Career

For about the past year, Priya Goel, MD, can be seen cruising around the island of Manhattan as she makes her way between visits to some of New York City’s most treasured residents: a small but essential group of patients born before the Empire State Building scraped the sky and the old Yankee Stadium had become the House That Ruth Built.

Dr. Goel, a family physician, works for Heal, a national home health care company that primarily serves people older than 65. Her practice has 10 patients older than 100 – the oldest is a 108-year-old man – whom she visits monthly.
 

The gray wave

Dr. Goel’s charges are among America’s latest baby boom – babies born a century ago, that is.

Between 1980 and 2019, the share of American centenarians, those aged 100 and up, grew faster than the total population. In 2019, 100,322 persons in the United States were at least 100 years old – more than triple the 1980 figure of 32,194, according to the U.S. Administration on Aging. By 2060, experts predict, the U.S. centenarian population will reach nearly 600,000.

Although some of the ultra-aged live in nursing homes, many continue to live independently. They require both routine and acute medical care. So, what does it take to be a physician for a centenarian?

Dr. Goel, who is in her mid-30s and could well be the great-granddaughter of some of her patients, urged her colleagues not to stereotype patients on the basis of age.

“You have to consider their functional and cognitive abilities, their ability to understand disease processes and make decisions for themselves,” Dr. Goel said. “Age is just one factor in the grand scheme of things.”

Visiting patients in their homes provides her with insights into how well they’re doing, including the safety of their environments and the depth of their social networks.

New York City has its peculiar demands. Heal provides Dr. Goel with a driver who chauffeurs her to her patient visits. She takes notes between stops.

“The idea is to have these patients remain in an environment where they’re comfortable, in surroundings where they’ve grown up or lived for many years,” she said. “A lot of them are in elevator buildings and they are wheelchair-bound or bed-bound and they physically can’t leave.”

She said she gets a far different view of the patient than does an office-based physician.

“When you go into their home, it’s very personal. You’re seeing what their daily environment is like, what their diet is like. You can see their food on the counter. You can see the level of hygiene,” Dr. Goel said. “You get to see their social support. Are their kids involved? Are they hoarding? Stuff that they wouldn’t just necessarily disclose but on a visit you get to see going into the home. It’s an extra layer of understanding that patient.”

Dr. Goel contrasted home care from care in a nursing home, where the patients are seen daily. On the basis of her observations, she decides whether to see her patients every month or every 3 months.

She applies this strategy to everyone from age 60 to over 100.
 

Tracking a growing group

Since 1995, geriatrician Thomas Perls, MD, has directed the New England Centenarian Study at Boston University. The study, largely funded by the National Institute on Aging, has enrolled 2,599 centenarian persons and 700 of their offspring. At any given time in the study, about 10% of the centenarians are alive. The study has a high mortality rate.

The people in Dr. Perls’s study range in age, but they top out at 119, the third oldest person ever in the world. Most centenarians are women.

“When we first began the study in 1995, the prevalence of centenarians in the United States was about 1 per 10,000 in the population,” Perls told this news organization. “And now, that prevalence has doubled to 1 per 5,000.”

Even if no one has achieved the record of Methuselah, the Biblical patriarch who was purported to have lived to the age of 969, some people always have lived into their 90s and beyond. Dr. Perls attributed the increase in longevity to control at the turn of the 20th century of typhoid fever, diphtheria, and other infectious diseases with effective public health measures, including the availability of clean water and improvement in socioeconomic conditions.

“Infant mortality just plummeted. So, come around 1915, 1920, we were no longer losing a quarter of our population to these diseases. That meant a quarter more of the population could age into adulthood and middle age,” he said. “A certain component of that group was, therefore, able to continue to age to a very, very old age.”

Other advances, such as antibiotics and vaccinations in the 1960s; the availability in the 1970s of much better detection and effective treatment of high blood pressure; the recognition of the harms of smoking; and much more effective treatment of cardiovascular disease and cancer have allowed many people who would have otherwise died in their 70s and 80s to live much longer. “I think what this means is that there is a substantial proportion of the population that has the biology to get to 100,” Dr. Perls said.

Perls said the Latino population and Blacks have a better track record than Whites in reaching the 100-year milestone. “The average life expectancy might be lower in these populations because of socioeconomic factors, but if they are able to get to around their early 80s, compared to Whites, their ability to get to 100 is actually better,” he said.

Asians fare best when it comes to longevity. While around 1% of White women in the United States live to 100, 10% of Asian women in Hong Kong hit that mark.

“I think some of that is better environment and health habits in Hong Kong than in the United States,” Dr. Perls said. “I think another piece may be a genetic advantage in East Asians. We’re looking into that.”

Dr. Perls said he agreed with Dr. Goel that health care providers and the lay public should not make assumptions on the basis of age alone as to how a person is doing. “People can age so very differently from one another,” he said.

Up to about age 90, the vast majority of those differences are determined by our health behaviors, such as smoking, alcohol use, exercise, sleep, the effect of our diets on weight, and access to good health care, including regular screening for problems such as high blood pressure, diabetes, and cancer. “People who are able to do everything right generally add healthy years to their lives, while those who do not have shorter life expectancies and longer periods of chronic diseases,” Dr. Perls said.

Paying diligent attention to these behaviors over the long run can have a huge payoff.

Dr. Perls’s team has found that to live beyond age 90 and on into the early 100s, protective genes can play a strong role. These genes help slow aging and decrease one’s risk for aging-related diseases. Centenarians usually have a history of aging very slowly and greatly delaying aging-related diseases and disability toward the ends of their lives.

Centenarians are the antithesis of the misguided belief that the older you get, the sicker you get. Quite the opposite occurs. For Dr. Perls, “the older you get, the healthier you’ve been.”
 

MD bias against the elderly?

Care of elderly patients is becoming essential in the practice of primary care physicians – but not all of them enjoy the work.

To be effective, physicians who treat centenarians must get a better idea of the individual patient’s functional status and comorbidities. “You absolutely cannot make assumptions on age alone,” Dr. Perls said.

The so-called “normal” temperature, 98.6° F, can spell trouble for centenarians and other very old patients, warned Natalie Baker, DNP, CRNP, an associate professor of nursing at the University of Alabama, Birmingham, and president of the 3,000-member Gerontological Advanced Practice Nurses Association.

“We have to be very cognizant of what we call a typical presentation of disease or illness and that a very subtle change in an older adult can signal a serious infection or illness,” Dr. Baker said. “If your patient has a high fever, that is a potential problem.”

The average temperature of an older adult is lower than the accepted 98.6° F, and their body’s response to an infection is slow to exhibit an increase in temperature, Dr. Baker said. “When treating centenarians, clinicians must be cognizant of other subtle signs of infection, such as decreased appetite or change in mentation,” she cautioned.

A decline in appetite or insomnia may be a subtle sign that these patients need to be evaluated, she added.
 

COVID-19 and centenarians

Three-quarters of the 1 million U.S. deaths from COVID-19 occurred in people aged 65 and older. However, Dr. Perls said centenarians may be a special subpopulation when it comes to COVID.

The Japanese Health Ministry, which follows the large centenarian population in that country, noted a marked jump in the number of centenarians during the pandemic – although the reasons for the increase aren’t clear.

Centenarians may be a bit different. Dr. Perls said some evidence suggests that the over-100 crowd may have better immune systems than younger people. “Part of the trick of getting to 100 is having a pretty good immune system,” he said.
 

Don’t mess with success

“There is no need at that point for us to try to alter their diet to what we think it might be,” Dr. Baker said. “There’s no need to start with diabetic education. They may tell you their secret is a shot of vodka every day. Why should we stop it at that age? Accept their lifestyles, because they’ve done something right to get to that age.”

Opinions differ on how to approach screening for centenarians.

Dr. Goel said guidelines for routine screening, such as colonoscopies, mammograms, and PAP smears, drop off for patients starting at 75. Dr. Perls said this strategy stems from the belief that people will die from other things first, so screening is no longer needed. Dr. Perls said he disagrees with this approach.

“Again, we can’t base our screening and health care decisions on age alone. If I have an independently functioning and robust 95-year-old man in my office, you can be sure I am going to continue recommending regular screening for colon cancer and other screenings that are normal for people who are 30 years younger,” he said.

Justin Zaghi, MD, chief medical officer at Heal, said screening patients in their late 90s and 100s for cancer generally doesn’t make sense except in some rare circumstances in which the cancer would be unlikely to be a cause of death. “However, if we are talking about screening for fall risks, hearing difficulties, poor vision, pain, and malnutrition, those screenings still absolutely make sense for patients in their late 90s and 100s,” Dr. Zaghi said.

One high-functioning 104-year-old patient of Dr. Perls underwent a total hip replacement for a hip fracture and is faring well. “Obviously, if she had end-stage dementia, we’d do everything to keep the person comfortable, or if they had medical problems that made surgery too high risk, then you don’t do it,” he said. “But if they’re otherwise, I would proceed.”
 

Avoid the ED

Dr. Goel said doctors should avoid sending patients to the emergency department, an often chaotic place that is especially unfriendly to centenarians and the very old. “Sometimes I’ve seen older patients who are being rushed to the ER, and I ask, What are the goals of care?” she said.

Clinicians caring for seniors should keep in mind that infections can cause seniors to appear confused – and this may lead the clinician to think the patient has dementia. Or, Dr. Goel said, a patient with dementia may suddenly experience much worse dementia.

“In either case, you want to make sure you’re not dealing with any underlying infection, like urinary tract infection, or pneumonia brewing, or skin infections,” she said. “Their skin is so much frailer. You want to make sure there are no bedsores.”

She has had patients whose children report that their usually placid centenarian parents are suddenly acting out. “We’ll do a urinary test and it definitely shows a urinary tract infection. You want to make sure you’re not missing out on something else before you attribute it to dementia,” she said.

Environmental changes, such as moving a patient to a new room in a hospital setting, can trigger an acute mental status change, such as delirium, she added. Helping older patients feel in control as much as possible is important.

“You want to make sure you’re orienting them to the time of day. Make sure they get up at the same time, go to bed at the same time, have clocks and calendars present – just making sure that they feel like they’re still in control of their body and their day,” she said.

Physicians should be aware of potential depression in these patients, whose experience of loss – an unavoidable consequence of outliving family and friends – can result in problems with sleep and diet, as well as a sense of social isolation.

Neal Flomenbaum, MD, professor and emergency physician-in-chief emeritus, New York–Presbyterian/Weill Cornell Medical Center in New York, said sometimes the best thing for these very elderly patients is to “get them in and out of ED as quickly as possible, and do what you can diagnostically.”

He noted that EDs have been making accommodations to serve the elderly, such as using LEDs that replicate outdoor lighting conditions, as well as providing seniors with separate rooms with glass doors to protect them from noise, separate air handlers to prevent infections, and adequate space for visitors.

These patients often are subject to trauma from falls.

“The bones don’t heal as well as in younger people, and treating their comorbidities is essential. Once they have trouble with one area and they’re lying in bed and can’t move much, they can get bedsores,” Dr. Flomenbaum said. “In the hospital, they are vulnerable to infections. So, you’re thinking of all of these things at the same time and how to treat them appropriately and then get them out of the hospital as soon as possible with whatever care that they need in their own homes if at all possible.”

“I always err on the side of less is more,” Dr. Goel said. “Obviously, if there is something – if they have a cough, they need an x-ray. That’s very basic. We want to take care of that. Give them the antibiotic if they need that. But rushing them in and out of the hospital doesn’t add to their quality of life.”

Dr. Flomenbaum, a pioneer in geriatric emergency medicine, says physicians need to be aware that centenarians and other very old patients don’t present the same way as younger adults.

He began to notice more than 20 years ago that every night, patients would turn up in his ED who were in their late 90s into their 100s. Some would come in with what their children identified as sudden-onset dementia – they didn’t know their own names and couldn’t identify their kids. They didn’t know the time or day. Dr. Flomenbaum said the children often asked whether their parents should enter a nursing home.

“And I’d say, ‘Not so fast. Well, let’s take a look at this.’ You don’t develop that kind of dementia overnight. It usually takes a while,” he said.

He said he ordered complete blood cell counts and oxygen saturation tests that frequently turned out to be abnormal. They didn’t have a fever, and infiltrates initially weren’t seen on chest x-rays.

With rehydration and supplemental oxygen, their symptoms started to improve, and it became obvious that the symptoms were not of dementia but of pneumonia, and that they required antibiotics, Dr. Flomenbaum said.
 

Dementia dilemma

Too often, on the basis of age, doctors assume patients have dementia or other cognitive impairments.

“What a shock and a surprise when doctors actually talk to folks and do a neurocognitive screen and find they’re just fine,” Dr. Perls said.

The decline in hearing and vision can lead to a misdiagnosis of cognitive impairment because the patients are not able to hear what you’re asking them. “It’s really important that the person can hear you – whether you use an amplifying device or they have hearing aids, that’s critical,” he said. “You just have to be a good doctor.”

Often the physical toll of aging exacerbates social difficulties. Poor hearing, for example, can accelerate cognitive impairment and cause people to interact less often, and less meaningfully, with their environment. For some, wearing hearing aids seems demeaning – until they hear what they’ve been missing.

“I get them to wear their hearing aids and, lo and behold, they’re a whole new person because they’re now able to take in their environment and interact with others,” Dr. Perls said.

Dr. Flomenbaum said alcohol abuse and drug reactions can cause delirium, which, unlike dementia, is potentially reversible. Yet many physicians cannot reliably differentiate between dementia and delirium, he added.

The geriatric specialists talk about the lessons they’ve learned and the gratification they get from caring for centenarians.

“I have come to realize the importance of family, of having a close circle, whether that’s through friends or neighbors,” Dr. Goel said. “This work is very rewarding because, if it wasn’t for homebound organizations, how would these people get care or get access to care?”

For Dr. Baker, a joy of the job is hearing centenarians share their life stories.

“I love to hear their stories about how they’ve overcome adversity, living through the depression and living through different wars,” she said. “I love talking to veterans, and I think that oftentimes, we do not value our older adults in our society as we should. Sometimes they are dismissed because they move slowly or are hard to communicate with due to hearing deficits. But they are, I think, a very important part of our lives.”
 

‘They’ve already won’

Most centenarians readily offer the secrets to their longevity. Aline Jacobsohn, of Boca Raton, Fla., is no different.

Ms. Jacobsohn, who will be 101 in October, thinks a diet of small portions of fish, vegetables, and fruit, which she has followed since her husband Leo died in 1982, has helped keep her healthy. She eats lots of salmon and herring and is a fan of spinach sautéed with olive oil. “The only thing I don’t eat is meat,” the trim and active Ms. Jacobsohn said in a recent interview over Zoom.

Her other secret: “Doctors. I like to stay away from them as much as possible.”

Shari Rosenbaum, MD, Jacobsohn’s internist, doesn’t dismiss that approach. She uses a version of it when managing her three centenarian patients, the oldest of whom is 103.

“Let them smoke! Let them drink! They’re happy. It’s not causing harm. Let them eat cake! They’ve already won,” said Dr. Rosenbaum, who is affiliated with Boca Raton–based MDVIP, a national membership-based network of 1,100 primary care physicians serving 368,000 patients. Of those, nearly 460 are centenarians.

“You’re not preventing those problems in this population,” she said. “They’re here to enjoy every moment that they have, and they might as well.”

Dr. Rosenbaum sees a divergence in her patients – those who will reach very old age, and those who won’t – starting in their 60s.

“The centenarians don’t have medical problems,” she said. “They don’t get cancer. They don’t get diabetes. Some of them take good care of themselves. Some don’t take such good care of themselves. But they are all optimists. They all see the glass half full. They all participate in life. They all have excellent support systems. They have good genes, a positive attitude toward life, and a strong social network.”

Ms. Jacobsohn – whose surname at the time was Bakst – grew up in Frankfurt am Main, Germany, during the rise of the Nazi regime. The family fled to Columbia in 1938, where she met and eventually married her husband, Leo, who ran a business importing clocks and watches in Cali.

In 1989, the Jacobsohns and their three children moved to south Florida to escape the dangers of kidnappings and ransoms posed by the drug cartels.

Ms. Jacobsohn agreed that she appears to have longevity genes – “good stock,” she calls it. “My mother died 23 days before she was 100. My grandmother lived till 99, almost 100,” she said.

Two years ago, she donated her car to a charity and stopped driving in the interest of her own safety and that of other drivers and pedestrians.

Ms. Jacobsohn has a strong support system. Two of her children live nearby and visit her nearly every day. A live-in companion helps her with the activities of daily life, including preparing meals.

Ms. Jacobsohn plays bridge regularly, and well. “I’m sorry to say that I’m a very good bridge player,” she said, frankly. “How is it possible that I’ve played bridge so well and then I don’t remember what I had for lunch yesterday?”

She reads, mainly a diet of history but occasionally novels, too. “They have to be engaging,” she said.

The loss of loved ones is an inevitable part of very old age. Her husband of 47 years died of emphysema, and one of her sons died in his 70s of prostate cancer.

She knows well the fate that awaits us all and accepts it philosophically.

“It’s a very normal thing that people die. You don’t live forever. So, whenever it comes, it’s okay. Enough is enough. Dayenu,” she said, using the Hebrew word for, “It would have been enough” – a favorite in the Passover Seder celebrating the ancient Jews’ liberation from slavery in Egypt.

Ms. Jacobsohn sang the song and then took a reporter on a Zoom tour of her tidy home and her large flower garden featuring Cattleya orchids from Colombia.

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

For about the past year, Priya Goel, MD, can be seen cruising around the island of Manhattan as she makes her way between visits to some of New York City’s most treasured residents: a small but essential group of patients born before the Empire State Building scraped the sky and the old Yankee Stadium had become the House That Ruth Built.

Dr. Goel, a family physician, works for Heal, a national home health care company that primarily serves people older than 65. Her practice has 10 patients older than 100 – the oldest is a 108-year-old man – whom she visits monthly.
 

The gray wave

Dr. Goel’s charges are among America’s latest baby boom – babies born a century ago, that is.

Between 1980 and 2019, the share of American centenarians, those aged 100 and up, grew faster than the total population. In 2019, 100,322 persons in the United States were at least 100 years old – more than triple the 1980 figure of 32,194, according to the U.S. Administration on Aging. By 2060, experts predict, the U.S. centenarian population will reach nearly 600,000.

Although some of the ultra-aged live in nursing homes, many continue to live independently. They require both routine and acute medical care. So, what does it take to be a physician for a centenarian?

Dr. Goel, who is in her mid-30s and could well be the great-granddaughter of some of her patients, urged her colleagues not to stereotype patients on the basis of age.

“You have to consider their functional and cognitive abilities, their ability to understand disease processes and make decisions for themselves,” Dr. Goel said. “Age is just one factor in the grand scheme of things.”

Visiting patients in their homes provides her with insights into how well they’re doing, including the safety of their environments and the depth of their social networks.

New York City has its peculiar demands. Heal provides Dr. Goel with a driver who chauffeurs her to her patient visits. She takes notes between stops.

“The idea is to have these patients remain in an environment where they’re comfortable, in surroundings where they’ve grown up or lived for many years,” she said. “A lot of them are in elevator buildings and they are wheelchair-bound or bed-bound and they physically can’t leave.”

She said she gets a far different view of the patient than does an office-based physician.

“When you go into their home, it’s very personal. You’re seeing what their daily environment is like, what their diet is like. You can see their food on the counter. You can see the level of hygiene,” Dr. Goel said. “You get to see their social support. Are their kids involved? Are they hoarding? Stuff that they wouldn’t just necessarily disclose but on a visit you get to see going into the home. It’s an extra layer of understanding that patient.”

Dr. Goel contrasted home care from care in a nursing home, where the patients are seen daily. On the basis of her observations, she decides whether to see her patients every month or every 3 months.

She applies this strategy to everyone from age 60 to over 100.
 

Tracking a growing group

Since 1995, geriatrician Thomas Perls, MD, has directed the New England Centenarian Study at Boston University. The study, largely funded by the National Institute on Aging, has enrolled 2,599 centenarian persons and 700 of their offspring. At any given time in the study, about 10% of the centenarians are alive. The study has a high mortality rate.

The people in Dr. Perls’s study range in age, but they top out at 119, the third oldest person ever in the world. Most centenarians are women.

“When we first began the study in 1995, the prevalence of centenarians in the United States was about 1 per 10,000 in the population,” Perls told this news organization. “And now, that prevalence has doubled to 1 per 5,000.”

Even if no one has achieved the record of Methuselah, the Biblical patriarch who was purported to have lived to the age of 969, some people always have lived into their 90s and beyond. Dr. Perls attributed the increase in longevity to control at the turn of the 20th century of typhoid fever, diphtheria, and other infectious diseases with effective public health measures, including the availability of clean water and improvement in socioeconomic conditions.

“Infant mortality just plummeted. So, come around 1915, 1920, we were no longer losing a quarter of our population to these diseases. That meant a quarter more of the population could age into adulthood and middle age,” he said. “A certain component of that group was, therefore, able to continue to age to a very, very old age.”

Other advances, such as antibiotics and vaccinations in the 1960s; the availability in the 1970s of much better detection and effective treatment of high blood pressure; the recognition of the harms of smoking; and much more effective treatment of cardiovascular disease and cancer have allowed many people who would have otherwise died in their 70s and 80s to live much longer. “I think what this means is that there is a substantial proportion of the population that has the biology to get to 100,” Dr. Perls said.

Perls said the Latino population and Blacks have a better track record than Whites in reaching the 100-year milestone. “The average life expectancy might be lower in these populations because of socioeconomic factors, but if they are able to get to around their early 80s, compared to Whites, their ability to get to 100 is actually better,” he said.

Asians fare best when it comes to longevity. While around 1% of White women in the United States live to 100, 10% of Asian women in Hong Kong hit that mark.

“I think some of that is better environment and health habits in Hong Kong than in the United States,” Dr. Perls said. “I think another piece may be a genetic advantage in East Asians. We’re looking into that.”

Dr. Perls said he agreed with Dr. Goel that health care providers and the lay public should not make assumptions on the basis of age alone as to how a person is doing. “People can age so very differently from one another,” he said.

Up to about age 90, the vast majority of those differences are determined by our health behaviors, such as smoking, alcohol use, exercise, sleep, the effect of our diets on weight, and access to good health care, including regular screening for problems such as high blood pressure, diabetes, and cancer. “People who are able to do everything right generally add healthy years to their lives, while those who do not have shorter life expectancies and longer periods of chronic diseases,” Dr. Perls said.

Paying diligent attention to these behaviors over the long run can have a huge payoff.

Dr. Perls’s team has found that to live beyond age 90 and on into the early 100s, protective genes can play a strong role. These genes help slow aging and decrease one’s risk for aging-related diseases. Centenarians usually have a history of aging very slowly and greatly delaying aging-related diseases and disability toward the ends of their lives.

Centenarians are the antithesis of the misguided belief that the older you get, the sicker you get. Quite the opposite occurs. For Dr. Perls, “the older you get, the healthier you’ve been.”
 

MD bias against the elderly?

Care of elderly patients is becoming essential in the practice of primary care physicians – but not all of them enjoy the work.

To be effective, physicians who treat centenarians must get a better idea of the individual patient’s functional status and comorbidities. “You absolutely cannot make assumptions on age alone,” Dr. Perls said.

The so-called “normal” temperature, 98.6° F, can spell trouble for centenarians and other very old patients, warned Natalie Baker, DNP, CRNP, an associate professor of nursing at the University of Alabama, Birmingham, and president of the 3,000-member Gerontological Advanced Practice Nurses Association.

“We have to be very cognizant of what we call a typical presentation of disease or illness and that a very subtle change in an older adult can signal a serious infection or illness,” Dr. Baker said. “If your patient has a high fever, that is a potential problem.”

The average temperature of an older adult is lower than the accepted 98.6° F, and their body’s response to an infection is slow to exhibit an increase in temperature, Dr. Baker said. “When treating centenarians, clinicians must be cognizant of other subtle signs of infection, such as decreased appetite or change in mentation,” she cautioned.

A decline in appetite or insomnia may be a subtle sign that these patients need to be evaluated, she added.
 

COVID-19 and centenarians

Three-quarters of the 1 million U.S. deaths from COVID-19 occurred in people aged 65 and older. However, Dr. Perls said centenarians may be a special subpopulation when it comes to COVID.

The Japanese Health Ministry, which follows the large centenarian population in that country, noted a marked jump in the number of centenarians during the pandemic – although the reasons for the increase aren’t clear.

Centenarians may be a bit different. Dr. Perls said some evidence suggests that the over-100 crowd may have better immune systems than younger people. “Part of the trick of getting to 100 is having a pretty good immune system,” he said.
 

Don’t mess with success

“There is no need at that point for us to try to alter their diet to what we think it might be,” Dr. Baker said. “There’s no need to start with diabetic education. They may tell you their secret is a shot of vodka every day. Why should we stop it at that age? Accept their lifestyles, because they’ve done something right to get to that age.”

Opinions differ on how to approach screening for centenarians.

Dr. Goel said guidelines for routine screening, such as colonoscopies, mammograms, and PAP smears, drop off for patients starting at 75. Dr. Perls said this strategy stems from the belief that people will die from other things first, so screening is no longer needed. Dr. Perls said he disagrees with this approach.

“Again, we can’t base our screening and health care decisions on age alone. If I have an independently functioning and robust 95-year-old man in my office, you can be sure I am going to continue recommending regular screening for colon cancer and other screenings that are normal for people who are 30 years younger,” he said.

Justin Zaghi, MD, chief medical officer at Heal, said screening patients in their late 90s and 100s for cancer generally doesn’t make sense except in some rare circumstances in which the cancer would be unlikely to be a cause of death. “However, if we are talking about screening for fall risks, hearing difficulties, poor vision, pain, and malnutrition, those screenings still absolutely make sense for patients in their late 90s and 100s,” Dr. Zaghi said.

One high-functioning 104-year-old patient of Dr. Perls underwent a total hip replacement for a hip fracture and is faring well. “Obviously, if she had end-stage dementia, we’d do everything to keep the person comfortable, or if they had medical problems that made surgery too high risk, then you don’t do it,” he said. “But if they’re otherwise, I would proceed.”
 

Avoid the ED

Dr. Goel said doctors should avoid sending patients to the emergency department, an often chaotic place that is especially unfriendly to centenarians and the very old. “Sometimes I’ve seen older patients who are being rushed to the ER, and I ask, What are the goals of care?” she said.

Clinicians caring for seniors should keep in mind that infections can cause seniors to appear confused – and this may lead the clinician to think the patient has dementia. Or, Dr. Goel said, a patient with dementia may suddenly experience much worse dementia.

“In either case, you want to make sure you’re not dealing with any underlying infection, like urinary tract infection, or pneumonia brewing, or skin infections,” she said. “Their skin is so much frailer. You want to make sure there are no bedsores.”

She has had patients whose children report that their usually placid centenarian parents are suddenly acting out. “We’ll do a urinary test and it definitely shows a urinary tract infection. You want to make sure you’re not missing out on something else before you attribute it to dementia,” she said.

Environmental changes, such as moving a patient to a new room in a hospital setting, can trigger an acute mental status change, such as delirium, she added. Helping older patients feel in control as much as possible is important.

“You want to make sure you’re orienting them to the time of day. Make sure they get up at the same time, go to bed at the same time, have clocks and calendars present – just making sure that they feel like they’re still in control of their body and their day,” she said.

Physicians should be aware of potential depression in these patients, whose experience of loss – an unavoidable consequence of outliving family and friends – can result in problems with sleep and diet, as well as a sense of social isolation.

Neal Flomenbaum, MD, professor and emergency physician-in-chief emeritus, New York–Presbyterian/Weill Cornell Medical Center in New York, said sometimes the best thing for these very elderly patients is to “get them in and out of ED as quickly as possible, and do what you can diagnostically.”

He noted that EDs have been making accommodations to serve the elderly, such as using LEDs that replicate outdoor lighting conditions, as well as providing seniors with separate rooms with glass doors to protect them from noise, separate air handlers to prevent infections, and adequate space for visitors.

These patients often are subject to trauma from falls.

“The bones don’t heal as well as in younger people, and treating their comorbidities is essential. Once they have trouble with one area and they’re lying in bed and can’t move much, they can get bedsores,” Dr. Flomenbaum said. “In the hospital, they are vulnerable to infections. So, you’re thinking of all of these things at the same time and how to treat them appropriately and then get them out of the hospital as soon as possible with whatever care that they need in their own homes if at all possible.”

“I always err on the side of less is more,” Dr. Goel said. “Obviously, if there is something – if they have a cough, they need an x-ray. That’s very basic. We want to take care of that. Give them the antibiotic if they need that. But rushing them in and out of the hospital doesn’t add to their quality of life.”

Dr. Flomenbaum, a pioneer in geriatric emergency medicine, says physicians need to be aware that centenarians and other very old patients don’t present the same way as younger adults.

He began to notice more than 20 years ago that every night, patients would turn up in his ED who were in their late 90s into their 100s. Some would come in with what their children identified as sudden-onset dementia – they didn’t know their own names and couldn’t identify their kids. They didn’t know the time or day. Dr. Flomenbaum said the children often asked whether their parents should enter a nursing home.

“And I’d say, ‘Not so fast. Well, let’s take a look at this.’ You don’t develop that kind of dementia overnight. It usually takes a while,” he said.

He said he ordered complete blood cell counts and oxygen saturation tests that frequently turned out to be abnormal. They didn’t have a fever, and infiltrates initially weren’t seen on chest x-rays.

With rehydration and supplemental oxygen, their symptoms started to improve, and it became obvious that the symptoms were not of dementia but of pneumonia, and that they required antibiotics, Dr. Flomenbaum said.
 

Dementia dilemma

Too often, on the basis of age, doctors assume patients have dementia or other cognitive impairments.

“What a shock and a surprise when doctors actually talk to folks and do a neurocognitive screen and find they’re just fine,” Dr. Perls said.

The decline in hearing and vision can lead to a misdiagnosis of cognitive impairment because the patients are not able to hear what you’re asking them. “It’s really important that the person can hear you – whether you use an amplifying device or they have hearing aids, that’s critical,” he said. “You just have to be a good doctor.”

Often the physical toll of aging exacerbates social difficulties. Poor hearing, for example, can accelerate cognitive impairment and cause people to interact less often, and less meaningfully, with their environment. For some, wearing hearing aids seems demeaning – until they hear what they’ve been missing.

“I get them to wear their hearing aids and, lo and behold, they’re a whole new person because they’re now able to take in their environment and interact with others,” Dr. Perls said.

Dr. Flomenbaum said alcohol abuse and drug reactions can cause delirium, which, unlike dementia, is potentially reversible. Yet many physicians cannot reliably differentiate between dementia and delirium, he added.

The geriatric specialists talk about the lessons they’ve learned and the gratification they get from caring for centenarians.

“I have come to realize the importance of family, of having a close circle, whether that’s through friends or neighbors,” Dr. Goel said. “This work is very rewarding because, if it wasn’t for homebound organizations, how would these people get care or get access to care?”

For Dr. Baker, a joy of the job is hearing centenarians share their life stories.

“I love to hear their stories about how they’ve overcome adversity, living through the depression and living through different wars,” she said. “I love talking to veterans, and I think that oftentimes, we do not value our older adults in our society as we should. Sometimes they are dismissed because they move slowly or are hard to communicate with due to hearing deficits. But they are, I think, a very important part of our lives.”
 

‘They’ve already won’

Most centenarians readily offer the secrets to their longevity. Aline Jacobsohn, of Boca Raton, Fla., is no different.

Ms. Jacobsohn, who will be 101 in October, thinks a diet of small portions of fish, vegetables, and fruit, which she has followed since her husband Leo died in 1982, has helped keep her healthy. She eats lots of salmon and herring and is a fan of spinach sautéed with olive oil. “The only thing I don’t eat is meat,” the trim and active Ms. Jacobsohn said in a recent interview over Zoom.

Her other secret: “Doctors. I like to stay away from them as much as possible.”

Shari Rosenbaum, MD, Jacobsohn’s internist, doesn’t dismiss that approach. She uses a version of it when managing her three centenarian patients, the oldest of whom is 103.

“Let them smoke! Let them drink! They’re happy. It’s not causing harm. Let them eat cake! They’ve already won,” said Dr. Rosenbaum, who is affiliated with Boca Raton–based MDVIP, a national membership-based network of 1,100 primary care physicians serving 368,000 patients. Of those, nearly 460 are centenarians.

“You’re not preventing those problems in this population,” she said. “They’re here to enjoy every moment that they have, and they might as well.”

Dr. Rosenbaum sees a divergence in her patients – those who will reach very old age, and those who won’t – starting in their 60s.

“The centenarians don’t have medical problems,” she said. “They don’t get cancer. They don’t get diabetes. Some of them take good care of themselves. Some don’t take such good care of themselves. But they are all optimists. They all see the glass half full. They all participate in life. They all have excellent support systems. They have good genes, a positive attitude toward life, and a strong social network.”

Ms. Jacobsohn – whose surname at the time was Bakst – grew up in Frankfurt am Main, Germany, during the rise of the Nazi regime. The family fled to Columbia in 1938, where she met and eventually married her husband, Leo, who ran a business importing clocks and watches in Cali.

In 1989, the Jacobsohns and their three children moved to south Florida to escape the dangers of kidnappings and ransoms posed by the drug cartels.

Ms. Jacobsohn agreed that she appears to have longevity genes – “good stock,” she calls it. “My mother died 23 days before she was 100. My grandmother lived till 99, almost 100,” she said.

Two years ago, she donated her car to a charity and stopped driving in the interest of her own safety and that of other drivers and pedestrians.

Ms. Jacobsohn has a strong support system. Two of her children live nearby and visit her nearly every day. A live-in companion helps her with the activities of daily life, including preparing meals.

Ms. Jacobsohn plays bridge regularly, and well. “I’m sorry to say that I’m a very good bridge player,” she said, frankly. “How is it possible that I’ve played bridge so well and then I don’t remember what I had for lunch yesterday?”

She reads, mainly a diet of history but occasionally novels, too. “They have to be engaging,” she said.

The loss of loved ones is an inevitable part of very old age. Her husband of 47 years died of emphysema, and one of her sons died in his 70s of prostate cancer.

She knows well the fate that awaits us all and accepts it philosophically.

“It’s a very normal thing that people die. You don’t live forever. So, whenever it comes, it’s okay. Enough is enough. Dayenu,” she said, using the Hebrew word for, “It would have been enough” – a favorite in the Passover Seder celebrating the ancient Jews’ liberation from slavery in Egypt.

Ms. Jacobsohn sang the song and then took a reporter on a Zoom tour of her tidy home and her large flower garden featuring Cattleya orchids from Colombia.

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

For about the past year, Priya Goel, MD, can be seen cruising around the island of Manhattan as she makes her way between visits to some of New York City’s most treasured residents: a small but essential group of patients born before the Empire State Building scraped the sky and the old Yankee Stadium had become the House That Ruth Built.

Dr. Goel, a family physician, works for Heal, a national home health care company that primarily serves people older than 65. Her practice has 10 patients older than 100 – the oldest is a 108-year-old man – whom she visits monthly.
 

The gray wave

Dr. Goel’s charges are among America’s latest baby boom – babies born a century ago, that is.

Between 1980 and 2019, the share of American centenarians, those aged 100 and up, grew faster than the total population. In 2019, 100,322 persons in the United States were at least 100 years old – more than triple the 1980 figure of 32,194, according to the U.S. Administration on Aging. By 2060, experts predict, the U.S. centenarian population will reach nearly 600,000.

Although some of the ultra-aged live in nursing homes, many continue to live independently. They require both routine and acute medical care. So, what does it take to be a physician for a centenarian?

Dr. Goel, who is in her mid-30s and could well be the great-granddaughter of some of her patients, urged her colleagues not to stereotype patients on the basis of age.

“You have to consider their functional and cognitive abilities, their ability to understand disease processes and make decisions for themselves,” Dr. Goel said. “Age is just one factor in the grand scheme of things.”

Visiting patients in their homes provides her with insights into how well they’re doing, including the safety of their environments and the depth of their social networks.

New York City has its peculiar demands. Heal provides Dr. Goel with a driver who chauffeurs her to her patient visits. She takes notes between stops.

“The idea is to have these patients remain in an environment where they’re comfortable, in surroundings where they’ve grown up or lived for many years,” she said. “A lot of them are in elevator buildings and they are wheelchair-bound or bed-bound and they physically can’t leave.”

She said she gets a far different view of the patient than does an office-based physician.

“When you go into their home, it’s very personal. You’re seeing what their daily environment is like, what their diet is like. You can see their food on the counter. You can see the level of hygiene,” Dr. Goel said. “You get to see their social support. Are their kids involved? Are they hoarding? Stuff that they wouldn’t just necessarily disclose but on a visit you get to see going into the home. It’s an extra layer of understanding that patient.”

Dr. Goel contrasted home care from care in a nursing home, where the patients are seen daily. On the basis of her observations, she decides whether to see her patients every month or every 3 months.

She applies this strategy to everyone from age 60 to over 100.
 

Tracking a growing group

Since 1995, geriatrician Thomas Perls, MD, has directed the New England Centenarian Study at Boston University. The study, largely funded by the National Institute on Aging, has enrolled 2,599 centenarian persons and 700 of their offspring. At any given time in the study, about 10% of the centenarians are alive. The study has a high mortality rate.

The people in Dr. Perls’s study range in age, but they top out at 119, the third oldest person ever in the world. Most centenarians are women.

“When we first began the study in 1995, the prevalence of centenarians in the United States was about 1 per 10,000 in the population,” Perls told this news organization. “And now, that prevalence has doubled to 1 per 5,000.”

Even if no one has achieved the record of Methuselah, the Biblical patriarch who was purported to have lived to the age of 969, some people always have lived into their 90s and beyond. Dr. Perls attributed the increase in longevity to control at the turn of the 20th century of typhoid fever, diphtheria, and other infectious diseases with effective public health measures, including the availability of clean water and improvement in socioeconomic conditions.

“Infant mortality just plummeted. So, come around 1915, 1920, we were no longer losing a quarter of our population to these diseases. That meant a quarter more of the population could age into adulthood and middle age,” he said. “A certain component of that group was, therefore, able to continue to age to a very, very old age.”

Other advances, such as antibiotics and vaccinations in the 1960s; the availability in the 1970s of much better detection and effective treatment of high blood pressure; the recognition of the harms of smoking; and much more effective treatment of cardiovascular disease and cancer have allowed many people who would have otherwise died in their 70s and 80s to live much longer. “I think what this means is that there is a substantial proportion of the population that has the biology to get to 100,” Dr. Perls said.

Perls said the Latino population and Blacks have a better track record than Whites in reaching the 100-year milestone. “The average life expectancy might be lower in these populations because of socioeconomic factors, but if they are able to get to around their early 80s, compared to Whites, their ability to get to 100 is actually better,” he said.

Asians fare best when it comes to longevity. While around 1% of White women in the United States live to 100, 10% of Asian women in Hong Kong hit that mark.

“I think some of that is better environment and health habits in Hong Kong than in the United States,” Dr. Perls said. “I think another piece may be a genetic advantage in East Asians. We’re looking into that.”

Dr. Perls said he agreed with Dr. Goel that health care providers and the lay public should not make assumptions on the basis of age alone as to how a person is doing. “People can age so very differently from one another,” he said.

Up to about age 90, the vast majority of those differences are determined by our health behaviors, such as smoking, alcohol use, exercise, sleep, the effect of our diets on weight, and access to good health care, including regular screening for problems such as high blood pressure, diabetes, and cancer. “People who are able to do everything right generally add healthy years to their lives, while those who do not have shorter life expectancies and longer periods of chronic diseases,” Dr. Perls said.

Paying diligent attention to these behaviors over the long run can have a huge payoff.

Dr. Perls’s team has found that to live beyond age 90 and on into the early 100s, protective genes can play a strong role. These genes help slow aging and decrease one’s risk for aging-related diseases. Centenarians usually have a history of aging very slowly and greatly delaying aging-related diseases and disability toward the ends of their lives.

Centenarians are the antithesis of the misguided belief that the older you get, the sicker you get. Quite the opposite occurs. For Dr. Perls, “the older you get, the healthier you’ve been.”
 

MD bias against the elderly?

Care of elderly patients is becoming essential in the practice of primary care physicians – but not all of them enjoy the work.

To be effective, physicians who treat centenarians must get a better idea of the individual patient’s functional status and comorbidities. “You absolutely cannot make assumptions on age alone,” Dr. Perls said.

The so-called “normal” temperature, 98.6° F, can spell trouble for centenarians and other very old patients, warned Natalie Baker, DNP, CRNP, an associate professor of nursing at the University of Alabama, Birmingham, and president of the 3,000-member Gerontological Advanced Practice Nurses Association.

“We have to be very cognizant of what we call a typical presentation of disease or illness and that a very subtle change in an older adult can signal a serious infection or illness,” Dr. Baker said. “If your patient has a high fever, that is a potential problem.”

The average temperature of an older adult is lower than the accepted 98.6° F, and their body’s response to an infection is slow to exhibit an increase in temperature, Dr. Baker said. “When treating centenarians, clinicians must be cognizant of other subtle signs of infection, such as decreased appetite or change in mentation,” she cautioned.

A decline in appetite or insomnia may be a subtle sign that these patients need to be evaluated, she added.
 

COVID-19 and centenarians

Three-quarters of the 1 million U.S. deaths from COVID-19 occurred in people aged 65 and older. However, Dr. Perls said centenarians may be a special subpopulation when it comes to COVID.

The Japanese Health Ministry, which follows the large centenarian population in that country, noted a marked jump in the number of centenarians during the pandemic – although the reasons for the increase aren’t clear.

Centenarians may be a bit different. Dr. Perls said some evidence suggests that the over-100 crowd may have better immune systems than younger people. “Part of the trick of getting to 100 is having a pretty good immune system,” he said.
 

Don’t mess with success

“There is no need at that point for us to try to alter their diet to what we think it might be,” Dr. Baker said. “There’s no need to start with diabetic education. They may tell you their secret is a shot of vodka every day. Why should we stop it at that age? Accept their lifestyles, because they’ve done something right to get to that age.”

Opinions differ on how to approach screening for centenarians.

Dr. Goel said guidelines for routine screening, such as colonoscopies, mammograms, and PAP smears, drop off for patients starting at 75. Dr. Perls said this strategy stems from the belief that people will die from other things first, so screening is no longer needed. Dr. Perls said he disagrees with this approach.

“Again, we can’t base our screening and health care decisions on age alone. If I have an independently functioning and robust 95-year-old man in my office, you can be sure I am going to continue recommending regular screening for colon cancer and other screenings that are normal for people who are 30 years younger,” he said.

Justin Zaghi, MD, chief medical officer at Heal, said screening patients in their late 90s and 100s for cancer generally doesn’t make sense except in some rare circumstances in which the cancer would be unlikely to be a cause of death. “However, if we are talking about screening for fall risks, hearing difficulties, poor vision, pain, and malnutrition, those screenings still absolutely make sense for patients in their late 90s and 100s,” Dr. Zaghi said.

One high-functioning 104-year-old patient of Dr. Perls underwent a total hip replacement for a hip fracture and is faring well. “Obviously, if she had end-stage dementia, we’d do everything to keep the person comfortable, or if they had medical problems that made surgery too high risk, then you don’t do it,” he said. “But if they’re otherwise, I would proceed.”
 

Avoid the ED

Dr. Goel said doctors should avoid sending patients to the emergency department, an often chaotic place that is especially unfriendly to centenarians and the very old. “Sometimes I’ve seen older patients who are being rushed to the ER, and I ask, What are the goals of care?” she said.

Clinicians caring for seniors should keep in mind that infections can cause seniors to appear confused – and this may lead the clinician to think the patient has dementia. Or, Dr. Goel said, a patient with dementia may suddenly experience much worse dementia.

“In either case, you want to make sure you’re not dealing with any underlying infection, like urinary tract infection, or pneumonia brewing, or skin infections,” she said. “Their skin is so much frailer. You want to make sure there are no bedsores.”

She has had patients whose children report that their usually placid centenarian parents are suddenly acting out. “We’ll do a urinary test and it definitely shows a urinary tract infection. You want to make sure you’re not missing out on something else before you attribute it to dementia,” she said.

Environmental changes, such as moving a patient to a new room in a hospital setting, can trigger an acute mental status change, such as delirium, she added. Helping older patients feel in control as much as possible is important.

“You want to make sure you’re orienting them to the time of day. Make sure they get up at the same time, go to bed at the same time, have clocks and calendars present – just making sure that they feel like they’re still in control of their body and their day,” she said.

Physicians should be aware of potential depression in these patients, whose experience of loss – an unavoidable consequence of outliving family and friends – can result in problems with sleep and diet, as well as a sense of social isolation.

Neal Flomenbaum, MD, professor and emergency physician-in-chief emeritus, New York–Presbyterian/Weill Cornell Medical Center in New York, said sometimes the best thing for these very elderly patients is to “get them in and out of ED as quickly as possible, and do what you can diagnostically.”

He noted that EDs have been making accommodations to serve the elderly, such as using LEDs that replicate outdoor lighting conditions, as well as providing seniors with separate rooms with glass doors to protect them from noise, separate air handlers to prevent infections, and adequate space for visitors.

These patients often are subject to trauma from falls.

“The bones don’t heal as well as in younger people, and treating their comorbidities is essential. Once they have trouble with one area and they’re lying in bed and can’t move much, they can get bedsores,” Dr. Flomenbaum said. “In the hospital, they are vulnerable to infections. So, you’re thinking of all of these things at the same time and how to treat them appropriately and then get them out of the hospital as soon as possible with whatever care that they need in their own homes if at all possible.”

“I always err on the side of less is more,” Dr. Goel said. “Obviously, if there is something – if they have a cough, they need an x-ray. That’s very basic. We want to take care of that. Give them the antibiotic if they need that. But rushing them in and out of the hospital doesn’t add to their quality of life.”

Dr. Flomenbaum, a pioneer in geriatric emergency medicine, says physicians need to be aware that centenarians and other very old patients don’t present the same way as younger adults.

He began to notice more than 20 years ago that every night, patients would turn up in his ED who were in their late 90s into their 100s. Some would come in with what their children identified as sudden-onset dementia – they didn’t know their own names and couldn’t identify their kids. They didn’t know the time or day. Dr. Flomenbaum said the children often asked whether their parents should enter a nursing home.

“And I’d say, ‘Not so fast. Well, let’s take a look at this.’ You don’t develop that kind of dementia overnight. It usually takes a while,” he said.

He said he ordered complete blood cell counts and oxygen saturation tests that frequently turned out to be abnormal. They didn’t have a fever, and infiltrates initially weren’t seen on chest x-rays.

With rehydration and supplemental oxygen, their symptoms started to improve, and it became obvious that the symptoms were not of dementia but of pneumonia, and that they required antibiotics, Dr. Flomenbaum said.
 

Dementia dilemma

Too often, on the basis of age, doctors assume patients have dementia or other cognitive impairments.

“What a shock and a surprise when doctors actually talk to folks and do a neurocognitive screen and find they’re just fine,” Dr. Perls said.

The decline in hearing and vision can lead to a misdiagnosis of cognitive impairment because the patients are not able to hear what you’re asking them. “It’s really important that the person can hear you – whether you use an amplifying device or they have hearing aids, that’s critical,” he said. “You just have to be a good doctor.”

Often the physical toll of aging exacerbates social difficulties. Poor hearing, for example, can accelerate cognitive impairment and cause people to interact less often, and less meaningfully, with their environment. For some, wearing hearing aids seems demeaning – until they hear what they’ve been missing.

“I get them to wear their hearing aids and, lo and behold, they’re a whole new person because they’re now able to take in their environment and interact with others,” Dr. Perls said.

Dr. Flomenbaum said alcohol abuse and drug reactions can cause delirium, which, unlike dementia, is potentially reversible. Yet many physicians cannot reliably differentiate between dementia and delirium, he added.

The geriatric specialists talk about the lessons they’ve learned and the gratification they get from caring for centenarians.

“I have come to realize the importance of family, of having a close circle, whether that’s through friends or neighbors,” Dr. Goel said. “This work is very rewarding because, if it wasn’t for homebound organizations, how would these people get care or get access to care?”

For Dr. Baker, a joy of the job is hearing centenarians share their life stories.

“I love to hear their stories about how they’ve overcome adversity, living through the depression and living through different wars,” she said. “I love talking to veterans, and I think that oftentimes, we do not value our older adults in our society as we should. Sometimes they are dismissed because they move slowly or are hard to communicate with due to hearing deficits. But they are, I think, a very important part of our lives.”
 

‘They’ve already won’

Most centenarians readily offer the secrets to their longevity. Aline Jacobsohn, of Boca Raton, Fla., is no different.

Ms. Jacobsohn, who will be 101 in October, thinks a diet of small portions of fish, vegetables, and fruit, which she has followed since her husband Leo died in 1982, has helped keep her healthy. She eats lots of salmon and herring and is a fan of spinach sautéed with olive oil. “The only thing I don’t eat is meat,” the trim and active Ms. Jacobsohn said in a recent interview over Zoom.

Her other secret: “Doctors. I like to stay away from them as much as possible.”

Shari Rosenbaum, MD, Jacobsohn’s internist, doesn’t dismiss that approach. She uses a version of it when managing her three centenarian patients, the oldest of whom is 103.

“Let them smoke! Let them drink! They’re happy. It’s not causing harm. Let them eat cake! They’ve already won,” said Dr. Rosenbaum, who is affiliated with Boca Raton–based MDVIP, a national membership-based network of 1,100 primary care physicians serving 368,000 patients. Of those, nearly 460 are centenarians.

“You’re not preventing those problems in this population,” she said. “They’re here to enjoy every moment that they have, and they might as well.”

Dr. Rosenbaum sees a divergence in her patients – those who will reach very old age, and those who won’t – starting in their 60s.

“The centenarians don’t have medical problems,” she said. “They don’t get cancer. They don’t get diabetes. Some of them take good care of themselves. Some don’t take such good care of themselves. But they are all optimists. They all see the glass half full. They all participate in life. They all have excellent support systems. They have good genes, a positive attitude toward life, and a strong social network.”

Ms. Jacobsohn – whose surname at the time was Bakst – grew up in Frankfurt am Main, Germany, during the rise of the Nazi regime. The family fled to Columbia in 1938, where she met and eventually married her husband, Leo, who ran a business importing clocks and watches in Cali.

In 1989, the Jacobsohns and their three children moved to south Florida to escape the dangers of kidnappings and ransoms posed by the drug cartels.

Ms. Jacobsohn agreed that she appears to have longevity genes – “good stock,” she calls it. “My mother died 23 days before she was 100. My grandmother lived till 99, almost 100,” she said.

Two years ago, she donated her car to a charity and stopped driving in the interest of her own safety and that of other drivers and pedestrians.

Ms. Jacobsohn has a strong support system. Two of her children live nearby and visit her nearly every day. A live-in companion helps her with the activities of daily life, including preparing meals.

Ms. Jacobsohn plays bridge regularly, and well. “I’m sorry to say that I’m a very good bridge player,” she said, frankly. “How is it possible that I’ve played bridge so well and then I don’t remember what I had for lunch yesterday?”

She reads, mainly a diet of history but occasionally novels, too. “They have to be engaging,” she said.

The loss of loved ones is an inevitable part of very old age. Her husband of 47 years died of emphysema, and one of her sons died in his 70s of prostate cancer.

She knows well the fate that awaits us all and accepts it philosophically.

“It’s a very normal thing that people die. You don’t live forever. So, whenever it comes, it’s okay. Enough is enough. Dayenu,” she said, using the Hebrew word for, “It would have been enough” – a favorite in the Passover Seder celebrating the ancient Jews’ liberation from slavery in Egypt.

Ms. Jacobsohn sang the song and then took a reporter on a Zoom tour of her tidy home and her large flower garden featuring Cattleya orchids from Colombia.

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

Taking ‘not enough hours in the day’ to new heights

It’s no secret that there’s a big doctor shortage in the United States. Going through medical school is long, expensive, and stressful, and it’s not like those long, stressful hours stop once you finally do get that degree. There is, however, an excellent reason to take that dive into doctorhood: You’ll gain mastery over time itself.

A study from the University of Chicago, Johns Hopkins University, and Imperial College London has revealed the truth. By using data pulled from the National Health and Nutrition Examination Survey, the researchers found that primary care physicians who see an average number of patients and follow all the current national guidelines for preventive care, chronic disease care, and acute care – plus administrative tasks – must work 26.7 hours a day. That works out to 14.1 hours of preventive care, 7.2 hours of chronic disease care, 2.2 hours of acute care, and 3.2 hours of documentation and inbox management.

liseykina/thinkstockphotos

Astute readers may note that this is a bit more than the traditional 8-hour workday. It is, in fact, more hours than there actually are in a day. As it turns out, Doctor Strange is more of a documentary than …

Hang on, we’re receiving word that doctors are not in fact wizards who can bend time and space to their will, nor are they sitting on a stash of Time-Turners they saved from the Ministry of Magic before Voldemort destroyed them all. They are, according to the study, overworked and overburdened with too many things and too little time. This is why outcomes haven’t improved despite technological advances and why burnout is so common. We’d be burned out too, having to work temporally impossible hours.

The study authors suggested a team-based approach to medicine that would spread the workload out to nurses, physician assistants, dietitians, etc., estimating that about two-thirds of what a primary care physician does can be handled by someone else. A team-based approach would reduce the physician’s required hours down to 9.3 hours a day, which is at least physically possible. It’s either that or we make the day longer, which sounds like the plot of an episode of Futurama. Swap overwork for global warming and a longer day for a longer year and it is actually the plot of an episode of Futurama.
 

After a hard day of thinking, brains need their rest

Do you ever feel like you have no more capacity to think or make any more decisions after a long day at work? Do you need a few extra cups of coffee to even make it through the day, even though you’re mostly just sitting around talking and typing? Have we got the research for you: Mental exhaustion is an actual thing. Imagine that double whammy of having a job that’s physically and mentally demanding.

A recent study in Current Biology explained why we feel so exhausted after doing something mentally demanding for several hours. Over that time, glutamate builds up in synapses of the prefrontal cortex, which affects our decision making and leads to cognitive lethargy. Your brain eventually becomes more interested in tasks that are less mentally fatiguing, and that’s probably why you’re reading this LOTME right now instead of getting back to work.

“Our findings show that cognitive work results in a true functional alteration – accumulation of noxious substances – so fatigue would indeed be a signal that makes us stop working but for a different purpose: to preserve the integrity of brain functioning,” senior author Mathias Pessiglione of Pitié-Salpêtrière University, Paris, said in a written statement.

©thinkstockphotos.com

The group of researchers conducted studies by using magnetic resonance spectroscopy to look at two groups of people over the course of a workday: One group had mentally tasking jobs and one didn’t. Those who had to think harder for their jobs had more signs of fatigue, such as reduced pupil dilation and glutamate in synapses of the prefrontal cortex. They also looked for more rewards that required less thinking.

For those whose mentally exhausting jobs probably won’t get better or change, the researchers suggest getting as much rest as possible. Those who don’t have that option will have to continue drinking those 7 cups of coffee a day. ... and reading LOTME.

Hmm, might be a new tagline for us in there somewhere. LOTME: Tired brains love us? When you’re too tired to think, think of LOTME? You can’t spell mental exhaustion without L-O-T-M-E?
 

Testosterone shows its warm and fuzzy side

Stereotypically, men are loud, knuckle-dragging Neanderthals. The hair coming out of our faces is kind of a dead giveaway, right? We grunt, we scratch, we start wars, we watch sports on TV. But why? It’s the testosterone. Everyone knows that. Testosterone makes men aggressive … or does it?

Since this sort of research generally isn’t done with actual men, investigators at Emory University used Mongolian gerbils. The advantage being that males exhibit cuddling behavior after females become pregnant and they don’t watch a lot of sports on TV. They introduced a male and female gerbil, who then formed a pair bond and the female became pregnant. When the male started displaying cuddling behaviors, the researchers injected him with testosterone, expecting to see his antisocial side.

“Instead, we were surprised that a male gerbil became even more cuddly and prosocial with his partner. He became like ‘super partner,’ ” lead author Aubrey Kelly, PhD, said in a written statement from the university.

Aubrey Kelly

For the next experiment, the female was removed and another male was introduced to a male who had already received a testosterone injection. That male was surprisingly unaggressive toward the intruder, at least initially. Then he received a second injection of testosterone. “It was like they suddenly woke up and realized they weren’t supposed to be friendly in that context,” Dr. Kelly said.

The testosterone seemed to influence the activity of oxytocin, the so-called “love hormone,” the investigators suggested. “It’s surprising because normally we think of testosterone as increasing sexual behaviors and aggression. But we’ve shown that it can have more nuanced effects, depending on the social context.”

The researchers were not as surprised when their use of the phrase “super partner” led to a bidding war between DC and Marvel. Then came the contact from the Department of Defense, wondering about weaponized testosterone: Would it be possible for some sort of bomb to turn Vlad “the Impaler” Putin into Vlad “the Cuddler” Putin?
 

Are instruments spreading the sounds of COVID?

COVID restrictions are practically a thing of the past now. With more people laxed on being in close proximity to each other and the CDC not even recommending social distancing anymore, live concerts and events are back in full swing. But with new variants on the rise and people being a little more cautious, should we be worried about musical instruments spreading COVID?

Yes and no.

A study published in Physics of Fluids looked at wind instruments specifically and how much aerosol is produced and dispersed when playing them. For the study, the investigators measured fog particles with a laser and aerosol concentration with a particle counter to see how fast these particles decay in the air from the distance of the instrument.

PxHere

Musicians in an orchestra typically would sit close together to produce the best sound, but with COVID that became an issue, senior author Paulo Arratia of the University of Pennsylvania, Philadelphia, noted in a separate written statement. By looking at the distance traveled by the particles coming from a single instrument and how quickly they decayed, they could determine if sitting in close proximity is an actual threat.

Well, the threat was no greater than talking to someone face to face. Particle exit speeds were lower than for a cough or a sneeze, and the maximum decay length was 2 meters from the instrument’s opening.

But that’s just one instrument: What kind of impact does a whole orchestra have on a space? The researchers are looking into that too, but for now they suggest that musicians continue to stay 6 feet away from each other.

So, yeah, there is a threat, but it’s probably safer for you to see that orchestra than have someone sneeze on you.

Music to our ears.

Taking ‘not enough hours in the day’ to new heights

It’s no secret that there’s a big doctor shortage in the United States. Going through medical school is long, expensive, and stressful, and it’s not like those long, stressful hours stop once you finally do get that degree. There is, however, an excellent reason to take that dive into doctorhood: You’ll gain mastery over time itself.

A study from the University of Chicago, Johns Hopkins University, and Imperial College London has revealed the truth. By using data pulled from the National Health and Nutrition Examination Survey, the researchers found that primary care physicians who see an average number of patients and follow all the current national guidelines for preventive care, chronic disease care, and acute care – plus administrative tasks – must work 26.7 hours a day. That works out to 14.1 hours of preventive care, 7.2 hours of chronic disease care, 2.2 hours of acute care, and 3.2 hours of documentation and inbox management.

liseykina/thinkstockphotos

Astute readers may note that this is a bit more than the traditional 8-hour workday. It is, in fact, more hours than there actually are in a day. As it turns out, Doctor Strange is more of a documentary than …

Hang on, we’re receiving word that doctors are not in fact wizards who can bend time and space to their will, nor are they sitting on a stash of Time-Turners they saved from the Ministry of Magic before Voldemort destroyed them all. They are, according to the study, overworked and overburdened with too many things and too little time. This is why outcomes haven’t improved despite technological advances and why burnout is so common. We’d be burned out too, having to work temporally impossible hours.

The study authors suggested a team-based approach to medicine that would spread the workload out to nurses, physician assistants, dietitians, etc., estimating that about two-thirds of what a primary care physician does can be handled by someone else. A team-based approach would reduce the physician’s required hours down to 9.3 hours a day, which is at least physically possible. It’s either that or we make the day longer, which sounds like the plot of an episode of Futurama. Swap overwork for global warming and a longer day for a longer year and it is actually the plot of an episode of Futurama.
 

After a hard day of thinking, brains need their rest

Do you ever feel like you have no more capacity to think or make any more decisions after a long day at work? Do you need a few extra cups of coffee to even make it through the day, even though you’re mostly just sitting around talking and typing? Have we got the research for you: Mental exhaustion is an actual thing. Imagine that double whammy of having a job that’s physically and mentally demanding.

A recent study in Current Biology explained why we feel so exhausted after doing something mentally demanding for several hours. Over that time, glutamate builds up in synapses of the prefrontal cortex, which affects our decision making and leads to cognitive lethargy. Your brain eventually becomes more interested in tasks that are less mentally fatiguing, and that’s probably why you’re reading this LOTME right now instead of getting back to work.

“Our findings show that cognitive work results in a true functional alteration – accumulation of noxious substances – so fatigue would indeed be a signal that makes us stop working but for a different purpose: to preserve the integrity of brain functioning,” senior author Mathias Pessiglione of Pitié-Salpêtrière University, Paris, said in a written statement.

©thinkstockphotos.com

The group of researchers conducted studies by using magnetic resonance spectroscopy to look at two groups of people over the course of a workday: One group had mentally tasking jobs and one didn’t. Those who had to think harder for their jobs had more signs of fatigue, such as reduced pupil dilation and glutamate in synapses of the prefrontal cortex. They also looked for more rewards that required less thinking.

For those whose mentally exhausting jobs probably won’t get better or change, the researchers suggest getting as much rest as possible. Those who don’t have that option will have to continue drinking those 7 cups of coffee a day. ... and reading LOTME.

Hmm, might be a new tagline for us in there somewhere. LOTME: Tired brains love us? When you’re too tired to think, think of LOTME? You can’t spell mental exhaustion without L-O-T-M-E?
 

Testosterone shows its warm and fuzzy side

Stereotypically, men are loud, knuckle-dragging Neanderthals. The hair coming out of our faces is kind of a dead giveaway, right? We grunt, we scratch, we start wars, we watch sports on TV. But why? It’s the testosterone. Everyone knows that. Testosterone makes men aggressive … or does it?

Since this sort of research generally isn’t done with actual men, investigators at Emory University used Mongolian gerbils. The advantage being that males exhibit cuddling behavior after females become pregnant and they don’t watch a lot of sports on TV. They introduced a male and female gerbil, who then formed a pair bond and the female became pregnant. When the male started displaying cuddling behaviors, the researchers injected him with testosterone, expecting to see his antisocial side.

“Instead, we were surprised that a male gerbil became even more cuddly and prosocial with his partner. He became like ‘super partner,’ ” lead author Aubrey Kelly, PhD, said in a written statement from the university.

Aubrey Kelly

For the next experiment, the female was removed and another male was introduced to a male who had already received a testosterone injection. That male was surprisingly unaggressive toward the intruder, at least initially. Then he received a second injection of testosterone. “It was like they suddenly woke up and realized they weren’t supposed to be friendly in that context,” Dr. Kelly said.

The testosterone seemed to influence the activity of oxytocin, the so-called “love hormone,” the investigators suggested. “It’s surprising because normally we think of testosterone as increasing sexual behaviors and aggression. But we’ve shown that it can have more nuanced effects, depending on the social context.”

The researchers were not as surprised when their use of the phrase “super partner” led to a bidding war between DC and Marvel. Then came the contact from the Department of Defense, wondering about weaponized testosterone: Would it be possible for some sort of bomb to turn Vlad “the Impaler” Putin into Vlad “the Cuddler” Putin?
 

Are instruments spreading the sounds of COVID?

COVID restrictions are practically a thing of the past now. With more people laxed on being in close proximity to each other and the CDC not even recommending social distancing anymore, live concerts and events are back in full swing. But with new variants on the rise and people being a little more cautious, should we be worried about musical instruments spreading COVID?

Yes and no.

A study published in Physics of Fluids looked at wind instruments specifically and how much aerosol is produced and dispersed when playing them. For the study, the investigators measured fog particles with a laser and aerosol concentration with a particle counter to see how fast these particles decay in the air from the distance of the instrument.

PxHere

Musicians in an orchestra typically would sit close together to produce the best sound, but with COVID that became an issue, senior author Paulo Arratia of the University of Pennsylvania, Philadelphia, noted in a separate written statement. By looking at the distance traveled by the particles coming from a single instrument and how quickly they decayed, they could determine if sitting in close proximity is an actual threat.

Well, the threat was no greater than talking to someone face to face. Particle exit speeds were lower than for a cough or a sneeze, and the maximum decay length was 2 meters from the instrument’s opening.

But that’s just one instrument: What kind of impact does a whole orchestra have on a space? The researchers are looking into that too, but for now they suggest that musicians continue to stay 6 feet away from each other.

So, yeah, there is a threat, but it’s probably safer for you to see that orchestra than have someone sneeze on you.

Music to our ears.

Taking ‘not enough hours in the day’ to new heights

It’s no secret that there’s a big doctor shortage in the United States. Going through medical school is long, expensive, and stressful, and it’s not like those long, stressful hours stop once you finally do get that degree. There is, however, an excellent reason to take that dive into doctorhood: You’ll gain mastery over time itself.

A study from the University of Chicago, Johns Hopkins University, and Imperial College London has revealed the truth. By using data pulled from the National Health and Nutrition Examination Survey, the researchers found that primary care physicians who see an average number of patients and follow all the current national guidelines for preventive care, chronic disease care, and acute care – plus administrative tasks – must work 26.7 hours a day. That works out to 14.1 hours of preventive care, 7.2 hours of chronic disease care, 2.2 hours of acute care, and 3.2 hours of documentation and inbox management.

liseykina/thinkstockphotos

Astute readers may note that this is a bit more than the traditional 8-hour workday. It is, in fact, more hours than there actually are in a day. As it turns out, Doctor Strange is more of a documentary than …

Hang on, we’re receiving word that doctors are not in fact wizards who can bend time and space to their will, nor are they sitting on a stash of Time-Turners they saved from the Ministry of Magic before Voldemort destroyed them all. They are, according to the study, overworked and overburdened with too many things and too little time. This is why outcomes haven’t improved despite technological advances and why burnout is so common. We’d be burned out too, having to work temporally impossible hours.

The study authors suggested a team-based approach to medicine that would spread the workload out to nurses, physician assistants, dietitians, etc., estimating that about two-thirds of what a primary care physician does can be handled by someone else. A team-based approach would reduce the physician’s required hours down to 9.3 hours a day, which is at least physically possible. It’s either that or we make the day longer, which sounds like the plot of an episode of Futurama. Swap overwork for global warming and a longer day for a longer year and it is actually the plot of an episode of Futurama.
 

After a hard day of thinking, brains need their rest

Do you ever feel like you have no more capacity to think or make any more decisions after a long day at work? Do you need a few extra cups of coffee to even make it through the day, even though you’re mostly just sitting around talking and typing? Have we got the research for you: Mental exhaustion is an actual thing. Imagine that double whammy of having a job that’s physically and mentally demanding.

A recent study in Current Biology explained why we feel so exhausted after doing something mentally demanding for several hours. Over that time, glutamate builds up in synapses of the prefrontal cortex, which affects our decision making and leads to cognitive lethargy. Your brain eventually becomes more interested in tasks that are less mentally fatiguing, and that’s probably why you’re reading this LOTME right now instead of getting back to work.

“Our findings show that cognitive work results in a true functional alteration – accumulation of noxious substances – so fatigue would indeed be a signal that makes us stop working but for a different purpose: to preserve the integrity of brain functioning,” senior author Mathias Pessiglione of Pitié-Salpêtrière University, Paris, said in a written statement.

©thinkstockphotos.com

The group of researchers conducted studies by using magnetic resonance spectroscopy to look at two groups of people over the course of a workday: One group had mentally tasking jobs and one didn’t. Those who had to think harder for their jobs had more signs of fatigue, such as reduced pupil dilation and glutamate in synapses of the prefrontal cortex. They also looked for more rewards that required less thinking.

For those whose mentally exhausting jobs probably won’t get better or change, the researchers suggest getting as much rest as possible. Those who don’t have that option will have to continue drinking those 7 cups of coffee a day. ... and reading LOTME.

Hmm, might be a new tagline for us in there somewhere. LOTME: Tired brains love us? When you’re too tired to think, think of LOTME? You can’t spell mental exhaustion without L-O-T-M-E?
 

Testosterone shows its warm and fuzzy side

Stereotypically, men are loud, knuckle-dragging Neanderthals. The hair coming out of our faces is kind of a dead giveaway, right? We grunt, we scratch, we start wars, we watch sports on TV. But why? It’s the testosterone. Everyone knows that. Testosterone makes men aggressive … or does it?

Since this sort of research generally isn’t done with actual men, investigators at Emory University used Mongolian gerbils. The advantage being that males exhibit cuddling behavior after females become pregnant and they don’t watch a lot of sports on TV. They introduced a male and female gerbil, who then formed a pair bond and the female became pregnant. When the male started displaying cuddling behaviors, the researchers injected him with testosterone, expecting to see his antisocial side.

“Instead, we were surprised that a male gerbil became even more cuddly and prosocial with his partner. He became like ‘super partner,’ ” lead author Aubrey Kelly, PhD, said in a written statement from the university.

Aubrey Kelly

For the next experiment, the female was removed and another male was introduced to a male who had already received a testosterone injection. That male was surprisingly unaggressive toward the intruder, at least initially. Then he received a second injection of testosterone. “It was like they suddenly woke up and realized they weren’t supposed to be friendly in that context,” Dr. Kelly said.

The testosterone seemed to influence the activity of oxytocin, the so-called “love hormone,” the investigators suggested. “It’s surprising because normally we think of testosterone as increasing sexual behaviors and aggression. But we’ve shown that it can have more nuanced effects, depending on the social context.”

The researchers were not as surprised when their use of the phrase “super partner” led to a bidding war between DC and Marvel. Then came the contact from the Department of Defense, wondering about weaponized testosterone: Would it be possible for some sort of bomb to turn Vlad “the Impaler” Putin into Vlad “the Cuddler” Putin?
 

Are instruments spreading the sounds of COVID?

COVID restrictions are practically a thing of the past now. With more people laxed on being in close proximity to each other and the CDC not even recommending social distancing anymore, live concerts and events are back in full swing. But with new variants on the rise and people being a little more cautious, should we be worried about musical instruments spreading COVID?

Yes and no.

A study published in Physics of Fluids looked at wind instruments specifically and how much aerosol is produced and dispersed when playing them. For the study, the investigators measured fog particles with a laser and aerosol concentration with a particle counter to see how fast these particles decay in the air from the distance of the instrument.

PxHere

Musicians in an orchestra typically would sit close together to produce the best sound, but with COVID that became an issue, senior author Paulo Arratia of the University of Pennsylvania, Philadelphia, noted in a separate written statement. By looking at the distance traveled by the particles coming from a single instrument and how quickly they decayed, they could determine if sitting in close proximity is an actual threat.

Well, the threat was no greater than talking to someone face to face. Particle exit speeds were lower than for a cough or a sneeze, and the maximum decay length was 2 meters from the instrument’s opening.

But that’s just one instrument: What kind of impact does a whole orchestra have on a space? The researchers are looking into that too, but for now they suggest that musicians continue to stay 6 feet away from each other.

So, yeah, there is a threat, but it’s probably safer for you to see that orchestra than have someone sneeze on you.

Music to our ears.

A few years ago I tracked down my medical school interviewer to thank him for giving me the opportunity to do what I felt I was called to do. I was surprised that, after 15 years, he actually remembered me and remembered details like walking to the courtyard to meet my father who’d driven me to the interview.

Gratitude throughout my career has grounded me in moments of hardship and highlighted joyful times that give me peace. Sharing my gratitude and letting him know I was happy felt important to me.

Choosing to practice family medicine has a lot to do with why I am happy in my career today.

One of my frustrations with health care had been its emphasis on treatment of sickness, rather than a broader one that incorporated prevention of sickness. During my third year of medical school, I was following a family and sports medicine faculty member who was focusing on aspects of lifestyle medicine to help a patient remain active and age gracefully. Seeing opportunities to practice preventative medicine in family medicine made me realize the specialty was the perfect fit for me.
 

Food as medicine

While participating in rotations I also realized you can find a subspecialty within family medicine.

During my fourth year of medical school, I followed an attending who was seeing a patient for hypertension, prediabetes and hypercholesterolemia. The attending told the patient to eat “healthier,” gave her a handout, and scheduled a follow up appointment for 6 months later.

My thoughts were: “That’s it? That’s how we counsel patients to improve their dietary habits?”

As the patient was leaving the exam room, I asked her what type of oil she cooked with, and I proceeded to share culinary tips from my mother – who was a self-taught and early adopter of the food-as-medicine movement.

Once I started my residency, I knew I’d want to incorporate lifestyle and dietary approaches at many of my patient visits.

I scheduled patients every month to monitor their weight, follow up on chronic conditions, but more importantly, to engage them in their health and empower them to make small lifestyle changes each month and report their efforts. I felt like I was their health coach and cheerleader.
 

My career in family medicine

Entering the job market allowed me to form my philosophy of treating patients with a mind, body, and spirit approach. I chose to practice value-based care, which aligns with my lifestyle and preventative medicine approach .

I currently practice in a small family medicine–only clinic that is part of a larger multispecialty system. Primary care specialties in my organization are valued, respected and central to a patient’s well being and care. We are encouraged to spend time with patients, assess barriers to care and work collaboratively with our healthcare team, so that preventative medicine approaches take the lead in a patient’s health. This supportive culture and environment is one where my passion for food as medicine has thrived.

One day I forgot to pack a lunch and instead brought a grocery bag of items to make a salad. When I realized I made too much, I sent an email to my staff to get some “free salad in my office.” This serendipitous moment started an informal office “salad club” each week. Continued support from my staff and leadership, allowed me to consider further extending this teaching to my patients and my colleagues.

Three years ago, I helped adopt a sustainable plant-forward menu for our physician meetings, complete with a recipe from the menu for physicians to replicate at home or give to their patients.

I also pursued adoption of shared medical appointments for our medical group. These appointments apply the “see one, do one, teach one” model in medicine, but with culinary medicine as the focus.

Knowing that my patients are all connected to their families through food, I sought this as an opportunity to dive in further with wellness opportunities at their next meal. After almost 2 years of working on this project, I was able to host my first shared medical appointment with a group of patients on March 12, 2020. The next day schools closed, lockdowns occurred, and the world changed.
 

Opportunities highlighted by the pandemic

We always knew health care was broken but adding the increasingly longer hours and COVID vaccine–hesitant patients that the pandemic brought made everything look dark at times. What has helped me stay hopeful and energetic for system changes is feeling gratitude and seeking bright lights.

My experiences seeing patients in telehealth visits are examples of some of the bright lights I found in the pandemic. During these visits, patients showed me something from their pantry, and we’d go over nutritional labels together.

Additionally, my patients became engaged with their own conditions and wanted to improve them because of news articles highlighting risk factors for COVID-19, such as obesity. I had an active audience when it came to talking about food-as-medicine approaches to improving risk factors and immunity. And since everyone was listening, I didn’t stop at food. I also talked about physical health, stress resiliency, planetary diets, sleep, connections, and lastly vaccines!

Once the vaccines were distributed, I naturally gravitated to having those conversations with patients and colleagues and on social media. Plus, the pandemic gave us moments of simple times to slow down, take more rests, be less overscheduled, consider work-life priorities, and, lastly, to be okay with not being totally okay.

In practicing primary care, we have a unique role in seeing medicine from a whole body, whole person, whole family perspective. There is an opportunity to highlight what is broken in medicine and aim to make it whole.

I’m currently looking at shared medical appointments as a new standard way to provide care to all patients, because it improves access, provides better quality visits and aligns my values, mission, and purpose.

In the midst of the pandemic, I helped advocate for a sustainable plant-forward menu that was launched throughout four different hospitals in the Sharp HealthCare system, in California, in 2020. Knowing that patients were served a menu I played a role in, gave me solace.

As part of the hospital food and nutrition team, I am grateful for the opportunity I have to work on a broader mission to address social determinants of health and seek opportunities to help the system work for our patients.

Public health communication has been lacking in the pandemic, but another bright light is that we were still the trusted messengers to our patients and our communities. I’m continually honored and humbled to be trusted with a whole family’s health.

Dr. Neison practices family medicine and culinary medicine at Sharp Rees-Stealy Medical Group in San Diego, and is cochair of climate and planetary health for SRS Medical Group. You can follow her on Instagram, LinkedIn, and Facebook @Flavors4WellnessMD.

A few years ago I tracked down my medical school interviewer to thank him for giving me the opportunity to do what I felt I was called to do. I was surprised that, after 15 years, he actually remembered me and remembered details like walking to the courtyard to meet my father who’d driven me to the interview.

Gratitude throughout my career has grounded me in moments of hardship and highlighted joyful times that give me peace. Sharing my gratitude and letting him know I was happy felt important to me.

Choosing to practice family medicine has a lot to do with why I am happy in my career today.

One of my frustrations with health care had been its emphasis on treatment of sickness, rather than a broader one that incorporated prevention of sickness. During my third year of medical school, I was following a family and sports medicine faculty member who was focusing on aspects of lifestyle medicine to help a patient remain active and age gracefully. Seeing opportunities to practice preventative medicine in family medicine made me realize the specialty was the perfect fit for me.
 

Food as medicine

While participating in rotations I also realized you can find a subspecialty within family medicine.

During my fourth year of medical school, I followed an attending who was seeing a patient for hypertension, prediabetes and hypercholesterolemia. The attending told the patient to eat “healthier,” gave her a handout, and scheduled a follow up appointment for 6 months later.

My thoughts were: “That’s it? That’s how we counsel patients to improve their dietary habits?”

As the patient was leaving the exam room, I asked her what type of oil she cooked with, and I proceeded to share culinary tips from my mother – who was a self-taught and early adopter of the food-as-medicine movement.

Once I started my residency, I knew I’d want to incorporate lifestyle and dietary approaches at many of my patient visits.

I scheduled patients every month to monitor their weight, follow up on chronic conditions, but more importantly, to engage them in their health and empower them to make small lifestyle changes each month and report their efforts. I felt like I was their health coach and cheerleader.
 

My career in family medicine

Entering the job market allowed me to form my philosophy of treating patients with a mind, body, and spirit approach. I chose to practice value-based care, which aligns with my lifestyle and preventative medicine approach .

I currently practice in a small family medicine–only clinic that is part of a larger multispecialty system. Primary care specialties in my organization are valued, respected and central to a patient’s well being and care. We are encouraged to spend time with patients, assess barriers to care and work collaboratively with our healthcare team, so that preventative medicine approaches take the lead in a patient’s health. This supportive culture and environment is one where my passion for food as medicine has thrived.

One day I forgot to pack a lunch and instead brought a grocery bag of items to make a salad. When I realized I made too much, I sent an email to my staff to get some “free salad in my office.” This serendipitous moment started an informal office “salad club” each week. Continued support from my staff and leadership, allowed me to consider further extending this teaching to my patients and my colleagues.

Three years ago, I helped adopt a sustainable plant-forward menu for our physician meetings, complete with a recipe from the menu for physicians to replicate at home or give to their patients.

I also pursued adoption of shared medical appointments for our medical group. These appointments apply the “see one, do one, teach one” model in medicine, but with culinary medicine as the focus.

Knowing that my patients are all connected to their families through food, I sought this as an opportunity to dive in further with wellness opportunities at their next meal. After almost 2 years of working on this project, I was able to host my first shared medical appointment with a group of patients on March 12, 2020. The next day schools closed, lockdowns occurred, and the world changed.
 

Opportunities highlighted by the pandemic

We always knew health care was broken but adding the increasingly longer hours and COVID vaccine–hesitant patients that the pandemic brought made everything look dark at times. What has helped me stay hopeful and energetic for system changes is feeling gratitude and seeking bright lights.

My experiences seeing patients in telehealth visits are examples of some of the bright lights I found in the pandemic. During these visits, patients showed me something from their pantry, and we’d go over nutritional labels together.

Additionally, my patients became engaged with their own conditions and wanted to improve them because of news articles highlighting risk factors for COVID-19, such as obesity. I had an active audience when it came to talking about food-as-medicine approaches to improving risk factors and immunity. And since everyone was listening, I didn’t stop at food. I also talked about physical health, stress resiliency, planetary diets, sleep, connections, and lastly vaccines!

Once the vaccines were distributed, I naturally gravitated to having those conversations with patients and colleagues and on social media. Plus, the pandemic gave us moments of simple times to slow down, take more rests, be less overscheduled, consider work-life priorities, and, lastly, to be okay with not being totally okay.

In practicing primary care, we have a unique role in seeing medicine from a whole body, whole person, whole family perspective. There is an opportunity to highlight what is broken in medicine and aim to make it whole.

I’m currently looking at shared medical appointments as a new standard way to provide care to all patients, because it improves access, provides better quality visits and aligns my values, mission, and purpose.

In the midst of the pandemic, I helped advocate for a sustainable plant-forward menu that was launched throughout four different hospitals in the Sharp HealthCare system, in California, in 2020. Knowing that patients were served a menu I played a role in, gave me solace.

As part of the hospital food and nutrition team, I am grateful for the opportunity I have to work on a broader mission to address social determinants of health and seek opportunities to help the system work for our patients.

Public health communication has been lacking in the pandemic, but another bright light is that we were still the trusted messengers to our patients and our communities. I’m continually honored and humbled to be trusted with a whole family’s health.

Dr. Neison practices family medicine and culinary medicine at Sharp Rees-Stealy Medical Group in San Diego, and is cochair of climate and planetary health for SRS Medical Group. You can follow her on Instagram, LinkedIn, and Facebook @Flavors4WellnessMD.

A few years ago I tracked down my medical school interviewer to thank him for giving me the opportunity to do what I felt I was called to do. I was surprised that, after 15 years, he actually remembered me and remembered details like walking to the courtyard to meet my father who’d driven me to the interview.

Gratitude throughout my career has grounded me in moments of hardship and highlighted joyful times that give me peace. Sharing my gratitude and letting him know I was happy felt important to me.

Choosing to practice family medicine has a lot to do with why I am happy in my career today.

One of my frustrations with health care had been its emphasis on treatment of sickness, rather than a broader one that incorporated prevention of sickness. During my third year of medical school, I was following a family and sports medicine faculty member who was focusing on aspects of lifestyle medicine to help a patient remain active and age gracefully. Seeing opportunities to practice preventative medicine in family medicine made me realize the specialty was the perfect fit for me.
 

Food as medicine

While participating in rotations I also realized you can find a subspecialty within family medicine.

During my fourth year of medical school, I followed an attending who was seeing a patient for hypertension, prediabetes and hypercholesterolemia. The attending told the patient to eat “healthier,” gave her a handout, and scheduled a follow up appointment for 6 months later.

My thoughts were: “That’s it? That’s how we counsel patients to improve their dietary habits?”

As the patient was leaving the exam room, I asked her what type of oil she cooked with, and I proceeded to share culinary tips from my mother – who was a self-taught and early adopter of the food-as-medicine movement.

Once I started my residency, I knew I’d want to incorporate lifestyle and dietary approaches at many of my patient visits.

I scheduled patients every month to monitor their weight, follow up on chronic conditions, but more importantly, to engage them in their health and empower them to make small lifestyle changes each month and report their efforts. I felt like I was their health coach and cheerleader.
 

My career in family medicine

Entering the job market allowed me to form my philosophy of treating patients with a mind, body, and spirit approach. I chose to practice value-based care, which aligns with my lifestyle and preventative medicine approach .

I currently practice in a small family medicine–only clinic that is part of a larger multispecialty system. Primary care specialties in my organization are valued, respected and central to a patient’s well being and care. We are encouraged to spend time with patients, assess barriers to care and work collaboratively with our healthcare team, so that preventative medicine approaches take the lead in a patient’s health. This supportive culture and environment is one where my passion for food as medicine has thrived.

One day I forgot to pack a lunch and instead brought a grocery bag of items to make a salad. When I realized I made too much, I sent an email to my staff to get some “free salad in my office.” This serendipitous moment started an informal office “salad club” each week. Continued support from my staff and leadership, allowed me to consider further extending this teaching to my patients and my colleagues.

Three years ago, I helped adopt a sustainable plant-forward menu for our physician meetings, complete with a recipe from the menu for physicians to replicate at home or give to their patients.

I also pursued adoption of shared medical appointments for our medical group. These appointments apply the “see one, do one, teach one” model in medicine, but with culinary medicine as the focus.

Knowing that my patients are all connected to their families through food, I sought this as an opportunity to dive in further with wellness opportunities at their next meal. After almost 2 years of working on this project, I was able to host my first shared medical appointment with a group of patients on March 12, 2020. The next day schools closed, lockdowns occurred, and the world changed.
 

Opportunities highlighted by the pandemic

We always knew health care was broken but adding the increasingly longer hours and COVID vaccine–hesitant patients that the pandemic brought made everything look dark at times. What has helped me stay hopeful and energetic for system changes is feeling gratitude and seeking bright lights.

My experiences seeing patients in telehealth visits are examples of some of the bright lights I found in the pandemic. During these visits, patients showed me something from their pantry, and we’d go over nutritional labels together.

Additionally, my patients became engaged with their own conditions and wanted to improve them because of news articles highlighting risk factors for COVID-19, such as obesity. I had an active audience when it came to talking about food-as-medicine approaches to improving risk factors and immunity. And since everyone was listening, I didn’t stop at food. I also talked about physical health, stress resiliency, planetary diets, sleep, connections, and lastly vaccines!

Once the vaccines were distributed, I naturally gravitated to having those conversations with patients and colleagues and on social media. Plus, the pandemic gave us moments of simple times to slow down, take more rests, be less overscheduled, consider work-life priorities, and, lastly, to be okay with not being totally okay.

In practicing primary care, we have a unique role in seeing medicine from a whole body, whole person, whole family perspective. There is an opportunity to highlight what is broken in medicine and aim to make it whole.

I’m currently looking at shared medical appointments as a new standard way to provide care to all patients, because it improves access, provides better quality visits and aligns my values, mission, and purpose.

In the midst of the pandemic, I helped advocate for a sustainable plant-forward menu that was launched throughout four different hospitals in the Sharp HealthCare system, in California, in 2020. Knowing that patients were served a menu I played a role in, gave me solace.

As part of the hospital food and nutrition team, I am grateful for the opportunity I have to work on a broader mission to address social determinants of health and seek opportunities to help the system work for our patients.

Public health communication has been lacking in the pandemic, but another bright light is that we were still the trusted messengers to our patients and our communities. I’m continually honored and humbled to be trusted with a whole family’s health.

Dr. Neison practices family medicine and culinary medicine at Sharp Rees-Stealy Medical Group in San Diego, and is cochair of climate and planetary health for SRS Medical Group. You can follow her on Instagram, LinkedIn, and Facebook @Flavors4WellnessMD.

CHICAGO – Geno Merli, MD, associate chief medical officer at Thomas Jefferson University Hospital, Philadelphia, and long-time hospital medicine expert, recalled a recent situation at his center, during a panel discussion.

It involved a 70-year-old man who had a history of prostate cancer, obstructive sleep apnea, and hernias. In January, he had a surgery for hernia repair. On the 3rd day after the procedure, he was transferred to the hospital medicine service at about 9 p.m. and was on a patient-controlled pump for pain and had abdominal drains. Because of the extensive surgery and because he had begun to walk shortly after the procedure, he wasn’t on thrombosis prevention medication, Dr. Merli explained at the annual meeting of the American College of Physicians.

The day after his transfer he was walking with a physical therapist when he became short of breath, his oxygen saturation dropped, and his heart rate soared. Bilateral pulmonary emboli were found, along with thrombosis in the right leg.

What was remarkable, Dr. Merli noted, was what the patient’s medical record was lacking.

He added, “I think if we start looking at this at our sites, we may find out that communication needs to be improved, and I believe standardized.”

This situation underscores the continuing need to refine handoffs between surgery and hospital medicine, a point in care that is primed for potential errors, the other panelists noted during the session.

Most important information is often not communicated

A 2010 study in pediatrics that looked at intern-to-intern handoffs found that the most important piece of information wasn’t communicated successfully 60% of the time – in other words, more often than not, the person on the receiving end didn’t really understand that crucial part of the scenario. Since then, the literature has been regularly populated with studies attempting to refine handoff procedures.

 Lily Ackermann, MD, hospitalist and clinical associate professor of medicine at Jefferson, said in the session that hospitalists need to be sure to reach out to surgery at important junctures in care.

 “I would say the No. 1 biggest mistake we make is not calling the surgery attending directly when clinical questions arise,” she said. “I think this is very important – attending [physician in hospital medicine] to attending [physician in surgery].”

 Murray Cohen, MD, director of acute care surgery at Jefferson, said he shared that concern.

“We want to be called, we want to be called for our patients,” he said in the session. “And we’re upset when you don’t call for our patients.”

Hospitalists should discuss blood loss, pain management, management of drains, deep vein thrombosis prevention, nutrition, infectious disease concerns, and timing of vaccines post procedure, Dr. Ackermann said during the presentation,

The panelists also emphasized that understanding the follow-up care that surgery was planning after a procedure is important, and to not just expect surgeons to actively follow a patient. They also reminded hospitalists to look at the wounds and make sure they understand how to handle the wounds going forward. Plus, when transferring a patient to surgery, hospitalists should understand when getting someone to surgery is urgent and not to order unnecessary tests as a formality when time is of the essence, they said.

IPASS: a formalized handoff process

The panelists all spoke highly of a formalized handoff process known as IPASS. This acronym reminds physicians to ask specific questions.

The I represents illness severity and calls for asking: “Is the patient stable or unstable?

The P stands for patient summary and is meant to prompt physicians to seek details about the procedure.

The A is for action list, which is meant to remind the physician to get the post-op plan for neurological, cardiovascular, gastrointestinal, and other areas.

The first S is for situational awareness, and calls for asking: What is the biggest concern over the next 24 hours?

The final S represents synthesis by the receiver, prompting a physician to summarize the information he or she has received about the patient.

Natalie Margules, MD, a clinical instructor and hospitalist at Jefferson who did not present in the session, reiterated the value of the IPASS system. Before it was used for handoffs, she said, “I was never taught anything formalized – basically, just ‘Tell them what’s important.’

Dr. Margules noted that she considers the framework’s call for the synthesis to be one of it most useful parts.

 Dr. Merli, Dr. Ackermann, and Dr. Cohen reported no relevant financial disclosures.

CHICAGO – Geno Merli, MD, associate chief medical officer at Thomas Jefferson University Hospital, Philadelphia, and long-time hospital medicine expert, recalled a recent situation at his center, during a panel discussion.

It involved a 70-year-old man who had a history of prostate cancer, obstructive sleep apnea, and hernias. In January, he had a surgery for hernia repair. On the 3rd day after the procedure, he was transferred to the hospital medicine service at about 9 p.m. and was on a patient-controlled pump for pain and had abdominal drains. Because of the extensive surgery and because he had begun to walk shortly after the procedure, he wasn’t on thrombosis prevention medication, Dr. Merli explained at the annual meeting of the American College of Physicians.

The day after his transfer he was walking with a physical therapist when he became short of breath, his oxygen saturation dropped, and his heart rate soared. Bilateral pulmonary emboli were found, along with thrombosis in the right leg.

What was remarkable, Dr. Merli noted, was what the patient’s medical record was lacking.

He added, “I think if we start looking at this at our sites, we may find out that communication needs to be improved, and I believe standardized.”

This situation underscores the continuing need to refine handoffs between surgery and hospital medicine, a point in care that is primed for potential errors, the other panelists noted during the session.

Most important information is often not communicated

A 2010 study in pediatrics that looked at intern-to-intern handoffs found that the most important piece of information wasn’t communicated successfully 60% of the time – in other words, more often than not, the person on the receiving end didn’t really understand that crucial part of the scenario. Since then, the literature has been regularly populated with studies attempting to refine handoff procedures.

 Lily Ackermann, MD, hospitalist and clinical associate professor of medicine at Jefferson, said in the session that hospitalists need to be sure to reach out to surgery at important junctures in care.

 “I would say the No. 1 biggest mistake we make is not calling the surgery attending directly when clinical questions arise,” she said. “I think this is very important – attending [physician in hospital medicine] to attending [physician in surgery].”

 Murray Cohen, MD, director of acute care surgery at Jefferson, said he shared that concern.

“We want to be called, we want to be called for our patients,” he said in the session. “And we’re upset when you don’t call for our patients.”

Hospitalists should discuss blood loss, pain management, management of drains, deep vein thrombosis prevention, nutrition, infectious disease concerns, and timing of vaccines post procedure, Dr. Ackermann said during the presentation,

The panelists also emphasized that understanding the follow-up care that surgery was planning after a procedure is important, and to not just expect surgeons to actively follow a patient. They also reminded hospitalists to look at the wounds and make sure they understand how to handle the wounds going forward. Plus, when transferring a patient to surgery, hospitalists should understand when getting someone to surgery is urgent and not to order unnecessary tests as a formality when time is of the essence, they said.

IPASS: a formalized handoff process

The panelists all spoke highly of a formalized handoff process known as IPASS. This acronym reminds physicians to ask specific questions.

The I represents illness severity and calls for asking: “Is the patient stable or unstable?

The P stands for patient summary and is meant to prompt physicians to seek details about the procedure.

The A is for action list, which is meant to remind the physician to get the post-op plan for neurological, cardiovascular, gastrointestinal, and other areas.

The first S is for situational awareness, and calls for asking: What is the biggest concern over the next 24 hours?

The final S represents synthesis by the receiver, prompting a physician to summarize the information he or she has received about the patient.

Natalie Margules, MD, a clinical instructor and hospitalist at Jefferson who did not present in the session, reiterated the value of the IPASS system. Before it was used for handoffs, she said, “I was never taught anything formalized – basically, just ‘Tell them what’s important.’

Dr. Margules noted that she considers the framework’s call for the synthesis to be one of it most useful parts.

 Dr. Merli, Dr. Ackermann, and Dr. Cohen reported no relevant financial disclosures.

CHICAGO – Geno Merli, MD, associate chief medical officer at Thomas Jefferson University Hospital, Philadelphia, and long-time hospital medicine expert, recalled a recent situation at his center, during a panel discussion.

It involved a 70-year-old man who had a history of prostate cancer, obstructive sleep apnea, and hernias. In January, he had a surgery for hernia repair. On the 3rd day after the procedure, he was transferred to the hospital medicine service at about 9 p.m. and was on a patient-controlled pump for pain and had abdominal drains. Because of the extensive surgery and because he had begun to walk shortly after the procedure, he wasn’t on thrombosis prevention medication, Dr. Merli explained at the annual meeting of the American College of Physicians.

The day after his transfer he was walking with a physical therapist when he became short of breath, his oxygen saturation dropped, and his heart rate soared. Bilateral pulmonary emboli were found, along with thrombosis in the right leg.

What was remarkable, Dr. Merli noted, was what the patient’s medical record was lacking.

He added, “I think if we start looking at this at our sites, we may find out that communication needs to be improved, and I believe standardized.”

This situation underscores the continuing need to refine handoffs between surgery and hospital medicine, a point in care that is primed for potential errors, the other panelists noted during the session.

Most important information is often not communicated

A 2010 study in pediatrics that looked at intern-to-intern handoffs found that the most important piece of information wasn’t communicated successfully 60% of the time – in other words, more often than not, the person on the receiving end didn’t really understand that crucial part of the scenario. Since then, the literature has been regularly populated with studies attempting to refine handoff procedures.

 Lily Ackermann, MD, hospitalist and clinical associate professor of medicine at Jefferson, said in the session that hospitalists need to be sure to reach out to surgery at important junctures in care.

 “I would say the No. 1 biggest mistake we make is not calling the surgery attending directly when clinical questions arise,” she said. “I think this is very important – attending [physician in hospital medicine] to attending [physician in surgery].”

 Murray Cohen, MD, director of acute care surgery at Jefferson, said he shared that concern.

“We want to be called, we want to be called for our patients,” he said in the session. “And we’re upset when you don’t call for our patients.”

Hospitalists should discuss blood loss, pain management, management of drains, deep vein thrombosis prevention, nutrition, infectious disease concerns, and timing of vaccines post procedure, Dr. Ackermann said during the presentation,

The panelists also emphasized that understanding the follow-up care that surgery was planning after a procedure is important, and to not just expect surgeons to actively follow a patient. They also reminded hospitalists to look at the wounds and make sure they understand how to handle the wounds going forward. Plus, when transferring a patient to surgery, hospitalists should understand when getting someone to surgery is urgent and not to order unnecessary tests as a formality when time is of the essence, they said.

IPASS: a formalized handoff process

The panelists all spoke highly of a formalized handoff process known as IPASS. This acronym reminds physicians to ask specific questions.

The I represents illness severity and calls for asking: “Is the patient stable or unstable?

The P stands for patient summary and is meant to prompt physicians to seek details about the procedure.

The A is for action list, which is meant to remind the physician to get the post-op plan for neurological, cardiovascular, gastrointestinal, and other areas.

The first S is for situational awareness, and calls for asking: What is the biggest concern over the next 24 hours?

The final S represents synthesis by the receiver, prompting a physician to summarize the information he or she has received about the patient.

Natalie Margules, MD, a clinical instructor and hospitalist at Jefferson who did not present in the session, reiterated the value of the IPASS system. Before it was used for handoffs, she said, “I was never taught anything formalized – basically, just ‘Tell them what’s important.’

Dr. Margules noted that she considers the framework’s call for the synthesis to be one of it most useful parts.

 Dr. Merli, Dr. Ackermann, and Dr. Cohen reported no relevant financial disclosures.

CHICAGO – The COVID pandemic left hospitalist Ngozi Nwankwo, MD, with the most difficult patient interactions she had ever experienced.

“At my hospital, it was such a big thing to make sure that families are called,” said Dr. Nwankwo, in an interview following a session on compassionate communication at the annual meeting of the American College of Physicians. “So you have 19 patients, and you have to call almost every family to update them. And then you call, and they say, ‘Call this person as well.’ You feel like you’re at your wit’s end a lot of times.”

Sometimes, she has had to dig deep to find the empathy for patients that she knows her patients deserve.

“You really want to care by thinking about where is this patient coming from? What’s going on in their lives? And not just label them a difficult patient,” she said.

Become curious

Auguste Fortin, MD, MPH, offered advice for handling patient interactions under these kinds of circumstances, while serving as a moderator during the session.

“When the going gets tough, turn to wonder.” Become curious about why a patient might be feeling the way they are, he said.

Dr. Fortin, professor of internal medicine at Yale University, New Haven, Conn., said using the ADOBE acronym, has helped him more effectively communicate with his patients. This tool cues him to keep the following in mind: acknowledge, discover, opportunity, boundary setting, and extend.

He went on to explain to the audience why thinking about these terms is useful when interacting with patients.

First, acknowledge the feelings of the patient. Noting that a patient is angry, perhaps counterintuitively, helps, he said. In fact, not acknowledging the anger “throws gasoline on the fire.”

Then, discover the cause of their emotion. Saying "tell me more" and "help me understand" can be powerful tools, he noted.

Next, take this as an opportunity for empathy – especially important to remember when you’re being verbally attacked.

Boundary setting is important, because it lets the patient know that the conversation won’t continue unless they show the same respect the physician is showing, he said.

Finally, physicians can extend the system of support by asking others – such as colleagues or security – for help.

Use the NURS guide to show empathy

Dr. Fortin said he uses the “NURS” guide or calling to mind “name, express, respect, and support” to show empathy:

This involves naming a patient’s emotion; expressing understanding, with phrases like "I can see how you could be …"; showing respect, acknowledging a patient is going through a lot; and offering support, by saying something like, "Let’s see what we can do together to get to the bottom of this," he explained.

“My lived experience in using [these] in this order is that by the end of it, the patient cannot stay mad at me,” Dr. Fortin said.

“It’s really quite remarkable,” he added.

Steps for nonviolent communication

Rebecca Andrews, MD, MS, another moderator for the session, offered these steps for “nonviolent communication”:

• Observing the situation without blame or judgment.
• Telling the person how this situation makes you feel.
• Connecting with a need of the other person.
• Making a request that is specific and based on action, rather than a request not to do something, such as "Would you be willing to … ?"

Dr. Andrews, who is professor of medicine at the University of Connecticut, Farmington, said this approach has worked well for her, both in interactions with patients and in her personal life.

“It is evidence based that compassion actually makes care better,” she noted.

Varun Jain, MD, a member of the audience, expressed gratitude to the session’s speakers for teaching him something that he had not learned in medical school or residency.

“Every week you will have one or two people who will be labeled as ‘difficult,’ ” and it was nice to have some proven advice on how to handle these tough interactions, said the hospitalist at St. Francis Hospital in Hartford, Conn.

“We never got any actual training on this, and we were expected to know this because we are just physicians, and physicians are expected to be compassionate,” Dr. Jain said. “No one taught us how to have compassion.”

Dr. Fortin and Dr. Andrews disclosed no relevant financial relationships.

CHICAGO – The COVID pandemic left hospitalist Ngozi Nwankwo, MD, with the most difficult patient interactions she had ever experienced.

“At my hospital, it was such a big thing to make sure that families are called,” said Dr. Nwankwo, in an interview following a session on compassionate communication at the annual meeting of the American College of Physicians. “So you have 19 patients, and you have to call almost every family to update them. And then you call, and they say, ‘Call this person as well.’ You feel like you’re at your wit’s end a lot of times.”

Sometimes, she has had to dig deep to find the empathy for patients that she knows her patients deserve.

“You really want to care by thinking about where is this patient coming from? What’s going on in their lives? And not just label them a difficult patient,” she said.

Become curious

Auguste Fortin, MD, MPH, offered advice for handling patient interactions under these kinds of circumstances, while serving as a moderator during the session.

“When the going gets tough, turn to wonder.” Become curious about why a patient might be feeling the way they are, he said.

Dr. Fortin, professor of internal medicine at Yale University, New Haven, Conn., said using the ADOBE acronym, has helped him more effectively communicate with his patients. This tool cues him to keep the following in mind: acknowledge, discover, opportunity, boundary setting, and extend.

He went on to explain to the audience why thinking about these terms is useful when interacting with patients.

First, acknowledge the feelings of the patient. Noting that a patient is angry, perhaps counterintuitively, helps, he said. In fact, not acknowledging the anger “throws gasoline on the fire.”

Then, discover the cause of their emotion. Saying "tell me more" and "help me understand" can be powerful tools, he noted.

Next, take this as an opportunity for empathy – especially important to remember when you’re being verbally attacked.

Boundary setting is important, because it lets the patient know that the conversation won’t continue unless they show the same respect the physician is showing, he said.

Finally, physicians can extend the system of support by asking others – such as colleagues or security – for help.

Use the NURS guide to show empathy

Dr. Fortin said he uses the “NURS” guide or calling to mind “name, express, respect, and support” to show empathy:

This involves naming a patient’s emotion; expressing understanding, with phrases like "I can see how you could be …"; showing respect, acknowledging a patient is going through a lot; and offering support, by saying something like, "Let’s see what we can do together to get to the bottom of this," he explained.

“My lived experience in using [these] in this order is that by the end of it, the patient cannot stay mad at me,” Dr. Fortin said.

“It’s really quite remarkable,” he added.

Steps for nonviolent communication

Rebecca Andrews, MD, MS, another moderator for the session, offered these steps for “nonviolent communication”:

• Observing the situation without blame or judgment.
• Telling the person how this situation makes you feel.
• Connecting with a need of the other person.
• Making a request that is specific and based on action, rather than a request not to do something, such as "Would you be willing to … ?"

Dr. Andrews, who is professor of medicine at the University of Connecticut, Farmington, said this approach has worked well for her, both in interactions with patients and in her personal life.

“It is evidence based that compassion actually makes care better,” she noted.

Varun Jain, MD, a member of the audience, expressed gratitude to the session’s speakers for teaching him something that he had not learned in medical school or residency.

“Every week you will have one or two people who will be labeled as ‘difficult,’ ” and it was nice to have some proven advice on how to handle these tough interactions, said the hospitalist at St. Francis Hospital in Hartford, Conn.

“We never got any actual training on this, and we were expected to know this because we are just physicians, and physicians are expected to be compassionate,” Dr. Jain said. “No one taught us how to have compassion.”

Dr. Fortin and Dr. Andrews disclosed no relevant financial relationships.

CHICAGO – The COVID pandemic left hospitalist Ngozi Nwankwo, MD, with the most difficult patient interactions she had ever experienced.

“At my hospital, it was such a big thing to make sure that families are called,” said Dr. Nwankwo, in an interview following a session on compassionate communication at the annual meeting of the American College of Physicians. “So you have 19 patients, and you have to call almost every family to update them. And then you call, and they say, ‘Call this person as well.’ You feel like you’re at your wit’s end a lot of times.”

Sometimes, she has had to dig deep to find the empathy for patients that she knows her patients deserve.

“You really want to care by thinking about where is this patient coming from? What’s going on in their lives? And not just label them a difficult patient,” she said.

Become curious

Auguste Fortin, MD, MPH, offered advice for handling patient interactions under these kinds of circumstances, while serving as a moderator during the session.

“When the going gets tough, turn to wonder.” Become curious about why a patient might be feeling the way they are, he said.

Dr. Fortin, professor of internal medicine at Yale University, New Haven, Conn., said using the ADOBE acronym, has helped him more effectively communicate with his patients. This tool cues him to keep the following in mind: acknowledge, discover, opportunity, boundary setting, and extend.

He went on to explain to the audience why thinking about these terms is useful when interacting with patients.

First, acknowledge the feelings of the patient. Noting that a patient is angry, perhaps counterintuitively, helps, he said. In fact, not acknowledging the anger “throws gasoline on the fire.”

Then, discover the cause of their emotion. Saying "tell me more" and "help me understand" can be powerful tools, he noted.

Next, take this as an opportunity for empathy – especially important to remember when you’re being verbally attacked.

Boundary setting is important, because it lets the patient know that the conversation won’t continue unless they show the same respect the physician is showing, he said.

Finally, physicians can extend the system of support by asking others – such as colleagues or security – for help.

Use the NURS guide to show empathy

Dr. Fortin said he uses the “NURS” guide or calling to mind “name, express, respect, and support” to show empathy:

This involves naming a patient’s emotion; expressing understanding, with phrases like "I can see how you could be …"; showing respect, acknowledging a patient is going through a lot; and offering support, by saying something like, "Let’s see what we can do together to get to the bottom of this," he explained.

“My lived experience in using [these] in this order is that by the end of it, the patient cannot stay mad at me,” Dr. Fortin said.

“It’s really quite remarkable,” he added.

Steps for nonviolent communication

Rebecca Andrews, MD, MS, another moderator for the session, offered these steps for “nonviolent communication”:

• Observing the situation without blame or judgment.
• Telling the person how this situation makes you feel.
• Connecting with a need of the other person.
• Making a request that is specific and based on action, rather than a request not to do something, such as "Would you be willing to … ?"

Dr. Andrews, who is professor of medicine at the University of Connecticut, Farmington, said this approach has worked well for her, both in interactions with patients and in her personal life.

“It is evidence based that compassion actually makes care better,” she noted.

Varun Jain, MD, a member of the audience, expressed gratitude to the session’s speakers for teaching him something that he had not learned in medical school or residency.

“Every week you will have one or two people who will be labeled as ‘difficult,’ ” and it was nice to have some proven advice on how to handle these tough interactions, said the hospitalist at St. Francis Hospital in Hartford, Conn.

“We never got any actual training on this, and we were expected to know this because we are just physicians, and physicians are expected to be compassionate,” Dr. Jain said. “No one taught us how to have compassion.”

Dr. Fortin and Dr. Andrews disclosed no relevant financial relationships.

During her final years practicing medicine, the internist Faith Thayer Fitzgerald, MD, glided from room to room on a razor scooter at UC Davis Medical Center in Sacramento, Calif, her colleague recalled.

Dr. Fitzgerald adopted this means of transportation to allow her to examine and talk to her patients, following a hip injury and surgery, which left her unable to do the amount of walking typically required to conduct rounds at a hospital.

Courtesy UC Davis Health

Her colleague, Mark C. Henderson, MD, MACP, described Dr. Fitzgerald as being “extremely dedicated to each patient,” having taken care of many of them for decades. Her will to find a way to practice with severe physical limitations exemplified this dedication, said Dr. Henderson, who worked in the hospital alongside her, including handing over patients to her.

Dr. Fitzgerald died on Dec. 3, 2021, at 78 years, after working in a career spanning 6 decades, including actively practicing internal medicine at UC Davis Medical Center for 40 years.

Her career also included working as a medical educator, influencing several people interviewed for this story in that role, and advising the staff of Internal Medicine News for more than 3 decades.

“Faith Fitzgerald was an incredible teacher and mentor for so many people,” noted Robert H. Hopkins Jr., MD, who practices general internal medicine and med-peds at the University of Arkansans for Medical Sciences, Little Rock and is a member of the editorial advisory board of Internal Medicine News.
 

‘The patient and the next generation’ were always in mind

A contributor to Dr. Fitzgerald’s success as an educator was her dogged commitment to her patients, said Dr. Henderson, who is associate dean for admissions at the University of California, Davis, and professor and vice chair for education in the department of internal medicine. The latter of these positions was previously held by Dr. Fitzgerald.

“She always arrived early for hospital rounds, often waking up her patients,” he said. “She evolved this practice to be present before all the chaos of the day ensued and honestly to spend quality of time with patients.”

“She always had two things in mind: the patient and the next generation,” Dr. Henderson continued. “A lot of times, because she had seen the patients earlier in the morning, she knew where to focus the team she was training” and “she could show her students and residents all of these interesting findings.”

“It was a very efficient way of conducting bedside teaching,” he added.

Dr. Fitzgerald taught primarily in the department of internal medicine at UC Davis Health. She joined the faculty of that school in 1980. Her 38-year-long career there included serving as residency program director for nearly 20 years, chief of general medicine, vice chair for education, and the medical school’s first associate dean for humanities and bioethics.

Several people who knew Dr. Fitzgerald well also attributed her effectiveness as a teacher and a doctor to the kindness she showed all people no matter their background or station in life.

“Every patient she saw in clinic, she booked for an hour ‘til the day she left UC Davis,” noted Carmelina Raffetto, Dr. Fitzgerald’s closest friend and former administrative assistant, during UC Davis Health’s virtual memorial ceremony for Dr. Fitzgerald.

“Her patients all had her phone number, her pager. ... She loved teaching, she loved her patients, and she loved staff.

“She treated all of us equally. Whether you were in housekeeping or in the cafeteria, or if you were just walking down the hall, she had kind words and she never wanted anyone to feel that they weren’t’ special,” added Ms. Raffetto, who is currently executive director of the Northern California American College of Physicians chapter.

Throughout her career, she received over three dozen teaching awards, according to a statement from UC Davis. In 2002, for example, Dr. Fitzgerald received the Alpha Omega Alpha medical honor society’s Robert J. Glaser Award for providing medical students with an outstanding educational experience. Additional teaching awards included the American College of Physicians Distinguished Teacher Award, the California Medical Association Golden Apple Award and the UC San Francisco Gold Headed Cane.

She also received awards from UC Davis, including the Hibbard Williams Lifetime Achievement award, the Tupper Award for Excellence in Teaching and the UC Davis School of Medicine Golden Apple Award. She was also chosen as the UC Davis Senior Class Outstanding Clinical Teacher seven times and was named the Department of Medicine Distinguished Faculty Teacher on four separate occasions, the statement said.
 

Her early life and family

Dr. Fitzgerald was born in Boston on Sept. 24, 1943, and “knew from early childhood that she would be a physician,” according to her biography on Changing the Face of Medicine.

She completed undergraduate studies at the University of California, Santa Barbara. She graduated from the University of California, San Francisco, in 1969 and completed her residency in internal medicine at the same institution. In addition to teaching at UC Davis, Dr. Fitzgerald served as assistant professor of medicine at University of Michigan, Ann Arbor, for 2 years early in her career.

Dr. Fitzgerald is survived by her brother, Sean, and sister-in-law, Deborah Fitzgerald. Dr. Fitzgerald lived with and cared for her mother, Irene Fitzgerald – who passed away in 2005 – for more than a decade.

Dr. Fitzgerald asked for any donations in her memory to be used to establish scholarships for medical students with financial need, as she had been supported by scholarship money long ago while a student at the University of California. Donations to the Faith Fitzgerald, MD, Medical Student Scholarship Fund can be made here.

During her final years practicing medicine, the internist Faith Thayer Fitzgerald, MD, glided from room to room on a razor scooter at UC Davis Medical Center in Sacramento, Calif, her colleague recalled.

Dr. Fitzgerald adopted this means of transportation to allow her to examine and talk to her patients, following a hip injury and surgery, which left her unable to do the amount of walking typically required to conduct rounds at a hospital.

Courtesy UC Davis Health

Her colleague, Mark C. Henderson, MD, MACP, described Dr. Fitzgerald as being “extremely dedicated to each patient,” having taken care of many of them for decades. Her will to find a way to practice with severe physical limitations exemplified this dedication, said Dr. Henderson, who worked in the hospital alongside her, including handing over patients to her.

Dr. Fitzgerald died on Dec. 3, 2021, at 78 years, after working in a career spanning 6 decades, including actively practicing internal medicine at UC Davis Medical Center for 40 years.

Her career also included working as a medical educator, influencing several people interviewed for this story in that role, and advising the staff of Internal Medicine News for more than 3 decades.

“Faith Fitzgerald was an incredible teacher and mentor for so many people,” noted Robert H. Hopkins Jr., MD, who practices general internal medicine and med-peds at the University of Arkansans for Medical Sciences, Little Rock and is a member of the editorial advisory board of Internal Medicine News.
 

‘The patient and the next generation’ were always in mind

A contributor to Dr. Fitzgerald’s success as an educator was her dogged commitment to her patients, said Dr. Henderson, who is associate dean for admissions at the University of California, Davis, and professor and vice chair for education in the department of internal medicine. The latter of these positions was previously held by Dr. Fitzgerald.

“She always arrived early for hospital rounds, often waking up her patients,” he said. “She evolved this practice to be present before all the chaos of the day ensued and honestly to spend quality of time with patients.”

“She always had two things in mind: the patient and the next generation,” Dr. Henderson continued. “A lot of times, because she had seen the patients earlier in the morning, she knew where to focus the team she was training” and “she could show her students and residents all of these interesting findings.”

“It was a very efficient way of conducting bedside teaching,” he added.

Dr. Fitzgerald taught primarily in the department of internal medicine at UC Davis Health. She joined the faculty of that school in 1980. Her 38-year-long career there included serving as residency program director for nearly 20 years, chief of general medicine, vice chair for education, and the medical school’s first associate dean for humanities and bioethics.

Several people who knew Dr. Fitzgerald well also attributed her effectiveness as a teacher and a doctor to the kindness she showed all people no matter their background or station in life.

“Every patient she saw in clinic, she booked for an hour ‘til the day she left UC Davis,” noted Carmelina Raffetto, Dr. Fitzgerald’s closest friend and former administrative assistant, during UC Davis Health’s virtual memorial ceremony for Dr. Fitzgerald.

“Her patients all had her phone number, her pager. ... She loved teaching, she loved her patients, and she loved staff.

“She treated all of us equally. Whether you were in housekeeping or in the cafeteria, or if you were just walking down the hall, she had kind words and she never wanted anyone to feel that they weren’t’ special,” added Ms. Raffetto, who is currently executive director of the Northern California American College of Physicians chapter.

Throughout her career, she received over three dozen teaching awards, according to a statement from UC Davis. In 2002, for example, Dr. Fitzgerald received the Alpha Omega Alpha medical honor society’s Robert J. Glaser Award for providing medical students with an outstanding educational experience. Additional teaching awards included the American College of Physicians Distinguished Teacher Award, the California Medical Association Golden Apple Award and the UC San Francisco Gold Headed Cane.

She also received awards from UC Davis, including the Hibbard Williams Lifetime Achievement award, the Tupper Award for Excellence in Teaching and the UC Davis School of Medicine Golden Apple Award. She was also chosen as the UC Davis Senior Class Outstanding Clinical Teacher seven times and was named the Department of Medicine Distinguished Faculty Teacher on four separate occasions, the statement said.
 

Her early life and family

Dr. Fitzgerald was born in Boston on Sept. 24, 1943, and “knew from early childhood that she would be a physician,” according to her biography on Changing the Face of Medicine.

She completed undergraduate studies at the University of California, Santa Barbara. She graduated from the University of California, San Francisco, in 1969 and completed her residency in internal medicine at the same institution. In addition to teaching at UC Davis, Dr. Fitzgerald served as assistant professor of medicine at University of Michigan, Ann Arbor, for 2 years early in her career.

Dr. Fitzgerald is survived by her brother, Sean, and sister-in-law, Deborah Fitzgerald. Dr. Fitzgerald lived with and cared for her mother, Irene Fitzgerald – who passed away in 2005 – for more than a decade.

Dr. Fitzgerald asked for any donations in her memory to be used to establish scholarships for medical students with financial need, as she had been supported by scholarship money long ago while a student at the University of California. Donations to the Faith Fitzgerald, MD, Medical Student Scholarship Fund can be made here.

During her final years practicing medicine, the internist Faith Thayer Fitzgerald, MD, glided from room to room on a razor scooter at UC Davis Medical Center in Sacramento, Calif, her colleague recalled.

Dr. Fitzgerald adopted this means of transportation to allow her to examine and talk to her patients, following a hip injury and surgery, which left her unable to do the amount of walking typically required to conduct rounds at a hospital.

Courtesy UC Davis Health

Her colleague, Mark C. Henderson, MD, MACP, described Dr. Fitzgerald as being “extremely dedicated to each patient,” having taken care of many of them for decades. Her will to find a way to practice with severe physical limitations exemplified this dedication, said Dr. Henderson, who worked in the hospital alongside her, including handing over patients to her.

Dr. Fitzgerald died on Dec. 3, 2021, at 78 years, after working in a career spanning 6 decades, including actively practicing internal medicine at UC Davis Medical Center for 40 years.

Her career also included working as a medical educator, influencing several people interviewed for this story in that role, and advising the staff of Internal Medicine News for more than 3 decades.

“Faith Fitzgerald was an incredible teacher and mentor for so many people,” noted Robert H. Hopkins Jr., MD, who practices general internal medicine and med-peds at the University of Arkansans for Medical Sciences, Little Rock and is a member of the editorial advisory board of Internal Medicine News.
 

‘The patient and the next generation’ were always in mind

A contributor to Dr. Fitzgerald’s success as an educator was her dogged commitment to her patients, said Dr. Henderson, who is associate dean for admissions at the University of California, Davis, and professor and vice chair for education in the department of internal medicine. The latter of these positions was previously held by Dr. Fitzgerald.

“She always arrived early for hospital rounds, often waking up her patients,” he said. “She evolved this practice to be present before all the chaos of the day ensued and honestly to spend quality of time with patients.”

“She always had two things in mind: the patient and the next generation,” Dr. Henderson continued. “A lot of times, because she had seen the patients earlier in the morning, she knew where to focus the team she was training” and “she could show her students and residents all of these interesting findings.”

“It was a very efficient way of conducting bedside teaching,” he added.

Dr. Fitzgerald taught primarily in the department of internal medicine at UC Davis Health. She joined the faculty of that school in 1980. Her 38-year-long career there included serving as residency program director for nearly 20 years, chief of general medicine, vice chair for education, and the medical school’s first associate dean for humanities and bioethics.

Several people who knew Dr. Fitzgerald well also attributed her effectiveness as a teacher and a doctor to the kindness she showed all people no matter their background or station in life.

“Every patient she saw in clinic, she booked for an hour ‘til the day she left UC Davis,” noted Carmelina Raffetto, Dr. Fitzgerald’s closest friend and former administrative assistant, during UC Davis Health’s virtual memorial ceremony for Dr. Fitzgerald.

“Her patients all had her phone number, her pager. ... She loved teaching, she loved her patients, and she loved staff.

“She treated all of us equally. Whether you were in housekeeping or in the cafeteria, or if you were just walking down the hall, she had kind words and she never wanted anyone to feel that they weren’t’ special,” added Ms. Raffetto, who is currently executive director of the Northern California American College of Physicians chapter.

Throughout her career, she received over three dozen teaching awards, according to a statement from UC Davis. In 2002, for example, Dr. Fitzgerald received the Alpha Omega Alpha medical honor society’s Robert J. Glaser Award for providing medical students with an outstanding educational experience. Additional teaching awards included the American College of Physicians Distinguished Teacher Award, the California Medical Association Golden Apple Award and the UC San Francisco Gold Headed Cane.

She also received awards from UC Davis, including the Hibbard Williams Lifetime Achievement award, the Tupper Award for Excellence in Teaching and the UC Davis School of Medicine Golden Apple Award. She was also chosen as the UC Davis Senior Class Outstanding Clinical Teacher seven times and was named the Department of Medicine Distinguished Faculty Teacher on four separate occasions, the statement said.
 

Her early life and family

Dr. Fitzgerald was born in Boston on Sept. 24, 1943, and “knew from early childhood that she would be a physician,” according to her biography on Changing the Face of Medicine.

She completed undergraduate studies at the University of California, Santa Barbara. She graduated from the University of California, San Francisco, in 1969 and completed her residency in internal medicine at the same institution. In addition to teaching at UC Davis, Dr. Fitzgerald served as assistant professor of medicine at University of Michigan, Ann Arbor, for 2 years early in her career.

Dr. Fitzgerald is survived by her brother, Sean, and sister-in-law, Deborah Fitzgerald. Dr. Fitzgerald lived with and cared for her mother, Irene Fitzgerald – who passed away in 2005 – for more than a decade.

Dr. Fitzgerald asked for any donations in her memory to be used to establish scholarships for medical students with financial need, as she had been supported by scholarship money long ago while a student at the University of California. Donations to the Faith Fitzgerald, MD, Medical Student Scholarship Fund can be made here.

Physician employment contracts include some new dangers. This includes physicians taking a new job, but it also includes already-employed doctors who are being asked to resign a new contract that contains new conditions. A number of these new clauses have arisen because of COVID-19. When the pandemic dramatically reduced patient flow, many employers didn’t have enough money to pay doctors and didn’t always have physicians in the right location or practice setting.

Vowing this would never happen again, some employers have rewritten their physician contracts to make it easier to reassign and terminate physicians.

Here are 12 potential land mines in a physician employment contract, some of which were added as a result of the pandemic.
 

You could be immediately terminated without notice

One outcome of the pandemic is the growing use of “force majeure” clauses, which give the employer the right to reduce your compensation or even terminate you due to a natural disaster, which could include COVID.

“COVID made employers aware of the potential impact of disasters on their operations,” said Dan Shay, a health law attorney at Alice Gosfield & Associates in Philadelphia. “Therefore, even as the threat of COVID abates in many places, employers are continuing to put this provision in the contract.”

What can you do? “One way to get some protection is to rule out a termination without cause in the first year,” said Michael A. Cassidy, a physician contract attorney at Tucker Arensberg in Pittsburgh.

The force majeure clause is less likely to affect salary, but could impact bonus and incentive tied to performance. It’s wise to try to specifically limit how much the force majeure could reduce pay tied to performance, and to be prepared to negotiate that aspect of your contract.
 

No protections if you’re let go through no fault of your own

You could lose your job if your employer could not generate enough business and has to let some doctors go. This happened quite often in the early days of the COVID pandemic.

In these situations, the doctor has not done anything wrong to prompt the termination, but the restrictive covenant may still apply, meaning that the doctor would have to leave the area to find work.

What can you do? You’re in a good position to get this changed, said Christopher L. Nuland, a solo physician contract attorney in Jacksonville, Fla. “Many employers recognize that it would be draconian to require a restrictive covenant in this case, and they will agree to modify this provision.”

Similarly, the employer may not cover your tail insurance even if you were let go from your work through no fault of your own. Most malpractice policies for employer physicians require buying an extra policy, called a tail, if you leave. In some cases, the employer won’t provide a tail and will make the departing doctor buy it.

In these cases, “try for a compromise, such as stipulating that the party that caused the termination should pay for the tail,” Mr. Nuland said. “The employer may not agree to anything more than that because they want to set up a disincentive against you leaving.”
 

Employer could unilaterally alter your compensation

Many recent contracts give the employer the option to unilaterally modify compensation, such as changing the base salary or raising the target required for meeting the productivity bonus, said Ericka L. Adler, a physician contract attorney at Roetzel & Andress in Chicago.

Ms. Adler thought this change could have been prompted by employers’ financial problems during the pandemic. In the early months of COVID, many physicians were not making much money for the employer but still had to be paid. So employers added a clause saying they could reduce compensation at any time, she said.

What can you do? Harsh provisions like this often come up in contracts with private equity firms, Mr. Cassidy said. “The contract might say the employer can adjust compensation or even terminate physicians based on productivity or their profitability. And it may say that if they reassign you to a new location and you refuse, they can terminate you.”

“If you can’t get these clauses removed, try to reduce the impact of a termination by providing longer notice periods or by inserting a severance agreement,” Mr. Cassidy said.
 

Accelerating notice for without-cause terminations

Physicians who are convicted of a felony or other moral issue can usually be terminated immediately. But if you are terminated for other reasons – that is, “without cause” – you are given notice at a certain number of days before you have to leave (typically 60-90 days), so that you have time to find a new job.

Some recent contracts, however, allow for very little notice in without-cause terminations, which allows the employer to fire you in as little as 0 days after providing notice, Ms. Adler said.

“This means that, even if 90 days’ notice is provided in the contract, the employer can decide that your last day will be an earlier date,” she said.

Why is this happening? Ms. Adler said employers want to begin reallocating resources and patients as soon as possible. The problem came to employers’ attention during the COVID pandemic, when they were contractually forced to pay doctors for doing little or nothing during the notice period.

What can you do? Possibly not much, other than attempt to negotiate. “Large employers typically don’t want to drop this provision, but at the least, the doctor needs to understand the risk it creates for them,” she said.
 

You could be assigned to far-off locations

As patient care needs changed dramatically during the pandemic, employers needed to reassign doctors to new locations.

Some new contracts allow employers to simply inform the doctor that they are changing the work location. However, “you don’t want to be assigned to a new work location that is 50 miles away,” Mr. Nuland said.

What can you do? Mr. Nuland recommended adding new language saying that, if the new assignment is more than 20 miles away, both parties would have to approve it.

You could end up working too many off-hours

“Most employers won’t issue a specific work schedule,” Mr. Nuland said. “They want the flexibility to assign evening or weekend work, and it would be difficult for a young doctor to change this.”

What can you do? Mr. Nuland recommended trying to set some limits. “You can try to limit off-hours work to two times a month or something like that,” she said. And if you need to have a special schedule, such as not working on Fridays, Adler advises that this should be put into the contract.

If you can’t get anything changed in the contract, Mr. Nuland said the next-best thing is to ask employers to tell you specifically what they plan to do with you. “Most employers will give you an informal idea of what’s expected – maybe not an exact schedule, but it’s quite likely they will honor it.”
 

You wouldn’t be able to work nearby if you left the job

Most contracts have a noncompete clause, also known as a “restrictive covenant,” which prevents employed physicians from working in the area if they left the job.

“Almost every doctor I represent has told me that they’re not concerned about the noncompete clause because, they believe, it is not enforceable anyway,” Ms. Adler said. “This is incorrect.”

Mr. Nuland said the faster pace of job-changing during the pandemic makes it all the more likely that doctors have to deal with a restrictive covenant. At the same time, some employers have been expanding the restriction – either by enlarging the radius where the restriction applies or by making the restriction apply to each of their sites, so that each one has a restricted radius around it.

For example, one contract Mr. Nuland is currently reviewing has a 20-mile radius that in effect becomes a 120-mile radius because the employer is counting four offices.

What can you do? Mr. Nuland advised trying to reduce the impact of the noncompete – for instance, making it apply only to the offices where you worked, or trading more time for less distance. “If you have a 2-year, 20-mile restriction, ask for a 3-year, 10-mile restriction, where the radius could be easier to deal with,” he said.
 

You might end up with too much call

Contracts rarely detail your call schedule because employers want flexibility to expand call as patient care needs change, but you can try adding some specificity, said Sanja Ord, a physician contract attorney at Greensfelder, Hemker & Gale in St. Louis.

Contracts often use wide-open language to describe call, such as simply making it “subject to the house call policies,” Mr. Cassidy said. Language that is more beneficial to the physician would say that call must be “equal” among “similarly situated” physicians.

But Ms. Ord said even provisions for equal call can turn out to be onerous if there are too few doctors in the call roster, so it’s a good idea to find out just how many doctors will be participating in call.

Still, Adler said even that strategy can’t remove all risk. What happens, she asked, if several physicians participating in call decide to leave? Then you might end up with call every other night.

What can you do? Mr. Cassidy recommends specifying a maximum amount of call – for example, no more frequent than one in four nights.
 

Physician must pay for reimbursement claw-backs by payers

When auditors for Medicare or other payers find overpayments after the fact, called a ‘claw-back,’ the provider must pay them back. But which provider has to do that – you or your employer?

In many cases, your employer’s billing office may have introduced the error, but there may be a clause in the contract stating that the physician is solely responsible for all claw-backs. That could be costly.

What can you do? Mr. Shay said the clause should state that you have to pay only when it is the result of your own error or omission, and also not when it was made at the direction of the employer.
 

Some work may be outside of your subspecialty

In some cases, the employer may assign subspecialized doctors to work outside their subspecialty, Mr. Nuland said.

For example, he said he represented an endocrinologist who expected to see only diabetes patients but was assigned to some general internal medicine work as well, and an otolaryngologist client of his who completed a fellowship on facial plastic surgery was expected to do liposuction in a cosmetic surgery group.

What can you do? To prevent this from happening, Mr. Nuland recommends a clause stating that your work will be restricted to your subspecialty.

What the employer promised isn’t in the contract

“Beware of promises that are not in the contract,” Mr. Shay said. “You might feel you can really trust your new boss and what he tells you, but what if that person resigns, or the organization gets a new owner who doesn’t honor unwritten agreements?”

Many contracts have an integration clause, which specifies that the contract constitutes the complete agreement between the two parties, and it nullifies any other oral or written promises made to the physician.

For example, the employer might have promised a relocation bonus and a sign-on bonus, but for some reason it didn’t get into the contract, Ms. Ord said. In those cases, the employer is under no obligation to honor the promise.

What can you do? Mr. Cassidy said it is possible to hold the employer to a commitment made outside the contract. The alternative document, such as an offer letter, has to specifically state that the commitment is protected from the integration clause in the contract, he said, adding: “It is still better to have the commitment put into the contract.”
 

Contract is simply accepted as is

“Generally, the bigger the employer, the less likely they will alter an agreement just to make you happy,” Mr. Shay said.

But even in these contracts, he said there is still opportunity to fix errors and ambiguities that could harm you later – or even alter a provision if you can’t remove it outright.

The back-and-forth is important, Ms. Adler said. “Negotiation means trying to have some control over your job and your life.”

Mr. Cassidy said a big part of contract review is facing up to the possibility that you may have to resign or be let go.

“Many physicians don’t like to think about leaving when they’re just starting a job, but they need to,” he said. “You need to begin with the end in mind. Think about what would happen if this job didn’t work out.”

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

Physician employment contracts include some new dangers. This includes physicians taking a new job, but it also includes already-employed doctors who are being asked to resign a new contract that contains new conditions. A number of these new clauses have arisen because of COVID-19. When the pandemic dramatically reduced patient flow, many employers didn’t have enough money to pay doctors and didn’t always have physicians in the right location or practice setting.

Vowing this would never happen again, some employers have rewritten their physician contracts to make it easier to reassign and terminate physicians.

Here are 12 potential land mines in a physician employment contract, some of which were added as a result of the pandemic.
 

You could be immediately terminated without notice

One outcome of the pandemic is the growing use of “force majeure” clauses, which give the employer the right to reduce your compensation or even terminate you due to a natural disaster, which could include COVID.

“COVID made employers aware of the potential impact of disasters on their operations,” said Dan Shay, a health law attorney at Alice Gosfield & Associates in Philadelphia. “Therefore, even as the threat of COVID abates in many places, employers are continuing to put this provision in the contract.”

What can you do? “One way to get some protection is to rule out a termination without cause in the first year,” said Michael A. Cassidy, a physician contract attorney at Tucker Arensberg in Pittsburgh.

The force majeure clause is less likely to affect salary, but could impact bonus and incentive tied to performance. It’s wise to try to specifically limit how much the force majeure could reduce pay tied to performance, and to be prepared to negotiate that aspect of your contract.
 

No protections if you’re let go through no fault of your own

You could lose your job if your employer could not generate enough business and has to let some doctors go. This happened quite often in the early days of the COVID pandemic.

In these situations, the doctor has not done anything wrong to prompt the termination, but the restrictive covenant may still apply, meaning that the doctor would have to leave the area to find work.

What can you do? You’re in a good position to get this changed, said Christopher L. Nuland, a solo physician contract attorney in Jacksonville, Fla. “Many employers recognize that it would be draconian to require a restrictive covenant in this case, and they will agree to modify this provision.”

Similarly, the employer may not cover your tail insurance even if you were let go from your work through no fault of your own. Most malpractice policies for employer physicians require buying an extra policy, called a tail, if you leave. In some cases, the employer won’t provide a tail and will make the departing doctor buy it.

In these cases, “try for a compromise, such as stipulating that the party that caused the termination should pay for the tail,” Mr. Nuland said. “The employer may not agree to anything more than that because they want to set up a disincentive against you leaving.”
 

Employer could unilaterally alter your compensation

Many recent contracts give the employer the option to unilaterally modify compensation, such as changing the base salary or raising the target required for meeting the productivity bonus, said Ericka L. Adler, a physician contract attorney at Roetzel & Andress in Chicago.

Ms. Adler thought this change could have been prompted by employers’ financial problems during the pandemic. In the early months of COVID, many physicians were not making much money for the employer but still had to be paid. So employers added a clause saying they could reduce compensation at any time, she said.

What can you do? Harsh provisions like this often come up in contracts with private equity firms, Mr. Cassidy said. “The contract might say the employer can adjust compensation or even terminate physicians based on productivity or their profitability. And it may say that if they reassign you to a new location and you refuse, they can terminate you.”

“If you can’t get these clauses removed, try to reduce the impact of a termination by providing longer notice periods or by inserting a severance agreement,” Mr. Cassidy said.
 

Accelerating notice for without-cause terminations

Physicians who are convicted of a felony or other moral issue can usually be terminated immediately. But if you are terminated for other reasons – that is, “without cause” – you are given notice at a certain number of days before you have to leave (typically 60-90 days), so that you have time to find a new job.

Some recent contracts, however, allow for very little notice in without-cause terminations, which allows the employer to fire you in as little as 0 days after providing notice, Ms. Adler said.

“This means that, even if 90 days’ notice is provided in the contract, the employer can decide that your last day will be an earlier date,” she said.

Why is this happening? Ms. Adler said employers want to begin reallocating resources and patients as soon as possible. The problem came to employers’ attention during the COVID pandemic, when they were contractually forced to pay doctors for doing little or nothing during the notice period.

What can you do? Possibly not much, other than attempt to negotiate. “Large employers typically don’t want to drop this provision, but at the least, the doctor needs to understand the risk it creates for them,” she said.
 

You could be assigned to far-off locations

As patient care needs changed dramatically during the pandemic, employers needed to reassign doctors to new locations.

Some new contracts allow employers to simply inform the doctor that they are changing the work location. However, “you don’t want to be assigned to a new work location that is 50 miles away,” Mr. Nuland said.

What can you do? Mr. Nuland recommended adding new language saying that, if the new assignment is more than 20 miles away, both parties would have to approve it.

You could end up working too many off-hours

“Most employers won’t issue a specific work schedule,” Mr. Nuland said. “They want the flexibility to assign evening or weekend work, and it would be difficult for a young doctor to change this.”

What can you do? Mr. Nuland recommended trying to set some limits. “You can try to limit off-hours work to two times a month or something like that,” she said. And if you need to have a special schedule, such as not working on Fridays, Adler advises that this should be put into the contract.

If you can’t get anything changed in the contract, Mr. Nuland said the next-best thing is to ask employers to tell you specifically what they plan to do with you. “Most employers will give you an informal idea of what’s expected – maybe not an exact schedule, but it’s quite likely they will honor it.”
 

You wouldn’t be able to work nearby if you left the job

Most contracts have a noncompete clause, also known as a “restrictive covenant,” which prevents employed physicians from working in the area if they left the job.

“Almost every doctor I represent has told me that they’re not concerned about the noncompete clause because, they believe, it is not enforceable anyway,” Ms. Adler said. “This is incorrect.”

Mr. Nuland said the faster pace of job-changing during the pandemic makes it all the more likely that doctors have to deal with a restrictive covenant. At the same time, some employers have been expanding the restriction – either by enlarging the radius where the restriction applies or by making the restriction apply to each of their sites, so that each one has a restricted radius around it.

For example, one contract Mr. Nuland is currently reviewing has a 20-mile radius that in effect becomes a 120-mile radius because the employer is counting four offices.

What can you do? Mr. Nuland advised trying to reduce the impact of the noncompete – for instance, making it apply only to the offices where you worked, or trading more time for less distance. “If you have a 2-year, 20-mile restriction, ask for a 3-year, 10-mile restriction, where the radius could be easier to deal with,” he said.
 

You might end up with too much call

Contracts rarely detail your call schedule because employers want flexibility to expand call as patient care needs change, but you can try adding some specificity, said Sanja Ord, a physician contract attorney at Greensfelder, Hemker & Gale in St. Louis.

Contracts often use wide-open language to describe call, such as simply making it “subject to the house call policies,” Mr. Cassidy said. Language that is more beneficial to the physician would say that call must be “equal” among “similarly situated” physicians.

But Ms. Ord said even provisions for equal call can turn out to be onerous if there are too few doctors in the call roster, so it’s a good idea to find out just how many doctors will be participating in call.

Still, Adler said even that strategy can’t remove all risk. What happens, she asked, if several physicians participating in call decide to leave? Then you might end up with call every other night.

What can you do? Mr. Cassidy recommends specifying a maximum amount of call – for example, no more frequent than one in four nights.
 

Physician must pay for reimbursement claw-backs by payers

When auditors for Medicare or other payers find overpayments after the fact, called a ‘claw-back,’ the provider must pay them back. But which provider has to do that – you or your employer?

In many cases, your employer’s billing office may have introduced the error, but there may be a clause in the contract stating that the physician is solely responsible for all claw-backs. That could be costly.

What can you do? Mr. Shay said the clause should state that you have to pay only when it is the result of your own error or omission, and also not when it was made at the direction of the employer.
 

Some work may be outside of your subspecialty

In some cases, the employer may assign subspecialized doctors to work outside their subspecialty, Mr. Nuland said.

For example, he said he represented an endocrinologist who expected to see only diabetes patients but was assigned to some general internal medicine work as well, and an otolaryngologist client of his who completed a fellowship on facial plastic surgery was expected to do liposuction in a cosmetic surgery group.

What can you do? To prevent this from happening, Mr. Nuland recommends a clause stating that your work will be restricted to your subspecialty.

What the employer promised isn’t in the contract

“Beware of promises that are not in the contract,” Mr. Shay said. “You might feel you can really trust your new boss and what he tells you, but what if that person resigns, or the organization gets a new owner who doesn’t honor unwritten agreements?”

Many contracts have an integration clause, which specifies that the contract constitutes the complete agreement between the two parties, and it nullifies any other oral or written promises made to the physician.

For example, the employer might have promised a relocation bonus and a sign-on bonus, but for some reason it didn’t get into the contract, Ms. Ord said. In those cases, the employer is under no obligation to honor the promise.

What can you do? Mr. Cassidy said it is possible to hold the employer to a commitment made outside the contract. The alternative document, such as an offer letter, has to specifically state that the commitment is protected from the integration clause in the contract, he said, adding: “It is still better to have the commitment put into the contract.”
 

Contract is simply accepted as is

“Generally, the bigger the employer, the less likely they will alter an agreement just to make you happy,” Mr. Shay said.

But even in these contracts, he said there is still opportunity to fix errors and ambiguities that could harm you later – or even alter a provision if you can’t remove it outright.

The back-and-forth is important, Ms. Adler said. “Negotiation means trying to have some control over your job and your life.”

Mr. Cassidy said a big part of contract review is facing up to the possibility that you may have to resign or be let go.

“Many physicians don’t like to think about leaving when they’re just starting a job, but they need to,” he said. “You need to begin with the end in mind. Think about what would happen if this job didn’t work out.”

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

Physician employment contracts include some new dangers. This includes physicians taking a new job, but it also includes already-employed doctors who are being asked to resign a new contract that contains new conditions. A number of these new clauses have arisen because of COVID-19. When the pandemic dramatically reduced patient flow, many employers didn’t have enough money to pay doctors and didn’t always have physicians in the right location or practice setting.

Vowing this would never happen again, some employers have rewritten their physician contracts to make it easier to reassign and terminate physicians.

Here are 12 potential land mines in a physician employment contract, some of which were added as a result of the pandemic.
 

You could be immediately terminated without notice

One outcome of the pandemic is the growing use of “force majeure” clauses, which give the employer the right to reduce your compensation or even terminate you due to a natural disaster, which could include COVID.

“COVID made employers aware of the potential impact of disasters on their operations,” said Dan Shay, a health law attorney at Alice Gosfield & Associates in Philadelphia. “Therefore, even as the threat of COVID abates in many places, employers are continuing to put this provision in the contract.”

What can you do? “One way to get some protection is to rule out a termination without cause in the first year,” said Michael A. Cassidy, a physician contract attorney at Tucker Arensberg in Pittsburgh.

The force majeure clause is less likely to affect salary, but could impact bonus and incentive tied to performance. It’s wise to try to specifically limit how much the force majeure could reduce pay tied to performance, and to be prepared to negotiate that aspect of your contract.
 

No protections if you’re let go through no fault of your own

You could lose your job if your employer could not generate enough business and has to let some doctors go. This happened quite often in the early days of the COVID pandemic.

In these situations, the doctor has not done anything wrong to prompt the termination, but the restrictive covenant may still apply, meaning that the doctor would have to leave the area to find work.

What can you do? You’re in a good position to get this changed, said Christopher L. Nuland, a solo physician contract attorney in Jacksonville, Fla. “Many employers recognize that it would be draconian to require a restrictive covenant in this case, and they will agree to modify this provision.”

Similarly, the employer may not cover your tail insurance even if you were let go from your work through no fault of your own. Most malpractice policies for employer physicians require buying an extra policy, called a tail, if you leave. In some cases, the employer won’t provide a tail and will make the departing doctor buy it.

In these cases, “try for a compromise, such as stipulating that the party that caused the termination should pay for the tail,” Mr. Nuland said. “The employer may not agree to anything more than that because they want to set up a disincentive against you leaving.”
 

Employer could unilaterally alter your compensation

Many recent contracts give the employer the option to unilaterally modify compensation, such as changing the base salary or raising the target required for meeting the productivity bonus, said Ericka L. Adler, a physician contract attorney at Roetzel & Andress in Chicago.

Ms. Adler thought this change could have been prompted by employers’ financial problems during the pandemic. In the early months of COVID, many physicians were not making much money for the employer but still had to be paid. So employers added a clause saying they could reduce compensation at any time, she said.

What can you do? Harsh provisions like this often come up in contracts with private equity firms, Mr. Cassidy said. “The contract might say the employer can adjust compensation or even terminate physicians based on productivity or their profitability. And it may say that if they reassign you to a new location and you refuse, they can terminate you.”

“If you can’t get these clauses removed, try to reduce the impact of a termination by providing longer notice periods or by inserting a severance agreement,” Mr. Cassidy said.
 

Accelerating notice for without-cause terminations

Physicians who are convicted of a felony or other moral issue can usually be terminated immediately. But if you are terminated for other reasons – that is, “without cause” – you are given notice at a certain number of days before you have to leave (typically 60-90 days), so that you have time to find a new job.

Some recent contracts, however, allow for very little notice in without-cause terminations, which allows the employer to fire you in as little as 0 days after providing notice, Ms. Adler said.

“This means that, even if 90 days’ notice is provided in the contract, the employer can decide that your last day will be an earlier date,” she said.

Why is this happening? Ms. Adler said employers want to begin reallocating resources and patients as soon as possible. The problem came to employers’ attention during the COVID pandemic, when they were contractually forced to pay doctors for doing little or nothing during the notice period.

What can you do? Possibly not much, other than attempt to negotiate. “Large employers typically don’t want to drop this provision, but at the least, the doctor needs to understand the risk it creates for them,” she said.
 

You could be assigned to far-off locations

As patient care needs changed dramatically during the pandemic, employers needed to reassign doctors to new locations.

Some new contracts allow employers to simply inform the doctor that they are changing the work location. However, “you don’t want to be assigned to a new work location that is 50 miles away,” Mr. Nuland said.

What can you do? Mr. Nuland recommended adding new language saying that, if the new assignment is more than 20 miles away, both parties would have to approve it.

You could end up working too many off-hours

“Most employers won’t issue a specific work schedule,” Mr. Nuland said. “They want the flexibility to assign evening or weekend work, and it would be difficult for a young doctor to change this.”

What can you do? Mr. Nuland recommended trying to set some limits. “You can try to limit off-hours work to two times a month or something like that,” she said. And if you need to have a special schedule, such as not working on Fridays, Adler advises that this should be put into the contract.

If you can’t get anything changed in the contract, Mr. Nuland said the next-best thing is to ask employers to tell you specifically what they plan to do with you. “Most employers will give you an informal idea of what’s expected – maybe not an exact schedule, but it’s quite likely they will honor it.”
 

You wouldn’t be able to work nearby if you left the job

Most contracts have a noncompete clause, also known as a “restrictive covenant,” which prevents employed physicians from working in the area if they left the job.

“Almost every doctor I represent has told me that they’re not concerned about the noncompete clause because, they believe, it is not enforceable anyway,” Ms. Adler said. “This is incorrect.”

Mr. Nuland said the faster pace of job-changing during the pandemic makes it all the more likely that doctors have to deal with a restrictive covenant. At the same time, some employers have been expanding the restriction – either by enlarging the radius where the restriction applies or by making the restriction apply to each of their sites, so that each one has a restricted radius around it.

For example, one contract Mr. Nuland is currently reviewing has a 20-mile radius that in effect becomes a 120-mile radius because the employer is counting four offices.

What can you do? Mr. Nuland advised trying to reduce the impact of the noncompete – for instance, making it apply only to the offices where you worked, or trading more time for less distance. “If you have a 2-year, 20-mile restriction, ask for a 3-year, 10-mile restriction, where the radius could be easier to deal with,” he said.
 

You might end up with too much call

Contracts rarely detail your call schedule because employers want flexibility to expand call as patient care needs change, but you can try adding some specificity, said Sanja Ord, a physician contract attorney at Greensfelder, Hemker & Gale in St. Louis.

Contracts often use wide-open language to describe call, such as simply making it “subject to the house call policies,” Mr. Cassidy said. Language that is more beneficial to the physician would say that call must be “equal” among “similarly situated” physicians.

But Ms. Ord said even provisions for equal call can turn out to be onerous if there are too few doctors in the call roster, so it’s a good idea to find out just how many doctors will be participating in call.

Still, Adler said even that strategy can’t remove all risk. What happens, she asked, if several physicians participating in call decide to leave? Then you might end up with call every other night.

What can you do? Mr. Cassidy recommends specifying a maximum amount of call – for example, no more frequent than one in four nights.
 

Physician must pay for reimbursement claw-backs by payers

When auditors for Medicare or other payers find overpayments after the fact, called a ‘claw-back,’ the provider must pay them back. But which provider has to do that – you or your employer?

In many cases, your employer’s billing office may have introduced the error, but there may be a clause in the contract stating that the physician is solely responsible for all claw-backs. That could be costly.

What can you do? Mr. Shay said the clause should state that you have to pay only when it is the result of your own error or omission, and also not when it was made at the direction of the employer.
 

Some work may be outside of your subspecialty

In some cases, the employer may assign subspecialized doctors to work outside their subspecialty, Mr. Nuland said.

For example, he said he represented an endocrinologist who expected to see only diabetes patients but was assigned to some general internal medicine work as well, and an otolaryngologist client of his who completed a fellowship on facial plastic surgery was expected to do liposuction in a cosmetic surgery group.

What can you do? To prevent this from happening, Mr. Nuland recommends a clause stating that your work will be restricted to your subspecialty.

What the employer promised isn’t in the contract

“Beware of promises that are not in the contract,” Mr. Shay said. “You might feel you can really trust your new boss and what he tells you, but what if that person resigns, or the organization gets a new owner who doesn’t honor unwritten agreements?”

Many contracts have an integration clause, which specifies that the contract constitutes the complete agreement between the two parties, and it nullifies any other oral or written promises made to the physician.

For example, the employer might have promised a relocation bonus and a sign-on bonus, but for some reason it didn’t get into the contract, Ms. Ord said. In those cases, the employer is under no obligation to honor the promise.

What can you do? Mr. Cassidy said it is possible to hold the employer to a commitment made outside the contract. The alternative document, such as an offer letter, has to specifically state that the commitment is protected from the integration clause in the contract, he said, adding: “It is still better to have the commitment put into the contract.”
 

Contract is simply accepted as is

“Generally, the bigger the employer, the less likely they will alter an agreement just to make you happy,” Mr. Shay said.

But even in these contracts, he said there is still opportunity to fix errors and ambiguities that could harm you later – or even alter a provision if you can’t remove it outright.

The back-and-forth is important, Ms. Adler said. “Negotiation means trying to have some control over your job and your life.”

Mr. Cassidy said a big part of contract review is facing up to the possibility that you may have to resign or be let go.

“Many physicians don’t like to think about leaving when they’re just starting a job, but they need to,” he said. “You need to begin with the end in mind. Think about what would happen if this job didn’t work out.”

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

The number of physicians who have chosen early retirement or have left medicine because of the COVID-19 pandemic may be considerably lower than previously thought, results of a new study suggest.

The research letter in the Journal of the American Medical Association, based on Medicare claims data, stated that “practice interruption rates were similar before and during the COVID-19 pandemic, except for a spike in April 2020.”

By contrast, in a Physicians Foundation Survey conducted in August 2020, 8% of physicians said they had closed their practices as a result of COVID, and 4% of the respondents said they planned to leave their practices within the next 12 months.

Similarly, a Jackson Physician Search survey in the fourth quarter of 2020 found that 54% of physicians surveyed had changed their employment plans. Of those doctors, 21% said they might hang up their white coat for early retirement. That works out to about 11% of the respondents.

The JAMA study’s authors analyzed the Medicare claims data from Jan. 1, 2019, to Dec. 30, 2020, to see how many physicians with Medicare patients had stopped filing claims for a period during those 2 years.

If a doctor had ceased submitting claims and then resumed filing them within 6 months after the last billing month, the lapse in filing was defined as “interruption with return.” If a physician stopped filing claims to Medicare and did not resume within 6 months, the gap in filing was called “interruption without return.”

In April 2020, 6.9% of physicians billing Medicare had a practice interruption, compared to 1.4% in 2019. But only 1.1% of physicians stopped practice in April 2020 and did not return, compared with 0.33% in 2019.

Physicians aged 55 or older had higher rates of interruption both with and without return than younger doctors did. The change in interruption rates for older doctors was 7.2% vs. 3.9% for younger physicians. The change in older physicians’ interruption-without-return rate was 1.3% vs. 0.34% for younger colleagues.

“Female physicians, specialists, physicians in smaller practices, those not in a health professional shortage area, and those practicing in a metropolitan area experienced greater increases in practice interruption rates in April 2020 vs. April 2019,” the study states. “But those groups typically had higher rates of return, so the overall changes in practice interruptions without return were similar across characteristics other than age.”
 

Significance for retirement rate

Discussing these results, the authors stressed that practice interruptions without return can’t necessarily be attributed to retirement, and that practice interruptions with return don’t necessarily signify that doctors had been furloughed from their practices.

Also, they said, “this measure of practice interruption likely misses meaningful interruptions that lasted for less than a month or did not involve complete cessation in treating Medicare patients.”

Nevertheless, “the study does capture a signal of some doctors probably retiring,” Jonathan Weiner, DPH, professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, said in an interview.

But he added, “Some of those people who interrupted their practices and didn’t return may still come back. And there are probably a lot of other doctors who are leaving or changing practices that they didn’t capture.” For example, it’s possible that some doctors who went to work for other health care organizations stopped billing under their own names.

In Dr. Weiner’s view, the true percentage of physicians who have retired since the start of the pandemic is probably somewhere between the portion of doctors who interrupted their practice without return, according to the JAMA study, and the percentage of physicians who said they had closed their practices in the Physicians Foundation survey.
 

No mass exodus seen

Michael Belkin, JD, divisional vice president of recruiting for Merritt Hawkins, a physician search firm, said in an interview that the real number may be closer to the interruption-without-return figure in the JAMA study.

While many physician practices were disrupted in spring of 2020, he said, “it really didn’t result in a mass exodus [from health care]. We’re not talking to a lot of candidates who retired or walked away from their practices. We are talking to candidates who slowed down last year and then realized that they wanted to get back into medicine. And now they’re actively looking.”

One change in job candidates’ attitude, Mr. Belkin said, is that, because of COVID-19–related burnout, their quality of life is more important to them.

“They want to know, ‘What’s the culture of the employer like? What did they do last year during COVID? How did they handle it? Have they put together any protocols for the next pandemic?’ “
 

Demand for doctors has returned

In the summer of 2020, there was a major drop in physician recruitment by hospitals and health systems, partly because of fewer patient visits and procedures. But demand for doctors has bounced back over the past year, Mr. Belkin noted. One reason is the pent-up need for care among patients who avoided health care providers in 2020.

Another reason is that some employed doctors – particularly older physicians – have slowed down. Many doctors prefer to work remotely 1 or 2 days a week, providing telehealth visits to patients. That has led to a loss of productivity in many health care organizations and, consequently, a need to hire additional physicians.

Nevertheless, not many doctors are heading for the exit earlier than physicians did before COVID-19.

“They may work reduced hours,” Mr. Belkin said. “But the sense from a physician’s perspective is that this is all they know. For them to walk away from their life in medicine, from who they are, is problematic. So they’re continuing to practice, but at a reduced capacity.”

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

The number of physicians who have chosen early retirement or have left medicine because of the COVID-19 pandemic may be considerably lower than previously thought, results of a new study suggest.

The research letter in the Journal of the American Medical Association, based on Medicare claims data, stated that “practice interruption rates were similar before and during the COVID-19 pandemic, except for a spike in April 2020.”

By contrast, in a Physicians Foundation Survey conducted in August 2020, 8% of physicians said they had closed their practices as a result of COVID, and 4% of the respondents said they planned to leave their practices within the next 12 months.

Similarly, a Jackson Physician Search survey in the fourth quarter of 2020 found that 54% of physicians surveyed had changed their employment plans. Of those doctors, 21% said they might hang up their white coat for early retirement. That works out to about 11% of the respondents.

The JAMA study’s authors analyzed the Medicare claims data from Jan. 1, 2019, to Dec. 30, 2020, to see how many physicians with Medicare patients had stopped filing claims for a period during those 2 years.

If a doctor had ceased submitting claims and then resumed filing them within 6 months after the last billing month, the lapse in filing was defined as “interruption with return.” If a physician stopped filing claims to Medicare and did not resume within 6 months, the gap in filing was called “interruption without return.”

In April 2020, 6.9% of physicians billing Medicare had a practice interruption, compared to 1.4% in 2019. But only 1.1% of physicians stopped practice in April 2020 and did not return, compared with 0.33% in 2019.

Physicians aged 55 or older had higher rates of interruption both with and without return than younger doctors did. The change in interruption rates for older doctors was 7.2% vs. 3.9% for younger physicians. The change in older physicians’ interruption-without-return rate was 1.3% vs. 0.34% for younger colleagues.

“Female physicians, specialists, physicians in smaller practices, those not in a health professional shortage area, and those practicing in a metropolitan area experienced greater increases in practice interruption rates in April 2020 vs. April 2019,” the study states. “But those groups typically had higher rates of return, so the overall changes in practice interruptions without return were similar across characteristics other than age.”
 

Significance for retirement rate

Discussing these results, the authors stressed that practice interruptions without return can’t necessarily be attributed to retirement, and that practice interruptions with return don’t necessarily signify that doctors had been furloughed from their practices.

Also, they said, “this measure of practice interruption likely misses meaningful interruptions that lasted for less than a month or did not involve complete cessation in treating Medicare patients.”

Nevertheless, “the study does capture a signal of some doctors probably retiring,” Jonathan Weiner, DPH, professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, said in an interview.

But he added, “Some of those people who interrupted their practices and didn’t return may still come back. And there are probably a lot of other doctors who are leaving or changing practices that they didn’t capture.” For example, it’s possible that some doctors who went to work for other health care organizations stopped billing under their own names.

In Dr. Weiner’s view, the true percentage of physicians who have retired since the start of the pandemic is probably somewhere between the portion of doctors who interrupted their practice without return, according to the JAMA study, and the percentage of physicians who said they had closed their practices in the Physicians Foundation survey.
 

No mass exodus seen

Michael Belkin, JD, divisional vice president of recruiting for Merritt Hawkins, a physician search firm, said in an interview that the real number may be closer to the interruption-without-return figure in the JAMA study.

While many physician practices were disrupted in spring of 2020, he said, “it really didn’t result in a mass exodus [from health care]. We’re not talking to a lot of candidates who retired or walked away from their practices. We are talking to candidates who slowed down last year and then realized that they wanted to get back into medicine. And now they’re actively looking.”

One change in job candidates’ attitude, Mr. Belkin said, is that, because of COVID-19–related burnout, their quality of life is more important to them.

“They want to know, ‘What’s the culture of the employer like? What did they do last year during COVID? How did they handle it? Have they put together any protocols for the next pandemic?’ “
 

Demand for doctors has returned

In the summer of 2020, there was a major drop in physician recruitment by hospitals and health systems, partly because of fewer patient visits and procedures. But demand for doctors has bounced back over the past year, Mr. Belkin noted. One reason is the pent-up need for care among patients who avoided health care providers in 2020.

Another reason is that some employed doctors – particularly older physicians – have slowed down. Many doctors prefer to work remotely 1 or 2 days a week, providing telehealth visits to patients. That has led to a loss of productivity in many health care organizations and, consequently, a need to hire additional physicians.

Nevertheless, not many doctors are heading for the exit earlier than physicians did before COVID-19.

“They may work reduced hours,” Mr. Belkin said. “But the sense from a physician’s perspective is that this is all they know. For them to walk away from their life in medicine, from who they are, is problematic. So they’re continuing to practice, but at a reduced capacity.”

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

The number of physicians who have chosen early retirement or have left medicine because of the COVID-19 pandemic may be considerably lower than previously thought, results of a new study suggest.

The research letter in the Journal of the American Medical Association, based on Medicare claims data, stated that “practice interruption rates were similar before and during the COVID-19 pandemic, except for a spike in April 2020.”

By contrast, in a Physicians Foundation Survey conducted in August 2020, 8% of physicians said they had closed their practices as a result of COVID, and 4% of the respondents said they planned to leave their practices within the next 12 months.

Similarly, a Jackson Physician Search survey in the fourth quarter of 2020 found that 54% of physicians surveyed had changed their employment plans. Of those doctors, 21% said they might hang up their white coat for early retirement. That works out to about 11% of the respondents.

The JAMA study’s authors analyzed the Medicare claims data from Jan. 1, 2019, to Dec. 30, 2020, to see how many physicians with Medicare patients had stopped filing claims for a period during those 2 years.

If a doctor had ceased submitting claims and then resumed filing them within 6 months after the last billing month, the lapse in filing was defined as “interruption with return.” If a physician stopped filing claims to Medicare and did not resume within 6 months, the gap in filing was called “interruption without return.”

In April 2020, 6.9% of physicians billing Medicare had a practice interruption, compared to 1.4% in 2019. But only 1.1% of physicians stopped practice in April 2020 and did not return, compared with 0.33% in 2019.

Physicians aged 55 or older had higher rates of interruption both with and without return than younger doctors did. The change in interruption rates for older doctors was 7.2% vs. 3.9% for younger physicians. The change in older physicians’ interruption-without-return rate was 1.3% vs. 0.34% for younger colleagues.

“Female physicians, specialists, physicians in smaller practices, those not in a health professional shortage area, and those practicing in a metropolitan area experienced greater increases in practice interruption rates in April 2020 vs. April 2019,” the study states. “But those groups typically had higher rates of return, so the overall changes in practice interruptions without return were similar across characteristics other than age.”
 

Significance for retirement rate

Discussing these results, the authors stressed that practice interruptions without return can’t necessarily be attributed to retirement, and that practice interruptions with return don’t necessarily signify that doctors had been furloughed from their practices.

Also, they said, “this measure of practice interruption likely misses meaningful interruptions that lasted for less than a month or did not involve complete cessation in treating Medicare patients.”

Nevertheless, “the study does capture a signal of some doctors probably retiring,” Jonathan Weiner, DPH, professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, said in an interview.

But he added, “Some of those people who interrupted their practices and didn’t return may still come back. And there are probably a lot of other doctors who are leaving or changing practices that they didn’t capture.” For example, it’s possible that some doctors who went to work for other health care organizations stopped billing under their own names.

In Dr. Weiner’s view, the true percentage of physicians who have retired since the start of the pandemic is probably somewhere between the portion of doctors who interrupted their practice without return, according to the JAMA study, and the percentage of physicians who said they had closed their practices in the Physicians Foundation survey.
 

No mass exodus seen

Michael Belkin, JD, divisional vice president of recruiting for Merritt Hawkins, a physician search firm, said in an interview that the real number may be closer to the interruption-without-return figure in the JAMA study.

While many physician practices were disrupted in spring of 2020, he said, “it really didn’t result in a mass exodus [from health care]. We’re not talking to a lot of candidates who retired or walked away from their practices. We are talking to candidates who slowed down last year and then realized that they wanted to get back into medicine. And now they’re actively looking.”

One change in job candidates’ attitude, Mr. Belkin said, is that, because of COVID-19–related burnout, their quality of life is more important to them.

“They want to know, ‘What’s the culture of the employer like? What did they do last year during COVID? How did they handle it? Have they put together any protocols for the next pandemic?’ “
 

Demand for doctors has returned

In the summer of 2020, there was a major drop in physician recruitment by hospitals and health systems, partly because of fewer patient visits and procedures. But demand for doctors has bounced back over the past year, Mr. Belkin noted. One reason is the pent-up need for care among patients who avoided health care providers in 2020.

Another reason is that some employed doctors – particularly older physicians – have slowed down. Many doctors prefer to work remotely 1 or 2 days a week, providing telehealth visits to patients. That has led to a loss of productivity in many health care organizations and, consequently, a need to hire additional physicians.

Nevertheless, not many doctors are heading for the exit earlier than physicians did before COVID-19.

“They may work reduced hours,” Mr. Belkin said. “But the sense from a physician’s perspective is that this is all they know. For them to walk away from their life in medicine, from who they are, is problematic. So they’re continuing to practice, but at a reduced capacity.”

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

The 30-day mortality rate was significantly lower among hospitalized patients treated by full-time clinicians, compared with those treated by part-time clinicians, in a new study.

The number of physicians working part time in the United States has increased by nearly 11% since 1993, and as more physicians opt for part-time work, quality of care deserves further study, the investigators wrote in JAMA Internal Medicine. Most studies comparing outcomes for patients treated by full-timers and part-timers have focused on outpatient care settings, where mortality is low and the potential for confounding is high, according to the study authors Hirotaka Kato, PhD, of Keio University in Tokyo, and colleagues. The new study, in contrast, is based on data from nearly 400,000 hospitalizations.

The researchers conducted a cross-sectional analysis on a 20% random sample of Medicare patients aged 65 years and older who were treated by a hospitalist for an emergency medical condition between 2011 and 2016. They examined associations between the number of days per year worked by hospitalists and they 30-day mortality rates among the patients they treated. The researchers analyzed a total of 392,797 hospitalizations in which patients were treated by 19,170 hospitalists. The mean age of the hospitalists was 41 years; 39% were female. Clinician work days were divided into quartiles.

Overall, the 30-day mortality was significantly higher among patients treated by clinicians in the bottom quartile with the fewest number of days worked, compared with those treated by clinicians in the top quartile with the most days worked (10.5% vs. 9.6%). The rates were similar in the second and third quartiles (10.0% and 9.5%).

The average number of days worked clinically per year was 57.6 in the lowest quartile versus 163.3 in the highest quartile, a 65% difference. No significant associations were noted between days worked and patient outcomes with regard to physician age, gender, or hospital teaching status.

Hospital 30-day readmission rates were examined as a secondary outcome, but there was no association between patient readmission and the number of days worked by the clinician. The adjusted 30-day readmission rate for clinicians in the bottom quartile of days worked, compared with those in the top quartile, was 15.3% versus 15.2% (P = .61).

The researchers found no difference in patients’ severity of illness (defined by expected mortality) or reason for admission between physicians in the different quartiles of days worked. They eliminated confounding from hospital-level differences by comparing outcomes of patients between physicians in the same hospital.
 

Possible explanations for worse patient outcomes

“As the number of physicians who engage in part-time clinical work continues to increase, these findings should lead to careful consideration by health systems to reevaluate preventive measures to address potential unintended patient harm,” the researchers wrote.

The researchers proposed several reasons for the association between fewer clinical work days and worse patient outcomes. First, physicians putting in less clinical time may be less updated on the latest guidelines, their skills may decline with less frequent patient care, and they may be less familiar with the nurses, medical assistants, and support staff, which may contribute to poor teamwork. The researchers also stated that some part-time physicians may need to balance nonclinical responsibilities, such as research or administrative tasks, concurrently with inpatient care. “It is also possible that physicians with less clinical knowledge or skills select to become part-time physicians, whereas physicians with higher clinical performance decide to work full time,” they noted.

The study findings were limited by several factors including the observational design and potential for unmeasured confounding variables, and the results may not generalize to younger patients or surgical patients, the researchers noted. Also, the study did not include care by hospitalists that was not billed, days in which clinicians treated non-Medicare patients or patients not part of the Medicare sample, or information about the reasons for clinicians’ part-time work.

However, the results were strengthened by the large sample size, and suggest the need for better institutional support to maintain the clinical performance of physicians who may be balancing a range of obligations, they concluded.

Clinician work issues have renewed relevance

“The data in this paper are from 2016 and earlier, but it is possibly event more relevant today than then,” Eileen Barrett, MD, of the University of New Mexico, Albuquerque, said in an interview. “The pandemic has exacerbated stressors being experienced by physicians and other health care workers, including higher clinical workloads and burnout, and spotlighted gendered effects on women in the workforce, which is likely to drive more physicians to part-time work.

“Reporting these findings now is so important so they can contribute to a shared mental model of the challenges physicians and hospitals face as we seek solutions to deliver high-quality and high-value care with an engaged, professionally fulfilled workforce,” she emphasized.

Dr. Barrett said she was surprised that the study did not show differences in readmission rates depending on the number of shifts worked, and also that the results were not different when considering expected mortality.

“However unpopular it may be to say so, physicians and administrators should assume these results apply to their practice unless they have examined their own data and know it does not,” Dr. Barrett said. “With that in mind, hospitals, administrators, and regulatory bodies have an urgent need to examine and reduce the forces driving physicians to part-time clinical work. Some of these factors include the absence of childcare, excessive paperwork, burnout, administrative duties, and valued experiences such as teaching, leadership, and research that keep clinicians from the bedside.

“Additionally, steps should be taken to reduce the administrative complexity that makes providing the best care to patients difficult and requires hospitalists to create ‘workarounds,’ because those who work fewer clinical hours may not know how to do these, nor how to advocate for their patients,” Dr. Barrett emphasized.

“Additional research is needed to determine how mortality varies by number of clinical shifts for pediatric and obstetric patients who are infrequently covered by Medicare, also how the pandemic and increasing administrative complexity since the time the data was obtained affect patient care,” Dr. Barrett noted.

The study was supported by a grant from the Japan Society for the Promotion of Science to lead author Dr. Kato, who had no financial conflicts to disclose. Dr. Barrett, who serves on the editorial advisory board of Internal Medicine News, had no financial conflicts.

The 30-day mortality rate was significantly lower among hospitalized patients treated by full-time clinicians, compared with those treated by part-time clinicians, in a new study.

The number of physicians working part time in the United States has increased by nearly 11% since 1993, and as more physicians opt for part-time work, quality of care deserves further study, the investigators wrote in JAMA Internal Medicine. Most studies comparing outcomes for patients treated by full-timers and part-timers have focused on outpatient care settings, where mortality is low and the potential for confounding is high, according to the study authors Hirotaka Kato, PhD, of Keio University in Tokyo, and colleagues. The new study, in contrast, is based on data from nearly 400,000 hospitalizations.

The researchers conducted a cross-sectional analysis on a 20% random sample of Medicare patients aged 65 years and older who were treated by a hospitalist for an emergency medical condition between 2011 and 2016. They examined associations between the number of days per year worked by hospitalists and they 30-day mortality rates among the patients they treated. The researchers analyzed a total of 392,797 hospitalizations in which patients were treated by 19,170 hospitalists. The mean age of the hospitalists was 41 years; 39% were female. Clinician work days were divided into quartiles.

Overall, the 30-day mortality was significantly higher among patients treated by clinicians in the bottom quartile with the fewest number of days worked, compared with those treated by clinicians in the top quartile with the most days worked (10.5% vs. 9.6%). The rates were similar in the second and third quartiles (10.0% and 9.5%).

The average number of days worked clinically per year was 57.6 in the lowest quartile versus 163.3 in the highest quartile, a 65% difference. No significant associations were noted between days worked and patient outcomes with regard to physician age, gender, or hospital teaching status.

Hospital 30-day readmission rates were examined as a secondary outcome, but there was no association between patient readmission and the number of days worked by the clinician. The adjusted 30-day readmission rate for clinicians in the bottom quartile of days worked, compared with those in the top quartile, was 15.3% versus 15.2% (P = .61).

The researchers found no difference in patients’ severity of illness (defined by expected mortality) or reason for admission between physicians in the different quartiles of days worked. They eliminated confounding from hospital-level differences by comparing outcomes of patients between physicians in the same hospital.
 

Possible explanations for worse patient outcomes

“As the number of physicians who engage in part-time clinical work continues to increase, these findings should lead to careful consideration by health systems to reevaluate preventive measures to address potential unintended patient harm,” the researchers wrote.

The researchers proposed several reasons for the association between fewer clinical work days and worse patient outcomes. First, physicians putting in less clinical time may be less updated on the latest guidelines, their skills may decline with less frequent patient care, and they may be less familiar with the nurses, medical assistants, and support staff, which may contribute to poor teamwork. The researchers also stated that some part-time physicians may need to balance nonclinical responsibilities, such as research or administrative tasks, concurrently with inpatient care. “It is also possible that physicians with less clinical knowledge or skills select to become part-time physicians, whereas physicians with higher clinical performance decide to work full time,” they noted.

The study findings were limited by several factors including the observational design and potential for unmeasured confounding variables, and the results may not generalize to younger patients or surgical patients, the researchers noted. Also, the study did not include care by hospitalists that was not billed, days in which clinicians treated non-Medicare patients or patients not part of the Medicare sample, or information about the reasons for clinicians’ part-time work.

However, the results were strengthened by the large sample size, and suggest the need for better institutional support to maintain the clinical performance of physicians who may be balancing a range of obligations, they concluded.

Clinician work issues have renewed relevance

“The data in this paper are from 2016 and earlier, but it is possibly event more relevant today than then,” Eileen Barrett, MD, of the University of New Mexico, Albuquerque, said in an interview. “The pandemic has exacerbated stressors being experienced by physicians and other health care workers, including higher clinical workloads and burnout, and spotlighted gendered effects on women in the workforce, which is likely to drive more physicians to part-time work.

“Reporting these findings now is so important so they can contribute to a shared mental model of the challenges physicians and hospitals face as we seek solutions to deliver high-quality and high-value care with an engaged, professionally fulfilled workforce,” she emphasized.

Dr. Barrett said she was surprised that the study did not show differences in readmission rates depending on the number of shifts worked, and also that the results were not different when considering expected mortality.

“However unpopular it may be to say so, physicians and administrators should assume these results apply to their practice unless they have examined their own data and know it does not,” Dr. Barrett said. “With that in mind, hospitals, administrators, and regulatory bodies have an urgent need to examine and reduce the forces driving physicians to part-time clinical work. Some of these factors include the absence of childcare, excessive paperwork, burnout, administrative duties, and valued experiences such as teaching, leadership, and research that keep clinicians from the bedside.

“Additionally, steps should be taken to reduce the administrative complexity that makes providing the best care to patients difficult and requires hospitalists to create ‘workarounds,’ because those who work fewer clinical hours may not know how to do these, nor how to advocate for their patients,” Dr. Barrett emphasized.

“Additional research is needed to determine how mortality varies by number of clinical shifts for pediatric and obstetric patients who are infrequently covered by Medicare, also how the pandemic and increasing administrative complexity since the time the data was obtained affect patient care,” Dr. Barrett noted.

The study was supported by a grant from the Japan Society for the Promotion of Science to lead author Dr. Kato, who had no financial conflicts to disclose. Dr. Barrett, who serves on the editorial advisory board of Internal Medicine News, had no financial conflicts.

The 30-day mortality rate was significantly lower among hospitalized patients treated by full-time clinicians, compared with those treated by part-time clinicians, in a new study.

The number of physicians working part time in the United States has increased by nearly 11% since 1993, and as more physicians opt for part-time work, quality of care deserves further study, the investigators wrote in JAMA Internal Medicine. Most studies comparing outcomes for patients treated by full-timers and part-timers have focused on outpatient care settings, where mortality is low and the potential for confounding is high, according to the study authors Hirotaka Kato, PhD, of Keio University in Tokyo, and colleagues. The new study, in contrast, is based on data from nearly 400,000 hospitalizations.

The researchers conducted a cross-sectional analysis on a 20% random sample of Medicare patients aged 65 years and older who were treated by a hospitalist for an emergency medical condition between 2011 and 2016. They examined associations between the number of days per year worked by hospitalists and they 30-day mortality rates among the patients they treated. The researchers analyzed a total of 392,797 hospitalizations in which patients were treated by 19,170 hospitalists. The mean age of the hospitalists was 41 years; 39% were female. Clinician work days were divided into quartiles.

Overall, the 30-day mortality was significantly higher among patients treated by clinicians in the bottom quartile with the fewest number of days worked, compared with those treated by clinicians in the top quartile with the most days worked (10.5% vs. 9.6%). The rates were similar in the second and third quartiles (10.0% and 9.5%).

The average number of days worked clinically per year was 57.6 in the lowest quartile versus 163.3 in the highest quartile, a 65% difference. No significant associations were noted between days worked and patient outcomes with regard to physician age, gender, or hospital teaching status.

Hospital 30-day readmission rates were examined as a secondary outcome, but there was no association between patient readmission and the number of days worked by the clinician. The adjusted 30-day readmission rate for clinicians in the bottom quartile of days worked, compared with those in the top quartile, was 15.3% versus 15.2% (P = .61).

The researchers found no difference in patients’ severity of illness (defined by expected mortality) or reason for admission between physicians in the different quartiles of days worked. They eliminated confounding from hospital-level differences by comparing outcomes of patients between physicians in the same hospital.
 

Possible explanations for worse patient outcomes

“As the number of physicians who engage in part-time clinical work continues to increase, these findings should lead to careful consideration by health systems to reevaluate preventive measures to address potential unintended patient harm,” the researchers wrote.

The researchers proposed several reasons for the association between fewer clinical work days and worse patient outcomes. First, physicians putting in less clinical time may be less updated on the latest guidelines, their skills may decline with less frequent patient care, and they may be less familiar with the nurses, medical assistants, and support staff, which may contribute to poor teamwork. The researchers also stated that some part-time physicians may need to balance nonclinical responsibilities, such as research or administrative tasks, concurrently with inpatient care. “It is also possible that physicians with less clinical knowledge or skills select to become part-time physicians, whereas physicians with higher clinical performance decide to work full time,” they noted.

The study findings were limited by several factors including the observational design and potential for unmeasured confounding variables, and the results may not generalize to younger patients or surgical patients, the researchers noted. Also, the study did not include care by hospitalists that was not billed, days in which clinicians treated non-Medicare patients or patients not part of the Medicare sample, or information about the reasons for clinicians’ part-time work.

However, the results were strengthened by the large sample size, and suggest the need for better institutional support to maintain the clinical performance of physicians who may be balancing a range of obligations, they concluded.

Clinician work issues have renewed relevance

“The data in this paper are from 2016 and earlier, but it is possibly event more relevant today than then,” Eileen Barrett, MD, of the University of New Mexico, Albuquerque, said in an interview. “The pandemic has exacerbated stressors being experienced by physicians and other health care workers, including higher clinical workloads and burnout, and spotlighted gendered effects on women in the workforce, which is likely to drive more physicians to part-time work.

“Reporting these findings now is so important so they can contribute to a shared mental model of the challenges physicians and hospitals face as we seek solutions to deliver high-quality and high-value care with an engaged, professionally fulfilled workforce,” she emphasized.

Dr. Barrett said she was surprised that the study did not show differences in readmission rates depending on the number of shifts worked, and also that the results were not different when considering expected mortality.

“However unpopular it may be to say so, physicians and administrators should assume these results apply to their practice unless they have examined their own data and know it does not,” Dr. Barrett said. “With that in mind, hospitals, administrators, and regulatory bodies have an urgent need to examine and reduce the forces driving physicians to part-time clinical work. Some of these factors include the absence of childcare, excessive paperwork, burnout, administrative duties, and valued experiences such as teaching, leadership, and research that keep clinicians from the bedside.

“Additionally, steps should be taken to reduce the administrative complexity that makes providing the best care to patients difficult and requires hospitalists to create ‘workarounds,’ because those who work fewer clinical hours may not know how to do these, nor how to advocate for their patients,” Dr. Barrett emphasized.

“Additional research is needed to determine how mortality varies by number of clinical shifts for pediatric and obstetric patients who are infrequently covered by Medicare, also how the pandemic and increasing administrative complexity since the time the data was obtained affect patient care,” Dr. Barrett noted.

The study was supported by a grant from the Japan Society for the Promotion of Science to lead author Dr. Kato, who had no financial conflicts to disclose. Dr. Barrett, who serves on the editorial advisory board of Internal Medicine News, had no financial conflicts.

Nearly half of female surgeons (42%) who were recently surveyed have had a miscarriage or stillbirth – twice the rate of women aged 30-40 years in the general population – according to an article published online July 28 in JAMA Surgery.

The authors, led by Erika L. Rangel, MD, division of general and gastrointestinal surgery, department of surgery, Brigham and Women’s Hospital, Boston, found that after the losses, the women took little or no time off.

Of 692 surgeons surveyed, 347 female surgeons had experienced a pregnancy loss. Of those, 244 had had a miscarriage at less than 10 weeks’ gestation, 92 had had a miscarriage between 10 and 20 weeks’ gestation, and 11 had had a stillbirth (loss at 20 weeks or later).
 

Most took no time off after miscarriage

After a miscarriage, 225 of 336 women (75%) took no time off work, and after a stillbirth, 5 of 11 (45%) took off 1 week or less, the authors found.

The study addressed an issue that people have talked about anecdotally or on social media, Dr. Rangel told this news organization.

“This was finally an opportunity to do a study of enough magnitude to show that there is a very quantifiable difference in complication rate, use of IVF [in vitro fertilization], and the age at which we have children. These are not just anecdotal stories,” she said.

For the study, a self-administered questionnaire was distributed electronically. Answers were collected from November 2020 to January 2021 through multiple U.S. surgical societies and social media among attending and resident surgeons with children. The control group for the study comprised 158 male surgeons who answered questions regarding their partners’ pregnancies.

Female surgeons had fewer children compared with male surgeons and their female partners (mean [SD],1.8 [0.8], versus 2.3 [1.1]; P < .001) and were more likely to delay having children because of surgical training (450 of 692 [65.0%] versus 69 of 158 [43.7%]; P < .001).

In addition, Dr. Rangel and colleagues found that 57% of female surgeons worked more than 60 hours a week during pregnancy and that 37% took more than six overnight calls.

The data show that female surgeons who operated 12 or more hours per week during the last trimester of pregnancy were at higher risk compared with those who operated fewer hours (odds ratio, 1.57; 95% confidence interval, 1.08-2.26).

“Pregnant surgeons should not be operating more than 12 hours a week when they are in the third trimester,” Dr. Rangel said.

“That is a modifiable risk factor,” she told this news organization. “It’s a very brief period of support – a couple of months of support for a woman who may do 25-30 more years of serving the public with surgical skills.”

She said that training programs should be organized so as to have colleagues cover operating room (OR) shifts to reduce the operating hours for pregnant colleagues. In addition, advanced practice health care professionals should be paid to take up the paperwork and perform non-OR care to reduce the stigma associated with pregnant trainees overburdening other surgical trainees.
 

‘It’s too big an ask’

Obstetrician-gynecologist Maryam Siddiqui, MD, said in an interview that she was particularly struck by the number of female surgeons who experience involuntary childlessness.

“That’s a big ask for people who want childbearing to be a part of the fulfillment of their life. It’s too big,” said Dr. Siddiqui, a gynecologic surgeon at UChicago Medicine.

She said the amount of detail in the article and the large number of participants were persuasive factors that can support establishing a more humane system than one in which one person at a time has to ask for change.

Pointing to the finding that three-fourths of the women in the study who had had miscarriages didn’t take time off, she said, “That’s not really humane. But they’re afraid to ask or they don’t want to reveal they’re trying [to get pregnant]. Why should you be afraid of building your family?”

The authors also found other adverse outcomes. Female surgeons were more likely to have musculoskeletal disorders compared with female nonsurgeon partners (36.9% versus 18.4%; P < .001), and they were more likely to undergo nonelective cesarean delivery (25.5% versus 15.3%; P = .01) and to experience postpartum depression (11.1% versus 5.7%; P = .04).

Dr. Siddiqui said the conditions that surgeons encounter on their return to work after childbirth are “a perfect storm” for postpartum depression among women who are not accustomed to being reliant on others.

Women often feel coerced into returning to work before they are physically or emotionally ready, then toggle back and forth from night shift to day shift, losing sleep, she said. “We can do better.”

One of the solutions, she said, is to provide better work coverage for the surgeon while she is pregnant and when she returns to work. That includes properly compensating the person covering for the surgeon by giving that person extra pay or additional time off.

“You have to value both people,” she said. “If both people are valued, there’s still collegiality.”

She acknowledged that that kind of compensation may be more readily available at large academic centers.

At UChicago, she said, they are creative with scheduling in training. For women at the height of pregnancy, rotations are less intensive, and trauma rotations are avoided.

Dr. Siddiqui said one of the most important aspects of the article is the authors’ list of two dozen ways, both big and small, to improve conditions.

Adopting such changes will become increasingly important for hiring and retaining female surgeons. “You want to work someplace where you’re respected as a whole person,” she said.

Sarah Blair, MD, a surgical oncologist at University of California, San Diego, stated that the number of miscarriages in particular provides disturbing proof of a problem women in surgery frequently discuss.

For nearly a decade, she led a women-in-surgery committee at UCSD in which they discussed such issues regarding pregnancy and medicine.

She said she hopes these data can help push for change in flexibility in residency so that women can graduate on time and have the families they want.

“There’s a movement away from time-based training to competency-based training, so maybe that will help women,” she said.
 

‘We have to figure this out’

“We will have to figure this out, because more than half of the people in medical school are women, and there are a lot more women in surgery than when I trained more than 20 years ago. It’s not a problem that’s going away,” she said.

One sign of improvement happened recently, Dr. Rangel said.

As previously reported, according to the American Board of Medical Specialties, as of July 1, 2021, residents and fellows are allowed a minimum 6 weeks away for medical leave or caregiving once during training, without having to use vacation time or sick leave and without having to extend their training.

“That’s huge,” she said. “But we still have a long way to go, because the residency programs still don’t have to have policy that abides that. It merely says you can take 6 weeks off and take your boards. It doesn’t say that the residency program has to allow you to take 6 weeks off.”

The authors noted that the United States and Papua New Guinea are the only countries in the world without federally mandated paid parental leave.

“Most U.S. female surgeons rely on their employer for this benefit, but only half of top-ranked medical schools offer paid leave, and 33%-65% of U.S. surgical training programs lack clear maternity leave policies,” she said.

Funding for the study was provided by the department of surgery at Brigham and Women’s Hospital. The study authors, Dr. Blair, and Dr. Siddiqui have disclosed no relevant financial relationships.

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

Nearly half of female surgeons (42%) who were recently surveyed have had a miscarriage or stillbirth – twice the rate of women aged 30-40 years in the general population – according to an article published online July 28 in JAMA Surgery.

The authors, led by Erika L. Rangel, MD, division of general and gastrointestinal surgery, department of surgery, Brigham and Women’s Hospital, Boston, found that after the losses, the women took little or no time off.

Of 692 surgeons surveyed, 347 female surgeons had experienced a pregnancy loss. Of those, 244 had had a miscarriage at less than 10 weeks’ gestation, 92 had had a miscarriage between 10 and 20 weeks’ gestation, and 11 had had a stillbirth (loss at 20 weeks or later).
 

Most took no time off after miscarriage

After a miscarriage, 225 of 336 women (75%) took no time off work, and after a stillbirth, 5 of 11 (45%) took off 1 week or less, the authors found.

The study addressed an issue that people have talked about anecdotally or on social media, Dr. Rangel told this news organization.

“This was finally an opportunity to do a study of enough magnitude to show that there is a very quantifiable difference in complication rate, use of IVF [in vitro fertilization], and the age at which we have children. These are not just anecdotal stories,” she said.

For the study, a self-administered questionnaire was distributed electronically. Answers were collected from November 2020 to January 2021 through multiple U.S. surgical societies and social media among attending and resident surgeons with children. The control group for the study comprised 158 male surgeons who answered questions regarding their partners’ pregnancies.

Female surgeons had fewer children compared with male surgeons and their female partners (mean [SD],1.8 [0.8], versus 2.3 [1.1]; P < .001) and were more likely to delay having children because of surgical training (450 of 692 [65.0%] versus 69 of 158 [43.7%]; P < .001).

In addition, Dr. Rangel and colleagues found that 57% of female surgeons worked more than 60 hours a week during pregnancy and that 37% took more than six overnight calls.

The data show that female surgeons who operated 12 or more hours per week during the last trimester of pregnancy were at higher risk compared with those who operated fewer hours (odds ratio, 1.57; 95% confidence interval, 1.08-2.26).

“Pregnant surgeons should not be operating more than 12 hours a week when they are in the third trimester,” Dr. Rangel said.

“That is a modifiable risk factor,” she told this news organization. “It’s a very brief period of support – a couple of months of support for a woman who may do 25-30 more years of serving the public with surgical skills.”

She said that training programs should be organized so as to have colleagues cover operating room (OR) shifts to reduce the operating hours for pregnant colleagues. In addition, advanced practice health care professionals should be paid to take up the paperwork and perform non-OR care to reduce the stigma associated with pregnant trainees overburdening other surgical trainees.
 

‘It’s too big an ask’

Obstetrician-gynecologist Maryam Siddiqui, MD, said in an interview that she was particularly struck by the number of female surgeons who experience involuntary childlessness.

“That’s a big ask for people who want childbearing to be a part of the fulfillment of their life. It’s too big,” said Dr. Siddiqui, a gynecologic surgeon at UChicago Medicine.

She said the amount of detail in the article and the large number of participants were persuasive factors that can support establishing a more humane system than one in which one person at a time has to ask for change.

Pointing to the finding that three-fourths of the women in the study who had had miscarriages didn’t take time off, she said, “That’s not really humane. But they’re afraid to ask or they don’t want to reveal they’re trying [to get pregnant]. Why should you be afraid of building your family?”

The authors also found other adverse outcomes. Female surgeons were more likely to have musculoskeletal disorders compared with female nonsurgeon partners (36.9% versus 18.4%; P < .001), and they were more likely to undergo nonelective cesarean delivery (25.5% versus 15.3%; P = .01) and to experience postpartum depression (11.1% versus 5.7%; P = .04).

Dr. Siddiqui said the conditions that surgeons encounter on their return to work after childbirth are “a perfect storm” for postpartum depression among women who are not accustomed to being reliant on others.

Women often feel coerced into returning to work before they are physically or emotionally ready, then toggle back and forth from night shift to day shift, losing sleep, she said. “We can do better.”

One of the solutions, she said, is to provide better work coverage for the surgeon while she is pregnant and when she returns to work. That includes properly compensating the person covering for the surgeon by giving that person extra pay or additional time off.

“You have to value both people,” she said. “If both people are valued, there’s still collegiality.”

She acknowledged that that kind of compensation may be more readily available at large academic centers.

At UChicago, she said, they are creative with scheduling in training. For women at the height of pregnancy, rotations are less intensive, and trauma rotations are avoided.

Dr. Siddiqui said one of the most important aspects of the article is the authors’ list of two dozen ways, both big and small, to improve conditions.

Adopting such changes will become increasingly important for hiring and retaining female surgeons. “You want to work someplace where you’re respected as a whole person,” she said.

Sarah Blair, MD, a surgical oncologist at University of California, San Diego, stated that the number of miscarriages in particular provides disturbing proof of a problem women in surgery frequently discuss.

For nearly a decade, she led a women-in-surgery committee at UCSD in which they discussed such issues regarding pregnancy and medicine.

She said she hopes these data can help push for change in flexibility in residency so that women can graduate on time and have the families they want.

“There’s a movement away from time-based training to competency-based training, so maybe that will help women,” she said.
 

‘We have to figure this out’

“We will have to figure this out, because more than half of the people in medical school are women, and there are a lot more women in surgery than when I trained more than 20 years ago. It’s not a problem that’s going away,” she said.

One sign of improvement happened recently, Dr. Rangel said.

As previously reported, according to the American Board of Medical Specialties, as of July 1, 2021, residents and fellows are allowed a minimum 6 weeks away for medical leave or caregiving once during training, without having to use vacation time or sick leave and without having to extend their training.

“That’s huge,” she said. “But we still have a long way to go, because the residency programs still don’t have to have policy that abides that. It merely says you can take 6 weeks off and take your boards. It doesn’t say that the residency program has to allow you to take 6 weeks off.”

The authors noted that the United States and Papua New Guinea are the only countries in the world without federally mandated paid parental leave.

“Most U.S. female surgeons rely on their employer for this benefit, but only half of top-ranked medical schools offer paid leave, and 33%-65% of U.S. surgical training programs lack clear maternity leave policies,” she said.

Funding for the study was provided by the department of surgery at Brigham and Women’s Hospital. The study authors, Dr. Blair, and Dr. Siddiqui have disclosed no relevant financial relationships.

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

Nearly half of female surgeons (42%) who were recently surveyed have had a miscarriage or stillbirth – twice the rate of women aged 30-40 years in the general population – according to an article published online July 28 in JAMA Surgery.

The authors, led by Erika L. Rangel, MD, division of general and gastrointestinal surgery, department of surgery, Brigham and Women’s Hospital, Boston, found that after the losses, the women took little or no time off.

Of 692 surgeons surveyed, 347 female surgeons had experienced a pregnancy loss. Of those, 244 had had a miscarriage at less than 10 weeks’ gestation, 92 had had a miscarriage between 10 and 20 weeks’ gestation, and 11 had had a stillbirth (loss at 20 weeks or later).
 

Most took no time off after miscarriage

After a miscarriage, 225 of 336 women (75%) took no time off work, and after a stillbirth, 5 of 11 (45%) took off 1 week or less, the authors found.

The study addressed an issue that people have talked about anecdotally or on social media, Dr. Rangel told this news organization.

“This was finally an opportunity to do a study of enough magnitude to show that there is a very quantifiable difference in complication rate, use of IVF [in vitro fertilization], and the age at which we have children. These are not just anecdotal stories,” she said.

For the study, a self-administered questionnaire was distributed electronically. Answers were collected from November 2020 to January 2021 through multiple U.S. surgical societies and social media among attending and resident surgeons with children. The control group for the study comprised 158 male surgeons who answered questions regarding their partners’ pregnancies.

Female surgeons had fewer children compared with male surgeons and their female partners (mean [SD],1.8 [0.8], versus 2.3 [1.1]; P < .001) and were more likely to delay having children because of surgical training (450 of 692 [65.0%] versus 69 of 158 [43.7%]; P < .001).

In addition, Dr. Rangel and colleagues found that 57% of female surgeons worked more than 60 hours a week during pregnancy and that 37% took more than six overnight calls.

The data show that female surgeons who operated 12 or more hours per week during the last trimester of pregnancy were at higher risk compared with those who operated fewer hours (odds ratio, 1.57; 95% confidence interval, 1.08-2.26).

“Pregnant surgeons should not be operating more than 12 hours a week when they are in the third trimester,” Dr. Rangel said.

“That is a modifiable risk factor,” she told this news organization. “It’s a very brief period of support – a couple of months of support for a woman who may do 25-30 more years of serving the public with surgical skills.”

She said that training programs should be organized so as to have colleagues cover operating room (OR) shifts to reduce the operating hours for pregnant colleagues. In addition, advanced practice health care professionals should be paid to take up the paperwork and perform non-OR care to reduce the stigma associated with pregnant trainees overburdening other surgical trainees.
 

‘It’s too big an ask’

Obstetrician-gynecologist Maryam Siddiqui, MD, said in an interview that she was particularly struck by the number of female surgeons who experience involuntary childlessness.

“That’s a big ask for people who want childbearing to be a part of the fulfillment of their life. It’s too big,” said Dr. Siddiqui, a gynecologic surgeon at UChicago Medicine.

She said the amount of detail in the article and the large number of participants were persuasive factors that can support establishing a more humane system than one in which one person at a time has to ask for change.

Pointing to the finding that three-fourths of the women in the study who had had miscarriages didn’t take time off, she said, “That’s not really humane. But they’re afraid to ask or they don’t want to reveal they’re trying [to get pregnant]. Why should you be afraid of building your family?”

The authors also found other adverse outcomes. Female surgeons were more likely to have musculoskeletal disorders compared with female nonsurgeon partners (36.9% versus 18.4%; P < .001), and they were more likely to undergo nonelective cesarean delivery (25.5% versus 15.3%; P = .01) and to experience postpartum depression (11.1% versus 5.7%; P = .04).

Dr. Siddiqui said the conditions that surgeons encounter on their return to work after childbirth are “a perfect storm” for postpartum depression among women who are not accustomed to being reliant on others.

Women often feel coerced into returning to work before they are physically or emotionally ready, then toggle back and forth from night shift to day shift, losing sleep, she said. “We can do better.”

One of the solutions, she said, is to provide better work coverage for the surgeon while she is pregnant and when she returns to work. That includes properly compensating the person covering for the surgeon by giving that person extra pay or additional time off.

“You have to value both people,” she said. “If both people are valued, there’s still collegiality.”

She acknowledged that that kind of compensation may be more readily available at large academic centers.

At UChicago, she said, they are creative with scheduling in training. For women at the height of pregnancy, rotations are less intensive, and trauma rotations are avoided.

Dr. Siddiqui said one of the most important aspects of the article is the authors’ list of two dozen ways, both big and small, to improve conditions.

Adopting such changes will become increasingly important for hiring and retaining female surgeons. “You want to work someplace where you’re respected as a whole person,” she said.

Sarah Blair, MD, a surgical oncologist at University of California, San Diego, stated that the number of miscarriages in particular provides disturbing proof of a problem women in surgery frequently discuss.

For nearly a decade, she led a women-in-surgery committee at UCSD in which they discussed such issues regarding pregnancy and medicine.

She said she hopes these data can help push for change in flexibility in residency so that women can graduate on time and have the families they want.

“There’s a movement away from time-based training to competency-based training, so maybe that will help women,” she said.
 

‘We have to figure this out’

“We will have to figure this out, because more than half of the people in medical school are women, and there are a lot more women in surgery than when I trained more than 20 years ago. It’s not a problem that’s going away,” she said.

One sign of improvement happened recently, Dr. Rangel said.

As previously reported, according to the American Board of Medical Specialties, as of July 1, 2021, residents and fellows are allowed a minimum 6 weeks away for medical leave or caregiving once during training, without having to use vacation time or sick leave and without having to extend their training.

“That’s huge,” she said. “But we still have a long way to go, because the residency programs still don’t have to have policy that abides that. It merely says you can take 6 weeks off and take your boards. It doesn’t say that the residency program has to allow you to take 6 weeks off.”

The authors noted that the United States and Papua New Guinea are the only countries in the world without federally mandated paid parental leave.

“Most U.S. female surgeons rely on their employer for this benefit, but only half of top-ranked medical schools offer paid leave, and 33%-65% of U.S. surgical training programs lack clear maternity leave policies,” she said.

Funding for the study was provided by the department of surgery at Brigham and Women’s Hospital. The study authors, Dr. Blair, and Dr. Siddiqui have disclosed no relevant financial relationships.

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