MDedge Surgery

AURORA, COLO. – Perianal Crohn’s disease with fistula is notoriously difficult to treat and can make patients’ lives miserable, but a new, minimally invasive approach involving local injection of mesenchymal stem cells is both safe and, in a significant proportion of patients, highly effective, according to a colorectal surgeon.

“It’s a really debilitating phenotype, a spectrum of phenotypes,” Amy Lightner, MD, of the Cleveland Clinic said at the annual Crohn’s & Colitis Congress®, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.

Although some patients have minimal symptoms, others may require multiple setons to aid in drainage and healing, while others may require fistulotomy, endorectal advancement flap, intersphincteric fistula tract (LIFT) procedure, diversion, or proctectomy.

“Why is it so difficult to treat? Well, part of it is that this is an anatomic defect, and this is why 90% of patients will come to the operating room and will see their surgeons on a frequent basis. The other part of that is that we have medical therapies to treat these fistulas but they’re really largely ineffective, because there is that anatomical defect, the hole there that needs to be closed,” Dr. Lightner said.

Up to 20% of patients may require a permanent stoma, and an additional 20% may require temporary fecal diversion.

Mesenchymal stem cells (MSC) are derived from bone marrow, fat stores, or umbilical cord tissues. Unlike embryonic stem cells, which have the ability to metamorphose into a multitude of other cell types, mesenchymal stem cells are differentiated “adult” cells.

They work by secreting anti-inflammatory cytokines and recruiting immune cells to stimulate tissue repair and healing. The cells are delivered in a minimally invasive outpatient setting, and there is no risk of incontinence compared with more invasive procedures such as fistulotomy or advancement flaps.
 

Effective and safe

MSCs were first used in Spain in 2003 to successfully treat a young women with a complex fistula with five perianal tracts converging into a rectovaginal fistula. The investigators injected a single dose of 9 x 10⁶ MSCs into the site, and the fistula healed within 3 months.

Since then in multiple clinical trials involving more than 400 patients, injection of MSCs has resulted in fistula closure and complete healing by 8-12 weeks in 50%-85% of patients, Dr. Lightner said.

The treatment effect is also durable, she said, pointing to data from the ADMIRE-CD study, in which 51.5% of Crohn’s disease patients with treatment-refractory complex perianal fistula were healed at 24 weeks following injection of adipose-derived stem cells, compared with 35.6% of controls. At 1 year of follow-up, respective rates of healing were 56.3% vs. 38.6%.

Dr. Lightner also cited a case report of a patient whose fistula remained healed 4 years after receiving MSCs for refractory perianal Crohn’s fistulas.

Although MSCs are derived from healthy donors, they do not bear cellular surface antigens that would instigate a destructive host immune response, and to date, there have been no reports from clinical trials of systemic infections or complications. The most frequently reported adverse events have been injection-site pain in about 12%-15% of patients, and perianal abscess in 5%-13%, with similar frequencies in treatment and control groups.

Dr. Lightner and colleagues are currently exploring additional indications for stem cell therapy with MSCs, including other complex fistula phenotypes, intestinal Crohn’s disease, and ulcerative colitis.
 

Other approaches

In a separate presentation, James D. Lewis, MD, MSCE, of the University of Pennsylvania in Philadelphia talked about what would be needed to achieve a “medical moonshot” with the goal of curing inflammatory bowel disease (IBD), and touched on hematopoietic stem cell transplants as a potential option for patients with chronic, severe, and intractable disease.

One of his patients was a woman in her 60s who was diagnosed with stricturing and penetrating Crohn’s disease in her 30s, with the disease involving the ileum and entire colon. She had previously undergone three small bowel resections and a partial colon resection, and had never experienced remission despite taking steroids, azathioprine, methotrexate, four anti-TNF drugs, ustekinumab (Stelara), and vedolizumab (Entyvio).

Following an autologous hematopoietic stem cell transplant, she had a Simple Endoscopic Score for Crohn’s Disease (SES-CD) of 0. Her course was complicated by demand ischemia and acute kidney injury.

An IBD specialist who was not involved in either study commented in an interview that both MSCs and stem cell transplants show promise for treatment-refractory IBD,

“Both approaches are very promising, but stem cell transplants for IBD haven’t been formally studied yet so the data aren’t as strong, but there is promise for the future,” said Berkeley N. Limketkai, MD, PhD, from the University of California, Los Angeles.

“The challenges, however, are also the morbidity associated with actually undergoing such procedures,” he continued. Short- and long-term morbidities associated with hematopoietic stem cell transplants may include mucositis; hemorrhagic cystitis; prolonged, severe pancytopenia; infection; graft-versus-host disease; graft failure; pulmonary complications, veno-occlusive disease of the liver; and thrombotic microangiopathy.

Dr. Limketkai said that over time as the protocols for stem cell transplants in IBD improve, the benefits for select patients may more clearly outweigh the risks.

Dr. Lightner’s work is supported by the Leona M. and Harry B. Helmsley Charitable Trust and the American Society of Colon and Rectal Surgery. She disclosed consulting fees from Boomerang Medical, Mesoblast Limited, Ossium Health, and Takeda Pharmaceuticals USA. Dr. Lewis’ work is supported by grants from the National Institutes of Health, and from AbbVie, Takeda, Janssen, and Nestlé Health Science. He has also served as a consultant to and data safety monitoring board member for several entities. Dr. Limketkai disclosed consulting for Azora Therapeutics.

AURORA, COLO. – Perianal Crohn’s disease with fistula is notoriously difficult to treat and can make patients’ lives miserable, but a new, minimally invasive approach involving local injection of mesenchymal stem cells is both safe and, in a significant proportion of patients, highly effective, according to a colorectal surgeon.

“It’s a really debilitating phenotype, a spectrum of phenotypes,” Amy Lightner, MD, of the Cleveland Clinic said at the annual Crohn’s & Colitis Congress®, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.

Although some patients have minimal symptoms, others may require multiple setons to aid in drainage and healing, while others may require fistulotomy, endorectal advancement flap, intersphincteric fistula tract (LIFT) procedure, diversion, or proctectomy.

“Why is it so difficult to treat? Well, part of it is that this is an anatomic defect, and this is why 90% of patients will come to the operating room and will see their surgeons on a frequent basis. The other part of that is that we have medical therapies to treat these fistulas but they’re really largely ineffective, because there is that anatomical defect, the hole there that needs to be closed,” Dr. Lightner said.

Up to 20% of patients may require a permanent stoma, and an additional 20% may require temporary fecal diversion.

Mesenchymal stem cells (MSC) are derived from bone marrow, fat stores, or umbilical cord tissues. Unlike embryonic stem cells, which have the ability to metamorphose into a multitude of other cell types, mesenchymal stem cells are differentiated “adult” cells.

They work by secreting anti-inflammatory cytokines and recruiting immune cells to stimulate tissue repair and healing. The cells are delivered in a minimally invasive outpatient setting, and there is no risk of incontinence compared with more invasive procedures such as fistulotomy or advancement flaps.
 

Effective and safe

MSCs were first used in Spain in 2003 to successfully treat a young women with a complex fistula with five perianal tracts converging into a rectovaginal fistula. The investigators injected a single dose of 9 x 10⁶ MSCs into the site, and the fistula healed within 3 months.

Since then in multiple clinical trials involving more than 400 patients, injection of MSCs has resulted in fistula closure and complete healing by 8-12 weeks in 50%-85% of patients, Dr. Lightner said.

The treatment effect is also durable, she said, pointing to data from the ADMIRE-CD study, in which 51.5% of Crohn’s disease patients with treatment-refractory complex perianal fistula were healed at 24 weeks following injection of adipose-derived stem cells, compared with 35.6% of controls. At 1 year of follow-up, respective rates of healing were 56.3% vs. 38.6%.

Dr. Lightner also cited a case report of a patient whose fistula remained healed 4 years after receiving MSCs for refractory perianal Crohn’s fistulas.

Although MSCs are derived from healthy donors, they do not bear cellular surface antigens that would instigate a destructive host immune response, and to date, there have been no reports from clinical trials of systemic infections or complications. The most frequently reported adverse events have been injection-site pain in about 12%-15% of patients, and perianal abscess in 5%-13%, with similar frequencies in treatment and control groups.

Dr. Lightner and colleagues are currently exploring additional indications for stem cell therapy with MSCs, including other complex fistula phenotypes, intestinal Crohn’s disease, and ulcerative colitis.
 

Other approaches

In a separate presentation, James D. Lewis, MD, MSCE, of the University of Pennsylvania in Philadelphia talked about what would be needed to achieve a “medical moonshot” with the goal of curing inflammatory bowel disease (IBD), and touched on hematopoietic stem cell transplants as a potential option for patients with chronic, severe, and intractable disease.

One of his patients was a woman in her 60s who was diagnosed with stricturing and penetrating Crohn’s disease in her 30s, with the disease involving the ileum and entire colon. She had previously undergone three small bowel resections and a partial colon resection, and had never experienced remission despite taking steroids, azathioprine, methotrexate, four anti-TNF drugs, ustekinumab (Stelara), and vedolizumab (Entyvio).

Following an autologous hematopoietic stem cell transplant, she had a Simple Endoscopic Score for Crohn’s Disease (SES-CD) of 0. Her course was complicated by demand ischemia and acute kidney injury.

An IBD specialist who was not involved in either study commented in an interview that both MSCs and stem cell transplants show promise for treatment-refractory IBD,

“Both approaches are very promising, but stem cell transplants for IBD haven’t been formally studied yet so the data aren’t as strong, but there is promise for the future,” said Berkeley N. Limketkai, MD, PhD, from the University of California, Los Angeles.

“The challenges, however, are also the morbidity associated with actually undergoing such procedures,” he continued. Short- and long-term morbidities associated with hematopoietic stem cell transplants may include mucositis; hemorrhagic cystitis; prolonged, severe pancytopenia; infection; graft-versus-host disease; graft failure; pulmonary complications, veno-occlusive disease of the liver; and thrombotic microangiopathy.

Dr. Limketkai said that over time as the protocols for stem cell transplants in IBD improve, the benefits for select patients may more clearly outweigh the risks.

Dr. Lightner’s work is supported by the Leona M. and Harry B. Helmsley Charitable Trust and the American Society of Colon and Rectal Surgery. She disclosed consulting fees from Boomerang Medical, Mesoblast Limited, Ossium Health, and Takeda Pharmaceuticals USA. Dr. Lewis’ work is supported by grants from the National Institutes of Health, and from AbbVie, Takeda, Janssen, and Nestlé Health Science. He has also served as a consultant to and data safety monitoring board member for several entities. Dr. Limketkai disclosed consulting for Azora Therapeutics.

AURORA, COLO. – Perianal Crohn’s disease with fistula is notoriously difficult to treat and can make patients’ lives miserable, but a new, minimally invasive approach involving local injection of mesenchymal stem cells is both safe and, in a significant proportion of patients, highly effective, according to a colorectal surgeon.

“It’s a really debilitating phenotype, a spectrum of phenotypes,” Amy Lightner, MD, of the Cleveland Clinic said at the annual Crohn’s & Colitis Congress®, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.

Although some patients have minimal symptoms, others may require multiple setons to aid in drainage and healing, while others may require fistulotomy, endorectal advancement flap, intersphincteric fistula tract (LIFT) procedure, diversion, or proctectomy.

“Why is it so difficult to treat? Well, part of it is that this is an anatomic defect, and this is why 90% of patients will come to the operating room and will see their surgeons on a frequent basis. The other part of that is that we have medical therapies to treat these fistulas but they’re really largely ineffective, because there is that anatomical defect, the hole there that needs to be closed,” Dr. Lightner said.

Up to 20% of patients may require a permanent stoma, and an additional 20% may require temporary fecal diversion.

Mesenchymal stem cells (MSC) are derived from bone marrow, fat stores, or umbilical cord tissues. Unlike embryonic stem cells, which have the ability to metamorphose into a multitude of other cell types, mesenchymal stem cells are differentiated “adult” cells.

They work by secreting anti-inflammatory cytokines and recruiting immune cells to stimulate tissue repair and healing. The cells are delivered in a minimally invasive outpatient setting, and there is no risk of incontinence compared with more invasive procedures such as fistulotomy or advancement flaps.
 

Effective and safe

MSCs were first used in Spain in 2003 to successfully treat a young women with a complex fistula with five perianal tracts converging into a rectovaginal fistula. The investigators injected a single dose of 9 x 10⁶ MSCs into the site, and the fistula healed within 3 months.

Since then in multiple clinical trials involving more than 400 patients, injection of MSCs has resulted in fistula closure and complete healing by 8-12 weeks in 50%-85% of patients, Dr. Lightner said.

The treatment effect is also durable, she said, pointing to data from the ADMIRE-CD study, in which 51.5% of Crohn’s disease patients with treatment-refractory complex perianal fistula were healed at 24 weeks following injection of adipose-derived stem cells, compared with 35.6% of controls. At 1 year of follow-up, respective rates of healing were 56.3% vs. 38.6%.

Dr. Lightner also cited a case report of a patient whose fistula remained healed 4 years after receiving MSCs for refractory perianal Crohn’s fistulas.

Although MSCs are derived from healthy donors, they do not bear cellular surface antigens that would instigate a destructive host immune response, and to date, there have been no reports from clinical trials of systemic infections or complications. The most frequently reported adverse events have been injection-site pain in about 12%-15% of patients, and perianal abscess in 5%-13%, with similar frequencies in treatment and control groups.

Dr. Lightner and colleagues are currently exploring additional indications for stem cell therapy with MSCs, including other complex fistula phenotypes, intestinal Crohn’s disease, and ulcerative colitis.
 

Other approaches

In a separate presentation, James D. Lewis, MD, MSCE, of the University of Pennsylvania in Philadelphia talked about what would be needed to achieve a “medical moonshot” with the goal of curing inflammatory bowel disease (IBD), and touched on hematopoietic stem cell transplants as a potential option for patients with chronic, severe, and intractable disease.

One of his patients was a woman in her 60s who was diagnosed with stricturing and penetrating Crohn’s disease in her 30s, with the disease involving the ileum and entire colon. She had previously undergone three small bowel resections and a partial colon resection, and had never experienced remission despite taking steroids, azathioprine, methotrexate, four anti-TNF drugs, ustekinumab (Stelara), and vedolizumab (Entyvio).

Following an autologous hematopoietic stem cell transplant, she had a Simple Endoscopic Score for Crohn’s Disease (SES-CD) of 0. Her course was complicated by demand ischemia and acute kidney injury.

An IBD specialist who was not involved in either study commented in an interview that both MSCs and stem cell transplants show promise for treatment-refractory IBD,

“Both approaches are very promising, but stem cell transplants for IBD haven’t been formally studied yet so the data aren’t as strong, but there is promise for the future,” said Berkeley N. Limketkai, MD, PhD, from the University of California, Los Angeles.

“The challenges, however, are also the morbidity associated with actually undergoing such procedures,” he continued. Short- and long-term morbidities associated with hematopoietic stem cell transplants may include mucositis; hemorrhagic cystitis; prolonged, severe pancytopenia; infection; graft-versus-host disease; graft failure; pulmonary complications, veno-occlusive disease of the liver; and thrombotic microangiopathy.

Dr. Limketkai said that over time as the protocols for stem cell transplants in IBD improve, the benefits for select patients may more clearly outweigh the risks.

Dr. Lightner’s work is supported by the Leona M. and Harry B. Helmsley Charitable Trust and the American Society of Colon and Rectal Surgery. She disclosed consulting fees from Boomerang Medical, Mesoblast Limited, Ossium Health, and Takeda Pharmaceuticals USA. Dr. Lewis’ work is supported by grants from the National Institutes of Health, and from AbbVie, Takeda, Janssen, and Nestlé Health Science. He has also served as a consultant to and data safety monitoring board member for several entities. Dr. Limketkai disclosed consulting for Azora Therapeutics.

Misinformation regarding COVID-19 has been cited as a public health threat since the beginning of the worldwide pandemic. Doctors and professional organizations are standing guard, hoping to protect patients from any harm that results from mistruths spread by colleagues.

Case in point: Several physicians and the American Board of Pathology filed complaints with Washington and Idaho medical boards alleging that Ryan Cole, MD, a board-certified pathologist who practices in Boise, Idaho, but who also holds a license in Washington, has spread antivaccine and pro-ivermectin statements on social media. Dr. Cole is one of the founders of America’s Frontline Doctors, a right-wing political organization. Dr. Cole did not respond to a request for comment.

Gary W. Procop, MD, CEO, American Board of Pathology, told this news organization that “as physicians and board-certified pathologists, we have a public trust, and we must be accountable to patients, society, and the profession. Misinformation can cause real harm to patients, which may include death. Misinformation diverts patients away from lifesaving vaccination and other preventive measures, promotes viral transmission, and recommends ineffective therapies that may be toxic instead of evidence-based medical care.”
 

Cavalcade of complaints

Several doctors also chimed in with formal complaints alleging that Cole is spreading unreliable information, according to a report from KTVB News. For example, a Boise doctor wrote in his complaint that Dr. Cole is “a major purveyor of misinformation” and called it “amazing” that the physician was continuing to publicly support debunked information about COVID-19 more than a year into the pandemic. The doctor also stated, “Cole is a health menace, abusing his status as a physician to mislead the public.”

As a result of such complaints, the Washington medical board has charged Cole with COVID-19–related violations. It is unclear whether or not the Idaho medical board will sanction the doctor. At least 12 medical boards have sanctioned doctors for similar violations since the start of the pandemic.

The statement of charges from the Washington medical board contends that since March 2021, Dr. Cole has made numerous misleading statements regarding the COVID-19 pandemic, vaccines, the use of ivermectin to treat COVID-19, and the effectiveness of masks.

In addition, the statement alleges that Dr. Cole treated several COVID-19 patients via telemedicine. During these sessions, he prescribed ivermectin, an antiparasite drug that has not been found to have any effectiveness in treating, curing, or preventing COVID-19. One of the patients died after receiving this treatment, according to the complaint.

Citing a study published in the New England Journal of Medicine, Dr. Procop pointed out that use of ivermectin, which is not approved by the U.S. Food and Drug Administration to treat COVID-19, is particularly troubling.

“There is a concern whenever an ineffective treatment is prescribed when more effective and scientifically proven therapies are available. Therapeutics have potential side effects, and toxicities have been associated with the use of ivermectin,” Dr. Procop said. “The benefits of therapy should always outweigh the risks of treatment.”

If the Washington medical board finds that Dr. Cole has engaged in unprofessional conduct, possible sanctions include revocation or suspension of his license. Washington state law also provides for a range of other possible sanctions, including restriction or limitation of his practice, requiring that he complete a specific program of remedial education or treatment, monitoring of his practice, censure or reprimand, probation, a fine of up to $5,000 for each violation, or refunding fees that his practice has billed to and collected from patients. Dr. Cole had until January 30 to respond to the medical board’s statement.

“The American Board of Pathology supports the actions of the Washington State Medical Board regarding their inquiries into any physician that holds license in their state who makes false and misleading medical claims, or provides medical care beyond their scope of practice, as indicated by their training,” Dr. Procop said.
 

Law in limbo

While medical boards are seeking to sanction professionals who spread falsehoods, the pause button has been hit on the California law that allows regulators to punish doctors for spreading false information about COVID-19 vaccinations and treatments.

The law went into effect Jan. 1 but was temporarily halted when U.S. District Judge William B. Shubb of the Eastern District of California granted a preliminary injunction against the law on Jan. 25, according to a report in the Sacramento Bee.

Mr. Shubb said the measure’s definition of “misinformation” was “unconstitutionally vague” under the due process clause of the 14th Amendment. He also criticized the law’s definition of “misinformation” as being “grammatically incoherent.”

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

Misinformation regarding COVID-19 has been cited as a public health threat since the beginning of the worldwide pandemic. Doctors and professional organizations are standing guard, hoping to protect patients from any harm that results from mistruths spread by colleagues.

Case in point: Several physicians and the American Board of Pathology filed complaints with Washington and Idaho medical boards alleging that Ryan Cole, MD, a board-certified pathologist who practices in Boise, Idaho, but who also holds a license in Washington, has spread antivaccine and pro-ivermectin statements on social media. Dr. Cole is one of the founders of America’s Frontline Doctors, a right-wing political organization. Dr. Cole did not respond to a request for comment.

Gary W. Procop, MD, CEO, American Board of Pathology, told this news organization that “as physicians and board-certified pathologists, we have a public trust, and we must be accountable to patients, society, and the profession. Misinformation can cause real harm to patients, which may include death. Misinformation diverts patients away from lifesaving vaccination and other preventive measures, promotes viral transmission, and recommends ineffective therapies that may be toxic instead of evidence-based medical care.”
 

Cavalcade of complaints

Several doctors also chimed in with formal complaints alleging that Cole is spreading unreliable information, according to a report from KTVB News. For example, a Boise doctor wrote in his complaint that Dr. Cole is “a major purveyor of misinformation” and called it “amazing” that the physician was continuing to publicly support debunked information about COVID-19 more than a year into the pandemic. The doctor also stated, “Cole is a health menace, abusing his status as a physician to mislead the public.”

As a result of such complaints, the Washington medical board has charged Cole with COVID-19–related violations. It is unclear whether or not the Idaho medical board will sanction the doctor. At least 12 medical boards have sanctioned doctors for similar violations since the start of the pandemic.

The statement of charges from the Washington medical board contends that since March 2021, Dr. Cole has made numerous misleading statements regarding the COVID-19 pandemic, vaccines, the use of ivermectin to treat COVID-19, and the effectiveness of masks.

In addition, the statement alleges that Dr. Cole treated several COVID-19 patients via telemedicine. During these sessions, he prescribed ivermectin, an antiparasite drug that has not been found to have any effectiveness in treating, curing, or preventing COVID-19. One of the patients died after receiving this treatment, according to the complaint.

Citing a study published in the New England Journal of Medicine, Dr. Procop pointed out that use of ivermectin, which is not approved by the U.S. Food and Drug Administration to treat COVID-19, is particularly troubling.

“There is a concern whenever an ineffective treatment is prescribed when more effective and scientifically proven therapies are available. Therapeutics have potential side effects, and toxicities have been associated with the use of ivermectin,” Dr. Procop said. “The benefits of therapy should always outweigh the risks of treatment.”

If the Washington medical board finds that Dr. Cole has engaged in unprofessional conduct, possible sanctions include revocation or suspension of his license. Washington state law also provides for a range of other possible sanctions, including restriction or limitation of his practice, requiring that he complete a specific program of remedial education or treatment, monitoring of his practice, censure or reprimand, probation, a fine of up to $5,000 for each violation, or refunding fees that his practice has billed to and collected from patients. Dr. Cole had until January 30 to respond to the medical board’s statement.

“The American Board of Pathology supports the actions of the Washington State Medical Board regarding their inquiries into any physician that holds license in their state who makes false and misleading medical claims, or provides medical care beyond their scope of practice, as indicated by their training,” Dr. Procop said.
 

Law in limbo

While medical boards are seeking to sanction professionals who spread falsehoods, the pause button has been hit on the California law that allows regulators to punish doctors for spreading false information about COVID-19 vaccinations and treatments.

The law went into effect Jan. 1 but was temporarily halted when U.S. District Judge William B. Shubb of the Eastern District of California granted a preliminary injunction against the law on Jan. 25, according to a report in the Sacramento Bee.

Mr. Shubb said the measure’s definition of “misinformation” was “unconstitutionally vague” under the due process clause of the 14th Amendment. He also criticized the law’s definition of “misinformation” as being “grammatically incoherent.”

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

Misinformation regarding COVID-19 has been cited as a public health threat since the beginning of the worldwide pandemic. Doctors and professional organizations are standing guard, hoping to protect patients from any harm that results from mistruths spread by colleagues.

Case in point: Several physicians and the American Board of Pathology filed complaints with Washington and Idaho medical boards alleging that Ryan Cole, MD, a board-certified pathologist who practices in Boise, Idaho, but who also holds a license in Washington, has spread antivaccine and pro-ivermectin statements on social media. Dr. Cole is one of the founders of America’s Frontline Doctors, a right-wing political organization. Dr. Cole did not respond to a request for comment.

Gary W. Procop, MD, CEO, American Board of Pathology, told this news organization that “as physicians and board-certified pathologists, we have a public trust, and we must be accountable to patients, society, and the profession. Misinformation can cause real harm to patients, which may include death. Misinformation diverts patients away from lifesaving vaccination and other preventive measures, promotes viral transmission, and recommends ineffective therapies that may be toxic instead of evidence-based medical care.”
 

Cavalcade of complaints

Several doctors also chimed in with formal complaints alleging that Cole is spreading unreliable information, according to a report from KTVB News. For example, a Boise doctor wrote in his complaint that Dr. Cole is “a major purveyor of misinformation” and called it “amazing” that the physician was continuing to publicly support debunked information about COVID-19 more than a year into the pandemic. The doctor also stated, “Cole is a health menace, abusing his status as a physician to mislead the public.”

As a result of such complaints, the Washington medical board has charged Cole with COVID-19–related violations. It is unclear whether or not the Idaho medical board will sanction the doctor. At least 12 medical boards have sanctioned doctors for similar violations since the start of the pandemic.

The statement of charges from the Washington medical board contends that since March 2021, Dr. Cole has made numerous misleading statements regarding the COVID-19 pandemic, vaccines, the use of ivermectin to treat COVID-19, and the effectiveness of masks.

In addition, the statement alleges that Dr. Cole treated several COVID-19 patients via telemedicine. During these sessions, he prescribed ivermectin, an antiparasite drug that has not been found to have any effectiveness in treating, curing, or preventing COVID-19. One of the patients died after receiving this treatment, according to the complaint.

Citing a study published in the New England Journal of Medicine, Dr. Procop pointed out that use of ivermectin, which is not approved by the U.S. Food and Drug Administration to treat COVID-19, is particularly troubling.

“There is a concern whenever an ineffective treatment is prescribed when more effective and scientifically proven therapies are available. Therapeutics have potential side effects, and toxicities have been associated with the use of ivermectin,” Dr. Procop said. “The benefits of therapy should always outweigh the risks of treatment.”

If the Washington medical board finds that Dr. Cole has engaged in unprofessional conduct, possible sanctions include revocation or suspension of his license. Washington state law also provides for a range of other possible sanctions, including restriction or limitation of his practice, requiring that he complete a specific program of remedial education or treatment, monitoring of his practice, censure or reprimand, probation, a fine of up to $5,000 for each violation, or refunding fees that his practice has billed to and collected from patients. Dr. Cole had until January 30 to respond to the medical board’s statement.

“The American Board of Pathology supports the actions of the Washington State Medical Board regarding their inquiries into any physician that holds license in their state who makes false and misleading medical claims, or provides medical care beyond their scope of practice, as indicated by their training,” Dr. Procop said.
 

Law in limbo

While medical boards are seeking to sanction professionals who spread falsehoods, the pause button has been hit on the California law that allows regulators to punish doctors for spreading false information about COVID-19 vaccinations and treatments.

The law went into effect Jan. 1 but was temporarily halted when U.S. District Judge William B. Shubb of the Eastern District of California granted a preliminary injunction against the law on Jan. 25, according to a report in the Sacramento Bee.

Mr. Shubb said the measure’s definition of “misinformation” was “unconstitutionally vague” under the due process clause of the 14th Amendment. He also criticized the law’s definition of “misinformation” as being “grammatically incoherent.”

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

For a patient who needs a liver, living donation offers an alternative to staying on a list of more than 10,000 people waiting for a transplant. But what happens when your donor is not a match? To expand the number of living liver donations in the United States, the United Network for Organ Sharing (UNOS) has launched the first national paired liver donation pilot program.

“It’s an exciting time to be caring for patients who need liver transplants,” Benjamin Samstein, MD, chief of liver transplantation at New York–Presbyterian/Weill Cornell Medical Center, New York, said in an interview. He is the principal investigator for the UNOS pilot program. “I do believe it is within our grasp to make sure that nobody dies while waiting for an organ,” he said.

The initiative involves 15 U.S. transplant centers. So far, one recipient-donor pair has enrolled in the program. The pilot program has three main goals: Increase access to living donor transplants; increase access to transplants earlier, when recipients are in better health; and work out how to create and sustain a national program.
 

What is paired donation?

In 2020, 1,095 people died while waiting for a liver transplant, according to a report from the Organ Procurement and Transplant Network (OPTN) – a public-private partnership that includes more than 250 transplant centers and 50 organ procurement organizations across the country.

Most liver transplants involve deceased donors. One way to improve access to lifesaving transplants is through living donation, by which a healthy individual donates part of his or her liver. Someone can participate in nondirected or “altruistic” donation, in which someone donates a liver to someone they don’t know, or they can donate to a specific individual (usually a blood relative or a spouse).

With living liver donation, someone may receive a liver earlier, before getting sick enough to be given priority on the wait-list for deceased donation. Because the recipients are in better health, they may have an easier time recovering from the surgery, Ruthanne Leishman, who manages paired donation programs at UNOS, said in an interview.

In some cases, an individual will want to donate an organ to a specific person, but testing reveals that the two would not be a good match. Paired donation allows incompatible donors and recipients to find matches with other incompatible pairs. Each donor matches with the other pairs’ recipient, so the organs are essentially swapped or exchanged between the two pairs.

“People who want to donate get excited about the fact that they are not just helping their loved one but they’re also helping somebody else,” Ms. Leishman said.

Paired kidney donation programs have been running since 2002, but paired liver donation is relatively new. Since the first U.S. living-donor liver transplant in 1989, the procedure has become safer and is a viable alternative to deceased liver donation. A growing number of living donor programs are popping up at transplant centers across the country.

Still, living-donor liver donation makes up a small percentage of the liver transplants that are performed every year. In 2022, 603 living-donor liver transplants were performed in the United States, compared to 8,925 liver transplants from deceased donors, according to OPTN data. Dr. Samstein estimates a couple dozen paired liver exchanges may have been performed in the United States over the past few years within individual hospital systems. A goal of this pilot program, along with increasing access to liver transplants, is to see whether paired liver donation works on a national level, Ms. Leishman said.
 

Challenges to building a national program

There are several notable differences between living donor kidney transplants and living donor liver transplants. For example, living donor liver transplant is a more complicated surgery and poses greater risk to the donor. According to the OPTN 2020 Annual Report, from 2015 to 2019, the rehospitalization rate for living liver donors was twice that of living kidney donors up to 6 weeks after transplant (4.7% vs. 2.4%). One year post transplant, the cumulative rehospitalization rate was 11.0% for living liver donors and 4.8% for living kidney donors.

The risk of dying because of living donation is also higher for liver donors compared to kidney donors. The National Kidney Association states that the odds of dying during kidney donation are about 3 in 100,000, while estimates for risk of death for living liver donors range from 1 in 500 to 1 in 1,000. But some of these estimates are from 10 or more years ago, and outcomes have likely improved, said Whitney Jackson, MD, medical director of living donor liver transplant at UCHealth University of Colorado Hospital, Aurora. Her program is participating in the UNOS pilot.

More recent data from OPTN provides some idea of risk: Of 3,967 liver donors who donated between March 1, 2008, to Sept. 30, 2022, three deaths were reported within 30 days of transplant. However, the causes of death were not specified and therefore may be unrelated to the surgery. By comparison, of 74,555 kidney donors during that date range, 10 deaths were reported at 30 days post surgery.

In addition to a more complex surgery, surgeons also have a smaller time window in which to transplant a liver than than they do to transplant a kidney. A kidney can remain viable in cold storage for 24-36 hours, and it can be transported via commercial airlines cross country. Livers have to be transplanted within 8-12 hours, according to the OPTN website. For living donation, the graft needs to be transplanted within about 4 hours, Dr. Samstein noted; this poses a logistical challenge for a national organ paired donation program.

“We worked around that with the idea that we would move the donor rather than the organ,” he said. The program will require a donor (and a support person) to travel to the recipient’s transplant center where the surgery will be performed. While 3 of the 15 pilot paired donation transplant centers are in New York City, the other programs are scattered across the country, meaning a donor may have to fly to a different city to undergo surgery.

Including the preoperative evaluation, meeting the surgical team, the surgery itself, and follow-up, the donor could stay for about a month. The program offers up to $10,000 of financial assistance for travel expenses (for both the donor and support person), as well as lost wages and dependent care (for the donor only). Health insurance coverage will also be provided by the pilot program, in partnership with the American Foundation for Donation and Transplant.

The program requires that transplant candidates (the recipients) be at least 12 years old, be on the waiting list for deceased liver donation at one of the pilot’s transplant centers, and have a Model for End-Stage Liver Disease (MELD) score of 25 or less. All potential donors must be 18 years or older and must undergo a medical and psychosocial evaluation. Nondirected donors can register with the program, and they will be paired with a candidate on the liver transplant waiting list at the same transplant center.

The 1-year pilot program is set to begin when the program conducts its first match run – an algorithm will help match pairs who are enrolled in the program. About five to seven enrolled pairs would be ideal for the first match run, a UNOS spokesperson said. It is possible that the 1-year pilot program could run without performing any paired transplants, but that’s unlikely if multiple pairs are enrolled in the system, the spokesperson said. At the time of this story’s publication, the one enrolled pair are a mother and daughter who are registered at the UCHealth Transplant Center in Colorado.
 

Is a national liver paired donor program feasible?

While the UNOS pilot program offers financial assistance for expenses related to liver donation, some transplant surgeons are skeptical about the potential travel component of the pilot program.

The pilot program requires that the donor bring one support person if there is a need to travel for the surgery, but undergoing major abdominal surgery from a transplant team they are not familiar with may be stressful, said Peter Abt, MD, a transplant surgeon at the Hospital of the University of Pennsylvania and the Children’s Hospital of Philadelphia. “That’s a big ask,” he said, “and I’m not sure many potential donors would be up to that.”

John Roberts, MD, a transplant surgeon at the University of California, San Francisco, agreed that the travel component may put additional stress on the donor, but “if it’s the only way for the recipient to get a transplant, then the donor might be motivated,” he added.

Dr. Jackson remains optimistic. “Our experience so far has been that, yes, some people have been hesitant for things like traveling, but a lot of people who seem to be genuinely dedicated to the idea of living donation have been very enthusiastic,” she noted.

Dr. Leishman agreed that the travel aspect appears to one of the greatest barriers to participants entering the program but noted that a goal of the pilot program is to understand better what works - and what doesn’t – when considering a liver paired donation program on a national scale. “[Our] steering committee has put together a really nice framework that they think will work, but they know it’s not perfect. We’re going to have to tweak it along the way,” she said.

More information on the paired liver donation pilot program can be found on the UNOS website.

The sources interviewed for this article reported no financial conflicts of interest.

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

This article was updated 2/15/23.

For a patient who needs a liver, living donation offers an alternative to staying on a list of more than 10,000 people waiting for a transplant. But what happens when your donor is not a match? To expand the number of living liver donations in the United States, the United Network for Organ Sharing (UNOS) has launched the first national paired liver donation pilot program.

“It’s an exciting time to be caring for patients who need liver transplants,” Benjamin Samstein, MD, chief of liver transplantation at New York–Presbyterian/Weill Cornell Medical Center, New York, said in an interview. He is the principal investigator for the UNOS pilot program. “I do believe it is within our grasp to make sure that nobody dies while waiting for an organ,” he said.

The initiative involves 15 U.S. transplant centers. So far, one recipient-donor pair has enrolled in the program. The pilot program has three main goals: Increase access to living donor transplants; increase access to transplants earlier, when recipients are in better health; and work out how to create and sustain a national program.
 

What is paired donation?

In 2020, 1,095 people died while waiting for a liver transplant, according to a report from the Organ Procurement and Transplant Network (OPTN) – a public-private partnership that includes more than 250 transplant centers and 50 organ procurement organizations across the country.

Most liver transplants involve deceased donors. One way to improve access to lifesaving transplants is through living donation, by which a healthy individual donates part of his or her liver. Someone can participate in nondirected or “altruistic” donation, in which someone donates a liver to someone they don’t know, or they can donate to a specific individual (usually a blood relative or a spouse).

With living liver donation, someone may receive a liver earlier, before getting sick enough to be given priority on the wait-list for deceased donation. Because the recipients are in better health, they may have an easier time recovering from the surgery, Ruthanne Leishman, who manages paired donation programs at UNOS, said in an interview.

In some cases, an individual will want to donate an organ to a specific person, but testing reveals that the two would not be a good match. Paired donation allows incompatible donors and recipients to find matches with other incompatible pairs. Each donor matches with the other pairs’ recipient, so the organs are essentially swapped or exchanged between the two pairs.

“People who want to donate get excited about the fact that they are not just helping their loved one but they’re also helping somebody else,” Ms. Leishman said.

Paired kidney donation programs have been running since 2002, but paired liver donation is relatively new. Since the first U.S. living-donor liver transplant in 1989, the procedure has become safer and is a viable alternative to deceased liver donation. A growing number of living donor programs are popping up at transplant centers across the country.

Still, living-donor liver donation makes up a small percentage of the liver transplants that are performed every year. In 2022, 603 living-donor liver transplants were performed in the United States, compared to 8,925 liver transplants from deceased donors, according to OPTN data. Dr. Samstein estimates a couple dozen paired liver exchanges may have been performed in the United States over the past few years within individual hospital systems. A goal of this pilot program, along with increasing access to liver transplants, is to see whether paired liver donation works on a national level, Ms. Leishman said.
 

Challenges to building a national program

There are several notable differences between living donor kidney transplants and living donor liver transplants. For example, living donor liver transplant is a more complicated surgery and poses greater risk to the donor. According to the OPTN 2020 Annual Report, from 2015 to 2019, the rehospitalization rate for living liver donors was twice that of living kidney donors up to 6 weeks after transplant (4.7% vs. 2.4%). One year post transplant, the cumulative rehospitalization rate was 11.0% for living liver donors and 4.8% for living kidney donors.

The risk of dying because of living donation is also higher for liver donors compared to kidney donors. The National Kidney Association states that the odds of dying during kidney donation are about 3 in 100,000, while estimates for risk of death for living liver donors range from 1 in 500 to 1 in 1,000. But some of these estimates are from 10 or more years ago, and outcomes have likely improved, said Whitney Jackson, MD, medical director of living donor liver transplant at UCHealth University of Colorado Hospital, Aurora. Her program is participating in the UNOS pilot.

More recent data from OPTN provides some idea of risk: Of 3,967 liver donors who donated between March 1, 2008, to Sept. 30, 2022, three deaths were reported within 30 days of transplant. However, the causes of death were not specified and therefore may be unrelated to the surgery. By comparison, of 74,555 kidney donors during that date range, 10 deaths were reported at 30 days post surgery.

In addition to a more complex surgery, surgeons also have a smaller time window in which to transplant a liver than than they do to transplant a kidney. A kidney can remain viable in cold storage for 24-36 hours, and it can be transported via commercial airlines cross country. Livers have to be transplanted within 8-12 hours, according to the OPTN website. For living donation, the graft needs to be transplanted within about 4 hours, Dr. Samstein noted; this poses a logistical challenge for a national organ paired donation program.

“We worked around that with the idea that we would move the donor rather than the organ,” he said. The program will require a donor (and a support person) to travel to the recipient’s transplant center where the surgery will be performed. While 3 of the 15 pilot paired donation transplant centers are in New York City, the other programs are scattered across the country, meaning a donor may have to fly to a different city to undergo surgery.

Including the preoperative evaluation, meeting the surgical team, the surgery itself, and follow-up, the donor could stay for about a month. The program offers up to $10,000 of financial assistance for travel expenses (for both the donor and support person), as well as lost wages and dependent care (for the donor only). Health insurance coverage will also be provided by the pilot program, in partnership with the American Foundation for Donation and Transplant.

The program requires that transplant candidates (the recipients) be at least 12 years old, be on the waiting list for deceased liver donation at one of the pilot’s transplant centers, and have a Model for End-Stage Liver Disease (MELD) score of 25 or less. All potential donors must be 18 years or older and must undergo a medical and psychosocial evaluation. Nondirected donors can register with the program, and they will be paired with a candidate on the liver transplant waiting list at the same transplant center.

The 1-year pilot program is set to begin when the program conducts its first match run – an algorithm will help match pairs who are enrolled in the program. About five to seven enrolled pairs would be ideal for the first match run, a UNOS spokesperson said. It is possible that the 1-year pilot program could run without performing any paired transplants, but that’s unlikely if multiple pairs are enrolled in the system, the spokesperson said. At the time of this story’s publication, the one enrolled pair are a mother and daughter who are registered at the UCHealth Transplant Center in Colorado.
 

Is a national liver paired donor program feasible?

While the UNOS pilot program offers financial assistance for expenses related to liver donation, some transplant surgeons are skeptical about the potential travel component of the pilot program.

The pilot program requires that the donor bring one support person if there is a need to travel for the surgery, but undergoing major abdominal surgery from a transplant team they are not familiar with may be stressful, said Peter Abt, MD, a transplant surgeon at the Hospital of the University of Pennsylvania and the Children’s Hospital of Philadelphia. “That’s a big ask,” he said, “and I’m not sure many potential donors would be up to that.”

John Roberts, MD, a transplant surgeon at the University of California, San Francisco, agreed that the travel component may put additional stress on the donor, but “if it’s the only way for the recipient to get a transplant, then the donor might be motivated,” he added.

Dr. Jackson remains optimistic. “Our experience so far has been that, yes, some people have been hesitant for things like traveling, but a lot of people who seem to be genuinely dedicated to the idea of living donation have been very enthusiastic,” she noted.

Dr. Leishman agreed that the travel aspect appears to one of the greatest barriers to participants entering the program but noted that a goal of the pilot program is to understand better what works - and what doesn’t – when considering a liver paired donation program on a national scale. “[Our] steering committee has put together a really nice framework that they think will work, but they know it’s not perfect. We’re going to have to tweak it along the way,” she said.

More information on the paired liver donation pilot program can be found on the UNOS website.

The sources interviewed for this article reported no financial conflicts of interest.

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

This article was updated 2/15/23.

For a patient who needs a liver, living donation offers an alternative to staying on a list of more than 10,000 people waiting for a transplant. But what happens when your donor is not a match? To expand the number of living liver donations in the United States, the United Network for Organ Sharing (UNOS) has launched the first national paired liver donation pilot program.

“It’s an exciting time to be caring for patients who need liver transplants,” Benjamin Samstein, MD, chief of liver transplantation at New York–Presbyterian/Weill Cornell Medical Center, New York, said in an interview. He is the principal investigator for the UNOS pilot program. “I do believe it is within our grasp to make sure that nobody dies while waiting for an organ,” he said.

The initiative involves 15 U.S. transplant centers. So far, one recipient-donor pair has enrolled in the program. The pilot program has three main goals: Increase access to living donor transplants; increase access to transplants earlier, when recipients are in better health; and work out how to create and sustain a national program.
 

What is paired donation?

In 2020, 1,095 people died while waiting for a liver transplant, according to a report from the Organ Procurement and Transplant Network (OPTN) – a public-private partnership that includes more than 250 transplant centers and 50 organ procurement organizations across the country.

Most liver transplants involve deceased donors. One way to improve access to lifesaving transplants is through living donation, by which a healthy individual donates part of his or her liver. Someone can participate in nondirected or “altruistic” donation, in which someone donates a liver to someone they don’t know, or they can donate to a specific individual (usually a blood relative or a spouse).

With living liver donation, someone may receive a liver earlier, before getting sick enough to be given priority on the wait-list for deceased donation. Because the recipients are in better health, they may have an easier time recovering from the surgery, Ruthanne Leishman, who manages paired donation programs at UNOS, said in an interview.

In some cases, an individual will want to donate an organ to a specific person, but testing reveals that the two would not be a good match. Paired donation allows incompatible donors and recipients to find matches with other incompatible pairs. Each donor matches with the other pairs’ recipient, so the organs are essentially swapped or exchanged between the two pairs.

“People who want to donate get excited about the fact that they are not just helping their loved one but they’re also helping somebody else,” Ms. Leishman said.

Paired kidney donation programs have been running since 2002, but paired liver donation is relatively new. Since the first U.S. living-donor liver transplant in 1989, the procedure has become safer and is a viable alternative to deceased liver donation. A growing number of living donor programs are popping up at transplant centers across the country.

Still, living-donor liver donation makes up a small percentage of the liver transplants that are performed every year. In 2022, 603 living-donor liver transplants were performed in the United States, compared to 8,925 liver transplants from deceased donors, according to OPTN data. Dr. Samstein estimates a couple dozen paired liver exchanges may have been performed in the United States over the past few years within individual hospital systems. A goal of this pilot program, along with increasing access to liver transplants, is to see whether paired liver donation works on a national level, Ms. Leishman said.
 

Challenges to building a national program

There are several notable differences between living donor kidney transplants and living donor liver transplants. For example, living donor liver transplant is a more complicated surgery and poses greater risk to the donor. According to the OPTN 2020 Annual Report, from 2015 to 2019, the rehospitalization rate for living liver donors was twice that of living kidney donors up to 6 weeks after transplant (4.7% vs. 2.4%). One year post transplant, the cumulative rehospitalization rate was 11.0% for living liver donors and 4.8% for living kidney donors.

The risk of dying because of living donation is also higher for liver donors compared to kidney donors. The National Kidney Association states that the odds of dying during kidney donation are about 3 in 100,000, while estimates for risk of death for living liver donors range from 1 in 500 to 1 in 1,000. But some of these estimates are from 10 or more years ago, and outcomes have likely improved, said Whitney Jackson, MD, medical director of living donor liver transplant at UCHealth University of Colorado Hospital, Aurora. Her program is participating in the UNOS pilot.

More recent data from OPTN provides some idea of risk: Of 3,967 liver donors who donated between March 1, 2008, to Sept. 30, 2022, three deaths were reported within 30 days of transplant. However, the causes of death were not specified and therefore may be unrelated to the surgery. By comparison, of 74,555 kidney donors during that date range, 10 deaths were reported at 30 days post surgery.

In addition to a more complex surgery, surgeons also have a smaller time window in which to transplant a liver than than they do to transplant a kidney. A kidney can remain viable in cold storage for 24-36 hours, and it can be transported via commercial airlines cross country. Livers have to be transplanted within 8-12 hours, according to the OPTN website. For living donation, the graft needs to be transplanted within about 4 hours, Dr. Samstein noted; this poses a logistical challenge for a national organ paired donation program.

“We worked around that with the idea that we would move the donor rather than the organ,” he said. The program will require a donor (and a support person) to travel to the recipient’s transplant center where the surgery will be performed. While 3 of the 15 pilot paired donation transplant centers are in New York City, the other programs are scattered across the country, meaning a donor may have to fly to a different city to undergo surgery.

Including the preoperative evaluation, meeting the surgical team, the surgery itself, and follow-up, the donor could stay for about a month. The program offers up to $10,000 of financial assistance for travel expenses (for both the donor and support person), as well as lost wages and dependent care (for the donor only). Health insurance coverage will also be provided by the pilot program, in partnership with the American Foundation for Donation and Transplant.

The program requires that transplant candidates (the recipients) be at least 12 years old, be on the waiting list for deceased liver donation at one of the pilot’s transplant centers, and have a Model for End-Stage Liver Disease (MELD) score of 25 or less. All potential donors must be 18 years or older and must undergo a medical and psychosocial evaluation. Nondirected donors can register with the program, and they will be paired with a candidate on the liver transplant waiting list at the same transplant center.

The 1-year pilot program is set to begin when the program conducts its first match run – an algorithm will help match pairs who are enrolled in the program. About five to seven enrolled pairs would be ideal for the first match run, a UNOS spokesperson said. It is possible that the 1-year pilot program could run without performing any paired transplants, but that’s unlikely if multiple pairs are enrolled in the system, the spokesperson said. At the time of this story’s publication, the one enrolled pair are a mother and daughter who are registered at the UCHealth Transplant Center in Colorado.
 

Is a national liver paired donor program feasible?

While the UNOS pilot program offers financial assistance for expenses related to liver donation, some transplant surgeons are skeptical about the potential travel component of the pilot program.

The pilot program requires that the donor bring one support person if there is a need to travel for the surgery, but undergoing major abdominal surgery from a transplant team they are not familiar with may be stressful, said Peter Abt, MD, a transplant surgeon at the Hospital of the University of Pennsylvania and the Children’s Hospital of Philadelphia. “That’s a big ask,” he said, “and I’m not sure many potential donors would be up to that.”

John Roberts, MD, a transplant surgeon at the University of California, San Francisco, agreed that the travel component may put additional stress on the donor, but “if it’s the only way for the recipient to get a transplant, then the donor might be motivated,” he added.

Dr. Jackson remains optimistic. “Our experience so far has been that, yes, some people have been hesitant for things like traveling, but a lot of people who seem to be genuinely dedicated to the idea of living donation have been very enthusiastic,” she noted.

Dr. Leishman agreed that the travel aspect appears to one of the greatest barriers to participants entering the program but noted that a goal of the pilot program is to understand better what works - and what doesn’t – when considering a liver paired donation program on a national scale. “[Our] steering committee has put together a really nice framework that they think will work, but they know it’s not perfect. We’re going to have to tweak it along the way,” she said.

More information on the paired liver donation pilot program can be found on the UNOS website.

The sources interviewed for this article reported no financial conflicts of interest.

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

This article was updated 2/15/23.

A surgeon in Tulsa shot by a disgruntled patient. A doctor in India beaten by a group of bereaved family members. A general practitioner in the United Kingdom threatened with stabbing. The reality is grim: Health care workers across the globe experience violence while at work. A new study identifies this trend and finds that 25% of health care workers polled were willing to quit because of such violence.

“That was pretty appalling,” Rahul Kashyap, MD, MBA, MBBS, recalls. Dr. Kashyap is one of the leaders of the Violence Study of Healthcare Workers and Systems (ViSHWaS), which polled an international sample of physicians, nurses, and hospital staff. This study has worrying implications, Dr. Kashyap says. In a time when hospital staff are reporting burnout in record numbers, further deterrents may be the last thing our health care system needs. But Dr. Kashyap hopes that bringing awareness to these trends may allow physicians, policymakers, and the public to mobilize and intervene before it’s too late.

Previous studies have revealed similar trends. The rate of workplace violence directed at U.S. health care workers is five times that of workers in any other industry, according to the Bureau of Labor Statistics. The same study found that attacks had increased 63% from 2011 to 2018. Other polls that focus on the pandemic show that nearly half of U.S. nurses believe that violence increased since the world shut down. Well before the pandemic, however, a study from the Indian Medical Association found that 75% of doctors experienced workplace violence.

With this history in mind, perhaps it’s not surprising that the idea for the study came from the authors’ personal experiences. They had seen coworkers go through attacks, or they had endured attacks themselves, Dr. Kashyap says. But they couldn’t find any global data to back up these experiences. So Dr. Kashyap and his colleagues formed a web of volunteers dedicated to creating a cross-sectional study.

They got in touch with researchers from countries across Asia, the Middle East, South America, North America, and Africa. The initial group agreed to reach out to their contacts, casting a wide net. Researchers used WhatsApp, LinkedIn, and text messages to distribute the survey. Health care workers in each country completed the brief questionnaire, recalling their prepandemic world and evaluating their current one.

Within 2 months, they had reached health care workers in more than 100 countries. They concluded the study when they received about 5,000 results, according to Dr. Kashyap, and then began the process of stratifying the data. For this report, they focused on critical care, emergency medicine, and anesthesiology, which resulted in 598 responses from 69 countries. Of these, India and the United States had the highest number of participants.

In all, 73% of participants reported facing physical or verbal violence while in the hospital; 48% said they felt less motivated to work because of that violence; 39% of respondents believed that the amount of violence they experienced was the same as before the COVID-19 pandemic; and 36% of respondents believed that violence had increased. Even though they were trained on guidelines from the Occupational Safety and Health Administration, 20% of participants felt unprepared to face violence.

Although the study didn’t analyze the reasons workers felt this way, Dr. Kashyap speculates that it could be related to the medical distrust that grew during the pandemic or the stress patients and health care professionals experienced during its peak.

Regardless, the researchers say their study is a starting point. Now that the trend has been highlighted, it may be acted on.

Moving forward, Dr. Kashyap believes that controlling for different variables could determine whether factors like gender or shift time put a worker at higher risk for violence. He hopes it’s possible to interrupt these patterns and reestablish trust in the hospital environment. “It’s aspirational, but you’re hoping that through studies like ViSHWaS, which means trust in Hindi ... [we could restore] the trust and confidence among health care providers for the patients and family members.”

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

A surgeon in Tulsa shot by a disgruntled patient. A doctor in India beaten by a group of bereaved family members. A general practitioner in the United Kingdom threatened with stabbing. The reality is grim: Health care workers across the globe experience violence while at work. A new study identifies this trend and finds that 25% of health care workers polled were willing to quit because of such violence.

“That was pretty appalling,” Rahul Kashyap, MD, MBA, MBBS, recalls. Dr. Kashyap is one of the leaders of the Violence Study of Healthcare Workers and Systems (ViSHWaS), which polled an international sample of physicians, nurses, and hospital staff. This study has worrying implications, Dr. Kashyap says. In a time when hospital staff are reporting burnout in record numbers, further deterrents may be the last thing our health care system needs. But Dr. Kashyap hopes that bringing awareness to these trends may allow physicians, policymakers, and the public to mobilize and intervene before it’s too late.

Previous studies have revealed similar trends. The rate of workplace violence directed at U.S. health care workers is five times that of workers in any other industry, according to the Bureau of Labor Statistics. The same study found that attacks had increased 63% from 2011 to 2018. Other polls that focus on the pandemic show that nearly half of U.S. nurses believe that violence increased since the world shut down. Well before the pandemic, however, a study from the Indian Medical Association found that 75% of doctors experienced workplace violence.

With this history in mind, perhaps it’s not surprising that the idea for the study came from the authors’ personal experiences. They had seen coworkers go through attacks, or they had endured attacks themselves, Dr. Kashyap says. But they couldn’t find any global data to back up these experiences. So Dr. Kashyap and his colleagues formed a web of volunteers dedicated to creating a cross-sectional study.

They got in touch with researchers from countries across Asia, the Middle East, South America, North America, and Africa. The initial group agreed to reach out to their contacts, casting a wide net. Researchers used WhatsApp, LinkedIn, and text messages to distribute the survey. Health care workers in each country completed the brief questionnaire, recalling their prepandemic world and evaluating their current one.

Within 2 months, they had reached health care workers in more than 100 countries. They concluded the study when they received about 5,000 results, according to Dr. Kashyap, and then began the process of stratifying the data. For this report, they focused on critical care, emergency medicine, and anesthesiology, which resulted in 598 responses from 69 countries. Of these, India and the United States had the highest number of participants.

In all, 73% of participants reported facing physical or verbal violence while in the hospital; 48% said they felt less motivated to work because of that violence; 39% of respondents believed that the amount of violence they experienced was the same as before the COVID-19 pandemic; and 36% of respondents believed that violence had increased. Even though they were trained on guidelines from the Occupational Safety and Health Administration, 20% of participants felt unprepared to face violence.

Although the study didn’t analyze the reasons workers felt this way, Dr. Kashyap speculates that it could be related to the medical distrust that grew during the pandemic or the stress patients and health care professionals experienced during its peak.

Regardless, the researchers say their study is a starting point. Now that the trend has been highlighted, it may be acted on.

Moving forward, Dr. Kashyap believes that controlling for different variables could determine whether factors like gender or shift time put a worker at higher risk for violence. He hopes it’s possible to interrupt these patterns and reestablish trust in the hospital environment. “It’s aspirational, but you’re hoping that through studies like ViSHWaS, which means trust in Hindi ... [we could restore] the trust and confidence among health care providers for the patients and family members.”

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

A surgeon in Tulsa shot by a disgruntled patient. A doctor in India beaten by a group of bereaved family members. A general practitioner in the United Kingdom threatened with stabbing. The reality is grim: Health care workers across the globe experience violence while at work. A new study identifies this trend and finds that 25% of health care workers polled were willing to quit because of such violence.

“That was pretty appalling,” Rahul Kashyap, MD, MBA, MBBS, recalls. Dr. Kashyap is one of the leaders of the Violence Study of Healthcare Workers and Systems (ViSHWaS), which polled an international sample of physicians, nurses, and hospital staff. This study has worrying implications, Dr. Kashyap says. In a time when hospital staff are reporting burnout in record numbers, further deterrents may be the last thing our health care system needs. But Dr. Kashyap hopes that bringing awareness to these trends may allow physicians, policymakers, and the public to mobilize and intervene before it’s too late.

Previous studies have revealed similar trends. The rate of workplace violence directed at U.S. health care workers is five times that of workers in any other industry, according to the Bureau of Labor Statistics. The same study found that attacks had increased 63% from 2011 to 2018. Other polls that focus on the pandemic show that nearly half of U.S. nurses believe that violence increased since the world shut down. Well before the pandemic, however, a study from the Indian Medical Association found that 75% of doctors experienced workplace violence.

With this history in mind, perhaps it’s not surprising that the idea for the study came from the authors’ personal experiences. They had seen coworkers go through attacks, or they had endured attacks themselves, Dr. Kashyap says. But they couldn’t find any global data to back up these experiences. So Dr. Kashyap and his colleagues formed a web of volunteers dedicated to creating a cross-sectional study.

They got in touch with researchers from countries across Asia, the Middle East, South America, North America, and Africa. The initial group agreed to reach out to their contacts, casting a wide net. Researchers used WhatsApp, LinkedIn, and text messages to distribute the survey. Health care workers in each country completed the brief questionnaire, recalling their prepandemic world and evaluating their current one.

Within 2 months, they had reached health care workers in more than 100 countries. They concluded the study when they received about 5,000 results, according to Dr. Kashyap, and then began the process of stratifying the data. For this report, they focused on critical care, emergency medicine, and anesthesiology, which resulted in 598 responses from 69 countries. Of these, India and the United States had the highest number of participants.

In all, 73% of participants reported facing physical or verbal violence while in the hospital; 48% said they felt less motivated to work because of that violence; 39% of respondents believed that the amount of violence they experienced was the same as before the COVID-19 pandemic; and 36% of respondents believed that violence had increased. Even though they were trained on guidelines from the Occupational Safety and Health Administration, 20% of participants felt unprepared to face violence.

Although the study didn’t analyze the reasons workers felt this way, Dr. Kashyap speculates that it could be related to the medical distrust that grew during the pandemic or the stress patients and health care professionals experienced during its peak.

Regardless, the researchers say their study is a starting point. Now that the trend has been highlighted, it may be acted on.

Moving forward, Dr. Kashyap believes that controlling for different variables could determine whether factors like gender or shift time put a worker at higher risk for violence. He hopes it’s possible to interrupt these patterns and reestablish trust in the hospital environment. “It’s aspirational, but you’re hoping that through studies like ViSHWaS, which means trust in Hindi ... [we could restore] the trust and confidence among health care providers for the patients and family members.”

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

At least one state licensing agency is revoking nursing licenses allegedly obtained in a multistate fake diploma scheme.

The U.S. Department of Justice recently announced charges against 25 owners, operators, and employees of three Florida nursing schools in a fraud scheme in which they sold as many as 7,600 fake nursing degrees.

The purchasers in the diploma scheme paid $10,000 to $15,000 for degrees and transcripts and some 2,800 of the buyers passed the national nursing licensing exam to become registered nurses (RNs) and licensed practice nurses/vocational nurses (LPN/VNs) around the country, according to The New York Times.

Many of the degree recipients went on to work at hospitals, nursing homes, and Veterans Affairs medical centers, according to the U.S. Attorney’s Office for the Southern District of Florida.

Several national nursing organizations cooperated with the investigation, and the Delaware Division of Professional Regulation already annulled 26 licenses, according to the Delaware Nurses Association. Fake licenses were issued in five states, according to federal reports.

“We are deeply unsettled by this egregious act,” DNA President Stephanie McClellan, MSN, RN, CMSRN, said in the group’s press statement. “We want all Delaware nurses to be aware of this active issue and to speak up if there is a concern regarding capacity to practice safely by a colleague/peer,” she said.

The Oregon State Board of Nursing is also investigating at least a dozen nurses who may have paid for their degrees, according to a Portland CBS affiliate.

The National Council of State Boards of Nursing said in a statement that it had helped authorities identify and monitor the individuals who allegedly provided the false degrees.
 

Nursing community reacts

News of the fraud scheme spread through the nursing community, including social media. “The recent report on falsified nursing school degrees is both heartbreaking and serves as an eye-opener,” tweeted Usha Menon, PhD, RN, FAAN, dean and health professor of the University of South Florida Health College of Nursing. “There was enough of a need that prompted these bad actors to develop a scheme that could’ve endangered dozens of lives.”

Jennifer Mensik Kennedy, PhD, MBA, RN, the new president of the American Nurses Association, also weighed in. “The accusation that personnel at once-accredited nursing schools allegedly participated in this scheme is simply deplorable. These unlawful and unethical acts disparage the reputation of actual nurses everywhere who have rightfully earned [their titles] through their education, hard work, dedication, and time.”

The false degrees and transcripts were issued by three once-accredited and now-shuttered nursing schools in South Florida: Palm Beach School of Nursing, Sacred Heart International Institute, and Sienna College.

The alleged co-conspirators reportedly made $114 million from the scheme, which dates back to 2016, according to several news reports. Each defendant faces up to 20 years in prison.

Most LPN programs charge $10,000 to $15,000 to complete a program, Robert Rosseter, a spokesperson for the American Association of Colleges of Nursing (AACN), told this news organization.

None were AACN members, and none were accredited by the Commission on Collegiate Nursing Education, which is AACN’s autonomous accrediting agency, Mr. Rosseter said. AACN membership is voluntary and is open to schools offering baccalaureate or higher degrees, he explained.

“What is disturbing about this investigation is that there are over 7,600 people around the country with fraudulent nursing credentials who are potentially in critical health care roles treating patients,” Chad Yarbrough, acting special agent in charge for the FBI in Miami, said in the federal justice department release.
 

‘Operation Nightingale’ based on tip

The federal action, dubbed “Operation Nightingale” after the nursing pioneer Florence Nightingale, began in 2019. It was based on a tip related to a case in Maryland, according to Nurse.org.

That case ensnared Palm Beach School of Nursing owner Johanah Napoleon, who reportedly was selling fake degrees for $6,000 to $18,000 each to two individuals in Maryland and Virginia. Ms. Napoleon was charged in 2021 and eventually pled guilty. The Florida Board of Nursing shut down the Palm Beach school in 2017 owing to its students’ low passing rate on the national licensing exam.

Two participants in the bigger scheme who had also worked with Ms. Napoleon – Geralda Adrien and Woosvelt Predestin – were indicted in 2021. Ms. Adrien owned private education companies for people who at aspired to be nurses, and Mr. Predestin was an employee. They were sentenced to 27 months in prison last year and helped the federal officials build the larger case.

The 25 individuals who were charged Jan. 25 operated in Delaware, New York, New Jersey, Texas, and Florida.
 

Schemes lured immigrants

In the scheme involving Siena College, some of the individuals acted as recruiters to direct nurses who were looking for employment to the school, where they allegedly would then pay for an RN or LPN/VN degree. The recipients of the false documents then used them to obtain jobs, including at a hospital in Georgia and a Veterans Affairs medical center in Maryland, according to one indictment. The president of Siena and her co-conspirators sold more than 2,000 fake diplomas, according to charging documents.

At the Palm Beach College of Nursing, individuals at various nursing prep and education programs allegedly helped others obtain fake degrees and transcripts, which were then used to pass RN and LPN/VN licensing exams in states that included Massachusetts, New Jersey, New York, and Ohio, according to the indictment.

Some individuals then secured employment with a nursing home in Ohio, a home health agency for pediatric patients in Massachusetts, and skilled nursing facilities in New York and New Jersey.

Prosecutors allege that the president of Sacred Heart International Institute and two other co-conspirators sold 588 fake diplomas.

The FBI said that some of the aspiring nurses who were talked into buying the degrees were LPNs who wanted to become RNs and that most of those lured into the scheme were from South Florida’s Haitian American immigrant community, Nurse.org reported.

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

At least one state licensing agency is revoking nursing licenses allegedly obtained in a multistate fake diploma scheme.

The U.S. Department of Justice recently announced charges against 25 owners, operators, and employees of three Florida nursing schools in a fraud scheme in which they sold as many as 7,600 fake nursing degrees.

The purchasers in the diploma scheme paid $10,000 to $15,000 for degrees and transcripts and some 2,800 of the buyers passed the national nursing licensing exam to become registered nurses (RNs) and licensed practice nurses/vocational nurses (LPN/VNs) around the country, according to The New York Times.

Many of the degree recipients went on to work at hospitals, nursing homes, and Veterans Affairs medical centers, according to the U.S. Attorney’s Office for the Southern District of Florida.

Several national nursing organizations cooperated with the investigation, and the Delaware Division of Professional Regulation already annulled 26 licenses, according to the Delaware Nurses Association. Fake licenses were issued in five states, according to federal reports.

“We are deeply unsettled by this egregious act,” DNA President Stephanie McClellan, MSN, RN, CMSRN, said in the group’s press statement. “We want all Delaware nurses to be aware of this active issue and to speak up if there is a concern regarding capacity to practice safely by a colleague/peer,” she said.

The Oregon State Board of Nursing is also investigating at least a dozen nurses who may have paid for their degrees, according to a Portland CBS affiliate.

The National Council of State Boards of Nursing said in a statement that it had helped authorities identify and monitor the individuals who allegedly provided the false degrees.
 

Nursing community reacts

News of the fraud scheme spread through the nursing community, including social media. “The recent report on falsified nursing school degrees is both heartbreaking and serves as an eye-opener,” tweeted Usha Menon, PhD, RN, FAAN, dean and health professor of the University of South Florida Health College of Nursing. “There was enough of a need that prompted these bad actors to develop a scheme that could’ve endangered dozens of lives.”

Jennifer Mensik Kennedy, PhD, MBA, RN, the new president of the American Nurses Association, also weighed in. “The accusation that personnel at once-accredited nursing schools allegedly participated in this scheme is simply deplorable. These unlawful and unethical acts disparage the reputation of actual nurses everywhere who have rightfully earned [their titles] through their education, hard work, dedication, and time.”

The false degrees and transcripts were issued by three once-accredited and now-shuttered nursing schools in South Florida: Palm Beach School of Nursing, Sacred Heart International Institute, and Sienna College.

The alleged co-conspirators reportedly made $114 million from the scheme, which dates back to 2016, according to several news reports. Each defendant faces up to 20 years in prison.

Most LPN programs charge $10,000 to $15,000 to complete a program, Robert Rosseter, a spokesperson for the American Association of Colleges of Nursing (AACN), told this news organization.

None were AACN members, and none were accredited by the Commission on Collegiate Nursing Education, which is AACN’s autonomous accrediting agency, Mr. Rosseter said. AACN membership is voluntary and is open to schools offering baccalaureate or higher degrees, he explained.

“What is disturbing about this investigation is that there are over 7,600 people around the country with fraudulent nursing credentials who are potentially in critical health care roles treating patients,” Chad Yarbrough, acting special agent in charge for the FBI in Miami, said in the federal justice department release.
 

‘Operation Nightingale’ based on tip

The federal action, dubbed “Operation Nightingale” after the nursing pioneer Florence Nightingale, began in 2019. It was based on a tip related to a case in Maryland, according to Nurse.org.

That case ensnared Palm Beach School of Nursing owner Johanah Napoleon, who reportedly was selling fake degrees for $6,000 to $18,000 each to two individuals in Maryland and Virginia. Ms. Napoleon was charged in 2021 and eventually pled guilty. The Florida Board of Nursing shut down the Palm Beach school in 2017 owing to its students’ low passing rate on the national licensing exam.

Two participants in the bigger scheme who had also worked with Ms. Napoleon – Geralda Adrien and Woosvelt Predestin – were indicted in 2021. Ms. Adrien owned private education companies for people who at aspired to be nurses, and Mr. Predestin was an employee. They were sentenced to 27 months in prison last year and helped the federal officials build the larger case.

The 25 individuals who were charged Jan. 25 operated in Delaware, New York, New Jersey, Texas, and Florida.
 

Schemes lured immigrants

In the scheme involving Siena College, some of the individuals acted as recruiters to direct nurses who were looking for employment to the school, where they allegedly would then pay for an RN or LPN/VN degree. The recipients of the false documents then used them to obtain jobs, including at a hospital in Georgia and a Veterans Affairs medical center in Maryland, according to one indictment. The president of Siena and her co-conspirators sold more than 2,000 fake diplomas, according to charging documents.

At the Palm Beach College of Nursing, individuals at various nursing prep and education programs allegedly helped others obtain fake degrees and transcripts, which were then used to pass RN and LPN/VN licensing exams in states that included Massachusetts, New Jersey, New York, and Ohio, according to the indictment.

Some individuals then secured employment with a nursing home in Ohio, a home health agency for pediatric patients in Massachusetts, and skilled nursing facilities in New York and New Jersey.

Prosecutors allege that the president of Sacred Heart International Institute and two other co-conspirators sold 588 fake diplomas.

The FBI said that some of the aspiring nurses who were talked into buying the degrees were LPNs who wanted to become RNs and that most of those lured into the scheme were from South Florida’s Haitian American immigrant community, Nurse.org reported.

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

At least one state licensing agency is revoking nursing licenses allegedly obtained in a multistate fake diploma scheme.

The U.S. Department of Justice recently announced charges against 25 owners, operators, and employees of three Florida nursing schools in a fraud scheme in which they sold as many as 7,600 fake nursing degrees.

The purchasers in the diploma scheme paid $10,000 to $15,000 for degrees and transcripts and some 2,800 of the buyers passed the national nursing licensing exam to become registered nurses (RNs) and licensed practice nurses/vocational nurses (LPN/VNs) around the country, according to The New York Times.

Many of the degree recipients went on to work at hospitals, nursing homes, and Veterans Affairs medical centers, according to the U.S. Attorney’s Office for the Southern District of Florida.

Several national nursing organizations cooperated with the investigation, and the Delaware Division of Professional Regulation already annulled 26 licenses, according to the Delaware Nurses Association. Fake licenses were issued in five states, according to federal reports.

“We are deeply unsettled by this egregious act,” DNA President Stephanie McClellan, MSN, RN, CMSRN, said in the group’s press statement. “We want all Delaware nurses to be aware of this active issue and to speak up if there is a concern regarding capacity to practice safely by a colleague/peer,” she said.

The Oregon State Board of Nursing is also investigating at least a dozen nurses who may have paid for their degrees, according to a Portland CBS affiliate.

The National Council of State Boards of Nursing said in a statement that it had helped authorities identify and monitor the individuals who allegedly provided the false degrees.
 

Nursing community reacts

News of the fraud scheme spread through the nursing community, including social media. “The recent report on falsified nursing school degrees is both heartbreaking and serves as an eye-opener,” tweeted Usha Menon, PhD, RN, FAAN, dean and health professor of the University of South Florida Health College of Nursing. “There was enough of a need that prompted these bad actors to develop a scheme that could’ve endangered dozens of lives.”

Jennifer Mensik Kennedy, PhD, MBA, RN, the new president of the American Nurses Association, also weighed in. “The accusation that personnel at once-accredited nursing schools allegedly participated in this scheme is simply deplorable. These unlawful and unethical acts disparage the reputation of actual nurses everywhere who have rightfully earned [their titles] through their education, hard work, dedication, and time.”

The false degrees and transcripts were issued by three once-accredited and now-shuttered nursing schools in South Florida: Palm Beach School of Nursing, Sacred Heart International Institute, and Sienna College.

The alleged co-conspirators reportedly made $114 million from the scheme, which dates back to 2016, according to several news reports. Each defendant faces up to 20 years in prison.

Most LPN programs charge $10,000 to $15,000 to complete a program, Robert Rosseter, a spokesperson for the American Association of Colleges of Nursing (AACN), told this news organization.

None were AACN members, and none were accredited by the Commission on Collegiate Nursing Education, which is AACN’s autonomous accrediting agency, Mr. Rosseter said. AACN membership is voluntary and is open to schools offering baccalaureate or higher degrees, he explained.

“What is disturbing about this investigation is that there are over 7,600 people around the country with fraudulent nursing credentials who are potentially in critical health care roles treating patients,” Chad Yarbrough, acting special agent in charge for the FBI in Miami, said in the federal justice department release.
 

‘Operation Nightingale’ based on tip

The federal action, dubbed “Operation Nightingale” after the nursing pioneer Florence Nightingale, began in 2019. It was based on a tip related to a case in Maryland, according to Nurse.org.

That case ensnared Palm Beach School of Nursing owner Johanah Napoleon, who reportedly was selling fake degrees for $6,000 to $18,000 each to two individuals in Maryland and Virginia. Ms. Napoleon was charged in 2021 and eventually pled guilty. The Florida Board of Nursing shut down the Palm Beach school in 2017 owing to its students’ low passing rate on the national licensing exam.

Two participants in the bigger scheme who had also worked with Ms. Napoleon – Geralda Adrien and Woosvelt Predestin – were indicted in 2021. Ms. Adrien owned private education companies for people who at aspired to be nurses, and Mr. Predestin was an employee. They were sentenced to 27 months in prison last year and helped the federal officials build the larger case.

The 25 individuals who were charged Jan. 25 operated in Delaware, New York, New Jersey, Texas, and Florida.
 

Schemes lured immigrants

In the scheme involving Siena College, some of the individuals acted as recruiters to direct nurses who were looking for employment to the school, where they allegedly would then pay for an RN or LPN/VN degree. The recipients of the false documents then used them to obtain jobs, including at a hospital in Georgia and a Veterans Affairs medical center in Maryland, according to one indictment. The president of Siena and her co-conspirators sold more than 2,000 fake diplomas, according to charging documents.

At the Palm Beach College of Nursing, individuals at various nursing prep and education programs allegedly helped others obtain fake degrees and transcripts, which were then used to pass RN and LPN/VN licensing exams in states that included Massachusetts, New Jersey, New York, and Ohio, according to the indictment.

Some individuals then secured employment with a nursing home in Ohio, a home health agency for pediatric patients in Massachusetts, and skilled nursing facilities in New York and New Jersey.

Prosecutors allege that the president of Sacred Heart International Institute and two other co-conspirators sold 588 fake diplomas.

The FBI said that some of the aspiring nurses who were talked into buying the degrees were LPNs who wanted to become RNs and that most of those lured into the scheme were from South Florida’s Haitian American immigrant community, Nurse.org reported.

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

The two national emergency declarations dealing with the COVID-19 pandemic will end May 11, President Joe Biden said on Jan. 30.

Doing so will have many effects, including the end of free vaccines and health services to fight the pandemic. The public health emergency has been renewed every 90 days since it was declared by the Trump administration in January 2020.

The declaration allowed major changes throughout the health care system to deal with the pandemic, including the free distribution of vaccines, testing, and treatments. In addition, telehealth services were expanded, and Medicaid and the Children’s Health Insurance Program were extended to millions more Americans.

Biden said the COVID-19 national emergency is set to expire March 1 while the declared public health emergency would currently expire on April 11. The president said both will be extended to end May 11.

There were nearly 300,000 newly reported COVID-19 cases in the United States for the week ending Jan. 25, according to CDC data, as well as more than 3,750 deaths.

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

The two national emergency declarations dealing with the COVID-19 pandemic will end May 11, President Joe Biden said on Jan. 30.

Doing so will have many effects, including the end of free vaccines and health services to fight the pandemic. The public health emergency has been renewed every 90 days since it was declared by the Trump administration in January 2020.

The declaration allowed major changes throughout the health care system to deal with the pandemic, including the free distribution of vaccines, testing, and treatments. In addition, telehealth services were expanded, and Medicaid and the Children’s Health Insurance Program were extended to millions more Americans.

Biden said the COVID-19 national emergency is set to expire March 1 while the declared public health emergency would currently expire on April 11. The president said both will be extended to end May 11.

There were nearly 300,000 newly reported COVID-19 cases in the United States for the week ending Jan. 25, according to CDC data, as well as more than 3,750 deaths.

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

The two national emergency declarations dealing with the COVID-19 pandemic will end May 11, President Joe Biden said on Jan. 30.

Doing so will have many effects, including the end of free vaccines and health services to fight the pandemic. The public health emergency has been renewed every 90 days since it was declared by the Trump administration in January 2020.

The declaration allowed major changes throughout the health care system to deal with the pandemic, including the free distribution of vaccines, testing, and treatments. In addition, telehealth services were expanded, and Medicaid and the Children’s Health Insurance Program were extended to millions more Americans.

Biden said the COVID-19 national emergency is set to expire March 1 while the declared public health emergency would currently expire on April 11. The president said both will be extended to end May 11.

There were nearly 300,000 newly reported COVID-19 cases in the United States for the week ending Jan. 25, according to CDC data, as well as more than 3,750 deaths.

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

Despite improvements in access to health coverage under the Affordable Care Act (ACA), racial disparities in breast cancer mortality rates persist and the underuse of advanced breast imaging may be one culprit, experts say.
 

In a recent position statement, researchers highlighted the disproportionally high breast cancer mortality rates among Black women in Louisiana – a state that has one of the highest breast cancer mortality rates in the nation. In 2019, the breast cancer mortality rate among Black women in Louisiana was 29.3 per 100,000 women compared with the national rate of 19.4 per 100,000.

Although Louisiana has made strides in improving access to breast cancer screening in recent years, the use of advanced imaging – specifically breast MRI – remains underused in this high-risk population. A major barrier to wider use of breast MRI has been cost, and ACA expansion led to higher, not lower, out-of-pocket costs for this screening modality.

“Breast MRI is a powerful imaging tool for early detection and for screening women at high risk for breast cancer,” wrote the researchers, led by Brooke L. Morrell, MD, of Louisiana State University Health and Sciences Center, New Orleans.

However, greater access to health care has not necessarily translated to increased breast MRI screening or improved survival among Black women. Even years after the adoption of the ACA, “Black women in Louisiana continue to die of breast cancer at rates significantly greater than the national average,” the authors wrote.

The position statement was published in Cancer.

Breast MRI is known to provide the highest rate of breast cancer detection among commonly used imaging options, with a sensitivity ranging from 81% to 100%. That’s about twice as high as the sensitivity range for mammography after factoring in breast density.

“This is of particular importance when we consider the risk‐based screening of younger populations, in which dense breasts are more prevalent,” the authors explained.

For Black women in particular, studies show nearly a quarter (23%) who develop breast cancer are diagnosed under the age of 50, compared with 16% of White women. Black women are also more likely to develop more aggressive, premenopausal breast cancers, including triple-negative breast cancer, that are more easily detected on MRI.

“Adding supplemental screening breast MRI to annual mammography in higher risk women has been shown to detect up to 18 additional cancers out of 1,000 patients,” Dr. Morrell said. And “many of these cancers are detected much earlier than with mammography alone.”

Still, with ACA expansion, out-of-pocket costs for breast MRI actually increased. This increase likely occurred, in part, because the financial protections outlined in the ACA’s Women’s Preventive Services Guidelines covered mammograms but not breast MRI.

More specifically, under the ACA, Medicaid and most private health insurance plans are required to provide coverage for mammograms at no cost to the patient. The percentage of health plans providing zero cost sharing for mammograms increased under the ACA from 81.9% to 96.8%, but the corresponding rates of zero cost sharing for breast MRI screening went in the opposite direction – from 43.1% in 2009 to only 26.2% in 2017, a 2022 study found.

This study also highlighted geographic variations in zero cost sharing and out-of-pocket costs for screening breast MRI, with a higher financial burden observed for women living in the South. In addition, studies have demonstrated that race and socioeconomic factors, including education and income, play a role in the underuse of screening, including breast MRI.

These factors all likely contribute to screening breast MRI remaining inaccessible to many women, Dr. Morrell and colleagues said.

The authors also outlined three key action items that could help address barriers to MRI breast screening, which include reducing the high cost of breast MRI, lobbying to include breast MRI in ACA protections, and addressing knowledge gaps among patients and clinicians to better identify women who might benefit from breast MRI.

On the financial front, the team explained that a central driver for high costs is the scan time for breast MRI, which could be substantially reduced from 30 to 5 minutes, using an abbreviated protocol.

“Widespread use of low‐cost breast abbreviated MRI screening could remove the cost barrier of adding breast MRI screening to ACA coverage,” without compromising diagnostic accuracy, the authors noted.

Further efforts should focus on overcoming cultural barriers, including fear and mistrust of the health care system among Black women. Outreach efforts could include public campaigns or town hall and church gatherings that enlist patient navigators, advocates, or community members.

“Our visibility in the community builds trust and affords us the opportunity to share knowledge that may empower women to be their own health advocates,” the authors wrote.

In terms of the feasibility of revising ACA policies to improve breast MRI access and affordability, Dr. Morrell pointed to improvements made in colon cancer screening.

“Studies have demonstrated that after ACA policy changes lowering out-of-pocket cost for colonoscopies, screening colonoscopy rates significantly increased among men, predominantly in socioeconomically disadvantaged population,” she noted. “Similarly, we should investigate how to this can be applied to screening breast MRI.”

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

Despite improvements in access to health coverage under the Affordable Care Act (ACA), racial disparities in breast cancer mortality rates persist and the underuse of advanced breast imaging may be one culprit, experts say.
 

In a recent position statement, researchers highlighted the disproportionally high breast cancer mortality rates among Black women in Louisiana – a state that has one of the highest breast cancer mortality rates in the nation. In 2019, the breast cancer mortality rate among Black women in Louisiana was 29.3 per 100,000 women compared with the national rate of 19.4 per 100,000.

Although Louisiana has made strides in improving access to breast cancer screening in recent years, the use of advanced imaging – specifically breast MRI – remains underused in this high-risk population. A major barrier to wider use of breast MRI has been cost, and ACA expansion led to higher, not lower, out-of-pocket costs for this screening modality.

“Breast MRI is a powerful imaging tool for early detection and for screening women at high risk for breast cancer,” wrote the researchers, led by Brooke L. Morrell, MD, of Louisiana State University Health and Sciences Center, New Orleans.

However, greater access to health care has not necessarily translated to increased breast MRI screening or improved survival among Black women. Even years after the adoption of the ACA, “Black women in Louisiana continue to die of breast cancer at rates significantly greater than the national average,” the authors wrote.

The position statement was published in Cancer.

Breast MRI is known to provide the highest rate of breast cancer detection among commonly used imaging options, with a sensitivity ranging from 81% to 100%. That’s about twice as high as the sensitivity range for mammography after factoring in breast density.

“This is of particular importance when we consider the risk‐based screening of younger populations, in which dense breasts are more prevalent,” the authors explained.

For Black women in particular, studies show nearly a quarter (23%) who develop breast cancer are diagnosed under the age of 50, compared with 16% of White women. Black women are also more likely to develop more aggressive, premenopausal breast cancers, including triple-negative breast cancer, that are more easily detected on MRI.

“Adding supplemental screening breast MRI to annual mammography in higher risk women has been shown to detect up to 18 additional cancers out of 1,000 patients,” Dr. Morrell said. And “many of these cancers are detected much earlier than with mammography alone.”

Still, with ACA expansion, out-of-pocket costs for breast MRI actually increased. This increase likely occurred, in part, because the financial protections outlined in the ACA’s Women’s Preventive Services Guidelines covered mammograms but not breast MRI.

More specifically, under the ACA, Medicaid and most private health insurance plans are required to provide coverage for mammograms at no cost to the patient. The percentage of health plans providing zero cost sharing for mammograms increased under the ACA from 81.9% to 96.8%, but the corresponding rates of zero cost sharing for breast MRI screening went in the opposite direction – from 43.1% in 2009 to only 26.2% in 2017, a 2022 study found.

This study also highlighted geographic variations in zero cost sharing and out-of-pocket costs for screening breast MRI, with a higher financial burden observed for women living in the South. In addition, studies have demonstrated that race and socioeconomic factors, including education and income, play a role in the underuse of screening, including breast MRI.

These factors all likely contribute to screening breast MRI remaining inaccessible to many women, Dr. Morrell and colleagues said.

The authors also outlined three key action items that could help address barriers to MRI breast screening, which include reducing the high cost of breast MRI, lobbying to include breast MRI in ACA protections, and addressing knowledge gaps among patients and clinicians to better identify women who might benefit from breast MRI.

On the financial front, the team explained that a central driver for high costs is the scan time for breast MRI, which could be substantially reduced from 30 to 5 minutes, using an abbreviated protocol.

“Widespread use of low‐cost breast abbreviated MRI screening could remove the cost barrier of adding breast MRI screening to ACA coverage,” without compromising diagnostic accuracy, the authors noted.

Further efforts should focus on overcoming cultural barriers, including fear and mistrust of the health care system among Black women. Outreach efforts could include public campaigns or town hall and church gatherings that enlist patient navigators, advocates, or community members.

“Our visibility in the community builds trust and affords us the opportunity to share knowledge that may empower women to be their own health advocates,” the authors wrote.

In terms of the feasibility of revising ACA policies to improve breast MRI access and affordability, Dr. Morrell pointed to improvements made in colon cancer screening.

“Studies have demonstrated that after ACA policy changes lowering out-of-pocket cost for colonoscopies, screening colonoscopy rates significantly increased among men, predominantly in socioeconomically disadvantaged population,” she noted. “Similarly, we should investigate how to this can be applied to screening breast MRI.”

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

Despite improvements in access to health coverage under the Affordable Care Act (ACA), racial disparities in breast cancer mortality rates persist and the underuse of advanced breast imaging may be one culprit, experts say.
 

In a recent position statement, researchers highlighted the disproportionally high breast cancer mortality rates among Black women in Louisiana – a state that has one of the highest breast cancer mortality rates in the nation. In 2019, the breast cancer mortality rate among Black women in Louisiana was 29.3 per 100,000 women compared with the national rate of 19.4 per 100,000.

Although Louisiana has made strides in improving access to breast cancer screening in recent years, the use of advanced imaging – specifically breast MRI – remains underused in this high-risk population. A major barrier to wider use of breast MRI has been cost, and ACA expansion led to higher, not lower, out-of-pocket costs for this screening modality.

“Breast MRI is a powerful imaging tool for early detection and for screening women at high risk for breast cancer,” wrote the researchers, led by Brooke L. Morrell, MD, of Louisiana State University Health and Sciences Center, New Orleans.

However, greater access to health care has not necessarily translated to increased breast MRI screening or improved survival among Black women. Even years after the adoption of the ACA, “Black women in Louisiana continue to die of breast cancer at rates significantly greater than the national average,” the authors wrote.

The position statement was published in Cancer.

Breast MRI is known to provide the highest rate of breast cancer detection among commonly used imaging options, with a sensitivity ranging from 81% to 100%. That’s about twice as high as the sensitivity range for mammography after factoring in breast density.

“This is of particular importance when we consider the risk‐based screening of younger populations, in which dense breasts are more prevalent,” the authors explained.

For Black women in particular, studies show nearly a quarter (23%) who develop breast cancer are diagnosed under the age of 50, compared with 16% of White women. Black women are also more likely to develop more aggressive, premenopausal breast cancers, including triple-negative breast cancer, that are more easily detected on MRI.

“Adding supplemental screening breast MRI to annual mammography in higher risk women has been shown to detect up to 18 additional cancers out of 1,000 patients,” Dr. Morrell said. And “many of these cancers are detected much earlier than with mammography alone.”

Still, with ACA expansion, out-of-pocket costs for breast MRI actually increased. This increase likely occurred, in part, because the financial protections outlined in the ACA’s Women’s Preventive Services Guidelines covered mammograms but not breast MRI.

More specifically, under the ACA, Medicaid and most private health insurance plans are required to provide coverage for mammograms at no cost to the patient. The percentage of health plans providing zero cost sharing for mammograms increased under the ACA from 81.9% to 96.8%, but the corresponding rates of zero cost sharing for breast MRI screening went in the opposite direction – from 43.1% in 2009 to only 26.2% in 2017, a 2022 study found.

This study also highlighted geographic variations in zero cost sharing and out-of-pocket costs for screening breast MRI, with a higher financial burden observed for women living in the South. In addition, studies have demonstrated that race and socioeconomic factors, including education and income, play a role in the underuse of screening, including breast MRI.

These factors all likely contribute to screening breast MRI remaining inaccessible to many women, Dr. Morrell and colleagues said.

The authors also outlined three key action items that could help address barriers to MRI breast screening, which include reducing the high cost of breast MRI, lobbying to include breast MRI in ACA protections, and addressing knowledge gaps among patients and clinicians to better identify women who might benefit from breast MRI.

On the financial front, the team explained that a central driver for high costs is the scan time for breast MRI, which could be substantially reduced from 30 to 5 minutes, using an abbreviated protocol.

“Widespread use of low‐cost breast abbreviated MRI screening could remove the cost barrier of adding breast MRI screening to ACA coverage,” without compromising diagnostic accuracy, the authors noted.

Further efforts should focus on overcoming cultural barriers, including fear and mistrust of the health care system among Black women. Outreach efforts could include public campaigns or town hall and church gatherings that enlist patient navigators, advocates, or community members.

“Our visibility in the community builds trust and affords us the opportunity to share knowledge that may empower women to be their own health advocates,” the authors wrote.

In terms of the feasibility of revising ACA policies to improve breast MRI access and affordability, Dr. Morrell pointed to improvements made in colon cancer screening.

“Studies have demonstrated that after ACA policy changes lowering out-of-pocket cost for colonoscopies, screening colonoscopy rates significantly increased among men, predominantly in socioeconomically disadvantaged population,” she noted. “Similarly, we should investigate how to this can be applied to screening breast MRI.”

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

When you became a doctor, you may have moved to one city for med school, another for residency, and a third to be an attending. All that moving can make it hard to maintain friendships. Factor in the challenges from the pandemic, and a physician’s life can be lonely. So, when a patient invites you for coffee or a game of pickleball, do you accept? For almost one-third of the physicians who responded to the Medscape Physician Friendships: The Joys and Challenges 2022, the answer might be yes.

About 29% said they develop friendships with patients. However, a lot depends on the circumstances. As one physician in the report said: “I have been a pediatrician for 35 years, and my patients have grown up and become productive adults in our small, rural, isolated area. You can’t help but know almost everyone.”

As the daughter of a cardiologist, Nishi Mehta, MD, a radiologist and founder of the largest physician-only Facebook group in the country, grew up with that small-town-everyone-knows-the-doctor model.

“When I was a kid, I’d go to the mall, and my friends and I would play a game: How long before a patient [of my dad’s] comes up to me?” she said. At the time, Dr. Mehta was embarrassed, but now she marvels that her dad knew his patients so well that they would recognize his daughter in crowded suburban mall.

In other instances, a physician may develop a friendly relationship after a patient leaves their care. For example, Leo Nissola, MD, now a full-time researcher and immunotherapy scientist in San Francisco, has stayed in touch with some of the patients he treated while at the University of Texas MD Anderson Cancer Center, Houston.

Dr. Nissola said it was important to stay connected with the patients he had meaningful relationships with. “It becomes challenging, though, when a former patient asks for medical advice.” At that moment, “you have to be explicitly clear that the relationship has changed.”
 

A hard line in the sand

The blurring of lines is one reason many doctors refuse to befriend patients, even after they are no longer treating them. The American College of Physicians Ethics Manual advises against treating anyone with whom you have a close relationship, including family and friends.

“Friendships can get in the way of patients being honest with you, which can interfere with medical care,” Dr. Mehta said. “If a patient has a concern related to something they wouldn’t want you to know as friends, it can get awkward. They may elect not to tell you.”

And on the flip side, friendship can provide a view into your private life that you may not welcome in the exam room.

“Let’s say you go out for drinks [with a patient], and you’re up late, but you have surgery the next day,” said Brandi Ring, MD, an ob.gyn. and the associate medical director at the Center for Children and Women in Houston. Now, one of your patients knows you were out until midnight when you had to be in the OR at 5:00 a.m.

Worse still, your relationship could color your decisions about a patient’s care, even unconsciously. It can be hard to maintain objectivity when you have an emotional investment in someone’s well-being.

“We don’t necessarily treat family and friends to the standards of medical care,” said Dr. Ring. “We go above and beyond. We might order more tests and more scans. We don’t always follow the guidelines, especially in critical illness.”

For all these reasons and more, the ACP advises against treating friends.
 

Put physician before friend

But adhering to those guidelines can lead physicians to make some painful decisions. Cutting yourself off from the possibility of friendship is never easy, and the Medscape report found that physicians tend to have fewer friends than the average American.

“Especially earlier in my practice, when I was a young parent, and I would see a lot of other young parents in the same stage in life, I’d think, ‘In other circumstances, I would be hanging out at the park with this person,’ “ said Kathleen Rowland, MD, a family medicine physician and vice chair of education in the department of family medicine at Rush University, Chicago. “But the hard part is, the doctor-patient relationship always comes first.”

To a certain extent, one’s specialty may determine the feasibility of becoming friends with a patient. While Dr. Mehta has never done so, as a radiologist, she doesn’t usually see patients repeatedly. Likewise, a young gerontologist may have little in common with his octogenarian patients. And an older pediatrician is not in the same life stage as his patients’ sleep-deprived new parents, possibly making them less attractive friends.

However, practicing family medicine is all about long-term physician-patient relationships. Getting to know patients and their families over many years can lead to a certain intimacy. Dr. Rowland said that, while a wonderful part of being a physician is getting that unique trust whereby patients tell you all sorts of things about their lives, she’s never gone down the friendship path.

“There’s the assumption I’ll take care of someone for a long period of time, and their partner and their kids, maybe another generation or two,” Dr. Rowland said. “People really do rely on that relationship to contribute to their health.”

Worse, nowadays, when people may be starved for connection, many patients want to feel emotionally close and cared for by their doctor, so it’d be easy to cross the line. While patients deserve a compassionate, caring doctor, the physician is left to walk the line between those boundaries. Dr. Rowland said, “It’s up to the clinician to say: ‘My role is as a doctor. You deserve caring friends, but I have to order your mammogram and your blood counts. My role is different.’ ”
 

Friendly but not friends

It can be tricky to navigate the boundary between a cordial, warm relationship with a patient and that patient inviting you to their daughter’s wedding.

“People may mistake being pleasant and friendly for being friends,” said Larry Blosser, MD, chief medical officer at Central Ohio Primary Care, Westerville. In his position, he sometimes hears from patients who have misunderstood their relationship with a doctor in the practice. When that happens, he advises the physician to consider the persona they’re presenting to the patient. If you’re overly friendly, there’s the potential for confusion, but you can’t be aloof and cold, he said.

Maintaining that awareness helps to prevent a patient’s offhand invitation to catch a movie or go on a hike. And verbalizing it to your patients can make your relationship clear from the get-go.

“I tell patients we’re a team. I’m the captain, and they’re my MVP. When the match is over, whatever the results, we’re done,” said Karenne Fru, MD, PhD, a fertility specialist at Oma Fertility Atlanta. Making deep connections is essential to her practice, so Dr. Fru structures her patient interactions carefully. “Infertility is such an isolating experience. While you’re with us, we care about what’s going on in your life, your pets, and your mom’s chemo. We need mutual trust for you to be compliant with the care.”

However, that approach won’t work when you see patients regularly, as with family practice or specialties that see the same patients repeatedly throughout the year. In those circumstances, the match is never over but one in which the onus is on the physician to establish a friendly yet professional rapport without letting your self-interest, loneliness, or lack of friends interfere.

“It’s been a very difficult couple of years for a lot of us. Depending on what kind of clinical work we do, some of us took care of healthy people that got very sick or passed away,” Dr. Rowland said. “Having the chance to reconnect with people and reestablish some of that closeness, both physical and emotional, is going to be good for us.”

Just continue conveying warm, trusting compassion for your patients without blurring the friend lines.

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

When you became a doctor, you may have moved to one city for med school, another for residency, and a third to be an attending. All that moving can make it hard to maintain friendships. Factor in the challenges from the pandemic, and a physician’s life can be lonely. So, when a patient invites you for coffee or a game of pickleball, do you accept? For almost one-third of the physicians who responded to the Medscape Physician Friendships: The Joys and Challenges 2022, the answer might be yes.

About 29% said they develop friendships with patients. However, a lot depends on the circumstances. As one physician in the report said: “I have been a pediatrician for 35 years, and my patients have grown up and become productive adults in our small, rural, isolated area. You can’t help but know almost everyone.”

As the daughter of a cardiologist, Nishi Mehta, MD, a radiologist and founder of the largest physician-only Facebook group in the country, grew up with that small-town-everyone-knows-the-doctor model.

“When I was a kid, I’d go to the mall, and my friends and I would play a game: How long before a patient [of my dad’s] comes up to me?” she said. At the time, Dr. Mehta was embarrassed, but now she marvels that her dad knew his patients so well that they would recognize his daughter in crowded suburban mall.

In other instances, a physician may develop a friendly relationship after a patient leaves their care. For example, Leo Nissola, MD, now a full-time researcher and immunotherapy scientist in San Francisco, has stayed in touch with some of the patients he treated while at the University of Texas MD Anderson Cancer Center, Houston.

Dr. Nissola said it was important to stay connected with the patients he had meaningful relationships with. “It becomes challenging, though, when a former patient asks for medical advice.” At that moment, “you have to be explicitly clear that the relationship has changed.”
 

A hard line in the sand

The blurring of lines is one reason many doctors refuse to befriend patients, even after they are no longer treating them. The American College of Physicians Ethics Manual advises against treating anyone with whom you have a close relationship, including family and friends.

“Friendships can get in the way of patients being honest with you, which can interfere with medical care,” Dr. Mehta said. “If a patient has a concern related to something they wouldn’t want you to know as friends, it can get awkward. They may elect not to tell you.”

And on the flip side, friendship can provide a view into your private life that you may not welcome in the exam room.

“Let’s say you go out for drinks [with a patient], and you’re up late, but you have surgery the next day,” said Brandi Ring, MD, an ob.gyn. and the associate medical director at the Center for Children and Women in Houston. Now, one of your patients knows you were out until midnight when you had to be in the OR at 5:00 a.m.

Worse still, your relationship could color your decisions about a patient’s care, even unconsciously. It can be hard to maintain objectivity when you have an emotional investment in someone’s well-being.

“We don’t necessarily treat family and friends to the standards of medical care,” said Dr. Ring. “We go above and beyond. We might order more tests and more scans. We don’t always follow the guidelines, especially in critical illness.”

For all these reasons and more, the ACP advises against treating friends.
 

Put physician before friend

But adhering to those guidelines can lead physicians to make some painful decisions. Cutting yourself off from the possibility of friendship is never easy, and the Medscape report found that physicians tend to have fewer friends than the average American.

“Especially earlier in my practice, when I was a young parent, and I would see a lot of other young parents in the same stage in life, I’d think, ‘In other circumstances, I would be hanging out at the park with this person,’ “ said Kathleen Rowland, MD, a family medicine physician and vice chair of education in the department of family medicine at Rush University, Chicago. “But the hard part is, the doctor-patient relationship always comes first.”

To a certain extent, one’s specialty may determine the feasibility of becoming friends with a patient. While Dr. Mehta has never done so, as a radiologist, she doesn’t usually see patients repeatedly. Likewise, a young gerontologist may have little in common with his octogenarian patients. And an older pediatrician is not in the same life stage as his patients’ sleep-deprived new parents, possibly making them less attractive friends.

However, practicing family medicine is all about long-term physician-patient relationships. Getting to know patients and their families over many years can lead to a certain intimacy. Dr. Rowland said that, while a wonderful part of being a physician is getting that unique trust whereby patients tell you all sorts of things about their lives, she’s never gone down the friendship path.

“There’s the assumption I’ll take care of someone for a long period of time, and their partner and their kids, maybe another generation or two,” Dr. Rowland said. “People really do rely on that relationship to contribute to their health.”

Worse, nowadays, when people may be starved for connection, many patients want to feel emotionally close and cared for by their doctor, so it’d be easy to cross the line. While patients deserve a compassionate, caring doctor, the physician is left to walk the line between those boundaries. Dr. Rowland said, “It’s up to the clinician to say: ‘My role is as a doctor. You deserve caring friends, but I have to order your mammogram and your blood counts. My role is different.’ ”
 

Friendly but not friends

It can be tricky to navigate the boundary between a cordial, warm relationship with a patient and that patient inviting you to their daughter’s wedding.

“People may mistake being pleasant and friendly for being friends,” said Larry Blosser, MD, chief medical officer at Central Ohio Primary Care, Westerville. In his position, he sometimes hears from patients who have misunderstood their relationship with a doctor in the practice. When that happens, he advises the physician to consider the persona they’re presenting to the patient. If you’re overly friendly, there’s the potential for confusion, but you can’t be aloof and cold, he said.

Maintaining that awareness helps to prevent a patient’s offhand invitation to catch a movie or go on a hike. And verbalizing it to your patients can make your relationship clear from the get-go.

“I tell patients we’re a team. I’m the captain, and they’re my MVP. When the match is over, whatever the results, we’re done,” said Karenne Fru, MD, PhD, a fertility specialist at Oma Fertility Atlanta. Making deep connections is essential to her practice, so Dr. Fru structures her patient interactions carefully. “Infertility is such an isolating experience. While you’re with us, we care about what’s going on in your life, your pets, and your mom’s chemo. We need mutual trust for you to be compliant with the care.”

However, that approach won’t work when you see patients regularly, as with family practice or specialties that see the same patients repeatedly throughout the year. In those circumstances, the match is never over but one in which the onus is on the physician to establish a friendly yet professional rapport without letting your self-interest, loneliness, or lack of friends interfere.

“It’s been a very difficult couple of years for a lot of us. Depending on what kind of clinical work we do, some of us took care of healthy people that got very sick or passed away,” Dr. Rowland said. “Having the chance to reconnect with people and reestablish some of that closeness, both physical and emotional, is going to be good for us.”

Just continue conveying warm, trusting compassion for your patients without blurring the friend lines.

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

When you became a doctor, you may have moved to one city for med school, another for residency, and a third to be an attending. All that moving can make it hard to maintain friendships. Factor in the challenges from the pandemic, and a physician’s life can be lonely. So, when a patient invites you for coffee or a game of pickleball, do you accept? For almost one-third of the physicians who responded to the Medscape Physician Friendships: The Joys and Challenges 2022, the answer might be yes.

About 29% said they develop friendships with patients. However, a lot depends on the circumstances. As one physician in the report said: “I have been a pediatrician for 35 years, and my patients have grown up and become productive adults in our small, rural, isolated area. You can’t help but know almost everyone.”

As the daughter of a cardiologist, Nishi Mehta, MD, a radiologist and founder of the largest physician-only Facebook group in the country, grew up with that small-town-everyone-knows-the-doctor model.

“When I was a kid, I’d go to the mall, and my friends and I would play a game: How long before a patient [of my dad’s] comes up to me?” she said. At the time, Dr. Mehta was embarrassed, but now she marvels that her dad knew his patients so well that they would recognize his daughter in crowded suburban mall.

In other instances, a physician may develop a friendly relationship after a patient leaves their care. For example, Leo Nissola, MD, now a full-time researcher and immunotherapy scientist in San Francisco, has stayed in touch with some of the patients he treated while at the University of Texas MD Anderson Cancer Center, Houston.

Dr. Nissola said it was important to stay connected with the patients he had meaningful relationships with. “It becomes challenging, though, when a former patient asks for medical advice.” At that moment, “you have to be explicitly clear that the relationship has changed.”
 

A hard line in the sand

The blurring of lines is one reason many doctors refuse to befriend patients, even after they are no longer treating them. The American College of Physicians Ethics Manual advises against treating anyone with whom you have a close relationship, including family and friends.

“Friendships can get in the way of patients being honest with you, which can interfere with medical care,” Dr. Mehta said. “If a patient has a concern related to something they wouldn’t want you to know as friends, it can get awkward. They may elect not to tell you.”

And on the flip side, friendship can provide a view into your private life that you may not welcome in the exam room.

“Let’s say you go out for drinks [with a patient], and you’re up late, but you have surgery the next day,” said Brandi Ring, MD, an ob.gyn. and the associate medical director at the Center for Children and Women in Houston. Now, one of your patients knows you were out until midnight when you had to be in the OR at 5:00 a.m.

Worse still, your relationship could color your decisions about a patient’s care, even unconsciously. It can be hard to maintain objectivity when you have an emotional investment in someone’s well-being.

“We don’t necessarily treat family and friends to the standards of medical care,” said Dr. Ring. “We go above and beyond. We might order more tests and more scans. We don’t always follow the guidelines, especially in critical illness.”

For all these reasons and more, the ACP advises against treating friends.
 

Put physician before friend

But adhering to those guidelines can lead physicians to make some painful decisions. Cutting yourself off from the possibility of friendship is never easy, and the Medscape report found that physicians tend to have fewer friends than the average American.

“Especially earlier in my practice, when I was a young parent, and I would see a lot of other young parents in the same stage in life, I’d think, ‘In other circumstances, I would be hanging out at the park with this person,’ “ said Kathleen Rowland, MD, a family medicine physician and vice chair of education in the department of family medicine at Rush University, Chicago. “But the hard part is, the doctor-patient relationship always comes first.”

To a certain extent, one’s specialty may determine the feasibility of becoming friends with a patient. While Dr. Mehta has never done so, as a radiologist, she doesn’t usually see patients repeatedly. Likewise, a young gerontologist may have little in common with his octogenarian patients. And an older pediatrician is not in the same life stage as his patients’ sleep-deprived new parents, possibly making them less attractive friends.

However, practicing family medicine is all about long-term physician-patient relationships. Getting to know patients and their families over many years can lead to a certain intimacy. Dr. Rowland said that, while a wonderful part of being a physician is getting that unique trust whereby patients tell you all sorts of things about their lives, she’s never gone down the friendship path.

“There’s the assumption I’ll take care of someone for a long period of time, and their partner and their kids, maybe another generation or two,” Dr. Rowland said. “People really do rely on that relationship to contribute to their health.”

Worse, nowadays, when people may be starved for connection, many patients want to feel emotionally close and cared for by their doctor, so it’d be easy to cross the line. While patients deserve a compassionate, caring doctor, the physician is left to walk the line between those boundaries. Dr. Rowland said, “It’s up to the clinician to say: ‘My role is as a doctor. You deserve caring friends, but I have to order your mammogram and your blood counts. My role is different.’ ”
 

Friendly but not friends

It can be tricky to navigate the boundary between a cordial, warm relationship with a patient and that patient inviting you to their daughter’s wedding.

“People may mistake being pleasant and friendly for being friends,” said Larry Blosser, MD, chief medical officer at Central Ohio Primary Care, Westerville. In his position, he sometimes hears from patients who have misunderstood their relationship with a doctor in the practice. When that happens, he advises the physician to consider the persona they’re presenting to the patient. If you’re overly friendly, there’s the potential for confusion, but you can’t be aloof and cold, he said.

Maintaining that awareness helps to prevent a patient’s offhand invitation to catch a movie or go on a hike. And verbalizing it to your patients can make your relationship clear from the get-go.

“I tell patients we’re a team. I’m the captain, and they’re my MVP. When the match is over, whatever the results, we’re done,” said Karenne Fru, MD, PhD, a fertility specialist at Oma Fertility Atlanta. Making deep connections is essential to her practice, so Dr. Fru structures her patient interactions carefully. “Infertility is such an isolating experience. While you’re with us, we care about what’s going on in your life, your pets, and your mom’s chemo. We need mutual trust for you to be compliant with the care.”

However, that approach won’t work when you see patients regularly, as with family practice or specialties that see the same patients repeatedly throughout the year. In those circumstances, the match is never over but one in which the onus is on the physician to establish a friendly yet professional rapport without letting your self-interest, loneliness, or lack of friends interfere.

“It’s been a very difficult couple of years for a lot of us. Depending on what kind of clinical work we do, some of us took care of healthy people that got very sick or passed away,” Dr. Rowland said. “Having the chance to reconnect with people and reestablish some of that closeness, both physical and emotional, is going to be good for us.”

Just continue conveying warm, trusting compassion for your patients without blurring the friend lines.

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

The Society of Thoracic Surgeons (STS) and its newly installed president have posted an apology for a speech delivered by its outgoing president that appeared, in part, to disparage affirmative action as a means to promote diversity, equity, and inclusion in the field.

The speech, entitled “Three Score & More,” presented Jan. 22 at the STS 58th annual meeting in San Diego by John H. Calhoon, MD, University of Texas Health Science Center at San Antonio, unleashed a cascade of tweets, some circumspect but many expressing outrage and dismay.

Many of the tweets were from individuals who acknowledged not hearing the speech but who had seen at least one accompanying slide which, by then, had been widely circulated on the platform. It contained phrases such as “Affirmative Action is not equal opportunity” and “Defining people by color, gender, religion only tends to ingrain bias and discrimination,” all under the heading of “Virtuous Ideals.”

Reactions on Twitter included comments such as “This is bad beyond description” and a description of the slide’s content as “the blueprint & thought process for those actively maintaining Whiteness & the Patriarchy in medicine.”

Following an early onslaught of such tweets, the STS and new president Thomas E. MacGillivray, MD, MedStar Health, Washington, issued a statement disowning at least the controversial parts of Dr. Calhoon’s presentation, stating they were “inconsistent with STS’s core values of diversity, equity, and inclusion.”

The post continues, “The STS apologizes for these remarks. We know these comments were hurtful and we regret the pain they have caused to so many valued colleagues.” It then states, “Diversity, equity, and inclusion are central principles of our Society, and what we strive for in our profession and our practice. STS is committed to learning from this experience and taking action to reinforce our commitment to these values.”

“I believe that either the slide and/or my remarks were misinterpreted by some. I don’t want to hurt anybody. I’m profoundly sorry and apologize,” Dr. Calhoon said in an interview.

“I’m proud of my own group’s record on diversity and using equity and inclusion to get there,” he said. “We’re committed to it. We’ve had a wonderfully diverse group. I tried to highlight that in my remarks.”

About the Twitter response to the slide in question, Dr. Calhoon said, “I have no idea how they were thinking.” He added, “I can only comment that I’m really proud of our record and, for that matter, the STS’s record on diversity, equity, and inclusion.”

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

The Society of Thoracic Surgeons (STS) and its newly installed president have posted an apology for a speech delivered by its outgoing president that appeared, in part, to disparage affirmative action as a means to promote diversity, equity, and inclusion in the field.

The speech, entitled “Three Score & More,” presented Jan. 22 at the STS 58th annual meeting in San Diego by John H. Calhoon, MD, University of Texas Health Science Center at San Antonio, unleashed a cascade of tweets, some circumspect but many expressing outrage and dismay.

Many of the tweets were from individuals who acknowledged not hearing the speech but who had seen at least one accompanying slide which, by then, had been widely circulated on the platform. It contained phrases such as “Affirmative Action is not equal opportunity” and “Defining people by color, gender, religion only tends to ingrain bias and discrimination,” all under the heading of “Virtuous Ideals.”

Reactions on Twitter included comments such as “This is bad beyond description” and a description of the slide’s content as “the blueprint & thought process for those actively maintaining Whiteness & the Patriarchy in medicine.”

Following an early onslaught of such tweets, the STS and new president Thomas E. MacGillivray, MD, MedStar Health, Washington, issued a statement disowning at least the controversial parts of Dr. Calhoon’s presentation, stating they were “inconsistent with STS’s core values of diversity, equity, and inclusion.”

The post continues, “The STS apologizes for these remarks. We know these comments were hurtful and we regret the pain they have caused to so many valued colleagues.” It then states, “Diversity, equity, and inclusion are central principles of our Society, and what we strive for in our profession and our practice. STS is committed to learning from this experience and taking action to reinforce our commitment to these values.”

“I believe that either the slide and/or my remarks were misinterpreted by some. I don’t want to hurt anybody. I’m profoundly sorry and apologize,” Dr. Calhoon said in an interview.

“I’m proud of my own group’s record on diversity and using equity and inclusion to get there,” he said. “We’re committed to it. We’ve had a wonderfully diverse group. I tried to highlight that in my remarks.”

About the Twitter response to the slide in question, Dr. Calhoon said, “I have no idea how they were thinking.” He added, “I can only comment that I’m really proud of our record and, for that matter, the STS’s record on diversity, equity, and inclusion.”

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

The Society of Thoracic Surgeons (STS) and its newly installed president have posted an apology for a speech delivered by its outgoing president that appeared, in part, to disparage affirmative action as a means to promote diversity, equity, and inclusion in the field.

The speech, entitled “Three Score & More,” presented Jan. 22 at the STS 58th annual meeting in San Diego by John H. Calhoon, MD, University of Texas Health Science Center at San Antonio, unleashed a cascade of tweets, some circumspect but many expressing outrage and dismay.

Many of the tweets were from individuals who acknowledged not hearing the speech but who had seen at least one accompanying slide which, by then, had been widely circulated on the platform. It contained phrases such as “Affirmative Action is not equal opportunity” and “Defining people by color, gender, religion only tends to ingrain bias and discrimination,” all under the heading of “Virtuous Ideals.”

Reactions on Twitter included comments such as “This is bad beyond description” and a description of the slide’s content as “the blueprint & thought process for those actively maintaining Whiteness & the Patriarchy in medicine.”

Following an early onslaught of such tweets, the STS and new president Thomas E. MacGillivray, MD, MedStar Health, Washington, issued a statement disowning at least the controversial parts of Dr. Calhoon’s presentation, stating they were “inconsistent with STS’s core values of diversity, equity, and inclusion.”

The post continues, “The STS apologizes for these remarks. We know these comments were hurtful and we regret the pain they have caused to so many valued colleagues.” It then states, “Diversity, equity, and inclusion are central principles of our Society, and what we strive for in our profession and our practice. STS is committed to learning from this experience and taking action to reinforce our commitment to these values.”

“I believe that either the slide and/or my remarks were misinterpreted by some. I don’t want to hurt anybody. I’m profoundly sorry and apologize,” Dr. Calhoon said in an interview.

“I’m proud of my own group’s record on diversity and using equity and inclusion to get there,” he said. “We’re committed to it. We’ve had a wonderfully diverse group. I tried to highlight that in my remarks.”

About the Twitter response to the slide in question, Dr. Calhoon said, “I have no idea how they were thinking.” He added, “I can only comment that I’m really proud of our record and, for that matter, the STS’s record on diversity, equity, and inclusion.”

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

A recent change in Medicare policy designed to increase access to left ventricular assist devices (LVADs) may have had the unintended consequence of increasing inequalities in access to heart transplant for patients with advanced heart failure.

In December 2020, the Centers for Medicare & Medicaid Services relaxed restrictions on centers that implant LVADs but don’t perform heart transplants. Specifically, they dropped the requirement that LVAD-only centers obtain permission from a Medicare-approved heart transplant center authorizing LVAD implantation with “bridge-to-transplant” (BTT) intent, meaning the patient is a transplant candidate.

zimmytws/gettyimages

While the relaxed requirement has the potential to increase access to LVADs for appropriate patients, a look back at 22,221 LVAD recipients found that patients who received LVADs at transplant-capable centers had a 79% higher likelihood of receiving a BTT LVAD designation.

The 2-year heart transplant rate following LVAD implant was 25.6% for patients who received an LVAD at a heart transplant center, compared with 11.9% at LVAD-only centers.

Thomas Cascino, MD, with University of Michigan Health Frankel Cardiovascular Center, Ann Arbor, and colleagues reported their findings in JAMA Network Open.
 

Differential assessment?

Nontransplant LVAD centers are increasing in number in the United States now that the CMS has made establishing an LVAD-only center easier.

“Although there should be enthusiasm for the potential of LVAD-only centers to increase access to LVAD, it appears that receiving an LVAD at a center that does not perform transplants results in differential assessment of transplant eligibility at the time of LVAD implant and inequities in receipt of transplant,” Dr. Cascino and colleagues said.

“Being cared for at a center that does not perform heart transplant should not result in a lesser chance to receive a heart transplant,” Dr. Cascino added in a university news release. “Our study shows that this disparity existed before the policy change, and we think it will likely grow larger now that there is less collaboration.”

The CMS policy will likely “further challenge equity in access to transplant for patients seeking care at nontransplant centers and may have the unintended consequence of contributing to increasing inequities in access to transplants, as has been feared,” the researchers wrote.

They also note that recent changes in the adult heart allocation system under the United Network for Organ Sharing have significantly reduced the likelihood of transplant after durable LVAD implant unless candidates are listed as being at higher urgency status owing to an LVAD complication or clinical deterioration.

“The reality is that durable LVADs are much less likely to be a bridge to the best therapy (that is, transplant) in the current allocation system. As a result, there is a critical need to select appropriate durable LVAD and transplant candidates at the initial evaluation,” the authors said.

“This puts the onus on the transplant community to select appropriate LVAD and transplant candidates during the initial evaluation. We need a system in which any patient can walk into the same hospital and get the right therapy for them,” Dr. Cascino added in the news release.

The research was supported in part through funding from the University of Michigan Health department of cardiac surgery and the National Institutes of Health, National Heart, Lung, and Blood Institute. Dr. Cascino has received grants from Johnson & Johnson.

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

A recent change in Medicare policy designed to increase access to left ventricular assist devices (LVADs) may have had the unintended consequence of increasing inequalities in access to heart transplant for patients with advanced heart failure.

In December 2020, the Centers for Medicare & Medicaid Services relaxed restrictions on centers that implant LVADs but don’t perform heart transplants. Specifically, they dropped the requirement that LVAD-only centers obtain permission from a Medicare-approved heart transplant center authorizing LVAD implantation with “bridge-to-transplant” (BTT) intent, meaning the patient is a transplant candidate.

zimmytws/gettyimages

While the relaxed requirement has the potential to increase access to LVADs for appropriate patients, a look back at 22,221 LVAD recipients found that patients who received LVADs at transplant-capable centers had a 79% higher likelihood of receiving a BTT LVAD designation.

The 2-year heart transplant rate following LVAD implant was 25.6% for patients who received an LVAD at a heart transplant center, compared with 11.9% at LVAD-only centers.

Thomas Cascino, MD, with University of Michigan Health Frankel Cardiovascular Center, Ann Arbor, and colleagues reported their findings in JAMA Network Open.
 

Differential assessment?

Nontransplant LVAD centers are increasing in number in the United States now that the CMS has made establishing an LVAD-only center easier.

“Although there should be enthusiasm for the potential of LVAD-only centers to increase access to LVAD, it appears that receiving an LVAD at a center that does not perform transplants results in differential assessment of transplant eligibility at the time of LVAD implant and inequities in receipt of transplant,” Dr. Cascino and colleagues said.

“Being cared for at a center that does not perform heart transplant should not result in a lesser chance to receive a heart transplant,” Dr. Cascino added in a university news release. “Our study shows that this disparity existed before the policy change, and we think it will likely grow larger now that there is less collaboration.”

The CMS policy will likely “further challenge equity in access to transplant for patients seeking care at nontransplant centers and may have the unintended consequence of contributing to increasing inequities in access to transplants, as has been feared,” the researchers wrote.

They also note that recent changes in the adult heart allocation system under the United Network for Organ Sharing have significantly reduced the likelihood of transplant after durable LVAD implant unless candidates are listed as being at higher urgency status owing to an LVAD complication or clinical deterioration.

“The reality is that durable LVADs are much less likely to be a bridge to the best therapy (that is, transplant) in the current allocation system. As a result, there is a critical need to select appropriate durable LVAD and transplant candidates at the initial evaluation,” the authors said.

“This puts the onus on the transplant community to select appropriate LVAD and transplant candidates during the initial evaluation. We need a system in which any patient can walk into the same hospital and get the right therapy for them,” Dr. Cascino added in the news release.

The research was supported in part through funding from the University of Michigan Health department of cardiac surgery and the National Institutes of Health, National Heart, Lung, and Blood Institute. Dr. Cascino has received grants from Johnson & Johnson.

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

A recent change in Medicare policy designed to increase access to left ventricular assist devices (LVADs) may have had the unintended consequence of increasing inequalities in access to heart transplant for patients with advanced heart failure.

In December 2020, the Centers for Medicare & Medicaid Services relaxed restrictions on centers that implant LVADs but don’t perform heart transplants. Specifically, they dropped the requirement that LVAD-only centers obtain permission from a Medicare-approved heart transplant center authorizing LVAD implantation with “bridge-to-transplant” (BTT) intent, meaning the patient is a transplant candidate.

zimmytws/gettyimages

While the relaxed requirement has the potential to increase access to LVADs for appropriate patients, a look back at 22,221 LVAD recipients found that patients who received LVADs at transplant-capable centers had a 79% higher likelihood of receiving a BTT LVAD designation.

The 2-year heart transplant rate following LVAD implant was 25.6% for patients who received an LVAD at a heart transplant center, compared with 11.9% at LVAD-only centers.

Thomas Cascino, MD, with University of Michigan Health Frankel Cardiovascular Center, Ann Arbor, and colleagues reported their findings in JAMA Network Open.
 

Differential assessment?

Nontransplant LVAD centers are increasing in number in the United States now that the CMS has made establishing an LVAD-only center easier.

“Although there should be enthusiasm for the potential of LVAD-only centers to increase access to LVAD, it appears that receiving an LVAD at a center that does not perform transplants results in differential assessment of transplant eligibility at the time of LVAD implant and inequities in receipt of transplant,” Dr. Cascino and colleagues said.

“Being cared for at a center that does not perform heart transplant should not result in a lesser chance to receive a heart transplant,” Dr. Cascino added in a university news release. “Our study shows that this disparity existed before the policy change, and we think it will likely grow larger now that there is less collaboration.”

The CMS policy will likely “further challenge equity in access to transplant for patients seeking care at nontransplant centers and may have the unintended consequence of contributing to increasing inequities in access to transplants, as has been feared,” the researchers wrote.

They also note that recent changes in the adult heart allocation system under the United Network for Organ Sharing have significantly reduced the likelihood of transplant after durable LVAD implant unless candidates are listed as being at higher urgency status owing to an LVAD complication or clinical deterioration.

“The reality is that durable LVADs are much less likely to be a bridge to the best therapy (that is, transplant) in the current allocation system. As a result, there is a critical need to select appropriate durable LVAD and transplant candidates at the initial evaluation,” the authors said.

“This puts the onus on the transplant community to select appropriate LVAD and transplant candidates during the initial evaluation. We need a system in which any patient can walk into the same hospital and get the right therapy for them,” Dr. Cascino added in the news release.

The research was supported in part through funding from the University of Michigan Health department of cardiac surgery and the National Institutes of Health, National Heart, Lung, and Blood Institute. Dr. Cascino has received grants from Johnson & Johnson.

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