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Let people take illegal drugs under medical supervision?
This transcript has been edited for clarity.
Hi. I’m Art Caplan. I’m the director of the division of medical ethics at New York University.
One is up in Washington Heights in Manhattan; the other, I believe, is over in Harlem.
These two centers will supervise people taking drugs. They have available all of the anti-overdose medications, such as Narcan. If you overdose, they will help you and try to counsel you to get off drugs, but they don’t insist that you do so. You can go there, even if you’re an addict, and continue to take drugs under supervision. This is called a risk-reduction strategy.
Some people note that there are over 100 centers like this worldwide. They’re in Canada, Switzerland, and many other countries, and they seem to work. “Working” means more people seem to come off drugs slowly – not huge numbers, but some – than if you don’t do something like this, and death rates from overdose go way down.
By the way, having these centers in place has other benefits. They save money because when someone overdoses out in the community, you have to pay all the costs of the ambulances and emergency rooms, and there are risks to the first responders due to fentanyl or other things. There are fewer syringes littering parks and public places where people shoot up. You have everything controlled when they come into a center, so that’s less burden on the community.
It turns out that you have less crime because people just aren’t out there harming or robbing other people to get money to get their next fix. The drugs are provided for them. Crime rates in neighborhoods around the world where these centers operate seem to dip. There are many positives.
There are also some negatives. People say it shouldn’t be the job of the state to keep people addicted. It’s just not the right role. Everything should be aimed at getting people off drugs, maybe including criminal penalties if that’s what it takes to get them to stop using.
My own view is that hasn’t worked. Implementing tough prison sentences in trying to fight the war on drugs just doesn’t seem to work. We had 100,000 deaths last year from drug overdoses. That number has been climbing. We all know that we’ve got a terrible epidemic of deaths due to drug overdose.
It seems to me that these centers that are involved in risk reduction are a better option for now, until we figure out some interventions that can cut the desire or the drive to use drugs, or antidotes that are effective for months or years, to prevent people from getting high no matter what drugs they take.
I’m going to come out and say that I think the New York experiment has worked. I think it has saved upward of 600 lives, they estimate, in the past year that would have been overdoses. I think costwise, it’s effective. [Reductions in] related damages and injuries from syringes being scattered around, and robbery, and so forth, are all to the good. There are even a few people coming off drugs due to counseling, which is a better outcome than we get when they’re just out in the streets.
I think other cities want to try this. I know Philadelphia does. I know New York wants to expand its program. The federal government isn’t sure, but I think the time has come to try an expansion. I think we’ve got something that – although far from perfect and I wish we had other tools – may be the best we’ve got. In the war on drugs, little victories ought to be reinforced.
Dr. Caplan disclosed that he has served as a director, officer, partner, employee, adviser, consultant, or trustee for Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position), and is a contributing author and adviser for Medscape. A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Hi. I’m Art Caplan. I’m the director of the division of medical ethics at New York University.
One is up in Washington Heights in Manhattan; the other, I believe, is over in Harlem.
These two centers will supervise people taking drugs. They have available all of the anti-overdose medications, such as Narcan. If you overdose, they will help you and try to counsel you to get off drugs, but they don’t insist that you do so. You can go there, even if you’re an addict, and continue to take drugs under supervision. This is called a risk-reduction strategy.
Some people note that there are over 100 centers like this worldwide. They’re in Canada, Switzerland, and many other countries, and they seem to work. “Working” means more people seem to come off drugs slowly – not huge numbers, but some – than if you don’t do something like this, and death rates from overdose go way down.
By the way, having these centers in place has other benefits. They save money because when someone overdoses out in the community, you have to pay all the costs of the ambulances and emergency rooms, and there are risks to the first responders due to fentanyl or other things. There are fewer syringes littering parks and public places where people shoot up. You have everything controlled when they come into a center, so that’s less burden on the community.
It turns out that you have less crime because people just aren’t out there harming or robbing other people to get money to get their next fix. The drugs are provided for them. Crime rates in neighborhoods around the world where these centers operate seem to dip. There are many positives.
There are also some negatives. People say it shouldn’t be the job of the state to keep people addicted. It’s just not the right role. Everything should be aimed at getting people off drugs, maybe including criminal penalties if that’s what it takes to get them to stop using.
My own view is that hasn’t worked. Implementing tough prison sentences in trying to fight the war on drugs just doesn’t seem to work. We had 100,000 deaths last year from drug overdoses. That number has been climbing. We all know that we’ve got a terrible epidemic of deaths due to drug overdose.
It seems to me that these centers that are involved in risk reduction are a better option for now, until we figure out some interventions that can cut the desire or the drive to use drugs, or antidotes that are effective for months or years, to prevent people from getting high no matter what drugs they take.
I’m going to come out and say that I think the New York experiment has worked. I think it has saved upward of 600 lives, they estimate, in the past year that would have been overdoses. I think costwise, it’s effective. [Reductions in] related damages and injuries from syringes being scattered around, and robbery, and so forth, are all to the good. There are even a few people coming off drugs due to counseling, which is a better outcome than we get when they’re just out in the streets.
I think other cities want to try this. I know Philadelphia does. I know New York wants to expand its program. The federal government isn’t sure, but I think the time has come to try an expansion. I think we’ve got something that – although far from perfect and I wish we had other tools – may be the best we’ve got. In the war on drugs, little victories ought to be reinforced.
Dr. Caplan disclosed that he has served as a director, officer, partner, employee, adviser, consultant, or trustee for Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position), and is a contributing author and adviser for Medscape. A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Hi. I’m Art Caplan. I’m the director of the division of medical ethics at New York University.
One is up in Washington Heights in Manhattan; the other, I believe, is over in Harlem.
These two centers will supervise people taking drugs. They have available all of the anti-overdose medications, such as Narcan. If you overdose, they will help you and try to counsel you to get off drugs, but they don’t insist that you do so. You can go there, even if you’re an addict, and continue to take drugs under supervision. This is called a risk-reduction strategy.
Some people note that there are over 100 centers like this worldwide. They’re in Canada, Switzerland, and many other countries, and they seem to work. “Working” means more people seem to come off drugs slowly – not huge numbers, but some – than if you don’t do something like this, and death rates from overdose go way down.
By the way, having these centers in place has other benefits. They save money because when someone overdoses out in the community, you have to pay all the costs of the ambulances and emergency rooms, and there are risks to the first responders due to fentanyl or other things. There are fewer syringes littering parks and public places where people shoot up. You have everything controlled when they come into a center, so that’s less burden on the community.
It turns out that you have less crime because people just aren’t out there harming or robbing other people to get money to get their next fix. The drugs are provided for them. Crime rates in neighborhoods around the world where these centers operate seem to dip. There are many positives.
There are also some negatives. People say it shouldn’t be the job of the state to keep people addicted. It’s just not the right role. Everything should be aimed at getting people off drugs, maybe including criminal penalties if that’s what it takes to get them to stop using.
My own view is that hasn’t worked. Implementing tough prison sentences in trying to fight the war on drugs just doesn’t seem to work. We had 100,000 deaths last year from drug overdoses. That number has been climbing. We all know that we’ve got a terrible epidemic of deaths due to drug overdose.
It seems to me that these centers that are involved in risk reduction are a better option for now, until we figure out some interventions that can cut the desire or the drive to use drugs, or antidotes that are effective for months or years, to prevent people from getting high no matter what drugs they take.
I’m going to come out and say that I think the New York experiment has worked. I think it has saved upward of 600 lives, they estimate, in the past year that would have been overdoses. I think costwise, it’s effective. [Reductions in] related damages and injuries from syringes being scattered around, and robbery, and so forth, are all to the good. There are even a few people coming off drugs due to counseling, which is a better outcome than we get when they’re just out in the streets.
I think other cities want to try this. I know Philadelphia does. I know New York wants to expand its program. The federal government isn’t sure, but I think the time has come to try an expansion. I think we’ve got something that – although far from perfect and I wish we had other tools – may be the best we’ve got. In the war on drugs, little victories ought to be reinforced.
Dr. Caplan disclosed that he has served as a director, officer, partner, employee, adviser, consultant, or trustee for Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position), and is a contributing author and adviser for Medscape. A version of this article first appeared on Medscape.com.
Why doctors are losing trust in patients; what should be done?
This transcript has been edited for clarity.
Hi. I’m Art Caplan. I’m at the division of medical ethics at New York University.
I want to talk about a paper that my colleagues in my division just published in Health Affairs.
As they pointed out, there’s a large amount of literature about what makes patients trust their doctor. There are many studies that show that, although patients sometimes have become more critical of the medical profession, in general they still try to trust their individual physician. Nurses remain in fairly high esteem among those who are getting hospital care.
What isn’t studied, as this paper properly points out, is, what can the doctor and the nurse do to trust the patient? How can that be assessed? Isn’t that just as important as saying that patients have to trust their doctors to do and comply with what they’re told?
What if doctors are afraid of violence? What if doctors are fearful that they can’t trust patients to listen, pay attention, or do what they’re being told? What if they think that patients are coming in with all kinds of disinformation, false information, or things they pick up on the Internet, so that even though you try your best to get across accurate and complete information about what to do about infectious diseases, taking care of a kid with strep throat, or whatever it might be, you’re thinking, Can I trust this patient to do what it is that I want them to do?
One particular problem that’s causing distrust is that more and more patients are showing stress and dependence on drugs and alcohol. That doesn’t make them less trustworthy per se, but it means they can’t regulate their own behavior as well.
That obviously has to be something that the physician or the nurse is thinking about. Is this person going to be able to contain anger? Is this person going to be able to handle bad news? Is this person going to deal with me when I tell them that some of the things they believe to be true about what’s good for their health care are false?
I think we have to really start to push administrators and people in positions of power to teach doctors and nurses how to defuse situations and how to make people more comfortable when they come in and the doctor suspects that they might be under the influence, impaired, or angry because of things they’ve seen on social media, whatever those might be – including concerns about racism, bigotry, and bias, which some patients are bringing into the clinic and the hospital setting.
We need more training. We’ve got to address this as a serious issue. What can we do to defuse situations where the doctor or the nurse rightly thinks that they can’t control or they can’t trust what the patient is thinking or how the patient might behave?
It’s also the case that I think we need more backup and quick access to security so that people feel safe and comfortable in providing care. We have to make sure that if you need someone to restrain a patient or to get somebody out of a situation, that they can get there quickly and respond rapidly, and that they know what to do to deescalate a situation.
It’s sad to say, but security in today’s health care world has to be something that we really test and check – not because we’re worried, as many places are, about a shooter entering the premises, which is its own bit of concern – but I’m just talking about when the doctor or the nurse says that this patient might be acting up, could get violent, or is someone I can’t trust.
My coauthors are basically saying that it’s not a one-way street. Yes, we have to figure out ways to make sure that our patients can trust what we say. Trust is absolutely the lubricant that makes health care flow. If patients don’t trust their doctors, they’re not going to do what they say. They’re not going to get their prescriptions filled. They’re not going to be compliant. They’re not going to try to lose weight or control their diabetes.
It also goes the other way. The doctor or the nurse has to trust the patient. They have to believe that they’re safe. They have to believe that the patient is capable of controlling themselves. They have to believe that the patient is capable of listening and hearing what they’re saying, and that they’re competent to follow up on instructions, including to come back if that’s what’s required.
Everybody has to feel secure in the environment in which they’re working. Security, sadly, has to be a priority if we’re going to have a health care workforce that really feels safe and comfortable dealing with a patient population that is increasingly aggressive and perhaps not as trustworthy.
That’s not news I like to read when my colleagues write it up, but it’s important and we have to take it seriously.
Dr. Caplan disclosed that he has served as a director, officer, partner, employee, adviser, consultant, or trustee for Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position), and is a contributing author and adviser for Medscape. A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Hi. I’m Art Caplan. I’m at the division of medical ethics at New York University.
I want to talk about a paper that my colleagues in my division just published in Health Affairs.
As they pointed out, there’s a large amount of literature about what makes patients trust their doctor. There are many studies that show that, although patients sometimes have become more critical of the medical profession, in general they still try to trust their individual physician. Nurses remain in fairly high esteem among those who are getting hospital care.
What isn’t studied, as this paper properly points out, is, what can the doctor and the nurse do to trust the patient? How can that be assessed? Isn’t that just as important as saying that patients have to trust their doctors to do and comply with what they’re told?
What if doctors are afraid of violence? What if doctors are fearful that they can’t trust patients to listen, pay attention, or do what they’re being told? What if they think that patients are coming in with all kinds of disinformation, false information, or things they pick up on the Internet, so that even though you try your best to get across accurate and complete information about what to do about infectious diseases, taking care of a kid with strep throat, or whatever it might be, you’re thinking, Can I trust this patient to do what it is that I want them to do?
One particular problem that’s causing distrust is that more and more patients are showing stress and dependence on drugs and alcohol. That doesn’t make them less trustworthy per se, but it means they can’t regulate their own behavior as well.
That obviously has to be something that the physician or the nurse is thinking about. Is this person going to be able to contain anger? Is this person going to be able to handle bad news? Is this person going to deal with me when I tell them that some of the things they believe to be true about what’s good for their health care are false?
I think we have to really start to push administrators and people in positions of power to teach doctors and nurses how to defuse situations and how to make people more comfortable when they come in and the doctor suspects that they might be under the influence, impaired, or angry because of things they’ve seen on social media, whatever those might be – including concerns about racism, bigotry, and bias, which some patients are bringing into the clinic and the hospital setting.
We need more training. We’ve got to address this as a serious issue. What can we do to defuse situations where the doctor or the nurse rightly thinks that they can’t control or they can’t trust what the patient is thinking or how the patient might behave?
It’s also the case that I think we need more backup and quick access to security so that people feel safe and comfortable in providing care. We have to make sure that if you need someone to restrain a patient or to get somebody out of a situation, that they can get there quickly and respond rapidly, and that they know what to do to deescalate a situation.
It’s sad to say, but security in today’s health care world has to be something that we really test and check – not because we’re worried, as many places are, about a shooter entering the premises, which is its own bit of concern – but I’m just talking about when the doctor or the nurse says that this patient might be acting up, could get violent, or is someone I can’t trust.
My coauthors are basically saying that it’s not a one-way street. Yes, we have to figure out ways to make sure that our patients can trust what we say. Trust is absolutely the lubricant that makes health care flow. If patients don’t trust their doctors, they’re not going to do what they say. They’re not going to get their prescriptions filled. They’re not going to be compliant. They’re not going to try to lose weight or control their diabetes.
It also goes the other way. The doctor or the nurse has to trust the patient. They have to believe that they’re safe. They have to believe that the patient is capable of controlling themselves. They have to believe that the patient is capable of listening and hearing what they’re saying, and that they’re competent to follow up on instructions, including to come back if that’s what’s required.
Everybody has to feel secure in the environment in which they’re working. Security, sadly, has to be a priority if we’re going to have a health care workforce that really feels safe and comfortable dealing with a patient population that is increasingly aggressive and perhaps not as trustworthy.
That’s not news I like to read when my colleagues write it up, but it’s important and we have to take it seriously.
Dr. Caplan disclosed that he has served as a director, officer, partner, employee, adviser, consultant, or trustee for Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position), and is a contributing author and adviser for Medscape. A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Hi. I’m Art Caplan. I’m at the division of medical ethics at New York University.
I want to talk about a paper that my colleagues in my division just published in Health Affairs.
As they pointed out, there’s a large amount of literature about what makes patients trust their doctor. There are many studies that show that, although patients sometimes have become more critical of the medical profession, in general they still try to trust their individual physician. Nurses remain in fairly high esteem among those who are getting hospital care.
What isn’t studied, as this paper properly points out, is, what can the doctor and the nurse do to trust the patient? How can that be assessed? Isn’t that just as important as saying that patients have to trust their doctors to do and comply with what they’re told?
What if doctors are afraid of violence? What if doctors are fearful that they can’t trust patients to listen, pay attention, or do what they’re being told? What if they think that patients are coming in with all kinds of disinformation, false information, or things they pick up on the Internet, so that even though you try your best to get across accurate and complete information about what to do about infectious diseases, taking care of a kid with strep throat, or whatever it might be, you’re thinking, Can I trust this patient to do what it is that I want them to do?
One particular problem that’s causing distrust is that more and more patients are showing stress and dependence on drugs and alcohol. That doesn’t make them less trustworthy per se, but it means they can’t regulate their own behavior as well.
That obviously has to be something that the physician or the nurse is thinking about. Is this person going to be able to contain anger? Is this person going to be able to handle bad news? Is this person going to deal with me when I tell them that some of the things they believe to be true about what’s good for their health care are false?
I think we have to really start to push administrators and people in positions of power to teach doctors and nurses how to defuse situations and how to make people more comfortable when they come in and the doctor suspects that they might be under the influence, impaired, or angry because of things they’ve seen on social media, whatever those might be – including concerns about racism, bigotry, and bias, which some patients are bringing into the clinic and the hospital setting.
We need more training. We’ve got to address this as a serious issue. What can we do to defuse situations where the doctor or the nurse rightly thinks that they can’t control or they can’t trust what the patient is thinking or how the patient might behave?
It’s also the case that I think we need more backup and quick access to security so that people feel safe and comfortable in providing care. We have to make sure that if you need someone to restrain a patient or to get somebody out of a situation, that they can get there quickly and respond rapidly, and that they know what to do to deescalate a situation.
It’s sad to say, but security in today’s health care world has to be something that we really test and check – not because we’re worried, as many places are, about a shooter entering the premises, which is its own bit of concern – but I’m just talking about when the doctor or the nurse says that this patient might be acting up, could get violent, or is someone I can’t trust.
My coauthors are basically saying that it’s not a one-way street. Yes, we have to figure out ways to make sure that our patients can trust what we say. Trust is absolutely the lubricant that makes health care flow. If patients don’t trust their doctors, they’re not going to do what they say. They’re not going to get their prescriptions filled. They’re not going to be compliant. They’re not going to try to lose weight or control their diabetes.
It also goes the other way. The doctor or the nurse has to trust the patient. They have to believe that they’re safe. They have to believe that the patient is capable of controlling themselves. They have to believe that the patient is capable of listening and hearing what they’re saying, and that they’re competent to follow up on instructions, including to come back if that’s what’s required.
Everybody has to feel secure in the environment in which they’re working. Security, sadly, has to be a priority if we’re going to have a health care workforce that really feels safe and comfortable dealing with a patient population that is increasingly aggressive and perhaps not as trustworthy.
That’s not news I like to read when my colleagues write it up, but it’s important and we have to take it seriously.
Dr. Caplan disclosed that he has served as a director, officer, partner, employee, adviser, consultant, or trustee for Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position), and is a contributing author and adviser for Medscape. A version of this article first appeared on Medscape.com.
No, you can’t see a different doctor: We need zero tolerance of patient bias
It was 1970. I was in my second year of medical school. I can remember the hurt and embarrassment as if it were yesterday.
Coming from the Deep South, I was very familiar with racial bias, but I did not expect it at that level and in that environment. From that point on, I was anxious at each patient encounter, concerned that this might happen again. And it did several times during my residency and fellowship.
The Occupational Safety and Health Administration defines workplace violence as “any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults.”
There is considerable media focus on incidents of physical violence against health care workers, but when patients, their families, or visitors openly display bias and request a different doctor, nurse, or technician for nonmedical reasons, the impact is profound. This is extremely hurtful to a professional who has worked long and hard to acquire skills and expertise. And, while speech may not constitute violence in the strictest sense of the word, there is growing evidence that it can be physically harmful through its effect on the nervous system, even if no physical contact is involved.
Incidents of bias occur regularly and are clearly on the rise. In most cases the request for a different health care worker is granted to honor the rights of the patient. The healthcare worker is left alone and emotionally wounded; the healthcare institutions are complicit.
This bias is mostly racial but can also be based on religion, sexual orientation, age, disability, body size, accent, or gender.
An entire issue of the American Medical Association Journal of Ethics was devoted to this topic. From recognizing that there are limits to what clinicians should be expected to tolerate when patients’ preferences express unjust bias, the issue also explored where those limits should be placed, why, and who is obliged to enforce them.
The newly adopted Mass General Patient Code of Conduct is evidence that health care systems are beginning to recognize this problem and that such behavior will not be tolerated.
But having a zero-tolerance policy is not enough. We must have procedures in place to discourage and mitigate the impact of patient bias.
A clear definition of what constitutes a bias incident is essential. All team members must be made aware of the procedures for reporting such incidents and the chain of command for escalation. Reporting should be encouraged, and resources must be made available to impacted team members. Surveillance, monitoring, and review are also essential as is clarification on when patient preferences should be honored.
The Mayo Clinic 5 Step Plan is an excellent example of a protocol to deal with patient bias against health care workers and is based on a thoughtful analysis of what constitutes an unreasonable request for a different clinician. I’m pleased to report that my health care system (Inova Health) is developing a similar protocol.
The health care setting should be a bias-free zone for both patients and health care workers. I have been a strong advocate of patients’ rights and worked hard to guard against bias and eliminate disparities in care, but health care workers have rights as well.
We should expect to be treated with respect.
The views expressed by the author are those of the author alone and do not represent the views of the Inova Health System. Dr. Francis is a cardiologist at Inova Heart and Vascular Institute, McLean, Va. He disclosed no conflicts of interest.
A version of this article first appeared on Medscape.com.
It was 1970. I was in my second year of medical school. I can remember the hurt and embarrassment as if it were yesterday.
Coming from the Deep South, I was very familiar with racial bias, but I did not expect it at that level and in that environment. From that point on, I was anxious at each patient encounter, concerned that this might happen again. And it did several times during my residency and fellowship.
The Occupational Safety and Health Administration defines workplace violence as “any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults.”
There is considerable media focus on incidents of physical violence against health care workers, but when patients, their families, or visitors openly display bias and request a different doctor, nurse, or technician for nonmedical reasons, the impact is profound. This is extremely hurtful to a professional who has worked long and hard to acquire skills and expertise. And, while speech may not constitute violence in the strictest sense of the word, there is growing evidence that it can be physically harmful through its effect on the nervous system, even if no physical contact is involved.
Incidents of bias occur regularly and are clearly on the rise. In most cases the request for a different health care worker is granted to honor the rights of the patient. The healthcare worker is left alone and emotionally wounded; the healthcare institutions are complicit.
This bias is mostly racial but can also be based on religion, sexual orientation, age, disability, body size, accent, or gender.
An entire issue of the American Medical Association Journal of Ethics was devoted to this topic. From recognizing that there are limits to what clinicians should be expected to tolerate when patients’ preferences express unjust bias, the issue also explored where those limits should be placed, why, and who is obliged to enforce them.
The newly adopted Mass General Patient Code of Conduct is evidence that health care systems are beginning to recognize this problem and that such behavior will not be tolerated.
But having a zero-tolerance policy is not enough. We must have procedures in place to discourage and mitigate the impact of patient bias.
A clear definition of what constitutes a bias incident is essential. All team members must be made aware of the procedures for reporting such incidents and the chain of command for escalation. Reporting should be encouraged, and resources must be made available to impacted team members. Surveillance, monitoring, and review are also essential as is clarification on when patient preferences should be honored.
The Mayo Clinic 5 Step Plan is an excellent example of a protocol to deal with patient bias against health care workers and is based on a thoughtful analysis of what constitutes an unreasonable request for a different clinician. I’m pleased to report that my health care system (Inova Health) is developing a similar protocol.
The health care setting should be a bias-free zone for both patients and health care workers. I have been a strong advocate of patients’ rights and worked hard to guard against bias and eliminate disparities in care, but health care workers have rights as well.
We should expect to be treated with respect.
The views expressed by the author are those of the author alone and do not represent the views of the Inova Health System. Dr. Francis is a cardiologist at Inova Heart and Vascular Institute, McLean, Va. He disclosed no conflicts of interest.
A version of this article first appeared on Medscape.com.
It was 1970. I was in my second year of medical school. I can remember the hurt and embarrassment as if it were yesterday.
Coming from the Deep South, I was very familiar with racial bias, but I did not expect it at that level and in that environment. From that point on, I was anxious at each patient encounter, concerned that this might happen again. And it did several times during my residency and fellowship.
The Occupational Safety and Health Administration defines workplace violence as “any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults.”
There is considerable media focus on incidents of physical violence against health care workers, but when patients, their families, or visitors openly display bias and request a different doctor, nurse, or technician for nonmedical reasons, the impact is profound. This is extremely hurtful to a professional who has worked long and hard to acquire skills and expertise. And, while speech may not constitute violence in the strictest sense of the word, there is growing evidence that it can be physically harmful through its effect on the nervous system, even if no physical contact is involved.
Incidents of bias occur regularly and are clearly on the rise. In most cases the request for a different health care worker is granted to honor the rights of the patient. The healthcare worker is left alone and emotionally wounded; the healthcare institutions are complicit.
This bias is mostly racial but can also be based on religion, sexual orientation, age, disability, body size, accent, or gender.
An entire issue of the American Medical Association Journal of Ethics was devoted to this topic. From recognizing that there are limits to what clinicians should be expected to tolerate when patients’ preferences express unjust bias, the issue also explored where those limits should be placed, why, and who is obliged to enforce them.
The newly adopted Mass General Patient Code of Conduct is evidence that health care systems are beginning to recognize this problem and that such behavior will not be tolerated.
But having a zero-tolerance policy is not enough. We must have procedures in place to discourage and mitigate the impact of patient bias.
A clear definition of what constitutes a bias incident is essential. All team members must be made aware of the procedures for reporting such incidents and the chain of command for escalation. Reporting should be encouraged, and resources must be made available to impacted team members. Surveillance, monitoring, and review are also essential as is clarification on when patient preferences should be honored.
The Mayo Clinic 5 Step Plan is an excellent example of a protocol to deal with patient bias against health care workers and is based on a thoughtful analysis of what constitutes an unreasonable request for a different clinician. I’m pleased to report that my health care system (Inova Health) is developing a similar protocol.
The health care setting should be a bias-free zone for both patients and health care workers. I have been a strong advocate of patients’ rights and worked hard to guard against bias and eliminate disparities in care, but health care workers have rights as well.
We should expect to be treated with respect.
The views expressed by the author are those of the author alone and do not represent the views of the Inova Health System. Dr. Francis is a cardiologist at Inova Heart and Vascular Institute, McLean, Va. He disclosed no conflicts of interest.
A version of this article first appeared on Medscape.com.
How a cheap liver drug may be the key to preventing COVID
Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I’m Dr F. Perry Wilson of the Yale School of Medicine.
As soon as the pandemic started, the search was on for a medication that could stave off infection, or at least the worst consequences of infection.
One that would be cheap to make, safe, easy to distribute, and, ideally, was already available. The search had a quest-like quality, like something from a fairy tale. Society, poisoned by COVID, would find the antidote out there, somewhere, if we looked hard enough.
You know the story. There were some pretty dramatic failures: hydroxychloroquine, ivermectin. There were some successes, like dexamethasone.
I’m not here today to tell you that the antidote has been found – no, it takes large randomized trials to figure that out. But
How do you make a case that an existing drug – UDCA, in this case – might be useful to prevent or treat COVID? In contrast to prior basic-science studies, like the original ivermectin study, which essentially took a bunch of cells and virus in a tube filled with varying concentrations of the antiparasitic agent, the authors of this paper appearing in Nature give us multiple, complementary lines of evidence. Let me walk you through it.
All good science starts with a biologically plausible hypothesis. In this case, the authors recognized that SARS-CoV-2, in all its variants, requires the presence of the ACE2 receptor on the surface of cells to bind.
That is the doorway to infection. Vaccines and antibodies block the key to this door, the spike protein and its receptor binding domain. But what if you could get rid of the doors altogether?
The authors first showed that ACE2 expression is controlled by a certain transcription factor known as the farnesoid X receptor, or FXR. Reducing the binding of FXR should therefore reduce ACE2 expression.
As luck would have it, UDCA – Actigall – reduces the levels of FXR and thus the expression of ACE2 in cells.
Okay. So we have a drug that can reduce ACE2, and we know that ACE2 is necessary for the virus to infect cells. Would UDCA prevent viral infection?
They started with test tubes, showing that cells were less likely to be infected by SARS-CoV-2 in the presence of UDCA at concentrations similar to what humans achieve in their blood after standard dosing. The red staining here is spike protein; you can see that it is markedly lower in the cells exposed to UDCA.
So far, so good. But test tubes aren’t people. So they moved up to mice and Syrian golden hamsters. These cute fellows are quite susceptible to human COVID and have been a model organism in countless studies
Mice and hamsters treated with UDCA in the presence of littermates with COVID infections were less likely to become infected themselves compared with mice not so treated. They also showed that mice and hamsters treated with UDCA had lower levels of ACE2 in their nasal passages.
Of course, mice aren’t humans either. So the researchers didn’t stop there.
To determine the effects of UDCA on human tissue, they utilized perfused human lungs that had been declined for transplantation. The lungs were perfused with a special fluid to keep them viable, and were mechanically ventilated. One lung was exposed to UDCA and the other served as a control. The authors were able to show that ACE2 levels went down in the exposed lung. And, importantly, when samples of tissue from both lungs were exposed to SARS-CoV-2, the lung tissue exposed to UDCA had lower levels of viral infection.
They didn’t stop there.
Eight human volunteers were recruited to take UDCA for 5 days. ACE2 levels in the nasal passages went down over the course of treatment. They confirmed those results from a proteomics dataset with several hundred people who had received UDCA for clinical reasons. Treated individuals had lower ACE2 levels.
Finally, they looked at the epidemiologic effect. They examined a dataset that contained information on over 1,000 patients with liver disease who had contracted COVID-19, 31 of whom had been receiving UDCA. Even after adjustment for baseline differences, those receiving UDCA were less likely to be hospitalized, require an ICU, or die.
Okay, we’ll stop there. Reading this study, all I could think was, Yes! This is how you generate evidence that you have a drug that might work – step by careful step.
But let’s be careful as well. Does this study show that taking Actigall will prevent COVID? Of course not. It doesn’t show that it will treat COVID either. But I bring it up because the rigor of this study stands in contrast to those that generated huge enthusiasm earlier in the pandemic only to let us down in randomized trials. If there has been a drug out there this whole time which will prevent or treat COVID, this is how we’ll find it. The next step? Test it in a randomized trial.
For Medscape, I’m Perry Wilson.
F. Perry Wilson, MD, MSCE, is an associate professor of medicine and director of Yale’s Clinical and Translational Research Accelerator. He disclosed no relevant financial relationships.
A version of this video transcript first appeared on Medscape.com.
Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I’m Dr F. Perry Wilson of the Yale School of Medicine.
As soon as the pandemic started, the search was on for a medication that could stave off infection, or at least the worst consequences of infection.
One that would be cheap to make, safe, easy to distribute, and, ideally, was already available. The search had a quest-like quality, like something from a fairy tale. Society, poisoned by COVID, would find the antidote out there, somewhere, if we looked hard enough.
You know the story. There were some pretty dramatic failures: hydroxychloroquine, ivermectin. There were some successes, like dexamethasone.
I’m not here today to tell you that the antidote has been found – no, it takes large randomized trials to figure that out. But
How do you make a case that an existing drug – UDCA, in this case – might be useful to prevent or treat COVID? In contrast to prior basic-science studies, like the original ivermectin study, which essentially took a bunch of cells and virus in a tube filled with varying concentrations of the antiparasitic agent, the authors of this paper appearing in Nature give us multiple, complementary lines of evidence. Let me walk you through it.
All good science starts with a biologically plausible hypothesis. In this case, the authors recognized that SARS-CoV-2, in all its variants, requires the presence of the ACE2 receptor on the surface of cells to bind.
That is the doorway to infection. Vaccines and antibodies block the key to this door, the spike protein and its receptor binding domain. But what if you could get rid of the doors altogether?
The authors first showed that ACE2 expression is controlled by a certain transcription factor known as the farnesoid X receptor, or FXR. Reducing the binding of FXR should therefore reduce ACE2 expression.
As luck would have it, UDCA – Actigall – reduces the levels of FXR and thus the expression of ACE2 in cells.
Okay. So we have a drug that can reduce ACE2, and we know that ACE2 is necessary for the virus to infect cells. Would UDCA prevent viral infection?
They started with test tubes, showing that cells were less likely to be infected by SARS-CoV-2 in the presence of UDCA at concentrations similar to what humans achieve in their blood after standard dosing. The red staining here is spike protein; you can see that it is markedly lower in the cells exposed to UDCA.
So far, so good. But test tubes aren’t people. So they moved up to mice and Syrian golden hamsters. These cute fellows are quite susceptible to human COVID and have been a model organism in countless studies
Mice and hamsters treated with UDCA in the presence of littermates with COVID infections were less likely to become infected themselves compared with mice not so treated. They also showed that mice and hamsters treated with UDCA had lower levels of ACE2 in their nasal passages.
Of course, mice aren’t humans either. So the researchers didn’t stop there.
To determine the effects of UDCA on human tissue, they utilized perfused human lungs that had been declined for transplantation. The lungs were perfused with a special fluid to keep them viable, and were mechanically ventilated. One lung was exposed to UDCA and the other served as a control. The authors were able to show that ACE2 levels went down in the exposed lung. And, importantly, when samples of tissue from both lungs were exposed to SARS-CoV-2, the lung tissue exposed to UDCA had lower levels of viral infection.
They didn’t stop there.
Eight human volunteers were recruited to take UDCA for 5 days. ACE2 levels in the nasal passages went down over the course of treatment. They confirmed those results from a proteomics dataset with several hundred people who had received UDCA for clinical reasons. Treated individuals had lower ACE2 levels.
Finally, they looked at the epidemiologic effect. They examined a dataset that contained information on over 1,000 patients with liver disease who had contracted COVID-19, 31 of whom had been receiving UDCA. Even after adjustment for baseline differences, those receiving UDCA were less likely to be hospitalized, require an ICU, or die.
Okay, we’ll stop there. Reading this study, all I could think was, Yes! This is how you generate evidence that you have a drug that might work – step by careful step.
But let’s be careful as well. Does this study show that taking Actigall will prevent COVID? Of course not. It doesn’t show that it will treat COVID either. But I bring it up because the rigor of this study stands in contrast to those that generated huge enthusiasm earlier in the pandemic only to let us down in randomized trials. If there has been a drug out there this whole time which will prevent or treat COVID, this is how we’ll find it. The next step? Test it in a randomized trial.
For Medscape, I’m Perry Wilson.
F. Perry Wilson, MD, MSCE, is an associate professor of medicine and director of Yale’s Clinical and Translational Research Accelerator. He disclosed no relevant financial relationships.
A version of this video transcript first appeared on Medscape.com.
Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I’m Dr F. Perry Wilson of the Yale School of Medicine.
As soon as the pandemic started, the search was on for a medication that could stave off infection, or at least the worst consequences of infection.
One that would be cheap to make, safe, easy to distribute, and, ideally, was already available. The search had a quest-like quality, like something from a fairy tale. Society, poisoned by COVID, would find the antidote out there, somewhere, if we looked hard enough.
You know the story. There were some pretty dramatic failures: hydroxychloroquine, ivermectin. There were some successes, like dexamethasone.
I’m not here today to tell you that the antidote has been found – no, it takes large randomized trials to figure that out. But
How do you make a case that an existing drug – UDCA, in this case – might be useful to prevent or treat COVID? In contrast to prior basic-science studies, like the original ivermectin study, which essentially took a bunch of cells and virus in a tube filled with varying concentrations of the antiparasitic agent, the authors of this paper appearing in Nature give us multiple, complementary lines of evidence. Let me walk you through it.
All good science starts with a biologically plausible hypothesis. In this case, the authors recognized that SARS-CoV-2, in all its variants, requires the presence of the ACE2 receptor on the surface of cells to bind.
That is the doorway to infection. Vaccines and antibodies block the key to this door, the spike protein and its receptor binding domain. But what if you could get rid of the doors altogether?
The authors first showed that ACE2 expression is controlled by a certain transcription factor known as the farnesoid X receptor, or FXR. Reducing the binding of FXR should therefore reduce ACE2 expression.
As luck would have it, UDCA – Actigall – reduces the levels of FXR and thus the expression of ACE2 in cells.
Okay. So we have a drug that can reduce ACE2, and we know that ACE2 is necessary for the virus to infect cells. Would UDCA prevent viral infection?
They started with test tubes, showing that cells were less likely to be infected by SARS-CoV-2 in the presence of UDCA at concentrations similar to what humans achieve in their blood after standard dosing. The red staining here is spike protein; you can see that it is markedly lower in the cells exposed to UDCA.
So far, so good. But test tubes aren’t people. So they moved up to mice and Syrian golden hamsters. These cute fellows are quite susceptible to human COVID and have been a model organism in countless studies
Mice and hamsters treated with UDCA in the presence of littermates with COVID infections were less likely to become infected themselves compared with mice not so treated. They also showed that mice and hamsters treated with UDCA had lower levels of ACE2 in their nasal passages.
Of course, mice aren’t humans either. So the researchers didn’t stop there.
To determine the effects of UDCA on human tissue, they utilized perfused human lungs that had been declined for transplantation. The lungs were perfused with a special fluid to keep them viable, and were mechanically ventilated. One lung was exposed to UDCA and the other served as a control. The authors were able to show that ACE2 levels went down in the exposed lung. And, importantly, when samples of tissue from both lungs were exposed to SARS-CoV-2, the lung tissue exposed to UDCA had lower levels of viral infection.
They didn’t stop there.
Eight human volunteers were recruited to take UDCA for 5 days. ACE2 levels in the nasal passages went down over the course of treatment. They confirmed those results from a proteomics dataset with several hundred people who had received UDCA for clinical reasons. Treated individuals had lower ACE2 levels.
Finally, they looked at the epidemiologic effect. They examined a dataset that contained information on over 1,000 patients with liver disease who had contracted COVID-19, 31 of whom had been receiving UDCA. Even after adjustment for baseline differences, those receiving UDCA were less likely to be hospitalized, require an ICU, or die.
Okay, we’ll stop there. Reading this study, all I could think was, Yes! This is how you generate evidence that you have a drug that might work – step by careful step.
But let’s be careful as well. Does this study show that taking Actigall will prevent COVID? Of course not. It doesn’t show that it will treat COVID either. But I bring it up because the rigor of this study stands in contrast to those that generated huge enthusiasm earlier in the pandemic only to let us down in randomized trials. If there has been a drug out there this whole time which will prevent or treat COVID, this is how we’ll find it. The next step? Test it in a randomized trial.
For Medscape, I’m Perry Wilson.
F. Perry Wilson, MD, MSCE, is an associate professor of medicine and director of Yale’s Clinical and Translational Research Accelerator. He disclosed no relevant financial relationships.
A version of this video transcript first appeared on Medscape.com.
Nurses questions answered: Could you face repercussions for your actions?
Nurses are the most trusted profession for one reason. They care.
Nurses are passionate about patient interactions, quality, and giving optimal support, often to the detriment of self-care. Many do not hesitate to voice concerns in an atmosphere that produces anxiety, whether it be regarding supplies, documentation, or staffing. As a result,
In October, three nurses at Ascension Saint Joseph in Joliet, Ill., were escorted off the premises of a hospital emergency room when they began an understaffed shift. They were removed from work by hospital security and then suspended for 1 week. It was a decision that was incomprehensible, because the emergency room faced an overwhelming influx of patients – 46 that evening alone – and only four nurses instead of the more than 10 approved staffing were on duty. Why were they suspended?
Hospital officials have been quiet in responding to their alarmed community as well as in answering the Illinois Nurses Association, who criticized the hospital’s response. It has been suggested that the nurses had been intensely vocal about staffing for several weeks and the hospital might have wanted to silence their voices.
In my opinion, this could be considered a professional repercussion of the post-pandemic work environment. Though the nurses were reinstated after the week expired, nursing organizations believed that the actions of their employer were too harsh.
There was a similar response by employers after a string of large strikes of California nurses earlier this year. For example, a walkout by nurses at Stanford Health Care and Lucile Packard Children’s Hospital resulted in the hospitals withholding wages during the strike period and stating they might withhold health coverage from striking workers.
“Our sincere hope is that an agreement can be reached promptly so that nurses don’t lose additional pay, don’t risk losing the subsidy for employer-paid health benefits, and can return to patient care,” the hospital newsletter StanfordPackardVoice.com reported before the strike began in April. “Nurses who choose to go out on strike will not paid for missed shifts and cannot use PTO, ESL, or Education Hours.”
Nurse: Could a similar repercussion be in my work future?
Nurses may take to picket lines or contact administrators (for example, Human Resources) for multiple reasons, but the most common issues are related to staffing, scheduling, mandatory overtime, or equipment required to do their job: safety or lifting equipment and broken or missing tools for monitoring patients. The lack of hospital security services to assist with violent or threatening patients has also become a concern.
Goodman: The inability to provide safe care is a common fear of all nurses, one that was exacerbated by health care workers leaving during the pandemic, primarily from nursing homes. Although overall safety has improved, that may not be the case in smaller, rural institutions. Staffing for all shifts may also be erratic as the country faces an uphill winter battle with influenza, respiratory syncytial virus, and newer COVID variants.
Report to your supervisor: First, be familiar with your institution’s policy regarding chain of command. Know where to take a complaint when staffing seems unsafe. Contact your immediate supervisor as soon as the situation has been assessed. They might be able to shift resources to your area or find coverage to help. In addition, keep accurate notes related to your actions.
I covered a night shift where I was directly responsible for the care of 13 subacute medical-surgical patients (new admissions and postoperative patients). Patients kept arriving with no regard for the load that was present. One of the patients was completely unhappy with her pain regimen and kept calling for assistance, as is often the case.
While I was doing my best to assess arrivals, another nurse contacted a supervisor. The next thing that happened was an on-site visit by hospital administrators (unusual!) who asked to see my assignment sheet. I had been hesitant to share the list, fearing recrimination from intermediate leadership (this was not my home unit). But it led to an immediate change in staffing. The ordeal ended amicably, but not all do. Thereafter, no nurse was expected to care for more than eight patients on the night shift.
Notify proper authorities: Nurses may believe contacting the Occupational Safety and Health Administration (OSHA) might be helpful; however, OSHA may not have jurisdiction over the hospital, as the Saint Joseph nurses discovered. Working without safety equipment or with reduced supplies (for example, automatic blood pressure cuffs, oxygen saturation monitors, isolation gear) may appear to be a federal complaint, but it depends where the nurse is employed. The hospital in Joliet was covered by the Illinois Department of Public Health.
Federal law entitles you to work in a safe place. Contacting OSHA for direction should not lead to recrimination for nurses. Although OSHA has been overwhelmed with complaints since the onset of the pandemic, their website directs nurses. For example, a whistleblower complaint can be filed up to 30 days after an incident of worker retaliation.
If you are a member of a nursing union, follow union guidelines related to your actions. Thousands of nurses went on strike in the past 2 years. Most remained employed and returned to work with negotiations complete. As far as the nurses in Massachusetts, the state does not have mandatory staffing ratios – most do not – which complicated contract negotiations. At this time, California is the only state that has mandatory nurse-patient ratios written into law.
It is also important to know state law and to be cognizant of nursing organizations within your geographic area. Staying connected means staying informed and having nursing resources.
Respond rationally: An additional reminder for nurses is not to react to a tense situation impulsively. Leaving an assignment unfinished or walking off the job is never a good idea. (A scheduled strike organized by union leaders is different). Leaving work is viewed by institutions as job abandonment and can be grounds for dismissal. Most states are currently “at will” employers, meaning hospitals can terminate nurses without due process.
Above all, know that nurses worry about providing safe practice and avoiding recrimination. Only one of these should be in your future.
Ms. Goodman has no disclosures.
A version of this article first appeared on Medscape.com.
Nurses are the most trusted profession for one reason. They care.
Nurses are passionate about patient interactions, quality, and giving optimal support, often to the detriment of self-care. Many do not hesitate to voice concerns in an atmosphere that produces anxiety, whether it be regarding supplies, documentation, or staffing. As a result,
In October, three nurses at Ascension Saint Joseph in Joliet, Ill., were escorted off the premises of a hospital emergency room when they began an understaffed shift. They were removed from work by hospital security and then suspended for 1 week. It was a decision that was incomprehensible, because the emergency room faced an overwhelming influx of patients – 46 that evening alone – and only four nurses instead of the more than 10 approved staffing were on duty. Why were they suspended?
Hospital officials have been quiet in responding to their alarmed community as well as in answering the Illinois Nurses Association, who criticized the hospital’s response. It has been suggested that the nurses had been intensely vocal about staffing for several weeks and the hospital might have wanted to silence their voices.
In my opinion, this could be considered a professional repercussion of the post-pandemic work environment. Though the nurses were reinstated after the week expired, nursing organizations believed that the actions of their employer were too harsh.
There was a similar response by employers after a string of large strikes of California nurses earlier this year. For example, a walkout by nurses at Stanford Health Care and Lucile Packard Children’s Hospital resulted in the hospitals withholding wages during the strike period and stating they might withhold health coverage from striking workers.
“Our sincere hope is that an agreement can be reached promptly so that nurses don’t lose additional pay, don’t risk losing the subsidy for employer-paid health benefits, and can return to patient care,” the hospital newsletter StanfordPackardVoice.com reported before the strike began in April. “Nurses who choose to go out on strike will not paid for missed shifts and cannot use PTO, ESL, or Education Hours.”
Nurse: Could a similar repercussion be in my work future?
Nurses may take to picket lines or contact administrators (for example, Human Resources) for multiple reasons, but the most common issues are related to staffing, scheduling, mandatory overtime, or equipment required to do their job: safety or lifting equipment and broken or missing tools for monitoring patients. The lack of hospital security services to assist with violent or threatening patients has also become a concern.
Goodman: The inability to provide safe care is a common fear of all nurses, one that was exacerbated by health care workers leaving during the pandemic, primarily from nursing homes. Although overall safety has improved, that may not be the case in smaller, rural institutions. Staffing for all shifts may also be erratic as the country faces an uphill winter battle with influenza, respiratory syncytial virus, and newer COVID variants.
Report to your supervisor: First, be familiar with your institution’s policy regarding chain of command. Know where to take a complaint when staffing seems unsafe. Contact your immediate supervisor as soon as the situation has been assessed. They might be able to shift resources to your area or find coverage to help. In addition, keep accurate notes related to your actions.
I covered a night shift where I was directly responsible for the care of 13 subacute medical-surgical patients (new admissions and postoperative patients). Patients kept arriving with no regard for the load that was present. One of the patients was completely unhappy with her pain regimen and kept calling for assistance, as is often the case.
While I was doing my best to assess arrivals, another nurse contacted a supervisor. The next thing that happened was an on-site visit by hospital administrators (unusual!) who asked to see my assignment sheet. I had been hesitant to share the list, fearing recrimination from intermediate leadership (this was not my home unit). But it led to an immediate change in staffing. The ordeal ended amicably, but not all do. Thereafter, no nurse was expected to care for more than eight patients on the night shift.
Notify proper authorities: Nurses may believe contacting the Occupational Safety and Health Administration (OSHA) might be helpful; however, OSHA may not have jurisdiction over the hospital, as the Saint Joseph nurses discovered. Working without safety equipment or with reduced supplies (for example, automatic blood pressure cuffs, oxygen saturation monitors, isolation gear) may appear to be a federal complaint, but it depends where the nurse is employed. The hospital in Joliet was covered by the Illinois Department of Public Health.
Federal law entitles you to work in a safe place. Contacting OSHA for direction should not lead to recrimination for nurses. Although OSHA has been overwhelmed with complaints since the onset of the pandemic, their website directs nurses. For example, a whistleblower complaint can be filed up to 30 days after an incident of worker retaliation.
If you are a member of a nursing union, follow union guidelines related to your actions. Thousands of nurses went on strike in the past 2 years. Most remained employed and returned to work with negotiations complete. As far as the nurses in Massachusetts, the state does not have mandatory staffing ratios – most do not – which complicated contract negotiations. At this time, California is the only state that has mandatory nurse-patient ratios written into law.
It is also important to know state law and to be cognizant of nursing organizations within your geographic area. Staying connected means staying informed and having nursing resources.
Respond rationally: An additional reminder for nurses is not to react to a tense situation impulsively. Leaving an assignment unfinished or walking off the job is never a good idea. (A scheduled strike organized by union leaders is different). Leaving work is viewed by institutions as job abandonment and can be grounds for dismissal. Most states are currently “at will” employers, meaning hospitals can terminate nurses without due process.
Above all, know that nurses worry about providing safe practice and avoiding recrimination. Only one of these should be in your future.
Ms. Goodman has no disclosures.
A version of this article first appeared on Medscape.com.
Nurses are the most trusted profession for one reason. They care.
Nurses are passionate about patient interactions, quality, and giving optimal support, often to the detriment of self-care. Many do not hesitate to voice concerns in an atmosphere that produces anxiety, whether it be regarding supplies, documentation, or staffing. As a result,
In October, three nurses at Ascension Saint Joseph in Joliet, Ill., were escorted off the premises of a hospital emergency room when they began an understaffed shift. They were removed from work by hospital security and then suspended for 1 week. It was a decision that was incomprehensible, because the emergency room faced an overwhelming influx of patients – 46 that evening alone – and only four nurses instead of the more than 10 approved staffing were on duty. Why were they suspended?
Hospital officials have been quiet in responding to their alarmed community as well as in answering the Illinois Nurses Association, who criticized the hospital’s response. It has been suggested that the nurses had been intensely vocal about staffing for several weeks and the hospital might have wanted to silence their voices.
In my opinion, this could be considered a professional repercussion of the post-pandemic work environment. Though the nurses were reinstated after the week expired, nursing organizations believed that the actions of their employer were too harsh.
There was a similar response by employers after a string of large strikes of California nurses earlier this year. For example, a walkout by nurses at Stanford Health Care and Lucile Packard Children’s Hospital resulted in the hospitals withholding wages during the strike period and stating they might withhold health coverage from striking workers.
“Our sincere hope is that an agreement can be reached promptly so that nurses don’t lose additional pay, don’t risk losing the subsidy for employer-paid health benefits, and can return to patient care,” the hospital newsletter StanfordPackardVoice.com reported before the strike began in April. “Nurses who choose to go out on strike will not paid for missed shifts and cannot use PTO, ESL, or Education Hours.”
Nurse: Could a similar repercussion be in my work future?
Nurses may take to picket lines or contact administrators (for example, Human Resources) for multiple reasons, but the most common issues are related to staffing, scheduling, mandatory overtime, or equipment required to do their job: safety or lifting equipment and broken or missing tools for monitoring patients. The lack of hospital security services to assist with violent or threatening patients has also become a concern.
Goodman: The inability to provide safe care is a common fear of all nurses, one that was exacerbated by health care workers leaving during the pandemic, primarily from nursing homes. Although overall safety has improved, that may not be the case in smaller, rural institutions. Staffing for all shifts may also be erratic as the country faces an uphill winter battle with influenza, respiratory syncytial virus, and newer COVID variants.
Report to your supervisor: First, be familiar with your institution’s policy regarding chain of command. Know where to take a complaint when staffing seems unsafe. Contact your immediate supervisor as soon as the situation has been assessed. They might be able to shift resources to your area or find coverage to help. In addition, keep accurate notes related to your actions.
I covered a night shift where I was directly responsible for the care of 13 subacute medical-surgical patients (new admissions and postoperative patients). Patients kept arriving with no regard for the load that was present. One of the patients was completely unhappy with her pain regimen and kept calling for assistance, as is often the case.
While I was doing my best to assess arrivals, another nurse contacted a supervisor. The next thing that happened was an on-site visit by hospital administrators (unusual!) who asked to see my assignment sheet. I had been hesitant to share the list, fearing recrimination from intermediate leadership (this was not my home unit). But it led to an immediate change in staffing. The ordeal ended amicably, but not all do. Thereafter, no nurse was expected to care for more than eight patients on the night shift.
Notify proper authorities: Nurses may believe contacting the Occupational Safety and Health Administration (OSHA) might be helpful; however, OSHA may not have jurisdiction over the hospital, as the Saint Joseph nurses discovered. Working without safety equipment or with reduced supplies (for example, automatic blood pressure cuffs, oxygen saturation monitors, isolation gear) may appear to be a federal complaint, but it depends where the nurse is employed. The hospital in Joliet was covered by the Illinois Department of Public Health.
Federal law entitles you to work in a safe place. Contacting OSHA for direction should not lead to recrimination for nurses. Although OSHA has been overwhelmed with complaints since the onset of the pandemic, their website directs nurses. For example, a whistleblower complaint can be filed up to 30 days after an incident of worker retaliation.
If you are a member of a nursing union, follow union guidelines related to your actions. Thousands of nurses went on strike in the past 2 years. Most remained employed and returned to work with negotiations complete. As far as the nurses in Massachusetts, the state does not have mandatory staffing ratios – most do not – which complicated contract negotiations. At this time, California is the only state that has mandatory nurse-patient ratios written into law.
It is also important to know state law and to be cognizant of nursing organizations within your geographic area. Staying connected means staying informed and having nursing resources.
Respond rationally: An additional reminder for nurses is not to react to a tense situation impulsively. Leaving an assignment unfinished or walking off the job is never a good idea. (A scheduled strike organized by union leaders is different). Leaving work is viewed by institutions as job abandonment and can be grounds for dismissal. Most states are currently “at will” employers, meaning hospitals can terminate nurses without due process.
Above all, know that nurses worry about providing safe practice and avoiding recrimination. Only one of these should be in your future.
Ms. Goodman has no disclosures.
A version of this article first appeared on Medscape.com.
Saururus chinensis
Also known as Asian or Chinese lizard’s tail (or Sam-baekcho in Korea), Saururus chinensis is an East Asian plant used in traditional medicine for various indications including edema, gonorrhea, jaundice, hypertension, leproma, pneumonia, and rheumatoid arthritis.1,2 Specifically, Korean traditional medicine practitioners as well as Native Americans and early colonists in what is now the United States used the botanical to treat cancer, edema, rheumatoid arthritis, and other inflammatory conditions.2-4 Modern research has produced evidence supporting the use of this plant in the dermatologic realm. This column focuses on the relevant bench science and possible applications.
Various beneficial effects
In 2008, Yoo et al. found that the ethanol extract of the dried aerial parts of S. chinensis exhibit anti-inflammatory, antiangiogenic, and antinociceptive properties, which they suggested may partially account for the established therapeutic effects of the plant.2 Also, Lee et al. reported in 2012 on the antiproliferative effects against human cancer cell lines of neolignans found in S. chinensis.5
Antioxidant properties have been associated with S. chinensis. In 2014, Kim et al. reported that S. chinensis extract attenuated the lipopolysaccharide (LPS)-stimulated neuroinflammatory response in BV-2 microglia cells, a result that the authors partly ascribed to the antioxidant constituents (particularly quercetin) of the plant.3
Atopic dermatitis
In 2008, Choi et al. determined that the leaves of S. chinensis impeded the formation of atopic dermatitis–like skin lesions in NC/Nga mice caused by repeated application of picryl chloride, potentially by stimulating the Th1 cell response, thus modulating Th1/Th2 imbalance. They concluded that S. chinensis has potential as an adjunct treatment option for atopic dermatitis.6
Anti-inflammatory activity
In 2010, Bae et al. studied the anti-inflammatory properties of sauchinone, a lignan derived from S. chinensis reputed to exert antioxidant, anti-inflammatory, and hepatoprotective activity,7 using LPS-stimulated RAW264.7 cells. They found that the lignan lowered tumor necrosis factor (TNF)–alpha synthesis by inhibiting the c-Raf-MEK1/2-ERK1/2 phosphorylation pathway, accounting for the anti-inflammatory effects of the S. chinensis constituent.8
More recently, Zhang et al. determined that the ethanol extract of S. chinensis leaves impaired proinflammatory gene expression by blocking the TAK1/AP-1 pathway in LPS-treated RAW264.7 macrophages. They suggested that such suppression is a significant step in the anti-inflammatory function exhibited by the plant.1
Photoprotection
Park et al. investigated in 2013 the beneficial effects of sauchinone. Specifically, they studied potential photoprotective effects of the lignan against UVB in HaCaT human epidermal keratinocytes. They found that sauchinone (5-40 mcm) conferred significant protection as evaluated by cell viability and a toxicity assay. At 20-40 mcm, sauchinone blocked the upregulation of matrix metalloproteinase (MMP)–1 proteins and decrease of type 1 collagen engendered by UVB exposure. The investigators further discovered that sauchinone diminished the synthesis of reactive oxygen species. Overall, they determined that sauchinone imparted protection by suppressing extracellular signal-regulated kinase, c-Jun N-terminal kinase, and p38 MAPK signaling through the activation of oxidative defense enzymes.7
Potential use as a depigmenting agent
In 2009, Seo et al. isolated the lignans manassantin A and B from S. chinensis and determined that these compounds dose-dependently impeded melanin synthesis in alpha-melanocyte stimulating hormone (alpha-MSH)–activated melanoma B16 cells. They also noted that manassantin A suppressed forskolin- or 3-isobutyl-1-methylxanthine (IBMX)–induced melanin production and diminished cellular levels of IBMX-inducible tyrosinase protein. The lignan had no effect on the catalytic activity of cell-free tyrosinase, an important enzyme in melanin pigment production. The researchers concluded that their results suggest the potential for S. chinensis to be used to treat hyperpigmentation disorders.9
Two years later Lee et al. found that manassantin A, derived from S. chinensis, steadily suppressed the cAMP elevator IBMX- or dibutyryl cAMP-induced melanin synthesis in B16 cells or in melan-a melanocytes by down-regulating the expression of tyrosinase or the TRP1 gene. The lignan also inhibited microphthalmia-associated transcription factor (MITF) induction via the IBMX-activated cAMP-responsive element-binding protein (CREB) pathway, thus preventing the Ser-133 phosphorylation of CREB. The researchers concluded that this molecular disruption of melanin production suggests the potential for the use of manassantin A as a skin depigmenting agent.10
That same year, another S. chinensis lignan gained interest. Yun et al. investigated the effects of the S. chinensis lignan component saucerneol D on melanin synthesis in cAMP-elevated melanocytes. They found that the lignan efficiently impeded melanin product in B16 melanoma cells stimulated with alpha-MSH or other cAMP elevators. Saucerneol D was also credited with down-regulating alpha-MSH–induced gene expression of tyrosinase at the transcription level in B16 cells, suppressing alpha-MSH–induced phosphorylation of CREB in the cells, and inhibiting MITF induction. The investigators concluded that their results point to the potential of the S. chinensis lignan saucerneol D for the treatment of hyperpigmentation disorders.11
In 2012, Chang et al. observed that an extract of S. chinensis and one of its constituent lignans, manassantin B, prevented melanosome transport in normal human melanocytes and Melan-a melanocytes, by interrupting the interaction between melanophilin and myosin Va. The investigators concluded that as a substance that can hinder melanosome transport, manassantin B displays potential for use as depigmenting product.12
The following year, Lee et al. studied the effects of S. chinensis extracts on the melanogenesis signaling pathway activated by alpha-MSH, finding dose-dependent inhibition without provoking cytotoxicity in B16F10 cells. Further, the team found evidence that the depigmenting activity exhibited by S. chinensis extracts may occur as a result of MITF and tyrosinase expression stemming from elevated activity of extracellular signal-regulated kinase (ERK). They concluded that their results support further examination of S. chinensis for its potential to contribute to skin whitening.5
Conclusion
Multiple lignan constituents in this plant-derived ingredient appear to yield anti-inflammatory, antioxidant, photoprotective, and antitumor properties. Its inhibitory effects on melanin production and its antiaging abilities make it worthy of further study and consideration of inclusion in antiaging skin care products.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur in Miami. She founded the division of cosmetic dermatology at the University of Miami in 1997. The third edition of her bestselling textbook, “Cosmetic Dermatology,” was published in 2022. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Johnson & Johnson, and Burt’s Bees. She is the CEO of Skin Type Solutions, a SaaS company used to generate skin care routines in the office and as an e-commerce solution. Write to her at [email protected].
References
1. Zhang J et al. J Ethnopharmacol. 2021 Oct 28;279:114400.
2. Yoo HJ et al. J Ethnopharmacol. 2008 Nov 20;120(2):282-6.
3. Kim BW et al. BMC Complement Altern Med. 2014 Dec 16;14:502.
4. Lee DH et al. Biol Pharm Bull. 2013;36(5):772-9.
5. Lee YJ et al. Biol Pharm Bull. 2012;35(8):1361-6.
6. Choi MS et al. Biol Pharm Bull. 2008 Jan;31(1):51-6.
7. Park G et al. Biol Pharm Bull. 2013;36(7):1134-9.
8. Bae HB et al. Int Immunopharmacol. 2010 Sep;10(9):1022-8.
9. Seo CS et al. Phytother Res. 2009 Nov;23(11):1531-6.
10. Lee HD et al. Exp Dermatol. 2011 Sep;20(9):761-3.
11. Yun JY et al. Arch Pharm Res. 2011 Aug;34(8):1339-45.
12. Chang H et al. Pigment Cell Melanoma Res. 2012 Nov;25(6):765-72.
Also known as Asian or Chinese lizard’s tail (or Sam-baekcho in Korea), Saururus chinensis is an East Asian plant used in traditional medicine for various indications including edema, gonorrhea, jaundice, hypertension, leproma, pneumonia, and rheumatoid arthritis.1,2 Specifically, Korean traditional medicine practitioners as well as Native Americans and early colonists in what is now the United States used the botanical to treat cancer, edema, rheumatoid arthritis, and other inflammatory conditions.2-4 Modern research has produced evidence supporting the use of this plant in the dermatologic realm. This column focuses on the relevant bench science and possible applications.
Various beneficial effects
In 2008, Yoo et al. found that the ethanol extract of the dried aerial parts of S. chinensis exhibit anti-inflammatory, antiangiogenic, and antinociceptive properties, which they suggested may partially account for the established therapeutic effects of the plant.2 Also, Lee et al. reported in 2012 on the antiproliferative effects against human cancer cell lines of neolignans found in S. chinensis.5
Antioxidant properties have been associated with S. chinensis. In 2014, Kim et al. reported that S. chinensis extract attenuated the lipopolysaccharide (LPS)-stimulated neuroinflammatory response in BV-2 microglia cells, a result that the authors partly ascribed to the antioxidant constituents (particularly quercetin) of the plant.3
Atopic dermatitis
In 2008, Choi et al. determined that the leaves of S. chinensis impeded the formation of atopic dermatitis–like skin lesions in NC/Nga mice caused by repeated application of picryl chloride, potentially by stimulating the Th1 cell response, thus modulating Th1/Th2 imbalance. They concluded that S. chinensis has potential as an adjunct treatment option for atopic dermatitis.6
Anti-inflammatory activity
In 2010, Bae et al. studied the anti-inflammatory properties of sauchinone, a lignan derived from S. chinensis reputed to exert antioxidant, anti-inflammatory, and hepatoprotective activity,7 using LPS-stimulated RAW264.7 cells. They found that the lignan lowered tumor necrosis factor (TNF)–alpha synthesis by inhibiting the c-Raf-MEK1/2-ERK1/2 phosphorylation pathway, accounting for the anti-inflammatory effects of the S. chinensis constituent.8
More recently, Zhang et al. determined that the ethanol extract of S. chinensis leaves impaired proinflammatory gene expression by blocking the TAK1/AP-1 pathway in LPS-treated RAW264.7 macrophages. They suggested that such suppression is a significant step in the anti-inflammatory function exhibited by the plant.1
Photoprotection
Park et al. investigated in 2013 the beneficial effects of sauchinone. Specifically, they studied potential photoprotective effects of the lignan against UVB in HaCaT human epidermal keratinocytes. They found that sauchinone (5-40 mcm) conferred significant protection as evaluated by cell viability and a toxicity assay. At 20-40 mcm, sauchinone blocked the upregulation of matrix metalloproteinase (MMP)–1 proteins and decrease of type 1 collagen engendered by UVB exposure. The investigators further discovered that sauchinone diminished the synthesis of reactive oxygen species. Overall, they determined that sauchinone imparted protection by suppressing extracellular signal-regulated kinase, c-Jun N-terminal kinase, and p38 MAPK signaling through the activation of oxidative defense enzymes.7
Potential use as a depigmenting agent
In 2009, Seo et al. isolated the lignans manassantin A and B from S. chinensis and determined that these compounds dose-dependently impeded melanin synthesis in alpha-melanocyte stimulating hormone (alpha-MSH)–activated melanoma B16 cells. They also noted that manassantin A suppressed forskolin- or 3-isobutyl-1-methylxanthine (IBMX)–induced melanin production and diminished cellular levels of IBMX-inducible tyrosinase protein. The lignan had no effect on the catalytic activity of cell-free tyrosinase, an important enzyme in melanin pigment production. The researchers concluded that their results suggest the potential for S. chinensis to be used to treat hyperpigmentation disorders.9
Two years later Lee et al. found that manassantin A, derived from S. chinensis, steadily suppressed the cAMP elevator IBMX- or dibutyryl cAMP-induced melanin synthesis in B16 cells or in melan-a melanocytes by down-regulating the expression of tyrosinase or the TRP1 gene. The lignan also inhibited microphthalmia-associated transcription factor (MITF) induction via the IBMX-activated cAMP-responsive element-binding protein (CREB) pathway, thus preventing the Ser-133 phosphorylation of CREB. The researchers concluded that this molecular disruption of melanin production suggests the potential for the use of manassantin A as a skin depigmenting agent.10
That same year, another S. chinensis lignan gained interest. Yun et al. investigated the effects of the S. chinensis lignan component saucerneol D on melanin synthesis in cAMP-elevated melanocytes. They found that the lignan efficiently impeded melanin product in B16 melanoma cells stimulated with alpha-MSH or other cAMP elevators. Saucerneol D was also credited with down-regulating alpha-MSH–induced gene expression of tyrosinase at the transcription level in B16 cells, suppressing alpha-MSH–induced phosphorylation of CREB in the cells, and inhibiting MITF induction. The investigators concluded that their results point to the potential of the S. chinensis lignan saucerneol D for the treatment of hyperpigmentation disorders.11
In 2012, Chang et al. observed that an extract of S. chinensis and one of its constituent lignans, manassantin B, prevented melanosome transport in normal human melanocytes and Melan-a melanocytes, by interrupting the interaction between melanophilin and myosin Va. The investigators concluded that as a substance that can hinder melanosome transport, manassantin B displays potential for use as depigmenting product.12
The following year, Lee et al. studied the effects of S. chinensis extracts on the melanogenesis signaling pathway activated by alpha-MSH, finding dose-dependent inhibition without provoking cytotoxicity in B16F10 cells. Further, the team found evidence that the depigmenting activity exhibited by S. chinensis extracts may occur as a result of MITF and tyrosinase expression stemming from elevated activity of extracellular signal-regulated kinase (ERK). They concluded that their results support further examination of S. chinensis for its potential to contribute to skin whitening.5
Conclusion
Multiple lignan constituents in this plant-derived ingredient appear to yield anti-inflammatory, antioxidant, photoprotective, and antitumor properties. Its inhibitory effects on melanin production and its antiaging abilities make it worthy of further study and consideration of inclusion in antiaging skin care products.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur in Miami. She founded the division of cosmetic dermatology at the University of Miami in 1997. The third edition of her bestselling textbook, “Cosmetic Dermatology,” was published in 2022. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Johnson & Johnson, and Burt’s Bees. She is the CEO of Skin Type Solutions, a SaaS company used to generate skin care routines in the office and as an e-commerce solution. Write to her at [email protected].
References
1. Zhang J et al. J Ethnopharmacol. 2021 Oct 28;279:114400.
2. Yoo HJ et al. J Ethnopharmacol. 2008 Nov 20;120(2):282-6.
3. Kim BW et al. BMC Complement Altern Med. 2014 Dec 16;14:502.
4. Lee DH et al. Biol Pharm Bull. 2013;36(5):772-9.
5. Lee YJ et al. Biol Pharm Bull. 2012;35(8):1361-6.
6. Choi MS et al. Biol Pharm Bull. 2008 Jan;31(1):51-6.
7. Park G et al. Biol Pharm Bull. 2013;36(7):1134-9.
8. Bae HB et al. Int Immunopharmacol. 2010 Sep;10(9):1022-8.
9. Seo CS et al. Phytother Res. 2009 Nov;23(11):1531-6.
10. Lee HD et al. Exp Dermatol. 2011 Sep;20(9):761-3.
11. Yun JY et al. Arch Pharm Res. 2011 Aug;34(8):1339-45.
12. Chang H et al. Pigment Cell Melanoma Res. 2012 Nov;25(6):765-72.
Also known as Asian or Chinese lizard’s tail (or Sam-baekcho in Korea), Saururus chinensis is an East Asian plant used in traditional medicine for various indications including edema, gonorrhea, jaundice, hypertension, leproma, pneumonia, and rheumatoid arthritis.1,2 Specifically, Korean traditional medicine practitioners as well as Native Americans and early colonists in what is now the United States used the botanical to treat cancer, edema, rheumatoid arthritis, and other inflammatory conditions.2-4 Modern research has produced evidence supporting the use of this plant in the dermatologic realm. This column focuses on the relevant bench science and possible applications.
Various beneficial effects
In 2008, Yoo et al. found that the ethanol extract of the dried aerial parts of S. chinensis exhibit anti-inflammatory, antiangiogenic, and antinociceptive properties, which they suggested may partially account for the established therapeutic effects of the plant.2 Also, Lee et al. reported in 2012 on the antiproliferative effects against human cancer cell lines of neolignans found in S. chinensis.5
Antioxidant properties have been associated with S. chinensis. In 2014, Kim et al. reported that S. chinensis extract attenuated the lipopolysaccharide (LPS)-stimulated neuroinflammatory response in BV-2 microglia cells, a result that the authors partly ascribed to the antioxidant constituents (particularly quercetin) of the plant.3
Atopic dermatitis
In 2008, Choi et al. determined that the leaves of S. chinensis impeded the formation of atopic dermatitis–like skin lesions in NC/Nga mice caused by repeated application of picryl chloride, potentially by stimulating the Th1 cell response, thus modulating Th1/Th2 imbalance. They concluded that S. chinensis has potential as an adjunct treatment option for atopic dermatitis.6
Anti-inflammatory activity
In 2010, Bae et al. studied the anti-inflammatory properties of sauchinone, a lignan derived from S. chinensis reputed to exert antioxidant, anti-inflammatory, and hepatoprotective activity,7 using LPS-stimulated RAW264.7 cells. They found that the lignan lowered tumor necrosis factor (TNF)–alpha synthesis by inhibiting the c-Raf-MEK1/2-ERK1/2 phosphorylation pathway, accounting for the anti-inflammatory effects of the S. chinensis constituent.8
More recently, Zhang et al. determined that the ethanol extract of S. chinensis leaves impaired proinflammatory gene expression by blocking the TAK1/AP-1 pathway in LPS-treated RAW264.7 macrophages. They suggested that such suppression is a significant step in the anti-inflammatory function exhibited by the plant.1
Photoprotection
Park et al. investigated in 2013 the beneficial effects of sauchinone. Specifically, they studied potential photoprotective effects of the lignan against UVB in HaCaT human epidermal keratinocytes. They found that sauchinone (5-40 mcm) conferred significant protection as evaluated by cell viability and a toxicity assay. At 20-40 mcm, sauchinone blocked the upregulation of matrix metalloproteinase (MMP)–1 proteins and decrease of type 1 collagen engendered by UVB exposure. The investigators further discovered that sauchinone diminished the synthesis of reactive oxygen species. Overall, they determined that sauchinone imparted protection by suppressing extracellular signal-regulated kinase, c-Jun N-terminal kinase, and p38 MAPK signaling through the activation of oxidative defense enzymes.7
Potential use as a depigmenting agent
In 2009, Seo et al. isolated the lignans manassantin A and B from S. chinensis and determined that these compounds dose-dependently impeded melanin synthesis in alpha-melanocyte stimulating hormone (alpha-MSH)–activated melanoma B16 cells. They also noted that manassantin A suppressed forskolin- or 3-isobutyl-1-methylxanthine (IBMX)–induced melanin production and diminished cellular levels of IBMX-inducible tyrosinase protein. The lignan had no effect on the catalytic activity of cell-free tyrosinase, an important enzyme in melanin pigment production. The researchers concluded that their results suggest the potential for S. chinensis to be used to treat hyperpigmentation disorders.9
Two years later Lee et al. found that manassantin A, derived from S. chinensis, steadily suppressed the cAMP elevator IBMX- or dibutyryl cAMP-induced melanin synthesis in B16 cells or in melan-a melanocytes by down-regulating the expression of tyrosinase or the TRP1 gene. The lignan also inhibited microphthalmia-associated transcription factor (MITF) induction via the IBMX-activated cAMP-responsive element-binding protein (CREB) pathway, thus preventing the Ser-133 phosphorylation of CREB. The researchers concluded that this molecular disruption of melanin production suggests the potential for the use of manassantin A as a skin depigmenting agent.10
That same year, another S. chinensis lignan gained interest. Yun et al. investigated the effects of the S. chinensis lignan component saucerneol D on melanin synthesis in cAMP-elevated melanocytes. They found that the lignan efficiently impeded melanin product in B16 melanoma cells stimulated with alpha-MSH or other cAMP elevators. Saucerneol D was also credited with down-regulating alpha-MSH–induced gene expression of tyrosinase at the transcription level in B16 cells, suppressing alpha-MSH–induced phosphorylation of CREB in the cells, and inhibiting MITF induction. The investigators concluded that their results point to the potential of the S. chinensis lignan saucerneol D for the treatment of hyperpigmentation disorders.11
In 2012, Chang et al. observed that an extract of S. chinensis and one of its constituent lignans, manassantin B, prevented melanosome transport in normal human melanocytes and Melan-a melanocytes, by interrupting the interaction between melanophilin and myosin Va. The investigators concluded that as a substance that can hinder melanosome transport, manassantin B displays potential for use as depigmenting product.12
The following year, Lee et al. studied the effects of S. chinensis extracts on the melanogenesis signaling pathway activated by alpha-MSH, finding dose-dependent inhibition without provoking cytotoxicity in B16F10 cells. Further, the team found evidence that the depigmenting activity exhibited by S. chinensis extracts may occur as a result of MITF and tyrosinase expression stemming from elevated activity of extracellular signal-regulated kinase (ERK). They concluded that their results support further examination of S. chinensis for its potential to contribute to skin whitening.5
Conclusion
Multiple lignan constituents in this plant-derived ingredient appear to yield anti-inflammatory, antioxidant, photoprotective, and antitumor properties. Its inhibitory effects on melanin production and its antiaging abilities make it worthy of further study and consideration of inclusion in antiaging skin care products.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur in Miami. She founded the division of cosmetic dermatology at the University of Miami in 1997. The third edition of her bestselling textbook, “Cosmetic Dermatology,” was published in 2022. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Johnson & Johnson, and Burt’s Bees. She is the CEO of Skin Type Solutions, a SaaS company used to generate skin care routines in the office and as an e-commerce solution. Write to her at [email protected].
References
1. Zhang J et al. J Ethnopharmacol. 2021 Oct 28;279:114400.
2. Yoo HJ et al. J Ethnopharmacol. 2008 Nov 20;120(2):282-6.
3. Kim BW et al. BMC Complement Altern Med. 2014 Dec 16;14:502.
4. Lee DH et al. Biol Pharm Bull. 2013;36(5):772-9.
5. Lee YJ et al. Biol Pharm Bull. 2012;35(8):1361-6.
6. Choi MS et al. Biol Pharm Bull. 2008 Jan;31(1):51-6.
7. Park G et al. Biol Pharm Bull. 2013;36(7):1134-9.
8. Bae HB et al. Int Immunopharmacol. 2010 Sep;10(9):1022-8.
9. Seo CS et al. Phytother Res. 2009 Nov;23(11):1531-6.
10. Lee HD et al. Exp Dermatol. 2011 Sep;20(9):761-3.
11. Yun JY et al. Arch Pharm Res. 2011 Aug;34(8):1339-45.
12. Chang H et al. Pigment Cell Melanoma Res. 2012 Nov;25(6):765-72.
New Year’s resolutions
I can’t presume to know what issues need addressing in your practice, but I do know the ones I get asked about most often, so I can offer some suggestions that might provide inspiration:
1. Keep your website up to date. Check it now, then make a note to check it regularly. Most people find their physicians online these days, and you don’t want them finding a year-old presentation with outdated photos, personnel, services, and rates. Keep your site current, or hire someone to do it for you.
2. Be an authoritative presence on social media. Like it or not, you should be on Facebook, Twitter (at least for now), Instagram, TikTok – wherever your patients congregate. Medical topics are popular search categories, and they are searching for expert advice. You are the expert. There is a ton of medical misinformation online, and it needs to be countered with accurate, factual data from bona fide experts.
3. Follow colleagues. No need to reinvent the wheel; many physicians have already developed large online followings. Track some of them down, follow them yourself, and use them as inspiration for your own online contributions. Your specialty society probably maintains a presence on Instagram and other sites as well, and they are a good source of topics and tips.
4. Post frequently. We all have a finite amount of time, but a few brief posts per week on various social media platforms will attract more attention, and garner more followers than an occasional long treatise. Add relevant hashtags to get more reach and engagement.
5. Participate in trends. When a topic is getting thousands of views, it a trending topic. Post on trending topics, and if you know the trend’s original authors, tag them. That will increase your audience, and the compliment might be reciprocated in the future.
6. Google yourself. You might be surprised by what you find. Being aware of what is being said about you online is a necessary exercise to maintain a healthy online reputation. The good reviews are ego builders, but it’s the bad reviews that you can learn from. They will help you identify your negative personality traits and motivate you to eliminate them.
7. Encrypt your mobile devices. The biggest HIPAA vulnerability in many practices is laptops and tablets carrying confidential patient information; losing one could be a disaster. Encryption software is cheap and readily available, and a lost or stolen mobile device will probably not be treated as a HIPAA breach if it is properly encrypted.
8. Back up your data. Now is an excellent time to verify that the information on your office and personal computers is being backed up – locally and online – on a regular schedule. Don’t wait until something crashes.
9. Keep a closer eye on your office finances. Most physicians delegate the bookkeeping, and that’s fine. But ignoring the financial side completely creates an atmosphere that facilitates embezzlement. Set aside a couple of hours each month to review the books personally. And make sure your employees know you’re doing it.
10. Make sure your long-range financial planning is on track. I’ve said this before, but it can’t be repeated too often. Economic conditions change all the time. Once a year, you should sit down with your accountant and lawyer and make sure your investments are well-diversified and all other aspects of your finances – budgets, credit ratings, insurance coverage, tax situations, college savings, estate plans, retirement accounts – are in the best shape possible.
11. Pay down your debt. Another oldie but goodie. Debt can destroy the best laid retirement plans. If you carry significant debt, set up a plan to pay it off as soon as you can.
12. Take more vacations. Remember Eastern’s First Law: Your last words will NOT be, “I wish I had spent more time in the office.” If you’ve been working too much, this is the year to start spending more time enjoying your life, your friends and family, and the world. As John Lennon said, “Life is what happens to you while you’re busy making other plans.”
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
I can’t presume to know what issues need addressing in your practice, but I do know the ones I get asked about most often, so I can offer some suggestions that might provide inspiration:
1. Keep your website up to date. Check it now, then make a note to check it regularly. Most people find their physicians online these days, and you don’t want them finding a year-old presentation with outdated photos, personnel, services, and rates. Keep your site current, or hire someone to do it for you.
2. Be an authoritative presence on social media. Like it or not, you should be on Facebook, Twitter (at least for now), Instagram, TikTok – wherever your patients congregate. Medical topics are popular search categories, and they are searching for expert advice. You are the expert. There is a ton of medical misinformation online, and it needs to be countered with accurate, factual data from bona fide experts.
3. Follow colleagues. No need to reinvent the wheel; many physicians have already developed large online followings. Track some of them down, follow them yourself, and use them as inspiration for your own online contributions. Your specialty society probably maintains a presence on Instagram and other sites as well, and they are a good source of topics and tips.
4. Post frequently. We all have a finite amount of time, but a few brief posts per week on various social media platforms will attract more attention, and garner more followers than an occasional long treatise. Add relevant hashtags to get more reach and engagement.
5. Participate in trends. When a topic is getting thousands of views, it a trending topic. Post on trending topics, and if you know the trend’s original authors, tag them. That will increase your audience, and the compliment might be reciprocated in the future.
6. Google yourself. You might be surprised by what you find. Being aware of what is being said about you online is a necessary exercise to maintain a healthy online reputation. The good reviews are ego builders, but it’s the bad reviews that you can learn from. They will help you identify your negative personality traits and motivate you to eliminate them.
7. Encrypt your mobile devices. The biggest HIPAA vulnerability in many practices is laptops and tablets carrying confidential patient information; losing one could be a disaster. Encryption software is cheap and readily available, and a lost or stolen mobile device will probably not be treated as a HIPAA breach if it is properly encrypted.
8. Back up your data. Now is an excellent time to verify that the information on your office and personal computers is being backed up – locally and online – on a regular schedule. Don’t wait until something crashes.
9. Keep a closer eye on your office finances. Most physicians delegate the bookkeeping, and that’s fine. But ignoring the financial side completely creates an atmosphere that facilitates embezzlement. Set aside a couple of hours each month to review the books personally. And make sure your employees know you’re doing it.
10. Make sure your long-range financial planning is on track. I’ve said this before, but it can’t be repeated too often. Economic conditions change all the time. Once a year, you should sit down with your accountant and lawyer and make sure your investments are well-diversified and all other aspects of your finances – budgets, credit ratings, insurance coverage, tax situations, college savings, estate plans, retirement accounts – are in the best shape possible.
11. Pay down your debt. Another oldie but goodie. Debt can destroy the best laid retirement plans. If you carry significant debt, set up a plan to pay it off as soon as you can.
12. Take more vacations. Remember Eastern’s First Law: Your last words will NOT be, “I wish I had spent more time in the office.” If you’ve been working too much, this is the year to start spending more time enjoying your life, your friends and family, and the world. As John Lennon said, “Life is what happens to you while you’re busy making other plans.”
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
I can’t presume to know what issues need addressing in your practice, but I do know the ones I get asked about most often, so I can offer some suggestions that might provide inspiration:
1. Keep your website up to date. Check it now, then make a note to check it regularly. Most people find their physicians online these days, and you don’t want them finding a year-old presentation with outdated photos, personnel, services, and rates. Keep your site current, or hire someone to do it for you.
2. Be an authoritative presence on social media. Like it or not, you should be on Facebook, Twitter (at least for now), Instagram, TikTok – wherever your patients congregate. Medical topics are popular search categories, and they are searching for expert advice. You are the expert. There is a ton of medical misinformation online, and it needs to be countered with accurate, factual data from bona fide experts.
3. Follow colleagues. No need to reinvent the wheel; many physicians have already developed large online followings. Track some of them down, follow them yourself, and use them as inspiration for your own online contributions. Your specialty society probably maintains a presence on Instagram and other sites as well, and they are a good source of topics and tips.
4. Post frequently. We all have a finite amount of time, but a few brief posts per week on various social media platforms will attract more attention, and garner more followers than an occasional long treatise. Add relevant hashtags to get more reach and engagement.
5. Participate in trends. When a topic is getting thousands of views, it a trending topic. Post on trending topics, and if you know the trend’s original authors, tag them. That will increase your audience, and the compliment might be reciprocated in the future.
6. Google yourself. You might be surprised by what you find. Being aware of what is being said about you online is a necessary exercise to maintain a healthy online reputation. The good reviews are ego builders, but it’s the bad reviews that you can learn from. They will help you identify your negative personality traits and motivate you to eliminate them.
7. Encrypt your mobile devices. The biggest HIPAA vulnerability in many practices is laptops and tablets carrying confidential patient information; losing one could be a disaster. Encryption software is cheap and readily available, and a lost or stolen mobile device will probably not be treated as a HIPAA breach if it is properly encrypted.
8. Back up your data. Now is an excellent time to verify that the information on your office and personal computers is being backed up – locally and online – on a regular schedule. Don’t wait until something crashes.
9. Keep a closer eye on your office finances. Most physicians delegate the bookkeeping, and that’s fine. But ignoring the financial side completely creates an atmosphere that facilitates embezzlement. Set aside a couple of hours each month to review the books personally. And make sure your employees know you’re doing it.
10. Make sure your long-range financial planning is on track. I’ve said this before, but it can’t be repeated too often. Economic conditions change all the time. Once a year, you should sit down with your accountant and lawyer and make sure your investments are well-diversified and all other aspects of your finances – budgets, credit ratings, insurance coverage, tax situations, college savings, estate plans, retirement accounts – are in the best shape possible.
11. Pay down your debt. Another oldie but goodie. Debt can destroy the best laid retirement plans. If you carry significant debt, set up a plan to pay it off as soon as you can.
12. Take more vacations. Remember Eastern’s First Law: Your last words will NOT be, “I wish I had spent more time in the office.” If you’ve been working too much, this is the year to start spending more time enjoying your life, your friends and family, and the world. As John Lennon said, “Life is what happens to you while you’re busy making other plans.”
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
A 9-year old female presented with 1 day of fever, fatigue, and sore throat
This condition typically presents in the setting of Streptococcus pyogenes pharyngitis, or strep throat, and is spread via mucosal transfer in close proximity such as classrooms and nurseries. The dermatologic symptoms are a result of the endotoxin produced by S. pyogenes, which is part of the group A Strep bacteria. Clinically, the presentation can be differentiated from an allergic eruption by its relation to acute pharyngitis, insidious onset, and lack of confluence of the lesions. Diagnosis is supported by a throat culture and rapid strep test, although a rapid test lacks reliability in older patients who are less commonly affected and likely to be carriers. First-line treatment is penicillin or amoxicillin, but first-generation cephalosporins, clindamycin, or erythromycin are sufficient if the patient is allergic to penicillins. Prognosis worsens as time between onset and treatment increases, but is overall excellent now with the introduction of antibiotics and improved hygiene.
Scarlet fever is among a list of many common childhood rashes, and it can be difficult to differentiate between these pathologies on clinical presentation. A few notable childhood dermatologic eruptions include erythema infectiosum (fifth disease), roseola (exanthema subitum or sixth disease), and measles. These cases can be distinguished clinically by the age of the patient, distribution, and quality of the symptoms. Laboratory testing may be used to confirm the diagnosis.
Erythema infectiosum is known as fifth disease or slapped-cheek rash because it commonly presents on the cheeks as a pink, maculopapular rash in a reticular pattern. The disease is caused by parvovirus B19 and is accompanied by low fever, malaise, headache, sore throat, and nausea, which precedes the erythematous rash. The facial rash appears first and is followed by patchy eruptions on the extremities. Appearance of the rash typically indicates the patient is no longer contagious, and patients are treated symptomatically with NSAIDs and antihistamines for associated pruritus.
Roseola infantum is commonly caused by human herpesvirus 6 and is usually found in children 3 years and younger. The defining symptom is a high fever, which is paired with a mild cough, runny nose, and diarrhea. A maculopapular rash appears after the fever subsides, starting centrally and spreading outward to the extremities. Although this rash is similar to measles, they can be differentiated by the order of onset. The rash caused by measles begins on the face and mouth (Koplik spots) and moves downward. Additionally, the patient appears generally healthy and the disease is self-limiting in roseola, while patients with measles will appear more ill and require further attention. Measles is caused by the measles virus of the genus Morbillivirus and is highly contagious. It is spread via respiratory route presenting with fever, cough, coryza, and conjunctivitis followed by the rash. Fortunately, the measles vaccine is in widespread use, so cases have declined over the years.
Our patient had a positive strep test. Influenza and coronavirus tests were negative. She was started on daily amoxicillin and the rash resolved within 2 days of taking the antibiotics.
This case and photo were submitted by Lucas Shapiro, BS, Nova Southeastern University, Tampa, and Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
References
Allmon A et al.. Am Fam Physician. 2015 Aug 1;92(3):211-6.
Moss WJ. Lancet. 2017 Dec 2;390(10111):2490-502.
Mullins TB and Krishnamurthy K. Roseola Infantum, in “StatPearls.” Treasure Islan, Fla.: StatPearls Publishing, 2022.
Pardo S and Perera TB. Scarlet Fever, in “StatPearls.” Treasure Island, Fla.: StatPearls Publishing, 2022.
This condition typically presents in the setting of Streptococcus pyogenes pharyngitis, or strep throat, and is spread via mucosal transfer in close proximity such as classrooms and nurseries. The dermatologic symptoms are a result of the endotoxin produced by S. pyogenes, which is part of the group A Strep bacteria. Clinically, the presentation can be differentiated from an allergic eruption by its relation to acute pharyngitis, insidious onset, and lack of confluence of the lesions. Diagnosis is supported by a throat culture and rapid strep test, although a rapid test lacks reliability in older patients who are less commonly affected and likely to be carriers. First-line treatment is penicillin or amoxicillin, but first-generation cephalosporins, clindamycin, or erythromycin are sufficient if the patient is allergic to penicillins. Prognosis worsens as time between onset and treatment increases, but is overall excellent now with the introduction of antibiotics and improved hygiene.
Scarlet fever is among a list of many common childhood rashes, and it can be difficult to differentiate between these pathologies on clinical presentation. A few notable childhood dermatologic eruptions include erythema infectiosum (fifth disease), roseola (exanthema subitum or sixth disease), and measles. These cases can be distinguished clinically by the age of the patient, distribution, and quality of the symptoms. Laboratory testing may be used to confirm the diagnosis.
Erythema infectiosum is known as fifth disease or slapped-cheek rash because it commonly presents on the cheeks as a pink, maculopapular rash in a reticular pattern. The disease is caused by parvovirus B19 and is accompanied by low fever, malaise, headache, sore throat, and nausea, which precedes the erythematous rash. The facial rash appears first and is followed by patchy eruptions on the extremities. Appearance of the rash typically indicates the patient is no longer contagious, and patients are treated symptomatically with NSAIDs and antihistamines for associated pruritus.
Roseola infantum is commonly caused by human herpesvirus 6 and is usually found in children 3 years and younger. The defining symptom is a high fever, which is paired with a mild cough, runny nose, and diarrhea. A maculopapular rash appears after the fever subsides, starting centrally and spreading outward to the extremities. Although this rash is similar to measles, they can be differentiated by the order of onset. The rash caused by measles begins on the face and mouth (Koplik spots) and moves downward. Additionally, the patient appears generally healthy and the disease is self-limiting in roseola, while patients with measles will appear more ill and require further attention. Measles is caused by the measles virus of the genus Morbillivirus and is highly contagious. It is spread via respiratory route presenting with fever, cough, coryza, and conjunctivitis followed by the rash. Fortunately, the measles vaccine is in widespread use, so cases have declined over the years.
Our patient had a positive strep test. Influenza and coronavirus tests were negative. She was started on daily amoxicillin and the rash resolved within 2 days of taking the antibiotics.
This case and photo were submitted by Lucas Shapiro, BS, Nova Southeastern University, Tampa, and Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
References
Allmon A et al.. Am Fam Physician. 2015 Aug 1;92(3):211-6.
Moss WJ. Lancet. 2017 Dec 2;390(10111):2490-502.
Mullins TB and Krishnamurthy K. Roseola Infantum, in “StatPearls.” Treasure Islan, Fla.: StatPearls Publishing, 2022.
Pardo S and Perera TB. Scarlet Fever, in “StatPearls.” Treasure Island, Fla.: StatPearls Publishing, 2022.
This condition typically presents in the setting of Streptococcus pyogenes pharyngitis, or strep throat, and is spread via mucosal transfer in close proximity such as classrooms and nurseries. The dermatologic symptoms are a result of the endotoxin produced by S. pyogenes, which is part of the group A Strep bacteria. Clinically, the presentation can be differentiated from an allergic eruption by its relation to acute pharyngitis, insidious onset, and lack of confluence of the lesions. Diagnosis is supported by a throat culture and rapid strep test, although a rapid test lacks reliability in older patients who are less commonly affected and likely to be carriers. First-line treatment is penicillin or amoxicillin, but first-generation cephalosporins, clindamycin, or erythromycin are sufficient if the patient is allergic to penicillins. Prognosis worsens as time between onset and treatment increases, but is overall excellent now with the introduction of antibiotics and improved hygiene.
Scarlet fever is among a list of many common childhood rashes, and it can be difficult to differentiate between these pathologies on clinical presentation. A few notable childhood dermatologic eruptions include erythema infectiosum (fifth disease), roseola (exanthema subitum or sixth disease), and measles. These cases can be distinguished clinically by the age of the patient, distribution, and quality of the symptoms. Laboratory testing may be used to confirm the diagnosis.
Erythema infectiosum is known as fifth disease or slapped-cheek rash because it commonly presents on the cheeks as a pink, maculopapular rash in a reticular pattern. The disease is caused by parvovirus B19 and is accompanied by low fever, malaise, headache, sore throat, and nausea, which precedes the erythematous rash. The facial rash appears first and is followed by patchy eruptions on the extremities. Appearance of the rash typically indicates the patient is no longer contagious, and patients are treated symptomatically with NSAIDs and antihistamines for associated pruritus.
Roseola infantum is commonly caused by human herpesvirus 6 and is usually found in children 3 years and younger. The defining symptom is a high fever, which is paired with a mild cough, runny nose, and diarrhea. A maculopapular rash appears after the fever subsides, starting centrally and spreading outward to the extremities. Although this rash is similar to measles, they can be differentiated by the order of onset. The rash caused by measles begins on the face and mouth (Koplik spots) and moves downward. Additionally, the patient appears generally healthy and the disease is self-limiting in roseola, while patients with measles will appear more ill and require further attention. Measles is caused by the measles virus of the genus Morbillivirus and is highly contagious. It is spread via respiratory route presenting with fever, cough, coryza, and conjunctivitis followed by the rash. Fortunately, the measles vaccine is in widespread use, so cases have declined over the years.
Our patient had a positive strep test. Influenza and coronavirus tests were negative. She was started on daily amoxicillin and the rash resolved within 2 days of taking the antibiotics.
This case and photo were submitted by Lucas Shapiro, BS, Nova Southeastern University, Tampa, and Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
References
Allmon A et al.. Am Fam Physician. 2015 Aug 1;92(3):211-6.
Moss WJ. Lancet. 2017 Dec 2;390(10111):2490-502.
Mullins TB and Krishnamurthy K. Roseola Infantum, in “StatPearls.” Treasure Islan, Fla.: StatPearls Publishing, 2022.
Pardo S and Perera TB. Scarlet Fever, in “StatPearls.” Treasure Island, Fla.: StatPearls Publishing, 2022.
Nurturing a Satisfying Career in Dermatology
The residents of our program asked me to serve as their commencement speaker in June. Since I was retiring from my position as department chair, this touching honor seemed a fitting capstone for my career. It gave me the opportunity to reflect on the enormity of the changes that have occurred between my graduation from residency in 1983 and the current time, which is marked by disruption from the digital revolution and the COVID-19 pandemic. Throughout this 40-year period, there were times of external global turmoil, economic instability, significant changes in the business of medicine, stressful changes in documentation of competency and certification, and the difficult transition to electronic medical records. Another epidemic—AIDS—changed surgical practices. During my residency, we did biopsies without wearing gloves or masks. Gloves were added to protect the person doing the procedure as well as to prevent spread of disease to other patients, not to reduce the infection rate for the patient undergoing the procedure. Of course, change in the last 40 years also occurred outside of work and included various familial stresses. The irritations of daily life easily mounted up to being overwhelming. However, I had gone to work every day for 40 years, seeking to do my best for my patients and my colleagues and the staff with whom I worked, sometimes feeling successful and sometimes feeling incompetent. Some days went smoothly, and some days were filled with challenges that I could not begin to imagine how I would solve. I have a habit of seeing problems rather than successes, which creates its own difficulties. I did, however, grab opportunities that continually improved my practice of medicine and allowed me to serve in several professional positions as well as in leadership positions of multiple professional societies. As I prepared the commencement address, I realized that the totality of my career was very satisfying.
The Merriam-Webster dictionary definition of satisfying is “producing pleasure or contentment by providing what is needed or wanted.”1 My use of the word means that my career over the long term has pleased me—maybe not some of the people I reported to, but rather me.
My approach to my career can be summarized in 3 words: purpose, serendipity, and curiosity.
The first element is purpose. Job satisfaction generally is associated with work being aligned with values, an appreciation that you are accomplishing the purpose with which you set out on your journey. It is not associated with every day being wonderful and problem free or every task being completed without setbacks or complications. The reality of working is not that every moment brings pure happiness or that every task fulfills a passion. How does a person ensure that the days add up to be satisfying? Start with values. Why did you decide to pursue medical school? Some may have chosen it for economic security, but there are many ways to achieve economic security. Maybe being a physician feeds into the family lore, but families generally have broad ranges of acceptable careers. Maybe it appealed scientifically, but a PhD in biology also fulfills that interest. Maybe it is that you noticed respect for physicians in the community when you were growing up, but that is changing and does not represent an internal value anyway. Consider your values carefully, write them down, and keep them at the forefront of the day. Go back to them consciously any time you have a rough day and understand why you are doing what you are doing. When you are 55 years old and going through your umpteenth change in reimbursement process, go back to the day you decided on medicine as a career. Focus on your values as the grounding for your purpose. Also note that purpose is different than goals. Some goals will be reached, and some will not. Goals change with external realities and/ or internal factors. Purpose and values remain the same if we have thoughtfully identified them.
The second element is serendipity. Serendipity often is thought of as luck, as karma, as being in the right place at the right time. It feels random, and at first glance it appears that purpose and serendipity are complete opposites and do not intersect. Serendipity is, however, not just luck. It is an ability to distinguish events and observations in meaningful ways. It is a close relative of creativity and benefits from sloppiness, playfulness, tinkering, and discussion. It cannot exist in a vacuum. History is replete with serendipitous discoveries. It is thought that James Watson and Francis Crick would never have been able to elucidate the nature of DNA without sharing offices with people with whom they argued daily. In fact, figuring out the DNA structure was not even the main focus of their laboratories. It was just a side angle that several people loved to think about. Appreciating serendipity by being truly open to opportunities that are out on the wings brings experiences that are deeply rewarding even if not planned. I had no idea at all, no plan, no goal of serving as president of the American Academy of Dermatology or as Department Chair, and yet these happened. These experiences have allowed me to work on my purpose as I have defined it. How can you harness serendipity in your own life? My philosophy may be somewhat simple, but I think if you show up every day doing the best job you can at the tasks on hand, doors will appear, at odd intervals and in odd directions. You must be open enough and in tune with your purpose to an extent that you can sense the direction in which to turn and what doorways through which to walk.
The third element is curiosity. One definition is that curiosity is the motivation to learn new information. Another definition is that curiosity is a special form of information seeking distinguished by the fact that it is internally motivated. We are all familiar with intellectual curiosity. For example, a patient has a basal cell carcinoma on the upper back. What does the literature say about the cure rates of various treatments for that particular tumor? In addition, we can be curious about other things as well. Is it a really small tumor? How was it found and why is the patient anxious? Why does it make me irritated that the patient is worried about such a small, easily treated tumor? Or is it a large neglected tumor? Why was it not treated before? Why does it make me sad that it is so large? Why does it annoy me that I have a difficult situation to manage? Being able to define an emotional reaction by being curious about its presence helps us manage destructive responses and promote more positive outcomes. This curiosity is related to emotional intelligence and is mindfully harnessed by effective leaders. Curiosity will get you through tough days when your office team is stressed and the tough years that are complicated by professional and personal challenges.
Curiosity also will help you identify your purpose and harness serendipity, and so we come full circle with our 3 elements: purpose, serendipity, and curiosity.
My wish for all of you is that when you are at the tail end of your career, you will look back and say, “This has been a great ride.” I am very grateful that I can acknowledge this for myself. I have been so fortunate to have found dermatology, where I can go to work every day making a difference for patients in a stimulating environment with good colleagues. One of my values is to try and make life better in some way for everyone around me, even if it is just a smile at the start of the workday. As I look back, this value has allowed me to meet interesting people, hear fascinating stories, make good friends, and have enduring relationships. I have held onto fellow travelers, and we have supported each other through tough times as well as celebrated together the good times.
Nurturing a satisfying career includes these essential fundamentals. First, accept the reality of constant change. Second, develop productive relationships with fellow travelers. And third and most importantly, go forth with purpose, serendipity, and curiosity.
- Merriam-Webster. Satisfying. Merriam-Webster.com Dictionary. Accessed November 18, 2022. https://www.merriam-webster.com/dictionary/satisfying
The residents of our program asked me to serve as their commencement speaker in June. Since I was retiring from my position as department chair, this touching honor seemed a fitting capstone for my career. It gave me the opportunity to reflect on the enormity of the changes that have occurred between my graduation from residency in 1983 and the current time, which is marked by disruption from the digital revolution and the COVID-19 pandemic. Throughout this 40-year period, there were times of external global turmoil, economic instability, significant changes in the business of medicine, stressful changes in documentation of competency and certification, and the difficult transition to electronic medical records. Another epidemic—AIDS—changed surgical practices. During my residency, we did biopsies without wearing gloves or masks. Gloves were added to protect the person doing the procedure as well as to prevent spread of disease to other patients, not to reduce the infection rate for the patient undergoing the procedure. Of course, change in the last 40 years also occurred outside of work and included various familial stresses. The irritations of daily life easily mounted up to being overwhelming. However, I had gone to work every day for 40 years, seeking to do my best for my patients and my colleagues and the staff with whom I worked, sometimes feeling successful and sometimes feeling incompetent. Some days went smoothly, and some days were filled with challenges that I could not begin to imagine how I would solve. I have a habit of seeing problems rather than successes, which creates its own difficulties. I did, however, grab opportunities that continually improved my practice of medicine and allowed me to serve in several professional positions as well as in leadership positions of multiple professional societies. As I prepared the commencement address, I realized that the totality of my career was very satisfying.
The Merriam-Webster dictionary definition of satisfying is “producing pleasure or contentment by providing what is needed or wanted.”1 My use of the word means that my career over the long term has pleased me—maybe not some of the people I reported to, but rather me.
My approach to my career can be summarized in 3 words: purpose, serendipity, and curiosity.
The first element is purpose. Job satisfaction generally is associated with work being aligned with values, an appreciation that you are accomplishing the purpose with which you set out on your journey. It is not associated with every day being wonderful and problem free or every task being completed without setbacks or complications. The reality of working is not that every moment brings pure happiness or that every task fulfills a passion. How does a person ensure that the days add up to be satisfying? Start with values. Why did you decide to pursue medical school? Some may have chosen it for economic security, but there are many ways to achieve economic security. Maybe being a physician feeds into the family lore, but families generally have broad ranges of acceptable careers. Maybe it appealed scientifically, but a PhD in biology also fulfills that interest. Maybe it is that you noticed respect for physicians in the community when you were growing up, but that is changing and does not represent an internal value anyway. Consider your values carefully, write them down, and keep them at the forefront of the day. Go back to them consciously any time you have a rough day and understand why you are doing what you are doing. When you are 55 years old and going through your umpteenth change in reimbursement process, go back to the day you decided on medicine as a career. Focus on your values as the grounding for your purpose. Also note that purpose is different than goals. Some goals will be reached, and some will not. Goals change with external realities and/ or internal factors. Purpose and values remain the same if we have thoughtfully identified them.
The second element is serendipity. Serendipity often is thought of as luck, as karma, as being in the right place at the right time. It feels random, and at first glance it appears that purpose and serendipity are complete opposites and do not intersect. Serendipity is, however, not just luck. It is an ability to distinguish events and observations in meaningful ways. It is a close relative of creativity and benefits from sloppiness, playfulness, tinkering, and discussion. It cannot exist in a vacuum. History is replete with serendipitous discoveries. It is thought that James Watson and Francis Crick would never have been able to elucidate the nature of DNA without sharing offices with people with whom they argued daily. In fact, figuring out the DNA structure was not even the main focus of their laboratories. It was just a side angle that several people loved to think about. Appreciating serendipity by being truly open to opportunities that are out on the wings brings experiences that are deeply rewarding even if not planned. I had no idea at all, no plan, no goal of serving as president of the American Academy of Dermatology or as Department Chair, and yet these happened. These experiences have allowed me to work on my purpose as I have defined it. How can you harness serendipity in your own life? My philosophy may be somewhat simple, but I think if you show up every day doing the best job you can at the tasks on hand, doors will appear, at odd intervals and in odd directions. You must be open enough and in tune with your purpose to an extent that you can sense the direction in which to turn and what doorways through which to walk.
The third element is curiosity. One definition is that curiosity is the motivation to learn new information. Another definition is that curiosity is a special form of information seeking distinguished by the fact that it is internally motivated. We are all familiar with intellectual curiosity. For example, a patient has a basal cell carcinoma on the upper back. What does the literature say about the cure rates of various treatments for that particular tumor? In addition, we can be curious about other things as well. Is it a really small tumor? How was it found and why is the patient anxious? Why does it make me irritated that the patient is worried about such a small, easily treated tumor? Or is it a large neglected tumor? Why was it not treated before? Why does it make me sad that it is so large? Why does it annoy me that I have a difficult situation to manage? Being able to define an emotional reaction by being curious about its presence helps us manage destructive responses and promote more positive outcomes. This curiosity is related to emotional intelligence and is mindfully harnessed by effective leaders. Curiosity will get you through tough days when your office team is stressed and the tough years that are complicated by professional and personal challenges.
Curiosity also will help you identify your purpose and harness serendipity, and so we come full circle with our 3 elements: purpose, serendipity, and curiosity.
My wish for all of you is that when you are at the tail end of your career, you will look back and say, “This has been a great ride.” I am very grateful that I can acknowledge this for myself. I have been so fortunate to have found dermatology, where I can go to work every day making a difference for patients in a stimulating environment with good colleagues. One of my values is to try and make life better in some way for everyone around me, even if it is just a smile at the start of the workday. As I look back, this value has allowed me to meet interesting people, hear fascinating stories, make good friends, and have enduring relationships. I have held onto fellow travelers, and we have supported each other through tough times as well as celebrated together the good times.
Nurturing a satisfying career includes these essential fundamentals. First, accept the reality of constant change. Second, develop productive relationships with fellow travelers. And third and most importantly, go forth with purpose, serendipity, and curiosity.
The residents of our program asked me to serve as their commencement speaker in June. Since I was retiring from my position as department chair, this touching honor seemed a fitting capstone for my career. It gave me the opportunity to reflect on the enormity of the changes that have occurred between my graduation from residency in 1983 and the current time, which is marked by disruption from the digital revolution and the COVID-19 pandemic. Throughout this 40-year period, there were times of external global turmoil, economic instability, significant changes in the business of medicine, stressful changes in documentation of competency and certification, and the difficult transition to electronic medical records. Another epidemic—AIDS—changed surgical practices. During my residency, we did biopsies without wearing gloves or masks. Gloves were added to protect the person doing the procedure as well as to prevent spread of disease to other patients, not to reduce the infection rate for the patient undergoing the procedure. Of course, change in the last 40 years also occurred outside of work and included various familial stresses. The irritations of daily life easily mounted up to being overwhelming. However, I had gone to work every day for 40 years, seeking to do my best for my patients and my colleagues and the staff with whom I worked, sometimes feeling successful and sometimes feeling incompetent. Some days went smoothly, and some days were filled with challenges that I could not begin to imagine how I would solve. I have a habit of seeing problems rather than successes, which creates its own difficulties. I did, however, grab opportunities that continually improved my practice of medicine and allowed me to serve in several professional positions as well as in leadership positions of multiple professional societies. As I prepared the commencement address, I realized that the totality of my career was very satisfying.
The Merriam-Webster dictionary definition of satisfying is “producing pleasure or contentment by providing what is needed or wanted.”1 My use of the word means that my career over the long term has pleased me—maybe not some of the people I reported to, but rather me.
My approach to my career can be summarized in 3 words: purpose, serendipity, and curiosity.
The first element is purpose. Job satisfaction generally is associated with work being aligned with values, an appreciation that you are accomplishing the purpose with which you set out on your journey. It is not associated with every day being wonderful and problem free or every task being completed without setbacks or complications. The reality of working is not that every moment brings pure happiness or that every task fulfills a passion. How does a person ensure that the days add up to be satisfying? Start with values. Why did you decide to pursue medical school? Some may have chosen it for economic security, but there are many ways to achieve economic security. Maybe being a physician feeds into the family lore, but families generally have broad ranges of acceptable careers. Maybe it appealed scientifically, but a PhD in biology also fulfills that interest. Maybe it is that you noticed respect for physicians in the community when you were growing up, but that is changing and does not represent an internal value anyway. Consider your values carefully, write them down, and keep them at the forefront of the day. Go back to them consciously any time you have a rough day and understand why you are doing what you are doing. When you are 55 years old and going through your umpteenth change in reimbursement process, go back to the day you decided on medicine as a career. Focus on your values as the grounding for your purpose. Also note that purpose is different than goals. Some goals will be reached, and some will not. Goals change with external realities and/ or internal factors. Purpose and values remain the same if we have thoughtfully identified them.
The second element is serendipity. Serendipity often is thought of as luck, as karma, as being in the right place at the right time. It feels random, and at first glance it appears that purpose and serendipity are complete opposites and do not intersect. Serendipity is, however, not just luck. It is an ability to distinguish events and observations in meaningful ways. It is a close relative of creativity and benefits from sloppiness, playfulness, tinkering, and discussion. It cannot exist in a vacuum. History is replete with serendipitous discoveries. It is thought that James Watson and Francis Crick would never have been able to elucidate the nature of DNA without sharing offices with people with whom they argued daily. In fact, figuring out the DNA structure was not even the main focus of their laboratories. It was just a side angle that several people loved to think about. Appreciating serendipity by being truly open to opportunities that are out on the wings brings experiences that are deeply rewarding even if not planned. I had no idea at all, no plan, no goal of serving as president of the American Academy of Dermatology or as Department Chair, and yet these happened. These experiences have allowed me to work on my purpose as I have defined it. How can you harness serendipity in your own life? My philosophy may be somewhat simple, but I think if you show up every day doing the best job you can at the tasks on hand, doors will appear, at odd intervals and in odd directions. You must be open enough and in tune with your purpose to an extent that you can sense the direction in which to turn and what doorways through which to walk.
The third element is curiosity. One definition is that curiosity is the motivation to learn new information. Another definition is that curiosity is a special form of information seeking distinguished by the fact that it is internally motivated. We are all familiar with intellectual curiosity. For example, a patient has a basal cell carcinoma on the upper back. What does the literature say about the cure rates of various treatments for that particular tumor? In addition, we can be curious about other things as well. Is it a really small tumor? How was it found and why is the patient anxious? Why does it make me irritated that the patient is worried about such a small, easily treated tumor? Or is it a large neglected tumor? Why was it not treated before? Why does it make me sad that it is so large? Why does it annoy me that I have a difficult situation to manage? Being able to define an emotional reaction by being curious about its presence helps us manage destructive responses and promote more positive outcomes. This curiosity is related to emotional intelligence and is mindfully harnessed by effective leaders. Curiosity will get you through tough days when your office team is stressed and the tough years that are complicated by professional and personal challenges.
Curiosity also will help you identify your purpose and harness serendipity, and so we come full circle with our 3 elements: purpose, serendipity, and curiosity.
My wish for all of you is that when you are at the tail end of your career, you will look back and say, “This has been a great ride.” I am very grateful that I can acknowledge this for myself. I have been so fortunate to have found dermatology, where I can go to work every day making a difference for patients in a stimulating environment with good colleagues. One of my values is to try and make life better in some way for everyone around me, even if it is just a smile at the start of the workday. As I look back, this value has allowed me to meet interesting people, hear fascinating stories, make good friends, and have enduring relationships. I have held onto fellow travelers, and we have supported each other through tough times as well as celebrated together the good times.
Nurturing a satisfying career includes these essential fundamentals. First, accept the reality of constant change. Second, develop productive relationships with fellow travelers. And third and most importantly, go forth with purpose, serendipity, and curiosity.
- Merriam-Webster. Satisfying. Merriam-Webster.com Dictionary. Accessed November 18, 2022. https://www.merriam-webster.com/dictionary/satisfying
- Merriam-Webster. Satisfying. Merriam-Webster.com Dictionary. Accessed November 18, 2022. https://www.merriam-webster.com/dictionary/satisfying
Eliminating the language of blame in lung cancer
“Do you smoke?” I asked the patient.
“Yes, and I got what I deserved,” he answered, clearly upset.
I ignored his reaction and continued with the exam, but in retrospect, I should have explained why doctors ask patients this question.
It was not my intention to be rude or blame the patient for his lung cancer diagnosis. Doctors ask patients if they smoke because a smoking history can change the type of treatment and it can be associated with other conditions that may interfere with treatment. It can also determine whether smoking cessation assistance should be offered to the patient. It is crucial that we as doctors know a patient’s medical history, but how we approach sensitive issues may determine if we even get the information we need. In this case, I didn’t explain why I asked the patient if he smoked. Had I taken the time to explain why I needed to know if and how long he smoked and that I was not blaming him for his lung cancer diagnosis, we may have had a more mutually respectful and beneficial relationship.
Almost all of my patients with lung cancer have been asked at one time or another – by a health care provider, friends, or acquaintances – “Do you smoke?” Whether or not they smoked, patients with lung cancer feel the weight of moral judgment being cast upon them by society.
It is common for people who smoke and who go on to develop lung cancer to be weighed down by guilt associated with their diagnosis. Patients with lung cancer face stigma-associated hurdles based on the “I did it to myself” mindset. This societal stigma is not without harm as it can result in emotional responses of guilt and self-blame. This internalized stigma may lead to psychosocial distress and decreased interactions with family, friends, and health care providers. The guilt may drive a patient to forgo lung cancer screening, minimize symptoms, delay seeking treatment, and not advocate for themselves with their physician. Some patients even decide to forgo all treatment.
What about patients who never smoked? They too feel tinged with blame. Many of these patients feel called upon to defend themselves by proclaiming loudly that they have never smoked.
Blame and shame also divides the lung cancer community, resulting in less advocacy. It may also impact research dollars for lung cancer. According to the Lung Cancer Research Foundation, “Despite being the leading cause of cancer mortality, lung cancer receives far less research funding than any other cancer.” By comparison, women with breast cancer are showered with far more resources, supportive services, fundraising events, and certainly more lobbying.
By making unintentional hurtful statements and using judgmental or denigrating language, the lung cancer community may unconsciously be playing a role in perpetuating stigmas associated with lung cancer. That kind of language can come across as blame.
The International Association for the Study of Lung Cancer has developed a language guide to help reduce stigma associated with lung cancer. The aim is to reduce and replace traditional medical language during our patient interactions, presentations, and publications with language that is more empathic and nonjudgmental.
For example, replace the term “cancer patient” with the term “the patient with cancer.” The patient is a person who happens to have been diagnosed with lung cancer, they are not “cancer.” Patients can be very sensitive to language and may misinterpret language that doctors commonly use. Language such as “the patient failed treatment” may be interpreted by patients as a personal failure. In reality, the treatment failed the patient, instead of the other way around. Instead, shift the blame from the patient to the cancer. Adopt terms like “the tumor did not respond to treatment.” Or, “the cancer progressed” instead of “the patient progressed.”
Language around smoking is particularly stigmatizing because it categorizes a person by a behavior. As health care providers, we should consider removing the term “smoker” from our interactions with patients and instead, use “patient who smokes” or ”patient with a smoking history.” Other ways health care providers can reduce stigma triggered by assessing smoking status include using supportive communication skills, providing a rationale for asking smoking related questions, offering help and tobacco cessation and other resources, and displaying empathic behavior, such as maintaining eye contact and a nonjudgmental body position orientated toward the patient.
Many of these common medical phrases were developed to enable efficient communication among health care professionals. Times have changed and patients should not be defined by an illness. They are people first. In addition to improving patient interactions in clinic, using nonjudgmental language whenever possible in presentations and publications is also extremely important, as patients are living longer and getting more involved in research and advocacy.
“Words have energy and power with the ability to help, to heal, to hinder, to hurt, to harm, to humiliate, and to humble,” says Yehuda Berg, author and codirector of the Kabbalah Centre International in Los Angeles.
Dr. Schiller is a medical oncologist and founding member of Oncologists United for Climate and Health. She is a former board member of the International Association for the Study of Lung Cancer and a current board member of the Lung Cancer Research Foundation.
“Do you smoke?” I asked the patient.
“Yes, and I got what I deserved,” he answered, clearly upset.
I ignored his reaction and continued with the exam, but in retrospect, I should have explained why doctors ask patients this question.
It was not my intention to be rude or blame the patient for his lung cancer diagnosis. Doctors ask patients if they smoke because a smoking history can change the type of treatment and it can be associated with other conditions that may interfere with treatment. It can also determine whether smoking cessation assistance should be offered to the patient. It is crucial that we as doctors know a patient’s medical history, but how we approach sensitive issues may determine if we even get the information we need. In this case, I didn’t explain why I asked the patient if he smoked. Had I taken the time to explain why I needed to know if and how long he smoked and that I was not blaming him for his lung cancer diagnosis, we may have had a more mutually respectful and beneficial relationship.
Almost all of my patients with lung cancer have been asked at one time or another – by a health care provider, friends, or acquaintances – “Do you smoke?” Whether or not they smoked, patients with lung cancer feel the weight of moral judgment being cast upon them by society.
It is common for people who smoke and who go on to develop lung cancer to be weighed down by guilt associated with their diagnosis. Patients with lung cancer face stigma-associated hurdles based on the “I did it to myself” mindset. This societal stigma is not without harm as it can result in emotional responses of guilt and self-blame. This internalized stigma may lead to psychosocial distress and decreased interactions with family, friends, and health care providers. The guilt may drive a patient to forgo lung cancer screening, minimize symptoms, delay seeking treatment, and not advocate for themselves with their physician. Some patients even decide to forgo all treatment.
What about patients who never smoked? They too feel tinged with blame. Many of these patients feel called upon to defend themselves by proclaiming loudly that they have never smoked.
Blame and shame also divides the lung cancer community, resulting in less advocacy. It may also impact research dollars for lung cancer. According to the Lung Cancer Research Foundation, “Despite being the leading cause of cancer mortality, lung cancer receives far less research funding than any other cancer.” By comparison, women with breast cancer are showered with far more resources, supportive services, fundraising events, and certainly more lobbying.
By making unintentional hurtful statements and using judgmental or denigrating language, the lung cancer community may unconsciously be playing a role in perpetuating stigmas associated with lung cancer. That kind of language can come across as blame.
The International Association for the Study of Lung Cancer has developed a language guide to help reduce stigma associated with lung cancer. The aim is to reduce and replace traditional medical language during our patient interactions, presentations, and publications with language that is more empathic and nonjudgmental.
For example, replace the term “cancer patient” with the term “the patient with cancer.” The patient is a person who happens to have been diagnosed with lung cancer, they are not “cancer.” Patients can be very sensitive to language and may misinterpret language that doctors commonly use. Language such as “the patient failed treatment” may be interpreted by patients as a personal failure. In reality, the treatment failed the patient, instead of the other way around. Instead, shift the blame from the patient to the cancer. Adopt terms like “the tumor did not respond to treatment.” Or, “the cancer progressed” instead of “the patient progressed.”
Language around smoking is particularly stigmatizing because it categorizes a person by a behavior. As health care providers, we should consider removing the term “smoker” from our interactions with patients and instead, use “patient who smokes” or ”patient with a smoking history.” Other ways health care providers can reduce stigma triggered by assessing smoking status include using supportive communication skills, providing a rationale for asking smoking related questions, offering help and tobacco cessation and other resources, and displaying empathic behavior, such as maintaining eye contact and a nonjudgmental body position orientated toward the patient.
Many of these common medical phrases were developed to enable efficient communication among health care professionals. Times have changed and patients should not be defined by an illness. They are people first. In addition to improving patient interactions in clinic, using nonjudgmental language whenever possible in presentations and publications is also extremely important, as patients are living longer and getting more involved in research and advocacy.
“Words have energy and power with the ability to help, to heal, to hinder, to hurt, to harm, to humiliate, and to humble,” says Yehuda Berg, author and codirector of the Kabbalah Centre International in Los Angeles.
Dr. Schiller is a medical oncologist and founding member of Oncologists United for Climate and Health. She is a former board member of the International Association for the Study of Lung Cancer and a current board member of the Lung Cancer Research Foundation.
“Do you smoke?” I asked the patient.
“Yes, and I got what I deserved,” he answered, clearly upset.
I ignored his reaction and continued with the exam, but in retrospect, I should have explained why doctors ask patients this question.
It was not my intention to be rude or blame the patient for his lung cancer diagnosis. Doctors ask patients if they smoke because a smoking history can change the type of treatment and it can be associated with other conditions that may interfere with treatment. It can also determine whether smoking cessation assistance should be offered to the patient. It is crucial that we as doctors know a patient’s medical history, but how we approach sensitive issues may determine if we even get the information we need. In this case, I didn’t explain why I asked the patient if he smoked. Had I taken the time to explain why I needed to know if and how long he smoked and that I was not blaming him for his lung cancer diagnosis, we may have had a more mutually respectful and beneficial relationship.
Almost all of my patients with lung cancer have been asked at one time or another – by a health care provider, friends, or acquaintances – “Do you smoke?” Whether or not they smoked, patients with lung cancer feel the weight of moral judgment being cast upon them by society.
It is common for people who smoke and who go on to develop lung cancer to be weighed down by guilt associated with their diagnosis. Patients with lung cancer face stigma-associated hurdles based on the “I did it to myself” mindset. This societal stigma is not without harm as it can result in emotional responses of guilt and self-blame. This internalized stigma may lead to psychosocial distress and decreased interactions with family, friends, and health care providers. The guilt may drive a patient to forgo lung cancer screening, minimize symptoms, delay seeking treatment, and not advocate for themselves with their physician. Some patients even decide to forgo all treatment.
What about patients who never smoked? They too feel tinged with blame. Many of these patients feel called upon to defend themselves by proclaiming loudly that they have never smoked.
Blame and shame also divides the lung cancer community, resulting in less advocacy. It may also impact research dollars for lung cancer. According to the Lung Cancer Research Foundation, “Despite being the leading cause of cancer mortality, lung cancer receives far less research funding than any other cancer.” By comparison, women with breast cancer are showered with far more resources, supportive services, fundraising events, and certainly more lobbying.
By making unintentional hurtful statements and using judgmental or denigrating language, the lung cancer community may unconsciously be playing a role in perpetuating stigmas associated with lung cancer. That kind of language can come across as blame.
The International Association for the Study of Lung Cancer has developed a language guide to help reduce stigma associated with lung cancer. The aim is to reduce and replace traditional medical language during our patient interactions, presentations, and publications with language that is more empathic and nonjudgmental.
For example, replace the term “cancer patient” with the term “the patient with cancer.” The patient is a person who happens to have been diagnosed with lung cancer, they are not “cancer.” Patients can be very sensitive to language and may misinterpret language that doctors commonly use. Language such as “the patient failed treatment” may be interpreted by patients as a personal failure. In reality, the treatment failed the patient, instead of the other way around. Instead, shift the blame from the patient to the cancer. Adopt terms like “the tumor did not respond to treatment.” Or, “the cancer progressed” instead of “the patient progressed.”
Language around smoking is particularly stigmatizing because it categorizes a person by a behavior. As health care providers, we should consider removing the term “smoker” from our interactions with patients and instead, use “patient who smokes” or ”patient with a smoking history.” Other ways health care providers can reduce stigma triggered by assessing smoking status include using supportive communication skills, providing a rationale for asking smoking related questions, offering help and tobacco cessation and other resources, and displaying empathic behavior, such as maintaining eye contact and a nonjudgmental body position orientated toward the patient.
Many of these common medical phrases were developed to enable efficient communication among health care professionals. Times have changed and patients should not be defined by an illness. They are people first. In addition to improving patient interactions in clinic, using nonjudgmental language whenever possible in presentations and publications is also extremely important, as patients are living longer and getting more involved in research and advocacy.
“Words have energy and power with the ability to help, to heal, to hinder, to hurt, to harm, to humiliate, and to humble,” says Yehuda Berg, author and codirector of the Kabbalah Centre International in Los Angeles.
Dr. Schiller is a medical oncologist and founding member of Oncologists United for Climate and Health. She is a former board member of the International Association for the Study of Lung Cancer and a current board member of the Lung Cancer Research Foundation.