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Even Intentional Weight Loss Linked With Cancer
This transcript has been edited for clarity.
As anyone who has been through medical training will tell you, some little scenes just stick with you. I had been seeing a patient in our resident clinic in West Philly for a couple of years. She was in her mid-60s with diabetes and hypertension and a distant smoking history. She was overweight and had been trying to improve her diet and lose weight since I started seeing her. One day she came in and was delighted to report that she had finally started shedding some pounds — about 15 in the past 2 months.
I enthusiastically told my preceptor that my careful dietary counseling had finally done the job. She looked through the chart for a moment and asked, “Is she up to date on her cancer screening?” A workup revealed adenocarcinoma of the lung. The patient did well, actually, but the story stuck with me.
The textbooks call it “unintentional weight loss,” often in big, scary letters, and every doctor will go just a bit pale if a patient tells them that, despite efforts not to, they are losing weight. But true unintentional weight loss is not that common. After all, most of us are at least half-heartedly trying to lose weight all the time. Should doctors be worried when we are successful?
A new study suggests that perhaps they should. We’re talking about this study, appearing in JAMA, which combined participants from two long-running observational cohorts: 120,000 women from the Nurses’ Health Study, and 50,000 men from the Health Professionals Follow-Up Study. (These cohorts started in the 1970s and 1980s, so we’ll give them a pass on the gender-specific study designs.)
The rationale of enrolling healthcare providers in these cohort studies is that they would be reliable witnesses of their own health status. If a nurse or doctor says they have pancreatic cancer, it’s likely that they truly have pancreatic cancer. Detailed health surveys were distributed to the participants every other year, and the average follow-up was more than a decade.
Participants recorded their weight — as an aside, a nested study found that self-reported rate was extremely well correlated with professionally measured weight — and whether they had received a cancer diagnosis since the last survey.
This allowed researchers to look at the phenomenon described above. Would weight loss precede a new diagnosis of cancer? And, more interestingly, would intentional weight loss precede a new diagnosis of cancer.
I don’t think it will surprise you to hear that individuals in the highest category of weight loss, those who lost more than 10% of their body weight over a 2-year period, had a larger risk of being diagnosed with cancer in the next year. That’s the yellow line in this graph. In fact, they had about a 40% higher risk than those who did not lose weight.
Increased risk was found across multiple cancer types, though cancers of the gastrointestinal tract, not surprisingly, were most strongly associated with antecedent weight loss.
What about intentionality of weight loss? Unfortunately, the surveys did not ask participants whether they were trying to lose weight. Rather, the surveys asked about exercise and dietary habits. The researchers leveraged these responses to create three categories of participants: those who seemed to be trying to lose weight (defined as people who had increased their exercise and dietary quality); those who didn’t seem to be trying to lose weight (they changed neither exercise nor dietary behaviors); and a middle group, which changed one or the other of these behaviors but not both.
Let’s look at those who really seemed to be trying to lose weight. Over 2 years, they got more exercise and improved their diet.
If they succeeded in losing 10% or more of their body weight, they still had a higher risk for cancer than those who had not lost weight — about 30% higher, which is not that different from the 40% increased risk when you include those folks who weren’t changing their lifestyle.
This is why this study is important. The classic teaching is that unintentional weight loss is a bad thing and needs a workup. That’s fine. But we live in a world where perhaps the majority of people are, at any given time, trying to lose weight.
We need to be careful here. I am not by any means trying to say that people who have successfully lost weight have cancer. Both of the following statements can be true:
Significant weight loss, whether intentional or not, is associated with a higher risk for cancer.
Most people with significant weight loss will not have cancer.
Both of these can be true because cancer is, fortunately, rare. Of people who lose weight, the vast majority will lose weight because they are engaging in healthier behaviors. A small number may lose weight because something else is wrong. It’s just hard to tell the two apart.
Out of the nearly 200,000 people in this study, only around 16,000 developed cancer during follow-up. Again, although the chance of having cancer is slightly higher if someone has experienced weight loss, the chance is still very low.
We also need to avoid suggesting that weight loss causes cancer. Some people lose weight because of an existing, as of yet undiagnosed cancer and its metabolic effects. This is borne out if you look at the risk of being diagnosed with cancer as you move further away from the interval of weight loss.
The further you get from the year of that 10% weight loss, the less likely you are to be diagnosed with cancer. Most of these cancers are diagnosed within a year of losing weight. In other words, if you’re reading this and getting worried that you lost weight 10 years ago, you’re probably out of the woods. That was, most likely, just you getting healthier.
Last thing: We have methods for weight loss now that are way more effective than diet or exercise. I’m looking at you, Ozempic. But aside from the weight loss wonder drugs, we have surgery and other interventions. This study did not capture any of that data. Ozempic wasn’t even on the market during this study, so we can’t say anything about the relationship between weight loss and cancer among people using nonlifestyle mechanisms to lose weight.
It’s a complicated system. But the clinically actionable point here is to notice if patients have lost weight. If they’ve lost it without trying, further workup is reasonable. If they’ve lost it but were trying to lose it, tell them “good job.” And consider a workup anyway.
Dr. Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
As anyone who has been through medical training will tell you, some little scenes just stick with you. I had been seeing a patient in our resident clinic in West Philly for a couple of years. She was in her mid-60s with diabetes and hypertension and a distant smoking history. She was overweight and had been trying to improve her diet and lose weight since I started seeing her. One day she came in and was delighted to report that she had finally started shedding some pounds — about 15 in the past 2 months.
I enthusiastically told my preceptor that my careful dietary counseling had finally done the job. She looked through the chart for a moment and asked, “Is she up to date on her cancer screening?” A workup revealed adenocarcinoma of the lung. The patient did well, actually, but the story stuck with me.
The textbooks call it “unintentional weight loss,” often in big, scary letters, and every doctor will go just a bit pale if a patient tells them that, despite efforts not to, they are losing weight. But true unintentional weight loss is not that common. After all, most of us are at least half-heartedly trying to lose weight all the time. Should doctors be worried when we are successful?
A new study suggests that perhaps they should. We’re talking about this study, appearing in JAMA, which combined participants from two long-running observational cohorts: 120,000 women from the Nurses’ Health Study, and 50,000 men from the Health Professionals Follow-Up Study. (These cohorts started in the 1970s and 1980s, so we’ll give them a pass on the gender-specific study designs.)
The rationale of enrolling healthcare providers in these cohort studies is that they would be reliable witnesses of their own health status. If a nurse or doctor says they have pancreatic cancer, it’s likely that they truly have pancreatic cancer. Detailed health surveys were distributed to the participants every other year, and the average follow-up was more than a decade.
Participants recorded their weight — as an aside, a nested study found that self-reported rate was extremely well correlated with professionally measured weight — and whether they had received a cancer diagnosis since the last survey.
This allowed researchers to look at the phenomenon described above. Would weight loss precede a new diagnosis of cancer? And, more interestingly, would intentional weight loss precede a new diagnosis of cancer.
I don’t think it will surprise you to hear that individuals in the highest category of weight loss, those who lost more than 10% of their body weight over a 2-year period, had a larger risk of being diagnosed with cancer in the next year. That’s the yellow line in this graph. In fact, they had about a 40% higher risk than those who did not lose weight.
Increased risk was found across multiple cancer types, though cancers of the gastrointestinal tract, not surprisingly, were most strongly associated with antecedent weight loss.
What about intentionality of weight loss? Unfortunately, the surveys did not ask participants whether they were trying to lose weight. Rather, the surveys asked about exercise and dietary habits. The researchers leveraged these responses to create three categories of participants: those who seemed to be trying to lose weight (defined as people who had increased their exercise and dietary quality); those who didn’t seem to be trying to lose weight (they changed neither exercise nor dietary behaviors); and a middle group, which changed one or the other of these behaviors but not both.
Let’s look at those who really seemed to be trying to lose weight. Over 2 years, they got more exercise and improved their diet.
If they succeeded in losing 10% or more of their body weight, they still had a higher risk for cancer than those who had not lost weight — about 30% higher, which is not that different from the 40% increased risk when you include those folks who weren’t changing their lifestyle.
This is why this study is important. The classic teaching is that unintentional weight loss is a bad thing and needs a workup. That’s fine. But we live in a world where perhaps the majority of people are, at any given time, trying to lose weight.
We need to be careful here. I am not by any means trying to say that people who have successfully lost weight have cancer. Both of the following statements can be true:
Significant weight loss, whether intentional or not, is associated with a higher risk for cancer.
Most people with significant weight loss will not have cancer.
Both of these can be true because cancer is, fortunately, rare. Of people who lose weight, the vast majority will lose weight because they are engaging in healthier behaviors. A small number may lose weight because something else is wrong. It’s just hard to tell the two apart.
Out of the nearly 200,000 people in this study, only around 16,000 developed cancer during follow-up. Again, although the chance of having cancer is slightly higher if someone has experienced weight loss, the chance is still very low.
We also need to avoid suggesting that weight loss causes cancer. Some people lose weight because of an existing, as of yet undiagnosed cancer and its metabolic effects. This is borne out if you look at the risk of being diagnosed with cancer as you move further away from the interval of weight loss.
The further you get from the year of that 10% weight loss, the less likely you are to be diagnosed with cancer. Most of these cancers are diagnosed within a year of losing weight. In other words, if you’re reading this and getting worried that you lost weight 10 years ago, you’re probably out of the woods. That was, most likely, just you getting healthier.
Last thing: We have methods for weight loss now that are way more effective than diet or exercise. I’m looking at you, Ozempic. But aside from the weight loss wonder drugs, we have surgery and other interventions. This study did not capture any of that data. Ozempic wasn’t even on the market during this study, so we can’t say anything about the relationship between weight loss and cancer among people using nonlifestyle mechanisms to lose weight.
It’s a complicated system. But the clinically actionable point here is to notice if patients have lost weight. If they’ve lost it without trying, further workup is reasonable. If they’ve lost it but were trying to lose it, tell them “good job.” And consider a workup anyway.
Dr. Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
As anyone who has been through medical training will tell you, some little scenes just stick with you. I had been seeing a patient in our resident clinic in West Philly for a couple of years. She was in her mid-60s with diabetes and hypertension and a distant smoking history. She was overweight and had been trying to improve her diet and lose weight since I started seeing her. One day she came in and was delighted to report that she had finally started shedding some pounds — about 15 in the past 2 months.
I enthusiastically told my preceptor that my careful dietary counseling had finally done the job. She looked through the chart for a moment and asked, “Is she up to date on her cancer screening?” A workup revealed adenocarcinoma of the lung. The patient did well, actually, but the story stuck with me.
The textbooks call it “unintentional weight loss,” often in big, scary letters, and every doctor will go just a bit pale if a patient tells them that, despite efforts not to, they are losing weight. But true unintentional weight loss is not that common. After all, most of us are at least half-heartedly trying to lose weight all the time. Should doctors be worried when we are successful?
A new study suggests that perhaps they should. We’re talking about this study, appearing in JAMA, which combined participants from two long-running observational cohorts: 120,000 women from the Nurses’ Health Study, and 50,000 men from the Health Professionals Follow-Up Study. (These cohorts started in the 1970s and 1980s, so we’ll give them a pass on the gender-specific study designs.)
The rationale of enrolling healthcare providers in these cohort studies is that they would be reliable witnesses of their own health status. If a nurse or doctor says they have pancreatic cancer, it’s likely that they truly have pancreatic cancer. Detailed health surveys were distributed to the participants every other year, and the average follow-up was more than a decade.
Participants recorded their weight — as an aside, a nested study found that self-reported rate was extremely well correlated with professionally measured weight — and whether they had received a cancer diagnosis since the last survey.
This allowed researchers to look at the phenomenon described above. Would weight loss precede a new diagnosis of cancer? And, more interestingly, would intentional weight loss precede a new diagnosis of cancer.
I don’t think it will surprise you to hear that individuals in the highest category of weight loss, those who lost more than 10% of their body weight over a 2-year period, had a larger risk of being diagnosed with cancer in the next year. That’s the yellow line in this graph. In fact, they had about a 40% higher risk than those who did not lose weight.
Increased risk was found across multiple cancer types, though cancers of the gastrointestinal tract, not surprisingly, were most strongly associated with antecedent weight loss.
What about intentionality of weight loss? Unfortunately, the surveys did not ask participants whether they were trying to lose weight. Rather, the surveys asked about exercise and dietary habits. The researchers leveraged these responses to create three categories of participants: those who seemed to be trying to lose weight (defined as people who had increased their exercise and dietary quality); those who didn’t seem to be trying to lose weight (they changed neither exercise nor dietary behaviors); and a middle group, which changed one or the other of these behaviors but not both.
Let’s look at those who really seemed to be trying to lose weight. Over 2 years, they got more exercise and improved their diet.
If they succeeded in losing 10% or more of their body weight, they still had a higher risk for cancer than those who had not lost weight — about 30% higher, which is not that different from the 40% increased risk when you include those folks who weren’t changing their lifestyle.
This is why this study is important. The classic teaching is that unintentional weight loss is a bad thing and needs a workup. That’s fine. But we live in a world where perhaps the majority of people are, at any given time, trying to lose weight.
We need to be careful here. I am not by any means trying to say that people who have successfully lost weight have cancer. Both of the following statements can be true:
Significant weight loss, whether intentional or not, is associated with a higher risk for cancer.
Most people with significant weight loss will not have cancer.
Both of these can be true because cancer is, fortunately, rare. Of people who lose weight, the vast majority will lose weight because they are engaging in healthier behaviors. A small number may lose weight because something else is wrong. It’s just hard to tell the two apart.
Out of the nearly 200,000 people in this study, only around 16,000 developed cancer during follow-up. Again, although the chance of having cancer is slightly higher if someone has experienced weight loss, the chance is still very low.
We also need to avoid suggesting that weight loss causes cancer. Some people lose weight because of an existing, as of yet undiagnosed cancer and its metabolic effects. This is borne out if you look at the risk of being diagnosed with cancer as you move further away from the interval of weight loss.
The further you get from the year of that 10% weight loss, the less likely you are to be diagnosed with cancer. Most of these cancers are diagnosed within a year of losing weight. In other words, if you’re reading this and getting worried that you lost weight 10 years ago, you’re probably out of the woods. That was, most likely, just you getting healthier.
Last thing: We have methods for weight loss now that are way more effective than diet or exercise. I’m looking at you, Ozempic. But aside from the weight loss wonder drugs, we have surgery and other interventions. This study did not capture any of that data. Ozempic wasn’t even on the market during this study, so we can’t say anything about the relationship between weight loss and cancer among people using nonlifestyle mechanisms to lose weight.
It’s a complicated system. But the clinically actionable point here is to notice if patients have lost weight. If they’ve lost it without trying, further workup is reasonable. If they’ve lost it but were trying to lose it, tell them “good job.” And consider a workup anyway.
Dr. Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
A Healthy Dose of Superstition
Mr. Smith was once a nice guy.
These days, unfortunately, he’s anything but. The ravages of a neurodegenerative disease have left him demented, impulsive, and agitated.
His family is trying to find placement for him, and in the meantime I’m doing my best to keep his behavior controlled. Like many things in medicine, this is as much art as science. A tablet of this, a capsule of that, increase this slightly, add something for PRN use ... a witch’s brew of modern medicine.
Because of his worsening, his wife was calling us several times a week with updates, not in an annoying way but in an “I need help” way. I began answering the phone myself if I saw her number come up, because it was easier and faster for me to deal with her directly, and I knew she wasn’t calling for fun.
A few months ago I stopped a medication that didn’t seem to be doing much and started a different one.
And then things went quiet. His wife’s calls went from 3-4 a week to none.
This worried me. I mean, maybe the new medicine was working. ... but the sudden silence was deafening.
One week went by, then two ... I did a Google search to make sure he and his wife hadn’t died or been in the news.
Of course, I could have picked up the phone and called his wife, but why tempt fate?
Three weeks ... I was sure my MA, who handles far more calls than I do, had probably noticed this, too.
It would have been easy to mention it, but even with 16 years of school and 5 years of medical training, not to mention 3,000-4,000 years of hard-earned science behind me, there was the old grade school notion of jinxing myself. To say something is to invite trouble.
Four weeks. Finally, his wife called in and reached my MA. The medication had been working, but now was wearing off and the dose needed to be adjusted. So we did that.
Afterward I mentioned the time lapse to my MA, that I’d been afraid of jinxing it by saying something to her, and she told me she’d been thinking the same thing.
Funny when you think about it. We’re both educated people, believers in science, and (I hope) intelligent. We’re living in a (by human standards) technologically advanced time.
Yet, the old superstitions are still there, the idea that we somehow have magical control over time, space, random chance, and the actions of others by not talking about a phone call (or the lack of one).
Surprisingly (or maybe not), this is pretty normal. When on call we never say “quiet,” for fear of enraging the mysterious Call Gods. If needed, we use “the Q word.”
We still try not to walk under ladders, avoid stepping on sidewalk cracks, carry good luck charms, cross fingers, and fight over wishbones.
Superstitions such as saying “bless you” or “gesundheit” when someone sneezes are so ingrained into us that they’re now part of good manners and polite society.
I’ve worked in quite a few hospitals over the years. Not one of them had a room on any floor that ended in 13, always jumping from 12 to 14.
Civilization is roughly 10,000-15,000 years old. We have the internet and can travel to (relatively nearby) space and back. We have probes exploring — and even leaving — our solar system.
But
I’m going to knock on wood now.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Mr. Smith was once a nice guy.
These days, unfortunately, he’s anything but. The ravages of a neurodegenerative disease have left him demented, impulsive, and agitated.
His family is trying to find placement for him, and in the meantime I’m doing my best to keep his behavior controlled. Like many things in medicine, this is as much art as science. A tablet of this, a capsule of that, increase this slightly, add something for PRN use ... a witch’s brew of modern medicine.
Because of his worsening, his wife was calling us several times a week with updates, not in an annoying way but in an “I need help” way. I began answering the phone myself if I saw her number come up, because it was easier and faster for me to deal with her directly, and I knew she wasn’t calling for fun.
A few months ago I stopped a medication that didn’t seem to be doing much and started a different one.
And then things went quiet. His wife’s calls went from 3-4 a week to none.
This worried me. I mean, maybe the new medicine was working. ... but the sudden silence was deafening.
One week went by, then two ... I did a Google search to make sure he and his wife hadn’t died or been in the news.
Of course, I could have picked up the phone and called his wife, but why tempt fate?
Three weeks ... I was sure my MA, who handles far more calls than I do, had probably noticed this, too.
It would have been easy to mention it, but even with 16 years of school and 5 years of medical training, not to mention 3,000-4,000 years of hard-earned science behind me, there was the old grade school notion of jinxing myself. To say something is to invite trouble.
Four weeks. Finally, his wife called in and reached my MA. The medication had been working, but now was wearing off and the dose needed to be adjusted. So we did that.
Afterward I mentioned the time lapse to my MA, that I’d been afraid of jinxing it by saying something to her, and she told me she’d been thinking the same thing.
Funny when you think about it. We’re both educated people, believers in science, and (I hope) intelligent. We’re living in a (by human standards) technologically advanced time.
Yet, the old superstitions are still there, the idea that we somehow have magical control over time, space, random chance, and the actions of others by not talking about a phone call (or the lack of one).
Surprisingly (or maybe not), this is pretty normal. When on call we never say “quiet,” for fear of enraging the mysterious Call Gods. If needed, we use “the Q word.”
We still try not to walk under ladders, avoid stepping on sidewalk cracks, carry good luck charms, cross fingers, and fight over wishbones.
Superstitions such as saying “bless you” or “gesundheit” when someone sneezes are so ingrained into us that they’re now part of good manners and polite society.
I’ve worked in quite a few hospitals over the years. Not one of them had a room on any floor that ended in 13, always jumping from 12 to 14.
Civilization is roughly 10,000-15,000 years old. We have the internet and can travel to (relatively nearby) space and back. We have probes exploring — and even leaving — our solar system.
But
I’m going to knock on wood now.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Mr. Smith was once a nice guy.
These days, unfortunately, he’s anything but. The ravages of a neurodegenerative disease have left him demented, impulsive, and agitated.
His family is trying to find placement for him, and in the meantime I’m doing my best to keep his behavior controlled. Like many things in medicine, this is as much art as science. A tablet of this, a capsule of that, increase this slightly, add something for PRN use ... a witch’s brew of modern medicine.
Because of his worsening, his wife was calling us several times a week with updates, not in an annoying way but in an “I need help” way. I began answering the phone myself if I saw her number come up, because it was easier and faster for me to deal with her directly, and I knew she wasn’t calling for fun.
A few months ago I stopped a medication that didn’t seem to be doing much and started a different one.
And then things went quiet. His wife’s calls went from 3-4 a week to none.
This worried me. I mean, maybe the new medicine was working. ... but the sudden silence was deafening.
One week went by, then two ... I did a Google search to make sure he and his wife hadn’t died or been in the news.
Of course, I could have picked up the phone and called his wife, but why tempt fate?
Three weeks ... I was sure my MA, who handles far more calls than I do, had probably noticed this, too.
It would have been easy to mention it, but even with 16 years of school and 5 years of medical training, not to mention 3,000-4,000 years of hard-earned science behind me, there was the old grade school notion of jinxing myself. To say something is to invite trouble.
Four weeks. Finally, his wife called in and reached my MA. The medication had been working, but now was wearing off and the dose needed to be adjusted. So we did that.
Afterward I mentioned the time lapse to my MA, that I’d been afraid of jinxing it by saying something to her, and she told me she’d been thinking the same thing.
Funny when you think about it. We’re both educated people, believers in science, and (I hope) intelligent. We’re living in a (by human standards) technologically advanced time.
Yet, the old superstitions are still there, the idea that we somehow have magical control over time, space, random chance, and the actions of others by not talking about a phone call (or the lack of one).
Surprisingly (or maybe not), this is pretty normal. When on call we never say “quiet,” for fear of enraging the mysterious Call Gods. If needed, we use “the Q word.”
We still try not to walk under ladders, avoid stepping on sidewalk cracks, carry good luck charms, cross fingers, and fight over wishbones.
Superstitions such as saying “bless you” or “gesundheit” when someone sneezes are so ingrained into us that they’re now part of good manners and polite society.
I’ve worked in quite a few hospitals over the years. Not one of them had a room on any floor that ended in 13, always jumping from 12 to 14.
Civilization is roughly 10,000-15,000 years old. We have the internet and can travel to (relatively nearby) space and back. We have probes exploring — and even leaving — our solar system.
But
I’m going to knock on wood now.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Burnout and Work-Based Well-Being Programs
Since very few of us practice medicine without being either an employer or an employee, we should probably be paying more attention to research in industrial and employee relations, not an area most of us have studied. One of the hot topics for employers in these days of low unemployment is the question of whether to offer free wellness-enhancing programs companywide.
Almost by definition anything “free” has a good public relations aura surrounding it. Recent surveys have shown that a large chunk of the population is feeling stressed. If your boss is offering you a free opportunity to help you feel better about yourself, he/she must understand at least a bit of what you are going through.
From the employer’s standpoint these programs offer the potential for a double win. On one hand, offering a free well-being program is a perk the company can tout as it competes in the tight market for new employees. On the other hand, if the program is effective then the employees will be happier. And we all know that happy workers are more productive and less likely to leave and feed the expensive cycle of hiring and training new workers to replace the unhappy and disgruntled workers who have quit. Even if the employer’s total focus is on the company’s bottom line, offering a wellness program should pay a dividend.
Well ... this may be one of those situations where wishful thinking isn’t going to work. A recent study published in Industrial Relations Journal suggests that these well-being programs, which include employee mental services, may not be living up to their promise. In this large study of nearly 50,00 workers in the United Kingdom, the researcher discovered that workers who had been offered coaching and relaxation classes, internet-based apps, and courses in time management and financial health were “no better off” than their coworkers who had not participated in these programs. In fact, training programs in stress management and resilience appeared to possibly have had a negative effect.
In a New York Times article about this study, the British researcher recommends that employers who are interested in improving their worker’s mental health should turn their attention to “core organizational practices” meaning pay scales, work schedules, and performance reviews.
Not surprisingly, this study has raised some controversy. There are a lot of people invested emotionally and in some cases financially in programs similar to the ones that appeared to be ineffective in this study. Critics argue the study was too short, or too small, or failed to select programs with a proven track record.
Even given these potential flaws, physicians, particularly those who of us who feel they approaching burnout, should take this investigator’s message seriously. Certainly some of us could be doing a better job of building resilience into our lifestyles and may be helped by the kind of well-being programs tested in this study. However, the biggest contribution to the burnout phenomenon is coming from the work environments that are asking too much of even the most resilient among us. This study makes it clear that including work schedules, time-gobbling electronic systems, and short staffing. Trotting out a few feel-good mindfulness programs is not going to do the job.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Since very few of us practice medicine without being either an employer or an employee, we should probably be paying more attention to research in industrial and employee relations, not an area most of us have studied. One of the hot topics for employers in these days of low unemployment is the question of whether to offer free wellness-enhancing programs companywide.
Almost by definition anything “free” has a good public relations aura surrounding it. Recent surveys have shown that a large chunk of the population is feeling stressed. If your boss is offering you a free opportunity to help you feel better about yourself, he/she must understand at least a bit of what you are going through.
From the employer’s standpoint these programs offer the potential for a double win. On one hand, offering a free well-being program is a perk the company can tout as it competes in the tight market for new employees. On the other hand, if the program is effective then the employees will be happier. And we all know that happy workers are more productive and less likely to leave and feed the expensive cycle of hiring and training new workers to replace the unhappy and disgruntled workers who have quit. Even if the employer’s total focus is on the company’s bottom line, offering a wellness program should pay a dividend.
Well ... this may be one of those situations where wishful thinking isn’t going to work. A recent study published in Industrial Relations Journal suggests that these well-being programs, which include employee mental services, may not be living up to their promise. In this large study of nearly 50,00 workers in the United Kingdom, the researcher discovered that workers who had been offered coaching and relaxation classes, internet-based apps, and courses in time management and financial health were “no better off” than their coworkers who had not participated in these programs. In fact, training programs in stress management and resilience appeared to possibly have had a negative effect.
In a New York Times article about this study, the British researcher recommends that employers who are interested in improving their worker’s mental health should turn their attention to “core organizational practices” meaning pay scales, work schedules, and performance reviews.
Not surprisingly, this study has raised some controversy. There are a lot of people invested emotionally and in some cases financially in programs similar to the ones that appeared to be ineffective in this study. Critics argue the study was too short, or too small, or failed to select programs with a proven track record.
Even given these potential flaws, physicians, particularly those who of us who feel they approaching burnout, should take this investigator’s message seriously. Certainly some of us could be doing a better job of building resilience into our lifestyles and may be helped by the kind of well-being programs tested in this study. However, the biggest contribution to the burnout phenomenon is coming from the work environments that are asking too much of even the most resilient among us. This study makes it clear that including work schedules, time-gobbling electronic systems, and short staffing. Trotting out a few feel-good mindfulness programs is not going to do the job.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Since very few of us practice medicine without being either an employer or an employee, we should probably be paying more attention to research in industrial and employee relations, not an area most of us have studied. One of the hot topics for employers in these days of low unemployment is the question of whether to offer free wellness-enhancing programs companywide.
Almost by definition anything “free” has a good public relations aura surrounding it. Recent surveys have shown that a large chunk of the population is feeling stressed. If your boss is offering you a free opportunity to help you feel better about yourself, he/she must understand at least a bit of what you are going through.
From the employer’s standpoint these programs offer the potential for a double win. On one hand, offering a free well-being program is a perk the company can tout as it competes in the tight market for new employees. On the other hand, if the program is effective then the employees will be happier. And we all know that happy workers are more productive and less likely to leave and feed the expensive cycle of hiring and training new workers to replace the unhappy and disgruntled workers who have quit. Even if the employer’s total focus is on the company’s bottom line, offering a wellness program should pay a dividend.
Well ... this may be one of those situations where wishful thinking isn’t going to work. A recent study published in Industrial Relations Journal suggests that these well-being programs, which include employee mental services, may not be living up to their promise. In this large study of nearly 50,00 workers in the United Kingdom, the researcher discovered that workers who had been offered coaching and relaxation classes, internet-based apps, and courses in time management and financial health were “no better off” than their coworkers who had not participated in these programs. In fact, training programs in stress management and resilience appeared to possibly have had a negative effect.
In a New York Times article about this study, the British researcher recommends that employers who are interested in improving their worker’s mental health should turn their attention to “core organizational practices” meaning pay scales, work schedules, and performance reviews.
Not surprisingly, this study has raised some controversy. There are a lot of people invested emotionally and in some cases financially in programs similar to the ones that appeared to be ineffective in this study. Critics argue the study was too short, or too small, or failed to select programs with a proven track record.
Even given these potential flaws, physicians, particularly those who of us who feel they approaching burnout, should take this investigator’s message seriously. Certainly some of us could be doing a better job of building resilience into our lifestyles and may be helped by the kind of well-being programs tested in this study. However, the biggest contribution to the burnout phenomenon is coming from the work environments that are asking too much of even the most resilient among us. This study makes it clear that including work schedules, time-gobbling electronic systems, and short staffing. Trotting out a few feel-good mindfulness programs is not going to do the job.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Tackling Sexism in Medicine
This interview was recorded Dec. 8, 2023. The transcript has been edited for clarity.
Kathrin LaFaver, MD: I have the pleasure of talking with Dr. Elizabeth Loder today. Dr. Loder is the vice chair of academic affairs in the department of neurology and a staff physician at Graham Headache Center at Brigham and Women’s Hospital in Boston. She’s also a professor of neurology at Harvard Medical School and has been a mentor to many headache specialists in the field.
We’ll be talking about the topic of sexism in medicine.
Elizabeth W. Loder, MD, MPH: Thank you so much, Dr. LaFaver. I’m very pleased to be here to talk about something that I think is very important.
Dr. LaFaver: Dr. Loder, you were a speaker at our Women in Neurology third annual conference in Florida, giving a talk on this very topic, sexism in medicine. It was very helpful, especially for many younger women entering the field of neurology, to hear that some of the experiences they’re having are not unique to them, but unfortunately remain a more systemic issue.
To get us started, could you define sexism in medicine for us, and how you got interested in this topic?
Sexism Can Be Subtle
Dr. Loder: You’re absolutely right. It’s nice for women, particularly those entering the field, to know that they’re not alone.
What is sexism? Well, it’s generally considered to be prejudice or discrimination against someone based on their sex or gender. One thing that’s important to remember is it’s not always extremely obvious. It’s not always intentional. I think most of us, I’d include myself in that, have sexist views. We may not always be aware of them. This is part of the unconscious bias that many of us have been trained to think.
As one example, we’re socialized — or I certainly was — to think of doctors as male. When a patient says, “I saw a cardiologist,” in my mind, I think that that person might have been male. Sometimes, I will ask, “What did he say?” That’s an example of sexism.
Sexism can be internalized. It can come from any source. We’re all implicated in it. I think that’s very important to remember. This is not a case of them doing something to us. This is something that is much more widespread and engendered in the society that we live in.
Dr. LaFaver: I think that’s really important to realize. Could you mention some other examples, specifically in the field of neurology, that you have encountered?
Dr. Loder: Certainly, looking over my own career — and I’m at a point now where I can look at early, mid, and late career — things were, of course, very different when I began. I would say that sexism was much more overt.
Very early in my career, I experienced a large amount of hostility from a boss. I ended up having to leave. This was, I believe, based on my sex. It turned out that leaving was a good thing for me, but it was a very unpleasant experience.
I also became a leader in my professional society. During my path to leadership and seeing other women attempt to make progress within the organization, I certainly saw behavior that I would characterize as rooted in sexism. To its credit, though, the professional society to which I belong, I think, has become one of the most progressive societies out there. The women within have been able to affect quite a bit of change in that professional organization.
I dealt with a case of sexual harassment in my own division when I was a division chief, which gave me insight into institutional policies and procedures meant to deal with situations like that, which, I think, leave something to be desired. That’s changing.
Now, I work in academic affairs, and I see how likely or unlikely people, based on their sex, are to put themselves forward for promotion, how likely they are to believe in their own capabilities. I also work as a medical journal editor, and I see generally that women are more hesitant to proclaim themselves experts and to accept invitations to provide or write editorial commentary. Sometimes, they do not perceive themselves as being expert enough to do so. I have seen many of these things over my career.
Dr. LaFaver: Thank you for sharing. I think it’s important to realize that it›s not just unidirectional but sometimes affects women and kind of goes both ways.
As you mentioned, these issues are not always overt. In recent years, microaggressions has become more of a term that has been used. Could you talk a bit about that? What are the microaggressions and how do they affect women?
Microaggressions and Migraine Mavens
Dr. Loder: The term microaggression has become very popular, and I think many people find it somewhat irritating. That, to me, is inherent in what a microaggression is. Microaggressions, by definition, are small things. It’s hard to prove that they were rooted in sexism. Sometimes, there’s a large amount of ambiguity about it. It can be as simple as inviting a pregnant woman to sit down because you perceive that she needs to sit, commenting on somebody’s shoes, or things like that.
Often, they’re unintentional. Sometimes, they come from a place of what we might term benevolent sexism, people trying to be helpful to a woman because they perceive that she’s weaker or she might not be able to do something, or maybe she has family responsibilities. They think that they’re being helpful. These things happen when we perceive people to be different in some way, as women are perceived to be different in terms of their responsibilities in the home or different in terms of what we expect from them in the workplace.
The problem with microaggressions is because they’re small, each one of them, I think the temptation is often to say, “Oh you know, they didn’t mean it. It’s not that big a deal. It was just a comment on your shoes.” If a woman brings that up, she’s often made to feel, sometimes by other women, that she should just chill out. This isn’t a big deal.
The problem is that they may not be a big deal in and of themselves, but when they are repeated over a long period of time, they can really sap somebody’s confidence in herself, make her question her own competence, and can have a cumulative effect that is very negative.
Although I think many people are skeptical about microaggressions as an important contribution to how women do in the workplace and in other settings, they are, in my opinion, important. I’ll just emphasize again that they come from everywhere, including other women and colleagues who mean to be helpful.
Dr. LaFaver: I know you have led a team of headache specialists and wrote a fantastic article about navigating sexism at work and what not to say to your female colleagues. Could you share some tips for them to navigate sexism at work and, specifically, as it applies to our careers in medicine.
Dr. Loder: Thank you for calling out that article. It actually grew organically out of a Facebook group that I started called Migraine Mavens. I’ve worked in the headache field throughout my career, and I experienced something that, to me, was kind of discouraging that I felt was sexist within our field. I just thought, What can I do? I thought, Well, maybe there’s some strength to be had in sharing this with other women, and maybe we should have our own social media community, so I formed this group.
After I gave a talk at the American Headache Society about sexism in the headache field, one of the members sent me a message saying, “Your talk was very timely. Immediately after you gave this talk, somebody stopped me in the hall and said, ‘Congratulations on your leadership position in the society, but are you really sure you can do this because you’ve got young children at home?’ Your talk was very needed.”
People started just discussing within the group, “Oh, this happened to me,” “That happened to me.” We began to brainstorm what we could have done differently. When these things happen, people are not necessarily prepared for them, and later on, you lie awake thinking of what you could have said.
We decided to write a paper. It ended up being published in The Journal of Head and Face Pain, and it was based on real vignettes from people in the group. We anonymized them so that people would not recognize themselves necessarily, but they’re all real. They’re things that really happened to women in the group.
We first describe the vignette — what happened. Then we explain, for those who need the explanation, what’s wrong with it. Why is it wrong to tell somebody to smile, for example. What could you do differently? What could somebody who sees this happen do, the so-called bystander or upstander? If you witness something like that, can you help the person toward whom this problematic behavior is directed? We came up with some examples. The all-purpose thing is to say, “What did you just say?” Make them repeat it, which often helps people to realize how inappropriate it is.
This got published as an article. It became quite the subject of attention on X [formerly Twitter] and elsewhere. I guess the term going viral would apply to this. It included a large amount of real-world advice. The thing I really loved about it was that it was written by the women in the group who had experienced these things. I would characterize it as having been somewhat therapeutic. We got many messages from women in other disciplines, outside medicine, saying that this happens in oceanography, for example. I think what we described really resonated beyond the field of headache medicine and neurology.
Institutional Sexism
Dr. LaFaver: Looking beyond the individual person, do you have any recommendations for medical institutions to share in order to do better and maybe create an environment that is less sexist?
Dr. Loder: Yes. I think many institutions try to deal with the problem of lack of diversity, whether it›s women or other underrepresented groups, by hiring. That’s one way to go about it, but I think retention strategies are also very important, and they need to pay attention to the work environment.
Every institution now has guidelines about harassment, bullying, sexism, racism, and so on. In general though — and I’m not speaking about any particular institution — these policies and procedures are often crafted with an eye toward protecting the institution. I would advise institutions to be a bit more genuine about this, and not to think so quickly about what can we do to prevent the institution from facing a charge of sexism, or what can we do to deny or dismiss these allegations, toward thinking, what can we do to really and truly be helpful to these women? In other words, approach it from the point of view of trying to help the people involved instead of trying to help the institution. That will make a very big difference.
I also think that citizenship activities, serving on committees, doing thankless tasks behind the scenes, and clinical work, seeing patients ... Women are overrepresented among clinicians. Of course, we know that research and bringing in big grants is often prioritized over clinical care, despite what institutions may say about that in public. I think those activities should be valued more highly, both in terms of pay and in terms of academic recognition.
In regard to the issue of salary, I would encourage institutions to publish salaries or at least make them easily findable by people within the institution. I think there should be objective criteria for salary determinations. The most important thing is that I do not think that women should be expected to negotiate their salaries. Women are judged differently than men when they attempt to negotiate salaries. It often backfires for them. It also is something that many women do not feel comfortable doing.
Waiting until somebody tries to negotiate a higher salary really guarantees, embeds, and operationalizes sex differences in salaries. We need to move away from the idea that you have to be a go-getter and that you have to ask for this raise. There should be objective criteria, salaries should be revisited on a regular basis, and the kinds of activities that women do that are undervalued should be more recognized in terms of money and advancement within academia.
Dr. LaFaver: I couldn’t agree more. One of the other topics discussed at the Women in Neurology conference was mid-career development, retention, and career paths. I think it’s known that many women leave academic medicine mid-career. I think these are excellent suggestions and hopefully will help to make careers successful for men and women, without needing to worry about being treated differently or unfairly.
Thank you so much. This was a wonderful overview of this topic.
Dr. Loder: You’re welcome, Dr. LaFaver. Thank you so much for asking me to speak on this topic. I really appreciate it.
Dr. LaFaver: Thanks, everyone.
Dr. LaFaver is a neurologist at Saratoga Hospital Medical Group, Saratoga Springs, New York. Dr. LaFaver and Dr. Loder disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
This interview was recorded Dec. 8, 2023. The transcript has been edited for clarity.
Kathrin LaFaver, MD: I have the pleasure of talking with Dr. Elizabeth Loder today. Dr. Loder is the vice chair of academic affairs in the department of neurology and a staff physician at Graham Headache Center at Brigham and Women’s Hospital in Boston. She’s also a professor of neurology at Harvard Medical School and has been a mentor to many headache specialists in the field.
We’ll be talking about the topic of sexism in medicine.
Elizabeth W. Loder, MD, MPH: Thank you so much, Dr. LaFaver. I’m very pleased to be here to talk about something that I think is very important.
Dr. LaFaver: Dr. Loder, you were a speaker at our Women in Neurology third annual conference in Florida, giving a talk on this very topic, sexism in medicine. It was very helpful, especially for many younger women entering the field of neurology, to hear that some of the experiences they’re having are not unique to them, but unfortunately remain a more systemic issue.
To get us started, could you define sexism in medicine for us, and how you got interested in this topic?
Sexism Can Be Subtle
Dr. Loder: You’re absolutely right. It’s nice for women, particularly those entering the field, to know that they’re not alone.
What is sexism? Well, it’s generally considered to be prejudice or discrimination against someone based on their sex or gender. One thing that’s important to remember is it’s not always extremely obvious. It’s not always intentional. I think most of us, I’d include myself in that, have sexist views. We may not always be aware of them. This is part of the unconscious bias that many of us have been trained to think.
As one example, we’re socialized — or I certainly was — to think of doctors as male. When a patient says, “I saw a cardiologist,” in my mind, I think that that person might have been male. Sometimes, I will ask, “What did he say?” That’s an example of sexism.
Sexism can be internalized. It can come from any source. We’re all implicated in it. I think that’s very important to remember. This is not a case of them doing something to us. This is something that is much more widespread and engendered in the society that we live in.
Dr. LaFaver: I think that’s really important to realize. Could you mention some other examples, specifically in the field of neurology, that you have encountered?
Dr. Loder: Certainly, looking over my own career — and I’m at a point now where I can look at early, mid, and late career — things were, of course, very different when I began. I would say that sexism was much more overt.
Very early in my career, I experienced a large amount of hostility from a boss. I ended up having to leave. This was, I believe, based on my sex. It turned out that leaving was a good thing for me, but it was a very unpleasant experience.
I also became a leader in my professional society. During my path to leadership and seeing other women attempt to make progress within the organization, I certainly saw behavior that I would characterize as rooted in sexism. To its credit, though, the professional society to which I belong, I think, has become one of the most progressive societies out there. The women within have been able to affect quite a bit of change in that professional organization.
I dealt with a case of sexual harassment in my own division when I was a division chief, which gave me insight into institutional policies and procedures meant to deal with situations like that, which, I think, leave something to be desired. That’s changing.
Now, I work in academic affairs, and I see how likely or unlikely people, based on their sex, are to put themselves forward for promotion, how likely they are to believe in their own capabilities. I also work as a medical journal editor, and I see generally that women are more hesitant to proclaim themselves experts and to accept invitations to provide or write editorial commentary. Sometimes, they do not perceive themselves as being expert enough to do so. I have seen many of these things over my career.
Dr. LaFaver: Thank you for sharing. I think it’s important to realize that it›s not just unidirectional but sometimes affects women and kind of goes both ways.
As you mentioned, these issues are not always overt. In recent years, microaggressions has become more of a term that has been used. Could you talk a bit about that? What are the microaggressions and how do they affect women?
Microaggressions and Migraine Mavens
Dr. Loder: The term microaggression has become very popular, and I think many people find it somewhat irritating. That, to me, is inherent in what a microaggression is. Microaggressions, by definition, are small things. It’s hard to prove that they were rooted in sexism. Sometimes, there’s a large amount of ambiguity about it. It can be as simple as inviting a pregnant woman to sit down because you perceive that she needs to sit, commenting on somebody’s shoes, or things like that.
Often, they’re unintentional. Sometimes, they come from a place of what we might term benevolent sexism, people trying to be helpful to a woman because they perceive that she’s weaker or she might not be able to do something, or maybe she has family responsibilities. They think that they’re being helpful. These things happen when we perceive people to be different in some way, as women are perceived to be different in terms of their responsibilities in the home or different in terms of what we expect from them in the workplace.
The problem with microaggressions is because they’re small, each one of them, I think the temptation is often to say, “Oh you know, they didn’t mean it. It’s not that big a deal. It was just a comment on your shoes.” If a woman brings that up, she’s often made to feel, sometimes by other women, that she should just chill out. This isn’t a big deal.
The problem is that they may not be a big deal in and of themselves, but when they are repeated over a long period of time, they can really sap somebody’s confidence in herself, make her question her own competence, and can have a cumulative effect that is very negative.
Although I think many people are skeptical about microaggressions as an important contribution to how women do in the workplace and in other settings, they are, in my opinion, important. I’ll just emphasize again that they come from everywhere, including other women and colleagues who mean to be helpful.
Dr. LaFaver: I know you have led a team of headache specialists and wrote a fantastic article about navigating sexism at work and what not to say to your female colleagues. Could you share some tips for them to navigate sexism at work and, specifically, as it applies to our careers in medicine.
Dr. Loder: Thank you for calling out that article. It actually grew organically out of a Facebook group that I started called Migraine Mavens. I’ve worked in the headache field throughout my career, and I experienced something that, to me, was kind of discouraging that I felt was sexist within our field. I just thought, What can I do? I thought, Well, maybe there’s some strength to be had in sharing this with other women, and maybe we should have our own social media community, so I formed this group.
After I gave a talk at the American Headache Society about sexism in the headache field, one of the members sent me a message saying, “Your talk was very timely. Immediately after you gave this talk, somebody stopped me in the hall and said, ‘Congratulations on your leadership position in the society, but are you really sure you can do this because you’ve got young children at home?’ Your talk was very needed.”
People started just discussing within the group, “Oh, this happened to me,” “That happened to me.” We began to brainstorm what we could have done differently. When these things happen, people are not necessarily prepared for them, and later on, you lie awake thinking of what you could have said.
We decided to write a paper. It ended up being published in The Journal of Head and Face Pain, and it was based on real vignettes from people in the group. We anonymized them so that people would not recognize themselves necessarily, but they’re all real. They’re things that really happened to women in the group.
We first describe the vignette — what happened. Then we explain, for those who need the explanation, what’s wrong with it. Why is it wrong to tell somebody to smile, for example. What could you do differently? What could somebody who sees this happen do, the so-called bystander or upstander? If you witness something like that, can you help the person toward whom this problematic behavior is directed? We came up with some examples. The all-purpose thing is to say, “What did you just say?” Make them repeat it, which often helps people to realize how inappropriate it is.
This got published as an article. It became quite the subject of attention on X [formerly Twitter] and elsewhere. I guess the term going viral would apply to this. It included a large amount of real-world advice. The thing I really loved about it was that it was written by the women in the group who had experienced these things. I would characterize it as having been somewhat therapeutic. We got many messages from women in other disciplines, outside medicine, saying that this happens in oceanography, for example. I think what we described really resonated beyond the field of headache medicine and neurology.
Institutional Sexism
Dr. LaFaver: Looking beyond the individual person, do you have any recommendations for medical institutions to share in order to do better and maybe create an environment that is less sexist?
Dr. Loder: Yes. I think many institutions try to deal with the problem of lack of diversity, whether it›s women or other underrepresented groups, by hiring. That’s one way to go about it, but I think retention strategies are also very important, and they need to pay attention to the work environment.
Every institution now has guidelines about harassment, bullying, sexism, racism, and so on. In general though — and I’m not speaking about any particular institution — these policies and procedures are often crafted with an eye toward protecting the institution. I would advise institutions to be a bit more genuine about this, and not to think so quickly about what can we do to prevent the institution from facing a charge of sexism, or what can we do to deny or dismiss these allegations, toward thinking, what can we do to really and truly be helpful to these women? In other words, approach it from the point of view of trying to help the people involved instead of trying to help the institution. That will make a very big difference.
I also think that citizenship activities, serving on committees, doing thankless tasks behind the scenes, and clinical work, seeing patients ... Women are overrepresented among clinicians. Of course, we know that research and bringing in big grants is often prioritized over clinical care, despite what institutions may say about that in public. I think those activities should be valued more highly, both in terms of pay and in terms of academic recognition.
In regard to the issue of salary, I would encourage institutions to publish salaries or at least make them easily findable by people within the institution. I think there should be objective criteria for salary determinations. The most important thing is that I do not think that women should be expected to negotiate their salaries. Women are judged differently than men when they attempt to negotiate salaries. It often backfires for them. It also is something that many women do not feel comfortable doing.
Waiting until somebody tries to negotiate a higher salary really guarantees, embeds, and operationalizes sex differences in salaries. We need to move away from the idea that you have to be a go-getter and that you have to ask for this raise. There should be objective criteria, salaries should be revisited on a regular basis, and the kinds of activities that women do that are undervalued should be more recognized in terms of money and advancement within academia.
Dr. LaFaver: I couldn’t agree more. One of the other topics discussed at the Women in Neurology conference was mid-career development, retention, and career paths. I think it’s known that many women leave academic medicine mid-career. I think these are excellent suggestions and hopefully will help to make careers successful for men and women, without needing to worry about being treated differently or unfairly.
Thank you so much. This was a wonderful overview of this topic.
Dr. Loder: You’re welcome, Dr. LaFaver. Thank you so much for asking me to speak on this topic. I really appreciate it.
Dr. LaFaver: Thanks, everyone.
Dr. LaFaver is a neurologist at Saratoga Hospital Medical Group, Saratoga Springs, New York. Dr. LaFaver and Dr. Loder disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
This interview was recorded Dec. 8, 2023. The transcript has been edited for clarity.
Kathrin LaFaver, MD: I have the pleasure of talking with Dr. Elizabeth Loder today. Dr. Loder is the vice chair of academic affairs in the department of neurology and a staff physician at Graham Headache Center at Brigham and Women’s Hospital in Boston. She’s also a professor of neurology at Harvard Medical School and has been a mentor to many headache specialists in the field.
We’ll be talking about the topic of sexism in medicine.
Elizabeth W. Loder, MD, MPH: Thank you so much, Dr. LaFaver. I’m very pleased to be here to talk about something that I think is very important.
Dr. LaFaver: Dr. Loder, you were a speaker at our Women in Neurology third annual conference in Florida, giving a talk on this very topic, sexism in medicine. It was very helpful, especially for many younger women entering the field of neurology, to hear that some of the experiences they’re having are not unique to them, but unfortunately remain a more systemic issue.
To get us started, could you define sexism in medicine for us, and how you got interested in this topic?
Sexism Can Be Subtle
Dr. Loder: You’re absolutely right. It’s nice for women, particularly those entering the field, to know that they’re not alone.
What is sexism? Well, it’s generally considered to be prejudice or discrimination against someone based on their sex or gender. One thing that’s important to remember is it’s not always extremely obvious. It’s not always intentional. I think most of us, I’d include myself in that, have sexist views. We may not always be aware of them. This is part of the unconscious bias that many of us have been trained to think.
As one example, we’re socialized — or I certainly was — to think of doctors as male. When a patient says, “I saw a cardiologist,” in my mind, I think that that person might have been male. Sometimes, I will ask, “What did he say?” That’s an example of sexism.
Sexism can be internalized. It can come from any source. We’re all implicated in it. I think that’s very important to remember. This is not a case of them doing something to us. This is something that is much more widespread and engendered in the society that we live in.
Dr. LaFaver: I think that’s really important to realize. Could you mention some other examples, specifically in the field of neurology, that you have encountered?
Dr. Loder: Certainly, looking over my own career — and I’m at a point now where I can look at early, mid, and late career — things were, of course, very different when I began. I would say that sexism was much more overt.
Very early in my career, I experienced a large amount of hostility from a boss. I ended up having to leave. This was, I believe, based on my sex. It turned out that leaving was a good thing for me, but it was a very unpleasant experience.
I also became a leader in my professional society. During my path to leadership and seeing other women attempt to make progress within the organization, I certainly saw behavior that I would characterize as rooted in sexism. To its credit, though, the professional society to which I belong, I think, has become one of the most progressive societies out there. The women within have been able to affect quite a bit of change in that professional organization.
I dealt with a case of sexual harassment in my own division when I was a division chief, which gave me insight into institutional policies and procedures meant to deal with situations like that, which, I think, leave something to be desired. That’s changing.
Now, I work in academic affairs, and I see how likely or unlikely people, based on their sex, are to put themselves forward for promotion, how likely they are to believe in their own capabilities. I also work as a medical journal editor, and I see generally that women are more hesitant to proclaim themselves experts and to accept invitations to provide or write editorial commentary. Sometimes, they do not perceive themselves as being expert enough to do so. I have seen many of these things over my career.
Dr. LaFaver: Thank you for sharing. I think it’s important to realize that it›s not just unidirectional but sometimes affects women and kind of goes both ways.
As you mentioned, these issues are not always overt. In recent years, microaggressions has become more of a term that has been used. Could you talk a bit about that? What are the microaggressions and how do they affect women?
Microaggressions and Migraine Mavens
Dr. Loder: The term microaggression has become very popular, and I think many people find it somewhat irritating. That, to me, is inherent in what a microaggression is. Microaggressions, by definition, are small things. It’s hard to prove that they were rooted in sexism. Sometimes, there’s a large amount of ambiguity about it. It can be as simple as inviting a pregnant woman to sit down because you perceive that she needs to sit, commenting on somebody’s shoes, or things like that.
Often, they’re unintentional. Sometimes, they come from a place of what we might term benevolent sexism, people trying to be helpful to a woman because they perceive that she’s weaker or she might not be able to do something, or maybe she has family responsibilities. They think that they’re being helpful. These things happen when we perceive people to be different in some way, as women are perceived to be different in terms of their responsibilities in the home or different in terms of what we expect from them in the workplace.
The problem with microaggressions is because they’re small, each one of them, I think the temptation is often to say, “Oh you know, they didn’t mean it. It’s not that big a deal. It was just a comment on your shoes.” If a woman brings that up, she’s often made to feel, sometimes by other women, that she should just chill out. This isn’t a big deal.
The problem is that they may not be a big deal in and of themselves, but when they are repeated over a long period of time, they can really sap somebody’s confidence in herself, make her question her own competence, and can have a cumulative effect that is very negative.
Although I think many people are skeptical about microaggressions as an important contribution to how women do in the workplace and in other settings, they are, in my opinion, important. I’ll just emphasize again that they come from everywhere, including other women and colleagues who mean to be helpful.
Dr. LaFaver: I know you have led a team of headache specialists and wrote a fantastic article about navigating sexism at work and what not to say to your female colleagues. Could you share some tips for them to navigate sexism at work and, specifically, as it applies to our careers in medicine.
Dr. Loder: Thank you for calling out that article. It actually grew organically out of a Facebook group that I started called Migraine Mavens. I’ve worked in the headache field throughout my career, and I experienced something that, to me, was kind of discouraging that I felt was sexist within our field. I just thought, What can I do? I thought, Well, maybe there’s some strength to be had in sharing this with other women, and maybe we should have our own social media community, so I formed this group.
After I gave a talk at the American Headache Society about sexism in the headache field, one of the members sent me a message saying, “Your talk was very timely. Immediately after you gave this talk, somebody stopped me in the hall and said, ‘Congratulations on your leadership position in the society, but are you really sure you can do this because you’ve got young children at home?’ Your talk was very needed.”
People started just discussing within the group, “Oh, this happened to me,” “That happened to me.” We began to brainstorm what we could have done differently. When these things happen, people are not necessarily prepared for them, and later on, you lie awake thinking of what you could have said.
We decided to write a paper. It ended up being published in The Journal of Head and Face Pain, and it was based on real vignettes from people in the group. We anonymized them so that people would not recognize themselves necessarily, but they’re all real. They’re things that really happened to women in the group.
We first describe the vignette — what happened. Then we explain, for those who need the explanation, what’s wrong with it. Why is it wrong to tell somebody to smile, for example. What could you do differently? What could somebody who sees this happen do, the so-called bystander or upstander? If you witness something like that, can you help the person toward whom this problematic behavior is directed? We came up with some examples. The all-purpose thing is to say, “What did you just say?” Make them repeat it, which often helps people to realize how inappropriate it is.
This got published as an article. It became quite the subject of attention on X [formerly Twitter] and elsewhere. I guess the term going viral would apply to this. It included a large amount of real-world advice. The thing I really loved about it was that it was written by the women in the group who had experienced these things. I would characterize it as having been somewhat therapeutic. We got many messages from women in other disciplines, outside medicine, saying that this happens in oceanography, for example. I think what we described really resonated beyond the field of headache medicine and neurology.
Institutional Sexism
Dr. LaFaver: Looking beyond the individual person, do you have any recommendations for medical institutions to share in order to do better and maybe create an environment that is less sexist?
Dr. Loder: Yes. I think many institutions try to deal with the problem of lack of diversity, whether it›s women or other underrepresented groups, by hiring. That’s one way to go about it, but I think retention strategies are also very important, and they need to pay attention to the work environment.
Every institution now has guidelines about harassment, bullying, sexism, racism, and so on. In general though — and I’m not speaking about any particular institution — these policies and procedures are often crafted with an eye toward protecting the institution. I would advise institutions to be a bit more genuine about this, and not to think so quickly about what can we do to prevent the institution from facing a charge of sexism, or what can we do to deny or dismiss these allegations, toward thinking, what can we do to really and truly be helpful to these women? In other words, approach it from the point of view of trying to help the people involved instead of trying to help the institution. That will make a very big difference.
I also think that citizenship activities, serving on committees, doing thankless tasks behind the scenes, and clinical work, seeing patients ... Women are overrepresented among clinicians. Of course, we know that research and bringing in big grants is often prioritized over clinical care, despite what institutions may say about that in public. I think those activities should be valued more highly, both in terms of pay and in terms of academic recognition.
In regard to the issue of salary, I would encourage institutions to publish salaries or at least make them easily findable by people within the institution. I think there should be objective criteria for salary determinations. The most important thing is that I do not think that women should be expected to negotiate their salaries. Women are judged differently than men when they attempt to negotiate salaries. It often backfires for them. It also is something that many women do not feel comfortable doing.
Waiting until somebody tries to negotiate a higher salary really guarantees, embeds, and operationalizes sex differences in salaries. We need to move away from the idea that you have to be a go-getter and that you have to ask for this raise. There should be objective criteria, salaries should be revisited on a regular basis, and the kinds of activities that women do that are undervalued should be more recognized in terms of money and advancement within academia.
Dr. LaFaver: I couldn’t agree more. One of the other topics discussed at the Women in Neurology conference was mid-career development, retention, and career paths. I think it’s known that many women leave academic medicine mid-career. I think these are excellent suggestions and hopefully will help to make careers successful for men and women, without needing to worry about being treated differently or unfairly.
Thank you so much. This was a wonderful overview of this topic.
Dr. Loder: You’re welcome, Dr. LaFaver. Thank you so much for asking me to speak on this topic. I really appreciate it.
Dr. LaFaver: Thanks, everyone.
Dr. LaFaver is a neurologist at Saratoga Hospital Medical Group, Saratoga Springs, New York. Dr. LaFaver and Dr. Loder disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Why Don’t Physicians Call In Sick?
I began practicing medicine on July 1, 1981. In the 43-plus years since then,
There are several reasons, both good and bad, why this is so: (1) like most physicians, I am a terrible patient; (2) as a solo practitioner, there was (until recently — I’ll get to that in a minute) no one else to see an office full of patients who had waited significant amounts of time for their appointments and in many cases had taken off work themselves to keep them; and (3) there is an unspoken rule against it. Taking sick days is highly frowned upon in the medical world. As a medical student, intern, and resident I was told in so many words not to call in sick, no matter how serious the illness might be.
Apparently, I was not the only doctor-in-training to receive that message. In a survey reported in JAMA Pediatrics several years ago, 95% of the physicians and advanced practice clinicians (APCs) surveyed believed that working while sick put patients at risk — yet 83% reported working sick at least one time over the prior year. They understood the risks, but did it anyway.
There is no question that this practice does put patients’ health at risk. The JAMA study linked numerous reports of outbreaks traceable to symptomatic healthcare workers. Some outbreaks of flu, staph infections, norovirus, and pertussis were shown to originate from a sick physician or supporting staff member. These associations have led to increased morbidity and mortality, as well as excess costs. Those of us who treat immunocompromised patients on a regular basis risk inducing a life-threatening illness by unnecessarily exposing them to pathogens.
The JAMA survey results also confirmed my own observation that many physicians feel boxed in by their institutions or practice situations. “The study illustrates the complex social and logistic factors that cause this behavior,” the authors wrote. “These results may inform efforts to design systems at our hospital to provide support for attending physicians and APCs and help them make the right choice to keep their patients and colleagues safe while caring for themselves.”
What might those efforts look like? For one thing, we can take the obvious and necessary steps to avoid getting sick in the first place, such as staying fit and hydrated, and eating well. We can keep up with routine health visits and measures such as colorectal screening, pap smears, and mammograms, and stay up to date with flu shots and all other essential immunizations.
Next, we can minimize the risk of spreading any illnesses we encounter in the course of our work by practicing the basic infectious disease prevention measures driven home so forcefully by the recent COVID-19 pandemic — washing our hands, using hand sanitizers, and, when appropriate, wearing gloves and masks.
Finally, we can work to overcome this institutional taboo against staying home when we do get sick. Work out a system of mutual coverage for such situations. Two years ago, I merged my solo practice with a local, larger group. I did it for a variety of reasons, but a principal one was to assure that a partner could cover for me if I became ill. Practitioners who choose to remain solo or in small groups should contact colleagues and work out a coverage agreement.
Now, during flu season, it is especially important to resist the temptation to work while sick. The CDC has guidelines for employees specific for the flu, which notes that “persons with the flu are most contagious during the first 3 days of their illness,” and should remain at home until at least 24 hours after their fever subsides (without the use of fever-reducing medications) or after symptoms have improved (at least 4-5 days after they started) — or, if they do not have a fever, after symptoms improve “for at least 4-5 days after the onset of symptoms.”
Of course, we need to remember that COVID-19 is still with us. With the constant evolution of new strains, it is especially important to avoid exposing patients and colleagues to the disease should you become infected. The most recent advice from the CDC includes the recommendation that those who are mildly ill and not moderately or severely immunocompromised should isolate after SARS-CoV-2 infection for at least 5 days after symptom onset (day 0 is the day symptoms appeared, and day 1 is the next full day thereafter) if fever has resolved for at least 24 hours (without taking fever-reducing medications) and other symptoms are improving. In addition, “a high-quality mask should be worn around others at home and in public through day 10.”
We should also extend these rules to our support staff, starting with providing them with adequate sick leave and encouraging them to use it when necessary. Research has found a direct correlation between preventative health care and the number of paid sick leave days a worker gets. In a study of over 3000 US workers, those with 10 paid sick days or more annually accessed preventative care more frequently than those without paid sick days.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
I began practicing medicine on July 1, 1981. In the 43-plus years since then,
There are several reasons, both good and bad, why this is so: (1) like most physicians, I am a terrible patient; (2) as a solo practitioner, there was (until recently — I’ll get to that in a minute) no one else to see an office full of patients who had waited significant amounts of time for their appointments and in many cases had taken off work themselves to keep them; and (3) there is an unspoken rule against it. Taking sick days is highly frowned upon in the medical world. As a medical student, intern, and resident I was told in so many words not to call in sick, no matter how serious the illness might be.
Apparently, I was not the only doctor-in-training to receive that message. In a survey reported in JAMA Pediatrics several years ago, 95% of the physicians and advanced practice clinicians (APCs) surveyed believed that working while sick put patients at risk — yet 83% reported working sick at least one time over the prior year. They understood the risks, but did it anyway.
There is no question that this practice does put patients’ health at risk. The JAMA study linked numerous reports of outbreaks traceable to symptomatic healthcare workers. Some outbreaks of flu, staph infections, norovirus, and pertussis were shown to originate from a sick physician or supporting staff member. These associations have led to increased morbidity and mortality, as well as excess costs. Those of us who treat immunocompromised patients on a regular basis risk inducing a life-threatening illness by unnecessarily exposing them to pathogens.
The JAMA survey results also confirmed my own observation that many physicians feel boxed in by their institutions or practice situations. “The study illustrates the complex social and logistic factors that cause this behavior,” the authors wrote. “These results may inform efforts to design systems at our hospital to provide support for attending physicians and APCs and help them make the right choice to keep their patients and colleagues safe while caring for themselves.”
What might those efforts look like? For one thing, we can take the obvious and necessary steps to avoid getting sick in the first place, such as staying fit and hydrated, and eating well. We can keep up with routine health visits and measures such as colorectal screening, pap smears, and mammograms, and stay up to date with flu shots and all other essential immunizations.
Next, we can minimize the risk of spreading any illnesses we encounter in the course of our work by practicing the basic infectious disease prevention measures driven home so forcefully by the recent COVID-19 pandemic — washing our hands, using hand sanitizers, and, when appropriate, wearing gloves and masks.
Finally, we can work to overcome this institutional taboo against staying home when we do get sick. Work out a system of mutual coverage for such situations. Two years ago, I merged my solo practice with a local, larger group. I did it for a variety of reasons, but a principal one was to assure that a partner could cover for me if I became ill. Practitioners who choose to remain solo or in small groups should contact colleagues and work out a coverage agreement.
Now, during flu season, it is especially important to resist the temptation to work while sick. The CDC has guidelines for employees specific for the flu, which notes that “persons with the flu are most contagious during the first 3 days of their illness,” and should remain at home until at least 24 hours after their fever subsides (without the use of fever-reducing medications) or after symptoms have improved (at least 4-5 days after they started) — or, if they do not have a fever, after symptoms improve “for at least 4-5 days after the onset of symptoms.”
Of course, we need to remember that COVID-19 is still with us. With the constant evolution of new strains, it is especially important to avoid exposing patients and colleagues to the disease should you become infected. The most recent advice from the CDC includes the recommendation that those who are mildly ill and not moderately or severely immunocompromised should isolate after SARS-CoV-2 infection for at least 5 days after symptom onset (day 0 is the day symptoms appeared, and day 1 is the next full day thereafter) if fever has resolved for at least 24 hours (without taking fever-reducing medications) and other symptoms are improving. In addition, “a high-quality mask should be worn around others at home and in public through day 10.”
We should also extend these rules to our support staff, starting with providing them with adequate sick leave and encouraging them to use it when necessary. Research has found a direct correlation between preventative health care and the number of paid sick leave days a worker gets. In a study of over 3000 US workers, those with 10 paid sick days or more annually accessed preventative care more frequently than those without paid sick days.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
I began practicing medicine on July 1, 1981. In the 43-plus years since then,
There are several reasons, both good and bad, why this is so: (1) like most physicians, I am a terrible patient; (2) as a solo practitioner, there was (until recently — I’ll get to that in a minute) no one else to see an office full of patients who had waited significant amounts of time for their appointments and in many cases had taken off work themselves to keep them; and (3) there is an unspoken rule against it. Taking sick days is highly frowned upon in the medical world. As a medical student, intern, and resident I was told in so many words not to call in sick, no matter how serious the illness might be.
Apparently, I was not the only doctor-in-training to receive that message. In a survey reported in JAMA Pediatrics several years ago, 95% of the physicians and advanced practice clinicians (APCs) surveyed believed that working while sick put patients at risk — yet 83% reported working sick at least one time over the prior year. They understood the risks, but did it anyway.
There is no question that this practice does put patients’ health at risk. The JAMA study linked numerous reports of outbreaks traceable to symptomatic healthcare workers. Some outbreaks of flu, staph infections, norovirus, and pertussis were shown to originate from a sick physician or supporting staff member. These associations have led to increased morbidity and mortality, as well as excess costs. Those of us who treat immunocompromised patients on a regular basis risk inducing a life-threatening illness by unnecessarily exposing them to pathogens.
The JAMA survey results also confirmed my own observation that many physicians feel boxed in by their institutions or practice situations. “The study illustrates the complex social and logistic factors that cause this behavior,” the authors wrote. “These results may inform efforts to design systems at our hospital to provide support for attending physicians and APCs and help them make the right choice to keep their patients and colleagues safe while caring for themselves.”
What might those efforts look like? For one thing, we can take the obvious and necessary steps to avoid getting sick in the first place, such as staying fit and hydrated, and eating well. We can keep up with routine health visits and measures such as colorectal screening, pap smears, and mammograms, and stay up to date with flu shots and all other essential immunizations.
Next, we can minimize the risk of spreading any illnesses we encounter in the course of our work by practicing the basic infectious disease prevention measures driven home so forcefully by the recent COVID-19 pandemic — washing our hands, using hand sanitizers, and, when appropriate, wearing gloves and masks.
Finally, we can work to overcome this institutional taboo against staying home when we do get sick. Work out a system of mutual coverage for such situations. Two years ago, I merged my solo practice with a local, larger group. I did it for a variety of reasons, but a principal one was to assure that a partner could cover for me if I became ill. Practitioners who choose to remain solo or in small groups should contact colleagues and work out a coverage agreement.
Now, during flu season, it is especially important to resist the temptation to work while sick. The CDC has guidelines for employees specific for the flu, which notes that “persons with the flu are most contagious during the first 3 days of their illness,” and should remain at home until at least 24 hours after their fever subsides (without the use of fever-reducing medications) or after symptoms have improved (at least 4-5 days after they started) — or, if they do not have a fever, after symptoms improve “for at least 4-5 days after the onset of symptoms.”
Of course, we need to remember that COVID-19 is still with us. With the constant evolution of new strains, it is especially important to avoid exposing patients and colleagues to the disease should you become infected. The most recent advice from the CDC includes the recommendation that those who are mildly ill and not moderately or severely immunocompromised should isolate after SARS-CoV-2 infection for at least 5 days after symptom onset (day 0 is the day symptoms appeared, and day 1 is the next full day thereafter) if fever has resolved for at least 24 hours (without taking fever-reducing medications) and other symptoms are improving. In addition, “a high-quality mask should be worn around others at home and in public through day 10.”
We should also extend these rules to our support staff, starting with providing them with adequate sick leave and encouraging them to use it when necessary. Research has found a direct correlation between preventative health care and the number of paid sick leave days a worker gets. In a study of over 3000 US workers, those with 10 paid sick days or more annually accessed preventative care more frequently than those without paid sick days.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Cutting Across the Bias
On a recent rainy afternoon I was speed skimming through the pile of publications sitting on the floor next to my Grampy’s chair. A bright patch of color jumped off the gray background of the printed page forcing me to pause and consider the content.
In the right upper corner was a photograph of an attractive Black woman nursing her baby. Her bare arms suggested she might be slightly overweight. She wore a simple off-white head wrap and smiled broadly as she played with her infant’s fingers. The image was a reproduction of a WIC poster encouraging women to take advantage of the program’s breastfeeding support services. The accompanying article from American Academy of Pediatrics offered ten strategies for achieving breastfeeding equity.
I must admit that I tend to shy away from discussions of equity because I’ve seldom found them very informative. However, the engaging image of this Black woman breastfeeding led me to read beyond the title.
The first of the strategies listed was “Check you biases.” I will certainly admit to having biases. We all have biases and see and interpret the world through lenses ground and tinted by our experiences and the environment we have inhabited. In the case of breastfeeding, I wasn’t sure where my biases lay. Maybe one of mine is reflected in a hesitancy to actively promote exclusive breastfeeding for the first 6 months. I prefer a more nuanced approach adjusted to the unique needs and limitations of each family. But I decided to chase down the Implicit Association Test (IAT) suggested in the article. I couldn’t make that link work, but found a long list of subjects on the Harvard Implicit Association Test website. None dealt with breastfeeding, so I chose the one described as Black/White.
If, like me, you have never had your implicit biases assessed by taking an IAT, you might find it interesting. Probably took me about 15 minutes using my laptop. There are a lot of demographic questions then some rapid-fire exercises in which you must provide your first response to a barrage of photos of faces and words. At times I sensed that the test makers were trying to trick me into making associations that I didn’t want to make by the order in which the exercises were presented. At the end I was told that I was a little slow in associating Black faces with positive words.
I’m not sure what this means. After doing a little internet searching I learned that one of the criticisms of the IAT is that, while it may hint at a bias, it is really more important whether you cut with or across that bias. If I acknowledge that where and how I grew up may have left me with some implicit biases, it is more important that I make a strong and honest effort to act independently of those biases.
In full disclosure I must tell you that there was one Black girl in my high school of a thousand students. I have lived and practiced in Maine for 50 years. At less than 2%, we are sixth from the bottom in Black population among other states. However, in the last 5 or 6 years here in Brunswick we have welcomed a large infusion of asylum seekers who come predominantly from Black African countries.
Skimming through the rest of the article, I found it hard to argue with the remaining nine recommendations for promoting breastfeeding, although most of them we not terribly applicable to small community practices. The photo of the Black woman nursing her baby at the top of the page remains as the primary message. The fact that I was drawn to that image is a testament to several of my biases and another example of a picture being worth far more than a thousand words.
I suspect that I’m not alone in appreciating the uniqueness of that image. Until recently, the standard photos of a mother breastfeeding have used trim White women as their models. I suspect and hope this poster will be effective in encouraging Black women to nurse. I urge you all to hang it in your office as a reminder to you and your staff of your biases and assumptions. Don’t bother to take the Implicit Association Test unless you’re retired and have 15 minutes to burn on a rainy afternoon.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
On a recent rainy afternoon I was speed skimming through the pile of publications sitting on the floor next to my Grampy’s chair. A bright patch of color jumped off the gray background of the printed page forcing me to pause and consider the content.
In the right upper corner was a photograph of an attractive Black woman nursing her baby. Her bare arms suggested she might be slightly overweight. She wore a simple off-white head wrap and smiled broadly as she played with her infant’s fingers. The image was a reproduction of a WIC poster encouraging women to take advantage of the program’s breastfeeding support services. The accompanying article from American Academy of Pediatrics offered ten strategies for achieving breastfeeding equity.
I must admit that I tend to shy away from discussions of equity because I’ve seldom found them very informative. However, the engaging image of this Black woman breastfeeding led me to read beyond the title.
The first of the strategies listed was “Check you biases.” I will certainly admit to having biases. We all have biases and see and interpret the world through lenses ground and tinted by our experiences and the environment we have inhabited. In the case of breastfeeding, I wasn’t sure where my biases lay. Maybe one of mine is reflected in a hesitancy to actively promote exclusive breastfeeding for the first 6 months. I prefer a more nuanced approach adjusted to the unique needs and limitations of each family. But I decided to chase down the Implicit Association Test (IAT) suggested in the article. I couldn’t make that link work, but found a long list of subjects on the Harvard Implicit Association Test website. None dealt with breastfeeding, so I chose the one described as Black/White.
If, like me, you have never had your implicit biases assessed by taking an IAT, you might find it interesting. Probably took me about 15 minutes using my laptop. There are a lot of demographic questions then some rapid-fire exercises in which you must provide your first response to a barrage of photos of faces and words. At times I sensed that the test makers were trying to trick me into making associations that I didn’t want to make by the order in which the exercises were presented. At the end I was told that I was a little slow in associating Black faces with positive words.
I’m not sure what this means. After doing a little internet searching I learned that one of the criticisms of the IAT is that, while it may hint at a bias, it is really more important whether you cut with or across that bias. If I acknowledge that where and how I grew up may have left me with some implicit biases, it is more important that I make a strong and honest effort to act independently of those biases.
In full disclosure I must tell you that there was one Black girl in my high school of a thousand students. I have lived and practiced in Maine for 50 years. At less than 2%, we are sixth from the bottom in Black population among other states. However, in the last 5 or 6 years here in Brunswick we have welcomed a large infusion of asylum seekers who come predominantly from Black African countries.
Skimming through the rest of the article, I found it hard to argue with the remaining nine recommendations for promoting breastfeeding, although most of them we not terribly applicable to small community practices. The photo of the Black woman nursing her baby at the top of the page remains as the primary message. The fact that I was drawn to that image is a testament to several of my biases and another example of a picture being worth far more than a thousand words.
I suspect that I’m not alone in appreciating the uniqueness of that image. Until recently, the standard photos of a mother breastfeeding have used trim White women as their models. I suspect and hope this poster will be effective in encouraging Black women to nurse. I urge you all to hang it in your office as a reminder to you and your staff of your biases and assumptions. Don’t bother to take the Implicit Association Test unless you’re retired and have 15 minutes to burn on a rainy afternoon.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
On a recent rainy afternoon I was speed skimming through the pile of publications sitting on the floor next to my Grampy’s chair. A bright patch of color jumped off the gray background of the printed page forcing me to pause and consider the content.
In the right upper corner was a photograph of an attractive Black woman nursing her baby. Her bare arms suggested she might be slightly overweight. She wore a simple off-white head wrap and smiled broadly as she played with her infant’s fingers. The image was a reproduction of a WIC poster encouraging women to take advantage of the program’s breastfeeding support services. The accompanying article from American Academy of Pediatrics offered ten strategies for achieving breastfeeding equity.
I must admit that I tend to shy away from discussions of equity because I’ve seldom found them very informative. However, the engaging image of this Black woman breastfeeding led me to read beyond the title.
The first of the strategies listed was “Check you biases.” I will certainly admit to having biases. We all have biases and see and interpret the world through lenses ground and tinted by our experiences and the environment we have inhabited. In the case of breastfeeding, I wasn’t sure where my biases lay. Maybe one of mine is reflected in a hesitancy to actively promote exclusive breastfeeding for the first 6 months. I prefer a more nuanced approach adjusted to the unique needs and limitations of each family. But I decided to chase down the Implicit Association Test (IAT) suggested in the article. I couldn’t make that link work, but found a long list of subjects on the Harvard Implicit Association Test website. None dealt with breastfeeding, so I chose the one described as Black/White.
If, like me, you have never had your implicit biases assessed by taking an IAT, you might find it interesting. Probably took me about 15 minutes using my laptop. There are a lot of demographic questions then some rapid-fire exercises in which you must provide your first response to a barrage of photos of faces and words. At times I sensed that the test makers were trying to trick me into making associations that I didn’t want to make by the order in which the exercises were presented. At the end I was told that I was a little slow in associating Black faces with positive words.
I’m not sure what this means. After doing a little internet searching I learned that one of the criticisms of the IAT is that, while it may hint at a bias, it is really more important whether you cut with or across that bias. If I acknowledge that where and how I grew up may have left me with some implicit biases, it is more important that I make a strong and honest effort to act independently of those biases.
In full disclosure I must tell you that there was one Black girl in my high school of a thousand students. I have lived and practiced in Maine for 50 years. At less than 2%, we are sixth from the bottom in Black population among other states. However, in the last 5 or 6 years here in Brunswick we have welcomed a large infusion of asylum seekers who come predominantly from Black African countries.
Skimming through the rest of the article, I found it hard to argue with the remaining nine recommendations for promoting breastfeeding, although most of them we not terribly applicable to small community practices. The photo of the Black woman nursing her baby at the top of the page remains as the primary message. The fact that I was drawn to that image is a testament to several of my biases and another example of a picture being worth far more than a thousand words.
I suspect that I’m not alone in appreciating the uniqueness of that image. Until recently, the standard photos of a mother breastfeeding have used trim White women as their models. I suspect and hope this poster will be effective in encouraging Black women to nurse. I urge you all to hang it in your office as a reminder to you and your staff of your biases and assumptions. Don’t bother to take the Implicit Association Test unless you’re retired and have 15 minutes to burn on a rainy afternoon.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
‘Stop Teaching’ Children It’s Their Fault They’re Fat
The US Preventive Services Task Force (USPSTF) has published draft recommendations that 6-year-olds with obesity be lectured to about diet and exercise.
Never mind that there are no reproducible or scalable studies demonstrating durable and clinically meaningful benefits of this for adults let alone children. Never mind that children are not household decision-makers on matters of grocery shopping, cooking, or exercise. Never mind the corollary that many children so lectured who fail to see an impact on their weight will perceive that as their own personal failures. And of course, never mind that we’re privileged to be in an era with safe, effective, pharmacotherapeutic options for obesity. No. We must teach children it’s their fault if they’re fat. Because ultimately that’s what many of them will learn.
That’s not to say there’s no room for counseling. But with children as young as 6, that counseling should be delivered exclusively to their parents and caregivers. That counseling should focus as much if not more so on the impact of weight bias and the biological basis of obesity rather than diet and exercise, while explicitly teaching parents the means to discuss nutrition without risking their children feeling worse about themselves, increasing the risk for conflict over changes, or heightening their children’s chance of developing eating disorders or maladaptive relationships with food.
But back to the USPSTF’s actual recommendation for those 6 years old and up. They’re recommending “at least” 26 hours of lectures over a year-long interprofessional intervention. Putting aside the reality that this isn’t scalable time-wise or cost-wise to reach even a fraction of the roughly 15 million US children with obesity, there is also the issue of service provision. Because when it comes to obesity, if the intervention is purely educational, even if you want to believe there is a syllabus out there that would have a dramatic impact, its impact will vary wildly depending on the skill and approach of the service providers. This inconvenient truth is also the one that makes it impossible to meaningfully compare program outcomes even when they share the same content.
The USPSTF’s draft recommendations also explicitly avoid what the American Academy of Pediatrics has rightly embraced: the use where appropriate of medications or surgery. While opponents of the use of pharmacotherapy for childhood obesity tend to point to a lack of long-term data as rationale for its denial, something that the USPSTF has done, again, we have long-term data demonstrating a lack of scalable, clinically meaningful efficacy for service only based programs.
Childhood obesity is a flood and its ongoing current is relentless. Given its tremendous impact, especially at its extremes, on both physical and mental health, this is yet another example of systemic weight bias in action — it’s as if the USPSTF is recommending a swimming lesson–only approach while actively fearmongering, despite an absence of plausible mechanistic risk, about the long-term use of life jackets.
Dr. Freedhoff is associate professor, Department of Family Medicine, University of Ottawa; Medical Director, Bariatric Medical Institute, Ottawa, Ontario, Canada. Dr. Freedhoff has disclosed ties with Bariatric Medical Institute, Constant Health, and Novo Nordisk.
A version of this article appeared on Medscape.com.
The US Preventive Services Task Force (USPSTF) has published draft recommendations that 6-year-olds with obesity be lectured to about diet and exercise.
Never mind that there are no reproducible or scalable studies demonstrating durable and clinically meaningful benefits of this for adults let alone children. Never mind that children are not household decision-makers on matters of grocery shopping, cooking, or exercise. Never mind the corollary that many children so lectured who fail to see an impact on their weight will perceive that as their own personal failures. And of course, never mind that we’re privileged to be in an era with safe, effective, pharmacotherapeutic options for obesity. No. We must teach children it’s their fault if they’re fat. Because ultimately that’s what many of them will learn.
That’s not to say there’s no room for counseling. But with children as young as 6, that counseling should be delivered exclusively to their parents and caregivers. That counseling should focus as much if not more so on the impact of weight bias and the biological basis of obesity rather than diet and exercise, while explicitly teaching parents the means to discuss nutrition without risking their children feeling worse about themselves, increasing the risk for conflict over changes, or heightening their children’s chance of developing eating disorders or maladaptive relationships with food.
But back to the USPSTF’s actual recommendation for those 6 years old and up. They’re recommending “at least” 26 hours of lectures over a year-long interprofessional intervention. Putting aside the reality that this isn’t scalable time-wise or cost-wise to reach even a fraction of the roughly 15 million US children with obesity, there is also the issue of service provision. Because when it comes to obesity, if the intervention is purely educational, even if you want to believe there is a syllabus out there that would have a dramatic impact, its impact will vary wildly depending on the skill and approach of the service providers. This inconvenient truth is also the one that makes it impossible to meaningfully compare program outcomes even when they share the same content.
The USPSTF’s draft recommendations also explicitly avoid what the American Academy of Pediatrics has rightly embraced: the use where appropriate of medications or surgery. While opponents of the use of pharmacotherapy for childhood obesity tend to point to a lack of long-term data as rationale for its denial, something that the USPSTF has done, again, we have long-term data demonstrating a lack of scalable, clinically meaningful efficacy for service only based programs.
Childhood obesity is a flood and its ongoing current is relentless. Given its tremendous impact, especially at its extremes, on both physical and mental health, this is yet another example of systemic weight bias in action — it’s as if the USPSTF is recommending a swimming lesson–only approach while actively fearmongering, despite an absence of plausible mechanistic risk, about the long-term use of life jackets.
Dr. Freedhoff is associate professor, Department of Family Medicine, University of Ottawa; Medical Director, Bariatric Medical Institute, Ottawa, Ontario, Canada. Dr. Freedhoff has disclosed ties with Bariatric Medical Institute, Constant Health, and Novo Nordisk.
A version of this article appeared on Medscape.com.
The US Preventive Services Task Force (USPSTF) has published draft recommendations that 6-year-olds with obesity be lectured to about diet and exercise.
Never mind that there are no reproducible or scalable studies demonstrating durable and clinically meaningful benefits of this for adults let alone children. Never mind that children are not household decision-makers on matters of grocery shopping, cooking, or exercise. Never mind the corollary that many children so lectured who fail to see an impact on their weight will perceive that as their own personal failures. And of course, never mind that we’re privileged to be in an era with safe, effective, pharmacotherapeutic options for obesity. No. We must teach children it’s their fault if they’re fat. Because ultimately that’s what many of them will learn.
That’s not to say there’s no room for counseling. But with children as young as 6, that counseling should be delivered exclusively to their parents and caregivers. That counseling should focus as much if not more so on the impact of weight bias and the biological basis of obesity rather than diet and exercise, while explicitly teaching parents the means to discuss nutrition without risking their children feeling worse about themselves, increasing the risk for conflict over changes, or heightening their children’s chance of developing eating disorders or maladaptive relationships with food.
But back to the USPSTF’s actual recommendation for those 6 years old and up. They’re recommending “at least” 26 hours of lectures over a year-long interprofessional intervention. Putting aside the reality that this isn’t scalable time-wise or cost-wise to reach even a fraction of the roughly 15 million US children with obesity, there is also the issue of service provision. Because when it comes to obesity, if the intervention is purely educational, even if you want to believe there is a syllabus out there that would have a dramatic impact, its impact will vary wildly depending on the skill and approach of the service providers. This inconvenient truth is also the one that makes it impossible to meaningfully compare program outcomes even when they share the same content.
The USPSTF’s draft recommendations also explicitly avoid what the American Academy of Pediatrics has rightly embraced: the use where appropriate of medications or surgery. While opponents of the use of pharmacotherapy for childhood obesity tend to point to a lack of long-term data as rationale for its denial, something that the USPSTF has done, again, we have long-term data demonstrating a lack of scalable, clinically meaningful efficacy for service only based programs.
Childhood obesity is a flood and its ongoing current is relentless. Given its tremendous impact, especially at its extremes, on both physical and mental health, this is yet another example of systemic weight bias in action — it’s as if the USPSTF is recommending a swimming lesson–only approach while actively fearmongering, despite an absence of plausible mechanistic risk, about the long-term use of life jackets.
Dr. Freedhoff is associate professor, Department of Family Medicine, University of Ottawa; Medical Director, Bariatric Medical Institute, Ottawa, Ontario, Canada. Dr. Freedhoff has disclosed ties with Bariatric Medical Institute, Constant Health, and Novo Nordisk.
A version of this article appeared on Medscape.com.
Tips and Techniques to Boost Colonoscopy Quality
This transcript has been edited for clarity.
When it comes to the use of colonoscopy to reduce the risk for cancer, quality is key.
There are a number of performance improvements we can make in our practices so that we can do better. This is evident in several recently published studies and a recent review article on the topic, which I’d like to profile for you; many of these key quality indicators you can implement now.
Even though it may take more time before they’re supported in the guidelines, you’ll see that the evidence behind these is extraordinarily strong.
Increasing the Adenoma Detection Rate
Certainly, we all do what we can to increase the adenoma detection rate (ADR).
However, at the moment, the nationally recommended benchmark is to achieve an ADR of 25%, which is inordinately low. The ADR rate reported in the GIQuIC registry data is closer to 39%, and in high-level detectors, it’s actually in the greater-than-50% range.
There’s no question that we can do more, and there are a number of ways to do that.
First, This may actually decrease your withdrawal time because you don’t spend so much time trying to face these folds.
In considering tools to aid ADR, don’t forget electronic chromoendoscopy (eg, narrow-band imaging).
There are a number of new artificial intelligence options out there as well, which have been reported to increase the ADR by approximately 10%. Of importance, this improvement even occurs among expert endoscopists.
There’s also important emerging data about ADR in fecal immunochemical test (FIT)–positive patients. FIT-positive status increases the ADR threshold by 15%-20%. This places you in an ADR range of approximately 50%, which is really the norm when screening patients that present for colonoscopy because of FIT positivity.
Adenoma Per Colonoscopy: A Possible ADR Substitute
Growing evidence supports the use of adenoma per colonoscopy (APC) as a substitute to ADR. This would allow you to record every adenoma and attribute it to that index colonoscopy.
A high-quality paper showed that the APC value should be around 0.6 to achieve the current ADR minimum threshold of 25%. Having the APC < 0.6 seems to be associated with an increased risk for residual polyp. Sessile serrated lesions also increased the hazard ratio for interval colorectal cancer. This was evaluated recently with data from the New Hampshire Colonoscopy Registry, which Dr Joseph Anderson has led for so long. They showed that 21% of endoscopists had an ADR of 25% or greater but still had APCs < 0.6.
Therefore, when it comes to remedial corrective work, doctors need to be reevaluated, retrained, and educated in the ways that they can incorporate this. The APC in high-level detectors is > 1.0.
APC may be something you want to consider using internally. It does require that you place each polyp into an individual jar, which can increase incremental cost. Nonetheless, there is clear evidence that APC positively changes outcomes.
Including Sessile Serrated Lesions in ADR Detectors
Unfortunately, some of the high-level ADR detectors aren’t so “high level” when it comes to detecting sessile serrated lesions. It’s not quite as concordant as we had previously thought.
Nonetheless, there are many adjunctive things you can do with sessile serrated lesions, including narrow-band imaging and chromoendoscopy.
When it comes to establishing a discriminant, the numbers should be 5%-6% if we’re going to set a quality ratio and an index. However, this is somewhat dependent on your pathologist because they have to read these correctly. Lesions that are ≥ 6 mm above the sigmoid colon and anything in the right colon should be evaluated really closely as a sessile serrated lesion.
I’ve had indications where the pathologist says the lesion is hyperplastic, to which I say, “I’m going to follow as a sessile serrated lesion.” This is because it’s apparent to me in the endoscopic appearance and the narrow-band imaging appearance that it was characteristic of sessile serrated lesions.
Best Practices in Bowel Preparations
The US Multi-Society Task Force recommends that adequate bowel preparation should occur in 85% or more of outpatients, and for the European Society for Gastrointestinal Endoscopy, it’s 90% or more.
I’ll pass along a tip I use in my patients undergoing bowel preparation: I make them aware that during this process, they want to see a clear, yellow, urine-like color to their stool. Otherwise, many patients will think if they’ve had some diarrhea, they don’t need to finish prep. Setting that expectation for them upfront is really important.
The nurses also should be aware of this because if there’s a murky brown effluent upon presentation for the colonoscopy, there’s a greater than 50% chance that they’re going to have had an inadequate preparation. In such cases, you would want to preempt the colonoscopy and perhaps send them out for a re-prep that day or bring them back for a rescheduled appointment.
Resection Considerations
There is substantial variation when it comes to lesion resection, which makes it an important quality indicator on which to focus: High-level detectors aren’t always high-level resectors.
There are two validated instruments that you can use to gauge the adequacy of resection. Those aren’t really ready for prime time in every practice, though they may be seen in fellowship programs.
The idea here is that you want to get a ≥ 2 mm margin for cold snare polypectomy in lesions 1-10 mm in size. This has been a challenge, as findings indicate we don’t do this that well.
Joseph Anderson and colleagues recently published a study using a 2-mm resection margin. They reported that this was only possible in approximately 28% of polyps. For a 1-mm margin, the rate was 84%.
We simply need to set clearer margins when setting our snare. Make sure you’re close enough to the polyp, push down on the snare, and get a good margin of tissue.
When the sample contracts are placed into the formalin, it’s not quite so simple to define the margin at the time of the surgical resection. This often requires an audit evaluation by the pathologist.
There are two other considerations regarding resection.
The first is about the referral for surgery. Referral should not occur for any benign lesions ascribed by your endoscopic advanced imaging techniques and classifications that are not thought to have intramucosal carcinoma. These should be referred to an expert endoscopic evaluation. If you can’t do it, then somebody else should. And you shouldn’t attempt it unless you can get it totally because resection of partially resected lesions is much more complicated. The European Society of Gastrointestinal Endoscopy says this applies to any benign lesion of any size, which I think really is the emerging standard of care. You should consider and offer that to the patient. It may require a referral for outside of your institution.
The second additional consideration is around the minimization of cold forceps for removal of polyps. The US Multi-Society Task Force says cold forceps shouldn’t be used for any lesions > 2 mm, whereas for the European Society of Gastrointestinal Endoscopy, it is > 3 mm. However, it’s still done very commonly in clinical practice. Nibbling the polyp is not an option. Cold snare is actually quicker, more effective, has better outcomes, and is something that you can bill for when you look at the coding.
In summary, there are a lot of things that we can do now to improve colonoscopy. Quality indicators continue to emerge with a compelling, excellent evidence base that strongly supports their use. Given that, I think most of these are actionable now, and it’s not necessary to wait for the guidelines to begin using them. I’d therefore challenge all of us to incorporate them in our continual efforts to do better.
Dr. Johnson is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease. He has disclosed ties with ISOTHRIVE and Johnson & Johnson.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
When it comes to the use of colonoscopy to reduce the risk for cancer, quality is key.
There are a number of performance improvements we can make in our practices so that we can do better. This is evident in several recently published studies and a recent review article on the topic, which I’d like to profile for you; many of these key quality indicators you can implement now.
Even though it may take more time before they’re supported in the guidelines, you’ll see that the evidence behind these is extraordinarily strong.
Increasing the Adenoma Detection Rate
Certainly, we all do what we can to increase the adenoma detection rate (ADR).
However, at the moment, the nationally recommended benchmark is to achieve an ADR of 25%, which is inordinately low. The ADR rate reported in the GIQuIC registry data is closer to 39%, and in high-level detectors, it’s actually in the greater-than-50% range.
There’s no question that we can do more, and there are a number of ways to do that.
First, This may actually decrease your withdrawal time because you don’t spend so much time trying to face these folds.
In considering tools to aid ADR, don’t forget electronic chromoendoscopy (eg, narrow-band imaging).
There are a number of new artificial intelligence options out there as well, which have been reported to increase the ADR by approximately 10%. Of importance, this improvement even occurs among expert endoscopists.
There’s also important emerging data about ADR in fecal immunochemical test (FIT)–positive patients. FIT-positive status increases the ADR threshold by 15%-20%. This places you in an ADR range of approximately 50%, which is really the norm when screening patients that present for colonoscopy because of FIT positivity.
Adenoma Per Colonoscopy: A Possible ADR Substitute
Growing evidence supports the use of adenoma per colonoscopy (APC) as a substitute to ADR. This would allow you to record every adenoma and attribute it to that index colonoscopy.
A high-quality paper showed that the APC value should be around 0.6 to achieve the current ADR minimum threshold of 25%. Having the APC < 0.6 seems to be associated with an increased risk for residual polyp. Sessile serrated lesions also increased the hazard ratio for interval colorectal cancer. This was evaluated recently with data from the New Hampshire Colonoscopy Registry, which Dr Joseph Anderson has led for so long. They showed that 21% of endoscopists had an ADR of 25% or greater but still had APCs < 0.6.
Therefore, when it comes to remedial corrective work, doctors need to be reevaluated, retrained, and educated in the ways that they can incorporate this. The APC in high-level detectors is > 1.0.
APC may be something you want to consider using internally. It does require that you place each polyp into an individual jar, which can increase incremental cost. Nonetheless, there is clear evidence that APC positively changes outcomes.
Including Sessile Serrated Lesions in ADR Detectors
Unfortunately, some of the high-level ADR detectors aren’t so “high level” when it comes to detecting sessile serrated lesions. It’s not quite as concordant as we had previously thought.
Nonetheless, there are many adjunctive things you can do with sessile serrated lesions, including narrow-band imaging and chromoendoscopy.
When it comes to establishing a discriminant, the numbers should be 5%-6% if we’re going to set a quality ratio and an index. However, this is somewhat dependent on your pathologist because they have to read these correctly. Lesions that are ≥ 6 mm above the sigmoid colon and anything in the right colon should be evaluated really closely as a sessile serrated lesion.
I’ve had indications where the pathologist says the lesion is hyperplastic, to which I say, “I’m going to follow as a sessile serrated lesion.” This is because it’s apparent to me in the endoscopic appearance and the narrow-band imaging appearance that it was characteristic of sessile serrated lesions.
Best Practices in Bowel Preparations
The US Multi-Society Task Force recommends that adequate bowel preparation should occur in 85% or more of outpatients, and for the European Society for Gastrointestinal Endoscopy, it’s 90% or more.
I’ll pass along a tip I use in my patients undergoing bowel preparation: I make them aware that during this process, they want to see a clear, yellow, urine-like color to their stool. Otherwise, many patients will think if they’ve had some diarrhea, they don’t need to finish prep. Setting that expectation for them upfront is really important.
The nurses also should be aware of this because if there’s a murky brown effluent upon presentation for the colonoscopy, there’s a greater than 50% chance that they’re going to have had an inadequate preparation. In such cases, you would want to preempt the colonoscopy and perhaps send them out for a re-prep that day or bring them back for a rescheduled appointment.
Resection Considerations
There is substantial variation when it comes to lesion resection, which makes it an important quality indicator on which to focus: High-level detectors aren’t always high-level resectors.
There are two validated instruments that you can use to gauge the adequacy of resection. Those aren’t really ready for prime time in every practice, though they may be seen in fellowship programs.
The idea here is that you want to get a ≥ 2 mm margin for cold snare polypectomy in lesions 1-10 mm in size. This has been a challenge, as findings indicate we don’t do this that well.
Joseph Anderson and colleagues recently published a study using a 2-mm resection margin. They reported that this was only possible in approximately 28% of polyps. For a 1-mm margin, the rate was 84%.
We simply need to set clearer margins when setting our snare. Make sure you’re close enough to the polyp, push down on the snare, and get a good margin of tissue.
When the sample contracts are placed into the formalin, it’s not quite so simple to define the margin at the time of the surgical resection. This often requires an audit evaluation by the pathologist.
There are two other considerations regarding resection.
The first is about the referral for surgery. Referral should not occur for any benign lesions ascribed by your endoscopic advanced imaging techniques and classifications that are not thought to have intramucosal carcinoma. These should be referred to an expert endoscopic evaluation. If you can’t do it, then somebody else should. And you shouldn’t attempt it unless you can get it totally because resection of partially resected lesions is much more complicated. The European Society of Gastrointestinal Endoscopy says this applies to any benign lesion of any size, which I think really is the emerging standard of care. You should consider and offer that to the patient. It may require a referral for outside of your institution.
The second additional consideration is around the minimization of cold forceps for removal of polyps. The US Multi-Society Task Force says cold forceps shouldn’t be used for any lesions > 2 mm, whereas for the European Society of Gastrointestinal Endoscopy, it is > 3 mm. However, it’s still done very commonly in clinical practice. Nibbling the polyp is not an option. Cold snare is actually quicker, more effective, has better outcomes, and is something that you can bill for when you look at the coding.
In summary, there are a lot of things that we can do now to improve colonoscopy. Quality indicators continue to emerge with a compelling, excellent evidence base that strongly supports their use. Given that, I think most of these are actionable now, and it’s not necessary to wait for the guidelines to begin using them. I’d therefore challenge all of us to incorporate them in our continual efforts to do better.
Dr. Johnson is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease. He has disclosed ties with ISOTHRIVE and Johnson & Johnson.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
When it comes to the use of colonoscopy to reduce the risk for cancer, quality is key.
There are a number of performance improvements we can make in our practices so that we can do better. This is evident in several recently published studies and a recent review article on the topic, which I’d like to profile for you; many of these key quality indicators you can implement now.
Even though it may take more time before they’re supported in the guidelines, you’ll see that the evidence behind these is extraordinarily strong.
Increasing the Adenoma Detection Rate
Certainly, we all do what we can to increase the adenoma detection rate (ADR).
However, at the moment, the nationally recommended benchmark is to achieve an ADR of 25%, which is inordinately low. The ADR rate reported in the GIQuIC registry data is closer to 39%, and in high-level detectors, it’s actually in the greater-than-50% range.
There’s no question that we can do more, and there are a number of ways to do that.
First, This may actually decrease your withdrawal time because you don’t spend so much time trying to face these folds.
In considering tools to aid ADR, don’t forget electronic chromoendoscopy (eg, narrow-band imaging).
There are a number of new artificial intelligence options out there as well, which have been reported to increase the ADR by approximately 10%. Of importance, this improvement even occurs among expert endoscopists.
There’s also important emerging data about ADR in fecal immunochemical test (FIT)–positive patients. FIT-positive status increases the ADR threshold by 15%-20%. This places you in an ADR range of approximately 50%, which is really the norm when screening patients that present for colonoscopy because of FIT positivity.
Adenoma Per Colonoscopy: A Possible ADR Substitute
Growing evidence supports the use of adenoma per colonoscopy (APC) as a substitute to ADR. This would allow you to record every adenoma and attribute it to that index colonoscopy.
A high-quality paper showed that the APC value should be around 0.6 to achieve the current ADR minimum threshold of 25%. Having the APC < 0.6 seems to be associated with an increased risk for residual polyp. Sessile serrated lesions also increased the hazard ratio for interval colorectal cancer. This was evaluated recently with data from the New Hampshire Colonoscopy Registry, which Dr Joseph Anderson has led for so long. They showed that 21% of endoscopists had an ADR of 25% or greater but still had APCs < 0.6.
Therefore, when it comes to remedial corrective work, doctors need to be reevaluated, retrained, and educated in the ways that they can incorporate this. The APC in high-level detectors is > 1.0.
APC may be something you want to consider using internally. It does require that you place each polyp into an individual jar, which can increase incremental cost. Nonetheless, there is clear evidence that APC positively changes outcomes.
Including Sessile Serrated Lesions in ADR Detectors
Unfortunately, some of the high-level ADR detectors aren’t so “high level” when it comes to detecting sessile serrated lesions. It’s not quite as concordant as we had previously thought.
Nonetheless, there are many adjunctive things you can do with sessile serrated lesions, including narrow-band imaging and chromoendoscopy.
When it comes to establishing a discriminant, the numbers should be 5%-6% if we’re going to set a quality ratio and an index. However, this is somewhat dependent on your pathologist because they have to read these correctly. Lesions that are ≥ 6 mm above the sigmoid colon and anything in the right colon should be evaluated really closely as a sessile serrated lesion.
I’ve had indications where the pathologist says the lesion is hyperplastic, to which I say, “I’m going to follow as a sessile serrated lesion.” This is because it’s apparent to me in the endoscopic appearance and the narrow-band imaging appearance that it was characteristic of sessile serrated lesions.
Best Practices in Bowel Preparations
The US Multi-Society Task Force recommends that adequate bowel preparation should occur in 85% or more of outpatients, and for the European Society for Gastrointestinal Endoscopy, it’s 90% or more.
I’ll pass along a tip I use in my patients undergoing bowel preparation: I make them aware that during this process, they want to see a clear, yellow, urine-like color to their stool. Otherwise, many patients will think if they’ve had some diarrhea, they don’t need to finish prep. Setting that expectation for them upfront is really important.
The nurses also should be aware of this because if there’s a murky brown effluent upon presentation for the colonoscopy, there’s a greater than 50% chance that they’re going to have had an inadequate preparation. In such cases, you would want to preempt the colonoscopy and perhaps send them out for a re-prep that day or bring them back for a rescheduled appointment.
Resection Considerations
There is substantial variation when it comes to lesion resection, which makes it an important quality indicator on which to focus: High-level detectors aren’t always high-level resectors.
There are two validated instruments that you can use to gauge the adequacy of resection. Those aren’t really ready for prime time in every practice, though they may be seen in fellowship programs.
The idea here is that you want to get a ≥ 2 mm margin for cold snare polypectomy in lesions 1-10 mm in size. This has been a challenge, as findings indicate we don’t do this that well.
Joseph Anderson and colleagues recently published a study using a 2-mm resection margin. They reported that this was only possible in approximately 28% of polyps. For a 1-mm margin, the rate was 84%.
We simply need to set clearer margins when setting our snare. Make sure you’re close enough to the polyp, push down on the snare, and get a good margin of tissue.
When the sample contracts are placed into the formalin, it’s not quite so simple to define the margin at the time of the surgical resection. This often requires an audit evaluation by the pathologist.
There are two other considerations regarding resection.
The first is about the referral for surgery. Referral should not occur for any benign lesions ascribed by your endoscopic advanced imaging techniques and classifications that are not thought to have intramucosal carcinoma. These should be referred to an expert endoscopic evaluation. If you can’t do it, then somebody else should. And you shouldn’t attempt it unless you can get it totally because resection of partially resected lesions is much more complicated. The European Society of Gastrointestinal Endoscopy says this applies to any benign lesion of any size, which I think really is the emerging standard of care. You should consider and offer that to the patient. It may require a referral for outside of your institution.
The second additional consideration is around the minimization of cold forceps for removal of polyps. The US Multi-Society Task Force says cold forceps shouldn’t be used for any lesions > 2 mm, whereas for the European Society of Gastrointestinal Endoscopy, it is > 3 mm. However, it’s still done very commonly in clinical practice. Nibbling the polyp is not an option. Cold snare is actually quicker, more effective, has better outcomes, and is something that you can bill for when you look at the coding.
In summary, there are a lot of things that we can do now to improve colonoscopy. Quality indicators continue to emerge with a compelling, excellent evidence base that strongly supports their use. Given that, I think most of these are actionable now, and it’s not necessary to wait for the guidelines to begin using them. I’d therefore challenge all of us to incorporate them in our continual efforts to do better.
Dr. Johnson is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease. He has disclosed ties with ISOTHRIVE and Johnson & Johnson.
A version of this article appeared on Medscape.com.
Biosimilar Business Deals Keep Up ‘Musical Chairs’ Game of Formulary Construction
As the saying goes, “The more things change, the more they stay the same.” That is particularly true when it comes to the affordability of drugs for our patients even after the launch of so many Humira biosimilars. And we still have the “musical chairs” game of formulary construction — when the music stops, who knows whether your patient’s drug found a chair to sit on. There seems to be only a few chairs available for the many adalimumab biosimilars playing the game.
Nothing has changed since my testimony before the FDA Arthritis Advisory Committee in July 2016 during the approval hearing of the first Humira biosimilar. Below is a quote from that meeting where I was speaking predominantly about the pharmacy side of drugs.
“I’d like to highlight the term ‘access’ because none of us are really naive enough to believe that just approving a biosimilar gives a patient true, hands-on access to the medication, because even if the biosimilar is offered at a 30% discount, I don’t have any patients that can afford it. This means that access is ultimately controlled by third-party payers.”
My prediction, that approving and launching biosimilars with lower prices would not ensure patient access to the drug unless it is paid for by insurance, is now our reality. Today, a drug with an 85% discount on the price of Humira is still unattainable for patients without a “payer.”
Competition and Lower Prices
Lawmakers and some in the media cry for more competition to lower prices. This is the main reason that there has been such a push to get biosimilars to the market as quickly as possible. It is abundantly clear that competition to get on the formulary is fierce. Placement of a medication on a formulary can make or break a manufacturer’s ability to get a return on the R&D and make a profit on that medication. For a small biotech manufacturer, it can be the difference between “life and death” of the company.
Does anyone remember when the first interchangeable biosimilar for the reference insulin glargine product Lantus (insulin glargine-yfgn; Semglee) came to market in 2021? Janet Woodcock, MD, then acting FDA commissioner, called it a “momentous day” and further said, “Today’s approval of the first interchangeable biosimilar product furthers FDA’s longstanding commitment to support a competitive marketplace for biological products and ultimately empowers patients by helping to increase access to safe, effective and high-quality medications at potentially lower cost.” There was a high-priced interchangeable biosimilar and an identical unbranded low-priced interchangeable biosimilar, and the only one that could get formulary placement was the high-priced drug.
Patients pay their cost share on the list price of the drug, and because most pharmacy benefit managers’ (PBMs’) formularies cover only the high-priced biosimilar, patients never share in the savings. So much for the “competitive marketplace” creating lower costs for patients. This is just one of hundreds of examples in which lower-priced drugs are excluded from the formulary. It is unfortunate that the bidding process from manufacturers to PBMs to “win” preferred formulary placement is like an art auction, where the highest bidder wins.
Biosimilars and Formulary Construction
For those of us who have been looking into PBMs for many years, it is no surprise that PBMs’ formulary construction has become a profit center for them. Now, with so many adalimumab biosimilars having entered the market, it has become the Wild West where only those with the most money to fork over to the PBMs get preferred placement. Unfortunately, many of the choices that make money for the PBM cost employers and patients more.
How did we get here? In the 1980s and 90s, the price of medications began to increase to the point that many were not affordable without insurance. And who better to construct the list of drugs that would be covered by insurance (formulary) than the PBMs who were already adjudicating the claims for these drugs. The Federal Trade Commission (FTC) realized the power inherent in constructing this list of medications known as the formulary. So when the manufacturer Merck acquired the PBM Medco in the mid-1990s, the FTC stepped in. The FTC surmised that making the drugs and deciding which ones will be paid for created a “conflict of interest” with anticompetitive ramifications.
So, in 1998, William J. Baer, director of the FTC’s Bureau of Competition, said, “Our investigation into the PBM industry has revealed that Merck’s acquisition of Medco has reduced competition in the market for pharmaceutical products … We have found that Medco has given favorable treatment to Merck drugs. As a result, in some cases, consumers have been denied access to the drugs of competing manufacturers. In addition, the merger has made it possible for Medco to share with Merck sensitive pricing information it gets from Merck’s competitors, which could foster collusion among drug manufacturers.” Wow!
These anticompetitive behaviors and conflicts of interest resulting from the Medco acquisition led the FTC to propose a consent agreement.
The agreement would require Merck-Medco to maintain an “open formulary” — one that includes drugs selected and approved by an independent Pharmacy and Therapeutics Committee regardless of the manufacturer. Medco would have to accept rebates and other price concessions and reflect these in the ranking of the drugs on the formulary. Merck would have to make known the availability of the open formulary to any drug maker with an agreement with Medco.
Let’s hope the FTC of 2024 remembers the stance of the FTC in the 1990s regarding anticompetitive behavior involved in formulary construction.
Conflicts of Interest
But today it is apparent that crafting formularies that pay only for the drugs that make the most money for the PBM is not a conflict of interest. In its policy manual, Cigna directly tells employers and employees that they are collecting and keeping rebates and fees on medical pharmaceuticals, and they are not for the benefit of the employer or the plan.
And now, in August 2023, CVS launched Cordavis, a subsidiary wholly owned by CVS. Cordavis/CVS has partnered with Sandoz, which makes Hyrimoz, an adalimumab biosimilar. There is a high-priced version that is discounted 5% from Humira, a lower-cost unbranded version that is discounted 80% off the list price of Humira, and a co-branded CVS/Sandoz version of Hyrimoz that is lower priced as well.
It isn’t a surprise that CVS’ Standard and Advanced Commercial and Chart formularies are offering only Sandoz adalimumab biosimilar products. While these formularies have excluded Humira, CVS has entered into an agreement with AbbVie to allow Humira on a number of their other formularies. It can be very confusing.
As stated earlier, in the 1990s, the FTC frowned upon manufacturers owning PBMs and allowing them to construct their own formularies. Here we have CVS Health, mothership for the PBM CVS Caremark, owning a company that will be co-producing biosimilars with other manufacturers and then determining which biosimilars are on their formularies. The FTC knew back then that the tendency would be to offer only their own drugs for coverage, thus reducing competition. This is exactly what the CVS-Cordavis-Sandoz partnership has done for their Standard and Advanced Commercial and Chart formularies. It is perhaps anti-competitive but certainly profitable.
Perhaps the FTC should require the same consent agreement that was given to Merck in 1998. CVS Caremark would then have to open their formularies to all competitors of their co-branded, co-produced Sandoz biosimilar.
Summary
It is the same old adage, “The more things change, the more they stay the same.” PBMs are still constructing formularies with biosimilars based on their profitability, with huge differences between gross and net cost. Patients still pay their cost share on the list (gross) price. With the CVS-Cordavis-Sandoz partnership, more vertical integration has led to yet another profit river. Self-funded employers are still getting the wool pulled over their eyes by the big three PBMs who threaten to take away rebates if they don’t choose the preferred formularies. The employers don’t realize that sometimes it is less expensive to choose the lower-priced drugs with no rebates, and that holds true for biosimilars as well.
Let’s hope that the FTC investigates the situation of a PBM partnering with a manufacturer and then choosing only that manufacturer’s drugs for many of their formularies.
We need to continue our advocacy for our patients because the medication that has kept them stable for so long may find itself without a chair the next time the music stops.
Dr. Feldman is a rheumatologist in private practice with The Rheumatology Group in New Orleans. She is the CSRO’s Vice President of Advocacy and Government Affairs and its immediate Past President, as well as past chair of the Alliance for Safe Biologic Medicines and a past member of the American College of Rheumatology insurance subcommittee. You can reach her at [email protected].
As the saying goes, “The more things change, the more they stay the same.” That is particularly true when it comes to the affordability of drugs for our patients even after the launch of so many Humira biosimilars. And we still have the “musical chairs” game of formulary construction — when the music stops, who knows whether your patient’s drug found a chair to sit on. There seems to be only a few chairs available for the many adalimumab biosimilars playing the game.
Nothing has changed since my testimony before the FDA Arthritis Advisory Committee in July 2016 during the approval hearing of the first Humira biosimilar. Below is a quote from that meeting where I was speaking predominantly about the pharmacy side of drugs.
“I’d like to highlight the term ‘access’ because none of us are really naive enough to believe that just approving a biosimilar gives a patient true, hands-on access to the medication, because even if the biosimilar is offered at a 30% discount, I don’t have any patients that can afford it. This means that access is ultimately controlled by third-party payers.”
My prediction, that approving and launching biosimilars with lower prices would not ensure patient access to the drug unless it is paid for by insurance, is now our reality. Today, a drug with an 85% discount on the price of Humira is still unattainable for patients without a “payer.”
Competition and Lower Prices
Lawmakers and some in the media cry for more competition to lower prices. This is the main reason that there has been such a push to get biosimilars to the market as quickly as possible. It is abundantly clear that competition to get on the formulary is fierce. Placement of a medication on a formulary can make or break a manufacturer’s ability to get a return on the R&D and make a profit on that medication. For a small biotech manufacturer, it can be the difference between “life and death” of the company.
Does anyone remember when the first interchangeable biosimilar for the reference insulin glargine product Lantus (insulin glargine-yfgn; Semglee) came to market in 2021? Janet Woodcock, MD, then acting FDA commissioner, called it a “momentous day” and further said, “Today’s approval of the first interchangeable biosimilar product furthers FDA’s longstanding commitment to support a competitive marketplace for biological products and ultimately empowers patients by helping to increase access to safe, effective and high-quality medications at potentially lower cost.” There was a high-priced interchangeable biosimilar and an identical unbranded low-priced interchangeable biosimilar, and the only one that could get formulary placement was the high-priced drug.
Patients pay their cost share on the list price of the drug, and because most pharmacy benefit managers’ (PBMs’) formularies cover only the high-priced biosimilar, patients never share in the savings. So much for the “competitive marketplace” creating lower costs for patients. This is just one of hundreds of examples in which lower-priced drugs are excluded from the formulary. It is unfortunate that the bidding process from manufacturers to PBMs to “win” preferred formulary placement is like an art auction, where the highest bidder wins.
Biosimilars and Formulary Construction
For those of us who have been looking into PBMs for many years, it is no surprise that PBMs’ formulary construction has become a profit center for them. Now, with so many adalimumab biosimilars having entered the market, it has become the Wild West where only those with the most money to fork over to the PBMs get preferred placement. Unfortunately, many of the choices that make money for the PBM cost employers and patients more.
How did we get here? In the 1980s and 90s, the price of medications began to increase to the point that many were not affordable without insurance. And who better to construct the list of drugs that would be covered by insurance (formulary) than the PBMs who were already adjudicating the claims for these drugs. The Federal Trade Commission (FTC) realized the power inherent in constructing this list of medications known as the formulary. So when the manufacturer Merck acquired the PBM Medco in the mid-1990s, the FTC stepped in. The FTC surmised that making the drugs and deciding which ones will be paid for created a “conflict of interest” with anticompetitive ramifications.
So, in 1998, William J. Baer, director of the FTC’s Bureau of Competition, said, “Our investigation into the PBM industry has revealed that Merck’s acquisition of Medco has reduced competition in the market for pharmaceutical products … We have found that Medco has given favorable treatment to Merck drugs. As a result, in some cases, consumers have been denied access to the drugs of competing manufacturers. In addition, the merger has made it possible for Medco to share with Merck sensitive pricing information it gets from Merck’s competitors, which could foster collusion among drug manufacturers.” Wow!
These anticompetitive behaviors and conflicts of interest resulting from the Medco acquisition led the FTC to propose a consent agreement.
The agreement would require Merck-Medco to maintain an “open formulary” — one that includes drugs selected and approved by an independent Pharmacy and Therapeutics Committee regardless of the manufacturer. Medco would have to accept rebates and other price concessions and reflect these in the ranking of the drugs on the formulary. Merck would have to make known the availability of the open formulary to any drug maker with an agreement with Medco.
Let’s hope the FTC of 2024 remembers the stance of the FTC in the 1990s regarding anticompetitive behavior involved in formulary construction.
Conflicts of Interest
But today it is apparent that crafting formularies that pay only for the drugs that make the most money for the PBM is not a conflict of interest. In its policy manual, Cigna directly tells employers and employees that they are collecting and keeping rebates and fees on medical pharmaceuticals, and they are not for the benefit of the employer or the plan.
And now, in August 2023, CVS launched Cordavis, a subsidiary wholly owned by CVS. Cordavis/CVS has partnered with Sandoz, which makes Hyrimoz, an adalimumab biosimilar. There is a high-priced version that is discounted 5% from Humira, a lower-cost unbranded version that is discounted 80% off the list price of Humira, and a co-branded CVS/Sandoz version of Hyrimoz that is lower priced as well.
It isn’t a surprise that CVS’ Standard and Advanced Commercial and Chart formularies are offering only Sandoz adalimumab biosimilar products. While these formularies have excluded Humira, CVS has entered into an agreement with AbbVie to allow Humira on a number of their other formularies. It can be very confusing.
As stated earlier, in the 1990s, the FTC frowned upon manufacturers owning PBMs and allowing them to construct their own formularies. Here we have CVS Health, mothership for the PBM CVS Caremark, owning a company that will be co-producing biosimilars with other manufacturers and then determining which biosimilars are on their formularies. The FTC knew back then that the tendency would be to offer only their own drugs for coverage, thus reducing competition. This is exactly what the CVS-Cordavis-Sandoz partnership has done for their Standard and Advanced Commercial and Chart formularies. It is perhaps anti-competitive but certainly profitable.
Perhaps the FTC should require the same consent agreement that was given to Merck in 1998. CVS Caremark would then have to open their formularies to all competitors of their co-branded, co-produced Sandoz biosimilar.
Summary
It is the same old adage, “The more things change, the more they stay the same.” PBMs are still constructing formularies with biosimilars based on their profitability, with huge differences between gross and net cost. Patients still pay their cost share on the list (gross) price. With the CVS-Cordavis-Sandoz partnership, more vertical integration has led to yet another profit river. Self-funded employers are still getting the wool pulled over their eyes by the big three PBMs who threaten to take away rebates if they don’t choose the preferred formularies. The employers don’t realize that sometimes it is less expensive to choose the lower-priced drugs with no rebates, and that holds true for biosimilars as well.
Let’s hope that the FTC investigates the situation of a PBM partnering with a manufacturer and then choosing only that manufacturer’s drugs for many of their formularies.
We need to continue our advocacy for our patients because the medication that has kept them stable for so long may find itself without a chair the next time the music stops.
Dr. Feldman is a rheumatologist in private practice with The Rheumatology Group in New Orleans. She is the CSRO’s Vice President of Advocacy and Government Affairs and its immediate Past President, as well as past chair of the Alliance for Safe Biologic Medicines and a past member of the American College of Rheumatology insurance subcommittee. You can reach her at [email protected].
As the saying goes, “The more things change, the more they stay the same.” That is particularly true when it comes to the affordability of drugs for our patients even after the launch of so many Humira biosimilars. And we still have the “musical chairs” game of formulary construction — when the music stops, who knows whether your patient’s drug found a chair to sit on. There seems to be only a few chairs available for the many adalimumab biosimilars playing the game.
Nothing has changed since my testimony before the FDA Arthritis Advisory Committee in July 2016 during the approval hearing of the first Humira biosimilar. Below is a quote from that meeting where I was speaking predominantly about the pharmacy side of drugs.
“I’d like to highlight the term ‘access’ because none of us are really naive enough to believe that just approving a biosimilar gives a patient true, hands-on access to the medication, because even if the biosimilar is offered at a 30% discount, I don’t have any patients that can afford it. This means that access is ultimately controlled by third-party payers.”
My prediction, that approving and launching biosimilars with lower prices would not ensure patient access to the drug unless it is paid for by insurance, is now our reality. Today, a drug with an 85% discount on the price of Humira is still unattainable for patients without a “payer.”
Competition and Lower Prices
Lawmakers and some in the media cry for more competition to lower prices. This is the main reason that there has been such a push to get biosimilars to the market as quickly as possible. It is abundantly clear that competition to get on the formulary is fierce. Placement of a medication on a formulary can make or break a manufacturer’s ability to get a return on the R&D and make a profit on that medication. For a small biotech manufacturer, it can be the difference between “life and death” of the company.
Does anyone remember when the first interchangeable biosimilar for the reference insulin glargine product Lantus (insulin glargine-yfgn; Semglee) came to market in 2021? Janet Woodcock, MD, then acting FDA commissioner, called it a “momentous day” and further said, “Today’s approval of the first interchangeable biosimilar product furthers FDA’s longstanding commitment to support a competitive marketplace for biological products and ultimately empowers patients by helping to increase access to safe, effective and high-quality medications at potentially lower cost.” There was a high-priced interchangeable biosimilar and an identical unbranded low-priced interchangeable biosimilar, and the only one that could get formulary placement was the high-priced drug.
Patients pay their cost share on the list price of the drug, and because most pharmacy benefit managers’ (PBMs’) formularies cover only the high-priced biosimilar, patients never share in the savings. So much for the “competitive marketplace” creating lower costs for patients. This is just one of hundreds of examples in which lower-priced drugs are excluded from the formulary. It is unfortunate that the bidding process from manufacturers to PBMs to “win” preferred formulary placement is like an art auction, where the highest bidder wins.
Biosimilars and Formulary Construction
For those of us who have been looking into PBMs for many years, it is no surprise that PBMs’ formulary construction has become a profit center for them. Now, with so many adalimumab biosimilars having entered the market, it has become the Wild West where only those with the most money to fork over to the PBMs get preferred placement. Unfortunately, many of the choices that make money for the PBM cost employers and patients more.
How did we get here? In the 1980s and 90s, the price of medications began to increase to the point that many were not affordable without insurance. And who better to construct the list of drugs that would be covered by insurance (formulary) than the PBMs who were already adjudicating the claims for these drugs. The Federal Trade Commission (FTC) realized the power inherent in constructing this list of medications known as the formulary. So when the manufacturer Merck acquired the PBM Medco in the mid-1990s, the FTC stepped in. The FTC surmised that making the drugs and deciding which ones will be paid for created a “conflict of interest” with anticompetitive ramifications.
So, in 1998, William J. Baer, director of the FTC’s Bureau of Competition, said, “Our investigation into the PBM industry has revealed that Merck’s acquisition of Medco has reduced competition in the market for pharmaceutical products … We have found that Medco has given favorable treatment to Merck drugs. As a result, in some cases, consumers have been denied access to the drugs of competing manufacturers. In addition, the merger has made it possible for Medco to share with Merck sensitive pricing information it gets from Merck’s competitors, which could foster collusion among drug manufacturers.” Wow!
These anticompetitive behaviors and conflicts of interest resulting from the Medco acquisition led the FTC to propose a consent agreement.
The agreement would require Merck-Medco to maintain an “open formulary” — one that includes drugs selected and approved by an independent Pharmacy and Therapeutics Committee regardless of the manufacturer. Medco would have to accept rebates and other price concessions and reflect these in the ranking of the drugs on the formulary. Merck would have to make known the availability of the open formulary to any drug maker with an agreement with Medco.
Let’s hope the FTC of 2024 remembers the stance of the FTC in the 1990s regarding anticompetitive behavior involved in formulary construction.
Conflicts of Interest
But today it is apparent that crafting formularies that pay only for the drugs that make the most money for the PBM is not a conflict of interest. In its policy manual, Cigna directly tells employers and employees that they are collecting and keeping rebates and fees on medical pharmaceuticals, and they are not for the benefit of the employer or the plan.
And now, in August 2023, CVS launched Cordavis, a subsidiary wholly owned by CVS. Cordavis/CVS has partnered with Sandoz, which makes Hyrimoz, an adalimumab biosimilar. There is a high-priced version that is discounted 5% from Humira, a lower-cost unbranded version that is discounted 80% off the list price of Humira, and a co-branded CVS/Sandoz version of Hyrimoz that is lower priced as well.
It isn’t a surprise that CVS’ Standard and Advanced Commercial and Chart formularies are offering only Sandoz adalimumab biosimilar products. While these formularies have excluded Humira, CVS has entered into an agreement with AbbVie to allow Humira on a number of their other formularies. It can be very confusing.
As stated earlier, in the 1990s, the FTC frowned upon manufacturers owning PBMs and allowing them to construct their own formularies. Here we have CVS Health, mothership for the PBM CVS Caremark, owning a company that will be co-producing biosimilars with other manufacturers and then determining which biosimilars are on their formularies. The FTC knew back then that the tendency would be to offer only their own drugs for coverage, thus reducing competition. This is exactly what the CVS-Cordavis-Sandoz partnership has done for their Standard and Advanced Commercial and Chart formularies. It is perhaps anti-competitive but certainly profitable.
Perhaps the FTC should require the same consent agreement that was given to Merck in 1998. CVS Caremark would then have to open their formularies to all competitors of their co-branded, co-produced Sandoz biosimilar.
Summary
It is the same old adage, “The more things change, the more they stay the same.” PBMs are still constructing formularies with biosimilars based on their profitability, with huge differences between gross and net cost. Patients still pay their cost share on the list (gross) price. With the CVS-Cordavis-Sandoz partnership, more vertical integration has led to yet another profit river. Self-funded employers are still getting the wool pulled over their eyes by the big three PBMs who threaten to take away rebates if they don’t choose the preferred formularies. The employers don’t realize that sometimes it is less expensive to choose the lower-priced drugs with no rebates, and that holds true for biosimilars as well.
Let’s hope that the FTC investigates the situation of a PBM partnering with a manufacturer and then choosing only that manufacturer’s drugs for many of their formularies.
We need to continue our advocacy for our patients because the medication that has kept them stable for so long may find itself without a chair the next time the music stops.
Dr. Feldman is a rheumatologist in private practice with The Rheumatology Group in New Orleans. She is the CSRO’s Vice President of Advocacy and Government Affairs and its immediate Past President, as well as past chair of the Alliance for Safe Biologic Medicines and a past member of the American College of Rheumatology insurance subcommittee. You can reach her at [email protected].
Coffee, COVID, and the Universal Antimicrobial
A recent article in Cell & Bioscience suggested that regular coffee consumption can reduce the risk of COVID infections.
The study does make some interesting points about the benefits of coffee’s different polyphenols and antioxidants and their effects on different COVID variants. Most of it is based on lab data, although one section, using serum from coffee versus water drinkers, did find that it was more effective at inhibiting the virions. Caffeinated versus decaffeinated didn’t matter.
I’m not saying coffee doesn’t impair the virus. The data are worth looking at. But the majority of adults in North America, Europe, and pretty much the entire planet drink coffee on a regular basis. A large number of them still caught COVID. Would they have had worse cases if they didn’t drink coffee? Maybe, maybe not.
The problem here is that, as always, preliminary data like this get pushed into mass media, making it sound like “COFFEE CURES COVID!!!” Never mind that that’s not what the article said, but it sure gets clicks and retweets and FaceBook “likes.”
Suddenly fringe groups are claiming the coffee cure was there all along, and hidden from them by the evil government-pharma-medical cartel. Others claim the research is flawed because of this or that. The signal gets drowned out by the noise.
Definitely, food can be a medicine. Look at all the benefits proven of the Mediterranean diet. Coffee may help, especially if we can identify and isolate the specific components that reduce COVID risk. But, as they always say at the end, the study is preliminary and further research is needed.
Once or twice a year, an adult with epilepsy comes in, waving a copy of the ketogenic diet around and upset that I never tried it on them — again proof of the evil government-pharma-medical cartel that I’m in league with. I calm them down and explain the diet in detail. Maybe 50% of them decide to go ahead with it. In 25 years of practice, my record for an otherwise normal adult sticking with it is 5 days.
You don’t have to go too far back to remember Linus Pauling, an absolutely brilliant scientist, but not the best of nutritionists. With two Nobel prizes behind him, he took a stab at medicine in the 1970s, arguing that megadoses of vitamin C worked for the common cold. While it may be good for us, and certainly most people like orange juice, but those claims about the common cold never panned out. In fact, we’re no closer to curing it now than we were then.
It might, but this doesn’t mean the “truth” is being maliciously hidden by an evil cartel. It just means we have (as always) more to learn.
I’ll still drink my single cup of coffee every weekday morning. I’m a creature of habit, and heaven knows I need the caffeine. If it also boosts my immune system, so much the better.
Besides, we still have that universal antimicrobial called chicken soup.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
A recent article in Cell & Bioscience suggested that regular coffee consumption can reduce the risk of COVID infections.
The study does make some interesting points about the benefits of coffee’s different polyphenols and antioxidants and their effects on different COVID variants. Most of it is based on lab data, although one section, using serum from coffee versus water drinkers, did find that it was more effective at inhibiting the virions. Caffeinated versus decaffeinated didn’t matter.
I’m not saying coffee doesn’t impair the virus. The data are worth looking at. But the majority of adults in North America, Europe, and pretty much the entire planet drink coffee on a regular basis. A large number of them still caught COVID. Would they have had worse cases if they didn’t drink coffee? Maybe, maybe not.
The problem here is that, as always, preliminary data like this get pushed into mass media, making it sound like “COFFEE CURES COVID!!!” Never mind that that’s not what the article said, but it sure gets clicks and retweets and FaceBook “likes.”
Suddenly fringe groups are claiming the coffee cure was there all along, and hidden from them by the evil government-pharma-medical cartel. Others claim the research is flawed because of this or that. The signal gets drowned out by the noise.
Definitely, food can be a medicine. Look at all the benefits proven of the Mediterranean diet. Coffee may help, especially if we can identify and isolate the specific components that reduce COVID risk. But, as they always say at the end, the study is preliminary and further research is needed.
Once or twice a year, an adult with epilepsy comes in, waving a copy of the ketogenic diet around and upset that I never tried it on them — again proof of the evil government-pharma-medical cartel that I’m in league with. I calm them down and explain the diet in detail. Maybe 50% of them decide to go ahead with it. In 25 years of practice, my record for an otherwise normal adult sticking with it is 5 days.
You don’t have to go too far back to remember Linus Pauling, an absolutely brilliant scientist, but not the best of nutritionists. With two Nobel prizes behind him, he took a stab at medicine in the 1970s, arguing that megadoses of vitamin C worked for the common cold. While it may be good for us, and certainly most people like orange juice, but those claims about the common cold never panned out. In fact, we’re no closer to curing it now than we were then.
It might, but this doesn’t mean the “truth” is being maliciously hidden by an evil cartel. It just means we have (as always) more to learn.
I’ll still drink my single cup of coffee every weekday morning. I’m a creature of habit, and heaven knows I need the caffeine. If it also boosts my immune system, so much the better.
Besides, we still have that universal antimicrobial called chicken soup.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
A recent article in Cell & Bioscience suggested that regular coffee consumption can reduce the risk of COVID infections.
The study does make some interesting points about the benefits of coffee’s different polyphenols and antioxidants and their effects on different COVID variants. Most of it is based on lab data, although one section, using serum from coffee versus water drinkers, did find that it was more effective at inhibiting the virions. Caffeinated versus decaffeinated didn’t matter.
I’m not saying coffee doesn’t impair the virus. The data are worth looking at. But the majority of adults in North America, Europe, and pretty much the entire planet drink coffee on a regular basis. A large number of them still caught COVID. Would they have had worse cases if they didn’t drink coffee? Maybe, maybe not.
The problem here is that, as always, preliminary data like this get pushed into mass media, making it sound like “COFFEE CURES COVID!!!” Never mind that that’s not what the article said, but it sure gets clicks and retweets and FaceBook “likes.”
Suddenly fringe groups are claiming the coffee cure was there all along, and hidden from them by the evil government-pharma-medical cartel. Others claim the research is flawed because of this or that. The signal gets drowned out by the noise.
Definitely, food can be a medicine. Look at all the benefits proven of the Mediterranean diet. Coffee may help, especially if we can identify and isolate the specific components that reduce COVID risk. But, as they always say at the end, the study is preliminary and further research is needed.
Once or twice a year, an adult with epilepsy comes in, waving a copy of the ketogenic diet around and upset that I never tried it on them — again proof of the evil government-pharma-medical cartel that I’m in league with. I calm them down and explain the diet in detail. Maybe 50% of them decide to go ahead with it. In 25 years of practice, my record for an otherwise normal adult sticking with it is 5 days.
You don’t have to go too far back to remember Linus Pauling, an absolutely brilliant scientist, but not the best of nutritionists. With two Nobel prizes behind him, he took a stab at medicine in the 1970s, arguing that megadoses of vitamin C worked for the common cold. While it may be good for us, and certainly most people like orange juice, but those claims about the common cold never panned out. In fact, we’re no closer to curing it now than we were then.
It might, but this doesn’t mean the “truth” is being maliciously hidden by an evil cartel. It just means we have (as always) more to learn.
I’ll still drink my single cup of coffee every weekday morning. I’m a creature of habit, and heaven knows I need the caffeine. If it also boosts my immune system, so much the better.
Besides, we still have that universal antimicrobial called chicken soup.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.