User login
Weighing the Benefits of Integrating AI-based Clinical Notes Into Your Practice
Picture a healthcare system where physicians aren’t bogged down by excessive charting but are instead fully present with their patients, offering undivided attention and personalized care. In a recent X post, Stuart Blitz, COO and co-founder of Hone Health, sparked a thought-provoking conversation. “The problem with US healthcare is physicians are burned out since they spend way too much time charting, not enough with patients,” he wrote. “If you created a health system that did zero charting, you’d attract the best physicians and all patients would go there. Who is working on this?”
This resonates with many in the medical community, myself included, because the strain of extensive documentation detracts from patient care. Having worked in both large and small healthcare systems, I know the burden of extensive charting is a palpable challenge, often detracting from the time we can devote to our patients.
The first part of this two-part series examines the overarching benefits of artificial intelligence (AI)–based clinical documentation in modern healthcare, a field witnessing a paradigm shift thanks to advancements in AI.
Transformative Evolution of Clinical Documentation
The transition from manual documentation to AI-driven solutions marks a significant shift in the field, with a number of products in development including Nuance, Abridge, Ambience, ScribeAmerica, 3M, and DeepScribe. These tools use ambient clinical intelligence (ACI) to automate documentation, capturing patient conversations and translating them into structured clinical summaries. This innovation aligns with the vision of reducing charting burdens and enhancing patient-physician interactions.
How does it work? ACI refers to a sophisticated form of AI applied in healthcare settings, particularly focusing on enhancing the clinical documentation process without disrupting the natural flow of the consultation. Here’s a technical yet practical breakdown of ACI and the algorithms it typically employs:
Data capture and processing: ACI systems employ various sensors and processing units, typically integrated into clinical settings. These sensors, like microphones and cameras, gather diverse data such as audio from patient-doctor dialogues and visual cues. This information is then processed in real-time or near–real-time.
Natural language processing (NLP): A core component of ACI is advanced NLP algorithms. These algorithms analyze the captured audio data, transcribing spoken words into text. NLP goes beyond mere transcription; it involves understanding context, extracting relevant medical information (like symptoms, diagnoses, and treatment plans), and interpreting the nuances of human language.
Deep learning: Machine learning, particularly deep-learning techniques, are employed to improve the accuracy of ACI systems continually. These algorithms can learn from vast datasets of clinical interactions, enhancing their ability to transcribe and interpret future conversations accurately. As they learn, they become better at understanding different accents, complex medical terms, and variations in speech patterns.
Integration with electronic health records (EHRs): ACI systems are often designed to integrate seamlessly with existing EHR systems. They can automatically populate patient records with information from patient-clinician interactions, reducing manual entry and potential errors.
Customization and personalization: Many ACI systems offer customizable templates or allow clinicians to tailor documentation workflows. This flexibility ensures that the output aligns with the specific needs and preferences of healthcare providers.
Ethical and privacy considerations: ACI systems must navigate significant ethical and privacy concerns, especially related to patient consent and data security. These systems need to comply with healthcare privacy regulations such as HIPAA. They need to securely manage sensitive patient data and restrict access to authorized personnel only.
Broad-Spectrum Benefits of AI in Documentation
- Reducing clinician burnout: By automating the documentation process, AI tools like DAX Copilot alleviate a significant contributor to physician burnout, enabling clinicians to focus more on patient care.
- Enhanced patient care: With AI handling documentation, clinicians can engage more with their patients, leading to improved care quality and patient satisfaction.
- Data accuracy and quality: AI-driven documentation captures detailed patient encounters accurately, ensuring high-quality and comprehensive medical records.
- Response to the growing need for efficient healthcare: AI-based documentation is a direct response to the growing call for more efficient healthcare practices, where clinicians spend less time on paperwork and more with patients.
The shift toward AI-based clinical documentation represents a critical step in addressing the inefficiencies in healthcare systems. It’s a move towards a more patient-centered approach, where clinicians can focus more on patient care by reducing the time spent on excessive charting. Hopefully, we can integrate these solutions into our clinics at a large enough scale to make such an impact.
In the next column, we will explore in-depth insights from Kenneth Harper at Nuance on the technical implementation of these tools, with DAX as an example.
I would love to read your comments on AI in clinical trials as well as other AI-related topics. Write me at [email protected] or find me on X @DrBonillaOnc.
Dr. Loaiza-Bonilla is the co-founder and chief medical officer at Massive Bio, a company connecting patients to clinical trials using artificial intelligence. His research and professional interests focus on precision medicine, clinical trial design, digital health, entrepreneurship, and patient advocacy. Dr Loaiza-Bonilla serves as medical director of oncology research at Capital Health in New Jersey, where he maintains a connection to patient care by attending to patients 2 days a week. He has served as a consultant for Verify, PSI CRO, Bayer, AstraZeneca, Cardinal Health, BrightInsight, The Lynx Group, Fresenius, Pfizer, Ipsen, and Guardant; served as a speaker or a member of a speakers bureau for Amgen, Guardant, Eisai, Ipsen, Natera, Merck, Bristol-Myers Squibb, and AstraZeneca. He holds a 5% or greater equity interest in Massive Bio.
A version of this article appeared on Medscape.com.
Picture a healthcare system where physicians aren’t bogged down by excessive charting but are instead fully present with their patients, offering undivided attention and personalized care. In a recent X post, Stuart Blitz, COO and co-founder of Hone Health, sparked a thought-provoking conversation. “The problem with US healthcare is physicians are burned out since they spend way too much time charting, not enough with patients,” he wrote. “If you created a health system that did zero charting, you’d attract the best physicians and all patients would go there. Who is working on this?”
This resonates with many in the medical community, myself included, because the strain of extensive documentation detracts from patient care. Having worked in both large and small healthcare systems, I know the burden of extensive charting is a palpable challenge, often detracting from the time we can devote to our patients.
The first part of this two-part series examines the overarching benefits of artificial intelligence (AI)–based clinical documentation in modern healthcare, a field witnessing a paradigm shift thanks to advancements in AI.
Transformative Evolution of Clinical Documentation
The transition from manual documentation to AI-driven solutions marks a significant shift in the field, with a number of products in development including Nuance, Abridge, Ambience, ScribeAmerica, 3M, and DeepScribe. These tools use ambient clinical intelligence (ACI) to automate documentation, capturing patient conversations and translating them into structured clinical summaries. This innovation aligns with the vision of reducing charting burdens and enhancing patient-physician interactions.
How does it work? ACI refers to a sophisticated form of AI applied in healthcare settings, particularly focusing on enhancing the clinical documentation process without disrupting the natural flow of the consultation. Here’s a technical yet practical breakdown of ACI and the algorithms it typically employs:
Data capture and processing: ACI systems employ various sensors and processing units, typically integrated into clinical settings. These sensors, like microphones and cameras, gather diverse data such as audio from patient-doctor dialogues and visual cues. This information is then processed in real-time or near–real-time.
Natural language processing (NLP): A core component of ACI is advanced NLP algorithms. These algorithms analyze the captured audio data, transcribing spoken words into text. NLP goes beyond mere transcription; it involves understanding context, extracting relevant medical information (like symptoms, diagnoses, and treatment plans), and interpreting the nuances of human language.
Deep learning: Machine learning, particularly deep-learning techniques, are employed to improve the accuracy of ACI systems continually. These algorithms can learn from vast datasets of clinical interactions, enhancing their ability to transcribe and interpret future conversations accurately. As they learn, they become better at understanding different accents, complex medical terms, and variations in speech patterns.
Integration with electronic health records (EHRs): ACI systems are often designed to integrate seamlessly with existing EHR systems. They can automatically populate patient records with information from patient-clinician interactions, reducing manual entry and potential errors.
Customization and personalization: Many ACI systems offer customizable templates or allow clinicians to tailor documentation workflows. This flexibility ensures that the output aligns with the specific needs and preferences of healthcare providers.
Ethical and privacy considerations: ACI systems must navigate significant ethical and privacy concerns, especially related to patient consent and data security. These systems need to comply with healthcare privacy regulations such as HIPAA. They need to securely manage sensitive patient data and restrict access to authorized personnel only.
Broad-Spectrum Benefits of AI in Documentation
- Reducing clinician burnout: By automating the documentation process, AI tools like DAX Copilot alleviate a significant contributor to physician burnout, enabling clinicians to focus more on patient care.
- Enhanced patient care: With AI handling documentation, clinicians can engage more with their patients, leading to improved care quality and patient satisfaction.
- Data accuracy and quality: AI-driven documentation captures detailed patient encounters accurately, ensuring high-quality and comprehensive medical records.
- Response to the growing need for efficient healthcare: AI-based documentation is a direct response to the growing call for more efficient healthcare practices, where clinicians spend less time on paperwork and more with patients.
The shift toward AI-based clinical documentation represents a critical step in addressing the inefficiencies in healthcare systems. It’s a move towards a more patient-centered approach, where clinicians can focus more on patient care by reducing the time spent on excessive charting. Hopefully, we can integrate these solutions into our clinics at a large enough scale to make such an impact.
In the next column, we will explore in-depth insights from Kenneth Harper at Nuance on the technical implementation of these tools, with DAX as an example.
I would love to read your comments on AI in clinical trials as well as other AI-related topics. Write me at [email protected] or find me on X @DrBonillaOnc.
Dr. Loaiza-Bonilla is the co-founder and chief medical officer at Massive Bio, a company connecting patients to clinical trials using artificial intelligence. His research and professional interests focus on precision medicine, clinical trial design, digital health, entrepreneurship, and patient advocacy. Dr Loaiza-Bonilla serves as medical director of oncology research at Capital Health in New Jersey, where he maintains a connection to patient care by attending to patients 2 days a week. He has served as a consultant for Verify, PSI CRO, Bayer, AstraZeneca, Cardinal Health, BrightInsight, The Lynx Group, Fresenius, Pfizer, Ipsen, and Guardant; served as a speaker or a member of a speakers bureau for Amgen, Guardant, Eisai, Ipsen, Natera, Merck, Bristol-Myers Squibb, and AstraZeneca. He holds a 5% or greater equity interest in Massive Bio.
A version of this article appeared on Medscape.com.
Picture a healthcare system where physicians aren’t bogged down by excessive charting but are instead fully present with their patients, offering undivided attention and personalized care. In a recent X post, Stuart Blitz, COO and co-founder of Hone Health, sparked a thought-provoking conversation. “The problem with US healthcare is physicians are burned out since they spend way too much time charting, not enough with patients,” he wrote. “If you created a health system that did zero charting, you’d attract the best physicians and all patients would go there. Who is working on this?”
This resonates with many in the medical community, myself included, because the strain of extensive documentation detracts from patient care. Having worked in both large and small healthcare systems, I know the burden of extensive charting is a palpable challenge, often detracting from the time we can devote to our patients.
The first part of this two-part series examines the overarching benefits of artificial intelligence (AI)–based clinical documentation in modern healthcare, a field witnessing a paradigm shift thanks to advancements in AI.
Transformative Evolution of Clinical Documentation
The transition from manual documentation to AI-driven solutions marks a significant shift in the field, with a number of products in development including Nuance, Abridge, Ambience, ScribeAmerica, 3M, and DeepScribe. These tools use ambient clinical intelligence (ACI) to automate documentation, capturing patient conversations and translating them into structured clinical summaries. This innovation aligns with the vision of reducing charting burdens and enhancing patient-physician interactions.
How does it work? ACI refers to a sophisticated form of AI applied in healthcare settings, particularly focusing on enhancing the clinical documentation process without disrupting the natural flow of the consultation. Here’s a technical yet practical breakdown of ACI and the algorithms it typically employs:
Data capture and processing: ACI systems employ various sensors and processing units, typically integrated into clinical settings. These sensors, like microphones and cameras, gather diverse data such as audio from patient-doctor dialogues and visual cues. This information is then processed in real-time or near–real-time.
Natural language processing (NLP): A core component of ACI is advanced NLP algorithms. These algorithms analyze the captured audio data, transcribing spoken words into text. NLP goes beyond mere transcription; it involves understanding context, extracting relevant medical information (like symptoms, diagnoses, and treatment plans), and interpreting the nuances of human language.
Deep learning: Machine learning, particularly deep-learning techniques, are employed to improve the accuracy of ACI systems continually. These algorithms can learn from vast datasets of clinical interactions, enhancing their ability to transcribe and interpret future conversations accurately. As they learn, they become better at understanding different accents, complex medical terms, and variations in speech patterns.
Integration with electronic health records (EHRs): ACI systems are often designed to integrate seamlessly with existing EHR systems. They can automatically populate patient records with information from patient-clinician interactions, reducing manual entry and potential errors.
Customization and personalization: Many ACI systems offer customizable templates or allow clinicians to tailor documentation workflows. This flexibility ensures that the output aligns with the specific needs and preferences of healthcare providers.
Ethical and privacy considerations: ACI systems must navigate significant ethical and privacy concerns, especially related to patient consent and data security. These systems need to comply with healthcare privacy regulations such as HIPAA. They need to securely manage sensitive patient data and restrict access to authorized personnel only.
Broad-Spectrum Benefits of AI in Documentation
- Reducing clinician burnout: By automating the documentation process, AI tools like DAX Copilot alleviate a significant contributor to physician burnout, enabling clinicians to focus more on patient care.
- Enhanced patient care: With AI handling documentation, clinicians can engage more with their patients, leading to improved care quality and patient satisfaction.
- Data accuracy and quality: AI-driven documentation captures detailed patient encounters accurately, ensuring high-quality and comprehensive medical records.
- Response to the growing need for efficient healthcare: AI-based documentation is a direct response to the growing call for more efficient healthcare practices, where clinicians spend less time on paperwork and more with patients.
The shift toward AI-based clinical documentation represents a critical step in addressing the inefficiencies in healthcare systems. It’s a move towards a more patient-centered approach, where clinicians can focus more on patient care by reducing the time spent on excessive charting. Hopefully, we can integrate these solutions into our clinics at a large enough scale to make such an impact.
In the next column, we will explore in-depth insights from Kenneth Harper at Nuance on the technical implementation of these tools, with DAX as an example.
I would love to read your comments on AI in clinical trials as well as other AI-related topics. Write me at [email protected] or find me on X @DrBonillaOnc.
Dr. Loaiza-Bonilla is the co-founder and chief medical officer at Massive Bio, a company connecting patients to clinical trials using artificial intelligence. His research and professional interests focus on precision medicine, clinical trial design, digital health, entrepreneurship, and patient advocacy. Dr Loaiza-Bonilla serves as medical director of oncology research at Capital Health in New Jersey, where he maintains a connection to patient care by attending to patients 2 days a week. He has served as a consultant for Verify, PSI CRO, Bayer, AstraZeneca, Cardinal Health, BrightInsight, The Lynx Group, Fresenius, Pfizer, Ipsen, and Guardant; served as a speaker or a member of a speakers bureau for Amgen, Guardant, Eisai, Ipsen, Natera, Merck, Bristol-Myers Squibb, and AstraZeneca. He holds a 5% or greater equity interest in Massive Bio.
A version of this article appeared on Medscape.com.
Burnout
In last month’s column, I discussed employees who are “clock watchers” and how to address this issue in your practice if it exists. Here’s another scenario you may encounter from the Office Politics Forum at the recent American Academy of Dermatology annual meeting:
A 40-year-old dermatologist has practiced in the same office since residency and is loved by patients and staff. He remained with the practice through its takeover by a local hospital three years previously. Recently, over a 3-month period, everyone in the office notices a change in this dermatologist’s behavior. He no longer appears happy, is argumentative with staff and patients alike, often dismisses patients’ concerns, and calls in sick during the practice’s busiest days.
. According to the American Medical Association’s National Burnout Benchmarking report, over 50% of physicians report some characteristics of burnout, which include emotional exhaustion, depersonalization, and a feeling of decreased personal achievement.
The causes of physician burnout are multifactorial and vary in importance, depending on the individual and on which authorities you consult. Here are some of the most prevalent, based on my experience and research:
Bureaucratic and Administrative Tasks: The burden of paperwork and other administrative responsibilities has increased, consuming time that could be spent on patient care or personal well-being.
Electronic Health Record (EHR) Stress: As I (and many others) have predicted for decades, the demands of EHR documentation and the associated clerical tasks have become a major source of what is now called “technostress,” detracting from the efficiency and effectiveness of healthcare delivery.
Insurance and Regulatory Demands: Navigating insurance appeals and prior authorizations, meeting regulatory requirements, and dealing with the complexities of healthcare reimbursement systems add to the stress and frustration experienced by physicians.
Lack of Autonomy and Control: As small practices consolidate, physicians often face constraints on their professional autonomy, with limited control over their work environment, schedules, and clinical decision-making, leading to feelings of helplessness and dissatisfaction.
Emotional Exhaustion from Patient Care: The emotional toll of caring for patients, especially in high-stakes or emotionally charged specialties, can lead to compassion fatigue and burnout. This may account for the results of a 2023 Medscape report in which physicians reporting the most burnout worked in emergency medicine, internal medicine, pediatrics, obstetrics/gynecology, and infectious diseases.
Work-Life Imbalance: The demanding nature of the profession often leads to difficulties in balancing professional responsibilities with personal life, contributing to burnout.
Inadequate Support and Recognition: A lack of support from healthcare institutions and insufficient recognition of the challenges faced by physicians can exacerbate feelings of isolation and undervaluation.
Addressing physician burnout requires a systems-based approach that targets these root causes at all levels, from individual coping strategies to organizational and systemic changes in the healthcare industry. Here are some strategies that have worked for me and others:
Optimize Practice Efficiency: This is the consistent theme of this column over several decades: Streamline office processes to enhance the quality of care while reducing unnecessary workload. This can involve adopting efficient patient scheduling systems, improving clinic flow, and utilizing technology like patient portals judiciously to avoid increasing the task load without compensation.
Promote Work-Life Balance: Encourage a culture that values work-life balance. This can include flexible scheduling, respecting off-duty hours by limiting non-emergency work communications, and using your vacation time. Remember Eastern’s First Law: Your last words will NOT be, “I wish I had spent more time in the office.”
Implement Medical Scribes: I’ve written frequently about this, including a recent column on the new artificial intelligence (AI) scribes, such as DeepCura, DeepScribe, Nuance, Suki, Augmedix, Tali AI, Iodine Software, ScribeLink, and Amazon Web Services’ new HealthScribe product. Utilizing medical scribes to handle documentation can significantly reduce the administrative burden, allowing physicians to focus more on patient care rather than paperwork, potentially improving both physician and patient satisfaction. (As always, I have no financial interest in any product or service mentioned in this column.)
Provide Professional Development Opportunities: Offer opportunities for professional growth and development. This can include attending conferences, participating in research, or providing time and resources for continuing education. Such opportunities can reinvigorate a physician’s passion for medicine and improve job satisfaction.
Foster a Supportive Work Environment: Create a supportive work culture where staff and physicians feel comfortable discussing challenges and seeking support. Regular meetings or check-ins can help identify early signs of burnout and address them proactively.
Evaluate and Adjust Workloads: Regularly assess physician workloads to ensure they are manageable. Adjusting patient loads, redistributing tasks among team members, or hiring additional staff can help prevent burnout.
Leadership Training and Support: Provide training for leaders within the practice on recognizing signs of burnout and effective management strategies. Supportive leadership is crucial in creating an environment where physicians feel valued and heard.
Peer Support and Mentorship Programs: Establish peer support or mentorship programs where physicians can share experiences, offer advice, and provide emotional support to each other.
Feedback and Continuous Improvement: Managers should regularly solicit feedback from physicians regarding their workload, job satisfaction, and suggestions for improvements. Actively work on implementing feasible changes to address concerns.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
In last month’s column, I discussed employees who are “clock watchers” and how to address this issue in your practice if it exists. Here’s another scenario you may encounter from the Office Politics Forum at the recent American Academy of Dermatology annual meeting:
A 40-year-old dermatologist has practiced in the same office since residency and is loved by patients and staff. He remained with the practice through its takeover by a local hospital three years previously. Recently, over a 3-month period, everyone in the office notices a change in this dermatologist’s behavior. He no longer appears happy, is argumentative with staff and patients alike, often dismisses patients’ concerns, and calls in sick during the practice’s busiest days.
. According to the American Medical Association’s National Burnout Benchmarking report, over 50% of physicians report some characteristics of burnout, which include emotional exhaustion, depersonalization, and a feeling of decreased personal achievement.
The causes of physician burnout are multifactorial and vary in importance, depending on the individual and on which authorities you consult. Here are some of the most prevalent, based on my experience and research:
Bureaucratic and Administrative Tasks: The burden of paperwork and other administrative responsibilities has increased, consuming time that could be spent on patient care or personal well-being.
Electronic Health Record (EHR) Stress: As I (and many others) have predicted for decades, the demands of EHR documentation and the associated clerical tasks have become a major source of what is now called “technostress,” detracting from the efficiency and effectiveness of healthcare delivery.
Insurance and Regulatory Demands: Navigating insurance appeals and prior authorizations, meeting regulatory requirements, and dealing with the complexities of healthcare reimbursement systems add to the stress and frustration experienced by physicians.
Lack of Autonomy and Control: As small practices consolidate, physicians often face constraints on their professional autonomy, with limited control over their work environment, schedules, and clinical decision-making, leading to feelings of helplessness and dissatisfaction.
Emotional Exhaustion from Patient Care: The emotional toll of caring for patients, especially in high-stakes or emotionally charged specialties, can lead to compassion fatigue and burnout. This may account for the results of a 2023 Medscape report in which physicians reporting the most burnout worked in emergency medicine, internal medicine, pediatrics, obstetrics/gynecology, and infectious diseases.
Work-Life Imbalance: The demanding nature of the profession often leads to difficulties in balancing professional responsibilities with personal life, contributing to burnout.
Inadequate Support and Recognition: A lack of support from healthcare institutions and insufficient recognition of the challenges faced by physicians can exacerbate feelings of isolation and undervaluation.
Addressing physician burnout requires a systems-based approach that targets these root causes at all levels, from individual coping strategies to organizational and systemic changes in the healthcare industry. Here are some strategies that have worked for me and others:
Optimize Practice Efficiency: This is the consistent theme of this column over several decades: Streamline office processes to enhance the quality of care while reducing unnecessary workload. This can involve adopting efficient patient scheduling systems, improving clinic flow, and utilizing technology like patient portals judiciously to avoid increasing the task load without compensation.
Promote Work-Life Balance: Encourage a culture that values work-life balance. This can include flexible scheduling, respecting off-duty hours by limiting non-emergency work communications, and using your vacation time. Remember Eastern’s First Law: Your last words will NOT be, “I wish I had spent more time in the office.”
Implement Medical Scribes: I’ve written frequently about this, including a recent column on the new artificial intelligence (AI) scribes, such as DeepCura, DeepScribe, Nuance, Suki, Augmedix, Tali AI, Iodine Software, ScribeLink, and Amazon Web Services’ new HealthScribe product. Utilizing medical scribes to handle documentation can significantly reduce the administrative burden, allowing physicians to focus more on patient care rather than paperwork, potentially improving both physician and patient satisfaction. (As always, I have no financial interest in any product or service mentioned in this column.)
Provide Professional Development Opportunities: Offer opportunities for professional growth and development. This can include attending conferences, participating in research, or providing time and resources for continuing education. Such opportunities can reinvigorate a physician’s passion for medicine and improve job satisfaction.
Foster a Supportive Work Environment: Create a supportive work culture where staff and physicians feel comfortable discussing challenges and seeking support. Regular meetings or check-ins can help identify early signs of burnout and address them proactively.
Evaluate and Adjust Workloads: Regularly assess physician workloads to ensure they are manageable. Adjusting patient loads, redistributing tasks among team members, or hiring additional staff can help prevent burnout.
Leadership Training and Support: Provide training for leaders within the practice on recognizing signs of burnout and effective management strategies. Supportive leadership is crucial in creating an environment where physicians feel valued and heard.
Peer Support and Mentorship Programs: Establish peer support or mentorship programs where physicians can share experiences, offer advice, and provide emotional support to each other.
Feedback and Continuous Improvement: Managers should regularly solicit feedback from physicians regarding their workload, job satisfaction, and suggestions for improvements. Actively work on implementing feasible changes to address concerns.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
In last month’s column, I discussed employees who are “clock watchers” and how to address this issue in your practice if it exists. Here’s another scenario you may encounter from the Office Politics Forum at the recent American Academy of Dermatology annual meeting:
A 40-year-old dermatologist has practiced in the same office since residency and is loved by patients and staff. He remained with the practice through its takeover by a local hospital three years previously. Recently, over a 3-month period, everyone in the office notices a change in this dermatologist’s behavior. He no longer appears happy, is argumentative with staff and patients alike, often dismisses patients’ concerns, and calls in sick during the practice’s busiest days.
. According to the American Medical Association’s National Burnout Benchmarking report, over 50% of physicians report some characteristics of burnout, which include emotional exhaustion, depersonalization, and a feeling of decreased personal achievement.
The causes of physician burnout are multifactorial and vary in importance, depending on the individual and on which authorities you consult. Here are some of the most prevalent, based on my experience and research:
Bureaucratic and Administrative Tasks: The burden of paperwork and other administrative responsibilities has increased, consuming time that could be spent on patient care or personal well-being.
Electronic Health Record (EHR) Stress: As I (and many others) have predicted for decades, the demands of EHR documentation and the associated clerical tasks have become a major source of what is now called “technostress,” detracting from the efficiency and effectiveness of healthcare delivery.
Insurance and Regulatory Demands: Navigating insurance appeals and prior authorizations, meeting regulatory requirements, and dealing with the complexities of healthcare reimbursement systems add to the stress and frustration experienced by physicians.
Lack of Autonomy and Control: As small practices consolidate, physicians often face constraints on their professional autonomy, with limited control over their work environment, schedules, and clinical decision-making, leading to feelings of helplessness and dissatisfaction.
Emotional Exhaustion from Patient Care: The emotional toll of caring for patients, especially in high-stakes or emotionally charged specialties, can lead to compassion fatigue and burnout. This may account for the results of a 2023 Medscape report in which physicians reporting the most burnout worked in emergency medicine, internal medicine, pediatrics, obstetrics/gynecology, and infectious diseases.
Work-Life Imbalance: The demanding nature of the profession often leads to difficulties in balancing professional responsibilities with personal life, contributing to burnout.
Inadequate Support and Recognition: A lack of support from healthcare institutions and insufficient recognition of the challenges faced by physicians can exacerbate feelings of isolation and undervaluation.
Addressing physician burnout requires a systems-based approach that targets these root causes at all levels, from individual coping strategies to organizational and systemic changes in the healthcare industry. Here are some strategies that have worked for me and others:
Optimize Practice Efficiency: This is the consistent theme of this column over several decades: Streamline office processes to enhance the quality of care while reducing unnecessary workload. This can involve adopting efficient patient scheduling systems, improving clinic flow, and utilizing technology like patient portals judiciously to avoid increasing the task load without compensation.
Promote Work-Life Balance: Encourage a culture that values work-life balance. This can include flexible scheduling, respecting off-duty hours by limiting non-emergency work communications, and using your vacation time. Remember Eastern’s First Law: Your last words will NOT be, “I wish I had spent more time in the office.”
Implement Medical Scribes: I’ve written frequently about this, including a recent column on the new artificial intelligence (AI) scribes, such as DeepCura, DeepScribe, Nuance, Suki, Augmedix, Tali AI, Iodine Software, ScribeLink, and Amazon Web Services’ new HealthScribe product. Utilizing medical scribes to handle documentation can significantly reduce the administrative burden, allowing physicians to focus more on patient care rather than paperwork, potentially improving both physician and patient satisfaction. (As always, I have no financial interest in any product or service mentioned in this column.)
Provide Professional Development Opportunities: Offer opportunities for professional growth and development. This can include attending conferences, participating in research, or providing time and resources for continuing education. Such opportunities can reinvigorate a physician’s passion for medicine and improve job satisfaction.
Foster a Supportive Work Environment: Create a supportive work culture where staff and physicians feel comfortable discussing challenges and seeking support. Regular meetings or check-ins can help identify early signs of burnout and address them proactively.
Evaluate and Adjust Workloads: Regularly assess physician workloads to ensure they are manageable. Adjusting patient loads, redistributing tasks among team members, or hiring additional staff can help prevent burnout.
Leadership Training and Support: Provide training for leaders within the practice on recognizing signs of burnout and effective management strategies. Supportive leadership is crucial in creating an environment where physicians feel valued and heard.
Peer Support and Mentorship Programs: Establish peer support or mentorship programs where physicians can share experiences, offer advice, and provide emotional support to each other.
Feedback and Continuous Improvement: Managers should regularly solicit feedback from physicians regarding their workload, job satisfaction, and suggestions for improvements. Actively work on implementing feasible changes to address concerns.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
‘Difficult Patient’: Stigmatizing Words and Medical Error
This transcript has been edited for clarity.
When I was doing my nephrology training, I had an attending who would write notes that were, well, kind of funny. I remember one time we were seeing a patient whose first name was “Lucky.” He dryly opened his section of the consult note as follows: “This is a 56-year-old woman with an ironic name who presents with acute renal failure.”
As an exhausted renal fellow, I appreciated the bit of color amid the ongoing series of tragedies that was the consult service. But let’s be clear — writing like this in the medical record is not a good idea. It wasn’t a good idea then, when any record might end up disclosed during a malpractice suit, and it’s really not a good idea now, when patients have ready and automated access to all the notes we write about them.
And yet, worse language than that of my attending appears in hospital notes all the time; there is research about this. Specifically, I’m talking about language that does not have high clinical utility but telegraphs the biases of the person writing the note. This is known as “stigmatizing language” and it can be overt or subtle.
For example, a physician wrote “I listed several fictitious medication names and she reported she was taking them.”
This casts suspicions about the patient’s credibility, as does the more subtle statement, “he claims nicotine patches don’t work for him.” Stigmatizing language may cast the patient in a difficult light, like this note: “she persevered on the fact that ... ‘you wouldn’t understand.’ ”
Stay with me.
We are going to start by defining a very sick patient population: those admitted to the hospital and who, within 48 hours, have either been transferred to the intensive care unit or died. Because of the severity of illness in this population we’ve just defined, figuring out whether a diagnostic or other error was made would be extremely high yield; these can mean the difference between life and death.
In a letter appearing in JAMA Internal Medicine, researchers examined a group of more than 2300 patients just like this from 29 hospitals, scouring the medical records for evidence of these types of errors.
Nearly one in four (23.2%) had at least one diagnostic error, which could include a missed physical exam finding, failure to ask a key question on history taking, inadequate testing, and so on.
Understanding why we make these errors is clearly critical to improving care for these patients. The researchers hypothesized that stigmatizing language might lead to errors like this. For example, by demonstrating that you don’t find a patient credible, you may ignore statements that would help make a better diagnosis.
Just over 5% of these patients had evidence of stigmatizing language in their medical notes. Like earlier studies, this language was more common if the patient was Black or had unstable housing.
Critically, stigmatizing language was more likely to be found among those who had diagnostic errors — a rate of 8.2% vs 4.1%. After adjustment for factors like race, the presence of stigmatizing language was associated with roughly a doubling of the risk for diagnostic errors.
Now, I’m all for eliminating stigmatizing language from our medical notes. And, given the increased transparency of all medical notes these days, I expect that we’ll see less of this over time. But of course, the fact that a physician doesn’t write something that disparages the patient does not necessarily mean that they don’t retain that bias. That said, those comments have an effect on all the other team members who care for that patient as well; it sets a tone and can entrench an individual’s bias more broadly. We should strive to eliminate our biases when it comes to caring for patients. But perhaps the second best thing is to work to keep those biases to ourselves.
Dr. Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
When I was doing my nephrology training, I had an attending who would write notes that were, well, kind of funny. I remember one time we were seeing a patient whose first name was “Lucky.” He dryly opened his section of the consult note as follows: “This is a 56-year-old woman with an ironic name who presents with acute renal failure.”
As an exhausted renal fellow, I appreciated the bit of color amid the ongoing series of tragedies that was the consult service. But let’s be clear — writing like this in the medical record is not a good idea. It wasn’t a good idea then, when any record might end up disclosed during a malpractice suit, and it’s really not a good idea now, when patients have ready and automated access to all the notes we write about them.
And yet, worse language than that of my attending appears in hospital notes all the time; there is research about this. Specifically, I’m talking about language that does not have high clinical utility but telegraphs the biases of the person writing the note. This is known as “stigmatizing language” and it can be overt or subtle.
For example, a physician wrote “I listed several fictitious medication names and she reported she was taking them.”
This casts suspicions about the patient’s credibility, as does the more subtle statement, “he claims nicotine patches don’t work for him.” Stigmatizing language may cast the patient in a difficult light, like this note: “she persevered on the fact that ... ‘you wouldn’t understand.’ ”
Stay with me.
We are going to start by defining a very sick patient population: those admitted to the hospital and who, within 48 hours, have either been transferred to the intensive care unit or died. Because of the severity of illness in this population we’ve just defined, figuring out whether a diagnostic or other error was made would be extremely high yield; these can mean the difference between life and death.
In a letter appearing in JAMA Internal Medicine, researchers examined a group of more than 2300 patients just like this from 29 hospitals, scouring the medical records for evidence of these types of errors.
Nearly one in four (23.2%) had at least one diagnostic error, which could include a missed physical exam finding, failure to ask a key question on history taking, inadequate testing, and so on.
Understanding why we make these errors is clearly critical to improving care for these patients. The researchers hypothesized that stigmatizing language might lead to errors like this. For example, by demonstrating that you don’t find a patient credible, you may ignore statements that would help make a better diagnosis.
Just over 5% of these patients had evidence of stigmatizing language in their medical notes. Like earlier studies, this language was more common if the patient was Black or had unstable housing.
Critically, stigmatizing language was more likely to be found among those who had diagnostic errors — a rate of 8.2% vs 4.1%. After adjustment for factors like race, the presence of stigmatizing language was associated with roughly a doubling of the risk for diagnostic errors.
Now, I’m all for eliminating stigmatizing language from our medical notes. And, given the increased transparency of all medical notes these days, I expect that we’ll see less of this over time. But of course, the fact that a physician doesn’t write something that disparages the patient does not necessarily mean that they don’t retain that bias. That said, those comments have an effect on all the other team members who care for that patient as well; it sets a tone and can entrench an individual’s bias more broadly. We should strive to eliminate our biases when it comes to caring for patients. But perhaps the second best thing is to work to keep those biases to ourselves.
Dr. Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
When I was doing my nephrology training, I had an attending who would write notes that were, well, kind of funny. I remember one time we were seeing a patient whose first name was “Lucky.” He dryly opened his section of the consult note as follows: “This is a 56-year-old woman with an ironic name who presents with acute renal failure.”
As an exhausted renal fellow, I appreciated the bit of color amid the ongoing series of tragedies that was the consult service. But let’s be clear — writing like this in the medical record is not a good idea. It wasn’t a good idea then, when any record might end up disclosed during a malpractice suit, and it’s really not a good idea now, when patients have ready and automated access to all the notes we write about them.
And yet, worse language than that of my attending appears in hospital notes all the time; there is research about this. Specifically, I’m talking about language that does not have high clinical utility but telegraphs the biases of the person writing the note. This is known as “stigmatizing language” and it can be overt or subtle.
For example, a physician wrote “I listed several fictitious medication names and she reported she was taking them.”
This casts suspicions about the patient’s credibility, as does the more subtle statement, “he claims nicotine patches don’t work for him.” Stigmatizing language may cast the patient in a difficult light, like this note: “she persevered on the fact that ... ‘you wouldn’t understand.’ ”
Stay with me.
We are going to start by defining a very sick patient population: those admitted to the hospital and who, within 48 hours, have either been transferred to the intensive care unit or died. Because of the severity of illness in this population we’ve just defined, figuring out whether a diagnostic or other error was made would be extremely high yield; these can mean the difference between life and death.
In a letter appearing in JAMA Internal Medicine, researchers examined a group of more than 2300 patients just like this from 29 hospitals, scouring the medical records for evidence of these types of errors.
Nearly one in four (23.2%) had at least one diagnostic error, which could include a missed physical exam finding, failure to ask a key question on history taking, inadequate testing, and so on.
Understanding why we make these errors is clearly critical to improving care for these patients. The researchers hypothesized that stigmatizing language might lead to errors like this. For example, by demonstrating that you don’t find a patient credible, you may ignore statements that would help make a better diagnosis.
Just over 5% of these patients had evidence of stigmatizing language in their medical notes. Like earlier studies, this language was more common if the patient was Black or had unstable housing.
Critically, stigmatizing language was more likely to be found among those who had diagnostic errors — a rate of 8.2% vs 4.1%. After adjustment for factors like race, the presence of stigmatizing language was associated with roughly a doubling of the risk for diagnostic errors.
Now, I’m all for eliminating stigmatizing language from our medical notes. And, given the increased transparency of all medical notes these days, I expect that we’ll see less of this over time. But of course, the fact that a physician doesn’t write something that disparages the patient does not necessarily mean that they don’t retain that bias. That said, those comments have an effect on all the other team members who care for that patient as well; it sets a tone and can entrench an individual’s bias more broadly. We should strive to eliminate our biases when it comes to caring for patients. But perhaps the second best thing is to work to keep those biases to ourselves.
Dr. Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Meat Linked to Higher Erectile Dysfunction Risk
Rachel S. Rubin, MD: Welcome to another episode of Sex Matters. I’m Dr. Rachel Rubin. I’m a urologist and sexual medicine specialist based in the Washington, DC area, and I interview amazingly cool people doing research in sexual medicine.
I heard an incredible lecture while I was at the Mayo Clinic urology conference by Dr. Stacy Loeb, who is a wonderful researcher of all things prostate cancer and men’s health, who is now talking more plant-based diets. Her lecture was so good, I begged her to join me for this discussion.
Dr. Loeb, I would love for you to introduce yourself.
Stacy Loeb, MD: I’m Dr. Loeb. I’m a urologist at New York University in the Manhattan VA, and I recently became board certified in lifestyle medicine because it’s so important for sexual health and, really, everything that we do.
Dr. Rubin: You recently became very interested in studying plant-based diets. How did that start, and how has the research evolved over time?
Dr. Loeb: It’s really amazing. For one thing, more of our patients with prostate cancer die of heart disease than of prostate cancer. And erectile dysfunction is really an early warning sign of cardiovascular disease. We felt like it was incumbent upon us, even within urology and sexual medicine, to better understand the basis for lifestyle modification that can help with these issues.
Dr. Rubin: Tell us more about what you found for erectile dysfunction. How much benefit do people get by switching to a plant-based diet?
Dr. Loeb: First we looked at erectile function in men without prostate cancer in the health professionals follow-up study, a very large cohort study out of Harvard University. We found that among omnivorous people, those who ate more plant-based and less animal-based food were less likely to have incident erectile dysfunction. Then, we published a new paper looking at patients with prostate cancer. These men have extra challenges for sexual function because in addition to the standard cardiovascular changes with aging, prostate cancer treatment can affect the nerves that are involved in erections. But amazingly, even in that population, we found that the men who ate more plant-based and less animal-based food had better scores for erectile function.
That was really good news, and it’s a win-win. There is no reason not to counsel our patients to eat more plant-based foods. Meat is not masculine. Meat is associated with a higher risk for erectile dysfunction and is considered carcinogenic. It’s just something that we should try to stay away from.
Dr. Rubin: How do you counsel patients who might not be ready to go fully plant-based? Is a little better than nothing? How do you even start these conversations with people? Do you have any tips for primary care doctors?
Dr. Loeb: Great question. A little bit is very much better than nothing. In fact, in the health professionals follow-up study, we actually looked at quintiles of people who ate the most meat and animal-based foods and the least plant-based foods all the way up to the most plant-based and the least animal-based diets. Along that spectrum, it really does make a big difference. Anywhere that patients can start from is definitely better than nothing.
Simple things such as Meatless Monday or choosing a few days that they will give up animal-based foods will help. For some people, trying new things is easier than cutting things out, for example, trying a milk substitute such as oat, almond, or soy milk instead of dairy milk. That could be a great first step, or trying some dishes that don’t include meat — maybe a tofu stir fry or a taco or burrito without the meat.
There are many great options out there. In terms of resources for doctors, the Physicians Committee for Responsible Medicine has a great website. They have fact sheets for a lot of the common questions that people ask such as how can I get enough protein or calcium on a plant-based diet? This isn’t a problem at all. In fact, Novak Djokovic and many other elite athletes eat plant-based diets, and they get enough protein with a much higher requirement than most of us who are not elite athletes. These fact sheets explain which plant foods are the best
I also like Nutritionfacts.org. They also have all kinds of great videos and resources. Both of these websites have recipes that were created by doctors and nutritionists.
We can suggest that our patients work with a nutritionist or join a virtual program. For example, Plant Powered here in New York has virtual plant-based jumpstart programs. People around the country can get in on programs that have nutritionists and health coaches — for people who want a boost.
Dr. Rubin: The data are really compelling. When you were speaking, not a person in the room was interested in having a steak that night for dinner, even with a steakhouse in the hotel.
What do you say to men who have prostate cancer or suffer from erectile dysfunction? Do any data show that by going plant-based you may show improvements? We have recent studies that show that regular exercise might be as good as Viagra.
Dr. Loeb: It’s definitely not too late, even if you’ve already been diagnosed with these conditions. In my own practice, I have seen changes in patients. In fact, one of the case scenarios that I submitted for the lifestyle medicine boards was a patient who adopted a whole food, plant-based diet and no longer uses Viagra. This is definitely something that’s possible to do with intensive lifestyle modification.
Dr. Rubin: Maybe vegetables are the new sexual health aide. How can people find out more? I know you have a Sirius XM radio show.
Dr. Loeb: It’s the Men’s Health Show on Sirius XM channel 110. It’s on Wednesdays from 6:00 to 8:00 PM ET, or you can listen to it on demand anytime through the Sirius XM app.
Dr. Rubin: You have done an enormous amount of research in prostate cancer and sexual medicine. You are an all-star in the field. Thank you for sharing all of your knowledge about plant-based diets. You’ve given us all a lot to think about today.
Dr. Rubin has disclosed the following relevant financial relationships: Serve(d) as a speaker for Sprout; received research grant from Maternal Medical; received income in an amount equal to or greater than $250 from Absorption Pharmaceuticals, GSK, and Endo.
A version of this article appeared on Medscape.com.
Rachel S. Rubin, MD: Welcome to another episode of Sex Matters. I’m Dr. Rachel Rubin. I’m a urologist and sexual medicine specialist based in the Washington, DC area, and I interview amazingly cool people doing research in sexual medicine.
I heard an incredible lecture while I was at the Mayo Clinic urology conference by Dr. Stacy Loeb, who is a wonderful researcher of all things prostate cancer and men’s health, who is now talking more plant-based diets. Her lecture was so good, I begged her to join me for this discussion.
Dr. Loeb, I would love for you to introduce yourself.
Stacy Loeb, MD: I’m Dr. Loeb. I’m a urologist at New York University in the Manhattan VA, and I recently became board certified in lifestyle medicine because it’s so important for sexual health and, really, everything that we do.
Dr. Rubin: You recently became very interested in studying plant-based diets. How did that start, and how has the research evolved over time?
Dr. Loeb: It’s really amazing. For one thing, more of our patients with prostate cancer die of heart disease than of prostate cancer. And erectile dysfunction is really an early warning sign of cardiovascular disease. We felt like it was incumbent upon us, even within urology and sexual medicine, to better understand the basis for lifestyle modification that can help with these issues.
Dr. Rubin: Tell us more about what you found for erectile dysfunction. How much benefit do people get by switching to a plant-based diet?
Dr. Loeb: First we looked at erectile function in men without prostate cancer in the health professionals follow-up study, a very large cohort study out of Harvard University. We found that among omnivorous people, those who ate more plant-based and less animal-based food were less likely to have incident erectile dysfunction. Then, we published a new paper looking at patients with prostate cancer. These men have extra challenges for sexual function because in addition to the standard cardiovascular changes with aging, prostate cancer treatment can affect the nerves that are involved in erections. But amazingly, even in that population, we found that the men who ate more plant-based and less animal-based food had better scores for erectile function.
That was really good news, and it’s a win-win. There is no reason not to counsel our patients to eat more plant-based foods. Meat is not masculine. Meat is associated with a higher risk for erectile dysfunction and is considered carcinogenic. It’s just something that we should try to stay away from.
Dr. Rubin: How do you counsel patients who might not be ready to go fully plant-based? Is a little better than nothing? How do you even start these conversations with people? Do you have any tips for primary care doctors?
Dr. Loeb: Great question. A little bit is very much better than nothing. In fact, in the health professionals follow-up study, we actually looked at quintiles of people who ate the most meat and animal-based foods and the least plant-based foods all the way up to the most plant-based and the least animal-based diets. Along that spectrum, it really does make a big difference. Anywhere that patients can start from is definitely better than nothing.
Simple things such as Meatless Monday or choosing a few days that they will give up animal-based foods will help. For some people, trying new things is easier than cutting things out, for example, trying a milk substitute such as oat, almond, or soy milk instead of dairy milk. That could be a great first step, or trying some dishes that don’t include meat — maybe a tofu stir fry or a taco or burrito without the meat.
There are many great options out there. In terms of resources for doctors, the Physicians Committee for Responsible Medicine has a great website. They have fact sheets for a lot of the common questions that people ask such as how can I get enough protein or calcium on a plant-based diet? This isn’t a problem at all. In fact, Novak Djokovic and many other elite athletes eat plant-based diets, and they get enough protein with a much higher requirement than most of us who are not elite athletes. These fact sheets explain which plant foods are the best
I also like Nutritionfacts.org. They also have all kinds of great videos and resources. Both of these websites have recipes that were created by doctors and nutritionists.
We can suggest that our patients work with a nutritionist or join a virtual program. For example, Plant Powered here in New York has virtual plant-based jumpstart programs. People around the country can get in on programs that have nutritionists and health coaches — for people who want a boost.
Dr. Rubin: The data are really compelling. When you were speaking, not a person in the room was interested in having a steak that night for dinner, even with a steakhouse in the hotel.
What do you say to men who have prostate cancer or suffer from erectile dysfunction? Do any data show that by going plant-based you may show improvements? We have recent studies that show that regular exercise might be as good as Viagra.
Dr. Loeb: It’s definitely not too late, even if you’ve already been diagnosed with these conditions. In my own practice, I have seen changes in patients. In fact, one of the case scenarios that I submitted for the lifestyle medicine boards was a patient who adopted a whole food, plant-based diet and no longer uses Viagra. This is definitely something that’s possible to do with intensive lifestyle modification.
Dr. Rubin: Maybe vegetables are the new sexual health aide. How can people find out more? I know you have a Sirius XM radio show.
Dr. Loeb: It’s the Men’s Health Show on Sirius XM channel 110. It’s on Wednesdays from 6:00 to 8:00 PM ET, or you can listen to it on demand anytime through the Sirius XM app.
Dr. Rubin: You have done an enormous amount of research in prostate cancer and sexual medicine. You are an all-star in the field. Thank you for sharing all of your knowledge about plant-based diets. You’ve given us all a lot to think about today.
Dr. Rubin has disclosed the following relevant financial relationships: Serve(d) as a speaker for Sprout; received research grant from Maternal Medical; received income in an amount equal to or greater than $250 from Absorption Pharmaceuticals, GSK, and Endo.
A version of this article appeared on Medscape.com.
Rachel S. Rubin, MD: Welcome to another episode of Sex Matters. I’m Dr. Rachel Rubin. I’m a urologist and sexual medicine specialist based in the Washington, DC area, and I interview amazingly cool people doing research in sexual medicine.
I heard an incredible lecture while I was at the Mayo Clinic urology conference by Dr. Stacy Loeb, who is a wonderful researcher of all things prostate cancer and men’s health, who is now talking more plant-based diets. Her lecture was so good, I begged her to join me for this discussion.
Dr. Loeb, I would love for you to introduce yourself.
Stacy Loeb, MD: I’m Dr. Loeb. I’m a urologist at New York University in the Manhattan VA, and I recently became board certified in lifestyle medicine because it’s so important for sexual health and, really, everything that we do.
Dr. Rubin: You recently became very interested in studying plant-based diets. How did that start, and how has the research evolved over time?
Dr. Loeb: It’s really amazing. For one thing, more of our patients with prostate cancer die of heart disease than of prostate cancer. And erectile dysfunction is really an early warning sign of cardiovascular disease. We felt like it was incumbent upon us, even within urology and sexual medicine, to better understand the basis for lifestyle modification that can help with these issues.
Dr. Rubin: Tell us more about what you found for erectile dysfunction. How much benefit do people get by switching to a plant-based diet?
Dr. Loeb: First we looked at erectile function in men without prostate cancer in the health professionals follow-up study, a very large cohort study out of Harvard University. We found that among omnivorous people, those who ate more plant-based and less animal-based food were less likely to have incident erectile dysfunction. Then, we published a new paper looking at patients with prostate cancer. These men have extra challenges for sexual function because in addition to the standard cardiovascular changes with aging, prostate cancer treatment can affect the nerves that are involved in erections. But amazingly, even in that population, we found that the men who ate more plant-based and less animal-based food had better scores for erectile function.
That was really good news, and it’s a win-win. There is no reason not to counsel our patients to eat more plant-based foods. Meat is not masculine. Meat is associated with a higher risk for erectile dysfunction and is considered carcinogenic. It’s just something that we should try to stay away from.
Dr. Rubin: How do you counsel patients who might not be ready to go fully plant-based? Is a little better than nothing? How do you even start these conversations with people? Do you have any tips for primary care doctors?
Dr. Loeb: Great question. A little bit is very much better than nothing. In fact, in the health professionals follow-up study, we actually looked at quintiles of people who ate the most meat and animal-based foods and the least plant-based foods all the way up to the most plant-based and the least animal-based diets. Along that spectrum, it really does make a big difference. Anywhere that patients can start from is definitely better than nothing.
Simple things such as Meatless Monday or choosing a few days that they will give up animal-based foods will help. For some people, trying new things is easier than cutting things out, for example, trying a milk substitute such as oat, almond, or soy milk instead of dairy milk. That could be a great first step, or trying some dishes that don’t include meat — maybe a tofu stir fry or a taco or burrito without the meat.
There are many great options out there. In terms of resources for doctors, the Physicians Committee for Responsible Medicine has a great website. They have fact sheets for a lot of the common questions that people ask such as how can I get enough protein or calcium on a plant-based diet? This isn’t a problem at all. In fact, Novak Djokovic and many other elite athletes eat plant-based diets, and they get enough protein with a much higher requirement than most of us who are not elite athletes. These fact sheets explain which plant foods are the best
I also like Nutritionfacts.org. They also have all kinds of great videos and resources. Both of these websites have recipes that were created by doctors and nutritionists.
We can suggest that our patients work with a nutritionist or join a virtual program. For example, Plant Powered here in New York has virtual plant-based jumpstart programs. People around the country can get in on programs that have nutritionists and health coaches — for people who want a boost.
Dr. Rubin: The data are really compelling. When you were speaking, not a person in the room was interested in having a steak that night for dinner, even with a steakhouse in the hotel.
What do you say to men who have prostate cancer or suffer from erectile dysfunction? Do any data show that by going plant-based you may show improvements? We have recent studies that show that regular exercise might be as good as Viagra.
Dr. Loeb: It’s definitely not too late, even if you’ve already been diagnosed with these conditions. In my own practice, I have seen changes in patients. In fact, one of the case scenarios that I submitted for the lifestyle medicine boards was a patient who adopted a whole food, plant-based diet and no longer uses Viagra. This is definitely something that’s possible to do with intensive lifestyle modification.
Dr. Rubin: Maybe vegetables are the new sexual health aide. How can people find out more? I know you have a Sirius XM radio show.
Dr. Loeb: It’s the Men’s Health Show on Sirius XM channel 110. It’s on Wednesdays from 6:00 to 8:00 PM ET, or you can listen to it on demand anytime through the Sirius XM app.
Dr. Rubin: You have done an enormous amount of research in prostate cancer and sexual medicine. You are an all-star in the field. Thank you for sharing all of your knowledge about plant-based diets. You’ve given us all a lot to think about today.
Dr. Rubin has disclosed the following relevant financial relationships: Serve(d) as a speaker for Sprout; received research grant from Maternal Medical; received income in an amount equal to or greater than $250 from Absorption Pharmaceuticals, GSK, and Endo.
A version of this article appeared on Medscape.com.
‘No Pulse’: An MD’s First Night Off in 2 Weeks Turns Grave
Emergencies happen anywhere, anytime, and sometimes, medical professionals find themselves in situations where they are the only ones who can help. Is There a Doctor in the House? is a series by this news organization that tells these stories.
It was my first night off after 12 days. It was a Friday night, and I went to a bar in Naples to get a beer with some friends. As it turned out, it wasn’t a night off after all.
As soon as we got inside, we heard over the speaker that they needed medical personnel and to please go to the left side of the bar. I thought it would be syncope or something like that.
I went over there and saw a woman holding up a man. He was basically leaning all over her. The light was low, and the music was pounding. I started to assess him and tried to get him to answer me. No response. I checked for pulses — nothing.
The woman helped me lower him to the floor. I checked again for a pulse. Still nothing. I said, “Call 911,” and started compressions.
The difficult part was the place was completely dark. I knew where his body was on the floor. I could see his chest. But I couldn’t see his face at all.
It was also extremely loud with the music thumping. After a while, they finally shut it off.
Pretty soon, the security personnel from the bar brought me an automated external defibrillator, and it showed the man was having V-fib arrest. I shocked him. Still no pulse. I continued with cardiopulmonary resuscitation (CPR).
I hadn’t noticed, but lots of people were crowding around us. Somebody came up and said, “He’s my friend. He has a 9-year-old daughter. He can’t die. Let me help with the compressions.” I was like, “Go for it.”
The guy started kind of pushing on the man’s abdomen. He had no idea how to do compressions. I said, “Okay, let me take over again.”
Out of the crowd, nobody else volunteered to help. No one asked me, “Hey, what can I do?” Meanwhile, I found out later that someone was filming the whole thing on their phone.
But what the guy said about the man’s young daughter stayed in my brain. I thought, we need to keep going.
I did more compressions and shocked him again. Still no pulse. At that point, the police and emergency medical services showed up. They checked, nothing had changed, so they got him into the ambulance.
I asked one of the paramedics, “Where are you taking him? I can call ahead.”
But he said, “That’s HIPAA. We can’t tell you.” They also wouldn’t let me go with him in the ambulance.
“I have an active Florida license, and I work in the ICU [intensive care unit],” I said.
“No, we need to follow our protocol,” he replied.
I understood that, but I just wanted to help.
It was around 10:30 PM by then, and I was drenched in sweat. I had to go home. The first thing I did after taking a shower was open the computer and check my system. I needed to find out what happened to the guy.
I was looking for admissions, and I didn’t see him. I called the main hospital downtown and the one in North Naples. I couldn’t find him anywhere. I stayed up until almost 1:00 AM checking for his name. At that point I thought, okay, maybe he died.
The next night, Saturday, I was home and got a call from one of my colleagues. “Hey, were you in a bar yesterday? Did you do CPR on somebody?”
“How did you know?” I said.
He said the paramedics had described me — “a tall doctor with glasses who was a nice guy.” It was funny that he knew that was me.
He told me, “The guy’s alive. He’s sick and needs to be put on dialysis, but he’s alive.”
Apparently, the guy had gone to the emergency department at North Naples, and the doctors in the emergency room (ER) worked on him for over an hour. They did continuous CPR and shocked him for close to 40 minutes. They finally got his pulse back, and after that, he was transferred to the main hospital ICU. They didn’t admit him at the ER, which was why I couldn’t find his name.
On Sunday, I was checking my patients’ charts for the ICU that coming week. And there he was. I saw his name and the documentation by the ED that CPR was provided by a critical care doctor in the field. He was still alive. That gave me so much joy.
So, the man I had helped became my patient. When I saw him on Monday, he was intubated and needed dialysis. I finally saw his face and thought, Oh, so that’s what you look like. I hadn’t realized he was only 39 years old.
When he was awake, I explained to him I was the doctor that provided CPR at the bar. He was very grateful, but of course, he didn’t remember anything.
Eventually, I met his daughter, and she just said, “Thank you for allowing me to have my dad.”
The funny part is that he broke his leg. Well, that’s not funny, but no one had any idea how it happened. That was his only complaint. He was asking me, “Doctor, how did you break my leg?”
“Hey, I have no idea how you broke your leg,” I replied. “I was trying to save your life.”
He was in the hospital for almost a month but made a full recovery. The amazing part: After all the evaluations, he has no neurological deficits. He’s back to a normal life now.
They never found a cause for the cardiac arrest. I mean, he had an ejection fraction of 10%. All my money was on something drug related, but that wasn’t the case. They’d done a cardiac cut, and there was no obstruction. They couldn’t find a reason.
We’ve become friends. He still works as a DJ at the bar. He changed his name to “DJ the Survivor” or something like that.
Sometimes, he’ll text me: “Doctor, what are you doing? You want to come down to the bar?”
I’m like, “No. I don’t.”
It’s been more than a year, but I remember every detail. When you go into medicine, you dream that one day you’ll be able to say, “I saved somebody.”
He texted me a year later and told me he’s celebrating two birthdays now. He said, “I’m turning 1 year old today!”
I think about the value of life. How we can take it for granted. We think, I’m young, nothing is going to happen to me. But this guy was 39. He went to work and died that night.
I was able to help bring him back. That makes me thankful for every day.
Jose Valle Giler, MD, is a pulmonary, critical care, and sleep medicine physician at NCH Healthcare System in Naples, Florida.
A version of this article appeared on Medscape.com .
Emergencies happen anywhere, anytime, and sometimes, medical professionals find themselves in situations where they are the only ones who can help. Is There a Doctor in the House? is a series by this news organization that tells these stories.
It was my first night off after 12 days. It was a Friday night, and I went to a bar in Naples to get a beer with some friends. As it turned out, it wasn’t a night off after all.
As soon as we got inside, we heard over the speaker that they needed medical personnel and to please go to the left side of the bar. I thought it would be syncope or something like that.
I went over there and saw a woman holding up a man. He was basically leaning all over her. The light was low, and the music was pounding. I started to assess him and tried to get him to answer me. No response. I checked for pulses — nothing.
The woman helped me lower him to the floor. I checked again for a pulse. Still nothing. I said, “Call 911,” and started compressions.
The difficult part was the place was completely dark. I knew where his body was on the floor. I could see his chest. But I couldn’t see his face at all.
It was also extremely loud with the music thumping. After a while, they finally shut it off.
Pretty soon, the security personnel from the bar brought me an automated external defibrillator, and it showed the man was having V-fib arrest. I shocked him. Still no pulse. I continued with cardiopulmonary resuscitation (CPR).
I hadn’t noticed, but lots of people were crowding around us. Somebody came up and said, “He’s my friend. He has a 9-year-old daughter. He can’t die. Let me help with the compressions.” I was like, “Go for it.”
The guy started kind of pushing on the man’s abdomen. He had no idea how to do compressions. I said, “Okay, let me take over again.”
Out of the crowd, nobody else volunteered to help. No one asked me, “Hey, what can I do?” Meanwhile, I found out later that someone was filming the whole thing on their phone.
But what the guy said about the man’s young daughter stayed in my brain. I thought, we need to keep going.
I did more compressions and shocked him again. Still no pulse. At that point, the police and emergency medical services showed up. They checked, nothing had changed, so they got him into the ambulance.
I asked one of the paramedics, “Where are you taking him? I can call ahead.”
But he said, “That’s HIPAA. We can’t tell you.” They also wouldn’t let me go with him in the ambulance.
“I have an active Florida license, and I work in the ICU [intensive care unit],” I said.
“No, we need to follow our protocol,” he replied.
I understood that, but I just wanted to help.
It was around 10:30 PM by then, and I was drenched in sweat. I had to go home. The first thing I did after taking a shower was open the computer and check my system. I needed to find out what happened to the guy.
I was looking for admissions, and I didn’t see him. I called the main hospital downtown and the one in North Naples. I couldn’t find him anywhere. I stayed up until almost 1:00 AM checking for his name. At that point I thought, okay, maybe he died.
The next night, Saturday, I was home and got a call from one of my colleagues. “Hey, were you in a bar yesterday? Did you do CPR on somebody?”
“How did you know?” I said.
He said the paramedics had described me — “a tall doctor with glasses who was a nice guy.” It was funny that he knew that was me.
He told me, “The guy’s alive. He’s sick and needs to be put on dialysis, but he’s alive.”
Apparently, the guy had gone to the emergency department at North Naples, and the doctors in the emergency room (ER) worked on him for over an hour. They did continuous CPR and shocked him for close to 40 minutes. They finally got his pulse back, and after that, he was transferred to the main hospital ICU. They didn’t admit him at the ER, which was why I couldn’t find his name.
On Sunday, I was checking my patients’ charts for the ICU that coming week. And there he was. I saw his name and the documentation by the ED that CPR was provided by a critical care doctor in the field. He was still alive. That gave me so much joy.
So, the man I had helped became my patient. When I saw him on Monday, he was intubated and needed dialysis. I finally saw his face and thought, Oh, so that’s what you look like. I hadn’t realized he was only 39 years old.
When he was awake, I explained to him I was the doctor that provided CPR at the bar. He was very grateful, but of course, he didn’t remember anything.
Eventually, I met his daughter, and she just said, “Thank you for allowing me to have my dad.”
The funny part is that he broke his leg. Well, that’s not funny, but no one had any idea how it happened. That was his only complaint. He was asking me, “Doctor, how did you break my leg?”
“Hey, I have no idea how you broke your leg,” I replied. “I was trying to save your life.”
He was in the hospital for almost a month but made a full recovery. The amazing part: After all the evaluations, he has no neurological deficits. He’s back to a normal life now.
They never found a cause for the cardiac arrest. I mean, he had an ejection fraction of 10%. All my money was on something drug related, but that wasn’t the case. They’d done a cardiac cut, and there was no obstruction. They couldn’t find a reason.
We’ve become friends. He still works as a DJ at the bar. He changed his name to “DJ the Survivor” or something like that.
Sometimes, he’ll text me: “Doctor, what are you doing? You want to come down to the bar?”
I’m like, “No. I don’t.”
It’s been more than a year, but I remember every detail. When you go into medicine, you dream that one day you’ll be able to say, “I saved somebody.”
He texted me a year later and told me he’s celebrating two birthdays now. He said, “I’m turning 1 year old today!”
I think about the value of life. How we can take it for granted. We think, I’m young, nothing is going to happen to me. But this guy was 39. He went to work and died that night.
I was able to help bring him back. That makes me thankful for every day.
Jose Valle Giler, MD, is a pulmonary, critical care, and sleep medicine physician at NCH Healthcare System in Naples, Florida.
A version of this article appeared on Medscape.com .
Emergencies happen anywhere, anytime, and sometimes, medical professionals find themselves in situations where they are the only ones who can help. Is There a Doctor in the House? is a series by this news organization that tells these stories.
It was my first night off after 12 days. It was a Friday night, and I went to a bar in Naples to get a beer with some friends. As it turned out, it wasn’t a night off after all.
As soon as we got inside, we heard over the speaker that they needed medical personnel and to please go to the left side of the bar. I thought it would be syncope or something like that.
I went over there and saw a woman holding up a man. He was basically leaning all over her. The light was low, and the music was pounding. I started to assess him and tried to get him to answer me. No response. I checked for pulses — nothing.
The woman helped me lower him to the floor. I checked again for a pulse. Still nothing. I said, “Call 911,” and started compressions.
The difficult part was the place was completely dark. I knew where his body was on the floor. I could see his chest. But I couldn’t see his face at all.
It was also extremely loud with the music thumping. After a while, they finally shut it off.
Pretty soon, the security personnel from the bar brought me an automated external defibrillator, and it showed the man was having V-fib arrest. I shocked him. Still no pulse. I continued with cardiopulmonary resuscitation (CPR).
I hadn’t noticed, but lots of people were crowding around us. Somebody came up and said, “He’s my friend. He has a 9-year-old daughter. He can’t die. Let me help with the compressions.” I was like, “Go for it.”
The guy started kind of pushing on the man’s abdomen. He had no idea how to do compressions. I said, “Okay, let me take over again.”
Out of the crowd, nobody else volunteered to help. No one asked me, “Hey, what can I do?” Meanwhile, I found out later that someone was filming the whole thing on their phone.
But what the guy said about the man’s young daughter stayed in my brain. I thought, we need to keep going.
I did more compressions and shocked him again. Still no pulse. At that point, the police and emergency medical services showed up. They checked, nothing had changed, so they got him into the ambulance.
I asked one of the paramedics, “Where are you taking him? I can call ahead.”
But he said, “That’s HIPAA. We can’t tell you.” They also wouldn’t let me go with him in the ambulance.
“I have an active Florida license, and I work in the ICU [intensive care unit],” I said.
“No, we need to follow our protocol,” he replied.
I understood that, but I just wanted to help.
It was around 10:30 PM by then, and I was drenched in sweat. I had to go home. The first thing I did after taking a shower was open the computer and check my system. I needed to find out what happened to the guy.
I was looking for admissions, and I didn’t see him. I called the main hospital downtown and the one in North Naples. I couldn’t find him anywhere. I stayed up until almost 1:00 AM checking for his name. At that point I thought, okay, maybe he died.
The next night, Saturday, I was home and got a call from one of my colleagues. “Hey, were you in a bar yesterday? Did you do CPR on somebody?”
“How did you know?” I said.
He said the paramedics had described me — “a tall doctor with glasses who was a nice guy.” It was funny that he knew that was me.
He told me, “The guy’s alive. He’s sick and needs to be put on dialysis, but he’s alive.”
Apparently, the guy had gone to the emergency department at North Naples, and the doctors in the emergency room (ER) worked on him for over an hour. They did continuous CPR and shocked him for close to 40 minutes. They finally got his pulse back, and after that, he was transferred to the main hospital ICU. They didn’t admit him at the ER, which was why I couldn’t find his name.
On Sunday, I was checking my patients’ charts for the ICU that coming week. And there he was. I saw his name and the documentation by the ED that CPR was provided by a critical care doctor in the field. He was still alive. That gave me so much joy.
So, the man I had helped became my patient. When I saw him on Monday, he was intubated and needed dialysis. I finally saw his face and thought, Oh, so that’s what you look like. I hadn’t realized he was only 39 years old.
When he was awake, I explained to him I was the doctor that provided CPR at the bar. He was very grateful, but of course, he didn’t remember anything.
Eventually, I met his daughter, and she just said, “Thank you for allowing me to have my dad.”
The funny part is that he broke his leg. Well, that’s not funny, but no one had any idea how it happened. That was his only complaint. He was asking me, “Doctor, how did you break my leg?”
“Hey, I have no idea how you broke your leg,” I replied. “I was trying to save your life.”
He was in the hospital for almost a month but made a full recovery. The amazing part: After all the evaluations, he has no neurological deficits. He’s back to a normal life now.
They never found a cause for the cardiac arrest. I mean, he had an ejection fraction of 10%. All my money was on something drug related, but that wasn’t the case. They’d done a cardiac cut, and there was no obstruction. They couldn’t find a reason.
We’ve become friends. He still works as a DJ at the bar. He changed his name to “DJ the Survivor” or something like that.
Sometimes, he’ll text me: “Doctor, what are you doing? You want to come down to the bar?”
I’m like, “No. I don’t.”
It’s been more than a year, but I remember every detail. When you go into medicine, you dream that one day you’ll be able to say, “I saved somebody.”
He texted me a year later and told me he’s celebrating two birthdays now. He said, “I’m turning 1 year old today!”
I think about the value of life. How we can take it for granted. We think, I’m young, nothing is going to happen to me. But this guy was 39. He went to work and died that night.
I was able to help bring him back. That makes me thankful for every day.
Jose Valle Giler, MD, is a pulmonary, critical care, and sleep medicine physician at NCH Healthcare System in Naples, Florida.
A version of this article appeared on Medscape.com .
A 30-Year-Old White Female Presented With a 4-Month History of Scaly, Erythematous Patches and Plaques on Her Trunk and Extremities
Tumor necrosis factor (TNF)-alpha inhibitors are used to treat a variety of autoimmune conditions including psoriasis, psoriatic arthritis, rheumatoid arthritis (RA), spondyloarthritis, and inflammatory bowel disease (IBD). Interestingly, they have also been observed to cause paradoxical psoriasis with an incidence between 0.6%-5.3%, most commonly occurring in patients with underlying Crohn’s disease and rheumatoid arthritis (RA). Infliximab is the most common TNF inhibitor associated with this condition (52.6%-62.6% of cases) followed by etanercept (12%-29%). .
Psoriasis is traditionally divided into two types. Patients with type I psoriasis have a family history, develop symptoms before the age of 40 and are often positive for HLA-Cw6. Type II psoriasis is not related to HLA-Cw6, lacks a family history, and typically manifests after age 40. Psoriatic lesions are well-defined, erythematous plaques with silvery scales most commonly appearing on extensor surfaces and the scalp. Variants include nail psoriasis, pustular psoriasis, inverse psoriasis, and guttate psoriasis.
Although psoriasis is typically a clinical diagnosis, histologic examination may be used to differentiate from other dermatoses if necessary. The lesions of TNF inhibitor-induced psoriasis characteristically display patterns similar to primary psoriasis, including parakeratosis, microabscesses, and rete ridges. Eosinophilic hypersensitivity reactions and features overlapping with eczematous hypersensitivity (psoriasiform dermatitis) may also be present.
The pathogenesis of this condition is not well understood, but theories include a variety of immune processes including interferon overproduction, interleukin and T-cell activation, and the presence of an infectious nidus. Classical psoriasis is related to type 1 interferon release, so theoretically, immunosuppression caused by TNF inhibitor treatment may permit uncontrolled production of interferons, resulting in psoriatic lesions. Another theory is that interleukin (IL)-23, a pro-inflammatory cytokine, promotes activation of T-helper 17 (Th17) cells. Th17 cells are part of the pathogenesis of primary psoriasis and other inflammatory conditions, such as RA and inflammatory bowel disease. Of note, individuals with gastrointestinal inflammatory diseases are already known to be at a greater risk for developing psoriasis. Immunosuppression caused by a TNF inhibitor may leave patients more susceptible to other infections, which may induce psoriatic plaques.
There are multiple approaches to treatment depending on the severity of the disease. If the psoriatic eruption is mild, the medication may be continued. This “treat-through” method is often considered when stopping the current immunotherapy would cause the patient significant issues. Moderate to severe cases of TNF inhibitor-induced psoriasis may warrant switching TNF inhibitor therapy or completely changing the drug class used in the treatment of the underlying autoimmune condition. Additional treatments include topical and oral steroids, UV therapy, methotrexate, cyclosporine, and acitretin.
This case and the photo were submitted by Lucas Shapiro, BS, of Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, Florida, and Leon S. Maratchi, MD, Gastro Health, Hollywood, Florida. The column was edited by Donna Bilu Martin, MD.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Florida. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
References
1. Li SJ et al. J Psoriasis Psoriatic Arthritis. 2019 Apr;4(2):70-80. doi: 10.1177/2475530318810851.
2. Lu J and Lu Y. J Transl Autoimmun. 2023 Sep 6:7:100211. doi: 10.1016/j.jtauto.2023.100211.
3. Nair PA and Badri T. Psoriasis. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: www.ncbi.nlm.nih.gov/books/NBK448194/
Tumor necrosis factor (TNF)-alpha inhibitors are used to treat a variety of autoimmune conditions including psoriasis, psoriatic arthritis, rheumatoid arthritis (RA), spondyloarthritis, and inflammatory bowel disease (IBD). Interestingly, they have also been observed to cause paradoxical psoriasis with an incidence between 0.6%-5.3%, most commonly occurring in patients with underlying Crohn’s disease and rheumatoid arthritis (RA). Infliximab is the most common TNF inhibitor associated with this condition (52.6%-62.6% of cases) followed by etanercept (12%-29%). .
Psoriasis is traditionally divided into two types. Patients with type I psoriasis have a family history, develop symptoms before the age of 40 and are often positive for HLA-Cw6. Type II psoriasis is not related to HLA-Cw6, lacks a family history, and typically manifests after age 40. Psoriatic lesions are well-defined, erythematous plaques with silvery scales most commonly appearing on extensor surfaces and the scalp. Variants include nail psoriasis, pustular psoriasis, inverse psoriasis, and guttate psoriasis.
Although psoriasis is typically a clinical diagnosis, histologic examination may be used to differentiate from other dermatoses if necessary. The lesions of TNF inhibitor-induced psoriasis characteristically display patterns similar to primary psoriasis, including parakeratosis, microabscesses, and rete ridges. Eosinophilic hypersensitivity reactions and features overlapping with eczematous hypersensitivity (psoriasiform dermatitis) may also be present.
The pathogenesis of this condition is not well understood, but theories include a variety of immune processes including interferon overproduction, interleukin and T-cell activation, and the presence of an infectious nidus. Classical psoriasis is related to type 1 interferon release, so theoretically, immunosuppression caused by TNF inhibitor treatment may permit uncontrolled production of interferons, resulting in psoriatic lesions. Another theory is that interleukin (IL)-23, a pro-inflammatory cytokine, promotes activation of T-helper 17 (Th17) cells. Th17 cells are part of the pathogenesis of primary psoriasis and other inflammatory conditions, such as RA and inflammatory bowel disease. Of note, individuals with gastrointestinal inflammatory diseases are already known to be at a greater risk for developing psoriasis. Immunosuppression caused by a TNF inhibitor may leave patients more susceptible to other infections, which may induce psoriatic plaques.
There are multiple approaches to treatment depending on the severity of the disease. If the psoriatic eruption is mild, the medication may be continued. This “treat-through” method is often considered when stopping the current immunotherapy would cause the patient significant issues. Moderate to severe cases of TNF inhibitor-induced psoriasis may warrant switching TNF inhibitor therapy or completely changing the drug class used in the treatment of the underlying autoimmune condition. Additional treatments include topical and oral steroids, UV therapy, methotrexate, cyclosporine, and acitretin.
This case and the photo were submitted by Lucas Shapiro, BS, of Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, Florida, and Leon S. Maratchi, MD, Gastro Health, Hollywood, Florida. The column was edited by Donna Bilu Martin, MD.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Florida. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
References
1. Li SJ et al. J Psoriasis Psoriatic Arthritis. 2019 Apr;4(2):70-80. doi: 10.1177/2475530318810851.
2. Lu J and Lu Y. J Transl Autoimmun. 2023 Sep 6:7:100211. doi: 10.1016/j.jtauto.2023.100211.
3. Nair PA and Badri T. Psoriasis. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: www.ncbi.nlm.nih.gov/books/NBK448194/
Tumor necrosis factor (TNF)-alpha inhibitors are used to treat a variety of autoimmune conditions including psoriasis, psoriatic arthritis, rheumatoid arthritis (RA), spondyloarthritis, and inflammatory bowel disease (IBD). Interestingly, they have also been observed to cause paradoxical psoriasis with an incidence between 0.6%-5.3%, most commonly occurring in patients with underlying Crohn’s disease and rheumatoid arthritis (RA). Infliximab is the most common TNF inhibitor associated with this condition (52.6%-62.6% of cases) followed by etanercept (12%-29%). .
Psoriasis is traditionally divided into two types. Patients with type I psoriasis have a family history, develop symptoms before the age of 40 and are often positive for HLA-Cw6. Type II psoriasis is not related to HLA-Cw6, lacks a family history, and typically manifests after age 40. Psoriatic lesions are well-defined, erythematous plaques with silvery scales most commonly appearing on extensor surfaces and the scalp. Variants include nail psoriasis, pustular psoriasis, inverse psoriasis, and guttate psoriasis.
Although psoriasis is typically a clinical diagnosis, histologic examination may be used to differentiate from other dermatoses if necessary. The lesions of TNF inhibitor-induced psoriasis characteristically display patterns similar to primary psoriasis, including parakeratosis, microabscesses, and rete ridges. Eosinophilic hypersensitivity reactions and features overlapping with eczematous hypersensitivity (psoriasiform dermatitis) may also be present.
The pathogenesis of this condition is not well understood, but theories include a variety of immune processes including interferon overproduction, interleukin and T-cell activation, and the presence of an infectious nidus. Classical psoriasis is related to type 1 interferon release, so theoretically, immunosuppression caused by TNF inhibitor treatment may permit uncontrolled production of interferons, resulting in psoriatic lesions. Another theory is that interleukin (IL)-23, a pro-inflammatory cytokine, promotes activation of T-helper 17 (Th17) cells. Th17 cells are part of the pathogenesis of primary psoriasis and other inflammatory conditions, such as RA and inflammatory bowel disease. Of note, individuals with gastrointestinal inflammatory diseases are already known to be at a greater risk for developing psoriasis. Immunosuppression caused by a TNF inhibitor may leave patients more susceptible to other infections, which may induce psoriatic plaques.
There are multiple approaches to treatment depending on the severity of the disease. If the psoriatic eruption is mild, the medication may be continued. This “treat-through” method is often considered when stopping the current immunotherapy would cause the patient significant issues. Moderate to severe cases of TNF inhibitor-induced psoriasis may warrant switching TNF inhibitor therapy or completely changing the drug class used in the treatment of the underlying autoimmune condition. Additional treatments include topical and oral steroids, UV therapy, methotrexate, cyclosporine, and acitretin.
This case and the photo were submitted by Lucas Shapiro, BS, of Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, Florida, and Leon S. Maratchi, MD, Gastro Health, Hollywood, Florida. The column was edited by Donna Bilu Martin, MD.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Florida. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
References
1. Li SJ et al. J Psoriasis Psoriatic Arthritis. 2019 Apr;4(2):70-80. doi: 10.1177/2475530318810851.
2. Lu J and Lu Y. J Transl Autoimmun. 2023 Sep 6:7:100211. doi: 10.1016/j.jtauto.2023.100211.
3. Nair PA and Badri T. Psoriasis. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: www.ncbi.nlm.nih.gov/books/NBK448194/
Using AI to Transform Diabetic Foot and Limb Preservation
Diabetic foot complications represent a major global health challenge, with a high prevalence among patients with diabetes. A diabetic foot ulcer (DFU) not only affects the patient›s quality of life but also increases the risk for amputation.
Worldwide, a DFU occurs every second, and an amputation occurs every 20 seconds. The limitations of current detection and intervention methods underline the urgent need for innovative solutions.
Recent advances in artificial intelligence (AI) have paved the way for individualized risk prediction models for chronic wound management. These models use deep learning algorithms to analyze clinical data and images, providing personalized treatment plans that may improve healing outcomes and reduce the risk for amputation.
AI-powered tools can also be deployed for the diagnosis of diabetic foot complications. Using image analysis and pattern recognition, AI tools are learning to accurately detect signs of DFUs and other complications, facilitating early and effective intervention. Our group and others have been working not only on imaging devices but also on thermographic tools that — with the help of AI — can create an automated “foot selfie” to predict and prevent problems before they start.
AI’s predictive capabilities are instrumental to its clinical value. By identifying patients at high risk for DFUs, healthcare providers can implement preemptive measures, significantly reducing the likelihood of severe complications.
Although the potential benefits of AI in diabetic foot care are immense, integrating these tools into clinical practice poses challenges. These include ensuring the reliability of AI predictions, addressing data privacy concerns, and training healthcare professionals on the use of AI technologies.
As in so many other areas in our lives, AI holds the promise to revolutionize diabetic foot and limb preservation, offering hope for improved patient outcomes through early detection, precise diagnosis, and personalized care. However, realizing this potential requires ongoing research, development, and collaboration across the medical and technological fields to ensure these innovative solutions can be effectively integrated into standard care practices.
Dr. Armstrong is professor of surgery, Keck School of Medicine of University of Southern California, Los Angeles, California. He has disclosed the following relevant financial relationships: Partially supported by National Institutes of Health; National Institute of Diabetes; Digestive and Kidney Disease Award Number 1R01124789-01A1.
A version of this article first appeared on Medscape.com.
Diabetic foot complications represent a major global health challenge, with a high prevalence among patients with diabetes. A diabetic foot ulcer (DFU) not only affects the patient›s quality of life but also increases the risk for amputation.
Worldwide, a DFU occurs every second, and an amputation occurs every 20 seconds. The limitations of current detection and intervention methods underline the urgent need for innovative solutions.
Recent advances in artificial intelligence (AI) have paved the way for individualized risk prediction models for chronic wound management. These models use deep learning algorithms to analyze clinical data and images, providing personalized treatment plans that may improve healing outcomes and reduce the risk for amputation.
AI-powered tools can also be deployed for the diagnosis of diabetic foot complications. Using image analysis and pattern recognition, AI tools are learning to accurately detect signs of DFUs and other complications, facilitating early and effective intervention. Our group and others have been working not only on imaging devices but also on thermographic tools that — with the help of AI — can create an automated “foot selfie” to predict and prevent problems before they start.
AI’s predictive capabilities are instrumental to its clinical value. By identifying patients at high risk for DFUs, healthcare providers can implement preemptive measures, significantly reducing the likelihood of severe complications.
Although the potential benefits of AI in diabetic foot care are immense, integrating these tools into clinical practice poses challenges. These include ensuring the reliability of AI predictions, addressing data privacy concerns, and training healthcare professionals on the use of AI technologies.
As in so many other areas in our lives, AI holds the promise to revolutionize diabetic foot and limb preservation, offering hope for improved patient outcomes through early detection, precise diagnosis, and personalized care. However, realizing this potential requires ongoing research, development, and collaboration across the medical and technological fields to ensure these innovative solutions can be effectively integrated into standard care practices.
Dr. Armstrong is professor of surgery, Keck School of Medicine of University of Southern California, Los Angeles, California. He has disclosed the following relevant financial relationships: Partially supported by National Institutes of Health; National Institute of Diabetes; Digestive and Kidney Disease Award Number 1R01124789-01A1.
A version of this article first appeared on Medscape.com.
Diabetic foot complications represent a major global health challenge, with a high prevalence among patients with diabetes. A diabetic foot ulcer (DFU) not only affects the patient›s quality of life but also increases the risk for amputation.
Worldwide, a DFU occurs every second, and an amputation occurs every 20 seconds. The limitations of current detection and intervention methods underline the urgent need for innovative solutions.
Recent advances in artificial intelligence (AI) have paved the way for individualized risk prediction models for chronic wound management. These models use deep learning algorithms to analyze clinical data and images, providing personalized treatment plans that may improve healing outcomes and reduce the risk for amputation.
AI-powered tools can also be deployed for the diagnosis of diabetic foot complications. Using image analysis and pattern recognition, AI tools are learning to accurately detect signs of DFUs and other complications, facilitating early and effective intervention. Our group and others have been working not only on imaging devices but also on thermographic tools that — with the help of AI — can create an automated “foot selfie” to predict and prevent problems before they start.
AI’s predictive capabilities are instrumental to its clinical value. By identifying patients at high risk for DFUs, healthcare providers can implement preemptive measures, significantly reducing the likelihood of severe complications.
Although the potential benefits of AI in diabetic foot care are immense, integrating these tools into clinical practice poses challenges. These include ensuring the reliability of AI predictions, addressing data privacy concerns, and training healthcare professionals on the use of AI technologies.
As in so many other areas in our lives, AI holds the promise to revolutionize diabetic foot and limb preservation, offering hope for improved patient outcomes through early detection, precise diagnosis, and personalized care. However, realizing this potential requires ongoing research, development, and collaboration across the medical and technological fields to ensure these innovative solutions can be effectively integrated into standard care practices.
Dr. Armstrong is professor of surgery, Keck School of Medicine of University of Southern California, Los Angeles, California. He has disclosed the following relevant financial relationships: Partially supported by National Institutes of Health; National Institute of Diabetes; Digestive and Kidney Disease Award Number 1R01124789-01A1.
A version of this article first appeared on Medscape.com.
Moral Injury in Health Care: A Unified Definition and its Relationship to Burnout
Moral injury was identified by health care professionals (HCPs) as a driver of occupational distress prior to the COVID-19 pandemic, but the crisis expanded the appeal and investigation of the term.1 HCPs now consider moral injury an essential component of the framework to describe their distress, because using the term burnout alone fails to capture their full experience and has proven resistant to interventions.2 Moral injury goes beyond the transdiagnostic symptoms of exhaustion and cynicism and beyond operational, demand-resource mismatches that characterize burnout. It describes the frustration, anger, and helplessness associated with relational ruptures and the existential threats to a clinician’s professional identity as business interests erode their ability to put their patients’ needs ahead of corporate and health care system obligations.3
Proper characterization of moral injury in health care—separate from the military environments where it originated—is stymied by an ill-defined relationship between 2 definitions of the term and by an unclear relationship between moral injury and the long-standing body of scholarship in burnout. To clarify the concept, inform research agendas, and open avenues for more effective solutions to the crisis of HCP distress, we propose a unified conceptualization of moral injury and its association with burnout in health care.
CONTEXTUAL DISTINCTIONS
It is important to properly distinguish between the original use of moral injury in the military and its expanded use in civilian circumstances. Health care and the military are both professions whereupon donning the “uniform” of a physician—or soldier, sailor, airman, or marine—members must comport with strict expectations of behavior, including the refusal to engage in illegal actions or those contrary to professional ethics. Individuals in both professions acquire a highly specialized body of knowledge and enter an implied contract to provide critical services to society, specifically healing and protection, respectively. Members of both professions are trained to make complex judgments with integrity under conditions of technical and ethical uncertainty, upon which they take highly skilled action. Medical and military professionals must be free to act on their ethical principles, without confounding demands.4 However, the context of each profession’s commitment to society carries different moral implications.
The risk of moral injury is inherent in military service. The military promises protection with an implicit acknowledgment of the need to use lethal force to uphold the agreement. In contrast, HCPs promise healing and care. The military promises to protect our society, with an implicit acknowledgment of the need to use lethal force to uphold the agreement. Some military actions may inflict harm without the hope of benefitting an individual, and are therefore potentially morally injurious. The health care contract with society, promising healing and care, is devoid of inherent moral injury due to harm without potential individual benefit. Therefore, the presence of moral injury in health care settings are warning signs of a dysfunctional environment.
One complex example of the dysfunctional environments is illustrative. The military and health care are among the few industries where supply creates demand. For example, the more bad state actors there are, the more demand for the military. As we have seen since the 1950s, the more technology and therapeutics we create in health care, coupled with a larger share paid for by third parties, the greater the demand for and use of them.5 In a fee for service environment, corporate greed feeds on this reality. In most other environments, more technological and therapeutic options inevitably pit clinicians against multiple other factions: payers, who do not want to underwrite them; patients, who sometimes demand them without justification or later rail against spiraling health care costs; and administrators, especially in capitated systems, who watch their bottom lines erode. The moral injury risk in this instance demands a collective conversation among stakeholders regarding the structural determinants of health—how we choose to distribute limited resources. The intermediary of moral injury is a useful measure of the harm that results from ignoring or avoiding such challenges.
HARMONIZING DEFINITIONS
Moral injury is inherently nuanced. The 2 dominant definitions arise from work with combat veterans and create additional and perhaps unnecessary complexity. Unifying these 2 definitions eliminates inadvertent confusion, preventing the risk of unbridled interdisciplinary investigation which leads to a lack of precision in the meaning of moral injury and other related concepts, such as burnout.6
The first definition was developed by Jonathan Shay in 1994 and outlines 3 necessarycomponents, viewing the violator as a powerholder: (1) betrayal of what is right, (2) by someone who holds legitimate authority, (3) in a high stakes situation.7 Litz and colleagues describe moral injury another way: “Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”8 The violator is posited to be either the self or others.
Rather than representing “self” or “other” imposed moral injury, we propose the 2 definitions are related as exposure (ie, the perceived betrayal) and response (ie, the resulting transgression). An individual who experiences a betrayal by a legitimate authority has an opportunity to choose their response. They may acquiesce and transgress their moral beliefs (eg, their oath to provide ethical health care), or they could refuse, by speaking out, or in some way resisting the authority’s betrayal. The case of Ray Brovont is a useful illustration of reconciling the definitions (Box).9
Myriad factors—known as potentially morally injurious events—drive moral injury, such as resource-constrained decision making, witnessing the behaviors of colleagues that violate deeply held moral beliefs, questionable billing practices, and more. Each begins with a betrayal. Spotlighting the betrayal, refusing to perpetuate it, or taking actions toward change, may reduce the risk of experiencing moral injury.9 Conversely, acquiescing and transgressing one’s oath, the profession’s covenant with society, increases the risk of experiencing moral injury.8
Many HCPs believe they are not always free to resist betrayal, fearing retaliation, job loss, blacklisting, or worse. They feel constrained by debt accrued while receiving their education, being their household’s primary earner, community ties, practicing a niche specialty that requires working for a tertiary referral center, or perhaps believing the situation will be the same elsewhere. To not stand up or speak out is to choose complicity with corporate greed that uses HCPs to undermine their professional duties, which significantly increases the risk of experiencing moral injury.
MORAL INJURY AND BURNOUT
In addition to reconciling the definitions of moral injury, the relationship between moral injury and burnout are still being elucidated. We suggest that moral injury and burnout represent independent and potentially interrelated pathways to distress (Figure). Exposure to chronic, inconsonant, and transactional demands, which things like shorter work hours, better self-care, or improved health system operations might mitigate, manifests as burnout. In contrast, moral injury arises when a superior’s actions or a system’s policies and practices—such as justifiable but unnecessary testing, or referral restrictions to prevent revenue leakage—undermine one’s professional obligations to prioritize the patient’s best interest.
If concerns from HCPs about transactional demands are persistently dismissed, such inaction may be perceived as a betrayal, raising the risk of moral injury. Additionally, the resignation or helplessness of moral injury perceived as inescapable may present with emotional exhaustion, ineffectiveness, and depersonalization, all hallmarks of burnout. Both conditions can mediate and moderate the relationship between triggers for workplace distress and resulting psychological, physical, and existential harm.
CONCLUSIONS
Moral injury is increasingly recognized as a source of distress among HCPs, resulting from structural constraints on their ability to deliver optimal care and their own unwillingness to stand up for their patients, their oaths, and their professions.1 Unlike the military, where moral injury is inherent in the contract with society, moral injury in health care (and the relational rupture it connotes) is a signal of systemic dysfunction, fractured trust, and the need for relational repair.
Health care is at a crossroads, experiencing a workforce retention crisis while simultaneously predicting a significant increase in care needs by Baby Boomers over the next 3 decades.
Health care does not have the luxury of experimenting another 30 years with interventions that have limited impact. We must design a new generation of approaches, shaped by lessons learned from the pandemic while acknowledging that prepandemic standards were already failing the workforce. A unified definition of moral injury must be integrated to frame clinician distress alongside burnout, recentering ethical decision making, rather than profit, at the heart of health care. Harmonizing the definitions of moral injury and clarifying the relationship of moral injury with burnout reduces the need for further reinterpretations, allowing for more robust, easily comparable studies focused on identifying risk factors, as well as rapidly implementing effective mitigation strategies.
1. Griffin BJ, Weber MC, Hinkson KD, et al. Toward a dimensional contextual model of moral injury: a scoping review on healthcare workers. Curr Treat Options Psych. 2023;10:199-216. doi:10.1007/s40501-023-00296-4
2. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. The National Academies Press; 2019. doi:10.17226/25521
3. Dean W, Talbot S, Dean A. Reframing clinician distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
4. Gardner HE, Schulman LS. The professions in America today: crucial but fragile. Daedalus. 2005;134(3):13-18. doi:10.1162/0011526054622132
5. Fuchs VR. Major trends in the U.S. health economy since 1950. N Engl J Med. 2012;366(11):973-977. doi:10.1056/NEJMp1200478
6. Molendijk T. Warnings against romanticising moral injury. Br J Psychiatry. 2022;220(1):1-3. doi:10.1192/bjp.2021.114
7. Shay J. Moral injury. Psychoanalytic Psychol. 2014;31(2):182-191. doi:10.1037/a0036090
8. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695-706. doi:10.1016/j.cpr.2009.07.003
9. Brovont v KS-I Med. Servs., P.A., 622 SW3d 671 (Mo Ct App 2020).
Wendy Dean, MDa; Deborah Morris, DClinPsychb,c; Mustfa K. Manzur, MD, MPH, MSd,e,f; Simon Talbot, MDg.h
Correspondence: Wendy Dean (wdean@moralinjury. healthcare)
aMoral Injury of Healthcare, Carlisle, Pennsylvania
bCentre for Developmental and Complex Trauma, St. Andrew’s Healthcare, Northampton, United Kingdom
cThe University of Buckingham, United Kingdom
dAlbert Einstein College of Medicine, Bronx, New York
eMontefiore Medical Center, Bronx, New York
fJacobi Medical Center, Bronx, New York
gBrigham and Women’s Hospital, Boston, Massachusetts
hHarvard Medical School, Boston, Massachusetts
Author disclosures
Wendy Dean and Simon Talbot are cofounders of Moral Injury of Healthcare, a nonprofit organization. Dean is a speaker for LeighHealth Speakers Bureau. The University of Florida and Rothman Orthopedic Institute have made payments to Moral Injury of Healthcare.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Ethics and consent
The Veterans Affairs Greater Los Angeles Healthcare System institutional review board determined that this study was exempt. The datasets generated and/or analyzed during the current study are not publicly available but may be available from the corresponding author on reasonable request.
Wendy Dean, MDa; Deborah Morris, DClinPsychb,c; Mustfa K. Manzur, MD, MPH, MSd,e,f; Simon Talbot, MDg.h
Correspondence: Wendy Dean (wdean@moralinjury. healthcare)
aMoral Injury of Healthcare, Carlisle, Pennsylvania
bCentre for Developmental and Complex Trauma, St. Andrew’s Healthcare, Northampton, United Kingdom
cThe University of Buckingham, United Kingdom
dAlbert Einstein College of Medicine, Bronx, New York
eMontefiore Medical Center, Bronx, New York
fJacobi Medical Center, Bronx, New York
gBrigham and Women’s Hospital, Boston, Massachusetts
hHarvard Medical School, Boston, Massachusetts
Author disclosures
Wendy Dean and Simon Talbot are cofounders of Moral Injury of Healthcare, a nonprofit organization. Dean is a speaker for LeighHealth Speakers Bureau. The University of Florida and Rothman Orthopedic Institute have made payments to Moral Injury of Healthcare.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Ethics and consent
The Veterans Affairs Greater Los Angeles Healthcare System institutional review board determined that this study was exempt. The datasets generated and/or analyzed during the current study are not publicly available but may be available from the corresponding author on reasonable request.
Wendy Dean, MDa; Deborah Morris, DClinPsychb,c; Mustfa K. Manzur, MD, MPH, MSd,e,f; Simon Talbot, MDg.h
Correspondence: Wendy Dean (wdean@moralinjury. healthcare)
aMoral Injury of Healthcare, Carlisle, Pennsylvania
bCentre for Developmental and Complex Trauma, St. Andrew’s Healthcare, Northampton, United Kingdom
cThe University of Buckingham, United Kingdom
dAlbert Einstein College of Medicine, Bronx, New York
eMontefiore Medical Center, Bronx, New York
fJacobi Medical Center, Bronx, New York
gBrigham and Women’s Hospital, Boston, Massachusetts
hHarvard Medical School, Boston, Massachusetts
Author disclosures
Wendy Dean and Simon Talbot are cofounders of Moral Injury of Healthcare, a nonprofit organization. Dean is a speaker for LeighHealth Speakers Bureau. The University of Florida and Rothman Orthopedic Institute have made payments to Moral Injury of Healthcare.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Ethics and consent
The Veterans Affairs Greater Los Angeles Healthcare System institutional review board determined that this study was exempt. The datasets generated and/or analyzed during the current study are not publicly available but may be available from the corresponding author on reasonable request.
Moral injury was identified by health care professionals (HCPs) as a driver of occupational distress prior to the COVID-19 pandemic, but the crisis expanded the appeal and investigation of the term.1 HCPs now consider moral injury an essential component of the framework to describe their distress, because using the term burnout alone fails to capture their full experience and has proven resistant to interventions.2 Moral injury goes beyond the transdiagnostic symptoms of exhaustion and cynicism and beyond operational, demand-resource mismatches that characterize burnout. It describes the frustration, anger, and helplessness associated with relational ruptures and the existential threats to a clinician’s professional identity as business interests erode their ability to put their patients’ needs ahead of corporate and health care system obligations.3
Proper characterization of moral injury in health care—separate from the military environments where it originated—is stymied by an ill-defined relationship between 2 definitions of the term and by an unclear relationship between moral injury and the long-standing body of scholarship in burnout. To clarify the concept, inform research agendas, and open avenues for more effective solutions to the crisis of HCP distress, we propose a unified conceptualization of moral injury and its association with burnout in health care.
CONTEXTUAL DISTINCTIONS
It is important to properly distinguish between the original use of moral injury in the military and its expanded use in civilian circumstances. Health care and the military are both professions whereupon donning the “uniform” of a physician—or soldier, sailor, airman, or marine—members must comport with strict expectations of behavior, including the refusal to engage in illegal actions or those contrary to professional ethics. Individuals in both professions acquire a highly specialized body of knowledge and enter an implied contract to provide critical services to society, specifically healing and protection, respectively. Members of both professions are trained to make complex judgments with integrity under conditions of technical and ethical uncertainty, upon which they take highly skilled action. Medical and military professionals must be free to act on their ethical principles, without confounding demands.4 However, the context of each profession’s commitment to society carries different moral implications.
The risk of moral injury is inherent in military service. The military promises protection with an implicit acknowledgment of the need to use lethal force to uphold the agreement. In contrast, HCPs promise healing and care. The military promises to protect our society, with an implicit acknowledgment of the need to use lethal force to uphold the agreement. Some military actions may inflict harm without the hope of benefitting an individual, and are therefore potentially morally injurious. The health care contract with society, promising healing and care, is devoid of inherent moral injury due to harm without potential individual benefit. Therefore, the presence of moral injury in health care settings are warning signs of a dysfunctional environment.
One complex example of the dysfunctional environments is illustrative. The military and health care are among the few industries where supply creates demand. For example, the more bad state actors there are, the more demand for the military. As we have seen since the 1950s, the more technology and therapeutics we create in health care, coupled with a larger share paid for by third parties, the greater the demand for and use of them.5 In a fee for service environment, corporate greed feeds on this reality. In most other environments, more technological and therapeutic options inevitably pit clinicians against multiple other factions: payers, who do not want to underwrite them; patients, who sometimes demand them without justification or later rail against spiraling health care costs; and administrators, especially in capitated systems, who watch their bottom lines erode. The moral injury risk in this instance demands a collective conversation among stakeholders regarding the structural determinants of health—how we choose to distribute limited resources. The intermediary of moral injury is a useful measure of the harm that results from ignoring or avoiding such challenges.
HARMONIZING DEFINITIONS
Moral injury is inherently nuanced. The 2 dominant definitions arise from work with combat veterans and create additional and perhaps unnecessary complexity. Unifying these 2 definitions eliminates inadvertent confusion, preventing the risk of unbridled interdisciplinary investigation which leads to a lack of precision in the meaning of moral injury and other related concepts, such as burnout.6
The first definition was developed by Jonathan Shay in 1994 and outlines 3 necessarycomponents, viewing the violator as a powerholder: (1) betrayal of what is right, (2) by someone who holds legitimate authority, (3) in a high stakes situation.7 Litz and colleagues describe moral injury another way: “Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”8 The violator is posited to be either the self or others.
Rather than representing “self” or “other” imposed moral injury, we propose the 2 definitions are related as exposure (ie, the perceived betrayal) and response (ie, the resulting transgression). An individual who experiences a betrayal by a legitimate authority has an opportunity to choose their response. They may acquiesce and transgress their moral beliefs (eg, their oath to provide ethical health care), or they could refuse, by speaking out, or in some way resisting the authority’s betrayal. The case of Ray Brovont is a useful illustration of reconciling the definitions (Box).9
Myriad factors—known as potentially morally injurious events—drive moral injury, such as resource-constrained decision making, witnessing the behaviors of colleagues that violate deeply held moral beliefs, questionable billing practices, and more. Each begins with a betrayal. Spotlighting the betrayal, refusing to perpetuate it, or taking actions toward change, may reduce the risk of experiencing moral injury.9 Conversely, acquiescing and transgressing one’s oath, the profession’s covenant with society, increases the risk of experiencing moral injury.8
Many HCPs believe they are not always free to resist betrayal, fearing retaliation, job loss, blacklisting, or worse. They feel constrained by debt accrued while receiving their education, being their household’s primary earner, community ties, practicing a niche specialty that requires working for a tertiary referral center, or perhaps believing the situation will be the same elsewhere. To not stand up or speak out is to choose complicity with corporate greed that uses HCPs to undermine their professional duties, which significantly increases the risk of experiencing moral injury.
MORAL INJURY AND BURNOUT
In addition to reconciling the definitions of moral injury, the relationship between moral injury and burnout are still being elucidated. We suggest that moral injury and burnout represent independent and potentially interrelated pathways to distress (Figure). Exposure to chronic, inconsonant, and transactional demands, which things like shorter work hours, better self-care, or improved health system operations might mitigate, manifests as burnout. In contrast, moral injury arises when a superior’s actions or a system’s policies and practices—such as justifiable but unnecessary testing, or referral restrictions to prevent revenue leakage—undermine one’s professional obligations to prioritize the patient’s best interest.
If concerns from HCPs about transactional demands are persistently dismissed, such inaction may be perceived as a betrayal, raising the risk of moral injury. Additionally, the resignation or helplessness of moral injury perceived as inescapable may present with emotional exhaustion, ineffectiveness, and depersonalization, all hallmarks of burnout. Both conditions can mediate and moderate the relationship between triggers for workplace distress and resulting psychological, physical, and existential harm.
CONCLUSIONS
Moral injury is increasingly recognized as a source of distress among HCPs, resulting from structural constraints on their ability to deliver optimal care and their own unwillingness to stand up for their patients, their oaths, and their professions.1 Unlike the military, where moral injury is inherent in the contract with society, moral injury in health care (and the relational rupture it connotes) is a signal of systemic dysfunction, fractured trust, and the need for relational repair.
Health care is at a crossroads, experiencing a workforce retention crisis while simultaneously predicting a significant increase in care needs by Baby Boomers over the next 3 decades.
Health care does not have the luxury of experimenting another 30 years with interventions that have limited impact. We must design a new generation of approaches, shaped by lessons learned from the pandemic while acknowledging that prepandemic standards were already failing the workforce. A unified definition of moral injury must be integrated to frame clinician distress alongside burnout, recentering ethical decision making, rather than profit, at the heart of health care. Harmonizing the definitions of moral injury and clarifying the relationship of moral injury with burnout reduces the need for further reinterpretations, allowing for more robust, easily comparable studies focused on identifying risk factors, as well as rapidly implementing effective mitigation strategies.
Moral injury was identified by health care professionals (HCPs) as a driver of occupational distress prior to the COVID-19 pandemic, but the crisis expanded the appeal and investigation of the term.1 HCPs now consider moral injury an essential component of the framework to describe their distress, because using the term burnout alone fails to capture their full experience and has proven resistant to interventions.2 Moral injury goes beyond the transdiagnostic symptoms of exhaustion and cynicism and beyond operational, demand-resource mismatches that characterize burnout. It describes the frustration, anger, and helplessness associated with relational ruptures and the existential threats to a clinician’s professional identity as business interests erode their ability to put their patients’ needs ahead of corporate and health care system obligations.3
Proper characterization of moral injury in health care—separate from the military environments where it originated—is stymied by an ill-defined relationship between 2 definitions of the term and by an unclear relationship between moral injury and the long-standing body of scholarship in burnout. To clarify the concept, inform research agendas, and open avenues for more effective solutions to the crisis of HCP distress, we propose a unified conceptualization of moral injury and its association with burnout in health care.
CONTEXTUAL DISTINCTIONS
It is important to properly distinguish between the original use of moral injury in the military and its expanded use in civilian circumstances. Health care and the military are both professions whereupon donning the “uniform” of a physician—or soldier, sailor, airman, or marine—members must comport with strict expectations of behavior, including the refusal to engage in illegal actions or those contrary to professional ethics. Individuals in both professions acquire a highly specialized body of knowledge and enter an implied contract to provide critical services to society, specifically healing and protection, respectively. Members of both professions are trained to make complex judgments with integrity under conditions of technical and ethical uncertainty, upon which they take highly skilled action. Medical and military professionals must be free to act on their ethical principles, without confounding demands.4 However, the context of each profession’s commitment to society carries different moral implications.
The risk of moral injury is inherent in military service. The military promises protection with an implicit acknowledgment of the need to use lethal force to uphold the agreement. In contrast, HCPs promise healing and care. The military promises to protect our society, with an implicit acknowledgment of the need to use lethal force to uphold the agreement. Some military actions may inflict harm without the hope of benefitting an individual, and are therefore potentially morally injurious. The health care contract with society, promising healing and care, is devoid of inherent moral injury due to harm without potential individual benefit. Therefore, the presence of moral injury in health care settings are warning signs of a dysfunctional environment.
One complex example of the dysfunctional environments is illustrative. The military and health care are among the few industries where supply creates demand. For example, the more bad state actors there are, the more demand for the military. As we have seen since the 1950s, the more technology and therapeutics we create in health care, coupled with a larger share paid for by third parties, the greater the demand for and use of them.5 In a fee for service environment, corporate greed feeds on this reality. In most other environments, more technological and therapeutic options inevitably pit clinicians against multiple other factions: payers, who do not want to underwrite them; patients, who sometimes demand them without justification or later rail against spiraling health care costs; and administrators, especially in capitated systems, who watch their bottom lines erode. The moral injury risk in this instance demands a collective conversation among stakeholders regarding the structural determinants of health—how we choose to distribute limited resources. The intermediary of moral injury is a useful measure of the harm that results from ignoring or avoiding such challenges.
HARMONIZING DEFINITIONS
Moral injury is inherently nuanced. The 2 dominant definitions arise from work with combat veterans and create additional and perhaps unnecessary complexity. Unifying these 2 definitions eliminates inadvertent confusion, preventing the risk of unbridled interdisciplinary investigation which leads to a lack of precision in the meaning of moral injury and other related concepts, such as burnout.6
The first definition was developed by Jonathan Shay in 1994 and outlines 3 necessarycomponents, viewing the violator as a powerholder: (1) betrayal of what is right, (2) by someone who holds legitimate authority, (3) in a high stakes situation.7 Litz and colleagues describe moral injury another way: “Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”8 The violator is posited to be either the self or others.
Rather than representing “self” or “other” imposed moral injury, we propose the 2 definitions are related as exposure (ie, the perceived betrayal) and response (ie, the resulting transgression). An individual who experiences a betrayal by a legitimate authority has an opportunity to choose their response. They may acquiesce and transgress their moral beliefs (eg, their oath to provide ethical health care), or they could refuse, by speaking out, or in some way resisting the authority’s betrayal. The case of Ray Brovont is a useful illustration of reconciling the definitions (Box).9
Myriad factors—known as potentially morally injurious events—drive moral injury, such as resource-constrained decision making, witnessing the behaviors of colleagues that violate deeply held moral beliefs, questionable billing practices, and more. Each begins with a betrayal. Spotlighting the betrayal, refusing to perpetuate it, or taking actions toward change, may reduce the risk of experiencing moral injury.9 Conversely, acquiescing and transgressing one’s oath, the profession’s covenant with society, increases the risk of experiencing moral injury.8
Many HCPs believe they are not always free to resist betrayal, fearing retaliation, job loss, blacklisting, or worse. They feel constrained by debt accrued while receiving their education, being their household’s primary earner, community ties, practicing a niche specialty that requires working for a tertiary referral center, or perhaps believing the situation will be the same elsewhere. To not stand up or speak out is to choose complicity with corporate greed that uses HCPs to undermine their professional duties, which significantly increases the risk of experiencing moral injury.
MORAL INJURY AND BURNOUT
In addition to reconciling the definitions of moral injury, the relationship between moral injury and burnout are still being elucidated. We suggest that moral injury and burnout represent independent and potentially interrelated pathways to distress (Figure). Exposure to chronic, inconsonant, and transactional demands, which things like shorter work hours, better self-care, or improved health system operations might mitigate, manifests as burnout. In contrast, moral injury arises when a superior’s actions or a system’s policies and practices—such as justifiable but unnecessary testing, or referral restrictions to prevent revenue leakage—undermine one’s professional obligations to prioritize the patient’s best interest.
If concerns from HCPs about transactional demands are persistently dismissed, such inaction may be perceived as a betrayal, raising the risk of moral injury. Additionally, the resignation or helplessness of moral injury perceived as inescapable may present with emotional exhaustion, ineffectiveness, and depersonalization, all hallmarks of burnout. Both conditions can mediate and moderate the relationship between triggers for workplace distress and resulting psychological, physical, and existential harm.
CONCLUSIONS
Moral injury is increasingly recognized as a source of distress among HCPs, resulting from structural constraints on their ability to deliver optimal care and their own unwillingness to stand up for their patients, their oaths, and their professions.1 Unlike the military, where moral injury is inherent in the contract with society, moral injury in health care (and the relational rupture it connotes) is a signal of systemic dysfunction, fractured trust, and the need for relational repair.
Health care is at a crossroads, experiencing a workforce retention crisis while simultaneously predicting a significant increase in care needs by Baby Boomers over the next 3 decades.
Health care does not have the luxury of experimenting another 30 years with interventions that have limited impact. We must design a new generation of approaches, shaped by lessons learned from the pandemic while acknowledging that prepandemic standards were already failing the workforce. A unified definition of moral injury must be integrated to frame clinician distress alongside burnout, recentering ethical decision making, rather than profit, at the heart of health care. Harmonizing the definitions of moral injury and clarifying the relationship of moral injury with burnout reduces the need for further reinterpretations, allowing for more robust, easily comparable studies focused on identifying risk factors, as well as rapidly implementing effective mitigation strategies.
1. Griffin BJ, Weber MC, Hinkson KD, et al. Toward a dimensional contextual model of moral injury: a scoping review on healthcare workers. Curr Treat Options Psych. 2023;10:199-216. doi:10.1007/s40501-023-00296-4
2. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. The National Academies Press; 2019. doi:10.17226/25521
3. Dean W, Talbot S, Dean A. Reframing clinician distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
4. Gardner HE, Schulman LS. The professions in America today: crucial but fragile. Daedalus. 2005;134(3):13-18. doi:10.1162/0011526054622132
5. Fuchs VR. Major trends in the U.S. health economy since 1950. N Engl J Med. 2012;366(11):973-977. doi:10.1056/NEJMp1200478
6. Molendijk T. Warnings against romanticising moral injury. Br J Psychiatry. 2022;220(1):1-3. doi:10.1192/bjp.2021.114
7. Shay J. Moral injury. Psychoanalytic Psychol. 2014;31(2):182-191. doi:10.1037/a0036090
8. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695-706. doi:10.1016/j.cpr.2009.07.003
9. Brovont v KS-I Med. Servs., P.A., 622 SW3d 671 (Mo Ct App 2020).
1. Griffin BJ, Weber MC, Hinkson KD, et al. Toward a dimensional contextual model of moral injury: a scoping review on healthcare workers. Curr Treat Options Psych. 2023;10:199-216. doi:10.1007/s40501-023-00296-4
2. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. The National Academies Press; 2019. doi:10.17226/25521
3. Dean W, Talbot S, Dean A. Reframing clinician distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
4. Gardner HE, Schulman LS. The professions in America today: crucial but fragile. Daedalus. 2005;134(3):13-18. doi:10.1162/0011526054622132
5. Fuchs VR. Major trends in the U.S. health economy since 1950. N Engl J Med. 2012;366(11):973-977. doi:10.1056/NEJMp1200478
6. Molendijk T. Warnings against romanticising moral injury. Br J Psychiatry. 2022;220(1):1-3. doi:10.1192/bjp.2021.114
7. Shay J. Moral injury. Psychoanalytic Psychol. 2014;31(2):182-191. doi:10.1037/a0036090
8. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695-706. doi:10.1016/j.cpr.2009.07.003
9. Brovont v KS-I Med. Servs., P.A., 622 SW3d 671 (Mo Ct App 2020).
Best Practices for Clinical Image Collection and Utilization in Patients With Skin of Color
Clinical images are integral to dermatologic care, research, and education. Studies have highlighted the underrepresentation of images of skin of color (SOC) in educational materials,1 clinical trials,2 and research publications.3 Recognition of this disparity has ignited a call to action by dermatologists and dermatologic organizations to address the gap by improving the collection and use of SOC images.4 It is critical to remind dermatologists of the importance of properly obtaining informed consent and ensuring images are not used without a patient’s permission, as images in journal articles, conference presentations, and educational materials can be widely distributed and shared. Herein, we summarize current practices of clinical image storage and make general recommendations on how dermatologists can better protect patient privacy. Certain cultural and social factors in patients with SOC should be considered when obtaining informed consent and collecting images.
Clinical Image Acquisition
Consenting procedures are crucial components of proper image usage. However, current consenting practices are inconsistent across various platforms, including academic journals, websites, printed text, social media, and educational presentations.5
Current regulations for use of patient health information in the United States are governed by the Health Insurance Portability and Accountability Act (HIPAA)of 1996. Although this act explicitly prohibits use of “full face photographic images and any comparable images” without consent from the patient or the patient’s representative, there is less restriction regarding the use of deidentified images.6 Some clinicians or researchers may consider using a black bar or a masking technique over the eyes or face, but this is not always a sufficient method of anonymizing an image.
One study investigating the different requirements listed by the top 20 dermatology journals (as determined by the Google Scholar h5-index) found that while 95% (19/20) of journals stated that written or signed consent or permission was a requirement for use of patient images, only 20% (4/20) instructed authors to inform the patient or the patient’s representative that images may become available on the internet.5 Once an article is accepted for publication by a medical journal, it eventually may be accessible online; however, patients may not be aware of this factor, which is particularly concerning for those with SOC due to the increased demand for diverse dermatologic resources and images as well as the highly digitalized manner in which we access and share media.
Furthermore, cultural and social factors exist that present challenges to informed decision-making during the consenting process for certain SOC populations such as a lack of trust in the medical and scientific research community, inadequate comprehension of the consent material, health illiteracy, language barriers, or use of complex terminology in consent documentation.7,8 Studies also have shown that patients in ethnic minority groups have greater barriers to health literacy compared to other patient groups, and patients with limited health literacy are less likely to ask questions during their medical visits.9,10 Therefore, when obtaining informed consent for images, it is important that measures are taken to ensure that the patient has full knowledge and understanding of what the consent covers, including the extent to which the images will be used and/or shared and whether the patient’s confidentiality and/or anonymity are at risk.
Recommendations—We propose that dermatologists should follow these recommendations:
1. Encourage influential dermatology organizations such as the American Academy of Dermatology to establish standardized consenting procedures for image acquisition and use, including requirements to provide (a) written consent for all patient images and (b) specific details as to where and how the image may be used and/or shared.
2. Ensure that consent terminology is presented at a sixth-grade reading level or below, minimize the use of medical jargon and complex terms, and provide consent documentation in the patient’s preferred language.
3. Allow patients to take the consent document home so they can have additional time to comprehensively review the material or have it reviewed by family or friends.
4. Employ strategies such as teach-back methods and encourage questions to maximize the level of understanding during the consent process.
Clinical Image Storage
Clinical image storage procedures can have an impact on a patient’s health information remaining anonymous and confidential. In a survey evaluating medical photography use among 153 US board-certified dermatologists, 69.1% of respondents reported emailing or texting images between patients and colleagues. Additionally, 30.3% (46/152) reported having patient photographs stored on their personal phone at the time of the survey, and 39.1% (18/46) of those individuals had images that showed identifiable features, such as the patient’s face or a tattoo.11
Although most providers state that their devices are password protected, it cannot be guaranteed that the device and consequently the images remain secure and inaccessible to unauthorized individuals. As sharing and viewing images continue to play an essential role in assessing disease state, progression, treatment response, and inclusion in research, we must establish and encourage clear guidelines for the storage and retention of such images.
Recommendations—We propose that dermatologists should follow these recommendations:
1. Store clinical images exclusively on password-protected devices and in password-protected files.
2. Use work-related cameras or electronic devices rather than personal devices, unless the personal device is being used to upload directly into the patient’s medical record. In such cases, use a HIPAA-compliant electronic medical record mobile application that does not store images on the application or the device itself.
3. Avoid using text-messaging systems or unencrypted email to share identifying images without clear patient consent.
Clinical Image Use
Once a thorough consenting process has been completed, it is crucial that the use and distribution of the clinical image are in accordance with the terms specified in the original consent. With the current state of technologic advancement, widespread social media usage, and constant sharing of information, adherence to these terms can be challenging. For example, an image initially intended for use in an educational presentation at a professional conference can be shared on social media if an audience member captures a photo of it. In another example, a patient may consent to their image being shown on a dermatologic website but that image can be duplicated and shared on other unauthorized sites and locations. This situation can be particularly distressing to patients whose image may include all or most of their face, an intimate area, or other physical features that they did not wish to share widely.
Individuals identifying as Black/African American, Latino/Hispanic, or Asian have been shown to express less comfort with providing permission for images of a nonidentifiable sensitive area to be taken (or obtained) or for use for teaching irrespective of identifiability compared to their White counterparts,12 which may be due to the aforementioned lack of trust in medical providers and the health care system in general, both of which may contribute to concerns with how a clinical image is used and/or shared. Although consent from a patient or the patient’s representative can be granted, we must ensure that the use of these images adheres to the patient’s initial agreement. Ultimately, medical providers, researchers, and other parties involved in acquiring or sharing patient images have both an ethical and legal responsibility to ensure that anonymity, privacy, and confidentiality are preserved to the greatest extent possible.
Recommendations—We propose that dermatologists should follow these recommendations:
1. Display a message on websites containing patient images stating that the sharing of the images outside the established guidelines and intended use is prohibited.
2. Place a watermark on images to discourage unauthorized duplication.
3. Issue explicit instructions to audiences prohibiting the copying or reproducing of any patient images during teaching events or presentations.
Final Thoughts
The use of clinical images is an essential component of dermatologic care, education, and research. Due to the higher demand for diverse and representative images and the dearth of images in the medical literature, many SOC images have been widely disseminated and utilized by dermatologists, raising concerns of the adequacy of informed consent for the storage and use of such material. Therefore, dermatologists should implement streamlined guidelines and consent procedures to ensure a patient’s informed consent is provided with full knowledge of how and where their images might be used and shared. Additional efforts should be made to protect patients’ privacy and unauthorized use of their images. Furthermore, we encourage our leading dermatology organizations to develop expert consensus on best practices for appropriate clinical image consent, storage, and use.
- Alvarado SM, Feng H. Representation of dark skin images of common dermatologic conditions in educational resources: a cross-sectional analysis [published online June 18, 2020]. J Am Acad Dermatol. 2021;84:1427-1431. doi:10.1016/j.jaad.2020.06.041
- Charrow A, Xia FD, Joyce C, et al. Diversity in dermatology clinical trials: a systematic review. JAMA Dermatol. 2017;153:193-198. doi:10.1001/jamadermatol.2016.4129
- Marroquin NA, Carboni A, Zueger M, et al. Skin of color representation trends in JAAD case reports 2015-2021: content analysis. JMIR Dermatol. 2023;6:e40816. doi:10.2196/40816
- Kim Y, Miller JJ, Hollins LC. Skin of color matters: a call to action. J Am Acad Dermatol. 2021;84:E273-E274. doi:10.1016/j.jaad.2020.11.026
- Nanda JK, Marchetti MA. Consent and deidentification of patient images in dermatology journals: observational study. JMIR Dermatol. 2022;5:E37398. doi:10.2196/37398
- US Department of Health and Human Services. Summary of the HIPAA privacy rule. Updated October 19, 2022. Accessed March 15, 2024. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html
- Quinn SC, Garza MA, Butler J, et al. Improving informed consent with minority participants: results from researcher and community surveys. J Empir Res Hum Res Ethics. 2012;7:44-55. doi:10.1525/jer.2012.7.5.44
- Hadden KB, Prince LY, Moore TD, et al. Improving readability of informed consents for research at an academic medical institution. J Clin Transl Sci. 2017;1:361-365. doi:10.1017/cts.2017.312
- Muvuka B, Combs RM, Ayangeakaa SD, et al. Health literacy in African-American communities: barriers and strategies. Health Lit Res Pract. 2020;4:E138-E143. doi:10.3928/24748307-20200617-01
- Menendez ME, van Hoorn BT, Mackert M, et al. Patients with limited health literacy ask fewer questions during office visits with hand surgeons. Clin Orthop Relat Res. 2017;475:1291-1297. doi:10.1007/s11999-016-5140-5
- Milam EC, Leger MC. Use of medical photography among dermatologists: a nationwide online survey study. J Eur Acad Dermatol Venereol. 2018;32:1804-1809. doi:10.1111/jdv.14839
- Leger MC, Wu T, Haimovic A, et al. Patient perspectives on medical photography in dermatology. Dermatol Surg. 2014;40:1028-1037. doi:10.1097/01.DSS.0000452632.22081.79
Clinical images are integral to dermatologic care, research, and education. Studies have highlighted the underrepresentation of images of skin of color (SOC) in educational materials,1 clinical trials,2 and research publications.3 Recognition of this disparity has ignited a call to action by dermatologists and dermatologic organizations to address the gap by improving the collection and use of SOC images.4 It is critical to remind dermatologists of the importance of properly obtaining informed consent and ensuring images are not used without a patient’s permission, as images in journal articles, conference presentations, and educational materials can be widely distributed and shared. Herein, we summarize current practices of clinical image storage and make general recommendations on how dermatologists can better protect patient privacy. Certain cultural and social factors in patients with SOC should be considered when obtaining informed consent and collecting images.
Clinical Image Acquisition
Consenting procedures are crucial components of proper image usage. However, current consenting practices are inconsistent across various platforms, including academic journals, websites, printed text, social media, and educational presentations.5
Current regulations for use of patient health information in the United States are governed by the Health Insurance Portability and Accountability Act (HIPAA)of 1996. Although this act explicitly prohibits use of “full face photographic images and any comparable images” without consent from the patient or the patient’s representative, there is less restriction regarding the use of deidentified images.6 Some clinicians or researchers may consider using a black bar or a masking technique over the eyes or face, but this is not always a sufficient method of anonymizing an image.
One study investigating the different requirements listed by the top 20 dermatology journals (as determined by the Google Scholar h5-index) found that while 95% (19/20) of journals stated that written or signed consent or permission was a requirement for use of patient images, only 20% (4/20) instructed authors to inform the patient or the patient’s representative that images may become available on the internet.5 Once an article is accepted for publication by a medical journal, it eventually may be accessible online; however, patients may not be aware of this factor, which is particularly concerning for those with SOC due to the increased demand for diverse dermatologic resources and images as well as the highly digitalized manner in which we access and share media.
Furthermore, cultural and social factors exist that present challenges to informed decision-making during the consenting process for certain SOC populations such as a lack of trust in the medical and scientific research community, inadequate comprehension of the consent material, health illiteracy, language barriers, or use of complex terminology in consent documentation.7,8 Studies also have shown that patients in ethnic minority groups have greater barriers to health literacy compared to other patient groups, and patients with limited health literacy are less likely to ask questions during their medical visits.9,10 Therefore, when obtaining informed consent for images, it is important that measures are taken to ensure that the patient has full knowledge and understanding of what the consent covers, including the extent to which the images will be used and/or shared and whether the patient’s confidentiality and/or anonymity are at risk.
Recommendations—We propose that dermatologists should follow these recommendations:
1. Encourage influential dermatology organizations such as the American Academy of Dermatology to establish standardized consenting procedures for image acquisition and use, including requirements to provide (a) written consent for all patient images and (b) specific details as to where and how the image may be used and/or shared.
2. Ensure that consent terminology is presented at a sixth-grade reading level or below, minimize the use of medical jargon and complex terms, and provide consent documentation in the patient’s preferred language.
3. Allow patients to take the consent document home so they can have additional time to comprehensively review the material or have it reviewed by family or friends.
4. Employ strategies such as teach-back methods and encourage questions to maximize the level of understanding during the consent process.
Clinical Image Storage
Clinical image storage procedures can have an impact on a patient’s health information remaining anonymous and confidential. In a survey evaluating medical photography use among 153 US board-certified dermatologists, 69.1% of respondents reported emailing or texting images between patients and colleagues. Additionally, 30.3% (46/152) reported having patient photographs stored on their personal phone at the time of the survey, and 39.1% (18/46) of those individuals had images that showed identifiable features, such as the patient’s face or a tattoo.11
Although most providers state that their devices are password protected, it cannot be guaranteed that the device and consequently the images remain secure and inaccessible to unauthorized individuals. As sharing and viewing images continue to play an essential role in assessing disease state, progression, treatment response, and inclusion in research, we must establish and encourage clear guidelines for the storage and retention of such images.
Recommendations—We propose that dermatologists should follow these recommendations:
1. Store clinical images exclusively on password-protected devices and in password-protected files.
2. Use work-related cameras or electronic devices rather than personal devices, unless the personal device is being used to upload directly into the patient’s medical record. In such cases, use a HIPAA-compliant electronic medical record mobile application that does not store images on the application or the device itself.
3. Avoid using text-messaging systems or unencrypted email to share identifying images without clear patient consent.
Clinical Image Use
Once a thorough consenting process has been completed, it is crucial that the use and distribution of the clinical image are in accordance with the terms specified in the original consent. With the current state of technologic advancement, widespread social media usage, and constant sharing of information, adherence to these terms can be challenging. For example, an image initially intended for use in an educational presentation at a professional conference can be shared on social media if an audience member captures a photo of it. In another example, a patient may consent to their image being shown on a dermatologic website but that image can be duplicated and shared on other unauthorized sites and locations. This situation can be particularly distressing to patients whose image may include all or most of their face, an intimate area, or other physical features that they did not wish to share widely.
Individuals identifying as Black/African American, Latino/Hispanic, or Asian have been shown to express less comfort with providing permission for images of a nonidentifiable sensitive area to be taken (or obtained) or for use for teaching irrespective of identifiability compared to their White counterparts,12 which may be due to the aforementioned lack of trust in medical providers and the health care system in general, both of which may contribute to concerns with how a clinical image is used and/or shared. Although consent from a patient or the patient’s representative can be granted, we must ensure that the use of these images adheres to the patient’s initial agreement. Ultimately, medical providers, researchers, and other parties involved in acquiring or sharing patient images have both an ethical and legal responsibility to ensure that anonymity, privacy, and confidentiality are preserved to the greatest extent possible.
Recommendations—We propose that dermatologists should follow these recommendations:
1. Display a message on websites containing patient images stating that the sharing of the images outside the established guidelines and intended use is prohibited.
2. Place a watermark on images to discourage unauthorized duplication.
3. Issue explicit instructions to audiences prohibiting the copying or reproducing of any patient images during teaching events or presentations.
Final Thoughts
The use of clinical images is an essential component of dermatologic care, education, and research. Due to the higher demand for diverse and representative images and the dearth of images in the medical literature, many SOC images have been widely disseminated and utilized by dermatologists, raising concerns of the adequacy of informed consent for the storage and use of such material. Therefore, dermatologists should implement streamlined guidelines and consent procedures to ensure a patient’s informed consent is provided with full knowledge of how and where their images might be used and shared. Additional efforts should be made to protect patients’ privacy and unauthorized use of their images. Furthermore, we encourage our leading dermatology organizations to develop expert consensus on best practices for appropriate clinical image consent, storage, and use.
Clinical images are integral to dermatologic care, research, and education. Studies have highlighted the underrepresentation of images of skin of color (SOC) in educational materials,1 clinical trials,2 and research publications.3 Recognition of this disparity has ignited a call to action by dermatologists and dermatologic organizations to address the gap by improving the collection and use of SOC images.4 It is critical to remind dermatologists of the importance of properly obtaining informed consent and ensuring images are not used without a patient’s permission, as images in journal articles, conference presentations, and educational materials can be widely distributed and shared. Herein, we summarize current practices of clinical image storage and make general recommendations on how dermatologists can better protect patient privacy. Certain cultural and social factors in patients with SOC should be considered when obtaining informed consent and collecting images.
Clinical Image Acquisition
Consenting procedures are crucial components of proper image usage. However, current consenting practices are inconsistent across various platforms, including academic journals, websites, printed text, social media, and educational presentations.5
Current regulations for use of patient health information in the United States are governed by the Health Insurance Portability and Accountability Act (HIPAA)of 1996. Although this act explicitly prohibits use of “full face photographic images and any comparable images” without consent from the patient or the patient’s representative, there is less restriction regarding the use of deidentified images.6 Some clinicians or researchers may consider using a black bar or a masking technique over the eyes or face, but this is not always a sufficient method of anonymizing an image.
One study investigating the different requirements listed by the top 20 dermatology journals (as determined by the Google Scholar h5-index) found that while 95% (19/20) of journals stated that written or signed consent or permission was a requirement for use of patient images, only 20% (4/20) instructed authors to inform the patient or the patient’s representative that images may become available on the internet.5 Once an article is accepted for publication by a medical journal, it eventually may be accessible online; however, patients may not be aware of this factor, which is particularly concerning for those with SOC due to the increased demand for diverse dermatologic resources and images as well as the highly digitalized manner in which we access and share media.
Furthermore, cultural and social factors exist that present challenges to informed decision-making during the consenting process for certain SOC populations such as a lack of trust in the medical and scientific research community, inadequate comprehension of the consent material, health illiteracy, language barriers, or use of complex terminology in consent documentation.7,8 Studies also have shown that patients in ethnic minority groups have greater barriers to health literacy compared to other patient groups, and patients with limited health literacy are less likely to ask questions during their medical visits.9,10 Therefore, when obtaining informed consent for images, it is important that measures are taken to ensure that the patient has full knowledge and understanding of what the consent covers, including the extent to which the images will be used and/or shared and whether the patient’s confidentiality and/or anonymity are at risk.
Recommendations—We propose that dermatologists should follow these recommendations:
1. Encourage influential dermatology organizations such as the American Academy of Dermatology to establish standardized consenting procedures for image acquisition and use, including requirements to provide (a) written consent for all patient images and (b) specific details as to where and how the image may be used and/or shared.
2. Ensure that consent terminology is presented at a sixth-grade reading level or below, minimize the use of medical jargon and complex terms, and provide consent documentation in the patient’s preferred language.
3. Allow patients to take the consent document home so they can have additional time to comprehensively review the material or have it reviewed by family or friends.
4. Employ strategies such as teach-back methods and encourage questions to maximize the level of understanding during the consent process.
Clinical Image Storage
Clinical image storage procedures can have an impact on a patient’s health information remaining anonymous and confidential. In a survey evaluating medical photography use among 153 US board-certified dermatologists, 69.1% of respondents reported emailing or texting images between patients and colleagues. Additionally, 30.3% (46/152) reported having patient photographs stored on their personal phone at the time of the survey, and 39.1% (18/46) of those individuals had images that showed identifiable features, such as the patient’s face or a tattoo.11
Although most providers state that their devices are password protected, it cannot be guaranteed that the device and consequently the images remain secure and inaccessible to unauthorized individuals. As sharing and viewing images continue to play an essential role in assessing disease state, progression, treatment response, and inclusion in research, we must establish and encourage clear guidelines for the storage and retention of such images.
Recommendations—We propose that dermatologists should follow these recommendations:
1. Store clinical images exclusively on password-protected devices and in password-protected files.
2. Use work-related cameras or electronic devices rather than personal devices, unless the personal device is being used to upload directly into the patient’s medical record. In such cases, use a HIPAA-compliant electronic medical record mobile application that does not store images on the application or the device itself.
3. Avoid using text-messaging systems or unencrypted email to share identifying images without clear patient consent.
Clinical Image Use
Once a thorough consenting process has been completed, it is crucial that the use and distribution of the clinical image are in accordance with the terms specified in the original consent. With the current state of technologic advancement, widespread social media usage, and constant sharing of information, adherence to these terms can be challenging. For example, an image initially intended for use in an educational presentation at a professional conference can be shared on social media if an audience member captures a photo of it. In another example, a patient may consent to their image being shown on a dermatologic website but that image can be duplicated and shared on other unauthorized sites and locations. This situation can be particularly distressing to patients whose image may include all or most of their face, an intimate area, or other physical features that they did not wish to share widely.
Individuals identifying as Black/African American, Latino/Hispanic, or Asian have been shown to express less comfort with providing permission for images of a nonidentifiable sensitive area to be taken (or obtained) or for use for teaching irrespective of identifiability compared to their White counterparts,12 which may be due to the aforementioned lack of trust in medical providers and the health care system in general, both of which may contribute to concerns with how a clinical image is used and/or shared. Although consent from a patient or the patient’s representative can be granted, we must ensure that the use of these images adheres to the patient’s initial agreement. Ultimately, medical providers, researchers, and other parties involved in acquiring or sharing patient images have both an ethical and legal responsibility to ensure that anonymity, privacy, and confidentiality are preserved to the greatest extent possible.
Recommendations—We propose that dermatologists should follow these recommendations:
1. Display a message on websites containing patient images stating that the sharing of the images outside the established guidelines and intended use is prohibited.
2. Place a watermark on images to discourage unauthorized duplication.
3. Issue explicit instructions to audiences prohibiting the copying or reproducing of any patient images during teaching events or presentations.
Final Thoughts
The use of clinical images is an essential component of dermatologic care, education, and research. Due to the higher demand for diverse and representative images and the dearth of images in the medical literature, many SOC images have been widely disseminated and utilized by dermatologists, raising concerns of the adequacy of informed consent for the storage and use of such material. Therefore, dermatologists should implement streamlined guidelines and consent procedures to ensure a patient’s informed consent is provided with full knowledge of how and where their images might be used and shared. Additional efforts should be made to protect patients’ privacy and unauthorized use of their images. Furthermore, we encourage our leading dermatology organizations to develop expert consensus on best practices for appropriate clinical image consent, storage, and use.
- Alvarado SM, Feng H. Representation of dark skin images of common dermatologic conditions in educational resources: a cross-sectional analysis [published online June 18, 2020]. J Am Acad Dermatol. 2021;84:1427-1431. doi:10.1016/j.jaad.2020.06.041
- Charrow A, Xia FD, Joyce C, et al. Diversity in dermatology clinical trials: a systematic review. JAMA Dermatol. 2017;153:193-198. doi:10.1001/jamadermatol.2016.4129
- Marroquin NA, Carboni A, Zueger M, et al. Skin of color representation trends in JAAD case reports 2015-2021: content analysis. JMIR Dermatol. 2023;6:e40816. doi:10.2196/40816
- Kim Y, Miller JJ, Hollins LC. Skin of color matters: a call to action. J Am Acad Dermatol. 2021;84:E273-E274. doi:10.1016/j.jaad.2020.11.026
- Nanda JK, Marchetti MA. Consent and deidentification of patient images in dermatology journals: observational study. JMIR Dermatol. 2022;5:E37398. doi:10.2196/37398
- US Department of Health and Human Services. Summary of the HIPAA privacy rule. Updated October 19, 2022. Accessed March 15, 2024. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html
- Quinn SC, Garza MA, Butler J, et al. Improving informed consent with minority participants: results from researcher and community surveys. J Empir Res Hum Res Ethics. 2012;7:44-55. doi:10.1525/jer.2012.7.5.44
- Hadden KB, Prince LY, Moore TD, et al. Improving readability of informed consents for research at an academic medical institution. J Clin Transl Sci. 2017;1:361-365. doi:10.1017/cts.2017.312
- Muvuka B, Combs RM, Ayangeakaa SD, et al. Health literacy in African-American communities: barriers and strategies. Health Lit Res Pract. 2020;4:E138-E143. doi:10.3928/24748307-20200617-01
- Menendez ME, van Hoorn BT, Mackert M, et al. Patients with limited health literacy ask fewer questions during office visits with hand surgeons. Clin Orthop Relat Res. 2017;475:1291-1297. doi:10.1007/s11999-016-5140-5
- Milam EC, Leger MC. Use of medical photography among dermatologists: a nationwide online survey study. J Eur Acad Dermatol Venereol. 2018;32:1804-1809. doi:10.1111/jdv.14839
- Leger MC, Wu T, Haimovic A, et al. Patient perspectives on medical photography in dermatology. Dermatol Surg. 2014;40:1028-1037. doi:10.1097/01.DSS.0000452632.22081.79
- Alvarado SM, Feng H. Representation of dark skin images of common dermatologic conditions in educational resources: a cross-sectional analysis [published online June 18, 2020]. J Am Acad Dermatol. 2021;84:1427-1431. doi:10.1016/j.jaad.2020.06.041
- Charrow A, Xia FD, Joyce C, et al. Diversity in dermatology clinical trials: a systematic review. JAMA Dermatol. 2017;153:193-198. doi:10.1001/jamadermatol.2016.4129
- Marroquin NA, Carboni A, Zueger M, et al. Skin of color representation trends in JAAD case reports 2015-2021: content analysis. JMIR Dermatol. 2023;6:e40816. doi:10.2196/40816
- Kim Y, Miller JJ, Hollins LC. Skin of color matters: a call to action. J Am Acad Dermatol. 2021;84:E273-E274. doi:10.1016/j.jaad.2020.11.026
- Nanda JK, Marchetti MA. Consent and deidentification of patient images in dermatology journals: observational study. JMIR Dermatol. 2022;5:E37398. doi:10.2196/37398
- US Department of Health and Human Services. Summary of the HIPAA privacy rule. Updated October 19, 2022. Accessed March 15, 2024. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html
- Quinn SC, Garza MA, Butler J, et al. Improving informed consent with minority participants: results from researcher and community surveys. J Empir Res Hum Res Ethics. 2012;7:44-55. doi:10.1525/jer.2012.7.5.44
- Hadden KB, Prince LY, Moore TD, et al. Improving readability of informed consents for research at an academic medical institution. J Clin Transl Sci. 2017;1:361-365. doi:10.1017/cts.2017.312
- Muvuka B, Combs RM, Ayangeakaa SD, et al. Health literacy in African-American communities: barriers and strategies. Health Lit Res Pract. 2020;4:E138-E143. doi:10.3928/24748307-20200617-01
- Menendez ME, van Hoorn BT, Mackert M, et al. Patients with limited health literacy ask fewer questions during office visits with hand surgeons. Clin Orthop Relat Res. 2017;475:1291-1297. doi:10.1007/s11999-016-5140-5
- Milam EC, Leger MC. Use of medical photography among dermatologists: a nationwide online survey study. J Eur Acad Dermatol Venereol. 2018;32:1804-1809. doi:10.1111/jdv.14839
- Leger MC, Wu T, Haimovic A, et al. Patient perspectives on medical photography in dermatology. Dermatol Surg. 2014;40:1028-1037. doi:10.1097/01.DSS.0000452632.22081.79
How to Cure Hedonic Eating?
Logan is a 62-year-old woman who has reached the pinnacle of professional success. She started a $50 million consumer products company and, after selling it, managed to develop another successful brand. She is healthy and happily married, with four adult children. And yet, despite all her achievements and stable family life, Logan was always bothered by her inability to lose weight.
Despite peddling in beauty, she felt perpetually overweight and, frankly, unattractive. She has no family history of obesity, drinks minimal alcohol, and follows an (allegedly) healthy diet. Logan had tried “everything” to lose weight — human growth hormone injections (not prescribed by me), Ozempic-like medications, Belviq, etc. — all to no avail.
Here’s the catch: After she finished with her busy days of meetings and spreadsheets, Logan sat down to read through countless emails and rewarded herself with all her favorite foods. Without realizing it, she often doubled her daily caloric intake in one sitting. She wasn’t hungry in these moments, rather just a little worn out and perhaps a little careless. She then proceeded to email her doctor (me) to report on this endless cycle of unwanted behavior.
In January 2024, a novel study from Turkey examined the relationship between hedonic eating, self-condemnation, and self-esteem. Surprising to no one, the study determined that higher hedonic hunger scores were associated with lower self-esteem and an increased propensity to self-stigmatize.
Oprah could have handily predicted this conclusion. Many years ago, she described food as a fake friend: Perhaps you’ve had a long and difficult day. While you’re busy eating your feelings, the heaping plate of pasta feels like your best buddy in the world. However, the moment the plate is empty, you realize that you feel worse than before. Not only do you have to unbutton your new jeans, but you also realize that you have just lost your ability to self-regulate.
While the positive association between hedonic eating and low self-esteem may seem self-evident, the solution is less obvious. Mindfulness is one possible approach to this issue. Mindfulness has been described as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” and has existed for thousands of years. Mindful eating, in particular, involves paying close attention to our food choices and how they affect our emotions, and typically includes some combination of:
- Slowing down eating/chewing thoroughly
- Eliminating distractions such as TV, computers, and phones — perhaps even eating in silence
- Eating only until physically satiated
- Distinguishing between true hunger and cravings
- Noticing the texture, flavors, and smell of food
- Paying attention to the effect of food on your mood
- Appreciating food
In our society, where processed food is so readily available and stress is so ubiquitous, eating can become a hedonic and fast-paced activity. Our brains don’t have time to process our bodies’ signals of fullness and, as a result, we often ingest many more calories than we need for a healthy lifestyle.
If mindless eating is part of the problem, mindful eating is part of the solution. Indeed, a meta-review of 10 scientific studies showed that mindful eating is as effective as conventional weight loss programs in regard to body mass index and waist circumference. On the basis of these studies — as well as some good old-fashioned common sense — intuitive eating is an important component of sustainable weight reduction.
Eventually, I convinced Logan to meet up with the psychologist in our group who specializes in emotional eating. Through weekly cognitive-behavioral therapy sessions, Logan was able to understand the impetus behind her self-defeating behavior and has finally been able to reverse some of her lifelong habits. Once she started practicing mindful eating, I was able to introduce Ozempic, and now Logan is happily shedding several pounds a week.
Dr. Messer has disclosed no relevant financial relationships.
Dr. Messer is clinical assistant professor, Mount Sinai School of Medicine and associate professor, Hofstra School of Medicine, both in New York City.
A version of this article first appeared on Medscape.com.
Logan is a 62-year-old woman who has reached the pinnacle of professional success. She started a $50 million consumer products company and, after selling it, managed to develop another successful brand. She is healthy and happily married, with four adult children. And yet, despite all her achievements and stable family life, Logan was always bothered by her inability to lose weight.
Despite peddling in beauty, she felt perpetually overweight and, frankly, unattractive. She has no family history of obesity, drinks minimal alcohol, and follows an (allegedly) healthy diet. Logan had tried “everything” to lose weight — human growth hormone injections (not prescribed by me), Ozempic-like medications, Belviq, etc. — all to no avail.
Here’s the catch: After she finished with her busy days of meetings and spreadsheets, Logan sat down to read through countless emails and rewarded herself with all her favorite foods. Without realizing it, she often doubled her daily caloric intake in one sitting. She wasn’t hungry in these moments, rather just a little worn out and perhaps a little careless. She then proceeded to email her doctor (me) to report on this endless cycle of unwanted behavior.
In January 2024, a novel study from Turkey examined the relationship between hedonic eating, self-condemnation, and self-esteem. Surprising to no one, the study determined that higher hedonic hunger scores were associated with lower self-esteem and an increased propensity to self-stigmatize.
Oprah could have handily predicted this conclusion. Many years ago, she described food as a fake friend: Perhaps you’ve had a long and difficult day. While you’re busy eating your feelings, the heaping plate of pasta feels like your best buddy in the world. However, the moment the plate is empty, you realize that you feel worse than before. Not only do you have to unbutton your new jeans, but you also realize that you have just lost your ability to self-regulate.
While the positive association between hedonic eating and low self-esteem may seem self-evident, the solution is less obvious. Mindfulness is one possible approach to this issue. Mindfulness has been described as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” and has existed for thousands of years. Mindful eating, in particular, involves paying close attention to our food choices and how they affect our emotions, and typically includes some combination of:
- Slowing down eating/chewing thoroughly
- Eliminating distractions such as TV, computers, and phones — perhaps even eating in silence
- Eating only until physically satiated
- Distinguishing between true hunger and cravings
- Noticing the texture, flavors, and smell of food
- Paying attention to the effect of food on your mood
- Appreciating food
In our society, where processed food is so readily available and stress is so ubiquitous, eating can become a hedonic and fast-paced activity. Our brains don’t have time to process our bodies’ signals of fullness and, as a result, we often ingest many more calories than we need for a healthy lifestyle.
If mindless eating is part of the problem, mindful eating is part of the solution. Indeed, a meta-review of 10 scientific studies showed that mindful eating is as effective as conventional weight loss programs in regard to body mass index and waist circumference. On the basis of these studies — as well as some good old-fashioned common sense — intuitive eating is an important component of sustainable weight reduction.
Eventually, I convinced Logan to meet up with the psychologist in our group who specializes in emotional eating. Through weekly cognitive-behavioral therapy sessions, Logan was able to understand the impetus behind her self-defeating behavior and has finally been able to reverse some of her lifelong habits. Once she started practicing mindful eating, I was able to introduce Ozempic, and now Logan is happily shedding several pounds a week.
Dr. Messer has disclosed no relevant financial relationships.
Dr. Messer is clinical assistant professor, Mount Sinai School of Medicine and associate professor, Hofstra School of Medicine, both in New York City.
A version of this article first appeared on Medscape.com.
Logan is a 62-year-old woman who has reached the pinnacle of professional success. She started a $50 million consumer products company and, after selling it, managed to develop another successful brand. She is healthy and happily married, with four adult children. And yet, despite all her achievements and stable family life, Logan was always bothered by her inability to lose weight.
Despite peddling in beauty, she felt perpetually overweight and, frankly, unattractive. She has no family history of obesity, drinks minimal alcohol, and follows an (allegedly) healthy diet. Logan had tried “everything” to lose weight — human growth hormone injections (not prescribed by me), Ozempic-like medications, Belviq, etc. — all to no avail.
Here’s the catch: After she finished with her busy days of meetings and spreadsheets, Logan sat down to read through countless emails and rewarded herself with all her favorite foods. Without realizing it, she often doubled her daily caloric intake in one sitting. She wasn’t hungry in these moments, rather just a little worn out and perhaps a little careless. She then proceeded to email her doctor (me) to report on this endless cycle of unwanted behavior.
In January 2024, a novel study from Turkey examined the relationship between hedonic eating, self-condemnation, and self-esteem. Surprising to no one, the study determined that higher hedonic hunger scores were associated with lower self-esteem and an increased propensity to self-stigmatize.
Oprah could have handily predicted this conclusion. Many years ago, she described food as a fake friend: Perhaps you’ve had a long and difficult day. While you’re busy eating your feelings, the heaping plate of pasta feels like your best buddy in the world. However, the moment the plate is empty, you realize that you feel worse than before. Not only do you have to unbutton your new jeans, but you also realize that you have just lost your ability to self-regulate.
While the positive association between hedonic eating and low self-esteem may seem self-evident, the solution is less obvious. Mindfulness is one possible approach to this issue. Mindfulness has been described as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” and has existed for thousands of years. Mindful eating, in particular, involves paying close attention to our food choices and how they affect our emotions, and typically includes some combination of:
- Slowing down eating/chewing thoroughly
- Eliminating distractions such as TV, computers, and phones — perhaps even eating in silence
- Eating only until physically satiated
- Distinguishing between true hunger and cravings
- Noticing the texture, flavors, and smell of food
- Paying attention to the effect of food on your mood
- Appreciating food
In our society, where processed food is so readily available and stress is so ubiquitous, eating can become a hedonic and fast-paced activity. Our brains don’t have time to process our bodies’ signals of fullness and, as a result, we often ingest many more calories than we need for a healthy lifestyle.
If mindless eating is part of the problem, mindful eating is part of the solution. Indeed, a meta-review of 10 scientific studies showed that mindful eating is as effective as conventional weight loss programs in regard to body mass index and waist circumference. On the basis of these studies — as well as some good old-fashioned common sense — intuitive eating is an important component of sustainable weight reduction.
Eventually, I convinced Logan to meet up with the psychologist in our group who specializes in emotional eating. Through weekly cognitive-behavioral therapy sessions, Logan was able to understand the impetus behind her self-defeating behavior and has finally been able to reverse some of her lifelong habits. Once she started practicing mindful eating, I was able to introduce Ozempic, and now Logan is happily shedding several pounds a week.
Dr. Messer has disclosed no relevant financial relationships.
Dr. Messer is clinical assistant professor, Mount Sinai School of Medicine and associate professor, Hofstra School of Medicine, both in New York City.
A version of this article first appeared on Medscape.com.