MDedge Pediatrics

Thunderstorm asthma can strike with little warning, leaving people with the symptoms of an asthma attack during or after the dark clouds pass. 

If you’re unfamiliar, the risk for a thunderstorm asthma attack grows when heavy storms arrive on a day with very high pollen or spores. The storm uplifts these particles, adds water, and causes them to explode into smaller grains. The electrical activity in a storm can do the same. Next, strong winds sweep these particles down and across the ground. People in the path of the storm can experience shortness of breath, coughing, and wheezing.

If thunderstorms are predicted to become more frequent and more severe with climate change, will the same hold true for thunderstorm asthma?   

“Yes, if only because the amount of pollen appears to be increasing in many areas due to climate change,” said Frank S. Virant, MD, chief of the Allergy Division at Seattle Children’s Hospital in Washington.

Most cases of thunderstorm asthma occur in the spring and early summer, but that also could change. Pollen seasons “have been getting longer and more intense,” said Shaan M. Waqar, MD, an allergist at ENT and Allergy Associates in Plainview, NY. 

“Thunderstorm asthma events are rare, but our changing environment and the increase in the number of people with allergies may make such events more common and more severe into the future,” agreed Paul J. Beggs, PhD, associate professor in the School of Natural Sciences at Macquarie University in Sydney, Australia.

How to Minimize Your Risk

If your patients are sensitive to pollen, advise them to continue to monitor outdoor levels, particularly during tree, grass, and weed pollen season, Dr. Virant recommended. Also patients should pay attention to weather reports. Watch for thunderstorms that could “amplify exposure to the pollen with 40-plus mile per hour winds and often colder air downdrafts.” Cold is an additional asthma trigger, he noted. 

People with asthma should try to stay indoors with windows and doors closed during strong thunderstorms and for several hours afterward. Using air filters can also help reduce risk, said Deepti V. Manian, MD, an allergist and immunologist at Stormont Vail Health in Topeka, Kansas.

Patients should continue controller therapies -- such as longer-acting inhalers and allergy medications -- and use a rescue inhaler or nebulizer for prompt treatment of symptoms, recommended Donald J. Dvorin, MD, of The Allergy and Asthma Doctors in Mount Laurel, NJ. Ideally, people seeking shelter indoors during storms should be “accompanied by friends or family who can help them transport quickly to a hospital if needed.”

Asthma Diagnosis Not Required

Even peoples who would not consider themselves to have asthma can be seriously affected. For example, people with hay fever, or allergic rhinitis as it’s also known, are also at risk, said Ajay Kevat, MBBS, MPH, of the respiratory department at Queensland Children’s Hospital in Brisbane, Australia.

People with hay fever can also experience stronger symptoms during and after thunderstorms. Optimally treating allergic rhinitis during the pollen season with non-sedation antihistamines and nasal steroids can help, Dr. Virant said, instead of “chasing symptoms with medication after they are already severe.” 

Part of the challenge is connecting severe weather to worse asthma symptoms. “In my experience, there is a lack of awareness surrounding thunderstorm asthma,” Dr. Manian said. For example, people with non-allergic rhinitis, also known as vasomotor rhinitis, can also experience the effects. “It often surprises many of my patients when I introduce the concept of vasomotor rhinitis, which can be triggered by environmental fluctuations.”

Gathering Clouds, Gathering Evidence

Climate change could also change which Americans experience the most storms. Researchers in a June 2022 study predicted fewer storms in the Southern plains and more storms in the Midwest and the Southeastern United States in the future.

Dr. Dvorin practices in Southern New Jersey, and in this area, “we fortunate in this area not to experience thunderstorm-induced asthma exacerbations,” he said. 

But climate change means that in the future, thunderstorm asthma could strike in places it has never been seen before, said Dr. Kevat, who wrote a thunderstorm asthma review article published online June 2020 in the Journal of Asthma and Allergy.

And this is not just a concern in the United States. Major thunderstorm asthma events have been reported in Italy, the United Kingdom, the Middle East, Asia, and Australia. In  November 2016, for instance, a strong set of storms swept across Melbourne, Australia. Temperatures dropped 10C (about 18F), humidity rose above 70%, and particulate matter like pollen became more concentrated in the air. 

This event spurred a “thunderstorm asthma epidemic of unprecedented magnitude, tempo, and geographical range and severity,” Dr. Beggs and colleagues wrote in their June 2018 report in The Lancet Planetary Health. 

Large-scale events like this can affect entire communities and quickly overwhelm local health care resources. Within 30 hours of the Melbourne storms, 3,365 people more than usual came to local emergency departments with respiratory issues — and 476 with asthma were admitted to the hospital. Ten people died: five in the hospital and five who could not be resuscitated or died while waiting for emergency services.

More research is needed “so as to best prepare for this unpredictable, significant public health threat,” Dr. Kevat wrote.

People whose asthma is triggered by pollen or mold spores are particularly at risk for thunderstorm asthma, Dr. Waqar said. If you’re unsure, an allergist can help diagnose and treat your allergic risks.

More severe thunderstorms are just one asthma trigger associated with climate change. Last summer, Canadian wildfires sent smoke across the northern U.S. and triggered widespread asthma exacerbations.

A version of this article appeared on WebMD.com. 

Thunderstorm asthma can strike with little warning, leaving people with the symptoms of an asthma attack during or after the dark clouds pass. 

If you’re unfamiliar, the risk for a thunderstorm asthma attack grows when heavy storms arrive on a day with very high pollen or spores. The storm uplifts these particles, adds water, and causes them to explode into smaller grains. The electrical activity in a storm can do the same. Next, strong winds sweep these particles down and across the ground. People in the path of the storm can experience shortness of breath, coughing, and wheezing.

If thunderstorms are predicted to become more frequent and more severe with climate change, will the same hold true for thunderstorm asthma?   

“Yes, if only because the amount of pollen appears to be increasing in many areas due to climate change,” said Frank S. Virant, MD, chief of the Allergy Division at Seattle Children’s Hospital in Washington.

Most cases of thunderstorm asthma occur in the spring and early summer, but that also could change. Pollen seasons “have been getting longer and more intense,” said Shaan M. Waqar, MD, an allergist at ENT and Allergy Associates in Plainview, NY. 

“Thunderstorm asthma events are rare, but our changing environment and the increase in the number of people with allergies may make such events more common and more severe into the future,” agreed Paul J. Beggs, PhD, associate professor in the School of Natural Sciences at Macquarie University in Sydney, Australia.

How to Minimize Your Risk

If your patients are sensitive to pollen, advise them to continue to monitor outdoor levels, particularly during tree, grass, and weed pollen season, Dr. Virant recommended. Also patients should pay attention to weather reports. Watch for thunderstorms that could “amplify exposure to the pollen with 40-plus mile per hour winds and often colder air downdrafts.” Cold is an additional asthma trigger, he noted. 

People with asthma should try to stay indoors with windows and doors closed during strong thunderstorms and for several hours afterward. Using air filters can also help reduce risk, said Deepti V. Manian, MD, an allergist and immunologist at Stormont Vail Health in Topeka, Kansas.

Patients should continue controller therapies -- such as longer-acting inhalers and allergy medications -- and use a rescue inhaler or nebulizer for prompt treatment of symptoms, recommended Donald J. Dvorin, MD, of The Allergy and Asthma Doctors in Mount Laurel, NJ. Ideally, people seeking shelter indoors during storms should be “accompanied by friends or family who can help them transport quickly to a hospital if needed.”

Asthma Diagnosis Not Required

Even peoples who would not consider themselves to have asthma can be seriously affected. For example, people with hay fever, or allergic rhinitis as it’s also known, are also at risk, said Ajay Kevat, MBBS, MPH, of the respiratory department at Queensland Children’s Hospital in Brisbane, Australia.

People with hay fever can also experience stronger symptoms during and after thunderstorms. Optimally treating allergic rhinitis during the pollen season with non-sedation antihistamines and nasal steroids can help, Dr. Virant said, instead of “chasing symptoms with medication after they are already severe.” 

Part of the challenge is connecting severe weather to worse asthma symptoms. “In my experience, there is a lack of awareness surrounding thunderstorm asthma,” Dr. Manian said. For example, people with non-allergic rhinitis, also known as vasomotor rhinitis, can also experience the effects. “It often surprises many of my patients when I introduce the concept of vasomotor rhinitis, which can be triggered by environmental fluctuations.”

Gathering Clouds, Gathering Evidence

Climate change could also change which Americans experience the most storms. Researchers in a June 2022 study predicted fewer storms in the Southern plains and more storms in the Midwest and the Southeastern United States in the future.

Dr. Dvorin practices in Southern New Jersey, and in this area, “we fortunate in this area not to experience thunderstorm-induced asthma exacerbations,” he said. 

But climate change means that in the future, thunderstorm asthma could strike in places it has never been seen before, said Dr. Kevat, who wrote a thunderstorm asthma review article published online June 2020 in the Journal of Asthma and Allergy.

And this is not just a concern in the United States. Major thunderstorm asthma events have been reported in Italy, the United Kingdom, the Middle East, Asia, and Australia. In  November 2016, for instance, a strong set of storms swept across Melbourne, Australia. Temperatures dropped 10C (about 18F), humidity rose above 70%, and particulate matter like pollen became more concentrated in the air. 

This event spurred a “thunderstorm asthma epidemic of unprecedented magnitude, tempo, and geographical range and severity,” Dr. Beggs and colleagues wrote in their June 2018 report in The Lancet Planetary Health. 

Large-scale events like this can affect entire communities and quickly overwhelm local health care resources. Within 30 hours of the Melbourne storms, 3,365 people more than usual came to local emergency departments with respiratory issues — and 476 with asthma were admitted to the hospital. Ten people died: five in the hospital and five who could not be resuscitated or died while waiting for emergency services.

More research is needed “so as to best prepare for this unpredictable, significant public health threat,” Dr. Kevat wrote.

People whose asthma is triggered by pollen or mold spores are particularly at risk for thunderstorm asthma, Dr. Waqar said. If you’re unsure, an allergist can help diagnose and treat your allergic risks.

More severe thunderstorms are just one asthma trigger associated with climate change. Last summer, Canadian wildfires sent smoke across the northern U.S. and triggered widespread asthma exacerbations.

A version of this article appeared on WebMD.com. 

Thunderstorm asthma can strike with little warning, leaving people with the symptoms of an asthma attack during or after the dark clouds pass. 

If you’re unfamiliar, the risk for a thunderstorm asthma attack grows when heavy storms arrive on a day with very high pollen or spores. The storm uplifts these particles, adds water, and causes them to explode into smaller grains. The electrical activity in a storm can do the same. Next, strong winds sweep these particles down and across the ground. People in the path of the storm can experience shortness of breath, coughing, and wheezing.

If thunderstorms are predicted to become more frequent and more severe with climate change, will the same hold true for thunderstorm asthma?   

“Yes, if only because the amount of pollen appears to be increasing in many areas due to climate change,” said Frank S. Virant, MD, chief of the Allergy Division at Seattle Children’s Hospital in Washington.

Most cases of thunderstorm asthma occur in the spring and early summer, but that also could change. Pollen seasons “have been getting longer and more intense,” said Shaan M. Waqar, MD, an allergist at ENT and Allergy Associates in Plainview, NY. 

“Thunderstorm asthma events are rare, but our changing environment and the increase in the number of people with allergies may make such events more common and more severe into the future,” agreed Paul J. Beggs, PhD, associate professor in the School of Natural Sciences at Macquarie University in Sydney, Australia.

How to Minimize Your Risk

If your patients are sensitive to pollen, advise them to continue to monitor outdoor levels, particularly during tree, grass, and weed pollen season, Dr. Virant recommended. Also patients should pay attention to weather reports. Watch for thunderstorms that could “amplify exposure to the pollen with 40-plus mile per hour winds and often colder air downdrafts.” Cold is an additional asthma trigger, he noted. 

People with asthma should try to stay indoors with windows and doors closed during strong thunderstorms and for several hours afterward. Using air filters can also help reduce risk, said Deepti V. Manian, MD, an allergist and immunologist at Stormont Vail Health in Topeka, Kansas.

Patients should continue controller therapies -- such as longer-acting inhalers and allergy medications -- and use a rescue inhaler or nebulizer for prompt treatment of symptoms, recommended Donald J. Dvorin, MD, of The Allergy and Asthma Doctors in Mount Laurel, NJ. Ideally, people seeking shelter indoors during storms should be “accompanied by friends or family who can help them transport quickly to a hospital if needed.”

Asthma Diagnosis Not Required

Even peoples who would not consider themselves to have asthma can be seriously affected. For example, people with hay fever, or allergic rhinitis as it’s also known, are also at risk, said Ajay Kevat, MBBS, MPH, of the respiratory department at Queensland Children’s Hospital in Brisbane, Australia.

People with hay fever can also experience stronger symptoms during and after thunderstorms. Optimally treating allergic rhinitis during the pollen season with non-sedation antihistamines and nasal steroids can help, Dr. Virant said, instead of “chasing symptoms with medication after they are already severe.” 

Part of the challenge is connecting severe weather to worse asthma symptoms. “In my experience, there is a lack of awareness surrounding thunderstorm asthma,” Dr. Manian said. For example, people with non-allergic rhinitis, also known as vasomotor rhinitis, can also experience the effects. “It often surprises many of my patients when I introduce the concept of vasomotor rhinitis, which can be triggered by environmental fluctuations.”

Gathering Clouds, Gathering Evidence

Climate change could also change which Americans experience the most storms. Researchers in a June 2022 study predicted fewer storms in the Southern plains and more storms in the Midwest and the Southeastern United States in the future.

Dr. Dvorin practices in Southern New Jersey, and in this area, “we fortunate in this area not to experience thunderstorm-induced asthma exacerbations,” he said. 

But climate change means that in the future, thunderstorm asthma could strike in places it has never been seen before, said Dr. Kevat, who wrote a thunderstorm asthma review article published online June 2020 in the Journal of Asthma and Allergy.

And this is not just a concern in the United States. Major thunderstorm asthma events have been reported in Italy, the United Kingdom, the Middle East, Asia, and Australia. In  November 2016, for instance, a strong set of storms swept across Melbourne, Australia. Temperatures dropped 10C (about 18F), humidity rose above 70%, and particulate matter like pollen became more concentrated in the air. 

This event spurred a “thunderstorm asthma epidemic of unprecedented magnitude, tempo, and geographical range and severity,” Dr. Beggs and colleagues wrote in their June 2018 report in The Lancet Planetary Health. 

Large-scale events like this can affect entire communities and quickly overwhelm local health care resources. Within 30 hours of the Melbourne storms, 3,365 people more than usual came to local emergency departments with respiratory issues — and 476 with asthma were admitted to the hospital. Ten people died: five in the hospital and five who could not be resuscitated or died while waiting for emergency services.

More research is needed “so as to best prepare for this unpredictable, significant public health threat,” Dr. Kevat wrote.

People whose asthma is triggered by pollen or mold spores are particularly at risk for thunderstorm asthma, Dr. Waqar said. If you’re unsure, an allergist can help diagnose and treat your allergic risks.

More severe thunderstorms are just one asthma trigger associated with climate change. Last summer, Canadian wildfires sent smoke across the northern U.S. and triggered widespread asthma exacerbations.

A version of this article appeared on WebMD.com. 

TOPLINE:

The odds of having cognitive impairment may be increased among children with atopic dermatitis, primarily among those with neurodevelopmental disorders, such as attention-deficit/hyperactivity disorder (ADHD) or a learning disability.

METHODOLOGY:

It remains unknown whether subpopulations of children with atopic dermatitis face a greater risk for cognitive impairment or not.

To determine the association, researchers drew from a weighted sample of 69,732,807 children with atopic dermatitis in the 2021 US National Health Interview Survey.

Main outcomes of interest were difficulty in learning or memory (cognitive impairment symptoms) as reported by the child’s caregiver.

The researchers performed logistic regression to compare the odds of learning or memory difficulties between 60,509,794 children without atopic dermatitis and 9,223,013 children with atopic dermatitis.

TAKEAWAY:

Children with versus without atopic dermatitis were more likely to experience difficulties with learning (10.8% [95% CI, 7.8%-15.8%] vs 5.9% [95% CI, 5.1%-6.9%]; P < .001) and difficulties with memory (11.1% [95% CI, 8.0%-15.9%] vs 5.8% [95% CI, 4.9%-6.9%]; P < .001).

On multivariable logistic regression adjusted for sociodemographic factors, asthma, food allergies, and seasonal allergies or hay fever, researchers found that having atopic dermatitis was associated with increased odds of difficulties in learning (adjusted odds ratio [aOR], 1.77; 95% CI, 1.28-2.45) and memory (aOR, 1.69; 95% CI, 1.19-2.41). 

When stratified by neurodevelopmental comorbidities, having atopic dermatitis was associated with a 2- to 3-fold greater odds of memory difficulties among children with any neurodevelopmental disorder (aOR, 2.26; 95% CI, 1.43-3.57), which included ADHD (aOR, 2.90; 95% CI, 1.60-5.24) or learning disabilities (aOR, 2.04; 95% CI, 1.04-4.00).

Having atopic dermatitis was not associated with learning or memory difficulties among children without neurodevelopmental conditions. 

IN PRACTICE:

“These findings may improve the risk stratification of children with atopic dermatitis for cognitive impairment and suggest that evaluation for cognitive impairment should be prioritized among children with atopic dermatitis and comorbid ADHD or learning disability,” the authors wrote.

SOURCE:

Corresponding author Joy Wan, MD, of the department of dermatology at Johns Hopkins University School of Medicine, Baltimore, and colleagues conducted the research, which was published on March 6, 2024, in JAMA Dermatology.

LIMITATIONS:

The study’s limitations were its cross-sectional design, reliance on caregiver reports, and the fact that National Health Interview Survey data do not include information on factors such as atopic dermatitis severity, age at atopic dermatitis diagnosis, and sleep. 

DISCLOSURES:

The study was supported by a grant from the National Institutes of Health. Dr. Wan reported receiving a grant from Pfizer and personal fees from Sun Pharmaceutical Industries and Janssen Pharmaceuticals outside the submitted work. No other study authors had disclosures to report. 

A version of this article appeared on Medscape.com.

TOPLINE:

The odds of having cognitive impairment may be increased among children with atopic dermatitis, primarily among those with neurodevelopmental disorders, such as attention-deficit/hyperactivity disorder (ADHD) or a learning disability.

METHODOLOGY:

It remains unknown whether subpopulations of children with atopic dermatitis face a greater risk for cognitive impairment or not.

To determine the association, researchers drew from a weighted sample of 69,732,807 children with atopic dermatitis in the 2021 US National Health Interview Survey.

Main outcomes of interest were difficulty in learning or memory (cognitive impairment symptoms) as reported by the child’s caregiver.

The researchers performed logistic regression to compare the odds of learning or memory difficulties between 60,509,794 children without atopic dermatitis and 9,223,013 children with atopic dermatitis.

TAKEAWAY:

Children with versus without atopic dermatitis were more likely to experience difficulties with learning (10.8% [95% CI, 7.8%-15.8%] vs 5.9% [95% CI, 5.1%-6.9%]; P < .001) and difficulties with memory (11.1% [95% CI, 8.0%-15.9%] vs 5.8% [95% CI, 4.9%-6.9%]; P < .001).

On multivariable logistic regression adjusted for sociodemographic factors, asthma, food allergies, and seasonal allergies or hay fever, researchers found that having atopic dermatitis was associated with increased odds of difficulties in learning (adjusted odds ratio [aOR], 1.77; 95% CI, 1.28-2.45) and memory (aOR, 1.69; 95% CI, 1.19-2.41). 

When stratified by neurodevelopmental comorbidities, having atopic dermatitis was associated with a 2- to 3-fold greater odds of memory difficulties among children with any neurodevelopmental disorder (aOR, 2.26; 95% CI, 1.43-3.57), which included ADHD (aOR, 2.90; 95% CI, 1.60-5.24) or learning disabilities (aOR, 2.04; 95% CI, 1.04-4.00).

Having atopic dermatitis was not associated with learning or memory difficulties among children without neurodevelopmental conditions. 

IN PRACTICE:

“These findings may improve the risk stratification of children with atopic dermatitis for cognitive impairment and suggest that evaluation for cognitive impairment should be prioritized among children with atopic dermatitis and comorbid ADHD or learning disability,” the authors wrote.

SOURCE:

Corresponding author Joy Wan, MD, of the department of dermatology at Johns Hopkins University School of Medicine, Baltimore, and colleagues conducted the research, which was published on March 6, 2024, in JAMA Dermatology.

LIMITATIONS:

The study’s limitations were its cross-sectional design, reliance on caregiver reports, and the fact that National Health Interview Survey data do not include information on factors such as atopic dermatitis severity, age at atopic dermatitis diagnosis, and sleep. 

DISCLOSURES:

The study was supported by a grant from the National Institutes of Health. Dr. Wan reported receiving a grant from Pfizer and personal fees from Sun Pharmaceutical Industries and Janssen Pharmaceuticals outside the submitted work. No other study authors had disclosures to report. 

A version of this article appeared on Medscape.com.

TOPLINE:

The odds of having cognitive impairment may be increased among children with atopic dermatitis, primarily among those with neurodevelopmental disorders, such as attention-deficit/hyperactivity disorder (ADHD) or a learning disability.

METHODOLOGY:

It remains unknown whether subpopulations of children with atopic dermatitis face a greater risk for cognitive impairment or not.

To determine the association, researchers drew from a weighted sample of 69,732,807 children with atopic dermatitis in the 2021 US National Health Interview Survey.

Main outcomes of interest were difficulty in learning or memory (cognitive impairment symptoms) as reported by the child’s caregiver.

The researchers performed logistic regression to compare the odds of learning or memory difficulties between 60,509,794 children without atopic dermatitis and 9,223,013 children with atopic dermatitis.

TAKEAWAY:

Children with versus without atopic dermatitis were more likely to experience difficulties with learning (10.8% [95% CI, 7.8%-15.8%] vs 5.9% [95% CI, 5.1%-6.9%]; P < .001) and difficulties with memory (11.1% [95% CI, 8.0%-15.9%] vs 5.8% [95% CI, 4.9%-6.9%]; P < .001).

On multivariable logistic regression adjusted for sociodemographic factors, asthma, food allergies, and seasonal allergies or hay fever, researchers found that having atopic dermatitis was associated with increased odds of difficulties in learning (adjusted odds ratio [aOR], 1.77; 95% CI, 1.28-2.45) and memory (aOR, 1.69; 95% CI, 1.19-2.41). 

When stratified by neurodevelopmental comorbidities, having atopic dermatitis was associated with a 2- to 3-fold greater odds of memory difficulties among children with any neurodevelopmental disorder (aOR, 2.26; 95% CI, 1.43-3.57), which included ADHD (aOR, 2.90; 95% CI, 1.60-5.24) or learning disabilities (aOR, 2.04; 95% CI, 1.04-4.00).

Having atopic dermatitis was not associated with learning or memory difficulties among children without neurodevelopmental conditions. 

IN PRACTICE:

“These findings may improve the risk stratification of children with atopic dermatitis for cognitive impairment and suggest that evaluation for cognitive impairment should be prioritized among children with atopic dermatitis and comorbid ADHD or learning disability,” the authors wrote.

SOURCE:

Corresponding author Joy Wan, MD, of the department of dermatology at Johns Hopkins University School of Medicine, Baltimore, and colleagues conducted the research, which was published on March 6, 2024, in JAMA Dermatology.

LIMITATIONS:

The study’s limitations were its cross-sectional design, reliance on caregiver reports, and the fact that National Health Interview Survey data do not include information on factors such as atopic dermatitis severity, age at atopic dermatitis diagnosis, and sleep. 

DISCLOSURES:

The study was supported by a grant from the National Institutes of Health. Dr. Wan reported receiving a grant from Pfizer and personal fees from Sun Pharmaceutical Industries and Janssen Pharmaceuticals outside the submitted work. No other study authors had disclosures to report. 

A version of this article appeared on Medscape.com.

Lawmakers have added a provision to raise Medicare payments to clinicians to a $460 billion bipartisan package of federal spending bills that passed in the House on March 6 and is expected to be passed in the Senate and signed by President Biden before then end of March 8, but industry groups have criticized it as paltry.

Lawmakers often tweak Medicare policy by adding provisions to other kinds of legislation, including the spending bills Congress must pass to keep the federal government running.

Physicians’ groups and some lawmakers have long pressed Congress to change Medicare payment rules with little success, even as inflation has caused physicians’ expenses to rise. Doctors now face a 3.4% cut to Medicare reimbursements in 2024, which would be only partly mitigated by the recently announced provision.

The Medical Group Management Association (MGMA) said the proposed increase would total 1.68%. The increase, part of a bipartisan package of bills released by the House and Senate Appropriations committees on March 3, would apply to the budget for fiscal 2024, which began on October 1, 2023.

“We are deeply disappointed with Congress’ half-hearted attempt to remedy the devastating blow physician practices were dealt by the 2024 Medicare Physician Fee Schedule,” Anders Gilberg, senior vice president of MGMA, said in a statement. “Anything less than a full reversal of the 3.4% cut is appallingly inadequate.”

The American Medical Association said it was “extremely disappointed” that the boost only eased, but did not fully reverse, a deeper planned cut.

The American Academy of Family Physicians (AAFP) also expressed disappointment with the proposed increase.

“The AAFP has repeatedly told Congress that the 3.4% Medicare payment reduction that went into effect on January 1 is untenable for family physicians and threatens patients’ access to primary care,” the group said in a statement.

“While we appreciate the partial relief, family physicians continue to face an annual threat of payment cuts that are detrimental to practices and patients,” AAFP said.

A version of this article appeared on Medscape.com.

Lawmakers have added a provision to raise Medicare payments to clinicians to a $460 billion bipartisan package of federal spending bills that passed in the House on March 6 and is expected to be passed in the Senate and signed by President Biden before then end of March 8, but industry groups have criticized it as paltry.

Lawmakers often tweak Medicare policy by adding provisions to other kinds of legislation, including the spending bills Congress must pass to keep the federal government running.

Physicians’ groups and some lawmakers have long pressed Congress to change Medicare payment rules with little success, even as inflation has caused physicians’ expenses to rise. Doctors now face a 3.4% cut to Medicare reimbursements in 2024, which would be only partly mitigated by the recently announced provision.

The Medical Group Management Association (MGMA) said the proposed increase would total 1.68%. The increase, part of a bipartisan package of bills released by the House and Senate Appropriations committees on March 3, would apply to the budget for fiscal 2024, which began on October 1, 2023.

“We are deeply disappointed with Congress’ half-hearted attempt to remedy the devastating blow physician practices were dealt by the 2024 Medicare Physician Fee Schedule,” Anders Gilberg, senior vice president of MGMA, said in a statement. “Anything less than a full reversal of the 3.4% cut is appallingly inadequate.”

The American Medical Association said it was “extremely disappointed” that the boost only eased, but did not fully reverse, a deeper planned cut.

The American Academy of Family Physicians (AAFP) also expressed disappointment with the proposed increase.

“The AAFP has repeatedly told Congress that the 3.4% Medicare payment reduction that went into effect on January 1 is untenable for family physicians and threatens patients’ access to primary care,” the group said in a statement.

“While we appreciate the partial relief, family physicians continue to face an annual threat of payment cuts that are detrimental to practices and patients,” AAFP said.

A version of this article appeared on Medscape.com.

Lawmakers have added a provision to raise Medicare payments to clinicians to a $460 billion bipartisan package of federal spending bills that passed in the House on March 6 and is expected to be passed in the Senate and signed by President Biden before then end of March 8, but industry groups have criticized it as paltry.

Lawmakers often tweak Medicare policy by adding provisions to other kinds of legislation, including the spending bills Congress must pass to keep the federal government running.

Physicians’ groups and some lawmakers have long pressed Congress to change Medicare payment rules with little success, even as inflation has caused physicians’ expenses to rise. Doctors now face a 3.4% cut to Medicare reimbursements in 2024, which would be only partly mitigated by the recently announced provision.

The Medical Group Management Association (MGMA) said the proposed increase would total 1.68%. The increase, part of a bipartisan package of bills released by the House and Senate Appropriations committees on March 3, would apply to the budget for fiscal 2024, which began on October 1, 2023.

“We are deeply disappointed with Congress’ half-hearted attempt to remedy the devastating blow physician practices were dealt by the 2024 Medicare Physician Fee Schedule,” Anders Gilberg, senior vice president of MGMA, said in a statement. “Anything less than a full reversal of the 3.4% cut is appallingly inadequate.”

The American Medical Association said it was “extremely disappointed” that the boost only eased, but did not fully reverse, a deeper planned cut.

The American Academy of Family Physicians (AAFP) also expressed disappointment with the proposed increase.

“The AAFP has repeatedly told Congress that the 3.4% Medicare payment reduction that went into effect on January 1 is untenable for family physicians and threatens patients’ access to primary care,” the group said in a statement.

“While we appreciate the partial relief, family physicians continue to face an annual threat of payment cuts that are detrimental to practices and patients,” AAFP said.

A version of this article appeared on Medscape.com.

TOPLINE:

Children treated with silver diamine fluoride (SDF) had outcomes similar to those who received sealants and atraumatic restoration (ART), according to findings from a new study published in JAMA Pediatrics

METHODOLOGY:

• School programs for dental sealants were first proposed as a way to reduce health inequities, but the technique is too expensive to be widely used.
• Silver diamine fluoride has antimicrobial properties that remineralize the teeth and is a cost-effective alternative to dental sealants.
• The trial included 4100 children from low-income and/or minority groups in New York City, who were aged between 5 to 13 years.
• Between 2018 and 2023, students exhibiting early tooth decay were randomized to receive either SDF or sealants and ART.
• Researchers compared the rates of new cavities and fillings between the two groups over time.

TAKEAWAY:

• Overall, the odds of developing dental cavities decreased by around 20% in both treatment groups.
• The prevalence of cavities among children treated with SDF was 10.2 per 1000 tooth-years compared with 9.8 per 1000 in the sealant and ART group.
• The difference in students who had no new cavities or fillings between the two groups was minimal, ranging from −0.001 to 0.031.
• Children who received SDF from a nurse had outcomes similar to those who were treated by a dental hygienist (odds ratio, 0.89; 95% CI, 0.67-1.19).

IN PRACTICE:

“Research indicates that treatment of early childhood caries using SDF by physicians in primary care settings is both feasible and acceptable…we conclude that SDF is an effective alternative for community-based prevention that may help address these existing barriers.”

SOURCE:

The study was funded by the Patient-Centered Outcomes Research Institute (PCORI). It was led by Ryan Richard Ruff, PhD, MPH, associate professor in the Department of Epidemiology & Health Promotion at New York University College of Dentistry, New York.

LIMITATIONS:

The authors reported that youth may have received dental care outside of the study, which could have influenced the results. To account for that risk, they identified students who received outside care. In addition, > 3000 students were not included in the final analysis due to attrition. 

DISCLOSURES:

Authors reported receiving grants from the National Institute on Minority Health and Health Disparities, the PCORI, and the National Institutes of Health. Richard Niederman, DMD, reported nonfinancial support from Colgate, GC America, and Elevate Oral Care and consulting fees from Delta Dental Washington outside the submitted work.

A version of this article appeared on Medscape.com.

TOPLINE:

Children treated with silver diamine fluoride (SDF) had outcomes similar to those who received sealants and atraumatic restoration (ART), according to findings from a new study published in JAMA Pediatrics

METHODOLOGY:

• School programs for dental sealants were first proposed as a way to reduce health inequities, but the technique is too expensive to be widely used.
• Silver diamine fluoride has antimicrobial properties that remineralize the teeth and is a cost-effective alternative to dental sealants.
• The trial included 4100 children from low-income and/or minority groups in New York City, who were aged between 5 to 13 years.
• Between 2018 and 2023, students exhibiting early tooth decay were randomized to receive either SDF or sealants and ART.
• Researchers compared the rates of new cavities and fillings between the two groups over time.

TAKEAWAY:

• Overall, the odds of developing dental cavities decreased by around 20% in both treatment groups.
• The prevalence of cavities among children treated with SDF was 10.2 per 1000 tooth-years compared with 9.8 per 1000 in the sealant and ART group.
• The difference in students who had no new cavities or fillings between the two groups was minimal, ranging from −0.001 to 0.031.
• Children who received SDF from a nurse had outcomes similar to those who were treated by a dental hygienist (odds ratio, 0.89; 95% CI, 0.67-1.19).

IN PRACTICE:

“Research indicates that treatment of early childhood caries using SDF by physicians in primary care settings is both feasible and acceptable…we conclude that SDF is an effective alternative for community-based prevention that may help address these existing barriers.”

SOURCE:

The study was funded by the Patient-Centered Outcomes Research Institute (PCORI). It was led by Ryan Richard Ruff, PhD, MPH, associate professor in the Department of Epidemiology & Health Promotion at New York University College of Dentistry, New York.

LIMITATIONS:

The authors reported that youth may have received dental care outside of the study, which could have influenced the results. To account for that risk, they identified students who received outside care. In addition, > 3000 students were not included in the final analysis due to attrition. 

DISCLOSURES:

Authors reported receiving grants from the National Institute on Minority Health and Health Disparities, the PCORI, and the National Institutes of Health. Richard Niederman, DMD, reported nonfinancial support from Colgate, GC America, and Elevate Oral Care and consulting fees from Delta Dental Washington outside the submitted work.

A version of this article appeared on Medscape.com.

TOPLINE:

Children treated with silver diamine fluoride (SDF) had outcomes similar to those who received sealants and atraumatic restoration (ART), according to findings from a new study published in JAMA Pediatrics

METHODOLOGY:

• School programs for dental sealants were first proposed as a way to reduce health inequities, but the technique is too expensive to be widely used.
• Silver diamine fluoride has antimicrobial properties that remineralize the teeth and is a cost-effective alternative to dental sealants.
• The trial included 4100 children from low-income and/or minority groups in New York City, who were aged between 5 to 13 years.
• Between 2018 and 2023, students exhibiting early tooth decay were randomized to receive either SDF or sealants and ART.
• Researchers compared the rates of new cavities and fillings between the two groups over time.

TAKEAWAY:

• Overall, the odds of developing dental cavities decreased by around 20% in both treatment groups.
• The prevalence of cavities among children treated with SDF was 10.2 per 1000 tooth-years compared with 9.8 per 1000 in the sealant and ART group.
• The difference in students who had no new cavities or fillings between the two groups was minimal, ranging from −0.001 to 0.031.
• Children who received SDF from a nurse had outcomes similar to those who were treated by a dental hygienist (odds ratio, 0.89; 95% CI, 0.67-1.19).

IN PRACTICE:

“Research indicates that treatment of early childhood caries using SDF by physicians in primary care settings is both feasible and acceptable…we conclude that SDF is an effective alternative for community-based prevention that may help address these existing barriers.”

SOURCE:

The study was funded by the Patient-Centered Outcomes Research Institute (PCORI). It was led by Ryan Richard Ruff, PhD, MPH, associate professor in the Department of Epidemiology & Health Promotion at New York University College of Dentistry, New York.

LIMITATIONS:

The authors reported that youth may have received dental care outside of the study, which could have influenced the results. To account for that risk, they identified students who received outside care. In addition, > 3000 students were not included in the final analysis due to attrition. 

DISCLOSURES:

Authors reported receiving grants from the National Institute on Minority Health and Health Disparities, the PCORI, and the National Institutes of Health. Richard Niederman, DMD, reported nonfinancial support from Colgate, GC America, and Elevate Oral Care and consulting fees from Delta Dental Washington outside the submitted work.

A version of this article appeared on Medscape.com.

Do I deserve to be here? Am I doing what I’m supposed to be doing? Is anyone going to tell me if I’m terrible?

Kerri Palamara McGrath, MD, remembered worrying over these questions as chief resident at Massachusetts General Hospital, Boston, Massachusetts, in 2009. Having graduated from New York Medical College, she felt out of step with her peers from Ivy League medical schools and considered herself lucky to be there. In order to measure up, she felt she had to work twice as hard as everybody else.

But as Dr. McGrath moved through residency and spoke with other trainees, she had a realization. Her constant fears, the nagging voice in her head saying she wasn’t good enough, these issues weren’t exclusive to her; they were pervasive.

Today, Dr. McGrath is the director of the Center for Physician Well-Being at Massachusetts General Hospital. The facility aims to address physician stress and equip doctors with the tools to navigate personal and professional issues. Dr. McGrath is also a physician coach, a growing nonclinical field, helping doctors identify their own stressors, values, and measures of success. This type of internal work, Dr. McGrath feels, can help alleviate imposter syndrome, that inner refrain saying: I’ll never be good enough.

What Is Imposter Syndrome?

While not a formal medical diagnosis, imposter syndrome has been defined as «an internal experience of intellectual phoniness.» It›s considered an inability to internalize success and a tendency to attribute gains to external factors — for example, being in the right place at the right time.

“Many people describe imposter phenomena in medicine as fearing that others are going to realize that they don’t belong somewhere or question why they’re there,” said Dr. McGrath.

It’s a “fear of being found out,” added Jessi Gold, MD, a psychiatrist who treats physicians. “In many ways, imposter syndrome shows up as a conflict between the outer self — the metaphorical mask you’re ‘putting on’ [in order] to achieve, and the inner self — how you feel like you’re not measuring up.”

Dr. McGrath said she experienced imposter syndrome before her medical career even began. She applied to 26 medical schools. Only one accepted her. “The whole time, I was like, ‘This is the only school you got into, so you’re obviously not good enough,’” she recalled. Later, having been chosen by a “coveted” institution like Mass General, “you assume that, at some point, someone will realize that the gig is up, that everybody’s better than you.”

Where Does Imposter Syndrome Come From?

Dr. McGrath felt that in medicine, high expectations are often coupled with low self-compassion. “We are so hard on ourselves, and when we set our expectations so high, we’re constantly disappointed in ourselves,” she said. External markers of success — papers published, promotions, or even social media — can further fuel this.

It can feel like “striving for excellence in a sea of excellence,” Dr. McGrath added, and this can invite comparison.

Ravi Parikh, MD, a medical oncologist and physician-scientist at the University of Pennsylvania, Philadelphia, Pennsylvania, remembered struggling with imposter syndrome early in his career. As a new doctor, he had a ton of questions, and yet those above him seemed able to make weighty decisions on their own. The comparison shook his confidence. “I remember thinking that when I became an attending, I would just magically not have to run decisions by people,” said Dr. Parikh. But even then, the “magical” self-assurance didn’t materialize.

Research found that imposter syndrome is more likely to affect women and groups that are underrepresented in medicine. But overall, the incidence is remarkably high.

A 2023 survey published in the Journal of the American College of Surgeons found that 90% of female surgeons and more than two-thirds of male ones experienced imposter syndrome. In a 2023 study on medical students in JAMA, it was nearly universal; 97% reported feelings of imposter syndrome with women 1.7 times more likely to report it than men and underrepresented groups often three times more likely.

‘I’m Clearly in the Minority Here’

The term “imposter” also suggests a lack of belonging. If medicine doesn’t “look like you,” this can create feelings of pressure, like you’re “representing a whole group with your mere existence,” said Dr. Gold, “and you have to keep proving yourself.”

Chloe Slocum, MD, MPH, an assistant professor of physical medicine and rehabilitation at Harvard Medical School, Boston, Massachusetts, remembered that feeling of conspicuous “otherness.” As a resident, Dr. Slocum began presenting at national meetings and later pursued physician leadership training. Many of her counterparts at these events were older males. “At some programs early on, I’d wonder, ‘I’m clearly in the minority here; did they really make the right decision including me in this?’”

Reactions from those around you can also have an impact. Dr. McGrath — who is 5’ 2” and describes herself as looking “very young” — noted that when she started out, neither patients nor other providers thought she was a doctor.

“I have tried everything in the book to be seen, in somebody else’s eyes, as more consistent with a doctor,” she said. “I’ve dressed down. I’ve dressed up. I’ve worn heels. I’ve worn flats. I’ve worn glasses. I’ve done all the things. When you’re constantly being told you don’t look like a doctor, you start questioning yourself.”

The Emotional Toll

If that sounds mentally exhausting, it is. Research found that imposter syndrome is often linked with burnout, depression, and anxiety.

The need to prove yourself and prevent being “found out” can push some doctors toward traditional measurements of success — promotions or published work, said Dr. Gold. But “if you’re trying to achieve in ways that you don’t value,” she warned, “you’re going to burn out.”

On the other hand, intense self-doubt can also limit advancement. After all, if you don’t think you’re good enough, you may not apply for job opportunities or leadership positions.

This mental burden can persist over years and even decades. A 2020 review of studies on imposter syndrome noted that “it would be reassuring to believe that imposter symptoms decline with age.” Unfortunately, several studies indicated that they do not.

How to Manage Imposter Syndrome

While it can be difficult to overcome imposter syndrome, there are ways to work through it and make it less pervasive or intense. Here are some tips from our experts:

• Prioritize your mental health. This can be difficult for some physicians, but don’t ignore symptoms of depression, anxiety, or burnout. Untreated mental health conditions cloud the ability to reflect on some of the existential questions that will help you navigate imposter syndrome, said Dr. Gold.
• Assess how often you need validation and why. Try to identify what you›re feeling, what needs aren›t being met, and how you can meet those needs. You can then consider where to get that validation either internally or by connecting with a colleague. Dr. McGrath encourages physicians to ask, “What does success look like for me?” and can you make success more personal and meaningful. It might sound shocking, but rather than an unattainable ideal, success should be something that feels good.
• Know the power of teamwork. As Dr. Parikh eventually realized, collaborative care is a common and beneficial part of medicine — not something that makes you a less-than physician. “There’s a lot of opportunity to crowdsource the medical decision-making process in ways that increase your own confidence as a doctor,” he said.
• Practice self-compassion. Critical voices in your head add to an already hard and stressful world. This is where self-compassion comes in. “We don’t have much control over medicine, but we have control over how medicine makes us feel,” Dr. Gold said. Imagine treating yourself how you would treat a friend.
• Consider a physician coach.  suggests that physician coaches can help lower rates of burnout and improve well-being, resilience, professional fulfillment, and self-worth. “Coaching looks into the future to help you envision what things would look like if you were feeling differently. It helps you explore what’s in your control and how you want to shape that,” said Dr. McGrath.
• Amplify the good. Apps and web-based tools can remind you to celebrate your own achievements. The “” exercise created by J. Bryan Sexton, PhD, at the Duke Center for Healthcare Safety & Quality for example, was documented in a . When healthcare workers reflected on three good things that happened each day for 2 weeks, they reported significant improvements in depression, burnout, and work-life balance.
• Do a values check. Dr. Gold often suggested that physicians with imposter syndrome ask themselves what they value, what medicine values, and how the two line up. Pausing to consider this can guide you toward useful strategies. If you value family life but feel like medicine doesn’t, for example, you might talk with a colleague who has navigated this conflict.

Dr. Gold added that reminding yourself of the range of options can be freeing. “There’s no ‘one career’ in medicine,” she said. “There are multiple ways to be happy in medicine; there are multiple ways to be happy outside of medicine. And you’re not a failure for the path you choose.”

A version of this article appeared on Medscape.com.

Do I deserve to be here? Am I doing what I’m supposed to be doing? Is anyone going to tell me if I’m terrible?

Kerri Palamara McGrath, MD, remembered worrying over these questions as chief resident at Massachusetts General Hospital, Boston, Massachusetts, in 2009. Having graduated from New York Medical College, she felt out of step with her peers from Ivy League medical schools and considered herself lucky to be there. In order to measure up, she felt she had to work twice as hard as everybody else.

But as Dr. McGrath moved through residency and spoke with other trainees, she had a realization. Her constant fears, the nagging voice in her head saying she wasn’t good enough, these issues weren’t exclusive to her; they were pervasive.

Today, Dr. McGrath is the director of the Center for Physician Well-Being at Massachusetts General Hospital. The facility aims to address physician stress and equip doctors with the tools to navigate personal and professional issues. Dr. McGrath is also a physician coach, a growing nonclinical field, helping doctors identify their own stressors, values, and measures of success. This type of internal work, Dr. McGrath feels, can help alleviate imposter syndrome, that inner refrain saying: I’ll never be good enough.

What Is Imposter Syndrome?

While not a formal medical diagnosis, imposter syndrome has been defined as «an internal experience of intellectual phoniness.» It›s considered an inability to internalize success and a tendency to attribute gains to external factors — for example, being in the right place at the right time.

“Many people describe imposter phenomena in medicine as fearing that others are going to realize that they don’t belong somewhere or question why they’re there,” said Dr. McGrath.

It’s a “fear of being found out,” added Jessi Gold, MD, a psychiatrist who treats physicians. “In many ways, imposter syndrome shows up as a conflict between the outer self — the metaphorical mask you’re ‘putting on’ [in order] to achieve, and the inner self — how you feel like you’re not measuring up.”

Dr. McGrath said she experienced imposter syndrome before her medical career even began. She applied to 26 medical schools. Only one accepted her. “The whole time, I was like, ‘This is the only school you got into, so you’re obviously not good enough,’” she recalled. Later, having been chosen by a “coveted” institution like Mass General, “you assume that, at some point, someone will realize that the gig is up, that everybody’s better than you.”

Where Does Imposter Syndrome Come From?

Dr. McGrath felt that in medicine, high expectations are often coupled with low self-compassion. “We are so hard on ourselves, and when we set our expectations so high, we’re constantly disappointed in ourselves,” she said. External markers of success — papers published, promotions, or even social media — can further fuel this.

It can feel like “striving for excellence in a sea of excellence,” Dr. McGrath added, and this can invite comparison.

Ravi Parikh, MD, a medical oncologist and physician-scientist at the University of Pennsylvania, Philadelphia, Pennsylvania, remembered struggling with imposter syndrome early in his career. As a new doctor, he had a ton of questions, and yet those above him seemed able to make weighty decisions on their own. The comparison shook his confidence. “I remember thinking that when I became an attending, I would just magically not have to run decisions by people,” said Dr. Parikh. But even then, the “magical” self-assurance didn’t materialize.

Research found that imposter syndrome is more likely to affect women and groups that are underrepresented in medicine. But overall, the incidence is remarkably high.

A 2023 survey published in the Journal of the American College of Surgeons found that 90% of female surgeons and more than two-thirds of male ones experienced imposter syndrome. In a 2023 study on medical students in JAMA, it was nearly universal; 97% reported feelings of imposter syndrome with women 1.7 times more likely to report it than men and underrepresented groups often three times more likely.

‘I’m Clearly in the Minority Here’

The term “imposter” also suggests a lack of belonging. If medicine doesn’t “look like you,” this can create feelings of pressure, like you’re “representing a whole group with your mere existence,” said Dr. Gold, “and you have to keep proving yourself.”

Chloe Slocum, MD, MPH, an assistant professor of physical medicine and rehabilitation at Harvard Medical School, Boston, Massachusetts, remembered that feeling of conspicuous “otherness.” As a resident, Dr. Slocum began presenting at national meetings and later pursued physician leadership training. Many of her counterparts at these events were older males. “At some programs early on, I’d wonder, ‘I’m clearly in the minority here; did they really make the right decision including me in this?’”

Reactions from those around you can also have an impact. Dr. McGrath — who is 5’ 2” and describes herself as looking “very young” — noted that when she started out, neither patients nor other providers thought she was a doctor.

“I have tried everything in the book to be seen, in somebody else’s eyes, as more consistent with a doctor,” she said. “I’ve dressed down. I’ve dressed up. I’ve worn heels. I’ve worn flats. I’ve worn glasses. I’ve done all the things. When you’re constantly being told you don’t look like a doctor, you start questioning yourself.”

The Emotional Toll

If that sounds mentally exhausting, it is. Research found that imposter syndrome is often linked with burnout, depression, and anxiety.

The need to prove yourself and prevent being “found out” can push some doctors toward traditional measurements of success — promotions or published work, said Dr. Gold. But “if you’re trying to achieve in ways that you don’t value,” she warned, “you’re going to burn out.”

On the other hand, intense self-doubt can also limit advancement. After all, if you don’t think you’re good enough, you may not apply for job opportunities or leadership positions.

This mental burden can persist over years and even decades. A 2020 review of studies on imposter syndrome noted that “it would be reassuring to believe that imposter symptoms decline with age.” Unfortunately, several studies indicated that they do not.

How to Manage Imposter Syndrome

While it can be difficult to overcome imposter syndrome, there are ways to work through it and make it less pervasive or intense. Here are some tips from our experts:

• Prioritize your mental health. This can be difficult for some physicians, but don’t ignore symptoms of depression, anxiety, or burnout. Untreated mental health conditions cloud the ability to reflect on some of the existential questions that will help you navigate imposter syndrome, said Dr. Gold.
• Assess how often you need validation and why. Try to identify what you›re feeling, what needs aren›t being met, and how you can meet those needs. You can then consider where to get that validation either internally or by connecting with a colleague. Dr. McGrath encourages physicians to ask, “What does success look like for me?” and can you make success more personal and meaningful. It might sound shocking, but rather than an unattainable ideal, success should be something that feels good.
• Know the power of teamwork. As Dr. Parikh eventually realized, collaborative care is a common and beneficial part of medicine — not something that makes you a less-than physician. “There’s a lot of opportunity to crowdsource the medical decision-making process in ways that increase your own confidence as a doctor,” he said.
• Practice self-compassion. Critical voices in your head add to an already hard and stressful world. This is where self-compassion comes in. “We don’t have much control over medicine, but we have control over how medicine makes us feel,” Dr. Gold said. Imagine treating yourself how you would treat a friend.
• Consider a physician coach.  suggests that physician coaches can help lower rates of burnout and improve well-being, resilience, professional fulfillment, and self-worth. “Coaching looks into the future to help you envision what things would look like if you were feeling differently. It helps you explore what’s in your control and how you want to shape that,” said Dr. McGrath.
• Amplify the good. Apps and web-based tools can remind you to celebrate your own achievements. The “” exercise created by J. Bryan Sexton, PhD, at the Duke Center for Healthcare Safety & Quality for example, was documented in a . When healthcare workers reflected on three good things that happened each day for 2 weeks, they reported significant improvements in depression, burnout, and work-life balance.
• Do a values check. Dr. Gold often suggested that physicians with imposter syndrome ask themselves what they value, what medicine values, and how the two line up. Pausing to consider this can guide you toward useful strategies. If you value family life but feel like medicine doesn’t, for example, you might talk with a colleague who has navigated this conflict.

Dr. Gold added that reminding yourself of the range of options can be freeing. “There’s no ‘one career’ in medicine,” she said. “There are multiple ways to be happy in medicine; there are multiple ways to be happy outside of medicine. And you’re not a failure for the path you choose.”

A version of this article appeared on Medscape.com.

Do I deserve to be here? Am I doing what I’m supposed to be doing? Is anyone going to tell me if I’m terrible?

Kerri Palamara McGrath, MD, remembered worrying over these questions as chief resident at Massachusetts General Hospital, Boston, Massachusetts, in 2009. Having graduated from New York Medical College, she felt out of step with her peers from Ivy League medical schools and considered herself lucky to be there. In order to measure up, she felt she had to work twice as hard as everybody else.

But as Dr. McGrath moved through residency and spoke with other trainees, she had a realization. Her constant fears, the nagging voice in her head saying she wasn’t good enough, these issues weren’t exclusive to her; they were pervasive.

Today, Dr. McGrath is the director of the Center for Physician Well-Being at Massachusetts General Hospital. The facility aims to address physician stress and equip doctors with the tools to navigate personal and professional issues. Dr. McGrath is also a physician coach, a growing nonclinical field, helping doctors identify their own stressors, values, and measures of success. This type of internal work, Dr. McGrath feels, can help alleviate imposter syndrome, that inner refrain saying: I’ll never be good enough.

What Is Imposter Syndrome?

While not a formal medical diagnosis, imposter syndrome has been defined as «an internal experience of intellectual phoniness.» It›s considered an inability to internalize success and a tendency to attribute gains to external factors — for example, being in the right place at the right time.

“Many people describe imposter phenomena in medicine as fearing that others are going to realize that they don’t belong somewhere or question why they’re there,” said Dr. McGrath.

It’s a “fear of being found out,” added Jessi Gold, MD, a psychiatrist who treats physicians. “In many ways, imposter syndrome shows up as a conflict between the outer self — the metaphorical mask you’re ‘putting on’ [in order] to achieve, and the inner self — how you feel like you’re not measuring up.”

Dr. McGrath said she experienced imposter syndrome before her medical career even began. She applied to 26 medical schools. Only one accepted her. “The whole time, I was like, ‘This is the only school you got into, so you’re obviously not good enough,’” she recalled. Later, having been chosen by a “coveted” institution like Mass General, “you assume that, at some point, someone will realize that the gig is up, that everybody’s better than you.”

Where Does Imposter Syndrome Come From?

Dr. McGrath felt that in medicine, high expectations are often coupled with low self-compassion. “We are so hard on ourselves, and when we set our expectations so high, we’re constantly disappointed in ourselves,” she said. External markers of success — papers published, promotions, or even social media — can further fuel this.

It can feel like “striving for excellence in a sea of excellence,” Dr. McGrath added, and this can invite comparison.

Ravi Parikh, MD, a medical oncologist and physician-scientist at the University of Pennsylvania, Philadelphia, Pennsylvania, remembered struggling with imposter syndrome early in his career. As a new doctor, he had a ton of questions, and yet those above him seemed able to make weighty decisions on their own. The comparison shook his confidence. “I remember thinking that when I became an attending, I would just magically not have to run decisions by people,” said Dr. Parikh. But even then, the “magical” self-assurance didn’t materialize.

Research found that imposter syndrome is more likely to affect women and groups that are underrepresented in medicine. But overall, the incidence is remarkably high.

A 2023 survey published in the Journal of the American College of Surgeons found that 90% of female surgeons and more than two-thirds of male ones experienced imposter syndrome. In a 2023 study on medical students in JAMA, it was nearly universal; 97% reported feelings of imposter syndrome with women 1.7 times more likely to report it than men and underrepresented groups often three times more likely.

‘I’m Clearly in the Minority Here’

The term “imposter” also suggests a lack of belonging. If medicine doesn’t “look like you,” this can create feelings of pressure, like you’re “representing a whole group with your mere existence,” said Dr. Gold, “and you have to keep proving yourself.”

Chloe Slocum, MD, MPH, an assistant professor of physical medicine and rehabilitation at Harvard Medical School, Boston, Massachusetts, remembered that feeling of conspicuous “otherness.” As a resident, Dr. Slocum began presenting at national meetings and later pursued physician leadership training. Many of her counterparts at these events were older males. “At some programs early on, I’d wonder, ‘I’m clearly in the minority here; did they really make the right decision including me in this?’”

Reactions from those around you can also have an impact. Dr. McGrath — who is 5’ 2” and describes herself as looking “very young” — noted that when she started out, neither patients nor other providers thought she was a doctor.

“I have tried everything in the book to be seen, in somebody else’s eyes, as more consistent with a doctor,” she said. “I’ve dressed down. I’ve dressed up. I’ve worn heels. I’ve worn flats. I’ve worn glasses. I’ve done all the things. When you’re constantly being told you don’t look like a doctor, you start questioning yourself.”

The Emotional Toll

If that sounds mentally exhausting, it is. Research found that imposter syndrome is often linked with burnout, depression, and anxiety.

The need to prove yourself and prevent being “found out” can push some doctors toward traditional measurements of success — promotions or published work, said Dr. Gold. But “if you’re trying to achieve in ways that you don’t value,” she warned, “you’re going to burn out.”

On the other hand, intense self-doubt can also limit advancement. After all, if you don’t think you’re good enough, you may not apply for job opportunities or leadership positions.

This mental burden can persist over years and even decades. A 2020 review of studies on imposter syndrome noted that “it would be reassuring to believe that imposter symptoms decline with age.” Unfortunately, several studies indicated that they do not.

How to Manage Imposter Syndrome

While it can be difficult to overcome imposter syndrome, there are ways to work through it and make it less pervasive or intense. Here are some tips from our experts:

• Prioritize your mental health. This can be difficult for some physicians, but don’t ignore symptoms of depression, anxiety, or burnout. Untreated mental health conditions cloud the ability to reflect on some of the existential questions that will help you navigate imposter syndrome, said Dr. Gold.
• Assess how often you need validation and why. Try to identify what you›re feeling, what needs aren›t being met, and how you can meet those needs. You can then consider where to get that validation either internally or by connecting with a colleague. Dr. McGrath encourages physicians to ask, “What does success look like for me?” and can you make success more personal and meaningful. It might sound shocking, but rather than an unattainable ideal, success should be something that feels good.
• Know the power of teamwork. As Dr. Parikh eventually realized, collaborative care is a common and beneficial part of medicine — not something that makes you a less-than physician. “There’s a lot of opportunity to crowdsource the medical decision-making process in ways that increase your own confidence as a doctor,” he said.
• Practice self-compassion. Critical voices in your head add to an already hard and stressful world. This is where self-compassion comes in. “We don’t have much control over medicine, but we have control over how medicine makes us feel,” Dr. Gold said. Imagine treating yourself how you would treat a friend.
• Consider a physician coach.  suggests that physician coaches can help lower rates of burnout and improve well-being, resilience, professional fulfillment, and self-worth. “Coaching looks into the future to help you envision what things would look like if you were feeling differently. It helps you explore what’s in your control and how you want to shape that,” said Dr. McGrath.
• Amplify the good. Apps and web-based tools can remind you to celebrate your own achievements. The “” exercise created by J. Bryan Sexton, PhD, at the Duke Center for Healthcare Safety & Quality for example, was documented in a . When healthcare workers reflected on three good things that happened each day for 2 weeks, they reported significant improvements in depression, burnout, and work-life balance.
• Do a values check. Dr. Gold often suggested that physicians with imposter syndrome ask themselves what they value, what medicine values, and how the two line up. Pausing to consider this can guide you toward useful strategies. If you value family life but feel like medicine doesn’t, for example, you might talk with a colleague who has navigated this conflict.

Dr. Gold added that reminding yourself of the range of options can be freeing. “There’s no ‘one career’ in medicine,” she said. “There are multiple ways to be happy in medicine; there are multiple ways to be happy outside of medicine. And you’re not a failure for the path you choose.”

A version of this article appeared on Medscape.com.

Calls to US poison centers related to psilocybin more than tripled among teens and more than doubled in young adults between 2019 and 2022, new research suggests. Investigators say the increase may be linked to decriminalization efforts in US cities and states.

METHODOLOGY:

• Investigators used data from the National Poison Data System (NPDS) to identify calls involving psilocybin between January 2013 and December 2022.
• Researchers focused on calls about individuals between the ages of 13 and 25 years.
• Exposures to psilocybin were examined based on demographics, clinical effects, level of care, and medical outcome.

TAKEAWAY:

• During the entire 10-year study period, 4055 psilocybin-involved exposures were reported in the age groups studied, with 66% being single-substance exposures and close to three quarters receiving medical attention.
• Psilocybin’s most common effects were hallucinations or delusions (37% of calls), agitation (28%), tachycardia (20%), and confusion (16%).
• The number of psilocybin-related calls to poison control centers for youth were largely unchanged from 2013 to 2018 but more than tripled among adolescents (aged 13-19 years) from 2019 and 2022 and more than doubled among young adults (aged 20-25 years) between 2018 and 2022 (P < .0001).

IN PRACTICE:

The increase in poison center calls coincides with psilocybin decriminalization efforts in several states in 2019, the authors noted. However, because those efforts only legalized use in adults aged 21 years and older, the rise among younger people is concerning, they added. “As psilocybin may become more widely available, it is important for parents to be aware that psilocybin is also available in edible forms such as chocolate and gummies. And we learned from our experience with edible cannabis that young children can mistake edibles for candy,” lead author Rita Farah, PharmD, MPH, PhD, Blue Ridge Poison Center epidemiologist, said in a news release.

SOURCE:

Christopher Holstege, MD, director of UVA Health’s Blue Ridge Poison Center and chief of the Division of Medical Toxicology at the UVA School of Medicine was the senior and corresponding author of the study. It was published online on February 26 in the Journal of Adolescent Health.

LIMITATIONS:

NPDS data are not designed to assess potential risk factors leading to increases in psilocybin-related cases. Moreover, because reports to poison control centers are voluntary and don’t capture all exposures, NPDS data likely under-represent cases of hallucinogenic mushroom poisonings. Lastly, NPDS data are susceptible to reporting and misclassification biases.

DISCLOSURES:

Funding source was not disclosed. The authors reported no relevant financial relationships.

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

Calls to US poison centers related to psilocybin more than tripled among teens and more than doubled in young adults between 2019 and 2022, new research suggests. Investigators say the increase may be linked to decriminalization efforts in US cities and states.

METHODOLOGY:

• Investigators used data from the National Poison Data System (NPDS) to identify calls involving psilocybin between January 2013 and December 2022.
• Researchers focused on calls about individuals between the ages of 13 and 25 years.
• Exposures to psilocybin were examined based on demographics, clinical effects, level of care, and medical outcome.

TAKEAWAY:

• During the entire 10-year study period, 4055 psilocybin-involved exposures were reported in the age groups studied, with 66% being single-substance exposures and close to three quarters receiving medical attention.
• Psilocybin’s most common effects were hallucinations or delusions (37% of calls), agitation (28%), tachycardia (20%), and confusion (16%).
• The number of psilocybin-related calls to poison control centers for youth were largely unchanged from 2013 to 2018 but more than tripled among adolescents (aged 13-19 years) from 2019 and 2022 and more than doubled among young adults (aged 20-25 years) between 2018 and 2022 (P < .0001).

IN PRACTICE:

The increase in poison center calls coincides with psilocybin decriminalization efforts in several states in 2019, the authors noted. However, because those efforts only legalized use in adults aged 21 years and older, the rise among younger people is concerning, they added. “As psilocybin may become more widely available, it is important for parents to be aware that psilocybin is also available in edible forms such as chocolate and gummies. And we learned from our experience with edible cannabis that young children can mistake edibles for candy,” lead author Rita Farah, PharmD, MPH, PhD, Blue Ridge Poison Center epidemiologist, said in a news release.

SOURCE:

Christopher Holstege, MD, director of UVA Health’s Blue Ridge Poison Center and chief of the Division of Medical Toxicology at the UVA School of Medicine was the senior and corresponding author of the study. It was published online on February 26 in the Journal of Adolescent Health.

LIMITATIONS:

NPDS data are not designed to assess potential risk factors leading to increases in psilocybin-related cases. Moreover, because reports to poison control centers are voluntary and don’t capture all exposures, NPDS data likely under-represent cases of hallucinogenic mushroom poisonings. Lastly, NPDS data are susceptible to reporting and misclassification biases.

DISCLOSURES:

Funding source was not disclosed. The authors reported no relevant financial relationships.

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

Calls to US poison centers related to psilocybin more than tripled among teens and more than doubled in young adults between 2019 and 2022, new research suggests. Investigators say the increase may be linked to decriminalization efforts in US cities and states.

METHODOLOGY:

• Investigators used data from the National Poison Data System (NPDS) to identify calls involving psilocybin between January 2013 and December 2022.
• Researchers focused on calls about individuals between the ages of 13 and 25 years.
• Exposures to psilocybin were examined based on demographics, clinical effects, level of care, and medical outcome.

TAKEAWAY:

• During the entire 10-year study period, 4055 psilocybin-involved exposures were reported in the age groups studied, with 66% being single-substance exposures and close to three quarters receiving medical attention.
• Psilocybin’s most common effects were hallucinations or delusions (37% of calls), agitation (28%), tachycardia (20%), and confusion (16%).
• The number of psilocybin-related calls to poison control centers for youth were largely unchanged from 2013 to 2018 but more than tripled among adolescents (aged 13-19 years) from 2019 and 2022 and more than doubled among young adults (aged 20-25 years) between 2018 and 2022 (P < .0001).

IN PRACTICE:

The increase in poison center calls coincides with psilocybin decriminalization efforts in several states in 2019, the authors noted. However, because those efforts only legalized use in adults aged 21 years and older, the rise among younger people is concerning, they added. “As psilocybin may become more widely available, it is important for parents to be aware that psilocybin is also available in edible forms such as chocolate and gummies. And we learned from our experience with edible cannabis that young children can mistake edibles for candy,” lead author Rita Farah, PharmD, MPH, PhD, Blue Ridge Poison Center epidemiologist, said in a news release.

SOURCE:

Christopher Holstege, MD, director of UVA Health’s Blue Ridge Poison Center and chief of the Division of Medical Toxicology at the UVA School of Medicine was the senior and corresponding author of the study. It was published online on February 26 in the Journal of Adolescent Health.

LIMITATIONS:

NPDS data are not designed to assess potential risk factors leading to increases in psilocybin-related cases. Moreover, because reports to poison control centers are voluntary and don’t capture all exposures, NPDS data likely under-represent cases of hallucinogenic mushroom poisonings. Lastly, NPDS data are susceptible to reporting and misclassification biases.

DISCLOSURES:

Funding source was not disclosed. The authors reported no relevant financial relationships.

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

This transcript has been edited for clarity.

I’m Dr. Neil Skolnik, and today I am going to talk about the 2023 update to the Global Strategy for Asthma Management and Prevention. We treat a lot of asthma, and there are some important changes, particularly around the use of albuterol. There are two main guidelines when it comes to asthma, the Global Initiative for Asthma (GINA) guideline and the US National Heart, Lung, and Blood Institute Guidelines. While I had the privilege of serving on the expert working group for the US guidelines, what I like about the GINA guidelines is that they are updated annually, and so they really help us keep up with rapid changes in the field.

Today, I’m going to focus on assessment and treatment.
 

Four Questions to Assess Asthma Control

Because over half of patients with asthma are not well controlled, it is important to assess control at every asthma visit. Asthma control has two domains: symptom control and the risk for future exacerbations. It is not enough to simply ask, “How is your asthma?” because many patients overrate their control and live with ongoing symptoms. There are many assessment tools; the Asthma Control Test (ACT) focuses on symptoms, and the new Asthma Impairment and Risk Questionnaire (AIRQ) assesses both symptoms and risk for exacerbations. The GINA assessment is probably the easiest to implement, with just four questions relevant to the past 4 weeks:

• Have you had daytime symptoms more than twice in one week?
• Have you had any night waking due to asthma?
• Have you needed short-acting beta-agonist (SABA), such as albuterol, rescue more than twice in one week?
• Have you had any activity limitation due to asthma?

Well-controlled asthma is defined as a negative response to all four of these questions, partly controlled asthma is one or two “yes” answers, and uncontrolled asthma is three to four positive responses. You can’t modify a patient’s therapy if you don’t know whether their asthma is well or poorly controlled. You’ll notice that these questions focus on symptom control. It is important also to ask about risk factors for exacerbations, particularly previous exacerbations.
 

Asthma Treatment Changes

The goals of treatment are control of symptoms and avoidance of exacerbations. The GINA guidelines emphasize that even patients with mild asthma can have severe or fatal exacerbations.

GINA recommends two management tracks. The preferred track uses inhaled corticosteroid (ICS)-formoterol as both maintenance and reliever therapy (MART). Track 2, without the use of ICS-formoterol for MART, is also offered, recognizing that the use of ICS-formoterol for MART is not approved by the US Food and Drug Administration. There is an easy-to-follow stepped-care diagram that is worth looking at; it’s on page 66 of the GINA guideline PDF.

For patients who have symptoms less than twice a month, begin with Step 1 therapy:

• Track 1: as-needed low-dose ICS-formoterol.
• Track 2: treatment with albuterol; also use ICS whenever albuterol is used.

For patients with symptoms more than twice a month (but not most days of the week) treatment can start with Step 2 therapy:

• Track 1: as-needed low-dose ICS-formoterol
• Track 2: daily low-dose ICS plus as-needed SABA

An option for rescue therapy for Track 2 across all steps of therapy is to use an ICS whenever a SABA is used for rescue to reduce the likelihood of exacerbation.

For patients with more severe asthma symptoms most days of the week, or whose asthma is waking them from sleep one or more times weekly, then you can start with Step 3 therapy as follows:

• Track 1: low dose ICS-formoterol as MART
• Track 2: low-dose ICS with long-acting beta-agonist (LABA) for maintenance, plus as needed SABA or as needed ICS-SABA

That’s going to cover most of our patients. As we see people back, if escalation of therapy is needed, then Step 4 therapy is:

• Track 1: medium-dose ICS-formoterol as MART
• Track 2: medium-dose ICS-LABA plus as needed SABA or as-needed ICS-SABA

For patients who remain uncontrolled, it’s important to realize that Step 5 gives you the option to add a long-acting muscarinic antagonist (LAMA). In my experience this can be very helpful. We can also consider going to high-dose ICS-LABS for maintenance. At this step, the patient usually has pretty severe, uncontrolled asthma and we can think about checking eosinophil counts, ordering pulmonary function tests, and referring to our specialist colleagues for consideration of biologic therapy.

It is important to see patients back regularly, and to assess asthma control. If a patient is not well controlled or has had exacerbations, consider stepping up therapy, or changing from albuterol alone as rescue to albuterol plus ICS for rescue. If they have been well controlled for a long time, consider de-escalation of therapy among patients on one of the higher therapy steps.

Dr. Skolnik has disclosed the following relevant financial relationships: Serve(d) on the advisory board for AstraZeneca, Teva, Eli Lilly and Company, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, Merck; and Bayer; serve(d) as a speaker or a member of a speakers bureau for AstraZeneca, Boehringer Ingelheim, Eli Lilly and Company, GlaxoSmithKline. Received research grant from Sanofi, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Bayer; and received income in an amount equal to or greater than $250 from AstraZeneca, Teva, Eli Lilly and Company, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, Merck, and Bayer.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

I’m Dr. Neil Skolnik, and today I am going to talk about the 2023 update to the Global Strategy for Asthma Management and Prevention. We treat a lot of asthma, and there are some important changes, particularly around the use of albuterol. There are two main guidelines when it comes to asthma, the Global Initiative for Asthma (GINA) guideline and the US National Heart, Lung, and Blood Institute Guidelines. While I had the privilege of serving on the expert working group for the US guidelines, what I like about the GINA guidelines is that they are updated annually, and so they really help us keep up with rapid changes in the field.

Today, I’m going to focus on assessment and treatment.
 

Four Questions to Assess Asthma Control

Because over half of patients with asthma are not well controlled, it is important to assess control at every asthma visit. Asthma control has two domains: symptom control and the risk for future exacerbations. It is not enough to simply ask, “How is your asthma?” because many patients overrate their control and live with ongoing symptoms. There are many assessment tools; the Asthma Control Test (ACT) focuses on symptoms, and the new Asthma Impairment and Risk Questionnaire (AIRQ) assesses both symptoms and risk for exacerbations. The GINA assessment is probably the easiest to implement, with just four questions relevant to the past 4 weeks:

• Have you had daytime symptoms more than twice in one week?
• Have you had any night waking due to asthma?
• Have you needed short-acting beta-agonist (SABA), such as albuterol, rescue more than twice in one week?
• Have you had any activity limitation due to asthma?

Well-controlled asthma is defined as a negative response to all four of these questions, partly controlled asthma is one or two “yes” answers, and uncontrolled asthma is three to four positive responses. You can’t modify a patient’s therapy if you don’t know whether their asthma is well or poorly controlled. You’ll notice that these questions focus on symptom control. It is important also to ask about risk factors for exacerbations, particularly previous exacerbations.
 

Asthma Treatment Changes

The goals of treatment are control of symptoms and avoidance of exacerbations. The GINA guidelines emphasize that even patients with mild asthma can have severe or fatal exacerbations.

GINA recommends two management tracks. The preferred track uses inhaled corticosteroid (ICS)-formoterol as both maintenance and reliever therapy (MART). Track 2, without the use of ICS-formoterol for MART, is also offered, recognizing that the use of ICS-formoterol for MART is not approved by the US Food and Drug Administration. There is an easy-to-follow stepped-care diagram that is worth looking at; it’s on page 66 of the GINA guideline PDF.

For patients who have symptoms less than twice a month, begin with Step 1 therapy:

• Track 1: as-needed low-dose ICS-formoterol.
• Track 2: treatment with albuterol; also use ICS whenever albuterol is used.

For patients with symptoms more than twice a month (but not most days of the week) treatment can start with Step 2 therapy:

• Track 1: as-needed low-dose ICS-formoterol
• Track 2: daily low-dose ICS plus as-needed SABA

An option for rescue therapy for Track 2 across all steps of therapy is to use an ICS whenever a SABA is used for rescue to reduce the likelihood of exacerbation.

For patients with more severe asthma symptoms most days of the week, or whose asthma is waking them from sleep one or more times weekly, then you can start with Step 3 therapy as follows:

• Track 1: low dose ICS-formoterol as MART
• Track 2: low-dose ICS with long-acting beta-agonist (LABA) for maintenance, plus as needed SABA or as needed ICS-SABA

That’s going to cover most of our patients. As we see people back, if escalation of therapy is needed, then Step 4 therapy is:

• Track 1: medium-dose ICS-formoterol as MART
• Track 2: medium-dose ICS-LABA plus as needed SABA or as-needed ICS-SABA

For patients who remain uncontrolled, it’s important to realize that Step 5 gives you the option to add a long-acting muscarinic antagonist (LAMA). In my experience this can be very helpful. We can also consider going to high-dose ICS-LABS for maintenance. At this step, the patient usually has pretty severe, uncontrolled asthma and we can think about checking eosinophil counts, ordering pulmonary function tests, and referring to our specialist colleagues for consideration of biologic therapy.

It is important to see patients back regularly, and to assess asthma control. If a patient is not well controlled or has had exacerbations, consider stepping up therapy, or changing from albuterol alone as rescue to albuterol plus ICS for rescue. If they have been well controlled for a long time, consider de-escalation of therapy among patients on one of the higher therapy steps.

Dr. Skolnik has disclosed the following relevant financial relationships: Serve(d) on the advisory board for AstraZeneca, Teva, Eli Lilly and Company, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, Merck; and Bayer; serve(d) as a speaker or a member of a speakers bureau for AstraZeneca, Boehringer Ingelheim, Eli Lilly and Company, GlaxoSmithKline. Received research grant from Sanofi, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Bayer; and received income in an amount equal to or greater than $250 from AstraZeneca, Teva, Eli Lilly and Company, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, Merck, and Bayer.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

I’m Dr. Neil Skolnik, and today I am going to talk about the 2023 update to the Global Strategy for Asthma Management and Prevention. We treat a lot of asthma, and there are some important changes, particularly around the use of albuterol. There are two main guidelines when it comes to asthma, the Global Initiative for Asthma (GINA) guideline and the US National Heart, Lung, and Blood Institute Guidelines. While I had the privilege of serving on the expert working group for the US guidelines, what I like about the GINA guidelines is that they are updated annually, and so they really help us keep up with rapid changes in the field.

Today, I’m going to focus on assessment and treatment.
 

Four Questions to Assess Asthma Control

Because over half of patients with asthma are not well controlled, it is important to assess control at every asthma visit. Asthma control has two domains: symptom control and the risk for future exacerbations. It is not enough to simply ask, “How is your asthma?” because many patients overrate their control and live with ongoing symptoms. There are many assessment tools; the Asthma Control Test (ACT) focuses on symptoms, and the new Asthma Impairment and Risk Questionnaire (AIRQ) assesses both symptoms and risk for exacerbations. The GINA assessment is probably the easiest to implement, with just four questions relevant to the past 4 weeks:

• Have you had daytime symptoms more than twice in one week?
• Have you had any night waking due to asthma?
• Have you needed short-acting beta-agonist (SABA), such as albuterol, rescue more than twice in one week?
• Have you had any activity limitation due to asthma?

Well-controlled asthma is defined as a negative response to all four of these questions, partly controlled asthma is one or two “yes” answers, and uncontrolled asthma is three to four positive responses. You can’t modify a patient’s therapy if you don’t know whether their asthma is well or poorly controlled. You’ll notice that these questions focus on symptom control. It is important also to ask about risk factors for exacerbations, particularly previous exacerbations.
 

Asthma Treatment Changes

The goals of treatment are control of symptoms and avoidance of exacerbations. The GINA guidelines emphasize that even patients with mild asthma can have severe or fatal exacerbations.

GINA recommends two management tracks. The preferred track uses inhaled corticosteroid (ICS)-formoterol as both maintenance and reliever therapy (MART). Track 2, without the use of ICS-formoterol for MART, is also offered, recognizing that the use of ICS-formoterol for MART is not approved by the US Food and Drug Administration. There is an easy-to-follow stepped-care diagram that is worth looking at; it’s on page 66 of the GINA guideline PDF.

For patients who have symptoms less than twice a month, begin with Step 1 therapy:

• Track 1: as-needed low-dose ICS-formoterol.
• Track 2: treatment with albuterol; also use ICS whenever albuterol is used.

For patients with symptoms more than twice a month (but not most days of the week) treatment can start with Step 2 therapy:

• Track 1: as-needed low-dose ICS-formoterol
• Track 2: daily low-dose ICS plus as-needed SABA

An option for rescue therapy for Track 2 across all steps of therapy is to use an ICS whenever a SABA is used for rescue to reduce the likelihood of exacerbation.

For patients with more severe asthma symptoms most days of the week, or whose asthma is waking them from sleep one or more times weekly, then you can start with Step 3 therapy as follows:

• Track 1: low dose ICS-formoterol as MART
• Track 2: low-dose ICS with long-acting beta-agonist (LABA) for maintenance, plus as needed SABA or as needed ICS-SABA

That’s going to cover most of our patients. As we see people back, if escalation of therapy is needed, then Step 4 therapy is:

• Track 1: medium-dose ICS-formoterol as MART
• Track 2: medium-dose ICS-LABA plus as needed SABA or as-needed ICS-SABA

For patients who remain uncontrolled, it’s important to realize that Step 5 gives you the option to add a long-acting muscarinic antagonist (LAMA). In my experience this can be very helpful. We can also consider going to high-dose ICS-LABS for maintenance. At this step, the patient usually has pretty severe, uncontrolled asthma and we can think about checking eosinophil counts, ordering pulmonary function tests, and referring to our specialist colleagues for consideration of biologic therapy.

It is important to see patients back regularly, and to assess asthma control. If a patient is not well controlled or has had exacerbations, consider stepping up therapy, or changing from albuterol alone as rescue to albuterol plus ICS for rescue. If they have been well controlled for a long time, consider de-escalation of therapy among patients on one of the higher therapy steps.

Dr. Skolnik has disclosed the following relevant financial relationships: Serve(d) on the advisory board for AstraZeneca, Teva, Eli Lilly and Company, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, Merck; and Bayer; serve(d) as a speaker or a member of a speakers bureau for AstraZeneca, Boehringer Ingelheim, Eli Lilly and Company, GlaxoSmithKline. Received research grant from Sanofi, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Bayer; and received income in an amount equal to or greater than $250 from AstraZeneca, Teva, Eli Lilly and Company, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, Merck, and Bayer.

A version of this article appeared on Medscape.com.

Hospital mergers and acquisitions continue to garner intense scrutiny from lawmakers, with pressure likely to hold steady following the recent announcement of new antitrust guidelines and state and federal investigations into potential healthcare monopolies.

In December, the US Department of Justice (DOJ) and the Federal Trade Commission (FTC) released updated guidelines outlining the factors they consider when determining if a merger illegally monopolizes a local healthcare market or jeopardizes access to critical healthcare services.

Last week, the DOJ also announced a UnitedHealth Group antitrust probe, just months after the healthcare conglomerate’s workforce numbers indicated it is now affiliated with or employs 10% of the US physician workforce.

While the impact of the latest guidelines is yet to be seen, concerns over healthcare market consolidation are not new. Over the past two decades, mergers have attracted attention for contributing to a decline in independent hospitals, said Rachel M. Werner, MD, PhD, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia, Pennsylvania.

“At this point, most hospitals are operating in a pretty concentrated market,” she said.

Here are five things to know about the current state of hospital mergers.

1. Record-Breaking Merger Enforcements

The DOJ and FTC reported the highest level of enforcement activity in over 20 years in fiscal year 2022 — the latest available data. Together, the agencies filed 50 merger enforcement actions and brought a record-breaking number of merger enforcement challenges, resulting in 11 approved actions, the restructuring or abandonment of seven mergers, and six business deals entering litigation.

Included in those statistics was a proposed merger between the two largest health systems in Rhode Island, Lifespan and Care New England Health System, which was abandoned after the FTC and the state Attorney General took steps to block it. the HCA branch in Utah Healthcare abandoned plans for to acquire five Salt Lake City area hospitals from competitor Steward Health Care System, as did RWJBarnabas Health after exploring a merger with Saint Peter's Healthcare System in New Jersey.

2. New Antitrust Guidelines Consider Labor Market

The new guidelines notably focus on labor competition, said Jody Boudreault, JD, attorney and chair of the Antitrust Life Sciences and Healthcare Group at Baker Botts law firm in Washington, DC. Health professionals typically have more employment opportunities in an urban area, unless hindered by restrictive noncompete agreements, and fewer options in rural settings.

In the Lifespan merger that fell through, Ms. Boudreault said that the newly created hospital system would have employed two thirds of Rhode Island's full-time nurses, limiting opportunities for local employment elsewhere.

“Going forward, I would expect federal authorities to review not only the competitive impact of the hospitals merging but also the competitive impact of the physician, and especially nursing, workforce,” she said.

FTC Chair Lina M. Khan noted similar labor market concerns.

In a statement to Congress, she said that hospital consolidation reduces options for employees, who fear “being blacklisted from further hiring in a system that controls many of the hospitals in the area” and “makes workers afraid to file complaints, organize their workplace, or leave before the end of a contract.”

3. Mergers Can Drive Care Costs Higher

When hospital markets become less competitive, the cost of care often increases. In Indiana, inpatient prices rose 13% in hospitals that merged. Another study found that prices at monopoly hospitals are 12% higher than in markets with four or more rivals. Even cross-market mergers, when hospitals in different geographic locations combine, can drive prices higher.

Dr. Werner told this news organization that more significant price hikes of 20-30% aren’t unheard of, with reimbursements by some commercial insurance companies rising as much as 50%. “That’s the direct price that the insurers pay, but the burden of those higher prices ultimately falls on patients through higher premiums,” she said.

Still, the American Hospital Association (AHA) says that mergers and acquisitions can significantly lower annual operating expenses per admission and reduce inpatient readmission rates and mortality measures. In comments to the FTC, the AHA stated that mergers could provide a lifeline for rural and community hospitals struggling with shrinking payer reimbursement and rising labor and supply costs. The business arrangements also could ensure these communities maintain continuity of care.

Although a cross-market merger may initially benefit cash-strapped rural hospitals, Dr. Werner urged caution.

“In the long run, it’s not clear that it is good for patients because we start to see decreased access to some types of service, like labor and delivery, which are services needed in rural markets,” she said.

4. Mergers to Watch in 2024

Ms. Boudreault, who represented RWJBarnabas in the abandoned Saint Peter’s transaction, says the courts widely accepted the old merger guidelines, and it will take time to see how the new measures are interpreted. “The guidelines don’t yet have the force of law, but they can be persuasive to a court.”

Looking ahead, she is watching how Steward Health Care navigates its impending financial collapse. The nation’s largest private for-profit health system was previously owned by private equity firm Cerberus Capital Management and includes nine Massachusetts hospitals plus entities in at least seven other states.

Ms. Boudreault also plans to monitor Jefferson Health’s intent to merge with Lehigh Valley Health Network. “It’s a pretty big deal because they would become a 30-hospital system,” said Ms. Boudreault. The newly formed network would become the largest employer in Philadelphia.

5. Merger and Acquisition Reversals Unlikely

Dr. Werner said that mergers and acquisitions are complicated business moves that are nearly impossible to undo once approved, so it makes sense for agencies to continue to evaluate them closely.

“The costs of healthcare are borne by us as a society,” she said. “We’re going to have to live with the ill effects of a consolidated market once we let hospitals merge, so they deserve additional scrutiny.”

A version of this article appeared on Medscape.com.

Hospital mergers and acquisitions continue to garner intense scrutiny from lawmakers, with pressure likely to hold steady following the recent announcement of new antitrust guidelines and state and federal investigations into potential healthcare monopolies.

In December, the US Department of Justice (DOJ) and the Federal Trade Commission (FTC) released updated guidelines outlining the factors they consider when determining if a merger illegally monopolizes a local healthcare market or jeopardizes access to critical healthcare services.

Last week, the DOJ also announced a UnitedHealth Group antitrust probe, just months after the healthcare conglomerate’s workforce numbers indicated it is now affiliated with or employs 10% of the US physician workforce.

While the impact of the latest guidelines is yet to be seen, concerns over healthcare market consolidation are not new. Over the past two decades, mergers have attracted attention for contributing to a decline in independent hospitals, said Rachel M. Werner, MD, PhD, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia, Pennsylvania.

“At this point, most hospitals are operating in a pretty concentrated market,” she said.

Here are five things to know about the current state of hospital mergers.

1. Record-Breaking Merger Enforcements

The DOJ and FTC reported the highest level of enforcement activity in over 20 years in fiscal year 2022 — the latest available data. Together, the agencies filed 50 merger enforcement actions and brought a record-breaking number of merger enforcement challenges, resulting in 11 approved actions, the restructuring or abandonment of seven mergers, and six business deals entering litigation.

Included in those statistics was a proposed merger between the two largest health systems in Rhode Island, Lifespan and Care New England Health System, which was abandoned after the FTC and the state Attorney General took steps to block it. the HCA branch in Utah Healthcare abandoned plans for to acquire five Salt Lake City area hospitals from competitor Steward Health Care System, as did RWJBarnabas Health after exploring a merger with Saint Peter's Healthcare System in New Jersey.

2. New Antitrust Guidelines Consider Labor Market

The new guidelines notably focus on labor competition, said Jody Boudreault, JD, attorney and chair of the Antitrust Life Sciences and Healthcare Group at Baker Botts law firm in Washington, DC. Health professionals typically have more employment opportunities in an urban area, unless hindered by restrictive noncompete agreements, and fewer options in rural settings.

In the Lifespan merger that fell through, Ms. Boudreault said that the newly created hospital system would have employed two thirds of Rhode Island's full-time nurses, limiting opportunities for local employment elsewhere.

“Going forward, I would expect federal authorities to review not only the competitive impact of the hospitals merging but also the competitive impact of the physician, and especially nursing, workforce,” she said.

FTC Chair Lina M. Khan noted similar labor market concerns.

In a statement to Congress, she said that hospital consolidation reduces options for employees, who fear “being blacklisted from further hiring in a system that controls many of the hospitals in the area” and “makes workers afraid to file complaints, organize their workplace, or leave before the end of a contract.”

3. Mergers Can Drive Care Costs Higher

When hospital markets become less competitive, the cost of care often increases. In Indiana, inpatient prices rose 13% in hospitals that merged. Another study found that prices at monopoly hospitals are 12% higher than in markets with four or more rivals. Even cross-market mergers, when hospitals in different geographic locations combine, can drive prices higher.

Dr. Werner told this news organization that more significant price hikes of 20-30% aren’t unheard of, with reimbursements by some commercial insurance companies rising as much as 50%. “That’s the direct price that the insurers pay, but the burden of those higher prices ultimately falls on patients through higher premiums,” she said.

Still, the American Hospital Association (AHA) says that mergers and acquisitions can significantly lower annual operating expenses per admission and reduce inpatient readmission rates and mortality measures. In comments to the FTC, the AHA stated that mergers could provide a lifeline for rural and community hospitals struggling with shrinking payer reimbursement and rising labor and supply costs. The business arrangements also could ensure these communities maintain continuity of care.

Although a cross-market merger may initially benefit cash-strapped rural hospitals, Dr. Werner urged caution.

“In the long run, it’s not clear that it is good for patients because we start to see decreased access to some types of service, like labor and delivery, which are services needed in rural markets,” she said.

4. Mergers to Watch in 2024

Ms. Boudreault, who represented RWJBarnabas in the abandoned Saint Peter’s transaction, says the courts widely accepted the old merger guidelines, and it will take time to see how the new measures are interpreted. “The guidelines don’t yet have the force of law, but they can be persuasive to a court.”

Looking ahead, she is watching how Steward Health Care navigates its impending financial collapse. The nation’s largest private for-profit health system was previously owned by private equity firm Cerberus Capital Management and includes nine Massachusetts hospitals plus entities in at least seven other states.

Ms. Boudreault also plans to monitor Jefferson Health’s intent to merge with Lehigh Valley Health Network. “It’s a pretty big deal because they would become a 30-hospital system,” said Ms. Boudreault. The newly formed network would become the largest employer in Philadelphia.

5. Merger and Acquisition Reversals Unlikely

Dr. Werner said that mergers and acquisitions are complicated business moves that are nearly impossible to undo once approved, so it makes sense for agencies to continue to evaluate them closely.

“The costs of healthcare are borne by us as a society,” she said. “We’re going to have to live with the ill effects of a consolidated market once we let hospitals merge, so they deserve additional scrutiny.”

A version of this article appeared on Medscape.com.

Hospital mergers and acquisitions continue to garner intense scrutiny from lawmakers, with pressure likely to hold steady following the recent announcement of new antitrust guidelines and state and federal investigations into potential healthcare monopolies.

In December, the US Department of Justice (DOJ) and the Federal Trade Commission (FTC) released updated guidelines outlining the factors they consider when determining if a merger illegally monopolizes a local healthcare market or jeopardizes access to critical healthcare services.

Last week, the DOJ also announced a UnitedHealth Group antitrust probe, just months after the healthcare conglomerate’s workforce numbers indicated it is now affiliated with or employs 10% of the US physician workforce.

While the impact of the latest guidelines is yet to be seen, concerns over healthcare market consolidation are not new. Over the past two decades, mergers have attracted attention for contributing to a decline in independent hospitals, said Rachel M. Werner, MD, PhD, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia, Pennsylvania.

“At this point, most hospitals are operating in a pretty concentrated market,” she said.

Here are five things to know about the current state of hospital mergers.

1. Record-Breaking Merger Enforcements

The DOJ and FTC reported the highest level of enforcement activity in over 20 years in fiscal year 2022 — the latest available data. Together, the agencies filed 50 merger enforcement actions and brought a record-breaking number of merger enforcement challenges, resulting in 11 approved actions, the restructuring or abandonment of seven mergers, and six business deals entering litigation.

Included in those statistics was a proposed merger between the two largest health systems in Rhode Island, Lifespan and Care New England Health System, which was abandoned after the FTC and the state Attorney General took steps to block it. the HCA branch in Utah Healthcare abandoned plans for to acquire five Salt Lake City area hospitals from competitor Steward Health Care System, as did RWJBarnabas Health after exploring a merger with Saint Peter's Healthcare System in New Jersey.

2. New Antitrust Guidelines Consider Labor Market

The new guidelines notably focus on labor competition, said Jody Boudreault, JD, attorney and chair of the Antitrust Life Sciences and Healthcare Group at Baker Botts law firm in Washington, DC. Health professionals typically have more employment opportunities in an urban area, unless hindered by restrictive noncompete agreements, and fewer options in rural settings.

In the Lifespan merger that fell through, Ms. Boudreault said that the newly created hospital system would have employed two thirds of Rhode Island's full-time nurses, limiting opportunities for local employment elsewhere.

“Going forward, I would expect federal authorities to review not only the competitive impact of the hospitals merging but also the competitive impact of the physician, and especially nursing, workforce,” she said.

FTC Chair Lina M. Khan noted similar labor market concerns.

In a statement to Congress, she said that hospital consolidation reduces options for employees, who fear “being blacklisted from further hiring in a system that controls many of the hospitals in the area” and “makes workers afraid to file complaints, organize their workplace, or leave before the end of a contract.”

3. Mergers Can Drive Care Costs Higher

When hospital markets become less competitive, the cost of care often increases. In Indiana, inpatient prices rose 13% in hospitals that merged. Another study found that prices at monopoly hospitals are 12% higher than in markets with four or more rivals. Even cross-market mergers, when hospitals in different geographic locations combine, can drive prices higher.

Dr. Werner told this news organization that more significant price hikes of 20-30% aren’t unheard of, with reimbursements by some commercial insurance companies rising as much as 50%. “That’s the direct price that the insurers pay, but the burden of those higher prices ultimately falls on patients through higher premiums,” she said.

Still, the American Hospital Association (AHA) says that mergers and acquisitions can significantly lower annual operating expenses per admission and reduce inpatient readmission rates and mortality measures. In comments to the FTC, the AHA stated that mergers could provide a lifeline for rural and community hospitals struggling with shrinking payer reimbursement and rising labor and supply costs. The business arrangements also could ensure these communities maintain continuity of care.

Although a cross-market merger may initially benefit cash-strapped rural hospitals, Dr. Werner urged caution.

“In the long run, it’s not clear that it is good for patients because we start to see decreased access to some types of service, like labor and delivery, which are services needed in rural markets,” she said.

4. Mergers to Watch in 2024

Ms. Boudreault, who represented RWJBarnabas in the abandoned Saint Peter’s transaction, says the courts widely accepted the old merger guidelines, and it will take time to see how the new measures are interpreted. “The guidelines don’t yet have the force of law, but they can be persuasive to a court.”

Looking ahead, she is watching how Steward Health Care navigates its impending financial collapse. The nation’s largest private for-profit health system was previously owned by private equity firm Cerberus Capital Management and includes nine Massachusetts hospitals plus entities in at least seven other states.

Ms. Boudreault also plans to monitor Jefferson Health’s intent to merge with Lehigh Valley Health Network. “It’s a pretty big deal because they would become a 30-hospital system,” said Ms. Boudreault. The newly formed network would become the largest employer in Philadelphia.

5. Merger and Acquisition Reversals Unlikely

Dr. Werner said that mergers and acquisitions are complicated business moves that are nearly impossible to undo once approved, so it makes sense for agencies to continue to evaluate them closely.

“The costs of healthcare are borne by us as a society,” she said. “We’re going to have to live with the ill effects of a consolidated market once we let hospitals merge, so they deserve additional scrutiny.”

A version of this article appeared on Medscape.com.

My first civilian job after finishing my training was as an associate and eventually a partner of a pediatrician whose office was in a wing of his large 19th-century home. The pediatrician in the neighboring town had his office in a small house next to his home. This model of small one- or two -provider offices in or nearby their homes was replicated up and down the coast. After 7 years, the 12-minute drive from my home to the office became intolerable and I asked to dissolve what was otherwise a successful partnership. I opened a one-provider office with a 6-minute bike ride commute and my wife served as the billing clerk and bookkeeper.

Those next 10 years of solo practice were the most rewarding, both economically and professionally. Eventually faced with the need to add another provider, I reluctantly joined a recently formed group of primary care physicians who, like me, had been running one- or two-provider offices often with spouses as support staff — basically Mom and Pop operations. However, the group was gradually absorbed by increasingly larger entities and our practices that once were as individual as our personalities became homogenized. Neither my patients nor I liked the new feel of the office.

Still pining for that small office vibe, I continue to wonder if it could be scaled up and adapted to today’s healthcare realities. I recently read a New York Times article describing how a pediatrician has launched such a practice model into the uncharted waters of Greater New York City.

At age 34, Dr. Michel Cohen, a Moroccan-French émigré, opened his storefront pediatric practice in 1994. The upper story housed his loft apartment. A self-described “hippie doctor,” Dr. Cohen developed a following based on his book on parenting and publicity surrounding his role in the even more popular book on French-style parenting titled Bringing up Bebe by Pamela Druckerman. By 2009 his practice had grown to three small storefront offices. However, they weren’t sufficiently profitable. He decided to shun the distractions of his celebrity practice trappings and instead focus on growth, hoping that the gravitas associated with even more office locations would allow him to offer better service and improve the bottom line. Sort of an “economy of scale” notion applied to the small office setting.

He now has 48 offices having added 12 new sites last year with 5 more planned for next year. These are all one- or two-physician installations with two exam rooms per provider. The offices are bright and colorful, focused on appealing to a child’s taste. The furniture is blond wood, most of it based on Dr. Cohen’s designs and in some cases handmade. Current staffing is 112 physicians and nurse practitioners and volume exceeds 100,000 visits per year.

The volume has allowed the practice to add a user-friendly patient portal and offer an after-hours call-in option. The larger volume means that staffing can be more easily adjusted to illness and vacations. The goal is to have the practitioners become identified with their sites and the patients assigned to them whenever possible. Uniformity in office designs allow a provider filling in from another site to easily find supplies and function within a familiar system.

While the sites have generally served upscale gentrified neighborhoods, the practice has recently expanded to less affluent areas and accepts Medicaid. Dr. Cohen’s dream is to expand his network nationally as a nonprofit in which low-income sites would be subsidized by the more profitable offices. A previous attempt at expansion with two offices in Southern California did not work out because the time zone difference didn’t mesh well with the Internet portal.

Wanting to hear a firsthand account from a family on how the Tribeca Pediatric system works, I contacted a neighbor who has recently moved his young family here to Brunswick. His impression was generally positive. He gave high marks to the patient portal for the ability to get school and camp forms and vaccination records quickly. Appointments made electronically was a plus, although the after-hours response time sometimes took an hour or two. He would have preferred to see their assigned provider for a higher percentage of visits, but this seems to be a common complaint even in systems with the greatest availability. Care was dispensed efficiently but didn’t seem to be overly rushed.

In the NY Times article there is one complaint by a former provider who felt she was getting burned out by the system and leaned on 10 minutes for sick visits and 20 minutes for well visits. Personally, I don’t see this as a problem. The length of a visit and the quality of the care are not always related. Given good support services and an efficiently run office, those slot guidelines seem very reasonable, realizing that a skilled clinician must have already learned to adjust his or her pace to the realities of the patient mix. However, as the pediatric sick population has leaned more toward behavioral and mental health problems, a primary care practice should be offering some option for these patients either in-house or with reliable referral relationships. Although the NY Times article doesn’t provide any numbers, it does mention that the providers are generally young and there is some turnover, possibly as providers use the practice as a “stepping stone.”

To some extent Dr. Cohen’s success seems to be the result of his real estate acumen and business sense. Because the majority of recent medical school graduates enter the work force with a substantial debt, it is difficult to imagine that a young physician would have Dr. Cohen’s entrepreneurial passion. However, clearly his success, at least in the short term, demonstrates that there is a substantial percentage of both patients and providers who prefer small personalized offices if given the option. It will be interesting to see if and how Tribeca Pediatrics expands and whether any of the larger existing networks attempt to imitate it.

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

My first civilian job after finishing my training was as an associate and eventually a partner of a pediatrician whose office was in a wing of his large 19th-century home. The pediatrician in the neighboring town had his office in a small house next to his home. This model of small one- or two -provider offices in or nearby their homes was replicated up and down the coast. After 7 years, the 12-minute drive from my home to the office became intolerable and I asked to dissolve what was otherwise a successful partnership. I opened a one-provider office with a 6-minute bike ride commute and my wife served as the billing clerk and bookkeeper.

Those next 10 years of solo practice were the most rewarding, both economically and professionally. Eventually faced with the need to add another provider, I reluctantly joined a recently formed group of primary care physicians who, like me, had been running one- or two-provider offices often with spouses as support staff — basically Mom and Pop operations. However, the group was gradually absorbed by increasingly larger entities and our practices that once were as individual as our personalities became homogenized. Neither my patients nor I liked the new feel of the office.

Still pining for that small office vibe, I continue to wonder if it could be scaled up and adapted to today’s healthcare realities. I recently read a New York Times article describing how a pediatrician has launched such a practice model into the uncharted waters of Greater New York City.

At age 34, Dr. Michel Cohen, a Moroccan-French émigré, opened his storefront pediatric practice in 1994. The upper story housed his loft apartment. A self-described “hippie doctor,” Dr. Cohen developed a following based on his book on parenting and publicity surrounding his role in the even more popular book on French-style parenting titled Bringing up Bebe by Pamela Druckerman. By 2009 his practice had grown to three small storefront offices. However, they weren’t sufficiently profitable. He decided to shun the distractions of his celebrity practice trappings and instead focus on growth, hoping that the gravitas associated with even more office locations would allow him to offer better service and improve the bottom line. Sort of an “economy of scale” notion applied to the small office setting.

He now has 48 offices having added 12 new sites last year with 5 more planned for next year. These are all one- or two-physician installations with two exam rooms per provider. The offices are bright and colorful, focused on appealing to a child’s taste. The furniture is blond wood, most of it based on Dr. Cohen’s designs and in some cases handmade. Current staffing is 112 physicians and nurse practitioners and volume exceeds 100,000 visits per year.

The volume has allowed the practice to add a user-friendly patient portal and offer an after-hours call-in option. The larger volume means that staffing can be more easily adjusted to illness and vacations. The goal is to have the practitioners become identified with their sites and the patients assigned to them whenever possible. Uniformity in office designs allow a provider filling in from another site to easily find supplies and function within a familiar system.

While the sites have generally served upscale gentrified neighborhoods, the practice has recently expanded to less affluent areas and accepts Medicaid. Dr. Cohen’s dream is to expand his network nationally as a nonprofit in which low-income sites would be subsidized by the more profitable offices. A previous attempt at expansion with two offices in Southern California did not work out because the time zone difference didn’t mesh well with the Internet portal.

Wanting to hear a firsthand account from a family on how the Tribeca Pediatric system works, I contacted a neighbor who has recently moved his young family here to Brunswick. His impression was generally positive. He gave high marks to the patient portal for the ability to get school and camp forms and vaccination records quickly. Appointments made electronically was a plus, although the after-hours response time sometimes took an hour or two. He would have preferred to see their assigned provider for a higher percentage of visits, but this seems to be a common complaint even in systems with the greatest availability. Care was dispensed efficiently but didn’t seem to be overly rushed.

In the NY Times article there is one complaint by a former provider who felt she was getting burned out by the system and leaned on 10 minutes for sick visits and 20 minutes for well visits. Personally, I don’t see this as a problem. The length of a visit and the quality of the care are not always related. Given good support services and an efficiently run office, those slot guidelines seem very reasonable, realizing that a skilled clinician must have already learned to adjust his or her pace to the realities of the patient mix. However, as the pediatric sick population has leaned more toward behavioral and mental health problems, a primary care practice should be offering some option for these patients either in-house or with reliable referral relationships. Although the NY Times article doesn’t provide any numbers, it does mention that the providers are generally young and there is some turnover, possibly as providers use the practice as a “stepping stone.”

To some extent Dr. Cohen’s success seems to be the result of his real estate acumen and business sense. Because the majority of recent medical school graduates enter the work force with a substantial debt, it is difficult to imagine that a young physician would have Dr. Cohen’s entrepreneurial passion. However, clearly his success, at least in the short term, demonstrates that there is a substantial percentage of both patients and providers who prefer small personalized offices if given the option. It will be interesting to see if and how Tribeca Pediatrics expands and whether any of the larger existing networks attempt to imitate it.

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

My first civilian job after finishing my training was as an associate and eventually a partner of a pediatrician whose office was in a wing of his large 19th-century home. The pediatrician in the neighboring town had his office in a small house next to his home. This model of small one- or two -provider offices in or nearby their homes was replicated up and down the coast. After 7 years, the 12-minute drive from my home to the office became intolerable and I asked to dissolve what was otherwise a successful partnership. I opened a one-provider office with a 6-minute bike ride commute and my wife served as the billing clerk and bookkeeper.

Those next 10 years of solo practice were the most rewarding, both economically and professionally. Eventually faced with the need to add another provider, I reluctantly joined a recently formed group of primary care physicians who, like me, had been running one- or two-provider offices often with spouses as support staff — basically Mom and Pop operations. However, the group was gradually absorbed by increasingly larger entities and our practices that once were as individual as our personalities became homogenized. Neither my patients nor I liked the new feel of the office.

Still pining for that small office vibe, I continue to wonder if it could be scaled up and adapted to today’s healthcare realities. I recently read a New York Times article describing how a pediatrician has launched such a practice model into the uncharted waters of Greater New York City.

At age 34, Dr. Michel Cohen, a Moroccan-French émigré, opened his storefront pediatric practice in 1994. The upper story housed his loft apartment. A self-described “hippie doctor,” Dr. Cohen developed a following based on his book on parenting and publicity surrounding his role in the even more popular book on French-style parenting titled Bringing up Bebe by Pamela Druckerman. By 2009 his practice had grown to three small storefront offices. However, they weren’t sufficiently profitable. He decided to shun the distractions of his celebrity practice trappings and instead focus on growth, hoping that the gravitas associated with even more office locations would allow him to offer better service and improve the bottom line. Sort of an “economy of scale” notion applied to the small office setting.

He now has 48 offices having added 12 new sites last year with 5 more planned for next year. These are all one- or two-physician installations with two exam rooms per provider. The offices are bright and colorful, focused on appealing to a child’s taste. The furniture is blond wood, most of it based on Dr. Cohen’s designs and in some cases handmade. Current staffing is 112 physicians and nurse practitioners and volume exceeds 100,000 visits per year.

The volume has allowed the practice to add a user-friendly patient portal and offer an after-hours call-in option. The larger volume means that staffing can be more easily adjusted to illness and vacations. The goal is to have the practitioners become identified with their sites and the patients assigned to them whenever possible. Uniformity in office designs allow a provider filling in from another site to easily find supplies and function within a familiar system.

While the sites have generally served upscale gentrified neighborhoods, the practice has recently expanded to less affluent areas and accepts Medicaid. Dr. Cohen’s dream is to expand his network nationally as a nonprofit in which low-income sites would be subsidized by the more profitable offices. A previous attempt at expansion with two offices in Southern California did not work out because the time zone difference didn’t mesh well with the Internet portal.

Wanting to hear a firsthand account from a family on how the Tribeca Pediatric system works, I contacted a neighbor who has recently moved his young family here to Brunswick. His impression was generally positive. He gave high marks to the patient portal for the ability to get school and camp forms and vaccination records quickly. Appointments made electronically was a plus, although the after-hours response time sometimes took an hour or two. He would have preferred to see their assigned provider for a higher percentage of visits, but this seems to be a common complaint even in systems with the greatest availability. Care was dispensed efficiently but didn’t seem to be overly rushed.

In the NY Times article there is one complaint by a former provider who felt she was getting burned out by the system and leaned on 10 minutes for sick visits and 20 minutes for well visits. Personally, I don’t see this as a problem. The length of a visit and the quality of the care are not always related. Given good support services and an efficiently run office, those slot guidelines seem very reasonable, realizing that a skilled clinician must have already learned to adjust his or her pace to the realities of the patient mix. However, as the pediatric sick population has leaned more toward behavioral and mental health problems, a primary care practice should be offering some option for these patients either in-house or with reliable referral relationships. Although the NY Times article doesn’t provide any numbers, it does mention that the providers are generally young and there is some turnover, possibly as providers use the practice as a “stepping stone.”

To some extent Dr. Cohen’s success seems to be the result of his real estate acumen and business sense. Because the majority of recent medical school graduates enter the work force with a substantial debt, it is difficult to imagine that a young physician would have Dr. Cohen’s entrepreneurial passion. However, clearly his success, at least in the short term, demonstrates that there is a substantial percentage of both patients and providers who prefer small personalized offices if given the option. It will be interesting to see if and how Tribeca Pediatrics expands and whether any of the larger existing networks attempt to imitate it.

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

This transcript has been edited for clarity.

Hi. I’m Art Caplan, at the Division of Medical Ethics at New York University’s Grossman School of Medicine.

Very recently, a homeopathic midwife in New York was fined $300,000 for giving out phony injections for kids who were looking to get immunized in order to go to school. She gave pellets, which are sometimes called nosodes, I believe, with homeopathic ingredients, meaning next to nothing in them, and then basically certified that these children — and there were over 1500 of them — were compliant with New York State requirements to be vaccinated to go to school.

However, homeopathy is straight-up bunk. We have seen it again and again discredited as just something that doesn’t work. It has a tradition, but it’s basically nonsense. It certainly doesn’t work as a way to vaccinate anybody.

This midwife basically lied and gave phony certification to the parents of these kids. I’m not talking about the COVID-19 vaccine. I’m talking measles, mumps, rubella, flu, and polio — the childhood immunization schedule. For whatever reason, they put their faith in her and she went along with this fraud.

I think the fine is appropriate, but I think she should be penalized further. Why? When you send 1500 kids to school, mostly in Long Island, New York, but to schools all over the place, you are setting up conditions to bring back epidemic diseases like measles.

We’re already seeing measles outbreaks. At least five states have them. There’s a significant measles outbreak in Philadelphia. Although I can’t say for sure, I believe those outbreaks are directly linked to parents, post–COVID-19, becoming vaccine hesitant and either not vaccinating and lying or going to alternative practitioners like this midwife and claiming that they have been vaccinated.

You’re doing harm not only to the children who you allow to go to school under phony pretenses, but also you’re putting their classmates at risk. We all know that measles is very, very contagious. You’re risking the return of a disease that leads to hospitalization and sometimes even death. That is basically unconscionable.

I think her license should be taken away and she should not be practicing anymore. I believe that anyone who is involved in this kind of phony, dangerous, fraudulent practice ought to be severely punished.

Pre–COVID-19, we had just about gotten rid of measles and mumps. We didn’t see these diseases. Sometimes parents got a bit lazy in childhood vaccination basically because we had used immunization to get rid of the diseases.

Going to alternative healers and allowing people to get away with fraudulent nonsense risks bringing back disabling and deadly killers is not fair to you, me, and other people who are put at risk. It’s not fair to the kids who go to school with other kids who they think are vaccinated but aren’t.

I’m Art Caplan, at the Division of Medical Ethics at the New York University Grossman School of Medicine. Thanks for watching.

Arthur L. Caplan, PhD, has disclosed the following relevant financial relationships: Served as a director, officer, partner, employee, adviser, consultant, or trustee for Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position); serves as a contributing author and adviser for Medscape.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

Hi. I’m Art Caplan, at the Division of Medical Ethics at New York University’s Grossman School of Medicine.

Very recently, a homeopathic midwife in New York was fined $300,000 for giving out phony injections for kids who were looking to get immunized in order to go to school. She gave pellets, which are sometimes called nosodes, I believe, with homeopathic ingredients, meaning next to nothing in them, and then basically certified that these children — and there were over 1500 of them — were compliant with New York State requirements to be vaccinated to go to school.

However, homeopathy is straight-up bunk. We have seen it again and again discredited as just something that doesn’t work. It has a tradition, but it’s basically nonsense. It certainly doesn’t work as a way to vaccinate anybody.

This midwife basically lied and gave phony certification to the parents of these kids. I’m not talking about the COVID-19 vaccine. I’m talking measles, mumps, rubella, flu, and polio — the childhood immunization schedule. For whatever reason, they put their faith in her and she went along with this fraud.

I think the fine is appropriate, but I think she should be penalized further. Why? When you send 1500 kids to school, mostly in Long Island, New York, but to schools all over the place, you are setting up conditions to bring back epidemic diseases like measles.

We’re already seeing measles outbreaks. At least five states have them. There’s a significant measles outbreak in Philadelphia. Although I can’t say for sure, I believe those outbreaks are directly linked to parents, post–COVID-19, becoming vaccine hesitant and either not vaccinating and lying or going to alternative practitioners like this midwife and claiming that they have been vaccinated.

You’re doing harm not only to the children who you allow to go to school under phony pretenses, but also you’re putting their classmates at risk. We all know that measles is very, very contagious. You’re risking the return of a disease that leads to hospitalization and sometimes even death. That is basically unconscionable.

I think her license should be taken away and she should not be practicing anymore. I believe that anyone who is involved in this kind of phony, dangerous, fraudulent practice ought to be severely punished.

Pre–COVID-19, we had just about gotten rid of measles and mumps. We didn’t see these diseases. Sometimes parents got a bit lazy in childhood vaccination basically because we had used immunization to get rid of the diseases.

Going to alternative healers and allowing people to get away with fraudulent nonsense risks bringing back disabling and deadly killers is not fair to you, me, and other people who are put at risk. It’s not fair to the kids who go to school with other kids who they think are vaccinated but aren’t.

I’m Art Caplan, at the Division of Medical Ethics at the New York University Grossman School of Medicine. Thanks for watching.

Arthur L. Caplan, PhD, has disclosed the following relevant financial relationships: Served as a director, officer, partner, employee, adviser, consultant, or trustee for Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position); serves as a contributing author and adviser for Medscape.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

Hi. I’m Art Caplan, at the Division of Medical Ethics at New York University’s Grossman School of Medicine.

Very recently, a homeopathic midwife in New York was fined $300,000 for giving out phony injections for kids who were looking to get immunized in order to go to school. She gave pellets, which are sometimes called nosodes, I believe, with homeopathic ingredients, meaning next to nothing in them, and then basically certified that these children — and there were over 1500 of them — were compliant with New York State requirements to be vaccinated to go to school.

However, homeopathy is straight-up bunk. We have seen it again and again discredited as just something that doesn’t work. It has a tradition, but it’s basically nonsense. It certainly doesn’t work as a way to vaccinate anybody.

This midwife basically lied and gave phony certification to the parents of these kids. I’m not talking about the COVID-19 vaccine. I’m talking measles, mumps, rubella, flu, and polio — the childhood immunization schedule. For whatever reason, they put their faith in her and she went along with this fraud.

I think the fine is appropriate, but I think she should be penalized further. Why? When you send 1500 kids to school, mostly in Long Island, New York, but to schools all over the place, you are setting up conditions to bring back epidemic diseases like measles.

We’re already seeing measles outbreaks. At least five states have them. There’s a significant measles outbreak in Philadelphia. Although I can’t say for sure, I believe those outbreaks are directly linked to parents, post–COVID-19, becoming vaccine hesitant and either not vaccinating and lying or going to alternative practitioners like this midwife and claiming that they have been vaccinated.

You’re doing harm not only to the children who you allow to go to school under phony pretenses, but also you’re putting their classmates at risk. We all know that measles is very, very contagious. You’re risking the return of a disease that leads to hospitalization and sometimes even death. That is basically unconscionable.

I think her license should be taken away and she should not be practicing anymore. I believe that anyone who is involved in this kind of phony, dangerous, fraudulent practice ought to be severely punished.

Pre–COVID-19, we had just about gotten rid of measles and mumps. We didn’t see these diseases. Sometimes parents got a bit lazy in childhood vaccination basically because we had used immunization to get rid of the diseases.

Going to alternative healers and allowing people to get away with fraudulent nonsense risks bringing back disabling and deadly killers is not fair to you, me, and other people who are put at risk. It’s not fair to the kids who go to school with other kids who they think are vaccinated but aren’t.

I’m Art Caplan, at the Division of Medical Ethics at the New York University Grossman School of Medicine. Thanks for watching.

Arthur L. Caplan, PhD, has disclosed the following relevant financial relationships: Served as a director, officer, partner, employee, adviser, consultant, or trustee for Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position); serves as a contributing author and adviser for Medscape.

A version of this article appeared on Medscape.com.