Commentary

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact [email protected].

Creating an optimal learning environment for medical students studying psychiatry is essential for their growth and development. Over the last 25 years, I have worked with hundreds of medical students in a busy urban emergency department (ED), and I have developed a style that has worked well for them and for me. A supportive, engaging atmosphere can significantly enhance students’ understanding of psychiatric conditions, therapeutic approaches, and patient care. To ensure a productive and inspiring learning experience, educators should consider several key factors.

The educators

Faculty physicians should invest themselves in the students’ individual growth and aspirations by providing personalized guidance that caters to each student’s goals and challenges.¹ Educators must also embody a passion for psychiatry. I’ve found that integrating a lighthearted and humorous approach to my teaching style can relieve stress and enhance learning. I’ve also found it crucial to demonstrate empathy and effective communication skills that students can emulate in their professional development.² Encourage students to take an active role in their learning process by engaging in clinical discussions and decision-making. Lastly, providing regular assessments and constructive feedback in a supportive manner allows students to better understand their strengths and weaknesses, and to continually improve their knowledge and skills.³

The students

Encourage students to fully express their unique personalities, perspectives, and learning styles. This diversity can fuel creativity and promote an atmosphere of inclusivity and enhanced learning. Teach students to recognize the value in each patient encounter, because each offers a unique opportunity to deepen their understanding of psychiatric conditions.⁴ Instead of being mere observers, students should actively participate in their education by involving themselves in clinical discussions, treatment planning, and decision-making.

The environment

A supportive, inclusive learning environment should foster diversity, inclusivity, and collaborative learning by creating an engaging atmosphere in which students can express themselves. In my experience, a sense of relaxed focus can help alleviate stress and enhance creativity. Emphasize a patient-centered approach to instill empathy and compassion in students and enrich their understanding of psychiatric conditions.⁴

The peers

Encourage students to engage in peer feedback, which will provide their fellow trainees additional perspective on their performance and offer an avenue for constructive criticism and improvement.³ Promoting collaborative learning will foster a sense of camaraderie, help students share their diverse perspectives, and enhance the learning experience. Peers also play a crucial role in reinforcing positive behaviors and attitudes.

My extensive experience educating medical students studying psychiatry in a busy ED has taught me that creating an exceptional learning environment requires understanding the role of educators, students, the environment, and peers. By implementing these principles, educators can contribute to their students’ professional growth, equipping them with the skills and mindset necessary to become a compassionate, competent, effective physician.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact [email protected].

Creating an optimal learning environment for medical students studying psychiatry is essential for their growth and development. Over the last 25 years, I have worked with hundreds of medical students in a busy urban emergency department (ED), and I have developed a style that has worked well for them and for me. A supportive, engaging atmosphere can significantly enhance students’ understanding of psychiatric conditions, therapeutic approaches, and patient care. To ensure a productive and inspiring learning experience, educators should consider several key factors.

The educators

Faculty physicians should invest themselves in the students’ individual growth and aspirations by providing personalized guidance that caters to each student’s goals and challenges.¹ Educators must also embody a passion for psychiatry. I’ve found that integrating a lighthearted and humorous approach to my teaching style can relieve stress and enhance learning. I’ve also found it crucial to demonstrate empathy and effective communication skills that students can emulate in their professional development.² Encourage students to take an active role in their learning process by engaging in clinical discussions and decision-making. Lastly, providing regular assessments and constructive feedback in a supportive manner allows students to better understand their strengths and weaknesses, and to continually improve their knowledge and skills.³

The students

Encourage students to fully express their unique personalities, perspectives, and learning styles. This diversity can fuel creativity and promote an atmosphere of inclusivity and enhanced learning. Teach students to recognize the value in each patient encounter, because each offers a unique opportunity to deepen their understanding of psychiatric conditions.⁴ Instead of being mere observers, students should actively participate in their education by involving themselves in clinical discussions, treatment planning, and decision-making.

The environment

A supportive, inclusive learning environment should foster diversity, inclusivity, and collaborative learning by creating an engaging atmosphere in which students can express themselves. In my experience, a sense of relaxed focus can help alleviate stress and enhance creativity. Emphasize a patient-centered approach to instill empathy and compassion in students and enrich their understanding of psychiatric conditions.⁴

The peers

Encourage students to engage in peer feedback, which will provide their fellow trainees additional perspective on their performance and offer an avenue for constructive criticism and improvement.³ Promoting collaborative learning will foster a sense of camaraderie, help students share their diverse perspectives, and enhance the learning experience. Peers also play a crucial role in reinforcing positive behaviors and attitudes.

My extensive experience educating medical students studying psychiatry in a busy ED has taught me that creating an exceptional learning environment requires understanding the role of educators, students, the environment, and peers. By implementing these principles, educators can contribute to their students’ professional growth, equipping them with the skills and mindset necessary to become a compassionate, competent, effective physician.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact [email protected].

Creating an optimal learning environment for medical students studying psychiatry is essential for their growth and development. Over the last 25 years, I have worked with hundreds of medical students in a busy urban emergency department (ED), and I have developed a style that has worked well for them and for me. A supportive, engaging atmosphere can significantly enhance students’ understanding of psychiatric conditions, therapeutic approaches, and patient care. To ensure a productive and inspiring learning experience, educators should consider several key factors.

The educators

Faculty physicians should invest themselves in the students’ individual growth and aspirations by providing personalized guidance that caters to each student’s goals and challenges.¹ Educators must also embody a passion for psychiatry. I’ve found that integrating a lighthearted and humorous approach to my teaching style can relieve stress and enhance learning. I’ve also found it crucial to demonstrate empathy and effective communication skills that students can emulate in their professional development.² Encourage students to take an active role in their learning process by engaging in clinical discussions and decision-making. Lastly, providing regular assessments and constructive feedback in a supportive manner allows students to better understand their strengths and weaknesses, and to continually improve their knowledge and skills.³

The students

Encourage students to fully express their unique personalities, perspectives, and learning styles. This diversity can fuel creativity and promote an atmosphere of inclusivity and enhanced learning. Teach students to recognize the value in each patient encounter, because each offers a unique opportunity to deepen their understanding of psychiatric conditions.⁴ Instead of being mere observers, students should actively participate in their education by involving themselves in clinical discussions, treatment planning, and decision-making.

The environment

A supportive, inclusive learning environment should foster diversity, inclusivity, and collaborative learning by creating an engaging atmosphere in which students can express themselves. In my experience, a sense of relaxed focus can help alleviate stress and enhance creativity. Emphasize a patient-centered approach to instill empathy and compassion in students and enrich their understanding of psychiatric conditions.⁴

The peers

Encourage students to engage in peer feedback, which will provide their fellow trainees additional perspective on their performance and offer an avenue for constructive criticism and improvement.³ Promoting collaborative learning will foster a sense of camaraderie, help students share their diverse perspectives, and enhance the learning experience. Peers also play a crucial role in reinforcing positive behaviors and attitudes.

My extensive experience educating medical students studying psychiatry in a busy ED has taught me that creating an exceptional learning environment requires understanding the role of educators, students, the environment, and peers. By implementing these principles, educators can contribute to their students’ professional growth, equipping them with the skills and mindset necessary to become a compassionate, competent, effective physician.

I was disheartened with the June 2023 issue of Current Psychiatry. This issue included “Optimizing benzodiazepine treatment of anxiety disorders” (p. 22-33,39, doi:10.12788/cp.0365). While these medications may be helpful for short-term treatment, I find their irresponsible use to be a much greater problem than their underutilization.¹

The benzodiazepine pharmacology discussed in this article is interesting, but it would be helpful if it had been integrated within a much more extensive discussion of careful prescribing practices. In 2020, the FDA updated the boxed warning to alert prescribers to the serious risks of abuse, addiction, physical dependence, and withdrawal reactions associated with benzodiazepines.² I would hope that an article on benzodiazepines would provide more discussion and guidance surrounding these important issues.

The June 2023 issue also included “High-dose stimulants for adult ADHD” (p. 34-39, doi:10.12788/cp.0366). This article provided esoteric advice on managing stimulant therapy in the setting of Roux-en-Y gastric bypass surgery, yet I would regard stimulant misuse as a far more common and pressing issue.^3,4 The recent Drug Enforcement Administration investigation of telehealth stimulant prescribing is a notable example of this problem.⁵

The patient discussed in this article was receiving large doses of stimulants for a purported case of refractory attention-deficit/hyperactivity disorder (ADHD). The article provided a sparse differential diagnosis for the patient’s intractable symptoms. While rapid metabolism may be an explanation, I would also like to know how the authors ruled out physiological dependence and/or addiction to a controlled substance. How was misuse excluded? Was urine drug testing (UDS) performed? UDS is highly irregular among prescribers,⁶ which suggests that practices for detecting covert substance abuse and stimulant misuse are inadequate. Wouldn’t such investigations be fundamental to ethical stimulant prescribing?

Jeff Sanders, MD, PhD
Atlanta, Georgia

References

1. Centers for Disease Control and Prevention. Trends in nonfatal and fatal overdoses involving benzodiazepines—38 states and the District of Columbia, 2019-2020. Accessed August 9, 2023. https://www.cdc.gov/mmwr/volumes/70/wr/mm7034a2.htm

2. US Food & Drug Administration. FDA requiring boxed warning updated to improve safe use of benzodiazepine drug class. Accessed August 14, 2023. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class

3. McCabe SE, Schulenberg JE, Wilens TE, et al. Prescription stimulant medical and nonmedical use among US secondary school students, 2005 to 2020. JAMA Netw Open. 2023;6(4):e238707. doi:10.1001/jamanetworkopen.2023.8707

4. US Food & Drug Administration. FDA updating warnings to improve safe use of prescription stimulants used to treat ADHD and other conditions. Accessed August 14, 2023. https://www.fda.gov/safety/medical-product-safety-information/fda-updating-warnings-improve-safe-use-prescription-stimulants-used-treat-adhd-and-other-conditions

5. Vaidya A. Report: telehealth company’s prescribing practices come under DEA scrutiny. September 16, 2022. Accessed August 9, 2023. https://mhealthintelligence.com/news/report-telehealth-company-dones-prescribing-practices-come-under-dea-scrutiny

6. Zionts A. Some ADHD patients are drug-tested often, while others are never asked. Kaiser Health News. March 25, 2023. Accessed August 9, 2023. https://www.nbcnews.com/news/amp/rcna76330

Continue to: Drs. Stimpfl and Strawn respond

We thank Dr. Sanders for highlighting the need for clinical equipoise in considering the risks and benefits of medications—something that is true for benzodiazepines, antipsychotics, antidepressants, and in fact all medications. He reminds us that the risks of misuse, dependence, and withdrawal associated with benzodiazepines led to a boxed warning in September 2020 and highlights recent trends of fatal and nonfatal benzodiazepine overdose, especially when combined with opiates.

Our article, which aimed to educate clinicians on benzodiazepine pharma­cology and patient-specific factors influencing benzodiazepine selection and dosing, did not focus significantly on the risks associated with benzodiazepines. We do encourage careful and individualized benzodiazepine prescribing. However, we wish to remind our colleagues that benzodiazepines, while associated with risks, continue to have utility in acute and periprocedural settings, and remain an important treatment option for patients with panic disorder, generalized anxiety disorder (especially while waiting for other medications to take effect), catatonia, seizure disorders, and alcohol withdrawal.

We agree that patient-specific risk assessment is essential, as some patients benefit from benzodiazepines despite the risks. However, we also acknowledge that some individuals are at higher risk for adverse outcomes, including those with concurrent opiate use or who are prescribed other sedative-hypnotics; older adults and those with neurocognitive disorders; and patients susceptible to respiratory depression due to other medical reasons (eg, myasthenia gravis, sleep apnea, and chronic obstructive pulmonary disease). Further, we agree that benzodiazepine use during pregnancy is generally not advised due to the risks of neonatal hypotonia and neonatal withdrawal syndrome¹ as well as a possible risk of cleft palate that has been reported in some studies.² Finally, paradoxical reactions may be more common at the extremes of age and in patients with intellectual disability or personality disorders.^3,4

Patient characteristics that have been associated with a higher risk of benzodiazepine use disorder include lower education/income, unemployment, having another substance use disorder, and severe psychopathology.⁵ In some studies, using benzodiazepines for prolonged periods at high doses as well as using those with a rapid onset of action was associated with an increased risk of benzodiazepine use disorder.^5-7

Ultimately, we concur with Dr. Sanders on the perils of the “irresponsible use” of medication and emphasize the need for discernment when choosing treatments to avoid rashly discarding an effective remedy while attempting to mitigate all conceivable risks.

Julia Stimpfl, MD
Jeffrey R. Strawn, MD
Cincinnati, Ohio

References

1. McElhatton PR. The effects of benzodiazepine use during pregnancy and lactation. Reprod Toxicol. 1994;8(6):461-475. doi:10.1016/0890-6238(94)90029-9

2. Enato E, Moretti M, Koren G. The fetal safety of benzodiazepines: an updated meta-analysis. J Obstet Gynaecol Can. 2011;33(1):46-48. doi:10.1016/S1701-2163(16)34772-7 Erratum in: J Obstet Gynaecol Can. 2011;33(4):319.

3. Hakimi Y, Petitpain N, Pinzani V, et al. Paradoxical adverse drug reactions: descriptive analysis of French reports. Eur J Clin Pharmacol. 2020;76(8):1169-1174. doi:10.1007/s00228-020-02892-2

4. Paton C. Benzodiazepines and disinhibition: a review. Psychiatric Bulletin. 2002;26(12):460-462. doi:10.1192/pb.26.12.460

5. Fride Tvete I, Bjørner T, Skomedal T. Risk factors for excessive benzodiazepine use in a working age population: a nationwide 5-year survey in Norway. Scand J Prim Health Care. 2015;33(4):252-259. doi:10.3109/02813432.2015.1117282

6. Griffiths RR, Johnson MW. Relative abuse liability of hypnotic drugs: a conceptual framework and algorithm for differentiating among compounds. J Clin Psychiatry. 2005;66 Suppl 9:31-41.

7. Kan CC, Hilberink SR, Breteler MH. Determination of the main risk factors for benzodiazepine dependence using a multivariate and multidimensional approach. Compr Psychiatry. 2004;45(2):88-94. doi:10.1016/j.comppsych.2003.12.007

Continue to: Drs. Sarma and Grady respond

Dr. Sanders’ letter highlights the potential caveats associated with prescribing controlled substances. We agree that our short case summary includes numerous interesting elements, each of which would be worthy of further exploration and discussion. Our choice was to highlight the patient history of bariatric surgery and use this as a springboard into a review of stimulants, including the newest formulations for ADHD. For more than 1 year, many generic stimulants have been in short supply, and patients and clinicians have been seeking other therapeutic options. Given this background and with newer, branded stimulant use becoming more commonplace, we believe our article was useful and timely.

Our original intent had been to include an example of a controlled substance agreement. Regrettably, there was simply not enough space for this document or the additional discussion that its inclusion would deem necessary. Nevertheless, had the May 2023 FDA requirement for manufacturers to update the labeling of prescription stimulants¹ to clarify misuse and abuse been published before our article’s final revision, we would have mentioned it and provided the appropriate link.

Subbu J. Sarma, MD, FAPA
Kansas City, Missouri

Sarah E. Grady, PharmD, BCPS, BCPP
Des Moines, Iowa

References

1. US Food & Drug Administration. FDA requires updates to clarify labeling of prescription stimulants used to treat ADHD and other conditions. Accessed August 9, 2023. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requires-updates-clarify-labeling-prescription-stimulants-used-treat-adhd-and-other-conditions

I was disheartened with the June 2023 issue of Current Psychiatry. This issue included “Optimizing benzodiazepine treatment of anxiety disorders” (p. 22-33,39, doi:10.12788/cp.0365). While these medications may be helpful for short-term treatment, I find their irresponsible use to be a much greater problem than their underutilization.¹

The benzodiazepine pharmacology discussed in this article is interesting, but it would be helpful if it had been integrated within a much more extensive discussion of careful prescribing practices. In 2020, the FDA updated the boxed warning to alert prescribers to the serious risks of abuse, addiction, physical dependence, and withdrawal reactions associated with benzodiazepines.² I would hope that an article on benzodiazepines would provide more discussion and guidance surrounding these important issues.

The June 2023 issue also included “High-dose stimulants for adult ADHD” (p. 34-39, doi:10.12788/cp.0366). This article provided esoteric advice on managing stimulant therapy in the setting of Roux-en-Y gastric bypass surgery, yet I would regard stimulant misuse as a far more common and pressing issue.^3,4 The recent Drug Enforcement Administration investigation of telehealth stimulant prescribing is a notable example of this problem.⁵

The patient discussed in this article was receiving large doses of stimulants for a purported case of refractory attention-deficit/hyperactivity disorder (ADHD). The article provided a sparse differential diagnosis for the patient’s intractable symptoms. While rapid metabolism may be an explanation, I would also like to know how the authors ruled out physiological dependence and/or addiction to a controlled substance. How was misuse excluded? Was urine drug testing (UDS) performed? UDS is highly irregular among prescribers,⁶ which suggests that practices for detecting covert substance abuse and stimulant misuse are inadequate. Wouldn’t such investigations be fundamental to ethical stimulant prescribing?

Jeff Sanders, MD, PhD
Atlanta, Georgia

References

1. Centers for Disease Control and Prevention. Trends in nonfatal and fatal overdoses involving benzodiazepines—38 states and the District of Columbia, 2019-2020. Accessed August 9, 2023. https://www.cdc.gov/mmwr/volumes/70/wr/mm7034a2.htm

2. US Food & Drug Administration. FDA requiring boxed warning updated to improve safe use of benzodiazepine drug class. Accessed August 14, 2023. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class

3. McCabe SE, Schulenberg JE, Wilens TE, et al. Prescription stimulant medical and nonmedical use among US secondary school students, 2005 to 2020. JAMA Netw Open. 2023;6(4):e238707. doi:10.1001/jamanetworkopen.2023.8707

4. US Food & Drug Administration. FDA updating warnings to improve safe use of prescription stimulants used to treat ADHD and other conditions. Accessed August 14, 2023. https://www.fda.gov/safety/medical-product-safety-information/fda-updating-warnings-improve-safe-use-prescription-stimulants-used-treat-adhd-and-other-conditions

5. Vaidya A. Report: telehealth company’s prescribing practices come under DEA scrutiny. September 16, 2022. Accessed August 9, 2023. https://mhealthintelligence.com/news/report-telehealth-company-dones-prescribing-practices-come-under-dea-scrutiny

6. Zionts A. Some ADHD patients are drug-tested often, while others are never asked. Kaiser Health News. March 25, 2023. Accessed August 9, 2023. https://www.nbcnews.com/news/amp/rcna76330

Continue to: Drs. Stimpfl and Strawn respond

We thank Dr. Sanders for highlighting the need for clinical equipoise in considering the risks and benefits of medications—something that is true for benzodiazepines, antipsychotics, antidepressants, and in fact all medications. He reminds us that the risks of misuse, dependence, and withdrawal associated with benzodiazepines led to a boxed warning in September 2020 and highlights recent trends of fatal and nonfatal benzodiazepine overdose, especially when combined with opiates.

Our article, which aimed to educate clinicians on benzodiazepine pharma­cology and patient-specific factors influencing benzodiazepine selection and dosing, did not focus significantly on the risks associated with benzodiazepines. We do encourage careful and individualized benzodiazepine prescribing. However, we wish to remind our colleagues that benzodiazepines, while associated with risks, continue to have utility in acute and periprocedural settings, and remain an important treatment option for patients with panic disorder, generalized anxiety disorder (especially while waiting for other medications to take effect), catatonia, seizure disorders, and alcohol withdrawal.

We agree that patient-specific risk assessment is essential, as some patients benefit from benzodiazepines despite the risks. However, we also acknowledge that some individuals are at higher risk for adverse outcomes, including those with concurrent opiate use or who are prescribed other sedative-hypnotics; older adults and those with neurocognitive disorders; and patients susceptible to respiratory depression due to other medical reasons (eg, myasthenia gravis, sleep apnea, and chronic obstructive pulmonary disease). Further, we agree that benzodiazepine use during pregnancy is generally not advised due to the risks of neonatal hypotonia and neonatal withdrawal syndrome¹ as well as a possible risk of cleft palate that has been reported in some studies.² Finally, paradoxical reactions may be more common at the extremes of age and in patients with intellectual disability or personality disorders.^3,4

Patient characteristics that have been associated with a higher risk of benzodiazepine use disorder include lower education/income, unemployment, having another substance use disorder, and severe psychopathology.⁵ In some studies, using benzodiazepines for prolonged periods at high doses as well as using those with a rapid onset of action was associated with an increased risk of benzodiazepine use disorder.^5-7

Ultimately, we concur with Dr. Sanders on the perils of the “irresponsible use” of medication and emphasize the need for discernment when choosing treatments to avoid rashly discarding an effective remedy while attempting to mitigate all conceivable risks.

Julia Stimpfl, MD
Jeffrey R. Strawn, MD
Cincinnati, Ohio

References

1. McElhatton PR. The effects of benzodiazepine use during pregnancy and lactation. Reprod Toxicol. 1994;8(6):461-475. doi:10.1016/0890-6238(94)90029-9

2. Enato E, Moretti M, Koren G. The fetal safety of benzodiazepines: an updated meta-analysis. J Obstet Gynaecol Can. 2011;33(1):46-48. doi:10.1016/S1701-2163(16)34772-7 Erratum in: J Obstet Gynaecol Can. 2011;33(4):319.

3. Hakimi Y, Petitpain N, Pinzani V, et al. Paradoxical adverse drug reactions: descriptive analysis of French reports. Eur J Clin Pharmacol. 2020;76(8):1169-1174. doi:10.1007/s00228-020-02892-2

4. Paton C. Benzodiazepines and disinhibition: a review. Psychiatric Bulletin. 2002;26(12):460-462. doi:10.1192/pb.26.12.460

5. Fride Tvete I, Bjørner T, Skomedal T. Risk factors for excessive benzodiazepine use in a working age population: a nationwide 5-year survey in Norway. Scand J Prim Health Care. 2015;33(4):252-259. doi:10.3109/02813432.2015.1117282

6. Griffiths RR, Johnson MW. Relative abuse liability of hypnotic drugs: a conceptual framework and algorithm for differentiating among compounds. J Clin Psychiatry. 2005;66 Suppl 9:31-41.

7. Kan CC, Hilberink SR, Breteler MH. Determination of the main risk factors for benzodiazepine dependence using a multivariate and multidimensional approach. Compr Psychiatry. 2004;45(2):88-94. doi:10.1016/j.comppsych.2003.12.007

Continue to: Drs. Sarma and Grady respond

Dr. Sanders’ letter highlights the potential caveats associated with prescribing controlled substances. We agree that our short case summary includes numerous interesting elements, each of which would be worthy of further exploration and discussion. Our choice was to highlight the patient history of bariatric surgery and use this as a springboard into a review of stimulants, including the newest formulations for ADHD. For more than 1 year, many generic stimulants have been in short supply, and patients and clinicians have been seeking other therapeutic options. Given this background and with newer, branded stimulant use becoming more commonplace, we believe our article was useful and timely.

Our original intent had been to include an example of a controlled substance agreement. Regrettably, there was simply not enough space for this document or the additional discussion that its inclusion would deem necessary. Nevertheless, had the May 2023 FDA requirement for manufacturers to update the labeling of prescription stimulants¹ to clarify misuse and abuse been published before our article’s final revision, we would have mentioned it and provided the appropriate link.

Subbu J. Sarma, MD, FAPA
Kansas City, Missouri

Sarah E. Grady, PharmD, BCPS, BCPP
Des Moines, Iowa

References

1. US Food & Drug Administration. FDA requires updates to clarify labeling of prescription stimulants used to treat ADHD and other conditions. Accessed August 9, 2023. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requires-updates-clarify-labeling-prescription-stimulants-used-treat-adhd-and-other-conditions

I was disheartened with the June 2023 issue of Current Psychiatry. This issue included “Optimizing benzodiazepine treatment of anxiety disorders” (p. 22-33,39, doi:10.12788/cp.0365). While these medications may be helpful for short-term treatment, I find their irresponsible use to be a much greater problem than their underutilization.¹

The benzodiazepine pharmacology discussed in this article is interesting, but it would be helpful if it had been integrated within a much more extensive discussion of careful prescribing practices. In 2020, the FDA updated the boxed warning to alert prescribers to the serious risks of abuse, addiction, physical dependence, and withdrawal reactions associated with benzodiazepines.² I would hope that an article on benzodiazepines would provide more discussion and guidance surrounding these important issues.

The June 2023 issue also included “High-dose stimulants for adult ADHD” (p. 34-39, doi:10.12788/cp.0366). This article provided esoteric advice on managing stimulant therapy in the setting of Roux-en-Y gastric bypass surgery, yet I would regard stimulant misuse as a far more common and pressing issue.^3,4 The recent Drug Enforcement Administration investigation of telehealth stimulant prescribing is a notable example of this problem.⁵

The patient discussed in this article was receiving large doses of stimulants for a purported case of refractory attention-deficit/hyperactivity disorder (ADHD). The article provided a sparse differential diagnosis for the patient’s intractable symptoms. While rapid metabolism may be an explanation, I would also like to know how the authors ruled out physiological dependence and/or addiction to a controlled substance. How was misuse excluded? Was urine drug testing (UDS) performed? UDS is highly irregular among prescribers,⁶ which suggests that practices for detecting covert substance abuse and stimulant misuse are inadequate. Wouldn’t such investigations be fundamental to ethical stimulant prescribing?

Jeff Sanders, MD, PhD
Atlanta, Georgia

References

1. Centers for Disease Control and Prevention. Trends in nonfatal and fatal overdoses involving benzodiazepines—38 states and the District of Columbia, 2019-2020. Accessed August 9, 2023. https://www.cdc.gov/mmwr/volumes/70/wr/mm7034a2.htm

2. US Food & Drug Administration. FDA requiring boxed warning updated to improve safe use of benzodiazepine drug class. Accessed August 14, 2023. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class

3. McCabe SE, Schulenberg JE, Wilens TE, et al. Prescription stimulant medical and nonmedical use among US secondary school students, 2005 to 2020. JAMA Netw Open. 2023;6(4):e238707. doi:10.1001/jamanetworkopen.2023.8707

4. US Food & Drug Administration. FDA updating warnings to improve safe use of prescription stimulants used to treat ADHD and other conditions. Accessed August 14, 2023. https://www.fda.gov/safety/medical-product-safety-information/fda-updating-warnings-improve-safe-use-prescription-stimulants-used-treat-adhd-and-other-conditions

5. Vaidya A. Report: telehealth company’s prescribing practices come under DEA scrutiny. September 16, 2022. Accessed August 9, 2023. https://mhealthintelligence.com/news/report-telehealth-company-dones-prescribing-practices-come-under-dea-scrutiny

6. Zionts A. Some ADHD patients are drug-tested often, while others are never asked. Kaiser Health News. March 25, 2023. Accessed August 9, 2023. https://www.nbcnews.com/news/amp/rcna76330

Continue to: Drs. Stimpfl and Strawn respond

We thank Dr. Sanders for highlighting the need for clinical equipoise in considering the risks and benefits of medications—something that is true for benzodiazepines, antipsychotics, antidepressants, and in fact all medications. He reminds us that the risks of misuse, dependence, and withdrawal associated with benzodiazepines led to a boxed warning in September 2020 and highlights recent trends of fatal and nonfatal benzodiazepine overdose, especially when combined with opiates.

Our article, which aimed to educate clinicians on benzodiazepine pharma­cology and patient-specific factors influencing benzodiazepine selection and dosing, did not focus significantly on the risks associated with benzodiazepines. We do encourage careful and individualized benzodiazepine prescribing. However, we wish to remind our colleagues that benzodiazepines, while associated with risks, continue to have utility in acute and periprocedural settings, and remain an important treatment option for patients with panic disorder, generalized anxiety disorder (especially while waiting for other medications to take effect), catatonia, seizure disorders, and alcohol withdrawal.

We agree that patient-specific risk assessment is essential, as some patients benefit from benzodiazepines despite the risks. However, we also acknowledge that some individuals are at higher risk for adverse outcomes, including those with concurrent opiate use or who are prescribed other sedative-hypnotics; older adults and those with neurocognitive disorders; and patients susceptible to respiratory depression due to other medical reasons (eg, myasthenia gravis, sleep apnea, and chronic obstructive pulmonary disease). Further, we agree that benzodiazepine use during pregnancy is generally not advised due to the risks of neonatal hypotonia and neonatal withdrawal syndrome¹ as well as a possible risk of cleft palate that has been reported in some studies.² Finally, paradoxical reactions may be more common at the extremes of age and in patients with intellectual disability or personality disorders.^3,4

Patient characteristics that have been associated with a higher risk of benzodiazepine use disorder include lower education/income, unemployment, having another substance use disorder, and severe psychopathology.⁵ In some studies, using benzodiazepines for prolonged periods at high doses as well as using those with a rapid onset of action was associated with an increased risk of benzodiazepine use disorder.^5-7

Ultimately, we concur with Dr. Sanders on the perils of the “irresponsible use” of medication and emphasize the need for discernment when choosing treatments to avoid rashly discarding an effective remedy while attempting to mitigate all conceivable risks.

Julia Stimpfl, MD
Jeffrey R. Strawn, MD
Cincinnati, Ohio

References

1. McElhatton PR. The effects of benzodiazepine use during pregnancy and lactation. Reprod Toxicol. 1994;8(6):461-475. doi:10.1016/0890-6238(94)90029-9

2. Enato E, Moretti M, Koren G. The fetal safety of benzodiazepines: an updated meta-analysis. J Obstet Gynaecol Can. 2011;33(1):46-48. doi:10.1016/S1701-2163(16)34772-7 Erratum in: J Obstet Gynaecol Can. 2011;33(4):319.

3. Hakimi Y, Petitpain N, Pinzani V, et al. Paradoxical adverse drug reactions: descriptive analysis of French reports. Eur J Clin Pharmacol. 2020;76(8):1169-1174. doi:10.1007/s00228-020-02892-2

4. Paton C. Benzodiazepines and disinhibition: a review. Psychiatric Bulletin. 2002;26(12):460-462. doi:10.1192/pb.26.12.460

5. Fride Tvete I, Bjørner T, Skomedal T. Risk factors for excessive benzodiazepine use in a working age population: a nationwide 5-year survey in Norway. Scand J Prim Health Care. 2015;33(4):252-259. doi:10.3109/02813432.2015.1117282

6. Griffiths RR, Johnson MW. Relative abuse liability of hypnotic drugs: a conceptual framework and algorithm for differentiating among compounds. J Clin Psychiatry. 2005;66 Suppl 9:31-41.

7. Kan CC, Hilberink SR, Breteler MH. Determination of the main risk factors for benzodiazepine dependence using a multivariate and multidimensional approach. Compr Psychiatry. 2004;45(2):88-94. doi:10.1016/j.comppsych.2003.12.007

Continue to: Drs. Sarma and Grady respond

Dr. Sanders’ letter highlights the potential caveats associated with prescribing controlled substances. We agree that our short case summary includes numerous interesting elements, each of which would be worthy of further exploration and discussion. Our choice was to highlight the patient history of bariatric surgery and use this as a springboard into a review of stimulants, including the newest formulations for ADHD. For more than 1 year, many generic stimulants have been in short supply, and patients and clinicians have been seeking other therapeutic options. Given this background and with newer, branded stimulant use becoming more commonplace, we believe our article was useful and timely.

Our original intent had been to include an example of a controlled substance agreement. Regrettably, there was simply not enough space for this document or the additional discussion that its inclusion would deem necessary. Nevertheless, had the May 2023 FDA requirement for manufacturers to update the labeling of prescription stimulants¹ to clarify misuse and abuse been published before our article’s final revision, we would have mentioned it and provided the appropriate link.

Subbu J. Sarma, MD, FAPA
Kansas City, Missouri

Sarah E. Grady, PharmD, BCPS, BCPP
Des Moines, Iowa

References

1. US Food & Drug Administration. FDA requires updates to clarify labeling of prescription stimulants used to treat ADHD and other conditions. Accessed August 9, 2023. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requires-updates-clarify-labeling-prescription-stimulants-used-treat-adhd-and-other-conditions

One of the most rewarding things about serving as editor of GI & Hepatology News is to consider new content that will further engage and bring value to our readership. In addition to reporting on scientific advances from our GI journals that can inform frontline clinical care of patients with gastrointestinal conditions, we have launched several new columns over the past year, including our monthly Member Spotlight and quarterly Health Policy and Advocacy columns, to diversify our content.

In our September 2023 issue, in addition to debuting a new cover design, we are pleased to introduce yet another new offering – the “Ethics Corner” column. It is intended to highlight important ethical considerations and challenges arising in GI practice and offer practical guidance on how to navigate them. In our inaugural Ethics Corner, AGA Ethics Committee members Dr. Sheldon Sloan and Dr. David Drew discuss the “good, the bad, and the ugly” of direct-to-consumer advertising (DTCA). They highlight the pros and cons of DTCA from an ethical perspective, illustrate how DTCA can impact everyday clinical interactions with patients, and provide insight into how to navigate these challenging conversations. We hope you enjoy this new addition to the newspaper and welcome your ideas for future Ethics Corner columns and other content.

Also in this month’s issue, we update you on AGA’s response to the American College of Physicians’ recent decision to recommend against initiating colon cancer screening at age 45, contrary to the recommendation of the GI community. We also present a story on Humira biosimilars and how they are likely to impact clinical practice. Finally, our September Member Spotlight features GI dietitian Renee Euler, MS, RD, LD, who discusses the intersection between diet and GI disorders, the importance of a team approach to GI care, and her work as a liaison between the AGA and Academy of Nutrition and Dietetics.

We hope you enjoy these, and all the stories featured in our September issue.

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

One of the most rewarding things about serving as editor of GI & Hepatology News is to consider new content that will further engage and bring value to our readership. In addition to reporting on scientific advances from our GI journals that can inform frontline clinical care of patients with gastrointestinal conditions, we have launched several new columns over the past year, including our monthly Member Spotlight and quarterly Health Policy and Advocacy columns, to diversify our content.

In our September 2023 issue, in addition to debuting a new cover design, we are pleased to introduce yet another new offering – the “Ethics Corner” column. It is intended to highlight important ethical considerations and challenges arising in GI practice and offer practical guidance on how to navigate them. In our inaugural Ethics Corner, AGA Ethics Committee members Dr. Sheldon Sloan and Dr. David Drew discuss the “good, the bad, and the ugly” of direct-to-consumer advertising (DTCA). They highlight the pros and cons of DTCA from an ethical perspective, illustrate how DTCA can impact everyday clinical interactions with patients, and provide insight into how to navigate these challenging conversations. We hope you enjoy this new addition to the newspaper and welcome your ideas for future Ethics Corner columns and other content.

Also in this month’s issue, we update you on AGA’s response to the American College of Physicians’ recent decision to recommend against initiating colon cancer screening at age 45, contrary to the recommendation of the GI community. We also present a story on Humira biosimilars and how they are likely to impact clinical practice. Finally, our September Member Spotlight features GI dietitian Renee Euler, MS, RD, LD, who discusses the intersection between diet and GI disorders, the importance of a team approach to GI care, and her work as a liaison between the AGA and Academy of Nutrition and Dietetics.

We hope you enjoy these, and all the stories featured in our September issue.

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

One of the most rewarding things about serving as editor of GI & Hepatology News is to consider new content that will further engage and bring value to our readership. In addition to reporting on scientific advances from our GI journals that can inform frontline clinical care of patients with gastrointestinal conditions, we have launched several new columns over the past year, including our monthly Member Spotlight and quarterly Health Policy and Advocacy columns, to diversify our content.

In our September 2023 issue, in addition to debuting a new cover design, we are pleased to introduce yet another new offering – the “Ethics Corner” column. It is intended to highlight important ethical considerations and challenges arising in GI practice and offer practical guidance on how to navigate them. In our inaugural Ethics Corner, AGA Ethics Committee members Dr. Sheldon Sloan and Dr. David Drew discuss the “good, the bad, and the ugly” of direct-to-consumer advertising (DTCA). They highlight the pros and cons of DTCA from an ethical perspective, illustrate how DTCA can impact everyday clinical interactions with patients, and provide insight into how to navigate these challenging conversations. We hope you enjoy this new addition to the newspaper and welcome your ideas for future Ethics Corner columns and other content.

Also in this month’s issue, we update you on AGA’s response to the American College of Physicians’ recent decision to recommend against initiating colon cancer screening at age 45, contrary to the recommendation of the GI community. We also present a story on Humira biosimilars and how they are likely to impact clinical practice. Finally, our September Member Spotlight features GI dietitian Renee Euler, MS, RD, LD, who discusses the intersection between diet and GI disorders, the importance of a team approach to GI care, and her work as a liaison between the AGA and Academy of Nutrition and Dietetics.

We hope you enjoy these, and all the stories featured in our September issue.

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

This transcript from Impact Factor has been edited for clarity.

If you are my age or older, and like me, you are something of a rule follower, then you’re getting screened for various cancers.

Colonoscopies, mammograms, cervical cancer screening, chest CTs for people with a significant smoking history. The tests are done and usually, but not always, they are negative. And if positive, usually, but not always, follow-up tests are negative, and if they aren’t and a new cancer is diagnosed you tell yourself, Well, at least we caught it early. Isn’t it good that I’m a rule follower? My life was just saved.

But it turns out, proving that cancer screening actually saves lives is quite difficult. Is it possible that all this screening is for nothing?

The benefits, risks, or perhaps futility of cancer screening is in the news this week because of this article, appearing in JAMA Internal Medicine.

It’s a meta-analysis of very specific randomized trials of cancer screening modalities and concludes that, with the exception of sigmoidoscopy for colon cancer screening, none of them meaningfully change life expectancy.

Now – a bit of inside baseball here – I almost never choose to discuss meta-analyses on Impact Factor. It’s hard enough to dig deep into the methodology of a single study, but with a meta-analysis, you’re sort of obligated to review all the included studies, and, what’s worse, the studies that were not included but might bear on the central question.

In this case, though, the topic is important enough to think about a bit more, and the conclusions have large enough implications for public health that we should question them a bit.

First, let’s run down the study as presented.

The authors searched for randomized trials of cancer screening modalities. This is important, and I think appropriate. They wanted studies that took some people and assigned them to screening, and some people to no screening – avoiding the confounding that would come from observational data (rule followers like me tend to live longer owing to a variety of healthful behaviors, not just cancer screening).

Dr. F. Perry Wilson

JAMA Internal Medicine

Dr. F. Perry Wilson

F. Perry Wilson, MD, MSCE, is an associate professor of medicine and director of Yale’s Clinical and Translational Research Accelerator. His science communication work can be found in the Huffington Post, on NPR, and on Medscape. He tweets @fperrywilson and his new book, How Medicine Works and When It Doesn’t, is available now. He has disclosed no relevant financial relationships.

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

This transcript from Impact Factor has been edited for clarity.

If you are my age or older, and like me, you are something of a rule follower, then you’re getting screened for various cancers.

Colonoscopies, mammograms, cervical cancer screening, chest CTs for people with a significant smoking history. The tests are done and usually, but not always, they are negative. And if positive, usually, but not always, follow-up tests are negative, and if they aren’t and a new cancer is diagnosed you tell yourself, Well, at least we caught it early. Isn’t it good that I’m a rule follower? My life was just saved.

But it turns out, proving that cancer screening actually saves lives is quite difficult. Is it possible that all this screening is for nothing?

The benefits, risks, or perhaps futility of cancer screening is in the news this week because of this article, appearing in JAMA Internal Medicine.

It’s a meta-analysis of very specific randomized trials of cancer screening modalities and concludes that, with the exception of sigmoidoscopy for colon cancer screening, none of them meaningfully change life expectancy.

Now – a bit of inside baseball here – I almost never choose to discuss meta-analyses on Impact Factor. It’s hard enough to dig deep into the methodology of a single study, but with a meta-analysis, you’re sort of obligated to review all the included studies, and, what’s worse, the studies that were not included but might bear on the central question.

In this case, though, the topic is important enough to think about a bit more, and the conclusions have large enough implications for public health that we should question them a bit.

First, let’s run down the study as presented.

The authors searched for randomized trials of cancer screening modalities. This is important, and I think appropriate. They wanted studies that took some people and assigned them to screening, and some people to no screening – avoiding the confounding that would come from observational data (rule followers like me tend to live longer owing to a variety of healthful behaviors, not just cancer screening).

Dr. F. Perry Wilson

JAMA Internal Medicine

Dr. F. Perry Wilson

F. Perry Wilson, MD, MSCE, is an associate professor of medicine and director of Yale’s Clinical and Translational Research Accelerator. His science communication work can be found in the Huffington Post, on NPR, and on Medscape. He tweets @fperrywilson and his new book, How Medicine Works and When It Doesn’t, is available now. He has disclosed no relevant financial relationships.

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

This transcript from Impact Factor has been edited for clarity.

If you are my age or older, and like me, you are something of a rule follower, then you’re getting screened for various cancers.

Colonoscopies, mammograms, cervical cancer screening, chest CTs for people with a significant smoking history. The tests are done and usually, but not always, they are negative. And if positive, usually, but not always, follow-up tests are negative, and if they aren’t and a new cancer is diagnosed you tell yourself, Well, at least we caught it early. Isn’t it good that I’m a rule follower? My life was just saved.

But it turns out, proving that cancer screening actually saves lives is quite difficult. Is it possible that all this screening is for nothing?

The benefits, risks, or perhaps futility of cancer screening is in the news this week because of this article, appearing in JAMA Internal Medicine.

It’s a meta-analysis of very specific randomized trials of cancer screening modalities and concludes that, with the exception of sigmoidoscopy for colon cancer screening, none of them meaningfully change life expectancy.

Now – a bit of inside baseball here – I almost never choose to discuss meta-analyses on Impact Factor. It’s hard enough to dig deep into the methodology of a single study, but with a meta-analysis, you’re sort of obligated to review all the included studies, and, what’s worse, the studies that were not included but might bear on the central question.

In this case, though, the topic is important enough to think about a bit more, and the conclusions have large enough implications for public health that we should question them a bit.

First, let’s run down the study as presented.

The authors searched for randomized trials of cancer screening modalities. This is important, and I think appropriate. They wanted studies that took some people and assigned them to screening, and some people to no screening – avoiding the confounding that would come from observational data (rule followers like me tend to live longer owing to a variety of healthful behaviors, not just cancer screening).

Dr. F. Perry Wilson

JAMA Internal Medicine

Dr. F. Perry Wilson

F. Perry Wilson, MD, MSCE, is an associate professor of medicine and director of Yale’s Clinical and Translational Research Accelerator. His science communication work can be found in the Huffington Post, on NPR, and on Medscape. He tweets @fperrywilson and his new book, How Medicine Works and When It Doesn’t, is available now. He has disclosed no relevant financial relationships.

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

Those who run Taylor Swift’s Eras Tour have something in common with those who run ERAS, the Electronic Residency Application Service. They cause agita to the people they purport to serve.

Most medical students won’t see Taylor Swift perform her hit song “Cruel Summer,” but they will spend thousands of dollars on ERAS as they prepare for the 2024 residency match. Medical students applying for residency tend to be as stressed out as Swifties trying to score concert tickets. Aside from the expenses of residency applications, students also face an increasingly complex application process: a match algorithm many of them do not understand and major changes to the application process that most learn about right before the application cycle begins.

I have gone through two matches myself, one for internal medicine and one for neurology, and I have also guided students through the process for almost a decade as a dean of student affairs at a medical school. Every summer, the application process is filled with numerous changes, often with little, if any, warning for the students. One year, for example, a specialty required additional essays tailored to each program. Though this requirement may have helped programs discern which students are most enthusiastic about their programs, it also disadvantaged students working on busier rotations, strapped for time to write as many as 70 additional essays in a matter of weeks.

Other recent changes have included “signaling” programs, selecting preferred regions, and preinterview recordings for some specialties. In 2023, students cannot include more than 10 activities on their ERAS application. I have spoken to students at numerous medical schools concerned about the difficulty of selecting 10 activities out of dozens of meaningful pursuits throughout their journeys; this challenge is particularly acute for students who had other careers before entering medical school.

The stress continues to mount even after residency applications have been submitted. Students often feel tied to their phones because offers for residency interviews roll in day and night by email, and if they wait more than a few hours to respond, they’re often moved to a waiting list for their preferred interview date. One year, while we were rounding on patients, a student stepped away to schedule an interview; while doing so, he missed out on managing a patient who developed a neurologic emergency. Thankfully, many but not all specialties have put rules in place to allow students more time to think through interview offers. Having more time to think, even if it’s just 48 hours, may decrease stress, limit the negative impacts on medical education, and promote informed decisions during interview season.

To be sure, most changes are being made in an effort to improve the experience of the students and programs. But as with anything, the result has been a mix of good and bad. The transition to virtual interviews allowed students to apply more broadly to programs without worrying about travel costs. The move also benefits students with disabilities who face accessibility and other challenges with traveling. However, virtual interviews came with several downsides, including but not limited to an increased number of applications submitted (recall that this was also a benefit), interview hoarding, and challenges of connecting personally via virtual platform. Despite the virtual format, applicants increasingly are doing in-person second looks, which some worry may give those applicants an additional advantage over applicants who do not have the time or financial resources to travel for a second look. Despite these shortcomings, it is important that virtual interviews remain an option for those applicants who need it.

Another change, which has been extensively debated in medical education in recent years, was the switch to pass/fail on the USMLE Step 1 exam. Though this move decreased the stress students experienced in the first 2 years of medical school, it has resulted in a new challenge as many residency programs put more emphasis on USMLE Step 2. Many medical students feel they do not have a good gauge of their competitiveness until a few weeks before they submit their application, particularly those applicants attending medical schools that do not provide them with information regarding their class standing until right before they submit their applications.

By the time Swift’s Eras Tour ends in the summer of 2024, medical students will already have matched and started their residency programs. At the same time, a new batch of students will be entering the next year’s match. Though the number of anticipated changes may not reach the level of seismic activity caused by the Swifties at her Seattle concert, many medical students fear that the changes may be just like tectonic plates shifting the match process away from its original purpose: to provide an orderly and fair mechanism for matching the preferences of applicants for U.S. residency positions with the preferences of residency program directors.

Dr. Etienne is with WMCHealth Good Samaritan Hospital, New York, and New York Medical College. He disclosed no relevant conflicts of interest.

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

Those who run Taylor Swift’s Eras Tour have something in common with those who run ERAS, the Electronic Residency Application Service. They cause agita to the people they purport to serve.

Most medical students won’t see Taylor Swift perform her hit song “Cruel Summer,” but they will spend thousands of dollars on ERAS as they prepare for the 2024 residency match. Medical students applying for residency tend to be as stressed out as Swifties trying to score concert tickets. Aside from the expenses of residency applications, students also face an increasingly complex application process: a match algorithm many of them do not understand and major changes to the application process that most learn about right before the application cycle begins.

I have gone through two matches myself, one for internal medicine and one for neurology, and I have also guided students through the process for almost a decade as a dean of student affairs at a medical school. Every summer, the application process is filled with numerous changes, often with little, if any, warning for the students. One year, for example, a specialty required additional essays tailored to each program. Though this requirement may have helped programs discern which students are most enthusiastic about their programs, it also disadvantaged students working on busier rotations, strapped for time to write as many as 70 additional essays in a matter of weeks.

Other recent changes have included “signaling” programs, selecting preferred regions, and preinterview recordings for some specialties. In 2023, students cannot include more than 10 activities on their ERAS application. I have spoken to students at numerous medical schools concerned about the difficulty of selecting 10 activities out of dozens of meaningful pursuits throughout their journeys; this challenge is particularly acute for students who had other careers before entering medical school.

The stress continues to mount even after residency applications have been submitted. Students often feel tied to their phones because offers for residency interviews roll in day and night by email, and if they wait more than a few hours to respond, they’re often moved to a waiting list for their preferred interview date. One year, while we were rounding on patients, a student stepped away to schedule an interview; while doing so, he missed out on managing a patient who developed a neurologic emergency. Thankfully, many but not all specialties have put rules in place to allow students more time to think through interview offers. Having more time to think, even if it’s just 48 hours, may decrease stress, limit the negative impacts on medical education, and promote informed decisions during interview season.

To be sure, most changes are being made in an effort to improve the experience of the students and programs. But as with anything, the result has been a mix of good and bad. The transition to virtual interviews allowed students to apply more broadly to programs without worrying about travel costs. The move also benefits students with disabilities who face accessibility and other challenges with traveling. However, virtual interviews came with several downsides, including but not limited to an increased number of applications submitted (recall that this was also a benefit), interview hoarding, and challenges of connecting personally via virtual platform. Despite the virtual format, applicants increasingly are doing in-person second looks, which some worry may give those applicants an additional advantage over applicants who do not have the time or financial resources to travel for a second look. Despite these shortcomings, it is important that virtual interviews remain an option for those applicants who need it.

Another change, which has been extensively debated in medical education in recent years, was the switch to pass/fail on the USMLE Step 1 exam. Though this move decreased the stress students experienced in the first 2 years of medical school, it has resulted in a new challenge as many residency programs put more emphasis on USMLE Step 2. Many medical students feel they do not have a good gauge of their competitiveness until a few weeks before they submit their application, particularly those applicants attending medical schools that do not provide them with information regarding their class standing until right before they submit their applications.

By the time Swift’s Eras Tour ends in the summer of 2024, medical students will already have matched and started their residency programs. At the same time, a new batch of students will be entering the next year’s match. Though the number of anticipated changes may not reach the level of seismic activity caused by the Swifties at her Seattle concert, many medical students fear that the changes may be just like tectonic plates shifting the match process away from its original purpose: to provide an orderly and fair mechanism for matching the preferences of applicants for U.S. residency positions with the preferences of residency program directors.

Dr. Etienne is with WMCHealth Good Samaritan Hospital, New York, and New York Medical College. He disclosed no relevant conflicts of interest.

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

Those who run Taylor Swift’s Eras Tour have something in common with those who run ERAS, the Electronic Residency Application Service. They cause agita to the people they purport to serve.

Most medical students won’t see Taylor Swift perform her hit song “Cruel Summer,” but they will spend thousands of dollars on ERAS as they prepare for the 2024 residency match. Medical students applying for residency tend to be as stressed out as Swifties trying to score concert tickets. Aside from the expenses of residency applications, students also face an increasingly complex application process: a match algorithm many of them do not understand and major changes to the application process that most learn about right before the application cycle begins.

I have gone through two matches myself, one for internal medicine and one for neurology, and I have also guided students through the process for almost a decade as a dean of student affairs at a medical school. Every summer, the application process is filled with numerous changes, often with little, if any, warning for the students. One year, for example, a specialty required additional essays tailored to each program. Though this requirement may have helped programs discern which students are most enthusiastic about their programs, it also disadvantaged students working on busier rotations, strapped for time to write as many as 70 additional essays in a matter of weeks.

Other recent changes have included “signaling” programs, selecting preferred regions, and preinterview recordings for some specialties. In 2023, students cannot include more than 10 activities on their ERAS application. I have spoken to students at numerous medical schools concerned about the difficulty of selecting 10 activities out of dozens of meaningful pursuits throughout their journeys; this challenge is particularly acute for students who had other careers before entering medical school.

The stress continues to mount even after residency applications have been submitted. Students often feel tied to their phones because offers for residency interviews roll in day and night by email, and if they wait more than a few hours to respond, they’re often moved to a waiting list for their preferred interview date. One year, while we were rounding on patients, a student stepped away to schedule an interview; while doing so, he missed out on managing a patient who developed a neurologic emergency. Thankfully, many but not all specialties have put rules in place to allow students more time to think through interview offers. Having more time to think, even if it’s just 48 hours, may decrease stress, limit the negative impacts on medical education, and promote informed decisions during interview season.

To be sure, most changes are being made in an effort to improve the experience of the students and programs. But as with anything, the result has been a mix of good and bad. The transition to virtual interviews allowed students to apply more broadly to programs without worrying about travel costs. The move also benefits students with disabilities who face accessibility and other challenges with traveling. However, virtual interviews came with several downsides, including but not limited to an increased number of applications submitted (recall that this was also a benefit), interview hoarding, and challenges of connecting personally via virtual platform. Despite the virtual format, applicants increasingly are doing in-person second looks, which some worry may give those applicants an additional advantage over applicants who do not have the time or financial resources to travel for a second look. Despite these shortcomings, it is important that virtual interviews remain an option for those applicants who need it.

Another change, which has been extensively debated in medical education in recent years, was the switch to pass/fail on the USMLE Step 1 exam. Though this move decreased the stress students experienced in the first 2 years of medical school, it has resulted in a new challenge as many residency programs put more emphasis on USMLE Step 2. Many medical students feel they do not have a good gauge of their competitiveness until a few weeks before they submit their application, particularly those applicants attending medical schools that do not provide them with information regarding their class standing until right before they submit their applications.

By the time Swift’s Eras Tour ends in the summer of 2024, medical students will already have matched and started their residency programs. At the same time, a new batch of students will be entering the next year’s match. Though the number of anticipated changes may not reach the level of seismic activity caused by the Swifties at her Seattle concert, many medical students fear that the changes may be just like tectonic plates shifting the match process away from its original purpose: to provide an orderly and fair mechanism for matching the preferences of applicants for U.S. residency positions with the preferences of residency program directors.

Dr. Etienne is with WMCHealth Good Samaritan Hospital, New York, and New York Medical College. He disclosed no relevant conflicts of interest.

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

Don’t look for the publication of a study detailing the probability of blood pressure reduction to normotensive among adults with hypertension who aren’t offered pharmacotherapy in a JAMA journal. It’s not because hypertension doesn’t respond to intentional behavior change. On the contrary, it absolutely does, but when it comes to hypertension, physicians don’t require patients to fail to manage their hypertension through personal responsibility before medications are discussed and involved.

Not so, of course, with obesity.

A few weeks ago a paper was published in JAMA Network Open entitled “Probability of 5% or greater weight loss or BMI reduction to healthy weight among adults with overweight or obesity,” which authors, peer reviewers, and editors deemed worthy of publication. Now, to be fair, it might be worthy of publication if the call to action and thrust of the paper was to chastise physicians for not offering patients effective treatments; the medical education system for failing to teach physicians how to effectively manage obesity; or, if medication is being offered, addressing the barriers to its use. Instead, the main thrust was that patients are failing to help themselves despite the known health benefits of sustained weight loss.

It’s not at all surprising that, despite known benefits, sustained weight loss without pharmacotherapy or surgery is elusive. Just as with virtually every other chronic noncommunicable disease with lifestyle levers, intentional behavior change as treatment – which, by definition for chronic diseases, needs to be employed in perpetuity – requires wide-ranging degrees of privilege and is not a reasonable expectation. And if outcomes from the FREEE trial are applicable broadly, this may be true even if the behavior change required is minimal, the cost is free, and the motivation is large.

The FREEE trial studied whether cost had a role to play in why so many people, even after a myocardial infarction, don’t follow through with the simplest of intentional behavior changes – taking prescribed medications – by providing free medications known to reduce the risk of having a second MI to study participants who had just suffered an MI.

Results showed that, although the group receiving free medications were taking more of them than the group that had a copay for them, at 1.5 years post-MI, only 41% of those receiving all their medications for free were taking them.

And what of those who have a copay? This study found that fewer than 30% of Medicare beneficiaries 65-74 years of age who were hospitalized for heart attacks filled their new statin prescriptions within 90 days of discharge. That the vast majority of patients who’d had actual heart attacks didn’t even take on the behavior change of simply filling their prescription for, let alone taking, a medication shown to reduce their risk of having another heart attack, speaks to the folly of believing that knowledge drives behavior change.

The message is that human beings, even when faced with knowledge – and in the aforementioned studies, knowledge coupled with a very real glimpse of personal mortality – struggle to deploy the most basic of behavior changes. And yet here we have a paper that concludes with the inference of surprise that few people, without treatment, lost clinically meaningful amounts of weight “despite the known benefits of clinically meaningful weight loss.”

While this paper does suggest in passing that yes, maybe we should offer effective treatments to patients with obesity, medicine needs to stop framing obesity as some surprising personal-responsibility knowledge gap and instead focus on the real problems at hand: the barriers to physicians treating obesity as they do every other chronic noncommunicable disease; why, unlike hypertension, for example, primary care providers are generally not well trained in its effective management; and why those who aren’t, despite obesity’s prevalence and impact, don’t see it as worthwhile to go out of their way to learn.

Dr. Freedhoff is an associate professor in the department of family medicine at the University of Ottawa (Ont.) and medical director of the Bariatric Medical Institute, also in Ottawa. He reported conflicts of interest with Constant Health, Novo Nordisk, and Weighty Matters.

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

Don’t look for the publication of a study detailing the probability of blood pressure reduction to normotensive among adults with hypertension who aren’t offered pharmacotherapy in a JAMA journal. It’s not because hypertension doesn’t respond to intentional behavior change. On the contrary, it absolutely does, but when it comes to hypertension, physicians don’t require patients to fail to manage their hypertension through personal responsibility before medications are discussed and involved.

Not so, of course, with obesity.

A few weeks ago a paper was published in JAMA Network Open entitled “Probability of 5% or greater weight loss or BMI reduction to healthy weight among adults with overweight or obesity,” which authors, peer reviewers, and editors deemed worthy of publication. Now, to be fair, it might be worthy of publication if the call to action and thrust of the paper was to chastise physicians for not offering patients effective treatments; the medical education system for failing to teach physicians how to effectively manage obesity; or, if medication is being offered, addressing the barriers to its use. Instead, the main thrust was that patients are failing to help themselves despite the known health benefits of sustained weight loss.

It’s not at all surprising that, despite known benefits, sustained weight loss without pharmacotherapy or surgery is elusive. Just as with virtually every other chronic noncommunicable disease with lifestyle levers, intentional behavior change as treatment – which, by definition for chronic diseases, needs to be employed in perpetuity – requires wide-ranging degrees of privilege and is not a reasonable expectation. And if outcomes from the FREEE trial are applicable broadly, this may be true even if the behavior change required is minimal, the cost is free, and the motivation is large.

The FREEE trial studied whether cost had a role to play in why so many people, even after a myocardial infarction, don’t follow through with the simplest of intentional behavior changes – taking prescribed medications – by providing free medications known to reduce the risk of having a second MI to study participants who had just suffered an MI.

Results showed that, although the group receiving free medications were taking more of them than the group that had a copay for them, at 1.5 years post-MI, only 41% of those receiving all their medications for free were taking them.

And what of those who have a copay? This study found that fewer than 30% of Medicare beneficiaries 65-74 years of age who were hospitalized for heart attacks filled their new statin prescriptions within 90 days of discharge. That the vast majority of patients who’d had actual heart attacks didn’t even take on the behavior change of simply filling their prescription for, let alone taking, a medication shown to reduce their risk of having another heart attack, speaks to the folly of believing that knowledge drives behavior change.

The message is that human beings, even when faced with knowledge – and in the aforementioned studies, knowledge coupled with a very real glimpse of personal mortality – struggle to deploy the most basic of behavior changes. And yet here we have a paper that concludes with the inference of surprise that few people, without treatment, lost clinically meaningful amounts of weight “despite the known benefits of clinically meaningful weight loss.”

While this paper does suggest in passing that yes, maybe we should offer effective treatments to patients with obesity, medicine needs to stop framing obesity as some surprising personal-responsibility knowledge gap and instead focus on the real problems at hand: the barriers to physicians treating obesity as they do every other chronic noncommunicable disease; why, unlike hypertension, for example, primary care providers are generally not well trained in its effective management; and why those who aren’t, despite obesity’s prevalence and impact, don’t see it as worthwhile to go out of their way to learn.

Dr. Freedhoff is an associate professor in the department of family medicine at the University of Ottawa (Ont.) and medical director of the Bariatric Medical Institute, also in Ottawa. He reported conflicts of interest with Constant Health, Novo Nordisk, and Weighty Matters.

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

Don’t look for the publication of a study detailing the probability of blood pressure reduction to normotensive among adults with hypertension who aren’t offered pharmacotherapy in a JAMA journal. It’s not because hypertension doesn’t respond to intentional behavior change. On the contrary, it absolutely does, but when it comes to hypertension, physicians don’t require patients to fail to manage their hypertension through personal responsibility before medications are discussed and involved.

Not so, of course, with obesity.

A few weeks ago a paper was published in JAMA Network Open entitled “Probability of 5% or greater weight loss or BMI reduction to healthy weight among adults with overweight or obesity,” which authors, peer reviewers, and editors deemed worthy of publication. Now, to be fair, it might be worthy of publication if the call to action and thrust of the paper was to chastise physicians for not offering patients effective treatments; the medical education system for failing to teach physicians how to effectively manage obesity; or, if medication is being offered, addressing the barriers to its use. Instead, the main thrust was that patients are failing to help themselves despite the known health benefits of sustained weight loss.

It’s not at all surprising that, despite known benefits, sustained weight loss without pharmacotherapy or surgery is elusive. Just as with virtually every other chronic noncommunicable disease with lifestyle levers, intentional behavior change as treatment – which, by definition for chronic diseases, needs to be employed in perpetuity – requires wide-ranging degrees of privilege and is not a reasonable expectation. And if outcomes from the FREEE trial are applicable broadly, this may be true even if the behavior change required is minimal, the cost is free, and the motivation is large.

The FREEE trial studied whether cost had a role to play in why so many people, even after a myocardial infarction, don’t follow through with the simplest of intentional behavior changes – taking prescribed medications – by providing free medications known to reduce the risk of having a second MI to study participants who had just suffered an MI.

Results showed that, although the group receiving free medications were taking more of them than the group that had a copay for them, at 1.5 years post-MI, only 41% of those receiving all their medications for free were taking them.

And what of those who have a copay? This study found that fewer than 30% of Medicare beneficiaries 65-74 years of age who were hospitalized for heart attacks filled their new statin prescriptions within 90 days of discharge. That the vast majority of patients who’d had actual heart attacks didn’t even take on the behavior change of simply filling their prescription for, let alone taking, a medication shown to reduce their risk of having another heart attack, speaks to the folly of believing that knowledge drives behavior change.

The message is that human beings, even when faced with knowledge – and in the aforementioned studies, knowledge coupled with a very real glimpse of personal mortality – struggle to deploy the most basic of behavior changes. And yet here we have a paper that concludes with the inference of surprise that few people, without treatment, lost clinically meaningful amounts of weight “despite the known benefits of clinically meaningful weight loss.”

While this paper does suggest in passing that yes, maybe we should offer effective treatments to patients with obesity, medicine needs to stop framing obesity as some surprising personal-responsibility knowledge gap and instead focus on the real problems at hand: the barriers to physicians treating obesity as they do every other chronic noncommunicable disease; why, unlike hypertension, for example, primary care providers are generally not well trained in its effective management; and why those who aren’t, despite obesity’s prevalence and impact, don’t see it as worthwhile to go out of their way to learn.

Dr. Freedhoff is an associate professor in the department of family medicine at the University of Ottawa (Ont.) and medical director of the Bariatric Medical Institute, also in Ottawa. He reported conflicts of interest with Constant Health, Novo Nordisk, and Weighty Matters.

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

There is amazing news for the world of obstetrics and for all pregnant women. The Food and Drug Administration recently approved a blood test that will predict, with 96% accuracy, if a pregnant woman will develop severe preeclampsia within 2 weeks. Severe preeclampsia is a critical obstetrical condition that can have serious outcomes for a mother and baby. It can lead to eclampsia, an obstetrical emergency, which often results in death of the mother and/or baby.

Based on research published in the Journal of the American Heart Association, the incidence of new‐onset hypertensive disorders of pregnancy (gestational hypertension and preeclampsia/eclampsia) have nearly doubled in the United States from 2007 to 2019. And they continue to climb.

According to the Preeclampsia Foundation, 5%-8% of all pregnancies in the United States will result in preeclampsia. Black women are at a 60% higher risk than white women, and according to various sources, other risk groups include those who became pregnant via in vitro fertilization, mothers of multiples (twins and triplets), women with gestational diabetes, women over age 35, women with chronic hypertension, obesity, polycystic ovary syndrome, sickle cell disease, rheumatoid arthritis, lupus, migraines, antiphospholipid syndrome, previous pregnancy with preeclampsia, family history, and scleroderma.
 

Screening and treatment

Preeclampsia is a multiorgan disease of pregnancy, and can be mild, but may quickly progress to severe, which can be life-threatening for mother and baby. It was previously referred to as toxemia or the high blood pressure disease of pregnancy. It primarily involves the cardiovascular, neurologic and renal systems, and the liver. Patients typically present with elevated blood pressures, but other symptoms may include headache, swelling of hands and feet, blurry/double vision or seeing spots, nausea/vomiting, and epigastric pain. It is diagnosed with elevated blood pressures, blood work, and protein in the urine.

Early screening for preeclampsia is done in the first trimester. Presently, a combination of prenatal blood work, blood pressure monitoring, and recognition of high-risk groups is used to determine a treatment plan going forward. The American Congress of Obstetricians and Gynecologists recommends women that fall into this group for potentially developing preeclampsia take daily aspirin as a preventative measure.

In its milder form, a pregnant woman can be observed as an outpatient – monitored with antepartum testing, lab work, and patient education to report significant symptoms as listed above. Teaching patients about fetal kick counts to monitor their baby’s movements is equally important. Women with mild preeclampsia usually can safely deliver at term, being induced between 37-39 weeks’ gestation.

On the other hand, if mild preeclampsia progresses to severe preeclampsia, delivery may be preterm for the safety of mother and baby. Severe preeclampsia can lead to maternal organ damage, seizures, and even death of mother and/or baby.

About 20% of women with severe preeclampsia will develop HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelets) syndrome, a life-threatening disease that often warrants immediate delivery. According to the National Library of Medicine, the mortality rate of women with HELLP syndrome is up to 24% and the perinatal death rate is up as high as 37%. These serious conditions can cause ineffective maternal clotting, liver rupture, placental abruption, and postpartum hemorrhage. It is most prevalent in the third trimester but can occur within 48 hours of delivery.

The only cure for preeclampsia in any form is delivery.

Patients with severe preeclampsia are hospitalized until delivery – sometimes a few days to a couple of weeks. Mother and baby are closely watched for further progression, including signs of organ damage in the mother and changes to the well-being of the baby. If the mother’s health is severely compromised, then the baby will be compromised as well. A preterm delivery may be necessary.
 

Impact of the new test

The National Institute of Health states that preterm babies born from preeclamptic mothers can suffer many health problems including cerebral palsy, deafness, blindness, epilepsy, and a host of other respiratory, cardiovascular, and endocrine issues. But the biggest issue is preterm birth, defined as birth before 37 weeks gestation. Being born preterm can require a long stay in the intensive care nursery.

This is where the first-of-its-kind prognostic blood test comes into play. The test’s ability to predict severe preeclampsia within 2 weeks can help save lives. The test can offer health care providers the ability to administer steroids for fetal lung maturity before delivery and be more prepared to care for what could be a very compromised newborn.

The blood test, which is recommended between 23-35 weeks gestation, involves analyzing a ratio between two proteins from the placenta, sFlt1 and PIGF. The higher the ratio, the higher the risk that severe preeclampsia will develop. Results can be available within 30 minutes, which is critical when contemplating treatment.

An example of the use of this ratio is illustrated with chronic hypertension in pregnancy, which is defined as elevated blood pressure before 20 weeks or even before conception. Since chronic hypertension can be a primary precursor to preeclampsia, patients with this condition are at higher risk. The FDA-approved blood test would be helpful in determining the plan of care; that is, delivery versus hospitalization versus monitor as an outpatient.

With a positive test result, a pregnant woman can be immediately hospitalized where she can get the care she and baby need as they await delivery. Since health care providers already know the high-risk groups, surveillance can begin early, utilizing this blood test to predict the progression to severe preeclampsia. Conversely, if the test is negative, a treatment plan can be made as an outpatient and the pregnancy continues.

Not all hospitals are equipped to care for premature babies. If delivery is not imminent, providers can use this blood test to identify those that should be transferred to a tertiary center for observation and monitoring. Mother and baby would then not be separated after birth.

We really don’t know who will develop severe preeclampsia and who won’t. This new blood test will be a critical tool as pregnant patients go through their second and third trimesters. It will be especially pivotal for these women, but important for all pregnant women in reducing maternal and fetal mortality and morbidity.

Ms. Barnett is a registered nurse in the department of obstetrics, Mills-Peninsula Medical Center, Burlingame, Calif. She has disclosed no relevant financial relationships.

There is amazing news for the world of obstetrics and for all pregnant women. The Food and Drug Administration recently approved a blood test that will predict, with 96% accuracy, if a pregnant woman will develop severe preeclampsia within 2 weeks. Severe preeclampsia is a critical obstetrical condition that can have serious outcomes for a mother and baby. It can lead to eclampsia, an obstetrical emergency, which often results in death of the mother and/or baby.

Based on research published in the Journal of the American Heart Association, the incidence of new‐onset hypertensive disorders of pregnancy (gestational hypertension and preeclampsia/eclampsia) have nearly doubled in the United States from 2007 to 2019. And they continue to climb.

According to the Preeclampsia Foundation, 5%-8% of all pregnancies in the United States will result in preeclampsia. Black women are at a 60% higher risk than white women, and according to various sources, other risk groups include those who became pregnant via in vitro fertilization, mothers of multiples (twins and triplets), women with gestational diabetes, women over age 35, women with chronic hypertension, obesity, polycystic ovary syndrome, sickle cell disease, rheumatoid arthritis, lupus, migraines, antiphospholipid syndrome, previous pregnancy with preeclampsia, family history, and scleroderma.
 

Screening and treatment

Preeclampsia is a multiorgan disease of pregnancy, and can be mild, but may quickly progress to severe, which can be life-threatening for mother and baby. It was previously referred to as toxemia or the high blood pressure disease of pregnancy. It primarily involves the cardiovascular, neurologic and renal systems, and the liver. Patients typically present with elevated blood pressures, but other symptoms may include headache, swelling of hands and feet, blurry/double vision or seeing spots, nausea/vomiting, and epigastric pain. It is diagnosed with elevated blood pressures, blood work, and protein in the urine.

Early screening for preeclampsia is done in the first trimester. Presently, a combination of prenatal blood work, blood pressure monitoring, and recognition of high-risk groups is used to determine a treatment plan going forward. The American Congress of Obstetricians and Gynecologists recommends women that fall into this group for potentially developing preeclampsia take daily aspirin as a preventative measure.

In its milder form, a pregnant woman can be observed as an outpatient – monitored with antepartum testing, lab work, and patient education to report significant symptoms as listed above. Teaching patients about fetal kick counts to monitor their baby’s movements is equally important. Women with mild preeclampsia usually can safely deliver at term, being induced between 37-39 weeks’ gestation.

On the other hand, if mild preeclampsia progresses to severe preeclampsia, delivery may be preterm for the safety of mother and baby. Severe preeclampsia can lead to maternal organ damage, seizures, and even death of mother and/or baby.

About 20% of women with severe preeclampsia will develop HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelets) syndrome, a life-threatening disease that often warrants immediate delivery. According to the National Library of Medicine, the mortality rate of women with HELLP syndrome is up to 24% and the perinatal death rate is up as high as 37%. These serious conditions can cause ineffective maternal clotting, liver rupture, placental abruption, and postpartum hemorrhage. It is most prevalent in the third trimester but can occur within 48 hours of delivery.

The only cure for preeclampsia in any form is delivery.

Patients with severe preeclampsia are hospitalized until delivery – sometimes a few days to a couple of weeks. Mother and baby are closely watched for further progression, including signs of organ damage in the mother and changes to the well-being of the baby. If the mother’s health is severely compromised, then the baby will be compromised as well. A preterm delivery may be necessary.
 

Impact of the new test

The National Institute of Health states that preterm babies born from preeclamptic mothers can suffer many health problems including cerebral palsy, deafness, blindness, epilepsy, and a host of other respiratory, cardiovascular, and endocrine issues. But the biggest issue is preterm birth, defined as birth before 37 weeks gestation. Being born preterm can require a long stay in the intensive care nursery.

This is where the first-of-its-kind prognostic blood test comes into play. The test’s ability to predict severe preeclampsia within 2 weeks can help save lives. The test can offer health care providers the ability to administer steroids for fetal lung maturity before delivery and be more prepared to care for what could be a very compromised newborn.

The blood test, which is recommended between 23-35 weeks gestation, involves analyzing a ratio between two proteins from the placenta, sFlt1 and PIGF. The higher the ratio, the higher the risk that severe preeclampsia will develop. Results can be available within 30 minutes, which is critical when contemplating treatment.

An example of the use of this ratio is illustrated with chronic hypertension in pregnancy, which is defined as elevated blood pressure before 20 weeks or even before conception. Since chronic hypertension can be a primary precursor to preeclampsia, patients with this condition are at higher risk. The FDA-approved blood test would be helpful in determining the plan of care; that is, delivery versus hospitalization versus monitor as an outpatient.

With a positive test result, a pregnant woman can be immediately hospitalized where she can get the care she and baby need as they await delivery. Since health care providers already know the high-risk groups, surveillance can begin early, utilizing this blood test to predict the progression to severe preeclampsia. Conversely, if the test is negative, a treatment plan can be made as an outpatient and the pregnancy continues.

Not all hospitals are equipped to care for premature babies. If delivery is not imminent, providers can use this blood test to identify those that should be transferred to a tertiary center for observation and monitoring. Mother and baby would then not be separated after birth.

We really don’t know who will develop severe preeclampsia and who won’t. This new blood test will be a critical tool as pregnant patients go through their second and third trimesters. It will be especially pivotal for these women, but important for all pregnant women in reducing maternal and fetal mortality and morbidity.

Ms. Barnett is a registered nurse in the department of obstetrics, Mills-Peninsula Medical Center, Burlingame, Calif. She has disclosed no relevant financial relationships.

There is amazing news for the world of obstetrics and for all pregnant women. The Food and Drug Administration recently approved a blood test that will predict, with 96% accuracy, if a pregnant woman will develop severe preeclampsia within 2 weeks. Severe preeclampsia is a critical obstetrical condition that can have serious outcomes for a mother and baby. It can lead to eclampsia, an obstetrical emergency, which often results in death of the mother and/or baby.

Based on research published in the Journal of the American Heart Association, the incidence of new‐onset hypertensive disorders of pregnancy (gestational hypertension and preeclampsia/eclampsia) have nearly doubled in the United States from 2007 to 2019. And they continue to climb.

According to the Preeclampsia Foundation, 5%-8% of all pregnancies in the United States will result in preeclampsia. Black women are at a 60% higher risk than white women, and according to various sources, other risk groups include those who became pregnant via in vitro fertilization, mothers of multiples (twins and triplets), women with gestational diabetes, women over age 35, women with chronic hypertension, obesity, polycystic ovary syndrome, sickle cell disease, rheumatoid arthritis, lupus, migraines, antiphospholipid syndrome, previous pregnancy with preeclampsia, family history, and scleroderma.
 

Screening and treatment

Preeclampsia is a multiorgan disease of pregnancy, and can be mild, but may quickly progress to severe, which can be life-threatening for mother and baby. It was previously referred to as toxemia or the high blood pressure disease of pregnancy. It primarily involves the cardiovascular, neurologic and renal systems, and the liver. Patients typically present with elevated blood pressures, but other symptoms may include headache, swelling of hands and feet, blurry/double vision or seeing spots, nausea/vomiting, and epigastric pain. It is diagnosed with elevated blood pressures, blood work, and protein in the urine.

Early screening for preeclampsia is done in the first trimester. Presently, a combination of prenatal blood work, blood pressure monitoring, and recognition of high-risk groups is used to determine a treatment plan going forward. The American Congress of Obstetricians and Gynecologists recommends women that fall into this group for potentially developing preeclampsia take daily aspirin as a preventative measure.

In its milder form, a pregnant woman can be observed as an outpatient – monitored with antepartum testing, lab work, and patient education to report significant symptoms as listed above. Teaching patients about fetal kick counts to monitor their baby’s movements is equally important. Women with mild preeclampsia usually can safely deliver at term, being induced between 37-39 weeks’ gestation.

On the other hand, if mild preeclampsia progresses to severe preeclampsia, delivery may be preterm for the safety of mother and baby. Severe preeclampsia can lead to maternal organ damage, seizures, and even death of mother and/or baby.

About 20% of women with severe preeclampsia will develop HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelets) syndrome, a life-threatening disease that often warrants immediate delivery. According to the National Library of Medicine, the mortality rate of women with HELLP syndrome is up to 24% and the perinatal death rate is up as high as 37%. These serious conditions can cause ineffective maternal clotting, liver rupture, placental abruption, and postpartum hemorrhage. It is most prevalent in the third trimester but can occur within 48 hours of delivery.

The only cure for preeclampsia in any form is delivery.

Patients with severe preeclampsia are hospitalized until delivery – sometimes a few days to a couple of weeks. Mother and baby are closely watched for further progression, including signs of organ damage in the mother and changes to the well-being of the baby. If the mother’s health is severely compromised, then the baby will be compromised as well. A preterm delivery may be necessary.
 

Impact of the new test

The National Institute of Health states that preterm babies born from preeclamptic mothers can suffer many health problems including cerebral palsy, deafness, blindness, epilepsy, and a host of other respiratory, cardiovascular, and endocrine issues. But the biggest issue is preterm birth, defined as birth before 37 weeks gestation. Being born preterm can require a long stay in the intensive care nursery.

This is where the first-of-its-kind prognostic blood test comes into play. The test’s ability to predict severe preeclampsia within 2 weeks can help save lives. The test can offer health care providers the ability to administer steroids for fetal lung maturity before delivery and be more prepared to care for what could be a very compromised newborn.

The blood test, which is recommended between 23-35 weeks gestation, involves analyzing a ratio between two proteins from the placenta, sFlt1 and PIGF. The higher the ratio, the higher the risk that severe preeclampsia will develop. Results can be available within 30 minutes, which is critical when contemplating treatment.

An example of the use of this ratio is illustrated with chronic hypertension in pregnancy, which is defined as elevated blood pressure before 20 weeks or even before conception. Since chronic hypertension can be a primary precursor to preeclampsia, patients with this condition are at higher risk. The FDA-approved blood test would be helpful in determining the plan of care; that is, delivery versus hospitalization versus monitor as an outpatient.

With a positive test result, a pregnant woman can be immediately hospitalized where she can get the care she and baby need as they await delivery. Since health care providers already know the high-risk groups, surveillance can begin early, utilizing this blood test to predict the progression to severe preeclampsia. Conversely, if the test is negative, a treatment plan can be made as an outpatient and the pregnancy continues.

Not all hospitals are equipped to care for premature babies. If delivery is not imminent, providers can use this blood test to identify those that should be transferred to a tertiary center for observation and monitoring. Mother and baby would then not be separated after birth.

We really don’t know who will develop severe preeclampsia and who won’t. This new blood test will be a critical tool as pregnant patients go through their second and third trimesters. It will be especially pivotal for these women, but important for all pregnant women in reducing maternal and fetal mortality and morbidity.

Ms. Barnett is a registered nurse in the department of obstetrics, Mills-Peninsula Medical Center, Burlingame, Calif. She has disclosed no relevant financial relationships.

Science supports the use of a whole food, predominantly plant-based dietary pattern for optimal health, including reduced risk for chronic disease, and best practice in treatment of leading chronic disease.

But clinicians who prescribe such eating patterns encounter a common concern from patients whose health may benefit.

“Where will I get my protein?”

We’ve all heard it, and it’s understandable. Patients know that protein is essential for their health and strength, and animal foods have developed a reputation for being the premier protein sources that humans should prioritize through diet. But widespread misconceptions about human needs for protein have inaccurately equated animal food as the best and only sources of protein, augmented by fad diets and modern food marketing. All of this leads to confusion about how much protein people should actually consume and the quality of protein found in plant foods, making many patients reluctant to fully embrace a whole food, predominately plant-based diet.

margouillatphotos/Thinkstock

To ensure that patients have all the facts when making dietary decisions, clinicians need to be prepared to respond to concerns about protein adequacy and quality with evidence-based information. A good starting point for these conversations is to assess how much protein patients are already consuming. A review of the 2015-2016 National Health and Nutrition Examination Survey found that women normally consume an average of 69 g and men an average of 97 g of protein daily.

As a general point of reference, the recommended dietary allowance for protein is about 0.8 g/kg of bodyweight (or 0.36 g/lb), which equates to about 52 g of protein per day for a 145-lb woman and 65 g for a 180-lb man. But for many patients, it may be best to get a more precise recommendation based upon age, gender and physical activity level by using a handy Department of Agriculture tool for health care professionals to calculate daily protein and other nutrient needs. Patients can also use one of countless apps to track their protein and other nutrient intake. By using the tool and a tracking app, both clinician and patients can be fully informed whether protein needs are being met.

The recommended daily allowances for protein are easily met by consuming a variety of whole plant foods, including a variety of minimally processed vegetables, fruits, whole grains, legumes, nuts, and seeds. One cup of cooked red lentils or black beans, for example, contains between 15 g and 18 g of protein. A quarter cup of almonds contains about 7 g of protein and one cup of cooked oats has 5 g.
 

What about those amino acids?

An area of contention around plant food protein is “complete versus incomplete protein,” terms used to describe whether a protein contains all nine essential amino acids that our bodies require from a single source. Animal food sources usually contain all the essential amino acids, whereas plant sources of protein may contain varying amounts of these amino acids or may even be missing some.

This leads to a misconception that someone adopting a diet of predominately plant food may have to stack or combine specific plant foods in a meal to ensure their protein intake includes an appropriate proportion of amino acids. But the process of protein breakdown turnover solves this problem. The body continuously breaks down protein and recombines it with amino acids stored in tissue for use when needed. Once absorbed by the small intestine, it doesn’t matter whether the protein or amino acids came from the same meal. As long as a person is eating a variety of plant-based protein sources, they will consume adequate amounts of all essential amino acids.

This is true even for athletes, older adults and pregnant women. It is also the position of the Academy of Nutrition and Dietetics that a whole-food, predominately plant-based eating pattern is appropriate for athletes and “all stages of the life cycle, including pregnancy, lactation, infancy, childhood, adolescence, older adulthood.”
 

The plant-based diet

For examples of healthy plant-based eating plans, The American College of Lifestyle Medicine offers a complimentary guide for a whole food, predominantly plant-based diet that demonstrates how easily the recommended dietary allowance of protein is satisfied. A breakfast of rolled oats, a lunch of bean burritos, and a dinner of mashed potatoes, with chickpeas with a couple snacks throughout the day, adds up to 71 g of protein. Other plant-based meal plans top 100 g or 90 g, with all meal plans meeting or surpassing recommended allowances.

Along with the protein, plant food delivers other beneficial nutrients and dietary components like fiber, antioxidants, anti-inflammatory properties, various vitamins and nutrients, and phytochemicals and vitamin D, without the saturated fats and sodium in meat. But U.S. adults get approximately two-thirds of their protein from animal sources, which lack fiber and have higher levels of saturated fats or sodium that can raise cholesterol and increase the risks for heart disease and stroke.

For clinicians, ACLM published a 10-part series of research white papers on the benefits of a whole food, plant-predominant dietary lifestyle and offers a catalogue of food as medicine continuing medical education and continuing education courses.

Patients hunger for knowledge about health-promoting nutrition but may have difficulty sorting myths from evidence-based facts. Each healthcare professional has an important and powerful opportunity to steer patients in a healthier direction through their diet.

Dr. Collings is director of lifestyle medicine, Silicon Valley Medical Development; President, American College of Lifestyle Medicine, Mountain View, Calif. She has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

Science supports the use of a whole food, predominantly plant-based dietary pattern for optimal health, including reduced risk for chronic disease, and best practice in treatment of leading chronic disease.

But clinicians who prescribe such eating patterns encounter a common concern from patients whose health may benefit.

“Where will I get my protein?”

We’ve all heard it, and it’s understandable. Patients know that protein is essential for their health and strength, and animal foods have developed a reputation for being the premier protein sources that humans should prioritize through diet. But widespread misconceptions about human needs for protein have inaccurately equated animal food as the best and only sources of protein, augmented by fad diets and modern food marketing. All of this leads to confusion about how much protein people should actually consume and the quality of protein found in plant foods, making many patients reluctant to fully embrace a whole food, predominately plant-based diet.

margouillatphotos/Thinkstock

To ensure that patients have all the facts when making dietary decisions, clinicians need to be prepared to respond to concerns about protein adequacy and quality with evidence-based information. A good starting point for these conversations is to assess how much protein patients are already consuming. A review of the 2015-2016 National Health and Nutrition Examination Survey found that women normally consume an average of 69 g and men an average of 97 g of protein daily.

As a general point of reference, the recommended dietary allowance for protein is about 0.8 g/kg of bodyweight (or 0.36 g/lb), which equates to about 52 g of protein per day for a 145-lb woman and 65 g for a 180-lb man. But for many patients, it may be best to get a more precise recommendation based upon age, gender and physical activity level by using a handy Department of Agriculture tool for health care professionals to calculate daily protein and other nutrient needs. Patients can also use one of countless apps to track their protein and other nutrient intake. By using the tool and a tracking app, both clinician and patients can be fully informed whether protein needs are being met.

The recommended daily allowances for protein are easily met by consuming a variety of whole plant foods, including a variety of minimally processed vegetables, fruits, whole grains, legumes, nuts, and seeds. One cup of cooked red lentils or black beans, for example, contains between 15 g and 18 g of protein. A quarter cup of almonds contains about 7 g of protein and one cup of cooked oats has 5 g.
 

What about those amino acids?

An area of contention around plant food protein is “complete versus incomplete protein,” terms used to describe whether a protein contains all nine essential amino acids that our bodies require from a single source. Animal food sources usually contain all the essential amino acids, whereas plant sources of protein may contain varying amounts of these amino acids or may even be missing some.

This leads to a misconception that someone adopting a diet of predominately plant food may have to stack or combine specific plant foods in a meal to ensure their protein intake includes an appropriate proportion of amino acids. But the process of protein breakdown turnover solves this problem. The body continuously breaks down protein and recombines it with amino acids stored in tissue for use when needed. Once absorbed by the small intestine, it doesn’t matter whether the protein or amino acids came from the same meal. As long as a person is eating a variety of plant-based protein sources, they will consume adequate amounts of all essential amino acids.

This is true even for athletes, older adults and pregnant women. It is also the position of the Academy of Nutrition and Dietetics that a whole-food, predominately plant-based eating pattern is appropriate for athletes and “all stages of the life cycle, including pregnancy, lactation, infancy, childhood, adolescence, older adulthood.”
 

The plant-based diet

For examples of healthy plant-based eating plans, The American College of Lifestyle Medicine offers a complimentary guide for a whole food, predominantly plant-based diet that demonstrates how easily the recommended dietary allowance of protein is satisfied. A breakfast of rolled oats, a lunch of bean burritos, and a dinner of mashed potatoes, with chickpeas with a couple snacks throughout the day, adds up to 71 g of protein. Other plant-based meal plans top 100 g or 90 g, with all meal plans meeting or surpassing recommended allowances.

Along with the protein, plant food delivers other beneficial nutrients and dietary components like fiber, antioxidants, anti-inflammatory properties, various vitamins and nutrients, and phytochemicals and vitamin D, without the saturated fats and sodium in meat. But U.S. adults get approximately two-thirds of their protein from animal sources, which lack fiber and have higher levels of saturated fats or sodium that can raise cholesterol and increase the risks for heart disease and stroke.

For clinicians, ACLM published a 10-part series of research white papers on the benefits of a whole food, plant-predominant dietary lifestyle and offers a catalogue of food as medicine continuing medical education and continuing education courses.

Patients hunger for knowledge about health-promoting nutrition but may have difficulty sorting myths from evidence-based facts. Each healthcare professional has an important and powerful opportunity to steer patients in a healthier direction through their diet.

Dr. Collings is director of lifestyle medicine, Silicon Valley Medical Development; President, American College of Lifestyle Medicine, Mountain View, Calif. She has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

Science supports the use of a whole food, predominantly plant-based dietary pattern for optimal health, including reduced risk for chronic disease, and best practice in treatment of leading chronic disease.

But clinicians who prescribe such eating patterns encounter a common concern from patients whose health may benefit.

“Where will I get my protein?”

We’ve all heard it, and it’s understandable. Patients know that protein is essential for their health and strength, and animal foods have developed a reputation for being the premier protein sources that humans should prioritize through diet. But widespread misconceptions about human needs for protein have inaccurately equated animal food as the best and only sources of protein, augmented by fad diets and modern food marketing. All of this leads to confusion about how much protein people should actually consume and the quality of protein found in plant foods, making many patients reluctant to fully embrace a whole food, predominately plant-based diet.

margouillatphotos/Thinkstock

To ensure that patients have all the facts when making dietary decisions, clinicians need to be prepared to respond to concerns about protein adequacy and quality with evidence-based information. A good starting point for these conversations is to assess how much protein patients are already consuming. A review of the 2015-2016 National Health and Nutrition Examination Survey found that women normally consume an average of 69 g and men an average of 97 g of protein daily.

As a general point of reference, the recommended dietary allowance for protein is about 0.8 g/kg of bodyweight (or 0.36 g/lb), which equates to about 52 g of protein per day for a 145-lb woman and 65 g for a 180-lb man. But for many patients, it may be best to get a more precise recommendation based upon age, gender and physical activity level by using a handy Department of Agriculture tool for health care professionals to calculate daily protein and other nutrient needs. Patients can also use one of countless apps to track their protein and other nutrient intake. By using the tool and a tracking app, both clinician and patients can be fully informed whether protein needs are being met.

The recommended daily allowances for protein are easily met by consuming a variety of whole plant foods, including a variety of minimally processed vegetables, fruits, whole grains, legumes, nuts, and seeds. One cup of cooked red lentils or black beans, for example, contains between 15 g and 18 g of protein. A quarter cup of almonds contains about 7 g of protein and one cup of cooked oats has 5 g.
 

What about those amino acids?

An area of contention around plant food protein is “complete versus incomplete protein,” terms used to describe whether a protein contains all nine essential amino acids that our bodies require from a single source. Animal food sources usually contain all the essential amino acids, whereas plant sources of protein may contain varying amounts of these amino acids or may even be missing some.

This leads to a misconception that someone adopting a diet of predominately plant food may have to stack or combine specific plant foods in a meal to ensure their protein intake includes an appropriate proportion of amino acids. But the process of protein breakdown turnover solves this problem. The body continuously breaks down protein and recombines it with amino acids stored in tissue for use when needed. Once absorbed by the small intestine, it doesn’t matter whether the protein or amino acids came from the same meal. As long as a person is eating a variety of plant-based protein sources, they will consume adequate amounts of all essential amino acids.

This is true even for athletes, older adults and pregnant women. It is also the position of the Academy of Nutrition and Dietetics that a whole-food, predominately plant-based eating pattern is appropriate for athletes and “all stages of the life cycle, including pregnancy, lactation, infancy, childhood, adolescence, older adulthood.”
 

The plant-based diet

For examples of healthy plant-based eating plans, The American College of Lifestyle Medicine offers a complimentary guide for a whole food, predominantly plant-based diet that demonstrates how easily the recommended dietary allowance of protein is satisfied. A breakfast of rolled oats, a lunch of bean burritos, and a dinner of mashed potatoes, with chickpeas with a couple snacks throughout the day, adds up to 71 g of protein. Other plant-based meal plans top 100 g or 90 g, with all meal plans meeting or surpassing recommended allowances.

Along with the protein, plant food delivers other beneficial nutrients and dietary components like fiber, antioxidants, anti-inflammatory properties, various vitamins and nutrients, and phytochemicals and vitamin D, without the saturated fats and sodium in meat. But U.S. adults get approximately two-thirds of their protein from animal sources, which lack fiber and have higher levels of saturated fats or sodium that can raise cholesterol and increase the risks for heart disease and stroke.

For clinicians, ACLM published a 10-part series of research white papers on the benefits of a whole food, plant-predominant dietary lifestyle and offers a catalogue of food as medicine continuing medical education and continuing education courses.

Patients hunger for knowledge about health-promoting nutrition but may have difficulty sorting myths from evidence-based facts. Each healthcare professional has an important and powerful opportunity to steer patients in a healthier direction through their diet.

Dr. Collings is director of lifestyle medicine, Silicon Valley Medical Development; President, American College of Lifestyle Medicine, Mountain View, Calif. She has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

A stylish 40-something-year-old walks into my office looking mildly sheepish. She is a well-known actress who was recently panned by the paparazzi for having “too much cellulite” after they illegally photographed her playing with her child on a private beach.

Without a doubt, she will request semaglutide (Ozempic) before long, but first we will need to wade through the morass of social condemnation out there about Ozempic to assure her that she is being neither immoral nor reckless for considering it.

After nearly 20 years of practicing medicine with a focus on weight loss and preventive care, here is how I see the situation:

Ozempic is nothing new, people! Endocrinologists have been using this class of medication since Byetta hit the market in 2005. We have had 18 years to make informed risk-benefit analyses.

People are obsessed with the risk for pancreatitis. Any type of weight loss can cause gallstones, and this is what can trigger pancreatitis. Unless you’re the type of person who worries that your balanced Weight Watchers diet is going to cause pancreatitis, you should probably remove this risk from your calculations.

Glucagonlike peptide–1 (GLP-1) receptor agonists are naturally occurring gut hormones that reduce inflammatory cascades and clotting risk. We are not giving a dangerous treatment (e.g., fen-phen) that increases cardiovascular risk – quite the contrary, in fact.

Just because influencers are promoting a product doesn’t mean the product is inherently worthless. One of my patients accused me of prescribing a medication that is the “laughingstock of America.” Try telling that to the scores of cardiologists who send patients to my colleagues and me to start Ozempic to help lower their patients’ risk for stroke and heart attack. Or tell this to my patient who survived an episode of rapid atrial fibrillation and was told by his cardiologist that he definitely would have died if he had not lost 30 pounds from Ozempic in the preceding year.

Sometimes it seems like society has become more judgmental about Ozempic than about plastic surgery for weight loss. If we have to choose between liposuction (which doesn’t reduce visceral fat – the dangerous type of fat) or Ozempic, the latter clearly wins because of its real health benefits.

How does it make any sense to say that this medication should be reserved for patients who already have obesity and type 2 diabetes? Why should we penalize patients who have not yet reached those thresholds by denying access to preventive care? Don’t we constantly hear about how our health care system would be much more efficient if we focused on preventive care and not just treatment?

Some people claim that we have to limit access to this medication because of drug shortages. Thankfully, the United States responds to supply and demand economics and will quickly adjust. 

I’ve had more patients than I can possibly number with severe binge eating disorders (resistant to years of therapy and medication) who finally developed healthy relationships with food while taking these types of medications. Mounjaro, I’m talking about you…

I always hear the argument that it is immoral to give these medications to patients with a history of restrictive eating patterns. Although every patient needs to be carefully evaluated, often these medications remove food as both the enemy and primary focus of every waking thought. They allow patients to refocus on other aspects of their lives – such as family, friends, hobbies, work – and regain a sense of purpose. If anyone wants to run a trial on this little hypothesis of mine, please reach out to me. 

Okay, I agree you might get a little constipated (most often described by patients as the “rabbit pellet phenomenon”), but it’s a small price to pay, no? I’ll throw in a few prunes with the prescription.

Suffice it to say, I did give my 40-something-year-old patient the medication she desired, and she has a new lease on life (as well as better blood pressure and cholesterol).

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

A stylish 40-something-year-old walks into my office looking mildly sheepish. She is a well-known actress who was recently panned by the paparazzi for having “too much cellulite” after they illegally photographed her playing with her child on a private beach.

Without a doubt, she will request semaglutide (Ozempic) before long, but first we will need to wade through the morass of social condemnation out there about Ozempic to assure her that she is being neither immoral nor reckless for considering it.

After nearly 20 years of practicing medicine with a focus on weight loss and preventive care, here is how I see the situation:

Ozempic is nothing new, people! Endocrinologists have been using this class of medication since Byetta hit the market in 2005. We have had 18 years to make informed risk-benefit analyses.

People are obsessed with the risk for pancreatitis. Any type of weight loss can cause gallstones, and this is what can trigger pancreatitis. Unless you’re the type of person who worries that your balanced Weight Watchers diet is going to cause pancreatitis, you should probably remove this risk from your calculations.

Glucagonlike peptide–1 (GLP-1) receptor agonists are naturally occurring gut hormones that reduce inflammatory cascades and clotting risk. We are not giving a dangerous treatment (e.g., fen-phen) that increases cardiovascular risk – quite the contrary, in fact.

Just because influencers are promoting a product doesn’t mean the product is inherently worthless. One of my patients accused me of prescribing a medication that is the “laughingstock of America.” Try telling that to the scores of cardiologists who send patients to my colleagues and me to start Ozempic to help lower their patients’ risk for stroke and heart attack. Or tell this to my patient who survived an episode of rapid atrial fibrillation and was told by his cardiologist that he definitely would have died if he had not lost 30 pounds from Ozempic in the preceding year.

Sometimes it seems like society has become more judgmental about Ozempic than about plastic surgery for weight loss. If we have to choose between liposuction (which doesn’t reduce visceral fat – the dangerous type of fat) or Ozempic, the latter clearly wins because of its real health benefits.

How does it make any sense to say that this medication should be reserved for patients who already have obesity and type 2 diabetes? Why should we penalize patients who have not yet reached those thresholds by denying access to preventive care? Don’t we constantly hear about how our health care system would be much more efficient if we focused on preventive care and not just treatment?

Some people claim that we have to limit access to this medication because of drug shortages. Thankfully, the United States responds to supply and demand economics and will quickly adjust. 

I’ve had more patients than I can possibly number with severe binge eating disorders (resistant to years of therapy and medication) who finally developed healthy relationships with food while taking these types of medications. Mounjaro, I’m talking about you…

I always hear the argument that it is immoral to give these medications to patients with a history of restrictive eating patterns. Although every patient needs to be carefully evaluated, often these medications remove food as both the enemy and primary focus of every waking thought. They allow patients to refocus on other aspects of their lives – such as family, friends, hobbies, work – and regain a sense of purpose. If anyone wants to run a trial on this little hypothesis of mine, please reach out to me. 

Okay, I agree you might get a little constipated (most often described by patients as the “rabbit pellet phenomenon”), but it’s a small price to pay, no? I’ll throw in a few prunes with the prescription.

Suffice it to say, I did give my 40-something-year-old patient the medication she desired, and she has a new lease on life (as well as better blood pressure and cholesterol).

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

A stylish 40-something-year-old walks into my office looking mildly sheepish. She is a well-known actress who was recently panned by the paparazzi for having “too much cellulite” after they illegally photographed her playing with her child on a private beach.

Without a doubt, she will request semaglutide (Ozempic) before long, but first we will need to wade through the morass of social condemnation out there about Ozempic to assure her that she is being neither immoral nor reckless for considering it.

After nearly 20 years of practicing medicine with a focus on weight loss and preventive care, here is how I see the situation:

Ozempic is nothing new, people! Endocrinologists have been using this class of medication since Byetta hit the market in 2005. We have had 18 years to make informed risk-benefit analyses.

People are obsessed with the risk for pancreatitis. Any type of weight loss can cause gallstones, and this is what can trigger pancreatitis. Unless you’re the type of person who worries that your balanced Weight Watchers diet is going to cause pancreatitis, you should probably remove this risk from your calculations.

Glucagonlike peptide–1 (GLP-1) receptor agonists are naturally occurring gut hormones that reduce inflammatory cascades and clotting risk. We are not giving a dangerous treatment (e.g., fen-phen) that increases cardiovascular risk – quite the contrary, in fact.

Just because influencers are promoting a product doesn’t mean the product is inherently worthless. One of my patients accused me of prescribing a medication that is the “laughingstock of America.” Try telling that to the scores of cardiologists who send patients to my colleagues and me to start Ozempic to help lower their patients’ risk for stroke and heart attack. Or tell this to my patient who survived an episode of rapid atrial fibrillation and was told by his cardiologist that he definitely would have died if he had not lost 30 pounds from Ozempic in the preceding year.

Sometimes it seems like society has become more judgmental about Ozempic than about plastic surgery for weight loss. If we have to choose between liposuction (which doesn’t reduce visceral fat – the dangerous type of fat) or Ozempic, the latter clearly wins because of its real health benefits.

How does it make any sense to say that this medication should be reserved for patients who already have obesity and type 2 diabetes? Why should we penalize patients who have not yet reached those thresholds by denying access to preventive care? Don’t we constantly hear about how our health care system would be much more efficient if we focused on preventive care and not just treatment?

Some people claim that we have to limit access to this medication because of drug shortages. Thankfully, the United States responds to supply and demand economics and will quickly adjust. 

I’ve had more patients than I can possibly number with severe binge eating disorders (resistant to years of therapy and medication) who finally developed healthy relationships with food while taking these types of medications. Mounjaro, I’m talking about you…

I always hear the argument that it is immoral to give these medications to patients with a history of restrictive eating patterns. Although every patient needs to be carefully evaluated, often these medications remove food as both the enemy and primary focus of every waking thought. They allow patients to refocus on other aspects of their lives – such as family, friends, hobbies, work – and regain a sense of purpose. If anyone wants to run a trial on this little hypothesis of mine, please reach out to me. 

Okay, I agree you might get a little constipated (most often described by patients as the “rabbit pellet phenomenon”), but it’s a small price to pay, no? I’ll throw in a few prunes with the prescription.

Suffice it to say, I did give my 40-something-year-old patient the medication she desired, and she has a new lease on life (as well as better blood pressure and cholesterol).

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