Commentary

On the first Friday in March, it has become an annual tradition to dress in blue to promote colorectal cancer awareness. Twitter feeds are filled with photos of members of our gastroenterology community (sometimes entire endoscopy units!) swathed in various shades of blue. This tradition was started in the mid-2000’s by a patient diagnosed with early-onset colorectal cancer who planned a fund raiser at her daughter’s elementary school where students were encouraged to wear a blue outfit and make a $1 donation to support awareness of this deadly but preventable cancer. What was once a local effort has now grown into a national phenomenon, and a powerful opportunity for the medical community to educate patients, friends, and family regarding risk factors for colorectal cancer and the importance of timely and effective screening. But while raising awareness is vital, it is only an initial step in the complex process of optimizing delivery of screening services and improving cancer outcomes through prevention and early detection.

In this month’s issue of GIHN, we report on a study from Cancer demonstrating the effectiveness of Spanish-speaking patient navigators in boosting colorectal cancer screening rates among Hispanic patients. We also highlight a quality improvement initiative at a large academic medical center demonstrating the impact of an electronic “primer” message delivered through the patient portal on screening completion rates in a mailed fecal immunochemical test outreach program. Finally, in this month’s Practice Management Toolbox column, Dr. Brill and Dr. Lieberman advise us on how to prepare for upcoming coverage changes impacting screening colonoscopy – a result of AGA’s tireless efforts to eliminate financial barriers impeding access to colorectal cancer screening.

As always, thank you for being a dedicated reader and please stay safe out there. Better days are ahead.

Megan A. Adams, MD, JD, MSc
Editor in Chief

On the first Friday in March, it has become an annual tradition to dress in blue to promote colorectal cancer awareness. Twitter feeds are filled with photos of members of our gastroenterology community (sometimes entire endoscopy units!) swathed in various shades of blue. This tradition was started in the mid-2000’s by a patient diagnosed with early-onset colorectal cancer who planned a fund raiser at her daughter’s elementary school where students were encouraged to wear a blue outfit and make a $1 donation to support awareness of this deadly but preventable cancer. What was once a local effort has now grown into a national phenomenon, and a powerful opportunity for the medical community to educate patients, friends, and family regarding risk factors for colorectal cancer and the importance of timely and effective screening. But while raising awareness is vital, it is only an initial step in the complex process of optimizing delivery of screening services and improving cancer outcomes through prevention and early detection.

In this month’s issue of GIHN, we report on a study from Cancer demonstrating the effectiveness of Spanish-speaking patient navigators in boosting colorectal cancer screening rates among Hispanic patients. We also highlight a quality improvement initiative at a large academic medical center demonstrating the impact of an electronic “primer” message delivered through the patient portal on screening completion rates in a mailed fecal immunochemical test outreach program. Finally, in this month’s Practice Management Toolbox column, Dr. Brill and Dr. Lieberman advise us on how to prepare for upcoming coverage changes impacting screening colonoscopy – a result of AGA’s tireless efforts to eliminate financial barriers impeding access to colorectal cancer screening.

As always, thank you for being a dedicated reader and please stay safe out there. Better days are ahead.

Megan A. Adams, MD, JD, MSc
Editor in Chief

On the first Friday in March, it has become an annual tradition to dress in blue to promote colorectal cancer awareness. Twitter feeds are filled with photos of members of our gastroenterology community (sometimes entire endoscopy units!) swathed in various shades of blue. This tradition was started in the mid-2000’s by a patient diagnosed with early-onset colorectal cancer who planned a fund raiser at her daughter’s elementary school where students were encouraged to wear a blue outfit and make a $1 donation to support awareness of this deadly but preventable cancer. What was once a local effort has now grown into a national phenomenon, and a powerful opportunity for the medical community to educate patients, friends, and family regarding risk factors for colorectal cancer and the importance of timely and effective screening. But while raising awareness is vital, it is only an initial step in the complex process of optimizing delivery of screening services and improving cancer outcomes through prevention and early detection.

In this month’s issue of GIHN, we report on a study from Cancer demonstrating the effectiveness of Spanish-speaking patient navigators in boosting colorectal cancer screening rates among Hispanic patients. We also highlight a quality improvement initiative at a large academic medical center demonstrating the impact of an electronic “primer” message delivered through the patient portal on screening completion rates in a mailed fecal immunochemical test outreach program. Finally, in this month’s Practice Management Toolbox column, Dr. Brill and Dr. Lieberman advise us on how to prepare for upcoming coverage changes impacting screening colonoscopy – a result of AGA’s tireless efforts to eliminate financial barriers impeding access to colorectal cancer screening.

As always, thank you for being a dedicated reader and please stay safe out there. Better days are ahead.

Megan A. Adams, MD, JD, MSc
Editor in Chief

When we refer to “regular table salt,” it is most commonly in the form of sodium chloride, which is also a major constituent of packaged and ultraprocessed foods.

The best approach to finding the “healthiest salt” – which really means the lowest in sodium – is to look for the amount on the label. “Sodium-free” usually indicates less than 5 mg of sodium per serving, and “low-sodium” usually means 140 mg or less per serving. In contrast, regular table salt can contain as much as 560 mg of sodium in one serving.

Other en vogue salts, such as pink Himalayan salt, sea salt, and kosher salt, are high in sodium content – like regular table salt – but because of their larger crystal size, less sodium is delivered per serving.

Georges Lievre / Fotolia.com

FDA issues guidance on reducing salt

Currently, the U.S. sodium dietary guidelines for persons older than 14 stipulate 2,300 mg/d, which is equivalent to 1 teaspoon a day. However it is estimated that the average person in the United States consumes more than this – around 3,400 mg of sodium daily.

In October 2021, the U.S. Food and Drug Administration published guidance on voluntary sodium limitations in commercially processed, packaged, and prepared food. The FDA’s short-term approach is to slowly reduce exposure to sodium in processed and restaurant food by 2025, on the basis that people will eventually get used to less salt, as has happened in the United Kingdom and other countries.

Such strategies to reduce salt intake are now being used in national programs in several countries. Many of these successful initiatives include active engagement with the food industry to reduce the amount of sodium added to processed food, as well as public awareness campaigns to alert consumers to the dangers of eating too much salt. This includes increasing potassium in manufactured foods, primarily to target hypertension and heart disease, as described by Clare Farrand, MSc, BSc, and colleagues, in the Journal of Clinical Hypertension. The authors also make several recommendations regarding salt reduction policies:

• Food manufacturers should gradually reduce sodium in food to the lowest possible levels and explore the use of potassium-based sodium replacers to reduce sodium levels even further.
• Governments should continue to monitor sodium and potassium levels in processed foods.
• Further consideration may need to be given to how best to label salt substitutes (namely potassium) in processed foods to ensure that people who may be adversely affected are aware.
• Governments should systematically monitor potassium intake at the population level, including for specific susceptible groups.
• Governments should continue to systematically monitor sodium (salt) intake and iodine intake at the population level to adjust salt iodization over time as necessary, depending on observed salt intake in specific targeted groups, to ensure that they have sufficient but not excessive iodine intakes as salt intakes are reduced.
• Governments should consider opportunities for promoting and subsidizing salt substitutes, particularly in countries where salt added during cooking or at the table is the major source of salt in the diet.

The new FDA document includes 163 subcategories of foods in its voluntary salt reduction strategy.
 

Salt substitutes, high blood pressure, and mortality

Lowering sodium intake is almost certainly beneficial for persons with high blood pressure. In 2020, a review in Hypertension highlighted the benefit of salt substitutes in reducing hypertension, reporting that they lower systolic blood pressure by 5.58 mm Hg and diastolic blood pressure by 2.88 mm Hg.

And changes to dietary sodium intake can potentially reduce or obviate the need for medications for essential hypertension in some individuals. Although there are only a few studies on this topic, a study by Bruce Neal, MB, ChB, PhD, and colleagues, revealed a reduction in stroke, cardiovascular events, and deaths with the use of potassium-based salt substitutes.
 

Salt substitutes and sodium and potassium handling in the kidneys

Many studies have shown that potassium-rich salt substitutes are safe in individuals with normal kidney function, but are they safe and beneficial for people with chronic kidney disease (CKD)?

For anyone who is on a renal diet, potassium and sodium intake goals are limited according to their absolute level of kidney function.

There have been case reports of life-threatening blood potassium levels (hyperkalemia) due to potassium-rich salt substitutes in people with CKD, but no larger published studies on this topic can be found.

A diet modeling study by Rebecca Morrison and colleagues evaluated varying degrees of potassium-enriched salt substituted bread products and their impact on dietary intake in persons with CKD. They used dietary data from the National Nutrition and Physical Activity Survey 2011-2012 in Australia for 12,152 participants, 154 of whom had CKD. Replacing the sodium in bread with varying amounts of potassium chloride (20%, 30%, and 40%) would result in one-third of people with CKD exceeding the safe limits for dietary potassium consumption (31.8%, 32.6%, and 33%, respectively), they found.

“Potassium chloride substitution in staple foods such as bread and bread products have serious and potentially fatal consequences for people who need to restrict dietary potassium. Improved food labelling is required for consumers to avoid excessive consumption,” Ms. Morrison and colleagues concluded. They added that more studies are needed to further understand the risks of potassium dietary intake and hyperkalemia in CKD from potassium-based salt substitutes.

The American Heart Association recommends no more than 1,500 mg of sodium intake daily for persons with CKD, diabetes, or high blood pressure; those older than 51; and African American persons of any age.

The recommended daily intake of potassium in persons with CKD can range from 2,000 mg to 4,000 mg, depending on the individual and their degree of CKD. The potassium content in some salt substitutes varies from 440 mg to 2,800 mg per teaspoon.

The best recommendation for individuals with CKD and a goal to reduce their sodium intake is to use herbs and lower-sodium seasonings as a substitute, but these should always be reviewed with their physician and renal nutritionist.

Dr. Brookins is a board-certified nephrologist and internist practicing in Georgia. She is the founder and owner of Remote Renal Care, a telehealth kidney practice. She reported no relevant conflicts of interest.

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

When we refer to “regular table salt,” it is most commonly in the form of sodium chloride, which is also a major constituent of packaged and ultraprocessed foods.

The best approach to finding the “healthiest salt” – which really means the lowest in sodium – is to look for the amount on the label. “Sodium-free” usually indicates less than 5 mg of sodium per serving, and “low-sodium” usually means 140 mg or less per serving. In contrast, regular table salt can contain as much as 560 mg of sodium in one serving.

Other en vogue salts, such as pink Himalayan salt, sea salt, and kosher salt, are high in sodium content – like regular table salt – but because of their larger crystal size, less sodium is delivered per serving.

Georges Lievre / Fotolia.com

FDA issues guidance on reducing salt

Currently, the U.S. sodium dietary guidelines for persons older than 14 stipulate 2,300 mg/d, which is equivalent to 1 teaspoon a day. However it is estimated that the average person in the United States consumes more than this – around 3,400 mg of sodium daily.

In October 2021, the U.S. Food and Drug Administration published guidance on voluntary sodium limitations in commercially processed, packaged, and prepared food. The FDA’s short-term approach is to slowly reduce exposure to sodium in processed and restaurant food by 2025, on the basis that people will eventually get used to less salt, as has happened in the United Kingdom and other countries.

Such strategies to reduce salt intake are now being used in national programs in several countries. Many of these successful initiatives include active engagement with the food industry to reduce the amount of sodium added to processed food, as well as public awareness campaigns to alert consumers to the dangers of eating too much salt. This includes increasing potassium in manufactured foods, primarily to target hypertension and heart disease, as described by Clare Farrand, MSc, BSc, and colleagues, in the Journal of Clinical Hypertension. The authors also make several recommendations regarding salt reduction policies:

• Food manufacturers should gradually reduce sodium in food to the lowest possible levels and explore the use of potassium-based sodium replacers to reduce sodium levels even further.
• Governments should continue to monitor sodium and potassium levels in processed foods.
• Further consideration may need to be given to how best to label salt substitutes (namely potassium) in processed foods to ensure that people who may be adversely affected are aware.
• Governments should systematically monitor potassium intake at the population level, including for specific susceptible groups.
• Governments should continue to systematically monitor sodium (salt) intake and iodine intake at the population level to adjust salt iodization over time as necessary, depending on observed salt intake in specific targeted groups, to ensure that they have sufficient but not excessive iodine intakes as salt intakes are reduced.
• Governments should consider opportunities for promoting and subsidizing salt substitutes, particularly in countries where salt added during cooking or at the table is the major source of salt in the diet.

The new FDA document includes 163 subcategories of foods in its voluntary salt reduction strategy.
 

Salt substitutes, high blood pressure, and mortality

Lowering sodium intake is almost certainly beneficial for persons with high blood pressure. In 2020, a review in Hypertension highlighted the benefit of salt substitutes in reducing hypertension, reporting that they lower systolic blood pressure by 5.58 mm Hg and diastolic blood pressure by 2.88 mm Hg.

And changes to dietary sodium intake can potentially reduce or obviate the need for medications for essential hypertension in some individuals. Although there are only a few studies on this topic, a study by Bruce Neal, MB, ChB, PhD, and colleagues, revealed a reduction in stroke, cardiovascular events, and deaths with the use of potassium-based salt substitutes.
 

Salt substitutes and sodium and potassium handling in the kidneys

Many studies have shown that potassium-rich salt substitutes are safe in individuals with normal kidney function, but are they safe and beneficial for people with chronic kidney disease (CKD)?

For anyone who is on a renal diet, potassium and sodium intake goals are limited according to their absolute level of kidney function.

There have been case reports of life-threatening blood potassium levels (hyperkalemia) due to potassium-rich salt substitutes in people with CKD, but no larger published studies on this topic can be found.

A diet modeling study by Rebecca Morrison and colleagues evaluated varying degrees of potassium-enriched salt substituted bread products and their impact on dietary intake in persons with CKD. They used dietary data from the National Nutrition and Physical Activity Survey 2011-2012 in Australia for 12,152 participants, 154 of whom had CKD. Replacing the sodium in bread with varying amounts of potassium chloride (20%, 30%, and 40%) would result in one-third of people with CKD exceeding the safe limits for dietary potassium consumption (31.8%, 32.6%, and 33%, respectively), they found.

“Potassium chloride substitution in staple foods such as bread and bread products have serious and potentially fatal consequences for people who need to restrict dietary potassium. Improved food labelling is required for consumers to avoid excessive consumption,” Ms. Morrison and colleagues concluded. They added that more studies are needed to further understand the risks of potassium dietary intake and hyperkalemia in CKD from potassium-based salt substitutes.

The American Heart Association recommends no more than 1,500 mg of sodium intake daily for persons with CKD, diabetes, or high blood pressure; those older than 51; and African American persons of any age.

The recommended daily intake of potassium in persons with CKD can range from 2,000 mg to 4,000 mg, depending on the individual and their degree of CKD. The potassium content in some salt substitutes varies from 440 mg to 2,800 mg per teaspoon.

The best recommendation for individuals with CKD and a goal to reduce their sodium intake is to use herbs and lower-sodium seasonings as a substitute, but these should always be reviewed with their physician and renal nutritionist.

Dr. Brookins is a board-certified nephrologist and internist practicing in Georgia. She is the founder and owner of Remote Renal Care, a telehealth kidney practice. She reported no relevant conflicts of interest.

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

When we refer to “regular table salt,” it is most commonly in the form of sodium chloride, which is also a major constituent of packaged and ultraprocessed foods.

The best approach to finding the “healthiest salt” – which really means the lowest in sodium – is to look for the amount on the label. “Sodium-free” usually indicates less than 5 mg of sodium per serving, and “low-sodium” usually means 140 mg or less per serving. In contrast, regular table salt can contain as much as 560 mg of sodium in one serving.

Other en vogue salts, such as pink Himalayan salt, sea salt, and kosher salt, are high in sodium content – like regular table salt – but because of their larger crystal size, less sodium is delivered per serving.

Georges Lievre / Fotolia.com

FDA issues guidance on reducing salt

Currently, the U.S. sodium dietary guidelines for persons older than 14 stipulate 2,300 mg/d, which is equivalent to 1 teaspoon a day. However it is estimated that the average person in the United States consumes more than this – around 3,400 mg of sodium daily.

In October 2021, the U.S. Food and Drug Administration published guidance on voluntary sodium limitations in commercially processed, packaged, and prepared food. The FDA’s short-term approach is to slowly reduce exposure to sodium in processed and restaurant food by 2025, on the basis that people will eventually get used to less salt, as has happened in the United Kingdom and other countries.

Such strategies to reduce salt intake are now being used in national programs in several countries. Many of these successful initiatives include active engagement with the food industry to reduce the amount of sodium added to processed food, as well as public awareness campaigns to alert consumers to the dangers of eating too much salt. This includes increasing potassium in manufactured foods, primarily to target hypertension and heart disease, as described by Clare Farrand, MSc, BSc, and colleagues, in the Journal of Clinical Hypertension. The authors also make several recommendations regarding salt reduction policies:

• Food manufacturers should gradually reduce sodium in food to the lowest possible levels and explore the use of potassium-based sodium replacers to reduce sodium levels even further.
• Governments should continue to monitor sodium and potassium levels in processed foods.
• Further consideration may need to be given to how best to label salt substitutes (namely potassium) in processed foods to ensure that people who may be adversely affected are aware.
• Governments should systematically monitor potassium intake at the population level, including for specific susceptible groups.
• Governments should continue to systematically monitor sodium (salt) intake and iodine intake at the population level to adjust salt iodization over time as necessary, depending on observed salt intake in specific targeted groups, to ensure that they have sufficient but not excessive iodine intakes as salt intakes are reduced.
• Governments should consider opportunities for promoting and subsidizing salt substitutes, particularly in countries where salt added during cooking or at the table is the major source of salt in the diet.

The new FDA document includes 163 subcategories of foods in its voluntary salt reduction strategy.
 

Salt substitutes, high blood pressure, and mortality

Lowering sodium intake is almost certainly beneficial for persons with high blood pressure. In 2020, a review in Hypertension highlighted the benefit of salt substitutes in reducing hypertension, reporting that they lower systolic blood pressure by 5.58 mm Hg and diastolic blood pressure by 2.88 mm Hg.

And changes to dietary sodium intake can potentially reduce or obviate the need for medications for essential hypertension in some individuals. Although there are only a few studies on this topic, a study by Bruce Neal, MB, ChB, PhD, and colleagues, revealed a reduction in stroke, cardiovascular events, and deaths with the use of potassium-based salt substitutes.
 

Salt substitutes and sodium and potassium handling in the kidneys

Many studies have shown that potassium-rich salt substitutes are safe in individuals with normal kidney function, but are they safe and beneficial for people with chronic kidney disease (CKD)?

For anyone who is on a renal diet, potassium and sodium intake goals are limited according to their absolute level of kidney function.

There have been case reports of life-threatening blood potassium levels (hyperkalemia) due to potassium-rich salt substitutes in people with CKD, but no larger published studies on this topic can be found.

A diet modeling study by Rebecca Morrison and colleagues evaluated varying degrees of potassium-enriched salt substituted bread products and their impact on dietary intake in persons with CKD. They used dietary data from the National Nutrition and Physical Activity Survey 2011-2012 in Australia for 12,152 participants, 154 of whom had CKD. Replacing the sodium in bread with varying amounts of potassium chloride (20%, 30%, and 40%) would result in one-third of people with CKD exceeding the safe limits for dietary potassium consumption (31.8%, 32.6%, and 33%, respectively), they found.

“Potassium chloride substitution in staple foods such as bread and bread products have serious and potentially fatal consequences for people who need to restrict dietary potassium. Improved food labelling is required for consumers to avoid excessive consumption,” Ms. Morrison and colleagues concluded. They added that more studies are needed to further understand the risks of potassium dietary intake and hyperkalemia in CKD from potassium-based salt substitutes.

The American Heart Association recommends no more than 1,500 mg of sodium intake daily for persons with CKD, diabetes, or high blood pressure; those older than 51; and African American persons of any age.

The recommended daily intake of potassium in persons with CKD can range from 2,000 mg to 4,000 mg, depending on the individual and their degree of CKD. The potassium content in some salt substitutes varies from 440 mg to 2,800 mg per teaspoon.

The best recommendation for individuals with CKD and a goal to reduce their sodium intake is to use herbs and lower-sodium seasonings as a substitute, but these should always be reviewed with their physician and renal nutritionist.

Dr. Brookins is a board-certified nephrologist and internist practicing in Georgia. She is the founder and owner of Remote Renal Care, a telehealth kidney practice. She reported no relevant conflicts of interest.

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

My wife and I had been married for 3 or 4 years when I became aware that a small cluster of my new in-laws had taken to referring to me as “Dr. I-don’t-know.” It wasn’t hard to figure out how I had earned this potentially derogatory moniker. As the only physician in the family it was not unusual for me to be peppered with medical questions. Most were unanswerable, at least by me. For example, “Will, how does aspirin work?” – which in the 1970s wasn’t something covered in medical school. Other questions were asked in a context that made it clear my answer was going to be so far removed from the preformed opinion of the questioner that Thanksgiving dinner didn’t feel like an appropriate occasion for my answer. “I don’t think I really know,” seemed to make the most sense.

In those early growing years of my outpatient general practice my in-laws weren’t the only people who must have thought of me as “Dr. I-don’t-know.” My training took place in well-thought-of teaching hospitals and during my senior residency and military tour I did enough moonlighting that by the time I entered private practice I had logged a lot of hours in the trenches. But, there were still a ton of things I didn’t know.

You probably remember how those first few years on the outside of the ivory towers felt with no one handy to ask. Even if there was someone a phone call away you didn’t want to appear as incompetent as you were by telling the patient or family that you needed to call the department head at your training program.

So, what did you do? You called. But you developed some clever language that could buy you time while you called your old mentor or hit the books. There was no Internet. Generally, that script would start with some version of “I don’t know, but ...”

As time passed and you gained more experience there were fewer questions and situations in which you needed to admit you were a few clues short of the answer. However, still, many times a day, you honestly didn’t know the answer. Hopefully, over time, you had perfected your delivery so that revealing your ignorance wasn’t driving patients away.

The art of saying “I don’t know” boils down to what you say after the “but” and how you say it. As long as you have offered a plan to find the answer and demonstrate that you are concerned about the patient, your ignorance will be tolerated and maybe even be appreciated.

“I don’t know the answer to that question, but let’s see if we can find a solution” could cover it. If finding that solution is going to require more time than the office visit allows – which it usually doesn’t – the promise of a timely response and a commitment to keep that promise is an absolute requirement. Repeated failure to keep promises is one of the quickest ways to sour a patient-doctor relationship and a potential practice killer.

I think my in-laws no longer refer to me as Dr. I-don’t-know. At least they have refrained from asking me any medical questions. But, my reputation as a physician unafraid to admit his ignorance continues here in town. Occasionally I encounter a parent of a former patient who fondly recalls my willingness to say “I don’t know.” If we had a family crest I would like it to include the motto “Ignoramus Sed Pertinet” (We don’t know but we care).
 

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

The headline on this article was updated on 2/28/22.

My wife and I had been married for 3 or 4 years when I became aware that a small cluster of my new in-laws had taken to referring to me as “Dr. I-don’t-know.” It wasn’t hard to figure out how I had earned this potentially derogatory moniker. As the only physician in the family it was not unusual for me to be peppered with medical questions. Most were unanswerable, at least by me. For example, “Will, how does aspirin work?” – which in the 1970s wasn’t something covered in medical school. Other questions were asked in a context that made it clear my answer was going to be so far removed from the preformed opinion of the questioner that Thanksgiving dinner didn’t feel like an appropriate occasion for my answer. “I don’t think I really know,” seemed to make the most sense.

In those early growing years of my outpatient general practice my in-laws weren’t the only people who must have thought of me as “Dr. I-don’t-know.” My training took place in well-thought-of teaching hospitals and during my senior residency and military tour I did enough moonlighting that by the time I entered private practice I had logged a lot of hours in the trenches. But, there were still a ton of things I didn’t know.

You probably remember how those first few years on the outside of the ivory towers felt with no one handy to ask. Even if there was someone a phone call away you didn’t want to appear as incompetent as you were by telling the patient or family that you needed to call the department head at your training program.

So, what did you do? You called. But you developed some clever language that could buy you time while you called your old mentor or hit the books. There was no Internet. Generally, that script would start with some version of “I don’t know, but ...”

As time passed and you gained more experience there were fewer questions and situations in which you needed to admit you were a few clues short of the answer. However, still, many times a day, you honestly didn’t know the answer. Hopefully, over time, you had perfected your delivery so that revealing your ignorance wasn’t driving patients away.

The art of saying “I don’t know” boils down to what you say after the “but” and how you say it. As long as you have offered a plan to find the answer and demonstrate that you are concerned about the patient, your ignorance will be tolerated and maybe even be appreciated.

“I don’t know the answer to that question, but let’s see if we can find a solution” could cover it. If finding that solution is going to require more time than the office visit allows – which it usually doesn’t – the promise of a timely response and a commitment to keep that promise is an absolute requirement. Repeated failure to keep promises is one of the quickest ways to sour a patient-doctor relationship and a potential practice killer.

I think my in-laws no longer refer to me as Dr. I-don’t-know. At least they have refrained from asking me any medical questions. But, my reputation as a physician unafraid to admit his ignorance continues here in town. Occasionally I encounter a parent of a former patient who fondly recalls my willingness to say “I don’t know.” If we had a family crest I would like it to include the motto “Ignoramus Sed Pertinet” (We don’t know but we care).
 

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

The headline on this article was updated on 2/28/22.

My wife and I had been married for 3 or 4 years when I became aware that a small cluster of my new in-laws had taken to referring to me as “Dr. I-don’t-know.” It wasn’t hard to figure out how I had earned this potentially derogatory moniker. As the only physician in the family it was not unusual for me to be peppered with medical questions. Most were unanswerable, at least by me. For example, “Will, how does aspirin work?” – which in the 1970s wasn’t something covered in medical school. Other questions were asked in a context that made it clear my answer was going to be so far removed from the preformed opinion of the questioner that Thanksgiving dinner didn’t feel like an appropriate occasion for my answer. “I don’t think I really know,” seemed to make the most sense.

In those early growing years of my outpatient general practice my in-laws weren’t the only people who must have thought of me as “Dr. I-don’t-know.” My training took place in well-thought-of teaching hospitals and during my senior residency and military tour I did enough moonlighting that by the time I entered private practice I had logged a lot of hours in the trenches. But, there were still a ton of things I didn’t know.

You probably remember how those first few years on the outside of the ivory towers felt with no one handy to ask. Even if there was someone a phone call away you didn’t want to appear as incompetent as you were by telling the patient or family that you needed to call the department head at your training program.

So, what did you do? You called. But you developed some clever language that could buy you time while you called your old mentor or hit the books. There was no Internet. Generally, that script would start with some version of “I don’t know, but ...”

As time passed and you gained more experience there were fewer questions and situations in which you needed to admit you were a few clues short of the answer. However, still, many times a day, you honestly didn’t know the answer. Hopefully, over time, you had perfected your delivery so that revealing your ignorance wasn’t driving patients away.

The art of saying “I don’t know” boils down to what you say after the “but” and how you say it. As long as you have offered a plan to find the answer and demonstrate that you are concerned about the patient, your ignorance will be tolerated and maybe even be appreciated.

“I don’t know the answer to that question, but let’s see if we can find a solution” could cover it. If finding that solution is going to require more time than the office visit allows – which it usually doesn’t – the promise of a timely response and a commitment to keep that promise is an absolute requirement. Repeated failure to keep promises is one of the quickest ways to sour a patient-doctor relationship and a potential practice killer.

I think my in-laws no longer refer to me as Dr. I-don’t-know. At least they have refrained from asking me any medical questions. But, my reputation as a physician unafraid to admit his ignorance continues here in town. Occasionally I encounter a parent of a former patient who fondly recalls my willingness to say “I don’t know.” If we had a family crest I would like it to include the motto “Ignoramus Sed Pertinet” (We don’t know but we care).
 

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

The headline on this article was updated on 2/28/22.

I have a secret. It’s one I think many physicians and nurses share. Sometimes, when I’m stretched too thin — overbooked, hungry, tired, fielding yet another appeal to an insurance company in the middle of a clinic day — I find myself momentarily resenting the patients on my schedule.

As soon as this happens, I feel immediate guilt. These are the worst moments of my day. Why the heck would I resent my patients? They’re the entire reason I’m there. I wouldn’t be a physician without patients to care for. I became a physician, and completed subspecialty training, to help patients. People.

Recently, I started thinking more about this emotion of resentment. What exactly is it, and where does it come from? Is what I’m feeling actually resentment? Or is it something else?

Two books I’ve recently read have helped me explore the complicated emotion of resentment and how it might play a role in burnout for both physicians and nurses.

First, Brené Brown’s most recent book, Atlas of the Heart: Mapping Meaningful Connection and the Language of Human Experience, provides a roadmap for 87 of our human emotions. (That’s right — 87!)

One emotion of the 87 that she shares has been a particular struggle for her has been our good old friend, resentment.

In her book, Dr Brown shares that she initially considered resentment to belong to the anger family of emotion. As I read this, I agreed. When I feel resentful, I associate that with feeling angry.

But she then writes about her discovery that resentment, in fact, belongs to the envy family. She explains how this discovery shook her world. I had to close the book for a moment at this point.

Wait a minute, I thought. If resentment is in the envy family, why do we (physicians) often find ourselves resenting patients who take up our time? What are we envious of?

I took some time to think about how this might be true. Could it be that I’m envious they have the time I don’t have? I want to have all the time in the world to answer their questions, but the reality is I don’t.

Or maybe it’s because sometimes I feel the patient is expecting me to offer them something more than is available. A cure when there might be none.

But is this actually true? Or is this my unrealistic expectation of myself?

Here’s how Brené Brown defines resentment in her book: “Resentment is the feeling of frustration, judgment, anger, ‘better than,’ and/or hidden envy related to perceived unfairness or injustice. It’s an emotion that we often experience when we fail to set boundaries or ask for what we need, or when expectations let us down because they were based on things we can’t control, like what other people think, what they feel, or how they’re going to react.”

Wow, I thought, Healthcare checks all of these boxes.

• Perceived unfairness of work schedules? Check.
• Perceived injustice? Of course — we see that in our dealings with insurance company denials every day.

But those are both extrinsic. What about the intrinsic factors she’s calling us out on here?

• Do we, as physicians, fail to set boundaries?
• Do we fail to ask for what we need?

Hard yes and yes. (Do we even know, as physicians, what our own boundaries are?)

And the last one:

• Do our expectations of how our clinic day will go let us down every day because they’re based on things we can’t control?

My brain had to repeat the critical parts of that: Expectations let us down when they’re based on things we can’t control.

But wait, my brain argued back; I’m the physician, I thought I was supposed to get to control things.

Next, the revelation: Could it be that a key to experiencing less resentment is accepting how much control we don’t have in a typical day?

And a corollary: How much does resentment factor into burnout? (To read more on my personal journey with burnout, see this piece).

It so happens that around this same time, I was reading another excellent book, Changing How We Think About Difficult Patients: A Guide for Physicians and Healthcare Professionals, by Joan Naidorf, DO.

Dr Naidorf is an emergency medicine physician of 30 years who wrote the book to “provid[e] insight and tools to manage our negative thoughts about difficult patients” and help “beleaguered colleagues…return to their benevolent guiding principles and find more enjoyment in their vitally important careers.”

As I read Dr Naidorf’s book, I thus did so with the mindset of wanting to further understand for myself where this specific emotion of resentment toward our “difficult” patients could come from and how to best understand it in order to get past it.

Dr. Naidorf writes, “Challenging patients will never stop appearing… You cannot change them or control them—the only person you can control is you.”

I wondered how much the resentment we might involuntarily feel at being asked to see a “difficult” patient has nothing to do with the patient but everything to do with it making us feel not in control of the situation.

Dr. Naidorf also writes, “Negative thoughts about challenging patients can cause, in otherwise capable clinicians, a sense of inadequacy and incompetence.”

Do we perhaps resent our challenging patients because of the negative thoughts they sometimes trigger in us? If so, how does this relate to envy, as Dr. Brown asserts resentment is tied to? Is it triggering us to feel inadequate?

“[Difficult patients] often make us question ourselves,” Dr. Naidorf writes, “and we need to feel comfortable with the answers.”

Again, the discrepancy between expectations and reality creates the negative emotion.

Or, as Dr. Naidorf writes, “What if you could stop judging others so harshly and accept them exactly as they are?”

Hmmm, I thought, then the cessation of harsh judgment and implementation of acceptance would have to apply to us too. The elusive concept of self-compassion.

Maybe the resentment/envy comes from us not allowing ourselves to behave in this way because to do so would allow too much vulnerability. Something most of us were conditioned to avoid to survive medical training.

Dr. Brown also writes about an “aha” moment she had in her struggle to understand resentment. “I’m not mad because you’re resting. I’m mad because I’m so bone tired and I want to rest. But, unlike you, I’m going to pretend that I don’t need to.”

I felt all too seen in that passage. Could it be my old nemesis, perfectionism, creeping its way back in? Is resentment the ugly stepsister to perfectionism?

Perhaps challenging patients can engender resentment because they make us feel like we’re not living up to our own unrealistic expectations. And in that case, we need to change our unrealistic expectations for ourselves.

Dr Naidorf’s book explores much more on the complex matter of what makes a “difficult” patient, but I chose to focus here only on the resentment piece as a tie-in to Dr. Brown’s book. I highly recommend both books for further reading to help physicians and nurses navigate the complex emotions our jobs can trigger.

Most importantly, recognizing that we have these transient negative emotions does not make us bad people or healthcare professionals. It only makes us human.

Dr. Lycette is medical director, Providence Oncology and Hematology Care Clinic, Seaside, Ore. She has disclosed having no relevant financial relationships.

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

I have a secret. It’s one I think many physicians and nurses share. Sometimes, when I’m stretched too thin — overbooked, hungry, tired, fielding yet another appeal to an insurance company in the middle of a clinic day — I find myself momentarily resenting the patients on my schedule.

As soon as this happens, I feel immediate guilt. These are the worst moments of my day. Why the heck would I resent my patients? They’re the entire reason I’m there. I wouldn’t be a physician without patients to care for. I became a physician, and completed subspecialty training, to help patients. People.

Recently, I started thinking more about this emotion of resentment. What exactly is it, and where does it come from? Is what I’m feeling actually resentment? Or is it something else?

Two books I’ve recently read have helped me explore the complicated emotion of resentment and how it might play a role in burnout for both physicians and nurses.

First, Brené Brown’s most recent book, Atlas of the Heart: Mapping Meaningful Connection and the Language of Human Experience, provides a roadmap for 87 of our human emotions. (That’s right — 87!)

One emotion of the 87 that she shares has been a particular struggle for her has been our good old friend, resentment.

In her book, Dr Brown shares that she initially considered resentment to belong to the anger family of emotion. As I read this, I agreed. When I feel resentful, I associate that with feeling angry.

But she then writes about her discovery that resentment, in fact, belongs to the envy family. She explains how this discovery shook her world. I had to close the book for a moment at this point.

Wait a minute, I thought. If resentment is in the envy family, why do we (physicians) often find ourselves resenting patients who take up our time? What are we envious of?

I took some time to think about how this might be true. Could it be that I’m envious they have the time I don’t have? I want to have all the time in the world to answer their questions, but the reality is I don’t.

Or maybe it’s because sometimes I feel the patient is expecting me to offer them something more than is available. A cure when there might be none.

But is this actually true? Or is this my unrealistic expectation of myself?

Here’s how Brené Brown defines resentment in her book: “Resentment is the feeling of frustration, judgment, anger, ‘better than,’ and/or hidden envy related to perceived unfairness or injustice. It’s an emotion that we often experience when we fail to set boundaries or ask for what we need, or when expectations let us down because they were based on things we can’t control, like what other people think, what they feel, or how they’re going to react.”

Wow, I thought, Healthcare checks all of these boxes.

• Perceived unfairness of work schedules? Check.
• Perceived injustice? Of course — we see that in our dealings with insurance company denials every day.

But those are both extrinsic. What about the intrinsic factors she’s calling us out on here?

• Do we, as physicians, fail to set boundaries?
• Do we fail to ask for what we need?

Hard yes and yes. (Do we even know, as physicians, what our own boundaries are?)

And the last one:

• Do our expectations of how our clinic day will go let us down every day because they’re based on things we can’t control?

My brain had to repeat the critical parts of that: Expectations let us down when they’re based on things we can’t control.

But wait, my brain argued back; I’m the physician, I thought I was supposed to get to control things.

Next, the revelation: Could it be that a key to experiencing less resentment is accepting how much control we don’t have in a typical day?

And a corollary: How much does resentment factor into burnout? (To read more on my personal journey with burnout, see this piece).

It so happens that around this same time, I was reading another excellent book, Changing How We Think About Difficult Patients: A Guide for Physicians and Healthcare Professionals, by Joan Naidorf, DO.

Dr Naidorf is an emergency medicine physician of 30 years who wrote the book to “provid[e] insight and tools to manage our negative thoughts about difficult patients” and help “beleaguered colleagues…return to their benevolent guiding principles and find more enjoyment in their vitally important careers.”

As I read Dr Naidorf’s book, I thus did so with the mindset of wanting to further understand for myself where this specific emotion of resentment toward our “difficult” patients could come from and how to best understand it in order to get past it.

Dr. Naidorf writes, “Challenging patients will never stop appearing… You cannot change them or control them—the only person you can control is you.”

I wondered how much the resentment we might involuntarily feel at being asked to see a “difficult” patient has nothing to do with the patient but everything to do with it making us feel not in control of the situation.

Dr. Naidorf also writes, “Negative thoughts about challenging patients can cause, in otherwise capable clinicians, a sense of inadequacy and incompetence.”

Do we perhaps resent our challenging patients because of the negative thoughts they sometimes trigger in us? If so, how does this relate to envy, as Dr. Brown asserts resentment is tied to? Is it triggering us to feel inadequate?

“[Difficult patients] often make us question ourselves,” Dr. Naidorf writes, “and we need to feel comfortable with the answers.”

Again, the discrepancy between expectations and reality creates the negative emotion.

Or, as Dr. Naidorf writes, “What if you could stop judging others so harshly and accept them exactly as they are?”

Hmmm, I thought, then the cessation of harsh judgment and implementation of acceptance would have to apply to us too. The elusive concept of self-compassion.

Maybe the resentment/envy comes from us not allowing ourselves to behave in this way because to do so would allow too much vulnerability. Something most of us were conditioned to avoid to survive medical training.

Dr. Brown also writes about an “aha” moment she had in her struggle to understand resentment. “I’m not mad because you’re resting. I’m mad because I’m so bone tired and I want to rest. But, unlike you, I’m going to pretend that I don’t need to.”

I felt all too seen in that passage. Could it be my old nemesis, perfectionism, creeping its way back in? Is resentment the ugly stepsister to perfectionism?

Perhaps challenging patients can engender resentment because they make us feel like we’re not living up to our own unrealistic expectations. And in that case, we need to change our unrealistic expectations for ourselves.

Dr Naidorf’s book explores much more on the complex matter of what makes a “difficult” patient, but I chose to focus here only on the resentment piece as a tie-in to Dr. Brown’s book. I highly recommend both books for further reading to help physicians and nurses navigate the complex emotions our jobs can trigger.

Most importantly, recognizing that we have these transient negative emotions does not make us bad people or healthcare professionals. It only makes us human.

Dr. Lycette is medical director, Providence Oncology and Hematology Care Clinic, Seaside, Ore. She has disclosed having no relevant financial relationships.

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

I have a secret. It’s one I think many physicians and nurses share. Sometimes, when I’m stretched too thin — overbooked, hungry, tired, fielding yet another appeal to an insurance company in the middle of a clinic day — I find myself momentarily resenting the patients on my schedule.

As soon as this happens, I feel immediate guilt. These are the worst moments of my day. Why the heck would I resent my patients? They’re the entire reason I’m there. I wouldn’t be a physician without patients to care for. I became a physician, and completed subspecialty training, to help patients. People.

Recently, I started thinking more about this emotion of resentment. What exactly is it, and where does it come from? Is what I’m feeling actually resentment? Or is it something else?

Two books I’ve recently read have helped me explore the complicated emotion of resentment and how it might play a role in burnout for both physicians and nurses.

First, Brené Brown’s most recent book, Atlas of the Heart: Mapping Meaningful Connection and the Language of Human Experience, provides a roadmap for 87 of our human emotions. (That’s right — 87!)

One emotion of the 87 that she shares has been a particular struggle for her has been our good old friend, resentment.

In her book, Dr Brown shares that she initially considered resentment to belong to the anger family of emotion. As I read this, I agreed. When I feel resentful, I associate that with feeling angry.

But she then writes about her discovery that resentment, in fact, belongs to the envy family. She explains how this discovery shook her world. I had to close the book for a moment at this point.

Wait a minute, I thought. If resentment is in the envy family, why do we (physicians) often find ourselves resenting patients who take up our time? What are we envious of?

I took some time to think about how this might be true. Could it be that I’m envious they have the time I don’t have? I want to have all the time in the world to answer their questions, but the reality is I don’t.

Or maybe it’s because sometimes I feel the patient is expecting me to offer them something more than is available. A cure when there might be none.

But is this actually true? Or is this my unrealistic expectation of myself?

Here’s how Brené Brown defines resentment in her book: “Resentment is the feeling of frustration, judgment, anger, ‘better than,’ and/or hidden envy related to perceived unfairness or injustice. It’s an emotion that we often experience when we fail to set boundaries or ask for what we need, or when expectations let us down because they were based on things we can’t control, like what other people think, what they feel, or how they’re going to react.”

Wow, I thought, Healthcare checks all of these boxes.

• Perceived unfairness of work schedules? Check.
• Perceived injustice? Of course — we see that in our dealings with insurance company denials every day.

But those are both extrinsic. What about the intrinsic factors she’s calling us out on here?

• Do we, as physicians, fail to set boundaries?
• Do we fail to ask for what we need?

Hard yes and yes. (Do we even know, as physicians, what our own boundaries are?)

And the last one:

• Do our expectations of how our clinic day will go let us down every day because they’re based on things we can’t control?

My brain had to repeat the critical parts of that: Expectations let us down when they’re based on things we can’t control.

But wait, my brain argued back; I’m the physician, I thought I was supposed to get to control things.

Next, the revelation: Could it be that a key to experiencing less resentment is accepting how much control we don’t have in a typical day?

And a corollary: How much does resentment factor into burnout? (To read more on my personal journey with burnout, see this piece).

It so happens that around this same time, I was reading another excellent book, Changing How We Think About Difficult Patients: A Guide for Physicians and Healthcare Professionals, by Joan Naidorf, DO.

Dr Naidorf is an emergency medicine physician of 30 years who wrote the book to “provid[e] insight and tools to manage our negative thoughts about difficult patients” and help “beleaguered colleagues…return to their benevolent guiding principles and find more enjoyment in their vitally important careers.”

As I read Dr Naidorf’s book, I thus did so with the mindset of wanting to further understand for myself where this specific emotion of resentment toward our “difficult” patients could come from and how to best understand it in order to get past it.

Dr. Naidorf writes, “Challenging patients will never stop appearing… You cannot change them or control them—the only person you can control is you.”

I wondered how much the resentment we might involuntarily feel at being asked to see a “difficult” patient has nothing to do with the patient but everything to do with it making us feel not in control of the situation.

Dr. Naidorf also writes, “Negative thoughts about challenging patients can cause, in otherwise capable clinicians, a sense of inadequacy and incompetence.”

Do we perhaps resent our challenging patients because of the negative thoughts they sometimes trigger in us? If so, how does this relate to envy, as Dr. Brown asserts resentment is tied to? Is it triggering us to feel inadequate?

“[Difficult patients] often make us question ourselves,” Dr. Naidorf writes, “and we need to feel comfortable with the answers.”

Again, the discrepancy between expectations and reality creates the negative emotion.

Or, as Dr. Naidorf writes, “What if you could stop judging others so harshly and accept them exactly as they are?”

Hmmm, I thought, then the cessation of harsh judgment and implementation of acceptance would have to apply to us too. The elusive concept of self-compassion.

Maybe the resentment/envy comes from us not allowing ourselves to behave in this way because to do so would allow too much vulnerability. Something most of us were conditioned to avoid to survive medical training.

Dr. Brown also writes about an “aha” moment she had in her struggle to understand resentment. “I’m not mad because you’re resting. I’m mad because I’m so bone tired and I want to rest. But, unlike you, I’m going to pretend that I don’t need to.”

I felt all too seen in that passage. Could it be my old nemesis, perfectionism, creeping its way back in? Is resentment the ugly stepsister to perfectionism?

Perhaps challenging patients can engender resentment because they make us feel like we’re not living up to our own unrealistic expectations. And in that case, we need to change our unrealistic expectations for ourselves.

Dr Naidorf’s book explores much more on the complex matter of what makes a “difficult” patient, but I chose to focus here only on the resentment piece as a tie-in to Dr. Brown’s book. I highly recommend both books for further reading to help physicians and nurses navigate the complex emotions our jobs can trigger.

Most importantly, recognizing that we have these transient negative emotions does not make us bad people or healthcare professionals. It only makes us human.

Dr. Lycette is medical director, Providence Oncology and Hematology Care Clinic, Seaside, Ore. She has disclosed having no relevant financial relationships.

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

“Just relax, stop thinking about it and, more than likely, it will happen.” If ever there was a controversial subject in medicine, especially in reproduction, the relationship between stress and infertility would be high on the list. Who among us has not overheard or even personally shared with an infertility patient that they should try and reduce their stress to improve fertility? The theory is certainly not new. Hippocrates, back in the 5th century B.C., was one of the first to associate a woman’s psychological state with her reproductive potential. His contention was that a physical sign of psychological stress in women (which scholars later dubbed “hysteria”) could result in sterility. In medieval times, a German abbess and mystic named Hildegard of Bingen posited women suffering from melancholy – a condition that we today might call depression – were infertile as a result.

The deeper meaning behind the flippant advice to relax is implicit blame; that is, a woman interprets the link of stress and infertility as a declaration that she is sabotaging reproduction. Not only is this assumption flawed, but it does further damage to a woman’s emotional fragility. To provide the presumption of stress affecting reproduction, a recent survey of over 5,000 infertility patients found, remarkably, 98% considered emotional stress as either a cause or a contributor to infertility, and 31% believed stress was a cause of miscarriage, although racial differences existed (J Assist Reprod Genet. 2021 Apr;38[4]:877-87). This relationship was mostly seen in women who used complementary and alternative medicine, Black women, and those who frequented Internet search engines. Whereas women who had a professional degree, had more infertility insurance coverage, and were nonreligious were less likely to attribute stress to infertility. Intriguingly, the more engaged the physicians, the less patients linked stress with infertility, while the contrary also applied.

The power of stress can be exemplified by the pathophysiology of amenorrhea. Functional hypothalamic amenorrhea is the most common cause of the female athlete triad of secondary amenorrhea in women of childbearing age. It is a reversible disorder caused by stress related to weight loss, excessive exercise and/or traumatic mental experiences (Endocrines. 2021;2:203-11). Stress of infertility has also been demonstrated to be equivalent to a diagnosis of cancer and other major medical morbidities (J Psychosom Obstet Gynaecol. 1993;14[Suppl]:45-52).

A definitive link between stress and infertility is evasive because of the lack of controlled, prospective longitudinal studies and the challenge of reducing variables in the analysis. The question remains which developed initially – the stress or the infertility? Infertility treatment is a physical, emotional, and financial investment. Stress and the duration of infertility are correlative. The additive factor is that poor insurance coverage for costly fertility treatment can not only heighten stress but, concurrently, subject the patient to the risk of exploitation driven by desperation whereby they accept unproven “add-ons” offered with assisted reproductive technologies (ART).

Both acute and chronic stress affect the number of oocytes retrieved and fertilized with ART as well as live birth delivery and birth weights (Fertil Steril. 2001;76:675-87). Men are also affected by stress, which is manifested by decreased libido and impaired semen, further compromised as the duration of infertility continues. The gut-derived hormone ghrelin appears to play a role with stress and reproduction (Endocr Rev. 2017;38:432-67).

As the relationship between stress and infertility is far from proven, there are conflicting study results. Two meta-analyses failed to show any association between stress and the outcomes of ART cycles (Hum Reprod. 2011;26:2763-76; BMJ. 2011;342:d223). In contrast, a recent study suggested stress during infertility treatment was contributed by the variables of low spousal support, financial constraints, and social coercion in the early years of marriage (J Hum Reprod Sci. 2018;11:172-9). Emotional distress was found to be three times greater in women whose families had unrealistic expectations from treatments.

Fortunately, psychotherapy during the ART cycle has demonstrated a benefit in outcomes. Domar revealed psychological support and cognitive behavior therapy resulted in higher pregnancy rates than in the control group (Fertil Steril. 2000;73:805-12). Another recent study appears to support stress reduction improving reproductive potential (Dialogues Clin Neurosci. 2018;20[1]:41-7).

Given the evidence provided in this article, it behooves infertility clinics to address baseline (chronic) stress and acute stress (because of infertility) prior to initiating treatment (see Figure). While the definitive answer addressing the impact of stress on reproduction remains unknown, we may share with our patients a definition in which they may find enlightenment, “Stress is trying to control an event in which one is incapable.”

Dr. Mark P Trolice is director of Fertility CARE: The IVF Center in Winter Park, Fla., and associate professor of obstetrics and gynecology at the University of Central Florida, Orlando.

“Just relax, stop thinking about it and, more than likely, it will happen.” If ever there was a controversial subject in medicine, especially in reproduction, the relationship between stress and infertility would be high on the list. Who among us has not overheard or even personally shared with an infertility patient that they should try and reduce their stress to improve fertility? The theory is certainly not new. Hippocrates, back in the 5th century B.C., was one of the first to associate a woman’s psychological state with her reproductive potential. His contention was that a physical sign of psychological stress in women (which scholars later dubbed “hysteria”) could result in sterility. In medieval times, a German abbess and mystic named Hildegard of Bingen posited women suffering from melancholy – a condition that we today might call depression – were infertile as a result.

The deeper meaning behind the flippant advice to relax is implicit blame; that is, a woman interprets the link of stress and infertility as a declaration that she is sabotaging reproduction. Not only is this assumption flawed, but it does further damage to a woman’s emotional fragility. To provide the presumption of stress affecting reproduction, a recent survey of over 5,000 infertility patients found, remarkably, 98% considered emotional stress as either a cause or a contributor to infertility, and 31% believed stress was a cause of miscarriage, although racial differences existed (J Assist Reprod Genet. 2021 Apr;38[4]:877-87). This relationship was mostly seen in women who used complementary and alternative medicine, Black women, and those who frequented Internet search engines. Whereas women who had a professional degree, had more infertility insurance coverage, and were nonreligious were less likely to attribute stress to infertility. Intriguingly, the more engaged the physicians, the less patients linked stress with infertility, while the contrary also applied.

The power of stress can be exemplified by the pathophysiology of amenorrhea. Functional hypothalamic amenorrhea is the most common cause of the female athlete triad of secondary amenorrhea in women of childbearing age. It is a reversible disorder caused by stress related to weight loss, excessive exercise and/or traumatic mental experiences (Endocrines. 2021;2:203-11). Stress of infertility has also been demonstrated to be equivalent to a diagnosis of cancer and other major medical morbidities (J Psychosom Obstet Gynaecol. 1993;14[Suppl]:45-52).

A definitive link between stress and infertility is evasive because of the lack of controlled, prospective longitudinal studies and the challenge of reducing variables in the analysis. The question remains which developed initially – the stress or the infertility? Infertility treatment is a physical, emotional, and financial investment. Stress and the duration of infertility are correlative. The additive factor is that poor insurance coverage for costly fertility treatment can not only heighten stress but, concurrently, subject the patient to the risk of exploitation driven by desperation whereby they accept unproven “add-ons” offered with assisted reproductive technologies (ART).

Both acute and chronic stress affect the number of oocytes retrieved and fertilized with ART as well as live birth delivery and birth weights (Fertil Steril. 2001;76:675-87). Men are also affected by stress, which is manifested by decreased libido and impaired semen, further compromised as the duration of infertility continues. The gut-derived hormone ghrelin appears to play a role with stress and reproduction (Endocr Rev. 2017;38:432-67).

As the relationship between stress and infertility is far from proven, there are conflicting study results. Two meta-analyses failed to show any association between stress and the outcomes of ART cycles (Hum Reprod. 2011;26:2763-76; BMJ. 2011;342:d223). In contrast, a recent study suggested stress during infertility treatment was contributed by the variables of low spousal support, financial constraints, and social coercion in the early years of marriage (J Hum Reprod Sci. 2018;11:172-9). Emotional distress was found to be three times greater in women whose families had unrealistic expectations from treatments.

Fortunately, psychotherapy during the ART cycle has demonstrated a benefit in outcomes. Domar revealed psychological support and cognitive behavior therapy resulted in higher pregnancy rates than in the control group (Fertil Steril. 2000;73:805-12). Another recent study appears to support stress reduction improving reproductive potential (Dialogues Clin Neurosci. 2018;20[1]:41-7).

Given the evidence provided in this article, it behooves infertility clinics to address baseline (chronic) stress and acute stress (because of infertility) prior to initiating treatment (see Figure). While the definitive answer addressing the impact of stress on reproduction remains unknown, we may share with our patients a definition in which they may find enlightenment, “Stress is trying to control an event in which one is incapable.”

Dr. Mark P Trolice is director of Fertility CARE: The IVF Center in Winter Park, Fla., and associate professor of obstetrics and gynecology at the University of Central Florida, Orlando.

“Just relax, stop thinking about it and, more than likely, it will happen.” If ever there was a controversial subject in medicine, especially in reproduction, the relationship between stress and infertility would be high on the list. Who among us has not overheard or even personally shared with an infertility patient that they should try and reduce their stress to improve fertility? The theory is certainly not new. Hippocrates, back in the 5th century B.C., was one of the first to associate a woman’s psychological state with her reproductive potential. His contention was that a physical sign of psychological stress in women (which scholars later dubbed “hysteria”) could result in sterility. In medieval times, a German abbess and mystic named Hildegard of Bingen posited women suffering from melancholy – a condition that we today might call depression – were infertile as a result.

The deeper meaning behind the flippant advice to relax is implicit blame; that is, a woman interprets the link of stress and infertility as a declaration that she is sabotaging reproduction. Not only is this assumption flawed, but it does further damage to a woman’s emotional fragility. To provide the presumption of stress affecting reproduction, a recent survey of over 5,000 infertility patients found, remarkably, 98% considered emotional stress as either a cause or a contributor to infertility, and 31% believed stress was a cause of miscarriage, although racial differences existed (J Assist Reprod Genet. 2021 Apr;38[4]:877-87). This relationship was mostly seen in women who used complementary and alternative medicine, Black women, and those who frequented Internet search engines. Whereas women who had a professional degree, had more infertility insurance coverage, and were nonreligious were less likely to attribute stress to infertility. Intriguingly, the more engaged the physicians, the less patients linked stress with infertility, while the contrary also applied.

The power of stress can be exemplified by the pathophysiology of amenorrhea. Functional hypothalamic amenorrhea is the most common cause of the female athlete triad of secondary amenorrhea in women of childbearing age. It is a reversible disorder caused by stress related to weight loss, excessive exercise and/or traumatic mental experiences (Endocrines. 2021;2:203-11). Stress of infertility has also been demonstrated to be equivalent to a diagnosis of cancer and other major medical morbidities (J Psychosom Obstet Gynaecol. 1993;14[Suppl]:45-52).

A definitive link between stress and infertility is evasive because of the lack of controlled, prospective longitudinal studies and the challenge of reducing variables in the analysis. The question remains which developed initially – the stress or the infertility? Infertility treatment is a physical, emotional, and financial investment. Stress and the duration of infertility are correlative. The additive factor is that poor insurance coverage for costly fertility treatment can not only heighten stress but, concurrently, subject the patient to the risk of exploitation driven by desperation whereby they accept unproven “add-ons” offered with assisted reproductive technologies (ART).

Both acute and chronic stress affect the number of oocytes retrieved and fertilized with ART as well as live birth delivery and birth weights (Fertil Steril. 2001;76:675-87). Men are also affected by stress, which is manifested by decreased libido and impaired semen, further compromised as the duration of infertility continues. The gut-derived hormone ghrelin appears to play a role with stress and reproduction (Endocr Rev. 2017;38:432-67).

As the relationship between stress and infertility is far from proven, there are conflicting study results. Two meta-analyses failed to show any association between stress and the outcomes of ART cycles (Hum Reprod. 2011;26:2763-76; BMJ. 2011;342:d223). In contrast, a recent study suggested stress during infertility treatment was contributed by the variables of low spousal support, financial constraints, and social coercion in the early years of marriage (J Hum Reprod Sci. 2018;11:172-9). Emotional distress was found to be three times greater in women whose families had unrealistic expectations from treatments.

Fortunately, psychotherapy during the ART cycle has demonstrated a benefit in outcomes. Domar revealed psychological support and cognitive behavior therapy resulted in higher pregnancy rates than in the control group (Fertil Steril. 2000;73:805-12). Another recent study appears to support stress reduction improving reproductive potential (Dialogues Clin Neurosci. 2018;20[1]:41-7).

Given the evidence provided in this article, it behooves infertility clinics to address baseline (chronic) stress and acute stress (because of infertility) prior to initiating treatment (see Figure). While the definitive answer addressing the impact of stress on reproduction remains unknown, we may share with our patients a definition in which they may find enlightenment, “Stress is trying to control an event in which one is incapable.”

Dr. Mark P Trolice is director of Fertility CARE: The IVF Center in Winter Park, Fla., and associate professor of obstetrics and gynecology at the University of Central Florida, Orlando.

On Oct. 4, staff, patients, and medical students at my institution received word that a fatal shooting had occurred inside the campus hospital. For staff, this was a painful event compounding the already stressful pandemic times, while for students, it was a harsh introduction to the emerging dangers of practicing medicine.

Sure, medicine is widely known to be a grueling profession that requires sacrifice, but few realize the dangers to their own safety that providers routinely face. Unfortunately, acts of violence targeting health care workers occur at surprisingly high rates.

Reports following the shooting indicated that the gunman had a personal conflict with a coworker, and thankfully, larger numbers of people had not been targeted. While this may seem like a one-off incident, any shooting inside a hospital is a serious matter. Hospitals should be places of healing. Yes, they are inevitably places of suffering as well, but this pain should never be human-inflicted.

Health care workers are widely admired in the community, and increasingly so due to their sacrifices during the COVID-19 pandemic. Even though there is more attention to our health care spaces, the epidemic of occupational violence against our country’s health care workers has gone largely unrecognized, and this danger has only worsened since the onset of the pandemic.

Acts of violence against health care workers not only include fatal shootings or stabbings but may also include physical or verbal aggressions by frustrated patients and visitors. It is likely that students entering the health care field will encounter such danger during their careers.

Health care workers have four times the likelihood of being assaulted on the job, compared with those working in private industry. The World Health Organization reports that 38% of health workers can expect to experience physical violence at some point in their careers, while verbal threatening was reportedly even more common. It is plausible that the true rate of violence surpasses these rates, as reporting them is entirely voluntary.

In fact, the American Journal of Managed Care reported in 2019 that 75% of workplace assaults occur in health care, yet only 30% of nurses and 26% of emergency department physicians report such experiences.

Anecdotally, many of my own physician mentors have shared stories of troubling or threatening situations they have faced throughout their careers. These types of situations can be difficult to avoid, as providers are trained and naturally inclined to empathize with their patients and help as much as possible, making it difficult to turn away potentially violent individuals.

Since the start of the COVID-19 pandemic, as the public became more fatigued, incidents of violence rose. Facing staffing shortages, visitor restrictions, and high-acuity patients, health care workers found it increasingly difficult to manage large caseloads. High levels of stress were affecting not only patients, who were facing some of the toughest times of their lives, but also staff, who experienced rising demands.

Yash Shah is a first-year medical student at Thomas Jefferson University in Philadelphia. He has disclosed no relevant financial relationships.

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

On Oct. 4, staff, patients, and medical students at my institution received word that a fatal shooting had occurred inside the campus hospital. For staff, this was a painful event compounding the already stressful pandemic times, while for students, it was a harsh introduction to the emerging dangers of practicing medicine.

Sure, medicine is widely known to be a grueling profession that requires sacrifice, but few realize the dangers to their own safety that providers routinely face. Unfortunately, acts of violence targeting health care workers occur at surprisingly high rates.

Reports following the shooting indicated that the gunman had a personal conflict with a coworker, and thankfully, larger numbers of people had not been targeted. While this may seem like a one-off incident, any shooting inside a hospital is a serious matter. Hospitals should be places of healing. Yes, they are inevitably places of suffering as well, but this pain should never be human-inflicted.

Health care workers are widely admired in the community, and increasingly so due to their sacrifices during the COVID-19 pandemic. Even though there is more attention to our health care spaces, the epidemic of occupational violence against our country’s health care workers has gone largely unrecognized, and this danger has only worsened since the onset of the pandemic.

Acts of violence against health care workers not only include fatal shootings or stabbings but may also include physical or verbal aggressions by frustrated patients and visitors. It is likely that students entering the health care field will encounter such danger during their careers.

Health care workers have four times the likelihood of being assaulted on the job, compared with those working in private industry. The World Health Organization reports that 38% of health workers can expect to experience physical violence at some point in their careers, while verbal threatening was reportedly even more common. It is plausible that the true rate of violence surpasses these rates, as reporting them is entirely voluntary.

In fact, the American Journal of Managed Care reported in 2019 that 75% of workplace assaults occur in health care, yet only 30% of nurses and 26% of emergency department physicians report such experiences.

Anecdotally, many of my own physician mentors have shared stories of troubling or threatening situations they have faced throughout their careers. These types of situations can be difficult to avoid, as providers are trained and naturally inclined to empathize with their patients and help as much as possible, making it difficult to turn away potentially violent individuals.

Since the start of the COVID-19 pandemic, as the public became more fatigued, incidents of violence rose. Facing staffing shortages, visitor restrictions, and high-acuity patients, health care workers found it increasingly difficult to manage large caseloads. High levels of stress were affecting not only patients, who were facing some of the toughest times of their lives, but also staff, who experienced rising demands.

Yash Shah is a first-year medical student at Thomas Jefferson University in Philadelphia. He has disclosed no relevant financial relationships.

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

On Oct. 4, staff, patients, and medical students at my institution received word that a fatal shooting had occurred inside the campus hospital. For staff, this was a painful event compounding the already stressful pandemic times, while for students, it was a harsh introduction to the emerging dangers of practicing medicine.

Sure, medicine is widely known to be a grueling profession that requires sacrifice, but few realize the dangers to their own safety that providers routinely face. Unfortunately, acts of violence targeting health care workers occur at surprisingly high rates.

Reports following the shooting indicated that the gunman had a personal conflict with a coworker, and thankfully, larger numbers of people had not been targeted. While this may seem like a one-off incident, any shooting inside a hospital is a serious matter. Hospitals should be places of healing. Yes, they are inevitably places of suffering as well, but this pain should never be human-inflicted.

Health care workers are widely admired in the community, and increasingly so due to their sacrifices during the COVID-19 pandemic. Even though there is more attention to our health care spaces, the epidemic of occupational violence against our country’s health care workers has gone largely unrecognized, and this danger has only worsened since the onset of the pandemic.

Acts of violence against health care workers not only include fatal shootings or stabbings but may also include physical or verbal aggressions by frustrated patients and visitors. It is likely that students entering the health care field will encounter such danger during their careers.

Health care workers have four times the likelihood of being assaulted on the job, compared with those working in private industry. The World Health Organization reports that 38% of health workers can expect to experience physical violence at some point in their careers, while verbal threatening was reportedly even more common. It is plausible that the true rate of violence surpasses these rates, as reporting them is entirely voluntary.

In fact, the American Journal of Managed Care reported in 2019 that 75% of workplace assaults occur in health care, yet only 30% of nurses and 26% of emergency department physicians report such experiences.

Anecdotally, many of my own physician mentors have shared stories of troubling or threatening situations they have faced throughout their careers. These types of situations can be difficult to avoid, as providers are trained and naturally inclined to empathize with their patients and help as much as possible, making it difficult to turn away potentially violent individuals.

Since the start of the COVID-19 pandemic, as the public became more fatigued, incidents of violence rose. Facing staffing shortages, visitor restrictions, and high-acuity patients, health care workers found it increasingly difficult to manage large caseloads. High levels of stress were affecting not only patients, who were facing some of the toughest times of their lives, but also staff, who experienced rising demands.

Yash Shah is a first-year medical student at Thomas Jefferson University in Philadelphia. He has disclosed no relevant financial relationships.

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

Have you experienced malpractice?

No, I’m not asking whether you have experienced litigation. I’m asking whether you, as a physician, have actually experienced substandard care from a colleague. I have heard many such experiences over the years, and mistreatment doesn’t seem to be getting any less frequent.

It seems to me that physicians may be especially prone to receiving substandard care. If true, there could be several explanations. The first is that, unlike the Pope, who has a dedicated confessor trained to minister to his spiritual needs, no one formally trains physicians to treat physicians. As a result, most of us feel slightly uneasy at treating other physicians. We naturally wish to keep our colleagues well, but at the same time realize that our clinical skills are being very closely scrutinized. What if they are found to be wanting? This discomfiture can make a physician treating a physician overly compulsive, or worse, overtly dismissive.

Second, we physicians are famously poor patients. We pretend we don’t need the advice we give others, to monitor our health and promptly seek care when something feels amiss. And, for the period during which we delay a medical encounter, we often attempt to diagnose and treat ourselves.

Sometimes we are successful, which reinforces this approach. Other times, we fail at being our own caregiver and present to someone else either too late, or with avoidable complications. In the former instance, we congratulate ourselves and learn nothing from the experience. In the latter, we may heap shame upon ourselves for our folly, and we may learn; but it could be a lethal lesson. In the worst scenario, our colleague gives in to frustration (or angst), and heaps even more shame onto their late-presenting physician patient.

Third, when we do submit to being a patient, we often demand VIP treatment. This is probably in response to our anxiety that some of the worst things we have seen happen to patients might happen to us if we are not vigilant to ensure we receive a higher level of care. But of course, such hypervigilance can lead to excessive care and testing, with all the attendant hazards, or alternatively to dilution of care if our caregivers decide we are just too much trouble.

Fourth, as a fifth-generation physician myself, I am convinced that physicians and physician family members are either prone to unusual manifestations of common diseases or unusual diseases, or that rare disease entities and complications are actually more common than literature suggests, and they simply aren’t pursued or diagnosed in nonphysician families.

No matter how we may have arrived in a position to need medical care, how often is such care substandard? And how do we respond when we suspect, or know, this to be the case? Are physicians more, or less, likely to take legal action in the face of it?

I certainly don’t know any statistics. Physicians are in an excellent position to take such action, because judges and juries will likely believe that a doctor can recognize negligence when we fall victim to it. But we may also be reluctant to publicly admit the way (or ways) in which we may have contributed to substandard care or outcome.

Based on decades of working with physician clients who have been sued, and having been sued myself (thus witnessing and also experiencing the effects of litigation), I am probably more reluctant than normal patients or physicians to consider taking legal action. This, despite the fact that I am also a lawyer and (through organized medicine) know many colleagues in all specialties who might serve as expert witnesses.

I have experienced serial substandard care, which has left me highly conflicted about the efficacy of my chosen profession. As a resident, I had my first odd pain condition and consulted an “elder statesperson” from my institution, whom I assumed to be a “doctor’s doctor” because he was a superb teacher (wrong!)

He completely missed the diagnosis and further belittled (indeed, libeled) me in the medical record. (Some years later, I learned that, during that period, he was increasingly demented and tended to view all female patients as having “wandering uterus” equivalents.) Fortunately, I found a better diagnostician, or at least one more willing to lend credence to my complaints, who successfully removed the first of several “zebra” lesions I have experienced.

As a young faculty member, I had an odd presentation of a recurring gynecologic condition, which was treated surgically, successfully, except that my fertility was cut in half – a possibility about which I had not been informed when giving operative consent. Would I have sued this fellow faculty member for that? Never, because she invariably treated me with respect as a colleague.

Later in my career after leaving academia, the same condition recurred in a new location. My old-school gynecologist desired to do an extensive procedure, to which I demurred unless specific pathology was found intraoperatively. Affronted, he subjected me to laparoscopy, did nothing but look, and then left the hospital leaving me and the PACU nurse to try to decipher his instructions (which said, basically, “I didn’t find anything; don’t bother me again.”). Several years of pain later, a younger gynecologist performed the correct procedure to address my problem, which has never recurred. Would I have sued him? No, because I believe he had a disability.

At age 59, I developed a new mole. My beloved general practitioner, in the waning years of his practice, forgot to consult a colleague to remove it for several months. When I forced the issue, the mole was removed and turned out to be a rare pediatric condition considered a precursor to melanoma. The same general practitioner had told me I needn’t worry about my “mild hypercalcemia.”

Ten years later I diagnosed my own parathyroid adenoma, in the interim losing 10% of my bone density. Would I have sued him? No, for he always showed he cared. (Though maybe, if I had fractured my spine or hip.)

If you have been the victim of physician malpractice, how did you respond?

Do we serve our profession well by how we handle substandard care – upon ourselves (or our loved ones)?

Dr. Andrew is a former assistant professor in the department of emergency medicine, Johns Hopkins University, Baltimore, and founder and principal of MDMentor, Victoria, B.C.

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

Have you experienced malpractice?

No, I’m not asking whether you have experienced litigation. I’m asking whether you, as a physician, have actually experienced substandard care from a colleague. I have heard many such experiences over the years, and mistreatment doesn’t seem to be getting any less frequent.

It seems to me that physicians may be especially prone to receiving substandard care. If true, there could be several explanations. The first is that, unlike the Pope, who has a dedicated confessor trained to minister to his spiritual needs, no one formally trains physicians to treat physicians. As a result, most of us feel slightly uneasy at treating other physicians. We naturally wish to keep our colleagues well, but at the same time realize that our clinical skills are being very closely scrutinized. What if they are found to be wanting? This discomfiture can make a physician treating a physician overly compulsive, or worse, overtly dismissive.

Second, we physicians are famously poor patients. We pretend we don’t need the advice we give others, to monitor our health and promptly seek care when something feels amiss. And, for the period during which we delay a medical encounter, we often attempt to diagnose and treat ourselves.

Sometimes we are successful, which reinforces this approach. Other times, we fail at being our own caregiver and present to someone else either too late, or with avoidable complications. In the former instance, we congratulate ourselves and learn nothing from the experience. In the latter, we may heap shame upon ourselves for our folly, and we may learn; but it could be a lethal lesson. In the worst scenario, our colleague gives in to frustration (or angst), and heaps even more shame onto their late-presenting physician patient.

Third, when we do submit to being a patient, we often demand VIP treatment. This is probably in response to our anxiety that some of the worst things we have seen happen to patients might happen to us if we are not vigilant to ensure we receive a higher level of care. But of course, such hypervigilance can lead to excessive care and testing, with all the attendant hazards, or alternatively to dilution of care if our caregivers decide we are just too much trouble.

Fourth, as a fifth-generation physician myself, I am convinced that physicians and physician family members are either prone to unusual manifestations of common diseases or unusual diseases, or that rare disease entities and complications are actually more common than literature suggests, and they simply aren’t pursued or diagnosed in nonphysician families.

No matter how we may have arrived in a position to need medical care, how often is such care substandard? And how do we respond when we suspect, or know, this to be the case? Are physicians more, or less, likely to take legal action in the face of it?

I certainly don’t know any statistics. Physicians are in an excellent position to take such action, because judges and juries will likely believe that a doctor can recognize negligence when we fall victim to it. But we may also be reluctant to publicly admit the way (or ways) in which we may have contributed to substandard care or outcome.

Based on decades of working with physician clients who have been sued, and having been sued myself (thus witnessing and also experiencing the effects of litigation), I am probably more reluctant than normal patients or physicians to consider taking legal action. This, despite the fact that I am also a lawyer and (through organized medicine) know many colleagues in all specialties who might serve as expert witnesses.

I have experienced serial substandard care, which has left me highly conflicted about the efficacy of my chosen profession. As a resident, I had my first odd pain condition and consulted an “elder statesperson” from my institution, whom I assumed to be a “doctor’s doctor” because he was a superb teacher (wrong!)

He completely missed the diagnosis and further belittled (indeed, libeled) me in the medical record. (Some years later, I learned that, during that period, he was increasingly demented and tended to view all female patients as having “wandering uterus” equivalents.) Fortunately, I found a better diagnostician, or at least one more willing to lend credence to my complaints, who successfully removed the first of several “zebra” lesions I have experienced.

As a young faculty member, I had an odd presentation of a recurring gynecologic condition, which was treated surgically, successfully, except that my fertility was cut in half – a possibility about which I had not been informed when giving operative consent. Would I have sued this fellow faculty member for that? Never, because she invariably treated me with respect as a colleague.

Later in my career after leaving academia, the same condition recurred in a new location. My old-school gynecologist desired to do an extensive procedure, to which I demurred unless specific pathology was found intraoperatively. Affronted, he subjected me to laparoscopy, did nothing but look, and then left the hospital leaving me and the PACU nurse to try to decipher his instructions (which said, basically, “I didn’t find anything; don’t bother me again.”). Several years of pain later, a younger gynecologist performed the correct procedure to address my problem, which has never recurred. Would I have sued him? No, because I believe he had a disability.

At age 59, I developed a new mole. My beloved general practitioner, in the waning years of his practice, forgot to consult a colleague to remove it for several months. When I forced the issue, the mole was removed and turned out to be a rare pediatric condition considered a precursor to melanoma. The same general practitioner had told me I needn’t worry about my “mild hypercalcemia.”

Ten years later I diagnosed my own parathyroid adenoma, in the interim losing 10% of my bone density. Would I have sued him? No, for he always showed he cared. (Though maybe, if I had fractured my spine or hip.)

If you have been the victim of physician malpractice, how did you respond?

Do we serve our profession well by how we handle substandard care – upon ourselves (or our loved ones)?

Dr. Andrew is a former assistant professor in the department of emergency medicine, Johns Hopkins University, Baltimore, and founder and principal of MDMentor, Victoria, B.C.

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

Have you experienced malpractice?

No, I’m not asking whether you have experienced litigation. I’m asking whether you, as a physician, have actually experienced substandard care from a colleague. I have heard many such experiences over the years, and mistreatment doesn’t seem to be getting any less frequent.

It seems to me that physicians may be especially prone to receiving substandard care. If true, there could be several explanations. The first is that, unlike the Pope, who has a dedicated confessor trained to minister to his spiritual needs, no one formally trains physicians to treat physicians. As a result, most of us feel slightly uneasy at treating other physicians. We naturally wish to keep our colleagues well, but at the same time realize that our clinical skills are being very closely scrutinized. What if they are found to be wanting? This discomfiture can make a physician treating a physician overly compulsive, or worse, overtly dismissive.

Second, we physicians are famously poor patients. We pretend we don’t need the advice we give others, to monitor our health and promptly seek care when something feels amiss. And, for the period during which we delay a medical encounter, we often attempt to diagnose and treat ourselves.

Sometimes we are successful, which reinforces this approach. Other times, we fail at being our own caregiver and present to someone else either too late, or with avoidable complications. In the former instance, we congratulate ourselves and learn nothing from the experience. In the latter, we may heap shame upon ourselves for our folly, and we may learn; but it could be a lethal lesson. In the worst scenario, our colleague gives in to frustration (or angst), and heaps even more shame onto their late-presenting physician patient.

Third, when we do submit to being a patient, we often demand VIP treatment. This is probably in response to our anxiety that some of the worst things we have seen happen to patients might happen to us if we are not vigilant to ensure we receive a higher level of care. But of course, such hypervigilance can lead to excessive care and testing, with all the attendant hazards, or alternatively to dilution of care if our caregivers decide we are just too much trouble.

Fourth, as a fifth-generation physician myself, I am convinced that physicians and physician family members are either prone to unusual manifestations of common diseases or unusual diseases, or that rare disease entities and complications are actually more common than literature suggests, and they simply aren’t pursued or diagnosed in nonphysician families.

No matter how we may have arrived in a position to need medical care, how often is such care substandard? And how do we respond when we suspect, or know, this to be the case? Are physicians more, or less, likely to take legal action in the face of it?

I certainly don’t know any statistics. Physicians are in an excellent position to take such action, because judges and juries will likely believe that a doctor can recognize negligence when we fall victim to it. But we may also be reluctant to publicly admit the way (or ways) in which we may have contributed to substandard care or outcome.

Based on decades of working with physician clients who have been sued, and having been sued myself (thus witnessing and also experiencing the effects of litigation), I am probably more reluctant than normal patients or physicians to consider taking legal action. This, despite the fact that I am also a lawyer and (through organized medicine) know many colleagues in all specialties who might serve as expert witnesses.

I have experienced serial substandard care, which has left me highly conflicted about the efficacy of my chosen profession. As a resident, I had my first odd pain condition and consulted an “elder statesperson” from my institution, whom I assumed to be a “doctor’s doctor” because he was a superb teacher (wrong!)

He completely missed the diagnosis and further belittled (indeed, libeled) me in the medical record. (Some years later, I learned that, during that period, he was increasingly demented and tended to view all female patients as having “wandering uterus” equivalents.) Fortunately, I found a better diagnostician, or at least one more willing to lend credence to my complaints, who successfully removed the first of several “zebra” lesions I have experienced.

As a young faculty member, I had an odd presentation of a recurring gynecologic condition, which was treated surgically, successfully, except that my fertility was cut in half – a possibility about which I had not been informed when giving operative consent. Would I have sued this fellow faculty member for that? Never, because she invariably treated me with respect as a colleague.

Later in my career after leaving academia, the same condition recurred in a new location. My old-school gynecologist desired to do an extensive procedure, to which I demurred unless specific pathology was found intraoperatively. Affronted, he subjected me to laparoscopy, did nothing but look, and then left the hospital leaving me and the PACU nurse to try to decipher his instructions (which said, basically, “I didn’t find anything; don’t bother me again.”). Several years of pain later, a younger gynecologist performed the correct procedure to address my problem, which has never recurred. Would I have sued him? No, because I believe he had a disability.

At age 59, I developed a new mole. My beloved general practitioner, in the waning years of his practice, forgot to consult a colleague to remove it for several months. When I forced the issue, the mole was removed and turned out to be a rare pediatric condition considered a precursor to melanoma. The same general practitioner had told me I needn’t worry about my “mild hypercalcemia.”

Ten years later I diagnosed my own parathyroid adenoma, in the interim losing 10% of my bone density. Would I have sued him? No, for he always showed he cared. (Though maybe, if I had fractured my spine or hip.)

If you have been the victim of physician malpractice, how did you respond?

Do we serve our profession well by how we handle substandard care – upon ourselves (or our loved ones)?

Dr. Andrew is a former assistant professor in the department of emergency medicine, Johns Hopkins University, Baltimore, and founder and principal of MDMentor, Victoria, B.C.

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

On Feb. 17, 2022, the updated Recommended Childhood and Adolescent Immunization Schedule was released by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention. Pediatric providers across the country eagerly await this annual update to learn what changes lie in store for recommended immunization practices. During the week that has gone by since the 2022 release, I’ve had a chance to reflect on some of the highlights that are worth noting.

The SARS-CoV-2 (COVID-19) vaccines are not on the schedule yet, undoubtedly because of the preliminary nature of the vaccine data for children and the emergency use authorization vaccine status. We currently have interim recommendations for childhood COVID-19 vaccines.
 

Brand new in 2022

Two new items in the 2022 schedules are worth reviewing. The first is an entirely new recommendation to administer dengue vaccine to children aged 9-16 years living in endemic areas, but only if they already have laboratory-confirmed past dengue infection. For U.S. practitioners, the endemic areas to remember are Puerto Rico and the U.S. Virgin islands in the Caribbean, as well as Pacific island areas, such as the Marshall Islands, Palau, and the Federated States of Micronesia. There is a link in the document to additional recommendations.

The second totally new item is the combination preparation, Vaxelis, which contains DTaP, inactivated poliovirus, Haemophilus influenzae b conjugate, and hepatitis B vaccines. There are extensive recommendations for how to work it into the vaccine schedule, including some situations when it should not be used.
 

Selected reminders in childhood immunization

I’ll start with some key reminders about what not to do. Remember that the live inactivated influenza virus vaccine (LAIV) is recommended to begin only at age 2 years and older, compared with the inactivated influenza vaccine, which begins at 6 months. In addition, LAIV is contraindicated in patients aged 2-4 years who have a history of asthma or wheezing. Remember to avoid live virus vaccines, such as LAIV, MMR, and varicella, during pregnancy but be ready to administer those vaccines right after delivery. Similarly, HPV vaccine should be delayed until after pregnancy.

There are many special situation recommendations; I’ll highlight only a few here. One reminder is that although MMR and hepatitis A are both recommended to begin at 12 months, infants aged 6-11 months who are undergoing international travel to high-risk areas can begin with one dose before departure and then receive a two-dose series after turning 12 months of age.

Pneumococcal vaccination. Some children should receive both the pneumococcal conjugate vaccine (PCV13) and the pneumococcal polysaccharide vaccine (PPSV23). Those groups include children with chronic heart disease, chronic lung disease, diabetes, cerebral spinal fluid leaks or cochlear implants, and sickle cell disease, as well as many other immunocompromising conditions. Kids who need both preparations should receive the conjugate vaccine first, but they should never receive the conjugate vaccine and the polysaccharide vaccine at the same visit.

Meningococcal vaccination. Meningococcal vaccine special situations can be quite complicated. For meningococcus A,C,W,Y (MenACWY) vaccination, children with immunocompromising conditions should receive different schedules from those of typical children, but the recommendations vary by preparation.

For adolescents aged 16-23 years, the decision whether to administer the meningococcal serogroup B (MenB) vaccine is based on shared clinical decision-making, a recommendation that began in 2020. Patients with certain immunocompromising conditions are considered at higher risk and should more routinely receive MenB vaccination, with recommendations varying depending on the preparation utilized. The MenB preparations are not interchangeable. In addition, patients may receive both MenACWY and MenB vaccines on the same day, but they should be given at different body sites.
 

A few final reminders

In certain cases, you might avoid administering what would otherwise be routine vaccinations. For example, the rotavirus series should not begin if the infant is aged 15 weeks or older. Only one dose of Haemophilus influenzae b vaccine is indicated after age 15 months and none at 60 months or older if the child does not have high-risk conditions.

Finally, the total number of doses for some vaccines, such as pneumococcus and polio, vary depending on how old the child is if not already fully vaccinated. For example, for pneumococcal conjugate vaccine catch-up in a healthy child, one dose after age 24 months would bring the child up to date. For inactivated poliovirus in children aged 4 years or older, a third dose given at least 6 months after the second dose would bring that child up to date.

The tables can be a challenge to interpret, but fortunately simpler tables for parents are available. These make excellent handouts to have available in the office!
 

Dr. Basco is professor of pediatrics at the Medical University of South Carolina, Charleston, and director of the division of general pediatrics. He disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

On Feb. 17, 2022, the updated Recommended Childhood and Adolescent Immunization Schedule was released by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention. Pediatric providers across the country eagerly await this annual update to learn what changes lie in store for recommended immunization practices. During the week that has gone by since the 2022 release, I’ve had a chance to reflect on some of the highlights that are worth noting.

The SARS-CoV-2 (COVID-19) vaccines are not on the schedule yet, undoubtedly because of the preliminary nature of the vaccine data for children and the emergency use authorization vaccine status. We currently have interim recommendations for childhood COVID-19 vaccines.
 

Brand new in 2022

Two new items in the 2022 schedules are worth reviewing. The first is an entirely new recommendation to administer dengue vaccine to children aged 9-16 years living in endemic areas, but only if they already have laboratory-confirmed past dengue infection. For U.S. practitioners, the endemic areas to remember are Puerto Rico and the U.S. Virgin islands in the Caribbean, as well as Pacific island areas, such as the Marshall Islands, Palau, and the Federated States of Micronesia. There is a link in the document to additional recommendations.

The second totally new item is the combination preparation, Vaxelis, which contains DTaP, inactivated poliovirus, Haemophilus influenzae b conjugate, and hepatitis B vaccines. There are extensive recommendations for how to work it into the vaccine schedule, including some situations when it should not be used.
 

Selected reminders in childhood immunization

I’ll start with some key reminders about what not to do. Remember that the live inactivated influenza virus vaccine (LAIV) is recommended to begin only at age 2 years and older, compared with the inactivated influenza vaccine, which begins at 6 months. In addition, LAIV is contraindicated in patients aged 2-4 years who have a history of asthma or wheezing. Remember to avoid live virus vaccines, such as LAIV, MMR, and varicella, during pregnancy but be ready to administer those vaccines right after delivery. Similarly, HPV vaccine should be delayed until after pregnancy.

There are many special situation recommendations; I’ll highlight only a few here. One reminder is that although MMR and hepatitis A are both recommended to begin at 12 months, infants aged 6-11 months who are undergoing international travel to high-risk areas can begin with one dose before departure and then receive a two-dose series after turning 12 months of age.

Pneumococcal vaccination. Some children should receive both the pneumococcal conjugate vaccine (PCV13) and the pneumococcal polysaccharide vaccine (PPSV23). Those groups include children with chronic heart disease, chronic lung disease, diabetes, cerebral spinal fluid leaks or cochlear implants, and sickle cell disease, as well as many other immunocompromising conditions. Kids who need both preparations should receive the conjugate vaccine first, but they should never receive the conjugate vaccine and the polysaccharide vaccine at the same visit.

Meningococcal vaccination. Meningococcal vaccine special situations can be quite complicated. For meningococcus A,C,W,Y (MenACWY) vaccination, children with immunocompromising conditions should receive different schedules from those of typical children, but the recommendations vary by preparation.

For adolescents aged 16-23 years, the decision whether to administer the meningococcal serogroup B (MenB) vaccine is based on shared clinical decision-making, a recommendation that began in 2020. Patients with certain immunocompromising conditions are considered at higher risk and should more routinely receive MenB vaccination, with recommendations varying depending on the preparation utilized. The MenB preparations are not interchangeable. In addition, patients may receive both MenACWY and MenB vaccines on the same day, but they should be given at different body sites.
 

A few final reminders

In certain cases, you might avoid administering what would otherwise be routine vaccinations. For example, the rotavirus series should not begin if the infant is aged 15 weeks or older. Only one dose of Haemophilus influenzae b vaccine is indicated after age 15 months and none at 60 months or older if the child does not have high-risk conditions.

Finally, the total number of doses for some vaccines, such as pneumococcus and polio, vary depending on how old the child is if not already fully vaccinated. For example, for pneumococcal conjugate vaccine catch-up in a healthy child, one dose after age 24 months would bring the child up to date. For inactivated poliovirus in children aged 4 years or older, a third dose given at least 6 months after the second dose would bring that child up to date.

The tables can be a challenge to interpret, but fortunately simpler tables for parents are available. These make excellent handouts to have available in the office!
 

Dr. Basco is professor of pediatrics at the Medical University of South Carolina, Charleston, and director of the division of general pediatrics. He disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

On Feb. 17, 2022, the updated Recommended Childhood and Adolescent Immunization Schedule was released by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention. Pediatric providers across the country eagerly await this annual update to learn what changes lie in store for recommended immunization practices. During the week that has gone by since the 2022 release, I’ve had a chance to reflect on some of the highlights that are worth noting.

The SARS-CoV-2 (COVID-19) vaccines are not on the schedule yet, undoubtedly because of the preliminary nature of the vaccine data for children and the emergency use authorization vaccine status. We currently have interim recommendations for childhood COVID-19 vaccines.
 

Brand new in 2022

Two new items in the 2022 schedules are worth reviewing. The first is an entirely new recommendation to administer dengue vaccine to children aged 9-16 years living in endemic areas, but only if they already have laboratory-confirmed past dengue infection. For U.S. practitioners, the endemic areas to remember are Puerto Rico and the U.S. Virgin islands in the Caribbean, as well as Pacific island areas, such as the Marshall Islands, Palau, and the Federated States of Micronesia. There is a link in the document to additional recommendations.

The second totally new item is the combination preparation, Vaxelis, which contains DTaP, inactivated poliovirus, Haemophilus influenzae b conjugate, and hepatitis B vaccines. There are extensive recommendations for how to work it into the vaccine schedule, including some situations when it should not be used.
 

Selected reminders in childhood immunization

I’ll start with some key reminders about what not to do. Remember that the live inactivated influenza virus vaccine (LAIV) is recommended to begin only at age 2 years and older, compared with the inactivated influenza vaccine, which begins at 6 months. In addition, LAIV is contraindicated in patients aged 2-4 years who have a history of asthma or wheezing. Remember to avoid live virus vaccines, such as LAIV, MMR, and varicella, during pregnancy but be ready to administer those vaccines right after delivery. Similarly, HPV vaccine should be delayed until after pregnancy.

There are many special situation recommendations; I’ll highlight only a few here. One reminder is that although MMR and hepatitis A are both recommended to begin at 12 months, infants aged 6-11 months who are undergoing international travel to high-risk areas can begin with one dose before departure and then receive a two-dose series after turning 12 months of age.

Pneumococcal vaccination. Some children should receive both the pneumococcal conjugate vaccine (PCV13) and the pneumococcal polysaccharide vaccine (PPSV23). Those groups include children with chronic heart disease, chronic lung disease, diabetes, cerebral spinal fluid leaks or cochlear implants, and sickle cell disease, as well as many other immunocompromising conditions. Kids who need both preparations should receive the conjugate vaccine first, but they should never receive the conjugate vaccine and the polysaccharide vaccine at the same visit.

Meningococcal vaccination. Meningococcal vaccine special situations can be quite complicated. For meningococcus A,C,W,Y (MenACWY) vaccination, children with immunocompromising conditions should receive different schedules from those of typical children, but the recommendations vary by preparation.

For adolescents aged 16-23 years, the decision whether to administer the meningococcal serogroup B (MenB) vaccine is based on shared clinical decision-making, a recommendation that began in 2020. Patients with certain immunocompromising conditions are considered at higher risk and should more routinely receive MenB vaccination, with recommendations varying depending on the preparation utilized. The MenB preparations are not interchangeable. In addition, patients may receive both MenACWY and MenB vaccines on the same day, but they should be given at different body sites.
 

A few final reminders

In certain cases, you might avoid administering what would otherwise be routine vaccinations. For example, the rotavirus series should not begin if the infant is aged 15 weeks or older. Only one dose of Haemophilus influenzae b vaccine is indicated after age 15 months and none at 60 months or older if the child does not have high-risk conditions.

Finally, the total number of doses for some vaccines, such as pneumococcus and polio, vary depending on how old the child is if not already fully vaccinated. For example, for pneumococcal conjugate vaccine catch-up in a healthy child, one dose after age 24 months would bring the child up to date. For inactivated poliovirus in children aged 4 years or older, a third dose given at least 6 months after the second dose would bring that child up to date.

The tables can be a challenge to interpret, but fortunately simpler tables for parents are available. These make excellent handouts to have available in the office!
 

Dr. Basco is professor of pediatrics at the Medical University of South Carolina, Charleston, and director of the division of general pediatrics. He disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

Introduction

Amidst an aggressive vaccination campaign for COVID-19, misinformation has spread over the Internet, affecting public perception and making some people hesitant to participate in ongoing immunization campaigns. Of chief concern are issues pertaining to fertility or viability of sperm – information circulating on social networks posits that the coronavirus vaccine may influence infertility in men, which, according to physicians, is not grounded in reality. From the perspective of evidence-based medicine, there is a dearth of information suggesting an untoward effect of the vaccine on male fertility. The risk of adverse reactions arising from approved vaccines is negligible, with mild, albeit controllable, side effects demonstrated by patients in clinical trials. Therefore, there is no plausible reason for the general public to avoid vaccinations.¹

Infertility following vaccination

The source of confusion can be traced back to a study conducted by researchers at the University of Miami Miller School of Medicine; the general public has conflated a side effect of the virus, namely, infertility and erectile dysfunction, with that of the vaccine.² According to Ranjith Ramasamy, MD, director of the urology program at Miller, “We were the first to demonstrate that the COVID virus, itself, can affect male fertility and be a potential cause for erectile dysfunction. We are now the first to examine if there is any impact of the COVID vaccine on male fertility potential, which we did not find.”³

Coronavirus can indeed cause significant damage to the testicular tissue of infected men by means of mediating ACE2 expression on Leydig and Sertoli cells of the testis. It should be noted that COVID-19 may potentially attack any type of cell in the body that expresses the enzyme ACE2. However, it is particularly harmful to cells with high levels of expression of this enzyme, such as testicular cells. The spermatogenesis process can be affected, thereby posing a risk to male fertility.⁴

Expanding on the theme of fertility during the pandemic, a number of false claims^5-7 about the vaccine and its overall effect on the placenta and fertility have also emerged as a contentious topic for debate on social media; doctors continue to explain why the theories are not reasonable or a cause for concern. The World Health Organization (WHO) provides recommendations on COVID-19 vaccinations for pregnant and/or lactating women and encourages a shared decision process involving risk/benefit assessment with the prescribing physician.⁵ Pregnant women, especially those with underlying comorbid conditions, are susceptible to developing severe symptom manifestations of COVID-19 with the disease also being associated with an increased likelihood of premature birth. As far as lactating women are concerned, the evidence thus far has indicated that the risk of side effects of the vaccine is very low, suggesting that these women could be vaccinated.⁵

The vaccine is the best option

While more studies are needed to ascertain the relationship between COVID-19 and male infertility, the vaccine is currently the best option for those who are concerned about their fertility from exposure to the coronavirus. Because of delayed wholesale acceptance of vaccines by the general population, clinicians should continue to emphasize the importance of preventive care with respect to disease exposure.⁶

In addition, those who are concerned with fertility can opt for ways to preserve their reproductive capacity, such as the removal of semen for freezing sperm, albeit with adherence to sperm-washing procedures to preclude cross-contamination from viruses.^8,9 For the preservation of sperm, the noninvasive method is often performed, preferably collected in several samples. Then, the semen is cryopreserved.⁸ In some instances, the sperm can also be removed directly from the testicles with a simple needle or by means of a minor surgical procedure.

A wait and try approach is advocated by clinicians for individuals who have already experienced COVID-19 symptoms and are therefore concerned about the prospect of childbearing.¹⁰ If the couple is unable to conceive after a year of trying, it is recommended that they consult a reproductive specialist; the clinician can carry out a comprehensive evaluation and order a series of tests to identify the source of the problem, indicating whether there are alternative methods for helping the couple to start a family (addressing the underlying factors involved in infertility, or treating via assisted reproduction procedures, such as in vitro fertilization).¹¹

Dr. Aman is faculty member at the biology department of City Colleges of Chicago, and a postdoctoral researcher at the International Maternal and Child Health Foundation (IMCHF). She disclosed no relevant financial relationships. Dr. Islam is a medical writer for the IMCHF, Montreal, is based in New York, and disclosed no relevant financial relationships. Mr. Choudhry is a research assistant at the IMCHF and he has no disclosures. Dr. Zia Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the IMCHF. He has no disclosures.

References

1. Berry SD et al. J Am Geriatr Soc. 2021 May;69(5):1140-6.

2. Achua JK et al. World J Men’s Health. 2021 Jan;39(1):65-74.

3. Broderick JM. Urology Times. 2021 June.

4. Huang C et al. Andrology. 2021 Jan;9(1):80-7.

5. Sajjadi NB et al. J Osteopath Med. 2021 Apr 12;121(6):583-7.

6. Sallam M et al. Vaccines. 2021 Jan;9(1):42.

7. Islam MS et al. PloS One. 2021 May 12;16(5):e0251605.

8. Tesarik J. J Fertil Preserv. 2021;2:art246111.

9. Adiga SK et al. Reprod BioMed Online. 2020 Dec;41(6):991-7.

10. FAQs related to COVID-19. Q: If I get sick or test positive for COVID-19, when is it safe to become pregnant? American Society for Reproductive Medicine.

11. Cross C. Wellness and Prevention: Why can’t I get pregnant? John Hopkins Medicine.

Introduction

Amidst an aggressive vaccination campaign for COVID-19, misinformation has spread over the Internet, affecting public perception and making some people hesitant to participate in ongoing immunization campaigns. Of chief concern are issues pertaining to fertility or viability of sperm – information circulating on social networks posits that the coronavirus vaccine may influence infertility in men, which, according to physicians, is not grounded in reality. From the perspective of evidence-based medicine, there is a dearth of information suggesting an untoward effect of the vaccine on male fertility. The risk of adverse reactions arising from approved vaccines is negligible, with mild, albeit controllable, side effects demonstrated by patients in clinical trials. Therefore, there is no plausible reason for the general public to avoid vaccinations.¹

Infertility following vaccination

The source of confusion can be traced back to a study conducted by researchers at the University of Miami Miller School of Medicine; the general public has conflated a side effect of the virus, namely, infertility and erectile dysfunction, with that of the vaccine.² According to Ranjith Ramasamy, MD, director of the urology program at Miller, “We were the first to demonstrate that the COVID virus, itself, can affect male fertility and be a potential cause for erectile dysfunction. We are now the first to examine if there is any impact of the COVID vaccine on male fertility potential, which we did not find.”³

Coronavirus can indeed cause significant damage to the testicular tissue of infected men by means of mediating ACE2 expression on Leydig and Sertoli cells of the testis. It should be noted that COVID-19 may potentially attack any type of cell in the body that expresses the enzyme ACE2. However, it is particularly harmful to cells with high levels of expression of this enzyme, such as testicular cells. The spermatogenesis process can be affected, thereby posing a risk to male fertility.⁴

Expanding on the theme of fertility during the pandemic, a number of false claims^5-7 about the vaccine and its overall effect on the placenta and fertility have also emerged as a contentious topic for debate on social media; doctors continue to explain why the theories are not reasonable or a cause for concern. The World Health Organization (WHO) provides recommendations on COVID-19 vaccinations for pregnant and/or lactating women and encourages a shared decision process involving risk/benefit assessment with the prescribing physician.⁵ Pregnant women, especially those with underlying comorbid conditions, are susceptible to developing severe symptom manifestations of COVID-19 with the disease also being associated with an increased likelihood of premature birth. As far as lactating women are concerned, the evidence thus far has indicated that the risk of side effects of the vaccine is very low, suggesting that these women could be vaccinated.⁵

The vaccine is the best option

While more studies are needed to ascertain the relationship between COVID-19 and male infertility, the vaccine is currently the best option for those who are concerned about their fertility from exposure to the coronavirus. Because of delayed wholesale acceptance of vaccines by the general population, clinicians should continue to emphasize the importance of preventive care with respect to disease exposure.⁶

In addition, those who are concerned with fertility can opt for ways to preserve their reproductive capacity, such as the removal of semen for freezing sperm, albeit with adherence to sperm-washing procedures to preclude cross-contamination from viruses.^8,9 For the preservation of sperm, the noninvasive method is often performed, preferably collected in several samples. Then, the semen is cryopreserved.⁸ In some instances, the sperm can also be removed directly from the testicles with a simple needle or by means of a minor surgical procedure.

A wait and try approach is advocated by clinicians for individuals who have already experienced COVID-19 symptoms and are therefore concerned about the prospect of childbearing.¹⁰ If the couple is unable to conceive after a year of trying, it is recommended that they consult a reproductive specialist; the clinician can carry out a comprehensive evaluation and order a series of tests to identify the source of the problem, indicating whether there are alternative methods for helping the couple to start a family (addressing the underlying factors involved in infertility, or treating via assisted reproduction procedures, such as in vitro fertilization).¹¹

Dr. Aman is faculty member at the biology department of City Colleges of Chicago, and a postdoctoral researcher at the International Maternal and Child Health Foundation (IMCHF). She disclosed no relevant financial relationships. Dr. Islam is a medical writer for the IMCHF, Montreal, is based in New York, and disclosed no relevant financial relationships. Mr. Choudhry is a research assistant at the IMCHF and he has no disclosures. Dr. Zia Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the IMCHF. He has no disclosures.

References

1. Berry SD et al. J Am Geriatr Soc. 2021 May;69(5):1140-6.

2. Achua JK et al. World J Men’s Health. 2021 Jan;39(1):65-74.

3. Broderick JM. Urology Times. 2021 June.

4. Huang C et al. Andrology. 2021 Jan;9(1):80-7.

5. Sajjadi NB et al. J Osteopath Med. 2021 Apr 12;121(6):583-7.

6. Sallam M et al. Vaccines. 2021 Jan;9(1):42.

7. Islam MS et al. PloS One. 2021 May 12;16(5):e0251605.

8. Tesarik J. J Fertil Preserv. 2021;2:art246111.

9. Adiga SK et al. Reprod BioMed Online. 2020 Dec;41(6):991-7.

10. FAQs related to COVID-19. Q: If I get sick or test positive for COVID-19, when is it safe to become pregnant? American Society for Reproductive Medicine.

11. Cross C. Wellness and Prevention: Why can’t I get pregnant? John Hopkins Medicine.

Introduction

Amidst an aggressive vaccination campaign for COVID-19, misinformation has spread over the Internet, affecting public perception and making some people hesitant to participate in ongoing immunization campaigns. Of chief concern are issues pertaining to fertility or viability of sperm – information circulating on social networks posits that the coronavirus vaccine may influence infertility in men, which, according to physicians, is not grounded in reality. From the perspective of evidence-based medicine, there is a dearth of information suggesting an untoward effect of the vaccine on male fertility. The risk of adverse reactions arising from approved vaccines is negligible, with mild, albeit controllable, side effects demonstrated by patients in clinical trials. Therefore, there is no plausible reason for the general public to avoid vaccinations.¹

Infertility following vaccination

The source of confusion can be traced back to a study conducted by researchers at the University of Miami Miller School of Medicine; the general public has conflated a side effect of the virus, namely, infertility and erectile dysfunction, with that of the vaccine.² According to Ranjith Ramasamy, MD, director of the urology program at Miller, “We were the first to demonstrate that the COVID virus, itself, can affect male fertility and be a potential cause for erectile dysfunction. We are now the first to examine if there is any impact of the COVID vaccine on male fertility potential, which we did not find.”³

Coronavirus can indeed cause significant damage to the testicular tissue of infected men by means of mediating ACE2 expression on Leydig and Sertoli cells of the testis. It should be noted that COVID-19 may potentially attack any type of cell in the body that expresses the enzyme ACE2. However, it is particularly harmful to cells with high levels of expression of this enzyme, such as testicular cells. The spermatogenesis process can be affected, thereby posing a risk to male fertility.⁴

Expanding on the theme of fertility during the pandemic, a number of false claims^5-7 about the vaccine and its overall effect on the placenta and fertility have also emerged as a contentious topic for debate on social media; doctors continue to explain why the theories are not reasonable or a cause for concern. The World Health Organization (WHO) provides recommendations on COVID-19 vaccinations for pregnant and/or lactating women and encourages a shared decision process involving risk/benefit assessment with the prescribing physician.⁵ Pregnant women, especially those with underlying comorbid conditions, are susceptible to developing severe symptom manifestations of COVID-19 with the disease also being associated with an increased likelihood of premature birth. As far as lactating women are concerned, the evidence thus far has indicated that the risk of side effects of the vaccine is very low, suggesting that these women could be vaccinated.⁵

The vaccine is the best option

While more studies are needed to ascertain the relationship between COVID-19 and male infertility, the vaccine is currently the best option for those who are concerned about their fertility from exposure to the coronavirus. Because of delayed wholesale acceptance of vaccines by the general population, clinicians should continue to emphasize the importance of preventive care with respect to disease exposure.⁶

In addition, those who are concerned with fertility can opt for ways to preserve their reproductive capacity, such as the removal of semen for freezing sperm, albeit with adherence to sperm-washing procedures to preclude cross-contamination from viruses.^8,9 For the preservation of sperm, the noninvasive method is often performed, preferably collected in several samples. Then, the semen is cryopreserved.⁸ In some instances, the sperm can also be removed directly from the testicles with a simple needle or by means of a minor surgical procedure.

A wait and try approach is advocated by clinicians for individuals who have already experienced COVID-19 symptoms and are therefore concerned about the prospect of childbearing.¹⁰ If the couple is unable to conceive after a year of trying, it is recommended that they consult a reproductive specialist; the clinician can carry out a comprehensive evaluation and order a series of tests to identify the source of the problem, indicating whether there are alternative methods for helping the couple to start a family (addressing the underlying factors involved in infertility, or treating via assisted reproduction procedures, such as in vitro fertilization).¹¹

Dr. Aman is faculty member at the biology department of City Colleges of Chicago, and a postdoctoral researcher at the International Maternal and Child Health Foundation (IMCHF). She disclosed no relevant financial relationships. Dr. Islam is a medical writer for the IMCHF, Montreal, is based in New York, and disclosed no relevant financial relationships. Mr. Choudhry is a research assistant at the IMCHF and he has no disclosures. Dr. Zia Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the IMCHF. He has no disclosures.

References

1. Berry SD et al. J Am Geriatr Soc. 2021 May;69(5):1140-6.

2. Achua JK et al. World J Men’s Health. 2021 Jan;39(1):65-74.

3. Broderick JM. Urology Times. 2021 June.

4. Huang C et al. Andrology. 2021 Jan;9(1):80-7.

5. Sajjadi NB et al. J Osteopath Med. 2021 Apr 12;121(6):583-7.

6. Sallam M et al. Vaccines. 2021 Jan;9(1):42.

7. Islam MS et al. PloS One. 2021 May 12;16(5):e0251605.

8. Tesarik J. J Fertil Preserv. 2021;2:art246111.

9. Adiga SK et al. Reprod BioMed Online. 2020 Dec;41(6):991-7.

10. FAQs related to COVID-19. Q: If I get sick or test positive for COVID-19, when is it safe to become pregnant? American Society for Reproductive Medicine.

11. Cross C. Wellness and Prevention: Why can’t I get pregnant? John Hopkins Medicine.

Acids peels are used to elicit a chemical exfoliation of the skin by hydrolyzing amide bonds between keratinocytes, reducing corneocyte adhesion, as well as inducing an inflammatory reaction stimulating tissue remodeling. Release of cytokines such as interleukin (IL)-1 and IL-6 by keratinocytes activates fibroblasts to increase the production of matrix metalloproteinases. These are involved in the production of hyaluronic acid and new collagen formation.

Mandelic acid was derived from bitter almonds (mandel is the German word for almond). It is a white powder originally used as an antibiotic for the treatment of urinary tract infections. Its antibacterial properties make it an excellent product for the topical treatment of acne, as well as for use in topical preparations to treat hyperpigmentation and photoaging. In cosmetic use, mandelic acid is a slow acting chemical peel that can be used in all skin types, including sensitive and rosacea-prone skin, as well as skin of color. Its large molecular size allows for the slow penetration of the acid on the skin and thus it can be carefully titrated.

Studies have shown its efficacy in reducing sebum content, acne, acne scarring, and hyperpigmentation. In clinical practice however, the most effective use of this acid is on sensitive skin. It is a great tool for clinicians to use as an effective exfoliant in less acid tolerant skin types. In commercially available concentrations of 5%-45%, mandelic acid can be used alone or in combination with other beta hydroxy peels, depending on the indication.

Most dermatologists and patients prefer in-office peels that induce noticeable peeling and resurfacing of the skin. Mandelic acid is one of the largest alpha hydroxy acids, a lipophilic acid that penetrates the skin slowly and uniformly, making it an ideal peel in sensitive or aging and thin skin types. Although many mandelic acid peels are available, however, there is a paucity of studies comparing their benefits and efficacies.

Dr. Lily Talakoub and Dr. Naissan O. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.

References

1. Wójcik A et al. Dermatol Alergol. 2013 Jun;30(3):140-5.

2. Soleymani T et al. J Clin Aesthet Dermatol. 2018;11(8):21-8.

Acids peels are used to elicit a chemical exfoliation of the skin by hydrolyzing amide bonds between keratinocytes, reducing corneocyte adhesion, as well as inducing an inflammatory reaction stimulating tissue remodeling. Release of cytokines such as interleukin (IL)-1 and IL-6 by keratinocytes activates fibroblasts to increase the production of matrix metalloproteinases. These are involved in the production of hyaluronic acid and new collagen formation.

Mandelic acid was derived from bitter almonds (mandel is the German word for almond). It is a white powder originally used as an antibiotic for the treatment of urinary tract infections. Its antibacterial properties make it an excellent product for the topical treatment of acne, as well as for use in topical preparations to treat hyperpigmentation and photoaging. In cosmetic use, mandelic acid is a slow acting chemical peel that can be used in all skin types, including sensitive and rosacea-prone skin, as well as skin of color. Its large molecular size allows for the slow penetration of the acid on the skin and thus it can be carefully titrated.

Studies have shown its efficacy in reducing sebum content, acne, acne scarring, and hyperpigmentation. In clinical practice however, the most effective use of this acid is on sensitive skin. It is a great tool for clinicians to use as an effective exfoliant in less acid tolerant skin types. In commercially available concentrations of 5%-45%, mandelic acid can be used alone or in combination with other beta hydroxy peels, depending on the indication.

Most dermatologists and patients prefer in-office peels that induce noticeable peeling and resurfacing of the skin. Mandelic acid is one of the largest alpha hydroxy acids, a lipophilic acid that penetrates the skin slowly and uniformly, making it an ideal peel in sensitive or aging and thin skin types. Although many mandelic acid peels are available, however, there is a paucity of studies comparing their benefits and efficacies.

Dr. Lily Talakoub and Dr. Naissan O. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.

References

1. Wójcik A et al. Dermatol Alergol. 2013 Jun;30(3):140-5.

2. Soleymani T et al. J Clin Aesthet Dermatol. 2018;11(8):21-8.

Acids peels are used to elicit a chemical exfoliation of the skin by hydrolyzing amide bonds between keratinocytes, reducing corneocyte adhesion, as well as inducing an inflammatory reaction stimulating tissue remodeling. Release of cytokines such as interleukin (IL)-1 and IL-6 by keratinocytes activates fibroblasts to increase the production of matrix metalloproteinases. These are involved in the production of hyaluronic acid and new collagen formation.

Mandelic acid was derived from bitter almonds (mandel is the German word for almond). It is a white powder originally used as an antibiotic for the treatment of urinary tract infections. Its antibacterial properties make it an excellent product for the topical treatment of acne, as well as for use in topical preparations to treat hyperpigmentation and photoaging. In cosmetic use, mandelic acid is a slow acting chemical peel that can be used in all skin types, including sensitive and rosacea-prone skin, as well as skin of color. Its large molecular size allows for the slow penetration of the acid on the skin and thus it can be carefully titrated.

Studies have shown its efficacy in reducing sebum content, acne, acne scarring, and hyperpigmentation. In clinical practice however, the most effective use of this acid is on sensitive skin. It is a great tool for clinicians to use as an effective exfoliant in less acid tolerant skin types. In commercially available concentrations of 5%-45%, mandelic acid can be used alone or in combination with other beta hydroxy peels, depending on the indication.

Most dermatologists and patients prefer in-office peels that induce noticeable peeling and resurfacing of the skin. Mandelic acid is one of the largest alpha hydroxy acids, a lipophilic acid that penetrates the skin slowly and uniformly, making it an ideal peel in sensitive or aging and thin skin types. Although many mandelic acid peels are available, however, there is a paucity of studies comparing their benefits and efficacies.

Dr. Lily Talakoub and Dr. Naissan O. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.

References

1. Wójcik A et al. Dermatol Alergol. 2013 Jun;30(3):140-5.

2. Soleymani T et al. J Clin Aesthet Dermatol. 2018;11(8):21-8.