MDedge Rheumatology

In case you are looking for a place to park your discretionary funds, I have recently learned that nonalcoholic beer is the fastest-growing segment of the beer industry. It is just barely outperforming the strong beer market while the standard beer market is flat. The reasons behind this surge in popularity are unclear. While the general population doesn’t seem to grasp the importance of diet and exercise, there seem to be enough folks who are health conscious to support a demand.

Possibly more important has been the emergence of a couple of small breweries that have been able to produce a nonalcoholic product that actually tastes as good as regular beer, and in some cases even better than the real stuff. In Europe, nonalcoholic beer has become popular as a rehydration drink among athletes. We recently found it everywhere we looked while bicycling in France. The large breweries have taken notice and it is hard to find a restaurant here in Maine that doesn’t offer nonalcoholic beer on its menu.

My history with beer goes back to preadolescence, when my father offered me a sip of his beer. I was never sure of his motive but that taste did not immediately whet my appetite for more. However, when I was in high school, New York State’s drinking age was 18 and beer just became part of growing up.

When I went into practice, my routine of having a can or bottle of beer with dinner presented a problem. When I was on call the odds of having to leave the house and see a patient or two was substantial. Back at the beginning I was never much concerned about having alcohol circulating through my brain but I didn’t want to be exhaling its vapors as I interacted with the parents and nurses. As I got older I became more aware that when I was tired, which was always the case at the end of a long office day, even just a glass of beer might impair my decision making. As a result, I drank only nonalcoholic beer when I was on call. Were I still practicing today this wouldn’t have represented a sacrifice on my part. However, until 5 years ago the nonalcoholic beer was not even a close approximation of the alcohol-containing product.

So this brings me to my question. Do you share any of my concerns about practicing under the influence of alcohol (P.U.I.)? And, if you have any concerns, how do you deal with them?

Do you make a distinction between physical and mental impairment? Would you have a drink if you were only fielding phone calls? Would your decision change if you knew you might be called in to perform surgery or start an intravenous on a premie?

Does the prospect of meeting face to face with your patient/parents change your decision? Is practicing telemedicine under the influence any less concerning to you than seeing patients in your office or the emergency room?

Can you imagine any extenuating circumstances? For example, let’s say you are the only pediatric ENT in your county. While you have office hours 4½ days per week, in effect you are on call 24/7 for emergencies. If you made a decision to never practice under the influence, does that mean you will never drink alcohol?

Am I making too big of a thing out of a can of beer or a glass of wine? We have certainly read concerns about patient safety when cared for by house officers working on schedules that leave them practicing while sleep deprived (P.W.S.D.) You don’t hear anything about physicians’ P.U.I. Is it a real problem? Certainly, with marijuana becoming legal in more states alcohol may not be the only influencer to consider.

In the bigger picture I suspect that P.W.S.D. is the bigger problem both for house officers and practicing physicians but it is time we swept away the cloud of silence around P.U.I and had a frank discussion about both among ourselves.
 

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].

In case you are looking for a place to park your discretionary funds, I have recently learned that nonalcoholic beer is the fastest-growing segment of the beer industry. It is just barely outperforming the strong beer market while the standard beer market is flat. The reasons behind this surge in popularity are unclear. While the general population doesn’t seem to grasp the importance of diet and exercise, there seem to be enough folks who are health conscious to support a demand.

Possibly more important has been the emergence of a couple of small breweries that have been able to produce a nonalcoholic product that actually tastes as good as regular beer, and in some cases even better than the real stuff. In Europe, nonalcoholic beer has become popular as a rehydration drink among athletes. We recently found it everywhere we looked while bicycling in France. The large breweries have taken notice and it is hard to find a restaurant here in Maine that doesn’t offer nonalcoholic beer on its menu.

My history with beer goes back to preadolescence, when my father offered me a sip of his beer. I was never sure of his motive but that taste did not immediately whet my appetite for more. However, when I was in high school, New York State’s drinking age was 18 and beer just became part of growing up.

When I went into practice, my routine of having a can or bottle of beer with dinner presented a problem. When I was on call the odds of having to leave the house and see a patient or two was substantial. Back at the beginning I was never much concerned about having alcohol circulating through my brain but I didn’t want to be exhaling its vapors as I interacted with the parents and nurses. As I got older I became more aware that when I was tired, which was always the case at the end of a long office day, even just a glass of beer might impair my decision making. As a result, I drank only nonalcoholic beer when I was on call. Were I still practicing today this wouldn’t have represented a sacrifice on my part. However, until 5 years ago the nonalcoholic beer was not even a close approximation of the alcohol-containing product.

So this brings me to my question. Do you share any of my concerns about practicing under the influence of alcohol (P.U.I.)? And, if you have any concerns, how do you deal with them?

Do you make a distinction between physical and mental impairment? Would you have a drink if you were only fielding phone calls? Would your decision change if you knew you might be called in to perform surgery or start an intravenous on a premie?

Does the prospect of meeting face to face with your patient/parents change your decision? Is practicing telemedicine under the influence any less concerning to you than seeing patients in your office or the emergency room?

Can you imagine any extenuating circumstances? For example, let’s say you are the only pediatric ENT in your county. While you have office hours 4½ days per week, in effect you are on call 24/7 for emergencies. If you made a decision to never practice under the influence, does that mean you will never drink alcohol?

Am I making too big of a thing out of a can of beer or a glass of wine? We have certainly read concerns about patient safety when cared for by house officers working on schedules that leave them practicing while sleep deprived (P.W.S.D.) You don’t hear anything about physicians’ P.U.I. Is it a real problem? Certainly, with marijuana becoming legal in more states alcohol may not be the only influencer to consider.

In the bigger picture I suspect that P.W.S.D. is the bigger problem both for house officers and practicing physicians but it is time we swept away the cloud of silence around P.U.I and had a frank discussion about both among ourselves.
 

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].

In case you are looking for a place to park your discretionary funds, I have recently learned that nonalcoholic beer is the fastest-growing segment of the beer industry. It is just barely outperforming the strong beer market while the standard beer market is flat. The reasons behind this surge in popularity are unclear. While the general population doesn’t seem to grasp the importance of diet and exercise, there seem to be enough folks who are health conscious to support a demand.

Possibly more important has been the emergence of a couple of small breweries that have been able to produce a nonalcoholic product that actually tastes as good as regular beer, and in some cases even better than the real stuff. In Europe, nonalcoholic beer has become popular as a rehydration drink among athletes. We recently found it everywhere we looked while bicycling in France. The large breweries have taken notice and it is hard to find a restaurant here in Maine that doesn’t offer nonalcoholic beer on its menu.

My history with beer goes back to preadolescence, when my father offered me a sip of his beer. I was never sure of his motive but that taste did not immediately whet my appetite for more. However, when I was in high school, New York State’s drinking age was 18 and beer just became part of growing up.

When I went into practice, my routine of having a can or bottle of beer with dinner presented a problem. When I was on call the odds of having to leave the house and see a patient or two was substantial. Back at the beginning I was never much concerned about having alcohol circulating through my brain but I didn’t want to be exhaling its vapors as I interacted with the parents and nurses. As I got older I became more aware that when I was tired, which was always the case at the end of a long office day, even just a glass of beer might impair my decision making. As a result, I drank only nonalcoholic beer when I was on call. Were I still practicing today this wouldn’t have represented a sacrifice on my part. However, until 5 years ago the nonalcoholic beer was not even a close approximation of the alcohol-containing product.

So this brings me to my question. Do you share any of my concerns about practicing under the influence of alcohol (P.U.I.)? And, if you have any concerns, how do you deal with them?

Do you make a distinction between physical and mental impairment? Would you have a drink if you were only fielding phone calls? Would your decision change if you knew you might be called in to perform surgery or start an intravenous on a premie?

Does the prospect of meeting face to face with your patient/parents change your decision? Is practicing telemedicine under the influence any less concerning to you than seeing patients in your office or the emergency room?

Can you imagine any extenuating circumstances? For example, let’s say you are the only pediatric ENT in your county. While you have office hours 4½ days per week, in effect you are on call 24/7 for emergencies. If you made a decision to never practice under the influence, does that mean you will never drink alcohol?

Am I making too big of a thing out of a can of beer or a glass of wine? We have certainly read concerns about patient safety when cared for by house officers working on schedules that leave them practicing while sleep deprived (P.W.S.D.) You don’t hear anything about physicians’ P.U.I. Is it a real problem? Certainly, with marijuana becoming legal in more states alcohol may not be the only influencer to consider.

In the bigger picture I suspect that P.W.S.D. is the bigger problem both for house officers and practicing physicians but it is time we swept away the cloud of silence around P.U.I and had a frank discussion about both among ourselves.
 

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].

Despite the recent uptick in leprosy cases in Central Florida, the disease is very rare, and casual contact with an infected person is likely to not result in transmission, according to Jose A. Lucar, MD.

“Contrary to historical beliefs, leprosy is not highly contagious,” Dr. Lucar, an infectious disease physician and associate professor of medicine at George Washington University, Washington, said in an interview. “For reasons that have to do with the makeup of genes that affect their immune system, most people are not susceptible to acquire leprosy. It’s really a small percentage of the population. It does require prolonged contact with someone with untreated leprosy – over several months – to acquire an infection. So, the risk from any type of casual contact is low.”

Dr. Lucar

According to a research letter published in the CDC’s Emerging Infectious Diseases, the number of reported leprosy cases has more than doubled in the past decade. Of the 159 new cases reported nationwide in 2020, Florida accounted for about one-fifth of cases, with most limited to the central part of the state. “In the U.S., there have been 150-250 cases reported each year over the past several years,” said Dr. Lucar, who was not affiliated with the research letter. “What seems to have changed is that since 2015, there has been a rise in cases in people who are U.S.-born “In the U.S., there have been 150-250 cases reported each year over the past several years,” said Dr. Lucar, who was not affiliated with the research letter. “What seems to have changed is that since 2015, there has been a rise in cases in people who are U.S.-born," and currently, about one-third of leprosy cases are in individuals born in the United States, he noted.

The research letter described a case of leprosy in a 54-year-old man who worked in landscaping, who sought treatment at a dermatology clinic in Central Florida in 2022 for a painful and progressive erythematous rash. The lesions began on his distal extensor extremities and progressed to involve his trunk and face. According to the report, the man denied any domestic or foreign travel, exposure to armadillos (a known source of transmission), prolonged contact with immigrants from leprosy-endemic countries, or connections with someone known to have leprosy. The authors concluded that the case “adds to the growing body of literature suggesting that central Florida represents an endemic location for leprosy. Travel to this area, even in the absence of other risk factors, should prompt consideration of leprosy in the appropriate clinical context.”

Dr. Lucar said that the mechanism of leprosy transmission is not fully understood, but armadillos, which typically traverse the southern United States, are naturally infected with the bacteria that causes leprosy. “It’s possible that they can spread it to people,” he said. “People who have occupations or hobbies that put them in potential contact with wildlife should avoid any close contact with armadillos. There’s also a discussion of whether [the spike in leprosy cases] may have to do with climate change. That is not yet confirmed. It’s not entirely clear why there’s been a recent rise. It remains an area of investigation.”

Meanwhile, clinicians should keep a high level of suspicion in patients who present with skin lesions compatible with leprosy. “These are typically discolored or numb patches on the skin,” Dr. Lucar said. “This can range from a single or a few lesions to very extensive involvement of the skin. The diminished sensation or loss of sensation within those skin patches is an important sign. There’s a loss of skin color but sometimes they can be reddish.” He emphasized that leprosy “does not spread easily from person to person; casual contact will not spread leprosy. It’s important for the public to understand that.”

Dr. Lucar reported no disclosures.

Despite the recent uptick in leprosy cases in Central Florida, the disease is very rare, and casual contact with an infected person is likely to not result in transmission, according to Jose A. Lucar, MD.

“Contrary to historical beliefs, leprosy is not highly contagious,” Dr. Lucar, an infectious disease physician and associate professor of medicine at George Washington University, Washington, said in an interview. “For reasons that have to do with the makeup of genes that affect their immune system, most people are not susceptible to acquire leprosy. It’s really a small percentage of the population. It does require prolonged contact with someone with untreated leprosy – over several months – to acquire an infection. So, the risk from any type of casual contact is low.”

Dr. Lucar

According to a research letter published in the CDC’s Emerging Infectious Diseases, the number of reported leprosy cases has more than doubled in the past decade. Of the 159 new cases reported nationwide in 2020, Florida accounted for about one-fifth of cases, with most limited to the central part of the state. “In the U.S., there have been 150-250 cases reported each year over the past several years,” said Dr. Lucar, who was not affiliated with the research letter. “What seems to have changed is that since 2015, there has been a rise in cases in people who are U.S.-born “In the U.S., there have been 150-250 cases reported each year over the past several years,” said Dr. Lucar, who was not affiliated with the research letter. “What seems to have changed is that since 2015, there has been a rise in cases in people who are U.S.-born," and currently, about one-third of leprosy cases are in individuals born in the United States, he noted.

The research letter described a case of leprosy in a 54-year-old man who worked in landscaping, who sought treatment at a dermatology clinic in Central Florida in 2022 for a painful and progressive erythematous rash. The lesions began on his distal extensor extremities and progressed to involve his trunk and face. According to the report, the man denied any domestic or foreign travel, exposure to armadillos (a known source of transmission), prolonged contact with immigrants from leprosy-endemic countries, or connections with someone known to have leprosy. The authors concluded that the case “adds to the growing body of literature suggesting that central Florida represents an endemic location for leprosy. Travel to this area, even in the absence of other risk factors, should prompt consideration of leprosy in the appropriate clinical context.”

Dr. Lucar said that the mechanism of leprosy transmission is not fully understood, but armadillos, which typically traverse the southern United States, are naturally infected with the bacteria that causes leprosy. “It’s possible that they can spread it to people,” he said. “People who have occupations or hobbies that put them in potential contact with wildlife should avoid any close contact with armadillos. There’s also a discussion of whether [the spike in leprosy cases] may have to do with climate change. That is not yet confirmed. It’s not entirely clear why there’s been a recent rise. It remains an area of investigation.”

Meanwhile, clinicians should keep a high level of suspicion in patients who present with skin lesions compatible with leprosy. “These are typically discolored or numb patches on the skin,” Dr. Lucar said. “This can range from a single or a few lesions to very extensive involvement of the skin. The diminished sensation or loss of sensation within those skin patches is an important sign. There’s a loss of skin color but sometimes they can be reddish.” He emphasized that leprosy “does not spread easily from person to person; casual contact will not spread leprosy. It’s important for the public to understand that.”

Dr. Lucar reported no disclosures.

Despite the recent uptick in leprosy cases in Central Florida, the disease is very rare, and casual contact with an infected person is likely to not result in transmission, according to Jose A. Lucar, MD.

“Contrary to historical beliefs, leprosy is not highly contagious,” Dr. Lucar, an infectious disease physician and associate professor of medicine at George Washington University, Washington, said in an interview. “For reasons that have to do with the makeup of genes that affect their immune system, most people are not susceptible to acquire leprosy. It’s really a small percentage of the population. It does require prolonged contact with someone with untreated leprosy – over several months – to acquire an infection. So, the risk from any type of casual contact is low.”

Dr. Lucar

According to a research letter published in the CDC’s Emerging Infectious Diseases, the number of reported leprosy cases has more than doubled in the past decade. Of the 159 new cases reported nationwide in 2020, Florida accounted for about one-fifth of cases, with most limited to the central part of the state. “In the U.S., there have been 150-250 cases reported each year over the past several years,” said Dr. Lucar, who was not affiliated with the research letter. “What seems to have changed is that since 2015, there has been a rise in cases in people who are U.S.-born “In the U.S., there have been 150-250 cases reported each year over the past several years,” said Dr. Lucar, who was not affiliated with the research letter. “What seems to have changed is that since 2015, there has been a rise in cases in people who are U.S.-born," and currently, about one-third of leprosy cases are in individuals born in the United States, he noted.

The research letter described a case of leprosy in a 54-year-old man who worked in landscaping, who sought treatment at a dermatology clinic in Central Florida in 2022 for a painful and progressive erythematous rash. The lesions began on his distal extensor extremities and progressed to involve his trunk and face. According to the report, the man denied any domestic or foreign travel, exposure to armadillos (a known source of transmission), prolonged contact with immigrants from leprosy-endemic countries, or connections with someone known to have leprosy. The authors concluded that the case “adds to the growing body of literature suggesting that central Florida represents an endemic location for leprosy. Travel to this area, even in the absence of other risk factors, should prompt consideration of leprosy in the appropriate clinical context.”

Dr. Lucar said that the mechanism of leprosy transmission is not fully understood, but armadillos, which typically traverse the southern United States, are naturally infected with the bacteria that causes leprosy. “It’s possible that they can spread it to people,” he said. “People who have occupations or hobbies that put them in potential contact with wildlife should avoid any close contact with armadillos. There’s also a discussion of whether [the spike in leprosy cases] may have to do with climate change. That is not yet confirmed. It’s not entirely clear why there’s been a recent rise. It remains an area of investigation.”

Meanwhile, clinicians should keep a high level of suspicion in patients who present with skin lesions compatible with leprosy. “These are typically discolored or numb patches on the skin,” Dr. Lucar said. “This can range from a single or a few lesions to very extensive involvement of the skin. The diminished sensation or loss of sensation within those skin patches is an important sign. There’s a loss of skin color but sometimes they can be reddish.” He emphasized that leprosy “does not spread easily from person to person; casual contact will not spread leprosy. It’s important for the public to understand that.”

Dr. Lucar reported no disclosures.

Medical education has changed drastically over the years. As theories and practices continue to change, what was once standard 10 or 20 years ago has been replaced with newer ideologies, processes, or technology. It seems likely, then, that you may disagree with some of the things that you learned as medical school has evolved.

This news organization asked physicians what they learned in med school that they now contest. Many of their answers include newer philosophies and practice methods.
 

Treat appropriately for pain

Jacqui O’Kane, DO, a 2013 med school graduate, was taught to avoid prescribing controlled medications whenever possible.

“Initially this attitude made sense to me,” says Dr. O’Kane, “but as I became an experienced physician – and patient – I saw the harm that such an attitude could cause. Patients on controlled medication long-term were often viewed as drug-seekers and treated as such, even if their regimen was largely regarded as appropriate. Likewise, those who could benefit from short-term controlled prescriptions were sometimes denied them because of their clinician’s fear.”

Today, Dr. O’Kane believes controlled medications should seldom be the first option for patients suffering pain, anxiety, or insomnia. But, she says, “they should remain on the table and without judgment for those who fail first-line treatment or for whom alternatives are contraindicated.”

Amy Baxter, MD, believes that the amount of time spent on pain education in school needs to change.

“Doctors in the U.S. get only 12 hours of pain education, and most of it is on pharmacology,” says Dr. Baxter, who graduated from med school in 1995. “In addition to incorrect information on home opioids and addiction, I was left with the impression that medication could treat chronic pain. I now have a completely different understanding of pain as a whole-brain warning system. The goal shouldn’t be pain-free, just more comfortable.”
 

Practice lifestyle and preventive medicine

Dolapo Babalola, MD, went to medical school eager to learn how to care for the human body and her family members’ illnesses, such as the debilitating effects of arthritic pain and other chronic diseases.

“I was taught the pathology behind arthritic pain, symptoms, signs, and treatment – that it has a genetic component and is inevitable to avoid – but nothing about how to prevent it,” says Dr. Babalola, a 2000 graduate.

Twenty years later, she discovered lifestyle medicine when she began to experience knee pain.

“I was introduced to the power of health restoration by discovering the root cause of diseases such as inflammation, hormonal imbalance, and insulin resistance due to poor lifestyle choices such as diet, inactivity, stress, inadequate sleep, and substance abuse,” she says.

Adebisi Alli, DO, who graduated in 2011, remembers being taught to treat type 2 diabetes by delaying progression rather than aiming for remission. But today, “lifestyle-led, team-based approaches are steadily becoming a first prescription across medical training with the goal to put diabetes in remission,” she says.
 

Patient care is at the core of medicine

Tracey O’Connell, MD, recalls her radiology residency in the early to mid-90s, when radiologists were integral to the health care team.

“We interacted with referrers and followed the course of patients’ diseases,” says Dr. O’Connell. “We knew patient histories, their stories. We were connected to other humans, doctors, nurses, teams, and the patients themselves.”

But with the advent of picture archiving and communication systems, high-speed CT and MRI, digital radiography, and voice recognition, the practice of radiology has changed dramatically.

“There’s no time to review or discuss cases anymore,” she says. “Reports went from eloquent and articulate documents with lists of differential diagnoses to short checklists and templates. The whole field of patient care has become dehumanizing, exactly the opposite of what humans need.”

Mache Seibel, MD, who graduated almost 50 years ago, agrees that patient care has lost its focus, to the detriment of patients.

“What I learned in medical school that is forgotten today is how to listen to patients, take a history, and do an examination using my hands and a stethoscope,” says Dr. Seibel. “Today with technology and time constraints, the focus is too much on the symptom without context, ordering a test, and getting the EMR boxes filled out.”
 

Physician, heal thyself

Priya Radhakrishnan, MD, remembers learning that a physician’s well-being was their responsibility. “We now know that well-being is the health system’s responsibility and that we need to diagnose ourselves and support each other, especially our trainees,” says Dr. Radhakrishna. She graduated in 1992. “Destigmatizing mental health is essential to well-being.”

Rachel Miller, MD, a 2009 med school graduate was taught that learning about health care systems and policy wasn’t necessary. Dr. Miller says they learned that policy knowledge would come in time. “I currently disagree. It is vital to understand aspects of health care systems and policy. Not knowing these things has partly contributed to the pervasiveness of burnout among physicians and other health care providers.”
 

Practice with gender at the forefront

Janice L. Werbinski, MD, an ob.gyn., and Elizabeth Anne Comen, MD, a breast cancer oncologist, remember when nearly all medical research was performed on the 140-lb White man. Doctors learned to treat patients through that male lens.

“The majority of the anatomy we saw in medical school was on a male figure,” says Dr. Comen, author of “All in Her Head,” a HarperCollins book slated to be released in February 2024. She graduated from med school in 2004. “The only time we saw anatomy for females was in the female reproductive system. That’s changing for the better.”

Dr. Werbinski chose a residency in obstetrics and gynecology in 1975 because she thought it was the only way she could serve female patients.

“I really thought that was the place for women’s health,” says Dr. Werbinski, cochair of the American Medical Women’s Association Sex & Gender Health Coalition.

“I am happy to say that significant awareness has grown since I graduated from medical school. I hope that when this question is asked of current medical students, they will be able to say that they know to practice with a sex- and gender-focused lens.”
 

Talk about racial disparities

John McHugh, MD, an ob.gyn., recalls learning little about the social determinants of health when he attended med school more than 30 years ago.

“We saw disparities in outcomes based on race and class but assumed that we would overcome them when we were in practice,” says Dr. McHugh, an AMWA Action Coalition for Equity member. “We didn’t understand the root causes of disparities and had never heard of concepts like epigenetics or weathering. I’m hopeful current research will help our understanding and today’s medical students will serve a safer, healthier, and more equitable world.”

Curtiland Deville, MD, an associate professor of radiation oncology, recalls having few conversations around race; racial disparities; and diversity, equity, and inclusion.

“When I went to medical school, it often felt like you weren’t supposed to talk about the differences in race,” says Dr. Deville, who graduated in 2005. But today, in the post-2020 era between COVID, during which health disparities got highlighted, and calls for racial justice taking center stage, Dr. Deville says many of the things they didn’t talk about have come to the forefront in our medical institutions.
 

Information at your fingertips

For Paru David, MD, a 1996 graduate, the most significant change is the amount of health and medical information available today. “Before, the information that was taught in medical school was obtained through textbooks or within journal articles,” says Dr. David.

“Now, we have databases of information. The key to success is being able to navigate the information available to us, digest it with a keen eye, and then apply it to patient care in a timely manner.”

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

Medical education has changed drastically over the years. As theories and practices continue to change, what was once standard 10 or 20 years ago has been replaced with newer ideologies, processes, or technology. It seems likely, then, that you may disagree with some of the things that you learned as medical school has evolved.

This news organization asked physicians what they learned in med school that they now contest. Many of their answers include newer philosophies and practice methods.
 

Treat appropriately for pain

Jacqui O’Kane, DO, a 2013 med school graduate, was taught to avoid prescribing controlled medications whenever possible.

“Initially this attitude made sense to me,” says Dr. O’Kane, “but as I became an experienced physician – and patient – I saw the harm that such an attitude could cause. Patients on controlled medication long-term were often viewed as drug-seekers and treated as such, even if their regimen was largely regarded as appropriate. Likewise, those who could benefit from short-term controlled prescriptions were sometimes denied them because of their clinician’s fear.”

Today, Dr. O’Kane believes controlled medications should seldom be the first option for patients suffering pain, anxiety, or insomnia. But, she says, “they should remain on the table and without judgment for those who fail first-line treatment or for whom alternatives are contraindicated.”

Amy Baxter, MD, believes that the amount of time spent on pain education in school needs to change.

“Doctors in the U.S. get only 12 hours of pain education, and most of it is on pharmacology,” says Dr. Baxter, who graduated from med school in 1995. “In addition to incorrect information on home opioids and addiction, I was left with the impression that medication could treat chronic pain. I now have a completely different understanding of pain as a whole-brain warning system. The goal shouldn’t be pain-free, just more comfortable.”
 

Practice lifestyle and preventive medicine

Dolapo Babalola, MD, went to medical school eager to learn how to care for the human body and her family members’ illnesses, such as the debilitating effects of arthritic pain and other chronic diseases.

“I was taught the pathology behind arthritic pain, symptoms, signs, and treatment – that it has a genetic component and is inevitable to avoid – but nothing about how to prevent it,” says Dr. Babalola, a 2000 graduate.

Twenty years later, she discovered lifestyle medicine when she began to experience knee pain.

“I was introduced to the power of health restoration by discovering the root cause of diseases such as inflammation, hormonal imbalance, and insulin resistance due to poor lifestyle choices such as diet, inactivity, stress, inadequate sleep, and substance abuse,” she says.

Adebisi Alli, DO, who graduated in 2011, remembers being taught to treat type 2 diabetes by delaying progression rather than aiming for remission. But today, “lifestyle-led, team-based approaches are steadily becoming a first prescription across medical training with the goal to put diabetes in remission,” she says.
 

Patient care is at the core of medicine

Tracey O’Connell, MD, recalls her radiology residency in the early to mid-90s, when radiologists were integral to the health care team.

“We interacted with referrers and followed the course of patients’ diseases,” says Dr. O’Connell. “We knew patient histories, their stories. We were connected to other humans, doctors, nurses, teams, and the patients themselves.”

But with the advent of picture archiving and communication systems, high-speed CT and MRI, digital radiography, and voice recognition, the practice of radiology has changed dramatically.

“There’s no time to review or discuss cases anymore,” she says. “Reports went from eloquent and articulate documents with lists of differential diagnoses to short checklists and templates. The whole field of patient care has become dehumanizing, exactly the opposite of what humans need.”

Mache Seibel, MD, who graduated almost 50 years ago, agrees that patient care has lost its focus, to the detriment of patients.

“What I learned in medical school that is forgotten today is how to listen to patients, take a history, and do an examination using my hands and a stethoscope,” says Dr. Seibel. “Today with technology and time constraints, the focus is too much on the symptom without context, ordering a test, and getting the EMR boxes filled out.”
 

Physician, heal thyself

Priya Radhakrishnan, MD, remembers learning that a physician’s well-being was their responsibility. “We now know that well-being is the health system’s responsibility and that we need to diagnose ourselves and support each other, especially our trainees,” says Dr. Radhakrishna. She graduated in 1992. “Destigmatizing mental health is essential to well-being.”

Rachel Miller, MD, a 2009 med school graduate was taught that learning about health care systems and policy wasn’t necessary. Dr. Miller says they learned that policy knowledge would come in time. “I currently disagree. It is vital to understand aspects of health care systems and policy. Not knowing these things has partly contributed to the pervasiveness of burnout among physicians and other health care providers.”
 

Practice with gender at the forefront

Janice L. Werbinski, MD, an ob.gyn., and Elizabeth Anne Comen, MD, a breast cancer oncologist, remember when nearly all medical research was performed on the 140-lb White man. Doctors learned to treat patients through that male lens.

“The majority of the anatomy we saw in medical school was on a male figure,” says Dr. Comen, author of “All in Her Head,” a HarperCollins book slated to be released in February 2024. She graduated from med school in 2004. “The only time we saw anatomy for females was in the female reproductive system. That’s changing for the better.”

Dr. Werbinski chose a residency in obstetrics and gynecology in 1975 because she thought it was the only way she could serve female patients.

“I really thought that was the place for women’s health,” says Dr. Werbinski, cochair of the American Medical Women’s Association Sex & Gender Health Coalition.

“I am happy to say that significant awareness has grown since I graduated from medical school. I hope that when this question is asked of current medical students, they will be able to say that they know to practice with a sex- and gender-focused lens.”
 

Talk about racial disparities

John McHugh, MD, an ob.gyn., recalls learning little about the social determinants of health when he attended med school more than 30 years ago.

“We saw disparities in outcomes based on race and class but assumed that we would overcome them when we were in practice,” says Dr. McHugh, an AMWA Action Coalition for Equity member. “We didn’t understand the root causes of disparities and had never heard of concepts like epigenetics or weathering. I’m hopeful current research will help our understanding and today’s medical students will serve a safer, healthier, and more equitable world.”

Curtiland Deville, MD, an associate professor of radiation oncology, recalls having few conversations around race; racial disparities; and diversity, equity, and inclusion.

“When I went to medical school, it often felt like you weren’t supposed to talk about the differences in race,” says Dr. Deville, who graduated in 2005. But today, in the post-2020 era between COVID, during which health disparities got highlighted, and calls for racial justice taking center stage, Dr. Deville says many of the things they didn’t talk about have come to the forefront in our medical institutions.
 

Information at your fingertips

For Paru David, MD, a 1996 graduate, the most significant change is the amount of health and medical information available today. “Before, the information that was taught in medical school was obtained through textbooks or within journal articles,” says Dr. David.

“Now, we have databases of information. The key to success is being able to navigate the information available to us, digest it with a keen eye, and then apply it to patient care in a timely manner.”

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

Medical education has changed drastically over the years. As theories and practices continue to change, what was once standard 10 or 20 years ago has been replaced with newer ideologies, processes, or technology. It seems likely, then, that you may disagree with some of the things that you learned as medical school has evolved.

This news organization asked physicians what they learned in med school that they now contest. Many of their answers include newer philosophies and practice methods.
 

Treat appropriately for pain

Jacqui O’Kane, DO, a 2013 med school graduate, was taught to avoid prescribing controlled medications whenever possible.

“Initially this attitude made sense to me,” says Dr. O’Kane, “but as I became an experienced physician – and patient – I saw the harm that such an attitude could cause. Patients on controlled medication long-term were often viewed as drug-seekers and treated as such, even if their regimen was largely regarded as appropriate. Likewise, those who could benefit from short-term controlled prescriptions were sometimes denied them because of their clinician’s fear.”

Today, Dr. O’Kane believes controlled medications should seldom be the first option for patients suffering pain, anxiety, or insomnia. But, she says, “they should remain on the table and without judgment for those who fail first-line treatment or for whom alternatives are contraindicated.”

Amy Baxter, MD, believes that the amount of time spent on pain education in school needs to change.

“Doctors in the U.S. get only 12 hours of pain education, and most of it is on pharmacology,” says Dr. Baxter, who graduated from med school in 1995. “In addition to incorrect information on home opioids and addiction, I was left with the impression that medication could treat chronic pain. I now have a completely different understanding of pain as a whole-brain warning system. The goal shouldn’t be pain-free, just more comfortable.”
 

Practice lifestyle and preventive medicine

Dolapo Babalola, MD, went to medical school eager to learn how to care for the human body and her family members’ illnesses, such as the debilitating effects of arthritic pain and other chronic diseases.

“I was taught the pathology behind arthritic pain, symptoms, signs, and treatment – that it has a genetic component and is inevitable to avoid – but nothing about how to prevent it,” says Dr. Babalola, a 2000 graduate.

Twenty years later, she discovered lifestyle medicine when she began to experience knee pain.

“I was introduced to the power of health restoration by discovering the root cause of diseases such as inflammation, hormonal imbalance, and insulin resistance due to poor lifestyle choices such as diet, inactivity, stress, inadequate sleep, and substance abuse,” she says.

Adebisi Alli, DO, who graduated in 2011, remembers being taught to treat type 2 diabetes by delaying progression rather than aiming for remission. But today, “lifestyle-led, team-based approaches are steadily becoming a first prescription across medical training with the goal to put diabetes in remission,” she says.
 

Patient care is at the core of medicine

Tracey O’Connell, MD, recalls her radiology residency in the early to mid-90s, when radiologists were integral to the health care team.

“We interacted with referrers and followed the course of patients’ diseases,” says Dr. O’Connell. “We knew patient histories, their stories. We were connected to other humans, doctors, nurses, teams, and the patients themselves.”

But with the advent of picture archiving and communication systems, high-speed CT and MRI, digital radiography, and voice recognition, the practice of radiology has changed dramatically.

“There’s no time to review or discuss cases anymore,” she says. “Reports went from eloquent and articulate documents with lists of differential diagnoses to short checklists and templates. The whole field of patient care has become dehumanizing, exactly the opposite of what humans need.”

Mache Seibel, MD, who graduated almost 50 years ago, agrees that patient care has lost its focus, to the detriment of patients.

“What I learned in medical school that is forgotten today is how to listen to patients, take a history, and do an examination using my hands and a stethoscope,” says Dr. Seibel. “Today with technology and time constraints, the focus is too much on the symptom without context, ordering a test, and getting the EMR boxes filled out.”
 

Physician, heal thyself

Priya Radhakrishnan, MD, remembers learning that a physician’s well-being was their responsibility. “We now know that well-being is the health system’s responsibility and that we need to diagnose ourselves and support each other, especially our trainees,” says Dr. Radhakrishna. She graduated in 1992. “Destigmatizing mental health is essential to well-being.”

Rachel Miller, MD, a 2009 med school graduate was taught that learning about health care systems and policy wasn’t necessary. Dr. Miller says they learned that policy knowledge would come in time. “I currently disagree. It is vital to understand aspects of health care systems and policy. Not knowing these things has partly contributed to the pervasiveness of burnout among physicians and other health care providers.”
 

Practice with gender at the forefront

Janice L. Werbinski, MD, an ob.gyn., and Elizabeth Anne Comen, MD, a breast cancer oncologist, remember when nearly all medical research was performed on the 140-lb White man. Doctors learned to treat patients through that male lens.

“The majority of the anatomy we saw in medical school was on a male figure,” says Dr. Comen, author of “All in Her Head,” a HarperCollins book slated to be released in February 2024. She graduated from med school in 2004. “The only time we saw anatomy for females was in the female reproductive system. That’s changing for the better.”

Dr. Werbinski chose a residency in obstetrics and gynecology in 1975 because she thought it was the only way she could serve female patients.

“I really thought that was the place for women’s health,” says Dr. Werbinski, cochair of the American Medical Women’s Association Sex & Gender Health Coalition.

“I am happy to say that significant awareness has grown since I graduated from medical school. I hope that when this question is asked of current medical students, they will be able to say that they know to practice with a sex- and gender-focused lens.”
 

Talk about racial disparities

John McHugh, MD, an ob.gyn., recalls learning little about the social determinants of health when he attended med school more than 30 years ago.

“We saw disparities in outcomes based on race and class but assumed that we would overcome them when we were in practice,” says Dr. McHugh, an AMWA Action Coalition for Equity member. “We didn’t understand the root causes of disparities and had never heard of concepts like epigenetics or weathering. I’m hopeful current research will help our understanding and today’s medical students will serve a safer, healthier, and more equitable world.”

Curtiland Deville, MD, an associate professor of radiation oncology, recalls having few conversations around race; racial disparities; and diversity, equity, and inclusion.

“When I went to medical school, it often felt like you weren’t supposed to talk about the differences in race,” says Dr. Deville, who graduated in 2005. But today, in the post-2020 era between COVID, during which health disparities got highlighted, and calls for racial justice taking center stage, Dr. Deville says many of the things they didn’t talk about have come to the forefront in our medical institutions.
 

Information at your fingertips

For Paru David, MD, a 1996 graduate, the most significant change is the amount of health and medical information available today. “Before, the information that was taught in medical school was obtained through textbooks or within journal articles,” says Dr. David.

“Now, we have databases of information. The key to success is being able to navigate the information available to us, digest it with a keen eye, and then apply it to patient care in a timely manner.”

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

In a new study, researchers report that they have found epigenetic methylation markers on 15 genes that appear to foreshadow psoriatic arthritis (PsA), a development that could bring scientists closer to developing a DNA test to predict which patients with psoriasis will develop the condition.

KTSDESIGN/SCIENCE PHOTO LIBRARY/Getty Images

While no predictive test is in sight yet, the findings published in Arthritis & Rheumatology mark an important step, study lead author Omar F. Cruz-Correa, PhD, of the Psoriatic Arthritis Research Program in the University Health Network, Toronto, said in an interview. “In the future, markers like these could be measured by dermatologists and even general practitioners to help identify new psoriasis patients at a high risk of developing PsA,” he said. “Then both the health care team and the patients themselves could be more aware of their increased risk and the pressing need of closer monitoring for musculoskeletal symptoms. Once the first symptoms appear, treatment can be initiated early on, helping to prevent permanent joint damage.”

An estimated 30% of patients with psoriasis will develop PsA, too, putting them at higher risk of disability and death. According to Dr. Cruz-Correa, “one of the more pressing matters in PsA is the lack of means of predicting which psoriasis patients will develop PsA.”

DNA methylation, the topic of the new study, has already been linked to psoriasis and PsA. It’s “relatively easy to measure and helps regulate gene expression in response to environmental effects,” Dr. Cruz-Correa said. “DNA methylation is also appealing because it serves as an intermediary between environment and genetic factors as it’s transmitted between generations of cells and influenced by external factors.”

For the new study, researchers examined the DNA of 117 patients with psoriasis – 58 who went on to develop PsA (“converters”) and another 59 who were matched to converters but did not develop PsA (“nonconverters”). The patients were in a larger group of 700 patients with psoriasis who had the disease for a mean of about 17 years at the time of blood sampling.

Samples from converters were taken an average of 5.16 years (± 12.77 years) before PsA set in.

The researchers report that they found “36 highly relevant methylation markers … across 15 genes and several intergenic regions. A classification model relying on these markers identified converters and nonconverters with an area under the ROC curve of 0.9644.”

Statistically, this number is high and means that “the DNA methylation markers are really good at identifying psoriasis patients who will develop PsA and those that will not,” at least in this specific patient group, Dr. Cruz-Correa said.

At this point, the number of markers is a bit too high to develop a feasible DNA test to predict PsA, he said. “However, the results from our study have also pointed us toward some interesting metabolic pathways that may warrant further study.”
 

What’s next?

The first step forward “is the validation of these predictive DNA methylation markers in a wider population of patients with varied clinical and demographic characteristics. This would help assess the potential for generalization of such a test,” Dr. Cruz-Correa said. “A second step is to assess the potential impact of these methylation markers on disease activity and treatment response, which are clinical outcomes of great importance to patients.”

Meanwhile, he said, “there are ongoing efforts to shed light into how DNA methylation integrates with other epigenetic mechanisms like micro-RNAs to regulate gene expression in concert with one another. An integrative look into these mechanisms may be able to give insight into the pathogenesis of psoriatic disease in a way that has not been possible before.”

In an interview, Johann E. Gudjonsson, MD, PhD, professor of skin molecular immunology at the University of Michigan, Ann Arbor, said the study “is interesting and important as it indicates that there are changes in the blood that occur before the development of psoriatic arthritis. However, it does not provide much in terms of novel insights into the mechanisms involved and is still a long way away from being useful as a clinical predictor or biomarker.”

The National Psoriasis Foundation, Krembil Foundation, and Canadian Institutes of Health Research provided support for the study. Dr. Cruz-Correa reports support from the National Psoriasis Foundation and the Arthritis Society. Dr. Gudjonsson has no relevant financial relationships.
 

In a new study, researchers report that they have found epigenetic methylation markers on 15 genes that appear to foreshadow psoriatic arthritis (PsA), a development that could bring scientists closer to developing a DNA test to predict which patients with psoriasis will develop the condition.

KTSDESIGN/SCIENCE PHOTO LIBRARY/Getty Images

While no predictive test is in sight yet, the findings published in Arthritis & Rheumatology mark an important step, study lead author Omar F. Cruz-Correa, PhD, of the Psoriatic Arthritis Research Program in the University Health Network, Toronto, said in an interview. “In the future, markers like these could be measured by dermatologists and even general practitioners to help identify new psoriasis patients at a high risk of developing PsA,” he said. “Then both the health care team and the patients themselves could be more aware of their increased risk and the pressing need of closer monitoring for musculoskeletal symptoms. Once the first symptoms appear, treatment can be initiated early on, helping to prevent permanent joint damage.”

An estimated 30% of patients with psoriasis will develop PsA, too, putting them at higher risk of disability and death. According to Dr. Cruz-Correa, “one of the more pressing matters in PsA is the lack of means of predicting which psoriasis patients will develop PsA.”

DNA methylation, the topic of the new study, has already been linked to psoriasis and PsA. It’s “relatively easy to measure and helps regulate gene expression in response to environmental effects,” Dr. Cruz-Correa said. “DNA methylation is also appealing because it serves as an intermediary between environment and genetic factors as it’s transmitted between generations of cells and influenced by external factors.”

For the new study, researchers examined the DNA of 117 patients with psoriasis – 58 who went on to develop PsA (“converters”) and another 59 who were matched to converters but did not develop PsA (“nonconverters”). The patients were in a larger group of 700 patients with psoriasis who had the disease for a mean of about 17 years at the time of blood sampling.

Samples from converters were taken an average of 5.16 years (± 12.77 years) before PsA set in.

The researchers report that they found “36 highly relevant methylation markers … across 15 genes and several intergenic regions. A classification model relying on these markers identified converters and nonconverters with an area under the ROC curve of 0.9644.”

Statistically, this number is high and means that “the DNA methylation markers are really good at identifying psoriasis patients who will develop PsA and those that will not,” at least in this specific patient group, Dr. Cruz-Correa said.

At this point, the number of markers is a bit too high to develop a feasible DNA test to predict PsA, he said. “However, the results from our study have also pointed us toward some interesting metabolic pathways that may warrant further study.”
 

What’s next?

The first step forward “is the validation of these predictive DNA methylation markers in a wider population of patients with varied clinical and demographic characteristics. This would help assess the potential for generalization of such a test,” Dr. Cruz-Correa said. “A second step is to assess the potential impact of these methylation markers on disease activity and treatment response, which are clinical outcomes of great importance to patients.”

Meanwhile, he said, “there are ongoing efforts to shed light into how DNA methylation integrates with other epigenetic mechanisms like micro-RNAs to regulate gene expression in concert with one another. An integrative look into these mechanisms may be able to give insight into the pathogenesis of psoriatic disease in a way that has not been possible before.”

In an interview, Johann E. Gudjonsson, MD, PhD, professor of skin molecular immunology at the University of Michigan, Ann Arbor, said the study “is interesting and important as it indicates that there are changes in the blood that occur before the development of psoriatic arthritis. However, it does not provide much in terms of novel insights into the mechanisms involved and is still a long way away from being useful as a clinical predictor or biomarker.”

The National Psoriasis Foundation, Krembil Foundation, and Canadian Institutes of Health Research provided support for the study. Dr. Cruz-Correa reports support from the National Psoriasis Foundation and the Arthritis Society. Dr. Gudjonsson has no relevant financial relationships.
 

In a new study, researchers report that they have found epigenetic methylation markers on 15 genes that appear to foreshadow psoriatic arthritis (PsA), a development that could bring scientists closer to developing a DNA test to predict which patients with psoriasis will develop the condition.

KTSDESIGN/SCIENCE PHOTO LIBRARY/Getty Images

While no predictive test is in sight yet, the findings published in Arthritis & Rheumatology mark an important step, study lead author Omar F. Cruz-Correa, PhD, of the Psoriatic Arthritis Research Program in the University Health Network, Toronto, said in an interview. “In the future, markers like these could be measured by dermatologists and even general practitioners to help identify new psoriasis patients at a high risk of developing PsA,” he said. “Then both the health care team and the patients themselves could be more aware of their increased risk and the pressing need of closer monitoring for musculoskeletal symptoms. Once the first symptoms appear, treatment can be initiated early on, helping to prevent permanent joint damage.”

An estimated 30% of patients with psoriasis will develop PsA, too, putting them at higher risk of disability and death. According to Dr. Cruz-Correa, “one of the more pressing matters in PsA is the lack of means of predicting which psoriasis patients will develop PsA.”

DNA methylation, the topic of the new study, has already been linked to psoriasis and PsA. It’s “relatively easy to measure and helps regulate gene expression in response to environmental effects,” Dr. Cruz-Correa said. “DNA methylation is also appealing because it serves as an intermediary between environment and genetic factors as it’s transmitted between generations of cells and influenced by external factors.”

For the new study, researchers examined the DNA of 117 patients with psoriasis – 58 who went on to develop PsA (“converters”) and another 59 who were matched to converters but did not develop PsA (“nonconverters”). The patients were in a larger group of 700 patients with psoriasis who had the disease for a mean of about 17 years at the time of blood sampling.

Samples from converters were taken an average of 5.16 years (± 12.77 years) before PsA set in.

The researchers report that they found “36 highly relevant methylation markers … across 15 genes and several intergenic regions. A classification model relying on these markers identified converters and nonconverters with an area under the ROC curve of 0.9644.”

Statistically, this number is high and means that “the DNA methylation markers are really good at identifying psoriasis patients who will develop PsA and those that will not,” at least in this specific patient group, Dr. Cruz-Correa said.

At this point, the number of markers is a bit too high to develop a feasible DNA test to predict PsA, he said. “However, the results from our study have also pointed us toward some interesting metabolic pathways that may warrant further study.”
 

What’s next?

The first step forward “is the validation of these predictive DNA methylation markers in a wider population of patients with varied clinical and demographic characteristics. This would help assess the potential for generalization of such a test,” Dr. Cruz-Correa said. “A second step is to assess the potential impact of these methylation markers on disease activity and treatment response, which are clinical outcomes of great importance to patients.”

Meanwhile, he said, “there are ongoing efforts to shed light into how DNA methylation integrates with other epigenetic mechanisms like micro-RNAs to regulate gene expression in concert with one another. An integrative look into these mechanisms may be able to give insight into the pathogenesis of psoriatic disease in a way that has not been possible before.”

In an interview, Johann E. Gudjonsson, MD, PhD, professor of skin molecular immunology at the University of Michigan, Ann Arbor, said the study “is interesting and important as it indicates that there are changes in the blood that occur before the development of psoriatic arthritis. However, it does not provide much in terms of novel insights into the mechanisms involved and is still a long way away from being useful as a clinical predictor or biomarker.”

The National Psoriasis Foundation, Krembil Foundation, and Canadian Institutes of Health Research provided support for the study. Dr. Cruz-Correa reports support from the National Psoriasis Foundation and the Arthritis Society. Dr. Gudjonsson has no relevant financial relationships.
 

One of the most controversial issues today is whether a physician should be permitted, or even obligated, to assist patients with a terminal or incurable illness to end their life – a process known as medical assistance in dying (MAID) or physician-assisted suicide (PAS.)

Until recently, this contentious issue applied only to patients with physical illnesses who want to end their suffering and who seek out a physician willing to assist with that objective. In the United States and other countries, this is the patient population who may be able to avail themselves of this option.

However, newly proposed legislation in Canada – which has the largest number of physician-assisted deaths worldwide – would expand the indication for MAID to include serious mental illness. Originally set to be passed in March 2023, the law has been deferred for final decision until March 2024.

A recent commentary by psychiatrist Dinah Miller, MD, explored the ethics of this proposed legislation for mental health professionals. “To offer the option of death facilitated by the very person who is trying to get [patients with serious mental illness] better seems so counter to everything I have learned and contradicts our role as psychiatrists who work so hard to prevent suicide,” Dr. Miller wrote. “As psychiatrists, do we offer hope to our most vulnerable patients, or do we offer death? Do we rail against suicide, or do we facilitate it?”

Dr. Miller’s piece garnered a huge amount of reader response that included many laudatory comments: a “nuanced and open-ended inquiry here,” “timely and honest,” and “beautifully written.” One reader thanked the author for “this thoughtful, questioning, and open reflection on what it means to be a psychiatrist facing a thorny and deeply personal practice and philosophical question.”
 

Cognitive distortion or objective reality?

Many readers were opposed to any type of physician involvement in hastening a patient’s death, regardless of whether the condition is medical or psychiatric. “Let others who wish to die make their own arrangement without the aid of the medical profession,” one reader wrote.

But others felt that for those with terminal physical illnesses or intractable pain, it is justified for medical professionals to either facilitate death or, at the very least, withhold life-prolonging treatments.

A critical-care physician described responding to families’ accusations that withdrawal of life-sustaining measures means “playing God.” On the contrary, the physician wrote, “there is a limit to our abilities; and withdrawing those life-prolonging interventions allows nature or God or whatever to play a role and take its course.”

Another U.S. reader pointed out that “multiple polls in this country have shown that the majority of the general public, physicians in general and psychiatrists in particular, support the option of MAID for the terminally ill. They do not find it at variance with their calling as physicians.”

“I and many of my elderly friends don’t fear death but fear prolonged dementia with its dependency and lack of quality of life,” one reader wrote. “We would be much more at peace if we could put in our advanced directive that we request MAID once some point of dependency has been reached.”

Another wrote that in the event of entering a state of “degrading dependency and hardship on the family, please let me go peacefully, without burdening others, into that good night [of death].”

Many felt that not only physical illness but also the prospect of cognitive degeneration – specifically dementia – also justifies assisting patient death.
 

“Enormous suffering”

One Canadian reader noted that provisions for advance consent are now in place in Canada for those facing the prospect of neurodegenerative disease and who are still mentally competent to make such decisions.

But therein lies the rub – the concept of an advanced directive goes to the question of decisional capacity. Dr. Miller noted that “depression distorts cognition and leads many patients to believe that they would be better off dead and that their loves ones would be better off without them.”

The concept of “cognitive distortion” implies that the illness itself may impede the decisional capacity required for an advanced directive or a decision made in the moment, in the absence of such a directive. Dr. Miller asked, “How do we determine whether patients with serious mental illness are competent to make such a decision or whether it is mental illness that is driving their perception of a future without hope?”

One reader attested to this from personal experience. “As both a physician and a sufferer of severe, often profound depression for 50 years, I can confidently say that ... the pursuit of death is the result of an impaired mental state, which simultaneously prevents a rational decision.”

Another agreed. “As a psychiatrist, I treated suicidal patients almost every day of my 27-year career. I believe in making every effort to prevent the suicide of a healthy depressed person and I do not support MAID for psychiatric conditions. But I do support MAID for the terminally ill.”

Other readers disagreed. In the words of one commentator, “I think that if we are going to help mentally ill people, we have to consider their choices. The stress imposed by a severe/intractable mental illness is as bad as any other devastating medical illness. If no one is going to hold their hand in life (as support services are limited and psychiatric treatments often fail), allow a medical professional to hold their hand through their final moments.”

A psychiatrist described very ill patients with treatment-resistant bipolar disorder who had not only received medications, including ketamine, but had also received electroconvulsive therapy and still did not respond.

“Their suffering is enormous and the truth is that there is no improvement for more than a few days or weeks and later they return to their hell. Appreciating that they would be better off dead for themselves and their families is not always a cognitive distortion but an objective evaluation of their reality.”

However, as another reader pointed out, an issue with the argument presented here is that it presupposes that MAID requires “clinical justification.” But in Canada, “MAID ... is understood as an expression of personal autonomy. Rooted in liberal political philosophy of individualism ... approval for death need not be based on a clinical assessment.” Instead, “death is seen as a ‘right’ that the state must therefore provide.”
 

Another form of eugenics?

Dr. Miller raised the ethical implications of racial and socioeconomic factors playing a role in the consideration of MAID for those with psychiatric illness.

“Might those who are poor, who have less access to expensive treatment options and social support, be more likely to request facilitated death?” she asks. “Do we risk facilitating a patient’s demise when other options are unavailable because of a lack of access to treatment or when social and financial struggles exacerbate a person’s hopelessness? Should we worry that psychiatric euthanasia will turn into a form of eugenics where those who can’t contribute are made to feel that they should bow out?”

Several readers agreed. “Looking at the disproportionate burden of illness, rates of imprisonment, and application of the death penalty indicates to me that race and socioeconomic status will be an immediate factor in how, where, and with whom MAID for mental illness would be practice in much, if not all, of the U.S.,” wrote one physician.

A Canadian reader expressed similar concerns. “I’ve seen a handful of people, including someone I considered a good friend, opt for MAID because it was easier than living as a disabled person in poverty without adequate mental health care.”

Another Canadian clinician noted that offering people good care can make all the difference. “As a Canadian mental health clinician who served youth with severe mental illness for over 20 years through our socialized medical network, I can attest to the difference good care usually makes in shifting clients from despair and a commitment to death to embracing life once again. Let’s not, as clinicians, embrace easing a government/state-sanctioned pathway to death.”

Some readers believe that these types of issues can’t be solved with a blanket approach, noting that each case is different. “Real life is always more complicated than academic discussions. Having served on a hospital ethics committee, I know that each case is unique,” one reader noted.

Another reader added, “I think all we can do as physicians is to let people decide for themselves and participate only if our conscience allows.”
 

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

One of the most controversial issues today is whether a physician should be permitted, or even obligated, to assist patients with a terminal or incurable illness to end their life – a process known as medical assistance in dying (MAID) or physician-assisted suicide (PAS.)

Until recently, this contentious issue applied only to patients with physical illnesses who want to end their suffering and who seek out a physician willing to assist with that objective. In the United States and other countries, this is the patient population who may be able to avail themselves of this option.

However, newly proposed legislation in Canada – which has the largest number of physician-assisted deaths worldwide – would expand the indication for MAID to include serious mental illness. Originally set to be passed in March 2023, the law has been deferred for final decision until March 2024.

A recent commentary by psychiatrist Dinah Miller, MD, explored the ethics of this proposed legislation for mental health professionals. “To offer the option of death facilitated by the very person who is trying to get [patients with serious mental illness] better seems so counter to everything I have learned and contradicts our role as psychiatrists who work so hard to prevent suicide,” Dr. Miller wrote. “As psychiatrists, do we offer hope to our most vulnerable patients, or do we offer death? Do we rail against suicide, or do we facilitate it?”

Dr. Miller’s piece garnered a huge amount of reader response that included many laudatory comments: a “nuanced and open-ended inquiry here,” “timely and honest,” and “beautifully written.” One reader thanked the author for “this thoughtful, questioning, and open reflection on what it means to be a psychiatrist facing a thorny and deeply personal practice and philosophical question.”
 

Cognitive distortion or objective reality?

Many readers were opposed to any type of physician involvement in hastening a patient’s death, regardless of whether the condition is medical or psychiatric. “Let others who wish to die make their own arrangement without the aid of the medical profession,” one reader wrote.

But others felt that for those with terminal physical illnesses or intractable pain, it is justified for medical professionals to either facilitate death or, at the very least, withhold life-prolonging treatments.

A critical-care physician described responding to families’ accusations that withdrawal of life-sustaining measures means “playing God.” On the contrary, the physician wrote, “there is a limit to our abilities; and withdrawing those life-prolonging interventions allows nature or God or whatever to play a role and take its course.”

Another U.S. reader pointed out that “multiple polls in this country have shown that the majority of the general public, physicians in general and psychiatrists in particular, support the option of MAID for the terminally ill. They do not find it at variance with their calling as physicians.”

“I and many of my elderly friends don’t fear death but fear prolonged dementia with its dependency and lack of quality of life,” one reader wrote. “We would be much more at peace if we could put in our advanced directive that we request MAID once some point of dependency has been reached.”

Another wrote that in the event of entering a state of “degrading dependency and hardship on the family, please let me go peacefully, without burdening others, into that good night [of death].”

Many felt that not only physical illness but also the prospect of cognitive degeneration – specifically dementia – also justifies assisting patient death.
 

“Enormous suffering”

One Canadian reader noted that provisions for advance consent are now in place in Canada for those facing the prospect of neurodegenerative disease and who are still mentally competent to make such decisions.

But therein lies the rub – the concept of an advanced directive goes to the question of decisional capacity. Dr. Miller noted that “depression distorts cognition and leads many patients to believe that they would be better off dead and that their loves ones would be better off without them.”

The concept of “cognitive distortion” implies that the illness itself may impede the decisional capacity required for an advanced directive or a decision made in the moment, in the absence of such a directive. Dr. Miller asked, “How do we determine whether patients with serious mental illness are competent to make such a decision or whether it is mental illness that is driving their perception of a future without hope?”

One reader attested to this from personal experience. “As both a physician and a sufferer of severe, often profound depression for 50 years, I can confidently say that ... the pursuit of death is the result of an impaired mental state, which simultaneously prevents a rational decision.”

Another agreed. “As a psychiatrist, I treated suicidal patients almost every day of my 27-year career. I believe in making every effort to prevent the suicide of a healthy depressed person and I do not support MAID for psychiatric conditions. But I do support MAID for the terminally ill.”

Other readers disagreed. In the words of one commentator, “I think that if we are going to help mentally ill people, we have to consider their choices. The stress imposed by a severe/intractable mental illness is as bad as any other devastating medical illness. If no one is going to hold their hand in life (as support services are limited and psychiatric treatments often fail), allow a medical professional to hold their hand through their final moments.”

A psychiatrist described very ill patients with treatment-resistant bipolar disorder who had not only received medications, including ketamine, but had also received electroconvulsive therapy and still did not respond.

“Their suffering is enormous and the truth is that there is no improvement for more than a few days or weeks and later they return to their hell. Appreciating that they would be better off dead for themselves and their families is not always a cognitive distortion but an objective evaluation of their reality.”

However, as another reader pointed out, an issue with the argument presented here is that it presupposes that MAID requires “clinical justification.” But in Canada, “MAID ... is understood as an expression of personal autonomy. Rooted in liberal political philosophy of individualism ... approval for death need not be based on a clinical assessment.” Instead, “death is seen as a ‘right’ that the state must therefore provide.”
 

Another form of eugenics?

Dr. Miller raised the ethical implications of racial and socioeconomic factors playing a role in the consideration of MAID for those with psychiatric illness.

“Might those who are poor, who have less access to expensive treatment options and social support, be more likely to request facilitated death?” she asks. “Do we risk facilitating a patient’s demise when other options are unavailable because of a lack of access to treatment or when social and financial struggles exacerbate a person’s hopelessness? Should we worry that psychiatric euthanasia will turn into a form of eugenics where those who can’t contribute are made to feel that they should bow out?”

Several readers agreed. “Looking at the disproportionate burden of illness, rates of imprisonment, and application of the death penalty indicates to me that race and socioeconomic status will be an immediate factor in how, where, and with whom MAID for mental illness would be practice in much, if not all, of the U.S.,” wrote one physician.

A Canadian reader expressed similar concerns. “I’ve seen a handful of people, including someone I considered a good friend, opt for MAID because it was easier than living as a disabled person in poverty without adequate mental health care.”

Another Canadian clinician noted that offering people good care can make all the difference. “As a Canadian mental health clinician who served youth with severe mental illness for over 20 years through our socialized medical network, I can attest to the difference good care usually makes in shifting clients from despair and a commitment to death to embracing life once again. Let’s not, as clinicians, embrace easing a government/state-sanctioned pathway to death.”

Some readers believe that these types of issues can’t be solved with a blanket approach, noting that each case is different. “Real life is always more complicated than academic discussions. Having served on a hospital ethics committee, I know that each case is unique,” one reader noted.

Another reader added, “I think all we can do as physicians is to let people decide for themselves and participate only if our conscience allows.”
 

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

One of the most controversial issues today is whether a physician should be permitted, or even obligated, to assist patients with a terminal or incurable illness to end their life – a process known as medical assistance in dying (MAID) or physician-assisted suicide (PAS.)

Until recently, this contentious issue applied only to patients with physical illnesses who want to end their suffering and who seek out a physician willing to assist with that objective. In the United States and other countries, this is the patient population who may be able to avail themselves of this option.

However, newly proposed legislation in Canada – which has the largest number of physician-assisted deaths worldwide – would expand the indication for MAID to include serious mental illness. Originally set to be passed in March 2023, the law has been deferred for final decision until March 2024.

A recent commentary by psychiatrist Dinah Miller, MD, explored the ethics of this proposed legislation for mental health professionals. “To offer the option of death facilitated by the very person who is trying to get [patients with serious mental illness] better seems so counter to everything I have learned and contradicts our role as psychiatrists who work so hard to prevent suicide,” Dr. Miller wrote. “As psychiatrists, do we offer hope to our most vulnerable patients, or do we offer death? Do we rail against suicide, or do we facilitate it?”

Dr. Miller’s piece garnered a huge amount of reader response that included many laudatory comments: a “nuanced and open-ended inquiry here,” “timely and honest,” and “beautifully written.” One reader thanked the author for “this thoughtful, questioning, and open reflection on what it means to be a psychiatrist facing a thorny and deeply personal practice and philosophical question.”
 

Cognitive distortion or objective reality?

Many readers were opposed to any type of physician involvement in hastening a patient’s death, regardless of whether the condition is medical or psychiatric. “Let others who wish to die make their own arrangement without the aid of the medical profession,” one reader wrote.

But others felt that for those with terminal physical illnesses or intractable pain, it is justified for medical professionals to either facilitate death or, at the very least, withhold life-prolonging treatments.

A critical-care physician described responding to families’ accusations that withdrawal of life-sustaining measures means “playing God.” On the contrary, the physician wrote, “there is a limit to our abilities; and withdrawing those life-prolonging interventions allows nature or God or whatever to play a role and take its course.”

Another U.S. reader pointed out that “multiple polls in this country have shown that the majority of the general public, physicians in general and psychiatrists in particular, support the option of MAID for the terminally ill. They do not find it at variance with their calling as physicians.”

“I and many of my elderly friends don’t fear death but fear prolonged dementia with its dependency and lack of quality of life,” one reader wrote. “We would be much more at peace if we could put in our advanced directive that we request MAID once some point of dependency has been reached.”

Another wrote that in the event of entering a state of “degrading dependency and hardship on the family, please let me go peacefully, without burdening others, into that good night [of death].”

Many felt that not only physical illness but also the prospect of cognitive degeneration – specifically dementia – also justifies assisting patient death.
 

“Enormous suffering”

One Canadian reader noted that provisions for advance consent are now in place in Canada for those facing the prospect of neurodegenerative disease and who are still mentally competent to make such decisions.

But therein lies the rub – the concept of an advanced directive goes to the question of decisional capacity. Dr. Miller noted that “depression distorts cognition and leads many patients to believe that they would be better off dead and that their loves ones would be better off without them.”

The concept of “cognitive distortion” implies that the illness itself may impede the decisional capacity required for an advanced directive or a decision made in the moment, in the absence of such a directive. Dr. Miller asked, “How do we determine whether patients with serious mental illness are competent to make such a decision or whether it is mental illness that is driving their perception of a future without hope?”

One reader attested to this from personal experience. “As both a physician and a sufferer of severe, often profound depression for 50 years, I can confidently say that ... the pursuit of death is the result of an impaired mental state, which simultaneously prevents a rational decision.”

Another agreed. “As a psychiatrist, I treated suicidal patients almost every day of my 27-year career. I believe in making every effort to prevent the suicide of a healthy depressed person and I do not support MAID for psychiatric conditions. But I do support MAID for the terminally ill.”

Other readers disagreed. In the words of one commentator, “I think that if we are going to help mentally ill people, we have to consider their choices. The stress imposed by a severe/intractable mental illness is as bad as any other devastating medical illness. If no one is going to hold their hand in life (as support services are limited and psychiatric treatments often fail), allow a medical professional to hold their hand through their final moments.”

A psychiatrist described very ill patients with treatment-resistant bipolar disorder who had not only received medications, including ketamine, but had also received electroconvulsive therapy and still did not respond.

“Their suffering is enormous and the truth is that there is no improvement for more than a few days or weeks and later they return to their hell. Appreciating that they would be better off dead for themselves and their families is not always a cognitive distortion but an objective evaluation of their reality.”

However, as another reader pointed out, an issue with the argument presented here is that it presupposes that MAID requires “clinical justification.” But in Canada, “MAID ... is understood as an expression of personal autonomy. Rooted in liberal political philosophy of individualism ... approval for death need not be based on a clinical assessment.” Instead, “death is seen as a ‘right’ that the state must therefore provide.”
 

Another form of eugenics?

Dr. Miller raised the ethical implications of racial and socioeconomic factors playing a role in the consideration of MAID for those with psychiatric illness.

“Might those who are poor, who have less access to expensive treatment options and social support, be more likely to request facilitated death?” she asks. “Do we risk facilitating a patient’s demise when other options are unavailable because of a lack of access to treatment or when social and financial struggles exacerbate a person’s hopelessness? Should we worry that psychiatric euthanasia will turn into a form of eugenics where those who can’t contribute are made to feel that they should bow out?”

Several readers agreed. “Looking at the disproportionate burden of illness, rates of imprisonment, and application of the death penalty indicates to me that race and socioeconomic status will be an immediate factor in how, where, and with whom MAID for mental illness would be practice in much, if not all, of the U.S.,” wrote one physician.

A Canadian reader expressed similar concerns. “I’ve seen a handful of people, including someone I considered a good friend, opt for MAID because it was easier than living as a disabled person in poverty without adequate mental health care.”

Another Canadian clinician noted that offering people good care can make all the difference. “As a Canadian mental health clinician who served youth with severe mental illness for over 20 years through our socialized medical network, I can attest to the difference good care usually makes in shifting clients from despair and a commitment to death to embracing life once again. Let’s not, as clinicians, embrace easing a government/state-sanctioned pathway to death.”

Some readers believe that these types of issues can’t be solved with a blanket approach, noting that each case is different. “Real life is always more complicated than academic discussions. Having served on a hospital ethics committee, I know that each case is unique,” one reader noted.

Another reader added, “I think all we can do as physicians is to let people decide for themselves and participate only if our conscience allows.”
 

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

More than 3 years into the COVID-19 era, most Americans have settled back into their prepandemic lifestyles. But a new dominant variant and rising hospitalization numbers may give way to another summer surge.

Since April, a new COVID variant has cropped up. According to recent Centers for Disease Control and Prevention data, EG.5 – from the Omicron family – now makes up 17% of all cases in the United States, up from 7.5% in the first week of July. 

A summary from the Center for Infectious Disease Research and Policy at the University of Minnesota says that EG.5, nicknamed “Eris” by health trackers, is nearly the same as its parent strain, XBB.1.9.2, but has one extra spike mutation. 

Along with the news of EG.5’s growing prevalence, COVID-related hospitalization rates have increased by 12.5% during the week ending on July 29 – the most significant uptick since December. Still, no connection has been made between the new variant and rising hospital admissions. And so far, experts have found no difference in the severity of illness or symptoms between Eris and the strains that came before it.
 

Cause for concern?

The COVID virus has a great tendency to mutate, said William Schaffner, MD, a professor of infectious diseases at Vanderbilt University, Nashville, Tenn. 

“Fortunately, these are relatively minor mutations.” Even so, SARS-CoV-2, the virus that causes COVID-19, continues to be highly contagious. “There isn’t any doubt that it’s spreading – but it’s not more serious.”

So, Dr. Schaffner doesn’t think it’s time to panic. He prefers calling it an “uptick” in cases instead of a “surge,” because a surge “sounds too big.”

While the numbers are still low, compared with 2022’s summer surge, experts still urge people to stay aware of changes in the virus. “I do not think that there is any cause for alarm,” agreed Bernard Camins, MD, an infectious disease specialist at Mount Sinai Hospital, New York.

So why the higher number of cases? “There has been an increase in COVID cases this summer, probably related to travel, socializing, and dwindling masking,” said Anne Liu, MD, an allergy, immunology, and infectious disease specialist at Stanford (Calif.) University. Even so, “because of an existing level of immunity from vaccination and prior infections, it has been limited and case severity has been lower than in prior surges.”
 

What the official numbers say

The CDC no longer updates its COVID Data Tracker Weekly Review. They stopped in May 2023 when the federal public health emergency ended.

But the agency continues to track COVID-19 cases, hospitalizations, ED visits, and deaths in different ways. The key takeaways include 9,056 new hospitalizations reported for the week ending July 29, 2023. That is relatively low, compared with July 30, 2022, when the weekly new hospitalization numbers topped 44,000. 

“Last year, we saw a summer wave with cases peaking around mid-July. In that sense, our summer wave is coming a bit later than last year,” said Pavitra Roychoudhury, PhD, an assistant professor and researcher in the vaccine and infectious disease division at the University of Washington, Seattle. 

“It’s unclear how high the peak will be during this current wave. Levels of SARS-CoV-2 in wastewater, as well as the number of hospitalizations, are currently lower than this time last year.” 

For part of the pandemic, the CDC recommended people monitor COVID numbers in their own communities. But the agency’s local guidance on COVID is tied to hospital admission levels, which are currently low for more than 99% of the country, even if they are increasing. 

So, while it’s good news that hospitalization numbers are smaller, it means the agency’s ability to identify local outbreaks or hot spots of SARS-CoV-2 is now more limited. 

It’s not just an uptick in hospitalizations nationwide, as other COVID-19 indicators, including ED visits, positive tests, and wastewater levels, are increasing across the United States. 

In terms of other metrics: 

• On June 19, 0.47% of ED visits resulted in a positive COVID diagnosis. On Aug. 4, that rate had more than doubled to 1.1%. 
• On July 29, 8.9% of people who took a COVID test reported a positive result. The positivity rate has been increasing since June 10, when 4.1% of tests came back positive. This figure only includes test results reported to the CDC. Results of home testing remain largely unknown. 
• The weekly percentage of deaths related to COVID-19 was 1% as of July 29. That’s low, compared with previous rates. For example, for the week ending July 30, 2022, it was 5.8%.

What about new COVID vaccines?

As long as the general public continue to make informed decisions and get the new Omicron vaccine or booster once it’s available, experts predict lower hospitalization rates this winter. 

“Everyone should get the Omicron booster when it becomes available,” recommended Dean Winslow, MD, a professor of medicine at Stanford University. 

In the meantime, “it is important to emphasize that COVID-19 is going to be with us for the foreseeable future,” he said. Since the symptoms linked to these newer Omicron subvariants are generally milder than with earlier variants, “if one has even mild cold symptoms, it is a good idea to test yourself for COVID-19 and start treatment early if one is elderly or otherwise at high risk for severe disease.”

Dr. Schaffner remains optimistic for now. “We anticipate that the vaccines we currently have available, and certainly the vaccine that is being developed for this fall, will continue to prevent severe disease associated with this virus.”

Although it’s difficult to predict an exact time line, Dr. Schaffner said they could be available by the end of September. 

His predictions assume “that we don’t have a new nasty variant that crops up somewhere in the world,” he said. “[If] things continue to move the way they have been, we anticipate that this vaccine ... will be really effective and help us keep out of the hospital during this winter, when we expect more of an increase of COVID once again.” 

Asked for his outlook on vaccine recommendations, Dr. Camins was less certain. “It is too soon to tell.” Guidance on COVID shots will be based on results of ongoing studies. “It would be prudent, however, for everyone to plan on getting the flu shot in September.”

Stay alert and stay realistic

Cautious optimism and a call to remain vigilant seem like the consensus at the moment. While the numbers remain low so far and the uptick in new cases and hospitalizations are relatively small, compared with past scenarios, “it makes sense to boost our anti-Omicron antibody levels with immunizations before fall and winter,” Dr. Liu said. 

“It’s just advisable for everyone – especially those who are at higher risk for hospitalization or death – to be aware,” Dr. Camins said, “so they can form their own decisions to participate in activities that may put them at risk for contracting COVID-19.”

While respiratory virus work best at keeping people with the flu, COVID, or RSV out of the hospital, they’re not as good at preventing milder infections. Dr. Schaffner said: “If we don’t expect perfection, we won’t be so disappointed.”

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

More than 3 years into the COVID-19 era, most Americans have settled back into their prepandemic lifestyles. But a new dominant variant and rising hospitalization numbers may give way to another summer surge.

Since April, a new COVID variant has cropped up. According to recent Centers for Disease Control and Prevention data, EG.5 – from the Omicron family – now makes up 17% of all cases in the United States, up from 7.5% in the first week of July. 

A summary from the Center for Infectious Disease Research and Policy at the University of Minnesota says that EG.5, nicknamed “Eris” by health trackers, is nearly the same as its parent strain, XBB.1.9.2, but has one extra spike mutation. 

Along with the news of EG.5’s growing prevalence, COVID-related hospitalization rates have increased by 12.5% during the week ending on July 29 – the most significant uptick since December. Still, no connection has been made between the new variant and rising hospital admissions. And so far, experts have found no difference in the severity of illness or symptoms between Eris and the strains that came before it.
 

Cause for concern?

The COVID virus has a great tendency to mutate, said William Schaffner, MD, a professor of infectious diseases at Vanderbilt University, Nashville, Tenn. 

“Fortunately, these are relatively minor mutations.” Even so, SARS-CoV-2, the virus that causes COVID-19, continues to be highly contagious. “There isn’t any doubt that it’s spreading – but it’s not more serious.”

So, Dr. Schaffner doesn’t think it’s time to panic. He prefers calling it an “uptick” in cases instead of a “surge,” because a surge “sounds too big.”

While the numbers are still low, compared with 2022’s summer surge, experts still urge people to stay aware of changes in the virus. “I do not think that there is any cause for alarm,” agreed Bernard Camins, MD, an infectious disease specialist at Mount Sinai Hospital, New York.

So why the higher number of cases? “There has been an increase in COVID cases this summer, probably related to travel, socializing, and dwindling masking,” said Anne Liu, MD, an allergy, immunology, and infectious disease specialist at Stanford (Calif.) University. Even so, “because of an existing level of immunity from vaccination and prior infections, it has been limited and case severity has been lower than in prior surges.”
 

What the official numbers say

The CDC no longer updates its COVID Data Tracker Weekly Review. They stopped in May 2023 when the federal public health emergency ended.

But the agency continues to track COVID-19 cases, hospitalizations, ED visits, and deaths in different ways. The key takeaways include 9,056 new hospitalizations reported for the week ending July 29, 2023. That is relatively low, compared with July 30, 2022, when the weekly new hospitalization numbers topped 44,000. 

“Last year, we saw a summer wave with cases peaking around mid-July. In that sense, our summer wave is coming a bit later than last year,” said Pavitra Roychoudhury, PhD, an assistant professor and researcher in the vaccine and infectious disease division at the University of Washington, Seattle. 

“It’s unclear how high the peak will be during this current wave. Levels of SARS-CoV-2 in wastewater, as well as the number of hospitalizations, are currently lower than this time last year.” 

For part of the pandemic, the CDC recommended people monitor COVID numbers in their own communities. But the agency’s local guidance on COVID is tied to hospital admission levels, which are currently low for more than 99% of the country, even if they are increasing. 

So, while it’s good news that hospitalization numbers are smaller, it means the agency’s ability to identify local outbreaks or hot spots of SARS-CoV-2 is now more limited. 

It’s not just an uptick in hospitalizations nationwide, as other COVID-19 indicators, including ED visits, positive tests, and wastewater levels, are increasing across the United States. 

In terms of other metrics: 

• On June 19, 0.47% of ED visits resulted in a positive COVID diagnosis. On Aug. 4, that rate had more than doubled to 1.1%. 
• On July 29, 8.9% of people who took a COVID test reported a positive result. The positivity rate has been increasing since June 10, when 4.1% of tests came back positive. This figure only includes test results reported to the CDC. Results of home testing remain largely unknown. 
• The weekly percentage of deaths related to COVID-19 was 1% as of July 29. That’s low, compared with previous rates. For example, for the week ending July 30, 2022, it was 5.8%.

What about new COVID vaccines?

As long as the general public continue to make informed decisions and get the new Omicron vaccine or booster once it’s available, experts predict lower hospitalization rates this winter. 

“Everyone should get the Omicron booster when it becomes available,” recommended Dean Winslow, MD, a professor of medicine at Stanford University. 

In the meantime, “it is important to emphasize that COVID-19 is going to be with us for the foreseeable future,” he said. Since the symptoms linked to these newer Omicron subvariants are generally milder than with earlier variants, “if one has even mild cold symptoms, it is a good idea to test yourself for COVID-19 and start treatment early if one is elderly or otherwise at high risk for severe disease.”

Dr. Schaffner remains optimistic for now. “We anticipate that the vaccines we currently have available, and certainly the vaccine that is being developed for this fall, will continue to prevent severe disease associated with this virus.”

Although it’s difficult to predict an exact time line, Dr. Schaffner said they could be available by the end of September. 

His predictions assume “that we don’t have a new nasty variant that crops up somewhere in the world,” he said. “[If] things continue to move the way they have been, we anticipate that this vaccine ... will be really effective and help us keep out of the hospital during this winter, when we expect more of an increase of COVID once again.” 

Asked for his outlook on vaccine recommendations, Dr. Camins was less certain. “It is too soon to tell.” Guidance on COVID shots will be based on results of ongoing studies. “It would be prudent, however, for everyone to plan on getting the flu shot in September.”

Stay alert and stay realistic

Cautious optimism and a call to remain vigilant seem like the consensus at the moment. While the numbers remain low so far and the uptick in new cases and hospitalizations are relatively small, compared with past scenarios, “it makes sense to boost our anti-Omicron antibody levels with immunizations before fall and winter,” Dr. Liu said. 

“It’s just advisable for everyone – especially those who are at higher risk for hospitalization or death – to be aware,” Dr. Camins said, “so they can form their own decisions to participate in activities that may put them at risk for contracting COVID-19.”

While respiratory virus work best at keeping people with the flu, COVID, or RSV out of the hospital, they’re not as good at preventing milder infections. Dr. Schaffner said: “If we don’t expect perfection, we won’t be so disappointed.”

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

More than 3 years into the COVID-19 era, most Americans have settled back into their prepandemic lifestyles. But a new dominant variant and rising hospitalization numbers may give way to another summer surge.

Since April, a new COVID variant has cropped up. According to recent Centers for Disease Control and Prevention data, EG.5 – from the Omicron family – now makes up 17% of all cases in the United States, up from 7.5% in the first week of July. 

A summary from the Center for Infectious Disease Research and Policy at the University of Minnesota says that EG.5, nicknamed “Eris” by health trackers, is nearly the same as its parent strain, XBB.1.9.2, but has one extra spike mutation. 

Along with the news of EG.5’s growing prevalence, COVID-related hospitalization rates have increased by 12.5% during the week ending on July 29 – the most significant uptick since December. Still, no connection has been made between the new variant and rising hospital admissions. And so far, experts have found no difference in the severity of illness or symptoms between Eris and the strains that came before it.
 

Cause for concern?

The COVID virus has a great tendency to mutate, said William Schaffner, MD, a professor of infectious diseases at Vanderbilt University, Nashville, Tenn. 

“Fortunately, these are relatively minor mutations.” Even so, SARS-CoV-2, the virus that causes COVID-19, continues to be highly contagious. “There isn’t any doubt that it’s spreading – but it’s not more serious.”

So, Dr. Schaffner doesn’t think it’s time to panic. He prefers calling it an “uptick” in cases instead of a “surge,” because a surge “sounds too big.”

While the numbers are still low, compared with 2022’s summer surge, experts still urge people to stay aware of changes in the virus. “I do not think that there is any cause for alarm,” agreed Bernard Camins, MD, an infectious disease specialist at Mount Sinai Hospital, New York.

So why the higher number of cases? “There has been an increase in COVID cases this summer, probably related to travel, socializing, and dwindling masking,” said Anne Liu, MD, an allergy, immunology, and infectious disease specialist at Stanford (Calif.) University. Even so, “because of an existing level of immunity from vaccination and prior infections, it has been limited and case severity has been lower than in prior surges.”
 

What the official numbers say

The CDC no longer updates its COVID Data Tracker Weekly Review. They stopped in May 2023 when the federal public health emergency ended.

But the agency continues to track COVID-19 cases, hospitalizations, ED visits, and deaths in different ways. The key takeaways include 9,056 new hospitalizations reported for the week ending July 29, 2023. That is relatively low, compared with July 30, 2022, when the weekly new hospitalization numbers topped 44,000. 

“Last year, we saw a summer wave with cases peaking around mid-July. In that sense, our summer wave is coming a bit later than last year,” said Pavitra Roychoudhury, PhD, an assistant professor and researcher in the vaccine and infectious disease division at the University of Washington, Seattle. 

“It’s unclear how high the peak will be during this current wave. Levels of SARS-CoV-2 in wastewater, as well as the number of hospitalizations, are currently lower than this time last year.” 

For part of the pandemic, the CDC recommended people monitor COVID numbers in their own communities. But the agency’s local guidance on COVID is tied to hospital admission levels, which are currently low for more than 99% of the country, even if they are increasing. 

So, while it’s good news that hospitalization numbers are smaller, it means the agency’s ability to identify local outbreaks or hot spots of SARS-CoV-2 is now more limited. 

It’s not just an uptick in hospitalizations nationwide, as other COVID-19 indicators, including ED visits, positive tests, and wastewater levels, are increasing across the United States. 

In terms of other metrics: 

• On June 19, 0.47% of ED visits resulted in a positive COVID diagnosis. On Aug. 4, that rate had more than doubled to 1.1%. 
• On July 29, 8.9% of people who took a COVID test reported a positive result. The positivity rate has been increasing since June 10, when 4.1% of tests came back positive. This figure only includes test results reported to the CDC. Results of home testing remain largely unknown. 
• The weekly percentage of deaths related to COVID-19 was 1% as of July 29. That’s low, compared with previous rates. For example, for the week ending July 30, 2022, it was 5.8%.

What about new COVID vaccines?

As long as the general public continue to make informed decisions and get the new Omicron vaccine or booster once it’s available, experts predict lower hospitalization rates this winter. 

“Everyone should get the Omicron booster when it becomes available,” recommended Dean Winslow, MD, a professor of medicine at Stanford University. 

In the meantime, “it is important to emphasize that COVID-19 is going to be with us for the foreseeable future,” he said. Since the symptoms linked to these newer Omicron subvariants are generally milder than with earlier variants, “if one has even mild cold symptoms, it is a good idea to test yourself for COVID-19 and start treatment early if one is elderly or otherwise at high risk for severe disease.”

Dr. Schaffner remains optimistic for now. “We anticipate that the vaccines we currently have available, and certainly the vaccine that is being developed for this fall, will continue to prevent severe disease associated with this virus.”

Although it’s difficult to predict an exact time line, Dr. Schaffner said they could be available by the end of September. 

His predictions assume “that we don’t have a new nasty variant that crops up somewhere in the world,” he said. “[If] things continue to move the way they have been, we anticipate that this vaccine ... will be really effective and help us keep out of the hospital during this winter, when we expect more of an increase of COVID once again.” 

Asked for his outlook on vaccine recommendations, Dr. Camins was less certain. “It is too soon to tell.” Guidance on COVID shots will be based on results of ongoing studies. “It would be prudent, however, for everyone to plan on getting the flu shot in September.”

Stay alert and stay realistic

Cautious optimism and a call to remain vigilant seem like the consensus at the moment. While the numbers remain low so far and the uptick in new cases and hospitalizations are relatively small, compared with past scenarios, “it makes sense to boost our anti-Omicron antibody levels with immunizations before fall and winter,” Dr. Liu said. 

“It’s just advisable for everyone – especially those who are at higher risk for hospitalization or death – to be aware,” Dr. Camins said, “so they can form their own decisions to participate in activities that may put them at risk for contracting COVID-19.”

While respiratory virus work best at keeping people with the flu, COVID, or RSV out of the hospital, they’re not as good at preventing milder infections. Dr. Schaffner said: “If we don’t expect perfection, we won’t be so disappointed.”

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

A new predictive tool known as the Psoriatic Arthritis Risk Estimation Tool (PRESTO) is now available to help clinicians estimate the risk of psoriatic arthritis (PsA) in their patients with psoriasis.

Though it requires further validation, researchers led by rheumatologist Lihi Eder, MD, PhD, of the Women’s College Research Institute at Women’s College Hospital, Toronto, characterized the development and validation of PRESTO as “an important first step in the development and testing of interventional strategies that may ultimately halt disease progression,” they wrote in their study of the tool, which published in Arthritis & Rheumatology. Dr. Eder presented a summary of progress on the effort at the 2023 annual meeting of the Canadian Rheumatology Association.

To develop and validate the tool, the researchers evaluated 635 patients from the University of Toronto Psoriasis Cohort, which was launched in 2006 as a prospective longitudinal cohort study to examine risk factors for the development of PsA among patients with psoriasis. Patients enrolled in the cohort have a dermatologist-confirmed diagnosis of psoriasis and are assessed by a rheumatologist prior to enrollment to exclude those with inflammatory arthritis in the past or at the time of assessment.

To develop prediction models for PsA, Dr. Eder and colleagues used information from the patient cohort demographics, psoriasis characteristics, comorbidities, medications, and musculoskeletal symptoms. Next, they used multivariable logistic regression models adjusting for covariates, duration of psoriasis, and the log duration at risk to estimate the probability of developing PsA within 1-year and 5-year time windows from consecutive study visits.

The mean age of the study participants was 47 years, 76% were White, and 57% were male; and they had psoriasis for a mean of 16 years. The researchers found that 51 patients developed PsA during the 1-year follow-up, and 71 developed PsA during the 5-year follow-up. The risk of developing PsA within 1 year was associated with younger age, male sex, family history of psoriasis, back stiffness, nail pitting, joint stiffness, use of biologic medications, patient global health, and pain severity (area under the curve, 72.3).

In addition, the risk of developing PsA within 5 years was associated with morning stiffness, psoriatic nail lesions, psoriasis severity, fatigue, pain, and use of systemic non-biologic medication or phototherapy (AUC, 74.9). Calibration plots showed reasonable agreement between predicted and observed probabilities.

“Interestingly, several previously reported risk factors for PsA, such as HLA-B27, family history of PsA, uveitis, and flexural psoriasis, were not included in the risk prediction model due to their scarcity in our cohort,” the researchers wrote. “This finding may be due to immortal time bias which can complicate the development of risk prediction models for PsA. Genetic factors or their surrogates (e.g., family history of PsA) are associated with the development of PsA concurrently or shortly after the onset of psoriasis.”

They acknowledged certain limitations of the study, including its relatively small sample size and questionable generalizability of the study findings, “as most of the patients were recruited from dermatology clinics leading to overrepresentation of moderate-severe psoriasis. Therefore, PRESTO will require an external validation to assess its performance in other populations of psoriasis patients with different characteristics.”

Saakshi Khattri, MD, a board-certified dermatologist, rheumatologist, and internist at the Icahn School of Medicine at Mount Sinai, New York, who was not involved in the study and was asked to comment on the results, characterized the PRESTO tool as “an interesting step in the right direction, but it’s the first step.”

courtesy Dr. Saakshi Khattri

Since dermatologists are usually the first point of contact for psoriasis patients, she added, “a risk calculator can be helpful, but the question remains: When do we refer them to a rheumatologist? If the risk comes to 5%, is that a low risk that doesn’t need referral to rheumatology? I don’t think those questions have been answered here. From a rheumatology perspective, does the risk calculator help me decide when to intervene? At present, I’m not sure it does. Perhaps a higher score might make us intervene sooner if our clinical exam doesn’t show swollen or tender joints.”

Clinical exam findings and history she considers as a rheumatologist before making treatment recommendations include the following: Are there swollen and tender joints? Does the patient report morning stiffness for upwards of 30 minutes? Do they have enthesitis or dactylitis? Is there axial involvement? “Imaging can help if there isn’t anything on clinical exam and the history is compelling and/or the patient has risk factors for PsA,” she said.

The study’s finding of biologic use being associated with risk of developing PsA at year 1 but not at year 5 is “confusing,” Dr. Khattri added. “My concern is, will that now dissuade our moderate to severe psoriasis patients from using biologics to clear their psoriasis? We know that biologics are indicated for moderate to severe psoriasis. We also know psoriasis is associated with increased cardiovascular risk and there’s data to suggest that treatment with biologics with its resultant decrease in systemic inflammation can decrease cardiovascular risk.”

The study was supported by a New Investigator Grant from the Physician Services Incorporated Foundation. Dr. Eder disclosed that she is supported by the Canada Research Chair in Inflammatory Rheumatic Diseases. Dr. Khattri reported that she is a member of the advisory board for UCB, Janssen, AbbVie, Regeneron, Sanofi, Lilly, Argenx, and Arcutis. She has also received research funds from Incyte, AbbVie, Leo, Galderma, Pfizer, and Acelyrin.

A new predictive tool known as the Psoriatic Arthritis Risk Estimation Tool (PRESTO) is now available to help clinicians estimate the risk of psoriatic arthritis (PsA) in their patients with psoriasis.

Though it requires further validation, researchers led by rheumatologist Lihi Eder, MD, PhD, of the Women’s College Research Institute at Women’s College Hospital, Toronto, characterized the development and validation of PRESTO as “an important first step in the development and testing of interventional strategies that may ultimately halt disease progression,” they wrote in their study of the tool, which published in Arthritis & Rheumatology. Dr. Eder presented a summary of progress on the effort at the 2023 annual meeting of the Canadian Rheumatology Association.

To develop and validate the tool, the researchers evaluated 635 patients from the University of Toronto Psoriasis Cohort, which was launched in 2006 as a prospective longitudinal cohort study to examine risk factors for the development of PsA among patients with psoriasis. Patients enrolled in the cohort have a dermatologist-confirmed diagnosis of psoriasis and are assessed by a rheumatologist prior to enrollment to exclude those with inflammatory arthritis in the past or at the time of assessment.

To develop prediction models for PsA, Dr. Eder and colleagues used information from the patient cohort demographics, psoriasis characteristics, comorbidities, medications, and musculoskeletal symptoms. Next, they used multivariable logistic regression models adjusting for covariates, duration of psoriasis, and the log duration at risk to estimate the probability of developing PsA within 1-year and 5-year time windows from consecutive study visits.

The mean age of the study participants was 47 years, 76% were White, and 57% were male; and they had psoriasis for a mean of 16 years. The researchers found that 51 patients developed PsA during the 1-year follow-up, and 71 developed PsA during the 5-year follow-up. The risk of developing PsA within 1 year was associated with younger age, male sex, family history of psoriasis, back stiffness, nail pitting, joint stiffness, use of biologic medications, patient global health, and pain severity (area under the curve, 72.3).

In addition, the risk of developing PsA within 5 years was associated with morning stiffness, psoriatic nail lesions, psoriasis severity, fatigue, pain, and use of systemic non-biologic medication or phototherapy (AUC, 74.9). Calibration plots showed reasonable agreement between predicted and observed probabilities.

“Interestingly, several previously reported risk factors for PsA, such as HLA-B27, family history of PsA, uveitis, and flexural psoriasis, were not included in the risk prediction model due to their scarcity in our cohort,” the researchers wrote. “This finding may be due to immortal time bias which can complicate the development of risk prediction models for PsA. Genetic factors or their surrogates (e.g., family history of PsA) are associated with the development of PsA concurrently or shortly after the onset of psoriasis.”

They acknowledged certain limitations of the study, including its relatively small sample size and questionable generalizability of the study findings, “as most of the patients were recruited from dermatology clinics leading to overrepresentation of moderate-severe psoriasis. Therefore, PRESTO will require an external validation to assess its performance in other populations of psoriasis patients with different characteristics.”

Saakshi Khattri, MD, a board-certified dermatologist, rheumatologist, and internist at the Icahn School of Medicine at Mount Sinai, New York, who was not involved in the study and was asked to comment on the results, characterized the PRESTO tool as “an interesting step in the right direction, but it’s the first step.”

courtesy Dr. Saakshi Khattri

Since dermatologists are usually the first point of contact for psoriasis patients, she added, “a risk calculator can be helpful, but the question remains: When do we refer them to a rheumatologist? If the risk comes to 5%, is that a low risk that doesn’t need referral to rheumatology? I don’t think those questions have been answered here. From a rheumatology perspective, does the risk calculator help me decide when to intervene? At present, I’m not sure it does. Perhaps a higher score might make us intervene sooner if our clinical exam doesn’t show swollen or tender joints.”

Clinical exam findings and history she considers as a rheumatologist before making treatment recommendations include the following: Are there swollen and tender joints? Does the patient report morning stiffness for upwards of 30 minutes? Do they have enthesitis or dactylitis? Is there axial involvement? “Imaging can help if there isn’t anything on clinical exam and the history is compelling and/or the patient has risk factors for PsA,” she said.

The study’s finding of biologic use being associated with risk of developing PsA at year 1 but not at year 5 is “confusing,” Dr. Khattri added. “My concern is, will that now dissuade our moderate to severe psoriasis patients from using biologics to clear their psoriasis? We know that biologics are indicated for moderate to severe psoriasis. We also know psoriasis is associated with increased cardiovascular risk and there’s data to suggest that treatment with biologics with its resultant decrease in systemic inflammation can decrease cardiovascular risk.”

The study was supported by a New Investigator Grant from the Physician Services Incorporated Foundation. Dr. Eder disclosed that she is supported by the Canada Research Chair in Inflammatory Rheumatic Diseases. Dr. Khattri reported that she is a member of the advisory board for UCB, Janssen, AbbVie, Regeneron, Sanofi, Lilly, Argenx, and Arcutis. She has also received research funds from Incyte, AbbVie, Leo, Galderma, Pfizer, and Acelyrin.

A new predictive tool known as the Psoriatic Arthritis Risk Estimation Tool (PRESTO) is now available to help clinicians estimate the risk of psoriatic arthritis (PsA) in their patients with psoriasis.

Though it requires further validation, researchers led by rheumatologist Lihi Eder, MD, PhD, of the Women’s College Research Institute at Women’s College Hospital, Toronto, characterized the development and validation of PRESTO as “an important first step in the development and testing of interventional strategies that may ultimately halt disease progression,” they wrote in their study of the tool, which published in Arthritis & Rheumatology. Dr. Eder presented a summary of progress on the effort at the 2023 annual meeting of the Canadian Rheumatology Association.

To develop and validate the tool, the researchers evaluated 635 patients from the University of Toronto Psoriasis Cohort, which was launched in 2006 as a prospective longitudinal cohort study to examine risk factors for the development of PsA among patients with psoriasis. Patients enrolled in the cohort have a dermatologist-confirmed diagnosis of psoriasis and are assessed by a rheumatologist prior to enrollment to exclude those with inflammatory arthritis in the past or at the time of assessment.

To develop prediction models for PsA, Dr. Eder and colleagues used information from the patient cohort demographics, psoriasis characteristics, comorbidities, medications, and musculoskeletal symptoms. Next, they used multivariable logistic regression models adjusting for covariates, duration of psoriasis, and the log duration at risk to estimate the probability of developing PsA within 1-year and 5-year time windows from consecutive study visits.

The mean age of the study participants was 47 years, 76% were White, and 57% were male; and they had psoriasis for a mean of 16 years. The researchers found that 51 patients developed PsA during the 1-year follow-up, and 71 developed PsA during the 5-year follow-up. The risk of developing PsA within 1 year was associated with younger age, male sex, family history of psoriasis, back stiffness, nail pitting, joint stiffness, use of biologic medications, patient global health, and pain severity (area under the curve, 72.3).

In addition, the risk of developing PsA within 5 years was associated with morning stiffness, psoriatic nail lesions, psoriasis severity, fatigue, pain, and use of systemic non-biologic medication or phototherapy (AUC, 74.9). Calibration plots showed reasonable agreement between predicted and observed probabilities.

“Interestingly, several previously reported risk factors for PsA, such as HLA-B27, family history of PsA, uveitis, and flexural psoriasis, were not included in the risk prediction model due to their scarcity in our cohort,” the researchers wrote. “This finding may be due to immortal time bias which can complicate the development of risk prediction models for PsA. Genetic factors or their surrogates (e.g., family history of PsA) are associated with the development of PsA concurrently or shortly after the onset of psoriasis.”

They acknowledged certain limitations of the study, including its relatively small sample size and questionable generalizability of the study findings, “as most of the patients were recruited from dermatology clinics leading to overrepresentation of moderate-severe psoriasis. Therefore, PRESTO will require an external validation to assess its performance in other populations of psoriasis patients with different characteristics.”

Saakshi Khattri, MD, a board-certified dermatologist, rheumatologist, and internist at the Icahn School of Medicine at Mount Sinai, New York, who was not involved in the study and was asked to comment on the results, characterized the PRESTO tool as “an interesting step in the right direction, but it’s the first step.”

courtesy Dr. Saakshi Khattri

Since dermatologists are usually the first point of contact for psoriasis patients, she added, “a risk calculator can be helpful, but the question remains: When do we refer them to a rheumatologist? If the risk comes to 5%, is that a low risk that doesn’t need referral to rheumatology? I don’t think those questions have been answered here. From a rheumatology perspective, does the risk calculator help me decide when to intervene? At present, I’m not sure it does. Perhaps a higher score might make us intervene sooner if our clinical exam doesn’t show swollen or tender joints.”

Clinical exam findings and history she considers as a rheumatologist before making treatment recommendations include the following: Are there swollen and tender joints? Does the patient report morning stiffness for upwards of 30 minutes? Do they have enthesitis or dactylitis? Is there axial involvement? “Imaging can help if there isn’t anything on clinical exam and the history is compelling and/or the patient has risk factors for PsA,” she said.

The study’s finding of biologic use being associated with risk of developing PsA at year 1 but not at year 5 is “confusing,” Dr. Khattri added. “My concern is, will that now dissuade our moderate to severe psoriasis patients from using biologics to clear their psoriasis? We know that biologics are indicated for moderate to severe psoriasis. We also know psoriasis is associated with increased cardiovascular risk and there’s data to suggest that treatment with biologics with its resultant decrease in systemic inflammation can decrease cardiovascular risk.”

The study was supported by a New Investigator Grant from the Physician Services Incorporated Foundation. Dr. Eder disclosed that she is supported by the Canada Research Chair in Inflammatory Rheumatic Diseases. Dr. Khattri reported that she is a member of the advisory board for UCB, Janssen, AbbVie, Regeneron, Sanofi, Lilly, Argenx, and Arcutis. She has also received research funds from Incyte, AbbVie, Leo, Galderma, Pfizer, and Acelyrin.

Presenting obesity as a chronic medical condition, rather than as a failure to eat less and move more, may improve self-esteem among patients with obesity and enhance their relationships with their doctors, a new study suggests.

In an online study, patients with obesity reported significantly less internalized weight bias and significantly enhanced perceptions of positive communication with their medical providers after watching a video of a doctor who framed obesity as a treatable medical condition, compared with a video of a doctor who emphasized willpower.

“Recent research has identified the dominant role that biology (both genetics as well as homeostatic, hedonic, and executive brain systems) and environment, rather than willpower, play in the development of obesity and the resistance to weight loss,” wrote study authors Sara English, a medical student, and Michael Vallis, MD, associate professor of family medicine, both at Dalhousie University, Halifax, N.S. “Yet the false narrative that ideal or goal weight can be achieved by eating less and moving more using willpower continues to dominate the public narrative.”

The findings were published in Clinical Obesity.
 

Medical complexity

The public discussion generally places all responsibility for the health outcomes of obesity on the patient. As a result, patients with obesity face bias and stigma from the public and the health care system, wrote the authors.

This stigmatization contributes to increased mortality and morbidity by promoting maladaptive eating behaviors and stress. It also causes mistrust of health care professionals, which, in turn, leads to worse health outcomes and increased health care costs.

The 2020 Canadian clinical practice guidelines for obesity management in adults emphasize that obesity is complex and that nonbehavioral factors strongly influence it. They recommend that treatment focus on improving patient-centered health outcomes and address the root causes of obesity, instead of focusing on weight loss alone.

In the present study, Ms. English and Dr. Vallis evaluated how presenting obesity as a treatable medical condition affected participants’ internalized weight bias and their perceived relationship with their health care provider. They asked 61 patients with obesity (average age, 49 years; average body mass index, 41 kg/m²) to watch two videos, the first showing a doctor endorsing the traditional “eat less, move more approach,” and the second showing a doctor describing obesity as a chronic, treatable medical condition.

Nearly half (49.5%) of participants reported that their health care provider rarely or never discusses weight loss, and almost two-thirds of participants (64%) reported feeling stigmatized by their health care provider because of their weight at least some of the time.

After having watched each video, participants were asked to imagine that they were being treated by the corresponding doctor and to complete two measures: the Weight Bias Internalization Scale (WBIS), which measures the degree to which a respondent believes the negative stereotypes about obese people, and the Patient-Health Care Provider Communication Scale (PHCPCS), which assesses the quality of patient–health care provider communication.

Virtually all participants preferred the care provider in the video with the revised presentation of obesity. Only one preferred the traditional video. The video with the revised presentation was associated with significant reductions in internalized weight bias. Participants’ WBIS total score decreased from 4.49 to 3.36 (P < .001). The revised narrative video also had a positive effect on patients’ perception of their health care providers. The PHCPCS total score increased from 2.65 to 4.20 (P < .001).
 

A chronic disease

In a comment, Yoni Freedhoff, MD, associate professor of family medicine at the University of Ottawa, said: “If you’re asking me if it is a good idea to treat obesity like a chronic disease, the answer would be yes, we absolutely should. It is a chronic disease, and it shouldn’t have a treatment paradigm different from the other chronic diseases.” Dr. Freedhoff did not participate in the study.

“We certainly don’t blame patients for having other chronic conditions,” Dr. Freedhoff added. “We don’t have a narrative that, in order for them to qualify for medication or other treatment options, they have to audition for them by failing lifestyle approaches first. And yet, I’d say at least 85% of chronic noncommunicable diseases have lifestyle factors, but obesity is the only one where we consider that there is a necessity for these lifestyle changes, as if there have been studies demonstrating durable and reproducible outcomes for lifestyle in obesity. There have not.” 

Telling patients and doctors that obesity is a chronic disease driven by biology, not a failure of willpower, is going to reduce stigma, “which is what this study was able to demonstrate to some degree,” Dr. Freedhoff said.

“What is more stigmatizing? Being told that if you just try hard enough, you’ll succeed, and if you don’t succeed, the corollary, of course, is that you did not try hard enough? Versus, you’ve got a medical condition where you’ve got biological drivers beyond your locus of control, affecting behaviors that, in turn, contribute to your adiposity? I’m pretty sure the second statement will have far less impact on a person’s internalized weight bias than what we’ve unfortunately been doing up until now with the focus on willpower,” Dr. Freedhoff said.

No funding for the study was reported. Ms. English and Dr. Vallis reported no relevant financial relationships. Dr. Freedhoff reported receiving clinical grants from Novo Nordisk.

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

Presenting obesity as a chronic medical condition, rather than as a failure to eat less and move more, may improve self-esteem among patients with obesity and enhance their relationships with their doctors, a new study suggests.

In an online study, patients with obesity reported significantly less internalized weight bias and significantly enhanced perceptions of positive communication with their medical providers after watching a video of a doctor who framed obesity as a treatable medical condition, compared with a video of a doctor who emphasized willpower.

“Recent research has identified the dominant role that biology (both genetics as well as homeostatic, hedonic, and executive brain systems) and environment, rather than willpower, play in the development of obesity and the resistance to weight loss,” wrote study authors Sara English, a medical student, and Michael Vallis, MD, associate professor of family medicine, both at Dalhousie University, Halifax, N.S. “Yet the false narrative that ideal or goal weight can be achieved by eating less and moving more using willpower continues to dominate the public narrative.”

The findings were published in Clinical Obesity.
 

Medical complexity

The public discussion generally places all responsibility for the health outcomes of obesity on the patient. As a result, patients with obesity face bias and stigma from the public and the health care system, wrote the authors.

This stigmatization contributes to increased mortality and morbidity by promoting maladaptive eating behaviors and stress. It also causes mistrust of health care professionals, which, in turn, leads to worse health outcomes and increased health care costs.

The 2020 Canadian clinical practice guidelines for obesity management in adults emphasize that obesity is complex and that nonbehavioral factors strongly influence it. They recommend that treatment focus on improving patient-centered health outcomes and address the root causes of obesity, instead of focusing on weight loss alone.

In the present study, Ms. English and Dr. Vallis evaluated how presenting obesity as a treatable medical condition affected participants’ internalized weight bias and their perceived relationship with their health care provider. They asked 61 patients with obesity (average age, 49 years; average body mass index, 41 kg/m²) to watch two videos, the first showing a doctor endorsing the traditional “eat less, move more approach,” and the second showing a doctor describing obesity as a chronic, treatable medical condition.

Nearly half (49.5%) of participants reported that their health care provider rarely or never discusses weight loss, and almost two-thirds of participants (64%) reported feeling stigmatized by their health care provider because of their weight at least some of the time.

After having watched each video, participants were asked to imagine that they were being treated by the corresponding doctor and to complete two measures: the Weight Bias Internalization Scale (WBIS), which measures the degree to which a respondent believes the negative stereotypes about obese people, and the Patient-Health Care Provider Communication Scale (PHCPCS), which assesses the quality of patient–health care provider communication.

Virtually all participants preferred the care provider in the video with the revised presentation of obesity. Only one preferred the traditional video. The video with the revised presentation was associated with significant reductions in internalized weight bias. Participants’ WBIS total score decreased from 4.49 to 3.36 (P < .001). The revised narrative video also had a positive effect on patients’ perception of their health care providers. The PHCPCS total score increased from 2.65 to 4.20 (P < .001).
 

A chronic disease

In a comment, Yoni Freedhoff, MD, associate professor of family medicine at the University of Ottawa, said: “If you’re asking me if it is a good idea to treat obesity like a chronic disease, the answer would be yes, we absolutely should. It is a chronic disease, and it shouldn’t have a treatment paradigm different from the other chronic diseases.” Dr. Freedhoff did not participate in the study.

“We certainly don’t blame patients for having other chronic conditions,” Dr. Freedhoff added. “We don’t have a narrative that, in order for them to qualify for medication or other treatment options, they have to audition for them by failing lifestyle approaches first. And yet, I’d say at least 85% of chronic noncommunicable diseases have lifestyle factors, but obesity is the only one where we consider that there is a necessity for these lifestyle changes, as if there have been studies demonstrating durable and reproducible outcomes for lifestyle in obesity. There have not.” 

Telling patients and doctors that obesity is a chronic disease driven by biology, not a failure of willpower, is going to reduce stigma, “which is what this study was able to demonstrate to some degree,” Dr. Freedhoff said.

“What is more stigmatizing? Being told that if you just try hard enough, you’ll succeed, and if you don’t succeed, the corollary, of course, is that you did not try hard enough? Versus, you’ve got a medical condition where you’ve got biological drivers beyond your locus of control, affecting behaviors that, in turn, contribute to your adiposity? I’m pretty sure the second statement will have far less impact on a person’s internalized weight bias than what we’ve unfortunately been doing up until now with the focus on willpower,” Dr. Freedhoff said.

No funding for the study was reported. Ms. English and Dr. Vallis reported no relevant financial relationships. Dr. Freedhoff reported receiving clinical grants from Novo Nordisk.

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

Presenting obesity as a chronic medical condition, rather than as a failure to eat less and move more, may improve self-esteem among patients with obesity and enhance their relationships with their doctors, a new study suggests.

In an online study, patients with obesity reported significantly less internalized weight bias and significantly enhanced perceptions of positive communication with their medical providers after watching a video of a doctor who framed obesity as a treatable medical condition, compared with a video of a doctor who emphasized willpower.

“Recent research has identified the dominant role that biology (both genetics as well as homeostatic, hedonic, and executive brain systems) and environment, rather than willpower, play in the development of obesity and the resistance to weight loss,” wrote study authors Sara English, a medical student, and Michael Vallis, MD, associate professor of family medicine, both at Dalhousie University, Halifax, N.S. “Yet the false narrative that ideal or goal weight can be achieved by eating less and moving more using willpower continues to dominate the public narrative.”

The findings were published in Clinical Obesity.
 

Medical complexity

The public discussion generally places all responsibility for the health outcomes of obesity on the patient. As a result, patients with obesity face bias and stigma from the public and the health care system, wrote the authors.

This stigmatization contributes to increased mortality and morbidity by promoting maladaptive eating behaviors and stress. It also causes mistrust of health care professionals, which, in turn, leads to worse health outcomes and increased health care costs.

The 2020 Canadian clinical practice guidelines for obesity management in adults emphasize that obesity is complex and that nonbehavioral factors strongly influence it. They recommend that treatment focus on improving patient-centered health outcomes and address the root causes of obesity, instead of focusing on weight loss alone.

In the present study, Ms. English and Dr. Vallis evaluated how presenting obesity as a treatable medical condition affected participants’ internalized weight bias and their perceived relationship with their health care provider. They asked 61 patients with obesity (average age, 49 years; average body mass index, 41 kg/m²) to watch two videos, the first showing a doctor endorsing the traditional “eat less, move more approach,” and the second showing a doctor describing obesity as a chronic, treatable medical condition.

Nearly half (49.5%) of participants reported that their health care provider rarely or never discusses weight loss, and almost two-thirds of participants (64%) reported feeling stigmatized by their health care provider because of their weight at least some of the time.

After having watched each video, participants were asked to imagine that they were being treated by the corresponding doctor and to complete two measures: the Weight Bias Internalization Scale (WBIS), which measures the degree to which a respondent believes the negative stereotypes about obese people, and the Patient-Health Care Provider Communication Scale (PHCPCS), which assesses the quality of patient–health care provider communication.

Virtually all participants preferred the care provider in the video with the revised presentation of obesity. Only one preferred the traditional video. The video with the revised presentation was associated with significant reductions in internalized weight bias. Participants’ WBIS total score decreased from 4.49 to 3.36 (P < .001). The revised narrative video also had a positive effect on patients’ perception of their health care providers. The PHCPCS total score increased from 2.65 to 4.20 (P < .001).
 

A chronic disease

In a comment, Yoni Freedhoff, MD, associate professor of family medicine at the University of Ottawa, said: “If you’re asking me if it is a good idea to treat obesity like a chronic disease, the answer would be yes, we absolutely should. It is a chronic disease, and it shouldn’t have a treatment paradigm different from the other chronic diseases.” Dr. Freedhoff did not participate in the study.

“We certainly don’t blame patients for having other chronic conditions,” Dr. Freedhoff added. “We don’t have a narrative that, in order for them to qualify for medication or other treatment options, they have to audition for them by failing lifestyle approaches first. And yet, I’d say at least 85% of chronic noncommunicable diseases have lifestyle factors, but obesity is the only one where we consider that there is a necessity for these lifestyle changes, as if there have been studies demonstrating durable and reproducible outcomes for lifestyle in obesity. There have not.” 

Telling patients and doctors that obesity is a chronic disease driven by biology, not a failure of willpower, is going to reduce stigma, “which is what this study was able to demonstrate to some degree,” Dr. Freedhoff said.

“What is more stigmatizing? Being told that if you just try hard enough, you’ll succeed, and if you don’t succeed, the corollary, of course, is that you did not try hard enough? Versus, you’ve got a medical condition where you’ve got biological drivers beyond your locus of control, affecting behaviors that, in turn, contribute to your adiposity? I’m pretty sure the second statement will have far less impact on a person’s internalized weight bias than what we’ve unfortunately been doing up until now with the focus on willpower,” Dr. Freedhoff said.

No funding for the study was reported. Ms. English and Dr. Vallis reported no relevant financial relationships. Dr. Freedhoff reported receiving clinical grants from Novo Nordisk.

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

TOPLINE:
 

Patients with spondyloarthritis (SpA) experience similar gut microbiota dysbiosis with related inflammatory conditions, such as acute anterior uveitis (AAU) and Crohn’s disease (CD), new data show.

METHODOLOGY:

• Researchers performed 16S rRNA sequencing on stool samples from 277 adult patients from the German Spondyloarthritis Inception Cohort (102 with SpA, 72 with CD, and 103 with AAU) and 62 control patients with chronic back pain for whom SpA had been ruled out.
• Patients were treatment naive to biologic disease-modifying antirheumatic drugs or had not received them for more than 3 months prior to study enrollment.
• The study is the first to identify the same microbiota in patients with SpA, AAU, and CD.

TAKEAWAY:

• “Our results showed a shared depletion of predominately Lachnospiraceae taxa, most notably Fusicatenibacter, which partially mediated increased CRP [C-reactive protein], and was most abundant in controls receiving NSAID monotherapy,” the researchers wrote.
• Among patients who tested positive for HLA-B27, an allele associated with SpA and other spondyloarthropathies, levels of Faecalibacterium were increased; among patients with SpA, levels of Collinsella were enriched; and among patients with CD, there was an abundance of beneficial Ruminococcus bacteria.
• The results suggest the diagnostic and therapeutic potential of the gut microbiome for mediating disease activity for patients with autoimmune diseases.
• Additional research is needed to clarify the roles of different bacteria in gut-joint inflammation and to understand the relationship between genetics and gut microbes.

IN PRACTICE:

The study is too preliminary to have applications for practice.

SOURCE:

Co–first authors Morgan Essex, MSc, and Valeria Rios Rodriguez, MD, of Charité–Universitätsmedizin Berlin and colleagues conducted the study, which was published online July 20, 2023, in Arthritis and Rheumatology.

LIMITATIONS:

• The results were limited by several factors, including the restriction to amplicon sequencing, which prevented in-depth characterization of the gut microbiome.
• More studies are needed to validate the findings, especially regarding gut bacteria as potential mediators of inflammation or disease activity. The researchers recommended studies with whole-genome sequencing and fecal metabolite quantification.

DISCLOSURES:

The study was supported in part by the Deutsche Forschungsgemeinschaft. Additional funding came from the German Federal Ministry for Health and Research and the Berlin Institute of Health. Two patient cohorts were partially and separately supported by grants from Novartis and AbbVie.

A version of this article appeared on Medscape.com.

TOPLINE:
 

Patients with spondyloarthritis (SpA) experience similar gut microbiota dysbiosis with related inflammatory conditions, such as acute anterior uveitis (AAU) and Crohn’s disease (CD), new data show.

METHODOLOGY:

• Researchers performed 16S rRNA sequencing on stool samples from 277 adult patients from the German Spondyloarthritis Inception Cohort (102 with SpA, 72 with CD, and 103 with AAU) and 62 control patients with chronic back pain for whom SpA had been ruled out.
• Patients were treatment naive to biologic disease-modifying antirheumatic drugs or had not received them for more than 3 months prior to study enrollment.
• The study is the first to identify the same microbiota in patients with SpA, AAU, and CD.

TAKEAWAY:

• “Our results showed a shared depletion of predominately Lachnospiraceae taxa, most notably Fusicatenibacter, which partially mediated increased CRP [C-reactive protein], and was most abundant in controls receiving NSAID monotherapy,” the researchers wrote.
• Among patients who tested positive for HLA-B27, an allele associated with SpA and other spondyloarthropathies, levels of Faecalibacterium were increased; among patients with SpA, levels of Collinsella were enriched; and among patients with CD, there was an abundance of beneficial Ruminococcus bacteria.
• The results suggest the diagnostic and therapeutic potential of the gut microbiome for mediating disease activity for patients with autoimmune diseases.
• Additional research is needed to clarify the roles of different bacteria in gut-joint inflammation and to understand the relationship between genetics and gut microbes.

IN PRACTICE:

The study is too preliminary to have applications for practice.

SOURCE:

Co–first authors Morgan Essex, MSc, and Valeria Rios Rodriguez, MD, of Charité–Universitätsmedizin Berlin and colleagues conducted the study, which was published online July 20, 2023, in Arthritis and Rheumatology.

LIMITATIONS:

• The results were limited by several factors, including the restriction to amplicon sequencing, which prevented in-depth characterization of the gut microbiome.
• More studies are needed to validate the findings, especially regarding gut bacteria as potential mediators of inflammation or disease activity. The researchers recommended studies with whole-genome sequencing and fecal metabolite quantification.

DISCLOSURES:

The study was supported in part by the Deutsche Forschungsgemeinschaft. Additional funding came from the German Federal Ministry for Health and Research and the Berlin Institute of Health. Two patient cohorts were partially and separately supported by grants from Novartis and AbbVie.

A version of this article appeared on Medscape.com.

TOPLINE:
 

Patients with spondyloarthritis (SpA) experience similar gut microbiota dysbiosis with related inflammatory conditions, such as acute anterior uveitis (AAU) and Crohn’s disease (CD), new data show.

METHODOLOGY:

• Researchers performed 16S rRNA sequencing on stool samples from 277 adult patients from the German Spondyloarthritis Inception Cohort (102 with SpA, 72 with CD, and 103 with AAU) and 62 control patients with chronic back pain for whom SpA had been ruled out.
• Patients were treatment naive to biologic disease-modifying antirheumatic drugs or had not received them for more than 3 months prior to study enrollment.
• The study is the first to identify the same microbiota in patients with SpA, AAU, and CD.

TAKEAWAY:

• “Our results showed a shared depletion of predominately Lachnospiraceae taxa, most notably Fusicatenibacter, which partially mediated increased CRP [C-reactive protein], and was most abundant in controls receiving NSAID monotherapy,” the researchers wrote.
• Among patients who tested positive for HLA-B27, an allele associated with SpA and other spondyloarthropathies, levels of Faecalibacterium were increased; among patients with SpA, levels of Collinsella were enriched; and among patients with CD, there was an abundance of beneficial Ruminococcus bacteria.
• The results suggest the diagnostic and therapeutic potential of the gut microbiome for mediating disease activity for patients with autoimmune diseases.
• Additional research is needed to clarify the roles of different bacteria in gut-joint inflammation and to understand the relationship between genetics and gut microbes.

IN PRACTICE:

The study is too preliminary to have applications for practice.

SOURCE:

Co–first authors Morgan Essex, MSc, and Valeria Rios Rodriguez, MD, of Charité–Universitätsmedizin Berlin and colleagues conducted the study, which was published online July 20, 2023, in Arthritis and Rheumatology.

LIMITATIONS:

• The results were limited by several factors, including the restriction to amplicon sequencing, which prevented in-depth characterization of the gut microbiome.
• More studies are needed to validate the findings, especially regarding gut bacteria as potential mediators of inflammation or disease activity. The researchers recommended studies with whole-genome sequencing and fecal metabolite quantification.

DISCLOSURES:

The study was supported in part by the Deutsche Forschungsgemeinschaft. Additional funding came from the German Federal Ministry for Health and Research and the Berlin Institute of Health. Two patient cohorts were partially and separately supported by grants from Novartis and AbbVie.

A version of this article appeared on Medscape.com.

Use current health and desire for pregnancy to guide contraception discussions in primary care, according to authors of an updated report.

In an installment of the American College of Physicians’ In the Clinic series, Rachel Cannon, MD, Kelly Treder, MD, and Elisabeth J. Woodhams, MD, all of Boston Medical Center, presented an article on the complex topic of contraception for patients with chronic illness.

“Many patients with chronic illness or complex medical issues interact with a primary care provider on a frequent basis, which provides a great access point for contraceptive counseling with a provider they trust and know,” said Dr. Cannon and Dr. Treder in a joint interview. “We wanted to create a ‘go to’ resource for primary care physicians to review contraceptive options and counseling best practices for all of their patients. Contraceptive care is part of overall health care and should be included in the primary care encounter.”

The authors discussed the types of contraception, as well as risks and benefits, and offered guidance for choosing a contraceptive method for medically complex patients.

“In recent years, there has been a shift in contraceptive counseling toward shared decision-making, a counseling strategy that honors the patient as the expert in their body and their life experiences and emphasizes their autonomy and values,” the authors said. “For providers, this translates to understanding that contraceptive efficacy is not the only important characteristic to patients, and that many other important factors contribute to an individual’s decision to use a particular method or not use birth control at all,” they said.
 

Start the conversation

Start by assessing a patient’s interest in and readiness for pregnancy, if applicable, the authors said. One example of a screen, the PATH questionnaire (Parent/Pregnancy Attitudes, Timing, and How important), is designed for patients in any demographic, and includes questions about the timing and desire for pregnancy and feelings about birth control, as well as options for patients to express uncertainty or ambivalence about pregnancy and contraception.

Some patients may derive benefits from hormonal contraceptives beyond pregnancy prevention, the authors wrote. Combined hormonal contraceptives (CHCs) may improve menorrhagia, and data suggest that CHC use also may reduce risk for some cancer types, including endometrial and ovarian cancers, they said.

Overall, contraceptive counseling should include discussions of safety, efficacy, and the patient’s lived experience.
 

Clinical considerations and contraindications

Medically complex patients who desire contraception may consider hormonal or nonhormonal methods based on their preferences and medical conditions, but clinicians need to consider comorbidities and contraindications, the authors wrote.

When a woman of childbearing age with any complex medical issue starts a new medication or receives a new diagnosis, contraception and pregnancy planning should be part of the discussion, the authors said. Safe and successful pregnancies are possible for women with complex medical issues when underlying health concerns are identified and addressed in advance, they added. Alternatively, for patients seeking to avoid pregnancy permanently, options for sterilization can be part of an informed discussion.

The Centers for Disease Control and Prevention’s Medical Eligibility Criteria for Contraceptive Use offers clinicians detailed information about the risks of both contraceptives and pregnancy for patients with various medical conditions, according to the authors.

The CDC document lists medical conditions associated with an increased risk for adverse health events if the individual becomes pregnant. These conditions include breast cancer, complicated valvular heart disease, cystic fibrosis, diabetes, endometrial or ovarian cancer, epilepsy, hypertension, bariatric surgery within 2 years of the pregnancy, HIV, ischemic heart disease, severe cirrhosis, stroke, lupus, solid organ transplant within 2 years of the pregnancy, and tuberculosis. Women with these and other conditions associated with increased risk of adverse events if pregnancy occurs should be advised of the high failure rate of barrier and behavior-based contraceptive methods, and informed about options for long-acting contraceptives, according to the CDC.
 

Risks, benefits, and balance

“It is important to remember that the alternative to contraception for many patients is pregnancy – for many patients with complex medical conditions, pregnancy is far more dangerous than any contraceptive method,” Dr. Cannon and Dr. Treder said in an interview. “This is important to consider when thinking about relative contraindications to a certain method or when thinking about ‘less effective’ contraception methods. The most effective method is a method the patient will actually continue to use,” they said.

The recent approval of the over-the-counter minipill is “a huge win for reproductive health care,” said Dr. Cannon and Dr. Treder. The minipill has very few contraindications, and it is the most effective over-the-counter contraceptive now available, they said.

“An over-the-counter contraceptive pill can increase access to contraception without having to see a physician in the clinic, freeing patients from many of the challenges of navigating the health care system,” the authors added.

As for additional research, the establishment of a long-term safety record may help support other OTC contraceptive methods in the future, the authors said.
 

Contraceptive counseling is everyone’s specialty

In an accompanying editorial, Amy A. Sarma, MD, a cardiologist at Massachusetts General Hospital, Boston, shared an example of the importance of contraceptive discussions with medically complex patients outside of an ob.gyn. setting. A young woman with a family history of myocardial infarction had neglected her own primary care until an MI of her own sent her to the hospital. While hospitalized, the patient was diagnosed with diabetes, hypertension, and hyperlipidemia.

“Her cardiology care team made every effort to optimize her cardiac care, but no one considered that she was also a woman of childbearing potential despite the teratogenic potential of several of her prescribed medications,” Dr. Sarma wrote. When the patient visited Dr. Sarma to discuss prevention of future MIs, Dr. Sarma took the opportunity to discuss the cardiovascular risks of pregnancy and the risks for this patient not only because of her recent MI, but also because of her chronic health conditions.

As it happened, the woman did not want a high-risk pregnancy and was interested in contraceptive methods. Dr. Sarma pointed out that, had the woman been engaged in routine primary care, these issues would have arisen in that setting, but like many younger women with cardiovascular disease, she did not make her own primary care a priority, and had missed out on other opportunities to discuss contraception. “Her MI opened a window of opportunity to help prevent an unintended and high-risk pregnancy,” Dr. Sarma noted.

Dr. Sarma’s patient anecdote illustrated the point of the In the Clinic review: that any clinician can discuss pregnancy and contraception with patients of childbearing age who have medical comorbidities that could affect a pregnancy. “All clinicians who care for patients of reproductive potential should become comfortable discussing pregnancy intent, preconception risk assessment, and contraceptive counseling,” Dr. Sarma said.

The research for this article was funded by the American College of Physicians. The review authors had no financial conflicts to disclose. Dr. Sarma had no financial conflicts to disclose.

Use current health and desire for pregnancy to guide contraception discussions in primary care, according to authors of an updated report.

In an installment of the American College of Physicians’ In the Clinic series, Rachel Cannon, MD, Kelly Treder, MD, and Elisabeth J. Woodhams, MD, all of Boston Medical Center, presented an article on the complex topic of contraception for patients with chronic illness.

“Many patients with chronic illness or complex medical issues interact with a primary care provider on a frequent basis, which provides a great access point for contraceptive counseling with a provider they trust and know,” said Dr. Cannon and Dr. Treder in a joint interview. “We wanted to create a ‘go to’ resource for primary care physicians to review contraceptive options and counseling best practices for all of their patients. Contraceptive care is part of overall health care and should be included in the primary care encounter.”

The authors discussed the types of contraception, as well as risks and benefits, and offered guidance for choosing a contraceptive method for medically complex patients.

“In recent years, there has been a shift in contraceptive counseling toward shared decision-making, a counseling strategy that honors the patient as the expert in their body and their life experiences and emphasizes their autonomy and values,” the authors said. “For providers, this translates to understanding that contraceptive efficacy is not the only important characteristic to patients, and that many other important factors contribute to an individual’s decision to use a particular method or not use birth control at all,” they said.
 

Start the conversation

Start by assessing a patient’s interest in and readiness for pregnancy, if applicable, the authors said. One example of a screen, the PATH questionnaire (Parent/Pregnancy Attitudes, Timing, and How important), is designed for patients in any demographic, and includes questions about the timing and desire for pregnancy and feelings about birth control, as well as options for patients to express uncertainty or ambivalence about pregnancy and contraception.

Some patients may derive benefits from hormonal contraceptives beyond pregnancy prevention, the authors wrote. Combined hormonal contraceptives (CHCs) may improve menorrhagia, and data suggest that CHC use also may reduce risk for some cancer types, including endometrial and ovarian cancers, they said.

Overall, contraceptive counseling should include discussions of safety, efficacy, and the patient’s lived experience.
 

Clinical considerations and contraindications

Medically complex patients who desire contraception may consider hormonal or nonhormonal methods based on their preferences and medical conditions, but clinicians need to consider comorbidities and contraindications, the authors wrote.

When a woman of childbearing age with any complex medical issue starts a new medication or receives a new diagnosis, contraception and pregnancy planning should be part of the discussion, the authors said. Safe and successful pregnancies are possible for women with complex medical issues when underlying health concerns are identified and addressed in advance, they added. Alternatively, for patients seeking to avoid pregnancy permanently, options for sterilization can be part of an informed discussion.

The Centers for Disease Control and Prevention’s Medical Eligibility Criteria for Contraceptive Use offers clinicians detailed information about the risks of both contraceptives and pregnancy for patients with various medical conditions, according to the authors.

The CDC document lists medical conditions associated with an increased risk for adverse health events if the individual becomes pregnant. These conditions include breast cancer, complicated valvular heart disease, cystic fibrosis, diabetes, endometrial or ovarian cancer, epilepsy, hypertension, bariatric surgery within 2 years of the pregnancy, HIV, ischemic heart disease, severe cirrhosis, stroke, lupus, solid organ transplant within 2 years of the pregnancy, and tuberculosis. Women with these and other conditions associated with increased risk of adverse events if pregnancy occurs should be advised of the high failure rate of barrier and behavior-based contraceptive methods, and informed about options for long-acting contraceptives, according to the CDC.
 

Risks, benefits, and balance

“It is important to remember that the alternative to contraception for many patients is pregnancy – for many patients with complex medical conditions, pregnancy is far more dangerous than any contraceptive method,” Dr. Cannon and Dr. Treder said in an interview. “This is important to consider when thinking about relative contraindications to a certain method or when thinking about ‘less effective’ contraception methods. The most effective method is a method the patient will actually continue to use,” they said.

The recent approval of the over-the-counter minipill is “a huge win for reproductive health care,” said Dr. Cannon and Dr. Treder. The minipill has very few contraindications, and it is the most effective over-the-counter contraceptive now available, they said.

“An over-the-counter contraceptive pill can increase access to contraception without having to see a physician in the clinic, freeing patients from many of the challenges of navigating the health care system,” the authors added.

As for additional research, the establishment of a long-term safety record may help support other OTC contraceptive methods in the future, the authors said.
 

Contraceptive counseling is everyone’s specialty

In an accompanying editorial, Amy A. Sarma, MD, a cardiologist at Massachusetts General Hospital, Boston, shared an example of the importance of contraceptive discussions with medically complex patients outside of an ob.gyn. setting. A young woman with a family history of myocardial infarction had neglected her own primary care until an MI of her own sent her to the hospital. While hospitalized, the patient was diagnosed with diabetes, hypertension, and hyperlipidemia.

“Her cardiology care team made every effort to optimize her cardiac care, but no one considered that she was also a woman of childbearing potential despite the teratogenic potential of several of her prescribed medications,” Dr. Sarma wrote. When the patient visited Dr. Sarma to discuss prevention of future MIs, Dr. Sarma took the opportunity to discuss the cardiovascular risks of pregnancy and the risks for this patient not only because of her recent MI, but also because of her chronic health conditions.

As it happened, the woman did not want a high-risk pregnancy and was interested in contraceptive methods. Dr. Sarma pointed out that, had the woman been engaged in routine primary care, these issues would have arisen in that setting, but like many younger women with cardiovascular disease, she did not make her own primary care a priority, and had missed out on other opportunities to discuss contraception. “Her MI opened a window of opportunity to help prevent an unintended and high-risk pregnancy,” Dr. Sarma noted.

Dr. Sarma’s patient anecdote illustrated the point of the In the Clinic review: that any clinician can discuss pregnancy and contraception with patients of childbearing age who have medical comorbidities that could affect a pregnancy. “All clinicians who care for patients of reproductive potential should become comfortable discussing pregnancy intent, preconception risk assessment, and contraceptive counseling,” Dr. Sarma said.

The research for this article was funded by the American College of Physicians. The review authors had no financial conflicts to disclose. Dr. Sarma had no financial conflicts to disclose.

Use current health and desire for pregnancy to guide contraception discussions in primary care, according to authors of an updated report.

In an installment of the American College of Physicians’ In the Clinic series, Rachel Cannon, MD, Kelly Treder, MD, and Elisabeth J. Woodhams, MD, all of Boston Medical Center, presented an article on the complex topic of contraception for patients with chronic illness.

“Many patients with chronic illness or complex medical issues interact with a primary care provider on a frequent basis, which provides a great access point for contraceptive counseling with a provider they trust and know,” said Dr. Cannon and Dr. Treder in a joint interview. “We wanted to create a ‘go to’ resource for primary care physicians to review contraceptive options and counseling best practices for all of their patients. Contraceptive care is part of overall health care and should be included in the primary care encounter.”

The authors discussed the types of contraception, as well as risks and benefits, and offered guidance for choosing a contraceptive method for medically complex patients.

“In recent years, there has been a shift in contraceptive counseling toward shared decision-making, a counseling strategy that honors the patient as the expert in their body and their life experiences and emphasizes their autonomy and values,” the authors said. “For providers, this translates to understanding that contraceptive efficacy is not the only important characteristic to patients, and that many other important factors contribute to an individual’s decision to use a particular method or not use birth control at all,” they said.
 

Start the conversation

Start by assessing a patient’s interest in and readiness for pregnancy, if applicable, the authors said. One example of a screen, the PATH questionnaire (Parent/Pregnancy Attitudes, Timing, and How important), is designed for patients in any demographic, and includes questions about the timing and desire for pregnancy and feelings about birth control, as well as options for patients to express uncertainty or ambivalence about pregnancy and contraception.

Some patients may derive benefits from hormonal contraceptives beyond pregnancy prevention, the authors wrote. Combined hormonal contraceptives (CHCs) may improve menorrhagia, and data suggest that CHC use also may reduce risk for some cancer types, including endometrial and ovarian cancers, they said.

Overall, contraceptive counseling should include discussions of safety, efficacy, and the patient’s lived experience.
 

Clinical considerations and contraindications

Medically complex patients who desire contraception may consider hormonal or nonhormonal methods based on their preferences and medical conditions, but clinicians need to consider comorbidities and contraindications, the authors wrote.

When a woman of childbearing age with any complex medical issue starts a new medication or receives a new diagnosis, contraception and pregnancy planning should be part of the discussion, the authors said. Safe and successful pregnancies are possible for women with complex medical issues when underlying health concerns are identified and addressed in advance, they added. Alternatively, for patients seeking to avoid pregnancy permanently, options for sterilization can be part of an informed discussion.

The Centers for Disease Control and Prevention’s Medical Eligibility Criteria for Contraceptive Use offers clinicians detailed information about the risks of both contraceptives and pregnancy for patients with various medical conditions, according to the authors.

The CDC document lists medical conditions associated with an increased risk for adverse health events if the individual becomes pregnant. These conditions include breast cancer, complicated valvular heart disease, cystic fibrosis, diabetes, endometrial or ovarian cancer, epilepsy, hypertension, bariatric surgery within 2 years of the pregnancy, HIV, ischemic heart disease, severe cirrhosis, stroke, lupus, solid organ transplant within 2 years of the pregnancy, and tuberculosis. Women with these and other conditions associated with increased risk of adverse events if pregnancy occurs should be advised of the high failure rate of barrier and behavior-based contraceptive methods, and informed about options for long-acting contraceptives, according to the CDC.
 

Risks, benefits, and balance

“It is important to remember that the alternative to contraception for many patients is pregnancy – for many patients with complex medical conditions, pregnancy is far more dangerous than any contraceptive method,” Dr. Cannon and Dr. Treder said in an interview. “This is important to consider when thinking about relative contraindications to a certain method or when thinking about ‘less effective’ contraception methods. The most effective method is a method the patient will actually continue to use,” they said.

The recent approval of the over-the-counter minipill is “a huge win for reproductive health care,” said Dr. Cannon and Dr. Treder. The minipill has very few contraindications, and it is the most effective over-the-counter contraceptive now available, they said.

“An over-the-counter contraceptive pill can increase access to contraception without having to see a physician in the clinic, freeing patients from many of the challenges of navigating the health care system,” the authors added.

As for additional research, the establishment of a long-term safety record may help support other OTC contraceptive methods in the future, the authors said.
 

Contraceptive counseling is everyone’s specialty

In an accompanying editorial, Amy A. Sarma, MD, a cardiologist at Massachusetts General Hospital, Boston, shared an example of the importance of contraceptive discussions with medically complex patients outside of an ob.gyn. setting. A young woman with a family history of myocardial infarction had neglected her own primary care until an MI of her own sent her to the hospital. While hospitalized, the patient was diagnosed with diabetes, hypertension, and hyperlipidemia.

“Her cardiology care team made every effort to optimize her cardiac care, but no one considered that she was also a woman of childbearing potential despite the teratogenic potential of several of her prescribed medications,” Dr. Sarma wrote. When the patient visited Dr. Sarma to discuss prevention of future MIs, Dr. Sarma took the opportunity to discuss the cardiovascular risks of pregnancy and the risks for this patient not only because of her recent MI, but also because of her chronic health conditions.

As it happened, the woman did not want a high-risk pregnancy and was interested in contraceptive methods. Dr. Sarma pointed out that, had the woman been engaged in routine primary care, these issues would have arisen in that setting, but like many younger women with cardiovascular disease, she did not make her own primary care a priority, and had missed out on other opportunities to discuss contraception. “Her MI opened a window of opportunity to help prevent an unintended and high-risk pregnancy,” Dr. Sarma noted.

Dr. Sarma’s patient anecdote illustrated the point of the In the Clinic review: that any clinician can discuss pregnancy and contraception with patients of childbearing age who have medical comorbidities that could affect a pregnancy. “All clinicians who care for patients of reproductive potential should become comfortable discussing pregnancy intent, preconception risk assessment, and contraceptive counseling,” Dr. Sarma said.

The research for this article was funded by the American College of Physicians. The review authors had no financial conflicts to disclose. Dr. Sarma had no financial conflicts to disclose.