, they explain.

“For too long, STI prevention and treatment has been perceived as the sole responsibility of a narrow workforce of specialized STI and HIV service providers,” Dr. Guilamo-Ramos and his coauthor, Marco Thimm-Kaiser, MPH, associate in research at Duke University and epidemiologist at CLAFH, wrote in an email.

“However, the resources allocated to this STI specialty workforce have diminished over time, along with decreasing investments in the broader U.S. public health infrastructure,” they continued. “At the same time – and in part due to this underinvestment – STI rates have soared, reaching a record high for the sixth year in a row in 2019.”

Those factors led to the National Academies report, which recommends moving “away from the traditional, disease-focused perspective on STIs in favor of a holistic perspective of sexual health as an integral component of overall health and well-being,” Dr. Guilamo-Ramos and Mr. Thimm-Kaiser wrote to this news organization.

In their article, the authors review the limitations in the STI workforce, the implications of those limitations for the broader health care industry, and what it will take for STI and HIV specialists as well as regulators to ensure it’s possible to achieve the paradigm shift recommended by the National Academies.

Currently, the biggest limitation is access to care, said Laura Mercer, MD, MBA, of the department of obstetrics and gynecology and the ob.gyn. clerkship director at the University of Arizona, Phoenix. Dr. Mercer, who was not involved with the National Academies report or the analysis of it, said in an interview that it’s essential to emphasize “sexual health as a core element of routine primary and preventative care” to ensure it becomes more accessible to patients without the need to seek out specialty care.

Dr. Guilamo-Ramos and his colleagues drive home the importance of such a shift by noting that more than 200 million Americans live in counties with no practicing infectious disease physicians. The disparities are greatest in Southern states, which account for 40% of all reported STIs. The workforce shortage has continued to worsen alongside the deterioration of the clinical infrastructure supporting STI specialty services, the authors write.

Hence the need to expand accountability for care not only to primary-care physicians but also to nurses, pharmacists, physician assistants, nurse practitioners, and behavioral health practitioners. Doing so also requires normalizing sexual health services across health care professions.

“Prevention is a crucial first step” to this, Dr. Mercer said. “This is particularly important as we recall that almost half of new sexually transmitted infections occur in teenagers. Destigmatizing sexual health and sexual health education will also help encourage patients of all ages to request and accept testing.”

Further, with primary care practitioners managing most STI testing and treatment, subspecialists can focus primarily on complex or refractory cases, she added. Ways to help broaden care include developing point-of-care testing for STIs and improving the accuracy of existing testing, she said.

“The goal is to make routine sexual health services accessible in a wide range of settings, such as in primary care, at pharmacies, and in community-based settings, and to draw on a broader workforce for delivery of sexual health services,” Dr. Guilamo-Ramos and Mr. Thimm-Kaiser said in an interview.

Kevin Ault, MD, professor of obstetrics and gynecology and director of clinical and translational research at the University of Kansas Medical Center in Kansas City, said that many medical organizations, such as the American College of Obstetricians and Gynecologists, have long advocated incorporating sexual health into routine preventive care. He also noted that pharmacists have already become proactive in preventing STIs and could continue to do so.

“Vaccines for hepatitis and human papillomavirus are commonly available at pharmacies,” Dr. Ault said. He was not involved in the article by Dr. Guilamo-Ramos and colleagues or the original report. “Pharmacists could also fill a gap by administering injectable medications such as penicillin. States would have to approve changes in policy, but many states have already done this for expedited partner therapy.”

Dr. Guilamo-Ramos and Mr. Thimm-Kaiser noted similar barriers that must be removed to broaden delivery of STI services.

“Unfortunately, too many highly trained health care providers who are well-positioned for the delivery of sexual health services face regulatory or administrative barriers to practice to the full scope of their training,” they wrote. “These barriers can have a particularly negative impact in medically underserved communities, where physician shortages are common and where novel, decentralized health care service delivery models that draw on nonphysician providers may hold the greatest promise.”

As more diverse health care practitioners take on these roles, ID and HIV specialists can provide their expertise in developing training and technical assistance to support generalists, Dr. Guilamo-Ramos and Mr. Thimm-Kaiser wrote. They can also aid in aligning “clinical training curricula, licensing criteria, and practice guidelines with routine delivery of sexual health services.”

Dr. Guilamo-Ramos and his coauthors offer specific recommendations for professional training, licensing, and practice guidelines to help overcome the “insufficient knowledge, inadequate training, and absence of explicit protocols” that currently impede delivery of STI services in general practice settings.

Although the paradigm shift recommended by the National Academies is ambitious, it’s also necessary, and “none of the recommendations are out of reach,” Dr. Guilamo-Ramos and Mr. Thimm-Kaiser said in an interview. They pointed out how the COVID-19 pandemic has highlighted how underresourced the health care workforce and infrastructure are and how great health care disparities are.

“There is momentum toward rebuilding the nation’s health and public health system in a more effective and efficient way,” they said, and many of the STI report’s recommendations “overlap with priorities for the broader health and public health system moving forward.”

Dr. Mercer also believes the recommendations are realistic, “but only the beginning,” she told this news organization. “Comprehensive sexual education to expand knowledge about STI prevention and public health campaigns to help destigmatize sexual health care in general will remain crucial,” she said.

Sexual education, expanded access, and destigmatizing sexual care are particularly important for reaching the populations most in need of care, such as adolescents and young adults, as well as ethnic, racial, sexual, and gender-minority youth.

“It cannot be overstated how important of a priority population adolescents and young adults are,” Dr. Guilamo-Ramos and Mr. Thimm-Kaiser wrote. They noted that those aged 15-24 account for half of all STIs each year but represent only a quarter of the sexually active population. “Targeted efforts for STI prevention and treatment among adolescents and young adults are therefore essential for an overall successful strategy to address STIs and sexual health in the United States.”

The National Academies report was supported by the Centers for Disease Control and Prevention and the National Association of County and City Health Officials. Dr. Mercer, Dr. Ault, and Mr. Thimm-Kaiser have disclosed no relevant financial relationships. Dr. Guilamo-Ramos has received grants and personal fees from ViiV Health care.

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

The Centers for Disease Control and Prevention has recommended that everyone get a COVID-19 vaccine, even if they’ve had the virus before. Yet many skeptics have held off getting the shots, believing that immunity generated by their previous infection will protect them if they should encounter the virus again. 

A new study published in the CDC’s Morbidity and Mortality Weekly Report pokes holes in this notion. It shows people who have recovered from COVID-19 but haven’t been vaccinated have more than double the risk of testing positive for the virus again, compared with someone who was vaccinated after an initial infection.

The study looked at 738 Kentucky residents who had an initial bout of COVID-19 in 2020. About 250 of them tested positive for COVID-19 a second time between May and July of 2021, when the Delta variant became dominant in the United States. 

The study matched each person who’d been reinfected with two people of the same sex and roughly the same age who had caught their initial COVID infection within the same week. The researchers then cross-matched those cases with data from Kentucky’s Immunization Registry.

They found that those who were unvaccinated had more than double the risk of being reinfected during the Delta wave. Partial vaccination appeared to have no significant impact on the risk of reinfection.

Among those who were reinfected, 20% were fully vaccinated, while 34% of those who did not get reinfected were fully vaccinated.

The study is observational, meaning it can’t show cause and effect; and the researchers had no information on the severity of the infections. Alyson Cavanaugh, PhD, a member of the CDC’s Epidemic Intelligence Service who led the study, said it is possible that some of the people who tested positive a second time had asymptomatic infections that were picked up through routine screening.

Still, the study backs up previous research and suggests that vaccination offers important additional protection.

“Our laboratory studies have shown that there’s an added benefit of vaccine for people who’ve had previous COVID-19. This is a real-world, epidemiologic study that found that among people who’d previously already had COVID-19, those who were vaccinated had lower odds of being reinfected,” Dr. Cavanaugh said.

“If you have had COVID-19 before, please still get vaccinated,” said CDC Director Rochelle Walensky, MD, in a written media statement. “This study shows you are twice as likely to get infected again if you are unvaccinated. Getting the vaccine is the best way to protect yourself and others around you, especially as the more contagious Delta variant spreads around the country.”

In a White House COVID-19 Response Team briefing in May, Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Disease, explained why vaccines create stronger immunity than infection. He highlighted new research showing that two doses of an mRNA vaccine produce levels of neutralizing antibodies that are up to 10 times higher than the levels found in the blood of people who’ve recovered from COVID-19. Vaccines also enhance B cells and T cells in people who’ve recovered from COVID-19, which broadens the spectrum of protection and helps to fend off variants.

The study has some important limitations, which the authors acknowledged. The first is that second infections weren’t confirmed with genetic sequencing, so the researchers couldn’t definitively tell if a person tested positive a second time because they caught a new virus, or if they were somehow still shedding virus from their first infection. Given that the tests were at least 5 months apart, though, the researchers think reinfection is the most likely explanation.

Another bias in the study could have something to do with vaccination. Vaccinated people may have been less likely to be tested for COVID-19 after their vaccines, so the association or reinfection with a lack of vaccination may be overestimated. 

Also, people who were vaccinated at federal sites or in another state were not logged in the state’s immunization registry, which may have skewed the data.

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

The Centers for Disease Control and Prevention has recommended that everyone get a COVID-19 vaccine, even if they’ve had the virus before. Yet many skeptics have held off getting the shots, believing that immunity generated by their previous infection will protect them if they should encounter the virus again. 

A new study published in the CDC’s Morbidity and Mortality Weekly Report pokes holes in this notion. It shows people who have recovered from COVID-19 but haven’t been vaccinated have more than double the risk of testing positive for the virus again, compared with someone who was vaccinated after an initial infection.

The study looked at 738 Kentucky residents who had an initial bout of COVID-19 in 2020. About 250 of them tested positive for COVID-19 a second time between May and July of 2021, when the Delta variant became dominant in the United States. 

The study matched each person who’d been reinfected with two people of the same sex and roughly the same age who had caught their initial COVID infection within the same week. The researchers then cross-matched those cases with data from Kentucky’s Immunization Registry.

They found that those who were unvaccinated had more than double the risk of being reinfected during the Delta wave. Partial vaccination appeared to have no significant impact on the risk of reinfection.

Among those who were reinfected, 20% were fully vaccinated, while 34% of those who did not get reinfected were fully vaccinated.

The study is observational, meaning it can’t show cause and effect; and the researchers had no information on the severity of the infections. Alyson Cavanaugh, PhD, a member of the CDC’s Epidemic Intelligence Service who led the study, said it is possible that some of the people who tested positive a second time had asymptomatic infections that were picked up through routine screening.

Still, the study backs up previous research and suggests that vaccination offers important additional protection.

“Our laboratory studies have shown that there’s an added benefit of vaccine for people who’ve had previous COVID-19. This is a real-world, epidemiologic study that found that among people who’d previously already had COVID-19, those who were vaccinated had lower odds of being reinfected,” Dr. Cavanaugh said.

“If you have had COVID-19 before, please still get vaccinated,” said CDC Director Rochelle Walensky, MD, in a written media statement. “This study shows you are twice as likely to get infected again if you are unvaccinated. Getting the vaccine is the best way to protect yourself and others around you, especially as the more contagious Delta variant spreads around the country.”

In a White House COVID-19 Response Team briefing in May, Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Disease, explained why vaccines create stronger immunity than infection. He highlighted new research showing that two doses of an mRNA vaccine produce levels of neutralizing antibodies that are up to 10 times higher than the levels found in the blood of people who’ve recovered from COVID-19. Vaccines also enhance B cells and T cells in people who’ve recovered from COVID-19, which broadens the spectrum of protection and helps to fend off variants.

The study has some important limitations, which the authors acknowledged. The first is that second infections weren’t confirmed with genetic sequencing, so the researchers couldn’t definitively tell if a person tested positive a second time because they caught a new virus, or if they were somehow still shedding virus from their first infection. Given that the tests were at least 5 months apart, though, the researchers think reinfection is the most likely explanation.

Another bias in the study could have something to do with vaccination. Vaccinated people may have been less likely to be tested for COVID-19 after their vaccines, so the association or reinfection with a lack of vaccination may be overestimated. 

Also, people who were vaccinated at federal sites or in another state were not logged in the state’s immunization registry, which may have skewed the data.

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

The Centers for Disease Control and Prevention has recommended that everyone get a COVID-19 vaccine, even if they’ve had the virus before. Yet many skeptics have held off getting the shots, believing that immunity generated by their previous infection will protect them if they should encounter the virus again. 

A new study published in the CDC’s Morbidity and Mortality Weekly Report pokes holes in this notion. It shows people who have recovered from COVID-19 but haven’t been vaccinated have more than double the risk of testing positive for the virus again, compared with someone who was vaccinated after an initial infection.

The study looked at 738 Kentucky residents who had an initial bout of COVID-19 in 2020. About 250 of them tested positive for COVID-19 a second time between May and July of 2021, when the Delta variant became dominant in the United States. 

The study matched each person who’d been reinfected with two people of the same sex and roughly the same age who had caught their initial COVID infection within the same week. The researchers then cross-matched those cases with data from Kentucky’s Immunization Registry.

They found that those who were unvaccinated had more than double the risk of being reinfected during the Delta wave. Partial vaccination appeared to have no significant impact on the risk of reinfection.

Among those who were reinfected, 20% were fully vaccinated, while 34% of those who did not get reinfected were fully vaccinated.

The study is observational, meaning it can’t show cause and effect; and the researchers had no information on the severity of the infections. Alyson Cavanaugh, PhD, a member of the CDC’s Epidemic Intelligence Service who led the study, said it is possible that some of the people who tested positive a second time had asymptomatic infections that were picked up through routine screening.

Still, the study backs up previous research and suggests that vaccination offers important additional protection.

“Our laboratory studies have shown that there’s an added benefit of vaccine for people who’ve had previous COVID-19. This is a real-world, epidemiologic study that found that among people who’d previously already had COVID-19, those who were vaccinated had lower odds of being reinfected,” Dr. Cavanaugh said.

“If you have had COVID-19 before, please still get vaccinated,” said CDC Director Rochelle Walensky, MD, in a written media statement. “This study shows you are twice as likely to get infected again if you are unvaccinated. Getting the vaccine is the best way to protect yourself and others around you, especially as the more contagious Delta variant spreads around the country.”

In a White House COVID-19 Response Team briefing in May, Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Disease, explained why vaccines create stronger immunity than infection. He highlighted new research showing that two doses of an mRNA vaccine produce levels of neutralizing antibodies that are up to 10 times higher than the levels found in the blood of people who’ve recovered from COVID-19. Vaccines also enhance B cells and T cells in people who’ve recovered from COVID-19, which broadens the spectrum of protection and helps to fend off variants.

The study has some important limitations, which the authors acknowledged. The first is that second infections weren’t confirmed with genetic sequencing, so the researchers couldn’t definitively tell if a person tested positive a second time because they caught a new virus, or if they were somehow still shedding virus from their first infection. Given that the tests were at least 5 months apart, though, the researchers think reinfection is the most likely explanation.

Another bias in the study could have something to do with vaccination. Vaccinated people may have been less likely to be tested for COVID-19 after their vaccines, so the association or reinfection with a lack of vaccination may be overestimated. 

Also, people who were vaccinated at federal sites or in another state were not logged in the state’s immunization registry, which may have skewed the data.

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

Over the 10 years we’ve been writing this column, we have often found inspiration for topics while traveling – especially while flying. This is not just because of the idle time spent in the air, but instead because of the many ways that air travel and health care experiences are similar. Both industries focus heavily on safety, are tightly regulated, and employ highly trained individuals.

Consumers may recognize the similarities as well – health care and air travel are both well-known for long waits, uncertainty, and implicit risk. Both sectors are also notorious drivers of innovation, constantly leveraging new technologies in pursuit of better outcomes and experiences. Occasionally, however, advancements in technology can present unforeseen challenges and even compromise safety, with the potential to produce unexpected consequences.

A familiar reminder of this potential was provided to us at the commencement of a recent flight, when we were instructed to turn off our personal electronic devices or flip them into “airplane mode.” This same admonishment is often given to patients and visitors in health care settings – everywhere from clinic waiting rooms to intensive care units – though the reason for this is typically left vague. This got us thinking. We wondered, what is the real risk of smart phones in medicine , or aviation, for that matter. More importantly, what other emerging technologies have the potential to create issues we may not have anticipated?

Mayo Clinic findings on radio communication used by mobile phones

Once our flight landed, we did some research to answer our initial question about personal communication technology and its ability to interfere with sensitive electronic devices. Specifically, we wanted to know whether radio communication used by mobile phones could affect the operation of medical equipment, potentially leading to dire consequences for patients. Spoiler alert: There is very little evidence that this can occur. In fact, a well-documented study performed by the Mayo Clinic in 2007 found interference in 0 out of 300 tests performed. To quote the authors, “the incidence of clinically important interference was 0%.”

We could find no other studies since 2007 that strongly contradict Mayo’s findings, except for several anecdotal reports and articles that postulate the theoretical possibility.

This is confirmed by the American Heart Association, who maintains a list of devices that may interfere with ICDs and pacemakers on their website. According to the AHA, “wireless transmissions from the antennae of phones available in the United States are a very small risk to ICDs and even less of a risk for pacemakers.” And in case you’re wondering, the story is quite similar for airplanes as well.

The latest publication from NASA’s Aviation Safety Reporting System (ASRS) documents incidents related to personal electronic devices during air travel. Most involve smoke production – or even small fires – caused by malfunctioning phone batteries during charging. Only a few entries reference wireless interference, and these were all minor and unconfirmed events. As with health care environments, airplanes don’t appear to face significant risks from radio interference. But that doesn’t mean personal electronics are completely harmless to patients.

Smartphones’ risks to patient with cardiac devices

On May 13 of 2021, the FDA issued a warning to cardiac patients about their smart phones and smart watches. Many current personal electronic devices and accessories are equipped with strong magnets, such as those contained in the “MagSafe” connector on the iPhone 12, that can deactivate pacemakers and implanted cardiac defibrillators. These medical devices are designed to be manipulated by magnets for diagnostic and therapeutic purposes, but strong magnetic fields can disable them unintentionally, leading to catastrophic results.

Apple and other manufacturers have acknowledged this risk and recommend that smartphones and other devices be kept at least 6 inches from cardiac devices. Given the ubiquity of offending products, it is also imperative that we warn our patients about this risk to their physical wellbeing.

Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece.

Over the 10 years we’ve been writing this column, we have often found inspiration for topics while traveling – especially while flying. This is not just because of the idle time spent in the air, but instead because of the many ways that air travel and health care experiences are similar. Both industries focus heavily on safety, are tightly regulated, and employ highly trained individuals.

Consumers may recognize the similarities as well – health care and air travel are both well-known for long waits, uncertainty, and implicit risk. Both sectors are also notorious drivers of innovation, constantly leveraging new technologies in pursuit of better outcomes and experiences. Occasionally, however, advancements in technology can present unforeseen challenges and even compromise safety, with the potential to produce unexpected consequences.

A familiar reminder of this potential was provided to us at the commencement of a recent flight, when we were instructed to turn off our personal electronic devices or flip them into “airplane mode.” This same admonishment is often given to patients and visitors in health care settings – everywhere from clinic waiting rooms to intensive care units – though the reason for this is typically left vague. This got us thinking. We wondered, what is the real risk of smart phones in medicine , or aviation, for that matter. More importantly, what other emerging technologies have the potential to create issues we may not have anticipated?