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A group of internists is suing the American Board of Internal Medicine over its maintenance of certification (MOC) process, alleging that the board is monopolizing the MOC market.

jsmith/iStockphoto

The lawsuit, filed Dec. 6 in Pennsylvania district court, claims that ABIM is charging inflated monopoly prices for maintaining certification, that the organization is forcing physicians to purchase MOC, and that ABIM is inducing employers and others to require ABIM certification. The four plaintiff-physicians are asking a judge to find ABIM in violation of federal antitrust law and to bar the board from continuing its MOC process. The suit is filed as a class action on behalf of all internists and subspecialists required by ABIM to purchase MOC to maintain their ABIM certifications. The plaintiffs seek damages and injunctive relief, plus lawsuit and attorney costs arising from ABIM’s alleged antitrust violations.

In a statement, ABIM expressed disappointment at the lawsuit and said the organization will vigorously defend itself, adding that doing so will “consume resources far better dedicated to continuous improvement of its programs.”

ABIM declined to answer questions addressing specific accusations from the lawsuit. However, in an interview, ABIM President Richard Baron, MD, said that “ABIM board-certified physicians have taken the initiative to distinguish themselves. This is a credential that physicians earn. We offer certified physicians the opportunity to demonstrate to the medical community, their peers, and the public that they are current and have special expertise.”

ABIM has not yet filed a formal response to the lawsuit, which was due by Jan. 6. Court documents show that in January, ABIM entered the appearances of four attorneys that will represent the board in the case. From there, discovery and evidence gathering in the case will begin.

Katherine Murray Leisure, MD, an infectious disease specialist based in Plymouth, Mass., is one of the plaintiffs. While she said that she could not comment specifically on the lawsuit, she has written publicly about her ABIM concerns in the past.

In a 2015 letter to Dr. Baron and posted on an anti-MOC website, Dr. Murray outlined a litany of complaints against ABIM’s MOC process and called on the U.S. Congress to investigate ABIM’s financial, legal, and ethical conduct.

“[The American Board of Medical Specialties] and ABIM collected more than $10,000 in fees and lost practice hours every decade from each [diplomate] doing MOC,” Dr. Murray Leisure wrote. “MOC took weeks away from our offices, clinics, patients, families, specialty societies, and individual research. ABMS MOC removed hundreds, perhaps thousands … of America’s best, once board-certified physicians from full hospital careers and earnings whenever [diplomates] did not complete these high-stakes MOC programs. … The righteous and fast solution to such moral, ethical, scientific, and constitutional problems is to end MOC now.”

Plaintiffs Glen Dela Cruz Manalo, MD; Alexa Joshua, MD; and Gerard Kenney, MD, did not return messages seeking comment. When contacted, attorneys for the plaintiffs declined to comment.

The doctors’ 32-page lawsuit characterizes ABIM as an organization motivated by money that has made its MOC process increasingly more burdensome for physicians over the years without evidence that MOC has any beneficial impact on doctors, patients, or the public. Complying with ABIM’s MOC costs internists an average of $23,607 in financial cost and time lost over 10 years, and costs up to $40,495 for some specialists, according to the suit.

The physicians allege that ABIM controls in excess of 95% of the market for MOC of internists, in violation of federal antitrust laws, and that the organization has unlawfully obtained and maintained monopoly power for MOC services.

The board’s illegal tying of its initial certification to its MOC results in burdensome conditions, including “raising the cost of the practice of medicine, constraining the supply of internists thereby harming competition, decreasing the supply of certified internists, and increasing the cost of medical services to patients and consumers,” the suit claims.

The legal challenge details how MOC has personally and professionally impacted each of the four plaintiffs. Dr. Manalo, a gastroenterologist, lost his privileges at St. Vincent Healthcare in Billings, Mont., and was subsequently terminated after he declined to maintain his ABIM certification as a gastroenterologist. In a letter to ABIM, Dr. Manalo wrote that it was “unfair and outright discriminatory that practitioners certified on or after 1990 are the only ones required to certify,” according to the lawsuit. Dr. Manalo later took a position as staff gastroenterologist at Jonathan M. Wainwright Memorial Veterans Affairs Medical Center in Walla Walla, Wash., at a substantially reduced salary. He became unemployed in 2017.

Dr. Murray Leisure obtained an initial and lifelong board certification in internal medicine from ABIM in 1984 and an infectious disease certification in 1990. ABlM terminated Dr. Murray’s infectious diseases certification after she failed her MOC examination in 2009, which led to lost privileges at Jordan Hospital in Plymouth, Mass. The loss caused significant damage to Dr. Murray, including lost income, a tarnished reputation, and the lost opportunity to help patients, according to the lawsuit. Jordan Hospital restored her privileges after Dr. Murray passed her MOC examination in 2012.

Dr. Kenney lost a job opportunity with Mount Nittany Physicians Group in State College, Pa., after he declined to renew his ABIM certification in gastroenterology. He is currently a physician with the University of Pittsburgh Medical Center in Seneca, Pa.

That the ABIM website lists him as “not certified,” is misleading, and makes it appear that his initial certifications were revoked due to failure to pass a MOC examination or misconduct, rather than because the certifications lapsed, according to the suit. The description makes Dr. Kenney appear less qualified to patients, hospitals, insurance companies, medical corporations, other employers, and others, he claims.

Dr. Joshua could not renew her consulting and admitting privileges at Detroit Medical Center after she failed an MOC examination in 2014 and became uncertified in internal medicine, according to the suit. In addition, Blue Cross Blue Shield informed Dr. Joshua it would no longer cover her because it required ABIM certification for coverage. She unsuccessfully appealed based on her certification with the National Board of Physicians and Surgeons. As a result of her certification termination, Dr. Joshua can only practice outpatient medicine at Detroit Medical Center.

In an interview, Dr. Baron emphasized the number of modifications made to its MOC process in recent years after responding to physician concerns. This includes an overhaul of the organization’s governance structure to include more than 200 practicing physicians and opening new avenues for physicians to engage in the creation of assessment content that more closely reflects what they see in practice, he said. In addition, ABIM now surveys all specialists to contribute to the exam blueprint review and the creation of the new Item Writing Task Force.

*This story was updated on Feb. 6, 2019.

A group of internists is suing the American Board of Internal Medicine over its maintenance of certification (MOC) process, alleging that the board is monopolizing the MOC market.

jsmith/iStockphoto

The lawsuit, filed Dec. 6 in Pennsylvania district court, claims that ABIM is charging inflated monopoly prices for maintaining certification, that the organization is forcing physicians to purchase MOC, and that ABIM is inducing employers and others to require ABIM certification. The four plaintiff-physicians are asking a judge to find ABIM in violation of federal antitrust law and to bar the board from continuing its MOC process. The suit is filed as a class action on behalf of all internists and subspecialists required by ABIM to purchase MOC to maintain their ABIM certifications. The plaintiffs seek damages and injunctive relief, plus lawsuit and attorney costs arising from ABIM’s alleged antitrust violations.

In a statement, ABIM expressed disappointment at the lawsuit and said the organization will vigorously defend itself, adding that doing so will “consume resources far better dedicated to continuous improvement of its programs.”

ABIM declined to answer questions addressing specific accusations from the lawsuit. However, in an interview, ABIM President Richard Baron, MD, said that “ABIM board-certified physicians have taken the initiative to distinguish themselves. This is a credential that physicians earn. We offer certified physicians the opportunity to demonstrate to the medical community, their peers, and the public that they are current and have special expertise.”

ABIM has not yet filed a formal response to the lawsuit, which was due by Jan. 6. Court documents show that in January, ABIM entered the appearances of four attorneys that will represent the board in the case. From there, discovery and evidence gathering in the case will begin.

Katherine Murray Leisure, MD, an infectious disease specialist based in Plymouth, Mass., is one of the plaintiffs. While she said that she could not comment specifically on the lawsuit, she has written publicly about her ABIM concerns in the past.

In a 2015 letter to Dr. Baron and posted on an anti-MOC website, Dr. Murray outlined a litany of complaints against ABIM’s MOC process and called on the U.S. Congress to investigate ABIM’s financial, legal, and ethical conduct.

“[The American Board of Medical Specialties] and ABIM collected more than $10,000 in fees and lost practice hours every decade from each [diplomate] doing MOC,” Dr. Murray Leisure wrote. “MOC took weeks away from our offices, clinics, patients, families, specialty societies, and individual research. ABMS MOC removed hundreds, perhaps thousands … of America’s best, once board-certified physicians from full hospital careers and earnings whenever [diplomates] did not complete these high-stakes MOC programs. … The righteous and fast solution to such moral, ethical, scientific, and constitutional problems is to end MOC now.”

Plaintiffs Glen Dela Cruz Manalo, MD; Alexa Joshua, MD; and Gerard Kenney, MD, did not return messages seeking comment. When contacted, attorneys for the plaintiffs declined to comment.

The doctors’ 32-page lawsuit characterizes ABIM as an organization motivated by money that has made its MOC process increasingly more burdensome for physicians over the years without evidence that MOC has any beneficial impact on doctors, patients, or the public. Complying with ABIM’s MOC costs internists an average of $23,607 in financial cost and time lost over 10 years, and costs up to $40,495 for some specialists, according to the suit.

The physicians allege that ABIM controls in excess of 95% of the market for MOC of internists, in violation of federal antitrust laws, and that the organization has unlawfully obtained and maintained monopoly power for MOC services.

The board’s illegal tying of its initial certification to its MOC results in burdensome conditions, including “raising the cost of the practice of medicine, constraining the supply of internists thereby harming competition, decreasing the supply of certified internists, and increasing the cost of medical services to patients and consumers,” the suit claims.

The legal challenge details how MOC has personally and professionally impacted each of the four plaintiffs. Dr. Manalo, a gastroenterologist, lost his privileges at St. Vincent Healthcare in Billings, Mont., and was subsequently terminated after he declined to maintain his ABIM certification as a gastroenterologist. In a letter to ABIM, Dr. Manalo wrote that it was “unfair and outright discriminatory that practitioners certified on or after 1990 are the only ones required to certify,” according to the lawsuit. Dr. Manalo later took a position as staff gastroenterologist at Jonathan M. Wainwright Memorial Veterans Affairs Medical Center in Walla Walla, Wash., at a substantially reduced salary. He became unemployed in 2017.

Dr. Murray Leisure obtained an initial and lifelong board certification in internal medicine from ABIM in 1984 and an infectious disease certification in 1990. ABlM terminated Dr. Murray’s infectious diseases certification after she failed her MOC examination in 2009, which led to lost privileges at Jordan Hospital in Plymouth, Mass. The loss caused significant damage to Dr. Murray, including lost income, a tarnished reputation, and the lost opportunity to help patients, according to the lawsuit. Jordan Hospital restored her privileges after Dr. Murray passed her MOC examination in 2012.

Dr. Kenney lost a job opportunity with Mount Nittany Physicians Group in State College, Pa., after he declined to renew his ABIM certification in gastroenterology. He is currently a physician with the University of Pittsburgh Medical Center in Seneca, Pa.

That the ABIM website lists him as “not certified,” is misleading, and makes it appear that his initial certifications were revoked due to failure to pass a MOC examination or misconduct, rather than because the certifications lapsed, according to the suit. The description makes Dr. Kenney appear less qualified to patients, hospitals, insurance companies, medical corporations, other employers, and others, he claims.

Dr. Joshua could not renew her consulting and admitting privileges at Detroit Medical Center after she failed an MOC examination in 2014 and became uncertified in internal medicine, according to the suit. In addition, Blue Cross Blue Shield informed Dr. Joshua it would no longer cover her because it required ABIM certification for coverage. She unsuccessfully appealed based on her certification with the National Board of Physicians and Surgeons. As a result of her certification termination, Dr. Joshua can only practice outpatient medicine at Detroit Medical Center.

In an interview, Dr. Baron emphasized the number of modifications made to its MOC process in recent years after responding to physician concerns. This includes an overhaul of the organization’s governance structure to include more than 200 practicing physicians and opening new avenues for physicians to engage in the creation of assessment content that more closely reflects what they see in practice, he said. In addition, ABIM now surveys all specialists to contribute to the exam blueprint review and the creation of the new Item Writing Task Force.

*This story was updated on Feb. 6, 2019.

A group of internists is suing the American Board of Internal Medicine over its maintenance of certification (MOC) process, alleging that the board is monopolizing the MOC market.

jsmith/iStockphoto

The lawsuit, filed Dec. 6 in Pennsylvania district court, claims that ABIM is charging inflated monopoly prices for maintaining certification, that the organization is forcing physicians to purchase MOC, and that ABIM is inducing employers and others to require ABIM certification. The four plaintiff-physicians are asking a judge to find ABIM in violation of federal antitrust law and to bar the board from continuing its MOC process. The suit is filed as a class action on behalf of all internists and subspecialists required by ABIM to purchase MOC to maintain their ABIM certifications. The plaintiffs seek damages and injunctive relief, plus lawsuit and attorney costs arising from ABIM’s alleged antitrust violations.

In a statement, ABIM expressed disappointment at the lawsuit and said the organization will vigorously defend itself, adding that doing so will “consume resources far better dedicated to continuous improvement of its programs.”

ABIM declined to answer questions addressing specific accusations from the lawsuit. However, in an interview, ABIM President Richard Baron, MD, said that “ABIM board-certified physicians have taken the initiative to distinguish themselves. This is a credential that physicians earn. We offer certified physicians the opportunity to demonstrate to the medical community, their peers, and the public that they are current and have special expertise.”

ABIM has not yet filed a formal response to the lawsuit, which was due by Jan. 6. Court documents show that in January, ABIM entered the appearances of four attorneys that will represent the board in the case. From there, discovery and evidence gathering in the case will begin.

Katherine Murray Leisure, MD, an infectious disease specialist based in Plymouth, Mass., is one of the plaintiffs. While she said that she could not comment specifically on the lawsuit, she has written publicly about her ABIM concerns in the past.

In a 2015 letter to Dr. Baron and posted on an anti-MOC website, Dr. Murray outlined a litany of complaints against ABIM’s MOC process and called on the U.S. Congress to investigate ABIM’s financial, legal, and ethical conduct.

“[The American Board of Medical Specialties] and ABIM collected more than $10,000 in fees and lost practice hours every decade from each [diplomate] doing MOC,” Dr. Murray Leisure wrote. “MOC took weeks away from our offices, clinics, patients, families, specialty societies, and individual research. ABMS MOC removed hundreds, perhaps thousands … of America’s best, once board-certified physicians from full hospital careers and earnings whenever [diplomates] did not complete these high-stakes MOC programs. … The righteous and fast solution to such moral, ethical, scientific, and constitutional problems is to end MOC now.”

Plaintiffs Glen Dela Cruz Manalo, MD; Alexa Joshua, MD; and Gerard Kenney, MD, did not return messages seeking comment. When contacted, attorneys for the plaintiffs declined to comment.

The doctors’ 32-page lawsuit characterizes ABIM as an organization motivated by money that has made its MOC process increasingly more burdensome for physicians over the years without evidence that MOC has any beneficial impact on doctors, patients, or the public. Complying with ABIM’s MOC costs internists an average of $23,607 in financial cost and time lost over 10 years, and costs up to $40,495 for some specialists, according to the suit.

The physicians allege that ABIM controls in excess of 95% of the market for MOC of internists, in violation of federal antitrust laws, and that the organization has unlawfully obtained and maintained monopoly power for MOC services.

The board’s illegal tying of its initial certification to its MOC results in burdensome conditions, including “raising the cost of the practice of medicine, constraining the supply of internists thereby harming competition, decreasing the supply of certified internists, and increasing the cost of medical services to patients and consumers,” the suit claims.

The legal challenge details how MOC has personally and professionally impacted each of the four plaintiffs. Dr. Manalo, a gastroenterologist, lost his privileges at St. Vincent Healthcare in Billings, Mont., and was subsequently terminated after he declined to maintain his ABIM certification as a gastroenterologist. In a letter to ABIM, Dr. Manalo wrote that it was “unfair and outright discriminatory that practitioners certified on or after 1990 are the only ones required to certify,” according to the lawsuit. Dr. Manalo later took a position as staff gastroenterologist at Jonathan M. Wainwright Memorial Veterans Affairs Medical Center in Walla Walla, Wash., at a substantially reduced salary. He became unemployed in 2017.

Dr. Murray Leisure obtained an initial and lifelong board certification in internal medicine from ABIM in 1984 and an infectious disease certification in 1990. ABlM terminated Dr. Murray’s infectious diseases certification after she failed her MOC examination in 2009, which led to lost privileges at Jordan Hospital in Plymouth, Mass. The loss caused significant damage to Dr. Murray, including lost income, a tarnished reputation, and the lost opportunity to help patients, according to the lawsuit. Jordan Hospital restored her privileges after Dr. Murray passed her MOC examination in 2012.

Dr. Kenney lost a job opportunity with Mount Nittany Physicians Group in State College, Pa., after he declined to renew his ABIM certification in gastroenterology. He is currently a physician with the University of Pittsburgh Medical Center in Seneca, Pa.

That the ABIM website lists him as “not certified,” is misleading, and makes it appear that his initial certifications were revoked due to failure to pass a MOC examination or misconduct, rather than because the certifications lapsed, according to the suit. The description makes Dr. Kenney appear less qualified to patients, hospitals, insurance companies, medical corporations, other employers, and others, he claims.

Dr. Joshua could not renew her consulting and admitting privileges at Detroit Medical Center after she failed an MOC examination in 2014 and became uncertified in internal medicine, according to the suit. In addition, Blue Cross Blue Shield informed Dr. Joshua it would no longer cover her because it required ABIM certification for coverage. She unsuccessfully appealed based on her certification with the National Board of Physicians and Surgeons. As a result of her certification termination, Dr. Joshua can only practice outpatient medicine at Detroit Medical Center.

In an interview, Dr. Baron emphasized the number of modifications made to its MOC process in recent years after responding to physician concerns. This includes an overhaul of the organization’s governance structure to include more than 200 practicing physicians and opening new avenues for physicians to engage in the creation of assessment content that more closely reflects what they see in practice, he said. In addition, ABIM now surveys all specialists to contribute to the exam blueprint review and the creation of the new Item Writing Task Force.

*This story was updated on Feb. 6, 2019.

BONITA SPRINGS, FLA. – Treating disorders tied to the use of highly potent synthetic opioids (HPSO), such as fentanyl, is challenging at best, an expert said at the annual meeting of the American Academy of Addiction Psychiatry.

“We have essentially no data to guide pharmacotherapy management decisions for the leading cause of fatal overdose deaths in the U.S.,” said John J. Mariani, MD, associate professor of clinical psychiatry at Columbia University, New York. “In the absence of data to make evidence-based recommendations, we still need to treat patients.”

That means taking what is known about the properties of those drugs into account when making treatment decisions, he said. Fentanyl quickly crosses the blood-brain barrier and is rapidly distributed to peripheral tissue. It has a short duration of action, but its duration can be extended with multiple injections or an infusion, he said. Research suggests that it has opioid receptor affinity similar to that of morphine, and it’s not known why it is up to 100 times more potent than morphine.

From his own experience, he offered some suggestions on treating patients who use HPSOs:

• Buprenorphine: Clinicians using buprenorphine as induction treatment have to wait longer from the last use to the first dose because of its longer effective half-life, and other medications might be needed to manage withdrawal. For maintenance, higher doses possibly should be considered to prevent HPSO override and to maintain opioid tolerance.
• Extended-release naltrexone: This involves a more difficult induction, and there is a question of whether inpatient treatment is better than outpatient, he said. For maintenance, more frequent administration should be considered, with closer monitoring for the risk of override and more urine toxicology testing.
• Methadone: For induction, methadone could offer an advantage over buprenorphine, because there is no risk of precipitated withdrawal. For maintenance, Dr. Mariani said, it’s not known whether standard doses protect against raising tolerance out of the reach of HPSOs’ effects.
• Naloxone: He said there have been increasing reports of multiple doses being needed to reverse an overdose. Because of the shorter time between substance use and death with fentanyl, more reports have been filed on unsuccessful attempts to revive people with naloxone despite multiple doses or stronger doses. Some naloxone programs have been giving more than two standard doses or using devices that give higher doses, he said. Also, since many users never intend to take fentanyl but are exposed to it through what they thought was heroin, communication is vital, he said.

Addiction psychiatrists “need to educate patients, families, and other clinicians of this new risk of using opioids,” he said.

Meanwhile, in another talk, Thomas Kosten, MD, described progress in the efforts to develop a vaccine against fentanyl addiction, in the hopes of preventing overdoses. Researchers are taking cues from the failed attempt to develop a cocaine vaccine a few years ago, in which not enough antibodies were produced in about half the patients.

BONITA SPRINGS, FLA. – Treating disorders tied to the use of highly potent synthetic opioids (HPSO), such as fentanyl, is challenging at best, an expert said at the annual meeting of the American Academy of Addiction Psychiatry.

“We have essentially no data to guide pharmacotherapy management decisions for the leading cause of fatal overdose deaths in the U.S.,” said John J. Mariani, MD, associate professor of clinical psychiatry at Columbia University, New York. “In the absence of data to make evidence-based recommendations, we still need to treat patients.”

That means taking what is known about the properties of those drugs into account when making treatment decisions, he said. Fentanyl quickly crosses the blood-brain barrier and is rapidly distributed to peripheral tissue. It has a short duration of action, but its duration can be extended with multiple injections or an infusion, he said. Research suggests that it has opioid receptor affinity similar to that of morphine, and it’s not known why it is up to 100 times more potent than morphine.

From his own experience, he offered some suggestions on treating patients who use HPSOs:

• Buprenorphine: Clinicians using buprenorphine as induction treatment have to wait longer from the last use to the first dose because of its longer effective half-life, and other medications might be needed to manage withdrawal. For maintenance, higher doses possibly should be considered to prevent HPSO override and to maintain opioid tolerance.
• Extended-release naltrexone: This involves a more difficult induction, and there is a question of whether inpatient treatment is better than outpatient, he said. For maintenance, more frequent administration should be considered, with closer monitoring for the risk of override and more urine toxicology testing.
• Methadone: For induction, methadone could offer an advantage over buprenorphine, because there is no risk of precipitated withdrawal. For maintenance, Dr. Mariani said, it’s not known whether standard doses protect against raising tolerance out of the reach of HPSOs’ effects.
• Naloxone: He said there have been increasing reports of multiple doses being needed to reverse an overdose. Because of the shorter time between substance use and death with fentanyl, more reports have been filed on unsuccessful attempts to revive people with naloxone despite multiple doses or stronger doses. Some naloxone programs have been giving more than two standard doses or using devices that give higher doses, he said. Also, since many users never intend to take fentanyl but are exposed to it through what they thought was heroin, communication is vital, he said.

Addiction psychiatrists “need to educate patients, families, and other clinicians of this new risk of using opioids,” he said.

Meanwhile, in another talk, Thomas Kosten, MD, described progress in the efforts to develop a vaccine against fentanyl addiction, in the hopes of preventing overdoses. Researchers are taking cues from the failed attempt to develop a cocaine vaccine a few years ago, in which not enough antibodies were produced in about half the patients.

BONITA SPRINGS, FLA. – Treating disorders tied to the use of highly potent synthetic opioids (HPSO), such as fentanyl, is challenging at best, an expert said at the annual meeting of the American Academy of Addiction Psychiatry.

“We have essentially no data to guide pharmacotherapy management decisions for the leading cause of fatal overdose deaths in the U.S.,” said John J. Mariani, MD, associate professor of clinical psychiatry at Columbia University, New York. “In the absence of data to make evidence-based recommendations, we still need to treat patients.”

That means taking what is known about the properties of those drugs into account when making treatment decisions, he said. Fentanyl quickly crosses the blood-brain barrier and is rapidly distributed to peripheral tissue. It has a short duration of action, but its duration can be extended with multiple injections or an infusion, he said. Research suggests that it has opioid receptor affinity similar to that of morphine, and it’s not known why it is up to 100 times more potent than morphine.

From his own experience, he offered some suggestions on treating patients who use HPSOs:

• Buprenorphine: Clinicians using buprenorphine as induction treatment have to wait longer from the last use to the first dose because of its longer effective half-life, and other medications might be needed to manage withdrawal. For maintenance, higher doses possibly should be considered to prevent HPSO override and to maintain opioid tolerance.
• Extended-release naltrexone: This involves a more difficult induction, and there is a question of whether inpatient treatment is better than outpatient, he said. For maintenance, more frequent administration should be considered, with closer monitoring for the risk of override and more urine toxicology testing.
• Methadone: For induction, methadone could offer an advantage over buprenorphine, because there is no risk of precipitated withdrawal. For maintenance, Dr. Mariani said, it’s not known whether standard doses protect against raising tolerance out of the reach of HPSOs’ effects.
• Naloxone: He said there have been increasing reports of multiple doses being needed to reverse an overdose. Because of the shorter time between substance use and death with fentanyl, more reports have been filed on unsuccessful attempts to revive people with naloxone despite multiple doses or stronger doses. Some naloxone programs have been giving more than two standard doses or using devices that give higher doses, he said. Also, since many users never intend to take fentanyl but are exposed to it through what they thought was heroin, communication is vital, he said.

Addiction psychiatrists “need to educate patients, families, and other clinicians of this new risk of using opioids,” he said.

Meanwhile, in another talk, Thomas Kosten, MD, described progress in the efforts to develop a vaccine against fentanyl addiction, in the hopes of preventing overdoses. Researchers are taking cues from the failed attempt to develop a cocaine vaccine a few years ago, in which not enough antibodies were produced in about half the patients.

It’s well known that overuse is an enormous problem in medicine, and when it comes to antibiotics, the problem is even more striking.

FotoMaximum/Thinkstock

“Half of all inpatient antibiotic use is inappropriate,” says Valerie Vaughn, MD, MSc, a hospitalist at the University of Michigan, Ann Arbor, and coauthor of a BMJ editorial about EHRs and antibiotic overuse.

“This has led to an increase in antibiotic-related adverse events (~20% of all hospitalized patients on antibiotics), Clostridium difficile infections (half a million infections and 29,000 deaths in U.S. annually), and resistant bacteria (which now account for nearly 12% of all bacterial infections, costing $2.2 billion annually).”

EHRs can be a tool to combat that trend – if they are well designed. Clinicians are influenced by the design of their electronic health record, Dr. Vaughn said. “Rather than leave its influence to chance, we should capitalize on what is known about design to promote appropriate testing and treatment through the EHR.” Hospitalists – integral to quality improvement – can have a role in making these changes.

“These improvements will be the most effective if behavioral economics and nudging are considered while designing,” Dr. Vaughn said. “For example, when creating order sets, list recommended options first and when possible make them the default,” she said. “This little change will greatly improve appropriate use.”

For every hour physicians spend on direct patient care, they spend another two with the EHR, Dr. Vaughn wrote. “Given this degree of attention, it is not surprising that the EHR influences physician behavior, especially the overuse of low-value medical care. … Displaying brand-name instead of generic options leads to more expensive prescribing. Allowing labs to be ordered recurrently increases unnecessary phlebotomy. Even individually listing inappropriate antibiotics (rather than grouping them) can make them more noticeable, resulting in more broad-spectrum use.”

“All hospitalists – and humans – are affected by knee-jerk responses. One of the most common in medicine is the urge to treat a positive culture or any positive test. Recognize this urge and resist!” she said. “Antibiotics may be the correct response, but clinicians should first think about whether treatment is necessary based on that patient’s symptoms and comorbidities. Resist the knee-jerk urge to give antibiotics for every positive culture.”
 

Reference

Vaughn VM et al. Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care. BMJ Qual Saf. 24 Mar 2018. doi: 10.1136/bmjqs-2017-007578.

It’s well known that overuse is an enormous problem in medicine, and when it comes to antibiotics, the problem is even more striking.

FotoMaximum/Thinkstock

“Half of all inpatient antibiotic use is inappropriate,” says Valerie Vaughn, MD, MSc, a hospitalist at the University of Michigan, Ann Arbor, and coauthor of a BMJ editorial about EHRs and antibiotic overuse.

“This has led to an increase in antibiotic-related adverse events (~20% of all hospitalized patients on antibiotics), Clostridium difficile infections (half a million infections and 29,000 deaths in U.S. annually), and resistant bacteria (which now account for nearly 12% of all bacterial infections, costing $2.2 billion annually).”

EHRs can be a tool to combat that trend – if they are well designed. Clinicians are influenced by the design of their electronic health record, Dr. Vaughn said. “Rather than leave its influence to chance, we should capitalize on what is known about design to promote appropriate testing and treatment through the EHR.” Hospitalists – integral to quality improvement – can have a role in making these changes.

“These improvements will be the most effective if behavioral economics and nudging are considered while designing,” Dr. Vaughn said. “For example, when creating order sets, list recommended options first and when possible make them the default,” she said. “This little change will greatly improve appropriate use.”

For every hour physicians spend on direct patient care, they spend another two with the EHR, Dr. Vaughn wrote. “Given this degree of attention, it is not surprising that the EHR influences physician behavior, especially the overuse of low-value medical care. … Displaying brand-name instead of generic options leads to more expensive prescribing. Allowing labs to be ordered recurrently increases unnecessary phlebotomy. Even individually listing inappropriate antibiotics (rather than grouping them) can make them more noticeable, resulting in more broad-spectrum use.”

“All hospitalists – and humans – are affected by knee-jerk responses. One of the most common in medicine is the urge to treat a positive culture or any positive test. Recognize this urge and resist!” she said. “Antibiotics may be the correct response, but clinicians should first think about whether treatment is necessary based on that patient’s symptoms and comorbidities. Resist the knee-jerk urge to give antibiotics for every positive culture.”
 

Reference

Vaughn VM et al. Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care. BMJ Qual Saf. 24 Mar 2018. doi: 10.1136/bmjqs-2017-007578.

It’s well known that overuse is an enormous problem in medicine, and when it comes to antibiotics, the problem is even more striking.

FotoMaximum/Thinkstock

“Half of all inpatient antibiotic use is inappropriate,” says Valerie Vaughn, MD, MSc, a hospitalist at the University of Michigan, Ann Arbor, and coauthor of a BMJ editorial about EHRs and antibiotic overuse.

“This has led to an increase in antibiotic-related adverse events (~20% of all hospitalized patients on antibiotics), Clostridium difficile infections (half a million infections and 29,000 deaths in U.S. annually), and resistant bacteria (which now account for nearly 12% of all bacterial infections, costing $2.2 billion annually).”

EHRs can be a tool to combat that trend – if they are well designed. Clinicians are influenced by the design of their electronic health record, Dr. Vaughn said. “Rather than leave its influence to chance, we should capitalize on what is known about design to promote appropriate testing and treatment through the EHR.” Hospitalists – integral to quality improvement – can have a role in making these changes.

“These improvements will be the most effective if behavioral economics and nudging are considered while designing,” Dr. Vaughn said. “For example, when creating order sets, list recommended options first and when possible make them the default,” she said. “This little change will greatly improve appropriate use.”

For every hour physicians spend on direct patient care, they spend another two with the EHR, Dr. Vaughn wrote. “Given this degree of attention, it is not surprising that the EHR influences physician behavior, especially the overuse of low-value medical care. … Displaying brand-name instead of generic options leads to more expensive prescribing. Allowing labs to be ordered recurrently increases unnecessary phlebotomy. Even individually listing inappropriate antibiotics (rather than grouping them) can make them more noticeable, resulting in more broad-spectrum use.”

“All hospitalists – and humans – are affected by knee-jerk responses. One of the most common in medicine is the urge to treat a positive culture or any positive test. Recognize this urge and resist!” she said. “Antibiotics may be the correct response, but clinicians should first think about whether treatment is necessary based on that patient’s symptoms and comorbidities. Resist the knee-jerk urge to give antibiotics for every positive culture.”
 

Reference

Vaughn VM et al. Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care. BMJ Qual Saf. 24 Mar 2018. doi: 10.1136/bmjqs-2017-007578.

BONITA SPRINGS, FLA. – Urine drug screening is a vital part of clinical care, but many clinicians say they do not know enough about how the tests work, an expert said at the annual meeting of the American Academy of Addiction Psychiatry.

Rebecca Ann Payne, MD, said clinicians, including residents, tend to cite little training as a reason for their uncertainty about how to interpret urine drug screen results. Also, primary care clinicians say they need more education on implementing and interpreting the screens.

The good news is that medicine and pediatric residents said they felt that a 30-minute educational program significantly boosted their knowledge base and comfort in interpreting urine drug screens, said Dr. Payne, assistant professor of neuropsychiatry and behavioral science at Palmetto Health–University of South Carolina Medical Group. She offered several points that addiction psychiatrists should be aware of:

• Be careful not to put too much stock in the results.

“A positive test doesn’t necessarily mean there’s a substance use disorder,” she said. “You still need to walk through those criteria with your patients. And a positive test doesn’t mean they’re physically dependent upon it.” She said she sometimes hears from patients who say that they’d been on a certain treatment – then failed a test given by their clinician – and had their treatment stripped away.

“Drug testing is meant to be a source of information and should not dictate treatment,” she said. “I have found it’s not unusual to hear from the community that decisions are being made solely on the results of these tests, which can be problematic.”

• Point-of-care tests, which sometimes can be bought in drug stores, she said, are “much less than perfect.”

The false-positive rate for benzodiazepines has been found to be 61%; and for methadone, it is 46%; for opioids, 22%; and for amphetamines, 21%.

• Know what your lab is actually testing for, because “it’s not universal.”

She emphasized knowing the particulars of opiate testing.

“A lot of times in a hospital setting, your lab is really only testing those opiates that are directly derived from the poppy – we’re talking about things like codeine, heroin, morphine. They’re not testing for things like your semi-synthetics or your full-synthetic opiates.”

• Know the answer to the question: “Can you get a positive result on a marijuana drug screen just from passive inhalation?”

Physicians often will be confronted by patients who insist they were only in the car or in the same room with someone who was smoking marijuana. How likely is it that their test could be positive?

“Possible,” she said, “but not probable.”

Dr. Payne’s key interest areas include teaching medical students and residents, treating substance use and psychiatric disorders that are comorbid, and conducting research in addiction psychiatry.

BONITA SPRINGS, FLA. – Urine drug screening is a vital part of clinical care, but many clinicians say they do not know enough about how the tests work, an expert said at the annual meeting of the American Academy of Addiction Psychiatry.

Rebecca Ann Payne, MD, said clinicians, including residents, tend to cite little training as a reason for their uncertainty about how to interpret urine drug screen results. Also, primary care clinicians say they need more education on implementing and interpreting the screens.

The good news is that medicine and pediatric residents said they felt that a 30-minute educational program significantly boosted their knowledge base and comfort in interpreting urine drug screens, said Dr. Payne, assistant professor of neuropsychiatry and behavioral science at Palmetto Health–University of South Carolina Medical Group. She offered several points that addiction psychiatrists should be aware of:

• Be careful not to put too much stock in the results.

“A positive test doesn’t necessarily mean there’s a substance use disorder,” she said. “You still need to walk through those criteria with your patients. And a positive test doesn’t mean they’re physically dependent upon it.” She said she sometimes hears from patients who say that they’d been on a certain treatment – then failed a test given by their clinician – and had their treatment stripped away.

“Drug testing is meant to be a source of information and should not dictate treatment,” she said. “I have found it’s not unusual to hear from the community that decisions are being made solely on the results of these tests, which can be problematic.”

• Point-of-care tests, which sometimes can be bought in drug stores, she said, are “much less than perfect.”

The false-positive rate for benzodiazepines has been found to be 61%; and for methadone, it is 46%; for opioids, 22%; and for amphetamines, 21%.

• Know what your lab is actually testing for, because “it’s not universal.”

She emphasized knowing the particulars of opiate testing.

“A lot of times in a hospital setting, your lab is really only testing those opiates that are directly derived from the poppy – we’re talking about things like codeine, heroin, morphine. They’re not testing for things like your semi-synthetics or your full-synthetic opiates.”

• Know the answer to the question: “Can you get a positive result on a marijuana drug screen just from passive inhalation?”

Physicians often will be confronted by patients who insist they were only in the car or in the same room with someone who was smoking marijuana. How likely is it that their test could be positive?

“Possible,” she said, “but not probable.”

Dr. Payne’s key interest areas include teaching medical students and residents, treating substance use and psychiatric disorders that are comorbid, and conducting research in addiction psychiatry.

BONITA SPRINGS, FLA. – Urine drug screening is a vital part of clinical care, but many clinicians say they do not know enough about how the tests work, an expert said at the annual meeting of the American Academy of Addiction Psychiatry.

Rebecca Ann Payne, MD, said clinicians, including residents, tend to cite little training as a reason for their uncertainty about how to interpret urine drug screen results. Also, primary care clinicians say they need more education on implementing and interpreting the screens.

The good news is that medicine and pediatric residents said they felt that a 30-minute educational program significantly boosted their knowledge base and comfort in interpreting urine drug screens, said Dr. Payne, assistant professor of neuropsychiatry and behavioral science at Palmetto Health–University of South Carolina Medical Group. She offered several points that addiction psychiatrists should be aware of:

• Be careful not to put too much stock in the results.

“A positive test doesn’t necessarily mean there’s a substance use disorder,” she said. “You still need to walk through those criteria with your patients. And a positive test doesn’t mean they’re physically dependent upon it.” She said she sometimes hears from patients who say that they’d been on a certain treatment – then failed a test given by their clinician – and had their treatment stripped away.

“Drug testing is meant to be a source of information and should not dictate treatment,” she said. “I have found it’s not unusual to hear from the community that decisions are being made solely on the results of these tests, which can be problematic.”

• Point-of-care tests, which sometimes can be bought in drug stores, she said, are “much less than perfect.”

The false-positive rate for benzodiazepines has been found to be 61%; and for methadone, it is 46%; for opioids, 22%; and for amphetamines, 21%.

• Know what your lab is actually testing for, because “it’s not universal.”

She emphasized knowing the particulars of opiate testing.

“A lot of times in a hospital setting, your lab is really only testing those opiates that are directly derived from the poppy – we’re talking about things like codeine, heroin, morphine. They’re not testing for things like your semi-synthetics or your full-synthetic opiates.”

• Know the answer to the question: “Can you get a positive result on a marijuana drug screen just from passive inhalation?”

Physicians often will be confronted by patients who insist they were only in the car or in the same room with someone who was smoking marijuana. How likely is it that their test could be positive?

“Possible,” she said, “but not probable.”

Dr. Payne’s key interest areas include teaching medical students and residents, treating substance use and psychiatric disorders that are comorbid, and conducting research in addiction psychiatry.

The symptoms of burnout include emotional exhaustion, depersonalization, and reduced personal efficacy, and burnout is a widespread problem among hospitalists; recent data suggest that half of physicians are experiencing at least one such symptom.

Health care leaders are increasingly concerned that these levels of physician burnout pose a threat to patient quality and safety. “As a result, some health care systems are shifting emphasis from the Triple Aim – population health, reduced costs, and patient satisfaction – to the Quadruple Aim, which incorporates health care provider wellness,” according to a recent abstract.

The authors began their own attempt to address the problem when Penn State Health in Dauphin County, Pa., built a stand-alone children’s hospital and experienced bed demands that exceeded bed availability, creating decreased organizational efficiency, high stress, and elevated physician burnout.

The LEAN principles offer a process-focused, customer-centered methodology that improves efficiency and quality. “We redesigned our service line using LEAN principles, such as ‘staff to demand’ and ‘standardize work,’ ” the authors wrote. “To ‘staff to demand,’ we hired three additional FTE [full-time equivalent employees]. This allowed creation of two rounding teams ([up] from one) and reduced our patient-to-attending ratio from 15:1 to 8:1. Workflow was resequenced and standardized, which enabled teams to see discharges at the start of rounds. We also provided in-house evening and overnight resident supervision. Our model permitted flexibility in physicians’ schedules, deemphasized reliance on RVUs, and heightened purpose and efficiency in work as determinants of providers’ value-adding capacity.”

As a result, both service line and hospital efficiency improved and faculty stress decreased in their hospital. “Mean stress scores decreased from 23 (preintervention) to 15 over the first 2 years, and has remained steady for a period of 3 years. Our divisional work-life balance measurement 2 years after the intervention was 85%, well above the reported average of 41%. We have maintained a low physician turnover rate at 3.5% over the last 3 years.”
 

Reference

Keefer L et al. LEAN in: Our secrets to decreasing provider stress, maximizing efficiency on a pediatric hospitalist service [abstract]. Accessed April 6, 2018.


 

The symptoms of burnout include emotional exhaustion, depersonalization, and reduced personal efficacy, and burnout is a widespread problem among hospitalists; recent data suggest that half of physicians are experiencing at least one such symptom.

Health care leaders are increasingly concerned that these levels of physician burnout pose a threat to patient quality and safety. “As a result, some health care systems are shifting emphasis from the Triple Aim – population health, reduced costs, and patient satisfaction – to the Quadruple Aim, which incorporates health care provider wellness,” according to a recent abstract.

The authors began their own attempt to address the problem when Penn State Health in Dauphin County, Pa., built a stand-alone children’s hospital and experienced bed demands that exceeded bed availability, creating decreased organizational efficiency, high stress, and elevated physician burnout.

The LEAN principles offer a process-focused, customer-centered methodology that improves efficiency and quality. “We redesigned our service line using LEAN principles, such as ‘staff to demand’ and ‘standardize work,’ ” the authors wrote. “To ‘staff to demand,’ we hired three additional FTE [full-time equivalent employees]. This allowed creation of two rounding teams ([up] from one) and reduced our patient-to-attending ratio from 15:1 to 8:1. Workflow was resequenced and standardized, which enabled teams to see discharges at the start of rounds. We also provided in-house evening and overnight resident supervision. Our model permitted flexibility in physicians’ schedules, deemphasized reliance on RVUs, and heightened purpose and efficiency in work as determinants of providers’ value-adding capacity.”

As a result, both service line and hospital efficiency improved and faculty stress decreased in their hospital. “Mean stress scores decreased from 23 (preintervention) to 15 over the first 2 years, and has remained steady for a period of 3 years. Our divisional work-life balance measurement 2 years after the intervention was 85%, well above the reported average of 41%. We have maintained a low physician turnover rate at 3.5% over the last 3 years.”
 

Reference

Keefer L et al. LEAN in: Our secrets to decreasing provider stress, maximizing efficiency on a pediatric hospitalist service [abstract]. Accessed April 6, 2018.


 

The symptoms of burnout include emotional exhaustion, depersonalization, and reduced personal efficacy, and burnout is a widespread problem among hospitalists; recent data suggest that half of physicians are experiencing at least one such symptom.

Health care leaders are increasingly concerned that these levels of physician burnout pose a threat to patient quality and safety. “As a result, some health care systems are shifting emphasis from the Triple Aim – population health, reduced costs, and patient satisfaction – to the Quadruple Aim, which incorporates health care provider wellness,” according to a recent abstract.

The authors began their own attempt to address the problem when Penn State Health in Dauphin County, Pa., built a stand-alone children’s hospital and experienced bed demands that exceeded bed availability, creating decreased organizational efficiency, high stress, and elevated physician burnout.

The LEAN principles offer a process-focused, customer-centered methodology that improves efficiency and quality. “We redesigned our service line using LEAN principles, such as ‘staff to demand’ and ‘standardize work,’ ” the authors wrote. “To ‘staff to demand,’ we hired three additional FTE [full-time equivalent employees]. This allowed creation of two rounding teams ([up] from one) and reduced our patient-to-attending ratio from 15:1 to 8:1. Workflow was resequenced and standardized, which enabled teams to see discharges at the start of rounds. We also provided in-house evening and overnight resident supervision. Our model permitted flexibility in physicians’ schedules, deemphasized reliance on RVUs, and heightened purpose and efficiency in work as determinants of providers’ value-adding capacity.”

As a result, both service line and hospital efficiency improved and faculty stress decreased in their hospital. “Mean stress scores decreased from 23 (preintervention) to 15 over the first 2 years, and has remained steady for a period of 3 years. Our divisional work-life balance measurement 2 years after the intervention was 85%, well above the reported average of 41%. We have maintained a low physician turnover rate at 3.5% over the last 3 years.”
 

Reference

Keefer L et al. LEAN in: Our secrets to decreasing provider stress, maximizing efficiency on a pediatric hospitalist service [abstract]. Accessed April 6, 2018.


 

Veterans with chronic obstructive pulmonary disease (COPD) have seen a sharp increase since 2012 in rates of non-TB mycobacteria infections, which carry a significantly higher risk of death in COPD patients, according to findings from a nationwide study.

Dr. George Kubica/CDC

For their research, published in Frontiers of Medicine, Fahim Pyarali, MD, and colleagues at the University of Miami, reviewed data from Veterans Affairs hospitals to identify non-TB mycobacteria (NTM) infections among more than 2 million COPD patients seen between 2000 and 2015. Incidence of NTM infections was 34.2 per 100,000 COPD patients in 2001, a rate that remained steady until 2012, when it began climbing sharply through 2015 to reach 70.3 per 100,000 (P = .035). Dr. Pyarali and colleagues also found that, during the study period, prevalence of NTM climbed from 93.1 infections per 100,000 population in 2001 to 277.6 per 100,000 in 2015.

Hotspots for NTM infections included Puerto Rico, which had the highest prevalence seen in the study at 370 infections per 100,000 COPD population; Florida, with 351 per 100,000; and Washington, D.C., with 309 per 100,000. Additional hotspots were identified around Lake Michigan, in coastal Louisiana, and in parts of the Southwest.

Dr. Pyarali and colleagues noted that the geographical concentration of cases near oceans and lakes was “supported by previous findings that warmer temperatures, lower dissolved oxygen, and lower pH in the soils and waters provide a major environmental source for NTM organisms;” however, the study is the first to identify Puerto Rico as having exceptionally high prevalence. The reasons for this should be extensively investigated, the investigators argued.

The mortality risk was 43% higher among NTM-infected patients than in COPD patients without an NTM diagnosis (95% confidence interval, 1.31-1.58; P less than .001), independent of other comorbidities.

Though rates of NTM infection were seen rising steeply in men and women alike, Dr. Pyarali and colleagues noted as a limitation of their study its use of an overwhelmingly male population, writing that this may obscure “the true reach of NTM disease and mortality” in the general population. The average age of NTM diagnosis remained steady throughout the study period, suggesting that rising incidence is not attributable to earlier diagnosis.

Dr. Pyarali and colleagues reported no outside sources of funding or financial conflicts of interest.

SOURCE: Pyarali F et al. Front Med. 2018 Nov 6. doi: 10.3389/fmed2018.00311.

Veterans with chronic obstructive pulmonary disease (COPD) have seen a sharp increase since 2012 in rates of non-TB mycobacteria infections, which carry a significantly higher risk of death in COPD patients, according to findings from a nationwide study.

Dr. George Kubica/CDC

For their research, published in Frontiers of Medicine, Fahim Pyarali, MD, and colleagues at the University of Miami, reviewed data from Veterans Affairs hospitals to identify non-TB mycobacteria (NTM) infections among more than 2 million COPD patients seen between 2000 and 2015. Incidence of NTM infections was 34.2 per 100,000 COPD patients in 2001, a rate that remained steady until 2012, when it began climbing sharply through 2015 to reach 70.3 per 100,000 (P = .035). Dr. Pyarali and colleagues also found that, during the study period, prevalence of NTM climbed from 93.1 infections per 100,000 population in 2001 to 277.6 per 100,000 in 2015.

Hotspots for NTM infections included Puerto Rico, which had the highest prevalence seen in the study at 370 infections per 100,000 COPD population; Florida, with 351 per 100,000; and Washington, D.C., with 309 per 100,000. Additional hotspots were identified around Lake Michigan, in coastal Louisiana, and in parts of the Southwest.

Dr. Pyarali and colleagues noted that the geographical concentration of cases near oceans and lakes was “supported by previous findings that warmer temperatures, lower dissolved oxygen, and lower pH in the soils and waters provide a major environmental source for NTM organisms;” however, the study is the first to identify Puerto Rico as having exceptionally high prevalence. The reasons for this should be extensively investigated, the investigators argued.

The mortality risk was 43% higher among NTM-infected patients than in COPD patients without an NTM diagnosis (95% confidence interval, 1.31-1.58; P less than .001), independent of other comorbidities.

Though rates of NTM infection were seen rising steeply in men and women alike, Dr. Pyarali and colleagues noted as a limitation of their study its use of an overwhelmingly male population, writing that this may obscure “the true reach of NTM disease and mortality” in the general population. The average age of NTM diagnosis remained steady throughout the study period, suggesting that rising incidence is not attributable to earlier diagnosis.

Dr. Pyarali and colleagues reported no outside sources of funding or financial conflicts of interest.

SOURCE: Pyarali F et al. Front Med. 2018 Nov 6. doi: 10.3389/fmed2018.00311.

Veterans with chronic obstructive pulmonary disease (COPD) have seen a sharp increase since 2012 in rates of non-TB mycobacteria infections, which carry a significantly higher risk of death in COPD patients, according to findings from a nationwide study.

Dr. George Kubica/CDC

For their research, published in Frontiers of Medicine, Fahim Pyarali, MD, and colleagues at the University of Miami, reviewed data from Veterans Affairs hospitals to identify non-TB mycobacteria (NTM) infections among more than 2 million COPD patients seen between 2000 and 2015. Incidence of NTM infections was 34.2 per 100,000 COPD patients in 2001, a rate that remained steady until 2012, when it began climbing sharply through 2015 to reach 70.3 per 100,000 (P = .035). Dr. Pyarali and colleagues also found that, during the study period, prevalence of NTM climbed from 93.1 infections per 100,000 population in 2001 to 277.6 per 100,000 in 2015.

Hotspots for NTM infections included Puerto Rico, which had the highest prevalence seen in the study at 370 infections per 100,000 COPD population; Florida, with 351 per 100,000; and Washington, D.C., with 309 per 100,000. Additional hotspots were identified around Lake Michigan, in coastal Louisiana, and in parts of the Southwest.

Dr. Pyarali and colleagues noted that the geographical concentration of cases near oceans and lakes was “supported by previous findings that warmer temperatures, lower dissolved oxygen, and lower pH in the soils and waters provide a major environmental source for NTM organisms;” however, the study is the first to identify Puerto Rico as having exceptionally high prevalence. The reasons for this should be extensively investigated, the investigators argued.

The mortality risk was 43% higher among NTM-infected patients than in COPD patients without an NTM diagnosis (95% confidence interval, 1.31-1.58; P less than .001), independent of other comorbidities.

Though rates of NTM infection were seen rising steeply in men and women alike, Dr. Pyarali and colleagues noted as a limitation of their study its use of an overwhelmingly male population, writing that this may obscure “the true reach of NTM disease and mortality” in the general population. The average age of NTM diagnosis remained steady throughout the study period, suggesting that rising incidence is not attributable to earlier diagnosis.

Dr. Pyarali and colleagues reported no outside sources of funding or financial conflicts of interest.

SOURCE: Pyarali F et al. Front Med. 2018 Nov 6. doi: 10.3389/fmed2018.00311.

This fall I attended the 2018 Society of Hospital Medicine Leadership Academy, held in Vancouver. Once again, this conference sold out weeks ahead of time, and 300 hospitalists took time out of their busy schedules for learning and fun. There have been about 18 Leadership Academies over the years, with approximately 3,000 total participants, but this one may have been the best to date.

Why was it so good? Here are my top four reasons that Leadership Academy 2018 was the best ever:

Setting: Vancouver is just beautiful. My family has a strong maritime background, and I am a water person with saltwater in my veins. My inner sailor was overjoyed with the hotel’s views of False Creek and Vancouver Harbor, and I loved the mix of yachts and working boats. I even saw a seaplane! The hotel was a great match for the 300 hospitalists who traveled to the JW Marriott for 4 days of learning and relaxing. It was the perfect blend, whether for work or play; the hotel and city did not disappoint.

Networking: What’s more fun than getting to know 300 like-minded, leadership-oriented hospitalists for a few days? I am always energized by seeing old friends and making new ones. I really enjoy hearing about the professional adventures hospitalists at all career points are going through. Plus, I get really good advice on my own career! I also appreciate that a number of hospital medicine leaders (and even giants) come to SHM’s Leadership Academy. Over half of the SHM Board of Directors were there, as were a number of current and previous SHM presidents (Mark Williams, Jeff Wiese, Burke Kealey, Bob Harrington, Nasim Afsar, Rusty Holman, Ron Greeno, Chris Frost, and John Nelson), as well as Larry Wellikson, the CEO who has led our society through its many successes. All of these hospitalist leaders are there, having fun and networking, alongside everyone else.

Faculty: The faculty for all four courses (yes, Leadership Academy junkies, we’ve added a fourth course!) are absolutely phenomenal. I think the faculty are just the right blend of expert hospitalists (Jeff Glasheen, Rusty Holman, Jeff Wiese, Mark Williams, John Nelson) and national experts outside of hospital medicine. For example, Lenny Marcus of Harvard T.H. Chan School of Public Health, Boston, brings his experience coaching the Department of Defense, the White House, the Department of Homeland Security, and many others to the Influential Management and Mastering Teamwork courses. Lenny’s experience working with national leaders through disasters like the Boston Marathon bombing, Hurricane Katrina, and the Ebola outbreak make for more than riveting stories; there are real, tangible lessons for hospitalist leaders trying to improve clinical care. Nancy Spector is a pediatrician, nationally recognized for her work in mentoring, and is the executive director of Drexel University’s Executive Leadership in Academic Medicine. We have been fortunate to have her join the Academies, and Nancy successfully led the first group of hospitalists through the launch of SHM’s fourth leadership course, which I will describe in more detail below.

High energy & continued growth: There continues to be an enormous amount of energy around the Leadership Academy. The Vancouver courses sold out months ahead of the actual meeting! Hospitalists across the country continue to take on leadership roles and have told us that they value the skills they have learned from the courses.
 

Hospitalist leaders want more

In addition to the current 4-day courses (Strategic Essentials, Influential Management, and Mastering Teamwork), hospitalists are looking for a course that continues skill building once they return home.

That’s why SHM has developed a fourth Leadership Academy course. This course, called the Capstone Course, was launched in Vancouver and consists of 2 days of on-site skill development and team building (during the first 2 days of the traditional Leadership Academy) and 6 months of a longitudinal learning collaborative. The six-month learning collaborative component consists of a learning “pod” of five or six fellow hospitalists and monthly virtual meetings around crucial leadership topics. They are facilitated by an experienced Leadership Academy facilitator.

Dr. Spector is the lead faculty; her expertise made the Capstone launch a huge success. She will work with SHM and the Capstone participants throughout the entire 6 months to ensure the Capstone course is as high-quality as the previous three Academy courses.

If you haven’t been, I invite you to attend our next Leadership Academy. Over the years, despite being course director, I have learned many take-home skills from colleagues and leaders in the field that I use often. Just to name a few:

• Flexing my communications style: Tim Keogh’s lecture opened my eyes to the fact that not everyone is a data-driven introvert. I now know that some people need a social warm up, while others just want the facts, and that there are “huggers and shakers.” (In summary, it’s fine to shake hands with a hugger, but be wary of hugging a shaker.)
• I send birthday emails after I heard Jeff Wiese’s talk.
• Lenny Marcus taught me to be aware when I am “in the basement” emotionally. I now know to wait to send emails or confront others until I can get out of the basement.

And that’s just scratching the surface!

In closing, the Vancouver Leadership Academy was fantastic. Good friends, great professional development, a setting that was amazing, and an Academy that remains relevant and dynamic to our specialty. I can’t wait to see how the 2019 Leadership Academy shapes up for its debut in Nashville. My inner sailor may have to give way to my inner musician! I hope to see you and 300 of my closest friends there.

Learn more about SHM’s Leadership Academy at shmleadershipacademy.org.
 

Dr. Howell is a professor of medicine at Johns Hopkins University, Baltimore, and chief of the division of hospital medicine at Johns Hopkins Bayview Medical Center. He is also chief operating officer at the Society of Hospital Medicine and course director of the SHM Leadership Academy.

This fall I attended the 2018 Society of Hospital Medicine Leadership Academy, held in Vancouver. Once again, this conference sold out weeks ahead of time, and 300 hospitalists took time out of their busy schedules for learning and fun. There have been about 18 Leadership Academies over the years, with approximately 3,000 total participants, but this one may have been the best to date.

Why was it so good? Here are my top four reasons that Leadership Academy 2018 was the best ever:

Setting: Vancouver is just beautiful. My family has a strong maritime background, and I am a water person with saltwater in my veins. My inner sailor was overjoyed with the hotel’s views of False Creek and Vancouver Harbor, and I loved the mix of yachts and working boats. I even saw a seaplane! The hotel was a great match for the 300 hospitalists who traveled to the JW Marriott for 4 days of learning and relaxing. It was the perfect blend, whether for work or play; the hotel and city did not disappoint.

Networking: What’s more fun than getting to know 300 like-minded, leadership-oriented hospitalists for a few days? I am always energized by seeing old friends and making new ones. I really enjoy hearing about the professional adventures hospitalists at all career points are going through. Plus, I get really good advice on my own career! I also appreciate that a number of hospital medicine leaders (and even giants) come to SHM’s Leadership Academy. Over half of the SHM Board of Directors were there, as were a number of current and previous SHM presidents (Mark Williams, Jeff Wiese, Burke Kealey, Bob Harrington, Nasim Afsar, Rusty Holman, Ron Greeno, Chris Frost, and John Nelson), as well as Larry Wellikson, the CEO who has led our society through its many successes. All of these hospitalist leaders are there, having fun and networking, alongside everyone else.

Faculty: The faculty for all four courses (yes, Leadership Academy junkies, we’ve added a fourth course!) are absolutely phenomenal. I think the faculty are just the right blend of expert hospitalists (Jeff Glasheen, Rusty Holman, Jeff Wiese, Mark Williams, John Nelson) and national experts outside of hospital medicine. For example, Lenny Marcus of Harvard T.H. Chan School of Public Health, Boston, brings his experience coaching the Department of Defense, the White House, the Department of Homeland Security, and many others to the Influential Management and Mastering Teamwork courses. Lenny’s experience working with national leaders through disasters like the Boston Marathon bombing, Hurricane Katrina, and the Ebola outbreak make for more than riveting stories; there are real, tangible lessons for hospitalist leaders trying to improve clinical care. Nancy Spector is a pediatrician, nationally recognized for her work in mentoring, and is the executive director of Drexel University’s Executive Leadership in Academic Medicine. We have been fortunate to have her join the Academies, and Nancy successfully led the first group of hospitalists through the launch of SHM’s fourth leadership course, which I will describe in more detail below.

High energy & continued growth: There continues to be an enormous amount of energy around the Leadership Academy. The Vancouver courses sold out months ahead of the actual meeting! Hospitalists across the country continue to take on leadership roles and have told us that they value the skills they have learned from the courses.
 

Hospitalist leaders want more

In addition to the current 4-day courses (Strategic Essentials, Influential Management, and Mastering Teamwork), hospitalists are looking for a course that continues skill building once they return home.

That’s why SHM has developed a fourth Leadership Academy course. This course, called the Capstone Course, was launched in Vancouver and consists of 2 days of on-site skill development and team building (during the first 2 days of the traditional Leadership Academy) and 6 months of a longitudinal learning collaborative. The six-month learning collaborative component consists of a learning “pod” of five or six fellow hospitalists and monthly virtual meetings around crucial leadership topics. They are facilitated by an experienced Leadership Academy facilitator.

Dr. Spector is the lead faculty; her expertise made the Capstone launch a huge success. She will work with SHM and the Capstone participants throughout the entire 6 months to ensure the Capstone course is as high-quality as the previous three Academy courses.

If you haven’t been, I invite you to attend our next Leadership Academy. Over the years, despite being course director, I have learned many take-home skills from colleagues and leaders in the field that I use often. Just to name a few:

• Flexing my communications style: Tim Keogh’s lecture opened my eyes to the fact that not everyone is a data-driven introvert. I now know that some people need a social warm up, while others just want the facts, and that there are “huggers and shakers.” (In summary, it’s fine to shake hands with a hugger, but be wary of hugging a shaker.)
• I send birthday emails after I heard Jeff Wiese’s talk.
• Lenny Marcus taught me to be aware when I am “in the basement” emotionally. I now know to wait to send emails or confront others until I can get out of the basement.

And that’s just scratching the surface!

In closing, the Vancouver Leadership Academy was fantastic. Good friends, great professional development, a setting that was amazing, and an Academy that remains relevant and dynamic to our specialty. I can’t wait to see how the 2019 Leadership Academy shapes up for its debut in Nashville. My inner sailor may have to give way to my inner musician! I hope to see you and 300 of my closest friends there.

Learn more about SHM’s Leadership Academy at shmleadershipacademy.org.
 

Dr. Howell is a professor of medicine at Johns Hopkins University, Baltimore, and chief of the division of hospital medicine at Johns Hopkins Bayview Medical Center. He is also chief operating officer at the Society of Hospital Medicine and course director of the SHM Leadership Academy.

This fall I attended the 2018 Society of Hospital Medicine Leadership Academy, held in Vancouver. Once again, this conference sold out weeks ahead of time, and 300 hospitalists took time out of their busy schedules for learning and fun. There have been about 18 Leadership Academies over the years, with approximately 3,000 total participants, but this one may have been the best to date.

Why was it so good? Here are my top four reasons that Leadership Academy 2018 was the best ever:

Setting: Vancouver is just beautiful. My family has a strong maritime background, and I am a water person with saltwater in my veins. My inner sailor was overjoyed with the hotel’s views of False Creek and Vancouver Harbor, and I loved the mix of yachts and working boats. I even saw a seaplane! The hotel was a great match for the 300 hospitalists who traveled to the JW Marriott for 4 days of learning and relaxing. It was the perfect blend, whether for work or play; the hotel and city did not disappoint.

Networking: What’s more fun than getting to know 300 like-minded, leadership-oriented hospitalists for a few days? I am always energized by seeing old friends and making new ones. I really enjoy hearing about the professional adventures hospitalists at all career points are going through. Plus, I get really good advice on my own career! I also appreciate that a number of hospital medicine leaders (and even giants) come to SHM’s Leadership Academy. Over half of the SHM Board of Directors were there, as were a number of current and previous SHM presidents (Mark Williams, Jeff Wiese, Burke Kealey, Bob Harrington, Nasim Afsar, Rusty Holman, Ron Greeno, Chris Frost, and John Nelson), as well as Larry Wellikson, the CEO who has led our society through its many successes. All of these hospitalist leaders are there, having fun and networking, alongside everyone else.

Faculty: The faculty for all four courses (yes, Leadership Academy junkies, we’ve added a fourth course!) are absolutely phenomenal. I think the faculty are just the right blend of expert hospitalists (Jeff Glasheen, Rusty Holman, Jeff Wiese, Mark Williams, John Nelson) and national experts outside of hospital medicine. For example, Lenny Marcus of Harvard T.H. Chan School of Public Health, Boston, brings his experience coaching the Department of Defense, the White House, the Department of Homeland Security, and many others to the Influential Management and Mastering Teamwork courses. Lenny’s experience working with national leaders through disasters like the Boston Marathon bombing, Hurricane Katrina, and the Ebola outbreak make for more than riveting stories; there are real, tangible lessons for hospitalist leaders trying to improve clinical care. Nancy Spector is a pediatrician, nationally recognized for her work in mentoring, and is the executive director of Drexel University’s Executive Leadership in Academic Medicine. We have been fortunate to have her join the Academies, and Nancy successfully led the first group of hospitalists through the launch of SHM’s fourth leadership course, which I will describe in more detail below.

High energy & continued growth: There continues to be an enormous amount of energy around the Leadership Academy. The Vancouver courses sold out months ahead of the actual meeting! Hospitalists across the country continue to take on leadership roles and have told us that they value the skills they have learned from the courses.
 

Hospitalist leaders want more

In addition to the current 4-day courses (Strategic Essentials, Influential Management, and Mastering Teamwork), hospitalists are looking for a course that continues skill building once they return home.

That’s why SHM has developed a fourth Leadership Academy course. This course, called the Capstone Course, was launched in Vancouver and consists of 2 days of on-site skill development and team building (during the first 2 days of the traditional Leadership Academy) and 6 months of a longitudinal learning collaborative. The six-month learning collaborative component consists of a learning “pod” of five or six fellow hospitalists and monthly virtual meetings around crucial leadership topics. They are facilitated by an experienced Leadership Academy facilitator.

Dr. Spector is the lead faculty; her expertise made the Capstone launch a huge success. She will work with SHM and the Capstone participants throughout the entire 6 months to ensure the Capstone course is as high-quality as the previous three Academy courses.

If you haven’t been, I invite you to attend our next Leadership Academy. Over the years, despite being course director, I have learned many take-home skills from colleagues and leaders in the field that I use often. Just to name a few:

• Flexing my communications style: Tim Keogh’s lecture opened my eyes to the fact that not everyone is a data-driven introvert. I now know that some people need a social warm up, while others just want the facts, and that there are “huggers and shakers.” (In summary, it’s fine to shake hands with a hugger, but be wary of hugging a shaker.)
• I send birthday emails after I heard Jeff Wiese’s talk.
• Lenny Marcus taught me to be aware when I am “in the basement” emotionally. I now know to wait to send emails or confront others until I can get out of the basement.

And that’s just scratching the surface!

In closing, the Vancouver Leadership Academy was fantastic. Good friends, great professional development, a setting that was amazing, and an Academy that remains relevant and dynamic to our specialty. I can’t wait to see how the 2019 Leadership Academy shapes up for its debut in Nashville. My inner sailor may have to give way to my inner musician! I hope to see you and 300 of my closest friends there.

Learn more about SHM’s Leadership Academy at shmleadershipacademy.org.
 

Dr. Howell is a professor of medicine at Johns Hopkins University, Baltimore, and chief of the division of hospital medicine at Johns Hopkins Bayview Medical Center. He is also chief operating officer at the Society of Hospital Medicine and course director of the SHM Leadership Academy.

Leave policies for residents who become new parents are uneven, oft-ignored by training boards, and provide less time off than similar policies for faculty physicians. Those were the findings of a pair of research letters published in JAMA.

Kirti Magudia, MD, of the department of radiology at Brigham and Women’s Hospital in Boston and her colleagues reviewed childbearing and family leave policies for 15 graduate medical education (GME)–sponsoring institutions, all of which were affiliated with the top 12 U.S. medical schools. Though all 12 schools provided paid childbearing or family leave for faculty physicians, only 8 of the 15 did so for residents (JAMA. 2018 Dec 11;320[22)]:2372-4).

In programs that did provide leave, the average of 6.6 weeks of paid total maternity leave for residents was less than the 8.6 weeks faculty receive. Both are considerably less than proscribed by the Family and Medical Leave Act, which requires large employers to provide 12 weeks of unpaid leave, but only after 12 months of employment.

The research focused on only institutional policies for paid leave; unpaid leave and state policies may extend the average, and departments may offer leave that goes beyond specific policies, Dr. Magudia and her colleagues noted.

Changes in the residency population make now the right time for establishing consistent family leave policies, Dr. Magudia said in an interview. “We have people starting training later; we have more female trainees. And with the Match system, you’re not in control of exactly where you’re going. You may not have a support system where you end up, and a lot of the top training institutions are in high cost-of-living areas. All of those things together can make trainees especially vulnerable, and because trainees are temporary employees, changing policies to benefit them is very challenging.

“Wellness is a huge issue in medicine, and at large in society,” she said. “Making sure people have adequate parental leave goes a long way toward reducing stress levels and helping them cope with normal life transitions. We want to take steps that promote success among a diverse community of physicians; we want to retain as many people in the field as possible, and we want them to feel supported.”

Beyond asking all GME-sponsoring institutions to adopt parental leave policies, Dr. Magudia believes trainees must be better informed. “It should be clear to training program applicants what the policies are at those institutions,” she said. “That information is extremely difficult to obtain, as we’ve discovered. You can imagine that, if you are the applicant, it can be difficult to ask about those policies during the interview process because it may affect how things turn out.”

“If we can see changes like these made in the near future,” she added, “we will be in a good place.”

In the second study, Briony K. Varda, MD, of the department of urology at Boston Children’s Hospital, and her colleagues also noted the complications of balancing parental leave with training requirements from specialty boards. They compared leave policies among American Board of Medical Specialty member organizations and found that less than half specifically mentioned parental leave for resident physicians (JAMA. 2018 Dec 11;320[22]:2374-7).

Dr. Varda and her colleagues reviewed the websites of 24 ABMS boards to determine their leave policies; 22 had policies but only 11 cited parental leave as an option for residents. Twenty boards have time-based training requirements and allow for a median of 6 weeks leave for any reason; none of the boards had a specific policy for parental leave. In addition, only eight boards had “explicit and clear clarifying language” that would allow program directors to seek exemptions for their residents.

Though limitations like not detecting all available policies – and a subjective evaluation of the policies that were reviewed – could have impacted their study, the coauthors reiterated that the median of 6 weeks leave is less than the average leave for faculty physicians. They also emphasized the detriments associated with inadequate parental leave, including delayed childbearing, use of assisted reproduction technology, and difficulty breastfeeding.

Dr. Varda underlined the issues that arise for program directors, who “must weigh potentially conflicting factors such as adhering to board and institutional policies, maintaining adequate clinical service coverage, considering precedent within the program, and ensuring that resident physicians are well trained.” To balance the needs of all involved “novel approaches such as use of competency-based rather than time-based training milestones” to determine certification eligibility and, in return, lessen the stresses for new-parent residents, she noted.

The researchers disclosed no relevant conflicts of interest.

SOURCE: Magudia K et al. JAMA. 2018 Dec 11;320[22)]:2372-4; Varda B et al. JAMA. 2018 Dec 11;320[22]:2374-7.

Leave policies for residents who become new parents are uneven, oft-ignored by training boards, and provide less time off than similar policies for faculty physicians. Those were the findings of a pair of research letters published in JAMA.

Kirti Magudia, MD, of the department of radiology at Brigham and Women’s Hospital in Boston and her colleagues reviewed childbearing and family leave policies for 15 graduate medical education (GME)–sponsoring institutions, all of which were affiliated with the top 12 U.S. medical schools. Though all 12 schools provided paid childbearing or family leave for faculty physicians, only 8 of the 15 did so for residents (JAMA. 2018 Dec 11;320[22)]:2372-4).

In programs that did provide leave, the average of 6.6 weeks of paid total maternity leave for residents was less than the 8.6 weeks faculty receive. Both are considerably less than proscribed by the Family and Medical Leave Act, which requires large employers to provide 12 weeks of unpaid leave, but only after 12 months of employment.

The research focused on only institutional policies for paid leave; unpaid leave and state policies may extend the average, and departments may offer leave that goes beyond specific policies, Dr. Magudia and her colleagues noted.

Changes in the residency population make now the right time for establishing consistent family leave policies, Dr. Magudia said in an interview. “We have people starting training later; we have more female trainees. And with the Match system, you’re not in control of exactly where you’re going. You may not have a support system where you end up, and a lot of the top training institutions are in high cost-of-living areas. All of those things together can make trainees especially vulnerable, and because trainees are temporary employees, changing policies to benefit them is very challenging.

“Wellness is a huge issue in medicine, and at large in society,” she said. “Making sure people have adequate parental leave goes a long way toward reducing stress levels and helping them cope with normal life transitions. We want to take steps that promote success among a diverse community of physicians; we want to retain as many people in the field as possible, and we want them to feel supported.”

Beyond asking all GME-sponsoring institutions to adopt parental leave policies, Dr. Magudia believes trainees must be better informed. “It should be clear to training program applicants what the policies are at those institutions,” she said. “That information is extremely difficult to obtain, as we’ve discovered. You can imagine that, if you are the applicant, it can be difficult to ask about those policies during the interview process because it may affect how things turn out.”

“If we can see changes like these made in the near future,” she added, “we will be in a good place.”

In the second study, Briony K. Varda, MD, of the department of urology at Boston Children’s Hospital, and her colleagues also noted the complications of balancing parental leave with training requirements from specialty boards. They compared leave policies among American Board of Medical Specialty member organizations and found that less than half specifically mentioned parental leave for resident physicians (JAMA. 2018 Dec 11;320[22]:2374-7).

Dr. Varda and her colleagues reviewed the websites of 24 ABMS boards to determine their leave policies; 22 had policies but only 11 cited parental leave as an option for residents. Twenty boards have time-based training requirements and allow for a median of 6 weeks leave for any reason; none of the boards had a specific policy for parental leave. In addition, only eight boards had “explicit and clear clarifying language” that would allow program directors to seek exemptions for their residents.

Though limitations like not detecting all available policies – and a subjective evaluation of the policies that were reviewed – could have impacted their study, the coauthors reiterated that the median of 6 weeks leave is less than the average leave for faculty physicians. They also emphasized the detriments associated with inadequate parental leave, including delayed childbearing, use of assisted reproduction technology, and difficulty breastfeeding.

Dr. Varda underlined the issues that arise for program directors, who “must weigh potentially conflicting factors such as adhering to board and institutional policies, maintaining adequate clinical service coverage, considering precedent within the program, and ensuring that resident physicians are well trained.” To balance the needs of all involved “novel approaches such as use of competency-based rather than time-based training milestones” to determine certification eligibility and, in return, lessen the stresses for new-parent residents, she noted.

The researchers disclosed no relevant conflicts of interest.

SOURCE: Magudia K et al. JAMA. 2018 Dec 11;320[22)]:2372-4; Varda B et al. JAMA. 2018 Dec 11;320[22]:2374-7.

Leave policies for residents who become new parents are uneven, oft-ignored by training boards, and provide less time off than similar policies for faculty physicians. Those were the findings of a pair of research letters published in JAMA.

Kirti Magudia, MD, of the department of radiology at Brigham and Women’s Hospital in Boston and her colleagues reviewed childbearing and family leave policies for 15 graduate medical education (GME)–sponsoring institutions, all of which were affiliated with the top 12 U.S. medical schools. Though all 12 schools provided paid childbearing or family leave for faculty physicians, only 8 of the 15 did so for residents (JAMA. 2018 Dec 11;320[22)]:2372-4).

In programs that did provide leave, the average of 6.6 weeks of paid total maternity leave for residents was less than the 8.6 weeks faculty receive. Both are considerably less than proscribed by the Family and Medical Leave Act, which requires large employers to provide 12 weeks of unpaid leave, but only after 12 months of employment.

The research focused on only institutional policies for paid leave; unpaid leave and state policies may extend the average, and departments may offer leave that goes beyond specific policies, Dr. Magudia and her colleagues noted.

Changes in the residency population make now the right time for establishing consistent family leave policies, Dr. Magudia said in an interview. “We have people starting training later; we have more female trainees. And with the Match system, you’re not in control of exactly where you’re going. You may not have a support system where you end up, and a lot of the top training institutions are in high cost-of-living areas. All of those things together can make trainees especially vulnerable, and because trainees are temporary employees, changing policies to benefit them is very challenging.

“Wellness is a huge issue in medicine, and at large in society,” she said. “Making sure people have adequate parental leave goes a long way toward reducing stress levels and helping them cope with normal life transitions. We want to take steps that promote success among a diverse community of physicians; we want to retain as many people in the field as possible, and we want them to feel supported.”

Beyond asking all GME-sponsoring institutions to adopt parental leave policies, Dr. Magudia believes trainees must be better informed. “It should be clear to training program applicants what the policies are at those institutions,” she said. “That information is extremely difficult to obtain, as we’ve discovered. You can imagine that, if you are the applicant, it can be difficult to ask about those policies during the interview process because it may affect how things turn out.”

“If we can see changes like these made in the near future,” she added, “we will be in a good place.”

In the second study, Briony K. Varda, MD, of the department of urology at Boston Children’s Hospital, and her colleagues also noted the complications of balancing parental leave with training requirements from specialty boards. They compared leave policies among American Board of Medical Specialty member organizations and found that less than half specifically mentioned parental leave for resident physicians (JAMA. 2018 Dec 11;320[22]:2374-7).

Dr. Varda and her colleagues reviewed the websites of 24 ABMS boards to determine their leave policies; 22 had policies but only 11 cited parental leave as an option for residents. Twenty boards have time-based training requirements and allow for a median of 6 weeks leave for any reason; none of the boards had a specific policy for parental leave. In addition, only eight boards had “explicit and clear clarifying language” that would allow program directors to seek exemptions for their residents.

Though limitations like not detecting all available policies – and a subjective evaluation of the policies that were reviewed – could have impacted their study, the coauthors reiterated that the median of 6 weeks leave is less than the average leave for faculty physicians. They also emphasized the detriments associated with inadequate parental leave, including delayed childbearing, use of assisted reproduction technology, and difficulty breastfeeding.

Dr. Varda underlined the issues that arise for program directors, who “must weigh potentially conflicting factors such as adhering to board and institutional policies, maintaining adequate clinical service coverage, considering precedent within the program, and ensuring that resident physicians are well trained.” To balance the needs of all involved “novel approaches such as use of competency-based rather than time-based training milestones” to determine certification eligibility and, in return, lessen the stresses for new-parent residents, she noted.

The researchers disclosed no relevant conflicts of interest.

SOURCE: Magudia K et al. JAMA. 2018 Dec 11;320[22)]:2372-4; Varda B et al. JAMA. 2018 Dec 11;320[22]:2374-7.

SAN DIEGO – Want to have influence on social media? Dr. Amber Yates advises physicians to be authentic.

“People want to see that you’re a person and not strictly a physician,” said Dr. Yates, a pediatric hematologist at Texas Children’s Hospital in Houston, who has had an active Twitter presence for the last few years.

Dr. Yates – whose Twitter handle is @sicklecelldoc – said she dipped a toe in the social media waters because she wanted to bring accurate medical information to patients in the arena where they are seeking information.

“I want families to understand their condition as well as they can on whatever level they can, and so I just found this to be another way to do that ... outside of my clinic,” she said during an interview at the annual meeting of the American Society of Hematology.

But beyond correcting misinformation and serving as an advocate for patients, Dr. Yates said she gets professional benefits from being on Twitter. For instance, she uses the platform to find relevant articles as soon as they publish, without wading through all the journals.

“It’s allowed me to kind of streamline what I read,” she said.

Dr. Yates said Twitter is her social media platform of choice because it provides a simple, succinct way to communicate and provide links to more in-depth resources.

While social media can be fun and rewarding for physicians, Dr. Yates said think before you post. Ask yourself, “would you tell your chairperson this?”

Dr. Yates reported having no relevant financial disclosures.

[email protected]

SAN DIEGO – Want to have influence on social media? Dr. Amber Yates advises physicians to be authentic.

“People want to see that you’re a person and not strictly a physician,” said Dr. Yates, a pediatric hematologist at Texas Children’s Hospital in Houston, who has had an active Twitter presence for the last few years.

Dr. Yates – whose Twitter handle is @sicklecelldoc – said she dipped a toe in the social media waters because she wanted to bring accurate medical information to patients in the arena where they are seeking information.

“I want families to understand their condition as well as they can on whatever level they can, and so I just found this to be another way to do that ... outside of my clinic,” she said during an interview at the annual meeting of the American Society of Hematology.

But beyond correcting misinformation and serving as an advocate for patients, Dr. Yates said she gets professional benefits from being on Twitter. For instance, she uses the platform to find relevant articles as soon as they publish, without wading through all the journals.

“It’s allowed me to kind of streamline what I read,” she said.

Dr. Yates said Twitter is her social media platform of choice because it provides a simple, succinct way to communicate and provide links to more in-depth resources.

While social media can be fun and rewarding for physicians, Dr. Yates said think before you post. Ask yourself, “would you tell your chairperson this?”

Dr. Yates reported having no relevant financial disclosures.

[email protected]

SAN DIEGO – Want to have influence on social media? Dr. Amber Yates advises physicians to be authentic.

“People want to see that you’re a person and not strictly a physician,” said Dr. Yates, a pediatric hematologist at Texas Children’s Hospital in Houston, who has had an active Twitter presence for the last few years.

Dr. Yates – whose Twitter handle is @sicklecelldoc – said she dipped a toe in the social media waters because she wanted to bring accurate medical information to patients in the arena where they are seeking information.

“I want families to understand their condition as well as they can on whatever level they can, and so I just found this to be another way to do that ... outside of my clinic,” she said during an interview at the annual meeting of the American Society of Hematology.

But beyond correcting misinformation and serving as an advocate for patients, Dr. Yates said she gets professional benefits from being on Twitter. For instance, she uses the platform to find relevant articles as soon as they publish, without wading through all the journals.

“It’s allowed me to kind of streamline what I read,” she said.

Dr. Yates said Twitter is her social media platform of choice because it provides a simple, succinct way to communicate and provide links to more in-depth resources.

While social media can be fun and rewarding for physicians, Dr. Yates said think before you post. Ask yourself, “would you tell your chairperson this?”

Dr. Yates reported having no relevant financial disclosures.

[email protected]

The benefits of statins highly offset the associated risks in appropriate patients, according to a scientific statement issued by the American Heart Association.

“The review covers the general patient population, as well as demographic subgroups, including the elderly, children, pregnant women, East Asians, and patients with specific conditions.” wrote Connie B. Newman, MD, of New York University, together with her colleagues. The report is in Arteriosclerosis, Thrombosis, and Vascular Biology.

After an extensive review of the literature pertaining to statin safety and tolerability, Dr. Newman and her colleagues reported the compiled findings from several randomized controlled trials, in addition to observational data, where required. They found that the risk of serious muscle complications, such as rhabdomyolysis, attributable to statin use was less than 0.1%. Furthermore, they noted that the risk of serious hepatotoxicity was even less likely, occurring in about 1 in 10,000 patients treated with therapy.

“There is no convincing evidence for a causal relationship between statins and cancer, cataracts, cognitive dysfunction, peripheral neuropathy, erectile dysfunction, or tendinitis,” the experts wrote. “In U.S. clinical practices, roughly 10% of patients stop taking a statin because of subjective complaints, most commonly muscle symptoms without raised creatine kinase,” they further reported.

Contrastingly, data from randomized trials have shown that the change in the incidence of muscle-related symptoms in patients treated with statins versus placebo is less than 1%. Moreover, the incidence is even lower, with an estimated rate of 0.1%, in those who stopped statin therapy because of these symptoms. Given these results, Dr. Newman and her colleagues said that muscle-related symptoms among statin-treated patients are not due to the pharmacological activity of the statin.

“Restarting statin therapy in these patients can be challenging, but it is important, especially in patients at high risk of cardiovascular events, for whom prevention of these events is a priority,” they added.

A large proportion of the population takes statin therapy to lower the risk of major cardiovascular events, including ischemic stroke, myocardial infarction, and other adverse effects of cardiovascular disease. At maximal doses, statins may decrease LDL-cholesterol levels by roughly 55%-60%. In addition, given the multitude of available generics, statins are an economical treatment option for most patients.

However, Dr. Newman and her colleagues suggested that, when considering statin therapy in special populations, particularly in patients with end-stage renal failure or severe hepatic disease, commencing treatment is not recommended.

“The lack of proof of cardiovascular benefit in patients with end-stage renal disease suggests that initiating statin treatment in these patients is generally not warranted,” the experts wrote. “Data on safety in people with more serious liver disease are insufficient, and statin treatment is generally discouraged,” they added.

With respect to statin-induced adverse effects, they are usually reversible upon discontinuation of therapy, with the exception of hemorrhagic stroke. However, damage from an ischemic stroke or myocardial infarction may result in death. As a result, in patients who would benefit from statin therapy, based on most recent guidelines, cardiovascular benefits greatly exceed potential safety concerns.

Dr. Newman and her coauthors disclosed financial affiliations with Amgen, Kowa, Regeneron, Sanofi, and others.

SOURCE: Newman CB et al. Arterioscler Thromb Vasc Biol. 2018 Dec 10. doi: 10.1161/ATV.0000000000000073

The benefits of statins highly offset the associated risks in appropriate patients, according to a scientific statement issued by the American Heart Association.

“The review covers the general patient population, as well as demographic subgroups, including the elderly, children, pregnant women, East Asians, and patients with specific conditions.” wrote Connie B. Newman, MD, of New York University, together with her colleagues. The report is in Arteriosclerosis, Thrombosis, and Vascular Biology.

After an extensive review of the literature pertaining to statin safety and tolerability, Dr. Newman and her colleagues reported the compiled findings from several randomized controlled trials, in addition to observational data, where required. They found that the risk of serious muscle complications, such as rhabdomyolysis, attributable to statin use was less than 0.1%. Furthermore, they noted that the risk of serious hepatotoxicity was even less likely, occurring in about 1 in 10,000 patients treated with therapy.

“There is no convincing evidence for a causal relationship between statins and cancer, cataracts, cognitive dysfunction, peripheral neuropathy, erectile dysfunction, or tendinitis,” the experts wrote. “In U.S. clinical practices, roughly 10% of patients stop taking a statin because of subjective complaints, most commonly muscle symptoms without raised creatine kinase,” they further reported.

Contrastingly, data from randomized trials have shown that the change in the incidence of muscle-related symptoms in patients treated with statins versus placebo is less than 1%. Moreover, the incidence is even lower, with an estimated rate of 0.1%, in those who stopped statin therapy because of these symptoms. Given these results, Dr. Newman and her colleagues said that muscle-related symptoms among statin-treated patients are not due to the pharmacological activity of the statin.

“Restarting statin therapy in these patients can be challenging, but it is important, especially in patients at high risk of cardiovascular events, for whom prevention of these events is a priority,” they added.

A large proportion of the population takes statin therapy to lower the risk of major cardiovascular events, including ischemic stroke, myocardial infarction, and other adverse effects of cardiovascular disease. At maximal doses, statins may decrease LDL-cholesterol levels by roughly 55%-60%. In addition, given the multitude of available generics, statins are an economical treatment option for most patients.

However, Dr. Newman and her colleagues suggested that, when considering statin therapy in special populations, particularly in patients with end-stage renal failure or severe hepatic disease, commencing treatment is not recommended.

“The lack of proof of cardiovascular benefit in patients with end-stage renal disease suggests that initiating statin treatment in these patients is generally not warranted,” the experts wrote. “Data on safety in people with more serious liver disease are insufficient, and statin treatment is generally discouraged,” they added.

With respect to statin-induced adverse effects, they are usually reversible upon discontinuation of therapy, with the exception of hemorrhagic stroke. However, damage from an ischemic stroke or myocardial infarction may result in death. As a result, in patients who would benefit from statin therapy, based on most recent guidelines, cardiovascular benefits greatly exceed potential safety concerns.

Dr. Newman and her coauthors disclosed financial affiliations with Amgen, Kowa, Regeneron, Sanofi, and others.

SOURCE: Newman CB et al. Arterioscler Thromb Vasc Biol. 2018 Dec 10. doi: 10.1161/ATV.0000000000000073

The benefits of statins highly offset the associated risks in appropriate patients, according to a scientific statement issued by the American Heart Association.

“The review covers the general patient population, as well as demographic subgroups, including the elderly, children, pregnant women, East Asians, and patients with specific conditions.” wrote Connie B. Newman, MD, of New York University, together with her colleagues. The report is in Arteriosclerosis, Thrombosis, and Vascular Biology.

After an extensive review of the literature pertaining to statin safety and tolerability, Dr. Newman and her colleagues reported the compiled findings from several randomized controlled trials, in addition to observational data, where required. They found that the risk of serious muscle complications, such as rhabdomyolysis, attributable to statin use was less than 0.1%. Furthermore, they noted that the risk of serious hepatotoxicity was even less likely, occurring in about 1 in 10,000 patients treated with therapy.

“There is no convincing evidence for a causal relationship between statins and cancer, cataracts, cognitive dysfunction, peripheral neuropathy, erectile dysfunction, or tendinitis,” the experts wrote. “In U.S. clinical practices, roughly 10% of patients stop taking a statin because of subjective complaints, most commonly muscle symptoms without raised creatine kinase,” they further reported.

Contrastingly, data from randomized trials have shown that the change in the incidence of muscle-related symptoms in patients treated with statins versus placebo is less than 1%. Moreover, the incidence is even lower, with an estimated rate of 0.1%, in those who stopped statin therapy because of these symptoms. Given these results, Dr. Newman and her colleagues said that muscle-related symptoms among statin-treated patients are not due to the pharmacological activity of the statin.

“Restarting statin therapy in these patients can be challenging, but it is important, especially in patients at high risk of cardiovascular events, for whom prevention of these events is a priority,” they added.

A large proportion of the population takes statin therapy to lower the risk of major cardiovascular events, including ischemic stroke, myocardial infarction, and other adverse effects of cardiovascular disease. At maximal doses, statins may decrease LDL-cholesterol levels by roughly 55%-60%. In addition, given the multitude of available generics, statins are an economical treatment option for most patients.

However, Dr. Newman and her colleagues suggested that, when considering statin therapy in special populations, particularly in patients with end-stage renal failure or severe hepatic disease, commencing treatment is not recommended.

“The lack of proof of cardiovascular benefit in patients with end-stage renal disease suggests that initiating statin treatment in these patients is generally not warranted,” the experts wrote. “Data on safety in people with more serious liver disease are insufficient, and statin treatment is generally discouraged,” they added.

With respect to statin-induced adverse effects, they are usually reversible upon discontinuation of therapy, with the exception of hemorrhagic stroke. However, damage from an ischemic stroke or myocardial infarction may result in death. As a result, in patients who would benefit from statin therapy, based on most recent guidelines, cardiovascular benefits greatly exceed potential safety concerns.

Dr. Newman and her coauthors disclosed financial affiliations with Amgen, Kowa, Regeneron, Sanofi, and others.

SOURCE: Newman CB et al. Arterioscler Thromb Vasc Biol. 2018 Dec 10. doi: 10.1161/ATV.0000000000000073