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Emergency nurse Stephanee Beggs, RN, BSN, has made more than $2 million in three years selling her handwritten guides to study for the National Council Licensure Examination (NCLEX).

Ms. Beggs, 28, sells one-page study sheets or bundles of sheets, sometimes with colorful drawings, conversation bubbles and underlining, that boil down concepts for particular conditions into easy-to-understand language.

The biggest seller on Ms. Beggs’ online marketplace Etsy site, RNExplained, is a bundle of study guides covering eight core nursing classes. The notes range in price from $2 to $150. More than 70,000 customers have bought the $60 bundle, according to the website.

Ms. Beggs’ business developed in a “very unintentional” way when COVID hit with just months left in her nursing program at Mount Saint Mary’s University, Los Angeles, she told this news organization.

Classes had switched to Zoom, and she had no one to study with as she prepared to take her board exams.

“The best way I know how to study is to teach things out loud. But because I had nobody to teach out loud to, I would literally teach them to the wall,” Ms. Beggs said. “I would record myself so I could play it back and teach myself these topics that were hard for me to understand.”

Just for fun, she says, she posted them on TikTok and the responses started flowing in, with followers asking where she was selling the sheets. She now has more than 660,000 TikTok followers and 9 million likes.

Ms. Beggs said that every sheet highlights a condition, and she has made 308 of them.

Traditional classroom lessons typically teach one medical condition in 5-6 pages, Ms. Beggs said. “I go straight to the point.”

One reviewer on Ms. Beggs’ Etsy site appreciated the handwritten notes, calling them “simplified and concise.” Another commented: “Definitely helped me pass my last exam.”

Ms. Beggs says that her notes may seem simple, but each page represents comprehensive research.

“I have to go through not just one source of information to make sure my information is factual,” Ms. Beggs says. “What you teach in California might be a little different than what you teach in Florida. It’s very meticulous. The lab values will be a little different everywhere you go.”

She acknowledges her competition, noting that there are many other study guides for the NCLEX and nursing courses.
 

Nursing groups weigh in

Dawn Kappel, spokesperson for the National Council of State Boards of Nursing, which oversees NCLEX, said in an interview that “NCSBN has no issue with the current content of Stephanee Beggs’ business venture.”

For many students, the study guides will be helpful, especially for visual learners, said Carole Kenner, PhD, RN, dean and professor in the School of Nursing and Health Sciences at The College of New Jersey.

But for students “who are less confident in their knowledge, I would want to see a lot more in-depth explanation and rationale,” Dr. Kenner said.

“Since the NCLEX is moving to more cased-based scenarios, the next-gen unfolding cases, you really have to understand a lot of the rationale.”

The notes remind Dr. Kenner of traditional flash cards. “I don’t think it will work for all students, but even the fanciest of onsite review courses are useful to everyone,” she said.
 

‘Not cutting corners’

As an emergency nurse, Ms. Beggs said, “I have the experience as a nurse to show people that what you are learning will be seen in real life.”

“The way I teach my brand is not to take shortcuts. I love to teach to understand rather than teaching to memorize for an exam.”

She said she sees her guides as a supplement to learning, not a replacement.

“It’s not cutting corners,” she says. “I condense a medical condition that could take a very long time to understand and break it into layman’s terms.”

Ms. Beggs said when people hear about the $2 million, they often ask her whether she plans to give up her shifts in the emergency department for the more lucrative venture.

The answer is no, at least not yet.

“Aside from teaching, I genuinely love being at the bedside,” Ms. Beggs said. “I don’t foresee myself leaving that for good for as long as I can handle both.” She acknowledged, though, that her business now takes up most of her time.  

“I love everything about both aspects, so it’s hard for me to choose.”

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

Emergency nurse Stephanee Beggs, RN, BSN, has made more than $2 million in three years selling her handwritten guides to study for the National Council Licensure Examination (NCLEX).

Ms. Beggs, 28, sells one-page study sheets or bundles of sheets, sometimes with colorful drawings, conversation bubbles and underlining, that boil down concepts for particular conditions into easy-to-understand language.

The biggest seller on Ms. Beggs’ online marketplace Etsy site, RNExplained, is a bundle of study guides covering eight core nursing classes. The notes range in price from $2 to $150. More than 70,000 customers have bought the $60 bundle, according to the website.

Ms. Beggs’ business developed in a “very unintentional” way when COVID hit with just months left in her nursing program at Mount Saint Mary’s University, Los Angeles, she told this news organization.

Classes had switched to Zoom, and she had no one to study with as she prepared to take her board exams.

“The best way I know how to study is to teach things out loud. But because I had nobody to teach out loud to, I would literally teach them to the wall,” Ms. Beggs said. “I would record myself so I could play it back and teach myself these topics that were hard for me to understand.”

Just for fun, she says, she posted them on TikTok and the responses started flowing in, with followers asking where she was selling the sheets. She now has more than 660,000 TikTok followers and 9 million likes.

Ms. Beggs said that every sheet highlights a condition, and she has made 308 of them.

Traditional classroom lessons typically teach one medical condition in 5-6 pages, Ms. Beggs said. “I go straight to the point.”

One reviewer on Ms. Beggs’ Etsy site appreciated the handwritten notes, calling them “simplified and concise.” Another commented: “Definitely helped me pass my last exam.”

Ms. Beggs says that her notes may seem simple, but each page represents comprehensive research.

“I have to go through not just one source of information to make sure my information is factual,” Ms. Beggs says. “What you teach in California might be a little different than what you teach in Florida. It’s very meticulous. The lab values will be a little different everywhere you go.”

She acknowledges her competition, noting that there are many other study guides for the NCLEX and nursing courses.
 

Nursing groups weigh in

Dawn Kappel, spokesperson for the National Council of State Boards of Nursing, which oversees NCLEX, said in an interview that “NCSBN has no issue with the current content of Stephanee Beggs’ business venture.”

For many students, the study guides will be helpful, especially for visual learners, said Carole Kenner, PhD, RN, dean and professor in the School of Nursing and Health Sciences at The College of New Jersey.

But for students “who are less confident in their knowledge, I would want to see a lot more in-depth explanation and rationale,” Dr. Kenner said.

“Since the NCLEX is moving to more cased-based scenarios, the next-gen unfolding cases, you really have to understand a lot of the rationale.”

The notes remind Dr. Kenner of traditional flash cards. “I don’t think it will work for all students, but even the fanciest of onsite review courses are useful to everyone,” she said.
 

‘Not cutting corners’

As an emergency nurse, Ms. Beggs said, “I have the experience as a nurse to show people that what you are learning will be seen in real life.”

“The way I teach my brand is not to take shortcuts. I love to teach to understand rather than teaching to memorize for an exam.”

She said she sees her guides as a supplement to learning, not a replacement.

“It’s not cutting corners,” she says. “I condense a medical condition that could take a very long time to understand and break it into layman’s terms.”

Ms. Beggs said when people hear about the $2 million, they often ask her whether she plans to give up her shifts in the emergency department for the more lucrative venture.

The answer is no, at least not yet.

“Aside from teaching, I genuinely love being at the bedside,” Ms. Beggs said. “I don’t foresee myself leaving that for good for as long as I can handle both.” She acknowledged, though, that her business now takes up most of her time.  

“I love everything about both aspects, so it’s hard for me to choose.”

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

Emergency nurse Stephanee Beggs, RN, BSN, has made more than $2 million in three years selling her handwritten guides to study for the National Council Licensure Examination (NCLEX).

Ms. Beggs, 28, sells one-page study sheets or bundles of sheets, sometimes with colorful drawings, conversation bubbles and underlining, that boil down concepts for particular conditions into easy-to-understand language.

The biggest seller on Ms. Beggs’ online marketplace Etsy site, RNExplained, is a bundle of study guides covering eight core nursing classes. The notes range in price from $2 to $150. More than 70,000 customers have bought the $60 bundle, according to the website.

Ms. Beggs’ business developed in a “very unintentional” way when COVID hit with just months left in her nursing program at Mount Saint Mary’s University, Los Angeles, she told this news organization.

Classes had switched to Zoom, and she had no one to study with as she prepared to take her board exams.

“The best way I know how to study is to teach things out loud. But because I had nobody to teach out loud to, I would literally teach them to the wall,” Ms. Beggs said. “I would record myself so I could play it back and teach myself these topics that were hard for me to understand.”

Just for fun, she says, she posted them on TikTok and the responses started flowing in, with followers asking where she was selling the sheets. She now has more than 660,000 TikTok followers and 9 million likes.

Ms. Beggs said that every sheet highlights a condition, and she has made 308 of them.

Traditional classroom lessons typically teach one medical condition in 5-6 pages, Ms. Beggs said. “I go straight to the point.”

One reviewer on Ms. Beggs’ Etsy site appreciated the handwritten notes, calling them “simplified and concise.” Another commented: “Definitely helped me pass my last exam.”

Ms. Beggs says that her notes may seem simple, but each page represents comprehensive research.

“I have to go through not just one source of information to make sure my information is factual,” Ms. Beggs says. “What you teach in California might be a little different than what you teach in Florida. It’s very meticulous. The lab values will be a little different everywhere you go.”

She acknowledges her competition, noting that there are many other study guides for the NCLEX and nursing courses.
 

Nursing groups weigh in

Dawn Kappel, spokesperson for the National Council of State Boards of Nursing, which oversees NCLEX, said in an interview that “NCSBN has no issue with the current content of Stephanee Beggs’ business venture.”

For many students, the study guides will be helpful, especially for visual learners, said Carole Kenner, PhD, RN, dean and professor in the School of Nursing and Health Sciences at The College of New Jersey.

But for students “who are less confident in their knowledge, I would want to see a lot more in-depth explanation and rationale,” Dr. Kenner said.

“Since the NCLEX is moving to more cased-based scenarios, the next-gen unfolding cases, you really have to understand a lot of the rationale.”

The notes remind Dr. Kenner of traditional flash cards. “I don’t think it will work for all students, but even the fanciest of onsite review courses are useful to everyone,” she said.
 

‘Not cutting corners’

As an emergency nurse, Ms. Beggs said, “I have the experience as a nurse to show people that what you are learning will be seen in real life.”

“The way I teach my brand is not to take shortcuts. I love to teach to understand rather than teaching to memorize for an exam.”

She said she sees her guides as a supplement to learning, not a replacement.

“It’s not cutting corners,” she says. “I condense a medical condition that could take a very long time to understand and break it into layman’s terms.”

Ms. Beggs said when people hear about the $2 million, they often ask her whether she plans to give up her shifts in the emergency department for the more lucrative venture.

The answer is no, at least not yet.

“Aside from teaching, I genuinely love being at the bedside,” Ms. Beggs said. “I don’t foresee myself leaving that for good for as long as I can handle both.” She acknowledged, though, that her business now takes up most of her time.  

“I love everything about both aspects, so it’s hard for me to choose.”

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

Into thin, but healthy, air

Human civilization has essentially been built on proximity to water. Ancient civilizations in Mesopotamia, Egypt, Greece, China, and India were all intimately connected to either rivers or the ocean. Even today, with all our technology, about a third of Earth’s 8 billion people live within 100 vertical meters of sea level, and the median person lives at an elevation of just 200 meters.

pxfuel

All things considered, one might imagine life is pretty tough for the 2 million people living at an elevation of 4,500 meters (nearly 15,000 feet). Not too many Wal-Marts or McDonalds up there. Oh, and not much air either. And for most of us not named Spongebob, air is good.

Or is it? That’s the question posed by a new study. After all, the researchers said, people living at high altitudes, where the air has only 11% effective oxygen instead of the 21% we have at low altitude, have significantly lower rates of metabolic disorders such as diabetes and heart diseases. Maybe breathing isn’t all it’s cracked up to be.

To find out, the researchers placed a group of mice in environments with either 11% oxygen or 8% oxygen. This netted them a bunch of very tired mice. Hey, sudden altitude gain doesn’t go too well for us either, but after 3 weeks, all the mice in the hypoxic environments had regained their normal movement and were behaving as any mouse would.

While the critters seemed normal on the outside, a closer examination found the truth. Their metabolism had been permanently altered, and their blood sugar and weight went down and never bounced back up. Further examination through PET scans showed that the hypoxic mice’s organs showed an increase in glucose metabolism and that brown fat and skeletal muscles reduced the amount of sugar they used.

This goes against the prevailing assumption about hypoxic conditions, the researchers said, since it was previously theorized that the body simply burned more glucose in response to having less oxygen. And while that’s true, our organs also conspicuously use less glucose. Currently, many athletes use hypoxic environments to train, but these new data suggest that people with metabolic disorders also would see benefits from living in low-oxygen environments.

Do you know what this means? All we have to do to stop diabetes is take civilization and push it somewhere else. This can’t possibly end badly.
 

Sleep survey: The restless majority

Newsflash! This just in: Nobody is sleeping well.

When we go to bed, our goal is to get rest, right? Sorry America, but you’re falling short. In a recent survey conducted by OnePoll for Purple Mattress, almost two-thirds of the 2,011 participants considered themselves restless sleepers.

klebercordeiro/Getty Images

Not surprised. So what’s keeping us up?

Snoring partners (20%) and anxiety (26%) made the list, but the award for top complaint goes to body pain. Back pain was most prevalent, reported by 36% of respondents, followed by neck pain (33%) and shoulder pain (24%). No wonder, then, that only 10% of the group reported feeling well rested when they woke up.

Do you ever blame your tiredness on sleeping funny? Well, we all kind of sleep funny, and yet we’re still not sleeping well.

The largest proportion of people like to sleep on their side (48%), compared with 18% on their back and 17% on their stomach. The main reasons to choose certain positions were to ease soreness or sleep better, both at 28%. The largest share of participants (47%) reported sleeping in a “yearner” position, while 40% lay on their stomachs in the “free faller” position, and 39% reported using the “soldier” position.

Regardless of the method people use to get to sleep or the position they’re in, the goal is always the same. We’re all just trying to figure out what’s the right one for us.
 

Seen a UFO recently? Don’t blame COVID

First of all, because we know you’re going to be thinking it in a minute, no, we did not make this up. With COVID-19 still hanging around, there’s no need for fabrication on our part.

Jat AM/Pixabay

The pandemic, clearly, has caused humans to do some strange things over the last 3 years, but what about some of the more, shall we say … eccentric behavior that people were already exhibiting before COVID found its way into our lives?

If, like R. Chase Cockrell, PhD, of the University of Vermont and associates at the Center for UFO Studies, you were wondering if the pandemic affected UFO reporting, then wonder no more. After all, with all that extra time being spent outdoors back in 2020 and all the additional anxiety, surely somebody must have seen something.

The investigators started with the basics by analyzing data from the National UFO Reporting Center and the Mutual UFO Network. Sightings did increase by about 600 in each database during 2020, compared with 2018 and 2019, but not because of the pandemic.

That’s right, we can’t pin this one on our good friend SARS-CoV-2. Further analysis showed that the launches of SpaceX Starlink satellites – sometimes as many as 60 at a time – probably caused the increase in UFO sightings, which means that our favorite billionaire, Elon Musk, is to blame. Yup, the genial Mr. Muskellunge did something that even a global pandemic couldn’t, and yet we vaccinate for COVID.

Next week on tenuous connections: A new study links the 2020 presidential election to increased emergency department visits for external hemorrhoids.

See? That’s fabrication. We made that up.

This article was updated 5/15/23.

Into thin, but healthy, air

Human civilization has essentially been built on proximity to water. Ancient civilizations in Mesopotamia, Egypt, Greece, China, and India were all intimately connected to either rivers or the ocean. Even today, with all our technology, about a third of Earth’s 8 billion people live within 100 vertical meters of sea level, and the median person lives at an elevation of just 200 meters.

pxfuel

All things considered, one might imagine life is pretty tough for the 2 million people living at an elevation of 4,500 meters (nearly 15,000 feet). Not too many Wal-Marts or McDonalds up there. Oh, and not much air either. And for most of us not named Spongebob, air is good.

Or is it? That’s the question posed by a new study. After all, the researchers said, people living at high altitudes, where the air has only 11% effective oxygen instead of the 21% we have at low altitude, have significantly lower rates of metabolic disorders such as diabetes and heart diseases. Maybe breathing isn’t all it’s cracked up to be.

To find out, the researchers placed a group of mice in environments with either 11% oxygen or 8% oxygen. This netted them a bunch of very tired mice. Hey, sudden altitude gain doesn’t go too well for us either, but after 3 weeks, all the mice in the hypoxic environments had regained their normal movement and were behaving as any mouse would.

While the critters seemed normal on the outside, a closer examination found the truth. Their metabolism had been permanently altered, and their blood sugar and weight went down and never bounced back up. Further examination through PET scans showed that the hypoxic mice’s organs showed an increase in glucose metabolism and that brown fat and skeletal muscles reduced the amount of sugar they used.

This goes against the prevailing assumption about hypoxic conditions, the researchers said, since it was previously theorized that the body simply burned more glucose in response to having less oxygen. And while that’s true, our organs also conspicuously use less glucose. Currently, many athletes use hypoxic environments to train, but these new data suggest that people with metabolic disorders also would see benefits from living in low-oxygen environments.

Do you know what this means? All we have to do to stop diabetes is take civilization and push it somewhere else. This can’t possibly end badly.
 

Sleep survey: The restless majority

Newsflash! This just in: Nobody is sleeping well.

When we go to bed, our goal is to get rest, right? Sorry America, but you’re falling short. In a recent survey conducted by OnePoll for Purple Mattress, almost two-thirds of the 2,011 participants considered themselves restless sleepers.

klebercordeiro/Getty Images

Not surprised. So what’s keeping us up?

Snoring partners (20%) and anxiety (26%) made the list, but the award for top complaint goes to body pain. Back pain was most prevalent, reported by 36% of respondents, followed by neck pain (33%) and shoulder pain (24%). No wonder, then, that only 10% of the group reported feeling well rested when they woke up.

Do you ever blame your tiredness on sleeping funny? Well, we all kind of sleep funny, and yet we’re still not sleeping well.

The largest proportion of people like to sleep on their side (48%), compared with 18% on their back and 17% on their stomach. The main reasons to choose certain positions were to ease soreness or sleep better, both at 28%. The largest share of participants (47%) reported sleeping in a “yearner” position, while 40% lay on their stomachs in the “free faller” position, and 39% reported using the “soldier” position.

Regardless of the method people use to get to sleep or the position they’re in, the goal is always the same. We’re all just trying to figure out what’s the right one for us.
 

Seen a UFO recently? Don’t blame COVID

First of all, because we know you’re going to be thinking it in a minute, no, we did not make this up. With COVID-19 still hanging around, there’s no need for fabrication on our part.

Jat AM/Pixabay

The pandemic, clearly, has caused humans to do some strange things over the last 3 years, but what about some of the more, shall we say … eccentric behavior that people were already exhibiting before COVID found its way into our lives?

If, like R. Chase Cockrell, PhD, of the University of Vermont and associates at the Center for UFO Studies, you were wondering if the pandemic affected UFO reporting, then wonder no more. After all, with all that extra time being spent outdoors back in 2020 and all the additional anxiety, surely somebody must have seen something.

The investigators started with the basics by analyzing data from the National UFO Reporting Center and the Mutual UFO Network. Sightings did increase by about 600 in each database during 2020, compared with 2018 and 2019, but not because of the pandemic.

That’s right, we can’t pin this one on our good friend SARS-CoV-2. Further analysis showed that the launches of SpaceX Starlink satellites – sometimes as many as 60 at a time – probably caused the increase in UFO sightings, which means that our favorite billionaire, Elon Musk, is to blame. Yup, the genial Mr. Muskellunge did something that even a global pandemic couldn’t, and yet we vaccinate for COVID.

Next week on tenuous connections: A new study links the 2020 presidential election to increased emergency department visits for external hemorrhoids.

See? That’s fabrication. We made that up.

This article was updated 5/15/23.

Into thin, but healthy, air

Human civilization has essentially been built on proximity to water. Ancient civilizations in Mesopotamia, Egypt, Greece, China, and India were all intimately connected to either rivers or the ocean. Even today, with all our technology, about a third of Earth’s 8 billion people live within 100 vertical meters of sea level, and the median person lives at an elevation of just 200 meters.

pxfuel

All things considered, one might imagine life is pretty tough for the 2 million people living at an elevation of 4,500 meters (nearly 15,000 feet). Not too many Wal-Marts or McDonalds up there. Oh, and not much air either. And for most of us not named Spongebob, air is good.

Or is it? That’s the question posed by a new study. After all, the researchers said, people living at high altitudes, where the air has only 11% effective oxygen instead of the 21% we have at low altitude, have significantly lower rates of metabolic disorders such as diabetes and heart diseases. Maybe breathing isn’t all it’s cracked up to be.

To find out, the researchers placed a group of mice in environments with either 11% oxygen or 8% oxygen. This netted them a bunch of very tired mice. Hey, sudden altitude gain doesn’t go too well for us either, but after 3 weeks, all the mice in the hypoxic environments had regained their normal movement and were behaving as any mouse would.

While the critters seemed normal on the outside, a closer examination found the truth. Their metabolism had been permanently altered, and their blood sugar and weight went down and never bounced back up. Further examination through PET scans showed that the hypoxic mice’s organs showed an increase in glucose metabolism and that brown fat and skeletal muscles reduced the amount of sugar they used.

This goes against the prevailing assumption about hypoxic conditions, the researchers said, since it was previously theorized that the body simply burned more glucose in response to having less oxygen. And while that’s true, our organs also conspicuously use less glucose. Currently, many athletes use hypoxic environments to train, but these new data suggest that people with metabolic disorders also would see benefits from living in low-oxygen environments.

Do you know what this means? All we have to do to stop diabetes is take civilization and push it somewhere else. This can’t possibly end badly.
 

Sleep survey: The restless majority

Newsflash! This just in: Nobody is sleeping well.

When we go to bed, our goal is to get rest, right? Sorry America, but you’re falling short. In a recent survey conducted by OnePoll for Purple Mattress, almost two-thirds of the 2,011 participants considered themselves restless sleepers.

klebercordeiro/Getty Images

Not surprised. So what’s keeping us up?

Snoring partners (20%) and anxiety (26%) made the list, but the award for top complaint goes to body pain. Back pain was most prevalent, reported by 36% of respondents, followed by neck pain (33%) and shoulder pain (24%). No wonder, then, that only 10% of the group reported feeling well rested when they woke up.

Do you ever blame your tiredness on sleeping funny? Well, we all kind of sleep funny, and yet we’re still not sleeping well.

The largest proportion of people like to sleep on their side (48%), compared with 18% on their back and 17% on their stomach. The main reasons to choose certain positions were to ease soreness or sleep better, both at 28%. The largest share of participants (47%) reported sleeping in a “yearner” position, while 40% lay on their stomachs in the “free faller” position, and 39% reported using the “soldier” position.

Regardless of the method people use to get to sleep or the position they’re in, the goal is always the same. We’re all just trying to figure out what’s the right one for us.
 

Seen a UFO recently? Don’t blame COVID

First of all, because we know you’re going to be thinking it in a minute, no, we did not make this up. With COVID-19 still hanging around, there’s no need for fabrication on our part.

Jat AM/Pixabay

The pandemic, clearly, has caused humans to do some strange things over the last 3 years, but what about some of the more, shall we say … eccentric behavior that people were already exhibiting before COVID found its way into our lives?

If, like R. Chase Cockrell, PhD, of the University of Vermont and associates at the Center for UFO Studies, you were wondering if the pandemic affected UFO reporting, then wonder no more. After all, with all that extra time being spent outdoors back in 2020 and all the additional anxiety, surely somebody must have seen something.

The investigators started with the basics by analyzing data from the National UFO Reporting Center and the Mutual UFO Network. Sightings did increase by about 600 in each database during 2020, compared with 2018 and 2019, but not because of the pandemic.

That’s right, we can’t pin this one on our good friend SARS-CoV-2. Further analysis showed that the launches of SpaceX Starlink satellites – sometimes as many as 60 at a time – probably caused the increase in UFO sightings, which means that our favorite billionaire, Elon Musk, is to blame. Yup, the genial Mr. Muskellunge did something that even a global pandemic couldn’t, and yet we vaccinate for COVID.

Next week on tenuous connections: A new study links the 2020 presidential election to increased emergency department visits for external hemorrhoids.

See? That’s fabrication. We made that up.

This article was updated 5/15/23.

A substantial number of older women may experience worsening frailty after undergoing surgery and radiation therapy for early-stage breast cancer, according to a new study.

About 1 in 5 experienced clinically significant deterioration in frailty status after treatment, the study team found. Women at highest risk for declines in frailty following treatment had “robust” baseline frailty status at diagnosis and underwent more invasive mastectomy compared with lumpectomy.

The fact that “robust” older women were more likely to become frail after locoregional therapy suggests that “thoughtful treatment decisions should be undertaken in all older women, not simply those who have frailty at diagnosis,” said the investigators, led by Christina Minami, MD, of Dana-Farber/Brigham and Women’s Cancer Center in Boston.

The study findings emphasize that there is no one-size-fits-all approach to breast cancer treatment in the elderly, said Sarah P. Cate, MD, director, Breast Surgery Quality Program, Mount Sinai Health System, New York, who wasn’t involved in the research. “Some patients will sail through a surgery, and others are severely affected by it.”

The study was published online in JAMA Surgery.

Given the growing number of older adults with breast cancer, understanding how age-related syndromes, such as frailty, may alter cancer outcomes and how cancer treatments change aging trajectories remains important.

To investigate, Dr. Minami and colleagues used Surveillance, Epidemiology, and End Results Medicare data to identify 31,084 women (mean age, 73) who had been diagnosed with ductal carcinoma in situ (DCIS) or stage I HR-positive, ERBB2-positive breast cancer and who underwent surgery (23% mastectomy, 77% lumpectomy) and radiation therapy.

Worsening frailty status was defined as a decline of 0.03 or greater in a validated frailty index from the time of diagnosis to 1 year. This level of change has been linked to greater mortality risk and greater cost of care.

Frailty status at diagnosis was “robust” in 56% of the women, prefrail in 40%, mildly frail in 4%, and moderately to severely frail in 0.3%.

According to the researchers, 21.4% of the women experienced clinically significant declines in their frailty status after treatment. These declines occurred in 25% of women who underwent mastectomy and 20% of those who underwent lumpectomy.

After adjusting for covariates, there was a higher likelihood of worsening frailty among women who were robustly frail at baseline, in comparison with those who were moderately to severely frail at baseline (odds ratio, 6.12), and in those who underwent mastectomy vs. lumpectomy (OR, 1.31).

Older age and race were also linked to worsening frailty status following treatment. Compared with younger women (aged 65-74 years), older women were more likely to experience worsening frailty (OR, 1.21 for women aged 75-79; OR, 1.53 for those aged 80-84; OR, 1.94 for those aged 85 and older). In addition, Black women were more likely than non-Hispanic White women to experience worsening frailty after treatment (OR, 1.12).

“Previous studies have documented lasting declines in functional status after surgery in older patients with breast cancer, but breast cancer treatment has not been implicated in worsening frailty to date,” Dr. Minami and colleagues explain. But “given the substantial proportion of women experiencing worsening frailty and the significant difference by breast surgery type, frailty status as a cancer therapy outcome should be further explored.” In addition, “tailoring locoregional therapy intensity in this population is important,” they write.

Dr. Cate explained that randomized clinical trials such as COMET and LORIS, which explore the monitoring of patients with DCIS in lieu of active treatment, “will likely make a big impact on this population, as we currently do not have randomized controlled data for observation of breast cancer.”

Dr. Cate added as well that assessing a patient’s ECOG [Eastern Cooperative Oncology Group] performance status is vital “to determine who can really tolerate a breast cancer surgery” and that opting for antiestrogens, such as aromatase inhibitors, which can keep cancer at bay for years, “may be preferable for many older patients.”

The study was funded by Brigham and Women’s Hospital’s Department of Surgery’s Beal Fellowship. Dr. Minami and Dr. Cate have disclosed no relevant financial relationships.
 

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

A substantial number of older women may experience worsening frailty after undergoing surgery and radiation therapy for early-stage breast cancer, according to a new study.

About 1 in 5 experienced clinically significant deterioration in frailty status after treatment, the study team found. Women at highest risk for declines in frailty following treatment had “robust” baseline frailty status at diagnosis and underwent more invasive mastectomy compared with lumpectomy.

The fact that “robust” older women were more likely to become frail after locoregional therapy suggests that “thoughtful treatment decisions should be undertaken in all older women, not simply those who have frailty at diagnosis,” said the investigators, led by Christina Minami, MD, of Dana-Farber/Brigham and Women’s Cancer Center in Boston.

The study findings emphasize that there is no one-size-fits-all approach to breast cancer treatment in the elderly, said Sarah P. Cate, MD, director, Breast Surgery Quality Program, Mount Sinai Health System, New York, who wasn’t involved in the research. “Some patients will sail through a surgery, and others are severely affected by it.”

The study was published online in JAMA Surgery.

Given the growing number of older adults with breast cancer, understanding how age-related syndromes, such as frailty, may alter cancer outcomes and how cancer treatments change aging trajectories remains important.

To investigate, Dr. Minami and colleagues used Surveillance, Epidemiology, and End Results Medicare data to identify 31,084 women (mean age, 73) who had been diagnosed with ductal carcinoma in situ (DCIS) or stage I HR-positive, ERBB2-positive breast cancer and who underwent surgery (23% mastectomy, 77% lumpectomy) and radiation therapy.

Worsening frailty status was defined as a decline of 0.03 or greater in a validated frailty index from the time of diagnosis to 1 year. This level of change has been linked to greater mortality risk and greater cost of care.

Frailty status at diagnosis was “robust” in 56% of the women, prefrail in 40%, mildly frail in 4%, and moderately to severely frail in 0.3%.

According to the researchers, 21.4% of the women experienced clinically significant declines in their frailty status after treatment. These declines occurred in 25% of women who underwent mastectomy and 20% of those who underwent lumpectomy.

After adjusting for covariates, there was a higher likelihood of worsening frailty among women who were robustly frail at baseline, in comparison with those who were moderately to severely frail at baseline (odds ratio, 6.12), and in those who underwent mastectomy vs. lumpectomy (OR, 1.31).

Older age and race were also linked to worsening frailty status following treatment. Compared with younger women (aged 65-74 years), older women were more likely to experience worsening frailty (OR, 1.21 for women aged 75-79; OR, 1.53 for those aged 80-84; OR, 1.94 for those aged 85 and older). In addition, Black women were more likely than non-Hispanic White women to experience worsening frailty after treatment (OR, 1.12).

“Previous studies have documented lasting declines in functional status after surgery in older patients with breast cancer, but breast cancer treatment has not been implicated in worsening frailty to date,” Dr. Minami and colleagues explain. But “given the substantial proportion of women experiencing worsening frailty and the significant difference by breast surgery type, frailty status as a cancer therapy outcome should be further explored.” In addition, “tailoring locoregional therapy intensity in this population is important,” they write.

Dr. Cate explained that randomized clinical trials such as COMET and LORIS, which explore the monitoring of patients with DCIS in lieu of active treatment, “will likely make a big impact on this population, as we currently do not have randomized controlled data for observation of breast cancer.”

Dr. Cate added as well that assessing a patient’s ECOG [Eastern Cooperative Oncology Group] performance status is vital “to determine who can really tolerate a breast cancer surgery” and that opting for antiestrogens, such as aromatase inhibitors, which can keep cancer at bay for years, “may be preferable for many older patients.”

The study was funded by Brigham and Women’s Hospital’s Department of Surgery’s Beal Fellowship. Dr. Minami and Dr. Cate have disclosed no relevant financial relationships.
 

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

A substantial number of older women may experience worsening frailty after undergoing surgery and radiation therapy for early-stage breast cancer, according to a new study.

About 1 in 5 experienced clinically significant deterioration in frailty status after treatment, the study team found. Women at highest risk for declines in frailty following treatment had “robust” baseline frailty status at diagnosis and underwent more invasive mastectomy compared with lumpectomy.

The fact that “robust” older women were more likely to become frail after locoregional therapy suggests that “thoughtful treatment decisions should be undertaken in all older women, not simply those who have frailty at diagnosis,” said the investigators, led by Christina Minami, MD, of Dana-Farber/Brigham and Women’s Cancer Center in Boston.

The study findings emphasize that there is no one-size-fits-all approach to breast cancer treatment in the elderly, said Sarah P. Cate, MD, director, Breast Surgery Quality Program, Mount Sinai Health System, New York, who wasn’t involved in the research. “Some patients will sail through a surgery, and others are severely affected by it.”

The study was published online in JAMA Surgery.

Given the growing number of older adults with breast cancer, understanding how age-related syndromes, such as frailty, may alter cancer outcomes and how cancer treatments change aging trajectories remains important.

To investigate, Dr. Minami and colleagues used Surveillance, Epidemiology, and End Results Medicare data to identify 31,084 women (mean age, 73) who had been diagnosed with ductal carcinoma in situ (DCIS) or stage I HR-positive, ERBB2-positive breast cancer and who underwent surgery (23% mastectomy, 77% lumpectomy) and radiation therapy.

Worsening frailty status was defined as a decline of 0.03 or greater in a validated frailty index from the time of diagnosis to 1 year. This level of change has been linked to greater mortality risk and greater cost of care.

Frailty status at diagnosis was “robust” in 56% of the women, prefrail in 40%, mildly frail in 4%, and moderately to severely frail in 0.3%.

According to the researchers, 21.4% of the women experienced clinically significant declines in their frailty status after treatment. These declines occurred in 25% of women who underwent mastectomy and 20% of those who underwent lumpectomy.

After adjusting for covariates, there was a higher likelihood of worsening frailty among women who were robustly frail at baseline, in comparison with those who were moderately to severely frail at baseline (odds ratio, 6.12), and in those who underwent mastectomy vs. lumpectomy (OR, 1.31).

Older age and race were also linked to worsening frailty status following treatment. Compared with younger women (aged 65-74 years), older women were more likely to experience worsening frailty (OR, 1.21 for women aged 75-79; OR, 1.53 for those aged 80-84; OR, 1.94 for those aged 85 and older). In addition, Black women were more likely than non-Hispanic White women to experience worsening frailty after treatment (OR, 1.12).

“Previous studies have documented lasting declines in functional status after surgery in older patients with breast cancer, but breast cancer treatment has not been implicated in worsening frailty to date,” Dr. Minami and colleagues explain. But “given the substantial proportion of women experiencing worsening frailty and the significant difference by breast surgery type, frailty status as a cancer therapy outcome should be further explored.” In addition, “tailoring locoregional therapy intensity in this population is important,” they write.

Dr. Cate explained that randomized clinical trials such as COMET and LORIS, which explore the monitoring of patients with DCIS in lieu of active treatment, “will likely make a big impact on this population, as we currently do not have randomized controlled data for observation of breast cancer.”

Dr. Cate added as well that assessing a patient’s ECOG [Eastern Cooperative Oncology Group] performance status is vital “to determine who can really tolerate a breast cancer surgery” and that opting for antiestrogens, such as aromatase inhibitors, which can keep cancer at bay for years, “may be preferable for many older patients.”

The study was funded by Brigham and Women’s Hospital’s Department of Surgery’s Beal Fellowship. Dr. Minami and Dr. Cate have disclosed no relevant financial relationships.
 

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

Medical school graduates around the US took to social media after last week's Match Day to share their joy ― or explore their options if they did not match.

Take this post March 19 on Twitter: “I went unmatched this year; looking for research position at any institute for internal medicine.”

Most of the fourth-year medical students this news organization has followed in the run-up to Match Day found success, including an international medical graduate who matched into his chosen specialty after multiple disappointments.

“I’ve waited for this email for 8 years,” Sahil Bawa, MD, posted on Twitter on March 13. A few days later, when he learned about his residency position, he posted: “I’m beyond grateful. Will be moving to Alabama soon #familymedicine.”

Dr. Bawa, who matched into UAB Medicine Selma (Ala.), graduated from medical school in India in 2014. He said in an interview that he has visited the United States periodically since then to pass medical tests, obtain letters of recommendation, and participate in research.

Over the years he watched his Indian colleagues give up on becoming American doctors, find alternative careers, or resolve to practice in their native country. But he held onto the few success stories he saw on social media. “There were always one to two every year. It kept me going. If they can do it, I can do it.”

International medical graduates (IMGs) like Dr. Bawa applied in record numbers to Match2023, according to the National Resident Matching Program (NRMP), which announced the results on March 13 of its main residency match and the Supplemental Offer and Acceptance Program (SOAP) for unfilled positions or unmatched applicants.

Overall, 48,156 total applicants registered for the match, which was driven by the increase of non-U.S. IMG applicants and U.S. DO seniors over the past year, NRMP stated in its release. U.S. MD seniors had a match rate of nearly 94%, and U.S. DO seniors, nearly 92%. U.S. IMGs had a match rate of nearly 68%, an “all-time high,” and non-U.S. IMGs, nearly 60%, NRMP stated.

Three specialties that filled all of their 30 or more available positions were orthopedic surgery, plastic surgery (integrated), radiology – diagnostic, and thoracic surgery. Specialties with 30 or more positions that filled with the highest percentage of U.S. MD and DO seniors were plastic surgery (integrated), internal medicine-pediatrics, ob.gyn., and orthopedic surgery.

The number of available primary care positions increased slightly, NRMP reported. Considering “a serious and growing shortage of primary care physicians across the U.S.,” there were 571 more primary care positions than 2022. That’s an increase of about 3% over last year and 17% over the past 5 years. Primary care positions filled at a rate of 94%, which remained steady from 2022.

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

Medical school graduates around the US took to social media after last week's Match Day to share their joy ― or explore their options if they did not match.

Take this post March 19 on Twitter: “I went unmatched this year; looking for research position at any institute for internal medicine.”

Most of the fourth-year medical students this news organization has followed in the run-up to Match Day found success, including an international medical graduate who matched into his chosen specialty after multiple disappointments.

“I’ve waited for this email for 8 years,” Sahil Bawa, MD, posted on Twitter on March 13. A few days later, when he learned about his residency position, he posted: “I’m beyond grateful. Will be moving to Alabama soon #familymedicine.”

Dr. Bawa, who matched into UAB Medicine Selma (Ala.), graduated from medical school in India in 2014. He said in an interview that he has visited the United States periodically since then to pass medical tests, obtain letters of recommendation, and participate in research.

Over the years he watched his Indian colleagues give up on becoming American doctors, find alternative careers, or resolve to practice in their native country. But he held onto the few success stories he saw on social media. “There were always one to two every year. It kept me going. If they can do it, I can do it.”

International medical graduates (IMGs) like Dr. Bawa applied in record numbers to Match2023, according to the National Resident Matching Program (NRMP), which announced the results on March 13 of its main residency match and the Supplemental Offer and Acceptance Program (SOAP) for unfilled positions or unmatched applicants.

Overall, 48,156 total applicants registered for the match, which was driven by the increase of non-U.S. IMG applicants and U.S. DO seniors over the past year, NRMP stated in its release. U.S. MD seniors had a match rate of nearly 94%, and U.S. DO seniors, nearly 92%. U.S. IMGs had a match rate of nearly 68%, an “all-time high,” and non-U.S. IMGs, nearly 60%, NRMP stated.

Three specialties that filled all of their 30 or more available positions were orthopedic surgery, plastic surgery (integrated), radiology – diagnostic, and thoracic surgery. Specialties with 30 or more positions that filled with the highest percentage of U.S. MD and DO seniors were plastic surgery (integrated), internal medicine-pediatrics, ob.gyn., and orthopedic surgery.

The number of available primary care positions increased slightly, NRMP reported. Considering “a serious and growing shortage of primary care physicians across the U.S.,” there were 571 more primary care positions than 2022. That’s an increase of about 3% over last year and 17% over the past 5 years. Primary care positions filled at a rate of 94%, which remained steady from 2022.

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

Medical school graduates around the US took to social media after last week's Match Day to share their joy ― or explore their options if they did not match.

Take this post March 19 on Twitter: “I went unmatched this year; looking for research position at any institute for internal medicine.”

Most of the fourth-year medical students this news organization has followed in the run-up to Match Day found success, including an international medical graduate who matched into his chosen specialty after multiple disappointments.

“I’ve waited for this email for 8 years,” Sahil Bawa, MD, posted on Twitter on March 13. A few days later, when he learned about his residency position, he posted: “I’m beyond grateful. Will be moving to Alabama soon #familymedicine.”

Dr. Bawa, who matched into UAB Medicine Selma (Ala.), graduated from medical school in India in 2014. He said in an interview that he has visited the United States periodically since then to pass medical tests, obtain letters of recommendation, and participate in research.

Over the years he watched his Indian colleagues give up on becoming American doctors, find alternative careers, or resolve to practice in their native country. But he held onto the few success stories he saw on social media. “There were always one to two every year. It kept me going. If they can do it, I can do it.”

International medical graduates (IMGs) like Dr. Bawa applied in record numbers to Match2023, according to the National Resident Matching Program (NRMP), which announced the results on March 13 of its main residency match and the Supplemental Offer and Acceptance Program (SOAP) for unfilled positions or unmatched applicants.

Overall, 48,156 total applicants registered for the match, which was driven by the increase of non-U.S. IMG applicants and U.S. DO seniors over the past year, NRMP stated in its release. U.S. MD seniors had a match rate of nearly 94%, and U.S. DO seniors, nearly 92%. U.S. IMGs had a match rate of nearly 68%, an “all-time high,” and non-U.S. IMGs, nearly 60%, NRMP stated.

Three specialties that filled all of their 30 or more available positions were orthopedic surgery, plastic surgery (integrated), radiology – diagnostic, and thoracic surgery. Specialties with 30 or more positions that filled with the highest percentage of U.S. MD and DO seniors were plastic surgery (integrated), internal medicine-pediatrics, ob.gyn., and orthopedic surgery.

The number of available primary care positions increased slightly, NRMP reported. Considering “a serious and growing shortage of primary care physicians across the U.S.,” there were 571 more primary care positions than 2022. That’s an increase of about 3% over last year and 17% over the past 5 years. Primary care positions filled at a rate of 94%, which remained steady from 2022.

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

This transcript has been edited for clarity.

Hi. I’m Art Caplan. I’m at the division of medical ethics at New York University’s Grossman School of Medicine in New York City.

We’ve had an organ shortage for many decades now. We can do more transplants than we have organs made available. We try very hard to get organ donation from those who die. That’s a commendable thing to do. I think doctors should always be discussing the opportunity to donate organs upon death, even in primary care settings.

It’s good to find out what people’s attitudes are. Let them learn about organ donation as something they can think about. Let them talk about it with family and friends and partners so that they know their wishes.

However, despite these efforts to encourage organ donation, we still have far fewer organs than we could use to transplant people, many people die on waiting lists because there are no organs to give them, and we’re in a situation where demand for organ transplant is actually increasing.

There is more capacity to do transplants both in the United States and elsewhere, and more people are living longer, so organ failure starts to become more common before, let’s say, terminal illness is really there. Now, we have more people who might benefit from organ transplant in an aging population.

One place to turn to help reduce the shortage of organs is to living donation. At least insofar as kidneys go, kidney donation from living persons has become a prominent source of organs for those who need kidneys – most of whom are surviving on dialysis, by the way, at a very high cost and often with a quality of life that they don’t find particularly easy to accept.

Transplant is far preferred, even though they have to take immunosuppression to keep those organ transplants going, and that has its own risks and side effects. They still get more mobility. They still are able to have a broader diet. They enjoy life far more than they do having to show up for dialysis three times a week for a couple of hours, every week, for every week that they live.

There is an interest in living kidney donation. One battle has been that, well, maybe we could get more kidneys if we just paid people to sell us their kidneys. That has been resisted, and I’ve been resistant to that idea, too, because I worry that it leads to exploitation.

The people who sell their kidneys are poor. They’re often in debt. They feel coerced by their circumstances, so they make a kidney sale. This happens in countries like India, where there are markets underground, and you see that it’s the poorest of the poor who do this, and they don’t really work their way out of debt. They just wind up without a kidney, help relieve their debt a little bit, and pretty soon, because they don’t have a job or an income except that sale of a kidney, they’re not much better off than they were before they started.

Also, people who sell kidneys for money are more likely not to admit to their own health problems, raising risks about the quality of organs. Then, of course, it puts doctors in a position to take out an organ for pay, even though it doesn’t benefit you, so that you can sell it. This raises some questions about whether that’s consistent with medical ethics.

A different idea has emerged. New York State Governor Kathy Hochul just signed legislation that allows living donors to be compensated for legitimate costs. That’s a little different matter. You’re not buying the organ, but you’re saying that if you experience health care problems due to complications from a donation, if you need money for transportation, if you lost money because you did this altruistically and you had to take time off from work and had expenses for a babysitter, restaurants, or other things, the state is going to try to create funds that will compensate you.

That, I think we should agree, is not a bad idea. You’re in a situation there where you don’t want to make people who are heroic, altruistic, and trying to help others by donating a kidney end up financially worse off.

I think there’s a difference between making someone financially whole after the decision to make a kidney available and creating a market where the poorest of the poor come forward to just sell because they see no other choice in terms of how to get rid of debts. I see these situations as not ethically equivalent, so I support efforts to try to compensate people who are our heroes. I don’t think we should ask them to financially suffer.

We’ll watch to see what happens as the New York state law comes into effect. By the way, New York is one of the states that really lags in the supply of organs for transplant, so this measure is particularly important for that state. Many other states should be considering this legislation as well.

It’s one thing to reward, if you will, donors by making sure they don’t suffer financial loss. It’s a very different thing to say, let’s have a free market and we’ll pay whoever it is that’s willing to sell us a kidney to do so. The former seems to me to be humane and just, whereas the latter risks exploitation.
 

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

This transcript has been edited for clarity.

Hi. I’m Art Caplan. I’m at the division of medical ethics at New York University’s Grossman School of Medicine in New York City.

We’ve had an organ shortage for many decades now. We can do more transplants than we have organs made available. We try very hard to get organ donation from those who die. That’s a commendable thing to do. I think doctors should always be discussing the opportunity to donate organs upon death, even in primary care settings.

It’s good to find out what people’s attitudes are. Let them learn about organ donation as something they can think about. Let them talk about it with family and friends and partners so that they know their wishes.

However, despite these efforts to encourage organ donation, we still have far fewer organs than we could use to transplant people, many people die on waiting lists because there are no organs to give them, and we’re in a situation where demand for organ transplant is actually increasing.

There is more capacity to do transplants both in the United States and elsewhere, and more people are living longer, so organ failure starts to become more common before, let’s say, terminal illness is really there. Now, we have more people who might benefit from organ transplant in an aging population.

One place to turn to help reduce the shortage of organs is to living donation. At least insofar as kidneys go, kidney donation from living persons has become a prominent source of organs for those who need kidneys – most of whom are surviving on dialysis, by the way, at a very high cost and often with a quality of life that they don’t find particularly easy to accept.

Transplant is far preferred, even though they have to take immunosuppression to keep those organ transplants going, and that has its own risks and side effects. They still get more mobility. They still are able to have a broader diet. They enjoy life far more than they do having to show up for dialysis three times a week for a couple of hours, every week, for every week that they live.

There is an interest in living kidney donation. One battle has been that, well, maybe we could get more kidneys if we just paid people to sell us their kidneys. That has been resisted, and I’ve been resistant to that idea, too, because I worry that it leads to exploitation.

The people who sell their kidneys are poor. They’re often in debt. They feel coerced by their circumstances, so they make a kidney sale. This happens in countries like India, where there are markets underground, and you see that it’s the poorest of the poor who do this, and they don’t really work their way out of debt. They just wind up without a kidney, help relieve their debt a little bit, and pretty soon, because they don’t have a job or an income except that sale of a kidney, they’re not much better off than they were before they started.

Also, people who sell kidneys for money are more likely not to admit to their own health problems, raising risks about the quality of organs. Then, of course, it puts doctors in a position to take out an organ for pay, even though it doesn’t benefit you, so that you can sell it. This raises some questions about whether that’s consistent with medical ethics.

A different idea has emerged. New York State Governor Kathy Hochul just signed legislation that allows living donors to be compensated for legitimate costs. That’s a little different matter. You’re not buying the organ, but you’re saying that if you experience health care problems due to complications from a donation, if you need money for transportation, if you lost money because you did this altruistically and you had to take time off from work and had expenses for a babysitter, restaurants, or other things, the state is going to try to create funds that will compensate you.

That, I think we should agree, is not a bad idea. You’re in a situation there where you don’t want to make people who are heroic, altruistic, and trying to help others by donating a kidney end up financially worse off.

I think there’s a difference between making someone financially whole after the decision to make a kidney available and creating a market where the poorest of the poor come forward to just sell because they see no other choice in terms of how to get rid of debts. I see these situations as not ethically equivalent, so I support efforts to try to compensate people who are our heroes. I don’t think we should ask them to financially suffer.

We’ll watch to see what happens as the New York state law comes into effect. By the way, New York is one of the states that really lags in the supply of organs for transplant, so this measure is particularly important for that state. Many other states should be considering this legislation as well.

It’s one thing to reward, if you will, donors by making sure they don’t suffer financial loss. It’s a very different thing to say, let’s have a free market and we’ll pay whoever it is that’s willing to sell us a kidney to do so. The former seems to me to be humane and just, whereas the latter risks exploitation.
 

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

This transcript has been edited for clarity.

Hi. I’m Art Caplan. I’m at the division of medical ethics at New York University’s Grossman School of Medicine in New York City.

We’ve had an organ shortage for many decades now. We can do more transplants than we have organs made available. We try very hard to get organ donation from those who die. That’s a commendable thing to do. I think doctors should always be discussing the opportunity to donate organs upon death, even in primary care settings.

It’s good to find out what people’s attitudes are. Let them learn about organ donation as something they can think about. Let them talk about it with family and friends and partners so that they know their wishes.

However, despite these efforts to encourage organ donation, we still have far fewer organs than we could use to transplant people, many people die on waiting lists because there are no organs to give them, and we’re in a situation where demand for organ transplant is actually increasing.

There is more capacity to do transplants both in the United States and elsewhere, and more people are living longer, so organ failure starts to become more common before, let’s say, terminal illness is really there. Now, we have more people who might benefit from organ transplant in an aging population.

One place to turn to help reduce the shortage of organs is to living donation. At least insofar as kidneys go, kidney donation from living persons has become a prominent source of organs for those who need kidneys – most of whom are surviving on dialysis, by the way, at a very high cost and often with a quality of life that they don’t find particularly easy to accept.

Transplant is far preferred, even though they have to take immunosuppression to keep those organ transplants going, and that has its own risks and side effects. They still get more mobility. They still are able to have a broader diet. They enjoy life far more than they do having to show up for dialysis three times a week for a couple of hours, every week, for every week that they live.

There is an interest in living kidney donation. One battle has been that, well, maybe we could get more kidneys if we just paid people to sell us their kidneys. That has been resisted, and I’ve been resistant to that idea, too, because I worry that it leads to exploitation.

The people who sell their kidneys are poor. They’re often in debt. They feel coerced by their circumstances, so they make a kidney sale. This happens in countries like India, where there are markets underground, and you see that it’s the poorest of the poor who do this, and they don’t really work their way out of debt. They just wind up without a kidney, help relieve their debt a little bit, and pretty soon, because they don’t have a job or an income except that sale of a kidney, they’re not much better off than they were before they started.

Also, people who sell kidneys for money are more likely not to admit to their own health problems, raising risks about the quality of organs. Then, of course, it puts doctors in a position to take out an organ for pay, even though it doesn’t benefit you, so that you can sell it. This raises some questions about whether that’s consistent with medical ethics.

A different idea has emerged. New York State Governor Kathy Hochul just signed legislation that allows living donors to be compensated for legitimate costs. That’s a little different matter. You’re not buying the organ, but you’re saying that if you experience health care problems due to complications from a donation, if you need money for transportation, if you lost money because you did this altruistically and you had to take time off from work and had expenses for a babysitter, restaurants, or other things, the state is going to try to create funds that will compensate you.

That, I think we should agree, is not a bad idea. You’re in a situation there where you don’t want to make people who are heroic, altruistic, and trying to help others by donating a kidney end up financially worse off.

I think there’s a difference between making someone financially whole after the decision to make a kidney available and creating a market where the poorest of the poor come forward to just sell because they see no other choice in terms of how to get rid of debts. I see these situations as not ethically equivalent, so I support efforts to try to compensate people who are our heroes. I don’t think we should ask them to financially suffer.

We’ll watch to see what happens as the New York state law comes into effect. By the way, New York is one of the states that really lags in the supply of organs for transplant, so this measure is particularly important for that state. Many other states should be considering this legislation as well.

It’s one thing to reward, if you will, donors by making sure they don’t suffer financial loss. It’s a very different thing to say, let’s have a free market and we’ll pay whoever it is that’s willing to sell us a kidney to do so. The former seems to me to be humane and just, whereas the latter risks exploitation.
 

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

As chair of the Arkansas State Medical Board, Brian T. Hyatt, MD, often sat in judgment of other physicians. Now, state officials are investigating the psychiatrist for alleged Medicaid fraud. He has stepped down as board chair, and state officials have suspended all Medicaid payments to Dr. Hyatt and his practice, Pinnacle Premier Psychiatry in Rogers, Arkansas.

Dr. Hyatt billed 99.95% of the claims for his patients’ hospital care to Medicaid at the highest severity level, according to an affidavit filed by an investigator with the Medicaid Fraud Control Unit, Arkansas Attorney General’s Office. Other Arkansas psychiatrists billed that same level in only about 39% of claims, the affidavit states.

The possible upcoding alleged in the affidavit was a red flag that prompted the state to temporarily suspend Dr. Hyatt’s Medicaid payments.

Dr. Hyatt has until this Friday to file an appeal. He did not respond to requests from this news organization for comment.

The affidavit pointed to other concerns. For example, a whistleblower who worked at the Northwest Medical Center where Dr. Hyatt admitted patients claimed that Dr. Hyatt was only on the floor a few minutes a day and that he had no contact with patients. A review of hundreds of hours of video by state investigators revealed that Dr. Hyatt did not enter patients’ rooms, nor did he have any contact with patients, according to the affidavit. Dr. Hyatt served as the hospital’s behavioral unit director from 2018 until his contract was abruptly terminated in May 2022, according to the affidavit.

However, Dr. Hyatt claimed to have conducted daily face-to-face evaluation and management with patients, according to the affidavit. In addition, the whistleblower claimed that Dr. Hyatt did not want patients to know his name and instructed staff to cover up his name on patient armbands.
 

Detaining patients

Dr. Hyatt also faces accusations that he held patients against their will, according to civil lawsuits filed in Washington County, Ark., reports the Arkansas Advocate. 

Karla Adrian-Caceres filed suit on Jan. 17. Ms. Adrian-Caceres also named Brooke Green, Northwest Arkansas Hospitals, and 25 unidentified hospital employees as defendants.

According to the complaint, Ms. Adrian-Caceres, an engineering student at the University of Arkansas, arrived at the Northwest Medical Emergency Department after accidentally taking too many Tylenol on Jan. 18, 2022. She was then taken by ambulance to a Northwest psychiatric facility in Springdale, court records show.

According to the complaint, Ms. Adrian-Caceres said that she was given a sedative and asked to sign consent for admission while on the way to Northwest. She said that she “signed some documents without being able to read or understand them at the time.”

When she asked when she could go home, Ms. Adrian-Caceres said, “more than one employee told her there was a minimum stay and that if she asked to leave, they would take her to court where a judge would give her a longer stay because the judge always sides with Dr. Hyatt and Northwest,” according to court documents. Northwest employees stripped Ms. Adrian-Caceres, searched her body, took all of her possessions from her and issued underwear and a uniform, according to the lawsuit.

Ms. Adrian-Caceres’ mother, Katty Caceres, claimed in the lawsuit that she was prohibited from seeing her daughter. Ms. Caceres spoke with five different employees, four of whom had only their first names on their badges. Each of them reportedly said that they could not help, or that the plaintiff “would be in there for some time” and that it was Dr. Hyatt’s decision regarding how long that would be, according to court documents.

Katty Caceres hired a local attorney named Aaron Cash to represent her daughter. On Jan. 20, 2022, Mr. Cash faxed a letter to the hospital demanding her release. When Ms. Caceres arrived to pick up her daughter, she claimed that staff members indicated that the daughter was there voluntarily and refused to release her “at the direction of Dr Hyatt.” During a phone call later that day, the plaintiff told her mother that her status was being changed to an involuntary hold, court documents show.

“At one point she was threatened with the longer time in there if she kept asking to leave,” Mr. Cash told this news organization. In addition, staff members reportedly told Ms. Adrian-Caceres that the “judge always sided with Dr Hyatt” and she “would get way longer there, 30-45 days if [she] went before the judge,” according to Mr. Cash.

Mr. Cash said nine other patients have contacted his firm with similar allegations against Dr. Hyatt.

“We’ve talked to many people that have experienced the same threats,” Mr. Cash said. “When they’re asking to leave, they get these threats, they get coerced … and they’re never taken to court. They’re never given opportunity to talk to a judge or to have a public defender appointed.”
 

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

As chair of the Arkansas State Medical Board, Brian T. Hyatt, MD, often sat in judgment of other physicians. Now, state officials are investigating the psychiatrist for alleged Medicaid fraud. He has stepped down as board chair, and state officials have suspended all Medicaid payments to Dr. Hyatt and his practice, Pinnacle Premier Psychiatry in Rogers, Arkansas.

Dr. Hyatt billed 99.95% of the claims for his patients’ hospital care to Medicaid at the highest severity level, according to an affidavit filed by an investigator with the Medicaid Fraud Control Unit, Arkansas Attorney General’s Office. Other Arkansas psychiatrists billed that same level in only about 39% of claims, the affidavit states.

The possible upcoding alleged in the affidavit was a red flag that prompted the state to temporarily suspend Dr. Hyatt’s Medicaid payments.

Dr. Hyatt has until this Friday to file an appeal. He did not respond to requests from this news organization for comment.

The affidavit pointed to other concerns. For example, a whistleblower who worked at the Northwest Medical Center where Dr. Hyatt admitted patients claimed that Dr. Hyatt was only on the floor a few minutes a day and that he had no contact with patients. A review of hundreds of hours of video by state investigators revealed that Dr. Hyatt did not enter patients’ rooms, nor did he have any contact with patients, according to the affidavit. Dr. Hyatt served as the hospital’s behavioral unit director from 2018 until his contract was abruptly terminated in May 2022, according to the affidavit.

However, Dr. Hyatt claimed to have conducted daily face-to-face evaluation and management with patients, according to the affidavit. In addition, the whistleblower claimed that Dr. Hyatt did not want patients to know his name and instructed staff to cover up his name on patient armbands.
 

Detaining patients

Dr. Hyatt also faces accusations that he held patients against their will, according to civil lawsuits filed in Washington County, Ark., reports the Arkansas Advocate. 

Karla Adrian-Caceres filed suit on Jan. 17. Ms. Adrian-Caceres also named Brooke Green, Northwest Arkansas Hospitals, and 25 unidentified hospital employees as defendants.

According to the complaint, Ms. Adrian-Caceres, an engineering student at the University of Arkansas, arrived at the Northwest Medical Emergency Department after accidentally taking too many Tylenol on Jan. 18, 2022. She was then taken by ambulance to a Northwest psychiatric facility in Springdale, court records show.

According to the complaint, Ms. Adrian-Caceres said that she was given a sedative and asked to sign consent for admission while on the way to Northwest. She said that she “signed some documents without being able to read or understand them at the time.”

When she asked when she could go home, Ms. Adrian-Caceres said, “more than one employee told her there was a minimum stay and that if she asked to leave, they would take her to court where a judge would give her a longer stay because the judge always sides with Dr. Hyatt and Northwest,” according to court documents. Northwest employees stripped Ms. Adrian-Caceres, searched her body, took all of her possessions from her and issued underwear and a uniform, according to the lawsuit.

Ms. Adrian-Caceres’ mother, Katty Caceres, claimed in the lawsuit that she was prohibited from seeing her daughter. Ms. Caceres spoke with five different employees, four of whom had only their first names on their badges. Each of them reportedly said that they could not help, or that the plaintiff “would be in there for some time” and that it was Dr. Hyatt’s decision regarding how long that would be, according to court documents.

Katty Caceres hired a local attorney named Aaron Cash to represent her daughter. On Jan. 20, 2022, Mr. Cash faxed a letter to the hospital demanding her release. When Ms. Caceres arrived to pick up her daughter, she claimed that staff members indicated that the daughter was there voluntarily and refused to release her “at the direction of Dr Hyatt.” During a phone call later that day, the plaintiff told her mother that her status was being changed to an involuntary hold, court documents show.

“At one point she was threatened with the longer time in there if she kept asking to leave,” Mr. Cash told this news organization. In addition, staff members reportedly told Ms. Adrian-Caceres that the “judge always sided with Dr Hyatt” and she “would get way longer there, 30-45 days if [she] went before the judge,” according to Mr. Cash.

Mr. Cash said nine other patients have contacted his firm with similar allegations against Dr. Hyatt.

“We’ve talked to many people that have experienced the same threats,” Mr. Cash said. “When they’re asking to leave, they get these threats, they get coerced … and they’re never taken to court. They’re never given opportunity to talk to a judge or to have a public defender appointed.”
 

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

As chair of the Arkansas State Medical Board, Brian T. Hyatt, MD, often sat in judgment of other physicians. Now, state officials are investigating the psychiatrist for alleged Medicaid fraud. He has stepped down as board chair, and state officials have suspended all Medicaid payments to Dr. Hyatt and his practice, Pinnacle Premier Psychiatry in Rogers, Arkansas.

Dr. Hyatt billed 99.95% of the claims for his patients’ hospital care to Medicaid at the highest severity level, according to an affidavit filed by an investigator with the Medicaid Fraud Control Unit, Arkansas Attorney General’s Office. Other Arkansas psychiatrists billed that same level in only about 39% of claims, the affidavit states.

The possible upcoding alleged in the affidavit was a red flag that prompted the state to temporarily suspend Dr. Hyatt’s Medicaid payments.

Dr. Hyatt has until this Friday to file an appeal. He did not respond to requests from this news organization for comment.

The affidavit pointed to other concerns. For example, a whistleblower who worked at the Northwest Medical Center where Dr. Hyatt admitted patients claimed that Dr. Hyatt was only on the floor a few minutes a day and that he had no contact with patients. A review of hundreds of hours of video by state investigators revealed that Dr. Hyatt did not enter patients’ rooms, nor did he have any contact with patients, according to the affidavit. Dr. Hyatt served as the hospital’s behavioral unit director from 2018 until his contract was abruptly terminated in May 2022, according to the affidavit.

However, Dr. Hyatt claimed to have conducted daily face-to-face evaluation and management with patients, according to the affidavit. In addition, the whistleblower claimed that Dr. Hyatt did not want patients to know his name and instructed staff to cover up his name on patient armbands.
 

Detaining patients

Dr. Hyatt also faces accusations that he held patients against their will, according to civil lawsuits filed in Washington County, Ark., reports the Arkansas Advocate. 

Karla Adrian-Caceres filed suit on Jan. 17. Ms. Adrian-Caceres also named Brooke Green, Northwest Arkansas Hospitals, and 25 unidentified hospital employees as defendants.

According to the complaint, Ms. Adrian-Caceres, an engineering student at the University of Arkansas, arrived at the Northwest Medical Emergency Department after accidentally taking too many Tylenol on Jan. 18, 2022. She was then taken by ambulance to a Northwest psychiatric facility in Springdale, court records show.

According to the complaint, Ms. Adrian-Caceres said that she was given a sedative and asked to sign consent for admission while on the way to Northwest. She said that she “signed some documents without being able to read or understand them at the time.”

When she asked when she could go home, Ms. Adrian-Caceres said, “more than one employee told her there was a minimum stay and that if she asked to leave, they would take her to court where a judge would give her a longer stay because the judge always sides with Dr. Hyatt and Northwest,” according to court documents. Northwest employees stripped Ms. Adrian-Caceres, searched her body, took all of her possessions from her and issued underwear and a uniform, according to the lawsuit.

Ms. Adrian-Caceres’ mother, Katty Caceres, claimed in the lawsuit that she was prohibited from seeing her daughter. Ms. Caceres spoke with five different employees, four of whom had only their first names on their badges. Each of them reportedly said that they could not help, or that the plaintiff “would be in there for some time” and that it was Dr. Hyatt’s decision regarding how long that would be, according to court documents.

Katty Caceres hired a local attorney named Aaron Cash to represent her daughter. On Jan. 20, 2022, Mr. Cash faxed a letter to the hospital demanding her release. When Ms. Caceres arrived to pick up her daughter, she claimed that staff members indicated that the daughter was there voluntarily and refused to release her “at the direction of Dr Hyatt.” During a phone call later that day, the plaintiff told her mother that her status was being changed to an involuntary hold, court documents show.

“At one point she was threatened with the longer time in there if she kept asking to leave,” Mr. Cash told this news organization. In addition, staff members reportedly told Ms. Adrian-Caceres that the “judge always sided with Dr Hyatt” and she “would get way longer there, 30-45 days if [she] went before the judge,” according to Mr. Cash.

Mr. Cash said nine other patients have contacted his firm with similar allegations against Dr. Hyatt.

“We’ve talked to many people that have experienced the same threats,” Mr. Cash said. “When they’re asking to leave, they get these threats, they get coerced … and they’re never taken to court. They’re never given opportunity to talk to a judge or to have a public defender appointed.”
 

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

DENVER – People with lower expectations of how they would be able to use their knees during work activities after a total knee arthroplasty were more dissatisfied with their knee abilities 6 months after their surgery, according to a study presented at the OARSI 2023 World Congress.

Two out of 10 patients are dissatisfied after total knee arthroplasty, which is increasingly performed in younger and working patients who may have higher demands, presenter Yvonne van Zaanen, a physiotherapist in occupational health and ergonomics and a PhD candidate at Amsterdam University Medical Center, told attendees.

The findings suggest a correlation between patients’ low presurgical expectations of their ability to use their knees and having more difficulty with their knees postoperatively, she said. “We should take better care of working patients with low expectations by managing their preoperative expectations and improving their ability to perform work-related knee-straining activities in rehabilitation,” Ms. van Zaanen told attendees.

The researchers conducted a multicenter, prospective cohort study involving seven hospitals. They surveyed 175 employed individuals aged 18-65 years who were scheduled for a total knee arthroplasty and intended to return to work after their surgery. The first survey occurred before the operation, and the follow-up occurred 6 months after the surgery.

Just over half the participants were women (53%), and the average participant age was 59. Respondents had a mean body mass index (BMI) of 29 kg/m², and had a Knee injury and Osteoarthritis Outcome Score (KOOS) pain score of 42 (on a 0-to-100 scale in which lower scores are worse). About half the respondents (51%) had a job that involved knee-straining activities.

The researchers assessed participants’ ability to perform work-related, knee-straining activities using the Work, Osteoarthritis, or joint-Replacement Questionnaire (WORQ) tool, which considers the following activities: kneeling, crouching, clambering, taking the stairs, walking on rough terrain, working with hands below knee height, standing, lifting or carrying, pushing or pulling, walking on ground level, operating a vehicle, operating foot pedals, and sitting. The 0-to-100 scale rates the difficulty of using knees for each particular activity, with higher scores indicating greater ease and less pain in doing that activity.

Among the 107 patients who expected to be satisfied after their surgery, half (n = 53) were satisfied, compared with 12% (n = 13) who were unsatisfied; the remaining participants (n = 41, 38%) were neither satisfied nor dissatisfied. Among the 24 patients who expected to be dissatisfied after their surgery, one-third (n = 8) were satisfied and 42% (n = 10) were dissatisfied. The remaining 44 patients didn’t expect to be satisfied or dissatisfied before their surgery, and 41% of them were satisfied while 23% were dissatisfied.

The researchers found that patients’ expectation of their satisfaction level going into the surgery was the only preoperative factor to be prognostic for dissatisfaction 6 months after surgery, based on their WORQ score. That is, patients who expected to be dissatisfied before their surgery had approximately five times greater odds of being dissatisfied after their surgery than did those who expected to be satisfied with their ability to do knee-straining activities at work (odds ratio, 5.1; 95% confidence interval, 1.7-15.5). Among those with a WORQ score of 40, indicating a greater expectation of difficulty using their knees postoperatively, 55% were dissatisfied after their surgery, compared with 19% of those with a WORQ score of 85, who expected greater knee ability after their surgery.

The other factors that the researchers examined, which had no effect on WORQ scores, included age, sex, BMI, education, comorbidities, KOOS pain subscale, having a knee-straining job, having needed surgery because of work, or having preoperative sick leave.

One discussion prompted by the presentation focused specifically on individuals’ ability to kneel without much difficulty after their surgery, an activity that’s not typically considered likely, Ms. van Zaanen noted. One audience member, Gillian Hawker, MD, MSc, a professor of medicine in the division of rheumatology at the University of Toronto, questioned whether the field should accept that current reality from surgical intervention. Dr. Hawker described a cohort she had analyzed in which two-thirds of the participants had expected they would be able to kneel after their surgery, regardless of whether it was related to work or other activities.

“Kneeling is important, not just for work; it’s important for culture and religion and lots of other things,” Dr. Hawker said. “How will you help these people to kneel after knee replacement when the surgery isn’t really performed to enable people to do that?” In response, Ms. van Zaanen noted it might not be achievable, as the research literature demonstrates, but Dr. Hawker suggested that is itself problematic.

“I guess what I’m asking is, why are we settling for that? If it’s important to so many people, and an expectation of so many people, why don’t we technologically improve such that, post arthroplasty, people can kneel?”

Another commenter suggested that the study’s findings may not indicate a need to manage patients’ expectations prior to surgery so much as showing that some patients simply have realistic expectations of what they will and will not be able to do after knee replacement.

“Is it possible that people who had low expectations – those who expected to be dissatisfied afterwards – were appropriately understanding that they were likely to be dissatisfied afterwards, in which case, managing their expectations might do nothing for their dissatisfaction afterwards?” the commenter asked. It is likely necessary to conduct additional research about expectations before surgery and experiences after surgery to address that question, Ms. van Zaanen suggested.

Ms. van Zaanen and Dr. Hawker reported having no relevant financial relationships. The presentation did not note any external funding. The Congress was sponsored by the Osteoarthritis Research Society International.

DENVER – People with lower expectations of how they would be able to use their knees during work activities after a total knee arthroplasty were more dissatisfied with their knee abilities 6 months after their surgery, according to a study presented at the OARSI 2023 World Congress.

Two out of 10 patients are dissatisfied after total knee arthroplasty, which is increasingly performed in younger and working patients who may have higher demands, presenter Yvonne van Zaanen, a physiotherapist in occupational health and ergonomics and a PhD candidate at Amsterdam University Medical Center, told attendees.

The findings suggest a correlation between patients’ low presurgical expectations of their ability to use their knees and having more difficulty with their knees postoperatively, she said. “We should take better care of working patients with low expectations by managing their preoperative expectations and improving their ability to perform work-related knee-straining activities in rehabilitation,” Ms. van Zaanen told attendees.

The researchers conducted a multicenter, prospective cohort study involving seven hospitals. They surveyed 175 employed individuals aged 18-65 years who were scheduled for a total knee arthroplasty and intended to return to work after their surgery. The first survey occurred before the operation, and the follow-up occurred 6 months after the surgery.

Just over half the participants were women (53%), and the average participant age was 59. Respondents had a mean body mass index (BMI) of 29 kg/m², and had a Knee injury and Osteoarthritis Outcome Score (KOOS) pain score of 42 (on a 0-to-100 scale in which lower scores are worse). About half the respondents (51%) had a job that involved knee-straining activities.

The researchers assessed participants’ ability to perform work-related, knee-straining activities using the Work, Osteoarthritis, or joint-Replacement Questionnaire (WORQ) tool, which considers the following activities: kneeling, crouching, clambering, taking the stairs, walking on rough terrain, working with hands below knee height, standing, lifting or carrying, pushing or pulling, walking on ground level, operating a vehicle, operating foot pedals, and sitting. The 0-to-100 scale rates the difficulty of using knees for each particular activity, with higher scores indicating greater ease and less pain in doing that activity.

Among the 107 patients who expected to be satisfied after their surgery, half (n = 53) were satisfied, compared with 12% (n = 13) who were unsatisfied; the remaining participants (n = 41, 38%) were neither satisfied nor dissatisfied. Among the 24 patients who expected to be dissatisfied after their surgery, one-third (n = 8) were satisfied and 42% (n = 10) were dissatisfied. The remaining 44 patients didn’t expect to be satisfied or dissatisfied before their surgery, and 41% of them were satisfied while 23% were dissatisfied.

The researchers found that patients’ expectation of their satisfaction level going into the surgery was the only preoperative factor to be prognostic for dissatisfaction 6 months after surgery, based on their WORQ score. That is, patients who expected to be dissatisfied before their surgery had approximately five times greater odds of being dissatisfied after their surgery than did those who expected to be satisfied with their ability to do knee-straining activities at work (odds ratio, 5.1; 95% confidence interval, 1.7-15.5). Among those with a WORQ score of 40, indicating a greater expectation of difficulty using their knees postoperatively, 55% were dissatisfied after their surgery, compared with 19% of those with a WORQ score of 85, who expected greater knee ability after their surgery.

The other factors that the researchers examined, which had no effect on WORQ scores, included age, sex, BMI, education, comorbidities, KOOS pain subscale, having a knee-straining job, having needed surgery because of work, or having preoperative sick leave.

One discussion prompted by the presentation focused specifically on individuals’ ability to kneel without much difficulty after their surgery, an activity that’s not typically considered likely, Ms. van Zaanen noted. One audience member, Gillian Hawker, MD, MSc, a professor of medicine in the division of rheumatology at the University of Toronto, questioned whether the field should accept that current reality from surgical intervention. Dr. Hawker described a cohort she had analyzed in which two-thirds of the participants had expected they would be able to kneel after their surgery, regardless of whether it was related to work or other activities.

“Kneeling is important, not just for work; it’s important for culture and religion and lots of other things,” Dr. Hawker said. “How will you help these people to kneel after knee replacement when the surgery isn’t really performed to enable people to do that?” In response, Ms. van Zaanen noted it might not be achievable, as the research literature demonstrates, but Dr. Hawker suggested that is itself problematic.

“I guess what I’m asking is, why are we settling for that? If it’s important to so many people, and an expectation of so many people, why don’t we technologically improve such that, post arthroplasty, people can kneel?”

Another commenter suggested that the study’s findings may not indicate a need to manage patients’ expectations prior to surgery so much as showing that some patients simply have realistic expectations of what they will and will not be able to do after knee replacement.

“Is it possible that people who had low expectations – those who expected to be dissatisfied afterwards – were appropriately understanding that they were likely to be dissatisfied afterwards, in which case, managing their expectations might do nothing for their dissatisfaction afterwards?” the commenter asked. It is likely necessary to conduct additional research about expectations before surgery and experiences after surgery to address that question, Ms. van Zaanen suggested.

Ms. van Zaanen and Dr. Hawker reported having no relevant financial relationships. The presentation did not note any external funding. The Congress was sponsored by the Osteoarthritis Research Society International.

DENVER – People with lower expectations of how they would be able to use their knees during work activities after a total knee arthroplasty were more dissatisfied with their knee abilities 6 months after their surgery, according to a study presented at the OARSI 2023 World Congress.

Two out of 10 patients are dissatisfied after total knee arthroplasty, which is increasingly performed in younger and working patients who may have higher demands, presenter Yvonne van Zaanen, a physiotherapist in occupational health and ergonomics and a PhD candidate at Amsterdam University Medical Center, told attendees.

The findings suggest a correlation between patients’ low presurgical expectations of their ability to use their knees and having more difficulty with their knees postoperatively, she said. “We should take better care of working patients with low expectations by managing their preoperative expectations and improving their ability to perform work-related knee-straining activities in rehabilitation,” Ms. van Zaanen told attendees.

The researchers conducted a multicenter, prospective cohort study involving seven hospitals. They surveyed 175 employed individuals aged 18-65 years who were scheduled for a total knee arthroplasty and intended to return to work after their surgery. The first survey occurred before the operation, and the follow-up occurred 6 months after the surgery.

Just over half the participants were women (53%), and the average participant age was 59. Respondents had a mean body mass index (BMI) of 29 kg/m², and had a Knee injury and Osteoarthritis Outcome Score (KOOS) pain score of 42 (on a 0-to-100 scale in which lower scores are worse). About half the respondents (51%) had a job that involved knee-straining activities.

The researchers assessed participants’ ability to perform work-related, knee-straining activities using the Work, Osteoarthritis, or joint-Replacement Questionnaire (WORQ) tool, which considers the following activities: kneeling, crouching, clambering, taking the stairs, walking on rough terrain, working with hands below knee height, standing, lifting or carrying, pushing or pulling, walking on ground level, operating a vehicle, operating foot pedals, and sitting. The 0-to-100 scale rates the difficulty of using knees for each particular activity, with higher scores indicating greater ease and less pain in doing that activity.

Among the 107 patients who expected to be satisfied after their surgery, half (n = 53) were satisfied, compared with 12% (n = 13) who were unsatisfied; the remaining participants (n = 41, 38%) were neither satisfied nor dissatisfied. Among the 24 patients who expected to be dissatisfied after their surgery, one-third (n = 8) were satisfied and 42% (n = 10) were dissatisfied. The remaining 44 patients didn’t expect to be satisfied or dissatisfied before their surgery, and 41% of them were satisfied while 23% were dissatisfied.

The researchers found that patients’ expectation of their satisfaction level going into the surgery was the only preoperative factor to be prognostic for dissatisfaction 6 months after surgery, based on their WORQ score. That is, patients who expected to be dissatisfied before their surgery had approximately five times greater odds of being dissatisfied after their surgery than did those who expected to be satisfied with their ability to do knee-straining activities at work (odds ratio, 5.1; 95% confidence interval, 1.7-15.5). Among those with a WORQ score of 40, indicating a greater expectation of difficulty using their knees postoperatively, 55% were dissatisfied after their surgery, compared with 19% of those with a WORQ score of 85, who expected greater knee ability after their surgery.

The other factors that the researchers examined, which had no effect on WORQ scores, included age, sex, BMI, education, comorbidities, KOOS pain subscale, having a knee-straining job, having needed surgery because of work, or having preoperative sick leave.

One discussion prompted by the presentation focused specifically on individuals’ ability to kneel without much difficulty after their surgery, an activity that’s not typically considered likely, Ms. van Zaanen noted. One audience member, Gillian Hawker, MD, MSc, a professor of medicine in the division of rheumatology at the University of Toronto, questioned whether the field should accept that current reality from surgical intervention. Dr. Hawker described a cohort she had analyzed in which two-thirds of the participants had expected they would be able to kneel after their surgery, regardless of whether it was related to work or other activities.

“Kneeling is important, not just for work; it’s important for culture and religion and lots of other things,” Dr. Hawker said. “How will you help these people to kneel after knee replacement when the surgery isn’t really performed to enable people to do that?” In response, Ms. van Zaanen noted it might not be achievable, as the research literature demonstrates, but Dr. Hawker suggested that is itself problematic.

“I guess what I’m asking is, why are we settling for that? If it’s important to so many people, and an expectation of so many people, why don’t we technologically improve such that, post arthroplasty, people can kneel?”

Another commenter suggested that the study’s findings may not indicate a need to manage patients’ expectations prior to surgery so much as showing that some patients simply have realistic expectations of what they will and will not be able to do after knee replacement.

“Is it possible that people who had low expectations – those who expected to be dissatisfied afterwards – were appropriately understanding that they were likely to be dissatisfied afterwards, in which case, managing their expectations might do nothing for their dissatisfaction afterwards?” the commenter asked. It is likely necessary to conduct additional research about expectations before surgery and experiences after surgery to address that question, Ms. van Zaanen suggested.

Ms. van Zaanen and Dr. Hawker reported having no relevant financial relationships. The presentation did not note any external funding. The Congress was sponsored by the Osteoarthritis Research Society International.

Datascope/Getinge is recalling certain Cardiosave Hybrid and Cardiosave Rescue Intra-Aortic Balloon Pumps (IABPs) because the coiled cable connecting the display and base on some units may fail, causing an unexpected shutdown without warnings or alarms to alert the user.

The U.S. Food and Drug Administration has identified this as a class I recall, the most serious type of recall, because of the risk for serious injury or death.

The FDA warns that an unexpected pump shutdown and any interruption to therapy that occurs can lead to hemodynamic instability, organ damage, and/or death, especially in patients who are critically ill and most likely to receive therapy using these devices.

Wikimedia Commons/FitzColinGerald/Creative Commons License

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

Datascope/Getinge is recalling certain Cardiosave Hybrid and Cardiosave Rescue Intra-Aortic Balloon Pumps (IABPs) because the coiled cable connecting the display and base on some units may fail, causing an unexpected shutdown without warnings or alarms to alert the user.

The U.S. Food and Drug Administration has identified this as a class I recall, the most serious type of recall, because of the risk for serious injury or death.

The FDA warns that an unexpected pump shutdown and any interruption to therapy that occurs can lead to hemodynamic instability, organ damage, and/or death, especially in patients who are critically ill and most likely to receive therapy using these devices.

Wikimedia Commons/FitzColinGerald/Creative Commons License

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

Datascope/Getinge is recalling certain Cardiosave Hybrid and Cardiosave Rescue Intra-Aortic Balloon Pumps (IABPs) because the coiled cable connecting the display and base on some units may fail, causing an unexpected shutdown without warnings or alarms to alert the user.

The U.S. Food and Drug Administration has identified this as a class I recall, the most serious type of recall, because of the risk for serious injury or death.

The FDA warns that an unexpected pump shutdown and any interruption to therapy that occurs can lead to hemodynamic instability, organ damage, and/or death, especially in patients who are critically ill and most likely to receive therapy using these devices.

Wikimedia Commons/FitzColinGerald/Creative Commons License

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

Long-distance runners are often warned that they are wearing out their joints, but a new study found that running mileage, frequency, and pace were not associated with an increased risk of osteoarthritis.

Runners who had undergone knee or hip surgery or had a previous hip or knee injury that prevented running were most likely to have arthritis, researchers found. Family history of arthritis, higher body mass index (BMI), and older age were also associated with increased risk of the condition.

The study was presented at the American Academy of Orthopaedic Surgeons 2023 Annual Meeting.

It has generally been thought that running may increase risk of osteoarthritis because it puts more load on joints than walking or standing, noted Grace Hsiao-Wei Lo, MD, an assistant professor of immunology, allergy, and rheumatology at the Baylor College of Medicine, Houston, who was not involved with the work. Research in this area has yielded mixed results: A 2017 analysis of multiple studies found that competitive runners did have higher rates of arthritis than recreational runners, while another study conducted by Dr. Lo found that runners did not have an increased risk of knee osteoarthritis, compared with nonrunners. A 2018 study showed that marathon runners had lower instances of arthritis, compared with the general population.

In this new study, researchers surveyed 3,804 runners who participated in the 2019 or 2021 Chicago Marathon about their running history, average mileage per week, and average running pace. The survey also asked about known risk factors for osteoarthritis, including BMI, family history of arthritis, and past knee and hip injuries that prevented running.

Runners, on average, were about 44 years old and ran 27.9 miles per week. The largest proportion of respondents had completed 2-5 marathons (37.3%), around 21% of respondents had finished 6-10 marathons, and 17% were running their first marathon. Study participants had an average of 15 years of running experience, 1,892 reported a previous hip or knee injury, and 413 had undergone knee or hip surgery. Overall, 36.4% reported experiencing hip or knee pain in the past year, and 7.3% had been diagnosed with arthritis.

Researchers found that there was no association between the risk of osteoarthritis and weekly mileage, years spent running, number of marathons completed, or running pace. Respondents who had undergone knee or hip surgery had the highest risk of osteoarthritis (odds ratio, 5.85; P < .0001), followed by those with a history of knee or hip injuries that prevented running (OR, 5.04; P < .0001). Other identified risk factors were family history of arthritis (OR, 3.47; P < .0001), BMI (OR, 1.10; P < .0001), and older age (OR, 1.08; P < .0001).

The news should be encouraging for runners, said Matthew Hartwell, MD, an orthopedic surgeon at the University of California, San Francisco, who led the research. If someone does not have injuries or surgeries that keep them from running, “you can still continue to run,” he said. “There may not necessarily be this dose-response relationship where the more you run, the more you break down your knee or your hip.”

Still, 24.2% of runners reported that their physician had advised them to reduce their mileage or stop running altogether. Most runners (94.2%) said they planned to run another marathon.

“The results of this study are consistent with the experiences of many lifelong runners and observations of sports medicine professionals that osteoarthritis is not an inevitable consequence of distance running,” said Brett Toresdahl, MD, a sports medicine physician at the Hospital for Special Surgery in New York, who was not involved with the study.

Still, he emphasized that more research is necessary to understand whether running contributes to the risk of developing osteoarthritis. The participants in the study were current marathoners, he noted, so it is likely they have healthy joints that can tolerate running longer distances. “If there is a subset of people who have joints that are negatively affected by running, they wouldn’t likely be registering for a marathon,” he said in an email interview.

Dr. Lo added that comparing these marathoners to a group who did not run would help assess whether running can be harmful to joints. “To be fair, this is a challenging subject to study,” she said. “Osteoarthritis has a long natural history, and so it is difficult to evaluate this kind of question over many years of running and many years of evaluation of arthritis.”

While the research does not answer the question of whether running can lead to osteoarthritis, it helps show the need for long-term research on how running affects joints over time as well as one’s general health, Dr. Toresdahl noted. “I would not be surprised if future longitudinal research will come to the same conclusion that running for the majority of patients is a net benefit for overall health and at least net neutral for joint health when done in moderation,” he said.

Dr. Hartwell, Dr. Lo, and Dr. Toresdahl report no relevant financial relationships.

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

Long-distance runners are often warned that they are wearing out their joints, but a new study found that running mileage, frequency, and pace were not associated with an increased risk of osteoarthritis.

Runners who had undergone knee or hip surgery or had a previous hip or knee injury that prevented running were most likely to have arthritis, researchers found. Family history of arthritis, higher body mass index (BMI), and older age were also associated with increased risk of the condition.

The study was presented at the American Academy of Orthopaedic Surgeons 2023 Annual Meeting.

It has generally been thought that running may increase risk of osteoarthritis because it puts more load on joints than walking or standing, noted Grace Hsiao-Wei Lo, MD, an assistant professor of immunology, allergy, and rheumatology at the Baylor College of Medicine, Houston, who was not involved with the work. Research in this area has yielded mixed results: A 2017 analysis of multiple studies found that competitive runners did have higher rates of arthritis than recreational runners, while another study conducted by Dr. Lo found that runners did not have an increased risk of knee osteoarthritis, compared with nonrunners. A 2018 study showed that marathon runners had lower instances of arthritis, compared with the general population.

In this new study, researchers surveyed 3,804 runners who participated in the 2019 or 2021 Chicago Marathon about their running history, average mileage per week, and average running pace. The survey also asked about known risk factors for osteoarthritis, including BMI, family history of arthritis, and past knee and hip injuries that prevented running.

Runners, on average, were about 44 years old and ran 27.9 miles per week. The largest proportion of respondents had completed 2-5 marathons (37.3%), around 21% of respondents had finished 6-10 marathons, and 17% were running their first marathon. Study participants had an average of 15 years of running experience, 1,892 reported a previous hip or knee injury, and 413 had undergone knee or hip surgery. Overall, 36.4% reported experiencing hip or knee pain in the past year, and 7.3% had been diagnosed with arthritis.

Researchers found that there was no association between the risk of osteoarthritis and weekly mileage, years spent running, number of marathons completed, or running pace. Respondents who had undergone knee or hip surgery had the highest risk of osteoarthritis (odds ratio, 5.85; P < .0001), followed by those with a history of knee or hip injuries that prevented running (OR, 5.04; P < .0001). Other identified risk factors were family history of arthritis (OR, 3.47; P < .0001), BMI (OR, 1.10; P < .0001), and older age (OR, 1.08; P < .0001).

The news should be encouraging for runners, said Matthew Hartwell, MD, an orthopedic surgeon at the University of California, San Francisco, who led the research. If someone does not have injuries or surgeries that keep them from running, “you can still continue to run,” he said. “There may not necessarily be this dose-response relationship where the more you run, the more you break down your knee or your hip.”

Still, 24.2% of runners reported that their physician had advised them to reduce their mileage or stop running altogether. Most runners (94.2%) said they planned to run another marathon.

“The results of this study are consistent with the experiences of many lifelong runners and observations of sports medicine professionals that osteoarthritis is not an inevitable consequence of distance running,” said Brett Toresdahl, MD, a sports medicine physician at the Hospital for Special Surgery in New York, who was not involved with the study.

Still, he emphasized that more research is necessary to understand whether running contributes to the risk of developing osteoarthritis. The participants in the study were current marathoners, he noted, so it is likely they have healthy joints that can tolerate running longer distances. “If there is a subset of people who have joints that are negatively affected by running, they wouldn’t likely be registering for a marathon,” he said in an email interview.

Dr. Lo added that comparing these marathoners to a group who did not run would help assess whether running can be harmful to joints. “To be fair, this is a challenging subject to study,” she said. “Osteoarthritis has a long natural history, and so it is difficult to evaluate this kind of question over many years of running and many years of evaluation of arthritis.”

While the research does not answer the question of whether running can lead to osteoarthritis, it helps show the need for long-term research on how running affects joints over time as well as one’s general health, Dr. Toresdahl noted. “I would not be surprised if future longitudinal research will come to the same conclusion that running for the majority of patients is a net benefit for overall health and at least net neutral for joint health when done in moderation,” he said.

Dr. Hartwell, Dr. Lo, and Dr. Toresdahl report no relevant financial relationships.

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

Long-distance runners are often warned that they are wearing out their joints, but a new study found that running mileage, frequency, and pace were not associated with an increased risk of osteoarthritis.

Runners who had undergone knee or hip surgery or had a previous hip or knee injury that prevented running were most likely to have arthritis, researchers found. Family history of arthritis, higher body mass index (BMI), and older age were also associated with increased risk of the condition.

The study was presented at the American Academy of Orthopaedic Surgeons 2023 Annual Meeting.

It has generally been thought that running may increase risk of osteoarthritis because it puts more load on joints than walking or standing, noted Grace Hsiao-Wei Lo, MD, an assistant professor of immunology, allergy, and rheumatology at the Baylor College of Medicine, Houston, who was not involved with the work. Research in this area has yielded mixed results: A 2017 analysis of multiple studies found that competitive runners did have higher rates of arthritis than recreational runners, while another study conducted by Dr. Lo found that runners did not have an increased risk of knee osteoarthritis, compared with nonrunners. A 2018 study showed that marathon runners had lower instances of arthritis, compared with the general population.

In this new study, researchers surveyed 3,804 runners who participated in the 2019 or 2021 Chicago Marathon about their running history, average mileage per week, and average running pace. The survey also asked about known risk factors for osteoarthritis, including BMI, family history of arthritis, and past knee and hip injuries that prevented running.

Runners, on average, were about 44 years old and ran 27.9 miles per week. The largest proportion of respondents had completed 2-5 marathons (37.3%), around 21% of respondents had finished 6-10 marathons, and 17% were running their first marathon. Study participants had an average of 15 years of running experience, 1,892 reported a previous hip or knee injury, and 413 had undergone knee or hip surgery. Overall, 36.4% reported experiencing hip or knee pain in the past year, and 7.3% had been diagnosed with arthritis.

Researchers found that there was no association between the risk of osteoarthritis and weekly mileage, years spent running, number of marathons completed, or running pace. Respondents who had undergone knee or hip surgery had the highest risk of osteoarthritis (odds ratio, 5.85; P < .0001), followed by those with a history of knee or hip injuries that prevented running (OR, 5.04; P < .0001). Other identified risk factors were family history of arthritis (OR, 3.47; P < .0001), BMI (OR, 1.10; P < .0001), and older age (OR, 1.08; P < .0001).

The news should be encouraging for runners, said Matthew Hartwell, MD, an orthopedic surgeon at the University of California, San Francisco, who led the research. If someone does not have injuries or surgeries that keep them from running, “you can still continue to run,” he said. “There may not necessarily be this dose-response relationship where the more you run, the more you break down your knee or your hip.”

Still, 24.2% of runners reported that their physician had advised them to reduce their mileage or stop running altogether. Most runners (94.2%) said they planned to run another marathon.

“The results of this study are consistent with the experiences of many lifelong runners and observations of sports medicine professionals that osteoarthritis is not an inevitable consequence of distance running,” said Brett Toresdahl, MD, a sports medicine physician at the Hospital for Special Surgery in New York, who was not involved with the study.

Still, he emphasized that more research is necessary to understand whether running contributes to the risk of developing osteoarthritis. The participants in the study were current marathoners, he noted, so it is likely they have healthy joints that can tolerate running longer distances. “If there is a subset of people who have joints that are negatively affected by running, they wouldn’t likely be registering for a marathon,” he said in an email interview.

Dr. Lo added that comparing these marathoners to a group who did not run would help assess whether running can be harmful to joints. “To be fair, this is a challenging subject to study,” she said. “Osteoarthritis has a long natural history, and so it is difficult to evaluate this kind of question over many years of running and many years of evaluation of arthritis.”

While the research does not answer the question of whether running can lead to osteoarthritis, it helps show the need for long-term research on how running affects joints over time as well as one’s general health, Dr. Toresdahl noted. “I would not be surprised if future longitudinal research will come to the same conclusion that running for the majority of patients is a net benefit for overall health and at least net neutral for joint health when done in moderation,” he said.

Dr. Hartwell, Dr. Lo, and Dr. Toresdahl report no relevant financial relationships.

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

Baily Nagle, vice president of her graduating class at Harvard Medical School, Boston, celebrated “the luck of the Irish” on St. Patrick’s Day that allowed her to match into her chosen specialty and top choice of residency programs: anesthesia at Brigham and Women’s Hospital.

“I am feeling very excited and relieved – I matched,” she said in an interview upon hearing her good fortune on Match Monday, March 13. She had a similar reaction on Match Day, March 17. “After a lot of long nights and hard work, happy to have it pay off.”

Ms. Nagle was so determined to match into her specialty that she didn’t have any other specialties in mind as a backup.

The annual process of matching medical school graduates with compatible residency programs is an emotional roller coaster for all applicants, their personal March Madness, so to speak. But Ms. Nagle was one of the more fortunate applicants. She didn’t have to confront the heartbreak other applicants felt when the National Resident Matching Program (NRMP) announced results of the main residency match and the Supplemental Offer and Acceptance Program (SOAP), which offers alternate programs for unfilled positions or unmatched applicants.

During the 2023 Match process, this news organization has been following a handful of students, checking in with them periodically for updates on their progress. Most of them matched successfully, but at least one international medical graduate (IMG) did not. What the others have in common is that their hearts were set on a chosen specialty. Like Ms. Nagle, another student banked on landing his chosen specialty without a backup plan, whereas another said that she’d continue through the SOAP if she didn’t match successfully.

Overall, Match Day resulted in a record number of residency positions offered, most notably in primary care, which “hit an all-time high,” according to NRMP President and CEO Donna L. Lamb, DHSc, MBA, BSN. The number of positions has “consistently increased over the past 5 years, and most importantly the fill rate for primary care has remained steady,” Dr.. Lamb noted in the NRMP release of Match Day results. The release coincided with students learning through emails at noon Eastern Time to which residency or supplemental programs they were matched.

Though more applicants registered for the Match in 2023 than in 2022 – driven primarily by non-U.S. IMGs – the NRMP stated that it was surprised by the decrease in U.S. MD senior applicants.

U.S. MD seniors had a nearly 94% Match rate, a small increase over 2022. U.S. citizen IMGs saw a nearly 68% Match rate, which NRMP reported as an “all-time high” and about six percentage points over in 2022, whereas non-U.S. IMGs had a nearly 60% Match rate, a 1.3 percentage point increase over 2022.

Among the specialties that filled all available positions in 2023 were orthopedic surgery, plastic surgery (integrated), and radiology – diagnostic and thoracic surgery.
 

Not everyone matches

On March 13, the American College of Emergency Physicians issued a joint statement with other emergency medicine (EM) organizations about a high rate of unfilled EM positions expected in 2023.

NRMP acknowledged March 17 that 554 positions remained unfilled, an increase of 335 more unfilled positions than 2022. NRMP attributed the increase in unfilled positions in part to a decrease in the number of U.S. MD and U.S. DO seniors who submitted ranks for the specialty, which “could reflect changing applicant interests or projections about workforce opportunities post residency.”

Applicants who didn’t match usually try to obtain an unfilled position through SOAP. In 2023, 2,685 positions were unfilled after the matching algorithm was processed, an increase of nearly 19% over 2022. The vast majority of those positions were placed in SOAP, an increase of 17.5% over 2022.

Asim Ansari was one of the unlucky ones. Mr. Ansari was trying to match for the fifth time. He was unsuccessful in doing so again in 2023 in the Match and SOAP. Still, he was offered and accepted a child and adolescent psychiatry fellowship at Kansas University Medical Center in Kansas City. Psychiatry was his chosen specialty, so he was “feeling good. It’s a nice place to go to do the next 2 years.”

Mr. Ansari, who started the #MatchMadness support group for unmatched doctors on Twitter Spaces, was quick to cheer on his fellow matching peers on March 13 while revealing his own fate: “Congratulations to everyone who matched!!! Y’all are amazing. So proud of each one of you!!! I didn’t.”

Soon after the results, #MatchMadness held a #Soap2023 support session, and Mr. Ansari sought advice for those willing to review SOAP applications. Elsewhere on Twitter Match Day threads, a few doctors offered their support to those who planned to SOAP, students announced their matches, and others either congratulated or encouraged those still trying to match.
 

Couples match

Not everyone who matched considered the alternative. Before March 13, William Boyer said that he hadn’t given much thought to what would happen if he didn’t match because he was “optimistically confident” he would match into his chosen EM specialty. But he did and got his top choice of programs: Yale New Haven (Conn.) Hospital.

“I feel great,” he said in an interview. “I was definitely nervous opening the envelope” that revealed his residency program, “but there was a rush of relief” when he saw he landed Yale.

Earlier in the match cycle, he said in an interview that he “interviewed at a few ‘reach’ programs, so I hope I don’t match lower than expected on my rank list.”

Mr. Boyer considers himself “a mature applicant,” entering the University of South Carolina, Columbia, after 4 years as an insurance broker.

“I am celebrating today by playing pickleball with a few close medical friends who also matched this morning,” Mr. Boyer said on March 13. “I definitely had periods of nervousness leading up to this morning though that quickly turned into joy and relief” after learning he matched.

Mr. Boyer believes that his professional experience in the insurance industry and health care lobbying efforts with the National Association of Health Underwriters set him apart from other applicants.

“I changed careers to pursue this aspiration, which demonstrates my full dedication to the medical profession.”

He applied to 48 programs and was offered interviews to nearly half. Mr. Boyer visited the majority of those virtually. He said he targeted programs close to where his and his partner’s families are located: Massachusetts, North Carolina, and Texas. “My partner, who I met in medical school, matched into ortho as well so the whole household is very happy,” Mr. Boyer said.

She matched into her top choice as well on March 17, though a distance away at UT Health in San Antonio, he said. “We are both ecstatic. We both got our no. 1 choice. That was the plan going into it. We will make it work. I have 4 weeks of vacation.”

In his program choices, Mr. Boyer prioritized access to nature, minimal leadership turnover, a mix of clinical training sites, and adequate elective rotations and fellowship opportunities, such as in wilderness medicine and health policy.

NRMP reported that there were 1,239 couples participating in the Match; 1,095 had both partners match, and 114 had one partner match to residency training programs for a match rate of 93%.

Like Mr. Boyer, Hannah Hedriana matched into EM, one of the more popular despite the reported unfilled positions. In the past few years, it has consistently been one of the fastest-growing specialties, according to the NRMP.

Still Ms. Hedriana had a fall-back plan. “If I don’t match, then I do plan on going through SOAP. With the number of EM spots that were unfilled in 2022, there’s a chance I could still be an EM physician, but if not, then that’s okay with me.”

Her reaction on March 13, after learning she matched? “Super excited, celebrating with my friends right now.” On Match Day, she said she was “ecstatic” to be matched into Lakeland (Fla.) Regional Health. “This was my first choice so now I can stay close to family and friends,” she said in an interview soon after the results were released.

A first-generation, Filipino American student from the University of South Florida, Tampa, Ms. Hedriana comes from a family of health care professionals. Her father is a respiratory therapist turned physical therapist; her mother a registered nurse. Her sister is a patient care technician applying to nursing school.

Ms. Hedriana applied to 70 programs and interviewed mostly online with 24. Her goal was to stay on the East Coast.

“My partner is a licensed dentist in the state of Florida, and so for his career it would be more practical to stay in state, rather than get relicensed in another state, which could take months,” she said earlier in the matching cycle. “However, when we discussed choosing a residency program, he ultimately left it up to me and wanted me to pick where I thought I’d flourish best,” Ms. Hedriana said, adding that her family lives in Florida, too.

She said she sought a residency program that values family and teamwork.

“A program gets more points in my book if they have sites at nonprofit hospitals or has residents that regularly volunteer throughout their communities or participate in DEI [diversity, equity, and inclusion] initiatives.”

Ms. Hedriana noted that some specialties exclusively offered virtual interviews in 2023, whereas other specialties favored in-person interviews. “This year, many of my classmates were able to do multiple away rotations, which they saw as a positive regarding their chances of matching.” During COVID, in-person visits were limited.

“However, I’ve noticed that many of my classmates are not fond of the signaling aspect that was present for this year’s cycle,” she said. Signaling is a relatively new process that allows applicants to indicate interest in a limited number of residency programs. Not all residencies participate, but it’s growing in popularity among specialties, according to the American Medical Association.
 

‘Extremely competitive’

Ms. Nagle, a second lieutenant in the U.S. Air Force, applied to 12 programs and interviewed with half of them online. She said that she wasn’t targeting any specific type of program through the match.

“I believe you can get phenomenal training anywhere where you mesh with the residents and leadership. My ultimate priority is to (1) be near good people, (2) be near good food (Indian and Thai are a must), and (3) be near an international airport so I can flee the country during breaks.”

Meanwhile, she said that she found the application process, in which students have to articulate their entire medical school experience, extremely competitive. “I think this process is so easy to get wound up in and the anxiety can be palpable,” Ms. Nagle said. “People around you match your energy. So if you are a ball of anxiety then so are your attendings and residents – and that doesn’t bode well for passing the ‘do I want to be on call with them’ test.”

Looking back at medical school, Ms. Nagle recalled having a baby named after her during her first anesthesia rotation and being featured on The Kelly Clarkson Show. Ms. Nagle said that she had walked into the delivery room where new parents had been debating names of babies beginning with the letter B. “And when I introduced myself, they looked at each other and said, ‘Yep, that’s the one.’”

Mr. Boyer recounted how the majority of his medical school experience involved online education. “Roughly two-thirds of my first year was in-person prior to the pandemic. However, from spring break first year to in-person clinical rotations at the beginning of third year, we were all virtual. While I missed interacting with my classmates, I benefited from the virtual learning environment as I learn more efficiently from reading and visual aids than auditory lectures.”

Ms. Hedriana cited the friends and memories she made while learning to be a doctor. “Medical school was hard, but I wouldn’t have changed a thing.”

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

Baily Nagle, vice president of her graduating class at Harvard Medical School, Boston, celebrated “the luck of the Irish” on St. Patrick’s Day that allowed her to match into her chosen specialty and top choice of residency programs: anesthesia at Brigham and Women’s Hospital.

“I am feeling very excited and relieved – I matched,” she said in an interview upon hearing her good fortune on Match Monday, March 13. She had a similar reaction on Match Day, March 17. “After a lot of long nights and hard work, happy to have it pay off.”

Ms. Nagle was so determined to match into her specialty that she didn’t have any other specialties in mind as a backup.

The annual process of matching medical school graduates with compatible residency programs is an emotional roller coaster for all applicants, their personal March Madness, so to speak. But Ms. Nagle was one of the more fortunate applicants. She didn’t have to confront the heartbreak other applicants felt when the National Resident Matching Program (NRMP) announced results of the main residency match and the Supplemental Offer and Acceptance Program (SOAP), which offers alternate programs for unfilled positions or unmatched applicants.

During the 2023 Match process, this news organization has been following a handful of students, checking in with them periodically for updates on their progress. Most of them matched successfully, but at least one international medical graduate (IMG) did not. What the others have in common is that their hearts were set on a chosen specialty. Like Ms. Nagle, another student banked on landing his chosen specialty without a backup plan, whereas another said that she’d continue through the SOAP if she didn’t match successfully.

Overall, Match Day resulted in a record number of residency positions offered, most notably in primary care, which “hit an all-time high,” according to NRMP President and CEO Donna L. Lamb, DHSc, MBA, BSN. The number of positions has “consistently increased over the past 5 years, and most importantly the fill rate for primary care has remained steady,” Dr.. Lamb noted in the NRMP release of Match Day results. The release coincided with students learning through emails at noon Eastern Time to which residency or supplemental programs they were matched.

Though more applicants registered for the Match in 2023 than in 2022 – driven primarily by non-U.S. IMGs – the NRMP stated that it was surprised by the decrease in U.S. MD senior applicants.

U.S. MD seniors had a nearly 94% Match rate, a small increase over 2022. U.S. citizen IMGs saw a nearly 68% Match rate, which NRMP reported as an “all-time high” and about six percentage points over in 2022, whereas non-U.S. IMGs had a nearly 60% Match rate, a 1.3 percentage point increase over 2022.

Among the specialties that filled all available positions in 2023 were orthopedic surgery, plastic surgery (integrated), and radiology – diagnostic and thoracic surgery.
 

Not everyone matches

On March 13, the American College of Emergency Physicians issued a joint statement with other emergency medicine (EM) organizations about a high rate of unfilled EM positions expected in 2023.

NRMP acknowledged March 17 that 554 positions remained unfilled, an increase of 335 more unfilled positions than 2022. NRMP attributed the increase in unfilled positions in part to a decrease in the number of U.S. MD and U.S. DO seniors who submitted ranks for the specialty, which “could reflect changing applicant interests or projections about workforce opportunities post residency.”

Applicants who didn’t match usually try to obtain an unfilled position through SOAP. In 2023, 2,685 positions were unfilled after the matching algorithm was processed, an increase of nearly 19% over 2022. The vast majority of those positions were placed in SOAP, an increase of 17.5% over 2022.

Asim Ansari was one of the unlucky ones. Mr. Ansari was trying to match for the fifth time. He was unsuccessful in doing so again in 2023 in the Match and SOAP. Still, he was offered and accepted a child and adolescent psychiatry fellowship at Kansas University Medical Center in Kansas City. Psychiatry was his chosen specialty, so he was “feeling good. It’s a nice place to go to do the next 2 years.”

Mr. Ansari, who started the #MatchMadness support group for unmatched doctors on Twitter Spaces, was quick to cheer on his fellow matching peers on March 13 while revealing his own fate: “Congratulations to everyone who matched!!! Y’all are amazing. So proud of each one of you!!! I didn’t.”

Soon after the results, #MatchMadness held a #Soap2023 support session, and Mr. Ansari sought advice for those willing to review SOAP applications. Elsewhere on Twitter Match Day threads, a few doctors offered their support to those who planned to SOAP, students announced their matches, and others either congratulated or encouraged those still trying to match.
 

Couples match

Not everyone who matched considered the alternative. Before March 13, William Boyer said that he hadn’t given much thought to what would happen if he didn’t match because he was “optimistically confident” he would match into his chosen EM specialty. But he did and got his top choice of programs: Yale New Haven (Conn.) Hospital.

“I feel great,” he said in an interview. “I was definitely nervous opening the envelope” that revealed his residency program, “but there was a rush of relief” when he saw he landed Yale.

Earlier in the match cycle, he said in an interview that he “interviewed at a few ‘reach’ programs, so I hope I don’t match lower than expected on my rank list.”

Mr. Boyer considers himself “a mature applicant,” entering the University of South Carolina, Columbia, after 4 years as an insurance broker.

“I am celebrating today by playing pickleball with a few close medical friends who also matched this morning,” Mr. Boyer said on March 13. “I definitely had periods of nervousness leading up to this morning though that quickly turned into joy and relief” after learning he matched.

Mr. Boyer believes that his professional experience in the insurance industry and health care lobbying efforts with the National Association of Health Underwriters set him apart from other applicants.

“I changed careers to pursue this aspiration, which demonstrates my full dedication to the medical profession.”

He applied to 48 programs and was offered interviews to nearly half. Mr. Boyer visited the majority of those virtually. He said he targeted programs close to where his and his partner’s families are located: Massachusetts, North Carolina, and Texas. “My partner, who I met in medical school, matched into ortho as well so the whole household is very happy,” Mr. Boyer said.

She matched into her top choice as well on March 17, though a distance away at UT Health in San Antonio, he said. “We are both ecstatic. We both got our no. 1 choice. That was the plan going into it. We will make it work. I have 4 weeks of vacation.”

In his program choices, Mr. Boyer prioritized access to nature, minimal leadership turnover, a mix of clinical training sites, and adequate elective rotations and fellowship opportunities, such as in wilderness medicine and health policy.

NRMP reported that there were 1,239 couples participating in the Match; 1,095 had both partners match, and 114 had one partner match to residency training programs for a match rate of 93%.

Like Mr. Boyer, Hannah Hedriana matched into EM, one of the more popular despite the reported unfilled positions. In the past few years, it has consistently been one of the fastest-growing specialties, according to the NRMP.

Still Ms. Hedriana had a fall-back plan. “If I don’t match, then I do plan on going through SOAP. With the number of EM spots that were unfilled in 2022, there’s a chance I could still be an EM physician, but if not, then that’s okay with me.”

Her reaction on March 13, after learning she matched? “Super excited, celebrating with my friends right now.” On Match Day, she said she was “ecstatic” to be matched into Lakeland (Fla.) Regional Health. “This was my first choice so now I can stay close to family and friends,” she said in an interview soon after the results were released.

A first-generation, Filipino American student from the University of South Florida, Tampa, Ms. Hedriana comes from a family of health care professionals. Her father is a respiratory therapist turned physical therapist; her mother a registered nurse. Her sister is a patient care technician applying to nursing school.

Ms. Hedriana applied to 70 programs and interviewed mostly online with 24. Her goal was to stay on the East Coast.

“My partner is a licensed dentist in the state of Florida, and so for his career it would be more practical to stay in state, rather than get relicensed in another state, which could take months,” she said earlier in the matching cycle. “However, when we discussed choosing a residency program, he ultimately left it up to me and wanted me to pick where I thought I’d flourish best,” Ms. Hedriana said, adding that her family lives in Florida, too.

She said she sought a residency program that values family and teamwork.

“A program gets more points in my book if they have sites at nonprofit hospitals or has residents that regularly volunteer throughout their communities or participate in DEI [diversity, equity, and inclusion] initiatives.”

Ms. Hedriana noted that some specialties exclusively offered virtual interviews in 2023, whereas other specialties favored in-person interviews. “This year, many of my classmates were able to do multiple away rotations, which they saw as a positive regarding their chances of matching.” During COVID, in-person visits were limited.

“However, I’ve noticed that many of my classmates are not fond of the signaling aspect that was present for this year’s cycle,” she said. Signaling is a relatively new process that allows applicants to indicate interest in a limited number of residency programs. Not all residencies participate, but it’s growing in popularity among specialties, according to the American Medical Association.
 

‘Extremely competitive’

Ms. Nagle, a second lieutenant in the U.S. Air Force, applied to 12 programs and interviewed with half of them online. She said that she wasn’t targeting any specific type of program through the match.

“I believe you can get phenomenal training anywhere where you mesh with the residents and leadership. My ultimate priority is to (1) be near good people, (2) be near good food (Indian and Thai are a must), and (3) be near an international airport so I can flee the country during breaks.”

Meanwhile, she said that she found the application process, in which students have to articulate their entire medical school experience, extremely competitive. “I think this process is so easy to get wound up in and the anxiety can be palpable,” Ms. Nagle said. “People around you match your energy. So if you are a ball of anxiety then so are your attendings and residents – and that doesn’t bode well for passing the ‘do I want to be on call with them’ test.”

Looking back at medical school, Ms. Nagle recalled having a baby named after her during her first anesthesia rotation and being featured on The Kelly Clarkson Show. Ms. Nagle said that she had walked into the delivery room where new parents had been debating names of babies beginning with the letter B. “And when I introduced myself, they looked at each other and said, ‘Yep, that’s the one.’”

Mr. Boyer recounted how the majority of his medical school experience involved online education. “Roughly two-thirds of my first year was in-person prior to the pandemic. However, from spring break first year to in-person clinical rotations at the beginning of third year, we were all virtual. While I missed interacting with my classmates, I benefited from the virtual learning environment as I learn more efficiently from reading and visual aids than auditory lectures.”

Ms. Hedriana cited the friends and memories she made while learning to be a doctor. “Medical school was hard, but I wouldn’t have changed a thing.”

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

Baily Nagle, vice president of her graduating class at Harvard Medical School, Boston, celebrated “the luck of the Irish” on St. Patrick’s Day that allowed her to match into her chosen specialty and top choice of residency programs: anesthesia at Brigham and Women’s Hospital.

“I am feeling very excited and relieved – I matched,” she said in an interview upon hearing her good fortune on Match Monday, March 13. She had a similar reaction on Match Day, March 17. “After a lot of long nights and hard work, happy to have it pay off.”

Ms. Nagle was so determined to match into her specialty that she didn’t have any other specialties in mind as a backup.

The annual process of matching medical school graduates with compatible residency programs is an emotional roller coaster for all applicants, their personal March Madness, so to speak. But Ms. Nagle was one of the more fortunate applicants. She didn’t have to confront the heartbreak other applicants felt when the National Resident Matching Program (NRMP) announced results of the main residency match and the Supplemental Offer and Acceptance Program (SOAP), which offers alternate programs for unfilled positions or unmatched applicants.

During the 2023 Match process, this news organization has been following a handful of students, checking in with them periodically for updates on their progress. Most of them matched successfully, but at least one international medical graduate (IMG) did not. What the others have in common is that their hearts were set on a chosen specialty. Like Ms. Nagle, another student banked on landing his chosen specialty without a backup plan, whereas another said that she’d continue through the SOAP if she didn’t match successfully.

Overall, Match Day resulted in a record number of residency positions offered, most notably in primary care, which “hit an all-time high,” according to NRMP President and CEO Donna L. Lamb, DHSc, MBA, BSN. The number of positions has “consistently increased over the past 5 years, and most importantly the fill rate for primary care has remained steady,” Dr.. Lamb noted in the NRMP release of Match Day results. The release coincided with students learning through emails at noon Eastern Time to which residency or supplemental programs they were matched.

Though more applicants registered for the Match in 2023 than in 2022 – driven primarily by non-U.S. IMGs – the NRMP stated that it was surprised by the decrease in U.S. MD senior applicants.

U.S. MD seniors had a nearly 94% Match rate, a small increase over 2022. U.S. citizen IMGs saw a nearly 68% Match rate, which NRMP reported as an “all-time high” and about six percentage points over in 2022, whereas non-U.S. IMGs had a nearly 60% Match rate, a 1.3 percentage point increase over 2022.

Among the specialties that filled all available positions in 2023 were orthopedic surgery, plastic surgery (integrated), and radiology – diagnostic and thoracic surgery.
 

Not everyone matches

On March 13, the American College of Emergency Physicians issued a joint statement with other emergency medicine (EM) organizations about a high rate of unfilled EM positions expected in 2023.

NRMP acknowledged March 17 that 554 positions remained unfilled, an increase of 335 more unfilled positions than 2022. NRMP attributed the increase in unfilled positions in part to a decrease in the number of U.S. MD and U.S. DO seniors who submitted ranks for the specialty, which “could reflect changing applicant interests or projections about workforce opportunities post residency.”

Applicants who didn’t match usually try to obtain an unfilled position through SOAP. In 2023, 2,685 positions were unfilled after the matching algorithm was processed, an increase of nearly 19% over 2022. The vast majority of those positions were placed in SOAP, an increase of 17.5% over 2022.

Asim Ansari was one of the unlucky ones. Mr. Ansari was trying to match for the fifth time. He was unsuccessful in doing so again in 2023 in the Match and SOAP. Still, he was offered and accepted a child and adolescent psychiatry fellowship at Kansas University Medical Center in Kansas City. Psychiatry was his chosen specialty, so he was “feeling good. It’s a nice place to go to do the next 2 years.”

Mr. Ansari, who started the #MatchMadness support group for unmatched doctors on Twitter Spaces, was quick to cheer on his fellow matching peers on March 13 while revealing his own fate: “Congratulations to everyone who matched!!! Y’all are amazing. So proud of each one of you!!! I didn’t.”

Soon after the results, #MatchMadness held a #Soap2023 support session, and Mr. Ansari sought advice for those willing to review SOAP applications. Elsewhere on Twitter Match Day threads, a few doctors offered their support to those who planned to SOAP, students announced their matches, and others either congratulated or encouraged those still trying to match.
 

Couples match

Not everyone who matched considered the alternative. Before March 13, William Boyer said that he hadn’t given much thought to what would happen if he didn’t match because he was “optimistically confident” he would match into his chosen EM specialty. But he did and got his top choice of programs: Yale New Haven (Conn.) Hospital.

“I feel great,” he said in an interview. “I was definitely nervous opening the envelope” that revealed his residency program, “but there was a rush of relief” when he saw he landed Yale.

Earlier in the match cycle, he said in an interview that he “interviewed at a few ‘reach’ programs, so I hope I don’t match lower than expected on my rank list.”

Mr. Boyer considers himself “a mature applicant,” entering the University of South Carolina, Columbia, after 4 years as an insurance broker.

“I am celebrating today by playing pickleball with a few close medical friends who also matched this morning,” Mr. Boyer said on March 13. “I definitely had periods of nervousness leading up to this morning though that quickly turned into joy and relief” after learning he matched.

Mr. Boyer believes that his professional experience in the insurance industry and health care lobbying efforts with the National Association of Health Underwriters set him apart from other applicants.

“I changed careers to pursue this aspiration, which demonstrates my full dedication to the medical profession.”

He applied to 48 programs and was offered interviews to nearly half. Mr. Boyer visited the majority of those virtually. He said he targeted programs close to where his and his partner’s families are located: Massachusetts, North Carolina, and Texas. “My partner, who I met in medical school, matched into ortho as well so the whole household is very happy,” Mr. Boyer said.

She matched into her top choice as well on March 17, though a distance away at UT Health in San Antonio, he said. “We are both ecstatic. We both got our no. 1 choice. That was the plan going into it. We will make it work. I have 4 weeks of vacation.”

In his program choices, Mr. Boyer prioritized access to nature, minimal leadership turnover, a mix of clinical training sites, and adequate elective rotations and fellowship opportunities, such as in wilderness medicine and health policy.

NRMP reported that there were 1,239 couples participating in the Match; 1,095 had both partners match, and 114 had one partner match to residency training programs for a match rate of 93%.

Like Mr. Boyer, Hannah Hedriana matched into EM, one of the more popular despite the reported unfilled positions. In the past few years, it has consistently been one of the fastest-growing specialties, according to the NRMP.

Still Ms. Hedriana had a fall-back plan. “If I don’t match, then I do plan on going through SOAP. With the number of EM spots that were unfilled in 2022, there’s a chance I could still be an EM physician, but if not, then that’s okay with me.”

Her reaction on March 13, after learning she matched? “Super excited, celebrating with my friends right now.” On Match Day, she said she was “ecstatic” to be matched into Lakeland (Fla.) Regional Health. “This was my first choice so now I can stay close to family and friends,” she said in an interview soon after the results were released.

A first-generation, Filipino American student from the University of South Florida, Tampa, Ms. Hedriana comes from a family of health care professionals. Her father is a respiratory therapist turned physical therapist; her mother a registered nurse. Her sister is a patient care technician applying to nursing school.

Ms. Hedriana applied to 70 programs and interviewed mostly online with 24. Her goal was to stay on the East Coast.

“My partner is a licensed dentist in the state of Florida, and so for his career it would be more practical to stay in state, rather than get relicensed in another state, which could take months,” she said earlier in the matching cycle. “However, when we discussed choosing a residency program, he ultimately left it up to me and wanted me to pick where I thought I’d flourish best,” Ms. Hedriana said, adding that her family lives in Florida, too.

She said she sought a residency program that values family and teamwork.

“A program gets more points in my book if they have sites at nonprofit hospitals or has residents that regularly volunteer throughout their communities or participate in DEI [diversity, equity, and inclusion] initiatives.”

Ms. Hedriana noted that some specialties exclusively offered virtual interviews in 2023, whereas other specialties favored in-person interviews. “This year, many of my classmates were able to do multiple away rotations, which they saw as a positive regarding their chances of matching.” During COVID, in-person visits were limited.

“However, I’ve noticed that many of my classmates are not fond of the signaling aspect that was present for this year’s cycle,” she said. Signaling is a relatively new process that allows applicants to indicate interest in a limited number of residency programs. Not all residencies participate, but it’s growing in popularity among specialties, according to the American Medical Association.
 

‘Extremely competitive’

Ms. Nagle, a second lieutenant in the U.S. Air Force, applied to 12 programs and interviewed with half of them online. She said that she wasn’t targeting any specific type of program through the match.

“I believe you can get phenomenal training anywhere where you mesh with the residents and leadership. My ultimate priority is to (1) be near good people, (2) be near good food (Indian and Thai are a must), and (3) be near an international airport so I can flee the country during breaks.”

Meanwhile, she said that she found the application process, in which students have to articulate their entire medical school experience, extremely competitive. “I think this process is so easy to get wound up in and the anxiety can be palpable,” Ms. Nagle said. “People around you match your energy. So if you are a ball of anxiety then so are your attendings and residents – and that doesn’t bode well for passing the ‘do I want to be on call with them’ test.”

Looking back at medical school, Ms. Nagle recalled having a baby named after her during her first anesthesia rotation and being featured on The Kelly Clarkson Show. Ms. Nagle said that she had walked into the delivery room where new parents had been debating names of babies beginning with the letter B. “And when I introduced myself, they looked at each other and said, ‘Yep, that’s the one.’”

Mr. Boyer recounted how the majority of his medical school experience involved online education. “Roughly two-thirds of my first year was in-person prior to the pandemic. However, from spring break first year to in-person clinical rotations at the beginning of third year, we were all virtual. While I missed interacting with my classmates, I benefited from the virtual learning environment as I learn more efficiently from reading and visual aids than auditory lectures.”

Ms. Hedriana cited the friends and memories she made while learning to be a doctor. “Medical school was hard, but I wouldn’t have changed a thing.”

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