Commentary

One of the most malignant threats that is adversely impacting physicians is the insidious metastasis of the term “provider” within the national health care system over the past 2 to 3 decades.

This demeaning adjective is outrageously inappropriate and beneath the stature of medical doctors (MDs) who sacrificed 12 to 15 years of their lives in college, medical schools, residency programs, and post-residency fellowships to become physicians, specialists, and subspecialists. It is distressing to see hospitals, clinics, pharmacies, insurance corporations, and managed care companies refer to psychiatrists and other physicians as “providers.” It is time to fight back and restore our noble medical identity, which society has always respected and appreciated.

Our unique professional identify is at stake. We do not want to be lumped with nonphysicians as if we are interchangeable parts of a health care system or cogs in a wheel. No other mental health professional has the extensive training, scientific knowledge, clinical expertise, research accomplishments, and teaching/supervisory abilities that physicians have. We strongly uphold the sacred tenet of the physician-patient relationship, and adamantly reject its corruption into a provider-consumer transaction.

Even plumbers and electricians are not referred to as “providers.” Lawyers are not called legal aid providers. Teachers are not called knowledge providers, and administrators and CEOs are not called management providers. So why should physicians in any specialty, including psychiatry, obsequiously accept the denigration of their esteemed medical identify into the vague, amorphous ipseity of a “provider”? Family physicians, internists, and pediatricians used to be called primary care physicians, but have been reduced to primary care providers, which is insulting and degrading to these highly trained MD specialists.

The corruption and debasement of the professional identify of physicians and the propagation of the usage of the belittling term “provider” can be traced back to 3 entities:

1. The Nazi Third Reich. This is the most evil origin of the term “provider,” inflicted on Jewish physicians as part of the despicable persecution of German Jews in the 1930s. The Nazis decided to deprive pediatricians of being called physicians (“Arzt” in German) and forcefully relabeled them as “behandlers” or “providers,” thus erasing their noble medical identity.¹ In 1933, all Jewish pediatricians were expelled or forced to resign from the German Society of Pediatrics and were no longer allowed to be called doctors. This deliberate and systematic humiliation of pediatric clinicians and scientists was followed by deporting the lowly “providers” to concentration camps. So why perpetuate this pernicious Nazi terminology?

2. The Federal Government. The term “provider” was introduced and propagated in Public Law 93-641 titled “The National Health Planning and Resource Development Act of 1974.” In that document, patients were referred to as “consumers” and physicians as “providers” (this term was used 19 times in that law). At that time, the civil service employees who drafted the law that marginalized physicians by using generic, nonmedical nomenclature may not have realized the dire consequences of relabeling physicians as “providers.”

Continue to: Insurance companies, managed care companies, and consolidated health systems...

3. Insurance companies, managed care companies, and consolidated health systems have jubilantly adopted the term “provider” because they can equate physicians with less expensive, nonphysician clinicians (physician assistants, nurse practitioners, and certified registered nurse anesthetists), especially when physicians across several specialties (particularly psychiatry) are in short supply. None of these clinicians deserve to be labeled “providers,” either.

To understand why the term “provider” was used instead of “clinicians” or “clinical practitioner,” one must recognize the “businessification” of medicine and the commoditization of clinical care in our country. In some ways, health care has adopted a model similar to a fast-food joint, where workers provide customers with a hamburger. The question here is why did the 1.1 million physicians in the United States not halt this terminology shift before it spread and permeated the national health care system? Physicians who graduate from medical schools (not “provider” schools!) must vigorously and loudly fight back and put this wicked genie back in its bottle. This is feasible only if the American Medical Association (which would never conceive of itself as the “American Provider Association”), along with all 48 specialty organizations (Table), including the American Psychiatric Association (APA), unite and demand that physicians be called medical doctors or physicians, or by a term that reflects their specialty (orthopedists, psychiatrists, oncologists, gastroenterologists, anesthesiologists, cardiologists, etc.). This is an urgent issue to prevent the dissolution of our professional identity and its highly regarded societal image. It is a travesty that we physicians have allowed it to go on unopposed and to become entrenched in the dumbed-down jargon of health care. Physicians tend to avoid confrontation and adversarial stances, but we must unite and demand a return to the traditional nomenclature of medicine.

Much debate has emerged lately about an epidemic of “burnout” among physicians. Proposed causes include the savage increase in the amount of paperwork at the expense of patient care, the sense of helplessness that pre-authorization has inflicted on physicians’ decision-making, and the tyranny of relative value units (RVUs) as a benchmark for physician performance, as if healing patients is like manufacturing widgets. However, the blow to the self-esteem of physicians by being called “providers” daily is certainly another major factor contributing to burnout. It is perfectly legitimate for physicians to expect recognition for their long, rigorous, and uniquely advanced medical training, instead of being lumped together with less qualified professionals as anonymous “providers” in the name of politically correct pseudo-equality of all clinical practitioners. Let the administrators stop and contemplate whether tertiary or quaternary care for the most complex and severely ill patients in medical, surgical, or psychiatric intensive care units can operate without highly specialized physicians.

I urge APA leadership to take a visible and strong stand to rid psychiatrists of this assault on our medical identity. As I mentioned in my January 2020 editorial,² it is vital that the name of our national psychiatric organization (APA) be modified to the American Psychiatric Physicians Association, to remind all health care systems, as well as patients, the public, and the media, of our medical identity as physicians before we specialized in psychiatry.

Continue to: Patients, not clients

We should also emphasize that our suffering and medically ill patients with serious neuropsychiatric disorders such as schizophrenia, bipolar disorder, depression, panic disorder, or obsessive-compulsive disorder are patients, not clients. The terminology used in community mental health centers around the country almost universally includes “providers” and “clients.” This de-medicalization of psychiatrists and our patients must be corrected and reversed so that the public understands that treating mental illness is not a business transaction between a “provider” and a “client.” Using the correct terminology may help generate sympathy and compassion towards patients with serious psychiatric illnesses, just as it does for patients with cancer, heart disease, or stroke. The term “client” will never evoke the public sympathy and support that our patients truly deserve.

Let’s keep this issue alive and translate our demands into actions, both locally and nationally. Psychiatrists and physicians of all other specialties must stand up for their rights and inform their systems of care that they must be called by their legitimate and lawful name: physicians or medical doctors (never “providers”). This is an issue that unites all 1.1 million of us. The US health care system would collapse without us, and asking that we be called exactly what our medical license displays is our right and our professional identity.

One of the most malignant threats that is adversely impacting physicians is the insidious metastasis of the term “provider” within the national health care system over the past 2 to 3 decades.

This demeaning adjective is outrageously inappropriate and beneath the stature of medical doctors (MDs) who sacrificed 12 to 15 years of their lives in college, medical schools, residency programs, and post-residency fellowships to become physicians, specialists, and subspecialists. It is distressing to see hospitals, clinics, pharmacies, insurance corporations, and managed care companies refer to psychiatrists and other physicians as “providers.” It is time to fight back and restore our noble medical identity, which society has always respected and appreciated.

Our unique professional identify is at stake. We do not want to be lumped with nonphysicians as if we are interchangeable parts of a health care system or cogs in a wheel. No other mental health professional has the extensive training, scientific knowledge, clinical expertise, research accomplishments, and teaching/supervisory abilities that physicians have. We strongly uphold the sacred tenet of the physician-patient relationship, and adamantly reject its corruption into a provider-consumer transaction.

Even plumbers and electricians are not referred to as “providers.” Lawyers are not called legal aid providers. Teachers are not called knowledge providers, and administrators and CEOs are not called management providers. So why should physicians in any specialty, including psychiatry, obsequiously accept the denigration of their esteemed medical identify into the vague, amorphous ipseity of a “provider”? Family physicians, internists, and pediatricians used to be called primary care physicians, but have been reduced to primary care providers, which is insulting and degrading to these highly trained MD specialists.

The corruption and debasement of the professional identify of physicians and the propagation of the usage of the belittling term “provider” can be traced back to 3 entities:

1. The Nazi Third Reich. This is the most evil origin of the term “provider,” inflicted on Jewish physicians as part of the despicable persecution of German Jews in the 1930s. The Nazis decided to deprive pediatricians of being called physicians (“Arzt” in German) and forcefully relabeled them as “behandlers” or “providers,” thus erasing their noble medical identity.¹ In 1933, all Jewish pediatricians were expelled or forced to resign from the German Society of Pediatrics and were no longer allowed to be called doctors. This deliberate and systematic humiliation of pediatric clinicians and scientists was followed by deporting the lowly “providers” to concentration camps. So why perpetuate this pernicious Nazi terminology?

2. The Federal Government. The term “provider” was introduced and propagated in Public Law 93-641 titled “The National Health Planning and Resource Development Act of 1974.” In that document, patients were referred to as “consumers” and physicians as “providers” (this term was used 19 times in that law). At that time, the civil service employees who drafted the law that marginalized physicians by using generic, nonmedical nomenclature may not have realized the dire consequences of relabeling physicians as “providers.”

Continue to: Insurance companies, managed care companies, and consolidated health systems...

3. Insurance companies, managed care companies, and consolidated health systems have jubilantly adopted the term “provider” because they can equate physicians with less expensive, nonphysician clinicians (physician assistants, nurse practitioners, and certified registered nurse anesthetists), especially when physicians across several specialties (particularly psychiatry) are in short supply. None of these clinicians deserve to be labeled “providers,” either.

To understand why the term “provider” was used instead of “clinicians” or “clinical practitioner,” one must recognize the “businessification” of medicine and the commoditization of clinical care in our country. In some ways, health care has adopted a model similar to a fast-food joint, where workers provide customers with a hamburger. The question here is why did the 1.1 million physicians in the United States not halt this terminology shift before it spread and permeated the national health care system? Physicians who graduate from medical schools (not “provider” schools!) must vigorously and loudly fight back and put this wicked genie back in its bottle. This is feasible only if the American Medical Association (which would never conceive of itself as the “American Provider Association”), along with all 48 specialty organizations (Table), including the American Psychiatric Association (APA), unite and demand that physicians be called medical doctors or physicians, or by a term that reflects their specialty (orthopedists, psychiatrists, oncologists, gastroenterologists, anesthesiologists, cardiologists, etc.). This is an urgent issue to prevent the dissolution of our professional identity and its highly regarded societal image. It is a travesty that we physicians have allowed it to go on unopposed and to become entrenched in the dumbed-down jargon of health care. Physicians tend to avoid confrontation and adversarial stances, but we must unite and demand a return to the traditional nomenclature of medicine.

Much debate has emerged lately about an epidemic of “burnout” among physicians. Proposed causes include the savage increase in the amount of paperwork at the expense of patient care, the sense of helplessness that pre-authorization has inflicted on physicians’ decision-making, and the tyranny of relative value units (RVUs) as a benchmark for physician performance, as if healing patients is like manufacturing widgets. However, the blow to the self-esteem of physicians by being called “providers” daily is certainly another major factor contributing to burnout. It is perfectly legitimate for physicians to expect recognition for their long, rigorous, and uniquely advanced medical training, instead of being lumped together with less qualified professionals as anonymous “providers” in the name of politically correct pseudo-equality of all clinical practitioners. Let the administrators stop and contemplate whether tertiary or quaternary care for the most complex and severely ill patients in medical, surgical, or psychiatric intensive care units can operate without highly specialized physicians.

I urge APA leadership to take a visible and strong stand to rid psychiatrists of this assault on our medical identity. As I mentioned in my January 2020 editorial,² it is vital that the name of our national psychiatric organization (APA) be modified to the American Psychiatric Physicians Association, to remind all health care systems, as well as patients, the public, and the media, of our medical identity as physicians before we specialized in psychiatry.

Continue to: Patients, not clients

We should also emphasize that our suffering and medically ill patients with serious neuropsychiatric disorders such as schizophrenia, bipolar disorder, depression, panic disorder, or obsessive-compulsive disorder are patients, not clients. The terminology used in community mental health centers around the country almost universally includes “providers” and “clients.” This de-medicalization of psychiatrists and our patients must be corrected and reversed so that the public understands that treating mental illness is not a business transaction between a “provider” and a “client.” Using the correct terminology may help generate sympathy and compassion towards patients with serious psychiatric illnesses, just as it does for patients with cancer, heart disease, or stroke. The term “client” will never evoke the public sympathy and support that our patients truly deserve.

Let’s keep this issue alive and translate our demands into actions, both locally and nationally. Psychiatrists and physicians of all other specialties must stand up for their rights and inform their systems of care that they must be called by their legitimate and lawful name: physicians or medical doctors (never “providers”). This is an issue that unites all 1.1 million of us. The US health care system would collapse without us, and asking that we be called exactly what our medical license displays is our right and our professional identity.

One of the most malignant threats that is adversely impacting physicians is the insidious metastasis of the term “provider” within the national health care system over the past 2 to 3 decades.

This demeaning adjective is outrageously inappropriate and beneath the stature of medical doctors (MDs) who sacrificed 12 to 15 years of their lives in college, medical schools, residency programs, and post-residency fellowships to become physicians, specialists, and subspecialists. It is distressing to see hospitals, clinics, pharmacies, insurance corporations, and managed care companies refer to psychiatrists and other physicians as “providers.” It is time to fight back and restore our noble medical identity, which society has always respected and appreciated.

Our unique professional identify is at stake. We do not want to be lumped with nonphysicians as if we are interchangeable parts of a health care system or cogs in a wheel. No other mental health professional has the extensive training, scientific knowledge, clinical expertise, research accomplishments, and teaching/supervisory abilities that physicians have. We strongly uphold the sacred tenet of the physician-patient relationship, and adamantly reject its corruption into a provider-consumer transaction.

Even plumbers and electricians are not referred to as “providers.” Lawyers are not called legal aid providers. Teachers are not called knowledge providers, and administrators and CEOs are not called management providers. So why should physicians in any specialty, including psychiatry, obsequiously accept the denigration of their esteemed medical identify into the vague, amorphous ipseity of a “provider”? Family physicians, internists, and pediatricians used to be called primary care physicians, but have been reduced to primary care providers, which is insulting and degrading to these highly trained MD specialists.

The corruption and debasement of the professional identify of physicians and the propagation of the usage of the belittling term “provider” can be traced back to 3 entities:

1. The Nazi Third Reich. This is the most evil origin of the term “provider,” inflicted on Jewish physicians as part of the despicable persecution of German Jews in the 1930s. The Nazis decided to deprive pediatricians of being called physicians (“Arzt” in German) and forcefully relabeled them as “behandlers” or “providers,” thus erasing their noble medical identity.¹ In 1933, all Jewish pediatricians were expelled or forced to resign from the German Society of Pediatrics and were no longer allowed to be called doctors. This deliberate and systematic humiliation of pediatric clinicians and scientists was followed by deporting the lowly “providers” to concentration camps. So why perpetuate this pernicious Nazi terminology?

2. The Federal Government. The term “provider” was introduced and propagated in Public Law 93-641 titled “The National Health Planning and Resource Development Act of 1974.” In that document, patients were referred to as “consumers” and physicians as “providers” (this term was used 19 times in that law). At that time, the civil service employees who drafted the law that marginalized physicians by using generic, nonmedical nomenclature may not have realized the dire consequences of relabeling physicians as “providers.”

Continue to: Insurance companies, managed care companies, and consolidated health systems...

3. Insurance companies, managed care companies, and consolidated health systems have jubilantly adopted the term “provider” because they can equate physicians with less expensive, nonphysician clinicians (physician assistants, nurse practitioners, and certified registered nurse anesthetists), especially when physicians across several specialties (particularly psychiatry) are in short supply. None of these clinicians deserve to be labeled “providers,” either.

To understand why the term “provider” was used instead of “clinicians” or “clinical practitioner,” one must recognize the “businessification” of medicine and the commoditization of clinical care in our country. In some ways, health care has adopted a model similar to a fast-food joint, where workers provide customers with a hamburger. The question here is why did the 1.1 million physicians in the United States not halt this terminology shift before it spread and permeated the national health care system? Physicians who graduate from medical schools (not “provider” schools!) must vigorously and loudly fight back and put this wicked genie back in its bottle. This is feasible only if the American Medical Association (which would never conceive of itself as the “American Provider Association”), along with all 48 specialty organizations (Table), including the American Psychiatric Association (APA), unite and demand that physicians be called medical doctors or physicians, or by a term that reflects their specialty (orthopedists, psychiatrists, oncologists, gastroenterologists, anesthesiologists, cardiologists, etc.). This is an urgent issue to prevent the dissolution of our professional identity and its highly regarded societal image. It is a travesty that we physicians have allowed it to go on unopposed and to become entrenched in the dumbed-down jargon of health care. Physicians tend to avoid confrontation and adversarial stances, but we must unite and demand a return to the traditional nomenclature of medicine.

Much debate has emerged lately about an epidemic of “burnout” among physicians. Proposed causes include the savage increase in the amount of paperwork at the expense of patient care, the sense of helplessness that pre-authorization has inflicted on physicians’ decision-making, and the tyranny of relative value units (RVUs) as a benchmark for physician performance, as if healing patients is like manufacturing widgets. However, the blow to the self-esteem of physicians by being called “providers” daily is certainly another major factor contributing to burnout. It is perfectly legitimate for physicians to expect recognition for their long, rigorous, and uniquely advanced medical training, instead of being lumped together with less qualified professionals as anonymous “providers” in the name of politically correct pseudo-equality of all clinical practitioners. Let the administrators stop and contemplate whether tertiary or quaternary care for the most complex and severely ill patients in medical, surgical, or psychiatric intensive care units can operate without highly specialized physicians.

I urge APA leadership to take a visible and strong stand to rid psychiatrists of this assault on our medical identity. As I mentioned in my January 2020 editorial,² it is vital that the name of our national psychiatric organization (APA) be modified to the American Psychiatric Physicians Association, to remind all health care systems, as well as patients, the public, and the media, of our medical identity as physicians before we specialized in psychiatry.

Continue to: Patients, not clients

We should also emphasize that our suffering and medically ill patients with serious neuropsychiatric disorders such as schizophrenia, bipolar disorder, depression, panic disorder, or obsessive-compulsive disorder are patients, not clients. The terminology used in community mental health centers around the country almost universally includes “providers” and “clients.” This de-medicalization of psychiatrists and our patients must be corrected and reversed so that the public understands that treating mental illness is not a business transaction between a “provider” and a “client.” Using the correct terminology may help generate sympathy and compassion towards patients with serious psychiatric illnesses, just as it does for patients with cancer, heart disease, or stroke. The term “client” will never evoke the public sympathy and support that our patients truly deserve.

Let’s keep this issue alive and translate our demands into actions, both locally and nationally. Psychiatrists and physicians of all other specialties must stand up for their rights and inform their systems of care that they must be called by their legitimate and lawful name: physicians or medical doctors (never “providers”). This is an issue that unites all 1.1 million of us. The US health care system would collapse without us, and asking that we be called exactly what our medical license displays is our right and our professional identity.

As practicing clinicians, we all want to do what is best for patients. We hope our treatments will improve actual health outcomes (and not intermediate process metrics), so we make decisions based on “evidence” that lies on a continuum from “I hope” on one end to “I’m sure” on the other. This month, our three lead articles represent differing points along that continuum.

First, we consider H. pylori and gastric cancer. We know H. pylori eradication reduces ulcer risk and that H. pylori is a risk for gastric cancer. We did not know whether eradication reduces cancer risk. In a large retrospective study from the VA, Kumar et al demonstrated that eradication (not just treatment) substantially reduced subsequent gastric cancers. These data are not definitive, but they nudge us towards the “I’m sure” end of the continuum.

A second group of studies (both retrospective and prospective) suggests that successful weight loss after bariatric surgery was associated with a substantial reduction of risk for 13 cancer types related to obesity. Moderate evidence but again nudging us away from “I hope.”

A third article highlights the recent Clinical Practice Update on Barrett’s esophagus published by the AGA Clinical Practice Update Committee in Gastroenterology’s February 2020 issue. This practice update helps us understand the impact we will make on cancer reduction with surveillance and treatment of Barrett’s. Despite this publication, Barrett’s management remains closer to “hope” than “sure.”

The difficulty we face, as clinician or patient, is what to do when outcomes are really serious but evidence remains close to the “I hope” end. Take a reasonably healthy 68-year-old man with asymptomatic coronary disease, but a very high (and increasing) coronary artery calcium score, despite maximum statins and appropriate lifestyle practices. Should he initiate a PCSK9 inhibitor ($14,000 per year) absent evidence that it would alter cardiac risk? Recently, a retrospective study nudged us along the continuum (Peng et al. JACC Cardiovascular Imaging. 2020 Jan;13[1 Pt 1]:83-93). A serious outcome, suggestive but not definitive evidence, and no time for an RCT. Will such aggressive therapy help? I sure hope so.
 

John I. Allen, MD, MBA, AGAF
Editor in Chief

As practicing clinicians, we all want to do what is best for patients. We hope our treatments will improve actual health outcomes (and not intermediate process metrics), so we make decisions based on “evidence” that lies on a continuum from “I hope” on one end to “I’m sure” on the other. This month, our three lead articles represent differing points along that continuum.

First, we consider H. pylori and gastric cancer. We know H. pylori eradication reduces ulcer risk and that H. pylori is a risk for gastric cancer. We did not know whether eradication reduces cancer risk. In a large retrospective study from the VA, Kumar et al demonstrated that eradication (not just treatment) substantially reduced subsequent gastric cancers. These data are not definitive, but they nudge us towards the “I’m sure” end of the continuum.

A second group of studies (both retrospective and prospective) suggests that successful weight loss after bariatric surgery was associated with a substantial reduction of risk for 13 cancer types related to obesity. Moderate evidence but again nudging us away from “I hope.”

A third article highlights the recent Clinical Practice Update on Barrett’s esophagus published by the AGA Clinical Practice Update Committee in Gastroenterology’s February 2020 issue. This practice update helps us understand the impact we will make on cancer reduction with surveillance and treatment of Barrett’s. Despite this publication, Barrett’s management remains closer to “hope” than “sure.”

The difficulty we face, as clinician or patient, is what to do when outcomes are really serious but evidence remains close to the “I hope” end. Take a reasonably healthy 68-year-old man with asymptomatic coronary disease, but a very high (and increasing) coronary artery calcium score, despite maximum statins and appropriate lifestyle practices. Should he initiate a PCSK9 inhibitor ($14,000 per year) absent evidence that it would alter cardiac risk? Recently, a retrospective study nudged us along the continuum (Peng et al. JACC Cardiovascular Imaging. 2020 Jan;13[1 Pt 1]:83-93). A serious outcome, suggestive but not definitive evidence, and no time for an RCT. Will such aggressive therapy help? I sure hope so.
 

John I. Allen, MD, MBA, AGAF
Editor in Chief

As practicing clinicians, we all want to do what is best for patients. We hope our treatments will improve actual health outcomes (and not intermediate process metrics), so we make decisions based on “evidence” that lies on a continuum from “I hope” on one end to “I’m sure” on the other. This month, our three lead articles represent differing points along that continuum.

First, we consider H. pylori and gastric cancer. We know H. pylori eradication reduces ulcer risk and that H. pylori is a risk for gastric cancer. We did not know whether eradication reduces cancer risk. In a large retrospective study from the VA, Kumar et al demonstrated that eradication (not just treatment) substantially reduced subsequent gastric cancers. These data are not definitive, but they nudge us towards the “I’m sure” end of the continuum.

A second group of studies (both retrospective and prospective) suggests that successful weight loss after bariatric surgery was associated with a substantial reduction of risk for 13 cancer types related to obesity. Moderate evidence but again nudging us away from “I hope.”

A third article highlights the recent Clinical Practice Update on Barrett’s esophagus published by the AGA Clinical Practice Update Committee in Gastroenterology’s February 2020 issue. This practice update helps us understand the impact we will make on cancer reduction with surveillance and treatment of Barrett’s. Despite this publication, Barrett’s management remains closer to “hope” than “sure.”

The difficulty we face, as clinician or patient, is what to do when outcomes are really serious but evidence remains close to the “I hope” end. Take a reasonably healthy 68-year-old man with asymptomatic coronary disease, but a very high (and increasing) coronary artery calcium score, despite maximum statins and appropriate lifestyle practices. Should he initiate a PCSK9 inhibitor ($14,000 per year) absent evidence that it would alter cardiac risk? Recently, a retrospective study nudged us along the continuum (Peng et al. JACC Cardiovascular Imaging. 2020 Jan;13[1 Pt 1]:83-93). A serious outcome, suggestive but not definitive evidence, and no time for an RCT. Will such aggressive therapy help? I sure hope so.
 

John I. Allen, MD, MBA, AGAF
Editor in Chief

A number of years ago, a patient I was treating mentioned that she was not eating tomatoes. There had been stories in the news about people contracting bacterial infections from tomatoes, but I paused for a moment, then asked her: “Have there been any contaminated tomatoes here in Maryland?” There had not been and I was still happily eating salsa, but my patient thought about this differently: If disease-causing tomatoes were to come to our state, someone would be the first person to become ill. She did not want to take any risks. My patient, however, was a heavy smoker and already grappling with health issues that were caused by smoking, so I found her choice of what she should worry about and how it influenced her behavior to be perplexing. I realize it’s not the same; nicotine is an addiction, while tomatoes remain a choice for most of us, and it’s common for people to worry about very unlikely events even when we are surrounded by very real and statistically more probable threats to our well-being.

Today’s news reports are filled with stories about 2019 Novel Coronavirus (2019-nCoV), an illness that started in Wuhan, China; as of Jan. 31, 2020, there were 9,776 confirmed cases and 213 deaths. There have been an additional 118 cases reported outside of mainland China, including 6 in the United States, and no one outside of China has died.

The response to the virus has been remarkable: Wuhan, a city of more than 11 million inhabitants, is on lockdown, as are 15 other cities in China; 46 million people have been affected, the largest quarantine in human history. Travel is restricted in parts of China, airports all over the world are screening those who fly in from Wuhan, foreign governments are bringing their citizens home from Wuhan, and even Starbucks has temporarily closed half its stores in China. The economics of containing this virus are astounding.

In the meantime, the Centers for Disease Control and Prevention reports that, as of the week of Jan. 25, there have been 19 million cases of the flu in the United States. Of those stricken, 180,000 people have been hospitalized and 10,000 have died, including 68 pediatric patients. No cities are on lockdown, public transportation runs as usual, airports don’t screen passengers for flu symptoms, and Starbucks continues to serve vanilla lattes to any willing customer. Anxiety about illness is not new; we’ve seen it with SARS, Ebola, measles, and even around Chipotle’s food poisoning cases – to name just a few recent scares. We have also seen a lot of media on vaping-related deaths, and as of early January 2020, vaping-related illnesses affected 2,602 people with 59 deaths. It has been a topic of discussion among legislators, with an emphasis on either outlawing the flavoring that might appeal to younger people or simply outlawing e-cigarettes. No one, however, is talking about outlawing regular cigarettes, despite the fact that many people have switched from cigarettes to vaping products as a way to quit smoking. So, while vaping has caused 59 deaths since 2018, cigarettes are responsible for 480,000 fatalities a year in the United States and smokers live, on average, 10 years less than nonsmokers.

So what fuels anxiety about the latest health scare, and why aren’t we more anxious about the more common causes of premature mortality? Certainly, the newness and the unknown are factors in the coronavirus scare. It’s not certain how this illness was introduced into the human population, although one theory is that it started with the consumption of bats who carry the virus. It’s spreading fast, and in some people, it has been lethal. The incubation period is not known, or whether it is contagious before symptoms appear. Coronavirus is getting a lot of public health attention and the World Health Organization just announced that the virus is a public health emergency of international concern. On the televised news on Jan. 29, 2020, coronavirus was the top story in the United States, even though an impeachment trial is in progress for our country’s president.

The public health response of locking down cities may help contain the outbreak and prevent a global epidemic, although millions of people had already left Wuhan, so the heavy-handed attempt to prevent spread of the virus may well be too late. In the case of the Ebola virus – a much more lethal disease that was also thought to be introduced by bats – public health measures certainly curtailed global spread, and the epidemic of 2014-2016 was limited to 28,600 cases and 11,325 deaths, nearly all of them in West Africa.

Most of the things that cause people to die are not new and are not topics the media chooses to sensationalize. Dissemination of news has changed over the decades, with so much more of it, instant reports on social media, and competition for viewers that leads journalists to pull at our emotions. We might worry about getting food poisoning from romaine lettuce – if that is what the news is focusing on – but we don’t worry when we enter our cars, keep firearms in our homes, or light up cigarettes. And while we may, or may not, get flu shots and avoid those who have the flu, how and where we position both our anxiety and our resources does not always make sense. Certainly some people are predisposed to worry about both common and uncommon dangers, while others seem never to worry and engage in acts that many of us would consider dangerous. If we are looking for logic, it may be hard to find – there are those who would happily go bungee jumping but wouldn’t dream of leaving the house out without hand sanitizer.

The repercussions from this massive response to the Wuhan coronavirus are significant. For the millions of people on lockdown in China, each day gets emotionally harder; some may begin to have issues procuring food, and the financial losses for the economy will be significant. It’s not really possible to know yet if this response is warranted; we do know that infectious diseases can kill millions. The AIDS pandemic has taken the lives of 36 million people since 1981, and the influenza pandemic of 1918 resulted in an estimated 20 million to 50 million deaths after infecting 500 million people. Still, one might wonder if other, more mundane causes of morbidity and mortality – the ones that no longer garner our dread or make it to the front pages – might also be worthy of more hype and resources.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

A number of years ago, a patient I was treating mentioned that she was not eating tomatoes. There had been stories in the news about people contracting bacterial infections from tomatoes, but I paused for a moment, then asked her: “Have there been any contaminated tomatoes here in Maryland?” There had not been and I was still happily eating salsa, but my patient thought about this differently: If disease-causing tomatoes were to come to our state, someone would be the first person to become ill. She did not want to take any risks. My patient, however, was a heavy smoker and already grappling with health issues that were caused by smoking, so I found her choice of what she should worry about and how it influenced her behavior to be perplexing. I realize it’s not the same; nicotine is an addiction, while tomatoes remain a choice for most of us, and it’s common for people to worry about very unlikely events even when we are surrounded by very real and statistically more probable threats to our well-being.

Today’s news reports are filled with stories about 2019 Novel Coronavirus (2019-nCoV), an illness that started in Wuhan, China; as of Jan. 31, 2020, there were 9,776 confirmed cases and 213 deaths. There have been an additional 118 cases reported outside of mainland China, including 6 in the United States, and no one outside of China has died.

The response to the virus has been remarkable: Wuhan, a city of more than 11 million inhabitants, is on lockdown, as are 15 other cities in China; 46 million people have been affected, the largest quarantine in human history. Travel is restricted in parts of China, airports all over the world are screening those who fly in from Wuhan, foreign governments are bringing their citizens home from Wuhan, and even Starbucks has temporarily closed half its stores in China. The economics of containing this virus are astounding.

In the meantime, the Centers for Disease Control and Prevention reports that, as of the week of Jan. 25, there have been 19 million cases of the flu in the United States. Of those stricken, 180,000 people have been hospitalized and 10,000 have died, including 68 pediatric patients. No cities are on lockdown, public transportation runs as usual, airports don’t screen passengers for flu symptoms, and Starbucks continues to serve vanilla lattes to any willing customer. Anxiety about illness is not new; we’ve seen it with SARS, Ebola, measles, and even around Chipotle’s food poisoning cases – to name just a few recent scares. We have also seen a lot of media on vaping-related deaths, and as of early January 2020, vaping-related illnesses affected 2,602 people with 59 deaths. It has been a topic of discussion among legislators, with an emphasis on either outlawing the flavoring that might appeal to younger people or simply outlawing e-cigarettes. No one, however, is talking about outlawing regular cigarettes, despite the fact that many people have switched from cigarettes to vaping products as a way to quit smoking. So, while vaping has caused 59 deaths since 2018, cigarettes are responsible for 480,000 fatalities a year in the United States and smokers live, on average, 10 years less than nonsmokers.

So what fuels anxiety about the latest health scare, and why aren’t we more anxious about the more common causes of premature mortality? Certainly, the newness and the unknown are factors in the coronavirus scare. It’s not certain how this illness was introduced into the human population, although one theory is that it started with the consumption of bats who carry the virus. It’s spreading fast, and in some people, it has been lethal. The incubation period is not known, or whether it is contagious before symptoms appear. Coronavirus is getting a lot of public health attention and the World Health Organization just announced that the virus is a public health emergency of international concern. On the televised news on Jan. 29, 2020, coronavirus was the top story in the United States, even though an impeachment trial is in progress for our country’s president.

The public health response of locking down cities may help contain the outbreak and prevent a global epidemic, although millions of people had already left Wuhan, so the heavy-handed attempt to prevent spread of the virus may well be too late. In the case of the Ebola virus – a much more lethal disease that was also thought to be introduced by bats – public health measures certainly curtailed global spread, and the epidemic of 2014-2016 was limited to 28,600 cases and 11,325 deaths, nearly all of them in West Africa.

Most of the things that cause people to die are not new and are not topics the media chooses to sensationalize. Dissemination of news has changed over the decades, with so much more of it, instant reports on social media, and competition for viewers that leads journalists to pull at our emotions. We might worry about getting food poisoning from romaine lettuce – if that is what the news is focusing on – but we don’t worry when we enter our cars, keep firearms in our homes, or light up cigarettes. And while we may, or may not, get flu shots and avoid those who have the flu, how and where we position both our anxiety and our resources does not always make sense. Certainly some people are predisposed to worry about both common and uncommon dangers, while others seem never to worry and engage in acts that many of us would consider dangerous. If we are looking for logic, it may be hard to find – there are those who would happily go bungee jumping but wouldn’t dream of leaving the house out without hand sanitizer.

The repercussions from this massive response to the Wuhan coronavirus are significant. For the millions of people on lockdown in China, each day gets emotionally harder; some may begin to have issues procuring food, and the financial losses for the economy will be significant. It’s not really possible to know yet if this response is warranted; we do know that infectious diseases can kill millions. The AIDS pandemic has taken the lives of 36 million people since 1981, and the influenza pandemic of 1918 resulted in an estimated 20 million to 50 million deaths after infecting 500 million people. Still, one might wonder if other, more mundane causes of morbidity and mortality – the ones that no longer garner our dread or make it to the front pages – might also be worthy of more hype and resources.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

A number of years ago, a patient I was treating mentioned that she was not eating tomatoes. There had been stories in the news about people contracting bacterial infections from tomatoes, but I paused for a moment, then asked her: “Have there been any contaminated tomatoes here in Maryland?” There had not been and I was still happily eating salsa, but my patient thought about this differently: If disease-causing tomatoes were to come to our state, someone would be the first person to become ill. She did not want to take any risks. My patient, however, was a heavy smoker and already grappling with health issues that were caused by smoking, so I found her choice of what she should worry about and how it influenced her behavior to be perplexing. I realize it’s not the same; nicotine is an addiction, while tomatoes remain a choice for most of us, and it’s common for people to worry about very unlikely events even when we are surrounded by very real and statistically more probable threats to our well-being.

Today’s news reports are filled with stories about 2019 Novel Coronavirus (2019-nCoV), an illness that started in Wuhan, China; as of Jan. 31, 2020, there were 9,776 confirmed cases and 213 deaths. There have been an additional 118 cases reported outside of mainland China, including 6 in the United States, and no one outside of China has died.

The response to the virus has been remarkable: Wuhan, a city of more than 11 million inhabitants, is on lockdown, as are 15 other cities in China; 46 million people have been affected, the largest quarantine in human history. Travel is restricted in parts of China, airports all over the world are screening those who fly in from Wuhan, foreign governments are bringing their citizens home from Wuhan, and even Starbucks has temporarily closed half its stores in China. The economics of containing this virus are astounding.

In the meantime, the Centers for Disease Control and Prevention reports that, as of the week of Jan. 25, there have been 19 million cases of the flu in the United States. Of those stricken, 180,000 people have been hospitalized and 10,000 have died, including 68 pediatric patients. No cities are on lockdown, public transportation runs as usual, airports don’t screen passengers for flu symptoms, and Starbucks continues to serve vanilla lattes to any willing customer. Anxiety about illness is not new; we’ve seen it with SARS, Ebola, measles, and even around Chipotle’s food poisoning cases – to name just a few recent scares. We have also seen a lot of media on vaping-related deaths, and as of early January 2020, vaping-related illnesses affected 2,602 people with 59 deaths. It has been a topic of discussion among legislators, with an emphasis on either outlawing the flavoring that might appeal to younger people or simply outlawing e-cigarettes. No one, however, is talking about outlawing regular cigarettes, despite the fact that many people have switched from cigarettes to vaping products as a way to quit smoking. So, while vaping has caused 59 deaths since 2018, cigarettes are responsible for 480,000 fatalities a year in the United States and smokers live, on average, 10 years less than nonsmokers.

So what fuels anxiety about the latest health scare, and why aren’t we more anxious about the more common causes of premature mortality? Certainly, the newness and the unknown are factors in the coronavirus scare. It’s not certain how this illness was introduced into the human population, although one theory is that it started with the consumption of bats who carry the virus. It’s spreading fast, and in some people, it has been lethal. The incubation period is not known, or whether it is contagious before symptoms appear. Coronavirus is getting a lot of public health attention and the World Health Organization just announced that the virus is a public health emergency of international concern. On the televised news on Jan. 29, 2020, coronavirus was the top story in the United States, even though an impeachment trial is in progress for our country’s president.

The public health response of locking down cities may help contain the outbreak and prevent a global epidemic, although millions of people had already left Wuhan, so the heavy-handed attempt to prevent spread of the virus may well be too late. In the case of the Ebola virus – a much more lethal disease that was also thought to be introduced by bats – public health measures certainly curtailed global spread, and the epidemic of 2014-2016 was limited to 28,600 cases and 11,325 deaths, nearly all of them in West Africa.

Most of the things that cause people to die are not new and are not topics the media chooses to sensationalize. Dissemination of news has changed over the decades, with so much more of it, instant reports on social media, and competition for viewers that leads journalists to pull at our emotions. We might worry about getting food poisoning from romaine lettuce – if that is what the news is focusing on – but we don’t worry when we enter our cars, keep firearms in our homes, or light up cigarettes. And while we may, or may not, get flu shots and avoid those who have the flu, how and where we position both our anxiety and our resources does not always make sense. Certainly some people are predisposed to worry about both common and uncommon dangers, while others seem never to worry and engage in acts that many of us would consider dangerous. If we are looking for logic, it may be hard to find – there are those who would happily go bungee jumping but wouldn’t dream of leaving the house out without hand sanitizer.

The repercussions from this massive response to the Wuhan coronavirus are significant. For the millions of people on lockdown in China, each day gets emotionally harder; some may begin to have issues procuring food, and the financial losses for the economy will be significant. It’s not really possible to know yet if this response is warranted; we do know that infectious diseases can kill millions. The AIDS pandemic has taken the lives of 36 million people since 1981, and the influenza pandemic of 1918 resulted in an estimated 20 million to 50 million deaths after infecting 500 million people. Still, one might wonder if other, more mundane causes of morbidity and mortality – the ones that no longer garner our dread or make it to the front pages – might also be worthy of more hype and resources.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

Alzheimer disease and related dementias are a global health concern, affecting nearly 47 million people worldwide. Alzheimer disease and related dementias were among the top 10 causes of death worldwide in 2015 and are expected to increase by 10 million cases annually.¹ Despite the ethnic diversity of the US, there are considerable gaps in the literature regarding dementia and how it is diagnosed and treated among many ethnic and racial groups.

In 2012, President Barack Obama signed a declaration with the intention of decreasing ethnoracial disparities in Alzheimer disease research and treatment by increasing clinical care, research, and services targeted to racial and ethnic minorities.² Despite that declaration, in the US there are gaps in access to care for the geriatric population in general. The American Geriatrics Society estimates that the US has fewer than half the needed number of practicing geriatricians. In 2016, there was 1 geriatrician for every 1,924 Americans aged ≥ 65 years.³ Furthermore, health care providers (HCPs) are often not of the same ethnicity or adequately trained to assess and build relationships with ethnically and racially diverse populations.² Given the projected growth in the numbers of individuals worldwide with dementia, we have a responsibility to continue to develop strategies to provide more inclusive care.

By 2060, minority populations aged ≥ 65 years are expected to represent 45% of the US population, up from 22% in 2014.⁴ The growth of racial and ethnic minority groups are expected to exceed the growth of the non-Hispanic white population in the next few decades. By 2060, it is estimated that the US population will increase by 75% for non-Hispanic whites, 172% for African Americans, 270% for Asian and Pacific Islanders, 274% for American Indian and Alaska Natives, and 391% for Hispanics.⁴

A growing body of evidence suggests that Alzheimer disease and related dementias may disproportionately afflict minority groups in the US, which will become quite significant in the years ahead. The Alzheimer’s Association estimates that the prevalence of Alzheimer disease and other dementias among those aged > 65 years, is about twice the rate in African Americans and about 1.5 times the rate in Hispanics when compared with non-Hispanic whites.⁵ While increases in the incidence of Alzheimer disease and related dementias in non-Hispanic whites is expected to plateau around 2050, its incidence in ethnic and racial minority groups will continue to grow, especially among Hispanics.⁴ This stark realization provides additional compelling reasons for the US to develop preventative interventions or treatment options that may help delay the onset of the disease and to improve the quality of life of those with the disease or caregiving for those afflicted with it. Culturally competent care of these individuals is paramount.

Diagnosis

Early and accurate diagnosis of individuals with dementia confers many benefits, including early treatment; clinical trial participation; management of comorbid conditions; training, education, and support for patients and families; and legal, financial, and end of life care planning.³ Beyond the logistical concerns (such as HCP shortages), one of the challenges of assessing minority groups is finding staff who are culturally competent or speak the language necessary to accurately communicate and interact with these subgroups. Hispanics and African Americans often receive delayed or inadequate health care services or are diagnosed in an emergency department or other nontraditional setting.⁵

Even those individuals seeking or receiving care in primary care settings are not always forthcoming about their cognitive status. Only 56% of respondents in a recent survey of patients who had experienced subjective cognitive decline reported that they had discussed it with their HCP.⁴ This reticence is thought to be influenced by multiple factors, including distrust of the medical establishment, religious or spiritual beliefs, cultural or family beliefs and expectations about geriatric care, and lack of understanding about normal aging vs cognitive disorders. Furthermore, the sensitivity and specificity of current diagnostic tests for dementia have been questioned for nonwhite populations given the clinical presentation of dementia can vary across ethnoracial groups.⁵

As Luria noted, cognitive assessment tools developed and validated for use with one culture frequently results in experimental failures and are not valid for use with other cultural groups.¹ Cognitive testing results are influenced by educational and cultural factors, and this is one of the challenges in correctly diagnosing those of differing ethnoracial backgrounds. Individuals in racial and ethnic minorities may have limited formal education and/or high illiteracy rates and/or cultural nuances to problem solving, thinking, and memory that may not be reflected in current assessment tools.¹

There is hope that testing bias could be altered or eliminated using neuroimaging or biomarkers. However, the Alzheimer’s Disease Neuroimaging Initiative study of patients in the US and Canada included < 5% African American or Hispanic participants in its total sample. Few studies have systematically examined ethnoracial differences in amyloid positron emission tomography, and none have been published to date in ethnoracially diverse groups that assess the more recently developed tau imaging agents.¹

Diversity Among Caregivers

The research community must make greater efforts to improve recruitment of more diverse populations into clinical trials. Recent efforts by the National Institute on Aging in conjunction with the Alzheimer’s Association include developing a national strategy for clinical research recruitment and retention with an emphasis on local and diverse populations. This strategy should include various training modules, webinars, and similar educational opportunities for researchers and clinical HCPs, including HCPs from diverse ethnoracial backgrounds, to implement culturally appropriate research methodologies across these diverse groups. It is important that these educational materials be disseminated to caregivers in a way they can comprehend, as the impact on caregivers of those with Alzheimer disease and related dementias is considerable.

The US currently has 7 unpaid caregivers for every adult in the high-risk group of patients aged ≥ 65 years, but this will decline to a ratio of 4:1 by 2030.⁴ More than two-thirds of caregivers are non-Hispanic white, while 10% are African American, 8% are Hispanic, and 5% are Asian.³ About 34% of caregivers are themselves aged ≥ 65 years and are at risk for declines in their own health given the time and financial requirements of caring for someone else.³ In 2017, the 16.1 million family and other unpaid caregivers of people with dementia provided an estimated 18.4 billion hours of unpaid care, often resulting in considerable financial strain for these individuals. More than half of the caregivers report providing ≥ 21 hours of care per week; and 42% reported providing an average of 9 hours of care per day for people with dementia.

Caregivers report increased stress, sleep deprivation, depression and anxiety, and uncertainty in their ability to provide quality care to the individual with Alzheimer or a related dementia.³ The disproportionate prevalence of Alzheimer disease and other dementias in racially and ethnically diverse populations could further magnify already existing socioeconomic and other disparities and potentially lead to worsening of health outcomes in these groups.⁴ Given that minority populations tend to cluster geographically, community partnerships with local churches, senior centers, community centers, and other nontraditional settings may offer better opportunities for connecting with caregivers.

Conclusions

The growth and increasing diversity of the US older adult population in the coming decades require us as HCPs, researchers, and educators to dedicate more resources to ethnoracially diverse populations. There are still a great many unknowns about Alzheimer disease and dementia, most especially among nonwhites. Research, clinical care, and education must focus on outreach to marginalized groups so we may better be able to diagnose and treat the fastest growing older adult populations in the US. A complex combination of educational, cultural, social, and environmental factors likely contribute to delayed diagnosis and care of these groups, as well as lack of access to medical care, research venues, and trust issues between minority groups and the medical establishment. We all have an obligation to acknowledge these disparities and elicit the support of our colleagues and workplaces to raise awareness and dedicate necessary resources to this growing concern.

Alzheimer disease and related dementias are a global health concern, affecting nearly 47 million people worldwide. Alzheimer disease and related dementias were among the top 10 causes of death worldwide in 2015 and are expected to increase by 10 million cases annually.¹ Despite the ethnic diversity of the US, there are considerable gaps in the literature regarding dementia and how it is diagnosed and treated among many ethnic and racial groups.

In 2012, President Barack Obama signed a declaration with the intention of decreasing ethnoracial disparities in Alzheimer disease research and treatment by increasing clinical care, research, and services targeted to racial and ethnic minorities.² Despite that declaration, in the US there are gaps in access to care for the geriatric population in general. The American Geriatrics Society estimates that the US has fewer than half the needed number of practicing geriatricians. In 2016, there was 1 geriatrician for every 1,924 Americans aged ≥ 65 years.³ Furthermore, health care providers (HCPs) are often not of the same ethnicity or adequately trained to assess and build relationships with ethnically and racially diverse populations.² Given the projected growth in the numbers of individuals worldwide with dementia, we have a responsibility to continue to develop strategies to provide more inclusive care.

By 2060, minority populations aged ≥ 65 years are expected to represent 45% of the US population, up from 22% in 2014.⁴ The growth of racial and ethnic minority groups are expected to exceed the growth of the non-Hispanic white population in the next few decades. By 2060, it is estimated that the US population will increase by 75% for non-Hispanic whites, 172% for African Americans, 270% for Asian and Pacific Islanders, 274% for American Indian and Alaska Natives, and 391% for Hispanics.⁴

A growing body of evidence suggests that Alzheimer disease and related dementias may disproportionately afflict minority groups in the US, which will become quite significant in the years ahead. The Alzheimer’s Association estimates that the prevalence of Alzheimer disease and other dementias among those aged > 65 years, is about twice the rate in African Americans and about 1.5 times the rate in Hispanics when compared with non-Hispanic whites.⁵ While increases in the incidence of Alzheimer disease and related dementias in non-Hispanic whites is expected to plateau around 2050, its incidence in ethnic and racial minority groups will continue to grow, especially among Hispanics.⁴ This stark realization provides additional compelling reasons for the US to develop preventative interventions or treatment options that may help delay the onset of the disease and to improve the quality of life of those with the disease or caregiving for those afflicted with it. Culturally competent care of these individuals is paramount.

Diagnosis

Early and accurate diagnosis of individuals with dementia confers many benefits, including early treatment; clinical trial participation; management of comorbid conditions; training, education, and support for patients and families; and legal, financial, and end of life care planning.³ Beyond the logistical concerns (such as HCP shortages), one of the challenges of assessing minority groups is finding staff who are culturally competent or speak the language necessary to accurately communicate and interact with these subgroups. Hispanics and African Americans often receive delayed or inadequate health care services or are diagnosed in an emergency department or other nontraditional setting.⁵

Even those individuals seeking or receiving care in primary care settings are not always forthcoming about their cognitive status. Only 56% of respondents in a recent survey of patients who had experienced subjective cognitive decline reported that they had discussed it with their HCP.⁴ This reticence is thought to be influenced by multiple factors, including distrust of the medical establishment, religious or spiritual beliefs, cultural or family beliefs and expectations about geriatric care, and lack of understanding about normal aging vs cognitive disorders. Furthermore, the sensitivity and specificity of current diagnostic tests for dementia have been questioned for nonwhite populations given the clinical presentation of dementia can vary across ethnoracial groups.⁵

As Luria noted, cognitive assessment tools developed and validated for use with one culture frequently results in experimental failures and are not valid for use with other cultural groups.¹ Cognitive testing results are influenced by educational and cultural factors, and this is one of the challenges in correctly diagnosing those of differing ethnoracial backgrounds. Individuals in racial and ethnic minorities may have limited formal education and/or high illiteracy rates and/or cultural nuances to problem solving, thinking, and memory that may not be reflected in current assessment tools.¹

There is hope that testing bias could be altered or eliminated using neuroimaging or biomarkers. However, the Alzheimer’s Disease Neuroimaging Initiative study of patients in the US and Canada included < 5% African American or Hispanic participants in its total sample. Few studies have systematically examined ethnoracial differences in amyloid positron emission tomography, and none have been published to date in ethnoracially diverse groups that assess the more recently developed tau imaging agents.¹

Diversity Among Caregivers

The research community must make greater efforts to improve recruitment of more diverse populations into clinical trials. Recent efforts by the National Institute on Aging in conjunction with the Alzheimer’s Association include developing a national strategy for clinical research recruitment and retention with an emphasis on local and diverse populations. This strategy should include various training modules, webinars, and similar educational opportunities for researchers and clinical HCPs, including HCPs from diverse ethnoracial backgrounds, to implement culturally appropriate research methodologies across these diverse groups. It is important that these educational materials be disseminated to caregivers in a way they can comprehend, as the impact on caregivers of those with Alzheimer disease and related dementias is considerable.

The US currently has 7 unpaid caregivers for every adult in the high-risk group of patients aged ≥ 65 years, but this will decline to a ratio of 4:1 by 2030.⁴ More than two-thirds of caregivers are non-Hispanic white, while 10% are African American, 8% are Hispanic, and 5% are Asian.³ About 34% of caregivers are themselves aged ≥ 65 years and are at risk for declines in their own health given the time and financial requirements of caring for someone else.³ In 2017, the 16.1 million family and other unpaid caregivers of people with dementia provided an estimated 18.4 billion hours of unpaid care, often resulting in considerable financial strain for these individuals. More than half of the caregivers report providing ≥ 21 hours of care per week; and 42% reported providing an average of 9 hours of care per day for people with dementia.

Caregivers report increased stress, sleep deprivation, depression and anxiety, and uncertainty in their ability to provide quality care to the individual with Alzheimer or a related dementia.³ The disproportionate prevalence of Alzheimer disease and other dementias in racially and ethnically diverse populations could further magnify already existing socioeconomic and other disparities and potentially lead to worsening of health outcomes in these groups.⁴ Given that minority populations tend to cluster geographically, community partnerships with local churches, senior centers, community centers, and other nontraditional settings may offer better opportunities for connecting with caregivers.

Conclusions

The growth and increasing diversity of the US older adult population in the coming decades require us as HCPs, researchers, and educators to dedicate more resources to ethnoracially diverse populations. There are still a great many unknowns about Alzheimer disease and dementia, most especially among nonwhites. Research, clinical care, and education must focus on outreach to marginalized groups so we may better be able to diagnose and treat the fastest growing older adult populations in the US. A complex combination of educational, cultural, social, and environmental factors likely contribute to delayed diagnosis and care of these groups, as well as lack of access to medical care, research venues, and trust issues between minority groups and the medical establishment. We all have an obligation to acknowledge these disparities and elicit the support of our colleagues and workplaces to raise awareness and dedicate necessary resources to this growing concern.

Alzheimer disease and related dementias are a global health concern, affecting nearly 47 million people worldwide. Alzheimer disease and related dementias were among the top 10 causes of death worldwide in 2015 and are expected to increase by 10 million cases annually.¹ Despite the ethnic diversity of the US, there are considerable gaps in the literature regarding dementia and how it is diagnosed and treated among many ethnic and racial groups.

In 2012, President Barack Obama signed a declaration with the intention of decreasing ethnoracial disparities in Alzheimer disease research and treatment by increasing clinical care, research, and services targeted to racial and ethnic minorities.² Despite that declaration, in the US there are gaps in access to care for the geriatric population in general. The American Geriatrics Society estimates that the US has fewer than half the needed number of practicing geriatricians. In 2016, there was 1 geriatrician for every 1,924 Americans aged ≥ 65 years.³ Furthermore, health care providers (HCPs) are often not of the same ethnicity or adequately trained to assess and build relationships with ethnically and racially diverse populations.² Given the projected growth in the numbers of individuals worldwide with dementia, we have a responsibility to continue to develop strategies to provide more inclusive care.

By 2060, minority populations aged ≥ 65 years are expected to represent 45% of the US population, up from 22% in 2014.⁴ The growth of racial and ethnic minority groups are expected to exceed the growth of the non-Hispanic white population in the next few decades. By 2060, it is estimated that the US population will increase by 75% for non-Hispanic whites, 172% for African Americans, 270% for Asian and Pacific Islanders, 274% for American Indian and Alaska Natives, and 391% for Hispanics.⁴

A growing body of evidence suggests that Alzheimer disease and related dementias may disproportionately afflict minority groups in the US, which will become quite significant in the years ahead. The Alzheimer’s Association estimates that the prevalence of Alzheimer disease and other dementias among those aged > 65 years, is about twice the rate in African Americans and about 1.5 times the rate in Hispanics when compared with non-Hispanic whites.⁵ While increases in the incidence of Alzheimer disease and related dementias in non-Hispanic whites is expected to plateau around 2050, its incidence in ethnic and racial minority groups will continue to grow, especially among Hispanics.⁴ This stark realization provides additional compelling reasons for the US to develop preventative interventions or treatment options that may help delay the onset of the disease and to improve the quality of life of those with the disease or caregiving for those afflicted with it. Culturally competent care of these individuals is paramount.

Diagnosis

Early and accurate diagnosis of individuals with dementia confers many benefits, including early treatment; clinical trial participation; management of comorbid conditions; training, education, and support for patients and families; and legal, financial, and end of life care planning.³ Beyond the logistical concerns (such as HCP shortages), one of the challenges of assessing minority groups is finding staff who are culturally competent or speak the language necessary to accurately communicate and interact with these subgroups. Hispanics and African Americans often receive delayed or inadequate health care services or are diagnosed in an emergency department or other nontraditional setting.⁵

Even those individuals seeking or receiving care in primary care settings are not always forthcoming about their cognitive status. Only 56% of respondents in a recent survey of patients who had experienced subjective cognitive decline reported that they had discussed it with their HCP.⁴ This reticence is thought to be influenced by multiple factors, including distrust of the medical establishment, religious or spiritual beliefs, cultural or family beliefs and expectations about geriatric care, and lack of understanding about normal aging vs cognitive disorders. Furthermore, the sensitivity and specificity of current diagnostic tests for dementia have been questioned for nonwhite populations given the clinical presentation of dementia can vary across ethnoracial groups.⁵

As Luria noted, cognitive assessment tools developed and validated for use with one culture frequently results in experimental failures and are not valid for use with other cultural groups.¹ Cognitive testing results are influenced by educational and cultural factors, and this is one of the challenges in correctly diagnosing those of differing ethnoracial backgrounds. Individuals in racial and ethnic minorities may have limited formal education and/or high illiteracy rates and/or cultural nuances to problem solving, thinking, and memory that may not be reflected in current assessment tools.¹

There is hope that testing bias could be altered or eliminated using neuroimaging or biomarkers. However, the Alzheimer’s Disease Neuroimaging Initiative study of patients in the US and Canada included < 5% African American or Hispanic participants in its total sample. Few studies have systematically examined ethnoracial differences in amyloid positron emission tomography, and none have been published to date in ethnoracially diverse groups that assess the more recently developed tau imaging agents.¹

Diversity Among Caregivers

The research community must make greater efforts to improve recruitment of more diverse populations into clinical trials. Recent efforts by the National Institute on Aging in conjunction with the Alzheimer’s Association include developing a national strategy for clinical research recruitment and retention with an emphasis on local and diverse populations. This strategy should include various training modules, webinars, and similar educational opportunities for researchers and clinical HCPs, including HCPs from diverse ethnoracial backgrounds, to implement culturally appropriate research methodologies across these diverse groups. It is important that these educational materials be disseminated to caregivers in a way they can comprehend, as the impact on caregivers of those with Alzheimer disease and related dementias is considerable.

The US currently has 7 unpaid caregivers for every adult in the high-risk group of patients aged ≥ 65 years, but this will decline to a ratio of 4:1 by 2030.⁴ More than two-thirds of caregivers are non-Hispanic white, while 10% are African American, 8% are Hispanic, and 5% are Asian.³ About 34% of caregivers are themselves aged ≥ 65 years and are at risk for declines in their own health given the time and financial requirements of caring for someone else.³ In 2017, the 16.1 million family and other unpaid caregivers of people with dementia provided an estimated 18.4 billion hours of unpaid care, often resulting in considerable financial strain for these individuals. More than half of the caregivers report providing ≥ 21 hours of care per week; and 42% reported providing an average of 9 hours of care per day for people with dementia.

Caregivers report increased stress, sleep deprivation, depression and anxiety, and uncertainty in their ability to provide quality care to the individual with Alzheimer or a related dementia.³ The disproportionate prevalence of Alzheimer disease and other dementias in racially and ethnically diverse populations could further magnify already existing socioeconomic and other disparities and potentially lead to worsening of health outcomes in these groups.⁴ Given that minority populations tend to cluster geographically, community partnerships with local churches, senior centers, community centers, and other nontraditional settings may offer better opportunities for connecting with caregivers.

Conclusions

The growth and increasing diversity of the US older adult population in the coming decades require us as HCPs, researchers, and educators to dedicate more resources to ethnoracially diverse populations. There are still a great many unknowns about Alzheimer disease and dementia, most especially among nonwhites. Research, clinical care, and education must focus on outreach to marginalized groups so we may better be able to diagnose and treat the fastest growing older adult populations in the US. A complex combination of educational, cultural, social, and environmental factors likely contribute to delayed diagnosis and care of these groups, as well as lack of access to medical care, research venues, and trust issues between minority groups and the medical establishment. We all have an obligation to acknowledge these disparities and elicit the support of our colleagues and workplaces to raise awareness and dedicate necessary resources to this growing concern.

Like me, some of you may have been following the agonizing news about the unprecedented brushfires in Australia that have devastated human, animal, and vegetative life in that country so culturally akin to our own.¹ For many people who believe the overwhelming majority of scientific reports on climate change, these apocalyptic fires are an empirical demonstration of the truth of the dire prophecies for the future of our planet. Scientists have demonstrated that although climate change may not have caused the worst fires in Australia’s history, they may have contributed to the conditions that enabled them to spread so far and wide and reach such a destructive intensity.²The heartbreaking pictures of singed koalas and displaced people and the helpless feeling that all I can do from here is donate money set me to thinking about the relationship between the military, health, and climate change, which is the subject of this column.

As I write this in mid-January of a new decade and glance at the weather headlines, I read about an earthquake in Puerto Rico and tornadoes in the southern US. This makes it quite plausible that our comfortable lifestyle and technological civilization could in the coming decades go the way of the dinosaurs, also victims of climate change.

Initially, my first thought about this relationship is a negative one—images of scorched earth policies that stretch back to ancient wars jump to mind. Reflection and research on the topic though suggest that the relationship may be more complicated and conflicted. Alas, I can only touch on a few of the themes in this brief format.

It may not be as obvious that climate change also threatens the military, which is the guardian of that civilization. In 2018, for example, Hurricane Michael caused nearly $5 billion in damages to Tyndall Air Force Base in Florida.³ A year later, the US Department of Defense (DoD) released a report on the effects of climate change as mandated by Congress.⁴ Even though some congressional critics expressed concern about the report’s lack of depth and detail,⁵ the report asserted that, “The effects of a changing climate are a national security issue with potential impacts to Department of Defense (DoD or the Department) missions, operational plans, and installations.”⁴

The US Department of Veterans Affairs (VA) is not immune either. Natural disasters have already disrupted the delivery of health care at its many aging facilities. Climate change was called the “engine”⁶ driving Hurricane Maria, which in 2017 slammed into Puerto Rico, including its VA medical center, and resulted in shortages of supplies, staff, and basic utilities.⁷ The facility and the island are still trying to rebuild. In response to weather-exposed vulnerability in VA infrastructure, Senator and presidential candidate Elizabeth Warren (D-MA) and Senator Brian Schatz (D-HI), the ranking member of the Subcommittee on Military Construction, sent a letter to VA leadership arguing that “Strengthening VA’s resilience to climate change is consistent with the agency’s mission to deliver timely, high-quality care and benefits to America’s veterans.”⁸

It has been reported that the current administration has countered initiatives to prepare for the challenges of providing health care to service members and veterans in a climate changed world.⁹ Sadly, but predictably, in the politicized federal health care arena, the safety of our service members and, in turn, the domestic and national security and peace that depend on them are caught in the partisan debate over global warming, though it is not likely Congress or federal agency leaders will abandon planning to safeguard service members who will see duty and combat in a radically altered ecology and veterans and who will need to have VA continue to be the reliable safety net despite an increasingly erratic environment.¹⁰

Climate change is a divisive political issue; there is a proud tradition of conservatism and self-reliance in military members, active duty and veteran alike. That was why I was surprised and impressed when I saw the results of a recent survey on climate change. In January 2019, 293 active-duty service members and veterans were surveyed.

Participants were selected to reflect the ethnic makeup, educational level, and political allegiance of the military population, which enhanced the validity of the findings.¹¹Participants were asked to indicate whether they believed that the earth was warming secondary to human or natural processes; not growing warmer at all; or whether they were unsure. Similar to the general population, 46% agreed that climate change is anthropogenic.¹¹ More than three-fourths believed it was likely climate change would adversely affect the places they worked, like military installations; 61% thought it likely that global warming could lead to armed conflict over resources. Seven in 10 respondents believed that climate is changing vs 46% who did not. Of respondents who believe climate change is real, 87% see it as a threat to military bases compared with 60% who do not accept the science that the earth is warming.¹¹

This survey, though, is only a small study, and the military and VA are big tents under which a wide range of political persuasions and diverse beliefs co-exist. There are many readers of Federal Practitioner who will no doubt reject nearly every word I have written, in what I know is a controversial column. But it matters that the military and veteran constituency are thinking and speaking about the issue of climate change.¹¹ Why? The answer takes us back to the disaster in Australia. When the fires and the devastation they wrought escalated beyond the powers of the civil authorities to handle, it was the military whose technical skill, coordinated readiness, and personal courage and dedication that was called on to rescue thousands of civilians from the inferno.¹² So it will be in our country and around the world when disasters—manmade, natural, or both—threaten to engulf life in all its wondrous variety. Those who battle extreme weather will have unique health needs, and their valiant sacrifices deserve to have health care systems ready and able to treat them.

Like me, some of you may have been following the agonizing news about the unprecedented brushfires in Australia that have devastated human, animal, and vegetative life in that country so culturally akin to our own.¹ For many people who believe the overwhelming majority of scientific reports on climate change, these apocalyptic fires are an empirical demonstration of the truth of the dire prophecies for the future of our planet. Scientists have demonstrated that although climate change may not have caused the worst fires in Australia’s history, they may have contributed to the conditions that enabled them to spread so far and wide and reach such a destructive intensity.²The heartbreaking pictures of singed koalas and displaced people and the helpless feeling that all I can do from here is donate money set me to thinking about the relationship between the military, health, and climate change, which is the subject of this column.

As I write this in mid-January of a new decade and glance at the weather headlines, I read about an earthquake in Puerto Rico and tornadoes in the southern US. This makes it quite plausible that our comfortable lifestyle and technological civilization could in the coming decades go the way of the dinosaurs, also victims of climate change.

Initially, my first thought about this relationship is a negative one—images of scorched earth policies that stretch back to ancient wars jump to mind. Reflection and research on the topic though suggest that the relationship may be more complicated and conflicted. Alas, I can only touch on a few of the themes in this brief format.

It may not be as obvious that climate change also threatens the military, which is the guardian of that civilization. In 2018, for example, Hurricane Michael caused nearly $5 billion in damages to Tyndall Air Force Base in Florida.³ A year later, the US Department of Defense (DoD) released a report on the effects of climate change as mandated by Congress.⁴ Even though some congressional critics expressed concern about the report’s lack of depth and detail,⁵ the report asserted that, “The effects of a changing climate are a national security issue with potential impacts to Department of Defense (DoD or the Department) missions, operational plans, and installations.”⁴

The US Department of Veterans Affairs (VA) is not immune either. Natural disasters have already disrupted the delivery of health care at its many aging facilities. Climate change was called the “engine”⁶ driving Hurricane Maria, which in 2017 slammed into Puerto Rico, including its VA medical center, and resulted in shortages of supplies, staff, and basic utilities.⁷ The facility and the island are still trying to rebuild. In response to weather-exposed vulnerability in VA infrastructure, Senator and presidential candidate Elizabeth Warren (D-MA) and Senator Brian Schatz (D-HI), the ranking member of the Subcommittee on Military Construction, sent a letter to VA leadership arguing that “Strengthening VA’s resilience to climate change is consistent with the agency’s mission to deliver timely, high-quality care and benefits to America’s veterans.”⁸

It has been reported that the current administration has countered initiatives to prepare for the challenges of providing health care to service members and veterans in a climate changed world.⁹ Sadly, but predictably, in the politicized federal health care arena, the safety of our service members and, in turn, the domestic and national security and peace that depend on them are caught in the partisan debate over global warming, though it is not likely Congress or federal agency leaders will abandon planning to safeguard service members who will see duty and combat in a radically altered ecology and veterans and who will need to have VA continue to be the reliable safety net despite an increasingly erratic environment.¹⁰

Climate change is a divisive political issue; there is a proud tradition of conservatism and self-reliance in military members, active duty and veteran alike. That was why I was surprised and impressed when I saw the results of a recent survey on climate change. In January 2019, 293 active-duty service members and veterans were surveyed.

Participants were selected to reflect the ethnic makeup, educational level, and political allegiance of the military population, which enhanced the validity of the findings.¹¹Participants were asked to indicate whether they believed that the earth was warming secondary to human or natural processes; not growing warmer at all; or whether they were unsure. Similar to the general population, 46% agreed that climate change is anthropogenic.¹¹ More than three-fourths believed it was likely climate change would adversely affect the places they worked, like military installations; 61% thought it likely that global warming could lead to armed conflict over resources. Seven in 10 respondents believed that climate is changing vs 46% who did not. Of respondents who believe climate change is real, 87% see it as a threat to military bases compared with 60% who do not accept the science that the earth is warming.¹¹

This survey, though, is only a small study, and the military and VA are big tents under which a wide range of political persuasions and diverse beliefs co-exist. There are many readers of Federal Practitioner who will no doubt reject nearly every word I have written, in what I know is a controversial column. But it matters that the military and veteran constituency are thinking and speaking about the issue of climate change.¹¹ Why? The answer takes us back to the disaster in Australia. When the fires and the devastation they wrought escalated beyond the powers of the civil authorities to handle, it was the military whose technical skill, coordinated readiness, and personal courage and dedication that was called on to rescue thousands of civilians from the inferno.¹² So it will be in our country and around the world when disasters—manmade, natural, or both—threaten to engulf life in all its wondrous variety. Those who battle extreme weather will have unique health needs, and their valiant sacrifices deserve to have health care systems ready and able to treat them.

Like me, some of you may have been following the agonizing news about the unprecedented brushfires in Australia that have devastated human, animal, and vegetative life in that country so culturally akin to our own.¹ For many people who believe the overwhelming majority of scientific reports on climate change, these apocalyptic fires are an empirical demonstration of the truth of the dire prophecies for the future of our planet. Scientists have demonstrated that although climate change may not have caused the worst fires in Australia’s history, they may have contributed to the conditions that enabled them to spread so far and wide and reach such a destructive intensity.²The heartbreaking pictures of singed koalas and displaced people and the helpless feeling that all I can do from here is donate money set me to thinking about the relationship between the military, health, and climate change, which is the subject of this column.

As I write this in mid-January of a new decade and glance at the weather headlines, I read about an earthquake in Puerto Rico and tornadoes in the southern US. This makes it quite plausible that our comfortable lifestyle and technological civilization could in the coming decades go the way of the dinosaurs, also victims of climate change.

Initially, my first thought about this relationship is a negative one—images of scorched earth policies that stretch back to ancient wars jump to mind. Reflection and research on the topic though suggest that the relationship may be more complicated and conflicted. Alas, I can only touch on a few of the themes in this brief format.

It may not be as obvious that climate change also threatens the military, which is the guardian of that civilization. In 2018, for example, Hurricane Michael caused nearly $5 billion in damages to Tyndall Air Force Base in Florida.³ A year later, the US Department of Defense (DoD) released a report on the effects of climate change as mandated by Congress.⁴ Even though some congressional critics expressed concern about the report’s lack of depth and detail,⁵ the report asserted that, “The effects of a changing climate are a national security issue with potential impacts to Department of Defense (DoD or the Department) missions, operational plans, and installations.”⁴

The US Department of Veterans Affairs (VA) is not immune either. Natural disasters have already disrupted the delivery of health care at its many aging facilities. Climate change was called the “engine”⁶ driving Hurricane Maria, which in 2017 slammed into Puerto Rico, including its VA medical center, and resulted in shortages of supplies, staff, and basic utilities.⁷ The facility and the island are still trying to rebuild. In response to weather-exposed vulnerability in VA infrastructure, Senator and presidential candidate Elizabeth Warren (D-MA) and Senator Brian Schatz (D-HI), the ranking member of the Subcommittee on Military Construction, sent a letter to VA leadership arguing that “Strengthening VA’s resilience to climate change is consistent with the agency’s mission to deliver timely, high-quality care and benefits to America’s veterans.”⁸

It has been reported that the current administration has countered initiatives to prepare for the challenges of providing health care to service members and veterans in a climate changed world.⁹ Sadly, but predictably, in the politicized federal health care arena, the safety of our service members and, in turn, the domestic and national security and peace that depend on them are caught in the partisan debate over global warming, though it is not likely Congress or federal agency leaders will abandon planning to safeguard service members who will see duty and combat in a radically altered ecology and veterans and who will need to have VA continue to be the reliable safety net despite an increasingly erratic environment.¹⁰

Climate change is a divisive political issue; there is a proud tradition of conservatism and self-reliance in military members, active duty and veteran alike. That was why I was surprised and impressed when I saw the results of a recent survey on climate change. In January 2019, 293 active-duty service members and veterans were surveyed.

Participants were selected to reflect the ethnic makeup, educational level, and political allegiance of the military population, which enhanced the validity of the findings.¹¹Participants were asked to indicate whether they believed that the earth was warming secondary to human or natural processes; not growing warmer at all; or whether they were unsure. Similar to the general population, 46% agreed that climate change is anthropogenic.¹¹ More than three-fourths believed it was likely climate change would adversely affect the places they worked, like military installations; 61% thought it likely that global warming could lead to armed conflict over resources. Seven in 10 respondents believed that climate is changing vs 46% who did not. Of respondents who believe climate change is real, 87% see it as a threat to military bases compared with 60% who do not accept the science that the earth is warming.¹¹

This survey, though, is only a small study, and the military and VA are big tents under which a wide range of political persuasions and diverse beliefs co-exist. There are many readers of Federal Practitioner who will no doubt reject nearly every word I have written, in what I know is a controversial column. But it matters that the military and veteran constituency are thinking and speaking about the issue of climate change.¹¹ Why? The answer takes us back to the disaster in Australia. When the fires and the devastation they wrought escalated beyond the powers of the civil authorities to handle, it was the military whose technical skill, coordinated readiness, and personal courage and dedication that was called on to rescue thousands of civilians from the inferno.¹² So it will be in our country and around the world when disasters—manmade, natural, or both—threaten to engulf life in all its wondrous variety. Those who battle extreme weather will have unique health needs, and their valiant sacrifices deserve to have health care systems ready and able to treat them.

Although the last decade has brought appropriate increased interest in the diagnosis and treatment of postpartum depression, with screening initiatives across more than 40 states in place and even new medications being brought to market for treatment, far less attention has been given to diagnosis and treatment of a particularly serious psychiatric illness: postpartum psychosis.

Postpartum psychosis is relatively rare, with an incidence of 1 in 1,000 births, but it is one of the most serious complications of modern obstetrics. Clinically, women can experience rapid mood changes, most often with the presentation that is consistent with a manic-like psychosis, with associated symptoms of delusional thinking, hallucinations, paranoia and either depression or elation, or an amalgam of these so-called “mixed symptoms.” Onset of symptoms typically is early, within 72 hours as is classically described, but may have a somewhat later time of onset in some women.

Many investigators have studied risk factors for postpartum psychosis, and it has been well established that a history of mood disorder, particularly bipolar disorder, is one of the strongest predictors of risk for postpartum psychosis. Women with histories of postpartum psychosis are at very high risk of recurrence, with as many as 70%-90% of women experiencing recurrence if not prophylaxed with an appropriate agent. From a clinical point of view, women with postpartum psychosis typically are hospitalized, given that this is both a psychiatric and potential obstetrical emergency. In fact, the data would suggest that although postpartum suicide and infanticide are not common, they can be a tragic concomitant of postpartum psychosis (Am J Psychiatry. 2016 Dec 1;173[12]:1179-88).

A great amount of interest has been placed on the etiology of postpartum psychosis, as it’s a dramatic presentation with very rapid onset in the acute postpartum period. A rich evidence base with respect to an algorithm of treatment that maximizes likelihood of full recovery or sustaining of euthymia after recovery is limited. Few studies have looked systematically at the optimum way to treat postpartum psychosis. Clinical wisdom has dictated that, given the dramatic symptoms with which these patients present, most patients are treated with lithium and an antipsychotic medication as if they have a manic-like psychosis. It may take brief or extended periods of time for patients to stabilize. Once they are stabilized, one of the most challenging questions for clinicians is how long to treat. Again, an evidence base clearly informing this question is lacking.

Over the years, many clinicians have treated patients with postpartum psychosis as if they have bipolar disorder, given the index presentation of the illness, so some of these patients are treated with antimanic drugs indefinitely. However, clinical experience from several centers that treat women with postpartum psychosis suggests that in remitted patients, a proportion of them may be able to taper and discontinue treatment, then sustain well-being for protracted periods.

One obstacle with respect to treatment of postpartum psychosis derives from the short length of stay after delivery for many women. Some women who present with symptoms of postpartum psychosis in the first 24-48 hours frequently are managed with direct admission to an inpatient psychiatric service. But others may not develop symptoms until they are home, which may place both mother and newborn at risk.

Given that the risk for recurrent postpartum psychosis is so great (70%-90%), women with histories of postpartum psychosis invariably are prophylaxed with mood stabilizer prior to delivery in a subsequent pregnancy. In our own center, we have published on the value of such prophylactic intervention, not just in women with postpartum psychosis, but in women with bipolar disorder, who are, as noted, at great risk for developing postpartum psychotic symptoms (Am J Psychiatry. 1995 Nov;152[11]:1641-5.)

Although postpartum psychosis may be rare, over the last 3 decades we have seen a substantial number of women with postpartum psychosis and have been fascinated with the spectrum of symptoms with which some women with postpartum psychotic illness present. We also have been impressed with the time required for some women to recompensate from their illness and the course of their disorder after they have seemingly remitted. Some women appear to be able to discontinue treatment as noted above; others, particularly if there is any history of bipolar disorder, need to be maintained on treatment with mood stabilizer indefinitely.

To better understand the phenomenology of postpartum psychosis, as well as the longitudinal course of the illness, in 2019, the Mass General Hospital Postpartum Psychosis Project (MGHP3) was established. The project is conducted as a hospital-based registry where women with histories of postpartum psychosis over the last decade are invited to participate in an in-depth interview to understand both symptoms and course of underlying illness. This is complemented by obtaining a sample of saliva, which is used for genetic testing to try to identify a genetic underpinning associated with postpartum psychosis, as the question of genetic etiology of postpartum psychosis is still an open one.

As part of the MGHP3 project, clinicians across the country are able to contact perinatal psychiatrists in our center with expertise in the treatment of postpartum psychosis. Our psychiatrists also can counsel clinicians on issues regarding long-term management of postpartum psychosis because for many, knowledge of precisely how to manage this disorder or the follow-up treatment may be incomplete.

From a clinical point of view, the relevant questions really include not only acute treatment, which has already been outlined, but also the issue of duration of treatment. While some patients may be able to taper and discontinue treatment after, for example, a year of being totally well, to date we are unable to know who those patients are. We tend to be more conservative in our own center and treat patients with puerperal psychosis for a more protracted period of time, usually over several years. We also ask women about their family history of bipolar disorder or postpartum psychosis. Depending on the clinical course (if the patient really has sustained euthymia), we consider slow taper and ultimate discontinuation. As always, treatment decisions are tailored to individual clinical history, course, and patient wishes.

Postpartum psychosis remains one of the most serious illnesses that we find in reproductive psychiatry, and incomplete attention has been given to this devastating illness, which we read about periodically in newspapers and magazines. Greater understanding of postpartum psychosis will lead to a more precision-like psychiatric approach, tailoring treatment to the invariable heterogeneity of this illness.

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].

Although the last decade has brought appropriate increased interest in the diagnosis and treatment of postpartum depression, with screening initiatives across more than 40 states in place and even new medications being brought to market for treatment, far less attention has been given to diagnosis and treatment of a particularly serious psychiatric illness: postpartum psychosis.

Postpartum psychosis is relatively rare, with an incidence of 1 in 1,000 births, but it is one of the most serious complications of modern obstetrics. Clinically, women can experience rapid mood changes, most often with the presentation that is consistent with a manic-like psychosis, with associated symptoms of delusional thinking, hallucinations, paranoia and either depression or elation, or an amalgam of these so-called “mixed symptoms.” Onset of symptoms typically is early, within 72 hours as is classically described, but may have a somewhat later time of onset in some women.

Many investigators have studied risk factors for postpartum psychosis, and it has been well established that a history of mood disorder, particularly bipolar disorder, is one of the strongest predictors of risk for postpartum psychosis. Women with histories of postpartum psychosis are at very high risk of recurrence, with as many as 70%-90% of women experiencing recurrence if not prophylaxed with an appropriate agent. From a clinical point of view, women with postpartum psychosis typically are hospitalized, given that this is both a psychiatric and potential obstetrical emergency. In fact, the data would suggest that although postpartum suicide and infanticide are not common, they can be a tragic concomitant of postpartum psychosis (Am J Psychiatry. 2016 Dec 1;173[12]:1179-88).

A great amount of interest has been placed on the etiology of postpartum psychosis, as it’s a dramatic presentation with very rapid onset in the acute postpartum period. A rich evidence base with respect to an algorithm of treatment that maximizes likelihood of full recovery or sustaining of euthymia after recovery is limited. Few studies have looked systematically at the optimum way to treat postpartum psychosis. Clinical wisdom has dictated that, given the dramatic symptoms with which these patients present, most patients are treated with lithium and an antipsychotic medication as if they have a manic-like psychosis. It may take brief or extended periods of time for patients to stabilize. Once they are stabilized, one of the most challenging questions for clinicians is how long to treat. Again, an evidence base clearly informing this question is lacking.

Over the years, many clinicians have treated patients with postpartum psychosis as if they have bipolar disorder, given the index presentation of the illness, so some of these patients are treated with antimanic drugs indefinitely. However, clinical experience from several centers that treat women with postpartum psychosis suggests that in remitted patients, a proportion of them may be able to taper and discontinue treatment, then sustain well-being for protracted periods.

One obstacle with respect to treatment of postpartum psychosis derives from the short length of stay after delivery for many women. Some women who present with symptoms of postpartum psychosis in the first 24-48 hours frequently are managed with direct admission to an inpatient psychiatric service. But others may not develop symptoms until they are home, which may place both mother and newborn at risk.

Given that the risk for recurrent postpartum psychosis is so great (70%-90%), women with histories of postpartum psychosis invariably are prophylaxed with mood stabilizer prior to delivery in a subsequent pregnancy. In our own center, we have published on the value of such prophylactic intervention, not just in women with postpartum psychosis, but in women with bipolar disorder, who are, as noted, at great risk for developing postpartum psychotic symptoms (Am J Psychiatry. 1995 Nov;152[11]:1641-5.)

Although postpartum psychosis may be rare, over the last 3 decades we have seen a substantial number of women with postpartum psychosis and have been fascinated with the spectrum of symptoms with which some women with postpartum psychotic illness present. We also have been impressed with the time required for some women to recompensate from their illness and the course of their disorder after they have seemingly remitted. Some women appear to be able to discontinue treatment as noted above; others, particularly if there is any history of bipolar disorder, need to be maintained on treatment with mood stabilizer indefinitely.

To better understand the phenomenology of postpartum psychosis, as well as the longitudinal course of the illness, in 2019, the Mass General Hospital Postpartum Psychosis Project (MGHP3) was established. The project is conducted as a hospital-based registry where women with histories of postpartum psychosis over the last decade are invited to participate in an in-depth interview to understand both symptoms and course of underlying illness. This is complemented by obtaining a sample of saliva, which is used for genetic testing to try to identify a genetic underpinning associated with postpartum psychosis, as the question of genetic etiology of postpartum psychosis is still an open one.

As part of the MGHP3 project, clinicians across the country are able to contact perinatal psychiatrists in our center with expertise in the treatment of postpartum psychosis. Our psychiatrists also can counsel clinicians on issues regarding long-term management of postpartum psychosis because for many, knowledge of precisely how to manage this disorder or the follow-up treatment may be incomplete.

From a clinical point of view, the relevant questions really include not only acute treatment, which has already been outlined, but also the issue of duration of treatment. While some patients may be able to taper and discontinue treatment after, for example, a year of being totally well, to date we are unable to know who those patients are. We tend to be more conservative in our own center and treat patients with puerperal psychosis for a more protracted period of time, usually over several years. We also ask women about their family history of bipolar disorder or postpartum psychosis. Depending on the clinical course (if the patient really has sustained euthymia), we consider slow taper and ultimate discontinuation. As always, treatment decisions are tailored to individual clinical history, course, and patient wishes.

Postpartum psychosis remains one of the most serious illnesses that we find in reproductive psychiatry, and incomplete attention has been given to this devastating illness, which we read about periodically in newspapers and magazines. Greater understanding of postpartum psychosis will lead to a more precision-like psychiatric approach, tailoring treatment to the invariable heterogeneity of this illness.

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].

Although the last decade has brought appropriate increased interest in the diagnosis and treatment of postpartum depression, with screening initiatives across more than 40 states in place and even new medications being brought to market for treatment, far less attention has been given to diagnosis and treatment of a particularly serious psychiatric illness: postpartum psychosis.

Postpartum psychosis is relatively rare, with an incidence of 1 in 1,000 births, but it is one of the most serious complications of modern obstetrics. Clinically, women can experience rapid mood changes, most often with the presentation that is consistent with a manic-like psychosis, with associated symptoms of delusional thinking, hallucinations, paranoia and either depression or elation, or an amalgam of these so-called “mixed symptoms.” Onset of symptoms typically is early, within 72 hours as is classically described, but may have a somewhat later time of onset in some women.

Many investigators have studied risk factors for postpartum psychosis, and it has been well established that a history of mood disorder, particularly bipolar disorder, is one of the strongest predictors of risk for postpartum psychosis. Women with histories of postpartum psychosis are at very high risk of recurrence, with as many as 70%-90% of women experiencing recurrence if not prophylaxed with an appropriate agent. From a clinical point of view, women with postpartum psychosis typically are hospitalized, given that this is both a psychiatric and potential obstetrical emergency. In fact, the data would suggest that although postpartum suicide and infanticide are not common, they can be a tragic concomitant of postpartum psychosis (Am J Psychiatry. 2016 Dec 1;173[12]:1179-88).

A great amount of interest has been placed on the etiology of postpartum psychosis, as it’s a dramatic presentation with very rapid onset in the acute postpartum period. A rich evidence base with respect to an algorithm of treatment that maximizes likelihood of full recovery or sustaining of euthymia after recovery is limited. Few studies have looked systematically at the optimum way to treat postpartum psychosis. Clinical wisdom has dictated that, given the dramatic symptoms with which these patients present, most patients are treated with lithium and an antipsychotic medication as if they have a manic-like psychosis. It may take brief or extended periods of time for patients to stabilize. Once they are stabilized, one of the most challenging questions for clinicians is how long to treat. Again, an evidence base clearly informing this question is lacking.

Over the years, many clinicians have treated patients with postpartum psychosis as if they have bipolar disorder, given the index presentation of the illness, so some of these patients are treated with antimanic drugs indefinitely. However, clinical experience from several centers that treat women with postpartum psychosis suggests that in remitted patients, a proportion of them may be able to taper and discontinue treatment, then sustain well-being for protracted periods.

One obstacle with respect to treatment of postpartum psychosis derives from the short length of stay after delivery for many women. Some women who present with symptoms of postpartum psychosis in the first 24-48 hours frequently are managed with direct admission to an inpatient psychiatric service. But others may not develop symptoms until they are home, which may place both mother and newborn at risk.

Given that the risk for recurrent postpartum psychosis is so great (70%-90%), women with histories of postpartum psychosis invariably are prophylaxed with mood stabilizer prior to delivery in a subsequent pregnancy. In our own center, we have published on the value of such prophylactic intervention, not just in women with postpartum psychosis, but in women with bipolar disorder, who are, as noted, at great risk for developing postpartum psychotic symptoms (Am J Psychiatry. 1995 Nov;152[11]:1641-5.)

Although postpartum psychosis may be rare, over the last 3 decades we have seen a substantial number of women with postpartum psychosis and have been fascinated with the spectrum of symptoms with which some women with postpartum psychotic illness present. We also have been impressed with the time required for some women to recompensate from their illness and the course of their disorder after they have seemingly remitted. Some women appear to be able to discontinue treatment as noted above; others, particularly if there is any history of bipolar disorder, need to be maintained on treatment with mood stabilizer indefinitely.

To better understand the phenomenology of postpartum psychosis, as well as the longitudinal course of the illness, in 2019, the Mass General Hospital Postpartum Psychosis Project (MGHP3) was established. The project is conducted as a hospital-based registry where women with histories of postpartum psychosis over the last decade are invited to participate in an in-depth interview to understand both symptoms and course of underlying illness. This is complemented by obtaining a sample of saliva, which is used for genetic testing to try to identify a genetic underpinning associated with postpartum psychosis, as the question of genetic etiology of postpartum psychosis is still an open one.

As part of the MGHP3 project, clinicians across the country are able to contact perinatal psychiatrists in our center with expertise in the treatment of postpartum psychosis. Our psychiatrists also can counsel clinicians on issues regarding long-term management of postpartum psychosis because for many, knowledge of precisely how to manage this disorder or the follow-up treatment may be incomplete.

From a clinical point of view, the relevant questions really include not only acute treatment, which has already been outlined, but also the issue of duration of treatment. While some patients may be able to taper and discontinue treatment after, for example, a year of being totally well, to date we are unable to know who those patients are. We tend to be more conservative in our own center and treat patients with puerperal psychosis for a more protracted period of time, usually over several years. We also ask women about their family history of bipolar disorder or postpartum psychosis. Depending on the clinical course (if the patient really has sustained euthymia), we consider slow taper and ultimate discontinuation. As always, treatment decisions are tailored to individual clinical history, course, and patient wishes.

Postpartum psychosis remains one of the most serious illnesses that we find in reproductive psychiatry, and incomplete attention has been given to this devastating illness, which we read about periodically in newspapers and magazines. Greater understanding of postpartum psychosis will lead to a more precision-like psychiatric approach, tailoring treatment to the invariable heterogeneity of this illness.

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].

If you’ve knocked yourself out to earn a Merit-Based Incentive Payment System (MIPS) bonus payment, it’s pretty safe to say that getting a 1.68% payment boost probably didn’t feel like a “win” that was worth the effort.

And although it saved you from having a negative 5% payment adjustment, many physicians don’t feel that it was worth the effort.

On Jan. 6, the Centers for Medicare & Medicaid Services announced the 2020 payouts for MIPS.

Based on 2018 participation, the bonus for those who scored a perfect 100 is only a 1.68% boost in Medicare reimbursement, slightly lower than last year’s 1.88%. This decline comes as no surprise as the agency leader admits: “As the program matures, we expect that the increases in the performance thresholds in future program years will create a smaller distribution of positive payment adjustments.” Overall, more than 97% of participants avoided having a negative 5% payment adjustment.

Indeed, these bonus monies are based on a short-term appropriation of extra funds from Congress. After these temporary funds are no longer available, there will be little, if any, monies to distribute as the program is based on a “losers-feed-the-winners” construct.

It may be very tempting for many physicians to decide to ignore MIPS, with the rationale that 1.68% is not worth the effort. But don’t let your foot off the gas pedal yet, since the penalty for not participating in 2020 is a substantial 9%. Physicians should make sure that they, at minimum, achieve the 45 points necessary to avoid that pitfall this reporting year.

However, it is certainly time to reconsider efforts to participate at the highest level.
 

Should you or shouldn’t you bother with MIPS?

Let’s say you have $75,000 in revenue from Medicare Part B per year. Depending on the services you offer in your practice, that equates to 500-750 encounters with Medicare beneficiaries per year. (A reminder that MIPS affects only Part B; Medicare Advantage plans do not partake in the program.)

The recent announcement reveals that perfection would equate to an additional $1,260 per year. That’s only if you received the full 100 points; if you were simply an “exceptional performer,” the government will allot an additional $157. That’s less than you get paid for a single office visit.

The difference between perfection and compliance is approximately $1,000. Failure to participate, however, knocks $6,750 off your bottom line. Clearly, that’s a substantial financial loss that would affect most practices. Obviously, the numbers change if you have higher – or lower – Medicare revenue, but it’s important to do the math.

Why? Physicians are spending a significant amount of money to comply with the program requirements. This includes substantial payments to registries – typically $200 to >$1,000 per year – to report the quality measures for the program; electronic health record (EHR) systems, many of which require additional funding for the “upgrade” to a MIPS-compatible system, are also a sizable investment.

These hard costs pale in comparison with the time spent on understanding the ever-changing requirements of the program and the process by which your practice will implement them. Take, for example, something as innocuous as the required “Support Electronic Referral Loops by Receiving and Incorporating Health Information.”

You first must understand the elements of the measure: What is a “referral loop?” When do we need to generate one? To whom shall it be sent? What needs to be included in “health information?” What is the electronic address to which we should route the information? How do we obtain that address? Then you must determine how your EHR system captures and reports it.

Only then comes the hard part: How are we going to implement this? That’s only one of more than a dozen required elements: six quality measures, two (to four) improvement activities, and four promoting interoperability requirements. Each one of these elements has a host of requirements, all listed on multipage specification sheets.

The government does not seem to be listening. John Cullen, MD, president of the American Academy of Family Physicians, testified at the Senate Finance Committee in May 2019 that MIPS “has created a burdensome and extremely complex program that has increased practice costs ... ” Yet, later that year, CMS issued another hefty ruling that outlines significant changes to the program, despite the fact that it’s in its fourth performance year.
 

Turning frustration into action

Frustration or even anger may be one reaction, but now is an opportune time to determine your investment in the program. At a minimum, it’s vital to understand and meet the threshold to avoid the penalty. It’s been shifting to date, but it’s now set at 9% for perpetuity.

First, it’s crucial to check on your participation status. CMS revealed that the participation database was recently corrected for so-called inconsistencies, so it pays to double-check. It only takes seconds: Insert your NPI in the QPP Participation Status Tool to determine your eligibility for 2020.

In 2020, the threshold to avoid the penalty is 45 points. To get the 45 points, practices must participate in two improvement activities, which is not difficult as there are 118 options. That will garner 15 points. Then there are 45 points available from the quality category; you need at least 30 to reach the 45-point threshold for penalty avoidance.
 

Smart MIPS hacks that can help you

To obtain the additional 30 points, turn your attention to the quality category. There are 268 quality measures; choose at least six to measure. If you report directly from your EHR system, you’ll get a bonus point for each reported measure, plus one just for trying. (There are a few other opportunities for bonus points, such as improving your scores over last year.) Those bonus points give you a base with which to work, but getting to 45 will require effort to report successfully on at least a couple of the measures.

The quality category has a total of 100 points available, which are converted to 45 toward your composite score. Since you need 30 to reach that magical 45 (if 15 were attained from improvement activities), that means you must come up with 75 points in the quality category. Between the bonus points and measuring a handful of measures successfully through the year, you’ll achieve this threshold.

There are two other categories in the program: promoting interoperability (PI) and cost. The PI category mirrors the old “meaningful use” program; however, it has become increasingly difficult over the years. If you think that you can meet the required elements, you can pick up 25 more points toward your composite score.

Cost is a bit of an unknown, as the scoring is based on a retrospective review of your claims. You’ll likely pick up a few more points on this 15-point category, but there’s no method to determine performance until after the reporting period. Therefore, be cautious about relying on this category.

The best MIPS hack, however, is if you are a small practice. CMS – remarkably – defines a “small practice” as 15 or fewer eligible professionals. If you qualify under this paradigm, you have multiple options to ease compliance:

Apply for a “hardship exemption” simply on the basis of being small; the exemption relates to the promoting operability category, shifting those points to the quality category.

Gain three points per quality measure, regardless of data completeness; this compares to just one point for other physicians.

Capture all of the points available from the Improvement Activities category by confirming participation with just a single activity. (This also applies to all physicians in rural or Health Professional Shortage Areas.)

In the event that you don’t qualify as a “small practice” or you’re still falling short of the requirements, CMS allows for the ultimate “out”: You can apply for exemption on the basis of an “extreme and uncontrollable circumstance.” The applications for these exceptions open this summer.

Unless you qualify for the program exemption, it’s important to keep pace with the program to ensure that you reach the 45-point threshold. It may not, however, be worthwhile to gear up for all 100 points unless your estimate of the potential return – and what it costs you to get there – reveals otherwise. MIPS is not going anywhere; the program is written into the law.

But that doesn’t mean that CMS can’t make tweaks and updates. Hopefully, the revisions won’t create even more administrative burden as the program is quickly turning into a big stick with only a small carrot at the end.

Elizabeth Woodcock is president of Woodcock & Associates in Atlanta. She has disclosed no relevant financial relationships.
 

This article first appeared on Medscape.com.

If you’ve knocked yourself out to earn a Merit-Based Incentive Payment System (MIPS) bonus payment, it’s pretty safe to say that getting a 1.68% payment boost probably didn’t feel like a “win” that was worth the effort.

And although it saved you from having a negative 5% payment adjustment, many physicians don’t feel that it was worth the effort.

On Jan. 6, the Centers for Medicare & Medicaid Services announced the 2020 payouts for MIPS.

Based on 2018 participation, the bonus for those who scored a perfect 100 is only a 1.68% boost in Medicare reimbursement, slightly lower than last year’s 1.88%. This decline comes as no surprise as the agency leader admits: “As the program matures, we expect that the increases in the performance thresholds in future program years will create a smaller distribution of positive payment adjustments.” Overall, more than 97% of participants avoided having a negative 5% payment adjustment.

Indeed, these bonus monies are based on a short-term appropriation of extra funds from Congress. After these temporary funds are no longer available, there will be little, if any, monies to distribute as the program is based on a “losers-feed-the-winners” construct.

It may be very tempting for many physicians to decide to ignore MIPS, with the rationale that 1.68% is not worth the effort. But don’t let your foot off the gas pedal yet, since the penalty for not participating in 2020 is a substantial 9%. Physicians should make sure that they, at minimum, achieve the 45 points necessary to avoid that pitfall this reporting year.

However, it is certainly time to reconsider efforts to participate at the highest level.
 

Should you or shouldn’t you bother with MIPS?

Let’s say you have $75,000 in revenue from Medicare Part B per year. Depending on the services you offer in your practice, that equates to 500-750 encounters with Medicare beneficiaries per year. (A reminder that MIPS affects only Part B; Medicare Advantage plans do not partake in the program.)

The recent announcement reveals that perfection would equate to an additional $1,260 per year. That’s only if you received the full 100 points; if you were simply an “exceptional performer,” the government will allot an additional $157. That’s less than you get paid for a single office visit.

The difference between perfection and compliance is approximately $1,000. Failure to participate, however, knocks $6,750 off your bottom line. Clearly, that’s a substantial financial loss that would affect most practices. Obviously, the numbers change if you have higher – or lower – Medicare revenue, but it’s important to do the math.

Why? Physicians are spending a significant amount of money to comply with the program requirements. This includes substantial payments to registries – typically $200 to >$1,000 per year – to report the quality measures for the program; electronic health record (EHR) systems, many of which require additional funding for the “upgrade” to a MIPS-compatible system, are also a sizable investment.

These hard costs pale in comparison with the time spent on understanding the ever-changing requirements of the program and the process by which your practice will implement them. Take, for example, something as innocuous as the required “Support Electronic Referral Loops by Receiving and Incorporating Health Information.”

You first must understand the elements of the measure: What is a “referral loop?” When do we need to generate one? To whom shall it be sent? What needs to be included in “health information?” What is the electronic address to which we should route the information? How do we obtain that address? Then you must determine how your EHR system captures and reports it.

Only then comes the hard part: How are we going to implement this? That’s only one of more than a dozen required elements: six quality measures, two (to four) improvement activities, and four promoting interoperability requirements. Each one of these elements has a host of requirements, all listed on multipage specification sheets.

The government does not seem to be listening. John Cullen, MD, president of the American Academy of Family Physicians, testified at the Senate Finance Committee in May 2019 that MIPS “has created a burdensome and extremely complex program that has increased practice costs ... ” Yet, later that year, CMS issued another hefty ruling that outlines significant changes to the program, despite the fact that it’s in its fourth performance year.
 

Turning frustration into action

Frustration or even anger may be one reaction, but now is an opportune time to determine your investment in the program. At a minimum, it’s vital to understand and meet the threshold to avoid the penalty. It’s been shifting to date, but it’s now set at 9% for perpetuity.

First, it’s crucial to check on your participation status. CMS revealed that the participation database was recently corrected for so-called inconsistencies, so it pays to double-check. It only takes seconds: Insert your NPI in the QPP Participation Status Tool to determine your eligibility for 2020.

In 2020, the threshold to avoid the penalty is 45 points. To get the 45 points, practices must participate in two improvement activities, which is not difficult as there are 118 options. That will garner 15 points. Then there are 45 points available from the quality category; you need at least 30 to reach the 45-point threshold for penalty avoidance.
 

Smart MIPS hacks that can help you

To obtain the additional 30 points, turn your attention to the quality category. There are 268 quality measures; choose at least six to measure. If you report directly from your EHR system, you’ll get a bonus point for each reported measure, plus one just for trying. (There are a few other opportunities for bonus points, such as improving your scores over last year.) Those bonus points give you a base with which to work, but getting to 45 will require effort to report successfully on at least a couple of the measures.

The quality category has a total of 100 points available, which are converted to 45 toward your composite score. Since you need 30 to reach that magical 45 (if 15 were attained from improvement activities), that means you must come up with 75 points in the quality category. Between the bonus points and measuring a handful of measures successfully through the year, you’ll achieve this threshold.

There are two other categories in the program: promoting interoperability (PI) and cost. The PI category mirrors the old “meaningful use” program; however, it has become increasingly difficult over the years. If you think that you can meet the required elements, you can pick up 25 more points toward your composite score.

Cost is a bit of an unknown, as the scoring is based on a retrospective review of your claims. You’ll likely pick up a few more points on this 15-point category, but there’s no method to determine performance until after the reporting period. Therefore, be cautious about relying on this category.

The best MIPS hack, however, is if you are a small practice. CMS – remarkably – defines a “small practice” as 15 or fewer eligible professionals. If you qualify under this paradigm, you have multiple options to ease compliance:

Apply for a “hardship exemption” simply on the basis of being small; the exemption relates to the promoting operability category, shifting those points to the quality category.

Gain three points per quality measure, regardless of data completeness; this compares to just one point for other physicians.

Capture all of the points available from the Improvement Activities category by confirming participation with just a single activity. (This also applies to all physicians in rural or Health Professional Shortage Areas.)

In the event that you don’t qualify as a “small practice” or you’re still falling short of the requirements, CMS allows for the ultimate “out”: You can apply for exemption on the basis of an “extreme and uncontrollable circumstance.” The applications for these exceptions open this summer.

Unless you qualify for the program exemption, it’s important to keep pace with the program to ensure that you reach the 45-point threshold. It may not, however, be worthwhile to gear up for all 100 points unless your estimate of the potential return – and what it costs you to get there – reveals otherwise. MIPS is not going anywhere; the program is written into the law.

But that doesn’t mean that CMS can’t make tweaks and updates. Hopefully, the revisions won’t create even more administrative burden as the program is quickly turning into a big stick with only a small carrot at the end.

Elizabeth Woodcock is president of Woodcock & Associates in Atlanta. She has disclosed no relevant financial relationships.
 

This article first appeared on Medscape.com.

If you’ve knocked yourself out to earn a Merit-Based Incentive Payment System (MIPS) bonus payment, it’s pretty safe to say that getting a 1.68% payment boost probably didn’t feel like a “win” that was worth the effort.

And although it saved you from having a negative 5% payment adjustment, many physicians don’t feel that it was worth the effort.

On Jan. 6, the Centers for Medicare & Medicaid Services announced the 2020 payouts for MIPS.

Based on 2018 participation, the bonus for those who scored a perfect 100 is only a 1.68% boost in Medicare reimbursement, slightly lower than last year’s 1.88%. This decline comes as no surprise as the agency leader admits: “As the program matures, we expect that the increases in the performance thresholds in future program years will create a smaller distribution of positive payment adjustments.” Overall, more than 97% of participants avoided having a negative 5% payment adjustment.

Indeed, these bonus monies are based on a short-term appropriation of extra funds from Congress. After these temporary funds are no longer available, there will be little, if any, monies to distribute as the program is based on a “losers-feed-the-winners” construct.

It may be very tempting for many physicians to decide to ignore MIPS, with the rationale that 1.68% is not worth the effort. But don’t let your foot off the gas pedal yet, since the penalty for not participating in 2020 is a substantial 9%. Physicians should make sure that they, at minimum, achieve the 45 points necessary to avoid that pitfall this reporting year.

However, it is certainly time to reconsider efforts to participate at the highest level.
 

Should you or shouldn’t you bother with MIPS?

Let’s say you have $75,000 in revenue from Medicare Part B per year. Depending on the services you offer in your practice, that equates to 500-750 encounters with Medicare beneficiaries per year. (A reminder that MIPS affects only Part B; Medicare Advantage plans do not partake in the program.)

The recent announcement reveals that perfection would equate to an additional $1,260 per year. That’s only if you received the full 100 points; if you were simply an “exceptional performer,” the government will allot an additional $157. That’s less than you get paid for a single office visit.

The difference between perfection and compliance is approximately $1,000. Failure to participate, however, knocks $6,750 off your bottom line. Clearly, that’s a substantial financial loss that would affect most practices. Obviously, the numbers change if you have higher – or lower – Medicare revenue, but it’s important to do the math.

Why? Physicians are spending a significant amount of money to comply with the program requirements. This includes substantial payments to registries – typically $200 to >$1,000 per year – to report the quality measures for the program; electronic health record (EHR) systems, many of which require additional funding for the “upgrade” to a MIPS-compatible system, are also a sizable investment.

These hard costs pale in comparison with the time spent on understanding the ever-changing requirements of the program and the process by which your practice will implement them. Take, for example, something as innocuous as the required “Support Electronic Referral Loops by Receiving and Incorporating Health Information.”

You first must understand the elements of the measure: What is a “referral loop?” When do we need to generate one? To whom shall it be sent? What needs to be included in “health information?” What is the electronic address to which we should route the information? How do we obtain that address? Then you must determine how your EHR system captures and reports it.

Only then comes the hard part: How are we going to implement this? That’s only one of more than a dozen required elements: six quality measures, two (to four) improvement activities, and four promoting interoperability requirements. Each one of these elements has a host of requirements, all listed on multipage specification sheets.

The government does not seem to be listening. John Cullen, MD, president of the American Academy of Family Physicians, testified at the Senate Finance Committee in May 2019 that MIPS “has created a burdensome and extremely complex program that has increased practice costs ... ” Yet, later that year, CMS issued another hefty ruling that outlines significant changes to the program, despite the fact that it’s in its fourth performance year.
 

Turning frustration into action

Frustration or even anger may be one reaction, but now is an opportune time to determine your investment in the program. At a minimum, it’s vital to understand and meet the threshold to avoid the penalty. It’s been shifting to date, but it’s now set at 9% for perpetuity.

First, it’s crucial to check on your participation status. CMS revealed that the participation database was recently corrected for so-called inconsistencies, so it pays to double-check. It only takes seconds: Insert your NPI in the QPP Participation Status Tool to determine your eligibility for 2020.

In 2020, the threshold to avoid the penalty is 45 points. To get the 45 points, practices must participate in two improvement activities, which is not difficult as there are 118 options. That will garner 15 points. Then there are 45 points available from the quality category; you need at least 30 to reach the 45-point threshold for penalty avoidance.
 

Smart MIPS hacks that can help you

To obtain the additional 30 points, turn your attention to the quality category. There are 268 quality measures; choose at least six to measure. If you report directly from your EHR system, you’ll get a bonus point for each reported measure, plus one just for trying. (There are a few other opportunities for bonus points, such as improving your scores over last year.) Those bonus points give you a base with which to work, but getting to 45 will require effort to report successfully on at least a couple of the measures.

The quality category has a total of 100 points available, which are converted to 45 toward your composite score. Since you need 30 to reach that magical 45 (if 15 were attained from improvement activities), that means you must come up with 75 points in the quality category. Between the bonus points and measuring a handful of measures successfully through the year, you’ll achieve this threshold.

There are two other categories in the program: promoting interoperability (PI) and cost. The PI category mirrors the old “meaningful use” program; however, it has become increasingly difficult over the years. If you think that you can meet the required elements, you can pick up 25 more points toward your composite score.

Cost is a bit of an unknown, as the scoring is based on a retrospective review of your claims. You’ll likely pick up a few more points on this 15-point category, but there’s no method to determine performance until after the reporting period. Therefore, be cautious about relying on this category.

The best MIPS hack, however, is if you are a small practice. CMS – remarkably – defines a “small practice” as 15 or fewer eligible professionals. If you qualify under this paradigm, you have multiple options to ease compliance:

Apply for a “hardship exemption” simply on the basis of being small; the exemption relates to the promoting operability category, shifting those points to the quality category.

Gain three points per quality measure, regardless of data completeness; this compares to just one point for other physicians.

Capture all of the points available from the Improvement Activities category by confirming participation with just a single activity. (This also applies to all physicians in rural or Health Professional Shortage Areas.)

In the event that you don’t qualify as a “small practice” or you’re still falling short of the requirements, CMS allows for the ultimate “out”: You can apply for exemption on the basis of an “extreme and uncontrollable circumstance.” The applications for these exceptions open this summer.

Unless you qualify for the program exemption, it’s important to keep pace with the program to ensure that you reach the 45-point threshold. It may not, however, be worthwhile to gear up for all 100 points unless your estimate of the potential return – and what it costs you to get there – reveals otherwise. MIPS is not going anywhere; the program is written into the law.

But that doesn’t mean that CMS can’t make tweaks and updates. Hopefully, the revisions won’t create even more administrative burden as the program is quickly turning into a big stick with only a small carrot at the end.

Elizabeth Woodcock is president of Woodcock & Associates in Atlanta. She has disclosed no relevant financial relationships.
 

This article first appeared on Medscape.com.

For many years now, we have been lamenting the shortage of psychiatrists practicing in the United States. At this point, we must identify possible solutions.^1,2 Currently, the shortage of practicing psychiatrists in the United States could be as high as 45,000.³ The major problem is that the number of psychiatry residency positions will not increase in the foreseeable future, thus generating more psychiatrists is not an option.

Medicare pays about $150,000 per residency slot per year. To solve the mental health access problem, $27 billion (45,000 x $150,000 x 4 years)* would be required from Medicare, which is not feasible.⁴ The national average starting salary for psychiatrists from 2018-2019 was about $273,000 (much lower in academic institutions), according to Merritt Hawkins, the physician recruiting firm. That salary is modest, compared with those offered in other medical specialties. For this reason, many graduates choose other lucrative specialties. And we know that increasing the salaries of psychiatrists alone would not lead more people to choose psychiatry. On paper, it may say they work a 40-hour week, but they end up working 60 hours a week.

To make matters worse, family medicine and internal medicine doctors generally would rather not deal with people with mental illness and do “cherry-picking and lemon-dropping.” While many patients present to primary care with mental health issues, lack of time and education in psychiatric disorders and treatment hinder these physicians. In short, the mental health field cannot count on primary care physicians.

Meanwhile, there are thousands of unmatched residency graduates. In light of those realities, perhaps psychiatry residency programs could provide these unmatched graduates with 6 months of training and use them to supplement the workforce. These medical doctors, or “physician associates,” could be paired with a few psychiatrists to do clinical and administrative work. With one in four individuals having mental health issues, and more and more people seeking help because of increasing awareness and the benefits that accompanied the Affordable Care Act (ACA), physician associates might ease the workload of psychiatrists so that they can deliver better care to more people. We must take advantage of these two trends: The surge in unmatched graduates and “shrinking shrinks,” or the decline in the psychiatric workforce pool. (The Royal College of Physicians has established a category of clinicians called physician associates,⁵ but they are comparable to physician assistants in the United States. As you will see, the construct I am proposing is different.)

The current landscape

Currently, psychiatrists are under a lot of pressure to see a certain number of patients. Patients consistently complain that psychiatrists spend a maximum of 15 minutes with them, that the visits are interrupted by phone calls, and that they are not being heard and helped. Burnout, a silent epidemic among physicians, is relatively prevalent in psychiatry.⁶ Hence, some psychiatrists are reducing their hours and retiring early. Psychiatry has the third-oldest workforce, with 59% of current psychiatrists aged 55 years or older.⁷ A better pay/work ratio and work/life balance would enable psychiatrists to enjoy more fulfilling careers.

Many psychiatrists are spending a lot of their time in research, administration, and the classroom. In addition to those issues, the United States currently has a broken mental health care system.⁸ Finally, the medical practice landscape has changed dramatically in recent years, and those changes undermine both the effectiveness and well-being of clinicians.

The historical landscape

Some people proudly refer to the deinstitutionalization of mental asylums and state mental hospitals in the United States. But where have these patients gone? According to a U.S. Justice Department report, 2,220,300 adults were incarcerated in U.S. federal and state prisons and county jails in 2013.⁹ In addition, 4,751,400 adults in 2013 were on probation or parole. The percentages of inmates in state and federal prisons and local jails with a psychiatric diagnosis were 56%, 45%, and 64%, respectively.

I work at the Maryland correctional institutions, part of the Maryland Department of Public Safety and Correctional Services. One thing that I consistently hear from several correctional officers is “had these inmates received timely help and care, they wouldn’t have ended up behind bars.” Because of the criminalization of mental illness, in 44 states, the number of people with mental illness is higher in a jail or prison than in the largest state psychiatric hospital, according to the Treatment Advocacy Center. We have to be responsible for many of the inmates currently in correctional facilities for committing crimes related to mental health problems. In Maryland, a small state, there are 30,000 inmates in jails, and state and federal prison. The average cost of a meal is $1.36, thus $1.36 x 3 meals x 30,000 inmates = $122,400.00 for food alone for 1 day – this average does not take other expenses into account. By using money and manpower wisely and taking care of individuals’ mental health problems before they commit crimes, better outcomes could be achieved.

I used to work for MedOptions Inc. doing psychiatry consults at nursing homes and assisted-living facilities. Because of the shortage of psychiatrists and nurse practitioners, especially in the suburbs and rural areas, those patients could not be seen in a timely manner even for their 3-month routine follow-ups. As my colleagues and I have written previously, many elderly individuals with major neurocognitive disorders are not on the Food and Drug Administration­–approved cognitive enhancers, such as donepezil, galantamine, and memantine.¹⁰ Instead, those patients are on benzodiazepines, which are associated with cognitive impairments, and increased risk of pneumonia and falls. Benzodiazepines also can cause and/or worsen disinhibited behavior. Also, in those settings, crisis situations often are addressed days to weeks later because of the doctor shortage. This situation is going to get worse, because this patient population is growing.
 

Child and geriatric psychiatry shortages

Child and geriatric psychiatrist shortages are even higher than those in general psychiatry.¹¹ Many years of training and low salaries are a few of the reasons some choose not to do a fellowship. These residency graduates would rather join a practice at an attending salary than at a fellow’s salary, which requires an additional 1 to 2 years of training. Student loans of $100,000–$500,000 after residency also discourage some from pursuing fellowship opportunities. We need to consider models such as 2 years of residency with 2 years of a child psychiatry fellowship or 3 years of residency with 1 year of geriatric psychiatry fellowship. Working as an adult attending physician (50% of the time) and concurrently doing a fellowship (50% of the time) while receiving an attending salary might motivate more people to complete a fellowship.

In specialties such as radiology, international medical graduates (IMGs) who have completed residency training in radiology in other countries can complete a radiology fellowship in a particular area for several years and can practice in the United States as board-eligible certified MDs. Likewise, in line with the model proposed here, we could provide unmatched graduates who have no residency training with 3 to 4 years of child psychiatry and geriatric psychiatry training in addition to some adult psychiatry training.

Implementation of such a model might take care of the shortage of child and geriatric psychiatrists. In 2015, there were 56 geriatric psychiatry fellowship programs; 54 positions were filled, and 51 fellows completed training.¹² “It appears that a reasonable percentage of IMGs who obtain a fellowship in geriatric psychiatry do not have an intent of pursuing a career in the field,” Marc H. Zisselman, MD, former geriatric psychiatry fellowship director and currently with the Einstein Medical Center in Philadelphia, told me in 2016. These numbers are not at all sufficient to take care of the nation’s unmet need. Hence, implementing alternate strategies is imperative.
 

Administrative tasks and care

What consumes a psychiatrist’s time and leads to burnout? The answer has to do with administrative tasks at work. Administrative tasks are not an effective use of time for an MD who has spent more than a decade in medical school, residency, and fellowship training. Although electronic medical record (EMR) systems are considered a major advancement, engaging in the process throughout the day is associated with exhaustion.

Many physicians feel that EMRs have slowed them down, and some are not well-equipped to use them in quick and efficient ways. EMRs also have led to physicians making minimal eye contact in interviews with patients. Patients often complain: “I am talking, and the doctor is looking at the computer and typing.” Patients consider this behavior to be unprofessional and rude. In a survey of 57 U.S. physicians in family medicine, internal medicine, cardiology, and orthopedics, results showed that during the work day, 27% of their time was spent on direct clinical face time with patients and 49.2% was spent on EMR and desk work. While in the examination room with patients, physicians spent 52.9% of their time on direct clinical face time and 37.0% on EMR and desk work. Outside office hours, physicians spend up to 2 hours of personal time each night doing additional computer and other clerical work.¹³

Several EMR software systems, such as CareLogic, Cerner, Epic,NextGen, PointClickCare, and Sunrise, are used in the United States. The U.S. Veterans Affairs Medical Centers (VAMCs) use the computerized patient record system (CPRS) across the country. VA clinicians find CPRS extremely useful when they move from one VAMC to another. Likewise, hospitals and universities may use one software system such as the CPRS and thus, when clinicians change jobs, they find it hard to adapt to the new system.

Because psychiatrists are wasting a lot of time doing administrative tasks, they might be unable to do a good job with regard to making the right diagnoses and prescribing the best treatments.When I ask patients what are they diagnosed with, they tell me: “It depends on who you ask,” or “I’ve been diagnosed with everything.” This shows that we are not doing a good job or something is not right.

Currently, psychiatrists do not have the time and/or interest to make the right diagnoses and provide adequate psychoeducation for their patients. This also could be attributable to a variety of factors, including, but not limited to, time constraints, cynicism, and apathy. Time constraints also lead to the gross underutilization¹⁴ of relapse prevention strategies such as long-acting injectables and medications that can prevent suicide, such as lithium and clozapine.¹⁵

Other factors that undermine good care include not participating in continuing medical education (CME) and not staying up to date with the literature. For example, haloperidol continues to be one of the most frequently prescribed (probably, the most common) antipsychotic, although it is clearly neurotoxic^16,17 and other safer options are available.¹⁸ Board certification and maintenance of certification (MOC) are not synonymous with good clinical practice. Many physicians are finding it hard to complete daily documentation, let alone time for MOC. For a variety of reasons, many are not maintaining certification, and this number is likely to increase. Think about how much time is devoted to the one-to-one interview with the patient and direct patient care during the 15-minute medical check appointment and the hour-long new evaluation. In some clinics, psychiatrists are asked to see more than 25 patients in 4 hours. Some U.S.-based psychiatrists see 65 inpatients and initiate 10 new evaluations in a single day. Under those kinds of time constraints, how can we provide quality care?
 

A model that would address the shortage

Overall, 7,826 PGY-1 applicants were unmatched in 2019, according to data from the 2019 Main Residency Match.¹⁹ Psychiatry residency programs could give these unmatched graduates 6 months of training (arbitrary duration) in psychiatry, which is not at all difficult with the program modules that are available.²⁰ We could use them as physician associates as a major contributor to our workforce to complete administrative and other clinical tasks.

Administrative tasks are not necessarily negative, as all psychiatrists have done administrative tasks as medical students, residents, and fellows. However, at this point, administrative tasks are not an effective use of a psychiatrist’s time. Those physician associates could be paired with two to three psychiatrists to do administrative tasks (for making daytime and overnight phone calls; handling prescriptions, prior authorizations, and medication orders, especially over-the-counter and comfort medications in the inpatient units; doing chart reviews; ordering and checking laboratory tests; collecting collateral information from previous clinicians and records; printing medication education pamphlets; faxing; corresponding with insurance companies/utilization review; performing documentation; billing; and taking care of other clinical and administrative paperwork).

In addition, physician associates could collect information using rating scales such as the 9-item Patient Health Questionnaire for measurement-based care²¹ and Geriatric Depression Scale, both of which are currently not used in psychiatric practice because of time constraints and lack of manpower. Keep in mind that these individuals are medical doctors and could do a good job with these kinds of tasks. Most of them already have clinical experience in the United States and know the health care system. These MDs could conduct an initial interview (what medical students, residents, and fellows do) and present to the attending psychiatrist. Psychiatrists could then focus on the follow-up interview; diagnoses and treatment; major medical decision making, including shared decision making (patients feel that they are not part of the treatment plan); and seeing more patients, which is a more effective use of their time. This training would give these physician associates a chance to work as doctors and make a living. These MDs have completed medical school training after passing Medical College Admission Test – equivalent exams in their countries. They have passed all steps of the U.S. Medical Licensing Examination and have received Educational Commission for Foreign Medical Graduates certification. Some have even completed residency programs in their home countries.

Some U.S. states already have implemented these kinds of programs. In Arkansas, Kansas, and Missouri,^22,23 legislators have passed laws allowing unmatched graduates who have not completed a residency program to work in medically underserved areas with a collaborating physician. These physicians must directly supervise the new doctors for at least a month before they can see patients on their own. Another proposal that has been suggested to address the psychiatrist shortage is employing physician assistants to provide care.^24-26

The model proposed here is comparable to postdoctoral fellow-principal investigator and resident-attending collaborative work. At hospitals, a certified nurse assistant helps patients with health care needs under the supervision of a nurse. Similarly, a physician associate could help a psychiatrist under his or her supervision. In the Sheppard Pratt Health System in Baltimore, where I worked previously, for example, nurses dictate and prepare discharge summaries for the attending physician with whom they work. These are the kinds of tasks that physician associates could do as well.

The wait time to get a new evaluation with a psychiatrist is enormous. The policy is that a new patient admitted to an inpatient unit must be seen within 24 hours. With this model, the physician associates could see patients within a few hours, take care of their most immediate needs, take a history and conduct a physical, and write an admission note for the attending psychiatrist to sign. Currently, the outpatient practice is so busy that psychiatrists do not have the time to read the discharge summaries of patients referred to them after a recent hospitalization, which often leads to poor aftercare. The physician associates could read the discharge summaries and provide pertinent information to the attending psychiatrists.

In the inpatient units and emergency departments, nurses and social workers see patients before the attending physician, present patient information to the attending psychiatrist, and document their findings. It is redundant for the physician to write the same narrative again. Rather, the physician could add an addendum to the nurse’s or social worker’s notes and sign off. This would save a lot of time.

Numerous well-designed studies support the adoption of collaborative care models as one means of providing quality psychiatric care to larger populations.^27,28 The American Psychiatric Association (APA) is currently training 3,500 psychiatrists in collaborative care through the Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiative.^29,30 Despite this training and the services provided by the nurse practitioners and physician assistants, the shortage of psychiatrists has not been adequately addressed. Hence, we need to think outside the box to find other potential pragmatic solutions.

Simply increasing the hours of work or the number of nurse practitioners or physician assistants already in practice is not going to solve the problem completely. The model proposed here and previously³¹ is likely to improve the quality of care that we now provide. This model should not be seen as exploiting these unmatched medical graduates and setting up a two-tiered health care system. The salary for these physicians would be a small percentage (5%-10%; these are arbitrary percentages) from the reimbursement of the attending psychiatrist. This model would not affect the salary of the attending psychiatrists; with this model, they would be able to see 25%-50% more patients (again, arbitrary percentages) with the help and support from these physician associates.
 

Potential barriers to implementation

There could be inherent barriers and complications to implementation of this model that are difficult to foresee at this point. Nurse practitioners (222,000 plus) and physician assistants (83,000 plus) have a fixed and structured curriculum, have national examining boards and national organizations with recertification requirements, and are licensed as independent practitioners, at least as far as CME is concerned.

Physician associates would need a standardized curriculum and examinations to validate what they have studied and learned. This process might be an important part of the credentialing of these individuals, as well as evaluation of cultural competency. If this model is to successfully lead to formation of a specific clinical group, it might need its own specific identity, national organization, national standards of competency, national certification and recertification processes, and national conference and CME or at least a subsection in a national behavioral and medical health organization, such as the APA or the American Academy of Child and Adolescent Psychiatry.

It would be desirable to “field test” the physician associate concept to clarify implementation difficulties, including the ones described above, that could arise. The cost of implementation of this program should not be of much concern; the 6-month training could be on a volunteer basis, or a small stipend might be paid by graduate medical education funding. This model could prove to be rewarding long term, save trillions of health care dollars, and allow us to provide exceptional and timely care.
 

Conclusion

The 2020 Mental Health America annual State of Mental Health in America report found that more than 70% of youth with severe major depressive disorder were in need of treatment in 2017. The percentage of adults with any mental illness who did not receive treatment stood at about 57.2%.³² Meanwhile, from 1999 through 2014, the age-adjusted suicide rate in the United States increased 24%.³³ More individuals are seeking help because of increased awareness.^34,35 In light of the access to services afforded by the ACA, physician associates might ease the workload of psychiatrists and enable them to deliver better care to more people. We would not necessarily have to use the term “physician associate” and could generate better terminologies later. In short, let’s tap into the pools of unmatched graduates and shrinking shrinks! If this model is successful, it could be used in other specialties and countries. The stakes for our patients have never been higher.

References

1. Bishop TF et al. Health Aff. 2016;35(7):1271-7.

2. National Council Medical Director Institute. The psychiatric shortage: Causes and solutions. 2017. Washington: National Council for Behavioral Health.

3. Satiani A et al. Psychiatric Serv. 2018;69:710-3.

4. Carlat D. Psychiatric Times. 2010 Aug 3;27(8).

5. McCartney M. BMJ. 2017;359:j5022.

6. Maslach C and Leiter MP. World Psychiatry. 2016 Jun 5;15:103-11.

7. Merritt Hawkins. “The silent shortage: A white paper examining supply, demand and recruitment trends in psychiatry.” 2018.

8. Sederer LI and Sharfstein SS. JAMA. 2014 Sep 24;312:1195-6.

9. James DJ and Glaze LE. Mental health problems of prison and jail inmates. 2006 Sep. U.S. Justice Department, Bureau of Justice Statistics Special Report.

10. Koola MM et al. J Geriatr Care Res. 2018;5(2):57-67.

11. Buckley PF and Nasrallah HA. Curr Psychiatr. 2016;15:23-4.

12. American Medical Association Database. Open Residency and Fellowship Positions.

13. Sinsky C et al. Ann Intern Med. 2016;165:753-60.

14. Koola MM. Curr Psychiatr. 2017 Mar. 16(3):19-20,47,e1.

15. Koola MM and Sebastian J. HSOA J Psychiatry Depress Anxiety. 2016;(2):1-11.

16. Nasrallah HA and Chen AT. Ann Clin Psychiatry. 2017 Aug;29(3):195-202.

17. Nasrallah HA. Curr Psychiatr. 2013 Jul;7-8.

18. Chen AT and Nasrallah HA. Schizophr Res. 2019 Jun;208:1-7.

19. National Resident Matching Program, Results and Data: 2019 Main Residency Match. National Resident Matching Program, Washington, 2019.

20. Masters KJ. J Physician Assist Educ. 2015 Sep;26(3):136-43.

21. Koola MM et al. J Nerv Ment Dis. 2011;199(12):989-90.

22. “New Missouri licensing offers ‘Band-Aid’ for physician shortages.” Kansas City Business Journal. Updated 2017 May 16.

23. “After earning an MD, she’s headed back to school – to become a nurse.” STAT. 2016 Nov 8.

24. Keizer TB and Trangle MA. Acad Psychiatry. 2015 Dec;39(6):691-4.

25. Miller JG and Peterson DJ. Acad Psychiatry. 2015 Dec;39(6):685-6.

26. Smith MS. Curr Psychiatr. 2019 Sep;18(9):17-24.

27. Osofsky HJ et al. Acad Psychiatry. 2016 Oct;40(5):747-54.

28. Dreier-Wolfgramm A et al. Z Gerontol Geriatr. 2017 May;50(Suppl 2):68-77.

29. Huang H and Barkil-Oteo A. Psychosomatics. 2015 Nov-Dec;56(6):658-61.

30. Raney L et al. Fam Syst Health. 2014 Jun;32(2):147-8.

31. Koola MM. Curr Psychiatr. 2016 Dec. 15(12):33-4.

32. Mental Health America. State of Mental Health in America 2020.

33. Curtin SC et al. NCHS Data Brief. 2016 Apr;(241):1-8.

34. Kelly DL et al. Ann Intern Med. 2020;172(2):167-8.

35. Miller JP and Nasrallah HA. Curr Psychiatr. 2015;14(12):45-6.

Dr. Koola is an associate professor in the department of psychiatry and behavioral health at Stony Brook (N.Y.) University. His main area of interest is novel therapeutic discovery in the treatment of schizophrenia. He has a particular interest in improving the health care delivery system for people with psychiatric illness. Dr. Koola declared no conflicts of interest. He can be reached at [email protected].

*This commentary was updated 2/2/2020.

For many years now, we have been lamenting the shortage of psychiatrists practicing in the United States. At this point, we must identify possible solutions.^1,2 Currently, the shortage of practicing psychiatrists in the United States could be as high as 45,000.³ The major problem is that the number of psychiatry residency positions will not increase in the foreseeable future, thus generating more psychiatrists is not an option.

Medicare pays about $150,000 per residency slot per year. To solve the mental health access problem, $27 billion (45,000 x $150,000 x 4 years)* would be required from Medicare, which is not feasible.⁴ The national average starting salary for psychiatrists from 2018-2019 was about $273,000 (much lower in academic institutions), according to Merritt Hawkins, the physician recruiting firm. That salary is modest, compared with those offered in other medical specialties. For this reason, many graduates choose other lucrative specialties. And we know that increasing the salaries of psychiatrists alone would not lead more people to choose psychiatry. On paper, it may say they work a 40-hour week, but they end up working 60 hours a week.

To make matters worse, family medicine and internal medicine doctors generally would rather not deal with people with mental illness and do “cherry-picking and lemon-dropping.” While many patients present to primary care with mental health issues, lack of time and education in psychiatric disorders and treatment hinder these physicians. In short, the mental health field cannot count on primary care physicians.

Meanwhile, there are thousands of unmatched residency graduates. In light of those realities, perhaps psychiatry residency programs could provide these unmatched graduates with 6 months of training and use them to supplement the workforce. These medical doctors, or “physician associates,” could be paired with a few psychiatrists to do clinical and administrative work. With one in four individuals having mental health issues, and more and more people seeking help because of increasing awareness and the benefits that accompanied the Affordable Care Act (ACA), physician associates might ease the workload of psychiatrists so that they can deliver better care to more people. We must take advantage of these two trends: The surge in unmatched graduates and “shrinking shrinks,” or the decline in the psychiatric workforce pool. (The Royal College of Physicians has established a category of clinicians called physician associates,⁵ but they are comparable to physician assistants in the United States. As you will see, the construct I am proposing is different.)

The current landscape

Currently, psychiatrists are under a lot of pressure to see a certain number of patients. Patients consistently complain that psychiatrists spend a maximum of 15 minutes with them, that the visits are interrupted by phone calls, and that they are not being heard and helped. Burnout, a silent epidemic among physicians, is relatively prevalent in psychiatry.⁶ Hence, some psychiatrists are reducing their hours and retiring early. Psychiatry has the third-oldest workforce, with 59% of current psychiatrists aged 55 years or older.⁷ A better pay/work ratio and work/life balance would enable psychiatrists to enjoy more fulfilling careers.

Many psychiatrists are spending a lot of their time in research, administration, and the classroom. In addition to those issues, the United States currently has a broken mental health care system.⁸ Finally, the medical practice landscape has changed dramatically in recent years, and those changes undermine both the effectiveness and well-being of clinicians.

The historical landscape

Some people proudly refer to the deinstitutionalization of mental asylums and state mental hospitals in the United States. But where have these patients gone? According to a U.S. Justice Department report, 2,220,300 adults were incarcerated in U.S. federal and state prisons and county jails in 2013.⁹ In addition, 4,751,400 adults in 2013 were on probation or parole. The percentages of inmates in state and federal prisons and local jails with a psychiatric diagnosis were 56%, 45%, and 64%, respectively.

I work at the Maryland correctional institutions, part of the Maryland Department of Public Safety and Correctional Services. One thing that I consistently hear from several correctional officers is “had these inmates received timely help and care, they wouldn’t have ended up behind bars.” Because of the criminalization of mental illness, in 44 states, the number of people with mental illness is higher in a jail or prison than in the largest state psychiatric hospital, according to the Treatment Advocacy Center. We have to be responsible for many of the inmates currently in correctional facilities for committing crimes related to mental health problems. In Maryland, a small state, there are 30,000 inmates in jails, and state and federal prison. The average cost of a meal is $1.36, thus $1.36 x 3 meals x 30,000 inmates = $122,400.00 for food alone for 1 day – this average does not take other expenses into account. By using money and manpower wisely and taking care of individuals’ mental health problems before they commit crimes, better outcomes could be achieved.

I used to work for MedOptions Inc. doing psychiatry consults at nursing homes and assisted-living facilities. Because of the shortage of psychiatrists and nurse practitioners, especially in the suburbs and rural areas, those patients could not be seen in a timely manner even for their 3-month routine follow-ups. As my colleagues and I have written previously, many elderly individuals with major neurocognitive disorders are not on the Food and Drug Administration­–approved cognitive enhancers, such as donepezil, galantamine, and memantine.¹⁰ Instead, those patients are on benzodiazepines, which are associated with cognitive impairments, and increased risk of pneumonia and falls. Benzodiazepines also can cause and/or worsen disinhibited behavior. Also, in those settings, crisis situations often are addressed days to weeks later because of the doctor shortage. This situation is going to get worse, because this patient population is growing.
 

Child and geriatric psychiatry shortages

Child and geriatric psychiatrist shortages are even higher than those in general psychiatry.¹¹ Many years of training and low salaries are a few of the reasons some choose not to do a fellowship. These residency graduates would rather join a practice at an attending salary than at a fellow’s salary, which requires an additional 1 to 2 years of training. Student loans of $100,000–$500,000 after residency also discourage some from pursuing fellowship opportunities. We need to consider models such as 2 years of residency with 2 years of a child psychiatry fellowship or 3 years of residency with 1 year of geriatric psychiatry fellowship. Working as an adult attending physician (50% of the time) and concurrently doing a fellowship (50% of the time) while receiving an attending salary might motivate more people to complete a fellowship.

In specialties such as radiology, international medical graduates (IMGs) who have completed residency training in radiology in other countries can complete a radiology fellowship in a particular area for several years and can practice in the United States as board-eligible certified MDs. Likewise, in line with the model proposed here, we could provide unmatched graduates who have no residency training with 3 to 4 years of child psychiatry and geriatric psychiatry training in addition to some adult psychiatry training.

Implementation of such a model might take care of the shortage of child and geriatric psychiatrists. In 2015, there were 56 geriatric psychiatry fellowship programs; 54 positions were filled, and 51 fellows completed training.¹² “It appears that a reasonable percentage of IMGs who obtain a fellowship in geriatric psychiatry do not have an intent of pursuing a career in the field,” Marc H. Zisselman, MD, former geriatric psychiatry fellowship director and currently with the Einstein Medical Center in Philadelphia, told me in 2016. These numbers are not at all sufficient to take care of the nation’s unmet need. Hence, implementing alternate strategies is imperative.
 

Administrative tasks and care

What consumes a psychiatrist’s time and leads to burnout? The answer has to do with administrative tasks at work. Administrative tasks are not an effective use of time for an MD who has spent more than a decade in medical school, residency, and fellowship training. Although electronic medical record (EMR) systems are considered a major advancement, engaging in the process throughout the day is associated with exhaustion.

Many physicians feel that EMRs have slowed them down, and some are not well-equipped to use them in quick and efficient ways. EMRs also have led to physicians making minimal eye contact in interviews with patients. Patients often complain: “I am talking, and the doctor is looking at the computer and typing.” Patients consider this behavior to be unprofessional and rude. In a survey of 57 U.S. physicians in family medicine, internal medicine, cardiology, and orthopedics, results showed that during the work day, 27% of their time was spent on direct clinical face time with patients and 49.2% was spent on EMR and desk work. While in the examination room with patients, physicians spent 52.9% of their time on direct clinical face time and 37.0% on EMR and desk work. Outside office hours, physicians spend up to 2 hours of personal time each night doing additional computer and other clerical work.¹³

Several EMR software systems, such as CareLogic, Cerner, Epic,NextGen, PointClickCare, and Sunrise, are used in the United States. The U.S. Veterans Affairs Medical Centers (VAMCs) use the computerized patient record system (CPRS) across the country. VA clinicians find CPRS extremely useful when they move from one VAMC to another. Likewise, hospitals and universities may use one software system such as the CPRS and thus, when clinicians change jobs, they find it hard to adapt to the new system.

Because psychiatrists are wasting a lot of time doing administrative tasks, they might be unable to do a good job with regard to making the right diagnoses and prescribing the best treatments.When I ask patients what are they diagnosed with, they tell me: “It depends on who you ask,” or “I’ve been diagnosed with everything.” This shows that we are not doing a good job or something is not right.

Currently, psychiatrists do not have the time and/or interest to make the right diagnoses and provide adequate psychoeducation for their patients. This also could be attributable to a variety of factors, including, but not limited to, time constraints, cynicism, and apathy. Time constraints also lead to the gross underutilization¹⁴ of relapse prevention strategies such as long-acting injectables and medications that can prevent suicide, such as lithium and clozapine.¹⁵

Other factors that undermine good care include not participating in continuing medical education (CME) and not staying up to date with the literature. For example, haloperidol continues to be one of the most frequently prescribed (probably, the most common) antipsychotic, although it is clearly neurotoxic^16,17 and other safer options are available.¹⁸ Board certification and maintenance of certification (MOC) are not synonymous with good clinical practice. Many physicians are finding it hard to complete daily documentation, let alone time for MOC. For a variety of reasons, many are not maintaining certification, and this number is likely to increase. Think about how much time is devoted to the one-to-one interview with the patient and direct patient care during the 15-minute medical check appointment and the hour-long new evaluation. In some clinics, psychiatrists are asked to see more than 25 patients in 4 hours. Some U.S.-based psychiatrists see 65 inpatients and initiate 10 new evaluations in a single day. Under those kinds of time constraints, how can we provide quality care?
 

A model that would address the shortage

Overall, 7,826 PGY-1 applicants were unmatched in 2019, according to data from the 2019 Main Residency Match.¹⁹ Psychiatry residency programs could give these unmatched graduates 6 months of training (arbitrary duration) in psychiatry, which is not at all difficult with the program modules that are available.²⁰ We could use them as physician associates as a major contributor to our workforce to complete administrative and other clinical tasks.

Administrative tasks are not necessarily negative, as all psychiatrists have done administrative tasks as medical students, residents, and fellows. However, at this point, administrative tasks are not an effective use of a psychiatrist’s time. Those physician associates could be paired with two to three psychiatrists to do administrative tasks (for making daytime and overnight phone calls; handling prescriptions, prior authorizations, and medication orders, especially over-the-counter and comfort medications in the inpatient units; doing chart reviews; ordering and checking laboratory tests; collecting collateral information from previous clinicians and records; printing medication education pamphlets; faxing; corresponding with insurance companies/utilization review; performing documentation; billing; and taking care of other clinical and administrative paperwork).

In addition, physician associates could collect information using rating scales such as the 9-item Patient Health Questionnaire for measurement-based care²¹ and Geriatric Depression Scale, both of which are currently not used in psychiatric practice because of time constraints and lack of manpower. Keep in mind that these individuals are medical doctors and could do a good job with these kinds of tasks. Most of them already have clinical experience in the United States and know the health care system. These MDs could conduct an initial interview (what medical students, residents, and fellows do) and present to the attending psychiatrist. Psychiatrists could then focus on the follow-up interview; diagnoses and treatment; major medical decision making, including shared decision making (patients feel that they are not part of the treatment plan); and seeing more patients, which is a more effective use of their time. This training would give these physician associates a chance to work as doctors and make a living. These MDs have completed medical school training after passing Medical College Admission Test – equivalent exams in their countries. They have passed all steps of the U.S. Medical Licensing Examination and have received Educational Commission for Foreign Medical Graduates certification. Some have even completed residency programs in their home countries.

Some U.S. states already have implemented these kinds of programs. In Arkansas, Kansas, and Missouri,^22,23 legislators have passed laws allowing unmatched graduates who have not completed a residency program to work in medically underserved areas with a collaborating physician. These physicians must directly supervise the new doctors for at least a month before they can see patients on their own. Another proposal that has been suggested to address the psychiatrist shortage is employing physician assistants to provide care.^24-26

The model proposed here is comparable to postdoctoral fellow-principal investigator and resident-attending collaborative work. At hospitals, a certified nurse assistant helps patients with health care needs under the supervision of a nurse. Similarly, a physician associate could help a psychiatrist under his or her supervision. In the Sheppard Pratt Health System in Baltimore, where I worked previously, for example, nurses dictate and prepare discharge summaries for the attending physician with whom they work. These are the kinds of tasks that physician associates could do as well.

The wait time to get a new evaluation with a psychiatrist is enormous. The policy is that a new patient admitted to an inpatient unit must be seen within 24 hours. With this model, the physician associates could see patients within a few hours, take care of their most immediate needs, take a history and conduct a physical, and write an admission note for the attending psychiatrist to sign. Currently, the outpatient practice is so busy that psychiatrists do not have the time to read the discharge summaries of patients referred to them after a recent hospitalization, which often leads to poor aftercare. The physician associates could read the discharge summaries and provide pertinent information to the attending psychiatrists.

In the inpatient units and emergency departments, nurses and social workers see patients before the attending physician, present patient information to the attending psychiatrist, and document their findings. It is redundant for the physician to write the same narrative again. Rather, the physician could add an addendum to the nurse’s or social worker’s notes and sign off. This would save a lot of time.

Numerous well-designed studies support the adoption of collaborative care models as one means of providing quality psychiatric care to larger populations.^27,28 The American Psychiatric Association (APA) is currently training 3,500 psychiatrists in collaborative care through the Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiative.^29,30 Despite this training and the services provided by the nurse practitioners and physician assistants, the shortage of psychiatrists has not been adequately addressed. Hence, we need to think outside the box to find other potential pragmatic solutions.

Simply increasing the hours of work or the number of nurse practitioners or physician assistants already in practice is not going to solve the problem completely. The model proposed here and previously³¹ is likely to improve the quality of care that we now provide. This model should not be seen as exploiting these unmatched medical graduates and setting up a two-tiered health care system. The salary for these physicians would be a small percentage (5%-10%; these are arbitrary percentages) from the reimbursement of the attending psychiatrist. This model would not affect the salary of the attending psychiatrists; with this model, they would be able to see 25%-50% more patients (again, arbitrary percentages) with the help and support from these physician associates.
 

Potential barriers to implementation

There could be inherent barriers and complications to implementation of this model that are difficult to foresee at this point. Nurse practitioners (222,000 plus) and physician assistants (83,000 plus) have a fixed and structured curriculum, have national examining boards and national organizations with recertification requirements, and are licensed as independent practitioners, at least as far as CME is concerned.

Physician associates would need a standardized curriculum and examinations to validate what they have studied and learned. This process might be an important part of the credentialing of these individuals, as well as evaluation of cultural competency. If this model is to successfully lead to formation of a specific clinical group, it might need its own specific identity, national organization, national standards of competency, national certification and recertification processes, and national conference and CME or at least a subsection in a national behavioral and medical health organization, such as the APA or the American Academy of Child and Adolescent Psychiatry.

It would be desirable to “field test” the physician associate concept to clarify implementation difficulties, including the ones described above, that could arise. The cost of implementation of this program should not be of much concern; the 6-month training could be on a volunteer basis, or a small stipend might be paid by graduate medical education funding. This model could prove to be rewarding long term, save trillions of health care dollars, and allow us to provide exceptional and timely care.
 

Conclusion

The 2020 Mental Health America annual State of Mental Health in America report found that more than 70% of youth with severe major depressive disorder were in need of treatment in 2017. The percentage of adults with any mental illness who did not receive treatment stood at about 57.2%.³² Meanwhile, from 1999 through 2014, the age-adjusted suicide rate in the United States increased 24%.³³ More individuals are seeking help because of increased awareness.^34,35 In light of the access to services afforded by the ACA, physician associates might ease the workload of psychiatrists and enable them to deliver better care to more people. We would not necessarily have to use the term “physician associate” and could generate better terminologies later. In short, let’s tap into the pools of unmatched graduates and shrinking shrinks! If this model is successful, it could be used in other specialties and countries. The stakes for our patients have never been higher.

References

1. Bishop TF et al. Health Aff. 2016;35(7):1271-7.

2. National Council Medical Director Institute. The psychiatric shortage: Causes and solutions. 2017. Washington: National Council for Behavioral Health.

3. Satiani A et al. Psychiatric Serv. 2018;69:710-3.

4. Carlat D. Psychiatric Times. 2010 Aug 3;27(8).

5. McCartney M. BMJ. 2017;359:j5022.

6. Maslach C and Leiter MP. World Psychiatry. 2016 Jun 5;15:103-11.

7. Merritt Hawkins. “The silent shortage: A white paper examining supply, demand and recruitment trends in psychiatry.” 2018.

8. Sederer LI and Sharfstein SS. JAMA. 2014 Sep 24;312:1195-6.

9. James DJ and Glaze LE. Mental health problems of prison and jail inmates. 2006 Sep. U.S. Justice Department, Bureau of Justice Statistics Special Report.

10. Koola MM et al. J Geriatr Care Res. 2018;5(2):57-67.

11. Buckley PF and Nasrallah HA. Curr Psychiatr. 2016;15:23-4.

12. American Medical Association Database. Open Residency and Fellowship Positions.

13. Sinsky C et al. Ann Intern Med. 2016;165:753-60.

14. Koola MM. Curr Psychiatr. 2017 Mar. 16(3):19-20,47,e1.

15. Koola MM and Sebastian J. HSOA J Psychiatry Depress Anxiety. 2016;(2):1-11.

16. Nasrallah HA and Chen AT. Ann Clin Psychiatry. 2017 Aug;29(3):195-202.

17. Nasrallah HA. Curr Psychiatr. 2013 Jul;7-8.

18. Chen AT and Nasrallah HA. Schizophr Res. 2019 Jun;208:1-7.

19. National Resident Matching Program, Results and Data: 2019 Main Residency Match. National Resident Matching Program, Washington, 2019.

20. Masters KJ. J Physician Assist Educ. 2015 Sep;26(3):136-43.

21. Koola MM et al. J Nerv Ment Dis. 2011;199(12):989-90.

22. “New Missouri licensing offers ‘Band-Aid’ for physician shortages.” Kansas City Business Journal. Updated 2017 May 16.

23. “After earning an MD, she’s headed back to school – to become a nurse.” STAT. 2016 Nov 8.

24. Keizer TB and Trangle MA. Acad Psychiatry. 2015 Dec;39(6):691-4.

25. Miller JG and Peterson DJ. Acad Psychiatry. 2015 Dec;39(6):685-6.

26. Smith MS. Curr Psychiatr. 2019 Sep;18(9):17-24.

27. Osofsky HJ et al. Acad Psychiatry. 2016 Oct;40(5):747-54.

28. Dreier-Wolfgramm A et al. Z Gerontol Geriatr. 2017 May;50(Suppl 2):68-77.

29. Huang H and Barkil-Oteo A. Psychosomatics. 2015 Nov-Dec;56(6):658-61.

30. Raney L et al. Fam Syst Health. 2014 Jun;32(2):147-8.

31. Koola MM. Curr Psychiatr. 2016 Dec. 15(12):33-4.

32. Mental Health America. State of Mental Health in America 2020.

33. Curtin SC et al. NCHS Data Brief. 2016 Apr;(241):1-8.

34. Kelly DL et al. Ann Intern Med. 2020;172(2):167-8.

35. Miller JP and Nasrallah HA. Curr Psychiatr. 2015;14(12):45-6.

Dr. Koola is an associate professor in the department of psychiatry and behavioral health at Stony Brook (N.Y.) University. His main area of interest is novel therapeutic discovery in the treatment of schizophrenia. He has a particular interest in improving the health care delivery system for people with psychiatric illness. Dr. Koola declared no conflicts of interest. He can be reached at [email protected].

*This commentary was updated 2/2/2020.

For many years now, we have been lamenting the shortage of psychiatrists practicing in the United States. At this point, we must identify possible solutions.^1,2 Currently, the shortage of practicing psychiatrists in the United States could be as high as 45,000.³ The major problem is that the number of psychiatry residency positions will not increase in the foreseeable future, thus generating more psychiatrists is not an option.

Medicare pays about $150,000 per residency slot per year. To solve the mental health access problem, $27 billion (45,000 x $150,000 x 4 years)* would be required from Medicare, which is not feasible.⁴ The national average starting salary for psychiatrists from 2018-2019 was about $273,000 (much lower in academic institutions), according to Merritt Hawkins, the physician recruiting firm. That salary is modest, compared with those offered in other medical specialties. For this reason, many graduates choose other lucrative specialties. And we know that increasing the salaries of psychiatrists alone would not lead more people to choose psychiatry. On paper, it may say they work a 40-hour week, but they end up working 60 hours a week.

To make matters worse, family medicine and internal medicine doctors generally would rather not deal with people with mental illness and do “cherry-picking and lemon-dropping.” While many patients present to primary care with mental health issues, lack of time and education in psychiatric disorders and treatment hinder these physicians. In short, the mental health field cannot count on primary care physicians.

Meanwhile, there are thousands of unmatched residency graduates. In light of those realities, perhaps psychiatry residency programs could provide these unmatched graduates with 6 months of training and use them to supplement the workforce. These medical doctors, or “physician associates,” could be paired with a few psychiatrists to do clinical and administrative work. With one in four individuals having mental health issues, and more and more people seeking help because of increasing awareness and the benefits that accompanied the Affordable Care Act (ACA), physician associates might ease the workload of psychiatrists so that they can deliver better care to more people. We must take advantage of these two trends: The surge in unmatched graduates and “shrinking shrinks,” or the decline in the psychiatric workforce pool. (The Royal College of Physicians has established a category of clinicians called physician associates,⁵ but they are comparable to physician assistants in the United States. As you will see, the construct I am proposing is different.)

The current landscape

Currently, psychiatrists are under a lot of pressure to see a certain number of patients. Patients consistently complain that psychiatrists spend a maximum of 15 minutes with them, that the visits are interrupted by phone calls, and that they are not being heard and helped. Burnout, a silent epidemic among physicians, is relatively prevalent in psychiatry.⁶ Hence, some psychiatrists are reducing their hours and retiring early. Psychiatry has the third-oldest workforce, with 59% of current psychiatrists aged 55 years or older.⁷ A better pay/work ratio and work/life balance would enable psychiatrists to enjoy more fulfilling careers.

Many psychiatrists are spending a lot of their time in research, administration, and the classroom. In addition to those issues, the United States currently has a broken mental health care system.⁸ Finally, the medical practice landscape has changed dramatically in recent years, and those changes undermine both the effectiveness and well-being of clinicians.

The historical landscape

Some people proudly refer to the deinstitutionalization of mental asylums and state mental hospitals in the United States. But where have these patients gone? According to a U.S. Justice Department report, 2,220,300 adults were incarcerated in U.S. federal and state prisons and county jails in 2013.⁹ In addition, 4,751,400 adults in 2013 were on probation or parole. The percentages of inmates in state and federal prisons and local jails with a psychiatric diagnosis were 56%, 45%, and 64%, respectively.

I work at the Maryland correctional institutions, part of the Maryland Department of Public Safety and Correctional Services. One thing that I consistently hear from several correctional officers is “had these inmates received timely help and care, they wouldn’t have ended up behind bars.” Because of the criminalization of mental illness, in 44 states, the number of people with mental illness is higher in a jail or prison than in the largest state psychiatric hospital, according to the Treatment Advocacy Center. We have to be responsible for many of the inmates currently in correctional facilities for committing crimes related to mental health problems. In Maryland, a small state, there are 30,000 inmates in jails, and state and federal prison. The average cost of a meal is $1.36, thus $1.36 x 3 meals x 30,000 inmates = $122,400.00 for food alone for 1 day – this average does not take other expenses into account. By using money and manpower wisely and taking care of individuals’ mental health problems before they commit crimes, better outcomes could be achieved.

I used to work for MedOptions Inc. doing psychiatry consults at nursing homes and assisted-living facilities. Because of the shortage of psychiatrists and nurse practitioners, especially in the suburbs and rural areas, those patients could not be seen in a timely manner even for their 3-month routine follow-ups. As my colleagues and I have written previously, many elderly individuals with major neurocognitive disorders are not on the Food and Drug Administration­–approved cognitive enhancers, such as donepezil, galantamine, and memantine.¹⁰ Instead, those patients are on benzodiazepines, which are associated with cognitive impairments, and increased risk of pneumonia and falls. Benzodiazepines also can cause and/or worsen disinhibited behavior. Also, in those settings, crisis situations often are addressed days to weeks later because of the doctor shortage. This situation is going to get worse, because this patient population is growing.
 

Child and geriatric psychiatry shortages

Child and geriatric psychiatrist shortages are even higher than those in general psychiatry.¹¹ Many years of training and low salaries are a few of the reasons some choose not to do a fellowship. These residency graduates would rather join a practice at an attending salary than at a fellow’s salary, which requires an additional 1 to 2 years of training. Student loans of $100,000–$500,000 after residency also discourage some from pursuing fellowship opportunities. We need to consider models such as 2 years of residency with 2 years of a child psychiatry fellowship or 3 years of residency with 1 year of geriatric psychiatry fellowship. Working as an adult attending physician (50% of the time) and concurrently doing a fellowship (50% of the time) while receiving an attending salary might motivate more people to complete a fellowship.

In specialties such as radiology, international medical graduates (IMGs) who have completed residency training in radiology in other countries can complete a radiology fellowship in a particular area for several years and can practice in the United States as board-eligible certified MDs. Likewise, in line with the model proposed here, we could provide unmatched graduates who have no residency training with 3 to 4 years of child psychiatry and geriatric psychiatry training in addition to some adult psychiatry training.

Implementation of such a model might take care of the shortage of child and geriatric psychiatrists. In 2015, there were 56 geriatric psychiatry fellowship programs; 54 positions were filled, and 51 fellows completed training.¹² “It appears that a reasonable percentage of IMGs who obtain a fellowship in geriatric psychiatry do not have an intent of pursuing a career in the field,” Marc H. Zisselman, MD, former geriatric psychiatry fellowship director and currently with the Einstein Medical Center in Philadelphia, told me in 2016. These numbers are not at all sufficient to take care of the nation’s unmet need. Hence, implementing alternate strategies is imperative.
 

Administrative tasks and care

What consumes a psychiatrist’s time and leads to burnout? The answer has to do with administrative tasks at work. Administrative tasks are not an effective use of time for an MD who has spent more than a decade in medical school, residency, and fellowship training. Although electronic medical record (EMR) systems are considered a major advancement, engaging in the process throughout the day is associated with exhaustion.

Many physicians feel that EMRs have slowed them down, and some are not well-equipped to use them in quick and efficient ways. EMRs also have led to physicians making minimal eye contact in interviews with patients. Patients often complain: “I am talking, and the doctor is looking at the computer and typing.” Patients consider this behavior to be unprofessional and rude. In a survey of 57 U.S. physicians in family medicine, internal medicine, cardiology, and orthopedics, results showed that during the work day, 27% of their time was spent on direct clinical face time with patients and 49.2% was spent on EMR and desk work. While in the examination room with patients, physicians spent 52.9% of their time on direct clinical face time and 37.0% on EMR and desk work. Outside office hours, physicians spend up to 2 hours of personal time each night doing additional computer and other clerical work.¹³

Several EMR software systems, such as CareLogic, Cerner, Epic,NextGen, PointClickCare, and Sunrise, are used in the United States. The U.S. Veterans Affairs Medical Centers (VAMCs) use the computerized patient record system (CPRS) across the country. VA clinicians find CPRS extremely useful when they move from one VAMC to another. Likewise, hospitals and universities may use one software system such as the CPRS and thus, when clinicians change jobs, they find it hard to adapt to the new system.

Because psychiatrists are wasting a lot of time doing administrative tasks, they might be unable to do a good job with regard to making the right diagnoses and prescribing the best treatments.When I ask patients what are they diagnosed with, they tell me: “It depends on who you ask,” or “I’ve been diagnosed with everything.” This shows that we are not doing a good job or something is not right.

Currently, psychiatrists do not have the time and/or interest to make the right diagnoses and provide adequate psychoeducation for their patients. This also could be attributable to a variety of factors, including, but not limited to, time constraints, cynicism, and apathy. Time constraints also lead to the gross underutilization¹⁴ of relapse prevention strategies such as long-acting injectables and medications that can prevent suicide, such as lithium and clozapine.¹⁵

Other factors that undermine good care include not participating in continuing medical education (CME) and not staying up to date with the literature. For example, haloperidol continues to be one of the most frequently prescribed (probably, the most common) antipsychotic, although it is clearly neurotoxic^16,17 and other safer options are available.¹⁸ Board certification and maintenance of certification (MOC) are not synonymous with good clinical practice. Many physicians are finding it hard to complete daily documentation, let alone time for MOC. For a variety of reasons, many are not maintaining certification, and this number is likely to increase. Think about how much time is devoted to the one-to-one interview with the patient and direct patient care during the 15-minute medical check appointment and the hour-long new evaluation. In some clinics, psychiatrists are asked to see more than 25 patients in 4 hours. Some U.S.-based psychiatrists see 65 inpatients and initiate 10 new evaluations in a single day. Under those kinds of time constraints, how can we provide quality care?
 

A model that would address the shortage

Overall, 7,826 PGY-1 applicants were unmatched in 2019, according to data from the 2019 Main Residency Match.¹⁹ Psychiatry residency programs could give these unmatched graduates 6 months of training (arbitrary duration) in psychiatry, which is not at all difficult with the program modules that are available.²⁰ We could use them as physician associates as a major contributor to our workforce to complete administrative and other clinical tasks.

Administrative tasks are not necessarily negative, as all psychiatrists have done administrative tasks as medical students, residents, and fellows. However, at this point, administrative tasks are not an effective use of a psychiatrist’s time. Those physician associates could be paired with two to three psychiatrists to do administrative tasks (for making daytime and overnight phone calls; handling prescriptions, prior authorizations, and medication orders, especially over-the-counter and comfort medications in the inpatient units; doing chart reviews; ordering and checking laboratory tests; collecting collateral information from previous clinicians and records; printing medication education pamphlets; faxing; corresponding with insurance companies/utilization review; performing documentation; billing; and taking care of other clinical and administrative paperwork).

In addition, physician associates could collect information using rating scales such as the 9-item Patient Health Questionnaire for measurement-based care²¹ and Geriatric Depression Scale, both of which are currently not used in psychiatric practice because of time constraints and lack of manpower. Keep in mind that these individuals are medical doctors and could do a good job with these kinds of tasks. Most of them already have clinical experience in the United States and know the health care system. These MDs could conduct an initial interview (what medical students, residents, and fellows do) and present to the attending psychiatrist. Psychiatrists could then focus on the follow-up interview; diagnoses and treatment; major medical decision making, including shared decision making (patients feel that they are not part of the treatment plan); and seeing more patients, which is a more effective use of their time. This training would give these physician associates a chance to work as doctors and make a living. These MDs have completed medical school training after passing Medical College Admission Test – equivalent exams in their countries. They have passed all steps of the U.S. Medical Licensing Examination and have received Educational Commission for Foreign Medical Graduates certification. Some have even completed residency programs in their home countries.

Some U.S. states already have implemented these kinds of programs. In Arkansas, Kansas, and Missouri,^22,23 legislators have passed laws allowing unmatched graduates who have not completed a residency program to work in medically underserved areas with a collaborating physician. These physicians must directly supervise the new doctors for at least a month before they can see patients on their own. Another proposal that has been suggested to address the psychiatrist shortage is employing physician assistants to provide care.^24-26

The model proposed here is comparable to postdoctoral fellow-principal investigator and resident-attending collaborative work. At hospitals, a certified nurse assistant helps patients with health care needs under the supervision of a nurse. Similarly, a physician associate could help a psychiatrist under his or her supervision. In the Sheppard Pratt Health System in Baltimore, where I worked previously, for example, nurses dictate and prepare discharge summaries for the attending physician with whom they work. These are the kinds of tasks that physician associates could do as well.

The wait time to get a new evaluation with a psychiatrist is enormous. The policy is that a new patient admitted to an inpatient unit must be seen within 24 hours. With this model, the physician associates could see patients within a few hours, take care of their most immediate needs, take a history and conduct a physical, and write an admission note for the attending psychiatrist to sign. Currently, the outpatient practice is so busy that psychiatrists do not have the time to read the discharge summaries of patients referred to them after a recent hospitalization, which often leads to poor aftercare. The physician associates could read the discharge summaries and provide pertinent information to the attending psychiatrists.

In the inpatient units and emergency departments, nurses and social workers see patients before the attending physician, present patient information to the attending psychiatrist, and document their findings. It is redundant for the physician to write the same narrative again. Rather, the physician could add an addendum to the nurse’s or social worker’s notes and sign off. This would save a lot of time.

Numerous well-designed studies support the adoption of collaborative care models as one means of providing quality psychiatric care to larger populations.^27,28 The American Psychiatric Association (APA) is currently training 3,500 psychiatrists in collaborative care through the Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiative.^29,30 Despite this training and the services provided by the nurse practitioners and physician assistants, the shortage of psychiatrists has not been adequately addressed. Hence, we need to think outside the box to find other potential pragmatic solutions.

Simply increasing the hours of work or the number of nurse practitioners or physician assistants already in practice is not going to solve the problem completely. The model proposed here and previously³¹ is likely to improve the quality of care that we now provide. This model should not be seen as exploiting these unmatched medical graduates and setting up a two-tiered health care system. The salary for these physicians would be a small percentage (5%-10%; these are arbitrary percentages) from the reimbursement of the attending psychiatrist. This model would not affect the salary of the attending psychiatrists; with this model, they would be able to see 25%-50% more patients (again, arbitrary percentages) with the help and support from these physician associates.
 

Potential barriers to implementation

There could be inherent barriers and complications to implementation of this model that are difficult to foresee at this point. Nurse practitioners (222,000 plus) and physician assistants (83,000 plus) have a fixed and structured curriculum, have national examining boards and national organizations with recertification requirements, and are licensed as independent practitioners, at least as far as CME is concerned.

Physician associates would need a standardized curriculum and examinations to validate what they have studied and learned. This process might be an important part of the credentialing of these individuals, as well as evaluation of cultural competency. If this model is to successfully lead to formation of a specific clinical group, it might need its own specific identity, national organization, national standards of competency, national certification and recertification processes, and national conference and CME or at least a subsection in a national behavioral and medical health organization, such as the APA or the American Academy of Child and Adolescent Psychiatry.

It would be desirable to “field test” the physician associate concept to clarify implementation difficulties, including the ones described above, that could arise. The cost of implementation of this program should not be of much concern; the 6-month training could be on a volunteer basis, or a small stipend might be paid by graduate medical education funding. This model could prove to be rewarding long term, save trillions of health care dollars, and allow us to provide exceptional and timely care.
 

Conclusion

The 2020 Mental Health America annual State of Mental Health in America report found that more than 70% of youth with severe major depressive disorder were in need of treatment in 2017. The percentage of adults with any mental illness who did not receive treatment stood at about 57.2%.³² Meanwhile, from 1999 through 2014, the age-adjusted suicide rate in the United States increased 24%.³³ More individuals are seeking help because of increased awareness.^34,35 In light of the access to services afforded by the ACA, physician associates might ease the workload of psychiatrists and enable them to deliver better care to more people. We would not necessarily have to use the term “physician associate” and could generate better terminologies later. In short, let’s tap into the pools of unmatched graduates and shrinking shrinks! If this model is successful, it could be used in other specialties and countries. The stakes for our patients have never been higher.

References

1. Bishop TF et al. Health Aff. 2016;35(7):1271-7.

2. National Council Medical Director Institute. The psychiatric shortage: Causes and solutions. 2017. Washington: National Council for Behavioral Health.

3. Satiani A et al. Psychiatric Serv. 2018;69:710-3.

4. Carlat D. Psychiatric Times. 2010 Aug 3;27(8).

5. McCartney M. BMJ. 2017;359:j5022.

6. Maslach C and Leiter MP. World Psychiatry. 2016 Jun 5;15:103-11.

7. Merritt Hawkins. “The silent shortage: A white paper examining supply, demand and recruitment trends in psychiatry.” 2018.

8. Sederer LI and Sharfstein SS. JAMA. 2014 Sep 24;312:1195-6.

9. James DJ and Glaze LE. Mental health problems of prison and jail inmates. 2006 Sep. U.S. Justice Department, Bureau of Justice Statistics Special Report.

10. Koola MM et al. J Geriatr Care Res. 2018;5(2):57-67.

11. Buckley PF and Nasrallah HA. Curr Psychiatr. 2016;15:23-4.

12. American Medical Association Database. Open Residency and Fellowship Positions.

13. Sinsky C et al. Ann Intern Med. 2016;165:753-60.

14. Koola MM. Curr Psychiatr. 2017 Mar. 16(3):19-20,47,e1.

15. Koola MM and Sebastian J. HSOA J Psychiatry Depress Anxiety. 2016;(2):1-11.

16. Nasrallah HA and Chen AT. Ann Clin Psychiatry. 2017 Aug;29(3):195-202.

17. Nasrallah HA. Curr Psychiatr. 2013 Jul;7-8.

18. Chen AT and Nasrallah HA. Schizophr Res. 2019 Jun;208:1-7.

19. National Resident Matching Program, Results and Data: 2019 Main Residency Match. National Resident Matching Program, Washington, 2019.

20. Masters KJ. J Physician Assist Educ. 2015 Sep;26(3):136-43.

21. Koola MM et al. J Nerv Ment Dis. 2011;199(12):989-90.

22. “New Missouri licensing offers ‘Band-Aid’ for physician shortages.” Kansas City Business Journal. Updated 2017 May 16.

23. “After earning an MD, she’s headed back to school – to become a nurse.” STAT. 2016 Nov 8.

24. Keizer TB and Trangle MA. Acad Psychiatry. 2015 Dec;39(6):691-4.

25. Miller JG and Peterson DJ. Acad Psychiatry. 2015 Dec;39(6):685-6.

26. Smith MS. Curr Psychiatr. 2019 Sep;18(9):17-24.

27. Osofsky HJ et al. Acad Psychiatry. 2016 Oct;40(5):747-54.

28. Dreier-Wolfgramm A et al. Z Gerontol Geriatr. 2017 May;50(Suppl 2):68-77.

29. Huang H and Barkil-Oteo A. Psychosomatics. 2015 Nov-Dec;56(6):658-61.

30. Raney L et al. Fam Syst Health. 2014 Jun;32(2):147-8.

31. Koola MM. Curr Psychiatr. 2016 Dec. 15(12):33-4.

32. Mental Health America. State of Mental Health in America 2020.

33. Curtin SC et al. NCHS Data Brief. 2016 Apr;(241):1-8.

34. Kelly DL et al. Ann Intern Med. 2020;172(2):167-8.

35. Miller JP and Nasrallah HA. Curr Psychiatr. 2015;14(12):45-6.

Dr. Koola is an associate professor in the department of psychiatry and behavioral health at Stony Brook (N.Y.) University. His main area of interest is novel therapeutic discovery in the treatment of schizophrenia. He has a particular interest in improving the health care delivery system for people with psychiatric illness. Dr. Koola declared no conflicts of interest. He can be reached at [email protected].

*This commentary was updated 2/2/2020.

Emerging viruses that spread to humans from an animal host are commonplace and represent some of the deadliest diseases known. Given the details of the Wuhan coronavirus (2019-nCoV) outbreak, including the genetic profile of the disease agent, the hypothesis of a snake origin was the first raised in the peer-reviewed literature.

SISTEMA 12/Wikimedia Commons/CC BY-SA 4.0

It is a highly controversial origin story, however, given that mammals have been the sources of all other such zoonotic coronaviruses, as well as a host of other zoonotic diseases.

An animal source for emerging infections such as the 2019-nCoV is the default hypothesis, because “around 60% of all infectious diseases in humans are zoonotic, as are 75% of all emerging infectious diseases,” according to a United Nations report. The report goes on to say that, “on average, one new infectious disease emerges in humans every 4 months.”

To appreciate the emergence and nature of 2019-nCoV, it is important to examine the history of zoonotic outbreaks of other such diseases, especially with regard to the “mixing-vessel” phenomenon, which has been noted in closely related coronaviruses, including SARS and MERS, as well as the widely disparate HIV, Ebola, and influenza viruses.
 

Mutants in the mixing vessel

The mixing-vessel phenomenon is conceptually easy but molecularly complex. A single animal is coinfected with two related viruses; the virus genomes recombine together (virus “sex”) in that animal to form a new variant of virus. Such new mutant viruses can be more or less infective, more or less deadly, and more or less able to jump the species or even genus barrier. An emerging viral zoonosis can occur when a human being is exposed to one of these new viruses (either from the origin species or another species intermediate) that is capable of also infecting a human cell. Such exposure can occur from close proximity to animal waste or body fluids, as in the farm environment, or from wildlife pets or the capturing and slaughtering of wildlife for food, as is proposed in the case of the Wuhan seafood market scenario. In fact, the scientists who postulated a snake intermediary as the potential mixing vessel also stated that 2019‐nCoV appears to be a recombinant virus between a bat coronavirus and an origin‐unknown coronavirus.

Coronaviruses in particular have a history of moving from animal to human hosts (and even back again), and their detailed genetic pattern and taxonomy can reveal the animal origin of these diseases.
 

Going batty

Bats, in particular, have been shown to be a reservoir species for both alphacoronaviruses and betacoronaviruses. Given their ecology and behavior, they have been found to play a key role in transmitting coronaviruses between species. A highly pertinent example of this is the SARS coronavirus, which was shown to have likely originated in Chinese horseshoe bats. The SARS virus, which is genetically closely related to the new Wuhan coronavirus, first infected humans in the Guangdong province of southern China in 2002.

Scientists speculate that the virus was then either transmitted directly to humans from bats, or passed through an intermediate host species, with SARS-like viruses isolated from Himalayan palm civets found in a live-animal market in Guangdong. The virus infection was also detected in other animals (including a raccoon dog, Nyctereutes procyonoides) and in humans working at the market.

The MERS coronavirus is a betacoronavirus that was first reported in Saudi Arabia in 2012. It turned out to be far more deadly than either SARS or the Wuhan virus (at least as far as current estimates of the new coronavirus’s behavior). The MERS genotype was found to be closely related to MERS-like viruses in bats in Saudi Arabia, Africa, Europe, and Asia. Studies done on the cell receptor for MERS showed an apparently conserved viral receptor in both bats and humans. And an identical strain of MERS was found in bats in a nearby cave and near the workplace of the first known human patient.

Wikimedia Commons/Mickey Samuni-Blank

However, in many of the other locations of the outbreak in the Middle East, there appeared to be limited contact between bats and humans, so scientists looked for another vector species, perhaps one that was acting as an intermediate. A high seroprevalence of MERS-CoV or a closely related virus was found in camels across the Arabian Peninsula and parts of eastern and northern Africa, while tests for MERS antibodies were negative in the most-likely other species of livestock or pet animals, including chickens, cows, goats, horses, and sheep.

In addition, the MERS-related CoV carried by camels was genetically highly similar to that detected in humans, as demonstrated in one particular outbreak on a farm in Qatar where the genetic sequences of MERS-CoV in the nasal swabs from 3 of 14 seropositive camels were similar to those of 2 human cases on the same farm. Similar genomic results were found in MERS-CoV from nasal swabs from camels in Saudi Arabia.
 

Other mixing-vessel zoonoses

HIV, the viral cause of AIDS, provides an almost-textbook origin story of the rise of a zoonotic supervillain. The virus was genetically traced to have a chimpanzee-to-human origin, but it was found to be more complicated than that. The virus first emerged in the 1920s in Africa in what is now the Democratic Republic of the Congo, well before its rise to a global pandemic in the 1980s.

Researchers believe the chimpanzee virus is a hybrid of the simian immunodeficiency viruses (SIVs) naturally infecting two different monkey species: the red-capped mangabey (Cercocebus torquatus) and the greater spot-nosed monkey (Cercopithecus nictitans). Chimpanzees kill and eat monkeys, which is likely how they acquired the monkey viruses. The viruses hybridized in a chimpanzee; the hybrid virus then spread through the chimpanzee population and was later transmitted to humans who captured and slaughtered chimps for meat (becoming exposed to their blood). This was the most likely origin of HIV-1.

HIV-1 also shows one of the major risks of zoonotic infections. They can continue to mutate in its human host, increasing the risk of greater virulence, but also interfering with the production of a universally effective vaccine. Since its transmission to humans, for example, many subtypes of the HIV-1 strain have developed, with genetic differences even in the same subtypes found to be up to 20%.

CDC/Frederick A. Murphy

Ebolavirus, first detected in 1976, is another case of bats being the potential culprit. Genetic analysis has shown that African fruit bats are likely involved in the spread of the virus and may be its reservoir host. Further evidence of this was found in the most recent human-infecting Bombali variant of the virus, which was identified in samples from bats collected from Sierra Leone.

It was also found that pigs can also become infected with Zaire ebolavirus, leading to the fear that pigs could serve as a mixing vessel for it and other filoviruses. Pigs have their own forms of Ebola-like disease viruses, which are not currently transmissible to humans, but could provide a potential mixing-vessel reservoir.
 

Emergent influenzas

The Western world has been most affected by these highly mutable, multispecies zoonotic viruses. The 1957 and 1968 flu pandemics contained a mixture of gene segments from human and avian influenza viruses. “What is clear from genetic analysis of the viruses that caused these past pandemics is that reassortment (gene swapping) occurred to produce novel influenza viruses that caused the pandemics. In both of these cases, the new viruses that emerged showed major differences from the parent viruses,” according to the Centers for Disease Control and Prevention.

Influenza is, however, a good example that all zoonoses are not the result of a mixing-vessel phenomenon, with evidence showing that the origin of the catastrophic 1918 virus pandemic likely resulted from a bird influenza virus directly infecting humans and pigs at about the same time without reassortment, according to the CDC.
 

Building a protective infrastructure

The first 2 decades of the 21st century saw a huge increase in efforts to develop an infrastructure to monitor and potentially prevent the spread of new zoonoses. As part of a global effort led by the United Nations, the U.S. Agency for International AID developed the PREDICT program in 2009 “to strengthen global capacity for detection and discovery of zoonotic viruses with pandemic potential. Those include coronaviruses, the family to which SARS and MERS belong; paramyxoviruses, like Nipah virus; influenza viruses; and filoviruses, like the ebolavirus.”

PREDICT funding to the EcoHealth Alliance led to discovery of the likely bat origins of the Zaire ebolavirus during the 2013-2016 outbreak. And throughout the existence of PREDICT, more than 145,000 animals and people were surveyed in areas of likely zoonotic outbreaks, leading to the detection of more than “1,100 unique viruses, including zoonotic diseases of public health concern such as Bombali ebolavirus, Zaire ebolavirus, Marburg virus, and MERS- and SARS-like coronaviruses,” according to PREDICT partner, the University of California, Davis.

PREDICT-2 was launched in 2014 with the continuing goals of “identifying and better characterizing pathogens of known epidemic and unknown pandemic potential; recognizing animal reservoirs and amplification hosts of human-infectious viruses; and efficiently targeting intervention action at human behaviors which amplify disease transmission at critical animal-animal and animal-human interfaces in hotspots of viral evolution, spillover, amplification, and spread.”

However, in October 2019, the Trump administration cut all funding to the PREDICT program, leading to its shutdown. In a New York Times interview, Peter Daszak, president of the EcoHealth Alliance, stated: “PREDICT was an approach to heading off pandemics, instead of sitting there waiting for them to emerge and then mobilizing.”

Ultimately, in addition to its human cost, the current Wuhan coronavirus outbreak can be looked at an object lesson – a test of the pandemic surveillance and control systems currently in place, and a practice run for the next and potentially deadlier zoonotic outbreaks to come. Perhaps it is also a reminder that cutting resources to detect zoonoses at their source in their animal hosts – before they enter the human chain– is perhaps not the most prudent of ideas.

[email protected]

Mark Lesney is the managing editor of MDedge.com/IDPractioner. He has a PhD in plant virology and a PhD in the history of science, with a focus on the history of biotechnology and medicine. He has served as an adjunct assistant professor of the department of biochemistry and molecular & celluar biology at Georgetown University, Washington.

Emerging viruses that spread to humans from an animal host are commonplace and represent some of the deadliest diseases known. Given the details of the Wuhan coronavirus (2019-nCoV) outbreak, including the genetic profile of the disease agent, the hypothesis of a snake origin was the first raised in the peer-reviewed literature.

SISTEMA 12/Wikimedia Commons/CC BY-SA 4.0

It is a highly controversial origin story, however, given that mammals have been the sources of all other such zoonotic coronaviruses, as well as a host of other zoonotic diseases.

An animal source for emerging infections such as the 2019-nCoV is the default hypothesis, because “around 60% of all infectious diseases in humans are zoonotic, as are 75% of all emerging infectious diseases,” according to a United Nations report. The report goes on to say that, “on average, one new infectious disease emerges in humans every 4 months.”

To appreciate the emergence and nature of 2019-nCoV, it is important to examine the history of zoonotic outbreaks of other such diseases, especially with regard to the “mixing-vessel” phenomenon, which has been noted in closely related coronaviruses, including SARS and MERS, as well as the widely disparate HIV, Ebola, and influenza viruses.
 

Mutants in the mixing vessel

The mixing-vessel phenomenon is conceptually easy but molecularly complex. A single animal is coinfected with two related viruses; the virus genomes recombine together (virus “sex”) in that animal to form a new variant of virus. Such new mutant viruses can be more or less infective, more or less deadly, and more or less able to jump the species or even genus barrier. An emerging viral zoonosis can occur when a human being is exposed to one of these new viruses (either from the origin species or another species intermediate) that is capable of also infecting a human cell. Such exposure can occur from close proximity to animal waste or body fluids, as in the farm environment, or from wildlife pets or the capturing and slaughtering of wildlife for food, as is proposed in the case of the Wuhan seafood market scenario. In fact, the scientists who postulated a snake intermediary as the potential mixing vessel also stated that 2019‐nCoV appears to be a recombinant virus between a bat coronavirus and an origin‐unknown coronavirus.

Coronaviruses in particular have a history of moving from animal to human hosts (and even back again), and their detailed genetic pattern and taxonomy can reveal the animal origin of these diseases.
 

Going batty

Bats, in particular, have been shown to be a reservoir species for both alphacoronaviruses and betacoronaviruses. Given their ecology and behavior, they have been found to play a key role in transmitting coronaviruses between species. A highly pertinent example of this is the SARS coronavirus, which was shown to have likely originated in Chinese horseshoe bats. The SARS virus, which is genetically closely related to the new Wuhan coronavirus, first infected humans in the Guangdong province of southern China in 2002.

Scientists speculate that the virus was then either transmitted directly to humans from bats, or passed through an intermediate host species, with SARS-like viruses isolated from Himalayan palm civets found in a live-animal market in Guangdong. The virus infection was also detected in other animals (including a raccoon dog, Nyctereutes procyonoides) and in humans working at the market.

The MERS coronavirus is a betacoronavirus that was first reported in Saudi Arabia in 2012. It turned out to be far more deadly than either SARS or the Wuhan virus (at least as far as current estimates of the new coronavirus’s behavior). The MERS genotype was found to be closely related to MERS-like viruses in bats in Saudi Arabia, Africa, Europe, and Asia. Studies done on the cell receptor for MERS showed an apparently conserved viral receptor in both bats and humans. And an identical strain of MERS was found in bats in a nearby cave and near the workplace of the first known human patient.

Wikimedia Commons/Mickey Samuni-Blank

However, in many of the other locations of the outbreak in the Middle East, there appeared to be limited contact between bats and humans, so scientists looked for another vector species, perhaps one that was acting as an intermediate. A high seroprevalence of MERS-CoV or a closely related virus was found in camels across the Arabian Peninsula and parts of eastern and northern Africa, while tests for MERS antibodies were negative in the most-likely other species of livestock or pet animals, including chickens, cows, goats, horses, and sheep.

In addition, the MERS-related CoV carried by camels was genetically highly similar to that detected in humans, as demonstrated in one particular outbreak on a farm in Qatar where the genetic sequences of MERS-CoV in the nasal swabs from 3 of 14 seropositive camels were similar to those of 2 human cases on the same farm. Similar genomic results were found in MERS-CoV from nasal swabs from camels in Saudi Arabia.
 

Other mixing-vessel zoonoses

HIV, the viral cause of AIDS, provides an almost-textbook origin story of the rise of a zoonotic supervillain. The virus was genetically traced to have a chimpanzee-to-human origin, but it was found to be more complicated than that. The virus first emerged in the 1920s in Africa in what is now the Democratic Republic of the Congo, well before its rise to a global pandemic in the 1980s.

Researchers believe the chimpanzee virus is a hybrid of the simian immunodeficiency viruses (SIVs) naturally infecting two different monkey species: the red-capped mangabey (Cercocebus torquatus) and the greater spot-nosed monkey (Cercopithecus nictitans). Chimpanzees kill and eat monkeys, which is likely how they acquired the monkey viruses. The viruses hybridized in a chimpanzee; the hybrid virus then spread through the chimpanzee population and was later transmitted to humans who captured and slaughtered chimps for meat (becoming exposed to their blood). This was the most likely origin of HIV-1.

HIV-1 also shows one of the major risks of zoonotic infections. They can continue to mutate in its human host, increasing the risk of greater virulence, but also interfering with the production of a universally effective vaccine. Since its transmission to humans, for example, many subtypes of the HIV-1 strain have developed, with genetic differences even in the same subtypes found to be up to 20%.

CDC/Frederick A. Murphy

Ebolavirus, first detected in 1976, is another case of bats being the potential culprit. Genetic analysis has shown that African fruit bats are likely involved in the spread of the virus and may be its reservoir host. Further evidence of this was found in the most recent human-infecting Bombali variant of the virus, which was identified in samples from bats collected from Sierra Leone.

It was also found that pigs can also become infected with Zaire ebolavirus, leading to the fear that pigs could serve as a mixing vessel for it and other filoviruses. Pigs have their own forms of Ebola-like disease viruses, which are not currently transmissible to humans, but could provide a potential mixing-vessel reservoir.
 

Emergent influenzas

The Western world has been most affected by these highly mutable, multispecies zoonotic viruses. The 1957 and 1968 flu pandemics contained a mixture of gene segments from human and avian influenza viruses. “What is clear from genetic analysis of the viruses that caused these past pandemics is that reassortment (gene swapping) occurred to produce novel influenza viruses that caused the pandemics. In both of these cases, the new viruses that emerged showed major differences from the parent viruses,” according to the Centers for Disease Control and Prevention.

Influenza is, however, a good example that all zoonoses are not the result of a mixing-vessel phenomenon, with evidence showing that the origin of the catastrophic 1918 virus pandemic likely resulted from a bird influenza virus directly infecting humans and pigs at about the same time without reassortment, according to the CDC.
 

Building a protective infrastructure

The first 2 decades of the 21st century saw a huge increase in efforts to develop an infrastructure to monitor and potentially prevent the spread of new zoonoses. As part of a global effort led by the United Nations, the U.S. Agency for International AID developed the PREDICT program in 2009 “to strengthen global capacity for detection and discovery of zoonotic viruses with pandemic potential. Those include coronaviruses, the family to which SARS and MERS belong; paramyxoviruses, like Nipah virus; influenza viruses; and filoviruses, like the ebolavirus.”

PREDICT funding to the EcoHealth Alliance led to discovery of the likely bat origins of the Zaire ebolavirus during the 2013-2016 outbreak. And throughout the existence of PREDICT, more than 145,000 animals and people were surveyed in areas of likely zoonotic outbreaks, leading to the detection of more than “1,100 unique viruses, including zoonotic diseases of public health concern such as Bombali ebolavirus, Zaire ebolavirus, Marburg virus, and MERS- and SARS-like coronaviruses,” according to PREDICT partner, the University of California, Davis.

PREDICT-2 was launched in 2014 with the continuing goals of “identifying and better characterizing pathogens of known epidemic and unknown pandemic potential; recognizing animal reservoirs and amplification hosts of human-infectious viruses; and efficiently targeting intervention action at human behaviors which amplify disease transmission at critical animal-animal and animal-human interfaces in hotspots of viral evolution, spillover, amplification, and spread.”

However, in October 2019, the Trump administration cut all funding to the PREDICT program, leading to its shutdown. In a New York Times interview, Peter Daszak, president of the EcoHealth Alliance, stated: “PREDICT was an approach to heading off pandemics, instead of sitting there waiting for them to emerge and then mobilizing.”

Ultimately, in addition to its human cost, the current Wuhan coronavirus outbreak can be looked at an object lesson – a test of the pandemic surveillance and control systems currently in place, and a practice run for the next and potentially deadlier zoonotic outbreaks to come. Perhaps it is also a reminder that cutting resources to detect zoonoses at their source in their animal hosts – before they enter the human chain– is perhaps not the most prudent of ideas.

[email protected]

Mark Lesney is the managing editor of MDedge.com/IDPractioner. He has a PhD in plant virology and a PhD in the history of science, with a focus on the history of biotechnology and medicine. He has served as an adjunct assistant professor of the department of biochemistry and molecular & celluar biology at Georgetown University, Washington.

Emerging viruses that spread to humans from an animal host are commonplace and represent some of the deadliest diseases known. Given the details of the Wuhan coronavirus (2019-nCoV) outbreak, including the genetic profile of the disease agent, the hypothesis of a snake origin was the first raised in the peer-reviewed literature.

SISTEMA 12/Wikimedia Commons/CC BY-SA 4.0

It is a highly controversial origin story, however, given that mammals have been the sources of all other such zoonotic coronaviruses, as well as a host of other zoonotic diseases.

An animal source for emerging infections such as the 2019-nCoV is the default hypothesis, because “around 60% of all infectious diseases in humans are zoonotic, as are 75% of all emerging infectious diseases,” according to a United Nations report. The report goes on to say that, “on average, one new infectious disease emerges in humans every 4 months.”

To appreciate the emergence and nature of 2019-nCoV, it is important to examine the history of zoonotic outbreaks of other such diseases, especially with regard to the “mixing-vessel” phenomenon, which has been noted in closely related coronaviruses, including SARS and MERS, as well as the widely disparate HIV, Ebola, and influenza viruses.
 

Mutants in the mixing vessel

The mixing-vessel phenomenon is conceptually easy but molecularly complex. A single animal is coinfected with two related viruses; the virus genomes recombine together (virus “sex”) in that animal to form a new variant of virus. Such new mutant viruses can be more or less infective, more or less deadly, and more or less able to jump the species or even genus barrier. An emerging viral zoonosis can occur when a human being is exposed to one of these new viruses (either from the origin species or another species intermediate) that is capable of also infecting a human cell. Such exposure can occur from close proximity to animal waste or body fluids, as in the farm environment, or from wildlife pets or the capturing and slaughtering of wildlife for food, as is proposed in the case of the Wuhan seafood market scenario. In fact, the scientists who postulated a snake intermediary as the potential mixing vessel also stated that 2019‐nCoV appears to be a recombinant virus between a bat coronavirus and an origin‐unknown coronavirus.

Coronaviruses in particular have a history of moving from animal to human hosts (and even back again), and their detailed genetic pattern and taxonomy can reveal the animal origin of these diseases.
 

Going batty

Bats, in particular, have been shown to be a reservoir species for both alphacoronaviruses and betacoronaviruses. Given their ecology and behavior, they have been found to play a key role in transmitting coronaviruses between species. A highly pertinent example of this is the SARS coronavirus, which was shown to have likely originated in Chinese horseshoe bats. The SARS virus, which is genetically closely related to the new Wuhan coronavirus, first infected humans in the Guangdong province of southern China in 2002.

Scientists speculate that the virus was then either transmitted directly to humans from bats, or passed through an intermediate host species, with SARS-like viruses isolated from Himalayan palm civets found in a live-animal market in Guangdong. The virus infection was also detected in other animals (including a raccoon dog, Nyctereutes procyonoides) and in humans working at the market.

The MERS coronavirus is a betacoronavirus that was first reported in Saudi Arabia in 2012. It turned out to be far more deadly than either SARS or the Wuhan virus (at least as far as current estimates of the new coronavirus’s behavior). The MERS genotype was found to be closely related to MERS-like viruses in bats in Saudi Arabia, Africa, Europe, and Asia. Studies done on the cell receptor for MERS showed an apparently conserved viral receptor in both bats and humans. And an identical strain of MERS was found in bats in a nearby cave and near the workplace of the first known human patient.

Wikimedia Commons/Mickey Samuni-Blank

However, in many of the other locations of the outbreak in the Middle East, there appeared to be limited contact between bats and humans, so scientists looked for another vector species, perhaps one that was acting as an intermediate. A high seroprevalence of MERS-CoV or a closely related virus was found in camels across the Arabian Peninsula and parts of eastern and northern Africa, while tests for MERS antibodies were negative in the most-likely other species of livestock or pet animals, including chickens, cows, goats, horses, and sheep.

In addition, the MERS-related CoV carried by camels was genetically highly similar to that detected in humans, as demonstrated in one particular outbreak on a farm in Qatar where the genetic sequences of MERS-CoV in the nasal swabs from 3 of 14 seropositive camels were similar to those of 2 human cases on the same farm. Similar genomic results were found in MERS-CoV from nasal swabs from camels in Saudi Arabia.
 

Other mixing-vessel zoonoses

HIV, the viral cause of AIDS, provides an almost-textbook origin story of the rise of a zoonotic supervillain. The virus was genetically traced to have a chimpanzee-to-human origin, but it was found to be more complicated than that. The virus first emerged in the 1920s in Africa in what is now the Democratic Republic of the Congo, well before its rise to a global pandemic in the 1980s.

Researchers believe the chimpanzee virus is a hybrid of the simian immunodeficiency viruses (SIVs) naturally infecting two different monkey species: the red-capped mangabey (Cercocebus torquatus) and the greater spot-nosed monkey (Cercopithecus nictitans). Chimpanzees kill and eat monkeys, which is likely how they acquired the monkey viruses. The viruses hybridized in a chimpanzee; the hybrid virus then spread through the chimpanzee population and was later transmitted to humans who captured and slaughtered chimps for meat (becoming exposed to their blood). This was the most likely origin of HIV-1.

HIV-1 also shows one of the major risks of zoonotic infections. They can continue to mutate in its human host, increasing the risk of greater virulence, but also interfering with the production of a universally effective vaccine. Since its transmission to humans, for example, many subtypes of the HIV-1 strain have developed, with genetic differences even in the same subtypes found to be up to 20%.

CDC/Frederick A. Murphy

Ebolavirus, first detected in 1976, is another case of bats being the potential culprit. Genetic analysis has shown that African fruit bats are likely involved in the spread of the virus and may be its reservoir host. Further evidence of this was found in the most recent human-infecting Bombali variant of the virus, which was identified in samples from bats collected from Sierra Leone.

It was also found that pigs can also become infected with Zaire ebolavirus, leading to the fear that pigs could serve as a mixing vessel for it and other filoviruses. Pigs have their own forms of Ebola-like disease viruses, which are not currently transmissible to humans, but could provide a potential mixing-vessel reservoir.
 

Emergent influenzas

The Western world has been most affected by these highly mutable, multispecies zoonotic viruses. The 1957 and 1968 flu pandemics contained a mixture of gene segments from human and avian influenza viruses. “What is clear from genetic analysis of the viruses that caused these past pandemics is that reassortment (gene swapping) occurred to produce novel influenza viruses that caused the pandemics. In both of these cases, the new viruses that emerged showed major differences from the parent viruses,” according to the Centers for Disease Control and Prevention.

Influenza is, however, a good example that all zoonoses are not the result of a mixing-vessel phenomenon, with evidence showing that the origin of the catastrophic 1918 virus pandemic likely resulted from a bird influenza virus directly infecting humans and pigs at about the same time without reassortment, according to the CDC.
 

Building a protective infrastructure

The first 2 decades of the 21st century saw a huge increase in efforts to develop an infrastructure to monitor and potentially prevent the spread of new zoonoses. As part of a global effort led by the United Nations, the U.S. Agency for International AID developed the PREDICT program in 2009 “to strengthen global capacity for detection and discovery of zoonotic viruses with pandemic potential. Those include coronaviruses, the family to which SARS and MERS belong; paramyxoviruses, like Nipah virus; influenza viruses; and filoviruses, like the ebolavirus.”

PREDICT funding to the EcoHealth Alliance led to discovery of the likely bat origins of the Zaire ebolavirus during the 2013-2016 outbreak. And throughout the existence of PREDICT, more than 145,000 animals and people were surveyed in areas of likely zoonotic outbreaks, leading to the detection of more than “1,100 unique viruses, including zoonotic diseases of public health concern such as Bombali ebolavirus, Zaire ebolavirus, Marburg virus, and MERS- and SARS-like coronaviruses,” according to PREDICT partner, the University of California, Davis.

PREDICT-2 was launched in 2014 with the continuing goals of “identifying and better characterizing pathogens of known epidemic and unknown pandemic potential; recognizing animal reservoirs and amplification hosts of human-infectious viruses; and efficiently targeting intervention action at human behaviors which amplify disease transmission at critical animal-animal and animal-human interfaces in hotspots of viral evolution, spillover, amplification, and spread.”

However, in October 2019, the Trump administration cut all funding to the PREDICT program, leading to its shutdown. In a New York Times interview, Peter Daszak, president of the EcoHealth Alliance, stated: “PREDICT was an approach to heading off pandemics, instead of sitting there waiting for them to emerge and then mobilizing.”

Ultimately, in addition to its human cost, the current Wuhan coronavirus outbreak can be looked at an object lesson – a test of the pandemic surveillance and control systems currently in place, and a practice run for the next and potentially deadlier zoonotic outbreaks to come. Perhaps it is also a reminder that cutting resources to detect zoonoses at their source in their animal hosts – before they enter the human chain– is perhaps not the most prudent of ideas.

[email protected]

Mark Lesney is the managing editor of MDedge.com/IDPractioner. He has a PhD in plant virology and a PhD in the history of science, with a focus on the history of biotechnology and medicine. He has served as an adjunct assistant professor of the department of biochemistry and molecular & celluar biology at Georgetown University, Washington.

According to the DSM-V, gender dysphoria in adolescents and adults “involves a difference between one’s experienced/expressed gender and assigned gender, and significant distress or problems functioning. It lasts at least 6 months,” and several other criteria must be met.¹ Many patients with gender dysphoria also identify as transgender. A “transition” or “transitioning” is a process by which individuals come to inhabit their gender identity.² A gender transition may take many forms, and only some people will choose to include medical assistance in their transition process. Although the scope of this article will not address these concerns, it should be noted that many people in the transgender and gender nonconforming community would object to the concepts of gender dysphoria and gender transition because they rely on a binary model of gender that may exclude individuals that see themselves as something other than “man or woman.”

sturti/Getty Images

There are both medical and surgical options for medical assistance in a gender transition. This article will focus on the surgical care of patients assigned female at birth who are seeking masculinizing surgical therapy. Many writers will discuss “gender-affirming” surgery, but we will use the term “gender-reaffirming” surgery because transgender patients have already affirmed their own genders and do not require surgery to inhabit this affirmation. Surgical options might include bilateral mastectomy, hysterectomy, bilateral salpingo-oophorectomy (BSO), metoidioplasty (surgical formation of a neophallus with existing genital tissue), or phalloplasty. There currently is no single surgical subspecialty that encompasses training in all forms of gender-reaffirming surgical therapies. In some areas of the country, centers of excellence have given rise to multidisciplinary teams that combine the skill sets of surgical subspecialists to provide a streamlined approach to gender-reaffirming surgery. Because of the scarcity of these integrated centers, most patients seeking gender-reaffirming surgeries will need to find individual subspecialists whose surgical training focuses on one area of the body. For example, patients seeking all possible surgical options may need a breast surgeon to perform their mastectomy, an ob.gyn. to perform their hysterectomy and BSO, a urologist to perform their metoidioplasty, and a plastic surgeon to perform their phalloplasty. In these scenarios, a general ob.gyn. may be consulted to perform a gender-reaffirming hysterectomy with BSO.

There are many reasons why transgender men might desire hysterectomy/BSO as part of their transition. Removal of the uterus and cervix eliminates concerns surrounding menstruation, pregnancy, and cervical cancer screening, all of which may add to their experience of gender dysphoria. Furthermore, removal of the ovaries may simplify long-term hormonal therapy with testosterone by eliminating the need for estrogen suppression. Lastly, a hysterectomy/BSO is a lower-risk and more cost-effective masculinizing surgery, compared with metoidioplasty or phalloplasty.

While the technical aspect of performing a hysterectomy/BSO certainly is within the scope of training for a general ob.gyn., there are several nuances of which providers should be aware when planning gender-reaffirming surgery for a transgender man. During the preoperative planning phase, it is of utmost importance to provide an environment of safety so that the focus of the preop visit is not clouded by communication mishaps between office staff and the patient. These barriers can be avoided by implementing office intake forms that give patients the opportunity to inform the health care team of their chosen name and personal pronouns upon registration for the visit.

A pelvic exam is commonly performed by ob.gyns. to determine surgical approach for a hysterectomy/BSO. When approaching transgender male patients for preoperative pelvic exams, it is important to be mindful of the fact that this type of exam may trigger gender dysphoria. While pelvic exams should be handled in sensitive fashion regardless of a patient’s gender identity, a patient who is a transgender man may benefit from some added steps in discussing the pelvic exam. One approach is to acknowledge that these exams/discussions may be especially triggering of gender dysphoria, and ask if the patient would prefer certain words to be used or not used in reference to their anatomy. As with any patient, the provider should explain the purpose of the examination and offer opportunities for the patient to have some control in the exam such as by assisting with insertion of the speculum or designating a “safe word” that would signal the provider to stop or pause the exam. In some cases, patients may not be able to tolerate the pelvic exam while awake because of the degree of gender dysphoria that the exam would induce. Providers might consider noninvasive imaging studies to help with surgical planning if they find they need more information before scheduling the operation, or they may offer a staged procedure with exam under anesthesia prior to the definitive surgery.

In conclusion, performing a gender-reaffirming hysterectomy/BSO requires thoughtful preparation to ensure a safe surgical environment for this vulnerable population. Care should be taken to plan the operation with a culturally sensitive approach.

Dr. Joyner is an assistant professor at Emory University, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital, both in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Joyner and Dr. Bahng reported no relevant financial disclosures.

References

1. American Psychiatric Association. What is Gender Dysphoria? https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria

2. UCSF Transgender Care. Transition Roadmap. https://transcare.ucsf.edu/transition-roadmap

According to the DSM-V, gender dysphoria in adolescents and adults “involves a difference between one’s experienced/expressed gender and assigned gender, and significant distress or problems functioning. It lasts at least 6 months,” and several other criteria must be met.¹ Many patients with gender dysphoria also identify as transgender. A “transition” or “transitioning” is a process by which individuals come to inhabit their gender identity.² A gender transition may take many forms, and only some people will choose to include medical assistance in their transition process. Although the scope of this article will not address these concerns, it should be noted that many people in the transgender and gender nonconforming community would object to the concepts of gender dysphoria and gender transition because they rely on a binary model of gender that may exclude individuals that see themselves as something other than “man or woman.”

sturti/Getty Images

There are both medical and surgical options for medical assistance in a gender transition. This article will focus on the surgical care of patients assigned female at birth who are seeking masculinizing surgical therapy. Many writers will discuss “gender-affirming” surgery, but we will use the term “gender-reaffirming” surgery because transgender patients have already affirmed their own genders and do not require surgery to inhabit this affirmation. Surgical options might include bilateral mastectomy, hysterectomy, bilateral salpingo-oophorectomy (BSO), metoidioplasty (surgical formation of a neophallus with existing genital tissue), or phalloplasty. There currently is no single surgical subspecialty that encompasses training in all forms of gender-reaffirming surgical therapies. In some areas of the country, centers of excellence have given rise to multidisciplinary teams that combine the skill sets of surgical subspecialists to provide a streamlined approach to gender-reaffirming surgery. Because of the scarcity of these integrated centers, most patients seeking gender-reaffirming surgeries will need to find individual subspecialists whose surgical training focuses on one area of the body. For example, patients seeking all possible surgical options may need a breast surgeon to perform their mastectomy, an ob.gyn. to perform their hysterectomy and BSO, a urologist to perform their metoidioplasty, and a plastic surgeon to perform their phalloplasty. In these scenarios, a general ob.gyn. may be consulted to perform a gender-reaffirming hysterectomy with BSO.

There are many reasons why transgender men might desire hysterectomy/BSO as part of their transition. Removal of the uterus and cervix eliminates concerns surrounding menstruation, pregnancy, and cervical cancer screening, all of which may add to their experience of gender dysphoria. Furthermore, removal of the ovaries may simplify long-term hormonal therapy with testosterone by eliminating the need for estrogen suppression. Lastly, a hysterectomy/BSO is a lower-risk and more cost-effective masculinizing surgery, compared with metoidioplasty or phalloplasty.

While the technical aspect of performing a hysterectomy/BSO certainly is within the scope of training for a general ob.gyn., there are several nuances of which providers should be aware when planning gender-reaffirming surgery for a transgender man. During the preoperative planning phase, it is of utmost importance to provide an environment of safety so that the focus of the preop visit is not clouded by communication mishaps between office staff and the patient. These barriers can be avoided by implementing office intake forms that give patients the opportunity to inform the health care team of their chosen name and personal pronouns upon registration for the visit.

A pelvic exam is commonly performed by ob.gyns. to determine surgical approach for a hysterectomy/BSO. When approaching transgender male patients for preoperative pelvic exams, it is important to be mindful of the fact that this type of exam may trigger gender dysphoria. While pelvic exams should be handled in sensitive fashion regardless of a patient’s gender identity, a patient who is a transgender man may benefit from some added steps in discussing the pelvic exam. One approach is to acknowledge that these exams/discussions may be especially triggering of gender dysphoria, and ask if the patient would prefer certain words to be used or not used in reference to their anatomy. As with any patient, the provider should explain the purpose of the examination and offer opportunities for the patient to have some control in the exam such as by assisting with insertion of the speculum or designating a “safe word” that would signal the provider to stop or pause the exam. In some cases, patients may not be able to tolerate the pelvic exam while awake because of the degree of gender dysphoria that the exam would induce. Providers might consider noninvasive imaging studies to help with surgical planning if they find they need more information before scheduling the operation, or they may offer a staged procedure with exam under anesthesia prior to the definitive surgery.

In conclusion, performing a gender-reaffirming hysterectomy/BSO requires thoughtful preparation to ensure a safe surgical environment for this vulnerable population. Care should be taken to plan the operation with a culturally sensitive approach.

Dr. Joyner is an assistant professor at Emory University, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital, both in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Joyner and Dr. Bahng reported no relevant financial disclosures.

References

1. American Psychiatric Association. What is Gender Dysphoria? https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria

2. UCSF Transgender Care. Transition Roadmap. https://transcare.ucsf.edu/transition-roadmap

According to the DSM-V, gender dysphoria in adolescents and adults “involves a difference between one’s experienced/expressed gender and assigned gender, and significant distress or problems functioning. It lasts at least 6 months,” and several other criteria must be met.¹ Many patients with gender dysphoria also identify as transgender. A “transition” or “transitioning” is a process by which individuals come to inhabit their gender identity.² A gender transition may take many forms, and only some people will choose to include medical assistance in their transition process. Although the scope of this article will not address these concerns, it should be noted that many people in the transgender and gender nonconforming community would object to the concepts of gender dysphoria and gender transition because they rely on a binary model of gender that may exclude individuals that see themselves as something other than “man or woman.”

sturti/Getty Images

There are both medical and surgical options for medical assistance in a gender transition. This article will focus on the surgical care of patients assigned female at birth who are seeking masculinizing surgical therapy. Many writers will discuss “gender-affirming” surgery, but we will use the term “gender-reaffirming” surgery because transgender patients have already affirmed their own genders and do not require surgery to inhabit this affirmation. Surgical options might include bilateral mastectomy, hysterectomy, bilateral salpingo-oophorectomy (BSO), metoidioplasty (surgical formation of a neophallus with existing genital tissue), or phalloplasty. There currently is no single surgical subspecialty that encompasses training in all forms of gender-reaffirming surgical therapies. In some areas of the country, centers of excellence have given rise to multidisciplinary teams that combine the skill sets of surgical subspecialists to provide a streamlined approach to gender-reaffirming surgery. Because of the scarcity of these integrated centers, most patients seeking gender-reaffirming surgeries will need to find individual subspecialists whose surgical training focuses on one area of the body. For example, patients seeking all possible surgical options may need a breast surgeon to perform their mastectomy, an ob.gyn. to perform their hysterectomy and BSO, a urologist to perform their metoidioplasty, and a plastic surgeon to perform their phalloplasty. In these scenarios, a general ob.gyn. may be consulted to perform a gender-reaffirming hysterectomy with BSO.

There are many reasons why transgender men might desire hysterectomy/BSO as part of their transition. Removal of the uterus and cervix eliminates concerns surrounding menstruation, pregnancy, and cervical cancer screening, all of which may add to their experience of gender dysphoria. Furthermore, removal of the ovaries may simplify long-term hormonal therapy with testosterone by eliminating the need for estrogen suppression. Lastly, a hysterectomy/BSO is a lower-risk and more cost-effective masculinizing surgery, compared with metoidioplasty or phalloplasty.

While the technical aspect of performing a hysterectomy/BSO certainly is within the scope of training for a general ob.gyn., there are several nuances of which providers should be aware when planning gender-reaffirming surgery for a transgender man. During the preoperative planning phase, it is of utmost importance to provide an environment of safety so that the focus of the preop visit is not clouded by communication mishaps between office staff and the patient. These barriers can be avoided by implementing office intake forms that give patients the opportunity to inform the health care team of their chosen name and personal pronouns upon registration for the visit.

A pelvic exam is commonly performed by ob.gyns. to determine surgical approach for a hysterectomy/BSO. When approaching transgender male patients for preoperative pelvic exams, it is important to be mindful of the fact that this type of exam may trigger gender dysphoria. While pelvic exams should be handled in sensitive fashion regardless of a patient’s gender identity, a patient who is a transgender man may benefit from some added steps in discussing the pelvic exam. One approach is to acknowledge that these exams/discussions may be especially triggering of gender dysphoria, and ask if the patient would prefer certain words to be used or not used in reference to their anatomy. As with any patient, the provider should explain the purpose of the examination and offer opportunities for the patient to have some control in the exam such as by assisting with insertion of the speculum or designating a “safe word” that would signal the provider to stop or pause the exam. In some cases, patients may not be able to tolerate the pelvic exam while awake because of the degree of gender dysphoria that the exam would induce. Providers might consider noninvasive imaging studies to help with surgical planning if they find they need more information before scheduling the operation, or they may offer a staged procedure with exam under anesthesia prior to the definitive surgery.

In conclusion, performing a gender-reaffirming hysterectomy/BSO requires thoughtful preparation to ensure a safe surgical environment for this vulnerable population. Care should be taken to plan the operation with a culturally sensitive approach.

Dr. Joyner is an assistant professor at Emory University, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital, both in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Joyner and Dr. Bahng reported no relevant financial disclosures.

References

1. American Psychiatric Association. What is Gender Dysphoria? https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria

2. UCSF Transgender Care. Transition Roadmap. https://transcare.ucsf.edu/transition-roadmap