Commentary

Recalcitrant acne is a common, unwavering problem in dermatology practices nationwide. However, both gram positive and gram negative infections of the skin can go undiagnosed in patients with acne resistant to the armamentarium of oral and topical therapeutics. Although I often use isotretinoin in patients with cystic or recalcitrant acne, I almost always do a culture prior to initiating therapy, and more often than not, have discovered patients have gram negative and gram positive skin infections resistant to antibiotics commonly used to treat acne.

Yulia Lisitsa/iStock/Getty Images Plus

Makeup is one of the most common culprits of recalcitrant acne. In a study by Bashir and Lambert published in the Journal of Applied Microbiology, 70%-90% of makeup products tested – including lipstick, lip gloss, beauty blenders, eyeliners, and mascara – were found to be contaminated with bacteria. Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli were the most common culprits, and the product with the highest contamination rates were beauty blenders (the small sponges used to apply makeup), which also had high rates of fungal contamination.

Expiration dates on cosmetic products are used to indicate the length of time a preservative in a product can control bacterial contamination. They are printed on packaging as an open jar symbol with the 3M, 6M, 9M, and 12M label for the number of months the product can be opened and used. Unfortunately and unknowingly, most consumers use products beyond the expiration date, and the most common offender is mascara.

Gram positive and gram negative skin infections should be ruled out in all cases of recalcitrant acne. A reminder to note on all culture requisitions to grow gram negatives because not all labs will grow gram negatives on a skin swab. Counseling should also be given to those patients who wear makeup, which should include techniques to clean and sanitize makeup applicators including brushes, tools, and towels. Blenders are known to be used “wet” and are not dried when washed.

It is my recommendation that blenders be a one-time-use-only tool and disposed of after EVERY application. Instructions provided in my clinic are to wash all devices and brushes once a week with hot soapy water, and blow dry with a hair dryer immediately afterward. Lipsticks, mascara wands, and lip glosses should be sanitized with alcohol once a month. Finally, all products need to be disposed of after their expiry.

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

Resource

Basher A, Lambert P. J Appl Microbiol. 2019. doi: 10.1111/jam.14479.

Recalcitrant acne is a common, unwavering problem in dermatology practices nationwide. However, both gram positive and gram negative infections of the skin can go undiagnosed in patients with acne resistant to the armamentarium of oral and topical therapeutics. Although I often use isotretinoin in patients with cystic or recalcitrant acne, I almost always do a culture prior to initiating therapy, and more often than not, have discovered patients have gram negative and gram positive skin infections resistant to antibiotics commonly used to treat acne.

Yulia Lisitsa/iStock/Getty Images Plus

Makeup is one of the most common culprits of recalcitrant acne. In a study by Bashir and Lambert published in the Journal of Applied Microbiology, 70%-90% of makeup products tested – including lipstick, lip gloss, beauty blenders, eyeliners, and mascara – were found to be contaminated with bacteria. Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli were the most common culprits, and the product with the highest contamination rates were beauty blenders (the small sponges used to apply makeup), which also had high rates of fungal contamination.

Expiration dates on cosmetic products are used to indicate the length of time a preservative in a product can control bacterial contamination. They are printed on packaging as an open jar symbol with the 3M, 6M, 9M, and 12M label for the number of months the product can be opened and used. Unfortunately and unknowingly, most consumers use products beyond the expiration date, and the most common offender is mascara.

Gram positive and gram negative skin infections should be ruled out in all cases of recalcitrant acne. A reminder to note on all culture requisitions to grow gram negatives because not all labs will grow gram negatives on a skin swab. Counseling should also be given to those patients who wear makeup, which should include techniques to clean and sanitize makeup applicators including brushes, tools, and towels. Blenders are known to be used “wet” and are not dried when washed.

It is my recommendation that blenders be a one-time-use-only tool and disposed of after EVERY application. Instructions provided in my clinic are to wash all devices and brushes once a week with hot soapy water, and blow dry with a hair dryer immediately afterward. Lipsticks, mascara wands, and lip glosses should be sanitized with alcohol once a month. Finally, all products need to be disposed of after their expiry.

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

Resource

Basher A, Lambert P. J Appl Microbiol. 2019. doi: 10.1111/jam.14479.

Recalcitrant acne is a common, unwavering problem in dermatology practices nationwide. However, both gram positive and gram negative infections of the skin can go undiagnosed in patients with acne resistant to the armamentarium of oral and topical therapeutics. Although I often use isotretinoin in patients with cystic or recalcitrant acne, I almost always do a culture prior to initiating therapy, and more often than not, have discovered patients have gram negative and gram positive skin infections resistant to antibiotics commonly used to treat acne.

Yulia Lisitsa/iStock/Getty Images Plus

Makeup is one of the most common culprits of recalcitrant acne. In a study by Bashir and Lambert published in the Journal of Applied Microbiology, 70%-90% of makeup products tested – including lipstick, lip gloss, beauty blenders, eyeliners, and mascara – were found to be contaminated with bacteria. Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli were the most common culprits, and the product with the highest contamination rates were beauty blenders (the small sponges used to apply makeup), which also had high rates of fungal contamination.

Expiration dates on cosmetic products are used to indicate the length of time a preservative in a product can control bacterial contamination. They are printed on packaging as an open jar symbol with the 3M, 6M, 9M, and 12M label for the number of months the product can be opened and used. Unfortunately and unknowingly, most consumers use products beyond the expiration date, and the most common offender is mascara.

Gram positive and gram negative skin infections should be ruled out in all cases of recalcitrant acne. A reminder to note on all culture requisitions to grow gram negatives because not all labs will grow gram negatives on a skin swab. Counseling should also be given to those patients who wear makeup, which should include techniques to clean and sanitize makeup applicators including brushes, tools, and towels. Blenders are known to be used “wet” and are not dried when washed.

It is my recommendation that blenders be a one-time-use-only tool and disposed of after EVERY application. Instructions provided in my clinic are to wash all devices and brushes once a week with hot soapy water, and blow dry with a hair dryer immediately afterward. Lipsticks, mascara wands, and lip glosses should be sanitized with alcohol once a month. Finally, all products need to be disposed of after their expiry.

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

Resource

Basher A, Lambert P. J Appl Microbiol. 2019. doi: 10.1111/jam.14479.

It’s best practice to not set an alarm when on vacation. The point of vacation, after all, is to escape the rock-hard constraints of the daily grind. But the melody pulling me from slumber wasn’t coming from my phone. It was the ethereal chant of Fajr, morning prayer rising from surrounding mosques. I was in the medina of Marrakesh sleeping in a hotel that was once a home, called a riad. Some parts of the building date from the medieval period. Fajr occurs at dawn, before morning light. Getting from the bed to the toilet was treacherous – you must traverse cold, uneven steps to get there. Yet I had to get dressed: Morning yoga on our riad rooftop would start with sunrise. I guess even my vacations have agendas: I was in Morocco not only to holiday, but also to improve mind, body, and spirit.

ddoorly/iStock/Getty Images Plus

Wellness vacations are a rapidly growing treatment for burnout. They are a pulse dose of burnout therapy with a potential for lasting remission. For those who can afford them, your travel is fully arranged and activities such as yoga, cooking classes, hikes, and meditation are scheduled. This was my first wellness trip and it was transformative. Many times have I tried to disconnect from the distractions of life, but there is nothing so purifying as having no phone or Internet access. When I made peace with the reality that I couldn’t access EPIC or email, it was like a ringing in the ears had lifted: I could hear silence again.

This trip took us to three locations: Marrakesh, the Atlas Mountains, and the edge of the Sahara Desert. Yoga was prescribed twice a day. Morning practice was 90 minutes of shedding layers as the sun rose and our bodies warmed to increasingly difficult sequences. This was followed by Moroccan breakfast with fellow travelers from around the world. All were professionals and I wasn’t surprised to learn that burnout is common to many. I was surprised to realize that sharing stories with strangers about the vicissitudes of life was deeply bonding. (Or perhaps it was doing yoga inversions together.)

Also surprising was how easy it is to get lost in the maze that is Marrakesh. And yet, it was rewarding. Finding our way back through the mass of people, donkeys, and motorbikes along dark, unmarked alleys – without Waze – was intensely clarifying. Few things help you be present “in the moment” as being adrift and disoriented in a foreign city.

There was relaxation too. We made Khobz, traditional Moroccan bread by mixing just the right amounts of flour, yeast, sugar, oil, water, and salt. Knead, add, knead, add, and stop when done. We then walked a half mile to give our doughy creations to a baker who, with blackened calloused hands, worked an ancient communal oven. Then we waited patiently for the sardines ahead of us to finish baking first. I’ve no idea how long it all took – I had nowhere else to be.

The next day we hiked to a village in the Ourika Valley. There we had lunch at the home of a local Berber family. They served us their best tea, vegetable couscous, and lamb tagine while their chickens and donkeys watched us curiously. It was Thanksgiving (not on the Berber calendar of course) and sharing a meal prepared by a faraway stranger who doesn’t speak English makes you feel thankful in a refreshing way. Way more alike than different we are, I learned.

We finished our trip with a little desert “glamping.” The vast expanse of desert, interrupted by swirling winds and camel bellows quiets your mind, opens you to the immensity of life. That night we sat close to a bonfire and watched the Milky Way drift across the true black sky. I woke the next morning to the best night’s sleep I’ve had all year. My last wellness activity was unplanned, but meaningful nonetheless. As it happens, there’s no hot water in the desert and a bracingly cold shower marked the end of my treatment/vacation.

If the opposite of burned out is repleted, then I am. Also grateful to have such a transformative experience, for friends new and old who love me, and for hot water. Prescribe yourself one if you can.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

It’s best practice to not set an alarm when on vacation. The point of vacation, after all, is to escape the rock-hard constraints of the daily grind. But the melody pulling me from slumber wasn’t coming from my phone. It was the ethereal chant of Fajr, morning prayer rising from surrounding mosques. I was in the medina of Marrakesh sleeping in a hotel that was once a home, called a riad. Some parts of the building date from the medieval period. Fajr occurs at dawn, before morning light. Getting from the bed to the toilet was treacherous – you must traverse cold, uneven steps to get there. Yet I had to get dressed: Morning yoga on our riad rooftop would start with sunrise. I guess even my vacations have agendas: I was in Morocco not only to holiday, but also to improve mind, body, and spirit.

ddoorly/iStock/Getty Images Plus

Wellness vacations are a rapidly growing treatment for burnout. They are a pulse dose of burnout therapy with a potential for lasting remission. For those who can afford them, your travel is fully arranged and activities such as yoga, cooking classes, hikes, and meditation are scheduled. This was my first wellness trip and it was transformative. Many times have I tried to disconnect from the distractions of life, but there is nothing so purifying as having no phone or Internet access. When I made peace with the reality that I couldn’t access EPIC or email, it was like a ringing in the ears had lifted: I could hear silence again.

This trip took us to three locations: Marrakesh, the Atlas Mountains, and the edge of the Sahara Desert. Yoga was prescribed twice a day. Morning practice was 90 minutes of shedding layers as the sun rose and our bodies warmed to increasingly difficult sequences. This was followed by Moroccan breakfast with fellow travelers from around the world. All were professionals and I wasn’t surprised to learn that burnout is common to many. I was surprised to realize that sharing stories with strangers about the vicissitudes of life was deeply bonding. (Or perhaps it was doing yoga inversions together.)

Also surprising was how easy it is to get lost in the maze that is Marrakesh. And yet, it was rewarding. Finding our way back through the mass of people, donkeys, and motorbikes along dark, unmarked alleys – without Waze – was intensely clarifying. Few things help you be present “in the moment” as being adrift and disoriented in a foreign city.

There was relaxation too. We made Khobz, traditional Moroccan bread by mixing just the right amounts of flour, yeast, sugar, oil, water, and salt. Knead, add, knead, add, and stop when done. We then walked a half mile to give our doughy creations to a baker who, with blackened calloused hands, worked an ancient communal oven. Then we waited patiently for the sardines ahead of us to finish baking first. I’ve no idea how long it all took – I had nowhere else to be.

The next day we hiked to a village in the Ourika Valley. There we had lunch at the home of a local Berber family. They served us their best tea, vegetable couscous, and lamb tagine while their chickens and donkeys watched us curiously. It was Thanksgiving (not on the Berber calendar of course) and sharing a meal prepared by a faraway stranger who doesn’t speak English makes you feel thankful in a refreshing way. Way more alike than different we are, I learned.

We finished our trip with a little desert “glamping.” The vast expanse of desert, interrupted by swirling winds and camel bellows quiets your mind, opens you to the immensity of life. That night we sat close to a bonfire and watched the Milky Way drift across the true black sky. I woke the next morning to the best night’s sleep I’ve had all year. My last wellness activity was unplanned, but meaningful nonetheless. As it happens, there’s no hot water in the desert and a bracingly cold shower marked the end of my treatment/vacation.

If the opposite of burned out is repleted, then I am. Also grateful to have such a transformative experience, for friends new and old who love me, and for hot water. Prescribe yourself one if you can.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

It’s best practice to not set an alarm when on vacation. The point of vacation, after all, is to escape the rock-hard constraints of the daily grind. But the melody pulling me from slumber wasn’t coming from my phone. It was the ethereal chant of Fajr, morning prayer rising from surrounding mosques. I was in the medina of Marrakesh sleeping in a hotel that was once a home, called a riad. Some parts of the building date from the medieval period. Fajr occurs at dawn, before morning light. Getting from the bed to the toilet was treacherous – you must traverse cold, uneven steps to get there. Yet I had to get dressed: Morning yoga on our riad rooftop would start with sunrise. I guess even my vacations have agendas: I was in Morocco not only to holiday, but also to improve mind, body, and spirit.

ddoorly/iStock/Getty Images Plus

Wellness vacations are a rapidly growing treatment for burnout. They are a pulse dose of burnout therapy with a potential for lasting remission. For those who can afford them, your travel is fully arranged and activities such as yoga, cooking classes, hikes, and meditation are scheduled. This was my first wellness trip and it was transformative. Many times have I tried to disconnect from the distractions of life, but there is nothing so purifying as having no phone or Internet access. When I made peace with the reality that I couldn’t access EPIC or email, it was like a ringing in the ears had lifted: I could hear silence again.

This trip took us to three locations: Marrakesh, the Atlas Mountains, and the edge of the Sahara Desert. Yoga was prescribed twice a day. Morning practice was 90 minutes of shedding layers as the sun rose and our bodies warmed to increasingly difficult sequences. This was followed by Moroccan breakfast with fellow travelers from around the world. All were professionals and I wasn’t surprised to learn that burnout is common to many. I was surprised to realize that sharing stories with strangers about the vicissitudes of life was deeply bonding. (Or perhaps it was doing yoga inversions together.)

Also surprising was how easy it is to get lost in the maze that is Marrakesh. And yet, it was rewarding. Finding our way back through the mass of people, donkeys, and motorbikes along dark, unmarked alleys – without Waze – was intensely clarifying. Few things help you be present “in the moment” as being adrift and disoriented in a foreign city.

There was relaxation too. We made Khobz, traditional Moroccan bread by mixing just the right amounts of flour, yeast, sugar, oil, water, and salt. Knead, add, knead, add, and stop when done. We then walked a half mile to give our doughy creations to a baker who, with blackened calloused hands, worked an ancient communal oven. Then we waited patiently for the sardines ahead of us to finish baking first. I’ve no idea how long it all took – I had nowhere else to be.

The next day we hiked to a village in the Ourika Valley. There we had lunch at the home of a local Berber family. They served us their best tea, vegetable couscous, and lamb tagine while their chickens and donkeys watched us curiously. It was Thanksgiving (not on the Berber calendar of course) and sharing a meal prepared by a faraway stranger who doesn’t speak English makes you feel thankful in a refreshing way. Way more alike than different we are, I learned.

We finished our trip with a little desert “glamping.” The vast expanse of desert, interrupted by swirling winds and camel bellows quiets your mind, opens you to the immensity of life. That night we sat close to a bonfire and watched the Milky Way drift across the true black sky. I woke the next morning to the best night’s sleep I’ve had all year. My last wellness activity was unplanned, but meaningful nonetheless. As it happens, there’s no hot water in the desert and a bracingly cold shower marked the end of my treatment/vacation.

If the opposite of burned out is repleted, then I am. Also grateful to have such a transformative experience, for friends new and old who love me, and for hot water. Prescribe yourself one if you can.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

For the last 25 years I have had the privilege of caring for a rural community, practicing full-scope family medicine including obstetrics with cesarean sections. I have had a deeply rewarding career, and delivering babies and watching them grow up has been one of the most gratifying parts of my work.

Sheri Porter/AAFP News

My concern is that, as the number of family physicians who practice maternity care has decreased, the infant and maternal mortality rate in the United States has increased, especially in rural and minority populations. Currently, 5 million women of reproductive age have no access to maternity care.

At the same time 23% of incoming family medicine residents would like to offer maternity care and are trained to do so, but few are able to find a job where this is possible.¹ This is unfortunate because family physicians have the training and expertise to provide comprehensive maternity care. Although they have lower rates of cesarean section than ob-gyns, with similar outcomes, family physicians do have surgical skills, including providing cesarean sections, that are often necessary for safe delivery.^2,3

In addition, family physicians have the internal medicine and behavioral health background to care for postpartum complications, as well as substance use disorders. Because they also care for children, they see postpartum women when they come in with their children for well-child checks. These visits offer an excellent opportunity to also check on the mother for postpartum depression and other signs of postpartum illness.

Centers for Disease Control and Prevention data reveal that maternal mortality can be divided into three nearly equal parts: pregnancy, delivery, and post partum. They define delivery as the week of delivery. The 48 hours post delivery accounted for only 12% of overall mortality. This means that even if women travel to metropolitan areas, they are likely to be home when they have fatal complications. The lack of trained and experienced physicians in the communities where women live increases their risks should they have complications. Most maternal fatalities occur when conditions are not recognized in a timely fashion. Some responses require procedural skills such as dilation and curettage (D&C).

As a member of the National Advisory Committee on Rural Health and Human Services, I visited several states to evaluate their rural health systems. We looked at infant mortality by county and found an enormous disparity between counties, largely caused by lack of prenatal services and obstetrical services.

These disparities between counties are getting worse. The United States is losing critical access hospitals at a rapid pace. We have lost 117 critical access hospitals in the last 10 years, with 40 in the last year alone. According to the National Rural Health Association, ^4,673 additional facilities – representing more than one-third of rural hospitals in the United States – are vulnerable and could close. The reasons are multiple, but the result has been an erosion of the rural safety net, especially with regard to maternity care.

These hospital closures force women to travel farther distances for maternity care, including cesarean sections, and this contributes to increased maternal and infant mortality.⁵ In a study from Canada, the complication rates increased substantially as distances increased. Women are more likely to have premature deliveries, deliver on the side of the road, or end up in inappropriate facilities.

The distance from delivery is directly related to outcomes. A study from the early 1990s showed that women did better if they received maternity care from local hospitals and physicians.⁶ From a family medicine perspective, this makes sense because traveling to a metropolitan area means isolation from family and social networks. Stress increases because pregnant women also are often the primary caregiver of other children and the primary wage earner of the family. Although we are unsure what impact stress has on pregnancy, we do know it does have an effect on greater risk of prematurity and poor outcomes.

Obstetricians provide excellent care, but they are not a panacea. Only half of U.S. counties have adequate ob.gyn. coverage. Moreover, in many of those counties, the ob.gyns. subspecialize in gynecologic surgery and infertility, but don’t provide obstetrical care. Another challenge: ob.gyns. cannot survive financially in smaller communities; our policies must include incentives to recruit and retain them in underserved areas.

Certified nurse midwives also provide excellent care and are an invaluable member of the patient-care team, but again, they cannot be the only solution. Obstetrical emergencies do occur, and mothers need a physician trained in providing on-site medical or surgical care. They also need a hospital with adequate staff to care for emergencies.

In communities large enough to support a multispecialty group, certified medical technicians, family physicians, and ob.gyns. would ideally work alongside each other. In small communities four family physicians can provide a high level of maternity care including surgical deliveries, while supporting themselves with caring for children and elders in clinics, hospitals, and EDs.

It is unconscionable that a country as wealthy as ours would accept rates of maternal and infant mortality that rival and are often worse than developing countries. Although the reasons are many, there is no excuse. Family physicians are an essential part of reversing this trend. We need policies that enable family physicians to help resolve the shortage of maternity care for underserved communities, to address the maternal and infant mortality rate, and to provide maternity care that is part of family medicine’s full scope of practice.

Dr. Cullen is board chair of the American Academy of Family Physicians and a practicing family physician in Valdez, Alaska.

References

1. Am Board Fam Med. 2017 Jul-Aug;30(4):405-6.

2. CMAJ. 2015 Oct 27;187:1125-32.

3. J Am Board Fam Med. 2013 Jul-Aug;26(4):366-72.

4. NRHA Save Rural Hospitals Action Center. www.ruralhealthweb.org/advocate/save-rural-hospitals.

5. BMC Health Serv Res. 2011 Jun 10;11:147.

6. Am J Public Health. 1990 Jul;80(7):814-8.

For the last 25 years I have had the privilege of caring for a rural community, practicing full-scope family medicine including obstetrics with cesarean sections. I have had a deeply rewarding career, and delivering babies and watching them grow up has been one of the most gratifying parts of my work.

Sheri Porter/AAFP News

My concern is that, as the number of family physicians who practice maternity care has decreased, the infant and maternal mortality rate in the United States has increased, especially in rural and minority populations. Currently, 5 million women of reproductive age have no access to maternity care.

At the same time 23% of incoming family medicine residents would like to offer maternity care and are trained to do so, but few are able to find a job where this is possible.¹ This is unfortunate because family physicians have the training and expertise to provide comprehensive maternity care. Although they have lower rates of cesarean section than ob-gyns, with similar outcomes, family physicians do have surgical skills, including providing cesarean sections, that are often necessary for safe delivery.^2,3

In addition, family physicians have the internal medicine and behavioral health background to care for postpartum complications, as well as substance use disorders. Because they also care for children, they see postpartum women when they come in with their children for well-child checks. These visits offer an excellent opportunity to also check on the mother for postpartum depression and other signs of postpartum illness.

Centers for Disease Control and Prevention data reveal that maternal mortality can be divided into three nearly equal parts: pregnancy, delivery, and post partum. They define delivery as the week of delivery. The 48 hours post delivery accounted for only 12% of overall mortality. This means that even if women travel to metropolitan areas, they are likely to be home when they have fatal complications. The lack of trained and experienced physicians in the communities where women live increases their risks should they have complications. Most maternal fatalities occur when conditions are not recognized in a timely fashion. Some responses require procedural skills such as dilation and curettage (D&C).

As a member of the National Advisory Committee on Rural Health and Human Services, I visited several states to evaluate their rural health systems. We looked at infant mortality by county and found an enormous disparity between counties, largely caused by lack of prenatal services and obstetrical services.

These disparities between counties are getting worse. The United States is losing critical access hospitals at a rapid pace. We have lost 117 critical access hospitals in the last 10 years, with 40 in the last year alone. According to the National Rural Health Association, ^4,673 additional facilities – representing more than one-third of rural hospitals in the United States – are vulnerable and could close. The reasons are multiple, but the result has been an erosion of the rural safety net, especially with regard to maternity care.

These hospital closures force women to travel farther distances for maternity care, including cesarean sections, and this contributes to increased maternal and infant mortality.⁵ In a study from Canada, the complication rates increased substantially as distances increased. Women are more likely to have premature deliveries, deliver on the side of the road, or end up in inappropriate facilities.

The distance from delivery is directly related to outcomes. A study from the early 1990s showed that women did better if they received maternity care from local hospitals and physicians.⁶ From a family medicine perspective, this makes sense because traveling to a metropolitan area means isolation from family and social networks. Stress increases because pregnant women also are often the primary caregiver of other children and the primary wage earner of the family. Although we are unsure what impact stress has on pregnancy, we do know it does have an effect on greater risk of prematurity and poor outcomes.

Obstetricians provide excellent care, but they are not a panacea. Only half of U.S. counties have adequate ob.gyn. coverage. Moreover, in many of those counties, the ob.gyns. subspecialize in gynecologic surgery and infertility, but don’t provide obstetrical care. Another challenge: ob.gyns. cannot survive financially in smaller communities; our policies must include incentives to recruit and retain them in underserved areas.

Certified nurse midwives also provide excellent care and are an invaluable member of the patient-care team, but again, they cannot be the only solution. Obstetrical emergencies do occur, and mothers need a physician trained in providing on-site medical or surgical care. They also need a hospital with adequate staff to care for emergencies.

In communities large enough to support a multispecialty group, certified medical technicians, family physicians, and ob.gyns. would ideally work alongside each other. In small communities four family physicians can provide a high level of maternity care including surgical deliveries, while supporting themselves with caring for children and elders in clinics, hospitals, and EDs.

It is unconscionable that a country as wealthy as ours would accept rates of maternal and infant mortality that rival and are often worse than developing countries. Although the reasons are many, there is no excuse. Family physicians are an essential part of reversing this trend. We need policies that enable family physicians to help resolve the shortage of maternity care for underserved communities, to address the maternal and infant mortality rate, and to provide maternity care that is part of family medicine’s full scope of practice.

Dr. Cullen is board chair of the American Academy of Family Physicians and a practicing family physician in Valdez, Alaska.

References

1. Am Board Fam Med. 2017 Jul-Aug;30(4):405-6.

2. CMAJ. 2015 Oct 27;187:1125-32.

3. J Am Board Fam Med. 2013 Jul-Aug;26(4):366-72.

4. NRHA Save Rural Hospitals Action Center. www.ruralhealthweb.org/advocate/save-rural-hospitals.

5. BMC Health Serv Res. 2011 Jun 10;11:147.

6. Am J Public Health. 1990 Jul;80(7):814-8.

For the last 25 years I have had the privilege of caring for a rural community, practicing full-scope family medicine including obstetrics with cesarean sections. I have had a deeply rewarding career, and delivering babies and watching them grow up has been one of the most gratifying parts of my work.

Sheri Porter/AAFP News

My concern is that, as the number of family physicians who practice maternity care has decreased, the infant and maternal mortality rate in the United States has increased, especially in rural and minority populations. Currently, 5 million women of reproductive age have no access to maternity care.

At the same time 23% of incoming family medicine residents would like to offer maternity care and are trained to do so, but few are able to find a job where this is possible.¹ This is unfortunate because family physicians have the training and expertise to provide comprehensive maternity care. Although they have lower rates of cesarean section than ob-gyns, with similar outcomes, family physicians do have surgical skills, including providing cesarean sections, that are often necessary for safe delivery.^2,3

In addition, family physicians have the internal medicine and behavioral health background to care for postpartum complications, as well as substance use disorders. Because they also care for children, they see postpartum women when they come in with their children for well-child checks. These visits offer an excellent opportunity to also check on the mother for postpartum depression and other signs of postpartum illness.

Centers for Disease Control and Prevention data reveal that maternal mortality can be divided into three nearly equal parts: pregnancy, delivery, and post partum. They define delivery as the week of delivery. The 48 hours post delivery accounted for only 12% of overall mortality. This means that even if women travel to metropolitan areas, they are likely to be home when they have fatal complications. The lack of trained and experienced physicians in the communities where women live increases their risks should they have complications. Most maternal fatalities occur when conditions are not recognized in a timely fashion. Some responses require procedural skills such as dilation and curettage (D&C).

As a member of the National Advisory Committee on Rural Health and Human Services, I visited several states to evaluate their rural health systems. We looked at infant mortality by county and found an enormous disparity between counties, largely caused by lack of prenatal services and obstetrical services.

These disparities between counties are getting worse. The United States is losing critical access hospitals at a rapid pace. We have lost 117 critical access hospitals in the last 10 years, with 40 in the last year alone. According to the National Rural Health Association, ^4,673 additional facilities – representing more than one-third of rural hospitals in the United States – are vulnerable and could close. The reasons are multiple, but the result has been an erosion of the rural safety net, especially with regard to maternity care.

These hospital closures force women to travel farther distances for maternity care, including cesarean sections, and this contributes to increased maternal and infant mortality.⁵ In a study from Canada, the complication rates increased substantially as distances increased. Women are more likely to have premature deliveries, deliver on the side of the road, or end up in inappropriate facilities.

The distance from delivery is directly related to outcomes. A study from the early 1990s showed that women did better if they received maternity care from local hospitals and physicians.⁶ From a family medicine perspective, this makes sense because traveling to a metropolitan area means isolation from family and social networks. Stress increases because pregnant women also are often the primary caregiver of other children and the primary wage earner of the family. Although we are unsure what impact stress has on pregnancy, we do know it does have an effect on greater risk of prematurity and poor outcomes.

Obstetricians provide excellent care, but they are not a panacea. Only half of U.S. counties have adequate ob.gyn. coverage. Moreover, in many of those counties, the ob.gyns. subspecialize in gynecologic surgery and infertility, but don’t provide obstetrical care. Another challenge: ob.gyns. cannot survive financially in smaller communities; our policies must include incentives to recruit and retain them in underserved areas.

Certified nurse midwives also provide excellent care and are an invaluable member of the patient-care team, but again, they cannot be the only solution. Obstetrical emergencies do occur, and mothers need a physician trained in providing on-site medical or surgical care. They also need a hospital with adequate staff to care for emergencies.

In communities large enough to support a multispecialty group, certified medical technicians, family physicians, and ob.gyns. would ideally work alongside each other. In small communities four family physicians can provide a high level of maternity care including surgical deliveries, while supporting themselves with caring for children and elders in clinics, hospitals, and EDs.

It is unconscionable that a country as wealthy as ours would accept rates of maternal and infant mortality that rival and are often worse than developing countries. Although the reasons are many, there is no excuse. Family physicians are an essential part of reversing this trend. We need policies that enable family physicians to help resolve the shortage of maternity care for underserved communities, to address the maternal and infant mortality rate, and to provide maternity care that is part of family medicine’s full scope of practice.

Dr. Cullen is board chair of the American Academy of Family Physicians and a practicing family physician in Valdez, Alaska.

References

1. Am Board Fam Med. 2017 Jul-Aug;30(4):405-6.

2. CMAJ. 2015 Oct 27;187:1125-32.

3. J Am Board Fam Med. 2013 Jul-Aug;26(4):366-72.

4. NRHA Save Rural Hospitals Action Center. www.ruralhealthweb.org/advocate/save-rural-hospitals.

5. BMC Health Serv Res. 2011 Jun 10;11:147.

6. Am J Public Health. 1990 Jul;80(7):814-8.

Medicine is a rewarding but demanding field. Part of being a professional is handling the stresses of the job. That ability is as important as tying strong horizontal mattress sutures, choosing correct antibiotics to treat staph, and gently breaking bad news.

doomu/Thinkstock

The divorce and suicide rate among physicians are evidence that many physicians handle stress poorly. Our rates of depression, burnout, alcoholism, and substance abuse are further evidence of the suffering caused by unmitigated stress. It is endemic and destructive, harming physicians, their loved ones, and their patients. While this situation has long been true, in the past decade its importance has become better recognized. Some scholars have added physician wellness or fulfillment as a fourth aim of medical care to complement the triple aims of patient outcomes, consumer experience, and financial stewardship.

The sources of stress can be either external or internal. Internally, many physicians feel torn between competing professional roles. Recently one fellow in pediatric intensive care wrote an insightful reflective essay about two conflicting roles (“Virtue and Suffering: Where the Personal and Professional Collide,” Lauren Rissman, MD. reflectivemeded.org). One side is the potential benefits of technology and modern medical interventions. The other side is compassion and knowing when to say enough. Finding that balance – or boundary – or mixture is difficult. Even more difficult is helping patients/parents who are struggling with those choices.

Some old models of the doctor-patient relationship insisted on an emotional detachment to promote objectivity. This often is paired with using nondirective counseling. The admonishment for a physician to be nondirective comes up in end-of-life care choices in the ICU. It comes up in genetic counseling, particularly in the prenatal time frame, and when I do ethics consults requiring values clarification and mediation. But I also have found times during shared decision making when the model of a fully informed consumer choice is not valid. There are situations in which a paradigm of emotional detachment impairs the ability to convey empathy, compassion, and presence. Being detached also may prevent the moments of personal connection between doctor and patient that are the intangible rewards of the vocation. A good physician knows how to choose among these idealized models. It requires being genuine when employing a diverse bag of bedside tools.

High technology and highly invasive care pose dilemmas in assessing outcomes, minimizing suffering, and ensuring financial stewardship. When one addresses those different types of dilemmas happening simultaneously, the initial approach can be to separate the different influences into separate vectors. But when one does this on a regular basis, it fractures one’s self-image. To survive and flourish, the physician juggling these competing, conflicting goals must shun the split personality and seek to live as an integrated moral agent. This integration is not achieved by working harder or longer or even smarter. It requires time and effort directed to self-reflection. When pediatric ethicists get together at conferences, I notice that about one-half of them are neonatal ICU docs and one-quarter are pediatric ICU docs. Many view their work in ethics as a survival mechanism. We all are looking for answers to questions we may not be able to fully articulate.

In this short column I will not endeavor to offer a neat package of advice on how to achieve being whole. Dr. Rissman in her essay is just starting her career while I’m nearing the end of mine. It is a lifelong process to integrate oneself rather than exist in turmoil. It truly is a journey, not a destination. After a career dedicated to considering technology, compassion, and costs, I know there are no simple solutions. I also know that it is important to keep seeking better answers.

To encourage group discussion of ethical problems, I have heard facilitators say that there are no right and wrong answers. I strongly disagree. In ethics, there often is more than one correct answer. Ethicists can write books on why one right answer is slightly better than another right answer for a particular individual or population. We live for debates over such minutiae. In the real world of medical ethics, there also are definitely wrong answers.

The difference between medical ethics and philosophy is that, when all the talking is done, in medical ethics something happens. That makes a difference. Professional athletes know the importance of recovery after an intense workout. Muscles have accumulated microscopic tears that must heal. Professional physicians must develop a personal regimen of caring for overexertion of their own emotional and moral/spiritual muscles in order to remain whole.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

Medicine is a rewarding but demanding field. Part of being a professional is handling the stresses of the job. That ability is as important as tying strong horizontal mattress sutures, choosing correct antibiotics to treat staph, and gently breaking bad news.

doomu/Thinkstock

The divorce and suicide rate among physicians are evidence that many physicians handle stress poorly. Our rates of depression, burnout, alcoholism, and substance abuse are further evidence of the suffering caused by unmitigated stress. It is endemic and destructive, harming physicians, their loved ones, and their patients. While this situation has long been true, in the past decade its importance has become better recognized. Some scholars have added physician wellness or fulfillment as a fourth aim of medical care to complement the triple aims of patient outcomes, consumer experience, and financial stewardship.

The sources of stress can be either external or internal. Internally, many physicians feel torn between competing professional roles. Recently one fellow in pediatric intensive care wrote an insightful reflective essay about two conflicting roles (“Virtue and Suffering: Where the Personal and Professional Collide,” Lauren Rissman, MD. reflectivemeded.org). One side is the potential benefits of technology and modern medical interventions. The other side is compassion and knowing when to say enough. Finding that balance – or boundary – or mixture is difficult. Even more difficult is helping patients/parents who are struggling with those choices.

Some old models of the doctor-patient relationship insisted on an emotional detachment to promote objectivity. This often is paired with using nondirective counseling. The admonishment for a physician to be nondirective comes up in end-of-life care choices in the ICU. It comes up in genetic counseling, particularly in the prenatal time frame, and when I do ethics consults requiring values clarification and mediation. But I also have found times during shared decision making when the model of a fully informed consumer choice is not valid. There are situations in which a paradigm of emotional detachment impairs the ability to convey empathy, compassion, and presence. Being detached also may prevent the moments of personal connection between doctor and patient that are the intangible rewards of the vocation. A good physician knows how to choose among these idealized models. It requires being genuine when employing a diverse bag of bedside tools.

High technology and highly invasive care pose dilemmas in assessing outcomes, minimizing suffering, and ensuring financial stewardship. When one addresses those different types of dilemmas happening simultaneously, the initial approach can be to separate the different influences into separate vectors. But when one does this on a regular basis, it fractures one’s self-image. To survive and flourish, the physician juggling these competing, conflicting goals must shun the split personality and seek to live as an integrated moral agent. This integration is not achieved by working harder or longer or even smarter. It requires time and effort directed to self-reflection. When pediatric ethicists get together at conferences, I notice that about one-half of them are neonatal ICU docs and one-quarter are pediatric ICU docs. Many view their work in ethics as a survival mechanism. We all are looking for answers to questions we may not be able to fully articulate.

In this short column I will not endeavor to offer a neat package of advice on how to achieve being whole. Dr. Rissman in her essay is just starting her career while I’m nearing the end of mine. It is a lifelong process to integrate oneself rather than exist in turmoil. It truly is a journey, not a destination. After a career dedicated to considering technology, compassion, and costs, I know there are no simple solutions. I also know that it is important to keep seeking better answers.

To encourage group discussion of ethical problems, I have heard facilitators say that there are no right and wrong answers. I strongly disagree. In ethics, there often is more than one correct answer. Ethicists can write books on why one right answer is slightly better than another right answer for a particular individual or population. We live for debates over such minutiae. In the real world of medical ethics, there also are definitely wrong answers.

The difference between medical ethics and philosophy is that, when all the talking is done, in medical ethics something happens. That makes a difference. Professional athletes know the importance of recovery after an intense workout. Muscles have accumulated microscopic tears that must heal. Professional physicians must develop a personal regimen of caring for overexertion of their own emotional and moral/spiritual muscles in order to remain whole.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

Medicine is a rewarding but demanding field. Part of being a professional is handling the stresses of the job. That ability is as important as tying strong horizontal mattress sutures, choosing correct antibiotics to treat staph, and gently breaking bad news.

doomu/Thinkstock

The divorce and suicide rate among physicians are evidence that many physicians handle stress poorly. Our rates of depression, burnout, alcoholism, and substance abuse are further evidence of the suffering caused by unmitigated stress. It is endemic and destructive, harming physicians, their loved ones, and their patients. While this situation has long been true, in the past decade its importance has become better recognized. Some scholars have added physician wellness or fulfillment as a fourth aim of medical care to complement the triple aims of patient outcomes, consumer experience, and financial stewardship.

The sources of stress can be either external or internal. Internally, many physicians feel torn between competing professional roles. Recently one fellow in pediatric intensive care wrote an insightful reflective essay about two conflicting roles (“Virtue and Suffering: Where the Personal and Professional Collide,” Lauren Rissman, MD. reflectivemeded.org). One side is the potential benefits of technology and modern medical interventions. The other side is compassion and knowing when to say enough. Finding that balance – or boundary – or mixture is difficult. Even more difficult is helping patients/parents who are struggling with those choices.

Some old models of the doctor-patient relationship insisted on an emotional detachment to promote objectivity. This often is paired with using nondirective counseling. The admonishment for a physician to be nondirective comes up in end-of-life care choices in the ICU. It comes up in genetic counseling, particularly in the prenatal time frame, and when I do ethics consults requiring values clarification and mediation. But I also have found times during shared decision making when the model of a fully informed consumer choice is not valid. There are situations in which a paradigm of emotional detachment impairs the ability to convey empathy, compassion, and presence. Being detached also may prevent the moments of personal connection between doctor and patient that are the intangible rewards of the vocation. A good physician knows how to choose among these idealized models. It requires being genuine when employing a diverse bag of bedside tools.

High technology and highly invasive care pose dilemmas in assessing outcomes, minimizing suffering, and ensuring financial stewardship. When one addresses those different types of dilemmas happening simultaneously, the initial approach can be to separate the different influences into separate vectors. But when one does this on a regular basis, it fractures one’s self-image. To survive and flourish, the physician juggling these competing, conflicting goals must shun the split personality and seek to live as an integrated moral agent. This integration is not achieved by working harder or longer or even smarter. It requires time and effort directed to self-reflection. When pediatric ethicists get together at conferences, I notice that about one-half of them are neonatal ICU docs and one-quarter are pediatric ICU docs. Many view their work in ethics as a survival mechanism. We all are looking for answers to questions we may not be able to fully articulate.

In this short column I will not endeavor to offer a neat package of advice on how to achieve being whole. Dr. Rissman in her essay is just starting her career while I’m nearing the end of mine. It is a lifelong process to integrate oneself rather than exist in turmoil. It truly is a journey, not a destination. After a career dedicated to considering technology, compassion, and costs, I know there are no simple solutions. I also know that it is important to keep seeking better answers.

To encourage group discussion of ethical problems, I have heard facilitators say that there are no right and wrong answers. I strongly disagree. In ethics, there often is more than one correct answer. Ethicists can write books on why one right answer is slightly better than another right answer for a particular individual or population. We live for debates over such minutiae. In the real world of medical ethics, there also are definitely wrong answers.

The difference between medical ethics and philosophy is that, when all the talking is done, in medical ethics something happens. That makes a difference. Professional athletes know the importance of recovery after an intense workout. Muscles have accumulated microscopic tears that must heal. Professional physicians must develop a personal regimen of caring for overexertion of their own emotional and moral/spiritual muscles in order to remain whole.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

The day wouldn’t be so bad if he would just go to sleep at night! How many times have you heard this plea from parents of your patients with ADHD? Sleep is important for everyone, but getting enough is both more important and more difficult for children with ADHD. About three-quarters of children with ADHD have significant problems with sleep, most even before any medication treatment. And inadequate sleep can exacerbate or even cause ADHD symptoms!

SeventyFour/iStock/Getty Images

Solving sleep problems for children with ADHD is not always simple. The kinds of sleep issues that are more common in children (and adults) with ADHD, compared with typical children, include behavioral bedtime resistance, circadian rhythm sleep disorder (CRSD), insomnia, morning sleepiness, night waking, periodic limb movement disorder (PLMD), restless leg syndrome (RLS), and sleep disordered breathing (SDB). Such a broad differential means a careful history and sometimes even lab studies may be needed.

Both initial and follow-up visits for ADHD should include a sleep history or, ideally, a tool such as BEARS sleep screening tool or Children’s Sleep Habits Questionnaire and a 2-week sleep diary (http://www.sleepfoundation.org/). These are good ways to collect signs of allergies or apnea (for SDB), limb movements or limb pain (for RLS or PLMD), mouth breathing, night waking, and snoring.

You also need to ask about alcohol, drugs, caffeine, and nicotine; asthma; comorbid conditions such as mental health disorders or their treatments; and enuresis (alone or part of nocturnal seizures).

Do I need to remind you to find out about electronics activating the child before bedtime – hidden under the covers, or signaling messages from friends in the middle of the night – and to encourage limits on these? Some sleep disorders warrant polysomnography in a sleep lab or from MyZeo.com (for PLMD and some SDB) or ferritin less than 50 mg/L (for RLS) for diagnosis and to guide treatment. Nasal steroids, antihistamines, or montelukast may help SDB when there are enlarged tonsils or adenoids, but adenotonsillectomy is usually curative.

The first line and most effective treatment for sleep problems in children with or without ADHD is improving sleep hygiene. Improved sleep “hygiene” sounds easy, but for children with ADHD and their parents, who often have ADHD too, changing behaviors can be tough! The key component is establishing habits for the entire sleep cycle: a steady pattern of reduced stimulation in the hour before bedtime (sans electronics); a friendly rather than irritated bedtime routine; and the same bedtime and wake up time, ideally 7 days per week. Bedtime stories read to the child can soothe at any age, not just toddlers! Of course, both children and families want fun and special occasions. For most, varying bedtime by up to 1 hour won’t mess up their biological clock, but for some even this should be avoided. Sleeping alone in a cool, dark, quiet room, nightly in the same bed (not used for other activities), is considered the ideal. Earplugs, white noise generators, and eye masks may be helpful. If sleeping with siblings is a necessity, bedtimes can be staggered to put the child to bed earlier or after others are asleep.

Struggles postponing bedtime may be part of a pattern of oppositionality common in ADHD, but the child may not be tired due to being off schedule (from CRSD), napping on the bus or after school, sleeping in mornings, or unrealistic parent expectations for sleep duration. Parents may want their hyperactive children to give them a break and go to bed at 8 p.m., but children aged 6-10 years need only 10-11 hours and those aged 10-17 years need 8.5-9.25 hours of sleep.

Not tired may instead be “wired” from lingering stimulant effects or even lack of such medication leaving the child overactive or rebounding from earlier medications. Lower afternoon doses or shorter-acting medication may solve lasting medication issues, but sometimes an additional low dose of stimulants actually will help a child with ADHD settle at bedtime. All stimulant medications can prolong sleep onset, often by 30 minutes, but this varies by individual and tends to resolve on its own a few weeks after a new or changed medicine. Switching medication category may allow a child to fall asleep faster. Atomoxetine and alpha agonists are less likely to delay sleep than methylphenidate (MPH).

What if sleep hygiene, behavioral methods, and adjusting ADHD medications is not enough? If sleep issues are causing significant problems, medication for sleep is worth a try. Controlled-release melatonin 1-2 hours before bedtime has data for effectiveness. There is no defined dose, so the lowest effective dose should be used, but 3-6 mg may be needed. Because many families with a child with ADHD are not organized enough to give medicine on this schedule, sublingual melatonin that acts in 15-20 minutes is a good alternative or even first choice. Clonidine 0.05-0.2 mg 1 hour before bedtime speeds sleep onset, lasts 3 hours, and does not carry over to sedation the next day. Stronger psychopharmaceuticals can assist sleep onset, including low dose mirtazapine or trazodone, but have the side effect of daytime sleepiness.

Management of waking in the middle of the night can be more difficult to treat as sleep drive has been dissipated. First, consider whether trips out of bed reflect a sleep association that has not been extinguished. Daytime atomoxetine or, better yet, MPH may improve night waking, and sometimes even a low-dose evening, long-acting medication, such as osmotic release oral system (OROS) extended release methylphenidate HCL (OROS MPH), helps. Short-acting clonidine or melatonin in the middle of the night or bedtime mirtazapine or trazodone also may be worth a try.

When dealing with sleep, keep in mind that 50% or more of children with ADHD have a coexisting mental health disorder. Anxiety, separation anxiety, depression, and dysthymia all often affect sleep onset, night waking, and sometimes early morning waking. The child or teen may need extra reassurance or company at bedtime (siblings or pets may suffice). Reading positive stories or playing soft music may be better at setting a positive mood and sense of safety for sleep, certainly more so than social media, which should be avoided.

Keep in mind that substance use is more common in ADHD as well as with those other mental health conditions and can interfere with restful sleep and make RLS worse. Bipolar disorder can be mistaken for ADHD as it often presents with hyperactivity but also can be comorbid. Sleep problems are increased sixfold when both are present. Prolonged periods awake at night and diminished need for sleep are signs that help differentiate bipolar from ADHD. Medication management for the bipolar disorder with atypicals can reduce sleep latency and reduce REM sleep, but also causes morning fatigue. Medications to treat other mental health problems can help sleep onset (for example, anticonvulsants, atypicals), or prolong it (SSRIs), change REM states (atypicals), and even exacerbate RLS (SSRIs). You can make changes or work with the child’s mental health specialist if medications are causing significant sleep problems.

When we help improve sleep for children with ADHD, it can lessen not only ADHD symptoms but also some symptoms of other mental health disorders, improve learning and behavior, and greatly improve family quality of life!
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

The day wouldn’t be so bad if he would just go to sleep at night! How many times have you heard this plea from parents of your patients with ADHD? Sleep is important for everyone, but getting enough is both more important and more difficult for children with ADHD. About three-quarters of children with ADHD have significant problems with sleep, most even before any medication treatment. And inadequate sleep can exacerbate or even cause ADHD symptoms!

SeventyFour/iStock/Getty Images

Solving sleep problems for children with ADHD is not always simple. The kinds of sleep issues that are more common in children (and adults) with ADHD, compared with typical children, include behavioral bedtime resistance, circadian rhythm sleep disorder (CRSD), insomnia, morning sleepiness, night waking, periodic limb movement disorder (PLMD), restless leg syndrome (RLS), and sleep disordered breathing (SDB). Such a broad differential means a careful history and sometimes even lab studies may be needed.

Both initial and follow-up visits for ADHD should include a sleep history or, ideally, a tool such as BEARS sleep screening tool or Children’s Sleep Habits Questionnaire and a 2-week sleep diary (http://www.sleepfoundation.org/). These are good ways to collect signs of allergies or apnea (for SDB), limb movements or limb pain (for RLS or PLMD), mouth breathing, night waking, and snoring.

You also need to ask about alcohol, drugs, caffeine, and nicotine; asthma; comorbid conditions such as mental health disorders or their treatments; and enuresis (alone or part of nocturnal seizures).

Do I need to remind you to find out about electronics activating the child before bedtime – hidden under the covers, or signaling messages from friends in the middle of the night – and to encourage limits on these? Some sleep disorders warrant polysomnography in a sleep lab or from MyZeo.com (for PLMD and some SDB) or ferritin less than 50 mg/L (for RLS) for diagnosis and to guide treatment. Nasal steroids, antihistamines, or montelukast may help SDB when there are enlarged tonsils or adenoids, but adenotonsillectomy is usually curative.

The first line and most effective treatment for sleep problems in children with or without ADHD is improving sleep hygiene. Improved sleep “hygiene” sounds easy, but for children with ADHD and their parents, who often have ADHD too, changing behaviors can be tough! The key component is establishing habits for the entire sleep cycle: a steady pattern of reduced stimulation in the hour before bedtime (sans electronics); a friendly rather than irritated bedtime routine; and the same bedtime and wake up time, ideally 7 days per week. Bedtime stories read to the child can soothe at any age, not just toddlers! Of course, both children and families want fun and special occasions. For most, varying bedtime by up to 1 hour won’t mess up their biological clock, but for some even this should be avoided. Sleeping alone in a cool, dark, quiet room, nightly in the same bed (not used for other activities), is considered the ideal. Earplugs, white noise generators, and eye masks may be helpful. If sleeping with siblings is a necessity, bedtimes can be staggered to put the child to bed earlier or after others are asleep.

Struggles postponing bedtime may be part of a pattern of oppositionality common in ADHD, but the child may not be tired due to being off schedule (from CRSD), napping on the bus or after school, sleeping in mornings, or unrealistic parent expectations for sleep duration. Parents may want their hyperactive children to give them a break and go to bed at 8 p.m., but children aged 6-10 years need only 10-11 hours and those aged 10-17 years need 8.5-9.25 hours of sleep.

Not tired may instead be “wired” from lingering stimulant effects or even lack of such medication leaving the child overactive or rebounding from earlier medications. Lower afternoon doses or shorter-acting medication may solve lasting medication issues, but sometimes an additional low dose of stimulants actually will help a child with ADHD settle at bedtime. All stimulant medications can prolong sleep onset, often by 30 minutes, but this varies by individual and tends to resolve on its own a few weeks after a new or changed medicine. Switching medication category may allow a child to fall asleep faster. Atomoxetine and alpha agonists are less likely to delay sleep than methylphenidate (MPH).

What if sleep hygiene, behavioral methods, and adjusting ADHD medications is not enough? If sleep issues are causing significant problems, medication for sleep is worth a try. Controlled-release melatonin 1-2 hours before bedtime has data for effectiveness. There is no defined dose, so the lowest effective dose should be used, but 3-6 mg may be needed. Because many families with a child with ADHD are not organized enough to give medicine on this schedule, sublingual melatonin that acts in 15-20 minutes is a good alternative or even first choice. Clonidine 0.05-0.2 mg 1 hour before bedtime speeds sleep onset, lasts 3 hours, and does not carry over to sedation the next day. Stronger psychopharmaceuticals can assist sleep onset, including low dose mirtazapine or trazodone, but have the side effect of daytime sleepiness.

Management of waking in the middle of the night can be more difficult to treat as sleep drive has been dissipated. First, consider whether trips out of bed reflect a sleep association that has not been extinguished. Daytime atomoxetine or, better yet, MPH may improve night waking, and sometimes even a low-dose evening, long-acting medication, such as osmotic release oral system (OROS) extended release methylphenidate HCL (OROS MPH), helps. Short-acting clonidine or melatonin in the middle of the night or bedtime mirtazapine or trazodone also may be worth a try.

When dealing with sleep, keep in mind that 50% or more of children with ADHD have a coexisting mental health disorder. Anxiety, separation anxiety, depression, and dysthymia all often affect sleep onset, night waking, and sometimes early morning waking. The child or teen may need extra reassurance or company at bedtime (siblings or pets may suffice). Reading positive stories or playing soft music may be better at setting a positive mood and sense of safety for sleep, certainly more so than social media, which should be avoided.

Keep in mind that substance use is more common in ADHD as well as with those other mental health conditions and can interfere with restful sleep and make RLS worse. Bipolar disorder can be mistaken for ADHD as it often presents with hyperactivity but also can be comorbid. Sleep problems are increased sixfold when both are present. Prolonged periods awake at night and diminished need for sleep are signs that help differentiate bipolar from ADHD. Medication management for the bipolar disorder with atypicals can reduce sleep latency and reduce REM sleep, but also causes morning fatigue. Medications to treat other mental health problems can help sleep onset (for example, anticonvulsants, atypicals), or prolong it (SSRIs), change REM states (atypicals), and even exacerbate RLS (SSRIs). You can make changes or work with the child’s mental health specialist if medications are causing significant sleep problems.

When we help improve sleep for children with ADHD, it can lessen not only ADHD symptoms but also some symptoms of other mental health disorders, improve learning and behavior, and greatly improve family quality of life!
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

The day wouldn’t be so bad if he would just go to sleep at night! How many times have you heard this plea from parents of your patients with ADHD? Sleep is important for everyone, but getting enough is both more important and more difficult for children with ADHD. About three-quarters of children with ADHD have significant problems with sleep, most even before any medication treatment. And inadequate sleep can exacerbate or even cause ADHD symptoms!

SeventyFour/iStock/Getty Images

Solving sleep problems for children with ADHD is not always simple. The kinds of sleep issues that are more common in children (and adults) with ADHD, compared with typical children, include behavioral bedtime resistance, circadian rhythm sleep disorder (CRSD), insomnia, morning sleepiness, night waking, periodic limb movement disorder (PLMD), restless leg syndrome (RLS), and sleep disordered breathing (SDB). Such a broad differential means a careful history and sometimes even lab studies may be needed.

Both initial and follow-up visits for ADHD should include a sleep history or, ideally, a tool such as BEARS sleep screening tool or Children’s Sleep Habits Questionnaire and a 2-week sleep diary (http://www.sleepfoundation.org/). These are good ways to collect signs of allergies or apnea (for SDB), limb movements or limb pain (for RLS or PLMD), mouth breathing, night waking, and snoring.

You also need to ask about alcohol, drugs, caffeine, and nicotine; asthma; comorbid conditions such as mental health disorders or their treatments; and enuresis (alone or part of nocturnal seizures).

Do I need to remind you to find out about electronics activating the child before bedtime – hidden under the covers, or signaling messages from friends in the middle of the night – and to encourage limits on these? Some sleep disorders warrant polysomnography in a sleep lab or from MyZeo.com (for PLMD and some SDB) or ferritin less than 50 mg/L (for RLS) for diagnosis and to guide treatment. Nasal steroids, antihistamines, or montelukast may help SDB when there are enlarged tonsils or adenoids, but adenotonsillectomy is usually curative.

The first line and most effective treatment for sleep problems in children with or without ADHD is improving sleep hygiene. Improved sleep “hygiene” sounds easy, but for children with ADHD and their parents, who often have ADHD too, changing behaviors can be tough! The key component is establishing habits for the entire sleep cycle: a steady pattern of reduced stimulation in the hour before bedtime (sans electronics); a friendly rather than irritated bedtime routine; and the same bedtime and wake up time, ideally 7 days per week. Bedtime stories read to the child can soothe at any age, not just toddlers! Of course, both children and families want fun and special occasions. For most, varying bedtime by up to 1 hour won’t mess up their biological clock, but for some even this should be avoided. Sleeping alone in a cool, dark, quiet room, nightly in the same bed (not used for other activities), is considered the ideal. Earplugs, white noise generators, and eye masks may be helpful. If sleeping with siblings is a necessity, bedtimes can be staggered to put the child to bed earlier or after others are asleep.

Struggles postponing bedtime may be part of a pattern of oppositionality common in ADHD, but the child may not be tired due to being off schedule (from CRSD), napping on the bus or after school, sleeping in mornings, or unrealistic parent expectations for sleep duration. Parents may want their hyperactive children to give them a break and go to bed at 8 p.m., but children aged 6-10 years need only 10-11 hours and those aged 10-17 years need 8.5-9.25 hours of sleep.

Not tired may instead be “wired” from lingering stimulant effects or even lack of such medication leaving the child overactive or rebounding from earlier medications. Lower afternoon doses or shorter-acting medication may solve lasting medication issues, but sometimes an additional low dose of stimulants actually will help a child with ADHD settle at bedtime. All stimulant medications can prolong sleep onset, often by 30 minutes, but this varies by individual and tends to resolve on its own a few weeks after a new or changed medicine. Switching medication category may allow a child to fall asleep faster. Atomoxetine and alpha agonists are less likely to delay sleep than methylphenidate (MPH).

What if sleep hygiene, behavioral methods, and adjusting ADHD medications is not enough? If sleep issues are causing significant problems, medication for sleep is worth a try. Controlled-release melatonin 1-2 hours before bedtime has data for effectiveness. There is no defined dose, so the lowest effective dose should be used, but 3-6 mg may be needed. Because many families with a child with ADHD are not organized enough to give medicine on this schedule, sublingual melatonin that acts in 15-20 minutes is a good alternative or even first choice. Clonidine 0.05-0.2 mg 1 hour before bedtime speeds sleep onset, lasts 3 hours, and does not carry over to sedation the next day. Stronger psychopharmaceuticals can assist sleep onset, including low dose mirtazapine or trazodone, but have the side effect of daytime sleepiness.

Management of waking in the middle of the night can be more difficult to treat as sleep drive has been dissipated. First, consider whether trips out of bed reflect a sleep association that has not been extinguished. Daytime atomoxetine or, better yet, MPH may improve night waking, and sometimes even a low-dose evening, long-acting medication, such as osmotic release oral system (OROS) extended release methylphenidate HCL (OROS MPH), helps. Short-acting clonidine or melatonin in the middle of the night or bedtime mirtazapine or trazodone also may be worth a try.

When dealing with sleep, keep in mind that 50% or more of children with ADHD have a coexisting mental health disorder. Anxiety, separation anxiety, depression, and dysthymia all often affect sleep onset, night waking, and sometimes early morning waking. The child or teen may need extra reassurance or company at bedtime (siblings or pets may suffice). Reading positive stories or playing soft music may be better at setting a positive mood and sense of safety for sleep, certainly more so than social media, which should be avoided.

Keep in mind that substance use is more common in ADHD as well as with those other mental health conditions and can interfere with restful sleep and make RLS worse. Bipolar disorder can be mistaken for ADHD as it often presents with hyperactivity but also can be comorbid. Sleep problems are increased sixfold when both are present. Prolonged periods awake at night and diminished need for sleep are signs that help differentiate bipolar from ADHD. Medication management for the bipolar disorder with atypicals can reduce sleep latency and reduce REM sleep, but also causes morning fatigue. Medications to treat other mental health problems can help sleep onset (for example, anticonvulsants, atypicals), or prolong it (SSRIs), change REM states (atypicals), and even exacerbate RLS (SSRIs). You can make changes or work with the child’s mental health specialist if medications are causing significant sleep problems.

When we help improve sleep for children with ADHD, it can lessen not only ADHD symptoms but also some symptoms of other mental health disorders, improve learning and behavior, and greatly improve family quality of life!
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

“I have the best job in the world.” This statement sums up how your colleagues feel about being a PA. Although there are certainly problems that deserve attention, the vast majority of clinicians, who are highly educated and practice in all specialties, state that they would re-enter the field if choosing again.

On the following pages, we focus on the details of the survey results, with breakouts by specialty, region, and practice setting. Be sure to check out which benefits your colleagues are getting, how much they’re being reimbursed for continuing medical education, information about salary by gender and time spent during the workweek, and much more. Participants, invited to comment, have provided several illuminating quotes, which we’ve included throughout the article, indicating what it’s like to be “in the trenches.”

WOULD YOU REPEAT THIS?

To get to the heart of the matter, we asked our survey takers “If you were to do it again, would you choose…”

• The same career
• The same educational preparation
• The same practice setting

To see what your colleagues said, go to the next page

The majority of your peers gave an enthusiastic thumbs up to PA practice as a profession choice. Knowing what you know now, 86% of you agreed that you would follow the same career path today as when you entered practice, which is up 5% from last year.

Educational preparation came in for a ringing endorsement, increasing since last year’s survey results (a 3% increase), and practice setting remained virtually the same.

Of PAs in practice between < 1 and 5 years, 94% felt their educational training was adequate; 53% felt their current responsibilities matched their expectations accurately; and 74% said their career expectations were met.

WOULD YOU TAKE A NEW JOB TODAY?

Continuing to probe about your level of satisfaction, we asked how you feel about changing your job. The answer choices were, “I would…”

• Change my job if I could get a better one (ie, better paid)
• Take any other job in which I could earn as much as I do now (ie, Yes, to leave the profession)
• Change both my job and my occupation (ie, I am burned out)
• Not make any changes (ie, No, not for any reason)

We also asked you how many times you’ve changed jobs since graduating from your PA program. The 4 answer choices ranged from “None” to “More than 3 times.” The final question asked which factors influence your decision about seeking/accepting a new position, allowing more than one choice from the list below.

• Salary/compensation
• Options for supplemental income
• Greater independence/more autonomy
• Opportunities for professional growth/development
• Formal career ladder for advancement
• Defined career path
• Recognition and appreciation
• Schedule flexibility
• Geographic location
• Access to and subsidy for more educational opportunities
• Employer reimbursement of school loans
• Specific state scope of practice and licensure law
• Work-life balance, including addressing burnout
• Working conditions
• Avoid toxic coworkers
• Top-of-the-line tools
• Telecommuting
• Cost of living
• Opportunity for outdoor activities/lifestyle

To see what your colleagues said, go to the next page

Compared to last year, PAs are 4% more likely to stay with their current job, stating that they would not make any changes, with 4% less likely to leave even if a higher salary were on offer. This is supported by the responses that indicate a fewer number of PAs (27%) have changed jobs at the highest rate (> 3 times) compared to 31% last year.

Although 19% of PAs have never changed jobs, 33% have changed 2 or 3 times, and 27% have changed more 3 times (down 4% from last year). However, more PAs report feeling burned out (up 2% from last year) and wish to leave for another profession (up 6% from last year) compared to last year.

Respondents indicated that the following 4 factors would strongly influence their decision to seek or accept a new position:

• Salary/compensation: 84%
• Work-life balance: 72%
• Schedule flexibility: 68%
• Working conditions: 64%

WHAT MAKES YOU MOST SATISFIED WITH YOUR WORK?

As you are aware, level of satisfaction depends on each of the following, which we asked respondents to rank from 1 to 5.

• Relationships with your colleagues (health care providers and clerical/administrative personnel)
• Quality and duration of patient relationships
• Respect received from patients, their families, and your community
• Ability to make a difference and provide significant help to patients, their families, and your community

To see what your colleagues said, go to the next page

Echoing the survey results—which ranked “Making a difference and providing significant help” as the topmost source of job satisfaction—one of your colleagues commented that, “Ability to offer meaningful support to client needs” affected their satisfaction. On the other hand, though, one clinician wrote, “I am starting to decrease my time in urgent care because I’m seeing more often that administration thinks we are selling a good, not a service—and because of lack of respect by patients as well.”

Compared to last year, the changes in response are

3% decrease: Making a difference and providing significant help

No change: Respect received from patients and their families

6% increase: Relationships with your colleagues

2% increase: Quality and duration of patient relationships

MOST SATISFIED BY SPECIALTY

Knowing that certain specialties offer more advantages than others, we presented a list of 19 medical specialties, asking which is your primary one. We also asked how often you typically feel satisfied with your job, with these answer choices.

• Never
• Occasionally
• About half the time
• Most of the time
• Always

To see what your colleagues said, go to the next page

• Dermatology: 73%, a 9% decrease over last year
• Primary Care: 72%, virtually unchanged from last year
• Orthopedic Surgery: 65%, a new entry this year
• Emergency Medicine: 57%, an 8% decrease over last year

As one clinician commented, being “First assistant in surgery” makes a difference in their job satisfaction.

MOST SATISFIED BY PRACTICE SETTING

Working conditions and coworker collegiality are integral to job satisfaction. To learn more about these factors, we asked you to identify the practice settings where you work.

• Academic setting (faculty); school/college health services
• Hospital: inpatient care; outpatient setting or community clinic
• Locum
• Physician practice: solo; single-specialty; multi-specialty
• Public health/occupational health setting; military/government
• Retail/convenient care; urgent care clinic
• Skilled nursing/long-term care facility

We also asked how often you typically feel satisfied with your job, with 5 answer choices ranging from “Never” to “Always.”

To see what your colleagues said, go to the next page

95% of PA respondents work as an employee; of these, 41% work in hospitals, and 31% work in physician offices.¹ Therefore, it is gratifying to see that hospital settings and physician groups are satisfying places to work. In addition, this data has not changed significantly since last year.

1. US Department of Health and Human Services, Health Resources and Services Administration, The U.S. Health Workforce Chartbook. Rockville, Maryland: U.S. Department of Health and Human Services, 2018. 

BENEFITS

As you are aware, having access to the right benefits can go a long way to increasing job satisfaction. In addition to salary as a choice, we listed 30 benefits choices—insurance coverage, additional compensation opportunities, reimbursements, and other—asking which are offered by your employer (access) and which, in lieu of a modest increase in salary, are most important regardless of access. Your responses allowed us to identify the top 7 among your peers.

To see what your colleagues said, go to the next page

You are willing to trade a modest increase in salary for the following important benefits whether you are a new job seeker or an experienced practitioner.

• Compensation: Paid time off, retirement saving plan with employer match
• Insurance coverage: Professional liability insurance, health & dental insurance for self/family (employer subsidized)
• Reimbursements: Licensing fees, professional development fund
• Other: Flexible leave policy

MOST SATISFIED BY REGION

Location, location, location. Where you work depends in part on where your family is; in part on what jobs are available; what affects your commute, taxes and take home pay; and hence your satisfaction. So, we asked where you work—West, Midwest, Northeast, or South—and paired the data with responses to the question about how often you typically feel satisfied with your job, with 5 answer choices ranging from “Never” to “Always.”

To see what your colleagues said, go to the next page

Geographic location is among the factors that influence the decision about seeking or accepting a new job for 53% of PA respondents. Compared to last year, satisfaction levels by region were

• 7% higher than last year in the Northeast
• 5% higher than last year in the South
• 12% lower than last year in the Midwest
• 17% lower than last year in the West

with 27% of PAs practicing in the Northeast; 32% in the South; 21% in the Midwest, and 19% in the West. 76% of PAs working in the South are “most of the time/always” satisfied with their job.

When base salaries are adjusted for cost of living, the top 10 ranked states are, from first to 10th, Oklahoma, Arkansas, Ohio, Texas, Michigan, Indiana, Iowa, New Mexico, Mississippi, and South Dakota.¹

1. American Academy of PAs. 2019 AAPA Salary Report. Alexandria, VA; 2019.

SALARY

Because you indicated that salary is second in importance only to professional liability insurance coverage as part of a desirable compensation package, we asked you to tell us what your salary bracket is. The amounts ranged from < $50,000 to > $175,000 per year (in $25,000 increments). Combining the responses to this question with those asking about gender and specialty, we are able to tie these factors together for you.

To see what your colleagues said, go to the next page

Approximately 5% of PAs earn $50K to $75K per year; 36%, earn $100K to $125K per year; and 5% earn > $175K per year. Similar to responses of previous years, women earn less than men in the PA profession.

PAs practicing in Emergency Medicine (EM) are the most highly compensated, with their median compensation being almost $117K.¹ In fact, among those in EM, we found that 35% earn between $125K and $150K per year, up from 27% from last year. Clinicians working in the emergency room encounter more stressors (a clinician noted “Abuse of the emergency room by patients with ridiculous complaints” as a source of dissatisfaction) than those encountered in other specialties, which may be related to the higher compensation.

Although most PAs feel they are adequately compensated, we found that of those who practice in Family Medicine, 19% earn less than $75K per year, up from 6% from last year.

1. American Academy of PAs. 2019 AAPA Salary Report. Alexandria, VA; 2019.

WORKWEEK

Job satisfaction, and its opposite, burnout are related to your workload (ie, what you do and how much autonomy you have in deciding how to proceed). To help us evaluate these factors, we asked your colleagues to indicate how many hours per week are typically spent in direct (examine/diagnose/treat) and indirect patient care (perform and interpret labs, x-rays, refill prescriptions, etc.), administrative duties, meetings, and teaching.

We were also interested in whether you assess, treat, and manage decisions

• Independently/by yourself
• In direct contact (in person or by phone) with a collaborating physician
• In consultation with a specialist when providing patient care.

Multiple answer choices were permitted.

To see what your colleagues said, go to the next page

As you can imagine, workload is a very hot topic. In response to, “What else affects your job satisfaction?” the greatest number of comments related to electronic charting and data collection. These activities are felt to demand so much time and effort that it takes away from patient care. The survey responses support this: Compared to last year, although the number of hours worked is the same this year, PAs now spend 1 hour less per week on patient care (direct and indirect) and 1 hour more on other duties (administrative and teaching). As one clinician put it, “…availability of medical assistant/administrative support is huge” in alleviating the sense of being overworked or overextended.

Aside from work hours, clinicians told us they seek positions that allow them “input on all issues related to practice” and flexibility on “what/who I am allowed to treat.” According to the survey, when providing patient care,

• 84% of PAs assess, treat, and manage decisions independently
• 37% collaborate with a physician
• 19% consult with a specialist

supporting the fact that 58% of PAs are satisfied most of the time; 12% are always satisfied.

A side note: Of the 50% of PAs who responded that they are involved in teaching students (78% of whom are PAs), they spend approximately 4 hours a week,

• Either as a clinical preceptor (35%)
• In the classroom (5%)
• Or both (10%).

CME REIMBURSEMENT

As we know, PAs earn continuing medical education (CME) credits in order to maintain certification. Therefore, we asked you to indicate how much financial reimbursement you receive annually for CME; answer choices range from $0 to > $2,000 per year (in $500 increments). We also queried you about how much time you are allotted annually for CME; choices were from “None” to “More than 5 weeks.”

To see what your colleagues said, go to the next page

Many of your colleagues responded to the question “What else affects your job satisfaction?” with “Support for continuing learning” and “Educational opportunities.” This is reflected by 51% of survey respondents who stated that “Reimbursement for professional development” was an important benefit (see “Top 7 Benefits” above).

This year, 84% of respondents reported receiving remuneration—either money or time allowed or both—for CME, down 3% from last year. Specifically,

• 16% received $0
• 6%, less than $500
• 10%, between $500 - $1,000
• 25%, between $1,001 - $1,500
• 19%, between $1,501 - $2,000
• 24%, more than $2,000

with average monetary compensation per year up approximately $200 over last year.

Responses to the amount of time you are allotted annually for CME ranged from “None” to “more than 5 weeks.”

• 25%, no time
• 31%, less than 1 week
• 38%, 1-2 weeks
• 3%, 3 weeks
• 1%, 4 weeks
• 0.25%, 5 weeks
• 1%, more than 5 weeks.

In closing, we offer thanks to all the survey participants whose answers helped us understand your current state of job satisfaction and most especially for your frank and enlightening responses to the open-ended questions.

METHODOLOGY

Fielded electronically under the Clinician Reviews logo, an introductory email letter signed by the Editors-in-Chief invited participation in the online 4th annual NP/PA Job Satisfaction Survey of 35 questions.

The survey was fielded August 23, 2019 to a random representative sample of NPs and PAs within the United States, excluding students. The first 150 respondents to complete the survey received a $25 Amazon.com gift certificate.

A total of 1,323 usable responses—a projectable sample size—were received by October 3, 2019, the final cut-off date.

Of the total respondents, 70% are NPs (931) and 30% are PAs (396), which is proportional to the universe of NPs and PAs.^1,2 This summary of results is based on only those respondents who designated their profession as NP or PA.

1. American Association of Nurse Practitioners. NP Fact Sheet. www.aanp.org/all-about-nps/np-fact-sheet. Accessed November 22, 2019.
2. NCCPA. 2018 Statistical Profile of Certified Physician Assistants: an Annual Report of the National Commission on Certification of Physician Assistants. https://prodcmsstoragesa.blob.core.windows.net/uploads/files/2018StatisticalProfileofCertifiedPhysicianAssistants.pdf. Accessed November 22, 2019.

“I have the best job in the world.” This statement sums up how your colleagues feel about being a PA. Although there are certainly problems that deserve attention, the vast majority of clinicians, who are highly educated and practice in all specialties, state that they would re-enter the field if choosing again.

On the following pages, we focus on the details of the survey results, with breakouts by specialty, region, and practice setting. Be sure to check out which benefits your colleagues are getting, how much they’re being reimbursed for continuing medical education, information about salary by gender and time spent during the workweek, and much more. Participants, invited to comment, have provided several illuminating quotes, which we’ve included throughout the article, indicating what it’s like to be “in the trenches.”

WOULD YOU REPEAT THIS?

To get to the heart of the matter, we asked our survey takers “If you were to do it again, would you choose…”

• The same career
• The same educational preparation
• The same practice setting

To see what your colleagues said, go to the next page

The majority of your peers gave an enthusiastic thumbs up to PA practice as a profession choice. Knowing what you know now, 86% of you agreed that you would follow the same career path today as when you entered practice, which is up 5% from last year.

Educational preparation came in for a ringing endorsement, increasing since last year’s survey results (a 3% increase), and practice setting remained virtually the same.

Of PAs in practice between < 1 and 5 years, 94% felt their educational training was adequate; 53% felt their current responsibilities matched their expectations accurately; and 74% said their career expectations were met.

WOULD YOU TAKE A NEW JOB TODAY?

Continuing to probe about your level of satisfaction, we asked how you feel about changing your job. The answer choices were, “I would…”

• Change my job if I could get a better one (ie, better paid)
• Take any other job in which I could earn as much as I do now (ie, Yes, to leave the profession)
• Change both my job and my occupation (ie, I am burned out)
• Not make any changes (ie, No, not for any reason)

We also asked you how many times you’ve changed jobs since graduating from your PA program. The 4 answer choices ranged from “None” to “More than 3 times.” The final question asked which factors influence your decision about seeking/accepting a new position, allowing more than one choice from the list below.

• Salary/compensation
• Options for supplemental income
• Greater independence/more autonomy
• Opportunities for professional growth/development
• Formal career ladder for advancement
• Defined career path
• Recognition and appreciation
• Schedule flexibility
• Geographic location
• Access to and subsidy for more educational opportunities
• Employer reimbursement of school loans
• Specific state scope of practice and licensure law
• Work-life balance, including addressing burnout
• Working conditions
• Avoid toxic coworkers
• Top-of-the-line tools
• Telecommuting
• Cost of living
• Opportunity for outdoor activities/lifestyle

To see what your colleagues said, go to the next page

Compared to last year, PAs are 4% more likely to stay with their current job, stating that they would not make any changes, with 4% less likely to leave even if a higher salary were on offer. This is supported by the responses that indicate a fewer number of PAs (27%) have changed jobs at the highest rate (> 3 times) compared to 31% last year.

Although 19% of PAs have never changed jobs, 33% have changed 2 or 3 times, and 27% have changed more 3 times (down 4% from last year). However, more PAs report feeling burned out (up 2% from last year) and wish to leave for another profession (up 6% from last year) compared to last year.

Respondents indicated that the following 4 factors would strongly influence their decision to seek or accept a new position:

• Salary/compensation: 84%
• Work-life balance: 72%
• Schedule flexibility: 68%
• Working conditions: 64%

WHAT MAKES YOU MOST SATISFIED WITH YOUR WORK?

As you are aware, level of satisfaction depends on each of the following, which we asked respondents to rank from 1 to 5.

• Relationships with your colleagues (health care providers and clerical/administrative personnel)
• Quality and duration of patient relationships
• Respect received from patients, their families, and your community
• Ability to make a difference and provide significant help to patients, their families, and your community

To see what your colleagues said, go to the next page

Echoing the survey results—which ranked “Making a difference and providing significant help” as the topmost source of job satisfaction—one of your colleagues commented that, “Ability to offer meaningful support to client needs” affected their satisfaction. On the other hand, though, one clinician wrote, “I am starting to decrease my time in urgent care because I’m seeing more often that administration thinks we are selling a good, not a service—and because of lack of respect by patients as well.”

Compared to last year, the changes in response are

3% decrease: Making a difference and providing significant help

No change: Respect received from patients and their families

6% increase: Relationships with your colleagues

2% increase: Quality and duration of patient relationships

MOST SATISFIED BY SPECIALTY

Knowing that certain specialties offer more advantages than others, we presented a list of 19 medical specialties, asking which is your primary one. We also asked how often you typically feel satisfied with your job, with these answer choices.

• Never
• Occasionally
• About half the time
• Most of the time
• Always

To see what your colleagues said, go to the next page

• Dermatology: 73%, a 9% decrease over last year
• Primary Care: 72%, virtually unchanged from last year
• Orthopedic Surgery: 65%, a new entry this year
• Emergency Medicine: 57%, an 8% decrease over last year

As one clinician commented, being “First assistant in surgery” makes a difference in their job satisfaction.

MOST SATISFIED BY PRACTICE SETTING

Working conditions and coworker collegiality are integral to job satisfaction. To learn more about these factors, we asked you to identify the practice settings where you work.

• Academic setting (faculty); school/college health services
• Hospital: inpatient care; outpatient setting or community clinic
• Locum
• Physician practice: solo; single-specialty; multi-specialty
• Public health/occupational health setting; military/government
• Retail/convenient care; urgent care clinic
• Skilled nursing/long-term care facility

We also asked how often you typically feel satisfied with your job, with 5 answer choices ranging from “Never” to “Always.”

To see what your colleagues said, go to the next page

95% of PA respondents work as an employee; of these, 41% work in hospitals, and 31% work in physician offices.¹ Therefore, it is gratifying to see that hospital settings and physician groups are satisfying places to work. In addition, this data has not changed significantly since last year.

1. US Department of Health and Human Services, Health Resources and Services Administration, The U.S. Health Workforce Chartbook. Rockville, Maryland: U.S. Department of Health and Human Services, 2018. 

BENEFITS

As you are aware, having access to the right benefits can go a long way to increasing job satisfaction. In addition to salary as a choice, we listed 30 benefits choices—insurance coverage, additional compensation opportunities, reimbursements, and other—asking which are offered by your employer (access) and which, in lieu of a modest increase in salary, are most important regardless of access. Your responses allowed us to identify the top 7 among your peers.

To see what your colleagues said, go to the next page

You are willing to trade a modest increase in salary for the following important benefits whether you are a new job seeker or an experienced practitioner.

• Compensation: Paid time off, retirement saving plan with employer match
• Insurance coverage: Professional liability insurance, health & dental insurance for self/family (employer subsidized)
• Reimbursements: Licensing fees, professional development fund
• Other: Flexible leave policy

MOST SATISFIED BY REGION

Location, location, location. Where you work depends in part on where your family is; in part on what jobs are available; what affects your commute, taxes and take home pay; and hence your satisfaction. So, we asked where you work—West, Midwest, Northeast, or South—and paired the data with responses to the question about how often you typically feel satisfied with your job, with 5 answer choices ranging from “Never” to “Always.”

To see what your colleagues said, go to the next page

Geographic location is among the factors that influence the decision about seeking or accepting a new job for 53% of PA respondents. Compared to last year, satisfaction levels by region were

• 7% higher than last year in the Northeast
• 5% higher than last year in the South
• 12% lower than last year in the Midwest
• 17% lower than last year in the West

with 27% of PAs practicing in the Northeast; 32% in the South; 21% in the Midwest, and 19% in the West. 76% of PAs working in the South are “most of the time/always” satisfied with their job.

When base salaries are adjusted for cost of living, the top 10 ranked states are, from first to 10th, Oklahoma, Arkansas, Ohio, Texas, Michigan, Indiana, Iowa, New Mexico, Mississippi, and South Dakota.¹

1. American Academy of PAs. 2019 AAPA Salary Report. Alexandria, VA; 2019.

SALARY

Because you indicated that salary is second in importance only to professional liability insurance coverage as part of a desirable compensation package, we asked you to tell us what your salary bracket is. The amounts ranged from < $50,000 to > $175,000 per year (in $25,000 increments). Combining the responses to this question with those asking about gender and specialty, we are able to tie these factors together for you.

To see what your colleagues said, go to the next page

Approximately 5% of PAs earn $50K to $75K per year; 36%, earn $100K to $125K per year; and 5% earn > $175K per year. Similar to responses of previous years, women earn less than men in the PA profession.

PAs practicing in Emergency Medicine (EM) are the most highly compensated, with their median compensation being almost $117K.¹ In fact, among those in EM, we found that 35% earn between $125K and $150K per year, up from 27% from last year. Clinicians working in the emergency room encounter more stressors (a clinician noted “Abuse of the emergency room by patients with ridiculous complaints” as a source of dissatisfaction) than those encountered in other specialties, which may be related to the higher compensation.

Although most PAs feel they are adequately compensated, we found that of those who practice in Family Medicine, 19% earn less than $75K per year, up from 6% from last year.

1. American Academy of PAs. 2019 AAPA Salary Report. Alexandria, VA; 2019.

WORKWEEK

Job satisfaction, and its opposite, burnout are related to your workload (ie, what you do and how much autonomy you have in deciding how to proceed). To help us evaluate these factors, we asked your colleagues to indicate how many hours per week are typically spent in direct (examine/diagnose/treat) and indirect patient care (perform and interpret labs, x-rays, refill prescriptions, etc.), administrative duties, meetings, and teaching.

We were also interested in whether you assess, treat, and manage decisions

• Independently/by yourself
• In direct contact (in person or by phone) with a collaborating physician
• In consultation with a specialist when providing patient care.

Multiple answer choices were permitted.

To see what your colleagues said, go to the next page

As you can imagine, workload is a very hot topic. In response to, “What else affects your job satisfaction?” the greatest number of comments related to electronic charting and data collection. These activities are felt to demand so much time and effort that it takes away from patient care. The survey responses support this: Compared to last year, although the number of hours worked is the same this year, PAs now spend 1 hour less per week on patient care (direct and indirect) and 1 hour more on other duties (administrative and teaching). As one clinician put it, “…availability of medical assistant/administrative support is huge” in alleviating the sense of being overworked or overextended.

Aside from work hours, clinicians told us they seek positions that allow them “input on all issues related to practice” and flexibility on “what/who I am allowed to treat.” According to the survey, when providing patient care,

• 84% of PAs assess, treat, and manage decisions independently
• 37% collaborate with a physician
• 19% consult with a specialist

supporting the fact that 58% of PAs are satisfied most of the time; 12% are always satisfied.

A side note: Of the 50% of PAs who responded that they are involved in teaching students (78% of whom are PAs), they spend approximately 4 hours a week,

• Either as a clinical preceptor (35%)
• In the classroom (5%)
• Or both (10%).

CME REIMBURSEMENT

As we know, PAs earn continuing medical education (CME) credits in order to maintain certification. Therefore, we asked you to indicate how much financial reimbursement you receive annually for CME; answer choices range from $0 to > $2,000 per year (in $500 increments). We also queried you about how much time you are allotted annually for CME; choices were from “None” to “More than 5 weeks.”

To see what your colleagues said, go to the next page

Many of your colleagues responded to the question “What else affects your job satisfaction?” with “Support for continuing learning” and “Educational opportunities.” This is reflected by 51% of survey respondents who stated that “Reimbursement for professional development” was an important benefit (see “Top 7 Benefits” above).

This year, 84% of respondents reported receiving remuneration—either money or time allowed or both—for CME, down 3% from last year. Specifically,

• 16% received $0
• 6%, less than $500
• 10%, between $500 - $1,000
• 25%, between $1,001 - $1,500
• 19%, between $1,501 - $2,000
• 24%, more than $2,000

with average monetary compensation per year up approximately $200 over last year.

Responses to the amount of time you are allotted annually for CME ranged from “None” to “more than 5 weeks.”

• 25%, no time
• 31%, less than 1 week
• 38%, 1-2 weeks
• 3%, 3 weeks
• 1%, 4 weeks
• 0.25%, 5 weeks
• 1%, more than 5 weeks.

In closing, we offer thanks to all the survey participants whose answers helped us understand your current state of job satisfaction and most especially for your frank and enlightening responses to the open-ended questions.

METHODOLOGY

Fielded electronically under the Clinician Reviews logo, an introductory email letter signed by the Editors-in-Chief invited participation in the online 4th annual NP/PA Job Satisfaction Survey of 35 questions.

The survey was fielded August 23, 2019 to a random representative sample of NPs and PAs within the United States, excluding students. The first 150 respondents to complete the survey received a $25 Amazon.com gift certificate.

A total of 1,323 usable responses—a projectable sample size—were received by October 3, 2019, the final cut-off date.

Of the total respondents, 70% are NPs (931) and 30% are PAs (396), which is proportional to the universe of NPs and PAs.^1,2 This summary of results is based on only those respondents who designated their profession as NP or PA.

1. American Association of Nurse Practitioners. NP Fact Sheet. www.aanp.org/all-about-nps/np-fact-sheet. Accessed November 22, 2019.
2. NCCPA. 2018 Statistical Profile of Certified Physician Assistants: an Annual Report of the National Commission on Certification of Physician Assistants. https://prodcmsstoragesa.blob.core.windows.net/uploads/files/2018StatisticalProfileofCertifiedPhysicianAssistants.pdf. Accessed November 22, 2019.

“I have the best job in the world.” This statement sums up how your colleagues feel about being a PA. Although there are certainly problems that deserve attention, the vast majority of clinicians, who are highly educated and practice in all specialties, state that they would re-enter the field if choosing again.

On the following pages, we focus on the details of the survey results, with breakouts by specialty, region, and practice setting. Be sure to check out which benefits your colleagues are getting, how much they’re being reimbursed for continuing medical education, information about salary by gender and time spent during the workweek, and much more. Participants, invited to comment, have provided several illuminating quotes, which we’ve included throughout the article, indicating what it’s like to be “in the trenches.”

WOULD YOU REPEAT THIS?

To get to the heart of the matter, we asked our survey takers “If you were to do it again, would you choose…”

• The same career
• The same educational preparation
• The same practice setting

To see what your colleagues said, go to the next page

The majority of your peers gave an enthusiastic thumbs up to PA practice as a profession choice. Knowing what you know now, 86% of you agreed that you would follow the same career path today as when you entered practice, which is up 5% from last year.

Educational preparation came in for a ringing endorsement, increasing since last year’s survey results (a 3% increase), and practice setting remained virtually the same.

Of PAs in practice between < 1 and 5 years, 94% felt their educational training was adequate; 53% felt their current responsibilities matched their expectations accurately; and 74% said their career expectations were met.

WOULD YOU TAKE A NEW JOB TODAY?

Continuing to probe about your level of satisfaction, we asked how you feel about changing your job. The answer choices were, “I would…”

• Change my job if I could get a better one (ie, better paid)
• Take any other job in which I could earn as much as I do now (ie, Yes, to leave the profession)
• Change both my job and my occupation (ie, I am burned out)
• Not make any changes (ie, No, not for any reason)

We also asked you how many times you’ve changed jobs since graduating from your PA program. The 4 answer choices ranged from “None” to “More than 3 times.” The final question asked which factors influence your decision about seeking/accepting a new position, allowing more than one choice from the list below.

• Salary/compensation
• Options for supplemental income
• Greater independence/more autonomy
• Opportunities for professional growth/development
• Formal career ladder for advancement
• Defined career path
• Recognition and appreciation
• Schedule flexibility
• Geographic location
• Access to and subsidy for more educational opportunities
• Employer reimbursement of school loans
• Specific state scope of practice and licensure law
• Work-life balance, including addressing burnout
• Working conditions
• Avoid toxic coworkers
• Top-of-the-line tools
• Telecommuting
• Cost of living
• Opportunity for outdoor activities/lifestyle

To see what your colleagues said, go to the next page

Compared to last year, PAs are 4% more likely to stay with their current job, stating that they would not make any changes, with 4% less likely to leave even if a higher salary were on offer. This is supported by the responses that indicate a fewer number of PAs (27%) have changed jobs at the highest rate (> 3 times) compared to 31% last year.

Although 19% of PAs have never changed jobs, 33% have changed 2 or 3 times, and 27% have changed more 3 times (down 4% from last year). However, more PAs report feeling burned out (up 2% from last year) and wish to leave for another profession (up 6% from last year) compared to last year.

Respondents indicated that the following 4 factors would strongly influence their decision to seek or accept a new position:

• Salary/compensation: 84%
• Work-life balance: 72%
• Schedule flexibility: 68%
• Working conditions: 64%

WHAT MAKES YOU MOST SATISFIED WITH YOUR WORK?

As you are aware, level of satisfaction depends on each of the following, which we asked respondents to rank from 1 to 5.

• Relationships with your colleagues (health care providers and clerical/administrative personnel)
• Quality and duration of patient relationships
• Respect received from patients, their families, and your community
• Ability to make a difference and provide significant help to patients, their families, and your community

To see what your colleagues said, go to the next page

Echoing the survey results—which ranked “Making a difference and providing significant help” as the topmost source of job satisfaction—one of your colleagues commented that, “Ability to offer meaningful support to client needs” affected their satisfaction. On the other hand, though, one clinician wrote, “I am starting to decrease my time in urgent care because I’m seeing more often that administration thinks we are selling a good, not a service—and because of lack of respect by patients as well.”

Compared to last year, the changes in response are

3% decrease: Making a difference and providing significant help

No change: Respect received from patients and their families

6% increase: Relationships with your colleagues

2% increase: Quality and duration of patient relationships

MOST SATISFIED BY SPECIALTY

Knowing that certain specialties offer more advantages than others, we presented a list of 19 medical specialties, asking which is your primary one. We also asked how often you typically feel satisfied with your job, with these answer choices.

• Never
• Occasionally
• About half the time
• Most of the time
• Always

To see what your colleagues said, go to the next page

• Dermatology: 73%, a 9% decrease over last year
• Primary Care: 72%, virtually unchanged from last year
• Orthopedic Surgery: 65%, a new entry this year
• Emergency Medicine: 57%, an 8% decrease over last year

As one clinician commented, being “First assistant in surgery” makes a difference in their job satisfaction.

MOST SATISFIED BY PRACTICE SETTING

Working conditions and coworker collegiality are integral to job satisfaction. To learn more about these factors, we asked you to identify the practice settings where you work.

• Academic setting (faculty); school/college health services
• Hospital: inpatient care; outpatient setting or community clinic
• Locum
• Physician practice: solo; single-specialty; multi-specialty
• Public health/occupational health setting; military/government
• Retail/convenient care; urgent care clinic
• Skilled nursing/long-term care facility

We also asked how often you typically feel satisfied with your job, with 5 answer choices ranging from “Never” to “Always.”

To see what your colleagues said, go to the next page

95% of PA respondents work as an employee; of these, 41% work in hospitals, and 31% work in physician offices.¹ Therefore, it is gratifying to see that hospital settings and physician groups are satisfying places to work. In addition, this data has not changed significantly since last year.

1. US Department of Health and Human Services, Health Resources and Services Administration, The U.S. Health Workforce Chartbook. Rockville, Maryland: U.S. Department of Health and Human Services, 2018. 

BENEFITS

As you are aware, having access to the right benefits can go a long way to increasing job satisfaction. In addition to salary as a choice, we listed 30 benefits choices—insurance coverage, additional compensation opportunities, reimbursements, and other—asking which are offered by your employer (access) and which, in lieu of a modest increase in salary, are most important regardless of access. Your responses allowed us to identify the top 7 among your peers.

To see what your colleagues said, go to the next page

You are willing to trade a modest increase in salary for the following important benefits whether you are a new job seeker or an experienced practitioner.

• Compensation: Paid time off, retirement saving plan with employer match
• Insurance coverage: Professional liability insurance, health & dental insurance for self/family (employer subsidized)
• Reimbursements: Licensing fees, professional development fund
• Other: Flexible leave policy

MOST SATISFIED BY REGION

Location, location, location. Where you work depends in part on where your family is; in part on what jobs are available; what affects your commute, taxes and take home pay; and hence your satisfaction. So, we asked where you work—West, Midwest, Northeast, or South—and paired the data with responses to the question about how often you typically feel satisfied with your job, with 5 answer choices ranging from “Never” to “Always.”

To see what your colleagues said, go to the next page

Geographic location is among the factors that influence the decision about seeking or accepting a new job for 53% of PA respondents. Compared to last year, satisfaction levels by region were

• 7% higher than last year in the Northeast
• 5% higher than last year in the South
• 12% lower than last year in the Midwest
• 17% lower than last year in the West

with 27% of PAs practicing in the Northeast; 32% in the South; 21% in the Midwest, and 19% in the West. 76% of PAs working in the South are “most of the time/always” satisfied with their job.

When base salaries are adjusted for cost of living, the top 10 ranked states are, from first to 10th, Oklahoma, Arkansas, Ohio, Texas, Michigan, Indiana, Iowa, New Mexico, Mississippi, and South Dakota.¹

1. American Academy of PAs. 2019 AAPA Salary Report. Alexandria, VA; 2019.

SALARY

Because you indicated that salary is second in importance only to professional liability insurance coverage as part of a desirable compensation package, we asked you to tell us what your salary bracket is. The amounts ranged from < $50,000 to > $175,000 per year (in $25,000 increments). Combining the responses to this question with those asking about gender and specialty, we are able to tie these factors together for you.

To see what your colleagues said, go to the next page

Approximately 5% of PAs earn $50K to $75K per year; 36%, earn $100K to $125K per year; and 5% earn > $175K per year. Similar to responses of previous years, women earn less than men in the PA profession.

PAs practicing in Emergency Medicine (EM) are the most highly compensated, with their median compensation being almost $117K.¹ In fact, among those in EM, we found that 35% earn between $125K and $150K per year, up from 27% from last year. Clinicians working in the emergency room encounter more stressors (a clinician noted “Abuse of the emergency room by patients with ridiculous complaints” as a source of dissatisfaction) than those encountered in other specialties, which may be related to the higher compensation.

Although most PAs feel they are adequately compensated, we found that of those who practice in Family Medicine, 19% earn less than $75K per year, up from 6% from last year.

1. American Academy of PAs. 2019 AAPA Salary Report. Alexandria, VA; 2019.

WORKWEEK

Job satisfaction, and its opposite, burnout are related to your workload (ie, what you do and how much autonomy you have in deciding how to proceed). To help us evaluate these factors, we asked your colleagues to indicate how many hours per week are typically spent in direct (examine/diagnose/treat) and indirect patient care (perform and interpret labs, x-rays, refill prescriptions, etc.), administrative duties, meetings, and teaching.

We were also interested in whether you assess, treat, and manage decisions

• Independently/by yourself
• In direct contact (in person or by phone) with a collaborating physician
• In consultation with a specialist when providing patient care.

Multiple answer choices were permitted.

To see what your colleagues said, go to the next page

As you can imagine, workload is a very hot topic. In response to, “What else affects your job satisfaction?” the greatest number of comments related to electronic charting and data collection. These activities are felt to demand so much time and effort that it takes away from patient care. The survey responses support this: Compared to last year, although the number of hours worked is the same this year, PAs now spend 1 hour less per week on patient care (direct and indirect) and 1 hour more on other duties (administrative and teaching). As one clinician put it, “…availability of medical assistant/administrative support is huge” in alleviating the sense of being overworked or overextended.

Aside from work hours, clinicians told us they seek positions that allow them “input on all issues related to practice” and flexibility on “what/who I am allowed to treat.” According to the survey, when providing patient care,

• 84% of PAs assess, treat, and manage decisions independently
• 37% collaborate with a physician
• 19% consult with a specialist

supporting the fact that 58% of PAs are satisfied most of the time; 12% are always satisfied.

A side note: Of the 50% of PAs who responded that they are involved in teaching students (78% of whom are PAs), they spend approximately 4 hours a week,

• Either as a clinical preceptor (35%)
• In the classroom (5%)
• Or both (10%).

CME REIMBURSEMENT

As we know, PAs earn continuing medical education (CME) credits in order to maintain certification. Therefore, we asked you to indicate how much financial reimbursement you receive annually for CME; answer choices range from $0 to > $2,000 per year (in $500 increments). We also queried you about how much time you are allotted annually for CME; choices were from “None” to “More than 5 weeks.”

To see what your colleagues said, go to the next page

Many of your colleagues responded to the question “What else affects your job satisfaction?” with “Support for continuing learning” and “Educational opportunities.” This is reflected by 51% of survey respondents who stated that “Reimbursement for professional development” was an important benefit (see “Top 7 Benefits” above).

This year, 84% of respondents reported receiving remuneration—either money or time allowed or both—for CME, down 3% from last year. Specifically,

• 16% received $0
• 6%, less than $500
• 10%, between $500 - $1,000
• 25%, between $1,001 - $1,500
• 19%, between $1,501 - $2,000
• 24%, more than $2,000

with average monetary compensation per year up approximately $200 over last year.

Responses to the amount of time you are allotted annually for CME ranged from “None” to “more than 5 weeks.”

• 25%, no time
• 31%, less than 1 week
• 38%, 1-2 weeks
• 3%, 3 weeks
• 1%, 4 weeks
• 0.25%, 5 weeks
• 1%, more than 5 weeks.

In closing, we offer thanks to all the survey participants whose answers helped us understand your current state of job satisfaction and most especially for your frank and enlightening responses to the open-ended questions.

METHODOLOGY

Fielded electronically under the Clinician Reviews logo, an introductory email letter signed by the Editors-in-Chief invited participation in the online 4th annual NP/PA Job Satisfaction Survey of 35 questions.

The survey was fielded August 23, 2019 to a random representative sample of NPs and PAs within the United States, excluding students. The first 150 respondents to complete the survey received a $25 Amazon.com gift certificate.

A total of 1,323 usable responses—a projectable sample size—were received by October 3, 2019, the final cut-off date.

Of the total respondents, 70% are NPs (931) and 30% are PAs (396), which is proportional to the universe of NPs and PAs.^1,2 This summary of results is based on only those respondents who designated their profession as NP or PA.

1. American Association of Nurse Practitioners. NP Fact Sheet. www.aanp.org/all-about-nps/np-fact-sheet. Accessed November 22, 2019.
2. NCCPA. 2018 Statistical Profile of Certified Physician Assistants: an Annual Report of the National Commission on Certification of Physician Assistants. https://prodcmsstoragesa.blob.core.windows.net/uploads/files/2018StatisticalProfileofCertifiedPhysicianAssistants.pdf. Accessed November 22, 2019.

“I have the best job in the world.” This statement sums up how your colleagues feel about being a NP. Although there are certainly problems that deserve attention, the vast majority of clinicians, who are highly educated and practice in all specialties, state that they would re-enter the field if choosing again.

On the following pages, we focus on the details of the survey results, with breakouts by specialty, region, and practice setting. Be sure to check out which benefits your colleagues are getting, how much they’re being reimbursed for continuing education, information about salary by gender and time spent during the workweek; and much more. Participants, invited to comment, have provided several illuminating quotes, which we’ve included throughout the article, indicating what it’s like to be “in the trenches.”

WOULD YOU REPEAT THIS?

To get to the heart of the matter, we asked our survey takers “If you were to do it again, would you choose…”

• The same career
• The same educational preparation
• The same practice setting 

To see what your colleagues said, go to the next page

The majority of your peers gave an enthusiastic thumbs up to NP practice as a profession choice. Knowing what you know now, 84% of you agreed that you’d follow the same career path today as when you entered practice, which is up 2% from last year. Educational preparation came in for a ringing endorsement, increasing substantially since last year’s survey results (a 9% increase) and of practice setting up 4%.

Of NPs in practice between < 1 and 5 years, 62% felt their educational training was adequate; 74% felt their current responsibilities matched their expectations fairly accurately; and they were evenly divided on whether or not their career expectations were met.

“I enjoy being an NP and working with patients from all ethnic groups who are mostly uninsured.”

WOULD YOU TAKE A NEW JOB TODAY?

Continuing to probe about your level of satisfaction, we asked how you feel about changing your job. The answer choices were, “I would…”

• Change my job if I could get a better one (ie, better paid)
• Take any other job in which I could earn as much as I do now (ie, Yes, to leave the profession)
• Change both my job and my occupation (ie, I am burned out)
• Not make any changes (e, No, not for any reason)

We also asked you how many times have you’ve changed jobs since graduating from your PA program. The 4 answer choices ranged from “None” to “More than 3 times.” The final question asked which factors influence your decision about seeking/accepting a new position, allowing more than one choice from the list below.

• Salary/compensation
• Options for supplemental income
• Greater independence/more autonomy
• Opportunities for professional growth/development
• Formal career ladder for advancement
• Defined career path
• Recognition and appreciation
• Schedule flexibility
• Geographic location
• Access to and subsidy for more educational opportunities
• Employer reimbursement of school loans
• Specific state scope of practice and licensure law
• Work-life balance, including addressing burnout
• Working conditions
• Avoid toxic coworkers
• Top-of-the-line tools
• Telecommuting Cost of living
• Opportunity for outdoor activities/lifestyle

To see what your colleagues said, go to the next page

Compared to last year, NPs are 2% more likely to stay with their current job, stating that they would not make any changes. However, a greater number of NPs (31%) have changed jobs at the highest rate (> 3 times) compared to 25% last year.

Although 13% of NPs have never changed jobs, 37% have changed 2 or 3 times, and 31% have changed more 3 times (up 6% from last year). However, more NPs report feeling burned out (up 4% from last year) and wish to leave for another profession (up 3% from last year) compared to last year.

Respondents indicated that the following 4 factors would strongly influence their decision to seek or accept a new position:

• Salary/compensation: 82%
• Work-life balance & Schedule flexibility: 65%
• Working conditions: 63%

WHAT MAKES YOU MOST SATISFIED WITH YOUR WORK?

As you are aware, level of satisfaction depends on each of the following, which we asked respondents to rank from 1 to 5.

• Relationships with your colleagues (health care providers and clerical/admin personnel)
• Quality and duration of patient relationships
• Respect received from patients, their families, and your community
• Ability to make a difference and provide significant help to patients, their families, and your community

To see what your colleagues said, go to the next page

Echoing the survey results—which ranked “Making a difference and providing significant help” as the topmost source of job satisfaction—one of your colleagues commented that, “Ability to offer meaningful support to client needs” affected their satisfaction. On the other hand, though, one clinician wrote, “I feel like we are losing the art of caring and healing because we are rushed/pushed to do and see more.”

Compared to last year, the changes in response are

2% increase: Making a difference and providing significant help

3% increase: Respect received from patients and their families

No change: Relationships with your colleagues

3% increase: Quality and duration of patient relationships

MOST SATISFIED BY SPECIALTY

Knowing that certain specialties offer more advantages than others, we presented a list of 19 medical specialties, asking which is your primary one. We also asked how often you typically feel satisfied with your job, with these answer choices:

• Never
• Occasionally
• About half the time
• Most of the time
• Always

To see what your colleagues said, go to the next page

Correlating the data from the 2 questions (primary specialty and frequency of satisfaction) we posed, your peers indicated that the following specialties offered the highest levels of satisfaction.

• Women’s Health: 80%, a 9% increase over last year
• Primary Care & Ob/Gyn: 72%, a 3% increase over last year
• Psychiatric/Mental Health: 67%, a 6% decrease over last year
• Pediatrics: 65%, a 9% decrease over last year

MOST SATISFIED BY PRACTICE SETTING

Working conditions and coworker collegiality are integral to job satisfaction. To learn more about these factors, we asked you to identify the practice settings where you work.

• Academic setting (faculty); school/college health services
• Hospital: inpatient care; outpatient setting or community clinic
• Locum
• Physician practice: solo; single-specialty; multi-specialty
• Public health/occupational health setting; military/government
• Retail/convenient care; urgent care clinic
• Skilled nursing/long-term care facility
• NP practice

We also asked how often you typically feel satisfied with your job, with 5 answer choices ranging from “Never” to “Always.”

To see what your colleagues said, go to the next page

91% of NP respondents work as an employee; of these, 39% work in hospitals, and 25% work in physician offices.¹ Therefore, it’s gratifying to see that hospital settings and physician groups are satisfying places to work. In addition, this data has not changed significantly since last year. Not surprisingly (based on comments that “ability to make administrative decisions and have a say in day-to-day operations” and “independent practice” matters), 83% of NPs who work solo were “most of the time/always” satisfied, compared with 72% of those in other practice settings.

1. US Department of Health and Human Services, Health Resources and Services Administration, The U.S. Health Workforce Chartbook. Rockville, Maryland: U.S. Department of Health and Human Services, 2018.

BENEFITS

As you are aware, having access to the right benefits can go a long way to increasing job satisfaction. In addition to salary as a choice, we listed 30 benefits choices—insurance coverage, additional compensation opportunities, reimbursements, and other—asking which are offered by your employer (access) and which, in lieu of a modest increase in salary, are most important regardless of access. Your responses allowed us to identify the top 7 among your peers.

To see what your colleagues said, go to the next page

You are willing to trade a modest increase in salary for the following important benefits whether you are a new job seeker or an experienced practitioner.

• Compensation: Paid time off, retirement saving plan with employer match
• Insurance coverage: Health & dental insurance for self/family (employer subsidized), professional liability insurance
• Reimbursements: Professional development fund, licensing fees
• Other: Flexible work policy

MOST SATISFIED BY REGION

Location, location, location. Where you work depends in part on where your family is; in part on what jobs are available; what affects your commute, taxes and take home pay; and hence your satisfaction. Therefore, we asked where you work—West, Midwest, Northeast, or South—and paired the data with responses to the question about how often you typically feel satisfied with your job, with 5 answer choices ranging from “Never” to “Always.”

To see what your colleagues said, go to the next page

Geographic location is among the factors that influence the decision about seeking or accepting a new job for 50% of NP respondents. Compared to last year, satisfaction levels by region were

• 5% higher than last year in the Midwest
• 4% higher than last year in the South
• 2% lower than last year in the Northeast
• 14% lower than last year in the West

with 34% of NPs practicing in the South; 25% in the Northeast; 20% in the Midwest and West, each. 78% of NPs working in the Midwest are “most of the time/always” satisfied with their job.

SALARY

Because you indicated that salary is the most importance part of a desirable compensation package, we asked you to tell us what your salary bracket is. The amounts ranged from < $50,000 to > $175,000 per year (in $25,000 increments). Combining the responses to this question with those asking about gender and specialty, we are able to tie these factors together for you.

To see what your colleagues said, go to the next page

Approximately 11% of NPs earn up to $75K per year; 36% earn $100K to $125K per year; and 5% earn > $175K per year. The mean, full-time salary in 2018 was $106K per year.¹ Similar to responses of previous years, women earn less than men in the NP profession.

Among NPs working in Psychiatric/Mental Health, we found that 28% earn between $125K to $150K per year, down 2% from last year. According to Pay Scale, the average salary for a Psychiatric NP is approximately $104K per year but varies according to job location.² Although most NPs feel they are adequately compensated, we found that of NPs who practice in Pediatrics, 19% earn less than $75K per year, virtually unchanged from last year.

1. NP Fact Sheet. 2018 AANP National Nurse Practitioner Sample Survey. https://www.aanp.org/about/all-about-nps/np-fact-sheet. Accessed December 19, 2019.
2. Pay Scale. https://www.payscale.com/research/US/Job=Psychiatric_Nurse_Practitioner_(NP)/Salary. Accessed December 18, 2019.

WORKWEEK

Job satisfaction, and its opposite, burnout are related to your workload (ie, what you do and how much autonomy you have in deciding how to proceed). To help us evaluate these factors, we asked your colleagues to indicate how many hours per week are typically spent in direct (examine/diagnose/treat) and indirect patient care (perform and interpret labs, x-rays, refill prescriptions, etc), administrative duties, meetings, and teaching.

We were also interested in whether you assess, treat, and manage decisions

• Independently/by yourself
• In direct contact (in person or by phone) with a collaborating physician
• In consultation with a specialist

when providing patient care. Multiple answer choices were permitted.

To see what your colleagues said, go to the next page

As you can imagine, workload is a very hot topic. In response to, “What else affects your job satisfaction?” the greatest number of comments related to electronic charting and data collection. These activities are felt to demand so much time and effort that it takes away from patient care. The survey responses support this: Compared to last year, although the number of hours worked is the same this year, NPs now spend 1 hour less per week on patient care (direct and indirect) and 1 hour more on other duties (administrative and teaching). As one clinician put it, “…every year the administrative tasks increase but the admin time allowed to do these tasks does not.”

Aside from work hours, clinicians told us they seek positions that allow them “input on all issues related to practice” and flexibility on “what /who I am allowed to treat.” According to the survey, when providing patient care,

• 87% of NPs assess, treat, and manage decisions independently
• 22% collaborate with a physician
• 8% consult with a specialist

supporting the fact that 61% of NPs satisfied with your job most of the time; 11% are always satisfied.

A side note: Of the 68% of NPs who responded that they are involved in teaching students (82% of whom are NPs), they spend approximately 7 hours a week

• Either as a clinical preceptor (52%)
• In the classroom (3%)
• Or both (13%).

CE REIMBURSEMENT

As we know, NPs earn continuing education (CE) credits in order to maintain certification. Therefore, we asked you to indicate how much financial reimbursement you receive annually for CME; answer choices range from $0 to > $2,000 per year (in $500 increments). We also queried you about how much time you are allotted annually for CME; choices were from “None” to “More than 5 weeks.”

To see what your colleagues said, go to the next page

Many of your colleagues responded to the question “What else affects your job satisfaction?” with “Support for continuing learning” and “Educational opportunities.” This is reflected by 54% of survey respondents who stated that “Reimbursement for professional development” was an important benefit (see “Top 7 Benefits” above).

This year, 76% of respondents reported receiving remuneration—either money or time allowed or both—for CE, virtually unchanged from last year. Specifically,

• 24% received $0
• 10%, less than $500
• 13%, between $500 - $1,000
• 19%, between $1,001 - $1,500
• 19%, between $1,501 - $2,000
• 16%, more than $2,000

with average monetary compensation per year up approximately $350 over last year.

Responses to the amount of time you are allotted annually for CME ranged from “None” to “more than 5 weeks.”

• 29%, no time
• 33%, less than 1 week
• 33%, 1-2 weeks
• 2%, 3 weeks
• 1%, 4 weeks
• 0.11%, 5 weeks
• 2%, more than 5 weeks.

In closing, we offer thanks to all the survey participants whose answers helped us understand your current state of job satisfaction and most especially for your frank and enlightening responses to the open-ended questions.

METHODOLOGY

Fielded electronically under the Clinician Reviews logo, an introductory email letter signed by the Editors-in-Chief invited participation in the online 4th annual NP/PA Job Satisfaction Survey of 35 questions.

The survey was fielded August 23, 2019 to a random representative sample of NPs and PAs within the United States, excluding students. The first 150 respondents to complete the survey received a $25 Amazon.com gift certificate.

A total of 1,323 usable responses—a projectable sample size—were received by October 3, 2019, the final cut-off date.

Of the total respondents, 70% are NPs (931) and 30% are PAs (396), which is proportional to the universe of NPs and PAs.^1,2 This summary of results is based on only those respondents who designated their profession as NP or PA.

1. American Association of Nurse Practitioners. NP Fact Sheet. www.aanp.org/all-about-nps/np-fact-sheet. Accessed November 22, 2019. 
2. NCCPA. 2018 Statistical Profile of Certified Physician Assistants: an Annual Report of the National Commission on Certification of Physician Assistants. https://prodcmsstoragesa.blob.core.windows.net/uploads/files/2018StatisticalProfileofCertifiedPhysicianAssistants.pdf. Accessed November 22, 2019.

“I have the best job in the world.” This statement sums up how your colleagues feel about being a NP. Although there are certainly problems that deserve attention, the vast majority of clinicians, who are highly educated and practice in all specialties, state that they would re-enter the field if choosing again.

On the following pages, we focus on the details of the survey results, with breakouts by specialty, region, and practice setting. Be sure to check out which benefits your colleagues are getting, how much they’re being reimbursed for continuing education, information about salary by gender and time spent during the workweek; and much more. Participants, invited to comment, have provided several illuminating quotes, which we’ve included throughout the article, indicating what it’s like to be “in the trenches.”

WOULD YOU REPEAT THIS?

To get to the heart of the matter, we asked our survey takers “If you were to do it again, would you choose…”

• The same career
• The same educational preparation
• The same practice setting 

To see what your colleagues said, go to the next page

The majority of your peers gave an enthusiastic thumbs up to NP practice as a profession choice. Knowing what you know now, 84% of you agreed that you’d follow the same career path today as when you entered practice, which is up 2% from last year. Educational preparation came in for a ringing endorsement, increasing substantially since last year’s survey results (a 9% increase) and of practice setting up 4%.

Of NPs in practice between < 1 and 5 years, 62% felt their educational training was adequate; 74% felt their current responsibilities matched their expectations fairly accurately; and they were evenly divided on whether or not their career expectations were met.

“I enjoy being an NP and working with patients from all ethnic groups who are mostly uninsured.”

WOULD YOU TAKE A NEW JOB TODAY?

Continuing to probe about your level of satisfaction, we asked how you feel about changing your job. The answer choices were, “I would…”

• Change my job if I could get a better one (ie, better paid)
• Take any other job in which I could earn as much as I do now (ie, Yes, to leave the profession)
• Change both my job and my occupation (ie, I am burned out)
• Not make any changes (e, No, not for any reason)

We also asked you how many times have you’ve changed jobs since graduating from your PA program. The 4 answer choices ranged from “None” to “More than 3 times.” The final question asked which factors influence your decision about seeking/accepting a new position, allowing more than one choice from the list below.

• Salary/compensation
• Options for supplemental income
• Greater independence/more autonomy
• Opportunities for professional growth/development
• Formal career ladder for advancement
• Defined career path
• Recognition and appreciation
• Schedule flexibility
• Geographic location
• Access to and subsidy for more educational opportunities
• Employer reimbursement of school loans
• Specific state scope of practice and licensure law
• Work-life balance, including addressing burnout
• Working conditions
• Avoid toxic coworkers
• Top-of-the-line tools
• Telecommuting Cost of living
• Opportunity for outdoor activities/lifestyle

To see what your colleagues said, go to the next page

Compared to last year, NPs are 2% more likely to stay with their current job, stating that they would not make any changes. However, a greater number of NPs (31%) have changed jobs at the highest rate (> 3 times) compared to 25% last year.

Although 13% of NPs have never changed jobs, 37% have changed 2 or 3 times, and 31% have changed more 3 times (up 6% from last year). However, more NPs report feeling burned out (up 4% from last year) and wish to leave for another profession (up 3% from last year) compared to last year.

Respondents indicated that the following 4 factors would strongly influence their decision to seek or accept a new position:

• Salary/compensation: 82%
• Work-life balance & Schedule flexibility: 65%
• Working conditions: 63%

WHAT MAKES YOU MOST SATISFIED WITH YOUR WORK?

As you are aware, level of satisfaction depends on each of the following, which we asked respondents to rank from 1 to 5.

• Relationships with your colleagues (health care providers and clerical/admin personnel)
• Quality and duration of patient relationships
• Respect received from patients, their families, and your community
• Ability to make a difference and provide significant help to patients, their families, and your community

To see what your colleagues said, go to the next page

Echoing the survey results—which ranked “Making a difference and providing significant help” as the topmost source of job satisfaction—one of your colleagues commented that, “Ability to offer meaningful support to client needs” affected their satisfaction. On the other hand, though, one clinician wrote, “I feel like we are losing the art of caring and healing because we are rushed/pushed to do and see more.”

Compared to last year, the changes in response are

2% increase: Making a difference and providing significant help

3% increase: Respect received from patients and their families

No change: Relationships with your colleagues

3% increase: Quality and duration of patient relationships

MOST SATISFIED BY SPECIALTY

Knowing that certain specialties offer more advantages than others, we presented a list of 19 medical specialties, asking which is your primary one. We also asked how often you typically feel satisfied with your job, with these answer choices:

• Never
• Occasionally
• About half the time
• Most of the time
• Always

To see what your colleagues said, go to the next page

Correlating the data from the 2 questions (primary specialty and frequency of satisfaction) we posed, your peers indicated that the following specialties offered the highest levels of satisfaction.

• Women’s Health: 80%, a 9% increase over last year
• Primary Care & Ob/Gyn: 72%, a 3% increase over last year
• Psychiatric/Mental Health: 67%, a 6% decrease over last year
• Pediatrics: 65%, a 9% decrease over last year

MOST SATISFIED BY PRACTICE SETTING

Working conditions and coworker collegiality are integral to job satisfaction. To learn more about these factors, we asked you to identify the practice settings where you work.

• Academic setting (faculty); school/college health services
• Hospital: inpatient care; outpatient setting or community clinic
• Locum
• Physician practice: solo; single-specialty; multi-specialty
• Public health/occupational health setting; military/government
• Retail/convenient care; urgent care clinic
• Skilled nursing/long-term care facility
• NP practice

We also asked how often you typically feel satisfied with your job, with 5 answer choices ranging from “Never” to “Always.”

To see what your colleagues said, go to the next page

91% of NP respondents work as an employee; of these, 39% work in hospitals, and 25% work in physician offices.¹ Therefore, it’s gratifying to see that hospital settings and physician groups are satisfying places to work. In addition, this data has not changed significantly since last year. Not surprisingly (based on comments that “ability to make administrative decisions and have a say in day-to-day operations” and “independent practice” matters), 83% of NPs who work solo were “most of the time/always” satisfied, compared with 72% of those in other practice settings.

1. US Department of Health and Human Services, Health Resources and Services Administration, The U.S. Health Workforce Chartbook. Rockville, Maryland: U.S. Department of Health and Human Services, 2018.

BENEFITS

As you are aware, having access to the right benefits can go a long way to increasing job satisfaction. In addition to salary as a choice, we listed 30 benefits choices—insurance coverage, additional compensation opportunities, reimbursements, and other—asking which are offered by your employer (access) and which, in lieu of a modest increase in salary, are most important regardless of access. Your responses allowed us to identify the top 7 among your peers.

To see what your colleagues said, go to the next page

You are willing to trade a modest increase in salary for the following important benefits whether you are a new job seeker or an experienced practitioner.

• Compensation: Paid time off, retirement saving plan with employer match
• Insurance coverage: Health & dental insurance for self/family (employer subsidized), professional liability insurance
• Reimbursements: Professional development fund, licensing fees
• Other: Flexible work policy

MOST SATISFIED BY REGION

Location, location, location. Where you work depends in part on where your family is; in part on what jobs are available; what affects your commute, taxes and take home pay; and hence your satisfaction. Therefore, we asked where you work—West, Midwest, Northeast, or South—and paired the data with responses to the question about how often you typically feel satisfied with your job, with 5 answer choices ranging from “Never” to “Always.”

To see what your colleagues said, go to the next page

Geographic location is among the factors that influence the decision about seeking or accepting a new job for 50% of NP respondents. Compared to last year, satisfaction levels by region were

• 5% higher than last year in the Midwest
• 4% higher than last year in the South
• 2% lower than last year in the Northeast
• 14% lower than last year in the West

with 34% of NPs practicing in the South; 25% in the Northeast; 20% in the Midwest and West, each. 78% of NPs working in the Midwest are “most of the time/always” satisfied with their job.

SALARY

Because you indicated that salary is the most importance part of a desirable compensation package, we asked you to tell us what your salary bracket is. The amounts ranged from < $50,000 to > $175,000 per year (in $25,000 increments). Combining the responses to this question with those asking about gender and specialty, we are able to tie these factors together for you.

To see what your colleagues said, go to the next page

Approximately 11% of NPs earn up to $75K per year; 36% earn $100K to $125K per year; and 5% earn > $175K per year. The mean, full-time salary in 2018 was $106K per year.¹ Similar to responses of previous years, women earn less than men in the NP profession.

Among NPs working in Psychiatric/Mental Health, we found that 28% earn between $125K to $150K per year, down 2% from last year. According to Pay Scale, the average salary for a Psychiatric NP is approximately $104K per year but varies according to job location.² Although most NPs feel they are adequately compensated, we found that of NPs who practice in Pediatrics, 19% earn less than $75K per year, virtually unchanged from last year.

1. NP Fact Sheet. 2018 AANP National Nurse Practitioner Sample Survey. https://www.aanp.org/about/all-about-nps/np-fact-sheet. Accessed December 19, 2019.
2. Pay Scale. https://www.payscale.com/research/US/Job=Psychiatric_Nurse_Practitioner_(NP)/Salary. Accessed December 18, 2019.

WORKWEEK

Job satisfaction, and its opposite, burnout are related to your workload (ie, what you do and how much autonomy you have in deciding how to proceed). To help us evaluate these factors, we asked your colleagues to indicate how many hours per week are typically spent in direct (examine/diagnose/treat) and indirect patient care (perform and interpret labs, x-rays, refill prescriptions, etc), administrative duties, meetings, and teaching.

We were also interested in whether you assess, treat, and manage decisions

• Independently/by yourself
• In direct contact (in person or by phone) with a collaborating physician
• In consultation with a specialist

when providing patient care. Multiple answer choices were permitted.

To see what your colleagues said, go to the next page

As you can imagine, workload is a very hot topic. In response to, “What else affects your job satisfaction?” the greatest number of comments related to electronic charting and data collection. These activities are felt to demand so much time and effort that it takes away from patient care. The survey responses support this: Compared to last year, although the number of hours worked is the same this year, NPs now spend 1 hour less per week on patient care (direct and indirect) and 1 hour more on other duties (administrative and teaching). As one clinician put it, “…every year the administrative tasks increase but the admin time allowed to do these tasks does not.”

Aside from work hours, clinicians told us they seek positions that allow them “input on all issues related to practice” and flexibility on “what /who I am allowed to treat.” According to the survey, when providing patient care,

• 87% of NPs assess, treat, and manage decisions independently
• 22% collaborate with a physician
• 8% consult with a specialist

supporting the fact that 61% of NPs satisfied with your job most of the time; 11% are always satisfied.

A side note: Of the 68% of NPs who responded that they are involved in teaching students (82% of whom are NPs), they spend approximately 7 hours a week

• Either as a clinical preceptor (52%)
• In the classroom (3%)
• Or both (13%).

CE REIMBURSEMENT

As we know, NPs earn continuing education (CE) credits in order to maintain certification. Therefore, we asked you to indicate how much financial reimbursement you receive annually for CME; answer choices range from $0 to > $2,000 per year (in $500 increments). We also queried you about how much time you are allotted annually for CME; choices were from “None” to “More than 5 weeks.”

To see what your colleagues said, go to the next page

Many of your colleagues responded to the question “What else affects your job satisfaction?” with “Support for continuing learning” and “Educational opportunities.” This is reflected by 54% of survey respondents who stated that “Reimbursement for professional development” was an important benefit (see “Top 7 Benefits” above).

This year, 76% of respondents reported receiving remuneration—either money or time allowed or both—for CE, virtually unchanged from last year. Specifically,

• 24% received $0
• 10%, less than $500
• 13%, between $500 - $1,000
• 19%, between $1,001 - $1,500
• 19%, between $1,501 - $2,000
• 16%, more than $2,000

with average monetary compensation per year up approximately $350 over last year.

Responses to the amount of time you are allotted annually for CME ranged from “None” to “more than 5 weeks.”

• 29%, no time
• 33%, less than 1 week
• 33%, 1-2 weeks
• 2%, 3 weeks
• 1%, 4 weeks
• 0.11%, 5 weeks
• 2%, more than 5 weeks.

In closing, we offer thanks to all the survey participants whose answers helped us understand your current state of job satisfaction and most especially for your frank and enlightening responses to the open-ended questions.

METHODOLOGY

Fielded electronically under the Clinician Reviews logo, an introductory email letter signed by the Editors-in-Chief invited participation in the online 4th annual NP/PA Job Satisfaction Survey of 35 questions.

The survey was fielded August 23, 2019 to a random representative sample of NPs and PAs within the United States, excluding students. The first 150 respondents to complete the survey received a $25 Amazon.com gift certificate.

A total of 1,323 usable responses—a projectable sample size—were received by October 3, 2019, the final cut-off date.

Of the total respondents, 70% are NPs (931) and 30% are PAs (396), which is proportional to the universe of NPs and PAs.^1,2 This summary of results is based on only those respondents who designated their profession as NP or PA.

1. American Association of Nurse Practitioners. NP Fact Sheet. www.aanp.org/all-about-nps/np-fact-sheet. Accessed November 22, 2019. 
2. NCCPA. 2018 Statistical Profile of Certified Physician Assistants: an Annual Report of the National Commission on Certification of Physician Assistants. https://prodcmsstoragesa.blob.core.windows.net/uploads/files/2018StatisticalProfileofCertifiedPhysicianAssistants.pdf. Accessed November 22, 2019.

“I have the best job in the world.” This statement sums up how your colleagues feel about being a NP. Although there are certainly problems that deserve attention, the vast majority of clinicians, who are highly educated and practice in all specialties, state that they would re-enter the field if choosing again.

On the following pages, we focus on the details of the survey results, with breakouts by specialty, region, and practice setting. Be sure to check out which benefits your colleagues are getting, how much they’re being reimbursed for continuing education, information about salary by gender and time spent during the workweek; and much more. Participants, invited to comment, have provided several illuminating quotes, which we’ve included throughout the article, indicating what it’s like to be “in the trenches.”

WOULD YOU REPEAT THIS?

To get to the heart of the matter, we asked our survey takers “If you were to do it again, would you choose…”

• The same career
• The same educational preparation
• The same practice setting 

To see what your colleagues said, go to the next page

The majority of your peers gave an enthusiastic thumbs up to NP practice as a profession choice. Knowing what you know now, 84% of you agreed that you’d follow the same career path today as when you entered practice, which is up 2% from last year. Educational preparation came in for a ringing endorsement, increasing substantially since last year’s survey results (a 9% increase) and of practice setting up 4%.

Of NPs in practice between < 1 and 5 years, 62% felt their educational training was adequate; 74% felt their current responsibilities matched their expectations fairly accurately; and they were evenly divided on whether or not their career expectations were met.

“I enjoy being an NP and working with patients from all ethnic groups who are mostly uninsured.”

WOULD YOU TAKE A NEW JOB TODAY?

Continuing to probe about your level of satisfaction, we asked how you feel about changing your job. The answer choices were, “I would…”

• Change my job if I could get a better one (ie, better paid)
• Take any other job in which I could earn as much as I do now (ie, Yes, to leave the profession)
• Change both my job and my occupation (ie, I am burned out)
• Not make any changes (e, No, not for any reason)

We also asked you how many times have you’ve changed jobs since graduating from your PA program. The 4 answer choices ranged from “None” to “More than 3 times.” The final question asked which factors influence your decision about seeking/accepting a new position, allowing more than one choice from the list below.

• Salary/compensation
• Options for supplemental income
• Greater independence/more autonomy
• Opportunities for professional growth/development
• Formal career ladder for advancement
• Defined career path
• Recognition and appreciation
• Schedule flexibility
• Geographic location
• Access to and subsidy for more educational opportunities
• Employer reimbursement of school loans
• Specific state scope of practice and licensure law
• Work-life balance, including addressing burnout
• Working conditions
• Avoid toxic coworkers
• Top-of-the-line tools
• Telecommuting Cost of living
• Opportunity for outdoor activities/lifestyle

To see what your colleagues said, go to the next page

Compared to last year, NPs are 2% more likely to stay with their current job, stating that they would not make any changes. However, a greater number of NPs (31%) have changed jobs at the highest rate (> 3 times) compared to 25% last year.

Although 13% of NPs have never changed jobs, 37% have changed 2 or 3 times, and 31% have changed more 3 times (up 6% from last year). However, more NPs report feeling burned out (up 4% from last year) and wish to leave for another profession (up 3% from last year) compared to last year.

Respondents indicated that the following 4 factors would strongly influence their decision to seek or accept a new position:

• Salary/compensation: 82%
• Work-life balance & Schedule flexibility: 65%
• Working conditions: 63%

WHAT MAKES YOU MOST SATISFIED WITH YOUR WORK?

As you are aware, level of satisfaction depends on each of the following, which we asked respondents to rank from 1 to 5.

• Relationships with your colleagues (health care providers and clerical/admin personnel)
• Quality and duration of patient relationships
• Respect received from patients, their families, and your community
• Ability to make a difference and provide significant help to patients, their families, and your community

To see what your colleagues said, go to the next page

Echoing the survey results—which ranked “Making a difference and providing significant help” as the topmost source of job satisfaction—one of your colleagues commented that, “Ability to offer meaningful support to client needs” affected their satisfaction. On the other hand, though, one clinician wrote, “I feel like we are losing the art of caring and healing because we are rushed/pushed to do and see more.”

Compared to last year, the changes in response are

2% increase: Making a difference and providing significant help

3% increase: Respect received from patients and their families

No change: Relationships with your colleagues

3% increase: Quality and duration of patient relationships

MOST SATISFIED BY SPECIALTY

Knowing that certain specialties offer more advantages than others, we presented a list of 19 medical specialties, asking which is your primary one. We also asked how often you typically feel satisfied with your job, with these answer choices:

• Never
• Occasionally
• About half the time
• Most of the time
• Always

To see what your colleagues said, go to the next page

Correlating the data from the 2 questions (primary specialty and frequency of satisfaction) we posed, your peers indicated that the following specialties offered the highest levels of satisfaction.

• Women’s Health: 80%, a 9% increase over last year
• Primary Care & Ob/Gyn: 72%, a 3% increase over last year
• Psychiatric/Mental Health: 67%, a 6% decrease over last year
• Pediatrics: 65%, a 9% decrease over last year

MOST SATISFIED BY PRACTICE SETTING

Working conditions and coworker collegiality are integral to job satisfaction. To learn more about these factors, we asked you to identify the practice settings where you work.

• Academic setting (faculty); school/college health services
• Hospital: inpatient care; outpatient setting or community clinic
• Locum
• Physician practice: solo; single-specialty; multi-specialty
• Public health/occupational health setting; military/government
• Retail/convenient care; urgent care clinic
• Skilled nursing/long-term care facility
• NP practice

We also asked how often you typically feel satisfied with your job, with 5 answer choices ranging from “Never” to “Always.”

To see what your colleagues said, go to the next page

91% of NP respondents work as an employee; of these, 39% work in hospitals, and 25% work in physician offices.¹ Therefore, it’s gratifying to see that hospital settings and physician groups are satisfying places to work. In addition, this data has not changed significantly since last year. Not surprisingly (based on comments that “ability to make administrative decisions and have a say in day-to-day operations” and “independent practice” matters), 83% of NPs who work solo were “most of the time/always” satisfied, compared with 72% of those in other practice settings.

1. US Department of Health and Human Services, Health Resources and Services Administration, The U.S. Health Workforce Chartbook. Rockville, Maryland: U.S. Department of Health and Human Services, 2018.

BENEFITS

As you are aware, having access to the right benefits can go a long way to increasing job satisfaction. In addition to salary as a choice, we listed 30 benefits choices—insurance coverage, additional compensation opportunities, reimbursements, and other—asking which are offered by your employer (access) and which, in lieu of a modest increase in salary, are most important regardless of access. Your responses allowed us to identify the top 7 among your peers.

To see what your colleagues said, go to the next page

You are willing to trade a modest increase in salary for the following important benefits whether you are a new job seeker or an experienced practitioner.

• Compensation: Paid time off, retirement saving plan with employer match
• Insurance coverage: Health & dental insurance for self/family (employer subsidized), professional liability insurance
• Reimbursements: Professional development fund, licensing fees
• Other: Flexible work policy

MOST SATISFIED BY REGION

Location, location, location. Where you work depends in part on where your family is; in part on what jobs are available; what affects your commute, taxes and take home pay; and hence your satisfaction. Therefore, we asked where you work—West, Midwest, Northeast, or South—and paired the data with responses to the question about how often you typically feel satisfied with your job, with 5 answer choices ranging from “Never” to “Always.”

To see what your colleagues said, go to the next page

Geographic location is among the factors that influence the decision about seeking or accepting a new job for 50% of NP respondents. Compared to last year, satisfaction levels by region were

• 5% higher than last year in the Midwest
• 4% higher than last year in the South
• 2% lower than last year in the Northeast
• 14% lower than last year in the West

with 34% of NPs practicing in the South; 25% in the Northeast; 20% in the Midwest and West, each. 78% of NPs working in the Midwest are “most of the time/always” satisfied with their job.

SALARY

Because you indicated that salary is the most importance part of a desirable compensation package, we asked you to tell us what your salary bracket is. The amounts ranged from < $50,000 to > $175,000 per year (in $25,000 increments). Combining the responses to this question with those asking about gender and specialty, we are able to tie these factors together for you.

To see what your colleagues said, go to the next page

Approximately 11% of NPs earn up to $75K per year; 36% earn $100K to $125K per year; and 5% earn > $175K per year. The mean, full-time salary in 2018 was $106K per year.¹ Similar to responses of previous years, women earn less than men in the NP profession.

Among NPs working in Psychiatric/Mental Health, we found that 28% earn between $125K to $150K per year, down 2% from last year. According to Pay Scale, the average salary for a Psychiatric NP is approximately $104K per year but varies according to job location.² Although most NPs feel they are adequately compensated, we found that of NPs who practice in Pediatrics, 19% earn less than $75K per year, virtually unchanged from last year.

1. NP Fact Sheet. 2018 AANP National Nurse Practitioner Sample Survey. https://www.aanp.org/about/all-about-nps/np-fact-sheet. Accessed December 19, 2019.
2. Pay Scale. https://www.payscale.com/research/US/Job=Psychiatric_Nurse_Practitioner_(NP)/Salary. Accessed December 18, 2019.

WORKWEEK

Job satisfaction, and its opposite, burnout are related to your workload (ie, what you do and how much autonomy you have in deciding how to proceed). To help us evaluate these factors, we asked your colleagues to indicate how many hours per week are typically spent in direct (examine/diagnose/treat) and indirect patient care (perform and interpret labs, x-rays, refill prescriptions, etc), administrative duties, meetings, and teaching.

We were also interested in whether you assess, treat, and manage decisions

• Independently/by yourself
• In direct contact (in person or by phone) with a collaborating physician
• In consultation with a specialist

when providing patient care. Multiple answer choices were permitted.

To see what your colleagues said, go to the next page

As you can imagine, workload is a very hot topic. In response to, “What else affects your job satisfaction?” the greatest number of comments related to electronic charting and data collection. These activities are felt to demand so much time and effort that it takes away from patient care. The survey responses support this: Compared to last year, although the number of hours worked is the same this year, NPs now spend 1 hour less per week on patient care (direct and indirect) and 1 hour more on other duties (administrative and teaching). As one clinician put it, “…every year the administrative tasks increase but the admin time allowed to do these tasks does not.”

Aside from work hours, clinicians told us they seek positions that allow them “input on all issues related to practice” and flexibility on “what /who I am allowed to treat.” According to the survey, when providing patient care,

• 87% of NPs assess, treat, and manage decisions independently
• 22% collaborate with a physician
• 8% consult with a specialist

supporting the fact that 61% of NPs satisfied with your job most of the time; 11% are always satisfied.

A side note: Of the 68% of NPs who responded that they are involved in teaching students (82% of whom are NPs), they spend approximately 7 hours a week

• Either as a clinical preceptor (52%)
• In the classroom (3%)
• Or both (13%).

CE REIMBURSEMENT

As we know, NPs earn continuing education (CE) credits in order to maintain certification. Therefore, we asked you to indicate how much financial reimbursement you receive annually for CME; answer choices range from $0 to > $2,000 per year (in $500 increments). We also queried you about how much time you are allotted annually for CME; choices were from “None” to “More than 5 weeks.”

To see what your colleagues said, go to the next page

Many of your colleagues responded to the question “What else affects your job satisfaction?” with “Support for continuing learning” and “Educational opportunities.” This is reflected by 54% of survey respondents who stated that “Reimbursement for professional development” was an important benefit (see “Top 7 Benefits” above).

This year, 76% of respondents reported receiving remuneration—either money or time allowed or both—for CE, virtually unchanged from last year. Specifically,

• 24% received $0
• 10%, less than $500
• 13%, between $500 - $1,000
• 19%, between $1,001 - $1,500
• 19%, between $1,501 - $2,000
• 16%, more than $2,000

with average monetary compensation per year up approximately $350 over last year.

Responses to the amount of time you are allotted annually for CME ranged from “None” to “more than 5 weeks.”

• 29%, no time
• 33%, less than 1 week
• 33%, 1-2 weeks
• 2%, 3 weeks
• 1%, 4 weeks
• 0.11%, 5 weeks
• 2%, more than 5 weeks.

In closing, we offer thanks to all the survey participants whose answers helped us understand your current state of job satisfaction and most especially for your frank and enlightening responses to the open-ended questions.

METHODOLOGY

Fielded electronically under the Clinician Reviews logo, an introductory email letter signed by the Editors-in-Chief invited participation in the online 4th annual NP/PA Job Satisfaction Survey of 35 questions.

The survey was fielded August 23, 2019 to a random representative sample of NPs and PAs within the United States, excluding students. The first 150 respondents to complete the survey received a $25 Amazon.com gift certificate.

A total of 1,323 usable responses—a projectable sample size—were received by October 3, 2019, the final cut-off date.

Of the total respondents, 70% are NPs (931) and 30% are PAs (396), which is proportional to the universe of NPs and PAs.^1,2 This summary of results is based on only those respondents who designated their profession as NP or PA.

1. American Association of Nurse Practitioners. NP Fact Sheet. www.aanp.org/all-about-nps/np-fact-sheet. Accessed November 22, 2019. 
2. NCCPA. 2018 Statistical Profile of Certified Physician Assistants: an Annual Report of the National Commission on Certification of Physician Assistants. https://prodcmsstoragesa.blob.core.windows.net/uploads/files/2018StatisticalProfileofCertifiedPhysicianAssistants.pdf. Accessed November 22, 2019.

This year in the United States, there were an estimated 22,530 new cases of ovarian cancer and an estimated 13,980 ovarian cancer deaths.¹ Ovarian cancer accounts for more deaths than any other female reproductive system cancer.² The high mortality rate is attributed to the advanced stage of cancer at initial presentation: Women diagnosed with localized disease have an estimated 5-year survival rate of 92%, while those diagnosed with advanced disease have a 5-year survival rate of 29%.³ For this reason, early detection of ovarian cancer is paramount.

A Personal Story

I think about ovarian cancer every day, because I am a survivor of this deadly disease. In 2018, at age 53, I received the diagnosis of stage 1A high-grade serous carcinoma of the left ovary. My cancer was discovered incidentally: I presented to my health care provider with a 6-month history of metrorrhagia and a prior history of regular menstruation with dysmenorrhea controlled with ibuprofen. My family and personal history of cancer was negative, I had a normal BMI, I didn’t smoke and consumed alcohol only moderately, my lifestyle was active, and I had no chronic diseases and used no medications regularly. My clinician performed a pelvic exam and ordered sexually transmitted infection testing and blood work (complete blood count, metabolic panel, and TSH). The differential diagnosis at this point included

• Thyroid dysfunction
• Perimenopause
• Sexually transmitted infection
• Coagulation defect
• Foreign body
• Infection.

All testing yielded normal findings. At my follow-up appointment, we discussed perimenopause symptoms and agreed that I would continue monitoring the bleeding. If at a later date I wanted to pursue an ultrasound, I was instructed to call the office. It was not suggested that I schedule a follow-up office visit.

Several months later, persistent metrorrhagia prompted me to request a transvaginal ultrasound (TVU)—resulting in the discovery of a left adnexal solid mass and probable endometrial polyp. A referral to a gynecologic oncologist resulted in further imaging, which confirmed the TVU results. Surgical intervention was recommended.

One week later, I underwent robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, left pelvic and periaortic lymph node dissection, and omentectomy. The pathology report confirmed stage 1A high-grade serous carcinoma of the left ovary, as well as stage 1A grade 1 endometrioid adenocarcinoma of the uterus. I required 6 cycles of chemotherapy before follow-up imaging yielded negative results, with no evidence of metastatic disease.

A Call to Action

The recently updated US Preventive Services Task Force guidelines continue not to recommend annual screening with TVU and/or cancer antigen 125 (CA-125) blood testing for ovarian cancer in asymptomatic, average-risk women. A review of the evidence found no mortality benefit and high false-positive rates, which led to unnecessary surgeries and physiologic stress due to excess cancer worry.⁴ This (lack of) recommendation leaves the clinician in the position of not performing or ordering screening tests, except in cases in which the patient presents with symptoms or requests screening for ovarian cancer.

Yet it cannot be overstated: The clinician’s role in identifying risk factors for and recognizing symptoms of ovarian cancer is extremely important in the absence of routine screening recommendations. Risk factors include a positive family history of gynecologic, breast, or colon cancers; genetic predisposition; personal history of breast cancer; use of menopausal hormone therapy; excess body weight; smoking; and sedentary lifestyle.³ In my case, my risk for ovarian cancer was average.

Continue to: With regard to symptoms...

With regard to symptoms, most women do not report any until ovarian cancer has reached advanced stages—and even then, the symptoms are vague and nonspecific.⁵ They may include urinary urgency or frequency; change in bowel habit; difficulty eating or feeling full quickly; persistent back, pelvic, or abdominal pain; extreme tiredness; vaginal bleeding after menopause; increased abdominal size; or bloating on most days.⁵

So what can we as clinicians do? First, if I may offer a word of caution: When confronted with those vague and nonspecific symptoms, be careful not to dismiss them out of hand as a result of aging, stress, or menopause. As my case demonstrates, for example, metrorrhagia is not necessarily a benign condition for the premenopausal woman.

Furthermore, we can empower patients by educating them about ovarian cancer symptoms and risk factors, information that may promote help-seeking behaviors that aid in early detection. In my case, the continued symptom of abnormal uterine bleeding prompted me to seek further assessment, which led to the discovery of ovarian cancer. Had I not been an educated and empowered patient, I would be telling a completely different story today—most likely one that would include advanced staging. Partner with your patient to discuss available diagnostic testing options and schedule follow-up appointments to monitor presenting complaints.

We also need to partner with our oncology colleagues and researchers. A positive diagnostic test result for possible malignancy necessitates referral to a gynecologic oncologist. Treatment by specialists in high-volume hospitals results in improved ovarian cancer outcomes.⁶ And we should advocate for continued research to support the discovery of an efficient population screening protocol for this deadly disease.

Finally, and perhaps most radically, I encourage you not to take a watch-and-wait approach in these situations. Ultrasounds are inexpensive, have low mortality risk, and achieve high sensitivity and specificity in detecting and managing adnexal abnormalities.⁷ In my opinion, the endorsement of TVU testing in this clinical situation is a proactive, prudent, and reasonable action compared with watching and waiting, and it may result in early detection as opposed to advanced disease.

Continue to: I hope that...

I hope that sharing my personal experience with ovarian cancer will compel health care providers to consider this disease as a differential diagnosis and perform appropriate testing when average-risk patients present with nonspecific symptoms. Ultimately, our collective goal should be to increase the survival rate and reduce the suffering associated with ovarian cancer.

This year in the United States, there were an estimated 22,530 new cases of ovarian cancer and an estimated 13,980 ovarian cancer deaths.¹ Ovarian cancer accounts for more deaths than any other female reproductive system cancer.² The high mortality rate is attributed to the advanced stage of cancer at initial presentation: Women diagnosed with localized disease have an estimated 5-year survival rate of 92%, while those diagnosed with advanced disease have a 5-year survival rate of 29%.³ For this reason, early detection of ovarian cancer is paramount.

A Personal Story

I think about ovarian cancer every day, because I am a survivor of this deadly disease. In 2018, at age 53, I received the diagnosis of stage 1A high-grade serous carcinoma of the left ovary. My cancer was discovered incidentally: I presented to my health care provider with a 6-month history of metrorrhagia and a prior history of regular menstruation with dysmenorrhea controlled with ibuprofen. My family and personal history of cancer was negative, I had a normal BMI, I didn’t smoke and consumed alcohol only moderately, my lifestyle was active, and I had no chronic diseases and used no medications regularly. My clinician performed a pelvic exam and ordered sexually transmitted infection testing and blood work (complete blood count, metabolic panel, and TSH). The differential diagnosis at this point included

• Thyroid dysfunction
• Perimenopause
• Sexually transmitted infection
• Coagulation defect
• Foreign body
• Infection.

All testing yielded normal findings. At my follow-up appointment, we discussed perimenopause symptoms and agreed that I would continue monitoring the bleeding. If at a later date I wanted to pursue an ultrasound, I was instructed to call the office. It was not suggested that I schedule a follow-up office visit.

Several months later, persistent metrorrhagia prompted me to request a transvaginal ultrasound (TVU)—resulting in the discovery of a left adnexal solid mass and probable endometrial polyp. A referral to a gynecologic oncologist resulted in further imaging, which confirmed the TVU results. Surgical intervention was recommended.

One week later, I underwent robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, left pelvic and periaortic lymph node dissection, and omentectomy. The pathology report confirmed stage 1A high-grade serous carcinoma of the left ovary, as well as stage 1A grade 1 endometrioid adenocarcinoma of the uterus. I required 6 cycles of chemotherapy before follow-up imaging yielded negative results, with no evidence of metastatic disease.

A Call to Action

The recently updated US Preventive Services Task Force guidelines continue not to recommend annual screening with TVU and/or cancer antigen 125 (CA-125) blood testing for ovarian cancer in asymptomatic, average-risk women. A review of the evidence found no mortality benefit and high false-positive rates, which led to unnecessary surgeries and physiologic stress due to excess cancer worry.⁴ This (lack of) recommendation leaves the clinician in the position of not performing or ordering screening tests, except in cases in which the patient presents with symptoms or requests screening for ovarian cancer.

Yet it cannot be overstated: The clinician’s role in identifying risk factors for and recognizing symptoms of ovarian cancer is extremely important in the absence of routine screening recommendations. Risk factors include a positive family history of gynecologic, breast, or colon cancers; genetic predisposition; personal history of breast cancer; use of menopausal hormone therapy; excess body weight; smoking; and sedentary lifestyle.³ In my case, my risk for ovarian cancer was average.

Continue to: With regard to symptoms...

With regard to symptoms, most women do not report any until ovarian cancer has reached advanced stages—and even then, the symptoms are vague and nonspecific.⁵ They may include urinary urgency or frequency; change in bowel habit; difficulty eating or feeling full quickly; persistent back, pelvic, or abdominal pain; extreme tiredness; vaginal bleeding after menopause; increased abdominal size; or bloating on most days.⁵

So what can we as clinicians do? First, if I may offer a word of caution: When confronted with those vague and nonspecific symptoms, be careful not to dismiss them out of hand as a result of aging, stress, or menopause. As my case demonstrates, for example, metrorrhagia is not necessarily a benign condition for the premenopausal woman.

Furthermore, we can empower patients by educating them about ovarian cancer symptoms and risk factors, information that may promote help-seeking behaviors that aid in early detection. In my case, the continued symptom of abnormal uterine bleeding prompted me to seek further assessment, which led to the discovery of ovarian cancer. Had I not been an educated and empowered patient, I would be telling a completely different story today—most likely one that would include advanced staging. Partner with your patient to discuss available diagnostic testing options and schedule follow-up appointments to monitor presenting complaints.

We also need to partner with our oncology colleagues and researchers. A positive diagnostic test result for possible malignancy necessitates referral to a gynecologic oncologist. Treatment by specialists in high-volume hospitals results in improved ovarian cancer outcomes.⁶ And we should advocate for continued research to support the discovery of an efficient population screening protocol for this deadly disease.

Finally, and perhaps most radically, I encourage you not to take a watch-and-wait approach in these situations. Ultrasounds are inexpensive, have low mortality risk, and achieve high sensitivity and specificity in detecting and managing adnexal abnormalities.⁷ In my opinion, the endorsement of TVU testing in this clinical situation is a proactive, prudent, and reasonable action compared with watching and waiting, and it may result in early detection as opposed to advanced disease.

Continue to: I hope that...

I hope that sharing my personal experience with ovarian cancer will compel health care providers to consider this disease as a differential diagnosis and perform appropriate testing when average-risk patients present with nonspecific symptoms. Ultimately, our collective goal should be to increase the survival rate and reduce the suffering associated with ovarian cancer.

This year in the United States, there were an estimated 22,530 new cases of ovarian cancer and an estimated 13,980 ovarian cancer deaths.¹ Ovarian cancer accounts for more deaths than any other female reproductive system cancer.² The high mortality rate is attributed to the advanced stage of cancer at initial presentation: Women diagnosed with localized disease have an estimated 5-year survival rate of 92%, while those diagnosed with advanced disease have a 5-year survival rate of 29%.³ For this reason, early detection of ovarian cancer is paramount.

A Personal Story

I think about ovarian cancer every day, because I am a survivor of this deadly disease. In 2018, at age 53, I received the diagnosis of stage 1A high-grade serous carcinoma of the left ovary. My cancer was discovered incidentally: I presented to my health care provider with a 6-month history of metrorrhagia and a prior history of regular menstruation with dysmenorrhea controlled with ibuprofen. My family and personal history of cancer was negative, I had a normal BMI, I didn’t smoke and consumed alcohol only moderately, my lifestyle was active, and I had no chronic diseases and used no medications regularly. My clinician performed a pelvic exam and ordered sexually transmitted infection testing and blood work (complete blood count, metabolic panel, and TSH). The differential diagnosis at this point included

• Thyroid dysfunction
• Perimenopause
• Sexually transmitted infection
• Coagulation defect
• Foreign body
• Infection.

All testing yielded normal findings. At my follow-up appointment, we discussed perimenopause symptoms and agreed that I would continue monitoring the bleeding. If at a later date I wanted to pursue an ultrasound, I was instructed to call the office. It was not suggested that I schedule a follow-up office visit.

Several months later, persistent metrorrhagia prompted me to request a transvaginal ultrasound (TVU)—resulting in the discovery of a left adnexal solid mass and probable endometrial polyp. A referral to a gynecologic oncologist resulted in further imaging, which confirmed the TVU results. Surgical intervention was recommended.

One week later, I underwent robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, left pelvic and periaortic lymph node dissection, and omentectomy. The pathology report confirmed stage 1A high-grade serous carcinoma of the left ovary, as well as stage 1A grade 1 endometrioid adenocarcinoma of the uterus. I required 6 cycles of chemotherapy before follow-up imaging yielded negative results, with no evidence of metastatic disease.

A Call to Action

The recently updated US Preventive Services Task Force guidelines continue not to recommend annual screening with TVU and/or cancer antigen 125 (CA-125) blood testing for ovarian cancer in asymptomatic, average-risk women. A review of the evidence found no mortality benefit and high false-positive rates, which led to unnecessary surgeries and physiologic stress due to excess cancer worry.⁴ This (lack of) recommendation leaves the clinician in the position of not performing or ordering screening tests, except in cases in which the patient presents with symptoms or requests screening for ovarian cancer.

Yet it cannot be overstated: The clinician’s role in identifying risk factors for and recognizing symptoms of ovarian cancer is extremely important in the absence of routine screening recommendations. Risk factors include a positive family history of gynecologic, breast, or colon cancers; genetic predisposition; personal history of breast cancer; use of menopausal hormone therapy; excess body weight; smoking; and sedentary lifestyle.³ In my case, my risk for ovarian cancer was average.

Continue to: With regard to symptoms...

With regard to symptoms, most women do not report any until ovarian cancer has reached advanced stages—and even then, the symptoms are vague and nonspecific.⁵ They may include urinary urgency or frequency; change in bowel habit; difficulty eating or feeling full quickly; persistent back, pelvic, or abdominal pain; extreme tiredness; vaginal bleeding after menopause; increased abdominal size; or bloating on most days.⁵

So what can we as clinicians do? First, if I may offer a word of caution: When confronted with those vague and nonspecific symptoms, be careful not to dismiss them out of hand as a result of aging, stress, or menopause. As my case demonstrates, for example, metrorrhagia is not necessarily a benign condition for the premenopausal woman.

Furthermore, we can empower patients by educating them about ovarian cancer symptoms and risk factors, information that may promote help-seeking behaviors that aid in early detection. In my case, the continued symptom of abnormal uterine bleeding prompted me to seek further assessment, which led to the discovery of ovarian cancer. Had I not been an educated and empowered patient, I would be telling a completely different story today—most likely one that would include advanced staging. Partner with your patient to discuss available diagnostic testing options and schedule follow-up appointments to monitor presenting complaints.

We also need to partner with our oncology colleagues and researchers. A positive diagnostic test result for possible malignancy necessitates referral to a gynecologic oncologist. Treatment by specialists in high-volume hospitals results in improved ovarian cancer outcomes.⁶ And we should advocate for continued research to support the discovery of an efficient population screening protocol for this deadly disease.

Finally, and perhaps most radically, I encourage you not to take a watch-and-wait approach in these situations. Ultrasounds are inexpensive, have low mortality risk, and achieve high sensitivity and specificity in detecting and managing adnexal abnormalities.⁷ In my opinion, the endorsement of TVU testing in this clinical situation is a proactive, prudent, and reasonable action compared with watching and waiting, and it may result in early detection as opposed to advanced disease.

Continue to: I hope that...

I hope that sharing my personal experience with ovarian cancer will compel health care providers to consider this disease as a differential diagnosis and perform appropriate testing when average-risk patients present with nonspecific symptoms. Ultimately, our collective goal should be to increase the survival rate and reduce the suffering associated with ovarian cancer.

A significant proportion of patients with major depressive disorder (MDD) either do not respond or have partial responses to the currently available Food and Drug Administration–approved antidepressants.

In controlled clinical trials, there is about a 40%-60% symptom remission rate with a 20%-40% remission rate in community-based treatment settings. Not only do those medications lack efficacy in treating MDD, but there are currently no cures for this debilitating illness. As a result, many patients with MDD continue to suffer.

In response to those poor outcomes, researchers and clinicians have developed algorithms aimed at diagnosing the condition of treatment-resistant depression (TRD),¹ which enable opportunities for various treatment methods.² Several studies underway across the United States are testing what some might consider medically invasive procedures, such as electroconvulsive therapy (ECT), deep brain stimulation (DBS), and vagus nerve stimulation (VNS). ECT often is considered the gold standard of treatment response, but it requires anesthesia, induces a convulsion, and needs a willing patient and clinician. DBS has been used more widely in neurological treatment of movement disorders. Pioneering neurosurgical treatment for TRD reported recently in the American Journal of Psychiatry found that DBS of an area in the brain called the subcallosal cingulate produces clear and apparently sustained antidepressant effects.³ VNS⁴ remains an experimental treatment for MDD. TMS is safe, noninvasive, and approved by the FDA for depression, but responses appear similar to those with usual antidepressants.

It is not surprising, given those outcomes, that ketamine was fast-tracked in 2016. The enthusiasm related to ketamine’s effect on MDD and TRD has grown over time as more research findings reach the public. While it is unknown how ketamine affects the biological neural network, a single intravenous dose of ketamine (0.5 mg/kg) in patients diagnosed with TRD can lead to improved depression symptoms outcomes within a few hours – and those effects were sustained in 65%-70% of patients at 24 hours. Antidepressants take many weeks to show effects. Ketamine’s exciting findings also offered hope to clinicians and patients trying to manage suicidal thoughts and plans. Ketamine was quickly approved by the FDA as a nasal spray medication.

Now, in another encouraging development, the FDA has granted the Usona Institute Breakthrough Therapy designation for psilocybin for the treatment of MDD. The medical benefits of psilocybin, or “magic mushrooms,” has a long empirical history in our literature. Most recently, psilocybin was featured on “60 Minutes,”⁵ and in his book, “How to Change Your Mind,”⁶Michael Pollan details how psychedelic drugs where used to investigate and treat psychiatric disorders until the 1960s, when street use and unsupervised administration led to restrictions on their research and clinical use.

We are now in a renaissance period⁷ where psychedelic drugs are being reestablished as a new approach to very important public health problems. With protocol-driven specific trials, they might become critical medications for a wide range of psychiatric disorders, such as depression, PTSD, anxiety, and addictions. Exciting findings are coming from Roland R. Griffiths, PhD, and his team at Johns Hopkins University’s Center for Psychedelic and Consciousness Research. In a recent study⁸ with cancer patients suffering from depression and anxiety, carefully administered, specific and supervised high doses of psilocybin produced decreases in depression and anxiety, and increases in quality of life and life meaning attitudes. Those improved attitudes, behavior, and responses were sustained by 80% of the sample 6 months post treatment.

Dr. Griffiths’ center is collaborating with Usona, and this collaboration should result in specific guidelines for dose, safety, and protection against abuse and diversion,⁹ as the study and FDA trials for ketamine have as well.¹⁰ It is very encouraging that psychedelic drugs are receiving fast-track designations, and this development reflects a shift in the risk-benefit considerations taking place in our society. Changing attitudes about depression and other psychiatric diseases are encouraging new approaches and new treatments. Psychiatric suffering and pain are being prioritized in research and appreciated by the general public as devastating. Serious, random assignment placebo-controlled and double- blind research studies will define just how valuable these medications might be, what is the safe dose and duration, and for whom they might prove more effective than existing treatments.

The process will take some time. And it is worth remembering that, although research has been promising,¹¹ the number of patients studied, research design, and outcomes are not yet proven for psilosybin.¹² The FDA fast-track makes sense, and the agency should continue supporting these efforts for psychedelics. In fact, we think the FDA also should support the promising trials of nitrous oxide¹³ (laughing gas), and other safe and novel approaches to successfully treat refractory depression. While we wait for personalized psychiatric medicines to be developed and validated through the long process of FDA approval, we will at least have a larger suite of treatment options to match patients with, along with some new algorithms that treat MDD,* TRD, and other disorders just are around the corner.

Dr. Patterson Silver Wolf is an associate professor at Washington University in St. Louis’s Brown School of Social Work. He is a training faculty member for two National Institutes of Health–funded (T32) training programs and serves as the director of the Community Academic Partnership on Addiction (CAPA). He’s chief research officer at the new CAPA Clinic, a teaching addiction treatment facility that is incorporating and testing various performance-based practice technology tools to respond to the opioid crisis and improve addiction treatment outcomes. Dr. Gold is professor of psychiatry (adjunct) at Washington University, St. Louis. He is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville. For more than 40 years, Dr. Gold has worked on developing models for understanding the effects of opioid, tobacco, cocaine, and other drugs, as well as food, on the brain and behavior. He has written several books and published more than 1,000 peer-reviewed scientific articles, texts, and practice guidelines.

References

1. Sackeim HA et al. J Psychiatr Res. 2019 Jun;113:125-36.

2. Conway CR et al. J Clin Psychiatry. 25 Nov;76(11):1569-70.

3. Crowell AL et al. Am J Psychiatry. 2019 Oct 4. doi: 10.1176.appi.ajp.2019.18121427.

4. Kumar A et al. Neuropsychiatr Dis Treat. 2019 Feb 13;15:457-68.

5. Psilocybin sessions: Psychedelics could help people with addiction and anxiety. “60 Minutes” CBS News. 2019 Oct 13.

6. Pollan M. How to Change Your Mind: What the New Science of Psychedelics Teaches Us About Consciousness, Dying, Addiction, Depression, and Transcendence (Penguin Random House, 2018).

7. Nutt D. Dialogues Clin Neurosci. 2019;21(2):139-47.

8. Griffiths RR et al. J Psychopharmacol 2016 Dec;30(12):1181-97.

9. Johnson MW et al. Neuropsychopharmacology. 2018 Nov;142:143-66.

10. Schwenk ES et al. Reg Anesth Pain Med. 2018 Jul;43(5):456-66.

11. Johnson MW et al. Neurotherapeutics. 2017 Jul;14(3):734-40.

12. Mutonni S et al. J Affect Disord. 2019 Nov.1;258:11-24.

13. Nagele P et al. J Clin Psychopharmacol. 2018 Apr;38(2):144-8.

*Correction, 1/9/2020: An earlier version of this story misidentified the intended disease state.

A significant proportion of patients with major depressive disorder (MDD) either do not respond or have partial responses to the currently available Food and Drug Administration–approved antidepressants.

In controlled clinical trials, there is about a 40%-60% symptom remission rate with a 20%-40% remission rate in community-based treatment settings. Not only do those medications lack efficacy in treating MDD, but there are currently no cures for this debilitating illness. As a result, many patients with MDD continue to suffer.

In response to those poor outcomes, researchers and clinicians have developed algorithms aimed at diagnosing the condition of treatment-resistant depression (TRD),¹ which enable opportunities for various treatment methods.² Several studies underway across the United States are testing what some might consider medically invasive procedures, such as electroconvulsive therapy (ECT), deep brain stimulation (DBS), and vagus nerve stimulation (VNS). ECT often is considered the gold standard of treatment response, but it requires anesthesia, induces a convulsion, and needs a willing patient and clinician. DBS has been used more widely in neurological treatment of movement disorders. Pioneering neurosurgical treatment for TRD reported recently in the American Journal of Psychiatry found that DBS of an area in the brain called the subcallosal cingulate produces clear and apparently sustained antidepressant effects.³ VNS⁴ remains an experimental treatment for MDD. TMS is safe, noninvasive, and approved by the FDA for depression, but responses appear similar to those with usual antidepressants.

It is not surprising, given those outcomes, that ketamine was fast-tracked in 2016. The enthusiasm related to ketamine’s effect on MDD and TRD has grown over time as more research findings reach the public. While it is unknown how ketamine affects the biological neural network, a single intravenous dose of ketamine (0.5 mg/kg) in patients diagnosed with TRD can lead to improved depression symptoms outcomes within a few hours – and those effects were sustained in 65%-70% of patients at 24 hours. Antidepressants take many weeks to show effects. Ketamine’s exciting findings also offered hope to clinicians and patients trying to manage suicidal thoughts and plans. Ketamine was quickly approved by the FDA as a nasal spray medication.

Now, in another encouraging development, the FDA has granted the Usona Institute Breakthrough Therapy designation for psilocybin for the treatment of MDD. The medical benefits of psilocybin, or “magic mushrooms,” has a long empirical history in our literature. Most recently, psilocybin was featured on “60 Minutes,”⁵ and in his book, “How to Change Your Mind,”⁶Michael Pollan details how psychedelic drugs where used to investigate and treat psychiatric disorders until the 1960s, when street use and unsupervised administration led to restrictions on their research and clinical use.

We are now in a renaissance period⁷ where psychedelic drugs are being reestablished as a new approach to very important public health problems. With protocol-driven specific trials, they might become critical medications for a wide range of psychiatric disorders, such as depression, PTSD, anxiety, and addictions. Exciting findings are coming from Roland R. Griffiths, PhD, and his team at Johns Hopkins University’s Center for Psychedelic and Consciousness Research. In a recent study⁸ with cancer patients suffering from depression and anxiety, carefully administered, specific and supervised high doses of psilocybin produced decreases in depression and anxiety, and increases in quality of life and life meaning attitudes. Those improved attitudes, behavior, and responses were sustained by 80% of the sample 6 months post treatment.

Dr. Griffiths’ center is collaborating with Usona, and this collaboration should result in specific guidelines for dose, safety, and protection against abuse and diversion,⁹ as the study and FDA trials for ketamine have as well.¹⁰ It is very encouraging that psychedelic drugs are receiving fast-track designations, and this development reflects a shift in the risk-benefit considerations taking place in our society. Changing attitudes about depression and other psychiatric diseases are encouraging new approaches and new treatments. Psychiatric suffering and pain are being prioritized in research and appreciated by the general public as devastating. Serious, random assignment placebo-controlled and double- blind research studies will define just how valuable these medications might be, what is the safe dose and duration, and for whom they might prove more effective than existing treatments.

The process will take some time. And it is worth remembering that, although research has been promising,¹¹ the number of patients studied, research design, and outcomes are not yet proven for psilosybin.¹² The FDA fast-track makes sense, and the agency should continue supporting these efforts for psychedelics. In fact, we think the FDA also should support the promising trials of nitrous oxide¹³ (laughing gas), and other safe and novel approaches to successfully treat refractory depression. While we wait for personalized psychiatric medicines to be developed and validated through the long process of FDA approval, we will at least have a larger suite of treatment options to match patients with, along with some new algorithms that treat MDD,* TRD, and other disorders just are around the corner.

Dr. Patterson Silver Wolf is an associate professor at Washington University in St. Louis’s Brown School of Social Work. He is a training faculty member for two National Institutes of Health–funded (T32) training programs and serves as the director of the Community Academic Partnership on Addiction (CAPA). He’s chief research officer at the new CAPA Clinic, a teaching addiction treatment facility that is incorporating and testing various performance-based practice technology tools to respond to the opioid crisis and improve addiction treatment outcomes. Dr. Gold is professor of psychiatry (adjunct) at Washington University, St. Louis. He is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville. For more than 40 years, Dr. Gold has worked on developing models for understanding the effects of opioid, tobacco, cocaine, and other drugs, as well as food, on the brain and behavior. He has written several books and published more than 1,000 peer-reviewed scientific articles, texts, and practice guidelines.

References

1. Sackeim HA et al. J Psychiatr Res. 2019 Jun;113:125-36.

2. Conway CR et al. J Clin Psychiatry. 25 Nov;76(11):1569-70.

3. Crowell AL et al. Am J Psychiatry. 2019 Oct 4. doi: 10.1176.appi.ajp.2019.18121427.

4. Kumar A et al. Neuropsychiatr Dis Treat. 2019 Feb 13;15:457-68.

5. Psilocybin sessions: Psychedelics could help people with addiction and anxiety. “60 Minutes” CBS News. 2019 Oct 13.

6. Pollan M. How to Change Your Mind: What the New Science of Psychedelics Teaches Us About Consciousness, Dying, Addiction, Depression, and Transcendence (Penguin Random House, 2018).

7. Nutt D. Dialogues Clin Neurosci. 2019;21(2):139-47.

8. Griffiths RR et al. J Psychopharmacol 2016 Dec;30(12):1181-97.

9. Johnson MW et al. Neuropsychopharmacology. 2018 Nov;142:143-66.

10. Schwenk ES et al. Reg Anesth Pain Med. 2018 Jul;43(5):456-66.

11. Johnson MW et al. Neurotherapeutics. 2017 Jul;14(3):734-40.

12. Mutonni S et al. J Affect Disord. 2019 Nov.1;258:11-24.

13. Nagele P et al. J Clin Psychopharmacol. 2018 Apr;38(2):144-8.

*Correction, 1/9/2020: An earlier version of this story misidentified the intended disease state.

A significant proportion of patients with major depressive disorder (MDD) either do not respond or have partial responses to the currently available Food and Drug Administration–approved antidepressants.

In controlled clinical trials, there is about a 40%-60% symptom remission rate with a 20%-40% remission rate in community-based treatment settings. Not only do those medications lack efficacy in treating MDD, but there are currently no cures for this debilitating illness. As a result, many patients with MDD continue to suffer.

In response to those poor outcomes, researchers and clinicians have developed algorithms aimed at diagnosing the condition of treatment-resistant depression (TRD),¹ which enable opportunities for various treatment methods.² Several studies underway across the United States are testing what some might consider medically invasive procedures, such as electroconvulsive therapy (ECT), deep brain stimulation (DBS), and vagus nerve stimulation (VNS). ECT often is considered the gold standard of treatment response, but it requires anesthesia, induces a convulsion, and needs a willing patient and clinician. DBS has been used more widely in neurological treatment of movement disorders. Pioneering neurosurgical treatment for TRD reported recently in the American Journal of Psychiatry found that DBS of an area in the brain called the subcallosal cingulate produces clear and apparently sustained antidepressant effects.³ VNS⁴ remains an experimental treatment for MDD. TMS is safe, noninvasive, and approved by the FDA for depression, but responses appear similar to those with usual antidepressants.

It is not surprising, given those outcomes, that ketamine was fast-tracked in 2016. The enthusiasm related to ketamine’s effect on MDD and TRD has grown over time as more research findings reach the public. While it is unknown how ketamine affects the biological neural network, a single intravenous dose of ketamine (0.5 mg/kg) in patients diagnosed with TRD can lead to improved depression symptoms outcomes within a few hours – and those effects were sustained in 65%-70% of patients at 24 hours. Antidepressants take many weeks to show effects. Ketamine’s exciting findings also offered hope to clinicians and patients trying to manage suicidal thoughts and plans. Ketamine was quickly approved by the FDA as a nasal spray medication.

Now, in another encouraging development, the FDA has granted the Usona Institute Breakthrough Therapy designation for psilocybin for the treatment of MDD. The medical benefits of psilocybin, or “magic mushrooms,” has a long empirical history in our literature. Most recently, psilocybin was featured on “60 Minutes,”⁵ and in his book, “How to Change Your Mind,”⁶Michael Pollan details how psychedelic drugs where used to investigate and treat psychiatric disorders until the 1960s, when street use and unsupervised administration led to restrictions on their research and clinical use.

We are now in a renaissance period⁷ where psychedelic drugs are being reestablished as a new approach to very important public health problems. With protocol-driven specific trials, they might become critical medications for a wide range of psychiatric disorders, such as depression, PTSD, anxiety, and addictions. Exciting findings are coming from Roland R. Griffiths, PhD, and his team at Johns Hopkins University’s Center for Psychedelic and Consciousness Research. In a recent study⁸ with cancer patients suffering from depression and anxiety, carefully administered, specific and supervised high doses of psilocybin produced decreases in depression and anxiety, and increases in quality of life and life meaning attitudes. Those improved attitudes, behavior, and responses were sustained by 80% of the sample 6 months post treatment.

Dr. Griffiths’ center is collaborating with Usona, and this collaboration should result in specific guidelines for dose, safety, and protection against abuse and diversion,⁹ as the study and FDA trials for ketamine have as well.¹⁰ It is very encouraging that psychedelic drugs are receiving fast-track designations, and this development reflects a shift in the risk-benefit considerations taking place in our society. Changing attitudes about depression and other psychiatric diseases are encouraging new approaches and new treatments. Psychiatric suffering and pain are being prioritized in research and appreciated by the general public as devastating. Serious, random assignment placebo-controlled and double- blind research studies will define just how valuable these medications might be, what is the safe dose and duration, and for whom they might prove more effective than existing treatments.

The process will take some time. And it is worth remembering that, although research has been promising,¹¹ the number of patients studied, research design, and outcomes are not yet proven for psilosybin.¹² The FDA fast-track makes sense, and the agency should continue supporting these efforts for psychedelics. In fact, we think the FDA also should support the promising trials of nitrous oxide¹³ (laughing gas), and other safe and novel approaches to successfully treat refractory depression. While we wait for personalized psychiatric medicines to be developed and validated through the long process of FDA approval, we will at least have a larger suite of treatment options to match patients with, along with some new algorithms that treat MDD,* TRD, and other disorders just are around the corner.

Dr. Patterson Silver Wolf is an associate professor at Washington University in St. Louis’s Brown School of Social Work. He is a training faculty member for two National Institutes of Health–funded (T32) training programs and serves as the director of the Community Academic Partnership on Addiction (CAPA). He’s chief research officer at the new CAPA Clinic, a teaching addiction treatment facility that is incorporating and testing various performance-based practice technology tools to respond to the opioid crisis and improve addiction treatment outcomes. Dr. Gold is professor of psychiatry (adjunct) at Washington University, St. Louis. He is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville. For more than 40 years, Dr. Gold has worked on developing models for understanding the effects of opioid, tobacco, cocaine, and other drugs, as well as food, on the brain and behavior. He has written several books and published more than 1,000 peer-reviewed scientific articles, texts, and practice guidelines.

References

1. Sackeim HA et al. J Psychiatr Res. 2019 Jun;113:125-36.

2. Conway CR et al. J Clin Psychiatry. 25 Nov;76(11):1569-70.

3. Crowell AL et al. Am J Psychiatry. 2019 Oct 4. doi: 10.1176.appi.ajp.2019.18121427.

4. Kumar A et al. Neuropsychiatr Dis Treat. 2019 Feb 13;15:457-68.

5. Psilocybin sessions: Psychedelics could help people with addiction and anxiety. “60 Minutes” CBS News. 2019 Oct 13.

6. Pollan M. How to Change Your Mind: What the New Science of Psychedelics Teaches Us About Consciousness, Dying, Addiction, Depression, and Transcendence (Penguin Random House, 2018).

7. Nutt D. Dialogues Clin Neurosci. 2019;21(2):139-47.

8. Griffiths RR et al. J Psychopharmacol 2016 Dec;30(12):1181-97.

9. Johnson MW et al. Neuropsychopharmacology. 2018 Nov;142:143-66.

10. Schwenk ES et al. Reg Anesth Pain Med. 2018 Jul;43(5):456-66.

11. Johnson MW et al. Neurotherapeutics. 2017 Jul;14(3):734-40.

12. Mutonni S et al. J Affect Disord. 2019 Nov.1;258:11-24.

13. Nagele P et al. J Clin Psychopharmacol. 2018 Apr;38(2):144-8.

*Correction, 1/9/2020: An earlier version of this story misidentified the intended disease state.

Family physicians try to base treatment decisions on the very best available evidence from randomized trials and other high-quality studies. Very often, however, the evidence is not conclusive. Family physicians are confronted with questions about a wide variety of treatments that may or may not be effective. The classic example for me is the use of chondroitin sulfate/glucosamine for knee osteoarthritis. The preponderance of evidence tells us it is not effective, but one long-term clinical trial did find some benefit.¹ And some patients swear by it!

In this issue of JFP, we have 2 articles that fall into this category: 1 by Hahn about the treatment of asthma with macrolides and the other by Sorsby et al about use of positive airway pressure (PAP) for obstructive sleep apnea (OSA).

The article by Hahn is an extensive literature review regarding the effectiveness of macrolides for asthma. Despite 2 meta-analyses and many clinical trials, the results are not conclusive; but they are highly suggestive that macrolides may benefit patients with new-onset asthma and severe asthma that does not respond completely to mainstream treatments. Why don't we have conclusive evidence? Because the right studies have not been done. Most studies of macrolides for asthma have not focused on these 2 groups, so any treatment effect may have been diluted by including patients not likely to respond.

Why don't we have conclusive evidence? Because the right studies have not been done.

The issue with PAP, also known as CPAP (or continuous positive airway pressure), for the treatment of OSA is different. In this case, the question is: What conditions and outcomes are improved by use of PAP? Studies strongly support that PAP is effective in reducing daytime sleepiness and motor vehicle accidents associated with OSA. Most of us had high hopes that PAP also would reduce the adverse cardiovascular outcomes associated with OSA. But the results of large randomized trials have not found a protective effective.

Enthusiasts argue that the studies have not been of sufficient duration and that the participants did not use their PAP devices long enough each night. Some follow-up studies have suggested a protective effective when the device is used for many years, but those studies have the major flaw of volunteer bias, meaning those who adhere to any treatment have better health outcomes than those who do not adhere.

What should you do when there is uncertainty regarding effectiveness? Use shared decision making: What does the patient want to do after you have explained the possible benefits and harms?

Family physicians try to base treatment decisions on the very best available evidence from randomized trials and other high-quality studies. Very often, however, the evidence is not conclusive. Family physicians are confronted with questions about a wide variety of treatments that may or may not be effective. The classic example for me is the use of chondroitin sulfate/glucosamine for knee osteoarthritis. The preponderance of evidence tells us it is not effective, but one long-term clinical trial did find some benefit.¹ And some patients swear by it!

In this issue of JFP, we have 2 articles that fall into this category: 1 by Hahn about the treatment of asthma with macrolides and the other by Sorsby et al about use of positive airway pressure (PAP) for obstructive sleep apnea (OSA).

The article by Hahn is an extensive literature review regarding the effectiveness of macrolides for asthma. Despite 2 meta-analyses and many clinical trials, the results are not conclusive; but they are highly suggestive that macrolides may benefit patients with new-onset asthma and severe asthma that does not respond completely to mainstream treatments. Why don't we have conclusive evidence? Because the right studies have not been done. Most studies of macrolides for asthma have not focused on these 2 groups, so any treatment effect may have been diluted by including patients not likely to respond.

Why don't we have conclusive evidence? Because the right studies have not been done.

The issue with PAP, also known as CPAP (or continuous positive airway pressure), for the treatment of OSA is different. In this case, the question is: What conditions and outcomes are improved by use of PAP? Studies strongly support that PAP is effective in reducing daytime sleepiness and motor vehicle accidents associated with OSA. Most of us had high hopes that PAP also would reduce the adverse cardiovascular outcomes associated with OSA. But the results of large randomized trials have not found a protective effective.

Enthusiasts argue that the studies have not been of sufficient duration and that the participants did not use their PAP devices long enough each night. Some follow-up studies have suggested a protective effective when the device is used for many years, but those studies have the major flaw of volunteer bias, meaning those who adhere to any treatment have better health outcomes than those who do not adhere.

What should you do when there is uncertainty regarding effectiveness? Use shared decision making: What does the patient want to do after you have explained the possible benefits and harms?

Family physicians try to base treatment decisions on the very best available evidence from randomized trials and other high-quality studies. Very often, however, the evidence is not conclusive. Family physicians are confronted with questions about a wide variety of treatments that may or may not be effective. The classic example for me is the use of chondroitin sulfate/glucosamine for knee osteoarthritis. The preponderance of evidence tells us it is not effective, but one long-term clinical trial did find some benefit.¹ And some patients swear by it!

In this issue of JFP, we have 2 articles that fall into this category: 1 by Hahn about the treatment of asthma with macrolides and the other by Sorsby et al about use of positive airway pressure (PAP) for obstructive sleep apnea (OSA).

The article by Hahn is an extensive literature review regarding the effectiveness of macrolides for asthma. Despite 2 meta-analyses and many clinical trials, the results are not conclusive; but they are highly suggestive that macrolides may benefit patients with new-onset asthma and severe asthma that does not respond completely to mainstream treatments. Why don't we have conclusive evidence? Because the right studies have not been done. Most studies of macrolides for asthma have not focused on these 2 groups, so any treatment effect may have been diluted by including patients not likely to respond.

Why don't we have conclusive evidence? Because the right studies have not been done.

The issue with PAP, also known as CPAP (or continuous positive airway pressure), for the treatment of OSA is different. In this case, the question is: What conditions and outcomes are improved by use of PAP? Studies strongly support that PAP is effective in reducing daytime sleepiness and motor vehicle accidents associated with OSA. Most of us had high hopes that PAP also would reduce the adverse cardiovascular outcomes associated with OSA. But the results of large randomized trials have not found a protective effective.

Enthusiasts argue that the studies have not been of sufficient duration and that the participants did not use their PAP devices long enough each night. Some follow-up studies have suggested a protective effective when the device is used for many years, but those studies have the major flaw of volunteer bias, meaning those who adhere to any treatment have better health outcomes than those who do not adhere.

What should you do when there is uncertainty regarding effectiveness? Use shared decision making: What does the patient want to do after you have explained the possible benefits and harms?