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Counseling on cannabis use in pregnancy
A flurry of research papers published this year has simultaneously documented a rise in the use of cannabis during pregnancy and offered more data about its potential harms. This confluence of findings is concerning and highlights the importance of screening our patients for cannabis use and engaging with them in a way in which we can maintain their trust and their commitment to prenatal care.
A retrospective cohort study involving 661,617 women in Ontario found a significant association between self-reported cannabis use in pregnancy and an increased risk of preterm birth (relative risk, 1.41), as well as a greater likelihood of small-for-gestational-age babies (RR, 1.53), placental abruption (RR, 1.72), and transfer to neonatal intensive care (RR, 1.40).1 The study, reported in JAMA in July 2019, carefully matched users with nonusers who had the same characteristics – for example, tobacco use or not.
This new information builds upon other meta-analyses that have demonstrated a decrease in birth weight and greater admittance to the neonatal ICU associated with cannabis use in pregnancy – and it supplements what some research suggests about long-term neurologic development and a potentially increased risk of attention and behavioral problems. Other outcomes that have been noted in long-term neurologic studies of children who were exposed to cannabis in utero include impaired visual acuity, verbal reasoning and comprehension, and short-term memory.2
Increases in use were recently documented in two studies. One, an analysis of data from the National Survey on Drug Use and Health (NSDUH) published in JAMA in June 2019, showed that, between 2002-2003 and 2016-2017, the use of cannabis “in the past month” increased from 3.4% to 7.0% among pregnant women overall, and from 6% to 12% during the first trimester.3
The use of cannabis on a daily or near-daily basis, moreover, increased from 0.9% to 3% among pregnant women overall and from 2% to 5% during the first trimester. The data were collected during face-to-face interviews and were adjusted for age, race/ethnicity, and family income.
In the second study – a cross-sectional study of 367,403 pregnancies among women who filled out a questionnaire on cannabis use during standard prenatal care at Kaiser Permanente Northern California – the adjusted prevalence of use in the year before pregnancy increased from 7% in 2009 to 13% in 2017, and the adjusted prevalence during pregnancy increased from 2% to 3%.4
As in the NSDUH analysis, daily use increased most rapidly (compared with weekly or monthly) such that, by 2017, 25% of those who reported using cannabis in the year before pregnancy – and 21% of those who used cannabis during pregnancy – were daily users. It is notable that Kaiser’s population is diverse in all respects, and that the annual relative rates of increase in cannabis use before and during pregnancy (at each level of frequency) were consistent across racial/ethnic and household income groups.
It’s also worth noting that, in earlier research covering a similar time period (2009-2016), the investigators found significant increases in use via urine toxicology testing that occurs at the first prenatal visit at Kaiser. The increase found through questionnaires, therefore, reflects more than a greater willingness to self-report.
Choosing a screening tool
Universal prenatal substance use screening is recommended by the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention, but we don’t have any specific recommendations on what this means. Who should be screening, and what should that screening look like? Should we use a biologic screen, a standardized screening tool, or simply ask patients whether they use illicit substances?
Screening tools seem advantageous in that they are low cost, noninvasive, potentially comprehensive, and not subject to false-positive results as biologic screens can be – but which tool or tools are best? There are several validated screening tools that can be used outside of pregnancy to determine an individual’s use of illicit substances and whether or not that use is problematic, but previous studies have not used biologic markers to validate substance use screeners in pregnancy. Nor have studies compared screeners in pregnancy.
In our prenatal population in Baltimore, we have not been getting the answers we want using various nonvalidated screening tools. Approximately 30% of patients are positive for cannabis by urine screen, but only half tell us about their use.
Through research in our two prenatal care practices (one serving mostly privately insured and the other serving primarily Medicaid-eligible patients), we assessed both the accuracy and the acceptability of three substance use screening tools that are brief and that have been validated (for the general population) by the World Health Organization for screening of multiple substances: the 4P’s Plus (Parents, Partner, Past, and Pregnancy), the National Institute on Drug Abuse Quick Screen–ASSIST (Modified Alcohol, Smoking and Substance Involvement Screening Test), and the SURP-P (Substance Use Risk Profile–Pregnancy) scale.
In one study, published in May 2019 in Obstetrics & Gynecology, we recruited 500 pregnant women and administered these three tests to each of them.5 We then compared results with those of urine and hair drug testing, and checked the test-retest reliability of each test by readministering them (albeit by telephone) a week later. Although hair testing is not an indicator of current substance use, we used it to validate the screening tools on less-recent use.
The tests with the highest sensitivity and negative predictive values – the qualities we most want for screening – were the SURP-P and the 4P’s Plus (sensitivity of 92.4% and 90.2%, respectively). Overall they were highly sensitive screening tools across all trimesters, races, and age groups, making them more ideal screening tests than the NIDA Quick Screen–ASSIST.
Of the two tests, the 4P’s Plus screening tool was the one preferred by staff from both practices. In a companion qualitative study, we conducted focus-group discussions with 40 practice staff who were responsible for administering or overseeing patient screening.6 The staff, who were unaware of the sensitivity findings, were asked what they thought about the acceptability to patients of each of the three tools and their usability in practice.
Most of the participating staff preferred the 4P’s Plus screening tool for several reasons: It is easy to understand, is brief and to the point, and it has nonjudgmental language and tone. The screener first asks the patient about her parents’ and her partner’s use of alcohol and drugs, and then asks the patient about her own use of alcohol and tobacco. Affirmative responses to these questions lead to additional questions.
The premise is that one’s genetics, history, and current exposures – as well as one’s own use of tobacco and alcohol – are significantly associated with the use of illicit substances. If the patient reports no parental history or partner usage, and has never drank or smoked before, it’s extremely unlikely that she is using other drugs. The progression of questions does indeed seem less judgmental than immediately asking: “Do you use drugs?”
For us, the insight from this staff perception study combined with the findings on accuracy mean that the 4P’s Plus may be the most useful and acceptable screening tool for routine use in prenatal care.
Talking with our patients
The increase in the use of cannabis before and after pregnancy parallels the movement toward state legalization and decriminalization. Historically, clinicians often have relied on illegality as their main focus of counseling when giving recommendations for cessation and abstinence in pregnancy.2 This approach not only leads to punitive counseling, which can fracture the doctor-patient relationship, but increasingly it is no longer valid. In our changing legal climate, we need to provide medically based counseling and be very clear with our patients that legalization does not equate to safety.
It is important that we neither minimize nor overstate the risks. The evidence base for adverse birth outcomes of cannabis use in pregnancy is quite robust, but the associations can be subtle and are moderated by other behaviors and environmental factors that continue to challenge researchers.
As with alcohol, there likely are dose-or trimester-dependent differences in perinatal outcomes, and it’s quite possible that different cannabis products and routes of consumption have different effects. At this point, however, we don’t know the full story, nor do we know the extent to which the literature is biased toward positive correlations – the reporting of adverse effects – compared with negative findings. It is our job as medical care providers to be comfortable in that gray area and to still counsel patients on what we do know, providing the best-possible medical advice based on the information available to us.
In talking with patients, I explain that cannabis may cause a spectrum of problems and that there certainly are risks. I also tell them that we’re uncertain about the conditions and magnitude of that risk and that some babies who are exposed to cannabis in utero may have no perceivable consequences. Such honesty is important for maintaining trust, especially as some patients may see friends and relatives who also are cannabis users have normal pregnancy outcomes.
Much of my concern about cannabis in pregnancy centers on its effect on the developing brain and on long-term neurologic development. I share this with patients – I tell them that cannabis crosses the placenta and may well affect their baby’s brain as it is developing. I explain that I do not know whether this effect would be big or small, but that it’s not a chance I’m willing to take for their baby.
It is also important to educate patients that cannabis products are untested and unregulated and that they may be contaminated with heavy metals, pesticides, and other toxins that may be harmful to themselves and their babies. Patients also should know that the potency of cannabis has been dramatically increasing; research shows that the tetrahydrocannabinol – the psychoactive component – concentration has tripled over the past 2 decades.7
Research tells us that women who use illicit drugs and alcohol categorically engage in some form of harm reduction once they learn they are pregnant, and the same is true for cannabis. This is seen in dramatically different rates of first- and third-trimester use in the new analysis of NSDUH data; third-trimester use is approximately halved.
Some women will not be able to discontinue use, however, or they may try to quit and fail in their attempts. As we should with substance use more broadly, we must meet patients where they are, view cannabis use as a chronic medical problem, offer our assistance in helping them reduce harms of their use, and understand that quitting is a process.
Screening for mental health disorders and trauma is, of course, especially important in patients who use cannabis and other substances recreationally. In cases of medical marijuana usage, I recommend, as ACOG and other have done, that we discuss the risks and benefits of continuing cannabis versus shifting to alternative medications if options exist.
All patients should be welcomed, congratulated on their pregnancy and on coming for prenatal care, and engaged in the overall process of optimizing their health and the health of their baby. Like any other health issue during pregnancy, cannabis use needs to be screened for and treated in an evidence-based manner, but it does not define the trajectory or success of a woman’s pregnancy or her ability to be a successful parent.
Dr. Mark is associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine.
References
1. JAMA. 2019 Jul 9;322(2):145-52.
2. Preventive Medicine 2017 May 18;104:46-9.
3. JAMA. 2019 Jul 9;322(2):167-9.
4. JAMA Netw Open. 2019 Jul 3;2(7):e196471.
5. Obstet Gynecol. 2019 May;133(5):952-61.
6. J. Addict Med. 2019 May 10. doi: 10.1097/ADM.0000000000000543.
7. Biol Psychiatry. 2016 Apr 1;79(7):613-9.
A flurry of research papers published this year has simultaneously documented a rise in the use of cannabis during pregnancy and offered more data about its potential harms. This confluence of findings is concerning and highlights the importance of screening our patients for cannabis use and engaging with them in a way in which we can maintain their trust and their commitment to prenatal care.
A retrospective cohort study involving 661,617 women in Ontario found a significant association between self-reported cannabis use in pregnancy and an increased risk of preterm birth (relative risk, 1.41), as well as a greater likelihood of small-for-gestational-age babies (RR, 1.53), placental abruption (RR, 1.72), and transfer to neonatal intensive care (RR, 1.40).1 The study, reported in JAMA in July 2019, carefully matched users with nonusers who had the same characteristics – for example, tobacco use or not.
This new information builds upon other meta-analyses that have demonstrated a decrease in birth weight and greater admittance to the neonatal ICU associated with cannabis use in pregnancy – and it supplements what some research suggests about long-term neurologic development and a potentially increased risk of attention and behavioral problems. Other outcomes that have been noted in long-term neurologic studies of children who were exposed to cannabis in utero include impaired visual acuity, verbal reasoning and comprehension, and short-term memory.2
Increases in use were recently documented in two studies. One, an analysis of data from the National Survey on Drug Use and Health (NSDUH) published in JAMA in June 2019, showed that, between 2002-2003 and 2016-2017, the use of cannabis “in the past month” increased from 3.4% to 7.0% among pregnant women overall, and from 6% to 12% during the first trimester.3
The use of cannabis on a daily or near-daily basis, moreover, increased from 0.9% to 3% among pregnant women overall and from 2% to 5% during the first trimester. The data were collected during face-to-face interviews and were adjusted for age, race/ethnicity, and family income.
In the second study – a cross-sectional study of 367,403 pregnancies among women who filled out a questionnaire on cannabis use during standard prenatal care at Kaiser Permanente Northern California – the adjusted prevalence of use in the year before pregnancy increased from 7% in 2009 to 13% in 2017, and the adjusted prevalence during pregnancy increased from 2% to 3%.4
As in the NSDUH analysis, daily use increased most rapidly (compared with weekly or monthly) such that, by 2017, 25% of those who reported using cannabis in the year before pregnancy – and 21% of those who used cannabis during pregnancy – were daily users. It is notable that Kaiser’s population is diverse in all respects, and that the annual relative rates of increase in cannabis use before and during pregnancy (at each level of frequency) were consistent across racial/ethnic and household income groups.
It’s also worth noting that, in earlier research covering a similar time period (2009-2016), the investigators found significant increases in use via urine toxicology testing that occurs at the first prenatal visit at Kaiser. The increase found through questionnaires, therefore, reflects more than a greater willingness to self-report.
Choosing a screening tool
Universal prenatal substance use screening is recommended by the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention, but we don’t have any specific recommendations on what this means. Who should be screening, and what should that screening look like? Should we use a biologic screen, a standardized screening tool, or simply ask patients whether they use illicit substances?
Screening tools seem advantageous in that they are low cost, noninvasive, potentially comprehensive, and not subject to false-positive results as biologic screens can be – but which tool or tools are best? There are several validated screening tools that can be used outside of pregnancy to determine an individual’s use of illicit substances and whether or not that use is problematic, but previous studies have not used biologic markers to validate substance use screeners in pregnancy. Nor have studies compared screeners in pregnancy.
In our prenatal population in Baltimore, we have not been getting the answers we want using various nonvalidated screening tools. Approximately 30% of patients are positive for cannabis by urine screen, but only half tell us about their use.
Through research in our two prenatal care practices (one serving mostly privately insured and the other serving primarily Medicaid-eligible patients), we assessed both the accuracy and the acceptability of three substance use screening tools that are brief and that have been validated (for the general population) by the World Health Organization for screening of multiple substances: the 4P’s Plus (Parents, Partner, Past, and Pregnancy), the National Institute on Drug Abuse Quick Screen–ASSIST (Modified Alcohol, Smoking and Substance Involvement Screening Test), and the SURP-P (Substance Use Risk Profile–Pregnancy) scale.
In one study, published in May 2019 in Obstetrics & Gynecology, we recruited 500 pregnant women and administered these three tests to each of them.5 We then compared results with those of urine and hair drug testing, and checked the test-retest reliability of each test by readministering them (albeit by telephone) a week later. Although hair testing is not an indicator of current substance use, we used it to validate the screening tools on less-recent use.
The tests with the highest sensitivity and negative predictive values – the qualities we most want for screening – were the SURP-P and the 4P’s Plus (sensitivity of 92.4% and 90.2%, respectively). Overall they were highly sensitive screening tools across all trimesters, races, and age groups, making them more ideal screening tests than the NIDA Quick Screen–ASSIST.
Of the two tests, the 4P’s Plus screening tool was the one preferred by staff from both practices. In a companion qualitative study, we conducted focus-group discussions with 40 practice staff who were responsible for administering or overseeing patient screening.6 The staff, who were unaware of the sensitivity findings, were asked what they thought about the acceptability to patients of each of the three tools and their usability in practice.
Most of the participating staff preferred the 4P’s Plus screening tool for several reasons: It is easy to understand, is brief and to the point, and it has nonjudgmental language and tone. The screener first asks the patient about her parents’ and her partner’s use of alcohol and drugs, and then asks the patient about her own use of alcohol and tobacco. Affirmative responses to these questions lead to additional questions.
The premise is that one’s genetics, history, and current exposures – as well as one’s own use of tobacco and alcohol – are significantly associated with the use of illicit substances. If the patient reports no parental history or partner usage, and has never drank or smoked before, it’s extremely unlikely that she is using other drugs. The progression of questions does indeed seem less judgmental than immediately asking: “Do you use drugs?”
For us, the insight from this staff perception study combined with the findings on accuracy mean that the 4P’s Plus may be the most useful and acceptable screening tool for routine use in prenatal care.
Talking with our patients
The increase in the use of cannabis before and after pregnancy parallels the movement toward state legalization and decriminalization. Historically, clinicians often have relied on illegality as their main focus of counseling when giving recommendations for cessation and abstinence in pregnancy.2 This approach not only leads to punitive counseling, which can fracture the doctor-patient relationship, but increasingly it is no longer valid. In our changing legal climate, we need to provide medically based counseling and be very clear with our patients that legalization does not equate to safety.
It is important that we neither minimize nor overstate the risks. The evidence base for adverse birth outcomes of cannabis use in pregnancy is quite robust, but the associations can be subtle and are moderated by other behaviors and environmental factors that continue to challenge researchers.
As with alcohol, there likely are dose-or trimester-dependent differences in perinatal outcomes, and it’s quite possible that different cannabis products and routes of consumption have different effects. At this point, however, we don’t know the full story, nor do we know the extent to which the literature is biased toward positive correlations – the reporting of adverse effects – compared with negative findings. It is our job as medical care providers to be comfortable in that gray area and to still counsel patients on what we do know, providing the best-possible medical advice based on the information available to us.
In talking with patients, I explain that cannabis may cause a spectrum of problems and that there certainly are risks. I also tell them that we’re uncertain about the conditions and magnitude of that risk and that some babies who are exposed to cannabis in utero may have no perceivable consequences. Such honesty is important for maintaining trust, especially as some patients may see friends and relatives who also are cannabis users have normal pregnancy outcomes.
Much of my concern about cannabis in pregnancy centers on its effect on the developing brain and on long-term neurologic development. I share this with patients – I tell them that cannabis crosses the placenta and may well affect their baby’s brain as it is developing. I explain that I do not know whether this effect would be big or small, but that it’s not a chance I’m willing to take for their baby.
It is also important to educate patients that cannabis products are untested and unregulated and that they may be contaminated with heavy metals, pesticides, and other toxins that may be harmful to themselves and their babies. Patients also should know that the potency of cannabis has been dramatically increasing; research shows that the tetrahydrocannabinol – the psychoactive component – concentration has tripled over the past 2 decades.7
Research tells us that women who use illicit drugs and alcohol categorically engage in some form of harm reduction once they learn they are pregnant, and the same is true for cannabis. This is seen in dramatically different rates of first- and third-trimester use in the new analysis of NSDUH data; third-trimester use is approximately halved.
Some women will not be able to discontinue use, however, or they may try to quit and fail in their attempts. As we should with substance use more broadly, we must meet patients where they are, view cannabis use as a chronic medical problem, offer our assistance in helping them reduce harms of their use, and understand that quitting is a process.
Screening for mental health disorders and trauma is, of course, especially important in patients who use cannabis and other substances recreationally. In cases of medical marijuana usage, I recommend, as ACOG and other have done, that we discuss the risks and benefits of continuing cannabis versus shifting to alternative medications if options exist.
All patients should be welcomed, congratulated on their pregnancy and on coming for prenatal care, and engaged in the overall process of optimizing their health and the health of their baby. Like any other health issue during pregnancy, cannabis use needs to be screened for and treated in an evidence-based manner, but it does not define the trajectory or success of a woman’s pregnancy or her ability to be a successful parent.
Dr. Mark is associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine.
References
1. JAMA. 2019 Jul 9;322(2):145-52.
2. Preventive Medicine 2017 May 18;104:46-9.
3. JAMA. 2019 Jul 9;322(2):167-9.
4. JAMA Netw Open. 2019 Jul 3;2(7):e196471.
5. Obstet Gynecol. 2019 May;133(5):952-61.
6. J. Addict Med. 2019 May 10. doi: 10.1097/ADM.0000000000000543.
7. Biol Psychiatry. 2016 Apr 1;79(7):613-9.
A flurry of research papers published this year has simultaneously documented a rise in the use of cannabis during pregnancy and offered more data about its potential harms. This confluence of findings is concerning and highlights the importance of screening our patients for cannabis use and engaging with them in a way in which we can maintain their trust and their commitment to prenatal care.
A retrospective cohort study involving 661,617 women in Ontario found a significant association between self-reported cannabis use in pregnancy and an increased risk of preterm birth (relative risk, 1.41), as well as a greater likelihood of small-for-gestational-age babies (RR, 1.53), placental abruption (RR, 1.72), and transfer to neonatal intensive care (RR, 1.40).1 The study, reported in JAMA in July 2019, carefully matched users with nonusers who had the same characteristics – for example, tobacco use or not.
This new information builds upon other meta-analyses that have demonstrated a decrease in birth weight and greater admittance to the neonatal ICU associated with cannabis use in pregnancy – and it supplements what some research suggests about long-term neurologic development and a potentially increased risk of attention and behavioral problems. Other outcomes that have been noted in long-term neurologic studies of children who were exposed to cannabis in utero include impaired visual acuity, verbal reasoning and comprehension, and short-term memory.2
Increases in use were recently documented in two studies. One, an analysis of data from the National Survey on Drug Use and Health (NSDUH) published in JAMA in June 2019, showed that, between 2002-2003 and 2016-2017, the use of cannabis “in the past month” increased from 3.4% to 7.0% among pregnant women overall, and from 6% to 12% during the first trimester.3
The use of cannabis on a daily or near-daily basis, moreover, increased from 0.9% to 3% among pregnant women overall and from 2% to 5% during the first trimester. The data were collected during face-to-face interviews and were adjusted for age, race/ethnicity, and family income.
In the second study – a cross-sectional study of 367,403 pregnancies among women who filled out a questionnaire on cannabis use during standard prenatal care at Kaiser Permanente Northern California – the adjusted prevalence of use in the year before pregnancy increased from 7% in 2009 to 13% in 2017, and the adjusted prevalence during pregnancy increased from 2% to 3%.4
As in the NSDUH analysis, daily use increased most rapidly (compared with weekly or monthly) such that, by 2017, 25% of those who reported using cannabis in the year before pregnancy – and 21% of those who used cannabis during pregnancy – were daily users. It is notable that Kaiser’s population is diverse in all respects, and that the annual relative rates of increase in cannabis use before and during pregnancy (at each level of frequency) were consistent across racial/ethnic and household income groups.
It’s also worth noting that, in earlier research covering a similar time period (2009-2016), the investigators found significant increases in use via urine toxicology testing that occurs at the first prenatal visit at Kaiser. The increase found through questionnaires, therefore, reflects more than a greater willingness to self-report.
Choosing a screening tool
Universal prenatal substance use screening is recommended by the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention, but we don’t have any specific recommendations on what this means. Who should be screening, and what should that screening look like? Should we use a biologic screen, a standardized screening tool, or simply ask patients whether they use illicit substances?
Screening tools seem advantageous in that they are low cost, noninvasive, potentially comprehensive, and not subject to false-positive results as biologic screens can be – but which tool or tools are best? There are several validated screening tools that can be used outside of pregnancy to determine an individual’s use of illicit substances and whether or not that use is problematic, but previous studies have not used biologic markers to validate substance use screeners in pregnancy. Nor have studies compared screeners in pregnancy.
In our prenatal population in Baltimore, we have not been getting the answers we want using various nonvalidated screening tools. Approximately 30% of patients are positive for cannabis by urine screen, but only half tell us about their use.
Through research in our two prenatal care practices (one serving mostly privately insured and the other serving primarily Medicaid-eligible patients), we assessed both the accuracy and the acceptability of three substance use screening tools that are brief and that have been validated (for the general population) by the World Health Organization for screening of multiple substances: the 4P’s Plus (Parents, Partner, Past, and Pregnancy), the National Institute on Drug Abuse Quick Screen–ASSIST (Modified Alcohol, Smoking and Substance Involvement Screening Test), and the SURP-P (Substance Use Risk Profile–Pregnancy) scale.
In one study, published in May 2019 in Obstetrics & Gynecology, we recruited 500 pregnant women and administered these three tests to each of them.5 We then compared results with those of urine and hair drug testing, and checked the test-retest reliability of each test by readministering them (albeit by telephone) a week later. Although hair testing is not an indicator of current substance use, we used it to validate the screening tools on less-recent use.
The tests with the highest sensitivity and negative predictive values – the qualities we most want for screening – were the SURP-P and the 4P’s Plus (sensitivity of 92.4% and 90.2%, respectively). Overall they were highly sensitive screening tools across all trimesters, races, and age groups, making them more ideal screening tests than the NIDA Quick Screen–ASSIST.
Of the two tests, the 4P’s Plus screening tool was the one preferred by staff from both practices. In a companion qualitative study, we conducted focus-group discussions with 40 practice staff who were responsible for administering or overseeing patient screening.6 The staff, who were unaware of the sensitivity findings, were asked what they thought about the acceptability to patients of each of the three tools and their usability in practice.
Most of the participating staff preferred the 4P’s Plus screening tool for several reasons: It is easy to understand, is brief and to the point, and it has nonjudgmental language and tone. The screener first asks the patient about her parents’ and her partner’s use of alcohol and drugs, and then asks the patient about her own use of alcohol and tobacco. Affirmative responses to these questions lead to additional questions.
The premise is that one’s genetics, history, and current exposures – as well as one’s own use of tobacco and alcohol – are significantly associated with the use of illicit substances. If the patient reports no parental history or partner usage, and has never drank or smoked before, it’s extremely unlikely that she is using other drugs. The progression of questions does indeed seem less judgmental than immediately asking: “Do you use drugs?”
For us, the insight from this staff perception study combined with the findings on accuracy mean that the 4P’s Plus may be the most useful and acceptable screening tool for routine use in prenatal care.
Talking with our patients
The increase in the use of cannabis before and after pregnancy parallels the movement toward state legalization and decriminalization. Historically, clinicians often have relied on illegality as their main focus of counseling when giving recommendations for cessation and abstinence in pregnancy.2 This approach not only leads to punitive counseling, which can fracture the doctor-patient relationship, but increasingly it is no longer valid. In our changing legal climate, we need to provide medically based counseling and be very clear with our patients that legalization does not equate to safety.
It is important that we neither minimize nor overstate the risks. The evidence base for adverse birth outcomes of cannabis use in pregnancy is quite robust, but the associations can be subtle and are moderated by other behaviors and environmental factors that continue to challenge researchers.
As with alcohol, there likely are dose-or trimester-dependent differences in perinatal outcomes, and it’s quite possible that different cannabis products and routes of consumption have different effects. At this point, however, we don’t know the full story, nor do we know the extent to which the literature is biased toward positive correlations – the reporting of adverse effects – compared with negative findings. It is our job as medical care providers to be comfortable in that gray area and to still counsel patients on what we do know, providing the best-possible medical advice based on the information available to us.
In talking with patients, I explain that cannabis may cause a spectrum of problems and that there certainly are risks. I also tell them that we’re uncertain about the conditions and magnitude of that risk and that some babies who are exposed to cannabis in utero may have no perceivable consequences. Such honesty is important for maintaining trust, especially as some patients may see friends and relatives who also are cannabis users have normal pregnancy outcomes.
Much of my concern about cannabis in pregnancy centers on its effect on the developing brain and on long-term neurologic development. I share this with patients – I tell them that cannabis crosses the placenta and may well affect their baby’s brain as it is developing. I explain that I do not know whether this effect would be big or small, but that it’s not a chance I’m willing to take for their baby.
It is also important to educate patients that cannabis products are untested and unregulated and that they may be contaminated with heavy metals, pesticides, and other toxins that may be harmful to themselves and their babies. Patients also should know that the potency of cannabis has been dramatically increasing; research shows that the tetrahydrocannabinol – the psychoactive component – concentration has tripled over the past 2 decades.7
Research tells us that women who use illicit drugs and alcohol categorically engage in some form of harm reduction once they learn they are pregnant, and the same is true for cannabis. This is seen in dramatically different rates of first- and third-trimester use in the new analysis of NSDUH data; third-trimester use is approximately halved.
Some women will not be able to discontinue use, however, or they may try to quit and fail in their attempts. As we should with substance use more broadly, we must meet patients where they are, view cannabis use as a chronic medical problem, offer our assistance in helping them reduce harms of their use, and understand that quitting is a process.
Screening for mental health disorders and trauma is, of course, especially important in patients who use cannabis and other substances recreationally. In cases of medical marijuana usage, I recommend, as ACOG and other have done, that we discuss the risks and benefits of continuing cannabis versus shifting to alternative medications if options exist.
All patients should be welcomed, congratulated on their pregnancy and on coming for prenatal care, and engaged in the overall process of optimizing their health and the health of their baby. Like any other health issue during pregnancy, cannabis use needs to be screened for and treated in an evidence-based manner, but it does not define the trajectory or success of a woman’s pregnancy or her ability to be a successful parent.
Dr. Mark is associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine.
References
1. JAMA. 2019 Jul 9;322(2):145-52.
2. Preventive Medicine 2017 May 18;104:46-9.
3. JAMA. 2019 Jul 9;322(2):167-9.
4. JAMA Netw Open. 2019 Jul 3;2(7):e196471.
5. Obstet Gynecol. 2019 May;133(5):952-61.
6. J. Addict Med. 2019 May 10. doi: 10.1097/ADM.0000000000000543.
7. Biol Psychiatry. 2016 Apr 1;79(7):613-9.
Moroccan Health Care: A Link to Radicalization and Proposed Solution
The relationship between the Kingdom of Morocco and the US began just after the US declared its own independence. It is one of the oldest of US partnerships with a foreign country, and since the end of the First Barbary War in 1805 it has remained one of the most stable. The Utah National Guard (UTNG) has an active state partnership program (SPP) with Morocco, which helps maintain that stability and fosters the relationship. The SPP provides the Kingdom of Morocco assistance in the areas of disaster medicine, prehospital medicine, and rural access to health care.
The objective of this review is to highlight the role the SPP plays in ensuring Morocco’s continued stability, enhancing its role as a leader among African nations, aiding its medically vulnerable rural populations to prevent recruitment by terrorist organizations, and maintaining its long-term relationship with the US.
Background
The Kingdom of Morocco resides in a geologically and politically unstable part of the world, yet it has been a stable constitutional monarchy. Like California, Morocco has a long coastline of more than 1,000 miles. It sits along an active earthquake fault line with a disaster response program that is only in its infancy. The Kingdom has a high youth unemployment rate and lacks adequate public education opportunities, which exacerbate feelings of government indifference. Morocco’s medical system is highly centralized, and large parts of the rural population lack access to basic medical care—potentially alienating the population. The Moroccan current disaster plan ORSEC (plan d’ Organization des Secours) was established in 1966 and updated in 2005 but does not provide a comprehensive, unified disaster response. The ORSEC plan is of French derivation and is not a list of actions but a general plan of organization and supply. 1
When governments fail to provide basic services—health care being just one—those services may be filled by groups seeking to influence the government and population by threatening acts of violence to achieve political, religious, and ideologic gain; for example, the Taliban in Afghanistan, the Muslim brotherhood in Egypt and in the West Bank, and the Islamic State in Iraq and Syria (ISIS) in Syria.2-5 These groups gain a foothold and legitimacy by providing mosques, youth groups, clinics, hospitals, and schools. 2-5
Identified Needs
Morocco is at risk of experiencing an earthquake and possible subsequent tsunami. In 1755, Morocco was impacted by the Great Lisbon earthquake and tsunami. Witnesses reported 15-meter waves with 24-meter crests.6 Building codes and architecture laws have changed little since the 1960 Agadir earthquake, which killed 12,000 people. The disaster response program—although improved since the 1960s—is still in the early stages of development, and another earthquake and possible subsequent tsunami would result in a disaster that could overwhelm the medical community of Morocco.
Perceived Government Indifference
The Moroccan constitutional monarchy is more stable than are the governments of its North African neighbors. King Mohammed VI presides over the government, and regular elections are held for members of Parliament, which names a prime minister. However, in August 2019, overall unemployment was at 8.5%, and youth unemployment was 22.3%.7 A United Nations report in August 2019 stated that literacy rates for Morocco were 71.7%. These data were from a 2015 census, the last year data were collected.8 These deficits in employment and education can foster anger toward the Moroccan government for not adequately providing these services and possibly introduce radicalization as a result of the population’s perceived government indifference and lack of economic mobility.
Access to Medical Care
Morocco has a 2-tiered medical system for providing services: urban and rural. In 2018 the Legatum Prosperity Index ranked Morocco 103 of 149 countries in health care. The prosperity index measures health variables, which include but were not limited to basic physical and mental health, health infrastructure, and preventive care.9 Outside the metropolitan areas, emergency medical care is nonexistent, primary care is sporadic, and there is little modern technology available.
Despite humanitarian efforts over many years, there is little to no medical care in the rural “medical desert.” A 2017 study from the University of Washington Institute for Health Metrics and Evaluation compared the global burden of disease in similar countries. The study found that Morocco was significantly higher than the mean in the prevalence of ischemic heart disease and Alzheimer disease, lower than the mean in the areas of neonatal disorders, lower respiratory infections, and tuberculosis, and statistically indistinct from the mean in stroke, congenital defects, road injuries, diabetes mellitus, and hypertensive heart disease compared with the disease prevalence of other countries of similar size and economic measures.10 The study also found a particularly acute disparity in access to health care in rural areas. In 2016, the Oxford Business Group reported staff shortages and disproportionate distribution of resources in the Moroccan health care system.11
Additionally, the lack of trained health care personnel has added to an already overstressed health care system. A chief stressor in a health care system is an insufficient replacement rate. Health employees working for the Moroccan Ministry of Health retire at a rate of 1,500 per year.10,11 These shortages may serve to further the feelings of frustration and government indifference. This frustration is momentarily decreased by humanitarian efforts that have taken place in the African continent in the past decades, but this band-aid approach to assisting the population that is medically underserved has done little to alleviate the long-term problem of access to care. And feelings of government abandonment can sow the seeds of discontent in the rural population, creating fertile ground for recruitment by terrorist organizations.2,3
Lack of Health Care and Radicalism
It has been postulated that there is a link between radicalization and lack of medical care. Depression and perceived government indifference are considered contributors to radicalization.12-16 In 2005, Victoroff suggested that there are certain psychological traits characteristic of “typical" terrorists: these include high affective valence regarding an ideologic issue, a personal stake (perceived oppression, persecution or humiliation, need for identity, glory, or vengeance), low cognitive ability, low tolerance for ambiguity, and a capacity to suppress instinctive and learned moral constraints against harming innocents.15 In 2009, Lafree and Ackerman suggested that terrorism feeds on the ability of groups to portray governments and their agents as illegitimate.16 It is possible that part of the illegitimacy campaign of radicalization and terrorist recruitment may be identification of the lack of health care by the government thus magnifying feelings of government abandonment in a vulnerable population.
In 2011, the new Moroccan constitution identified access to basic health care as a right of the Moroccan people.17 Additionally, in 2013, a government white paper was produced outlining the need to increase access to health care, particularly in rural areas, including a focus on infant and maternal mortality, diabetes mellitus (DM), heart disease, and respiratory problems.17,18
Proposed Solutions, A Beginning
A health outreach program with a regional health professional training center in a relatively stable country within the African Union (AU) would be a step toward delivering health care to Morocco and interested AU members. Interested nations have been and will continue to be invited to train at the Moroccan center and return to their countries and start training programs. This idea was echoed by the World Bank in a 2015 loan proposal to Morocco, which suggested that addressing disparities in access to health care is a social justice issue, with other benefits such as increased productivity, employment, lower out-of-pocket expenditures, and promotion of good governance.17
In 2012, Buhi reported that a positive regard for authorities and healthier influences seemed to be a protective factor against radicalization. He also suggested a public health approach to understanding and preventing violent radicalization.19 The solutions are complex, especially in rural areas and in vulnerable nations common to Africa.
Medical training efforts by the US Department of Defense (DoD), Medical Readiness Training Institute (DMRT), and international health specialists working with the military and civilian entities in neighboring African countries have improved response to regional disasters. However, to address the broader issues, a more permanent, cooperative possible solution may begin with the establishment in Morocco of a regional education center for disaster preparedness and for health care providers (HCPs). This would serve as a training program for disaster first responders. Graduates of the program would receive additional training to become HCPs similar to physician assistant (PA) and nurse practitioner (NP) programs in the US. Morocco is uniquely positioned to accomplish this due to its location, political stability, and ties with other African nations.
The goal of the Moroccan regional education center (within the King Mohammed V Hospital) is to bring together global health experts and increase the intellectual infrastructure of not only Morocco, but also offer this training program to interested countries within the AU. Advancement of the regional education center will require legislative changes to expand prescriptive privileges and scope of practice within each country. The medical element of the SPP as presently constituted without the regional education center will continue its humanitarian goals, but the proposed creation of the regional education center will educate participants to serve the rural communities within each participating country. Eventually the entire educational program will be the responsibility of the Moroccan military and the AU participants. This will require reprioritizing resources from the provision of humanitarian health care services to an HCP education approach.
Disaster Response
Deficits in disaster response capabilities have been identified by members of the Moroccan military with the assistance of the UTNG. The most glaring deficit identified was the disparity in training between military and civilian first responders. Thus, a training program was initiated by the Moroccan military and the UTNG that combined internationally recognized, durable, robust emergency training programs. These programs consisted of, but were not limited to, parts or entire programs of the following: basic disaster life support, advanced disaster life support, disaster casualty care, and advanced trauma life support. The goal of this training was to improve communication, reduce mortality, and create strike teams, which can quickly provide health care independent of a hospital during a disaster.
Patients can overwhelm hospitals in a disaster when need exceeds resources. In 1996, Mallonee reported that at least 67% of the patients who sought care at a hospital during the Oklahoma City bombing disaster did not need advanced medical treatment.20 Such patients could be seen at an identified casualty collection point by a strike team and treated and released rather than traveling to the hospital and using staff and resources that could be used more judiciously for the more seriously injured.21 These teams consist of trained first responders with an experienced HCP (physician, PA, NP) and a nurse and are trained to operate for up to 72 hours in a predetermined location and serve as a “filter” for the hospital. Their role is to treat and release the less severely injured and refer only the more severely injured to the hospital after basic stabilization, thus preserving precious resources necessary for the more seriously injured.
This disaster response training program was offered to the Moroccan military, ministry of health and ministry of tourism, and quickly turned into an Africa-wide interest. A regional training center was proposed. This was assisted with the cooperation of Weber State University in Ogden Utah, Utah Valley University in Orem, and private interests in a public/private/military state partnership. Program supplies and didactic instruction were and will be provided by the UTNG and supplemented through the DoD Africa command. Instruction will be a cooperative effort agreed on between the UTNG and the Moroccan military medical specialists within their specific area of expertise.
Underserved Communities
Finally, from this pool of interested strike team members, a health care provider school will be formed to educate, certify, and service the needs of the underserved communities in Morocco and interested AU countries. This program will be similar to the PA and NP programs in the US and will be geared to those graduates from the previous programs with intense classroom instruction for one year followed by a year of one-on-one preceptorship with an experienced physician. The goal of the program is to prepare individuals with patient care experience to fulfill a bigger role in health care in an underserved (usually austere, rural) area that currently has minimal health care presence. This fills a need identified by the World Bank in 2015 that the Moroccan government needs to respond to the demand for improved access to and quality of health care services—particularly to the rural poor.17
The Moroccan military has a presence in many medically underserved areas. The logical fit for the HCP program will be drawn from a pool of active-duty military individuals who express an interest and qualify through attendance in all phases of the training.
Conclusion
This program of disaster medical education, strike teams, and HCPs is currently training more than 200 students a year throughout Morocco. The proposed direction of this cooperative program to produce HCPs in rural areas will increase access to health care for the Moroccan people who are now underserved. Morocco, as a health care training hub in Africa, will increase access to health care for interested African countries. The goal politically will be to reduce feelings of government indifference in vulnerable populations and reduce recruitment into radical ideologies.
1. Nahon M, Michaloux M. L’organisation de la réponse de la sécurité civile: le dispositif ORSEC Organisation of civilian emergency services: The ORSEC plan. https://www.sciencedirect.com/science/article/pii/S2211423816300499#! Published July 2016. Accessed October 7, 2019.
2. Berman E. Hamas, Taliban and the Jewish underground: an economist's view of radical religious militias. NBER Working Paper No. w10004. https://ssrn.com/abstract=450885. Published September 2003. Accessed October 7, 2019.
3. Jordan J. Attacking the leader. Missing the mark; why terrorist groups survive decapitation strikes. Int Secur. 2014;38(4):7-38.
4. Grynkewich A. Welfare as warfare: how violent non-state groups use social services to attack the state. Stud Conflict Terrorism. 2008;31(4):350-370.
5. Marin M, Solomon H. Islamic State: understanding the nature of the beast and its funding. Contemp Rev Middle East. 2017;4(1):18-49.
6. Bressan D. November 1, 1755: the earthquake of Lisbon: wrath of god or natural disaster? Scientific American, History of Geology. https://blogs.scientificamerican.com/history-of-geology/november-1-1755-the-earthquake-of-lisbon-wraith-of-god-or-natural-disaster. Published November 2011. Accessed October 7, 2019.
7. Trading Economics. Morocco unemployment rate. Second quarter statistics. August 2019. https://tradingeconomics.com/morocco/unemployment-rate. Accessed October 7, 2019.
8. Knoema World Data Atlas 2015. Morocco adult literacy rates. https://knoema.com/atlas/Morocco/topics/Education/Literacy/Adult-literacy-rate. Accessed October 4, 2019.
9. The Legatum Prosperity Index 2018. Morocco. https://www.prosperity.com/globe/morocco. Accessed October 7, 2019.
10. University of Washington, Institute for Health Metrics and Evaluation. Morocco. http://www.healthdata.org/morocco. Published 2018. Accessed October 7, 2019.
11. Oxford Business Group. Access to health care broadens in Morocco. https://oxfordbusinessgroup.com/overview/forward-steps-access-care-has-broadened-and-infrastructure-improved-challenges-remain. Accessed September 12. 2019.
12. Wright NMJ, Hankins FM. Preventing radicalization and terrorism: Is there a GP response? Br J Gen Pract. 2016;66(647):288-289.
13. Buhi K, Everitt K, Jones E. Might depression psychosocial adversity, and limited social assets explain vulnerability to and resistance against violent radicalization? PlosOne. 2014;9(9):e105918.
14. DeAngelis T. Understanding terrorism. apa.org/monitor/2009/11/terrorism. Published November 2009. Accessed October 14, 2019.
15. Victoroff J. The mind of the terrorist: a review and critique of psychological approaches. J Conflict Resolut. 2005;49(1):3-42.
16. Lafree G, Ackerman G. The empirical study of terrorism: social and legal research. Ann Rev Law Soc Sci. 2009;5:347-374.
17. World Bank. Morocco—improving primary health in rural areas program-for-results project (English). http://documents.worldbank.org/curated/en/716821468274482723/Morocco-Improving-Primary-Health-in-Rural-Areas-Program-for-Results-Project. Published 2015. Accessed September 16, 2019.
18. Royaume du Maroc, Ministère de la Santé. Livre blanc: pour une nouvelle gouvernance du secteur de la santé. Paper presented at: 2nd National Health Conference; July 1-3, 2013; Marrakesh, Morocco.
19. Buhi K, Hicks MH, Lashley M, Jones E. A public health approach to understanding and preventing violent radicalization. BMC Med. 2012;10:16.
20. Mallonee S, Sahriat S, Stennies G, Waxweiler R, Hogan D, Jordan F. Physical injuries and fatalities resulting from the Oklahoma City bombing. JAMA. 1996;276(5):382-387.
21. Ushizawa H, Foxwell AR, Bice S, et al. Needs for disaster medicine: lessons from the field of the Great East Japan Earthquake. Western Pac Surveil Response J. 2013;4(1):51-55.
The relationship between the Kingdom of Morocco and the US began just after the US declared its own independence. It is one of the oldest of US partnerships with a foreign country, and since the end of the First Barbary War in 1805 it has remained one of the most stable. The Utah National Guard (UTNG) has an active state partnership program (SPP) with Morocco, which helps maintain that stability and fosters the relationship. The SPP provides the Kingdom of Morocco assistance in the areas of disaster medicine, prehospital medicine, and rural access to health care.
The objective of this review is to highlight the role the SPP plays in ensuring Morocco’s continued stability, enhancing its role as a leader among African nations, aiding its medically vulnerable rural populations to prevent recruitment by terrorist organizations, and maintaining its long-term relationship with the US.
Background
The Kingdom of Morocco resides in a geologically and politically unstable part of the world, yet it has been a stable constitutional monarchy. Like California, Morocco has a long coastline of more than 1,000 miles. It sits along an active earthquake fault line with a disaster response program that is only in its infancy. The Kingdom has a high youth unemployment rate and lacks adequate public education opportunities, which exacerbate feelings of government indifference. Morocco’s medical system is highly centralized, and large parts of the rural population lack access to basic medical care—potentially alienating the population. The Moroccan current disaster plan ORSEC (plan d’ Organization des Secours) was established in 1966 and updated in 2005 but does not provide a comprehensive, unified disaster response. The ORSEC plan is of French derivation and is not a list of actions but a general plan of organization and supply. 1
When governments fail to provide basic services—health care being just one—those services may be filled by groups seeking to influence the government and population by threatening acts of violence to achieve political, religious, and ideologic gain; for example, the Taliban in Afghanistan, the Muslim brotherhood in Egypt and in the West Bank, and the Islamic State in Iraq and Syria (ISIS) in Syria.2-5 These groups gain a foothold and legitimacy by providing mosques, youth groups, clinics, hospitals, and schools. 2-5
Identified Needs
Morocco is at risk of experiencing an earthquake and possible subsequent tsunami. In 1755, Morocco was impacted by the Great Lisbon earthquake and tsunami. Witnesses reported 15-meter waves with 24-meter crests.6 Building codes and architecture laws have changed little since the 1960 Agadir earthquake, which killed 12,000 people. The disaster response program—although improved since the 1960s—is still in the early stages of development, and another earthquake and possible subsequent tsunami would result in a disaster that could overwhelm the medical community of Morocco.
Perceived Government Indifference
The Moroccan constitutional monarchy is more stable than are the governments of its North African neighbors. King Mohammed VI presides over the government, and regular elections are held for members of Parliament, which names a prime minister. However, in August 2019, overall unemployment was at 8.5%, and youth unemployment was 22.3%.7 A United Nations report in August 2019 stated that literacy rates for Morocco were 71.7%. These data were from a 2015 census, the last year data were collected.8 These deficits in employment and education can foster anger toward the Moroccan government for not adequately providing these services and possibly introduce radicalization as a result of the population’s perceived government indifference and lack of economic mobility.
Access to Medical Care
Morocco has a 2-tiered medical system for providing services: urban and rural. In 2018 the Legatum Prosperity Index ranked Morocco 103 of 149 countries in health care. The prosperity index measures health variables, which include but were not limited to basic physical and mental health, health infrastructure, and preventive care.9 Outside the metropolitan areas, emergency medical care is nonexistent, primary care is sporadic, and there is little modern technology available.
Despite humanitarian efforts over many years, there is little to no medical care in the rural “medical desert.” A 2017 study from the University of Washington Institute for Health Metrics and Evaluation compared the global burden of disease in similar countries. The study found that Morocco was significantly higher than the mean in the prevalence of ischemic heart disease and Alzheimer disease, lower than the mean in the areas of neonatal disorders, lower respiratory infections, and tuberculosis, and statistically indistinct from the mean in stroke, congenital defects, road injuries, diabetes mellitus, and hypertensive heart disease compared with the disease prevalence of other countries of similar size and economic measures.10 The study also found a particularly acute disparity in access to health care in rural areas. In 2016, the Oxford Business Group reported staff shortages and disproportionate distribution of resources in the Moroccan health care system.11
Additionally, the lack of trained health care personnel has added to an already overstressed health care system. A chief stressor in a health care system is an insufficient replacement rate. Health employees working for the Moroccan Ministry of Health retire at a rate of 1,500 per year.10,11 These shortages may serve to further the feelings of frustration and government indifference. This frustration is momentarily decreased by humanitarian efforts that have taken place in the African continent in the past decades, but this band-aid approach to assisting the population that is medically underserved has done little to alleviate the long-term problem of access to care. And feelings of government abandonment can sow the seeds of discontent in the rural population, creating fertile ground for recruitment by terrorist organizations.2,3
Lack of Health Care and Radicalism
It has been postulated that there is a link between radicalization and lack of medical care. Depression and perceived government indifference are considered contributors to radicalization.12-16 In 2005, Victoroff suggested that there are certain psychological traits characteristic of “typical" terrorists: these include high affective valence regarding an ideologic issue, a personal stake (perceived oppression, persecution or humiliation, need for identity, glory, or vengeance), low cognitive ability, low tolerance for ambiguity, and a capacity to suppress instinctive and learned moral constraints against harming innocents.15 In 2009, Lafree and Ackerman suggested that terrorism feeds on the ability of groups to portray governments and their agents as illegitimate.16 It is possible that part of the illegitimacy campaign of radicalization and terrorist recruitment may be identification of the lack of health care by the government thus magnifying feelings of government abandonment in a vulnerable population.
In 2011, the new Moroccan constitution identified access to basic health care as a right of the Moroccan people.17 Additionally, in 2013, a government white paper was produced outlining the need to increase access to health care, particularly in rural areas, including a focus on infant and maternal mortality, diabetes mellitus (DM), heart disease, and respiratory problems.17,18
Proposed Solutions, A Beginning
A health outreach program with a regional health professional training center in a relatively stable country within the African Union (AU) would be a step toward delivering health care to Morocco and interested AU members. Interested nations have been and will continue to be invited to train at the Moroccan center and return to their countries and start training programs. This idea was echoed by the World Bank in a 2015 loan proposal to Morocco, which suggested that addressing disparities in access to health care is a social justice issue, with other benefits such as increased productivity, employment, lower out-of-pocket expenditures, and promotion of good governance.17
In 2012, Buhi reported that a positive regard for authorities and healthier influences seemed to be a protective factor against radicalization. He also suggested a public health approach to understanding and preventing violent radicalization.19 The solutions are complex, especially in rural areas and in vulnerable nations common to Africa.
Medical training efforts by the US Department of Defense (DoD), Medical Readiness Training Institute (DMRT), and international health specialists working with the military and civilian entities in neighboring African countries have improved response to regional disasters. However, to address the broader issues, a more permanent, cooperative possible solution may begin with the establishment in Morocco of a regional education center for disaster preparedness and for health care providers (HCPs). This would serve as a training program for disaster first responders. Graduates of the program would receive additional training to become HCPs similar to physician assistant (PA) and nurse practitioner (NP) programs in the US. Morocco is uniquely positioned to accomplish this due to its location, political stability, and ties with other African nations.
The goal of the Moroccan regional education center (within the King Mohammed V Hospital) is to bring together global health experts and increase the intellectual infrastructure of not only Morocco, but also offer this training program to interested countries within the AU. Advancement of the regional education center will require legislative changes to expand prescriptive privileges and scope of practice within each country. The medical element of the SPP as presently constituted without the regional education center will continue its humanitarian goals, but the proposed creation of the regional education center will educate participants to serve the rural communities within each participating country. Eventually the entire educational program will be the responsibility of the Moroccan military and the AU participants. This will require reprioritizing resources from the provision of humanitarian health care services to an HCP education approach.
Disaster Response
Deficits in disaster response capabilities have been identified by members of the Moroccan military with the assistance of the UTNG. The most glaring deficit identified was the disparity in training between military and civilian first responders. Thus, a training program was initiated by the Moroccan military and the UTNG that combined internationally recognized, durable, robust emergency training programs. These programs consisted of, but were not limited to, parts or entire programs of the following: basic disaster life support, advanced disaster life support, disaster casualty care, and advanced trauma life support. The goal of this training was to improve communication, reduce mortality, and create strike teams, which can quickly provide health care independent of a hospital during a disaster.
Patients can overwhelm hospitals in a disaster when need exceeds resources. In 1996, Mallonee reported that at least 67% of the patients who sought care at a hospital during the Oklahoma City bombing disaster did not need advanced medical treatment.20 Such patients could be seen at an identified casualty collection point by a strike team and treated and released rather than traveling to the hospital and using staff and resources that could be used more judiciously for the more seriously injured.21 These teams consist of trained first responders with an experienced HCP (physician, PA, NP) and a nurse and are trained to operate for up to 72 hours in a predetermined location and serve as a “filter” for the hospital. Their role is to treat and release the less severely injured and refer only the more severely injured to the hospital after basic stabilization, thus preserving precious resources necessary for the more seriously injured.
This disaster response training program was offered to the Moroccan military, ministry of health and ministry of tourism, and quickly turned into an Africa-wide interest. A regional training center was proposed. This was assisted with the cooperation of Weber State University in Ogden Utah, Utah Valley University in Orem, and private interests in a public/private/military state partnership. Program supplies and didactic instruction were and will be provided by the UTNG and supplemented through the DoD Africa command. Instruction will be a cooperative effort agreed on between the UTNG and the Moroccan military medical specialists within their specific area of expertise.
Underserved Communities
Finally, from this pool of interested strike team members, a health care provider school will be formed to educate, certify, and service the needs of the underserved communities in Morocco and interested AU countries. This program will be similar to the PA and NP programs in the US and will be geared to those graduates from the previous programs with intense classroom instruction for one year followed by a year of one-on-one preceptorship with an experienced physician. The goal of the program is to prepare individuals with patient care experience to fulfill a bigger role in health care in an underserved (usually austere, rural) area that currently has minimal health care presence. This fills a need identified by the World Bank in 2015 that the Moroccan government needs to respond to the demand for improved access to and quality of health care services—particularly to the rural poor.17
The Moroccan military has a presence in many medically underserved areas. The logical fit for the HCP program will be drawn from a pool of active-duty military individuals who express an interest and qualify through attendance in all phases of the training.
Conclusion
This program of disaster medical education, strike teams, and HCPs is currently training more than 200 students a year throughout Morocco. The proposed direction of this cooperative program to produce HCPs in rural areas will increase access to health care for the Moroccan people who are now underserved. Morocco, as a health care training hub in Africa, will increase access to health care for interested African countries. The goal politically will be to reduce feelings of government indifference in vulnerable populations and reduce recruitment into radical ideologies.
The relationship between the Kingdom of Morocco and the US began just after the US declared its own independence. It is one of the oldest of US partnerships with a foreign country, and since the end of the First Barbary War in 1805 it has remained one of the most stable. The Utah National Guard (UTNG) has an active state partnership program (SPP) with Morocco, which helps maintain that stability and fosters the relationship. The SPP provides the Kingdom of Morocco assistance in the areas of disaster medicine, prehospital medicine, and rural access to health care.
The objective of this review is to highlight the role the SPP plays in ensuring Morocco’s continued stability, enhancing its role as a leader among African nations, aiding its medically vulnerable rural populations to prevent recruitment by terrorist organizations, and maintaining its long-term relationship with the US.
Background
The Kingdom of Morocco resides in a geologically and politically unstable part of the world, yet it has been a stable constitutional monarchy. Like California, Morocco has a long coastline of more than 1,000 miles. It sits along an active earthquake fault line with a disaster response program that is only in its infancy. The Kingdom has a high youth unemployment rate and lacks adequate public education opportunities, which exacerbate feelings of government indifference. Morocco’s medical system is highly centralized, and large parts of the rural population lack access to basic medical care—potentially alienating the population. The Moroccan current disaster plan ORSEC (plan d’ Organization des Secours) was established in 1966 and updated in 2005 but does not provide a comprehensive, unified disaster response. The ORSEC plan is of French derivation and is not a list of actions but a general plan of organization and supply. 1
When governments fail to provide basic services—health care being just one—those services may be filled by groups seeking to influence the government and population by threatening acts of violence to achieve political, religious, and ideologic gain; for example, the Taliban in Afghanistan, the Muslim brotherhood in Egypt and in the West Bank, and the Islamic State in Iraq and Syria (ISIS) in Syria.2-5 These groups gain a foothold and legitimacy by providing mosques, youth groups, clinics, hospitals, and schools. 2-5
Identified Needs
Morocco is at risk of experiencing an earthquake and possible subsequent tsunami. In 1755, Morocco was impacted by the Great Lisbon earthquake and tsunami. Witnesses reported 15-meter waves with 24-meter crests.6 Building codes and architecture laws have changed little since the 1960 Agadir earthquake, which killed 12,000 people. The disaster response program—although improved since the 1960s—is still in the early stages of development, and another earthquake and possible subsequent tsunami would result in a disaster that could overwhelm the medical community of Morocco.
Perceived Government Indifference
The Moroccan constitutional monarchy is more stable than are the governments of its North African neighbors. King Mohammed VI presides over the government, and regular elections are held for members of Parliament, which names a prime minister. However, in August 2019, overall unemployment was at 8.5%, and youth unemployment was 22.3%.7 A United Nations report in August 2019 stated that literacy rates for Morocco were 71.7%. These data were from a 2015 census, the last year data were collected.8 These deficits in employment and education can foster anger toward the Moroccan government for not adequately providing these services and possibly introduce radicalization as a result of the population’s perceived government indifference and lack of economic mobility.
Access to Medical Care
Morocco has a 2-tiered medical system for providing services: urban and rural. In 2018 the Legatum Prosperity Index ranked Morocco 103 of 149 countries in health care. The prosperity index measures health variables, which include but were not limited to basic physical and mental health, health infrastructure, and preventive care.9 Outside the metropolitan areas, emergency medical care is nonexistent, primary care is sporadic, and there is little modern technology available.
Despite humanitarian efforts over many years, there is little to no medical care in the rural “medical desert.” A 2017 study from the University of Washington Institute for Health Metrics and Evaluation compared the global burden of disease in similar countries. The study found that Morocco was significantly higher than the mean in the prevalence of ischemic heart disease and Alzheimer disease, lower than the mean in the areas of neonatal disorders, lower respiratory infections, and tuberculosis, and statistically indistinct from the mean in stroke, congenital defects, road injuries, diabetes mellitus, and hypertensive heart disease compared with the disease prevalence of other countries of similar size and economic measures.10 The study also found a particularly acute disparity in access to health care in rural areas. In 2016, the Oxford Business Group reported staff shortages and disproportionate distribution of resources in the Moroccan health care system.11
Additionally, the lack of trained health care personnel has added to an already overstressed health care system. A chief stressor in a health care system is an insufficient replacement rate. Health employees working for the Moroccan Ministry of Health retire at a rate of 1,500 per year.10,11 These shortages may serve to further the feelings of frustration and government indifference. This frustration is momentarily decreased by humanitarian efforts that have taken place in the African continent in the past decades, but this band-aid approach to assisting the population that is medically underserved has done little to alleviate the long-term problem of access to care. And feelings of government abandonment can sow the seeds of discontent in the rural population, creating fertile ground for recruitment by terrorist organizations.2,3
Lack of Health Care and Radicalism
It has been postulated that there is a link between radicalization and lack of medical care. Depression and perceived government indifference are considered contributors to radicalization.12-16 In 2005, Victoroff suggested that there are certain psychological traits characteristic of “typical" terrorists: these include high affective valence regarding an ideologic issue, a personal stake (perceived oppression, persecution or humiliation, need for identity, glory, or vengeance), low cognitive ability, low tolerance for ambiguity, and a capacity to suppress instinctive and learned moral constraints against harming innocents.15 In 2009, Lafree and Ackerman suggested that terrorism feeds on the ability of groups to portray governments and their agents as illegitimate.16 It is possible that part of the illegitimacy campaign of radicalization and terrorist recruitment may be identification of the lack of health care by the government thus magnifying feelings of government abandonment in a vulnerable population.
In 2011, the new Moroccan constitution identified access to basic health care as a right of the Moroccan people.17 Additionally, in 2013, a government white paper was produced outlining the need to increase access to health care, particularly in rural areas, including a focus on infant and maternal mortality, diabetes mellitus (DM), heart disease, and respiratory problems.17,18
Proposed Solutions, A Beginning
A health outreach program with a regional health professional training center in a relatively stable country within the African Union (AU) would be a step toward delivering health care to Morocco and interested AU members. Interested nations have been and will continue to be invited to train at the Moroccan center and return to their countries and start training programs. This idea was echoed by the World Bank in a 2015 loan proposal to Morocco, which suggested that addressing disparities in access to health care is a social justice issue, with other benefits such as increased productivity, employment, lower out-of-pocket expenditures, and promotion of good governance.17
In 2012, Buhi reported that a positive regard for authorities and healthier influences seemed to be a protective factor against radicalization. He also suggested a public health approach to understanding and preventing violent radicalization.19 The solutions are complex, especially in rural areas and in vulnerable nations common to Africa.
Medical training efforts by the US Department of Defense (DoD), Medical Readiness Training Institute (DMRT), and international health specialists working with the military and civilian entities in neighboring African countries have improved response to regional disasters. However, to address the broader issues, a more permanent, cooperative possible solution may begin with the establishment in Morocco of a regional education center for disaster preparedness and for health care providers (HCPs). This would serve as a training program for disaster first responders. Graduates of the program would receive additional training to become HCPs similar to physician assistant (PA) and nurse practitioner (NP) programs in the US. Morocco is uniquely positioned to accomplish this due to its location, political stability, and ties with other African nations.
The goal of the Moroccan regional education center (within the King Mohammed V Hospital) is to bring together global health experts and increase the intellectual infrastructure of not only Morocco, but also offer this training program to interested countries within the AU. Advancement of the regional education center will require legislative changes to expand prescriptive privileges and scope of practice within each country. The medical element of the SPP as presently constituted without the regional education center will continue its humanitarian goals, but the proposed creation of the regional education center will educate participants to serve the rural communities within each participating country. Eventually the entire educational program will be the responsibility of the Moroccan military and the AU participants. This will require reprioritizing resources from the provision of humanitarian health care services to an HCP education approach.
Disaster Response
Deficits in disaster response capabilities have been identified by members of the Moroccan military with the assistance of the UTNG. The most glaring deficit identified was the disparity in training between military and civilian first responders. Thus, a training program was initiated by the Moroccan military and the UTNG that combined internationally recognized, durable, robust emergency training programs. These programs consisted of, but were not limited to, parts or entire programs of the following: basic disaster life support, advanced disaster life support, disaster casualty care, and advanced trauma life support. The goal of this training was to improve communication, reduce mortality, and create strike teams, which can quickly provide health care independent of a hospital during a disaster.
Patients can overwhelm hospitals in a disaster when need exceeds resources. In 1996, Mallonee reported that at least 67% of the patients who sought care at a hospital during the Oklahoma City bombing disaster did not need advanced medical treatment.20 Such patients could be seen at an identified casualty collection point by a strike team and treated and released rather than traveling to the hospital and using staff and resources that could be used more judiciously for the more seriously injured.21 These teams consist of trained first responders with an experienced HCP (physician, PA, NP) and a nurse and are trained to operate for up to 72 hours in a predetermined location and serve as a “filter” for the hospital. Their role is to treat and release the less severely injured and refer only the more severely injured to the hospital after basic stabilization, thus preserving precious resources necessary for the more seriously injured.
This disaster response training program was offered to the Moroccan military, ministry of health and ministry of tourism, and quickly turned into an Africa-wide interest. A regional training center was proposed. This was assisted with the cooperation of Weber State University in Ogden Utah, Utah Valley University in Orem, and private interests in a public/private/military state partnership. Program supplies and didactic instruction were and will be provided by the UTNG and supplemented through the DoD Africa command. Instruction will be a cooperative effort agreed on between the UTNG and the Moroccan military medical specialists within their specific area of expertise.
Underserved Communities
Finally, from this pool of interested strike team members, a health care provider school will be formed to educate, certify, and service the needs of the underserved communities in Morocco and interested AU countries. This program will be similar to the PA and NP programs in the US and will be geared to those graduates from the previous programs with intense classroom instruction for one year followed by a year of one-on-one preceptorship with an experienced physician. The goal of the program is to prepare individuals with patient care experience to fulfill a bigger role in health care in an underserved (usually austere, rural) area that currently has minimal health care presence. This fills a need identified by the World Bank in 2015 that the Moroccan government needs to respond to the demand for improved access to and quality of health care services—particularly to the rural poor.17
The Moroccan military has a presence in many medically underserved areas. The logical fit for the HCP program will be drawn from a pool of active-duty military individuals who express an interest and qualify through attendance in all phases of the training.
Conclusion
This program of disaster medical education, strike teams, and HCPs is currently training more than 200 students a year throughout Morocco. The proposed direction of this cooperative program to produce HCPs in rural areas will increase access to health care for the Moroccan people who are now underserved. Morocco, as a health care training hub in Africa, will increase access to health care for interested African countries. The goal politically will be to reduce feelings of government indifference in vulnerable populations and reduce recruitment into radical ideologies.
1. Nahon M, Michaloux M. L’organisation de la réponse de la sécurité civile: le dispositif ORSEC Organisation of civilian emergency services: The ORSEC plan. https://www.sciencedirect.com/science/article/pii/S2211423816300499#! Published July 2016. Accessed October 7, 2019.
2. Berman E. Hamas, Taliban and the Jewish underground: an economist's view of radical religious militias. NBER Working Paper No. w10004. https://ssrn.com/abstract=450885. Published September 2003. Accessed October 7, 2019.
3. Jordan J. Attacking the leader. Missing the mark; why terrorist groups survive decapitation strikes. Int Secur. 2014;38(4):7-38.
4. Grynkewich A. Welfare as warfare: how violent non-state groups use social services to attack the state. Stud Conflict Terrorism. 2008;31(4):350-370.
5. Marin M, Solomon H. Islamic State: understanding the nature of the beast and its funding. Contemp Rev Middle East. 2017;4(1):18-49.
6. Bressan D. November 1, 1755: the earthquake of Lisbon: wrath of god or natural disaster? Scientific American, History of Geology. https://blogs.scientificamerican.com/history-of-geology/november-1-1755-the-earthquake-of-lisbon-wraith-of-god-or-natural-disaster. Published November 2011. Accessed October 7, 2019.
7. Trading Economics. Morocco unemployment rate. Second quarter statistics. August 2019. https://tradingeconomics.com/morocco/unemployment-rate. Accessed October 7, 2019.
8. Knoema World Data Atlas 2015. Morocco adult literacy rates. https://knoema.com/atlas/Morocco/topics/Education/Literacy/Adult-literacy-rate. Accessed October 4, 2019.
9. The Legatum Prosperity Index 2018. Morocco. https://www.prosperity.com/globe/morocco. Accessed October 7, 2019.
10. University of Washington, Institute for Health Metrics and Evaluation. Morocco. http://www.healthdata.org/morocco. Published 2018. Accessed October 7, 2019.
11. Oxford Business Group. Access to health care broadens in Morocco. https://oxfordbusinessgroup.com/overview/forward-steps-access-care-has-broadened-and-infrastructure-improved-challenges-remain. Accessed September 12. 2019.
12. Wright NMJ, Hankins FM. Preventing radicalization and terrorism: Is there a GP response? Br J Gen Pract. 2016;66(647):288-289.
13. Buhi K, Everitt K, Jones E. Might depression psychosocial adversity, and limited social assets explain vulnerability to and resistance against violent radicalization? PlosOne. 2014;9(9):e105918.
14. DeAngelis T. Understanding terrorism. apa.org/monitor/2009/11/terrorism. Published November 2009. Accessed October 14, 2019.
15. Victoroff J. The mind of the terrorist: a review and critique of psychological approaches. J Conflict Resolut. 2005;49(1):3-42.
16. Lafree G, Ackerman G. The empirical study of terrorism: social and legal research. Ann Rev Law Soc Sci. 2009;5:347-374.
17. World Bank. Morocco—improving primary health in rural areas program-for-results project (English). http://documents.worldbank.org/curated/en/716821468274482723/Morocco-Improving-Primary-Health-in-Rural-Areas-Program-for-Results-Project. Published 2015. Accessed September 16, 2019.
18. Royaume du Maroc, Ministère de la Santé. Livre blanc: pour une nouvelle gouvernance du secteur de la santé. Paper presented at: 2nd National Health Conference; July 1-3, 2013; Marrakesh, Morocco.
19. Buhi K, Hicks MH, Lashley M, Jones E. A public health approach to understanding and preventing violent radicalization. BMC Med. 2012;10:16.
20. Mallonee S, Sahriat S, Stennies G, Waxweiler R, Hogan D, Jordan F. Physical injuries and fatalities resulting from the Oklahoma City bombing. JAMA. 1996;276(5):382-387.
21. Ushizawa H, Foxwell AR, Bice S, et al. Needs for disaster medicine: lessons from the field of the Great East Japan Earthquake. Western Pac Surveil Response J. 2013;4(1):51-55.
1. Nahon M, Michaloux M. L’organisation de la réponse de la sécurité civile: le dispositif ORSEC Organisation of civilian emergency services: The ORSEC plan. https://www.sciencedirect.com/science/article/pii/S2211423816300499#! Published July 2016. Accessed October 7, 2019.
2. Berman E. Hamas, Taliban and the Jewish underground: an economist's view of radical religious militias. NBER Working Paper No. w10004. https://ssrn.com/abstract=450885. Published September 2003. Accessed October 7, 2019.
3. Jordan J. Attacking the leader. Missing the mark; why terrorist groups survive decapitation strikes. Int Secur. 2014;38(4):7-38.
4. Grynkewich A. Welfare as warfare: how violent non-state groups use social services to attack the state. Stud Conflict Terrorism. 2008;31(4):350-370.
5. Marin M, Solomon H. Islamic State: understanding the nature of the beast and its funding. Contemp Rev Middle East. 2017;4(1):18-49.
6. Bressan D. November 1, 1755: the earthquake of Lisbon: wrath of god or natural disaster? Scientific American, History of Geology. https://blogs.scientificamerican.com/history-of-geology/november-1-1755-the-earthquake-of-lisbon-wraith-of-god-or-natural-disaster. Published November 2011. Accessed October 7, 2019.
7. Trading Economics. Morocco unemployment rate. Second quarter statistics. August 2019. https://tradingeconomics.com/morocco/unemployment-rate. Accessed October 7, 2019.
8. Knoema World Data Atlas 2015. Morocco adult literacy rates. https://knoema.com/atlas/Morocco/topics/Education/Literacy/Adult-literacy-rate. Accessed October 4, 2019.
9. The Legatum Prosperity Index 2018. Morocco. https://www.prosperity.com/globe/morocco. Accessed October 7, 2019.
10. University of Washington, Institute for Health Metrics and Evaluation. Morocco. http://www.healthdata.org/morocco. Published 2018. Accessed October 7, 2019.
11. Oxford Business Group. Access to health care broadens in Morocco. https://oxfordbusinessgroup.com/overview/forward-steps-access-care-has-broadened-and-infrastructure-improved-challenges-remain. Accessed September 12. 2019.
12. Wright NMJ, Hankins FM. Preventing radicalization and terrorism: Is there a GP response? Br J Gen Pract. 2016;66(647):288-289.
13. Buhi K, Everitt K, Jones E. Might depression psychosocial adversity, and limited social assets explain vulnerability to and resistance against violent radicalization? PlosOne. 2014;9(9):e105918.
14. DeAngelis T. Understanding terrorism. apa.org/monitor/2009/11/terrorism. Published November 2009. Accessed October 14, 2019.
15. Victoroff J. The mind of the terrorist: a review and critique of psychological approaches. J Conflict Resolut. 2005;49(1):3-42.
16. Lafree G, Ackerman G. The empirical study of terrorism: social and legal research. Ann Rev Law Soc Sci. 2009;5:347-374.
17. World Bank. Morocco—improving primary health in rural areas program-for-results project (English). http://documents.worldbank.org/curated/en/716821468274482723/Morocco-Improving-Primary-Health-in-Rural-Areas-Program-for-Results-Project. Published 2015. Accessed September 16, 2019.
18. Royaume du Maroc, Ministère de la Santé. Livre blanc: pour une nouvelle gouvernance du secteur de la santé. Paper presented at: 2nd National Health Conference; July 1-3, 2013; Marrakesh, Morocco.
19. Buhi K, Hicks MH, Lashley M, Jones E. A public health approach to understanding and preventing violent radicalization. BMC Med. 2012;10:16.
20. Mallonee S, Sahriat S, Stennies G, Waxweiler R, Hogan D, Jordan F. Physical injuries and fatalities resulting from the Oklahoma City bombing. JAMA. 1996;276(5):382-387.
21. Ushizawa H, Foxwell AR, Bice S, et al. Needs for disaster medicine: lessons from the field of the Great East Japan Earthquake. Western Pac Surveil Response J. 2013;4(1):51-55.
Does BSO status affect health outcomes for women taking estrogen for menopause?
Do health effects of menopausal estrogen therapy differ between women with bilateral oophorectomy versus those with conserved ovaries? To answer this question a group of investigators performed a subanalysis of the Women’s Health Initiative (WHI) Estrogen-Alone Trial,1 which included 40 clinical centers across the United States. They examined estrogen therapy outcomes by bilateral salpingo-oophorectomy (BSO) status, with additional stratification by 10-year age groups in 9,939 women aged 50 to 79 years with prior hysterectomy and known oophorectomy status. In the WHI trial, women were randomly assigned to conjugated equine estrogens (CEE) 0.625 mg/d or placebo for a median of 7.2 years. Investigators assessed the incidence of coronary heart disease and invasive breast cancer (the trial’s 2 primary end points), all-cause mortality, and a “global index”—these end points plus stroke, pulmonary embolism, colorectal cancer, and hip fracture—during the intervention phase and 18-year cumulative follow-up.
OBG Management caught up with lead author JoAnn E. Manson, MD, DrPH, NCMP, to discuss the study’s results.
OBG Management : How many women undergo BSO with their hysterectomy?
Dr. JoAnn E. Manson, MD, DrPH, NCMP: Of the 425,000 women who undergo hysterectomy in the United States for benign reasons each year,2,3 about 40% of them undergo BSO—so between 150,000 and 200,000 women per year undergo BSO with their hysterectomy.4,5
OBG Management : Although BSO is performed with hysterectomy to minimize patients’ future ovarian cancer risk, does BSO have health risks of its own, and how has estrogen been shown to affect these risks?
Dr. Manson: First, yes, BSO has been associated with health risks, especially when it is performed at a young age, such as before age 45. It has been linked to an increased risk of heart disease, osteoporosis, cognitive decline, and all-cause mortality. According to observational studies, estrogen therapy appears to offset many of these risks, particularly those related to heart disease and osteoporosis (the evidence is less clear on cognitive deficits).5
OBG Management : What did you find in your trial when you randomly assigned women in the age groups of 50 to 79 who underwent hysterectomy with and without BSO to estrogen therapy or placebo?
Dr. Manson: The WHI is the first study to be conducted in a randomized trial setting to analyze the health risks and benefits of estrogen therapy according to whether or not women had their ovaries removed. What we found was that the woman’s age had a strong influence on the effects of estrogen therapy among women who had BSO but only a negligible effect among women who had conserved ovaries. Overall, across the full age range, the effects of estrogen therapy did not differ substantially between women who had a BSO and those who had their ovaries conserved.
However, there were major differences by age group among the women who had BSO. A significant 32% reduction in all-cause mortality emerged during the 18-year follow-up period among the younger women (below age 60) who had BSO when they received estrogen therapy as compared with placebo. By contrast, the women who had conserved ovaries did not have this significant reduction in all-cause mortality, or in most of the other outcomes on estrogen compared with placebo. Overall, the effects of estrogen therapy tended to be relatively neutral in the women with conserved ovaries.
Now, the reduction in all-cause mortality with estrogen therapy was particularly pronounced among women who had BSO before age 45. They had a 40% statistically significant reduction in all-cause mortality with estrogen therapy compared with placebo. Also, among the women with BSO, there was a strong association between the timing of estrogen initiation and the magnitude of reduction in mortality. Women who started the estrogen therapy within 10 years of having the BSO had a 34% significant reduction in all-cause mortality, and those who started estrogen more than 20 years after having their ovaries removed had no reduction in mortality.
Continue to:
OBG Management : Do your data give support to the timing hypothesis?
Dr. Manson: Yes, our findings do support a timing hypothesis that was particularly pronounced for women who underwent BSO. It was the women who had early surgical menopause (before age 45) and those who started the estrogen therapy within 10 years of having their ovaries removed who had the greatest reduction in all-cause mortality and the most favorable benefit-risk profile from hormone therapy. So, the results do lend support to the timing hypothesis.
By contrast, women who had BSO at hysterectomy and began hormone therapy at age 70 or older had net adverse effects from hormone therapy. They posted a 40% increase in the global index—which is a summary measure of adverse effects on cardiovascular disease, cancer, and other major health outcomes. So, the women with BSO who were randomized in the trial at age 70 and older, had unfavorable results from estrogen therapy and an increase in the global index, in contrast to the women who were below age 60 or within 10 years of menopause.
OBG Management : Given your study findings, in which women would you recommend estrogen therapy? And are there groups of women in which you would advise avoiding estrogen therapy?
Dr. Manson: Current guidelines6,7 recommend estrogen therapy for women who have early menopause, particularly an early surgical menopause and BSO prior to the average age at natural menopause. Unless the woman has contraindications to estrogen therapy, the recommendations are to treat with estrogen until the average age of menopause—until about age 50 to 51.
Our study findings provide reassurance that, if a woman continues to have indications for estrogen (vasomotor symptoms, or other indications for estrogen therapy), there is relative safety of continuing estrogen-alone therapy through her 50s, until age 60. For example, a woman who, after the average age of menopause continues to have vasomotor symptoms, or if she has bone health problems, our study would suggest that estrogen therapy would continue to have a favorable benefit-risk profile until at least the age of 60. Decisions would have to be individualized, especially after age 60, with shared decision-making particularly important for those decisions. (Some women, depending on their risk profile, may continue to be candidates for estrogen therapy past age 60.)
So, this study provides reassurance regarding use of estrogen therapy for women in their 50s if they have had BSO. Actually, the women who had conserved ovaries also had relative safety with estrogen therapy until age 60. They just didn’t show the significant benefits for all-cause mortality. Overall, their pattern of health-related benefits and risks was neutral. Thus, if vasomotor symptom management, quality of life benefits, or bone health effects are sought, taking hormone therapy is a quite reasonable choice for these women.
By contrast, women who have had a BSO and are age 70 or older should really avoid initiating estrogen therapy because it would follow a prolonged period of estrogen deficiency, or very low estrogen levels, and these women appeared to have a net adverse effect from initiating hormone therapy (with increases in the global index found).
Continue to:
OBG Management : Did taking estrogen therapy prior to trial enrollment make a difference when it came to study outcomes?
Dr. Manson: We found minimal if any effect in our analyses. In fact, even the women who did not have prior (pre-randomization) use of estrogen therapy tended to do well on estrogen-alone therapy if they were younger than age 60. This was particularly true for the women who had BSO. Even if they had not used estrogen previously, and they were many years past the BSO, they still did well on estrogen therapy if they were below age 60.
1. Manson JE, Aragaki AK, Bassuk SS. Menopausal estrogen-alone therapy and health outcomes in women with and without bilateral oophorectomy: a randomized trial. Ann Intern Med. 2019 September 10. doi:10.7326/M19-0274.
2. Einarsson J. Are hysterectomy volumes in the US really falling? Contemporary OB/GYN. 1 September 2017. www.contemporaryobgyn.net/gynecology/are-hysterectomy-volumes-us-really-falling. November 4, 2019.
3. Temkin SM, Minasian L, Noone AM. The end of the hysterectomy epidemic and endometrial cancer incidence: what are the unintended consequences of declining hysterectomy rates? Front Oncol. 2016;6:89.
4. Doll KM, Dusetzina SB, Robinson W. Trends in inpatient and outpatient hysterectomy and oophorectomy rates among commercially insured women in the United States, 2000-2014. JAMA Surg. 2016;151:876-877.
5. Adelman MR, Sharp HT. Ovarian conservation vs removal at the time of benign hysterectomy. Am J Obstet Gynecol. 2018;218:269-279.
6. ACOG Practice Bulletin No. 141: management of menopausal symptoms [published corrections appear in: Obstet Gynecol. 2016;127(1):166. and Obstet Gynecol. 2018;131(3):604]. Obstet Gynecol. 2014;123:202-216.
7. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause. 2017;24:728-753.
Do health effects of menopausal estrogen therapy differ between women with bilateral oophorectomy versus those with conserved ovaries? To answer this question a group of investigators performed a subanalysis of the Women’s Health Initiative (WHI) Estrogen-Alone Trial,1 which included 40 clinical centers across the United States. They examined estrogen therapy outcomes by bilateral salpingo-oophorectomy (BSO) status, with additional stratification by 10-year age groups in 9,939 women aged 50 to 79 years with prior hysterectomy and known oophorectomy status. In the WHI trial, women were randomly assigned to conjugated equine estrogens (CEE) 0.625 mg/d or placebo for a median of 7.2 years. Investigators assessed the incidence of coronary heart disease and invasive breast cancer (the trial’s 2 primary end points), all-cause mortality, and a “global index”—these end points plus stroke, pulmonary embolism, colorectal cancer, and hip fracture—during the intervention phase and 18-year cumulative follow-up.
OBG Management caught up with lead author JoAnn E. Manson, MD, DrPH, NCMP, to discuss the study’s results.
OBG Management : How many women undergo BSO with their hysterectomy?
Dr. JoAnn E. Manson, MD, DrPH, NCMP: Of the 425,000 women who undergo hysterectomy in the United States for benign reasons each year,2,3 about 40% of them undergo BSO—so between 150,000 and 200,000 women per year undergo BSO with their hysterectomy.4,5
OBG Management : Although BSO is performed with hysterectomy to minimize patients’ future ovarian cancer risk, does BSO have health risks of its own, and how has estrogen been shown to affect these risks?
Dr. Manson: First, yes, BSO has been associated with health risks, especially when it is performed at a young age, such as before age 45. It has been linked to an increased risk of heart disease, osteoporosis, cognitive decline, and all-cause mortality. According to observational studies, estrogen therapy appears to offset many of these risks, particularly those related to heart disease and osteoporosis (the evidence is less clear on cognitive deficits).5
OBG Management : What did you find in your trial when you randomly assigned women in the age groups of 50 to 79 who underwent hysterectomy with and without BSO to estrogen therapy or placebo?
Dr. Manson: The WHI is the first study to be conducted in a randomized trial setting to analyze the health risks and benefits of estrogen therapy according to whether or not women had their ovaries removed. What we found was that the woman’s age had a strong influence on the effects of estrogen therapy among women who had BSO but only a negligible effect among women who had conserved ovaries. Overall, across the full age range, the effects of estrogen therapy did not differ substantially between women who had a BSO and those who had their ovaries conserved.
However, there were major differences by age group among the women who had BSO. A significant 32% reduction in all-cause mortality emerged during the 18-year follow-up period among the younger women (below age 60) who had BSO when they received estrogen therapy as compared with placebo. By contrast, the women who had conserved ovaries did not have this significant reduction in all-cause mortality, or in most of the other outcomes on estrogen compared with placebo. Overall, the effects of estrogen therapy tended to be relatively neutral in the women with conserved ovaries.
Now, the reduction in all-cause mortality with estrogen therapy was particularly pronounced among women who had BSO before age 45. They had a 40% statistically significant reduction in all-cause mortality with estrogen therapy compared with placebo. Also, among the women with BSO, there was a strong association between the timing of estrogen initiation and the magnitude of reduction in mortality. Women who started the estrogen therapy within 10 years of having the BSO had a 34% significant reduction in all-cause mortality, and those who started estrogen more than 20 years after having their ovaries removed had no reduction in mortality.
Continue to:
OBG Management : Do your data give support to the timing hypothesis?
Dr. Manson: Yes, our findings do support a timing hypothesis that was particularly pronounced for women who underwent BSO. It was the women who had early surgical menopause (before age 45) and those who started the estrogen therapy within 10 years of having their ovaries removed who had the greatest reduction in all-cause mortality and the most favorable benefit-risk profile from hormone therapy. So, the results do lend support to the timing hypothesis.
By contrast, women who had BSO at hysterectomy and began hormone therapy at age 70 or older had net adverse effects from hormone therapy. They posted a 40% increase in the global index—which is a summary measure of adverse effects on cardiovascular disease, cancer, and other major health outcomes. So, the women with BSO who were randomized in the trial at age 70 and older, had unfavorable results from estrogen therapy and an increase in the global index, in contrast to the women who were below age 60 or within 10 years of menopause.
OBG Management : Given your study findings, in which women would you recommend estrogen therapy? And are there groups of women in which you would advise avoiding estrogen therapy?
Dr. Manson: Current guidelines6,7 recommend estrogen therapy for women who have early menopause, particularly an early surgical menopause and BSO prior to the average age at natural menopause. Unless the woman has contraindications to estrogen therapy, the recommendations are to treat with estrogen until the average age of menopause—until about age 50 to 51.
Our study findings provide reassurance that, if a woman continues to have indications for estrogen (vasomotor symptoms, or other indications for estrogen therapy), there is relative safety of continuing estrogen-alone therapy through her 50s, until age 60. For example, a woman who, after the average age of menopause continues to have vasomotor symptoms, or if she has bone health problems, our study would suggest that estrogen therapy would continue to have a favorable benefit-risk profile until at least the age of 60. Decisions would have to be individualized, especially after age 60, with shared decision-making particularly important for those decisions. (Some women, depending on their risk profile, may continue to be candidates for estrogen therapy past age 60.)
So, this study provides reassurance regarding use of estrogen therapy for women in their 50s if they have had BSO. Actually, the women who had conserved ovaries also had relative safety with estrogen therapy until age 60. They just didn’t show the significant benefits for all-cause mortality. Overall, their pattern of health-related benefits and risks was neutral. Thus, if vasomotor symptom management, quality of life benefits, or bone health effects are sought, taking hormone therapy is a quite reasonable choice for these women.
By contrast, women who have had a BSO and are age 70 or older should really avoid initiating estrogen therapy because it would follow a prolonged period of estrogen deficiency, or very low estrogen levels, and these women appeared to have a net adverse effect from initiating hormone therapy (with increases in the global index found).
Continue to:
OBG Management : Did taking estrogen therapy prior to trial enrollment make a difference when it came to study outcomes?
Dr. Manson: We found minimal if any effect in our analyses. In fact, even the women who did not have prior (pre-randomization) use of estrogen therapy tended to do well on estrogen-alone therapy if they were younger than age 60. This was particularly true for the women who had BSO. Even if they had not used estrogen previously, and they were many years past the BSO, they still did well on estrogen therapy if they were below age 60.
Do health effects of menopausal estrogen therapy differ between women with bilateral oophorectomy versus those with conserved ovaries? To answer this question a group of investigators performed a subanalysis of the Women’s Health Initiative (WHI) Estrogen-Alone Trial,1 which included 40 clinical centers across the United States. They examined estrogen therapy outcomes by bilateral salpingo-oophorectomy (BSO) status, with additional stratification by 10-year age groups in 9,939 women aged 50 to 79 years with prior hysterectomy and known oophorectomy status. In the WHI trial, women were randomly assigned to conjugated equine estrogens (CEE) 0.625 mg/d or placebo for a median of 7.2 years. Investigators assessed the incidence of coronary heart disease and invasive breast cancer (the trial’s 2 primary end points), all-cause mortality, and a “global index”—these end points plus stroke, pulmonary embolism, colorectal cancer, and hip fracture—during the intervention phase and 18-year cumulative follow-up.
OBG Management caught up with lead author JoAnn E. Manson, MD, DrPH, NCMP, to discuss the study’s results.
OBG Management : How many women undergo BSO with their hysterectomy?
Dr. JoAnn E. Manson, MD, DrPH, NCMP: Of the 425,000 women who undergo hysterectomy in the United States for benign reasons each year,2,3 about 40% of them undergo BSO—so between 150,000 and 200,000 women per year undergo BSO with their hysterectomy.4,5
OBG Management : Although BSO is performed with hysterectomy to minimize patients’ future ovarian cancer risk, does BSO have health risks of its own, and how has estrogen been shown to affect these risks?
Dr. Manson: First, yes, BSO has been associated with health risks, especially when it is performed at a young age, such as before age 45. It has been linked to an increased risk of heart disease, osteoporosis, cognitive decline, and all-cause mortality. According to observational studies, estrogen therapy appears to offset many of these risks, particularly those related to heart disease and osteoporosis (the evidence is less clear on cognitive deficits).5
OBG Management : What did you find in your trial when you randomly assigned women in the age groups of 50 to 79 who underwent hysterectomy with and without BSO to estrogen therapy or placebo?
Dr. Manson: The WHI is the first study to be conducted in a randomized trial setting to analyze the health risks and benefits of estrogen therapy according to whether or not women had their ovaries removed. What we found was that the woman’s age had a strong influence on the effects of estrogen therapy among women who had BSO but only a negligible effect among women who had conserved ovaries. Overall, across the full age range, the effects of estrogen therapy did not differ substantially between women who had a BSO and those who had their ovaries conserved.
However, there were major differences by age group among the women who had BSO. A significant 32% reduction in all-cause mortality emerged during the 18-year follow-up period among the younger women (below age 60) who had BSO when they received estrogen therapy as compared with placebo. By contrast, the women who had conserved ovaries did not have this significant reduction in all-cause mortality, or in most of the other outcomes on estrogen compared with placebo. Overall, the effects of estrogen therapy tended to be relatively neutral in the women with conserved ovaries.
Now, the reduction in all-cause mortality with estrogen therapy was particularly pronounced among women who had BSO before age 45. They had a 40% statistically significant reduction in all-cause mortality with estrogen therapy compared with placebo. Also, among the women with BSO, there was a strong association between the timing of estrogen initiation and the magnitude of reduction in mortality. Women who started the estrogen therapy within 10 years of having the BSO had a 34% significant reduction in all-cause mortality, and those who started estrogen more than 20 years after having their ovaries removed had no reduction in mortality.
Continue to:
OBG Management : Do your data give support to the timing hypothesis?
Dr. Manson: Yes, our findings do support a timing hypothesis that was particularly pronounced for women who underwent BSO. It was the women who had early surgical menopause (before age 45) and those who started the estrogen therapy within 10 years of having their ovaries removed who had the greatest reduction in all-cause mortality and the most favorable benefit-risk profile from hormone therapy. So, the results do lend support to the timing hypothesis.
By contrast, women who had BSO at hysterectomy and began hormone therapy at age 70 or older had net adverse effects from hormone therapy. They posted a 40% increase in the global index—which is a summary measure of adverse effects on cardiovascular disease, cancer, and other major health outcomes. So, the women with BSO who were randomized in the trial at age 70 and older, had unfavorable results from estrogen therapy and an increase in the global index, in contrast to the women who were below age 60 or within 10 years of menopause.
OBG Management : Given your study findings, in which women would you recommend estrogen therapy? And are there groups of women in which you would advise avoiding estrogen therapy?
Dr. Manson: Current guidelines6,7 recommend estrogen therapy for women who have early menopause, particularly an early surgical menopause and BSO prior to the average age at natural menopause. Unless the woman has contraindications to estrogen therapy, the recommendations are to treat with estrogen until the average age of menopause—until about age 50 to 51.
Our study findings provide reassurance that, if a woman continues to have indications for estrogen (vasomotor symptoms, or other indications for estrogen therapy), there is relative safety of continuing estrogen-alone therapy through her 50s, until age 60. For example, a woman who, after the average age of menopause continues to have vasomotor symptoms, or if she has bone health problems, our study would suggest that estrogen therapy would continue to have a favorable benefit-risk profile until at least the age of 60. Decisions would have to be individualized, especially after age 60, with shared decision-making particularly important for those decisions. (Some women, depending on their risk profile, may continue to be candidates for estrogen therapy past age 60.)
So, this study provides reassurance regarding use of estrogen therapy for women in their 50s if they have had BSO. Actually, the women who had conserved ovaries also had relative safety with estrogen therapy until age 60. They just didn’t show the significant benefits for all-cause mortality. Overall, their pattern of health-related benefits and risks was neutral. Thus, if vasomotor symptom management, quality of life benefits, or bone health effects are sought, taking hormone therapy is a quite reasonable choice for these women.
By contrast, women who have had a BSO and are age 70 or older should really avoid initiating estrogen therapy because it would follow a prolonged period of estrogen deficiency, or very low estrogen levels, and these women appeared to have a net adverse effect from initiating hormone therapy (with increases in the global index found).
Continue to:
OBG Management : Did taking estrogen therapy prior to trial enrollment make a difference when it came to study outcomes?
Dr. Manson: We found minimal if any effect in our analyses. In fact, even the women who did not have prior (pre-randomization) use of estrogen therapy tended to do well on estrogen-alone therapy if they were younger than age 60. This was particularly true for the women who had BSO. Even if they had not used estrogen previously, and they were many years past the BSO, they still did well on estrogen therapy if they were below age 60.
1. Manson JE, Aragaki AK, Bassuk SS. Menopausal estrogen-alone therapy and health outcomes in women with and without bilateral oophorectomy: a randomized trial. Ann Intern Med. 2019 September 10. doi:10.7326/M19-0274.
2. Einarsson J. Are hysterectomy volumes in the US really falling? Contemporary OB/GYN. 1 September 2017. www.contemporaryobgyn.net/gynecology/are-hysterectomy-volumes-us-really-falling. November 4, 2019.
3. Temkin SM, Minasian L, Noone AM. The end of the hysterectomy epidemic and endometrial cancer incidence: what are the unintended consequences of declining hysterectomy rates? Front Oncol. 2016;6:89.
4. Doll KM, Dusetzina SB, Robinson W. Trends in inpatient and outpatient hysterectomy and oophorectomy rates among commercially insured women in the United States, 2000-2014. JAMA Surg. 2016;151:876-877.
5. Adelman MR, Sharp HT. Ovarian conservation vs removal at the time of benign hysterectomy. Am J Obstet Gynecol. 2018;218:269-279.
6. ACOG Practice Bulletin No. 141: management of menopausal symptoms [published corrections appear in: Obstet Gynecol. 2016;127(1):166. and Obstet Gynecol. 2018;131(3):604]. Obstet Gynecol. 2014;123:202-216.
7. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause. 2017;24:728-753.
1. Manson JE, Aragaki AK, Bassuk SS. Menopausal estrogen-alone therapy and health outcomes in women with and without bilateral oophorectomy: a randomized trial. Ann Intern Med. 2019 September 10. doi:10.7326/M19-0274.
2. Einarsson J. Are hysterectomy volumes in the US really falling? Contemporary OB/GYN. 1 September 2017. www.contemporaryobgyn.net/gynecology/are-hysterectomy-volumes-us-really-falling. November 4, 2019.
3. Temkin SM, Minasian L, Noone AM. The end of the hysterectomy epidemic and endometrial cancer incidence: what are the unintended consequences of declining hysterectomy rates? Front Oncol. 2016;6:89.
4. Doll KM, Dusetzina SB, Robinson W. Trends in inpatient and outpatient hysterectomy and oophorectomy rates among commercially insured women in the United States, 2000-2014. JAMA Surg. 2016;151:876-877.
5. Adelman MR, Sharp HT. Ovarian conservation vs removal at the time of benign hysterectomy. Am J Obstet Gynecol. 2018;218:269-279.
6. ACOG Practice Bulletin No. 141: management of menopausal symptoms [published corrections appear in: Obstet Gynecol. 2016;127(1):166. and Obstet Gynecol. 2018;131(3):604]. Obstet Gynecol. 2014;123:202-216.
7. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause. 2017;24:728-753.
Comment on “Intraoperative Electrosurgical Smoke During Outpatient Surgery: A Survey of Dermatologic Surgeon and Staff Preferences”
To the Editor:
We read with great interest the recent Cutis article by Golda et al,1 “Intraoperative Electrosurgical Smoke During Outpatient Surgery: A Survey of Dermatologic Surgeon and Staff Preferences.” We applaud the growing interest in the topic of dermatologist safety, as there are currently no established guidelines for precautions while performing surgical procedures. In 2018 we conducted a comprehensive review2 to characterize the specific risks, hazard reduction strategies available, and current use of surgical smoke safety techniques during surgery among dermatologists, and ultimately recommend guidance based on the current available evidence. To conduct this review, we collected data from 45 manuscripts in the dermatology, surgery, infectious disease, obstetrics, and cancer biology literature. Herein, we summarize key findings.2
Dermatologic surgeons, residents, staff, and patients are exposed to many infectious, inhalational, chemical, and mutagenic hazards when performing procedures that liberate smoke and plume. These risks are commonplace; however, they are particularly notable during ablative laser and laser hair removal procedures, which produce a heavy plume (averaging >100,000 particles/cm3). Brief periods of heavy plume exposure also are commonplace during electrosurgery.
Infectious particles in surgical plume have been extensively studied, and viral transmission has been demonstrated in animal studies. Human papillomavirus transmission appears to be the most prevalent risk. Surgical smoke has been shown to cause acute and chronic inhalational injury in rat and sheep studies.3-6
Additionally, chemicals with carcinogenic potential are present in surgical smoke and have been described.7,8 Chemicals in the greatest quantity include hydrocarbons, nitriles, fatty acids, and phenols. Although there have been no human studies on smoke carcinogenesis to date, surgical smoke has been shown to have carcinogenic properties in vitro.
Given these risks—both evidence based and theoretical—we believe that diligent hazard reduction strategies should be employed whenever possible. Surgical masks and high-efficiency particulate air respirators, such as N95 respirator masks, have been well studied and do provide smoke protection. High-efficiency particulate air masks can be worn when possible, especially during procedures that produce heavy plume, though surgical masks are capable of filtering most of the noxious chemicals in surgical smoke. It should be noted that proper fit with minimal air leak is the most important aspect of overall performance.
Smoke evacuators provide another level of protection. The physician should consider the evacuator’s filtration efficiency, capture velocity, and suction strength when evaluating overall performance. Furthermore, the smoke collection tip should be within 2 in of the surgical field to maximize efficacy. Maintenance for smoke evacuation systems should include regular (as defined by manufacturer instructions) flushing of the smoke evacuator lines.
Despite the risks of surgical smoke and the available options of minimizing these risks, the hazards of surgical smoke and the importance of protection are likely underemphasized. Many dermatologic surgeons do not use surgical masks or smoke evacuators in routine practice, according to several survey studies.9-11
It is important for the dermatologic community to consider effective ways of spreading awareness. We propose that surgical smoke safety be taught early in residency training. Additionally, smoke safety can be implemented into certification examinations. Access to masks and smoke evacuation devices are an important part of dermatology training. Accreditation Council for Graduate Medical Education funds should be appropriated to provide for such resources.
Finally, and perhaps most importantly, continued awareness should be established in the dermatology community via standardized guidelines and periodic updates in the dermatology literature and lectures at local and national conferences. Not until these strategies are implemented will surgical smoke protection be viewed as a necessary and important component of routine practice when performing dermatologic surgical procedures.
- Golda N, Merrill B, Neill B. Intraoperative electrosurgical smoke during outpatient surgery: a survey of dermatologic surgeon and staff preferences. Cutis. 2019;104:120-124.
- Georgesen C, Lipner SR. Surgical smoke: risk assessment and mitigation strategies. J Am Acad Dermatol. 2018;79:746-755.
- Wenig BL, Stenson KM, Wenig BM, et al. Effects of plume produced by the Nd:YAG laser and electrocautery on the respiratory system. Lasers Surg Med. 1993;13:242-245.
- Baggish MS, Elbakry M. The effects of laser smoke on the lungs of rats. Am J Obstet Gynecol. 1987;156:1260-1265.
- Baggish MS, Baltoyannis P, Sze E. Protection of the rat lung from the harmful effects of laser smoke. Lasers Surg Med. 1988;8:248-253.
- Freitag L, Chapman GA, Sielczak M, et al. Laser smoke effect on the bronchial system. Lasers Surg Med. 1987;7:283-288.
- Barrett WL, Garber SM. Surgical smoke: a review of the literature. Is this just a lot of hot air? Surg Endosc. 2003;17:979-987.
- Hensman C, Baty D, Willis RG, et al. Chemical composition of smoke produced by high-frequency electrosurgery in a closed gaseous environment. Surg Endosc. 1998;12:1017-1019.
- Edwards BE, Reiman RE. Results of a survey on current surgical smoke control practices. AORN J. 2008;87:739-749.
- Oganesyan G, Eimpunth S, Kim SS, et al. Surgical smoke in dermatologic surgery. Dermatol Surg. 2014;40:1373-1377.
- Chapman LW, Korta DZ, Lee PK, et al. Awareness of surgical smoke risks and assessment of safety practices during electrosurgery among US dermatology residents. JAMA Dermatol. 2017;153:467-468.
To the Editor:
We read with great interest the recent Cutis article by Golda et al,1 “Intraoperative Electrosurgical Smoke During Outpatient Surgery: A Survey of Dermatologic Surgeon and Staff Preferences.” We applaud the growing interest in the topic of dermatologist safety, as there are currently no established guidelines for precautions while performing surgical procedures. In 2018 we conducted a comprehensive review2 to characterize the specific risks, hazard reduction strategies available, and current use of surgical smoke safety techniques during surgery among dermatologists, and ultimately recommend guidance based on the current available evidence. To conduct this review, we collected data from 45 manuscripts in the dermatology, surgery, infectious disease, obstetrics, and cancer biology literature. Herein, we summarize key findings.2
Dermatologic surgeons, residents, staff, and patients are exposed to many infectious, inhalational, chemical, and mutagenic hazards when performing procedures that liberate smoke and plume. These risks are commonplace; however, they are particularly notable during ablative laser and laser hair removal procedures, which produce a heavy plume (averaging >100,000 particles/cm3). Brief periods of heavy plume exposure also are commonplace during electrosurgery.
Infectious particles in surgical plume have been extensively studied, and viral transmission has been demonstrated in animal studies. Human papillomavirus transmission appears to be the most prevalent risk. Surgical smoke has been shown to cause acute and chronic inhalational injury in rat and sheep studies.3-6
Additionally, chemicals with carcinogenic potential are present in surgical smoke and have been described.7,8 Chemicals in the greatest quantity include hydrocarbons, nitriles, fatty acids, and phenols. Although there have been no human studies on smoke carcinogenesis to date, surgical smoke has been shown to have carcinogenic properties in vitro.
Given these risks—both evidence based and theoretical—we believe that diligent hazard reduction strategies should be employed whenever possible. Surgical masks and high-efficiency particulate air respirators, such as N95 respirator masks, have been well studied and do provide smoke protection. High-efficiency particulate air masks can be worn when possible, especially during procedures that produce heavy plume, though surgical masks are capable of filtering most of the noxious chemicals in surgical smoke. It should be noted that proper fit with minimal air leak is the most important aspect of overall performance.
Smoke evacuators provide another level of protection. The physician should consider the evacuator’s filtration efficiency, capture velocity, and suction strength when evaluating overall performance. Furthermore, the smoke collection tip should be within 2 in of the surgical field to maximize efficacy. Maintenance for smoke evacuation systems should include regular (as defined by manufacturer instructions) flushing of the smoke evacuator lines.
Despite the risks of surgical smoke and the available options of minimizing these risks, the hazards of surgical smoke and the importance of protection are likely underemphasized. Many dermatologic surgeons do not use surgical masks or smoke evacuators in routine practice, according to several survey studies.9-11
It is important for the dermatologic community to consider effective ways of spreading awareness. We propose that surgical smoke safety be taught early in residency training. Additionally, smoke safety can be implemented into certification examinations. Access to masks and smoke evacuation devices are an important part of dermatology training. Accreditation Council for Graduate Medical Education funds should be appropriated to provide for such resources.
Finally, and perhaps most importantly, continued awareness should be established in the dermatology community via standardized guidelines and periodic updates in the dermatology literature and lectures at local and national conferences. Not until these strategies are implemented will surgical smoke protection be viewed as a necessary and important component of routine practice when performing dermatologic surgical procedures.
To the Editor:
We read with great interest the recent Cutis article by Golda et al,1 “Intraoperative Electrosurgical Smoke During Outpatient Surgery: A Survey of Dermatologic Surgeon and Staff Preferences.” We applaud the growing interest in the topic of dermatologist safety, as there are currently no established guidelines for precautions while performing surgical procedures. In 2018 we conducted a comprehensive review2 to characterize the specific risks, hazard reduction strategies available, and current use of surgical smoke safety techniques during surgery among dermatologists, and ultimately recommend guidance based on the current available evidence. To conduct this review, we collected data from 45 manuscripts in the dermatology, surgery, infectious disease, obstetrics, and cancer biology literature. Herein, we summarize key findings.2
Dermatologic surgeons, residents, staff, and patients are exposed to many infectious, inhalational, chemical, and mutagenic hazards when performing procedures that liberate smoke and plume. These risks are commonplace; however, they are particularly notable during ablative laser and laser hair removal procedures, which produce a heavy plume (averaging >100,000 particles/cm3). Brief periods of heavy plume exposure also are commonplace during electrosurgery.
Infectious particles in surgical plume have been extensively studied, and viral transmission has been demonstrated in animal studies. Human papillomavirus transmission appears to be the most prevalent risk. Surgical smoke has been shown to cause acute and chronic inhalational injury in rat and sheep studies.3-6
Additionally, chemicals with carcinogenic potential are present in surgical smoke and have been described.7,8 Chemicals in the greatest quantity include hydrocarbons, nitriles, fatty acids, and phenols. Although there have been no human studies on smoke carcinogenesis to date, surgical smoke has been shown to have carcinogenic properties in vitro.
Given these risks—both evidence based and theoretical—we believe that diligent hazard reduction strategies should be employed whenever possible. Surgical masks and high-efficiency particulate air respirators, such as N95 respirator masks, have been well studied and do provide smoke protection. High-efficiency particulate air masks can be worn when possible, especially during procedures that produce heavy plume, though surgical masks are capable of filtering most of the noxious chemicals in surgical smoke. It should be noted that proper fit with minimal air leak is the most important aspect of overall performance.
Smoke evacuators provide another level of protection. The physician should consider the evacuator’s filtration efficiency, capture velocity, and suction strength when evaluating overall performance. Furthermore, the smoke collection tip should be within 2 in of the surgical field to maximize efficacy. Maintenance for smoke evacuation systems should include regular (as defined by manufacturer instructions) flushing of the smoke evacuator lines.
Despite the risks of surgical smoke and the available options of minimizing these risks, the hazards of surgical smoke and the importance of protection are likely underemphasized. Many dermatologic surgeons do not use surgical masks or smoke evacuators in routine practice, according to several survey studies.9-11
It is important for the dermatologic community to consider effective ways of spreading awareness. We propose that surgical smoke safety be taught early in residency training. Additionally, smoke safety can be implemented into certification examinations. Access to masks and smoke evacuation devices are an important part of dermatology training. Accreditation Council for Graduate Medical Education funds should be appropriated to provide for such resources.
Finally, and perhaps most importantly, continued awareness should be established in the dermatology community via standardized guidelines and periodic updates in the dermatology literature and lectures at local and national conferences. Not until these strategies are implemented will surgical smoke protection be viewed as a necessary and important component of routine practice when performing dermatologic surgical procedures.
- Golda N, Merrill B, Neill B. Intraoperative electrosurgical smoke during outpatient surgery: a survey of dermatologic surgeon and staff preferences. Cutis. 2019;104:120-124.
- Georgesen C, Lipner SR. Surgical smoke: risk assessment and mitigation strategies. J Am Acad Dermatol. 2018;79:746-755.
- Wenig BL, Stenson KM, Wenig BM, et al. Effects of plume produced by the Nd:YAG laser and electrocautery on the respiratory system. Lasers Surg Med. 1993;13:242-245.
- Baggish MS, Elbakry M. The effects of laser smoke on the lungs of rats. Am J Obstet Gynecol. 1987;156:1260-1265.
- Baggish MS, Baltoyannis P, Sze E. Protection of the rat lung from the harmful effects of laser smoke. Lasers Surg Med. 1988;8:248-253.
- Freitag L, Chapman GA, Sielczak M, et al. Laser smoke effect on the bronchial system. Lasers Surg Med. 1987;7:283-288.
- Barrett WL, Garber SM. Surgical smoke: a review of the literature. Is this just a lot of hot air? Surg Endosc. 2003;17:979-987.
- Hensman C, Baty D, Willis RG, et al. Chemical composition of smoke produced by high-frequency electrosurgery in a closed gaseous environment. Surg Endosc. 1998;12:1017-1019.
- Edwards BE, Reiman RE. Results of a survey on current surgical smoke control practices. AORN J. 2008;87:739-749.
- Oganesyan G, Eimpunth S, Kim SS, et al. Surgical smoke in dermatologic surgery. Dermatol Surg. 2014;40:1373-1377.
- Chapman LW, Korta DZ, Lee PK, et al. Awareness of surgical smoke risks and assessment of safety practices during electrosurgery among US dermatology residents. JAMA Dermatol. 2017;153:467-468.
- Golda N, Merrill B, Neill B. Intraoperative electrosurgical smoke during outpatient surgery: a survey of dermatologic surgeon and staff preferences. Cutis. 2019;104:120-124.
- Georgesen C, Lipner SR. Surgical smoke: risk assessment and mitigation strategies. J Am Acad Dermatol. 2018;79:746-755.
- Wenig BL, Stenson KM, Wenig BM, et al. Effects of plume produced by the Nd:YAG laser and electrocautery on the respiratory system. Lasers Surg Med. 1993;13:242-245.
- Baggish MS, Elbakry M. The effects of laser smoke on the lungs of rats. Am J Obstet Gynecol. 1987;156:1260-1265.
- Baggish MS, Baltoyannis P, Sze E. Protection of the rat lung from the harmful effects of laser smoke. Lasers Surg Med. 1988;8:248-253.
- Freitag L, Chapman GA, Sielczak M, et al. Laser smoke effect on the bronchial system. Lasers Surg Med. 1987;7:283-288.
- Barrett WL, Garber SM. Surgical smoke: a review of the literature. Is this just a lot of hot air? Surg Endosc. 2003;17:979-987.
- Hensman C, Baty D, Willis RG, et al. Chemical composition of smoke produced by high-frequency electrosurgery in a closed gaseous environment. Surg Endosc. 1998;12:1017-1019.
- Edwards BE, Reiman RE. Results of a survey on current surgical smoke control practices. AORN J. 2008;87:739-749.
- Oganesyan G, Eimpunth S, Kim SS, et al. Surgical smoke in dermatologic surgery. Dermatol Surg. 2014;40:1373-1377.
- Chapman LW, Korta DZ, Lee PK, et al. Awareness of surgical smoke risks and assessment of safety practices during electrosurgery among US dermatology residents. JAMA Dermatol. 2017;153:467-468.
Disparity in endometrial cancer outcomes: What can we do?
While the incidence of most cancers is falling, endometrial cancer rates continue to rise, in large part because of increasing life expectancy and obesity rates. However, what is even more alarming is the observation that there is a clear disparity in outcomes between black and white women with this disease. But there are things that all health care providers, including nononcologists, can do to help to overcome this disparity.
Black women are nearly twice as likely as non-Hispanic white women to die from the endometrial cancer. The 5-year survival for stage III and IV cancer is 43% for non-Hispanic white women, yet only 25% for black women.1 For a long time, this survival disparity was assumed to be a function of the more aggressive cancer histologies, such as serous, which are more commonly seen in black women. These high-grade cancers are more likely to present in advanced stages and with poorer responses to treatments; however, the predisposition to aggressive cancers tells only part of the story of racial disparities in endometrial cancer and their presentation at later stages. Indeed, fueling the problem are the findings that black women report symptoms less, experience more delays in diagnosis or more frequent deviations from guideline-directed diagnostics, undergo more morbid surgical approaches, receive less surgical staging, are enrolled less in clinical trials, have lower socioeconomic status and lower rates of health insurance, and receive less differential administration of adjuvant therapies, as well as have a background of higher all-cause mortality and comorbidities. While this array of contributing factors may seem overwhelming, it also can be considered a guide for health care providers because most of these factors, unlike histologic cell type, are modifiable, and it is important that we all consider what role we can play in dismantling them.
Black women are less likely to receive guideline-recommended care upon presentation. Research by Kemi M. Doll, MD, from the University of Washington, Seattle, demonstrated that, among women with endometrial cancers, black women were less likely to have documented histories of postmenopausal bleeding within 2 years of the diagnosis, presumably because of factors related to underreporting and inadequate ascertainment by medical professionals of whether or not they had experienced postmenopausal bleeding.2 Additionally, when postmenopausal bleeding was reported by these women, they were less likely to receive the appropriate diagnostic work-up as described by American College of Obstetricians and Gynecologists guidelines, and their bleeding was more likely to be ascribed to nonmalignant pathologies. Her work raises the important question about how black women view the health care profession and their willingness to engage early in good faith that their concerns will be met. These concerns are understandable given the documented different responsiveness of providers to black patients’ symptoms such as pain.3
both of which are considered the standard of care.1,4 Lower rates of minimally invasive surgery expose black women to increased morbidity and are deleterious to quality of life, return to work, and functionality. If surgical staging is omitted, which is more common for these women, clinicians are less able to appropriately prescribe adjuvant therapies which might prevent lethal recurrences from unrecognized advanced cancer or they may overtreat early-stage cancers with adjuvant therapy to make up for gaps in staging information.1,5 However, adjuvant therapy is not a benign intervention, and itself is associated with morbidity.
As mentioned earlier, black women are at a higher risk for developing more aggressive cancer subtypes, and this phenomenon may appear unmodifiable. However, important research is looking at the concept of epigenetics and how modifiable environmental factors may contribute to the development of more aggressive types of cancer through gene expression. Additionally, differences in the gene mutations and gene expression of cancers more frequently acquired by black women may negatively influence how these cancers respond to conventional therapies. In the GOG210 study, which evaluated the outcomes of women with comprehensively staged endometrial cancer, black women demonstrated worse survival from cancer, even though they were more likely to receive chemotherapy.5 One explanation for this finding is that these women’s cancers were less responsive to conventional chemotherapy agents.
This raises a critical issue of disparity in clinical trial inclusion. Black women are underrepresented in clinical trials in the United States. There is a dark history in medical research and minority populations, particularly African American populations, which continues to be remembered and felt. However, not all of this underrepresentation may be from unwillingness to participate: For black women, issues of lack of access to or being considered for clinical trials is also a factor. But without adequate representation in trials of novel agents, we will not know whether they are effective for all populations, and indeed it would appear that we should not assume they are equally effective based on the results to date.
So how can we all individually help to overcome these disparities in endometrial cancer outcomes? To begin with, it is important to acknowledge that black women commonly report negative experiences with reproductive health care. From early in their lives, we must sensitively engage all of our patients and ensure they all feel heard and valued. They should know that their symptoms, including pain or bleeding, are taken and treated seriously. If we can do better with this throughout a woman’s earlier reproductive health care experiences, perhaps later in her life, when she experiences postmenopausal bleeding, she will feel comfortable raising this issue with her health care provider who in turn must take this symptom seriously and expeditiously engage all of the appropriate diagnostic resources. Health care delivery is about more than simply offering the best treatment. We also are responsible for education and shared decision making to ensure that we can deliver the best treatment.
We also can support organizations such as ECANA (Endometrial Cancer Action Network for African Americans) which serves to inform black women in their communities about the threat that endometrial cancer plays and empowers them through education about its symptoms and the need to seek care.
Systematically we must ensure black women have access to the same standards in surgical and nonsurgical management of these cancers. This includes referral of all women with cancer, including minorities, to high-volume centers with oncology specialists and explaining to those who may be reluctant to travel that this is associated with improved outcomes in the short and long term. We also must actively consider our black patients for clinical trials, sensitively educate them about their benefits, and overcome barriers to access. One simple way to do this is to explain that the treatments that we have developed for endometrial cancer have mostly been tested on white women, which may explain in part why they do not work so well for nonwhite women.
The racial disparity in endometrial cancer outcomes cannot entirely be attributed to the passive phenomenon of patient and tumor genetics, particularly with consideration that race is a social construct rather than a biological phenomenon. We can all make a difference through advocacy, access, education, and heightened awareness to combat this inequity and overcome these disparate outcomes.
Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She said she had no relevant financial disclosures. Email her at [email protected].
References
1. Gynecol Oncol. 2016 Oct;143(1):98-104.
2. Am J Obstet Gynecol. 2018 Dec;219(6):593.e1-14.
3. J Clin Oncol. 2012 Jun 1;30(16):1980-8.
4. Obstet Gynecol. 2016 Sep;128(3):526-34.
5. Am J Obstet Gynecol. 2018 Nov;219(5):459.e1-11.
While the incidence of most cancers is falling, endometrial cancer rates continue to rise, in large part because of increasing life expectancy and obesity rates. However, what is even more alarming is the observation that there is a clear disparity in outcomes between black and white women with this disease. But there are things that all health care providers, including nononcologists, can do to help to overcome this disparity.
Black women are nearly twice as likely as non-Hispanic white women to die from the endometrial cancer. The 5-year survival for stage III and IV cancer is 43% for non-Hispanic white women, yet only 25% for black women.1 For a long time, this survival disparity was assumed to be a function of the more aggressive cancer histologies, such as serous, which are more commonly seen in black women. These high-grade cancers are more likely to present in advanced stages and with poorer responses to treatments; however, the predisposition to aggressive cancers tells only part of the story of racial disparities in endometrial cancer and their presentation at later stages. Indeed, fueling the problem are the findings that black women report symptoms less, experience more delays in diagnosis or more frequent deviations from guideline-directed diagnostics, undergo more morbid surgical approaches, receive less surgical staging, are enrolled less in clinical trials, have lower socioeconomic status and lower rates of health insurance, and receive less differential administration of adjuvant therapies, as well as have a background of higher all-cause mortality and comorbidities. While this array of contributing factors may seem overwhelming, it also can be considered a guide for health care providers because most of these factors, unlike histologic cell type, are modifiable, and it is important that we all consider what role we can play in dismantling them.
Black women are less likely to receive guideline-recommended care upon presentation. Research by Kemi M. Doll, MD, from the University of Washington, Seattle, demonstrated that, among women with endometrial cancers, black women were less likely to have documented histories of postmenopausal bleeding within 2 years of the diagnosis, presumably because of factors related to underreporting and inadequate ascertainment by medical professionals of whether or not they had experienced postmenopausal bleeding.2 Additionally, when postmenopausal bleeding was reported by these women, they were less likely to receive the appropriate diagnostic work-up as described by American College of Obstetricians and Gynecologists guidelines, and their bleeding was more likely to be ascribed to nonmalignant pathologies. Her work raises the important question about how black women view the health care profession and their willingness to engage early in good faith that their concerns will be met. These concerns are understandable given the documented different responsiveness of providers to black patients’ symptoms such as pain.3
both of which are considered the standard of care.1,4 Lower rates of minimally invasive surgery expose black women to increased morbidity and are deleterious to quality of life, return to work, and functionality. If surgical staging is omitted, which is more common for these women, clinicians are less able to appropriately prescribe adjuvant therapies which might prevent lethal recurrences from unrecognized advanced cancer or they may overtreat early-stage cancers with adjuvant therapy to make up for gaps in staging information.1,5 However, adjuvant therapy is not a benign intervention, and itself is associated with morbidity.
As mentioned earlier, black women are at a higher risk for developing more aggressive cancer subtypes, and this phenomenon may appear unmodifiable. However, important research is looking at the concept of epigenetics and how modifiable environmental factors may contribute to the development of more aggressive types of cancer through gene expression. Additionally, differences in the gene mutations and gene expression of cancers more frequently acquired by black women may negatively influence how these cancers respond to conventional therapies. In the GOG210 study, which evaluated the outcomes of women with comprehensively staged endometrial cancer, black women demonstrated worse survival from cancer, even though they were more likely to receive chemotherapy.5 One explanation for this finding is that these women’s cancers were less responsive to conventional chemotherapy agents.
This raises a critical issue of disparity in clinical trial inclusion. Black women are underrepresented in clinical trials in the United States. There is a dark history in medical research and minority populations, particularly African American populations, which continues to be remembered and felt. However, not all of this underrepresentation may be from unwillingness to participate: For black women, issues of lack of access to or being considered for clinical trials is also a factor. But without adequate representation in trials of novel agents, we will not know whether they are effective for all populations, and indeed it would appear that we should not assume they are equally effective based on the results to date.
So how can we all individually help to overcome these disparities in endometrial cancer outcomes? To begin with, it is important to acknowledge that black women commonly report negative experiences with reproductive health care. From early in their lives, we must sensitively engage all of our patients and ensure they all feel heard and valued. They should know that their symptoms, including pain or bleeding, are taken and treated seriously. If we can do better with this throughout a woman’s earlier reproductive health care experiences, perhaps later in her life, when she experiences postmenopausal bleeding, she will feel comfortable raising this issue with her health care provider who in turn must take this symptom seriously and expeditiously engage all of the appropriate diagnostic resources. Health care delivery is about more than simply offering the best treatment. We also are responsible for education and shared decision making to ensure that we can deliver the best treatment.
We also can support organizations such as ECANA (Endometrial Cancer Action Network for African Americans) which serves to inform black women in their communities about the threat that endometrial cancer plays and empowers them through education about its symptoms and the need to seek care.
Systematically we must ensure black women have access to the same standards in surgical and nonsurgical management of these cancers. This includes referral of all women with cancer, including minorities, to high-volume centers with oncology specialists and explaining to those who may be reluctant to travel that this is associated with improved outcomes in the short and long term. We also must actively consider our black patients for clinical trials, sensitively educate them about their benefits, and overcome barriers to access. One simple way to do this is to explain that the treatments that we have developed for endometrial cancer have mostly been tested on white women, which may explain in part why they do not work so well for nonwhite women.
The racial disparity in endometrial cancer outcomes cannot entirely be attributed to the passive phenomenon of patient and tumor genetics, particularly with consideration that race is a social construct rather than a biological phenomenon. We can all make a difference through advocacy, access, education, and heightened awareness to combat this inequity and overcome these disparate outcomes.
Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She said she had no relevant financial disclosures. Email her at [email protected].
References
1. Gynecol Oncol. 2016 Oct;143(1):98-104.
2. Am J Obstet Gynecol. 2018 Dec;219(6):593.e1-14.
3. J Clin Oncol. 2012 Jun 1;30(16):1980-8.
4. Obstet Gynecol. 2016 Sep;128(3):526-34.
5. Am J Obstet Gynecol. 2018 Nov;219(5):459.e1-11.
While the incidence of most cancers is falling, endometrial cancer rates continue to rise, in large part because of increasing life expectancy and obesity rates. However, what is even more alarming is the observation that there is a clear disparity in outcomes between black and white women with this disease. But there are things that all health care providers, including nononcologists, can do to help to overcome this disparity.
Black women are nearly twice as likely as non-Hispanic white women to die from the endometrial cancer. The 5-year survival for stage III and IV cancer is 43% for non-Hispanic white women, yet only 25% for black women.1 For a long time, this survival disparity was assumed to be a function of the more aggressive cancer histologies, such as serous, which are more commonly seen in black women. These high-grade cancers are more likely to present in advanced stages and with poorer responses to treatments; however, the predisposition to aggressive cancers tells only part of the story of racial disparities in endometrial cancer and their presentation at later stages. Indeed, fueling the problem are the findings that black women report symptoms less, experience more delays in diagnosis or more frequent deviations from guideline-directed diagnostics, undergo more morbid surgical approaches, receive less surgical staging, are enrolled less in clinical trials, have lower socioeconomic status and lower rates of health insurance, and receive less differential administration of adjuvant therapies, as well as have a background of higher all-cause mortality and comorbidities. While this array of contributing factors may seem overwhelming, it also can be considered a guide for health care providers because most of these factors, unlike histologic cell type, are modifiable, and it is important that we all consider what role we can play in dismantling them.
Black women are less likely to receive guideline-recommended care upon presentation. Research by Kemi M. Doll, MD, from the University of Washington, Seattle, demonstrated that, among women with endometrial cancers, black women were less likely to have documented histories of postmenopausal bleeding within 2 years of the diagnosis, presumably because of factors related to underreporting and inadequate ascertainment by medical professionals of whether or not they had experienced postmenopausal bleeding.2 Additionally, when postmenopausal bleeding was reported by these women, they were less likely to receive the appropriate diagnostic work-up as described by American College of Obstetricians and Gynecologists guidelines, and their bleeding was more likely to be ascribed to nonmalignant pathologies. Her work raises the important question about how black women view the health care profession and their willingness to engage early in good faith that their concerns will be met. These concerns are understandable given the documented different responsiveness of providers to black patients’ symptoms such as pain.3
both of which are considered the standard of care.1,4 Lower rates of minimally invasive surgery expose black women to increased morbidity and are deleterious to quality of life, return to work, and functionality. If surgical staging is omitted, which is more common for these women, clinicians are less able to appropriately prescribe adjuvant therapies which might prevent lethal recurrences from unrecognized advanced cancer or they may overtreat early-stage cancers with adjuvant therapy to make up for gaps in staging information.1,5 However, adjuvant therapy is not a benign intervention, and itself is associated with morbidity.
As mentioned earlier, black women are at a higher risk for developing more aggressive cancer subtypes, and this phenomenon may appear unmodifiable. However, important research is looking at the concept of epigenetics and how modifiable environmental factors may contribute to the development of more aggressive types of cancer through gene expression. Additionally, differences in the gene mutations and gene expression of cancers more frequently acquired by black women may negatively influence how these cancers respond to conventional therapies. In the GOG210 study, which evaluated the outcomes of women with comprehensively staged endometrial cancer, black women demonstrated worse survival from cancer, even though they were more likely to receive chemotherapy.5 One explanation for this finding is that these women’s cancers were less responsive to conventional chemotherapy agents.
This raises a critical issue of disparity in clinical trial inclusion. Black women are underrepresented in clinical trials in the United States. There is a dark history in medical research and minority populations, particularly African American populations, which continues to be remembered and felt. However, not all of this underrepresentation may be from unwillingness to participate: For black women, issues of lack of access to or being considered for clinical trials is also a factor. But without adequate representation in trials of novel agents, we will not know whether they are effective for all populations, and indeed it would appear that we should not assume they are equally effective based on the results to date.
So how can we all individually help to overcome these disparities in endometrial cancer outcomes? To begin with, it is important to acknowledge that black women commonly report negative experiences with reproductive health care. From early in their lives, we must sensitively engage all of our patients and ensure they all feel heard and valued. They should know that their symptoms, including pain or bleeding, are taken and treated seriously. If we can do better with this throughout a woman’s earlier reproductive health care experiences, perhaps later in her life, when she experiences postmenopausal bleeding, she will feel comfortable raising this issue with her health care provider who in turn must take this symptom seriously and expeditiously engage all of the appropriate diagnostic resources. Health care delivery is about more than simply offering the best treatment. We also are responsible for education and shared decision making to ensure that we can deliver the best treatment.
We also can support organizations such as ECANA (Endometrial Cancer Action Network for African Americans) which serves to inform black women in their communities about the threat that endometrial cancer plays and empowers them through education about its symptoms and the need to seek care.
Systematically we must ensure black women have access to the same standards in surgical and nonsurgical management of these cancers. This includes referral of all women with cancer, including minorities, to high-volume centers with oncology specialists and explaining to those who may be reluctant to travel that this is associated with improved outcomes in the short and long term. We also must actively consider our black patients for clinical trials, sensitively educate them about their benefits, and overcome barriers to access. One simple way to do this is to explain that the treatments that we have developed for endometrial cancer have mostly been tested on white women, which may explain in part why they do not work so well for nonwhite women.
The racial disparity in endometrial cancer outcomes cannot entirely be attributed to the passive phenomenon of patient and tumor genetics, particularly with consideration that race is a social construct rather than a biological phenomenon. We can all make a difference through advocacy, access, education, and heightened awareness to combat this inequity and overcome these disparate outcomes.
Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She said she had no relevant financial disclosures. Email her at [email protected].
References
1. Gynecol Oncol. 2016 Oct;143(1):98-104.
2. Am J Obstet Gynecol. 2018 Dec;219(6):593.e1-14.
3. J Clin Oncol. 2012 Jun 1;30(16):1980-8.
4. Obstet Gynecol. 2016 Sep;128(3):526-34.
5. Am J Obstet Gynecol. 2018 Nov;219(5):459.e1-11.
Low-dose steroids for acute exacerbations of COPD in a non-ICU setting: Worth consideration
Despite guidelines recommending low-dose oral glucocorticoids over high-dose intravenous (IV) glucocorticoids for inpatient management of acute exacerbations of chronic obstructive pulmonary disease (COPD), we have observed that most patients still receive high-dose IV therapy before being transitioned to low-dose oral therapy at discharge. Clinical inertia undoubtedly plays a significant role in the slow adoption of new recommendations, but in this era of evidence-based practice, the unfortunate lack of data supporting low over high steroid doses for acute exacerbations of COPD also contributes to hesitancy of physicians.
A SIGNIFICANT AND GROWING BURDEN
COPD is one of the most common pulmonary conditions managed by hospitalists today, and by the year 2030, it is predicted to become the third leading cause of death worldwide.1
COPD is also a significant economic burden, costing $50 billion to manage in the United States, most of that from the cost of lengthy hospital stays.2 COPD patients have 1 to 2 exacerbations per year.3 Bacterial and viral infections are responsible for most exacerbations, and 15% to 20% are from air pollution and other environmental causes of airway inflammation.3
CHALLENGES TO CHANGING PRACTICE
Glucocorticoids are the gold standard for treatment of acute exacerbations of COPD. It is well-documented that compared with placebo, glucocorticoids reduce mortality risk, length of hospital stay, and exacerbation recurrence after 1 month.4 And while high-dose IV steroid therapy has been the standard approach, oral administration has been found to be noninferior to IV administration with regard to treatment and length of hospital stay.5
While adverse effects are more common at higher doses, the optimal dose and duration of systemic glucocorticoid therapy for acute exacerbations of COPD are still largely at the discretion of the physician. The 2019 report of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends low doses (40 mg) for no more than 5 to 7 days for exacerbations, based on reports that showed no worse outcomes with low-dose oral than with high-dose IV therapy.6,7 (In the 2010 study by Lindenauer et al,7 92% of nearly 80,000 patients received high-dose IV steroids, reflecting standard practice at that time.) However, the GOLD guidelines do not address mortality rates, length of stay, or readmission rates for either approach, as they are devised to direct treatment in patients with stable mild to advanced COPD, not exacerbations.
THE EVIDENCE FOR LOW-DOSE STEROIDS
Mortality rates
Aksoy et al8 established that, compared with placebo, low-dose steroids improved mortality rates in a subset of patients with acute exacerbations, specifically those with eosinophilic exacerbations. This study followed the 2013 Reduction in the Use of Corticosteroids in Exacerbated COPD (REDUCE) trial, which showed mortality rates were not lower with 14 days of low-dose prednisone treatment than with 5 days.9
Length of hospital stay
With regard to length of hospital stay, in 2011 Wang et al10 found no statistically significant difference between high- and low-dose steroid treatment.However, the REDUCE trial found that low-dose steroids shortened the median length of stay by 1 day compared with placebo.9
Hospital readmission rates
The REDUCE trial found no statistically significant difference in readmission rates when comparing 5 days of low-dose treatment vs 14 days.9 However, Aksoy et al8 found that readmission rates were significantly lower with low-dose treatment than with placebo.No study has yet examined readmission rates with high-dose vs low-dose steroid treatment.
What does the evidence tell us?
Low-dose oral glucocorticoid treatment shows definitive benefits in terms of lower mortality rates, shorter hospital length of stay, and lower readmission rates vs placebo in the treatment of acute exacerbations of COPD. Furthermore, a 14-day course is no better than 5 days in terms of mortality rates. And low-dose glucocorticoid treatment shows reduced mortality rates in addition to similar hospital length of stay when compared to high-dose glucocorticoid treatment.
Together, these findings lend credibility to the current GOLD recommendations. However, we have observed that in sharp contrast to the leading clinical guidelines, most patients hospitalized for acute exacerbations of COPD are still treated initially with high-dose IV corticosteroids. Why?
Obstacles that perpetuate the use of high-dose over low-dose treatment include lack of knowledge of glucocorticoid pharmacokinetics among clinicians, use of outdated order sets, and the reflex notion that more of a drug is more efficacious in its desired effect. In addition, administrative obstacles include using high-dose IV steroids to justify an inpatient stay or continued hospitalization.
COUNTERING THE OBSTACLES: THE HOSPITALIST’S ROLE
To counter these obstacles, we propose standardization of inpatient treatment of acute exacerbations of COPD to include initial low-dose steroid treatment in accordance with the most recent GOLD guidelines.6 This would benefit the patient by reducing undesirable effects of high-dose steroids, and at the same time reduce the economic burden of managing COPD exacerbations. Considering the large number of hospitalizations for COPD exacerbation each year, hospitalists can play a large role in this effort by routinely incorporating the low-dose steroid recommendation into their clinical practice.
- World Health Organization. Chronic respiratory diseases: burden of COPD. www.who.int/respiratory/copd/burden/en. Accessed October 16, 2019.
- Guarascio AJ, Ray SM, Finch CK, Self TH. The clinical and economic burden of chronic obstructive pulmonary disease in the USA. Clinicoecon Outcomes Res 2013; 5:235–245. doi:10.2147/CEOR.S34321
- Sethi S, Murphy TF. Infection in the pathogenesis and course of chronic obstructive pulmonary disease. N Engl J Med 2008; 359(22):2355–2365. doi:10.1056/NEJMra0800353
- Walters JA, Tan DJ, White CJ, Gibson PG, Wood-Baker R, Walters EH. Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2014; (9):CD001288. doi:10.1002/14651858.CD001288.pub4
- de Jong YP, Uil SM, Grotjohan HP, Postma DS, Kerstjens HA, van den Berg JW. Oral or IV prednisolone in the treatment of COPD exacerbations: a randomized, controlled, double-blind study. Chest 2007; 132(6):1741–1747. doi:10.1378/chest.07-0208
- Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2019 report. www.goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf. Accessed October 16, 2019.
- Lindenauer PK, Pekow PS, Lahti MC, Lee Y, Benjamin EM, Rothberg MB. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA 2010; 303(23):2359–2367. doi:10.1001/jama.2010.796
- Aksoy E, Güngör S, Agca MÇ, et al. A revised treatment approach for hospitalized patients with eosinophilic and neutrophilic exacerbations of chronic obstructive pulmonary disease. Turk Thorac J 2018; 19(4):193–200. doi:10.5152/TurkThoracJ.2018.18004
- Leuppi JD, Schuetz P, Bingisser R, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA 2013; 309(21):2223–2231. doi:10.1001/jama.2013.5023
- Wang PH, Cheng SL, Wang HC, et al. Systemic steroids in acute exacerbation of COPD—from guidelines to bedside. Int J Clin Pharmacol Ther 2011; 49(11):705–708. doi:10.5414/cp201588
Despite guidelines recommending low-dose oral glucocorticoids over high-dose intravenous (IV) glucocorticoids for inpatient management of acute exacerbations of chronic obstructive pulmonary disease (COPD), we have observed that most patients still receive high-dose IV therapy before being transitioned to low-dose oral therapy at discharge. Clinical inertia undoubtedly plays a significant role in the slow adoption of new recommendations, but in this era of evidence-based practice, the unfortunate lack of data supporting low over high steroid doses for acute exacerbations of COPD also contributes to hesitancy of physicians.
A SIGNIFICANT AND GROWING BURDEN
COPD is one of the most common pulmonary conditions managed by hospitalists today, and by the year 2030, it is predicted to become the third leading cause of death worldwide.1
COPD is also a significant economic burden, costing $50 billion to manage in the United States, most of that from the cost of lengthy hospital stays.2 COPD patients have 1 to 2 exacerbations per year.3 Bacterial and viral infections are responsible for most exacerbations, and 15% to 20% are from air pollution and other environmental causes of airway inflammation.3
CHALLENGES TO CHANGING PRACTICE
Glucocorticoids are the gold standard for treatment of acute exacerbations of COPD. It is well-documented that compared with placebo, glucocorticoids reduce mortality risk, length of hospital stay, and exacerbation recurrence after 1 month.4 And while high-dose IV steroid therapy has been the standard approach, oral administration has been found to be noninferior to IV administration with regard to treatment and length of hospital stay.5
While adverse effects are more common at higher doses, the optimal dose and duration of systemic glucocorticoid therapy for acute exacerbations of COPD are still largely at the discretion of the physician. The 2019 report of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends low doses (40 mg) for no more than 5 to 7 days for exacerbations, based on reports that showed no worse outcomes with low-dose oral than with high-dose IV therapy.6,7 (In the 2010 study by Lindenauer et al,7 92% of nearly 80,000 patients received high-dose IV steroids, reflecting standard practice at that time.) However, the GOLD guidelines do not address mortality rates, length of stay, or readmission rates for either approach, as they are devised to direct treatment in patients with stable mild to advanced COPD, not exacerbations.
THE EVIDENCE FOR LOW-DOSE STEROIDS
Mortality rates
Aksoy et al8 established that, compared with placebo, low-dose steroids improved mortality rates in a subset of patients with acute exacerbations, specifically those with eosinophilic exacerbations. This study followed the 2013 Reduction in the Use of Corticosteroids in Exacerbated COPD (REDUCE) trial, which showed mortality rates were not lower with 14 days of low-dose prednisone treatment than with 5 days.9
Length of hospital stay
With regard to length of hospital stay, in 2011 Wang et al10 found no statistically significant difference between high- and low-dose steroid treatment.However, the REDUCE trial found that low-dose steroids shortened the median length of stay by 1 day compared with placebo.9
Hospital readmission rates
The REDUCE trial found no statistically significant difference in readmission rates when comparing 5 days of low-dose treatment vs 14 days.9 However, Aksoy et al8 found that readmission rates were significantly lower with low-dose treatment than with placebo.No study has yet examined readmission rates with high-dose vs low-dose steroid treatment.
What does the evidence tell us?
Low-dose oral glucocorticoid treatment shows definitive benefits in terms of lower mortality rates, shorter hospital length of stay, and lower readmission rates vs placebo in the treatment of acute exacerbations of COPD. Furthermore, a 14-day course is no better than 5 days in terms of mortality rates. And low-dose glucocorticoid treatment shows reduced mortality rates in addition to similar hospital length of stay when compared to high-dose glucocorticoid treatment.
Together, these findings lend credibility to the current GOLD recommendations. However, we have observed that in sharp contrast to the leading clinical guidelines, most patients hospitalized for acute exacerbations of COPD are still treated initially with high-dose IV corticosteroids. Why?
Obstacles that perpetuate the use of high-dose over low-dose treatment include lack of knowledge of glucocorticoid pharmacokinetics among clinicians, use of outdated order sets, and the reflex notion that more of a drug is more efficacious in its desired effect. In addition, administrative obstacles include using high-dose IV steroids to justify an inpatient stay or continued hospitalization.
COUNTERING THE OBSTACLES: THE HOSPITALIST’S ROLE
To counter these obstacles, we propose standardization of inpatient treatment of acute exacerbations of COPD to include initial low-dose steroid treatment in accordance with the most recent GOLD guidelines.6 This would benefit the patient by reducing undesirable effects of high-dose steroids, and at the same time reduce the economic burden of managing COPD exacerbations. Considering the large number of hospitalizations for COPD exacerbation each year, hospitalists can play a large role in this effort by routinely incorporating the low-dose steroid recommendation into their clinical practice.
Despite guidelines recommending low-dose oral glucocorticoids over high-dose intravenous (IV) glucocorticoids for inpatient management of acute exacerbations of chronic obstructive pulmonary disease (COPD), we have observed that most patients still receive high-dose IV therapy before being transitioned to low-dose oral therapy at discharge. Clinical inertia undoubtedly plays a significant role in the slow adoption of new recommendations, but in this era of evidence-based practice, the unfortunate lack of data supporting low over high steroid doses for acute exacerbations of COPD also contributes to hesitancy of physicians.
A SIGNIFICANT AND GROWING BURDEN
COPD is one of the most common pulmonary conditions managed by hospitalists today, and by the year 2030, it is predicted to become the third leading cause of death worldwide.1
COPD is also a significant economic burden, costing $50 billion to manage in the United States, most of that from the cost of lengthy hospital stays.2 COPD patients have 1 to 2 exacerbations per year.3 Bacterial and viral infections are responsible for most exacerbations, and 15% to 20% are from air pollution and other environmental causes of airway inflammation.3
CHALLENGES TO CHANGING PRACTICE
Glucocorticoids are the gold standard for treatment of acute exacerbations of COPD. It is well-documented that compared with placebo, glucocorticoids reduce mortality risk, length of hospital stay, and exacerbation recurrence after 1 month.4 And while high-dose IV steroid therapy has been the standard approach, oral administration has been found to be noninferior to IV administration with regard to treatment and length of hospital stay.5
While adverse effects are more common at higher doses, the optimal dose and duration of systemic glucocorticoid therapy for acute exacerbations of COPD are still largely at the discretion of the physician. The 2019 report of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends low doses (40 mg) for no more than 5 to 7 days for exacerbations, based on reports that showed no worse outcomes with low-dose oral than with high-dose IV therapy.6,7 (In the 2010 study by Lindenauer et al,7 92% of nearly 80,000 patients received high-dose IV steroids, reflecting standard practice at that time.) However, the GOLD guidelines do not address mortality rates, length of stay, or readmission rates for either approach, as they are devised to direct treatment in patients with stable mild to advanced COPD, not exacerbations.
THE EVIDENCE FOR LOW-DOSE STEROIDS
Mortality rates
Aksoy et al8 established that, compared with placebo, low-dose steroids improved mortality rates in a subset of patients with acute exacerbations, specifically those with eosinophilic exacerbations. This study followed the 2013 Reduction in the Use of Corticosteroids in Exacerbated COPD (REDUCE) trial, which showed mortality rates were not lower with 14 days of low-dose prednisone treatment than with 5 days.9
Length of hospital stay
With regard to length of hospital stay, in 2011 Wang et al10 found no statistically significant difference between high- and low-dose steroid treatment.However, the REDUCE trial found that low-dose steroids shortened the median length of stay by 1 day compared with placebo.9
Hospital readmission rates
The REDUCE trial found no statistically significant difference in readmission rates when comparing 5 days of low-dose treatment vs 14 days.9 However, Aksoy et al8 found that readmission rates were significantly lower with low-dose treatment than with placebo.No study has yet examined readmission rates with high-dose vs low-dose steroid treatment.
What does the evidence tell us?
Low-dose oral glucocorticoid treatment shows definitive benefits in terms of lower mortality rates, shorter hospital length of stay, and lower readmission rates vs placebo in the treatment of acute exacerbations of COPD. Furthermore, a 14-day course is no better than 5 days in terms of mortality rates. And low-dose glucocorticoid treatment shows reduced mortality rates in addition to similar hospital length of stay when compared to high-dose glucocorticoid treatment.
Together, these findings lend credibility to the current GOLD recommendations. However, we have observed that in sharp contrast to the leading clinical guidelines, most patients hospitalized for acute exacerbations of COPD are still treated initially with high-dose IV corticosteroids. Why?
Obstacles that perpetuate the use of high-dose over low-dose treatment include lack of knowledge of glucocorticoid pharmacokinetics among clinicians, use of outdated order sets, and the reflex notion that more of a drug is more efficacious in its desired effect. In addition, administrative obstacles include using high-dose IV steroids to justify an inpatient stay or continued hospitalization.
COUNTERING THE OBSTACLES: THE HOSPITALIST’S ROLE
To counter these obstacles, we propose standardization of inpatient treatment of acute exacerbations of COPD to include initial low-dose steroid treatment in accordance with the most recent GOLD guidelines.6 This would benefit the patient by reducing undesirable effects of high-dose steroids, and at the same time reduce the economic burden of managing COPD exacerbations. Considering the large number of hospitalizations for COPD exacerbation each year, hospitalists can play a large role in this effort by routinely incorporating the low-dose steroid recommendation into their clinical practice.
- World Health Organization. Chronic respiratory diseases: burden of COPD. www.who.int/respiratory/copd/burden/en. Accessed October 16, 2019.
- Guarascio AJ, Ray SM, Finch CK, Self TH. The clinical and economic burden of chronic obstructive pulmonary disease in the USA. Clinicoecon Outcomes Res 2013; 5:235–245. doi:10.2147/CEOR.S34321
- Sethi S, Murphy TF. Infection in the pathogenesis and course of chronic obstructive pulmonary disease. N Engl J Med 2008; 359(22):2355–2365. doi:10.1056/NEJMra0800353
- Walters JA, Tan DJ, White CJ, Gibson PG, Wood-Baker R, Walters EH. Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2014; (9):CD001288. doi:10.1002/14651858.CD001288.pub4
- de Jong YP, Uil SM, Grotjohan HP, Postma DS, Kerstjens HA, van den Berg JW. Oral or IV prednisolone in the treatment of COPD exacerbations: a randomized, controlled, double-blind study. Chest 2007; 132(6):1741–1747. doi:10.1378/chest.07-0208
- Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2019 report. www.goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf. Accessed October 16, 2019.
- Lindenauer PK, Pekow PS, Lahti MC, Lee Y, Benjamin EM, Rothberg MB. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA 2010; 303(23):2359–2367. doi:10.1001/jama.2010.796
- Aksoy E, Güngör S, Agca MÇ, et al. A revised treatment approach for hospitalized patients with eosinophilic and neutrophilic exacerbations of chronic obstructive pulmonary disease. Turk Thorac J 2018; 19(4):193–200. doi:10.5152/TurkThoracJ.2018.18004
- Leuppi JD, Schuetz P, Bingisser R, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA 2013; 309(21):2223–2231. doi:10.1001/jama.2013.5023
- Wang PH, Cheng SL, Wang HC, et al. Systemic steroids in acute exacerbation of COPD—from guidelines to bedside. Int J Clin Pharmacol Ther 2011; 49(11):705–708. doi:10.5414/cp201588
- World Health Organization. Chronic respiratory diseases: burden of COPD. www.who.int/respiratory/copd/burden/en. Accessed October 16, 2019.
- Guarascio AJ, Ray SM, Finch CK, Self TH. The clinical and economic burden of chronic obstructive pulmonary disease in the USA. Clinicoecon Outcomes Res 2013; 5:235–245. doi:10.2147/CEOR.S34321
- Sethi S, Murphy TF. Infection in the pathogenesis and course of chronic obstructive pulmonary disease. N Engl J Med 2008; 359(22):2355–2365. doi:10.1056/NEJMra0800353
- Walters JA, Tan DJ, White CJ, Gibson PG, Wood-Baker R, Walters EH. Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2014; (9):CD001288. doi:10.1002/14651858.CD001288.pub4
- de Jong YP, Uil SM, Grotjohan HP, Postma DS, Kerstjens HA, van den Berg JW. Oral or IV prednisolone in the treatment of COPD exacerbations: a randomized, controlled, double-blind study. Chest 2007; 132(6):1741–1747. doi:10.1378/chest.07-0208
- Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2019 report. www.goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf. Accessed October 16, 2019.
- Lindenauer PK, Pekow PS, Lahti MC, Lee Y, Benjamin EM, Rothberg MB. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA 2010; 303(23):2359–2367. doi:10.1001/jama.2010.796
- Aksoy E, Güngör S, Agca MÇ, et al. A revised treatment approach for hospitalized patients with eosinophilic and neutrophilic exacerbations of chronic obstructive pulmonary disease. Turk Thorac J 2018; 19(4):193–200. doi:10.5152/TurkThoracJ.2018.18004
- Leuppi JD, Schuetz P, Bingisser R, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA 2013; 309(21):2223–2231. doi:10.1001/jama.2013.5023
- Wang PH, Cheng SL, Wang HC, et al. Systemic steroids in acute exacerbation of COPD—from guidelines to bedside. Int J Clin Pharmacol Ther 2011; 49(11):705–708. doi:10.5414/cp201588
Digital disruption
One of our lead articles stems from the annual Partners in Value meeting, which was developed by the AGA in partnership with the Digestive Health Physicians Association (Chicago, Oct. 4, 2019). This is an annual meeting about innovations and “what’s next” for GI practices. Anton Decker, MD, an expert in the business of GI and Chair of the Practice Management and Economics Committee, discussed “digital disruption.”
When we discuss digital innovations in health care, most think of telehealth, social media, self-care apps, and remote patient monitoring. As a health system executive, my viewpoint about digital technology has been expanded by other critical needs. At the University of Michigan, we are space constrained (land locked without sufficient parking) and are living with shrinking clinical margins. We see digital technology as a solution to both. As we consolidate our call centers from 27 sites to 1, we plan for 30% of our staff to work from home. Setting up a home work station costs $3,000, compared with office space costs (about $5,000/year). A new clinical site might cost $20 million to build, but that is a fraction of the true life-cycle cost of the building. We have a widely distributed patient base (imagine traveling from Michigan’s Upper Penisula to Ann Arbor for a 20-minute clinic visit).
Many people appreciate “seeing” their doctor from the comfort of their living room. We plan to convert at least 15% of patient visits to telehealth over the next few years although reimbursement rules are still limiting. This year, more than 80% of postsurgical visits (90-day bundled payment) were conducted virtually – mostly by NPs or PAs. Our GI psychologist converted 1,500 patient visit hours to virtual visits last year. In 2019, we completed over 4,000 evisits (management of simple conditions initiated by a patient – essential during flu season) and an increasing number of econsults (primary consultations to specialists). Project ECHO (N Engl J Med. 2011;364:2199) remains the star example of how digital health can improve access, especially for underserved communities.
Virtual care, telehealth, remote patient monitoring, telecommuting and other digital innovations are becoming standards for health systems. Now is the time to think of “face-to-face” visits as option B.
John I. Allen, MD, MBD, AGAF
Editor in Chief
One of our lead articles stems from the annual Partners in Value meeting, which was developed by the AGA in partnership with the Digestive Health Physicians Association (Chicago, Oct. 4, 2019). This is an annual meeting about innovations and “what’s next” for GI practices. Anton Decker, MD, an expert in the business of GI and Chair of the Practice Management and Economics Committee, discussed “digital disruption.”
When we discuss digital innovations in health care, most think of telehealth, social media, self-care apps, and remote patient monitoring. As a health system executive, my viewpoint about digital technology has been expanded by other critical needs. At the University of Michigan, we are space constrained (land locked without sufficient parking) and are living with shrinking clinical margins. We see digital technology as a solution to both. As we consolidate our call centers from 27 sites to 1, we plan for 30% of our staff to work from home. Setting up a home work station costs $3,000, compared with office space costs (about $5,000/year). A new clinical site might cost $20 million to build, but that is a fraction of the true life-cycle cost of the building. We have a widely distributed patient base (imagine traveling from Michigan’s Upper Penisula to Ann Arbor for a 20-minute clinic visit).
Many people appreciate “seeing” their doctor from the comfort of their living room. We plan to convert at least 15% of patient visits to telehealth over the next few years although reimbursement rules are still limiting. This year, more than 80% of postsurgical visits (90-day bundled payment) were conducted virtually – mostly by NPs or PAs. Our GI psychologist converted 1,500 patient visit hours to virtual visits last year. In 2019, we completed over 4,000 evisits (management of simple conditions initiated by a patient – essential during flu season) and an increasing number of econsults (primary consultations to specialists). Project ECHO (N Engl J Med. 2011;364:2199) remains the star example of how digital health can improve access, especially for underserved communities.
Virtual care, telehealth, remote patient monitoring, telecommuting and other digital innovations are becoming standards for health systems. Now is the time to think of “face-to-face” visits as option B.
John I. Allen, MD, MBD, AGAF
Editor in Chief
One of our lead articles stems from the annual Partners in Value meeting, which was developed by the AGA in partnership with the Digestive Health Physicians Association (Chicago, Oct. 4, 2019). This is an annual meeting about innovations and “what’s next” for GI practices. Anton Decker, MD, an expert in the business of GI and Chair of the Practice Management and Economics Committee, discussed “digital disruption.”
When we discuss digital innovations in health care, most think of telehealth, social media, self-care apps, and remote patient monitoring. As a health system executive, my viewpoint about digital technology has been expanded by other critical needs. At the University of Michigan, we are space constrained (land locked without sufficient parking) and are living with shrinking clinical margins. We see digital technology as a solution to both. As we consolidate our call centers from 27 sites to 1, we plan for 30% of our staff to work from home. Setting up a home work station costs $3,000, compared with office space costs (about $5,000/year). A new clinical site might cost $20 million to build, but that is a fraction of the true life-cycle cost of the building. We have a widely distributed patient base (imagine traveling from Michigan’s Upper Penisula to Ann Arbor for a 20-minute clinic visit).
Many people appreciate “seeing” their doctor from the comfort of their living room. We plan to convert at least 15% of patient visits to telehealth over the next few years although reimbursement rules are still limiting. This year, more than 80% of postsurgical visits (90-day bundled payment) were conducted virtually – mostly by NPs or PAs. Our GI psychologist converted 1,500 patient visit hours to virtual visits last year. In 2019, we completed over 4,000 evisits (management of simple conditions initiated by a patient – essential during flu season) and an increasing number of econsults (primary consultations to specialists). Project ECHO (N Engl J Med. 2011;364:2199) remains the star example of how digital health can improve access, especially for underserved communities.
Virtual care, telehealth, remote patient monitoring, telecommuting and other digital innovations are becoming standards for health systems. Now is the time to think of “face-to-face” visits as option B.
John I. Allen, MD, MBD, AGAF
Editor in Chief
AI and machine learning
Recent advances in neuroscience and genetics are providing a new view of brain function in health and disease.1 As discussed in Drs. Hripsime Kalanderian and Henry Nasrallah’s article “Artificial intelligence in psychiatry” (Evidence-Based Reviews,
In a 2016 article, Dr. Arshya Vahabzadeh2 wrote, “In the near term, humans will continue to make the majority of psychiatric diagnoses and provide treatment.” He predicted that data science—specifically machine learning—will help revolutionize how we diagnose, treat, and monitor depression. He foresees a future where AI machines or learning machines will more accurately diagnose and treat depression.
These predictions remind us of the promises made with the introduction of psychoactive drugs to the practice of psychiatry. In the 1970s, the increased emphasis on neurotransmitters led to new biologic models of mental illness and the expansion of the Diagnostic and Statistical Manual of Mental Disorders. The increased use of psychoactive medications relegated the practice of psychotherapy to other mental health professionals. Psychiatry became a “drug-intensive” specialty, and psychiatrists saw themselves as psychopharmacologists.3 During this time, psychiatry became progressively dominated by the pharmaceutical industry. The deregulation of the markets and the for-profit ideology of the pharmaceutical industry resulted in an economically and mutually beneficial alliance between pharmaceutical companies, academic faculty, and individual psychiatrists.
Using the same for-profit ideology and ethics of the pharmaceutical industry, technology-based corporations are making massive investments in the application of these technologies in neuroscience research and clinical practice. The “promise” that AI will diagnose and treat depression more accurately than clinicians will again radically change the psychiatrist’s role. Most of a psychiatrist’s clinical work eventually will be replicated by machine learning and technicians. The human-to-human encounter that is at core of the profession will be replaced by the machine-to-human encounter.4
From the social economic perspective, the American health care system is designed to increase profit and maximize the earnings of the industries.5 Unless social policy changes, expensive new technologies will increase the cost and limit accessibility to health care, benefiting the few at the expense of the majority of people. These technologies will produce a robust return on investment, but the wealth they create will benefit fewer and fewer people.
Several writers have called attention to the social, economic, and ethical consequences of these advances and recommended that the academics and technologists who support AI and machine learning in medicine must “receive sufficient training in ethics” and gain exposure to social and economic issues.6 Darcy et al7 warns of the risks of introducing these advanced technologies in medicine: “As machine learning enters the state-of-the-art clinical practice, medicine thus has the immense obligation to ensure that this technology is harnessed for societal and individual good, fulfilling the ethical basis of the profession.… Ethical design thinking is essential at every stage of development and application of machine learning in advancing health. Toward this
Marco T. Carpio, MD
Psychiatrist, Private Practice
Lynbrook, New York
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
1. Bargeman CI. How the new neuroscience will advance medicine. JAMA. 2015;314(3):221-222.
2. Vahabzadeh A. Can machine learning decode depression? Psychiatric News. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2016.4a3. Published April 11, 2016. Accessed October 16, 2019.
3. Angell M. The illusions of psychiatry. The New York Review. https://www.nybooks.com/articles/2011/07/14/illusions-of-psychiatry/. Published July 14, 2011. Accessed October 16, 2019.
4. Heath I, Nessa J. Objectification of physicians and loss of therapeutic power. Lancet. 2007;369(9565):886-888.
5. Wang D. Health care, American style: how did we arrive? Where will we go? Psychiatric Annals. 2014;44(7):342-348.
6. Nourbakhsh IR. The coming robot dystopia. Foreign Affairs. https://www.foreignaffairs.com/articles/2015-06-16/coming-robot-dystopia. Published July 2015. Accessed October 16, 2019.
7. Darcy AM, Louie AK, Roberts LW. Machine learning and the profession of medicine. JAMA. 2016;315(6):551-552.
Recent advances in neuroscience and genetics are providing a new view of brain function in health and disease.1 As discussed in Drs. Hripsime Kalanderian and Henry Nasrallah’s article “Artificial intelligence in psychiatry” (Evidence-Based Reviews,
In a 2016 article, Dr. Arshya Vahabzadeh2 wrote, “In the near term, humans will continue to make the majority of psychiatric diagnoses and provide treatment.” He predicted that data science—specifically machine learning—will help revolutionize how we diagnose, treat, and monitor depression. He foresees a future where AI machines or learning machines will more accurately diagnose and treat depression.
These predictions remind us of the promises made with the introduction of psychoactive drugs to the practice of psychiatry. In the 1970s, the increased emphasis on neurotransmitters led to new biologic models of mental illness and the expansion of the Diagnostic and Statistical Manual of Mental Disorders. The increased use of psychoactive medications relegated the practice of psychotherapy to other mental health professionals. Psychiatry became a “drug-intensive” specialty, and psychiatrists saw themselves as psychopharmacologists.3 During this time, psychiatry became progressively dominated by the pharmaceutical industry. The deregulation of the markets and the for-profit ideology of the pharmaceutical industry resulted in an economically and mutually beneficial alliance between pharmaceutical companies, academic faculty, and individual psychiatrists.
Using the same for-profit ideology and ethics of the pharmaceutical industry, technology-based corporations are making massive investments in the application of these technologies in neuroscience research and clinical practice. The “promise” that AI will diagnose and treat depression more accurately than clinicians will again radically change the psychiatrist’s role. Most of a psychiatrist’s clinical work eventually will be replicated by machine learning and technicians. The human-to-human encounter that is at core of the profession will be replaced by the machine-to-human encounter.4
From the social economic perspective, the American health care system is designed to increase profit and maximize the earnings of the industries.5 Unless social policy changes, expensive new technologies will increase the cost and limit accessibility to health care, benefiting the few at the expense of the majority of people. These technologies will produce a robust return on investment, but the wealth they create will benefit fewer and fewer people.
Several writers have called attention to the social, economic, and ethical consequences of these advances and recommended that the academics and technologists who support AI and machine learning in medicine must “receive sufficient training in ethics” and gain exposure to social and economic issues.6 Darcy et al7 warns of the risks of introducing these advanced technologies in medicine: “As machine learning enters the state-of-the-art clinical practice, medicine thus has the immense obligation to ensure that this technology is harnessed for societal and individual good, fulfilling the ethical basis of the profession.… Ethical design thinking is essential at every stage of development and application of machine learning in advancing health. Toward this
Marco T. Carpio, MD
Psychiatrist, Private Practice
Lynbrook, New York
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Recent advances in neuroscience and genetics are providing a new view of brain function in health and disease.1 As discussed in Drs. Hripsime Kalanderian and Henry Nasrallah’s article “Artificial intelligence in psychiatry” (Evidence-Based Reviews,
In a 2016 article, Dr. Arshya Vahabzadeh2 wrote, “In the near term, humans will continue to make the majority of psychiatric diagnoses and provide treatment.” He predicted that data science—specifically machine learning—will help revolutionize how we diagnose, treat, and monitor depression. He foresees a future where AI machines or learning machines will more accurately diagnose and treat depression.
These predictions remind us of the promises made with the introduction of psychoactive drugs to the practice of psychiatry. In the 1970s, the increased emphasis on neurotransmitters led to new biologic models of mental illness and the expansion of the Diagnostic and Statistical Manual of Mental Disorders. The increased use of psychoactive medications relegated the practice of psychotherapy to other mental health professionals. Psychiatry became a “drug-intensive” specialty, and psychiatrists saw themselves as psychopharmacologists.3 During this time, psychiatry became progressively dominated by the pharmaceutical industry. The deregulation of the markets and the for-profit ideology of the pharmaceutical industry resulted in an economically and mutually beneficial alliance between pharmaceutical companies, academic faculty, and individual psychiatrists.
Using the same for-profit ideology and ethics of the pharmaceutical industry, technology-based corporations are making massive investments in the application of these technologies in neuroscience research and clinical practice. The “promise” that AI will diagnose and treat depression more accurately than clinicians will again radically change the psychiatrist’s role. Most of a psychiatrist’s clinical work eventually will be replicated by machine learning and technicians. The human-to-human encounter that is at core of the profession will be replaced by the machine-to-human encounter.4
From the social economic perspective, the American health care system is designed to increase profit and maximize the earnings of the industries.5 Unless social policy changes, expensive new technologies will increase the cost and limit accessibility to health care, benefiting the few at the expense of the majority of people. These technologies will produce a robust return on investment, but the wealth they create will benefit fewer and fewer people.
Several writers have called attention to the social, economic, and ethical consequences of these advances and recommended that the academics and technologists who support AI and machine learning in medicine must “receive sufficient training in ethics” and gain exposure to social and economic issues.6 Darcy et al7 warns of the risks of introducing these advanced technologies in medicine: “As machine learning enters the state-of-the-art clinical practice, medicine thus has the immense obligation to ensure that this technology is harnessed for societal and individual good, fulfilling the ethical basis of the profession.… Ethical design thinking is essential at every stage of development and application of machine learning in advancing health. Toward this
Marco T. Carpio, MD
Psychiatrist, Private Practice
Lynbrook, New York
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
1. Bargeman CI. How the new neuroscience will advance medicine. JAMA. 2015;314(3):221-222.
2. Vahabzadeh A. Can machine learning decode depression? Psychiatric News. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2016.4a3. Published April 11, 2016. Accessed October 16, 2019.
3. Angell M. The illusions of psychiatry. The New York Review. https://www.nybooks.com/articles/2011/07/14/illusions-of-psychiatry/. Published July 14, 2011. Accessed October 16, 2019.
4. Heath I, Nessa J. Objectification of physicians and loss of therapeutic power. Lancet. 2007;369(9565):886-888.
5. Wang D. Health care, American style: how did we arrive? Where will we go? Psychiatric Annals. 2014;44(7):342-348.
6. Nourbakhsh IR. The coming robot dystopia. Foreign Affairs. https://www.foreignaffairs.com/articles/2015-06-16/coming-robot-dystopia. Published July 2015. Accessed October 16, 2019.
7. Darcy AM, Louie AK, Roberts LW. Machine learning and the profession of medicine. JAMA. 2016;315(6):551-552.
1. Bargeman CI. How the new neuroscience will advance medicine. JAMA. 2015;314(3):221-222.
2. Vahabzadeh A. Can machine learning decode depression? Psychiatric News. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2016.4a3. Published April 11, 2016. Accessed October 16, 2019.
3. Angell M. The illusions of psychiatry. The New York Review. https://www.nybooks.com/articles/2011/07/14/illusions-of-psychiatry/. Published July 14, 2011. Accessed October 16, 2019.
4. Heath I, Nessa J. Objectification of physicians and loss of therapeutic power. Lancet. 2007;369(9565):886-888.
5. Wang D. Health care, American style: how did we arrive? Where will we go? Psychiatric Annals. 2014;44(7):342-348.
6. Nourbakhsh IR. The coming robot dystopia. Foreign Affairs. https://www.foreignaffairs.com/articles/2015-06-16/coming-robot-dystopia. Published July 2015. Accessed October 16, 2019.
7. Darcy AM, Louie AK, Roberts LW. Machine learning and the profession of medicine. JAMA. 2016;315(6):551-552.
Anathemas of psychiatric practice
The quarterly report of the State Medical Board can be a sobering read. In addition to the usual updates about new regulations or requirements for licensed physicians, there is always the disciplinary actions “blacklist” of dozens of medical practitioners in all specialties whose licenses were revoked or suspended due to a shocking array of serious violations.
Those infractions range from Medicare billing fraud to prescribing narcotics to fictitious patients to engaging in sex with a patient to walking into the operating room drunk. It is truly disheartening to see dozens of physicians destroy their careers by committing a panoply of odious, repugnant, or illegal actions.
The term “anathema” comes to mind when I read about those miscreants. This Greek term is occasionally used in scholarly or religious publications, but rarely in everyday conversations or articles. Anathema refers to something detested, shunned, or denounced. When used by the clergy, it connotes something to condemn, such as a sinful or evil act.
Like all other medical specialists, we psychiatrists have a noble mission of treating and relieving the suffering of those afflicted with brain disorders that manifest as mood, thought, perceptual, behavioral, or cognitive abnormalities. Our main goal is to restore health, wellness, and quality of life to the millions of individuals who buckle under the weight of genetic redispersion, adverse environmental events, or both. So psychiatrists do a lot of “good,” which benefits all those who live with mental illness. However, psychiatric practice may have some pitfalls that occasionally lead to anathemas, no matter how diligently a practitioner tries to avoid them. The code of psychiatric ethics is a shield that can preempt anathemas from contaminating clinical practice, but human error will occur when the ethical compass fails.
Here are some examples of anathemas that may rear their ugly heads if a practitioner is not constantly on the alert. It is likely you, the readers of
- Sexual contact with a patient. This major anathema must not occur under any circumstance. It will have grave professional consequences for the practitioner and serious emotional repercussions for the patient.
- Breach of confidentiality. This is a sacred rule in psychiatric practice that must not be broken under any circumstance. Breaching confidentiality will rupture the therapeutic bond and trust that a patient has with a psychiatrist (or psychiatric nurse practitioner).
- Causing physical or emotional harm. This anathema can have serious legal implications in addition to being an unacceptable professional violation.
- Failure to assess patients for suicidal or homicidal risk. The life of the patient, and others, may be at stake if this critical component is missing in the evaluation of psychiatric patients, even if they appear “stable.”
- Irrational and hazardous polypharmacy. This type of harm must never occur during medical management of psychiatric patients, and may have legal consequences.
- Not seeking collateral information. This may seem like a “minor” anathema, but it can have major repercussions if a gap of clinically important data about the patient leads to erroneous diagnosis or inappropriate treatment. Regrettably, informants are sometimes unavailable.
- Assessing patients from the neck up only. Psychiatrists are, first and foremost, physicians who must evaluate the entire medical status of the patient, not just his/her mind. There are numerous bidirectional effects between the body and the brain that can influence diagnosis, holistic treatment, medical outcomes, and prognosis.
- Treating patients with medication only, without any concomitant psychotherapy. Such a suboptimal practice is an anathema that is not excusable due to a “lack of time.” Every psychiatric patient deserves a biopsychosocial treatment approach.
- Not inquiring about adherence at every visit. It is impossible to assess the effectiveness of treatment if adherence is partial or poor. Patients must be constantly reminded that while their psychiatrists are committed to their care, full adherence is a vital responsibility for them to fulfill to ensure optimal outcome.
- Ignoring the patient’s cues, both verbal and nonverbal. Being rushed by a large workload, a full schedule, or the demands of electronic medical records that distract a psychiatrist from fully attending to what the patient’s words, facial expressions, or body language convey can lead to a failure to meet the patient’s needs. Even worse, it may lead to missing a serious message a patient is consciously or unconsciously trying to relay.
- Lowering expectations. Nothing is more devastating for patients than to feel that the psychiatrist does not believe he/she will ever achieve wellness, or that they are beyond help and will never improve, recover, or overcome disabling psychiatric illness. This will generate profound hopelessness in vulnerable patients, who crave having a normal life free from illness or disability.
- Using the same medication for all patients. This is an anathema because one size does not fit all, and patients deserve to have their psychiatrists customize their pharmacotherapy to match their medical status and tolerability. For example, the 11 FDA-approved second-generation antipsychotics are not all the same, and a psychiatrist must select the member of that class that is most likely to be a good match for each patient based on that patient’s medical history and the safety/tolerability profile of each antipsychotic.
- Not continuously upgrading one’s practice to incorporate new evidence-based findings of more effective therapeutic strategies. It is an anathema to continue practicing what was learned in residency 25 to 30 years ago when there’s new knowledge and many advances permeating psychiatric practice today.
- Using alcohol or recreational drugs during a shift in the clinic or the hospital. No explanation is needed for this anathema!
- Prescribing for patients without a full evaluation. That’s poor clinical practice, and also is illegal.
- Billing for patients who were never examined. That’s fraudulent, and stupid!
In an editorial I wrote last year intended for graduates of psychiatry residency training programs about the “DNA of psychiatric practice,” I described what comprises good psychiatric practice.1 Anathemas can be regarded as “mutations” within the DNA of psychiatric practice. It is always my hope that none of the freshly minted psychiatrists going into practice will ever commit an anathema, and end up on the “list of shame” in their State Medical Board’s quarterly report….
1. Nasrallah HA. The DNA of psychiatric practice: a covenant with our patients. Current Psychiatry. 2018;17(5):20,22.
The quarterly report of the State Medical Board can be a sobering read. In addition to the usual updates about new regulations or requirements for licensed physicians, there is always the disciplinary actions “blacklist” of dozens of medical practitioners in all specialties whose licenses were revoked or suspended due to a shocking array of serious violations.
Those infractions range from Medicare billing fraud to prescribing narcotics to fictitious patients to engaging in sex with a patient to walking into the operating room drunk. It is truly disheartening to see dozens of physicians destroy their careers by committing a panoply of odious, repugnant, or illegal actions.
The term “anathema” comes to mind when I read about those miscreants. This Greek term is occasionally used in scholarly or religious publications, but rarely in everyday conversations or articles. Anathema refers to something detested, shunned, or denounced. When used by the clergy, it connotes something to condemn, such as a sinful or evil act.
Like all other medical specialists, we psychiatrists have a noble mission of treating and relieving the suffering of those afflicted with brain disorders that manifest as mood, thought, perceptual, behavioral, or cognitive abnormalities. Our main goal is to restore health, wellness, and quality of life to the millions of individuals who buckle under the weight of genetic redispersion, adverse environmental events, or both. So psychiatrists do a lot of “good,” which benefits all those who live with mental illness. However, psychiatric practice may have some pitfalls that occasionally lead to anathemas, no matter how diligently a practitioner tries to avoid them. The code of psychiatric ethics is a shield that can preempt anathemas from contaminating clinical practice, but human error will occur when the ethical compass fails.
Here are some examples of anathemas that may rear their ugly heads if a practitioner is not constantly on the alert. It is likely you, the readers of
- Sexual contact with a patient. This major anathema must not occur under any circumstance. It will have grave professional consequences for the practitioner and serious emotional repercussions for the patient.
- Breach of confidentiality. This is a sacred rule in psychiatric practice that must not be broken under any circumstance. Breaching confidentiality will rupture the therapeutic bond and trust that a patient has with a psychiatrist (or psychiatric nurse practitioner).
- Causing physical or emotional harm. This anathema can have serious legal implications in addition to being an unacceptable professional violation.
- Failure to assess patients for suicidal or homicidal risk. The life of the patient, and others, may be at stake if this critical component is missing in the evaluation of psychiatric patients, even if they appear “stable.”
- Irrational and hazardous polypharmacy. This type of harm must never occur during medical management of psychiatric patients, and may have legal consequences.
- Not seeking collateral information. This may seem like a “minor” anathema, but it can have major repercussions if a gap of clinically important data about the patient leads to erroneous diagnosis or inappropriate treatment. Regrettably, informants are sometimes unavailable.
- Assessing patients from the neck up only. Psychiatrists are, first and foremost, physicians who must evaluate the entire medical status of the patient, not just his/her mind. There are numerous bidirectional effects between the body and the brain that can influence diagnosis, holistic treatment, medical outcomes, and prognosis.
- Treating patients with medication only, without any concomitant psychotherapy. Such a suboptimal practice is an anathema that is not excusable due to a “lack of time.” Every psychiatric patient deserves a biopsychosocial treatment approach.
- Not inquiring about adherence at every visit. It is impossible to assess the effectiveness of treatment if adherence is partial or poor. Patients must be constantly reminded that while their psychiatrists are committed to their care, full adherence is a vital responsibility for them to fulfill to ensure optimal outcome.
- Ignoring the patient’s cues, both verbal and nonverbal. Being rushed by a large workload, a full schedule, or the demands of electronic medical records that distract a psychiatrist from fully attending to what the patient’s words, facial expressions, or body language convey can lead to a failure to meet the patient’s needs. Even worse, it may lead to missing a serious message a patient is consciously or unconsciously trying to relay.
- Lowering expectations. Nothing is more devastating for patients than to feel that the psychiatrist does not believe he/she will ever achieve wellness, or that they are beyond help and will never improve, recover, or overcome disabling psychiatric illness. This will generate profound hopelessness in vulnerable patients, who crave having a normal life free from illness or disability.
- Using the same medication for all patients. This is an anathema because one size does not fit all, and patients deserve to have their psychiatrists customize their pharmacotherapy to match their medical status and tolerability. For example, the 11 FDA-approved second-generation antipsychotics are not all the same, and a psychiatrist must select the member of that class that is most likely to be a good match for each patient based on that patient’s medical history and the safety/tolerability profile of each antipsychotic.
- Not continuously upgrading one’s practice to incorporate new evidence-based findings of more effective therapeutic strategies. It is an anathema to continue practicing what was learned in residency 25 to 30 years ago when there’s new knowledge and many advances permeating psychiatric practice today.
- Using alcohol or recreational drugs during a shift in the clinic or the hospital. No explanation is needed for this anathema!
- Prescribing for patients without a full evaluation. That’s poor clinical practice, and also is illegal.
- Billing for patients who were never examined. That’s fraudulent, and stupid!
In an editorial I wrote last year intended for graduates of psychiatry residency training programs about the “DNA of psychiatric practice,” I described what comprises good psychiatric practice.1 Anathemas can be regarded as “mutations” within the DNA of psychiatric practice. It is always my hope that none of the freshly minted psychiatrists going into practice will ever commit an anathema, and end up on the “list of shame” in their State Medical Board’s quarterly report….
The quarterly report of the State Medical Board can be a sobering read. In addition to the usual updates about new regulations or requirements for licensed physicians, there is always the disciplinary actions “blacklist” of dozens of medical practitioners in all specialties whose licenses were revoked or suspended due to a shocking array of serious violations.
Those infractions range from Medicare billing fraud to prescribing narcotics to fictitious patients to engaging in sex with a patient to walking into the operating room drunk. It is truly disheartening to see dozens of physicians destroy their careers by committing a panoply of odious, repugnant, or illegal actions.
The term “anathema” comes to mind when I read about those miscreants. This Greek term is occasionally used in scholarly or religious publications, but rarely in everyday conversations or articles. Anathema refers to something detested, shunned, or denounced. When used by the clergy, it connotes something to condemn, such as a sinful or evil act.
Like all other medical specialists, we psychiatrists have a noble mission of treating and relieving the suffering of those afflicted with brain disorders that manifest as mood, thought, perceptual, behavioral, or cognitive abnormalities. Our main goal is to restore health, wellness, and quality of life to the millions of individuals who buckle under the weight of genetic redispersion, adverse environmental events, or both. So psychiatrists do a lot of “good,” which benefits all those who live with mental illness. However, psychiatric practice may have some pitfalls that occasionally lead to anathemas, no matter how diligently a practitioner tries to avoid them. The code of psychiatric ethics is a shield that can preempt anathemas from contaminating clinical practice, but human error will occur when the ethical compass fails.
Here are some examples of anathemas that may rear their ugly heads if a practitioner is not constantly on the alert. It is likely you, the readers of
- Sexual contact with a patient. This major anathema must not occur under any circumstance. It will have grave professional consequences for the practitioner and serious emotional repercussions for the patient.
- Breach of confidentiality. This is a sacred rule in psychiatric practice that must not be broken under any circumstance. Breaching confidentiality will rupture the therapeutic bond and trust that a patient has with a psychiatrist (or psychiatric nurse practitioner).
- Causing physical or emotional harm. This anathema can have serious legal implications in addition to being an unacceptable professional violation.
- Failure to assess patients for suicidal or homicidal risk. The life of the patient, and others, may be at stake if this critical component is missing in the evaluation of psychiatric patients, even if they appear “stable.”
- Irrational and hazardous polypharmacy. This type of harm must never occur during medical management of psychiatric patients, and may have legal consequences.
- Not seeking collateral information. This may seem like a “minor” anathema, but it can have major repercussions if a gap of clinically important data about the patient leads to erroneous diagnosis or inappropriate treatment. Regrettably, informants are sometimes unavailable.
- Assessing patients from the neck up only. Psychiatrists are, first and foremost, physicians who must evaluate the entire medical status of the patient, not just his/her mind. There are numerous bidirectional effects between the body and the brain that can influence diagnosis, holistic treatment, medical outcomes, and prognosis.
- Treating patients with medication only, without any concomitant psychotherapy. Such a suboptimal practice is an anathema that is not excusable due to a “lack of time.” Every psychiatric patient deserves a biopsychosocial treatment approach.
- Not inquiring about adherence at every visit. It is impossible to assess the effectiveness of treatment if adherence is partial or poor. Patients must be constantly reminded that while their psychiatrists are committed to their care, full adherence is a vital responsibility for them to fulfill to ensure optimal outcome.
- Ignoring the patient’s cues, both verbal and nonverbal. Being rushed by a large workload, a full schedule, or the demands of electronic medical records that distract a psychiatrist from fully attending to what the patient’s words, facial expressions, or body language convey can lead to a failure to meet the patient’s needs. Even worse, it may lead to missing a serious message a patient is consciously or unconsciously trying to relay.
- Lowering expectations. Nothing is more devastating for patients than to feel that the psychiatrist does not believe he/she will ever achieve wellness, or that they are beyond help and will never improve, recover, or overcome disabling psychiatric illness. This will generate profound hopelessness in vulnerable patients, who crave having a normal life free from illness or disability.
- Using the same medication for all patients. This is an anathema because one size does not fit all, and patients deserve to have their psychiatrists customize their pharmacotherapy to match their medical status and tolerability. For example, the 11 FDA-approved second-generation antipsychotics are not all the same, and a psychiatrist must select the member of that class that is most likely to be a good match for each patient based on that patient’s medical history and the safety/tolerability profile of each antipsychotic.
- Not continuously upgrading one’s practice to incorporate new evidence-based findings of more effective therapeutic strategies. It is an anathema to continue practicing what was learned in residency 25 to 30 years ago when there’s new knowledge and many advances permeating psychiatric practice today.
- Using alcohol or recreational drugs during a shift in the clinic or the hospital. No explanation is needed for this anathema!
- Prescribing for patients without a full evaluation. That’s poor clinical practice, and also is illegal.
- Billing for patients who were never examined. That’s fraudulent, and stupid!
In an editorial I wrote last year intended for graduates of psychiatry residency training programs about the “DNA of psychiatric practice,” I described what comprises good psychiatric practice.1 Anathemas can be regarded as “mutations” within the DNA of psychiatric practice. It is always my hope that none of the freshly minted psychiatrists going into practice will ever commit an anathema, and end up on the “list of shame” in their State Medical Board’s quarterly report….
1. Nasrallah HA. The DNA of psychiatric practice: a covenant with our patients. Current Psychiatry. 2018;17(5):20,22.
1. Nasrallah HA. The DNA of psychiatric practice: a covenant with our patients. Current Psychiatry. 2018;17(5):20,22.
