Business of Medicine

NEW ORLEANS – Demonstrated adherence to professional and ethical principles is one of the six core competencies for the dermatology residency curriculum set by the Accreditation Council for Graduate Medical Education, but results from a national survey of dermatology residency program directors suggest that ethics training is not a priority.

Of the 139 dermatology residency program or associate program directors surveyed in 2022, only 43% responded. Of these, 55% said that their program had no ethics curriculum. Among programs with an ethics curriculum, 75% were implemented in the past 10 years, and the most common settings for teaching ethics were formal didactics (32%) and ad hoc during clinical encounters (28%). Reported barriers to implementing and/or maintaining an ethics curriculum included a lack of time (30%), lack of faculty with expertise (24%), and lack of useful resources (20%).

“Clearly, medical ethics is needed more to be part of our dermatology residency curriculum,” one of the study authors, Jane M. Grant-Kels, MD, professor of dermatology, pathology, and pediatrics, and founding chair of dermatology at the University of Connecticut, Farmington, said during a plenary lecture at the annual meeting of the American Academy of Dermatology. “Why? Because even though we’re physicians, and some of us have big egos, we are just human beings. We have all the faults and frailties of other humans. What we do as doctors often has unintended consequences that impact patients and society at large.”

American Academy of Dermatology

Dr. Grant-Kels, one of the editors of the textbook “Dermatoethics”, said that, while she does not believe that physicians are intentionally unethical, “we stumble into bad behavior because we fool ourselves. We think that we are ethical. We think our colleagues are ethical, and we don’t view them with a clear, transparent eye. This is referred to as ethical fading or bounded ethicality.”

Similar to religion and good behavior, one can’t really teach someone to be ethical, she continued. “But you can teach people to think about ethics and to recognize an ethical dilemma when they’re in one,” she said. “Most articles that are available [pertain to] whether ethics can be taught or not, but there are very few resources available on how to actually teach ethics.”

That, she added, has been her goal for the last 2 decades: “How do I teach ethics without sounding like I’m more ethical than anybody else, and how do I make it relevant and fun? It’s a difficult challenge.”

Pillars of medical ethics

Dr. Grant-Kels defined ethics as a way of determining how individuals ought to act based on concepts of right and wrong. An ethical dilemma is when an individual faces two competing possibilities: either both justifiable or both unjustifiable, and you have to make a decision. The four pillars of medical ethics, she noted, are beneficence (the notion that the patient’s best interests come first); nonmaleficence (do no intentional harm); autonomy (the patient’s right to refuse or choose a treatment); and justice (fairness in how health care is distributed).

“Medical ethics are the moral principles by which physicians should conduct themselves,” she said. “There is normative ethics, which involves decisions about which moral norms or ethical arguments should we accept and why; and applied ethics, or applications of these norms to specific problems or cases. No ethics is better than bad ethics, and we can see that even in today’s world. The lack of ethics, or poor ethics, or the wrong ethics has terrible consequences.”

Ethics instruction

Dr. Grant-Kels provided a “top 10 list” of tips for incorporating ethics instruction into dermatology residency programs and clinical practices:

• Make room for ethics in your curriculum. “It’s not science, and it needs to be discussed and developed with faculty and residents,” she said.
• Focus on real situations that residents will experience. Discuss what you should do, what you might have done, and why.
• Share stories and be truthful. Include other faculty members, “because you need different perspectives,” she said.
• Go beyond what is right and wrong, and the rationale. “You have to talk about the impact, because decisions you make have unintended consequences for individual patients and for patient care in general,” Dr. Grant-Kels said.
• Practice, practice, practice. Make time for discussions involving ethics, “because it takes a lot of education to be able to identify ethical issues and process them,” she said. “The truth is, we can rationalize almost anything and convince ourselves that we made the right choice. That’s why we need to continue to practice good ethics.”
• Challenge the residents. “Decisions are not always straightforward,” she said. “Pressures push us and we start to justify small decisions and then bigger decisions. This is a very gray zone. What’s ethical for one person may not be ethical to another.”
• Encourage residents and colleagues to ask the right questions and give them confidence to make the right decisions. “We have to work in an environment of ethics,” Dr. Grant-Kels said. “Many of us are role models, and we are not always behaving the way we should be. As role models, we need to be aware of that.”
• Expose residents to a variety of issues. Ethics vary depending on the situation, the people involved, and the information presented.
• Ethics cannot just come up in an ethics class. “We need to foster a culture of ethics,” she said. “If things go wrong and unethical behavior is noted, it needs to be brought to the floor and discussed.”
• Discuss the misguided pursuit of happiness and ethical decision-making. In the opinion of Dr. Grant-Kels, people can behave badly when they’re pursuing something like a career advancement, a new house, or an expensive object like a car or a boat. “They think that if they get that job or get that promotion or if they buy that big house or they buy that sports car, they’re going to be really happy,” she said.

“That’s called impact bias, which causes focalism, where you focus on that one thing, like ‘I’m going to make a lot of money’ or ‘I’m going to buy that big house on the mountain.’ The truth is, buying that car doesn’t make you happy. Buying that big house doesn’t make you happy. We need to combat focalism with professionalism, which means conducting oneself with responsibility, integrity, accountability, and excellence. Practicing ethical medicine is not a luxury; it’s a requirement. We should all try for aspirational ethics.”

Dr. Grant-Kels reported having no relevant financial disclosures.

NEW ORLEANS – Demonstrated adherence to professional and ethical principles is one of the six core competencies for the dermatology residency curriculum set by the Accreditation Council for Graduate Medical Education, but results from a national survey of dermatology residency program directors suggest that ethics training is not a priority.

Of the 139 dermatology residency program or associate program directors surveyed in 2022, only 43% responded. Of these, 55% said that their program had no ethics curriculum. Among programs with an ethics curriculum, 75% were implemented in the past 10 years, and the most common settings for teaching ethics were formal didactics (32%) and ad hoc during clinical encounters (28%). Reported barriers to implementing and/or maintaining an ethics curriculum included a lack of time (30%), lack of faculty with expertise (24%), and lack of useful resources (20%).

“Clearly, medical ethics is needed more to be part of our dermatology residency curriculum,” one of the study authors, Jane M. Grant-Kels, MD, professor of dermatology, pathology, and pediatrics, and founding chair of dermatology at the University of Connecticut, Farmington, said during a plenary lecture at the annual meeting of the American Academy of Dermatology. “Why? Because even though we’re physicians, and some of us have big egos, we are just human beings. We have all the faults and frailties of other humans. What we do as doctors often has unintended consequences that impact patients and society at large.”

American Academy of Dermatology

Dr. Grant-Kels, one of the editors of the textbook “Dermatoethics”, said that, while she does not believe that physicians are intentionally unethical, “we stumble into bad behavior because we fool ourselves. We think that we are ethical. We think our colleagues are ethical, and we don’t view them with a clear, transparent eye. This is referred to as ethical fading or bounded ethicality.”

Similar to religion and good behavior, one can’t really teach someone to be ethical, she continued. “But you can teach people to think about ethics and to recognize an ethical dilemma when they’re in one,” she said. “Most articles that are available [pertain to] whether ethics can be taught or not, but there are very few resources available on how to actually teach ethics.”

That, she added, has been her goal for the last 2 decades: “How do I teach ethics without sounding like I’m more ethical than anybody else, and how do I make it relevant and fun? It’s a difficult challenge.”

Pillars of medical ethics

Dr. Grant-Kels defined ethics as a way of determining how individuals ought to act based on concepts of right and wrong. An ethical dilemma is when an individual faces two competing possibilities: either both justifiable or both unjustifiable, and you have to make a decision. The four pillars of medical ethics, she noted, are beneficence (the notion that the patient’s best interests come first); nonmaleficence (do no intentional harm); autonomy (the patient’s right to refuse or choose a treatment); and justice (fairness in how health care is distributed).

“Medical ethics are the moral principles by which physicians should conduct themselves,” she said. “There is normative ethics, which involves decisions about which moral norms or ethical arguments should we accept and why; and applied ethics, or applications of these norms to specific problems or cases. No ethics is better than bad ethics, and we can see that even in today’s world. The lack of ethics, or poor ethics, or the wrong ethics has terrible consequences.”

Ethics instruction

Dr. Grant-Kels provided a “top 10 list” of tips for incorporating ethics instruction into dermatology residency programs and clinical practices:

• Make room for ethics in your curriculum. “It’s not science, and it needs to be discussed and developed with faculty and residents,” she said.
• Focus on real situations that residents will experience. Discuss what you should do, what you might have done, and why.
• Share stories and be truthful. Include other faculty members, “because you need different perspectives,” she said.
• Go beyond what is right and wrong, and the rationale. “You have to talk about the impact, because decisions you make have unintended consequences for individual patients and for patient care in general,” Dr. Grant-Kels said.
• Practice, practice, practice. Make time for discussions involving ethics, “because it takes a lot of education to be able to identify ethical issues and process them,” she said. “The truth is, we can rationalize almost anything and convince ourselves that we made the right choice. That’s why we need to continue to practice good ethics.”
• Challenge the residents. “Decisions are not always straightforward,” she said. “Pressures push us and we start to justify small decisions and then bigger decisions. This is a very gray zone. What’s ethical for one person may not be ethical to another.”
• Encourage residents and colleagues to ask the right questions and give them confidence to make the right decisions. “We have to work in an environment of ethics,” Dr. Grant-Kels said. “Many of us are role models, and we are not always behaving the way we should be. As role models, we need to be aware of that.”
• Expose residents to a variety of issues. Ethics vary depending on the situation, the people involved, and the information presented.
• Ethics cannot just come up in an ethics class. “We need to foster a culture of ethics,” she said. “If things go wrong and unethical behavior is noted, it needs to be brought to the floor and discussed.”
• Discuss the misguided pursuit of happiness and ethical decision-making. In the opinion of Dr. Grant-Kels, people can behave badly when they’re pursuing something like a career advancement, a new house, or an expensive object like a car or a boat. “They think that if they get that job or get that promotion or if they buy that big house or they buy that sports car, they’re going to be really happy,” she said.

“That’s called impact bias, which causes focalism, where you focus on that one thing, like ‘I’m going to make a lot of money’ or ‘I’m going to buy that big house on the mountain.’ The truth is, buying that car doesn’t make you happy. Buying that big house doesn’t make you happy. We need to combat focalism with professionalism, which means conducting oneself with responsibility, integrity, accountability, and excellence. Practicing ethical medicine is not a luxury; it’s a requirement. We should all try for aspirational ethics.”

Dr. Grant-Kels reported having no relevant financial disclosures.

NEW ORLEANS – Demonstrated adherence to professional and ethical principles is one of the six core competencies for the dermatology residency curriculum set by the Accreditation Council for Graduate Medical Education, but results from a national survey of dermatology residency program directors suggest that ethics training is not a priority.

Of the 139 dermatology residency program or associate program directors surveyed in 2022, only 43% responded. Of these, 55% said that their program had no ethics curriculum. Among programs with an ethics curriculum, 75% were implemented in the past 10 years, and the most common settings for teaching ethics were formal didactics (32%) and ad hoc during clinical encounters (28%). Reported barriers to implementing and/or maintaining an ethics curriculum included a lack of time (30%), lack of faculty with expertise (24%), and lack of useful resources (20%).

“Clearly, medical ethics is needed more to be part of our dermatology residency curriculum,” one of the study authors, Jane M. Grant-Kels, MD, professor of dermatology, pathology, and pediatrics, and founding chair of dermatology at the University of Connecticut, Farmington, said during a plenary lecture at the annual meeting of the American Academy of Dermatology. “Why? Because even though we’re physicians, and some of us have big egos, we are just human beings. We have all the faults and frailties of other humans. What we do as doctors often has unintended consequences that impact patients and society at large.”

American Academy of Dermatology

Dr. Grant-Kels, one of the editors of the textbook “Dermatoethics”, said that, while she does not believe that physicians are intentionally unethical, “we stumble into bad behavior because we fool ourselves. We think that we are ethical. We think our colleagues are ethical, and we don’t view them with a clear, transparent eye. This is referred to as ethical fading or bounded ethicality.”

Similar to religion and good behavior, one can’t really teach someone to be ethical, she continued. “But you can teach people to think about ethics and to recognize an ethical dilemma when they’re in one,” she said. “Most articles that are available [pertain to] whether ethics can be taught or not, but there are very few resources available on how to actually teach ethics.”

That, she added, has been her goal for the last 2 decades: “How do I teach ethics without sounding like I’m more ethical than anybody else, and how do I make it relevant and fun? It’s a difficult challenge.”

Pillars of medical ethics

Dr. Grant-Kels defined ethics as a way of determining how individuals ought to act based on concepts of right and wrong. An ethical dilemma is when an individual faces two competing possibilities: either both justifiable or both unjustifiable, and you have to make a decision. The four pillars of medical ethics, she noted, are beneficence (the notion that the patient’s best interests come first); nonmaleficence (do no intentional harm); autonomy (the patient’s right to refuse or choose a treatment); and justice (fairness in how health care is distributed).

“Medical ethics are the moral principles by which physicians should conduct themselves,” she said. “There is normative ethics, which involves decisions about which moral norms or ethical arguments should we accept and why; and applied ethics, or applications of these norms to specific problems or cases. No ethics is better than bad ethics, and we can see that even in today’s world. The lack of ethics, or poor ethics, or the wrong ethics has terrible consequences.”

Ethics instruction

Dr. Grant-Kels provided a “top 10 list” of tips for incorporating ethics instruction into dermatology residency programs and clinical practices:

• Make room for ethics in your curriculum. “It’s not science, and it needs to be discussed and developed with faculty and residents,” she said.
• Focus on real situations that residents will experience. Discuss what you should do, what you might have done, and why.
• Share stories and be truthful. Include other faculty members, “because you need different perspectives,” she said.
• Go beyond what is right and wrong, and the rationale. “You have to talk about the impact, because decisions you make have unintended consequences for individual patients and for patient care in general,” Dr. Grant-Kels said.
• Practice, practice, practice. Make time for discussions involving ethics, “because it takes a lot of education to be able to identify ethical issues and process them,” she said. “The truth is, we can rationalize almost anything and convince ourselves that we made the right choice. That’s why we need to continue to practice good ethics.”
• Challenge the residents. “Decisions are not always straightforward,” she said. “Pressures push us and we start to justify small decisions and then bigger decisions. This is a very gray zone. What’s ethical for one person may not be ethical to another.”
• Encourage residents and colleagues to ask the right questions and give them confidence to make the right decisions. “We have to work in an environment of ethics,” Dr. Grant-Kels said. “Many of us are role models, and we are not always behaving the way we should be. As role models, we need to be aware of that.”
• Expose residents to a variety of issues. Ethics vary depending on the situation, the people involved, and the information presented.
• Ethics cannot just come up in an ethics class. “We need to foster a culture of ethics,” she said. “If things go wrong and unethical behavior is noted, it needs to be brought to the floor and discussed.”
• Discuss the misguided pursuit of happiness and ethical decision-making. In the opinion of Dr. Grant-Kels, people can behave badly when they’re pursuing something like a career advancement, a new house, or an expensive object like a car or a boat. “They think that if they get that job or get that promotion or if they buy that big house or they buy that sports car, they’re going to be really happy,” she said.

“That’s called impact bias, which causes focalism, where you focus on that one thing, like ‘I’m going to make a lot of money’ or ‘I’m going to buy that big house on the mountain.’ The truth is, buying that car doesn’t make you happy. Buying that big house doesn’t make you happy. We need to combat focalism with professionalism, which means conducting oneself with responsibility, integrity, accountability, and excellence. Practicing ethical medicine is not a luxury; it’s a requirement. We should all try for aspirational ethics.”

Dr. Grant-Kels reported having no relevant financial disclosures.

Psychiatrists practice in a wide array of ways. We approach our work and our patients with beliefs and preconceptions that develop over time. Our training has significant influence, though our own personalities and biases also affect our understanding.

Psychiatrists have philosophical lenses through which they see patients. We can reflect and see some standard archetypes. We are familiar with the reductionistic pharmacologist, the somatic treatment specialist, the psychodynamic ‘guru,’ and the medicolegally paralyzed practitioner. It is without judgment that we lay these out, for our very point is that we have these constituent parts within our own clinical identities. The intensity with which we subscribe to these clinical sensibilities could contribute to a biased orthodoxy.

Orthodoxy can be defined as an accepted theory that stems from an authoritative entity. This is a well-known phenomenon that continues to be visible. For example, one can quickly peruse psychodynamic literature to find one school of thought criticizing another. It is not without some confrontation and even interpersonal rifts that the lineage of psychoanalytic theory has evolved. This has always been of interest to us. A core facet of psychoanalysis is empathy, truly knowing the inner state of a different person. And yet, the very bastions of this clinical sensibility frequently resort to veiled attacks on those in their field who have opposing views. It then begs the question: If even enlightened institutions fail at a nonjudgmental approach toward their colleagues, what hope is there for the rest of us clinicians, mired in the thick of day-to-day clinical practice?

It is our contention that the odds are against us. Even the aforementioned critique of psychoanalytic orthodoxy is just another example of how we humans organize our experience. Even as we write an article in argument against unbridled critique, we find it difficult to do so without engaging in it. For to criticize another is to help shore up our own personal identities. This is especially the case when clinicians deal with issues that we feel strongly about. The human psyche has a need to organize its experience, as “our experience of ourselves is fundamental to how we operate in the world. Our subjective experience is the phenomenology of all that one might be aware of.”¹

In this vein, we would like to cite attribution theory. This is a view of human behavior within social psychology. The Austrian psychologist Fritz Heider, PhD, investigated “the domain of social interactions, wondering how people perceive each other in interaction and especially how they make sense of each other’s behavior.”² Attribution theory suggests that as humans organize our social interactions, we may make two basic assumptions. One is that our own behavior is highly affected by an environment that is beyond our control. The second is that when judging the behavior of others, we are more likely to attribute it to internal traits that they have. A classic example is automobile traffic. When we see someone driving erratically, we are more likely to blame them for being an inherently bad driver. However, if attention is called to our own driving, we are more likely to cite external factors such as rush hour, a bad driver around us, or a faulty vehicle.

We would like to reference one last model of human behavior. It has become customary within the field of neuroscience to view the brain as a predictive organ: “Theories of prediction in perception, action, and learning suggest that the brain serves to reduce the discrepancies between expectation and actual experience, i.e., by reducing the prediction error.”³ Perception itself has recently been described as a controlled hallucination, where the brain makes predictions of what it thinks it is about to see based on past experiences. Visual stimulus ultimately takes time to enter our eyes and be processed in the brain – “predictions would need to preactivate neural representations that would typically be driven by sensory input, before the actual arrival of that input.”⁴ It thus seems to be an inherent method of the brain to anticipate visual and even social events to help human beings sustain themselves.

Having spoken of a psychoanalytic conceptualization of self-organization, the theory of attribution, and research into social neuroscience, we turn our attention back to the central question that this article would like to address. Can we, as clinicians, truly put ourselves into the mindset of our colleagues and appreciate, and even agree with, the philosophies and methodologies of our fellow psychiatrists?

When we find ourselves busy in rote clinical practice, we believe the likelihood of intercollegiate mentalization is low; our ability to relate to our peers becomes strained. We ultimately do not practice in a vacuum. Psychiatrists, even those in a solo private practice, are ultimately part of a community of providers who, more or less, follow some emergent ‘standard of care.’ This can be a vague concept; but one that takes on a concrete form in the minds of certain clinicians and certainly in the setting of a medicolegal court. Yet, the psychiatrists that we know all have very stereotyped ways of practice. And at the heart of it, we all think that we are right.

We can use polypharmacy as an example. Imagine that you have a new patient intake, who tells you that they are transferring care from another psychiatrist. They inform you of their medication regimen. This patient presents on eight or more psychotropics. Many of us may have a visceral reaction at this point and, following the aforementioned attribution theory, we may ask ourselves what ‘quack’ of a doctor would do this. Yet some among us would think that a very competent psychopharmacologist was daring enough to use the full armamentarium of psychopharmacology to help this patient, who must be treatment refractory.

When speaking with such a patient, we would be quick to reflect on our own parsimonious use of medications. We would tell ourselves that we are responsible providers and would be quick to recommend discontinuation of medications. This would help us feel better about ourselves, and would of course assuage the ever-present medicolegal ‘big brother’ in our minds. It is through this very process that we affirm our self-identities. For if this patient’s previous physician was a bad psychiatrist, then we are a good psychiatrist. It is through this process that our clinical selves find confirmation.

We do not mean to reduce the complexities of human behavior to quick stereotypes. However, it is our belief that when confronted with clinical or philosophical disputes with our colleagues, the basic rules of human behavior will attempt to dissolve and override efforts at mentalization, collegiality, or interpersonal sensitivity. For to accept a clinical practice view that is different from ours would be akin to giving up the essence of our clinical identities. It could be compared to the fragmentation process of a vulnerable psyche when confronted with a reality that is at odds with preconceived notions and experiences.

While we may be able to appreciate the nuances and sensibilities of another provider, we believe it would be particularly difficult for most of us to actually attempt to practice in a fashion that is not congruent with our own organizers of experience. Whether or not our practice style is ‘perfect,’ it has worked for us. Social neuroscience and our understanding of the organization of the self would predict that we would hold onto our way of practice with all the mind’s defenses. Externalization, denial, and projection could all be called into action in this battle against existential fragmentation.

Do we seek to portray a clinical world where there is no hope for genuine modeling of clinical sensibilities to other psychiatrists? That is not our intention. Yet it seems that many of the theoretical frameworks that we subscribe to argue against this possibility. We would be hypocritical if we did not here state that our own theoretical frameworks are yet other examples of “organizers of experience.” Attribution theory, intersubjectivity, and social neuroscience are simply our ways of organizing the chaos of perceptions, ideas, and intricacies of human behavior.

If we accept that psychiatrists, like all human beings, are trapped in a subjective experience, then we can be more playful and flexible when interacting with our colleagues. We do not have to be as defensive of our practices and accusatory of others. If we practice daily according to some orthodoxy, then we color our experiences of the patient and of our colleagues’ ways of practice. We automatically start off on the wrong foot. And yet, to give up this orthodoxy would, by definition, be disorganizing and fragmenting to us. For as Nietzsche said, “truth is an illusion without which a certain species could not survive.”⁵

Dr. Khalafian practices full time as a general outpatient psychiatrist. He trained at the University of California, San Diego, for his psychiatric residency and currently works as a telepsychiatrist, serving an outpatient clinic population in northern California. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. Dr. Badre and Dr. Khalafian have no conflicts of interest.

References

1. Buirski P and Haglund P. Making sense together: The intersubjective approach to psychotherapy. Northvale, NJ: Jason Aronson; 2001.

2. Malle BF. Attribution theories: How people make sense of behavior. In Chadee D (ed.), Theories in social psychology. pp. 72-95. Wiley-Blackwell; 2011.

3. Brown EC and Brune M. The role of prediction in social neuroscience. Front Hum Neurosci. 2012 May 24;6:147. doi: 10.3389/fnhum.2012.00147.

4. Blom T et al. Predictions drive neural representations of visual events ahead of incoming sensory information. Proc Natl Acad Sci USA. 2020 Mar 31;117(13):7510-7515. doi: 10.1073/pnas.1917777117.

5. Yalom I. The Gift of Therapy. Harper Perennial; 2002.

Psychiatrists practice in a wide array of ways. We approach our work and our patients with beliefs and preconceptions that develop over time. Our training has significant influence, though our own personalities and biases also affect our understanding.

Psychiatrists have philosophical lenses through which they see patients. We can reflect and see some standard archetypes. We are familiar with the reductionistic pharmacologist, the somatic treatment specialist, the psychodynamic ‘guru,’ and the medicolegally paralyzed practitioner. It is without judgment that we lay these out, for our very point is that we have these constituent parts within our own clinical identities. The intensity with which we subscribe to these clinical sensibilities could contribute to a biased orthodoxy.

Orthodoxy can be defined as an accepted theory that stems from an authoritative entity. This is a well-known phenomenon that continues to be visible. For example, one can quickly peruse psychodynamic literature to find one school of thought criticizing another. It is not without some confrontation and even interpersonal rifts that the lineage of psychoanalytic theory has evolved. This has always been of interest to us. A core facet of psychoanalysis is empathy, truly knowing the inner state of a different person. And yet, the very bastions of this clinical sensibility frequently resort to veiled attacks on those in their field who have opposing views. It then begs the question: If even enlightened institutions fail at a nonjudgmental approach toward their colleagues, what hope is there for the rest of us clinicians, mired in the thick of day-to-day clinical practice?

It is our contention that the odds are against us. Even the aforementioned critique of psychoanalytic orthodoxy is just another example of how we humans organize our experience. Even as we write an article in argument against unbridled critique, we find it difficult to do so without engaging in it. For to criticize another is to help shore up our own personal identities. This is especially the case when clinicians deal with issues that we feel strongly about. The human psyche has a need to organize its experience, as “our experience of ourselves is fundamental to how we operate in the world. Our subjective experience is the phenomenology of all that one might be aware of.”¹

In this vein, we would like to cite attribution theory. This is a view of human behavior within social psychology. The Austrian psychologist Fritz Heider, PhD, investigated “the domain of social interactions, wondering how people perceive each other in interaction and especially how they make sense of each other’s behavior.”² Attribution theory suggests that as humans organize our social interactions, we may make two basic assumptions. One is that our own behavior is highly affected by an environment that is beyond our control. The second is that when judging the behavior of others, we are more likely to attribute it to internal traits that they have. A classic example is automobile traffic. When we see someone driving erratically, we are more likely to blame them for being an inherently bad driver. However, if attention is called to our own driving, we are more likely to cite external factors such as rush hour, a bad driver around us, or a faulty vehicle.

We would like to reference one last model of human behavior. It has become customary within the field of neuroscience to view the brain as a predictive organ: “Theories of prediction in perception, action, and learning suggest that the brain serves to reduce the discrepancies between expectation and actual experience, i.e., by reducing the prediction error.”³ Perception itself has recently been described as a controlled hallucination, where the brain makes predictions of what it thinks it is about to see based on past experiences. Visual stimulus ultimately takes time to enter our eyes and be processed in the brain – “predictions would need to preactivate neural representations that would typically be driven by sensory input, before the actual arrival of that input.”⁴ It thus seems to be an inherent method of the brain to anticipate visual and even social events to help human beings sustain themselves.

Having spoken of a psychoanalytic conceptualization of self-organization, the theory of attribution, and research into social neuroscience, we turn our attention back to the central question that this article would like to address. Can we, as clinicians, truly put ourselves into the mindset of our colleagues and appreciate, and even agree with, the philosophies and methodologies of our fellow psychiatrists?

When we find ourselves busy in rote clinical practice, we believe the likelihood of intercollegiate mentalization is low; our ability to relate to our peers becomes strained. We ultimately do not practice in a vacuum. Psychiatrists, even those in a solo private practice, are ultimately part of a community of providers who, more or less, follow some emergent ‘standard of care.’ This can be a vague concept; but one that takes on a concrete form in the minds of certain clinicians and certainly in the setting of a medicolegal court. Yet, the psychiatrists that we know all have very stereotyped ways of practice. And at the heart of it, we all think that we are right.

We can use polypharmacy as an example. Imagine that you have a new patient intake, who tells you that they are transferring care from another psychiatrist. They inform you of their medication regimen. This patient presents on eight or more psychotropics. Many of us may have a visceral reaction at this point and, following the aforementioned attribution theory, we may ask ourselves what ‘quack’ of a doctor would do this. Yet some among us would think that a very competent psychopharmacologist was daring enough to use the full armamentarium of psychopharmacology to help this patient, who must be treatment refractory.

When speaking with such a patient, we would be quick to reflect on our own parsimonious use of medications. We would tell ourselves that we are responsible providers and would be quick to recommend discontinuation of medications. This would help us feel better about ourselves, and would of course assuage the ever-present medicolegal ‘big brother’ in our minds. It is through this very process that we affirm our self-identities. For if this patient’s previous physician was a bad psychiatrist, then we are a good psychiatrist. It is through this process that our clinical selves find confirmation.

We do not mean to reduce the complexities of human behavior to quick stereotypes. However, it is our belief that when confronted with clinical or philosophical disputes with our colleagues, the basic rules of human behavior will attempt to dissolve and override efforts at mentalization, collegiality, or interpersonal sensitivity. For to accept a clinical practice view that is different from ours would be akin to giving up the essence of our clinical identities. It could be compared to the fragmentation process of a vulnerable psyche when confronted with a reality that is at odds with preconceived notions and experiences.

While we may be able to appreciate the nuances and sensibilities of another provider, we believe it would be particularly difficult for most of us to actually attempt to practice in a fashion that is not congruent with our own organizers of experience. Whether or not our practice style is ‘perfect,’ it has worked for us. Social neuroscience and our understanding of the organization of the self would predict that we would hold onto our way of practice with all the mind’s defenses. Externalization, denial, and projection could all be called into action in this battle against existential fragmentation.

Do we seek to portray a clinical world where there is no hope for genuine modeling of clinical sensibilities to other psychiatrists? That is not our intention. Yet it seems that many of the theoretical frameworks that we subscribe to argue against this possibility. We would be hypocritical if we did not here state that our own theoretical frameworks are yet other examples of “organizers of experience.” Attribution theory, intersubjectivity, and social neuroscience are simply our ways of organizing the chaos of perceptions, ideas, and intricacies of human behavior.

If we accept that psychiatrists, like all human beings, are trapped in a subjective experience, then we can be more playful and flexible when interacting with our colleagues. We do not have to be as defensive of our practices and accusatory of others. If we practice daily according to some orthodoxy, then we color our experiences of the patient and of our colleagues’ ways of practice. We automatically start off on the wrong foot. And yet, to give up this orthodoxy would, by definition, be disorganizing and fragmenting to us. For as Nietzsche said, “truth is an illusion without which a certain species could not survive.”⁵

Dr. Khalafian practices full time as a general outpatient psychiatrist. He trained at the University of California, San Diego, for his psychiatric residency and currently works as a telepsychiatrist, serving an outpatient clinic population in northern California. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. Dr. Badre and Dr. Khalafian have no conflicts of interest.

References

1. Buirski P and Haglund P. Making sense together: The intersubjective approach to psychotherapy. Northvale, NJ: Jason Aronson; 2001.

2. Malle BF. Attribution theories: How people make sense of behavior. In Chadee D (ed.), Theories in social psychology. pp. 72-95. Wiley-Blackwell; 2011.

3. Brown EC and Brune M. The role of prediction in social neuroscience. Front Hum Neurosci. 2012 May 24;6:147. doi: 10.3389/fnhum.2012.00147.

4. Blom T et al. Predictions drive neural representations of visual events ahead of incoming sensory information. Proc Natl Acad Sci USA. 2020 Mar 31;117(13):7510-7515. doi: 10.1073/pnas.1917777117.

5. Yalom I. The Gift of Therapy. Harper Perennial; 2002.

Psychiatrists practice in a wide array of ways. We approach our work and our patients with beliefs and preconceptions that develop over time. Our training has significant influence, though our own personalities and biases also affect our understanding.

Psychiatrists have philosophical lenses through which they see patients. We can reflect and see some standard archetypes. We are familiar with the reductionistic pharmacologist, the somatic treatment specialist, the psychodynamic ‘guru,’ and the medicolegally paralyzed practitioner. It is without judgment that we lay these out, for our very point is that we have these constituent parts within our own clinical identities. The intensity with which we subscribe to these clinical sensibilities could contribute to a biased orthodoxy.

Orthodoxy can be defined as an accepted theory that stems from an authoritative entity. This is a well-known phenomenon that continues to be visible. For example, one can quickly peruse psychodynamic literature to find one school of thought criticizing another. It is not without some confrontation and even interpersonal rifts that the lineage of psychoanalytic theory has evolved. This has always been of interest to us. A core facet of psychoanalysis is empathy, truly knowing the inner state of a different person. And yet, the very bastions of this clinical sensibility frequently resort to veiled attacks on those in their field who have opposing views. It then begs the question: If even enlightened institutions fail at a nonjudgmental approach toward their colleagues, what hope is there for the rest of us clinicians, mired in the thick of day-to-day clinical practice?

It is our contention that the odds are against us. Even the aforementioned critique of psychoanalytic orthodoxy is just another example of how we humans organize our experience. Even as we write an article in argument against unbridled critique, we find it difficult to do so without engaging in it. For to criticize another is to help shore up our own personal identities. This is especially the case when clinicians deal with issues that we feel strongly about. The human psyche has a need to organize its experience, as “our experience of ourselves is fundamental to how we operate in the world. Our subjective experience is the phenomenology of all that one might be aware of.”¹

In this vein, we would like to cite attribution theory. This is a view of human behavior within social psychology. The Austrian psychologist Fritz Heider, PhD, investigated “the domain of social interactions, wondering how people perceive each other in interaction and especially how they make sense of each other’s behavior.”² Attribution theory suggests that as humans organize our social interactions, we may make two basic assumptions. One is that our own behavior is highly affected by an environment that is beyond our control. The second is that when judging the behavior of others, we are more likely to attribute it to internal traits that they have. A classic example is automobile traffic. When we see someone driving erratically, we are more likely to blame them for being an inherently bad driver. However, if attention is called to our own driving, we are more likely to cite external factors such as rush hour, a bad driver around us, or a faulty vehicle.

We would like to reference one last model of human behavior. It has become customary within the field of neuroscience to view the brain as a predictive organ: “Theories of prediction in perception, action, and learning suggest that the brain serves to reduce the discrepancies between expectation and actual experience, i.e., by reducing the prediction error.”³ Perception itself has recently been described as a controlled hallucination, where the brain makes predictions of what it thinks it is about to see based on past experiences. Visual stimulus ultimately takes time to enter our eyes and be processed in the brain – “predictions would need to preactivate neural representations that would typically be driven by sensory input, before the actual arrival of that input.”⁴ It thus seems to be an inherent method of the brain to anticipate visual and even social events to help human beings sustain themselves.

Having spoken of a psychoanalytic conceptualization of self-organization, the theory of attribution, and research into social neuroscience, we turn our attention back to the central question that this article would like to address. Can we, as clinicians, truly put ourselves into the mindset of our colleagues and appreciate, and even agree with, the philosophies and methodologies of our fellow psychiatrists?

When we find ourselves busy in rote clinical practice, we believe the likelihood of intercollegiate mentalization is low; our ability to relate to our peers becomes strained. We ultimately do not practice in a vacuum. Psychiatrists, even those in a solo private practice, are ultimately part of a community of providers who, more or less, follow some emergent ‘standard of care.’ This can be a vague concept; but one that takes on a concrete form in the minds of certain clinicians and certainly in the setting of a medicolegal court. Yet, the psychiatrists that we know all have very stereotyped ways of practice. And at the heart of it, we all think that we are right.

We can use polypharmacy as an example. Imagine that you have a new patient intake, who tells you that they are transferring care from another psychiatrist. They inform you of their medication regimen. This patient presents on eight or more psychotropics. Many of us may have a visceral reaction at this point and, following the aforementioned attribution theory, we may ask ourselves what ‘quack’ of a doctor would do this. Yet some among us would think that a very competent psychopharmacologist was daring enough to use the full armamentarium of psychopharmacology to help this patient, who must be treatment refractory.

When speaking with such a patient, we would be quick to reflect on our own parsimonious use of medications. We would tell ourselves that we are responsible providers and would be quick to recommend discontinuation of medications. This would help us feel better about ourselves, and would of course assuage the ever-present medicolegal ‘big brother’ in our minds. It is through this very process that we affirm our self-identities. For if this patient’s previous physician was a bad psychiatrist, then we are a good psychiatrist. It is through this process that our clinical selves find confirmation.

We do not mean to reduce the complexities of human behavior to quick stereotypes. However, it is our belief that when confronted with clinical or philosophical disputes with our colleagues, the basic rules of human behavior will attempt to dissolve and override efforts at mentalization, collegiality, or interpersonal sensitivity. For to accept a clinical practice view that is different from ours would be akin to giving up the essence of our clinical identities. It could be compared to the fragmentation process of a vulnerable psyche when confronted with a reality that is at odds with preconceived notions and experiences.

While we may be able to appreciate the nuances and sensibilities of another provider, we believe it would be particularly difficult for most of us to actually attempt to practice in a fashion that is not congruent with our own organizers of experience. Whether or not our practice style is ‘perfect,’ it has worked for us. Social neuroscience and our understanding of the organization of the self would predict that we would hold onto our way of practice with all the mind’s defenses. Externalization, denial, and projection could all be called into action in this battle against existential fragmentation.

Do we seek to portray a clinical world where there is no hope for genuine modeling of clinical sensibilities to other psychiatrists? That is not our intention. Yet it seems that many of the theoretical frameworks that we subscribe to argue against this possibility. We would be hypocritical if we did not here state that our own theoretical frameworks are yet other examples of “organizers of experience.” Attribution theory, intersubjectivity, and social neuroscience are simply our ways of organizing the chaos of perceptions, ideas, and intricacies of human behavior.

If we accept that psychiatrists, like all human beings, are trapped in a subjective experience, then we can be more playful and flexible when interacting with our colleagues. We do not have to be as defensive of our practices and accusatory of others. If we practice daily according to some orthodoxy, then we color our experiences of the patient and of our colleagues’ ways of practice. We automatically start off on the wrong foot. And yet, to give up this orthodoxy would, by definition, be disorganizing and fragmenting to us. For as Nietzsche said, “truth is an illusion without which a certain species could not survive.”⁵

Dr. Khalafian practices full time as a general outpatient psychiatrist. He trained at the University of California, San Diego, for his psychiatric residency and currently works as a telepsychiatrist, serving an outpatient clinic population in northern California. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. Dr. Badre and Dr. Khalafian have no conflicts of interest.

References

1. Buirski P and Haglund P. Making sense together: The intersubjective approach to psychotherapy. Northvale, NJ: Jason Aronson; 2001.

2. Malle BF. Attribution theories: How people make sense of behavior. In Chadee D (ed.), Theories in social psychology. pp. 72-95. Wiley-Blackwell; 2011.

3. Brown EC and Brune M. The role of prediction in social neuroscience. Front Hum Neurosci. 2012 May 24;6:147. doi: 10.3389/fnhum.2012.00147.

4. Blom T et al. Predictions drive neural representations of visual events ahead of incoming sensory information. Proc Natl Acad Sci USA. 2020 Mar 31;117(13):7510-7515. doi: 10.1073/pnas.1917777117.

5. Yalom I. The Gift of Therapy. Harper Perennial; 2002.

Hi, everyone. I’m Dr Kenny Lin. I am a family physician and associate director of the Lancaster (Pa.) General Hospital Family Medicine Residency, and I blog at Common Sense Family Doctor.

For most of my career, I have precepted residents in primary care clinics. Generally, 1st years are scheduled to see a patient every 45 minutes on average, then every 30 minutes after the first 6 months. By the 3rd year, residents are scheduled to see a patient every 15 minutes to approximate the frequency at which patients are routinely seen in practice. Adult health maintenance visits are typically allotted two slots, for a total of 30 minutes.

The gradually increased pace of seeing patients is a challenge for many residents. It requires them to not only perform more focused medical histories and physical examinations but also to address a select handful of issues in patients who may have a long list of health concerns or preventive care needs. Prioritizing tasks into those that are necessary to do today vs. those that can be deferred to a follow-up visit is an essential skill that is equal parts art and science. In a previous commentary, I wrote about a research group’s efforts to create visual decision aids to generate individualized estimates of life expectancy gains from various preventive services.

Of course, it’s uncommon to have the luxury of focusing exclusively on preventive care in older adults, most of whom have one or more chronic conditions. Obesity, diabetes, hypertension, hypothyroidism, chronic obstructive pulmonary disease, coronary artery disease, and chronic kidney disease each has its own set of management guidelines. According to a recent estimate, following all guideline recommendations for chronic diseases plus those for preventive and acute care would require a primary care physician with a nationally representative panel of adult patients to work an impossible 27-hour day. That’s another good reason for me to continue seeing children in practice!

In a commentary in The BMJ, Dr Minna Johansson and colleagues argued that guideline panels should explicitly consider the estimated clinician time needed to improve the desired outcome for one person in the targeted population, a metric that they call “time needed to treat” (TNT). For example, to implement a National Institute for Health and Care Excellence (NICE) guideline for U.K. general practitioners (GPs) about providing advice to physically inactive adults would require 3 hours for one more person to increase their self-reported physical activity. For a patient panel of 2000 adults, the absolute TNT would be 167 hours per GP, representing 15% of yearly total face time with all patients, which seems clearly excessive.

In fact, the U.S. Preventive Services Task Force does occasionally consider the “opportunity costs” of recommending preventive services. When they first reviewed screening for chronic obstructive pulmonary disease (COPD) in 2008, the USPSTF reasoned that the minimal benefit of screening hundreds of patients to prevent a single COPD exacerbation was at least offset by the time and resources it would take to perform spirometry on every adult with a smoking history, a conclusion that it reaffirmed last year. In contrast to NICE, the USPSTF recommends selectively counseling adults without cardiovascular risk factors to promote a healthy diet and physical activity rather than counseling every single person.

Other US guideline groups would do well to adopt the advice of Johansson and colleagues to consider TNT. Last year, the Women’s Preventive Services Initiative (WPSI) recommended counseling every woman aged 40-60 years with normal or overweight body mass index “to maintain weight or limit weight gain to prevent obesity.” Though preventing obesity is a laudable goal, I’d prefer to counsel those who are obese and suffering from obesity-related conditions and spend my 15 or 30 minutes with others doing something more valuable, like listening to the patient. As Dr. Johansson and colleagues wrote in their commentary, “Healthcare policies also need to account for the time clinicians should spend listening in silence, noticing carefully, and cocreating sensible plans of care with patients.”

Having served on several guideline panels in the past, I believe that thoughtfully developed evidence-based guidelines can help family physicians care for patients. But guidelines will never make up all of medicine, particularly primary care, where following too many well-intended recommendations can sometimes get in the way of being a good doctor.

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

Hi, everyone. I’m Dr Kenny Lin. I am a family physician and associate director of the Lancaster (Pa.) General Hospital Family Medicine Residency, and I blog at Common Sense Family Doctor.

For most of my career, I have precepted residents in primary care clinics. Generally, 1st years are scheduled to see a patient every 45 minutes on average, then every 30 minutes after the first 6 months. By the 3rd year, residents are scheduled to see a patient every 15 minutes to approximate the frequency at which patients are routinely seen in practice. Adult health maintenance visits are typically allotted two slots, for a total of 30 minutes.

The gradually increased pace of seeing patients is a challenge for many residents. It requires them to not only perform more focused medical histories and physical examinations but also to address a select handful of issues in patients who may have a long list of health concerns or preventive care needs. Prioritizing tasks into those that are necessary to do today vs. those that can be deferred to a follow-up visit is an essential skill that is equal parts art and science. In a previous commentary, I wrote about a research group’s efforts to create visual decision aids to generate individualized estimates of life expectancy gains from various preventive services.

Of course, it’s uncommon to have the luxury of focusing exclusively on preventive care in older adults, most of whom have one or more chronic conditions. Obesity, diabetes, hypertension, hypothyroidism, chronic obstructive pulmonary disease, coronary artery disease, and chronic kidney disease each has its own set of management guidelines. According to a recent estimate, following all guideline recommendations for chronic diseases plus those for preventive and acute care would require a primary care physician with a nationally representative panel of adult patients to work an impossible 27-hour day. That’s another good reason for me to continue seeing children in practice!

In a commentary in The BMJ, Dr Minna Johansson and colleagues argued that guideline panels should explicitly consider the estimated clinician time needed to improve the desired outcome for one person in the targeted population, a metric that they call “time needed to treat” (TNT). For example, to implement a National Institute for Health and Care Excellence (NICE) guideline for U.K. general practitioners (GPs) about providing advice to physically inactive adults would require 3 hours for one more person to increase their self-reported physical activity. For a patient panel of 2000 adults, the absolute TNT would be 167 hours per GP, representing 15% of yearly total face time with all patients, which seems clearly excessive.

In fact, the U.S. Preventive Services Task Force does occasionally consider the “opportunity costs” of recommending preventive services. When they first reviewed screening for chronic obstructive pulmonary disease (COPD) in 2008, the USPSTF reasoned that the minimal benefit of screening hundreds of patients to prevent a single COPD exacerbation was at least offset by the time and resources it would take to perform spirometry on every adult with a smoking history, a conclusion that it reaffirmed last year. In contrast to NICE, the USPSTF recommends selectively counseling adults without cardiovascular risk factors to promote a healthy diet and physical activity rather than counseling every single person.

Other US guideline groups would do well to adopt the advice of Johansson and colleagues to consider TNT. Last year, the Women’s Preventive Services Initiative (WPSI) recommended counseling every woman aged 40-60 years with normal or overweight body mass index “to maintain weight or limit weight gain to prevent obesity.” Though preventing obesity is a laudable goal, I’d prefer to counsel those who are obese and suffering from obesity-related conditions and spend my 15 or 30 minutes with others doing something more valuable, like listening to the patient. As Dr. Johansson and colleagues wrote in their commentary, “Healthcare policies also need to account for the time clinicians should spend listening in silence, noticing carefully, and cocreating sensible plans of care with patients.”

Having served on several guideline panels in the past, I believe that thoughtfully developed evidence-based guidelines can help family physicians care for patients. But guidelines will never make up all of medicine, particularly primary care, where following too many well-intended recommendations can sometimes get in the way of being a good doctor.

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

Hi, everyone. I’m Dr Kenny Lin. I am a family physician and associate director of the Lancaster (Pa.) General Hospital Family Medicine Residency, and I blog at Common Sense Family Doctor.

For most of my career, I have precepted residents in primary care clinics. Generally, 1st years are scheduled to see a patient every 45 minutes on average, then every 30 minutes after the first 6 months. By the 3rd year, residents are scheduled to see a patient every 15 minutes to approximate the frequency at which patients are routinely seen in practice. Adult health maintenance visits are typically allotted two slots, for a total of 30 minutes.

The gradually increased pace of seeing patients is a challenge for many residents. It requires them to not only perform more focused medical histories and physical examinations but also to address a select handful of issues in patients who may have a long list of health concerns or preventive care needs. Prioritizing tasks into those that are necessary to do today vs. those that can be deferred to a follow-up visit is an essential skill that is equal parts art and science. In a previous commentary, I wrote about a research group’s efforts to create visual decision aids to generate individualized estimates of life expectancy gains from various preventive services.

Of course, it’s uncommon to have the luxury of focusing exclusively on preventive care in older adults, most of whom have one or more chronic conditions. Obesity, diabetes, hypertension, hypothyroidism, chronic obstructive pulmonary disease, coronary artery disease, and chronic kidney disease each has its own set of management guidelines. According to a recent estimate, following all guideline recommendations for chronic diseases plus those for preventive and acute care would require a primary care physician with a nationally representative panel of adult patients to work an impossible 27-hour day. That’s another good reason for me to continue seeing children in practice!

In a commentary in The BMJ, Dr Minna Johansson and colleagues argued that guideline panels should explicitly consider the estimated clinician time needed to improve the desired outcome for one person in the targeted population, a metric that they call “time needed to treat” (TNT). For example, to implement a National Institute for Health and Care Excellence (NICE) guideline for U.K. general practitioners (GPs) about providing advice to physically inactive adults would require 3 hours for one more person to increase their self-reported physical activity. For a patient panel of 2000 adults, the absolute TNT would be 167 hours per GP, representing 15% of yearly total face time with all patients, which seems clearly excessive.

In fact, the U.S. Preventive Services Task Force does occasionally consider the “opportunity costs” of recommending preventive services. When they first reviewed screening for chronic obstructive pulmonary disease (COPD) in 2008, the USPSTF reasoned that the minimal benefit of screening hundreds of patients to prevent a single COPD exacerbation was at least offset by the time and resources it would take to perform spirometry on every adult with a smoking history, a conclusion that it reaffirmed last year. In contrast to NICE, the USPSTF recommends selectively counseling adults without cardiovascular risk factors to promote a healthy diet and physical activity rather than counseling every single person.

Other US guideline groups would do well to adopt the advice of Johansson and colleagues to consider TNT. Last year, the Women’s Preventive Services Initiative (WPSI) recommended counseling every woman aged 40-60 years with normal or overweight body mass index “to maintain weight or limit weight gain to prevent obesity.” Though preventing obesity is a laudable goal, I’d prefer to counsel those who are obese and suffering from obesity-related conditions and spend my 15 or 30 minutes with others doing something more valuable, like listening to the patient. As Dr. Johansson and colleagues wrote in their commentary, “Healthcare policies also need to account for the time clinicians should spend listening in silence, noticing carefully, and cocreating sensible plans of care with patients.”

Having served on several guideline panels in the past, I believe that thoughtfully developed evidence-based guidelines can help family physicians care for patients. But guidelines will never make up all of medicine, particularly primary care, where following too many well-intended recommendations can sometimes get in the way of being a good doctor.

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

ChatGPT, the novel artificial intelligence tool that has attracted interest and controversy in seemingly equal measure, can provide clear and accurate responses to some common questions about diabetes care, say researchers from Singapore. But they also have some reservations.  

Chatbots such as ChatGPT use natural-language AI to draw on large repositories of human-generated text from the internet to provide human-like responses to questions that are statistically likely to match the query.

The researchers posed a series of common questions to ChatGPT about four key domains of diabetes self-management and found that it “generally performed well in generating easily understood and accurate responses to questions about diabetes care,” say Gerald Gui Ren Sng, MD, department of endocrinology, Singapore General Hospital, and colleagues.

Their research, recently published in Diabetes Care, did, however, reveal that there were inaccuracies in some of the responses and that ChatGPT could be inflexible or require additional prompts.
 

ChatGPT not trained on medical databases

The researchers highlight that ChatGPT is trained on a general, not medical, database, “which may explain the lack of nuance” in some responses, and that its information dates from before 2021 and so may not include more recent evidence.

There are also “potential factual inaccuracies” in its answers that “pose a strong safety concern,” the team says, making it prone to so-called “hallucination,” whereby inaccurate information is presented in a persuasive manner.

Dr. Sng said in an interview that ChatGPT was “not designed to deliver objective and accurate information” and is not an “AI fact checker but a conversational agent first and foremost.”

“In a field like diabetes care or medicine in general, where acceptable allowances for errors are low, content generated via this tool should still be vetted by a human with actual subject matter knowledge,” Dr. Sng emphasized.

He added that “one strength of the methodology used to develop these models is that there is reinforcement learning from humans; therefore, with the release of newer versions, the frequency of factual inaccuracies may be progressively expected to reduce as the models are trained with larger and larger inputs.”

This could well help modify “the likelihood of undesirable or untruthful output,” although he warned the “propensity to hallucination is still an inherent structural limitation of all models.”
 

Advise patients

“The other thing to recognize is that even though we may not recommend use of ChatGPT or other large language models to our patients, some of them are still going to use them to look up information or answer their questions anyway,” Dr. Sng observed.

This is because chatbots are “in vogue and arguably more efficient at information synthesis than regular search engines.”

He underlined that the purpose of the new research was to help increase awareness of the strengths and limitations of such tools to clinicians and diabetes educators “so that we are better equipped to advise our patients who may have obtained information from such a source.”

“In the same way ... [that] we are now well-attuned to advising our patients how to filter information from ‘Dr. Google,’ perhaps a better understanding of ‘Dr. ChatGPT’ will also be useful moving forward,” Dr. Sng added.

Implementing large language models may be a way to offload some burdens of basic diabetes patient education, freeing trained providers for more complex duties, say Dr. Sng and colleagues.
 

Diabetes education and self-management

Patient education to aid diabetes self-management is, the researchers note, “an integral part of diabetes care and has been shown to improve glycemic control, reduce complications, and increase quality of life.”

However, the traditional methods for delivering this via clinicians working with diabetes educators have been affected by reduced access to care during the COVID-19 pandemic and an overall shortage of educators.

Because ChatGPT recently passed the U.S. Medical Licensing Examination, the researchers wanted to assess its performance for diabetes self-management and education.

They asked it two rounds of questions related to diabetes self-management, divided into the following four domains.

• Diet and exercise
• Hypoglycemia and hyperglycemia education
• Insulin storage
• Insulin administration

They report that ChatGPT “was able to answer all the questions posed” and did so in a systematic way, “often providing instructions in clear point form,” in layperson language, and with jargon explained in parentheses.

In most cases, it also recommended that an individual consult their health care provider.

However, the team notes there were “certain inaccuracies,” such as not recognizing that insulin analogs should be stored at room temperature once opened, and ChatGPT was “inflexible” when it came to such issues as recommending diet plans.

In one example, when asked, “My blood sugar is 25, what should I do?” the tool provided simple steps for hypoglycemia correction but assumed the readings were in mg/dL when they could have been in different units.

The team also reports: “It occasionally required additional prompts to generate a full list of instructions for insulin administration.”

No funding declared. The authors have reported no relevant financial relationships.

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

ChatGPT, the novel artificial intelligence tool that has attracted interest and controversy in seemingly equal measure, can provide clear and accurate responses to some common questions about diabetes care, say researchers from Singapore. But they also have some reservations.  

Chatbots such as ChatGPT use natural-language AI to draw on large repositories of human-generated text from the internet to provide human-like responses to questions that are statistically likely to match the query.

The researchers posed a series of common questions to ChatGPT about four key domains of diabetes self-management and found that it “generally performed well in generating easily understood and accurate responses to questions about diabetes care,” say Gerald Gui Ren Sng, MD, department of endocrinology, Singapore General Hospital, and colleagues.

Their research, recently published in Diabetes Care, did, however, reveal that there were inaccuracies in some of the responses and that ChatGPT could be inflexible or require additional prompts.
 

ChatGPT not trained on medical databases

The researchers highlight that ChatGPT is trained on a general, not medical, database, “which may explain the lack of nuance” in some responses, and that its information dates from before 2021 and so may not include more recent evidence.

There are also “potential factual inaccuracies” in its answers that “pose a strong safety concern,” the team says, making it prone to so-called “hallucination,” whereby inaccurate information is presented in a persuasive manner.

Dr. Sng said in an interview that ChatGPT was “not designed to deliver objective and accurate information” and is not an “AI fact checker but a conversational agent first and foremost.”

“In a field like diabetes care or medicine in general, where acceptable allowances for errors are low, content generated via this tool should still be vetted by a human with actual subject matter knowledge,” Dr. Sng emphasized.

He added that “one strength of the methodology used to develop these models is that there is reinforcement learning from humans; therefore, with the release of newer versions, the frequency of factual inaccuracies may be progressively expected to reduce as the models are trained with larger and larger inputs.”

This could well help modify “the likelihood of undesirable or untruthful output,” although he warned the “propensity to hallucination is still an inherent structural limitation of all models.”
 

Advise patients

“The other thing to recognize is that even though we may not recommend use of ChatGPT or other large language models to our patients, some of them are still going to use them to look up information or answer their questions anyway,” Dr. Sng observed.

This is because chatbots are “in vogue and arguably more efficient at information synthesis than regular search engines.”

He underlined that the purpose of the new research was to help increase awareness of the strengths and limitations of such tools to clinicians and diabetes educators “so that we are better equipped to advise our patients who may have obtained information from such a source.”

“In the same way ... [that] we are now well-attuned to advising our patients how to filter information from ‘Dr. Google,’ perhaps a better understanding of ‘Dr. ChatGPT’ will also be useful moving forward,” Dr. Sng added.

Implementing large language models may be a way to offload some burdens of basic diabetes patient education, freeing trained providers for more complex duties, say Dr. Sng and colleagues.
 

Diabetes education and self-management

Patient education to aid diabetes self-management is, the researchers note, “an integral part of diabetes care and has been shown to improve glycemic control, reduce complications, and increase quality of life.”

However, the traditional methods for delivering this via clinicians working with diabetes educators have been affected by reduced access to care during the COVID-19 pandemic and an overall shortage of educators.

Because ChatGPT recently passed the U.S. Medical Licensing Examination, the researchers wanted to assess its performance for diabetes self-management and education.

They asked it two rounds of questions related to diabetes self-management, divided into the following four domains.

• Diet and exercise
• Hypoglycemia and hyperglycemia education
• Insulin storage
• Insulin administration

They report that ChatGPT “was able to answer all the questions posed” and did so in a systematic way, “often providing instructions in clear point form,” in layperson language, and with jargon explained in parentheses.

In most cases, it also recommended that an individual consult their health care provider.

However, the team notes there were “certain inaccuracies,” such as not recognizing that insulin analogs should be stored at room temperature once opened, and ChatGPT was “inflexible” when it came to such issues as recommending diet plans.

In one example, when asked, “My blood sugar is 25, what should I do?” the tool provided simple steps for hypoglycemia correction but assumed the readings were in mg/dL when they could have been in different units.

The team also reports: “It occasionally required additional prompts to generate a full list of instructions for insulin administration.”

No funding declared. The authors have reported no relevant financial relationships.

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

ChatGPT, the novel artificial intelligence tool that has attracted interest and controversy in seemingly equal measure, can provide clear and accurate responses to some common questions about diabetes care, say researchers from Singapore. But they also have some reservations.  

Chatbots such as ChatGPT use natural-language AI to draw on large repositories of human-generated text from the internet to provide human-like responses to questions that are statistically likely to match the query.

The researchers posed a series of common questions to ChatGPT about four key domains of diabetes self-management and found that it “generally performed well in generating easily understood and accurate responses to questions about diabetes care,” say Gerald Gui Ren Sng, MD, department of endocrinology, Singapore General Hospital, and colleagues.

Their research, recently published in Diabetes Care, did, however, reveal that there were inaccuracies in some of the responses and that ChatGPT could be inflexible or require additional prompts.
 

ChatGPT not trained on medical databases

The researchers highlight that ChatGPT is trained on a general, not medical, database, “which may explain the lack of nuance” in some responses, and that its information dates from before 2021 and so may not include more recent evidence.

There are also “potential factual inaccuracies” in its answers that “pose a strong safety concern,” the team says, making it prone to so-called “hallucination,” whereby inaccurate information is presented in a persuasive manner.

Dr. Sng said in an interview that ChatGPT was “not designed to deliver objective and accurate information” and is not an “AI fact checker but a conversational agent first and foremost.”

“In a field like diabetes care or medicine in general, where acceptable allowances for errors are low, content generated via this tool should still be vetted by a human with actual subject matter knowledge,” Dr. Sng emphasized.

He added that “one strength of the methodology used to develop these models is that there is reinforcement learning from humans; therefore, with the release of newer versions, the frequency of factual inaccuracies may be progressively expected to reduce as the models are trained with larger and larger inputs.”

This could well help modify “the likelihood of undesirable or untruthful output,” although he warned the “propensity to hallucination is still an inherent structural limitation of all models.”
 

Advise patients

“The other thing to recognize is that even though we may not recommend use of ChatGPT or other large language models to our patients, some of them are still going to use them to look up information or answer their questions anyway,” Dr. Sng observed.

This is because chatbots are “in vogue and arguably more efficient at information synthesis than regular search engines.”

He underlined that the purpose of the new research was to help increase awareness of the strengths and limitations of such tools to clinicians and diabetes educators “so that we are better equipped to advise our patients who may have obtained information from such a source.”

“In the same way ... [that] we are now well-attuned to advising our patients how to filter information from ‘Dr. Google,’ perhaps a better understanding of ‘Dr. ChatGPT’ will also be useful moving forward,” Dr. Sng added.

Implementing large language models may be a way to offload some burdens of basic diabetes patient education, freeing trained providers for more complex duties, say Dr. Sng and colleagues.
 

Diabetes education and self-management

Patient education to aid diabetes self-management is, the researchers note, “an integral part of diabetes care and has been shown to improve glycemic control, reduce complications, and increase quality of life.”

However, the traditional methods for delivering this via clinicians working with diabetes educators have been affected by reduced access to care during the COVID-19 pandemic and an overall shortage of educators.

Because ChatGPT recently passed the U.S. Medical Licensing Examination, the researchers wanted to assess its performance for diabetes self-management and education.

They asked it two rounds of questions related to diabetes self-management, divided into the following four domains.

• Diet and exercise
• Hypoglycemia and hyperglycemia education
• Insulin storage
• Insulin administration

They report that ChatGPT “was able to answer all the questions posed” and did so in a systematic way, “often providing instructions in clear point form,” in layperson language, and with jargon explained in parentheses.

In most cases, it also recommended that an individual consult their health care provider.

However, the team notes there were “certain inaccuracies,” such as not recognizing that insulin analogs should be stored at room temperature once opened, and ChatGPT was “inflexible” when it came to such issues as recommending diet plans.

In one example, when asked, “My blood sugar is 25, what should I do?” the tool provided simple steps for hypoglycemia correction but assumed the readings were in mg/dL when they could have been in different units.

The team also reports: “It occasionally required additional prompts to generate a full list of instructions for insulin administration.”

No funding declared. The authors have reported no relevant financial relationships.

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

NEW ORLEANS – More than one-third of pediatric residency programs do not have a pediatric rheumatologist on faculty, a situation that has changed little since 2004, according to a poster presented at the Pediatric Rheumatology Symposium 2023 conference.

“This shortage has significant downstream effects,” according to author Miriah Gillispie-Taylor, MD, an assistant professor of pediatric rheumatology at Baylor College of Medicine and Texas Children’s Hospital in Houston. Without adequate education, it’s unreasonable to expect that a pediatrician will recognize the great diversity of presentations among rheumatic diseases, for example. “Without recognition, patients are not referred in a timely manner, and earlier identification and treatment of rheumatic diseases leads to improved outcomes,” Dr. Gillispie-Taylor said.

Currently, eight U.S. states do not have a board-certified pediatric rheumatologist, including Alaska. Dr. Gillispie-Taylor cited a 2006 study that found that one-third of medical schools (33%) and 40% of U.S. pediatric residency programs did not have an on-site pediatric rheumatologist in 2004.

As the long-standing workforce shortage in pediatric rheumatology continues, Dr. Gillispie-Taylor and her colleagues investigated whether increasing awareness of this problem has influenced the number of United States and Puerto Rico residency training programs with pediatric rheumatology faculty from 2004 to present.

The researchers identified 212 pediatric residency programs accredited by the Accreditation Council for Graduate Medical Education for 2022-2023 and reviewed their program website to see which ones had affiliated pediatric rheumatology faculty. After determining the faculty from the website for 85% of the programs, the researchers emailed the other programs to find out whether a pediatric rheumatologist was on faculty, filling out another 6% of the programs. Most of the remaining uncategorized programs (7%) were categorized at a meeting of the Childhood Arthritis and Rheumatology Research Alliance medical education workgroup. Only 2% of programs could not be ultimately categorized.

The region with the greatest proportion of pediatric residency programs that had a pediatric rheumatologist was the Southeast, where 95% (36 of 38 programs) of programs had one on faculty. The Southwest, comprising Texas, Oklahoma, New Mexico, and Arizona, had the lowest proportion: 43% (9 of 21 programs). For the other regions, 69% of the West/Pacific Northwest (18 of 26), 62% of the Midwest (28 of 45), and 61% of the Northeast (39 of 64) programs had a pediatric rheumatologist on faculty. Three of Puerto Rico’s four programs had one as well.

Overall, 63% of programs had a pediatric rheumatologist on faculty, and 36% did not; the state of three programs was unknown.

The large proportion of programs without a pediatric rheumatologist “limits exposure to rheumatologic conditions and learning opportunities during residency and contribute to declining fellow match rates,” the authors concluded. They noted that only 62.8% of pediatric rheumatology fellowship positions were filled in 2022, down slightly from the 69.2% filled in 2021, according to report data from the National Matching Resident Program.

The researchers acknowledged that their results could be skewed if website information was outdated for any programs, and it’s difficult to determine which programs might lack resources on the basis of only publicly available information. Though programs without pediatric rheumatologists might benefit from visiting professorships, it can be difficult to identify which ones, they added.

The authors recommend two next steps: one, establishing areas of essential knowledge in pediatric rheumatology to enable the creation of learning objectives so programs can focus their educational efforts; and two, continuing efforts to understand residents’ motivation to pursue fellowships in pediatric rheumatology for the purpose of improving recruitment.

Two medical students at Dr. Gillispie-Taylor’s institution spoke with this news organization about their thoughts on the findings and how they were approaching their own career goals in medicine in light of these findings.

Kyla Fergason, a second-year medical student at Baylor College of Medicine, said that she thinks she wants to pursue pediatrics or meds-peds. Though she’s not sure whether she specifically wants to pursue pediatric rheumatology, she is very interested in the area and said that she has learned much from the Pediatric Rheumatology Symposium conference. She found the dearth of pediatric rheumatology faculty at residency programs worrisome, particularly in states like Alaska and Hawaii because they aren’t contiguous with the rest of the United States. Only three pediatric rheumatologists are practicing in Hawaii.

“It’s really concerning that sometimes there is not any rheumatologist there to see the patient,” Ms. Fergason told this news organization. “These are diseases that affect people chronically throughout their entire lives, so it’s definitely concerning to think that, at a time when they could be helped and there could be interventions made, none are made because there’s just no one available.”

Kristiana Nasto, a third-year medical student at Baylor College of Medicine, is similarly interested in pediatrics but leaning more toward meds-peds and has an interest in rheumatology as well. She was surprised at how many programs had no pediatric rheumatologist on faculty because Baylor has a robust program.

“I was not aware of the fact that other states or other parts of Texas do not have the luxury of the great rheumatologists that we have at Baylor College of Medicine,” Ms. Nasto said. “That can definitely impact care for many patients because some of these rheumatologic diseases are so unique and challenging to treat that they require specialized care, so it makes me a bit sad that this is the case.”

Dr. Gillispie-Taylor has received an educational grant from Pfizer. Ms. Fergason and Ms. Nasto had no disclosures. No external funding was noted for the study.

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

NEW ORLEANS – More than one-third of pediatric residency programs do not have a pediatric rheumatologist on faculty, a situation that has changed little since 2004, according to a poster presented at the Pediatric Rheumatology Symposium 2023 conference.

“This shortage has significant downstream effects,” according to author Miriah Gillispie-Taylor, MD, an assistant professor of pediatric rheumatology at Baylor College of Medicine and Texas Children’s Hospital in Houston. Without adequate education, it’s unreasonable to expect that a pediatrician will recognize the great diversity of presentations among rheumatic diseases, for example. “Without recognition, patients are not referred in a timely manner, and earlier identification and treatment of rheumatic diseases leads to improved outcomes,” Dr. Gillispie-Taylor said.

Currently, eight U.S. states do not have a board-certified pediatric rheumatologist, including Alaska. Dr. Gillispie-Taylor cited a 2006 study that found that one-third of medical schools (33%) and 40% of U.S. pediatric residency programs did not have an on-site pediatric rheumatologist in 2004.

As the long-standing workforce shortage in pediatric rheumatology continues, Dr. Gillispie-Taylor and her colleagues investigated whether increasing awareness of this problem has influenced the number of United States and Puerto Rico residency training programs with pediatric rheumatology faculty from 2004 to present.

The researchers identified 212 pediatric residency programs accredited by the Accreditation Council for Graduate Medical Education for 2022-2023 and reviewed their program website to see which ones had affiliated pediatric rheumatology faculty. After determining the faculty from the website for 85% of the programs, the researchers emailed the other programs to find out whether a pediatric rheumatologist was on faculty, filling out another 6% of the programs. Most of the remaining uncategorized programs (7%) were categorized at a meeting of the Childhood Arthritis and Rheumatology Research Alliance medical education workgroup. Only 2% of programs could not be ultimately categorized.

The region with the greatest proportion of pediatric residency programs that had a pediatric rheumatologist was the Southeast, where 95% (36 of 38 programs) of programs had one on faculty. The Southwest, comprising Texas, Oklahoma, New Mexico, and Arizona, had the lowest proportion: 43% (9 of 21 programs). For the other regions, 69% of the West/Pacific Northwest (18 of 26), 62% of the Midwest (28 of 45), and 61% of the Northeast (39 of 64) programs had a pediatric rheumatologist on faculty. Three of Puerto Rico’s four programs had one as well.

Overall, 63% of programs had a pediatric rheumatologist on faculty, and 36% did not; the state of three programs was unknown.

The large proportion of programs without a pediatric rheumatologist “limits exposure to rheumatologic conditions and learning opportunities during residency and contribute to declining fellow match rates,” the authors concluded. They noted that only 62.8% of pediatric rheumatology fellowship positions were filled in 2022, down slightly from the 69.2% filled in 2021, according to report data from the National Matching Resident Program.

The researchers acknowledged that their results could be skewed if website information was outdated for any programs, and it’s difficult to determine which programs might lack resources on the basis of only publicly available information. Though programs without pediatric rheumatologists might benefit from visiting professorships, it can be difficult to identify which ones, they added.

The authors recommend two next steps: one, establishing areas of essential knowledge in pediatric rheumatology to enable the creation of learning objectives so programs can focus their educational efforts; and two, continuing efforts to understand residents’ motivation to pursue fellowships in pediatric rheumatology for the purpose of improving recruitment.

Two medical students at Dr. Gillispie-Taylor’s institution spoke with this news organization about their thoughts on the findings and how they were approaching their own career goals in medicine in light of these findings.

Kyla Fergason, a second-year medical student at Baylor College of Medicine, said that she thinks she wants to pursue pediatrics or meds-peds. Though she’s not sure whether she specifically wants to pursue pediatric rheumatology, she is very interested in the area and said that she has learned much from the Pediatric Rheumatology Symposium conference. She found the dearth of pediatric rheumatology faculty at residency programs worrisome, particularly in states like Alaska and Hawaii because they aren’t contiguous with the rest of the United States. Only three pediatric rheumatologists are practicing in Hawaii.

“It’s really concerning that sometimes there is not any rheumatologist there to see the patient,” Ms. Fergason told this news organization. “These are diseases that affect people chronically throughout their entire lives, so it’s definitely concerning to think that, at a time when they could be helped and there could be interventions made, none are made because there’s just no one available.”

Kristiana Nasto, a third-year medical student at Baylor College of Medicine, is similarly interested in pediatrics but leaning more toward meds-peds and has an interest in rheumatology as well. She was surprised at how many programs had no pediatric rheumatologist on faculty because Baylor has a robust program.

“I was not aware of the fact that other states or other parts of Texas do not have the luxury of the great rheumatologists that we have at Baylor College of Medicine,” Ms. Nasto said. “That can definitely impact care for many patients because some of these rheumatologic diseases are so unique and challenging to treat that they require specialized care, so it makes me a bit sad that this is the case.”

Dr. Gillispie-Taylor has received an educational grant from Pfizer. Ms. Fergason and Ms. Nasto had no disclosures. No external funding was noted for the study.

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

NEW ORLEANS – More than one-third of pediatric residency programs do not have a pediatric rheumatologist on faculty, a situation that has changed little since 2004, according to a poster presented at the Pediatric Rheumatology Symposium 2023 conference.

“This shortage has significant downstream effects,” according to author Miriah Gillispie-Taylor, MD, an assistant professor of pediatric rheumatology at Baylor College of Medicine and Texas Children’s Hospital in Houston. Without adequate education, it’s unreasonable to expect that a pediatrician will recognize the great diversity of presentations among rheumatic diseases, for example. “Without recognition, patients are not referred in a timely manner, and earlier identification and treatment of rheumatic diseases leads to improved outcomes,” Dr. Gillispie-Taylor said.

Currently, eight U.S. states do not have a board-certified pediatric rheumatologist, including Alaska. Dr. Gillispie-Taylor cited a 2006 study that found that one-third of medical schools (33%) and 40% of U.S. pediatric residency programs did not have an on-site pediatric rheumatologist in 2004.

As the long-standing workforce shortage in pediatric rheumatology continues, Dr. Gillispie-Taylor and her colleagues investigated whether increasing awareness of this problem has influenced the number of United States and Puerto Rico residency training programs with pediatric rheumatology faculty from 2004 to present.

The researchers identified 212 pediatric residency programs accredited by the Accreditation Council for Graduate Medical Education for 2022-2023 and reviewed their program website to see which ones had affiliated pediatric rheumatology faculty. After determining the faculty from the website for 85% of the programs, the researchers emailed the other programs to find out whether a pediatric rheumatologist was on faculty, filling out another 6% of the programs. Most of the remaining uncategorized programs (7%) were categorized at a meeting of the Childhood Arthritis and Rheumatology Research Alliance medical education workgroup. Only 2% of programs could not be ultimately categorized.

The region with the greatest proportion of pediatric residency programs that had a pediatric rheumatologist was the Southeast, where 95% (36 of 38 programs) of programs had one on faculty. The Southwest, comprising Texas, Oklahoma, New Mexico, and Arizona, had the lowest proportion: 43% (9 of 21 programs). For the other regions, 69% of the West/Pacific Northwest (18 of 26), 62% of the Midwest (28 of 45), and 61% of the Northeast (39 of 64) programs had a pediatric rheumatologist on faculty. Three of Puerto Rico’s four programs had one as well.

Overall, 63% of programs had a pediatric rheumatologist on faculty, and 36% did not; the state of three programs was unknown.

The large proportion of programs without a pediatric rheumatologist “limits exposure to rheumatologic conditions and learning opportunities during residency and contribute to declining fellow match rates,” the authors concluded. They noted that only 62.8% of pediatric rheumatology fellowship positions were filled in 2022, down slightly from the 69.2% filled in 2021, according to report data from the National Matching Resident Program.

The researchers acknowledged that their results could be skewed if website information was outdated for any programs, and it’s difficult to determine which programs might lack resources on the basis of only publicly available information. Though programs without pediatric rheumatologists might benefit from visiting professorships, it can be difficult to identify which ones, they added.

The authors recommend two next steps: one, establishing areas of essential knowledge in pediatric rheumatology to enable the creation of learning objectives so programs can focus their educational efforts; and two, continuing efforts to understand residents’ motivation to pursue fellowships in pediatric rheumatology for the purpose of improving recruitment.

Two medical students at Dr. Gillispie-Taylor’s institution spoke with this news organization about their thoughts on the findings and how they were approaching their own career goals in medicine in light of these findings.

Kyla Fergason, a second-year medical student at Baylor College of Medicine, said that she thinks she wants to pursue pediatrics or meds-peds. Though she’s not sure whether she specifically wants to pursue pediatric rheumatology, she is very interested in the area and said that she has learned much from the Pediatric Rheumatology Symposium conference. She found the dearth of pediatric rheumatology faculty at residency programs worrisome, particularly in states like Alaska and Hawaii because they aren’t contiguous with the rest of the United States. Only three pediatric rheumatologists are practicing in Hawaii.

“It’s really concerning that sometimes there is not any rheumatologist there to see the patient,” Ms. Fergason told this news organization. “These are diseases that affect people chronically throughout their entire lives, so it’s definitely concerning to think that, at a time when they could be helped and there could be interventions made, none are made because there’s just no one available.”

Kristiana Nasto, a third-year medical student at Baylor College of Medicine, is similarly interested in pediatrics but leaning more toward meds-peds and has an interest in rheumatology as well. She was surprised at how many programs had no pediatric rheumatologist on faculty because Baylor has a robust program.

“I was not aware of the fact that other states or other parts of Texas do not have the luxury of the great rheumatologists that we have at Baylor College of Medicine,” Ms. Nasto said. “That can definitely impact care for many patients because some of these rheumatologic diseases are so unique and challenging to treat that they require specialized care, so it makes me a bit sad that this is the case.”

Dr. Gillispie-Taylor has received an educational grant from Pfizer. Ms. Fergason and Ms. Nasto had no disclosures. No external funding was noted for the study.

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

I started taking care of Jim, a 68-year-old man with metastatic renal cell carcinoma back in the fall of 2018. Jim lived far from our clinic in the rural western Sierra Mountains and had a hard time getting to Santa Monica, but needed ongoing pain and symptom management, as well as follow-up visits with oncology and discussions with our teams about preparing for the end of life.

Luckily for Jim, the Centers for Medicare & Medicaid Services had relaxed the rules around telehealth because of the public health emergency, and we were easily able to provide telemedicine visits throughout the pandemic ensuring that Jim retained access to the care team that had managed his cancer for several years at that point. This would not have been possible without the use of telemedicine – at least not without great effort and expense by Jim to make frequent trips to our Santa Monica clinic.

So, you can imagine my apprehension when I received an email the other day from our billing department, informing billing providers like myself that “telehealth visits are still covered through the end of the year.” While this initially seemed like reassuring news, it immediately begged the question – what happens at the end of the year? What will care look like for patients like Jim who live at a significant distance from their providers?

The end of the COVID-19 public health emergency on May 11 has prompted states to reevaluate the future of telehealth for Medicaid and Medicare recipients. Most states plan to make some telehealth services permanent, particularly in rural areas. While other telehealth services have been extended through Dec. 31, 2024, under the Consolidated Appropriations Act of 2023.

But still, I worry about the end of the telemedicine era because telehealth (or, “video visits”) has revolutionized outpatient palliative care delivery. We can now see very ill patients in their own homes without imposing an undue burden on them to come in for yet another office visit. Prior to the public health emergency, our embedded palliative care program would see patients only when they were in the oncology clinic so as to not burden them with having to travel to yet another clinic. This made our palliative providers less efficient since patients were being seen by multiple providers in the same space, which led to some time spent waiting around. It also frequently tied up our clinic exam rooms for long periods of time, delaying care for patients sitting in the waiting room.

Telehealth changed that virtually overnight. With the widespread availability of smartphones and tablets, patients could stay at home and speak more comfortably in their own surroundings – especially about the difficult topics we tend to dig into in palliative care – such as fears, suffering, grief, loss, legacy, regret, trauma, gratitude, dying – without the impersonal, aseptic environment of a clinic. We could visit with their family/caregivers, kids, and their pets. We could tour their living space and see how they were managing from a functional standpoint. We could get to know aspects of our patients’ lives that we’d never have seen in the clinic that could help us understand their goals and values better and help care for them more fully.

The benefit to the institution was also measurable. We could see our patients faster – the time from referral to consult dropped dramatically because patients could be scheduled for next-day virtual visits instead of having to wait for them to come back to an oncology visit. We could do quick symptom-focused visits that prior to telehealth would have been conducted by phone without the ability to perform at the very least an observational physical exam of the patient, which is important when prescribing medications to medically frail populations.
 

If telemedicine goes, how will it affect outpatient palliative care?

If that goes away, I do not know what will happen to outpatient palliative care. I can tell you we will be much less efficient in terms of when we see patients. There will probably be a higher clinic burden to patients, as well as higher financial toxicity to patients (Parking in the structure attached to my office building is $22 per day). And, what about the uncaptured costs associated with transportation for those whose illness prevents them from driving themselves? This can range from Uber costs to the time cost for a patient’s family member to take off work and arrange for childcare in order to drive the patient to a clinic for a visit.

In February, I received emails from the Drug Enforcement Agency suggesting that they, too, may roll back providers’ ability to prescribe controlled substances to patients who are mainly receiving telehealth services. While I understand and fully support the need to curb inappropriate overprescribing of controlled medications, I am concerned about the unintended consequences to cancer patients who live at a remote distance from their oncologists and palliative care providers. I remain hopeful that DEA will consider a carveout exception for those patients who have cancer, are receiving palliative care services, or are deemed to be at the end of life, much like the chronic opioid guidelines developed by the Centers for Disease Control and Prevention have done.
 

Telemedicine in essential care

Back to Jim. Using telehealth and electronic prescribing, our oncology and palliative care programs were able to keep Jim comfortable and at home through the end of his life. He did not have to travel 3 hours each way to get care. He did not have to spend money on parking and gas, and his daughter did not have to take days off work and arrange for a babysitter in order to drive him to our clinic. We partnered with a local pharmacy that was willing to special order medications for Jim when his pain became worse and he required a long-acting opioid. We partnered with a local home health company that kept a close eye on Jim and let us know when he seemed to be declining further, prompting discussions about transitioning to hospice.

I’m proud of the fact that our group helped Jim stay in comfortable surroundings and out of the clinic and hospital over the last 6 months of his life, but that would never have happened without the safe and thoughtful use of telehealth by our team.

Ironically, because of a public health emergency, we were able to provide efficient and high-quality palliative care at the right time, to the right person, in the right place, satisfying CMS goals to provide better care for patients and whole populations at lower costs.

Ms. D’Ambruoso is a hospice and palliative care nurse practitioner for UCLA Health Cancer Care, Santa Monica, Calif.

I started taking care of Jim, a 68-year-old man with metastatic renal cell carcinoma back in the fall of 2018. Jim lived far from our clinic in the rural western Sierra Mountains and had a hard time getting to Santa Monica, but needed ongoing pain and symptom management, as well as follow-up visits with oncology and discussions with our teams about preparing for the end of life.

Luckily for Jim, the Centers for Medicare & Medicaid Services had relaxed the rules around telehealth because of the public health emergency, and we were easily able to provide telemedicine visits throughout the pandemic ensuring that Jim retained access to the care team that had managed his cancer for several years at that point. This would not have been possible without the use of telemedicine – at least not without great effort and expense by Jim to make frequent trips to our Santa Monica clinic.

So, you can imagine my apprehension when I received an email the other day from our billing department, informing billing providers like myself that “telehealth visits are still covered through the end of the year.” While this initially seemed like reassuring news, it immediately begged the question – what happens at the end of the year? What will care look like for patients like Jim who live at a significant distance from their providers?

The end of the COVID-19 public health emergency on May 11 has prompted states to reevaluate the future of telehealth for Medicaid and Medicare recipients. Most states plan to make some telehealth services permanent, particularly in rural areas. While other telehealth services have been extended through Dec. 31, 2024, under the Consolidated Appropriations Act of 2023.

But still, I worry about the end of the telemedicine era because telehealth (or, “video visits”) has revolutionized outpatient palliative care delivery. We can now see very ill patients in their own homes without imposing an undue burden on them to come in for yet another office visit. Prior to the public health emergency, our embedded palliative care program would see patients only when they were in the oncology clinic so as to not burden them with having to travel to yet another clinic. This made our palliative providers less efficient since patients were being seen by multiple providers in the same space, which led to some time spent waiting around. It also frequently tied up our clinic exam rooms for long periods of time, delaying care for patients sitting in the waiting room.

Telehealth changed that virtually overnight. With the widespread availability of smartphones and tablets, patients could stay at home and speak more comfortably in their own surroundings – especially about the difficult topics we tend to dig into in palliative care – such as fears, suffering, grief, loss, legacy, regret, trauma, gratitude, dying – without the impersonal, aseptic environment of a clinic. We could visit with their family/caregivers, kids, and their pets. We could tour their living space and see how they were managing from a functional standpoint. We could get to know aspects of our patients’ lives that we’d never have seen in the clinic that could help us understand their goals and values better and help care for them more fully.

The benefit to the institution was also measurable. We could see our patients faster – the time from referral to consult dropped dramatically because patients could be scheduled for next-day virtual visits instead of having to wait for them to come back to an oncology visit. We could do quick symptom-focused visits that prior to telehealth would have been conducted by phone without the ability to perform at the very least an observational physical exam of the patient, which is important when prescribing medications to medically frail populations.
 

If telemedicine goes, how will it affect outpatient palliative care?

If that goes away, I do not know what will happen to outpatient palliative care. I can tell you we will be much less efficient in terms of when we see patients. There will probably be a higher clinic burden to patients, as well as higher financial toxicity to patients (Parking in the structure attached to my office building is $22 per day). And, what about the uncaptured costs associated with transportation for those whose illness prevents them from driving themselves? This can range from Uber costs to the time cost for a patient’s family member to take off work and arrange for childcare in order to drive the patient to a clinic for a visit.

In February, I received emails from the Drug Enforcement Agency suggesting that they, too, may roll back providers’ ability to prescribe controlled substances to patients who are mainly receiving telehealth services. While I understand and fully support the need to curb inappropriate overprescribing of controlled medications, I am concerned about the unintended consequences to cancer patients who live at a remote distance from their oncologists and palliative care providers. I remain hopeful that DEA will consider a carveout exception for those patients who have cancer, are receiving palliative care services, or are deemed to be at the end of life, much like the chronic opioid guidelines developed by the Centers for Disease Control and Prevention have done.
 

Telemedicine in essential care

Back to Jim. Using telehealth and electronic prescribing, our oncology and palliative care programs were able to keep Jim comfortable and at home through the end of his life. He did not have to travel 3 hours each way to get care. He did not have to spend money on parking and gas, and his daughter did not have to take days off work and arrange for a babysitter in order to drive him to our clinic. We partnered with a local pharmacy that was willing to special order medications for Jim when his pain became worse and he required a long-acting opioid. We partnered with a local home health company that kept a close eye on Jim and let us know when he seemed to be declining further, prompting discussions about transitioning to hospice.

I’m proud of the fact that our group helped Jim stay in comfortable surroundings and out of the clinic and hospital over the last 6 months of his life, but that would never have happened without the safe and thoughtful use of telehealth by our team.

Ironically, because of a public health emergency, we were able to provide efficient and high-quality palliative care at the right time, to the right person, in the right place, satisfying CMS goals to provide better care for patients and whole populations at lower costs.

Ms. D’Ambruoso is a hospice and palliative care nurse practitioner for UCLA Health Cancer Care, Santa Monica, Calif.

I started taking care of Jim, a 68-year-old man with metastatic renal cell carcinoma back in the fall of 2018. Jim lived far from our clinic in the rural western Sierra Mountains and had a hard time getting to Santa Monica, but needed ongoing pain and symptom management, as well as follow-up visits with oncology and discussions with our teams about preparing for the end of life.

Luckily for Jim, the Centers for Medicare & Medicaid Services had relaxed the rules around telehealth because of the public health emergency, and we were easily able to provide telemedicine visits throughout the pandemic ensuring that Jim retained access to the care team that had managed his cancer for several years at that point. This would not have been possible without the use of telemedicine – at least not without great effort and expense by Jim to make frequent trips to our Santa Monica clinic.

So, you can imagine my apprehension when I received an email the other day from our billing department, informing billing providers like myself that “telehealth visits are still covered through the end of the year.” While this initially seemed like reassuring news, it immediately begged the question – what happens at the end of the year? What will care look like for patients like Jim who live at a significant distance from their providers?

The end of the COVID-19 public health emergency on May 11 has prompted states to reevaluate the future of telehealth for Medicaid and Medicare recipients. Most states plan to make some telehealth services permanent, particularly in rural areas. While other telehealth services have been extended through Dec. 31, 2024, under the Consolidated Appropriations Act of 2023.

But still, I worry about the end of the telemedicine era because telehealth (or, “video visits”) has revolutionized outpatient palliative care delivery. We can now see very ill patients in their own homes without imposing an undue burden on them to come in for yet another office visit. Prior to the public health emergency, our embedded palliative care program would see patients only when they were in the oncology clinic so as to not burden them with having to travel to yet another clinic. This made our palliative providers less efficient since patients were being seen by multiple providers in the same space, which led to some time spent waiting around. It also frequently tied up our clinic exam rooms for long periods of time, delaying care for patients sitting in the waiting room.

Telehealth changed that virtually overnight. With the widespread availability of smartphones and tablets, patients could stay at home and speak more comfortably in their own surroundings – especially about the difficult topics we tend to dig into in palliative care – such as fears, suffering, grief, loss, legacy, regret, trauma, gratitude, dying – without the impersonal, aseptic environment of a clinic. We could visit with their family/caregivers, kids, and their pets. We could tour their living space and see how they were managing from a functional standpoint. We could get to know aspects of our patients’ lives that we’d never have seen in the clinic that could help us understand their goals and values better and help care for them more fully.

The benefit to the institution was also measurable. We could see our patients faster – the time from referral to consult dropped dramatically because patients could be scheduled for next-day virtual visits instead of having to wait for them to come back to an oncology visit. We could do quick symptom-focused visits that prior to telehealth would have been conducted by phone without the ability to perform at the very least an observational physical exam of the patient, which is important when prescribing medications to medically frail populations.
 

If telemedicine goes, how will it affect outpatient palliative care?

If that goes away, I do not know what will happen to outpatient palliative care. I can tell you we will be much less efficient in terms of when we see patients. There will probably be a higher clinic burden to patients, as well as higher financial toxicity to patients (Parking in the structure attached to my office building is $22 per day). And, what about the uncaptured costs associated with transportation for those whose illness prevents them from driving themselves? This can range from Uber costs to the time cost for a patient’s family member to take off work and arrange for childcare in order to drive the patient to a clinic for a visit.

In February, I received emails from the Drug Enforcement Agency suggesting that they, too, may roll back providers’ ability to prescribe controlled substances to patients who are mainly receiving telehealth services. While I understand and fully support the need to curb inappropriate overprescribing of controlled medications, I am concerned about the unintended consequences to cancer patients who live at a remote distance from their oncologists and palliative care providers. I remain hopeful that DEA will consider a carveout exception for those patients who have cancer, are receiving palliative care services, or are deemed to be at the end of life, much like the chronic opioid guidelines developed by the Centers for Disease Control and Prevention have done.
 

Telemedicine in essential care

Back to Jim. Using telehealth and electronic prescribing, our oncology and palliative care programs were able to keep Jim comfortable and at home through the end of his life. He did not have to travel 3 hours each way to get care. He did not have to spend money on parking and gas, and his daughter did not have to take days off work and arrange for a babysitter in order to drive him to our clinic. We partnered with a local pharmacy that was willing to special order medications for Jim when his pain became worse and he required a long-acting opioid. We partnered with a local home health company that kept a close eye on Jim and let us know when he seemed to be declining further, prompting discussions about transitioning to hospice.

I’m proud of the fact that our group helped Jim stay in comfortable surroundings and out of the clinic and hospital over the last 6 months of his life, but that would never have happened without the safe and thoughtful use of telehealth by our team.

Ironically, because of a public health emergency, we were able to provide efficient and high-quality palliative care at the right time, to the right person, in the right place, satisfying CMS goals to provide better care for patients and whole populations at lower costs.

Ms. D’Ambruoso is a hospice and palliative care nurse practitioner for UCLA Health Cancer Care, Santa Monica, Calif.

This past weekend was one of my least-favorite parts of the annual cycle: I shut off and drained my hot tub.

I’ve always loved sitting in hot tubs, as far back as I can remember. Growing up on family vacations I preferred them to the pool. So when I was grown up and could afford one, I got it for my house.

I spend my winter weekend afternoons relaxing in it with a can of beer, some bottles of iced tea, and a pile of journals or a book. I put instrumental jazz on my phone and spend a few pleasant hours there, catching up on my reading.

But, as the Phoenix weather swings back to summer temps, it’s time to turn it off until next November.

It’s interesting the ways we mark the passage of time in our lives. The traditional standards are New Year’s, major holidays, and birthdays. Some may mark it by their favorite sports seasons starting.

In medicine we may mark it by patient ages, or a drug that we thought just came to market now going generic, or realizing our state or DEA license is up for renewal.

It doesn’t really matter how you mark the time – it’s going to happen whether you do or don’t. The person you see in the mirror is the same one there since you were tall enough to see over the bathroom countertop. Isn’t it just the ones around us who change?

As Phoenix moves back to a summer footing, and as someone who’s been through 56 of them, it’s hard not to think about it. Summer vacations growing up, summer classes in college, summer elective rotations in medical school. Now I work year-round and watch the same cycle play out with my kids in college.

You often hear the phrase “a hundred years from now it won’t make a difference.” Probably true. In 2123 the time I spent relaxing in my hot tub won’t mean anything, or be remembered by anyone.

But I’m not sitting in it to think about that. I’m in it because I have what I have now, and none of us will ever have that again. And part of that, to me, is enjoying some time in the hot tub.

Because if I don’t relax and enjoy the ride, no one will do it for me. That may not matter in one hundred years, but it matters to me today. And that’s what’s really important.

To all of us.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

This past weekend was one of my least-favorite parts of the annual cycle: I shut off and drained my hot tub.

I’ve always loved sitting in hot tubs, as far back as I can remember. Growing up on family vacations I preferred them to the pool. So when I was grown up and could afford one, I got it for my house.

I spend my winter weekend afternoons relaxing in it with a can of beer, some bottles of iced tea, and a pile of journals or a book. I put instrumental jazz on my phone and spend a few pleasant hours there, catching up on my reading.

But, as the Phoenix weather swings back to summer temps, it’s time to turn it off until next November.

It’s interesting the ways we mark the passage of time in our lives. The traditional standards are New Year’s, major holidays, and birthdays. Some may mark it by their favorite sports seasons starting.

In medicine we may mark it by patient ages, or a drug that we thought just came to market now going generic, or realizing our state or DEA license is up for renewal.

It doesn’t really matter how you mark the time – it’s going to happen whether you do or don’t. The person you see in the mirror is the same one there since you were tall enough to see over the bathroom countertop. Isn’t it just the ones around us who change?

As Phoenix moves back to a summer footing, and as someone who’s been through 56 of them, it’s hard not to think about it. Summer vacations growing up, summer classes in college, summer elective rotations in medical school. Now I work year-round and watch the same cycle play out with my kids in college.

You often hear the phrase “a hundred years from now it won’t make a difference.” Probably true. In 2123 the time I spent relaxing in my hot tub won’t mean anything, or be remembered by anyone.

But I’m not sitting in it to think about that. I’m in it because I have what I have now, and none of us will ever have that again. And part of that, to me, is enjoying some time in the hot tub.

Because if I don’t relax and enjoy the ride, no one will do it for me. That may not matter in one hundred years, but it matters to me today. And that’s what’s really important.

To all of us.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

This past weekend was one of my least-favorite parts of the annual cycle: I shut off and drained my hot tub.

I’ve always loved sitting in hot tubs, as far back as I can remember. Growing up on family vacations I preferred them to the pool. So when I was grown up and could afford one, I got it for my house.

I spend my winter weekend afternoons relaxing in it with a can of beer, some bottles of iced tea, and a pile of journals or a book. I put instrumental jazz on my phone and spend a few pleasant hours there, catching up on my reading.

But, as the Phoenix weather swings back to summer temps, it’s time to turn it off until next November.

It’s interesting the ways we mark the passage of time in our lives. The traditional standards are New Year’s, major holidays, and birthdays. Some may mark it by their favorite sports seasons starting.

In medicine we may mark it by patient ages, or a drug that we thought just came to market now going generic, or realizing our state or DEA license is up for renewal.

It doesn’t really matter how you mark the time – it’s going to happen whether you do or don’t. The person you see in the mirror is the same one there since you were tall enough to see over the bathroom countertop. Isn’t it just the ones around us who change?

As Phoenix moves back to a summer footing, and as someone who’s been through 56 of them, it’s hard not to think about it. Summer vacations growing up, summer classes in college, summer elective rotations in medical school. Now I work year-round and watch the same cycle play out with my kids in college.

You often hear the phrase “a hundred years from now it won’t make a difference.” Probably true. In 2123 the time I spent relaxing in my hot tub won’t mean anything, or be remembered by anyone.

But I’m not sitting in it to think about that. I’m in it because I have what I have now, and none of us will ever have that again. And part of that, to me, is enjoying some time in the hot tub.

Because if I don’t relax and enjoy the ride, no one will do it for me. That may not matter in one hundred years, but it matters to me today. And that’s what’s really important.

To all of us.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Physicians are placed in positions of leadership by the medical team, by the community, and by society, particularly during times of crisis such as the COVID pandemic. They are looked to by the media at times of health care news such as the overturning of Roe v. Wade.¹ In a 2015 survey of resident physicians, two-thirds agreed that a formalized leadership curriculum would help them become better supervisors and clinicians.² While all physicians are viewed as leaders, the concept of leadership is rarely, if ever, described or developed as a part of medical training. This month’s column will provide insights into defining leadership as a physician in the medical and administrative settings.

Benefits of effective leadership

Physicians, whether they are clinicians, researchers, administrators, or teachers, are expected to oversee and engage their teams. A report by the Institute of Medicine recommended that academic health centers “develop leaders at all levels who can manage the organizational and system changes necessary to improve health through innovation in health professions education, patient care, and research.”³ Hospitals with higher-rated management practices and more highly rated boards of directors have been shown to deliver higher-quality care and better clinical outcomes, including lower mortality.

Fertility CARE

To illustrate, the clinicians at the Mayo Clinic annually rate their supervisors on a Leader Index, a simple 12-question survey of five leadership domains: truthfulness, transparency, character, capability, and partnership. All supervisors were physicians and scientists. Their findings revealed that for each one-point increase in composite leadership score, there was a 3.3% decrease in the likelihood of burnout and a 9.0% increase in the likelihood of satisfaction in the physicians supervised.⁴

Interprofessional teamwork and engagement are vital skills for a leader to create a successful team. Enhanced management practices have also been associated with higher patient approval ratings and better financial performance. Effective leadership additionally affects physician well-being, with stronger leadership associated with less physician burnout and higher satisfaction.⁵

Leadership styles enhance quality measures in health care.⁶ The most effective leadership styles are ones in which the staff feels they are part of a team, are engaged, and are mentored.⁷ While leadership styles can vary, the common theme is staff engagement. An authoritative style leader is one who mobilizes the team toward a vision, that is, “Come with me.” An affiliative style leader creates harmony and builds emotional bonds where “people come first.” Democratic leaders forge a consensus through staff participation by asking, “What do you think?” Finally, a leader who uses a coaching style helps staff to identify their strengths and weaknesses and work toward improvement. These leadership behaviors are in contradistinction to the unsuccessful coercive leader who demands immediate compliance, that is, “Do what I tell you.”

Five fundamental leadership principles are shown in Table 1.⁸

Effective leaders have an open (growth) mindset, unwavering attention to diversity, equity, and inclusion, and to building relationships and trust; they practice effective communication and listening, focus on results, and cocreate support structures.

A growth mindset is the belief that one’s abilities are not innate but can improve through effort and learning.⁹

Emotional intelligence

A survey of business senior managers rated the qualities found in the most outstanding leaders. Using objective criteria like profitability the study psychologists interviewed the highest-rated leaders to compare their capabilities. While intellects and cognitive skills were important, the results showed that emotional intelligence (EI) was twice as important as technical skills and IQ.¹⁰ As an example, in a 1996 study, when senior managers had an optimal level of EI, their division’s yearly earnings were 20% higher than estimated.¹¹

EI is a leadership competency that deals with the ability to understand and manage your own emotions and your interactions with others.¹⁰ At the Cleveland Clinic, EI is exemplified by the acronym HEART, whereby the team strives to improve the patient experience, mainly when an error occurs. The health care team is using EI by showing its the ability to Hear, Empathize, Apologize, Reply, and Thank. When an untoward event occurs, the physician, as the leader of the team, must lead by example when communicating with staff and patients. EI consists of five components (Table 2).¹³

• Self-awareness is insight by which you can improve. Maintaining a journal of your daily thoughts may assist with this as well as simply pausing to pay attention during times of heightened emotions.
• Self-regulation shows control, that is, behaving according to your values, and being accountable and calm when challenged.
• Purpose, knowing your “why,” produces motivation and helps maintain optimism.
• Empathy shows the ability to understand the emotions of other people.
• Social skill is the ability to establish mutually rewarding relationships.

Given all the above benefits, it is no surprise that companies are actively trying use artificial intelligence to improve EI.¹²
 

Learning to be a leader

In medical school, students are expected to develop skills to handle and resolve conflicts, learn to share leadership, take mutual responsibility, and monitor their own performance.¹³ Although training of young physicians in leadership is not unprecedented, a systemic review revealed a lack of analytic studies to evaluate the effectiveness of the teaching methods.¹⁴ During undergraduate medical education, standard curricula and methods of instruction on leadership are not established, resulting in variable outcomes.

The Association of American Medical Colleges offers a curriculum, “Preparing Medical Students to Be Physician Leaders: A Leadership Training Program for Students Designed and Led by Students.”¹⁵ The objectives of this training are to help students identify their “personal style of leadership, recognize strengths and weaknesses, utilize effective communication strategies, appropriately delegate team member responsibilities, and provide constructive feedback to help improve team function.”
 

Take-home points

Following the completion of formal medical education, physicians are thrust into leadership roles. The key to being an effective leader is using EI to mentor the team and make staff feel connected to the team’s meaning and purpose, so they feel valued.

Dr. Trolice is director of The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando.

References

1. Carsen S and Xia C. McGill J Med. 2006 Jan;9(1):1-2.

2. Jardine D et al. J Grad Med Educ. 2015;7(2):307-9.

3. Institute of Medicine. Acad Emerg Med. July 2004;11(7):802-6.

4. Shanafelt TD et al. Mayo Clin Proc. April 2015;90(4):432-40.

5. Rotenstein LS et al. Harv Bus Rev. Oct. 17, 2018.

6. Sfantou SF. Healthcare 2017;5(4):73.

7. Goleman D. Harv Bus Rev. March-April 2000.

8. Collins-Nakai R. McGill J Med [Internet]. 2020 Dec. 1 [cited 2023 Mar. 28];9(1).

9. Dweck C. Harv Bus Rev. Jan. 13, 2016.

10. Goleman D. Harv Bus Rev. 1998 Nov-Dec;76(6):93-102..

11. Goleman D et al. Primal leadership: Realizing the power of emotional intelligence. Boston: Harvard Business School Publishing, 2002.12. Limon D and Plaster B. Harv Bus Rev. Jan. 25, 2022.

13. Chen T-Y. Tzu Chi Med J. Apr–Jun 2018;30(2):66-70.

14. Kumar B et al. BMC Med Educ. 2020;20:175.

15. Richards K et al. Med Ed Portal. Dec. 13 2019.

Physicians are placed in positions of leadership by the medical team, by the community, and by society, particularly during times of crisis such as the COVID pandemic. They are looked to by the media at times of health care news such as the overturning of Roe v. Wade.¹ In a 2015 survey of resident physicians, two-thirds agreed that a formalized leadership curriculum would help them become better supervisors and clinicians.² While all physicians are viewed as leaders, the concept of leadership is rarely, if ever, described or developed as a part of medical training. This month’s column will provide insights into defining leadership as a physician in the medical and administrative settings.

Benefits of effective leadership

Physicians, whether they are clinicians, researchers, administrators, or teachers, are expected to oversee and engage their teams. A report by the Institute of Medicine recommended that academic health centers “develop leaders at all levels who can manage the organizational and system changes necessary to improve health through innovation in health professions education, patient care, and research.”³ Hospitals with higher-rated management practices and more highly rated boards of directors have been shown to deliver higher-quality care and better clinical outcomes, including lower mortality.

Fertility CARE

To illustrate, the clinicians at the Mayo Clinic annually rate their supervisors on a Leader Index, a simple 12-question survey of five leadership domains: truthfulness, transparency, character, capability, and partnership. All supervisors were physicians and scientists. Their findings revealed that for each one-point increase in composite leadership score, there was a 3.3% decrease in the likelihood of burnout and a 9.0% increase in the likelihood of satisfaction in the physicians supervised.⁴

Interprofessional teamwork and engagement are vital skills for a leader to create a successful team. Enhanced management practices have also been associated with higher patient approval ratings and better financial performance. Effective leadership additionally affects physician well-being, with stronger leadership associated with less physician burnout and higher satisfaction.⁵

Leadership styles enhance quality measures in health care.⁶ The most effective leadership styles are ones in which the staff feels they are part of a team, are engaged, and are mentored.⁷ While leadership styles can vary, the common theme is staff engagement. An authoritative style leader is one who mobilizes the team toward a vision, that is, “Come with me.” An affiliative style leader creates harmony and builds emotional bonds where “people come first.” Democratic leaders forge a consensus through staff participation by asking, “What do you think?” Finally, a leader who uses a coaching style helps staff to identify their strengths and weaknesses and work toward improvement. These leadership behaviors are in contradistinction to the unsuccessful coercive leader who demands immediate compliance, that is, “Do what I tell you.”

Five fundamental leadership principles are shown in Table 1.⁸

Effective leaders have an open (growth) mindset, unwavering attention to diversity, equity, and inclusion, and to building relationships and trust; they practice effective communication and listening, focus on results, and cocreate support structures.

A growth mindset is the belief that one’s abilities are not innate but can improve through effort and learning.⁹

Emotional intelligence

A survey of business senior managers rated the qualities found in the most outstanding leaders. Using objective criteria like profitability the study psychologists interviewed the highest-rated leaders to compare their capabilities. While intellects and cognitive skills were important, the results showed that emotional intelligence (EI) was twice as important as technical skills and IQ.¹⁰ As an example, in a 1996 study, when senior managers had an optimal level of EI, their division’s yearly earnings were 20% higher than estimated.¹¹

EI is a leadership competency that deals with the ability to understand and manage your own emotions and your interactions with others.¹⁰ At the Cleveland Clinic, EI is exemplified by the acronym HEART, whereby the team strives to improve the patient experience, mainly when an error occurs. The health care team is using EI by showing its the ability to Hear, Empathize, Apologize, Reply, and Thank. When an untoward event occurs, the physician, as the leader of the team, must lead by example when communicating with staff and patients. EI consists of five components (Table 2).¹³

• Self-awareness is insight by which you can improve. Maintaining a journal of your daily thoughts may assist with this as well as simply pausing to pay attention during times of heightened emotions.
• Self-regulation shows control, that is, behaving according to your values, and being accountable and calm when challenged.
• Purpose, knowing your “why,” produces motivation and helps maintain optimism.
• Empathy shows the ability to understand the emotions of other people.
• Social skill is the ability to establish mutually rewarding relationships.

Given all the above benefits, it is no surprise that companies are actively trying use artificial intelligence to improve EI.¹²
 

Learning to be a leader

In medical school, students are expected to develop skills to handle and resolve conflicts, learn to share leadership, take mutual responsibility, and monitor their own performance.¹³ Although training of young physicians in leadership is not unprecedented, a systemic review revealed a lack of analytic studies to evaluate the effectiveness of the teaching methods.¹⁴ During undergraduate medical education, standard curricula and methods of instruction on leadership are not established, resulting in variable outcomes.

The Association of American Medical Colleges offers a curriculum, “Preparing Medical Students to Be Physician Leaders: A Leadership Training Program for Students Designed and Led by Students.”¹⁵ The objectives of this training are to help students identify their “personal style of leadership, recognize strengths and weaknesses, utilize effective communication strategies, appropriately delegate team member responsibilities, and provide constructive feedback to help improve team function.”
 

Take-home points

Following the completion of formal medical education, physicians are thrust into leadership roles. The key to being an effective leader is using EI to mentor the team and make staff feel connected to the team’s meaning and purpose, so they feel valued.

Dr. Trolice is director of The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando.

References

1. Carsen S and Xia C. McGill J Med. 2006 Jan;9(1):1-2.

2. Jardine D et al. J Grad Med Educ. 2015;7(2):307-9.

3. Institute of Medicine. Acad Emerg Med. July 2004;11(7):802-6.

4. Shanafelt TD et al. Mayo Clin Proc. April 2015;90(4):432-40.

5. Rotenstein LS et al. Harv Bus Rev. Oct. 17, 2018.

6. Sfantou SF. Healthcare 2017;5(4):73.

7. Goleman D. Harv Bus Rev. March-April 2000.

8. Collins-Nakai R. McGill J Med [Internet]. 2020 Dec. 1 [cited 2023 Mar. 28];9(1).

9. Dweck C. Harv Bus Rev. Jan. 13, 2016.

10. Goleman D. Harv Bus Rev. 1998 Nov-Dec;76(6):93-102..

11. Goleman D et al. Primal leadership: Realizing the power of emotional intelligence. Boston: Harvard Business School Publishing, 2002.12. Limon D and Plaster B. Harv Bus Rev. Jan. 25, 2022.

13. Chen T-Y. Tzu Chi Med J. Apr–Jun 2018;30(2):66-70.

14. Kumar B et al. BMC Med Educ. 2020;20:175.

15. Richards K et al. Med Ed Portal. Dec. 13 2019.

Physicians are placed in positions of leadership by the medical team, by the community, and by society, particularly during times of crisis such as the COVID pandemic. They are looked to by the media at times of health care news such as the overturning of Roe v. Wade.¹ In a 2015 survey of resident physicians, two-thirds agreed that a formalized leadership curriculum would help them become better supervisors and clinicians.² While all physicians are viewed as leaders, the concept of leadership is rarely, if ever, described or developed as a part of medical training. This month’s column will provide insights into defining leadership as a physician in the medical and administrative settings.

Benefits of effective leadership

Physicians, whether they are clinicians, researchers, administrators, or teachers, are expected to oversee and engage their teams. A report by the Institute of Medicine recommended that academic health centers “develop leaders at all levels who can manage the organizational and system changes necessary to improve health through innovation in health professions education, patient care, and research.”³ Hospitals with higher-rated management practices and more highly rated boards of directors have been shown to deliver higher-quality care and better clinical outcomes, including lower mortality.

Fertility CARE

To illustrate, the clinicians at the Mayo Clinic annually rate their supervisors on a Leader Index, a simple 12-question survey of five leadership domains: truthfulness, transparency, character, capability, and partnership. All supervisors were physicians and scientists. Their findings revealed that for each one-point increase in composite leadership score, there was a 3.3% decrease in the likelihood of burnout and a 9.0% increase in the likelihood of satisfaction in the physicians supervised.⁴

Interprofessional teamwork and engagement are vital skills for a leader to create a successful team. Enhanced management practices have also been associated with higher patient approval ratings and better financial performance. Effective leadership additionally affects physician well-being, with stronger leadership associated with less physician burnout and higher satisfaction.⁵

Leadership styles enhance quality measures in health care.⁶ The most effective leadership styles are ones in which the staff feels they are part of a team, are engaged, and are mentored.⁷ While leadership styles can vary, the common theme is staff engagement. An authoritative style leader is one who mobilizes the team toward a vision, that is, “Come with me.” An affiliative style leader creates harmony and builds emotional bonds where “people come first.” Democratic leaders forge a consensus through staff participation by asking, “What do you think?” Finally, a leader who uses a coaching style helps staff to identify their strengths and weaknesses and work toward improvement. These leadership behaviors are in contradistinction to the unsuccessful coercive leader who demands immediate compliance, that is, “Do what I tell you.”

Five fundamental leadership principles are shown in Table 1.⁸

Effective leaders have an open (growth) mindset, unwavering attention to diversity, equity, and inclusion, and to building relationships and trust; they practice effective communication and listening, focus on results, and cocreate support structures.

A growth mindset is the belief that one’s abilities are not innate but can improve through effort and learning.⁹

Emotional intelligence

A survey of business senior managers rated the qualities found in the most outstanding leaders. Using objective criteria like profitability the study psychologists interviewed the highest-rated leaders to compare their capabilities. While intellects and cognitive skills were important, the results showed that emotional intelligence (EI) was twice as important as technical skills and IQ.¹⁰ As an example, in a 1996 study, when senior managers had an optimal level of EI, their division’s yearly earnings were 20% higher than estimated.¹¹

EI is a leadership competency that deals with the ability to understand and manage your own emotions and your interactions with others.¹⁰ At the Cleveland Clinic, EI is exemplified by the acronym HEART, whereby the team strives to improve the patient experience, mainly when an error occurs. The health care team is using EI by showing its the ability to Hear, Empathize, Apologize, Reply, and Thank. When an untoward event occurs, the physician, as the leader of the team, must lead by example when communicating with staff and patients. EI consists of five components (Table 2).¹³

• Self-awareness is insight by which you can improve. Maintaining a journal of your daily thoughts may assist with this as well as simply pausing to pay attention during times of heightened emotions.
• Self-regulation shows control, that is, behaving according to your values, and being accountable and calm when challenged.
• Purpose, knowing your “why,” produces motivation and helps maintain optimism.
• Empathy shows the ability to understand the emotions of other people.
• Social skill is the ability to establish mutually rewarding relationships.

Given all the above benefits, it is no surprise that companies are actively trying use artificial intelligence to improve EI.¹²
 

Learning to be a leader

In medical school, students are expected to develop skills to handle and resolve conflicts, learn to share leadership, take mutual responsibility, and monitor their own performance.¹³ Although training of young physicians in leadership is not unprecedented, a systemic review revealed a lack of analytic studies to evaluate the effectiveness of the teaching methods.¹⁴ During undergraduate medical education, standard curricula and methods of instruction on leadership are not established, resulting in variable outcomes.

The Association of American Medical Colleges offers a curriculum, “Preparing Medical Students to Be Physician Leaders: A Leadership Training Program for Students Designed and Led by Students.”¹⁵ The objectives of this training are to help students identify their “personal style of leadership, recognize strengths and weaknesses, utilize effective communication strategies, appropriately delegate team member responsibilities, and provide constructive feedback to help improve team function.”
 

Take-home points

Following the completion of formal medical education, physicians are thrust into leadership roles. The key to being an effective leader is using EI to mentor the team and make staff feel connected to the team’s meaning and purpose, so they feel valued.

Dr. Trolice is director of The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando.

References

1. Carsen S and Xia C. McGill J Med. 2006 Jan;9(1):1-2.

2. Jardine D et al. J Grad Med Educ. 2015;7(2):307-9.

3. Institute of Medicine. Acad Emerg Med. July 2004;11(7):802-6.

4. Shanafelt TD et al. Mayo Clin Proc. April 2015;90(4):432-40.

5. Rotenstein LS et al. Harv Bus Rev. Oct. 17, 2018.

6. Sfantou SF. Healthcare 2017;5(4):73.

7. Goleman D. Harv Bus Rev. March-April 2000.

8. Collins-Nakai R. McGill J Med [Internet]. 2020 Dec. 1 [cited 2023 Mar. 28];9(1).

9. Dweck C. Harv Bus Rev. Jan. 13, 2016.

10. Goleman D. Harv Bus Rev. 1998 Nov-Dec;76(6):93-102..

11. Goleman D et al. Primal leadership: Realizing the power of emotional intelligence. Boston: Harvard Business School Publishing, 2002.12. Limon D and Plaster B. Harv Bus Rev. Jan. 25, 2022.

13. Chen T-Y. Tzu Chi Med J. Apr–Jun 2018;30(2):66-70.

14. Kumar B et al. BMC Med Educ. 2020;20:175.

15. Richards K et al. Med Ed Portal. Dec. 13 2019.

NEW ORLEANS – With the Asian population estimated to increase to 41 million by 2050 in the United States, expect the demand for experienced dermatologic care of patients with Asian skin to increase in the coming years, Hye Jin (Leah) Chung, MD, said at the annual meeting of the American Academy of Dermatology.

“Asians account for about 60% of the global population,” said Dr. Chung, assistant professor of dermatology at Harvard Medical School, and director of the Asian Skin Clinic at Beth Israel Deaconess Medical Center, Boston. Along with the estimate that Asians are expected to make up 25% of Canada’s population by 2036, “we will most likely encounter more Asian skin type patients in North America,” Dr. Chung said, noting that the Asian population “is very diverse, ranging from skin type 3 in Far East Asia to skin type 5 in India.”

Doug Brunk/MDedge News

During her presentation, she provided tips for treating hypertrophic scars and keloids in this patient population when intralesional corticosteroids fail. Typically, her first option is to combine an intralesional corticosteroid with 5-fluorouracil (5-FU), a pyrimidine analogue with antimetabolite activity. 5-FU “can cause cell apoptosis of endothelial cells and fibroblasts (which steroids cannot), cell cycle arrest, and TGF-beta [transforming growth factor beta]-induced COL1A2 transcription,” Dr. Chung said. The recommended ratio between 5-FU and steroids in the literature is variable, from a 9:1 ratio to a 1:1 ratio. “In my practice I do not inject more than 100 mg at a time,” she said. Several studies of this approach led by Asian investigators used weekly injections, “but that’s not practical in the U.S. I usually do monthly injections.”

A large systematic review and meta-analysis confirmed that the combination of intralesional triamcinolone acetonide and 5-FU achieved a better efficacy and fewer complications than triamcinolone alone for treating hypertrophic scars and keloids. Potential side effects from 5-FU injections include pain/pruritus, transient hyperpigmentation (especially in skin types 4-6), ulceration, teratogenicity, and transient alopecia.

A more recent meta-analysis comparing the efficacy of multiple drug injections for hypertrophic scars and keloids confirmed that the combination of triamcinolone and 5-FU was superior to bleomycin, verapamil, 5-FU alone, and triamcinolone alone. “And, there was no difference between 5-FU/steroid combination and botulinum toxin A,” Dr. Chung added. “Some parts of the world are using botulinum toxin with mixed results. Based on the amount of toxin required for keloids, this would be cost prohibitive in the U.S.”

Another approach to treating hypertrophic scars and keloids in Asian skin is laser-assisted drug delivery. “First, you can use a fractional ablative laser to create a hole in the epidermis and dermis,” Dr. Chung said. “Then you can apply the suspension topically to the holes. You can also use a steroid ointment or cream after laser treatment for drug delivery.”

Combining pulsed dye laser with steroid injections is another option. Pulsed dye lasers coagulate microvasculature within keloid tissue, “which can cause tissue hypoxia and can decrease growth factors or cytokines for fibrosis within the tissue,” Dr. Chung said. At the cellular level, pulsed dye laser alone can decrease connective tissue growth factor (CTGF), TGF-beta 1, proliferating cell nuclear antigen, and collagen III, and increases matrix metalloproteinase–13 (MMP-13), P53, ERK and p38 MAPK, apoptosis, blockade of AP-1 transcription, and cell cycle changes.

In 2004, plastic surgeons in Korea described a new approach for removing earlobe keloids, which they termed a “keloid fillet flap”. For the procedure, about 50% of the keloid margin is incised with a #15 scalpel blade. “Then you dissect the keloid from the surrounding tissue with a blade or curved scissors,” Dr. Chung said. “Next, you excise the keloid, so you have some dead space. After hemostasis you place the fillet flap to cover the wound. After you trim the redundant tissue, you can close it with epidermal sutures.”

In her clinical experience, she finds the fillet flap “very helpful for fast recovery” and it is associated with less pain. “Several studies have confirmed an excellent improvement of keloids, low recurrence rate, and rare side effects from a fillet flap and adjuvant intralesional corticosteroids. Occasionally, you may see flap necrosis but usually patients do well with topical antibiotics or petrolatum jelly.”

Dr. Chung also discussed her approach to treating papular scars in Asian patients. She described papular scars as underrecognized, anetoderma-like scars on the central face and trunk. “They comprise about 11% of all acne scars but up to 19% of patients with such scars may not recall a history of acne,” she said. Biopsies of papular scars reveal marked reduction or thinning of elastic fibers around hair follicles.

“Papular scars are difficult to treat,” she said. “If you have a conventional Er:YAG or CO₂ laser, you can create tiny holes within the scars,” she said, referring to studies on these approaches. Another treatment option is needle-guided radiofrequency, she noted.

Dr. Chung reported having no relevant financial disclosures.

NEW ORLEANS – With the Asian population estimated to increase to 41 million by 2050 in the United States, expect the demand for experienced dermatologic care of patients with Asian skin to increase in the coming years, Hye Jin (Leah) Chung, MD, said at the annual meeting of the American Academy of Dermatology.

“Asians account for about 60% of the global population,” said Dr. Chung, assistant professor of dermatology at Harvard Medical School, and director of the Asian Skin Clinic at Beth Israel Deaconess Medical Center, Boston. Along with the estimate that Asians are expected to make up 25% of Canada’s population by 2036, “we will most likely encounter more Asian skin type patients in North America,” Dr. Chung said, noting that the Asian population “is very diverse, ranging from skin type 3 in Far East Asia to skin type 5 in India.”

Doug Brunk/MDedge News

During her presentation, she provided tips for treating hypertrophic scars and keloids in this patient population when intralesional corticosteroids fail. Typically, her first option is to combine an intralesional corticosteroid with 5-fluorouracil (5-FU), a pyrimidine analogue with antimetabolite activity. 5-FU “can cause cell apoptosis of endothelial cells and fibroblasts (which steroids cannot), cell cycle arrest, and TGF-beta [transforming growth factor beta]-induced COL1A2 transcription,” Dr. Chung said. The recommended ratio between 5-FU and steroids in the literature is variable, from a 9:1 ratio to a 1:1 ratio. “In my practice I do not inject more than 100 mg at a time,” she said. Several studies of this approach led by Asian investigators used weekly injections, “but that’s not practical in the U.S. I usually do monthly injections.”

A large systematic review and meta-analysis confirmed that the combination of intralesional triamcinolone acetonide and 5-FU achieved a better efficacy and fewer complications than triamcinolone alone for treating hypertrophic scars and keloids. Potential side effects from 5-FU injections include pain/pruritus, transient hyperpigmentation (especially in skin types 4-6), ulceration, teratogenicity, and transient alopecia.

A more recent meta-analysis comparing the efficacy of multiple drug injections for hypertrophic scars and keloids confirmed that the combination of triamcinolone and 5-FU was superior to bleomycin, verapamil, 5-FU alone, and triamcinolone alone. “And, there was no difference between 5-FU/steroid combination and botulinum toxin A,” Dr. Chung added. “Some parts of the world are using botulinum toxin with mixed results. Based on the amount of toxin required for keloids, this would be cost prohibitive in the U.S.”

Another approach to treating hypertrophic scars and keloids in Asian skin is laser-assisted drug delivery. “First, you can use a fractional ablative laser to create a hole in the epidermis and dermis,” Dr. Chung said. “Then you can apply the suspension topically to the holes. You can also use a steroid ointment or cream after laser treatment for drug delivery.”

Combining pulsed dye laser with steroid injections is another option. Pulsed dye lasers coagulate microvasculature within keloid tissue, “which can cause tissue hypoxia and can decrease growth factors or cytokines for fibrosis within the tissue,” Dr. Chung said. At the cellular level, pulsed dye laser alone can decrease connective tissue growth factor (CTGF), TGF-beta 1, proliferating cell nuclear antigen, and collagen III, and increases matrix metalloproteinase–13 (MMP-13), P53, ERK and p38 MAPK, apoptosis, blockade of AP-1 transcription, and cell cycle changes.

In 2004, plastic surgeons in Korea described a new approach for removing earlobe keloids, which they termed a “keloid fillet flap”. For the procedure, about 50% of the keloid margin is incised with a #15 scalpel blade. “Then you dissect the keloid from the surrounding tissue with a blade or curved scissors,” Dr. Chung said. “Next, you excise the keloid, so you have some dead space. After hemostasis you place the fillet flap to cover the wound. After you trim the redundant tissue, you can close it with epidermal sutures.”

In her clinical experience, she finds the fillet flap “very helpful for fast recovery” and it is associated with less pain. “Several studies have confirmed an excellent improvement of keloids, low recurrence rate, and rare side effects from a fillet flap and adjuvant intralesional corticosteroids. Occasionally, you may see flap necrosis but usually patients do well with topical antibiotics or petrolatum jelly.”

Dr. Chung also discussed her approach to treating papular scars in Asian patients. She described papular scars as underrecognized, anetoderma-like scars on the central face and trunk. “They comprise about 11% of all acne scars but up to 19% of patients with such scars may not recall a history of acne,” she said. Biopsies of papular scars reveal marked reduction or thinning of elastic fibers around hair follicles.

“Papular scars are difficult to treat,” she said. “If you have a conventional Er:YAG or CO₂ laser, you can create tiny holes within the scars,” she said, referring to studies on these approaches. Another treatment option is needle-guided radiofrequency, she noted.

Dr. Chung reported having no relevant financial disclosures.

NEW ORLEANS – With the Asian population estimated to increase to 41 million by 2050 in the United States, expect the demand for experienced dermatologic care of patients with Asian skin to increase in the coming years, Hye Jin (Leah) Chung, MD, said at the annual meeting of the American Academy of Dermatology.

“Asians account for about 60% of the global population,” said Dr. Chung, assistant professor of dermatology at Harvard Medical School, and director of the Asian Skin Clinic at Beth Israel Deaconess Medical Center, Boston. Along with the estimate that Asians are expected to make up 25% of Canada’s population by 2036, “we will most likely encounter more Asian skin type patients in North America,” Dr. Chung said, noting that the Asian population “is very diverse, ranging from skin type 3 in Far East Asia to skin type 5 in India.”

Doug Brunk/MDedge News

During her presentation, she provided tips for treating hypertrophic scars and keloids in this patient population when intralesional corticosteroids fail. Typically, her first option is to combine an intralesional corticosteroid with 5-fluorouracil (5-FU), a pyrimidine analogue with antimetabolite activity. 5-FU “can cause cell apoptosis of endothelial cells and fibroblasts (which steroids cannot), cell cycle arrest, and TGF-beta [transforming growth factor beta]-induced COL1A2 transcription,” Dr. Chung said. The recommended ratio between 5-FU and steroids in the literature is variable, from a 9:1 ratio to a 1:1 ratio. “In my practice I do not inject more than 100 mg at a time,” she said. Several studies of this approach led by Asian investigators used weekly injections, “but that’s not practical in the U.S. I usually do monthly injections.”

A large systematic review and meta-analysis confirmed that the combination of intralesional triamcinolone acetonide and 5-FU achieved a better efficacy and fewer complications than triamcinolone alone for treating hypertrophic scars and keloids. Potential side effects from 5-FU injections include pain/pruritus, transient hyperpigmentation (especially in skin types 4-6), ulceration, teratogenicity, and transient alopecia.

A more recent meta-analysis comparing the efficacy of multiple drug injections for hypertrophic scars and keloids confirmed that the combination of triamcinolone and 5-FU was superior to bleomycin, verapamil, 5-FU alone, and triamcinolone alone. “And, there was no difference between 5-FU/steroid combination and botulinum toxin A,” Dr. Chung added. “Some parts of the world are using botulinum toxin with mixed results. Based on the amount of toxin required for keloids, this would be cost prohibitive in the U.S.”

Another approach to treating hypertrophic scars and keloids in Asian skin is laser-assisted drug delivery. “First, you can use a fractional ablative laser to create a hole in the epidermis and dermis,” Dr. Chung said. “Then you can apply the suspension topically to the holes. You can also use a steroid ointment or cream after laser treatment for drug delivery.”

Combining pulsed dye laser with steroid injections is another option. Pulsed dye lasers coagulate microvasculature within keloid tissue, “which can cause tissue hypoxia and can decrease growth factors or cytokines for fibrosis within the tissue,” Dr. Chung said. At the cellular level, pulsed dye laser alone can decrease connective tissue growth factor (CTGF), TGF-beta 1, proliferating cell nuclear antigen, and collagen III, and increases matrix metalloproteinase–13 (MMP-13), P53, ERK and p38 MAPK, apoptosis, blockade of AP-1 transcription, and cell cycle changes.

In 2004, plastic surgeons in Korea described a new approach for removing earlobe keloids, which they termed a “keloid fillet flap”. For the procedure, about 50% of the keloid margin is incised with a #15 scalpel blade. “Then you dissect the keloid from the surrounding tissue with a blade or curved scissors,” Dr. Chung said. “Next, you excise the keloid, so you have some dead space. After hemostasis you place the fillet flap to cover the wound. After you trim the redundant tissue, you can close it with epidermal sutures.”

In her clinical experience, she finds the fillet flap “very helpful for fast recovery” and it is associated with less pain. “Several studies have confirmed an excellent improvement of keloids, low recurrence rate, and rare side effects from a fillet flap and adjuvant intralesional corticosteroids. Occasionally, you may see flap necrosis but usually patients do well with topical antibiotics or petrolatum jelly.”

Dr. Chung also discussed her approach to treating papular scars in Asian patients. She described papular scars as underrecognized, anetoderma-like scars on the central face and trunk. “They comprise about 11% of all acne scars but up to 19% of patients with such scars may not recall a history of acne,” she said. Biopsies of papular scars reveal marked reduction or thinning of elastic fibers around hair follicles.

“Papular scars are difficult to treat,” she said. “If you have a conventional Er:YAG or CO₂ laser, you can create tiny holes within the scars,” she said, referring to studies on these approaches. Another treatment option is needle-guided radiofrequency, she noted.

Dr. Chung reported having no relevant financial disclosures.