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The Impact of a Paracentesis Clinic on Internal Medicine Resident Procedural Competency
Competency in paracentesis is an important procedural skill for medical practitioners caring for patients with decompensated liver cirrhosis. Paracentesis is performed to drain ascitic fluid for both diagnosis and/or therapeutic purposes.1 While this procedure can be performed without the use of ultrasound, it is preferable to use ultrasound to identify an area of fluid that is away from dangerous anatomy including bowel loops, the liver, and spleen. After prepping the area, lidocaine is administered locally. A catheter is then inserted until fluid begins flowing freely. The catheter is connected to a suction canister or collection kit, and the patient is monitored until the flow ceases. Samples can be sent for analysis to determine the etiology of ascites, identify concerns for infection, and more.
Paracentesis is a very common procedure. Barsuk and colleagues noted that between 2010 and 2012, 97,577 procedures were performed across 120 academic medical centers and 290 affiliated hospitals.2 Patients undergo paracentesis in a variety of settings including the emergency department, inpatient hospitalizations, and clinics. Some patients may require only 1 paracentesis procedure while others may require it regularly.
Due to the rising need for paracentesis in the Central Texas Veterans Affairs Hospital (CTVAH) in Temple, a paracentesis clinic was started in February 2018. The goal of the paracentesis clinic was multifocal—to reduce hospital admissions, improve access to regularly scheduled procedures, decrease wait times, and increase patient satisfaction.3 Through the CTVAH affiliation with the Texas A&M internal medicine residency program, the paracentesis clinic started involving and training residents on this procedure. Up to 3 residents are on weekly rotation and can perform up to 6 paracentesis procedures in a week. The purpose of this article was to evaluate resident competency in paracentesis after completion of the paracentesis clinic.
Methods
The paracentesis clinic schedules up to 3 patients on Tuesdays and Thursdays between 8
A survey was sent via email to all categorical internal medicine residents across all 3 program years at the time of data collection. Competency for paracentesis sign-off was defined as completing and logging 5 procedures supervised by a competent physician who confirmed that all portions of the procedure were performed correctly. Residents were also asked to answer questions on a scale from 1 to 10, with 1 representing no confidence and 10 representing strong confidence to practice independently (Table).
We also evaluated the number of procedures performed by internal medicine residents 3 years before the clinic was started in 2015 up to the completion of 2022. The numbers were obtained by examining procedural log data for each year for all internal medicine residents.
Results
Thirty-three residents completed the survey: 10 first-year internal medicine residents (PGY1), 12 second-year residents (PGY2), and 11 third-year residents (PGY3). The mean participation was 4.8 paracentesis sessions per person for the duration of the study. The range of paracentesis procedures performed varied based on PGY year: PGY1s performed 1 to > 10 procedures, PGY2s performed 2 to > 10 procedures, and PGY3s performed 5 to > 10 procedures. Thirty-six percent of residents completed > 10 procedures in the paracentesis clinic; 82% of PGY3s had completed > 10 procedures by December of their third year. Twenty-six residents (79%) were credentialed to perform paracentesis procedures independently after performing > 5 procedures, and 7 residents were not yet cleared for procedural independence.
In the survey, residents rated their comfort with performing paracentesis procedures independently at a mean of 7.9. The mean comfort reported by PGY1s was 7.2, PGY2s was 7.3, and PGY3s was 9.3. Residents also rated their opinion on whether or not the paracentesis clinic adequately prepared them for paracentesis procedural independence; the mean was 8.9 across all residents.
The total number of procedures performed by residents at CTVAH also increased. Starting in 2015, 3 years before the clinic was started, 38 procedures were performed by internal medicine residents, followed by 72 procedures in 2016; 76 in 2017; 58 in 2018; 94 in 2019; 88 in 2020; 136 in 2021; and 188 in 2022.
Discussion
Paracentesis is a simple but invasive procedure to relieve ascites, often relieving patients’ symptoms, preventing hospital admission, and increasing patient satisfaction.4 The CTVAH does not have the capacity to perform outpatient paracentesis effectively in its emergency or radiology departments. Furthermore, the use of the emergency or radiology departments for routine paracentesis may not be feasible due to the acuity of care being provided, as these procedures can be time consuming and can draw away critical resources and time from patients that need emergent care. The paracentesis clinic was then formed to provide veterans access to the procedural care they need, while also preparing residents to ably and confidently perform the procedure independently.
Based on our study, most residents were cleared to independently perform paracentesis procedures across all 3 years, with 79% of residents having completed the required 5 supervised procedures to independently practice. A study assessing unsupervised practice standards showed that paracentesis skill declines as soon as 3 months after training. However, retraining was shown to potentially interrupt this skill decline.5 Studies have shown that procedure-driven electives or services significantly improved paracentesis certification rates and total logged procedures, with minimal funding or scheduling changes required.6 Our clinic showed a significant increase in the number of procedures logged starting with the minimum of 38 procedures in 2015 and ending with 188 procedures logged at the end of 2022.
By allowing residents to routinely return to the paracentesis clinic across all 3 years, residents were more likely to feel comfortable independently performing the procedure, with residents reporting a mean comfort score of 7.9. The spaced repetition and ability to work with the clinic during elective time allows regular opportunities to undergo supervised training in a controlled environment and created scheduled retraining opportunities. Future studies should evaluate residents prior to each paracentesis clinic to ascertain if skill decline is occurring at a slower rate.
The inpatient effect of the clinic is also multifocal. Pham and colleagues showed that integrating paracentesis into timely training can reduce paracentesis delay and delays in care.7 By increasing the volume of procedures each resident performs and creating a sense of confidence amongst residents, the clinic increases the number of residents able and willing to perform inpatient procedures, thus reducing the number of unnecessary consultations and hospital resources. One of the reasons the paracentesis clinic was started was to allow patients to have scheduled times to remove fluid from their abdomen, thus cutting down on emergency department procedures and unnecessary admissions. Additionally, the benefits of early paracentesis procedural performance by residents and internal medicine physicians have been demonstrated in the literature. A study by Gaetano and colleagues noted that patients undergoing early paracentesis had reduced mortality of 5.5% vs 7.5% in those undergoing late paracentesis.8 This study also showed the in-hospital mortality rate was decreased with paracentesis (6.3%) vs without paracentesis (8.9%).8 By offering residents a chance to participate in the clinic, we have shown that regular opportunities to perform paracentesis may increase the number of physicians capable of independently practicing, improve procedural competency, and improve patient access to this procedure.
Limitations
Our study was not free of bias and has potential weaknesses. The survey was sent to all current residents who have participated in the paracentesis clinic, but not every resident filled out the survey (55% of all residents across 3 years completed the survey, 68.7% who had done clinic that year completed the survey). There is a possibility that those not signed off avoided doing the survey, but we are unable to confirm this. The survey also depended on resident recall of the number of paracenteses completed or looking at their procedure log. It is possible that some procedures were not documented, changing the true number. Additionally, rating comfortability with procedures is subjective, which may also create a source of potential weakness. Future projects should include a baseline survey for residents, followed by a repeat survey a year later to show changes from baseline competency.
Conclusions
A dedicated paracentesis clinic with internal medicine resident involvement may increase resident paracentesis procedural independence, the number of procedures available and performed, and procedural comfort level.
1. Aponte EM, O’Rourke MC, Katta S. Paracentesis. StatPearls [internet]. September 5, 2022. Accessed December 11, 2023. https://www.ncbi.nlm.nih.gov/books/NBK435998
2. Barsuk JH, Feinglass J, Kozmic SE, Hohmann SF, Ganger D, Wayne DB. Specialties performing paracentesis procedures at university hospitals: implications for training and certification. J Hosp Med. 2014;9(3):162-168. doi:10.1002/jhm.2153
3. Cheng Y-W, Sandrasegaran K, Cheng K, et al. A dedicated paracentesis clinic decreases healthcare utilization for serial paracenteses in decompensated cirrhosis. Abdominal Radiology. 2017;43(8):2190-2197. doi:10.1007/s00261-017-1406-y
4. Wang J, Khan S, Wyer P, et al. The role of ultrasound-guided therapeutic paracentesis in an outpatient transitional care program: A case series. Am J Hospice Palliat Med. 2018;35(9):1256-1260. doi:10.1177/1049909118755378
5. Sall D, Warm EJ, Kinnear B, Kelleher M, Jandarov R, O’Toole J. See one, do one, forget one: early skill decay after paracentesis training. J Gen Int Med. 2020;36(5):1346-1351. doi:10.1007/s11606-020-06242-x
6. Berger M, Divilov V, Paredes H, Kesar V, Sun E. Improving resident paracentesis certification rates by using an innovative resident driven procedure service. Am J Gastroenterol. 2018;113(suppl). doi:10.14309/00000434-201810001-00980
7. Pham C, Xu A, Suaez MG. S1250 a pilot study to improve resident paracentesis training and reduce paracentesis delay in admitted patients with cirrhosis. Am J Gastroenterol. 2022;117(10S). doi:10.14309/01.ajg.0000861640.53682.93
8. Gaetano JN, Micic D, Aronsohn A, et al. The benefit of paracentesis on hospitalized adults with cirrhosis and ascites. J Gastroenterol Hepatol. 2016;31(5):1025-1030. doi:10.1111/jgh.13255
Competency in paracentesis is an important procedural skill for medical practitioners caring for patients with decompensated liver cirrhosis. Paracentesis is performed to drain ascitic fluid for both diagnosis and/or therapeutic purposes.1 While this procedure can be performed without the use of ultrasound, it is preferable to use ultrasound to identify an area of fluid that is away from dangerous anatomy including bowel loops, the liver, and spleen. After prepping the area, lidocaine is administered locally. A catheter is then inserted until fluid begins flowing freely. The catheter is connected to a suction canister or collection kit, and the patient is monitored until the flow ceases. Samples can be sent for analysis to determine the etiology of ascites, identify concerns for infection, and more.
Paracentesis is a very common procedure. Barsuk and colleagues noted that between 2010 and 2012, 97,577 procedures were performed across 120 academic medical centers and 290 affiliated hospitals.2 Patients undergo paracentesis in a variety of settings including the emergency department, inpatient hospitalizations, and clinics. Some patients may require only 1 paracentesis procedure while others may require it regularly.
Due to the rising need for paracentesis in the Central Texas Veterans Affairs Hospital (CTVAH) in Temple, a paracentesis clinic was started in February 2018. The goal of the paracentesis clinic was multifocal—to reduce hospital admissions, improve access to regularly scheduled procedures, decrease wait times, and increase patient satisfaction.3 Through the CTVAH affiliation with the Texas A&M internal medicine residency program, the paracentesis clinic started involving and training residents on this procedure. Up to 3 residents are on weekly rotation and can perform up to 6 paracentesis procedures in a week. The purpose of this article was to evaluate resident competency in paracentesis after completion of the paracentesis clinic.
Methods
The paracentesis clinic schedules up to 3 patients on Tuesdays and Thursdays between 8
A survey was sent via email to all categorical internal medicine residents across all 3 program years at the time of data collection. Competency for paracentesis sign-off was defined as completing and logging 5 procedures supervised by a competent physician who confirmed that all portions of the procedure were performed correctly. Residents were also asked to answer questions on a scale from 1 to 10, with 1 representing no confidence and 10 representing strong confidence to practice independently (Table).
We also evaluated the number of procedures performed by internal medicine residents 3 years before the clinic was started in 2015 up to the completion of 2022. The numbers were obtained by examining procedural log data for each year for all internal medicine residents.
Results
Thirty-three residents completed the survey: 10 first-year internal medicine residents (PGY1), 12 second-year residents (PGY2), and 11 third-year residents (PGY3). The mean participation was 4.8 paracentesis sessions per person for the duration of the study. The range of paracentesis procedures performed varied based on PGY year: PGY1s performed 1 to > 10 procedures, PGY2s performed 2 to > 10 procedures, and PGY3s performed 5 to > 10 procedures. Thirty-six percent of residents completed > 10 procedures in the paracentesis clinic; 82% of PGY3s had completed > 10 procedures by December of their third year. Twenty-six residents (79%) were credentialed to perform paracentesis procedures independently after performing > 5 procedures, and 7 residents were not yet cleared for procedural independence.
In the survey, residents rated their comfort with performing paracentesis procedures independently at a mean of 7.9. The mean comfort reported by PGY1s was 7.2, PGY2s was 7.3, and PGY3s was 9.3. Residents also rated their opinion on whether or not the paracentesis clinic adequately prepared them for paracentesis procedural independence; the mean was 8.9 across all residents.
The total number of procedures performed by residents at CTVAH also increased. Starting in 2015, 3 years before the clinic was started, 38 procedures were performed by internal medicine residents, followed by 72 procedures in 2016; 76 in 2017; 58 in 2018; 94 in 2019; 88 in 2020; 136 in 2021; and 188 in 2022.
Discussion
Paracentesis is a simple but invasive procedure to relieve ascites, often relieving patients’ symptoms, preventing hospital admission, and increasing patient satisfaction.4 The CTVAH does not have the capacity to perform outpatient paracentesis effectively in its emergency or radiology departments. Furthermore, the use of the emergency or radiology departments for routine paracentesis may not be feasible due to the acuity of care being provided, as these procedures can be time consuming and can draw away critical resources and time from patients that need emergent care. The paracentesis clinic was then formed to provide veterans access to the procedural care they need, while also preparing residents to ably and confidently perform the procedure independently.
Based on our study, most residents were cleared to independently perform paracentesis procedures across all 3 years, with 79% of residents having completed the required 5 supervised procedures to independently practice. A study assessing unsupervised practice standards showed that paracentesis skill declines as soon as 3 months after training. However, retraining was shown to potentially interrupt this skill decline.5 Studies have shown that procedure-driven electives or services significantly improved paracentesis certification rates and total logged procedures, with minimal funding or scheduling changes required.6 Our clinic showed a significant increase in the number of procedures logged starting with the minimum of 38 procedures in 2015 and ending with 188 procedures logged at the end of 2022.
By allowing residents to routinely return to the paracentesis clinic across all 3 years, residents were more likely to feel comfortable independently performing the procedure, with residents reporting a mean comfort score of 7.9. The spaced repetition and ability to work with the clinic during elective time allows regular opportunities to undergo supervised training in a controlled environment and created scheduled retraining opportunities. Future studies should evaluate residents prior to each paracentesis clinic to ascertain if skill decline is occurring at a slower rate.
The inpatient effect of the clinic is also multifocal. Pham and colleagues showed that integrating paracentesis into timely training can reduce paracentesis delay and delays in care.7 By increasing the volume of procedures each resident performs and creating a sense of confidence amongst residents, the clinic increases the number of residents able and willing to perform inpatient procedures, thus reducing the number of unnecessary consultations and hospital resources. One of the reasons the paracentesis clinic was started was to allow patients to have scheduled times to remove fluid from their abdomen, thus cutting down on emergency department procedures and unnecessary admissions. Additionally, the benefits of early paracentesis procedural performance by residents and internal medicine physicians have been demonstrated in the literature. A study by Gaetano and colleagues noted that patients undergoing early paracentesis had reduced mortality of 5.5% vs 7.5% in those undergoing late paracentesis.8 This study also showed the in-hospital mortality rate was decreased with paracentesis (6.3%) vs without paracentesis (8.9%).8 By offering residents a chance to participate in the clinic, we have shown that regular opportunities to perform paracentesis may increase the number of physicians capable of independently practicing, improve procedural competency, and improve patient access to this procedure.
Limitations
Our study was not free of bias and has potential weaknesses. The survey was sent to all current residents who have participated in the paracentesis clinic, but not every resident filled out the survey (55% of all residents across 3 years completed the survey, 68.7% who had done clinic that year completed the survey). There is a possibility that those not signed off avoided doing the survey, but we are unable to confirm this. The survey also depended on resident recall of the number of paracenteses completed or looking at their procedure log. It is possible that some procedures were not documented, changing the true number. Additionally, rating comfortability with procedures is subjective, which may also create a source of potential weakness. Future projects should include a baseline survey for residents, followed by a repeat survey a year later to show changes from baseline competency.
Conclusions
A dedicated paracentesis clinic with internal medicine resident involvement may increase resident paracentesis procedural independence, the number of procedures available and performed, and procedural comfort level.
Competency in paracentesis is an important procedural skill for medical practitioners caring for patients with decompensated liver cirrhosis. Paracentesis is performed to drain ascitic fluid for both diagnosis and/or therapeutic purposes.1 While this procedure can be performed without the use of ultrasound, it is preferable to use ultrasound to identify an area of fluid that is away from dangerous anatomy including bowel loops, the liver, and spleen. After prepping the area, lidocaine is administered locally. A catheter is then inserted until fluid begins flowing freely. The catheter is connected to a suction canister or collection kit, and the patient is monitored until the flow ceases. Samples can be sent for analysis to determine the etiology of ascites, identify concerns for infection, and more.
Paracentesis is a very common procedure. Barsuk and colleagues noted that between 2010 and 2012, 97,577 procedures were performed across 120 academic medical centers and 290 affiliated hospitals.2 Patients undergo paracentesis in a variety of settings including the emergency department, inpatient hospitalizations, and clinics. Some patients may require only 1 paracentesis procedure while others may require it regularly.
Due to the rising need for paracentesis in the Central Texas Veterans Affairs Hospital (CTVAH) in Temple, a paracentesis clinic was started in February 2018. The goal of the paracentesis clinic was multifocal—to reduce hospital admissions, improve access to regularly scheduled procedures, decrease wait times, and increase patient satisfaction.3 Through the CTVAH affiliation with the Texas A&M internal medicine residency program, the paracentesis clinic started involving and training residents on this procedure. Up to 3 residents are on weekly rotation and can perform up to 6 paracentesis procedures in a week. The purpose of this article was to evaluate resident competency in paracentesis after completion of the paracentesis clinic.
Methods
The paracentesis clinic schedules up to 3 patients on Tuesdays and Thursdays between 8
A survey was sent via email to all categorical internal medicine residents across all 3 program years at the time of data collection. Competency for paracentesis sign-off was defined as completing and logging 5 procedures supervised by a competent physician who confirmed that all portions of the procedure were performed correctly. Residents were also asked to answer questions on a scale from 1 to 10, with 1 representing no confidence and 10 representing strong confidence to practice independently (Table).
We also evaluated the number of procedures performed by internal medicine residents 3 years before the clinic was started in 2015 up to the completion of 2022. The numbers were obtained by examining procedural log data for each year for all internal medicine residents.
Results
Thirty-three residents completed the survey: 10 first-year internal medicine residents (PGY1), 12 second-year residents (PGY2), and 11 third-year residents (PGY3). The mean participation was 4.8 paracentesis sessions per person for the duration of the study. The range of paracentesis procedures performed varied based on PGY year: PGY1s performed 1 to > 10 procedures, PGY2s performed 2 to > 10 procedures, and PGY3s performed 5 to > 10 procedures. Thirty-six percent of residents completed > 10 procedures in the paracentesis clinic; 82% of PGY3s had completed > 10 procedures by December of their third year. Twenty-six residents (79%) were credentialed to perform paracentesis procedures independently after performing > 5 procedures, and 7 residents were not yet cleared for procedural independence.
In the survey, residents rated their comfort with performing paracentesis procedures independently at a mean of 7.9. The mean comfort reported by PGY1s was 7.2, PGY2s was 7.3, and PGY3s was 9.3. Residents also rated their opinion on whether or not the paracentesis clinic adequately prepared them for paracentesis procedural independence; the mean was 8.9 across all residents.
The total number of procedures performed by residents at CTVAH also increased. Starting in 2015, 3 years before the clinic was started, 38 procedures were performed by internal medicine residents, followed by 72 procedures in 2016; 76 in 2017; 58 in 2018; 94 in 2019; 88 in 2020; 136 in 2021; and 188 in 2022.
Discussion
Paracentesis is a simple but invasive procedure to relieve ascites, often relieving patients’ symptoms, preventing hospital admission, and increasing patient satisfaction.4 The CTVAH does not have the capacity to perform outpatient paracentesis effectively in its emergency or radiology departments. Furthermore, the use of the emergency or radiology departments for routine paracentesis may not be feasible due to the acuity of care being provided, as these procedures can be time consuming and can draw away critical resources and time from patients that need emergent care. The paracentesis clinic was then formed to provide veterans access to the procedural care they need, while also preparing residents to ably and confidently perform the procedure independently.
Based on our study, most residents were cleared to independently perform paracentesis procedures across all 3 years, with 79% of residents having completed the required 5 supervised procedures to independently practice. A study assessing unsupervised practice standards showed that paracentesis skill declines as soon as 3 months after training. However, retraining was shown to potentially interrupt this skill decline.5 Studies have shown that procedure-driven electives or services significantly improved paracentesis certification rates and total logged procedures, with minimal funding or scheduling changes required.6 Our clinic showed a significant increase in the number of procedures logged starting with the minimum of 38 procedures in 2015 and ending with 188 procedures logged at the end of 2022.
By allowing residents to routinely return to the paracentesis clinic across all 3 years, residents were more likely to feel comfortable independently performing the procedure, with residents reporting a mean comfort score of 7.9. The spaced repetition and ability to work with the clinic during elective time allows regular opportunities to undergo supervised training in a controlled environment and created scheduled retraining opportunities. Future studies should evaluate residents prior to each paracentesis clinic to ascertain if skill decline is occurring at a slower rate.
The inpatient effect of the clinic is also multifocal. Pham and colleagues showed that integrating paracentesis into timely training can reduce paracentesis delay and delays in care.7 By increasing the volume of procedures each resident performs and creating a sense of confidence amongst residents, the clinic increases the number of residents able and willing to perform inpatient procedures, thus reducing the number of unnecessary consultations and hospital resources. One of the reasons the paracentesis clinic was started was to allow patients to have scheduled times to remove fluid from their abdomen, thus cutting down on emergency department procedures and unnecessary admissions. Additionally, the benefits of early paracentesis procedural performance by residents and internal medicine physicians have been demonstrated in the literature. A study by Gaetano and colleagues noted that patients undergoing early paracentesis had reduced mortality of 5.5% vs 7.5% in those undergoing late paracentesis.8 This study also showed the in-hospital mortality rate was decreased with paracentesis (6.3%) vs without paracentesis (8.9%).8 By offering residents a chance to participate in the clinic, we have shown that regular opportunities to perform paracentesis may increase the number of physicians capable of independently practicing, improve procedural competency, and improve patient access to this procedure.
Limitations
Our study was not free of bias and has potential weaknesses. The survey was sent to all current residents who have participated in the paracentesis clinic, but not every resident filled out the survey (55% of all residents across 3 years completed the survey, 68.7% who had done clinic that year completed the survey). There is a possibility that those not signed off avoided doing the survey, but we are unable to confirm this. The survey also depended on resident recall of the number of paracenteses completed or looking at their procedure log. It is possible that some procedures were not documented, changing the true number. Additionally, rating comfortability with procedures is subjective, which may also create a source of potential weakness. Future projects should include a baseline survey for residents, followed by a repeat survey a year later to show changes from baseline competency.
Conclusions
A dedicated paracentesis clinic with internal medicine resident involvement may increase resident paracentesis procedural independence, the number of procedures available and performed, and procedural comfort level.
1. Aponte EM, O’Rourke MC, Katta S. Paracentesis. StatPearls [internet]. September 5, 2022. Accessed December 11, 2023. https://www.ncbi.nlm.nih.gov/books/NBK435998
2. Barsuk JH, Feinglass J, Kozmic SE, Hohmann SF, Ganger D, Wayne DB. Specialties performing paracentesis procedures at university hospitals: implications for training and certification. J Hosp Med. 2014;9(3):162-168. doi:10.1002/jhm.2153
3. Cheng Y-W, Sandrasegaran K, Cheng K, et al. A dedicated paracentesis clinic decreases healthcare utilization for serial paracenteses in decompensated cirrhosis. Abdominal Radiology. 2017;43(8):2190-2197. doi:10.1007/s00261-017-1406-y
4. Wang J, Khan S, Wyer P, et al. The role of ultrasound-guided therapeutic paracentesis in an outpatient transitional care program: A case series. Am J Hospice Palliat Med. 2018;35(9):1256-1260. doi:10.1177/1049909118755378
5. Sall D, Warm EJ, Kinnear B, Kelleher M, Jandarov R, O’Toole J. See one, do one, forget one: early skill decay after paracentesis training. J Gen Int Med. 2020;36(5):1346-1351. doi:10.1007/s11606-020-06242-x
6. Berger M, Divilov V, Paredes H, Kesar V, Sun E. Improving resident paracentesis certification rates by using an innovative resident driven procedure service. Am J Gastroenterol. 2018;113(suppl). doi:10.14309/00000434-201810001-00980
7. Pham C, Xu A, Suaez MG. S1250 a pilot study to improve resident paracentesis training and reduce paracentesis delay in admitted patients with cirrhosis. Am J Gastroenterol. 2022;117(10S). doi:10.14309/01.ajg.0000861640.53682.93
8. Gaetano JN, Micic D, Aronsohn A, et al. The benefit of paracentesis on hospitalized adults with cirrhosis and ascites. J Gastroenterol Hepatol. 2016;31(5):1025-1030. doi:10.1111/jgh.13255
1. Aponte EM, O’Rourke MC, Katta S. Paracentesis. StatPearls [internet]. September 5, 2022. Accessed December 11, 2023. https://www.ncbi.nlm.nih.gov/books/NBK435998
2. Barsuk JH, Feinglass J, Kozmic SE, Hohmann SF, Ganger D, Wayne DB. Specialties performing paracentesis procedures at university hospitals: implications for training and certification. J Hosp Med. 2014;9(3):162-168. doi:10.1002/jhm.2153
3. Cheng Y-W, Sandrasegaran K, Cheng K, et al. A dedicated paracentesis clinic decreases healthcare utilization for serial paracenteses in decompensated cirrhosis. Abdominal Radiology. 2017;43(8):2190-2197. doi:10.1007/s00261-017-1406-y
4. Wang J, Khan S, Wyer P, et al. The role of ultrasound-guided therapeutic paracentesis in an outpatient transitional care program: A case series. Am J Hospice Palliat Med. 2018;35(9):1256-1260. doi:10.1177/1049909118755378
5. Sall D, Warm EJ, Kinnear B, Kelleher M, Jandarov R, O’Toole J. See one, do one, forget one: early skill decay after paracentesis training. J Gen Int Med. 2020;36(5):1346-1351. doi:10.1007/s11606-020-06242-x
6. Berger M, Divilov V, Paredes H, Kesar V, Sun E. Improving resident paracentesis certification rates by using an innovative resident driven procedure service. Am J Gastroenterol. 2018;113(suppl). doi:10.14309/00000434-201810001-00980
7. Pham C, Xu A, Suaez MG. S1250 a pilot study to improve resident paracentesis training and reduce paracentesis delay in admitted patients with cirrhosis. Am J Gastroenterol. 2022;117(10S). doi:10.14309/01.ajg.0000861640.53682.93
8. Gaetano JN, Micic D, Aronsohn A, et al. The benefit of paracentesis on hospitalized adults with cirrhosis and ascites. J Gastroenterol Hepatol. 2016;31(5):1025-1030. doi:10.1111/jgh.13255
Piperacillin/Tazobactam Use vs Cefepime May Be Associated With Acute Decompensated Heart Failure
Piperacillin/tazobactam (PTZ) is a combination IV antibiotic comprised of the semisynthetic antipseudomonal β-lactam, piperacillin sodium, and the β-lactamase inhibitor, tazobactam sodium.1 PTZ is extensively prescribed in the hospital setting for a multitude of infections including but not limited to the US Food and Drug Administration–approved indications: intra-abdominal infection, skin and skin structure infection (SSTI), urinary tract infection (UTI), and pneumonia. Given its broad spectrum of activity and relative safety profile, PTZ is a mainstay of many empiric IV antibiotic regimens. The primary elimination pathway for PTZ is renal excretion, and dosage adjustments are recommended with reduced creatinine clearance. Additionally, PTZ use has been associated with acute renal injury and delayed renal recovery.1-3
There are various mechanisms through which medications can contribute to acute decomopensated heart failure (ADHF).4 These mechanisms include direct cardiotoxicity; negative inotropic, lusitropic, or chronotropic effects; exacerbating hypertension; sodium loading; and drug-drug interactions that limit the benefits of heart failure (HF) medications. One potentially overlooked constituent of PTZ is the sodium content, with the standard formulation containing 65 mg of sodium per gram of piperacillin.1-3 Furthermore, PTZ must be diluted in 50 to 150 mL of diluent, commonly 0.9% sodium chloride, which can contribute an additional 177 to 531 mg of sodium per dose. PTZ prescribing information advises caution for use in patients with decreased renal, hepatic, and/or cardiac function and notes that geriatric patients, particularly with HF, may be at risk of impaired natriuresis in the setting of large sodium doses.
It is estimated that roughly 6.2 million adults in the United States have HF and prevalence continues to rise.5,6 Mortality rates after hospitalization due to HF are 20% to 25% at 1 year. Health care expenditures for the management of HF surpass $30 billion per year in the US, with most of this cost attributed to hospitalizations. Consequently, it is important to continue to identify and practice preventative strategies when managing patients with HF.
Methods
This single-center, retrospective, cohort study was conducted at James H. Quillen Veterans Affairs Medical Center (JHQVAMC) in Mountain Home, Tennessee, a 174-bed tertiary medical center. The purpose of this study was to compare the incidence of ADHF in patients who received PTZ vs cefepime (CFP). This project was reviewed by the JHQVAMC Institutional Review Board and deemed exempt as a clinical process improvement operations activity.
The antimicrobial stewardship team at JHQVAMC reviewed the use of PTZ in veterans between January 1, 2018, to December 31, 2019, and compared baseline demographics, history of HF, and outcomes in patients receiving analogous broad-spectrum empiric antibiotic therapy with CFP.
Statistical Analysis
Analysis was conducted with R Software. Pearson χ2 and t tests were used to compare baseline demographics, length of stay, readmission, and mortality. Significance used was α = .05.
Results
A retrospective chart review was performed on 389 veterans. Of the 389, 204 patients received at least 24 hours of PTZ, and 185 patients received CFP. The mean age in both groups was 75 years. Patients in the PTZ group were more likely to have been admitted with the diagnosis of pneumonia (105 vs 49, P < .001). However, 29 patients (15.7%) in the CFP group were admitted with a UTI diagnosis compared with 6 patients (2.9%) in the PTZ group (P < .001) and 62 patients (33.5%) in the CFP group were admitted with a SSTI diagnosis compared with 48 patients (23.5%) in the PTZ group (P = .03). Otherwise, there were no differences between other admitting diagnoses. Additionally, there was no difference in prior history of HF between groups (Table 1).
Twenty-five patients (12.3%) in the PTZ group and 4 patients (2.2%) in the CFP group were subsequently diagnosed with ADHF (P < .001). Hospital readmissions due to HF were higher in the PTZ group compared with the CFP group (11 vs 2, P = .02). Hospital readmission due to other causes was not significantly different between groups. Hospital readmission due to infection occurred in 18 patients who received PTZ and 25 who received CFP (8.8% vs 13.5%, P = .14). Hospital readmission due to any other indication occurred in 24 patients who received PTZ and 24 who received CFP (11.8% vs 13.0%, P = .72). There was no statistically significant difference in all-cause mortality during the associated admission or within 6 months of discharge between groups, with 59 total deaths in the PTZ group and 50 in the CFP group (28.9% vs 27.0%, P = .63).
There was no difference in length of stay outcomes between patients receiving PTZ compared with CFP. Twenty-eight patients in the PTZ group and 20 in the CFP group had a length of stay duration of < 3 days (13.7% vs 10.8%, P = .46). Seventy-three patients in the PTZ group and 76 in the CFP group had a length of stay duration of 4 to 6 days (36.3% vs 41.1%, P = .28). One hundred three patients in the PTZ group and 89 in the CFP group had a length of stay duration ≥ 7 days (50.5% vs 48.1%, P = .78). Table 2 includes a complete overview of primary and secondary endpoint results.
Discussion
The American Heart Association (AHA) lists PTZ as a medication that may cause or exacerbate HF, though no studies have identified a clear association between PTZ use and ADHF.4 Sodium restriction is consistently recommended as an important strategy for the prevention of ADHF. Accordingly, PTZ prescribing information and the AHA advise careful consideration with PTZ use in this patient population.1,4
The specific mechanism responsible for the association of PTZ with cardiac-related adverse outcomes is unclear. It is easy to presume that the sodium content of PTZ is solely responsible; however, other antibiotic regimens not included as agents of concern by the AHA, such as meropenem, can approach similar overall daily sodium amounts.4,7 Additionally, total sodium and volume can also be contributed by various IV medications and fluids. This study did not evaluate total sodium intake from all sources, but it is notable that this study identified a possible trend toward the risk of ADHF with PTZ use in a routine practice environment. It is reasonable to postulate additional intrinsic properties of PTZ may be contributing to the development of ADHF, such as its association with renal injury possibly resulting in increased fluid retainment and subsequent fluid volume overload.1,2,4 Other hypothesized mechanisms may include those previously described, such as direct myocardial toxicity; negative inotropic, lusitropic, or chronotropic effects; exacerbating hypertension; and drug-drug interactions that limit the benefits of HF medications, although these have not been overtly associated with PTZ in the literature to date.4,8
ADHF can present similarly to other acute pulmonary conditions, including pneumonia.9,10 It is important to acknowledge the challenge this creates for diagnosticians to differentiate between these conditions rapidly and precisely. As a result, this patient population is likely at increased risk of IV antibiotic exposure. Other studies have identified worse outcomes in patients who receive potentially unwarranted IV antibiotics in patients with ADHF.9,10 The results of this study further emphasize the importance of careful considerate antibiotic selection and overall avoidance of unnecessary antibiotic exposure to limit potential adverse outcomes.
Limitations
There are various limitations to this study. Firstly, no women were included due to the predominantly male population within the Veterans Health Administration system. Secondly, this study was retrospective in design and was therefore limited to the completeness and accuracy of the available data collected. Additionally, this study evaluated any ADHF episode during the associated hospitalization as the primary endpoint. The time to diagnosis of ADHF in relation to PTZ initiation was not evaluated, which may have helped better elucidate this possible association. Furthermore, while a significant statistical difference was identified, the smaller sample size may have limited the ability to accurately identify differences in lower event rate outcomes.
Conclusions
This study identifies an association between PTZ use and significant cardiac-related adverse outcomes, including increased incidence of ADHF and readmission due to HF exacerbation. While more research is needed to define the exact mechanisms by which PTZ may precipitate acute decompensation in patients with HF, it is judicious to consider close monitoring or the avoidance of PTZ when appropriate antibiotic alternatives are available in patients with a known history of HF.
1. Zosyn. Package insert. Wyeth Pharmaceuticals; 2020.
2. Jensen JU, Hein L, Lundgren B, et al. Kidney failure related to broad-spectrum antibiotics in critically ill patients: secondary end point results from a 1200 patient randomised trial. BMJ Open. 2012;2(2):e000635. Published 2012 Mar 11. doi:10.1136/bmjopen-2011-000635
3. Kadomura S, Takekuma Y, Sato Y, et al. Higher incidence of acute kidney injury in patients treated with piperacillin/tazobactam than in patients treated with cefepime: a single-center retrospective cohort study. J Pharm Health Care Sci. 2019;5:13. Published 2019 Jun 12. doi:10.1186/s40780-019-0142-6
4. Page RL 2nd, O’Bryant CL, Cheng D, et al. Drugs that may cause or exacerbate heart failure: a scientific statement from the American Heart Association. Circulation. 2016;134(6):e32-e69. doi:10.1161/CIR.0000000000000426
5. Bozkurt B, Hershberger RE, Butler J, et al. 2021 ACC/AHA key data elements and definitions for heart failure: a report of the American College of Cardiology/American Heart Association task force on clinical data standards. J Am Coll Cardiol. 2021;77(16):2053-2150.
6. Virani SS, Alonso A, Aparicio HJ, et al. Heart disease and stroke statistics-2021 update: a report from the American Heart Association. Circulation. 2021;143(8):e254-e743. doi:10.1161/CIR.0000000000000950
7. Merrem. Package insert. Pfizer Labs; 2021.
8. Keller GA, Alvarez PA, Ponte ML, et al. Drug-induced QTc interval prolongation: a multicenter study to detect drugs and clinical factors involved in every day practice. Curr Drug Saf. 2016;11(1):86-98. doi:10.2174/1574886311207040262
9. Wu S, Alikhil M, Forsyth R, Allen B. Impact of potentially unwarranted intravenous antibiotics targeting pulmonary infections in acute decompensated heart failure. J Pharm Technol. 2021;37(6):298-303. doi:10.1177/87551225211038020
10. Frisbee J, Heidel RH, Rasnake MS. Adverse outcomes associated with potentially inappropriate antibiotic use in heart failure admissions. Open Forum Infect Dis. 2019;6(6):ofz220. doi:10.1093/ofid/ofz220
Piperacillin/tazobactam (PTZ) is a combination IV antibiotic comprised of the semisynthetic antipseudomonal β-lactam, piperacillin sodium, and the β-lactamase inhibitor, tazobactam sodium.1 PTZ is extensively prescribed in the hospital setting for a multitude of infections including but not limited to the US Food and Drug Administration–approved indications: intra-abdominal infection, skin and skin structure infection (SSTI), urinary tract infection (UTI), and pneumonia. Given its broad spectrum of activity and relative safety profile, PTZ is a mainstay of many empiric IV antibiotic regimens. The primary elimination pathway for PTZ is renal excretion, and dosage adjustments are recommended with reduced creatinine clearance. Additionally, PTZ use has been associated with acute renal injury and delayed renal recovery.1-3
There are various mechanisms through which medications can contribute to acute decomopensated heart failure (ADHF).4 These mechanisms include direct cardiotoxicity; negative inotropic, lusitropic, or chronotropic effects; exacerbating hypertension; sodium loading; and drug-drug interactions that limit the benefits of heart failure (HF) medications. One potentially overlooked constituent of PTZ is the sodium content, with the standard formulation containing 65 mg of sodium per gram of piperacillin.1-3 Furthermore, PTZ must be diluted in 50 to 150 mL of diluent, commonly 0.9% sodium chloride, which can contribute an additional 177 to 531 mg of sodium per dose. PTZ prescribing information advises caution for use in patients with decreased renal, hepatic, and/or cardiac function and notes that geriatric patients, particularly with HF, may be at risk of impaired natriuresis in the setting of large sodium doses.
It is estimated that roughly 6.2 million adults in the United States have HF and prevalence continues to rise.5,6 Mortality rates after hospitalization due to HF are 20% to 25% at 1 year. Health care expenditures for the management of HF surpass $30 billion per year in the US, with most of this cost attributed to hospitalizations. Consequently, it is important to continue to identify and practice preventative strategies when managing patients with HF.
Methods
This single-center, retrospective, cohort study was conducted at James H. Quillen Veterans Affairs Medical Center (JHQVAMC) in Mountain Home, Tennessee, a 174-bed tertiary medical center. The purpose of this study was to compare the incidence of ADHF in patients who received PTZ vs cefepime (CFP). This project was reviewed by the JHQVAMC Institutional Review Board and deemed exempt as a clinical process improvement operations activity.
The antimicrobial stewardship team at JHQVAMC reviewed the use of PTZ in veterans between January 1, 2018, to December 31, 2019, and compared baseline demographics, history of HF, and outcomes in patients receiving analogous broad-spectrum empiric antibiotic therapy with CFP.
Statistical Analysis
Analysis was conducted with R Software. Pearson χ2 and t tests were used to compare baseline demographics, length of stay, readmission, and mortality. Significance used was α = .05.
Results
A retrospective chart review was performed on 389 veterans. Of the 389, 204 patients received at least 24 hours of PTZ, and 185 patients received CFP. The mean age in both groups was 75 years. Patients in the PTZ group were more likely to have been admitted with the diagnosis of pneumonia (105 vs 49, P < .001). However, 29 patients (15.7%) in the CFP group were admitted with a UTI diagnosis compared with 6 patients (2.9%) in the PTZ group (P < .001) and 62 patients (33.5%) in the CFP group were admitted with a SSTI diagnosis compared with 48 patients (23.5%) in the PTZ group (P = .03). Otherwise, there were no differences between other admitting diagnoses. Additionally, there was no difference in prior history of HF between groups (Table 1).
Twenty-five patients (12.3%) in the PTZ group and 4 patients (2.2%) in the CFP group were subsequently diagnosed with ADHF (P < .001). Hospital readmissions due to HF were higher in the PTZ group compared with the CFP group (11 vs 2, P = .02). Hospital readmission due to other causes was not significantly different between groups. Hospital readmission due to infection occurred in 18 patients who received PTZ and 25 who received CFP (8.8% vs 13.5%, P = .14). Hospital readmission due to any other indication occurred in 24 patients who received PTZ and 24 who received CFP (11.8% vs 13.0%, P = .72). There was no statistically significant difference in all-cause mortality during the associated admission or within 6 months of discharge between groups, with 59 total deaths in the PTZ group and 50 in the CFP group (28.9% vs 27.0%, P = .63).
There was no difference in length of stay outcomes between patients receiving PTZ compared with CFP. Twenty-eight patients in the PTZ group and 20 in the CFP group had a length of stay duration of < 3 days (13.7% vs 10.8%, P = .46). Seventy-three patients in the PTZ group and 76 in the CFP group had a length of stay duration of 4 to 6 days (36.3% vs 41.1%, P = .28). One hundred three patients in the PTZ group and 89 in the CFP group had a length of stay duration ≥ 7 days (50.5% vs 48.1%, P = .78). Table 2 includes a complete overview of primary and secondary endpoint results.
Discussion
The American Heart Association (AHA) lists PTZ as a medication that may cause or exacerbate HF, though no studies have identified a clear association between PTZ use and ADHF.4 Sodium restriction is consistently recommended as an important strategy for the prevention of ADHF. Accordingly, PTZ prescribing information and the AHA advise careful consideration with PTZ use in this patient population.1,4
The specific mechanism responsible for the association of PTZ with cardiac-related adverse outcomes is unclear. It is easy to presume that the sodium content of PTZ is solely responsible; however, other antibiotic regimens not included as agents of concern by the AHA, such as meropenem, can approach similar overall daily sodium amounts.4,7 Additionally, total sodium and volume can also be contributed by various IV medications and fluids. This study did not evaluate total sodium intake from all sources, but it is notable that this study identified a possible trend toward the risk of ADHF with PTZ use in a routine practice environment. It is reasonable to postulate additional intrinsic properties of PTZ may be contributing to the development of ADHF, such as its association with renal injury possibly resulting in increased fluid retainment and subsequent fluid volume overload.1,2,4 Other hypothesized mechanisms may include those previously described, such as direct myocardial toxicity; negative inotropic, lusitropic, or chronotropic effects; exacerbating hypertension; and drug-drug interactions that limit the benefits of HF medications, although these have not been overtly associated with PTZ in the literature to date.4,8
ADHF can present similarly to other acute pulmonary conditions, including pneumonia.9,10 It is important to acknowledge the challenge this creates for diagnosticians to differentiate between these conditions rapidly and precisely. As a result, this patient population is likely at increased risk of IV antibiotic exposure. Other studies have identified worse outcomes in patients who receive potentially unwarranted IV antibiotics in patients with ADHF.9,10 The results of this study further emphasize the importance of careful considerate antibiotic selection and overall avoidance of unnecessary antibiotic exposure to limit potential adverse outcomes.
Limitations
There are various limitations to this study. Firstly, no women were included due to the predominantly male population within the Veterans Health Administration system. Secondly, this study was retrospective in design and was therefore limited to the completeness and accuracy of the available data collected. Additionally, this study evaluated any ADHF episode during the associated hospitalization as the primary endpoint. The time to diagnosis of ADHF in relation to PTZ initiation was not evaluated, which may have helped better elucidate this possible association. Furthermore, while a significant statistical difference was identified, the smaller sample size may have limited the ability to accurately identify differences in lower event rate outcomes.
Conclusions
This study identifies an association between PTZ use and significant cardiac-related adverse outcomes, including increased incidence of ADHF and readmission due to HF exacerbation. While more research is needed to define the exact mechanisms by which PTZ may precipitate acute decompensation in patients with HF, it is judicious to consider close monitoring or the avoidance of PTZ when appropriate antibiotic alternatives are available in patients with a known history of HF.
Piperacillin/tazobactam (PTZ) is a combination IV antibiotic comprised of the semisynthetic antipseudomonal β-lactam, piperacillin sodium, and the β-lactamase inhibitor, tazobactam sodium.1 PTZ is extensively prescribed in the hospital setting for a multitude of infections including but not limited to the US Food and Drug Administration–approved indications: intra-abdominal infection, skin and skin structure infection (SSTI), urinary tract infection (UTI), and pneumonia. Given its broad spectrum of activity and relative safety profile, PTZ is a mainstay of many empiric IV antibiotic regimens. The primary elimination pathway for PTZ is renal excretion, and dosage adjustments are recommended with reduced creatinine clearance. Additionally, PTZ use has been associated with acute renal injury and delayed renal recovery.1-3
There are various mechanisms through which medications can contribute to acute decomopensated heart failure (ADHF).4 These mechanisms include direct cardiotoxicity; negative inotropic, lusitropic, or chronotropic effects; exacerbating hypertension; sodium loading; and drug-drug interactions that limit the benefits of heart failure (HF) medications. One potentially overlooked constituent of PTZ is the sodium content, with the standard formulation containing 65 mg of sodium per gram of piperacillin.1-3 Furthermore, PTZ must be diluted in 50 to 150 mL of diluent, commonly 0.9% sodium chloride, which can contribute an additional 177 to 531 mg of sodium per dose. PTZ prescribing information advises caution for use in patients with decreased renal, hepatic, and/or cardiac function and notes that geriatric patients, particularly with HF, may be at risk of impaired natriuresis in the setting of large sodium doses.
It is estimated that roughly 6.2 million adults in the United States have HF and prevalence continues to rise.5,6 Mortality rates after hospitalization due to HF are 20% to 25% at 1 year. Health care expenditures for the management of HF surpass $30 billion per year in the US, with most of this cost attributed to hospitalizations. Consequently, it is important to continue to identify and practice preventative strategies when managing patients with HF.
Methods
This single-center, retrospective, cohort study was conducted at James H. Quillen Veterans Affairs Medical Center (JHQVAMC) in Mountain Home, Tennessee, a 174-bed tertiary medical center. The purpose of this study was to compare the incidence of ADHF in patients who received PTZ vs cefepime (CFP). This project was reviewed by the JHQVAMC Institutional Review Board and deemed exempt as a clinical process improvement operations activity.
The antimicrobial stewardship team at JHQVAMC reviewed the use of PTZ in veterans between January 1, 2018, to December 31, 2019, and compared baseline demographics, history of HF, and outcomes in patients receiving analogous broad-spectrum empiric antibiotic therapy with CFP.
Statistical Analysis
Analysis was conducted with R Software. Pearson χ2 and t tests were used to compare baseline demographics, length of stay, readmission, and mortality. Significance used was α = .05.
Results
A retrospective chart review was performed on 389 veterans. Of the 389, 204 patients received at least 24 hours of PTZ, and 185 patients received CFP. The mean age in both groups was 75 years. Patients in the PTZ group were more likely to have been admitted with the diagnosis of pneumonia (105 vs 49, P < .001). However, 29 patients (15.7%) in the CFP group were admitted with a UTI diagnosis compared with 6 patients (2.9%) in the PTZ group (P < .001) and 62 patients (33.5%) in the CFP group were admitted with a SSTI diagnosis compared with 48 patients (23.5%) in the PTZ group (P = .03). Otherwise, there were no differences between other admitting diagnoses. Additionally, there was no difference in prior history of HF between groups (Table 1).
Twenty-five patients (12.3%) in the PTZ group and 4 patients (2.2%) in the CFP group were subsequently diagnosed with ADHF (P < .001). Hospital readmissions due to HF were higher in the PTZ group compared with the CFP group (11 vs 2, P = .02). Hospital readmission due to other causes was not significantly different between groups. Hospital readmission due to infection occurred in 18 patients who received PTZ and 25 who received CFP (8.8% vs 13.5%, P = .14). Hospital readmission due to any other indication occurred in 24 patients who received PTZ and 24 who received CFP (11.8% vs 13.0%, P = .72). There was no statistically significant difference in all-cause mortality during the associated admission or within 6 months of discharge between groups, with 59 total deaths in the PTZ group and 50 in the CFP group (28.9% vs 27.0%, P = .63).
There was no difference in length of stay outcomes between patients receiving PTZ compared with CFP. Twenty-eight patients in the PTZ group and 20 in the CFP group had a length of stay duration of < 3 days (13.7% vs 10.8%, P = .46). Seventy-three patients in the PTZ group and 76 in the CFP group had a length of stay duration of 4 to 6 days (36.3% vs 41.1%, P = .28). One hundred three patients in the PTZ group and 89 in the CFP group had a length of stay duration ≥ 7 days (50.5% vs 48.1%, P = .78). Table 2 includes a complete overview of primary and secondary endpoint results.
Discussion
The American Heart Association (AHA) lists PTZ as a medication that may cause or exacerbate HF, though no studies have identified a clear association between PTZ use and ADHF.4 Sodium restriction is consistently recommended as an important strategy for the prevention of ADHF. Accordingly, PTZ prescribing information and the AHA advise careful consideration with PTZ use in this patient population.1,4
The specific mechanism responsible for the association of PTZ with cardiac-related adverse outcomes is unclear. It is easy to presume that the sodium content of PTZ is solely responsible; however, other antibiotic regimens not included as agents of concern by the AHA, such as meropenem, can approach similar overall daily sodium amounts.4,7 Additionally, total sodium and volume can also be contributed by various IV medications and fluids. This study did not evaluate total sodium intake from all sources, but it is notable that this study identified a possible trend toward the risk of ADHF with PTZ use in a routine practice environment. It is reasonable to postulate additional intrinsic properties of PTZ may be contributing to the development of ADHF, such as its association with renal injury possibly resulting in increased fluid retainment and subsequent fluid volume overload.1,2,4 Other hypothesized mechanisms may include those previously described, such as direct myocardial toxicity; negative inotropic, lusitropic, or chronotropic effects; exacerbating hypertension; and drug-drug interactions that limit the benefits of HF medications, although these have not been overtly associated with PTZ in the literature to date.4,8
ADHF can present similarly to other acute pulmonary conditions, including pneumonia.9,10 It is important to acknowledge the challenge this creates for diagnosticians to differentiate between these conditions rapidly and precisely. As a result, this patient population is likely at increased risk of IV antibiotic exposure. Other studies have identified worse outcomes in patients who receive potentially unwarranted IV antibiotics in patients with ADHF.9,10 The results of this study further emphasize the importance of careful considerate antibiotic selection and overall avoidance of unnecessary antibiotic exposure to limit potential adverse outcomes.
Limitations
There are various limitations to this study. Firstly, no women were included due to the predominantly male population within the Veterans Health Administration system. Secondly, this study was retrospective in design and was therefore limited to the completeness and accuracy of the available data collected. Additionally, this study evaluated any ADHF episode during the associated hospitalization as the primary endpoint. The time to diagnosis of ADHF in relation to PTZ initiation was not evaluated, which may have helped better elucidate this possible association. Furthermore, while a significant statistical difference was identified, the smaller sample size may have limited the ability to accurately identify differences in lower event rate outcomes.
Conclusions
This study identifies an association between PTZ use and significant cardiac-related adverse outcomes, including increased incidence of ADHF and readmission due to HF exacerbation. While more research is needed to define the exact mechanisms by which PTZ may precipitate acute decompensation in patients with HF, it is judicious to consider close monitoring or the avoidance of PTZ when appropriate antibiotic alternatives are available in patients with a known history of HF.
1. Zosyn. Package insert. Wyeth Pharmaceuticals; 2020.
2. Jensen JU, Hein L, Lundgren B, et al. Kidney failure related to broad-spectrum antibiotics in critically ill patients: secondary end point results from a 1200 patient randomised trial. BMJ Open. 2012;2(2):e000635. Published 2012 Mar 11. doi:10.1136/bmjopen-2011-000635
3. Kadomura S, Takekuma Y, Sato Y, et al. Higher incidence of acute kidney injury in patients treated with piperacillin/tazobactam than in patients treated with cefepime: a single-center retrospective cohort study. J Pharm Health Care Sci. 2019;5:13. Published 2019 Jun 12. doi:10.1186/s40780-019-0142-6
4. Page RL 2nd, O’Bryant CL, Cheng D, et al. Drugs that may cause or exacerbate heart failure: a scientific statement from the American Heart Association. Circulation. 2016;134(6):e32-e69. doi:10.1161/CIR.0000000000000426
5. Bozkurt B, Hershberger RE, Butler J, et al. 2021 ACC/AHA key data elements and definitions for heart failure: a report of the American College of Cardiology/American Heart Association task force on clinical data standards. J Am Coll Cardiol. 2021;77(16):2053-2150.
6. Virani SS, Alonso A, Aparicio HJ, et al. Heart disease and stroke statistics-2021 update: a report from the American Heart Association. Circulation. 2021;143(8):e254-e743. doi:10.1161/CIR.0000000000000950
7. Merrem. Package insert. Pfizer Labs; 2021.
8. Keller GA, Alvarez PA, Ponte ML, et al. Drug-induced QTc interval prolongation: a multicenter study to detect drugs and clinical factors involved in every day practice. Curr Drug Saf. 2016;11(1):86-98. doi:10.2174/1574886311207040262
9. Wu S, Alikhil M, Forsyth R, Allen B. Impact of potentially unwarranted intravenous antibiotics targeting pulmonary infections in acute decompensated heart failure. J Pharm Technol. 2021;37(6):298-303. doi:10.1177/87551225211038020
10. Frisbee J, Heidel RH, Rasnake MS. Adverse outcomes associated with potentially inappropriate antibiotic use in heart failure admissions. Open Forum Infect Dis. 2019;6(6):ofz220. doi:10.1093/ofid/ofz220
1. Zosyn. Package insert. Wyeth Pharmaceuticals; 2020.
2. Jensen JU, Hein L, Lundgren B, et al. Kidney failure related to broad-spectrum antibiotics in critically ill patients: secondary end point results from a 1200 patient randomised trial. BMJ Open. 2012;2(2):e000635. Published 2012 Mar 11. doi:10.1136/bmjopen-2011-000635
3. Kadomura S, Takekuma Y, Sato Y, et al. Higher incidence of acute kidney injury in patients treated with piperacillin/tazobactam than in patients treated with cefepime: a single-center retrospective cohort study. J Pharm Health Care Sci. 2019;5:13. Published 2019 Jun 12. doi:10.1186/s40780-019-0142-6
4. Page RL 2nd, O’Bryant CL, Cheng D, et al. Drugs that may cause or exacerbate heart failure: a scientific statement from the American Heart Association. Circulation. 2016;134(6):e32-e69. doi:10.1161/CIR.0000000000000426
5. Bozkurt B, Hershberger RE, Butler J, et al. 2021 ACC/AHA key data elements and definitions for heart failure: a report of the American College of Cardiology/American Heart Association task force on clinical data standards. J Am Coll Cardiol. 2021;77(16):2053-2150.
6. Virani SS, Alonso A, Aparicio HJ, et al. Heart disease and stroke statistics-2021 update: a report from the American Heart Association. Circulation. 2021;143(8):e254-e743. doi:10.1161/CIR.0000000000000950
7. Merrem. Package insert. Pfizer Labs; 2021.
8. Keller GA, Alvarez PA, Ponte ML, et al. Drug-induced QTc interval prolongation: a multicenter study to detect drugs and clinical factors involved in every day practice. Curr Drug Saf. 2016;11(1):86-98. doi:10.2174/1574886311207040262
9. Wu S, Alikhil M, Forsyth R, Allen B. Impact of potentially unwarranted intravenous antibiotics targeting pulmonary infections in acute decompensated heart failure. J Pharm Technol. 2021;37(6):298-303. doi:10.1177/87551225211038020
10. Frisbee J, Heidel RH, Rasnake MS. Adverse outcomes associated with potentially inappropriate antibiotic use in heart failure admissions. Open Forum Infect Dis. 2019;6(6):ofz220. doi:10.1093/ofid/ofz220
Implementing Trustworthy AI in VA High Reliability Health Care Organizations
Artificial intelligence (AI) has lagged in health care but has considerable potential to improve quality, safety, clinician experience, and access to care. It is being tested in areas like billing, hospital operations, and preventing adverse events (eg, sepsis mortality) with some early success. However, there are still many barriers preventing the widespread use of AI, such as data problems, mismatched rewards, and workplace obstacles. Innovative projects, partnerships, better rewards, and more investment could remove barriers. Implemented reliably and safely, AI can add to what clinicians know, help them work faster, cut costs, and, most importantly, improve patient care.1
AI can potentially bring several clinical benefits, such as reducing the administrative strain on clinicians and granting them more time for direct patient care. It can also improve diagnostic accuracy by analyzing patient data and diagnostic images, providing differential diagnoses, and increasing access to care by providing medical information and essential online services to patients.2
High Reliability Organizations
High reliability health care organizations have considerable experience safely launching new programs. For example, the Patient Safety Adoption Framework gives practical tips for smoothly rolling out safety initiatives (Table 1). Developed with experts and diverse views, this framework has 5 key areas: leadership, culture and context, process, measurement, and person-centeredness. These address adoption problems, guide leaders step-by-step, and focus on leadership buy-in, safety culture, cooperation, and local customization. Checklists and tools make it systematic to go from ideas to action on patient safety.3
Leadership involves establishing organizational commitment behind new safety programs. This visible commitment signals importance and priorities to others. Leaders model desired behaviors and language around safety, allocate resources, remove obstacles, and keep initiatives energized over time through consistent messaging.4 Culture and context recognizes that safety culture differs across units and facilities. Local input tailors programs to fit and examines strengths to build on, like psychological safety. Surveys gauge the existing culture and its need for change. Process details how to plan, design, test, implement, and improve new safety practices and provides a phased roadmap from idea to results. Measurement collects data to drive improvement and show impact. Metrics track progress and allow benchmarking. Person-centeredness puts patients first in safety efforts through participation, education, and transparency.
The Veterans Health Administration piloted a comprehensive high reliability hospital (HRH) model. Over 3 years, the Veterans Health Administration focused on leadership, culture, and process improvement at a hospital. After initiating the model, the pilot hospital improved its safety culture, reported more minor safety issues, and reduced deaths and complications better than other hospitals. The high-reliability approach successfully instilled principles and improved culture and outcomes. The HRH model is set to be expanded to 18 more US Department of Veterans Affairs (VA) sites for further evaluation across diverse settings.5
Trustworthy AI Framework
AI systems are growing more powerful and widespread, including in health care. Unfortunately, irresponsible AI can introduce new harm. ChatGPT and other large language models, for example, sometimes are known to provide erroneous information in a compelling way. Clinicians and patients who use such programs can act on such information, which would lead to unforeseen negative consequences. Several frameworks on ethical AI have come from governmental groups.6-9 In 2023, the VA National AI Institute suggested a Trustworthy AI Framework based on core principles tailored for federal health care. The framework has 6 key principles: purposeful, effective and safe, secure and private, fair and equitable, transparent and explainable, and accountable and monitored (Table 2).10
First, AI must clearly help veterans while minimizing risks. To ensure purpose, the VA will assess patient and clinician needs and design AI that targets meaningful problems to avoid scope creep or feature bloat. For example, adding new features to the AI software after release can clutter and complicate the interface, making it difficult to use. Rigorous testing will confirm that AI meets intent prior to deployment. Second, AI is designed and checked for effectiveness, safety, and reliability. The VA pledges to monitor AI’s impact to ensure it performs as expected without unintended consequences. Algorithms will be stress tested across representative datasets and approval processes will screen for safety issues. Third, AI models are secured from vulnerabilities and misuse. Technical controls will prevent unauthorized access or changes to AI systems. Audits will check for appropriate internal usage per policies. Continual patches and upgrades will maintain security. Fourth, the VA manages AI for fairness, avoiding bias. They will proactively assess datasets and algorithms for potential biases based on protected attributes like race, gender, or age. Biased outputs will be addressed through techniques such as data augmentation, reweighting, and algorithm tweaks. Fifth, transparency explains AI’s role in care. Documentation will detail an AI system’s data sources, methodology, testing, limitations, and integration with clinical workflows. Clinicians and patients will receive education on interpreting AI outputs. Finally, the VA pledges to closely monitor AI systems to sustain trust. The VA will establish oversight processes to quickly identify any declines in reliability or unfair impacts on subgroups. AI models will be retrained as needed based on incoming data patterns.
Each Trustworthy AI Framework principle connects to others in existing frameworks. The purpose principle aligns with human-centric AI focused on benefits. Effectiveness and safety link to technical robustness and risk management principles. Security maps to privacy protection principles. Fairness connects to principles of avoiding bias and discrimination. Transparency corresponds with accountable and explainable AI. Monitoring and accountability tie back to governance principles. Overall, the VA framework aims to guide ethical AI based on context. It offers a model for managing risks and building trust in health care AI.
Combining VA principles with high-reliability safety principles can ensure that AI benefits veterans. The leadership and culture aspects will drive commitment to trustworthy AI practices. Leaders will communicate the importance of responsible AI through words and actions. Culture surveys can assess baseline awareness of AI ethics issues to target education. AI security and fairness will be emphasized as safety critical. The process aspect will institute policies and procedures to uphold AI principles through the project lifecycle. For example, structured testing processes will validate safety. Measurement will collect data on principles like transparency and fairness. Dashboards can track metrics like explainability and biases. A patient-centered approach will incorporate veteran perspectives on AI through participatory design and advisory councils. They can give input on AI explainability and potential biases based on their diverse backgrounds.
Conclusions
Joint principles will lead to successful AI that improves care while proactively managing risks. Involve leaders to stress the necessity of eliminating biases. Build security into the AI development process. Co-design AI transparency features with end users. Closely monitor the impact of AI across safety, fairness, and other principles. Adhering to both Trustworthy AI and high reliability organizations principles will earn veterans’ confidence. Health care organizations like the VA can integrate ethical AI safely via established frameworks. With responsible design and implementation, AI’s potential to enhance care quality, safety, and access can be realized.
Acknowledgments
We would like to acknowledge Joshua Mueller, Theo Tiffney, John Zachary, and Gil Alterovitz for their excellent work creating the VA Trustworthy Principles. This material is the result of work supported by resources and the use of facilities at the James A. Haley Veterans’ Hospital.
1. Sahni NR, Carrus B. Artificial intelligence in U.S. health care delivery. N Engl J Med. 2023;389(4):348-358. doi:10.1056/NEJMra2204673
2. Borkowski AA, Jakey CE, Mastorides SM, et al. Applications of ChatGPT and large language models in medicine and health care: benefits and pitfalls. Fed Pract. 2023;40(6):170-173. doi:10.12788/fp.0386
3. Moyal-Smith R, Margo J, Maloney FL, et al. The patient safety adoption framework: a practical framework to bridge the know-do gap. J Patient Saf. 2023;19(4):243-248. doi:10.1097/PTS.0000000000001118
4. Isaacks DB, Anderson TM, Moore SC, Patterson W, Govindan S. High reliability organization principles improve VA workplace burnout: the Truman THRIVE2 model. Am J Med Qual. 2021;36(6):422-428. doi:10.1097/01.JMQ.0000735516.35323.97
5. Sculli GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes. J Patient Saf. 2022;18(1):64-70. doi:10.1097/PTS.0000000000000788
6. National Institute of Standards and Technology. AI risk management framework. Accessed January 2, 2024. https://www.nist.gov/itl/ai-risk-management-framework
7. Executive Office of the President, Office of Science and Technology Policy. Blueprint for an AI Bill of Rights. Accessed January 11, 2024. https://www.whitehouse.gov/ostp/ai-bill-of-rights
8. Executive Office of the President. Executive Order 13960: promoting the use of trustworthy artificial intelligence in the federal government. Fed Regist. 2020;89(236):78939-78943.
9. Biden JR. Executive Order on the safe, secure, and trustworthy development and use of artificial intelligence. Published October 30, 2023. Accessed January 11, 2024. https://www.whitehouse.gov/briefing-room/presidential-actions/2023/10/30/executive-order-on-the-safe-secure-and-trustworthy-development-and-use-of-artificial-intelligence/
10. US Department of Veterans Affairs. Trustworthy AI. Accessed January 11, 2024. https://department.va.gov/ai/trustworthy/
Artificial intelligence (AI) has lagged in health care but has considerable potential to improve quality, safety, clinician experience, and access to care. It is being tested in areas like billing, hospital operations, and preventing adverse events (eg, sepsis mortality) with some early success. However, there are still many barriers preventing the widespread use of AI, such as data problems, mismatched rewards, and workplace obstacles. Innovative projects, partnerships, better rewards, and more investment could remove barriers. Implemented reliably and safely, AI can add to what clinicians know, help them work faster, cut costs, and, most importantly, improve patient care.1
AI can potentially bring several clinical benefits, such as reducing the administrative strain on clinicians and granting them more time for direct patient care. It can also improve diagnostic accuracy by analyzing patient data and diagnostic images, providing differential diagnoses, and increasing access to care by providing medical information and essential online services to patients.2
High Reliability Organizations
High reliability health care organizations have considerable experience safely launching new programs. For example, the Patient Safety Adoption Framework gives practical tips for smoothly rolling out safety initiatives (Table 1). Developed with experts and diverse views, this framework has 5 key areas: leadership, culture and context, process, measurement, and person-centeredness. These address adoption problems, guide leaders step-by-step, and focus on leadership buy-in, safety culture, cooperation, and local customization. Checklists and tools make it systematic to go from ideas to action on patient safety.3
Leadership involves establishing organizational commitment behind new safety programs. This visible commitment signals importance and priorities to others. Leaders model desired behaviors and language around safety, allocate resources, remove obstacles, and keep initiatives energized over time through consistent messaging.4 Culture and context recognizes that safety culture differs across units and facilities. Local input tailors programs to fit and examines strengths to build on, like psychological safety. Surveys gauge the existing culture and its need for change. Process details how to plan, design, test, implement, and improve new safety practices and provides a phased roadmap from idea to results. Measurement collects data to drive improvement and show impact. Metrics track progress and allow benchmarking. Person-centeredness puts patients first in safety efforts through participation, education, and transparency.
The Veterans Health Administration piloted a comprehensive high reliability hospital (HRH) model. Over 3 years, the Veterans Health Administration focused on leadership, culture, and process improvement at a hospital. After initiating the model, the pilot hospital improved its safety culture, reported more minor safety issues, and reduced deaths and complications better than other hospitals. The high-reliability approach successfully instilled principles and improved culture and outcomes. The HRH model is set to be expanded to 18 more US Department of Veterans Affairs (VA) sites for further evaluation across diverse settings.5
Trustworthy AI Framework
AI systems are growing more powerful and widespread, including in health care. Unfortunately, irresponsible AI can introduce new harm. ChatGPT and other large language models, for example, sometimes are known to provide erroneous information in a compelling way. Clinicians and patients who use such programs can act on such information, which would lead to unforeseen negative consequences. Several frameworks on ethical AI have come from governmental groups.6-9 In 2023, the VA National AI Institute suggested a Trustworthy AI Framework based on core principles tailored for federal health care. The framework has 6 key principles: purposeful, effective and safe, secure and private, fair and equitable, transparent and explainable, and accountable and monitored (Table 2).10
First, AI must clearly help veterans while minimizing risks. To ensure purpose, the VA will assess patient and clinician needs and design AI that targets meaningful problems to avoid scope creep or feature bloat. For example, adding new features to the AI software after release can clutter and complicate the interface, making it difficult to use. Rigorous testing will confirm that AI meets intent prior to deployment. Second, AI is designed and checked for effectiveness, safety, and reliability. The VA pledges to monitor AI’s impact to ensure it performs as expected without unintended consequences. Algorithms will be stress tested across representative datasets and approval processes will screen for safety issues. Third, AI models are secured from vulnerabilities and misuse. Technical controls will prevent unauthorized access or changes to AI systems. Audits will check for appropriate internal usage per policies. Continual patches and upgrades will maintain security. Fourth, the VA manages AI for fairness, avoiding bias. They will proactively assess datasets and algorithms for potential biases based on protected attributes like race, gender, or age. Biased outputs will be addressed through techniques such as data augmentation, reweighting, and algorithm tweaks. Fifth, transparency explains AI’s role in care. Documentation will detail an AI system’s data sources, methodology, testing, limitations, and integration with clinical workflows. Clinicians and patients will receive education on interpreting AI outputs. Finally, the VA pledges to closely monitor AI systems to sustain trust. The VA will establish oversight processes to quickly identify any declines in reliability or unfair impacts on subgroups. AI models will be retrained as needed based on incoming data patterns.
Each Trustworthy AI Framework principle connects to others in existing frameworks. The purpose principle aligns with human-centric AI focused on benefits. Effectiveness and safety link to technical robustness and risk management principles. Security maps to privacy protection principles. Fairness connects to principles of avoiding bias and discrimination. Transparency corresponds with accountable and explainable AI. Monitoring and accountability tie back to governance principles. Overall, the VA framework aims to guide ethical AI based on context. It offers a model for managing risks and building trust in health care AI.
Combining VA principles with high-reliability safety principles can ensure that AI benefits veterans. The leadership and culture aspects will drive commitment to trustworthy AI practices. Leaders will communicate the importance of responsible AI through words and actions. Culture surveys can assess baseline awareness of AI ethics issues to target education. AI security and fairness will be emphasized as safety critical. The process aspect will institute policies and procedures to uphold AI principles through the project lifecycle. For example, structured testing processes will validate safety. Measurement will collect data on principles like transparency and fairness. Dashboards can track metrics like explainability and biases. A patient-centered approach will incorporate veteran perspectives on AI through participatory design and advisory councils. They can give input on AI explainability and potential biases based on their diverse backgrounds.
Conclusions
Joint principles will lead to successful AI that improves care while proactively managing risks. Involve leaders to stress the necessity of eliminating biases. Build security into the AI development process. Co-design AI transparency features with end users. Closely monitor the impact of AI across safety, fairness, and other principles. Adhering to both Trustworthy AI and high reliability organizations principles will earn veterans’ confidence. Health care organizations like the VA can integrate ethical AI safely via established frameworks. With responsible design and implementation, AI’s potential to enhance care quality, safety, and access can be realized.
Acknowledgments
We would like to acknowledge Joshua Mueller, Theo Tiffney, John Zachary, and Gil Alterovitz for their excellent work creating the VA Trustworthy Principles. This material is the result of work supported by resources and the use of facilities at the James A. Haley Veterans’ Hospital.
Artificial intelligence (AI) has lagged in health care but has considerable potential to improve quality, safety, clinician experience, and access to care. It is being tested in areas like billing, hospital operations, and preventing adverse events (eg, sepsis mortality) with some early success. However, there are still many barriers preventing the widespread use of AI, such as data problems, mismatched rewards, and workplace obstacles. Innovative projects, partnerships, better rewards, and more investment could remove barriers. Implemented reliably and safely, AI can add to what clinicians know, help them work faster, cut costs, and, most importantly, improve patient care.1
AI can potentially bring several clinical benefits, such as reducing the administrative strain on clinicians and granting them more time for direct patient care. It can also improve diagnostic accuracy by analyzing patient data and diagnostic images, providing differential diagnoses, and increasing access to care by providing medical information and essential online services to patients.2
High Reliability Organizations
High reliability health care organizations have considerable experience safely launching new programs. For example, the Patient Safety Adoption Framework gives practical tips for smoothly rolling out safety initiatives (Table 1). Developed with experts and diverse views, this framework has 5 key areas: leadership, culture and context, process, measurement, and person-centeredness. These address adoption problems, guide leaders step-by-step, and focus on leadership buy-in, safety culture, cooperation, and local customization. Checklists and tools make it systematic to go from ideas to action on patient safety.3
Leadership involves establishing organizational commitment behind new safety programs. This visible commitment signals importance and priorities to others. Leaders model desired behaviors and language around safety, allocate resources, remove obstacles, and keep initiatives energized over time through consistent messaging.4 Culture and context recognizes that safety culture differs across units and facilities. Local input tailors programs to fit and examines strengths to build on, like psychological safety. Surveys gauge the existing culture and its need for change. Process details how to plan, design, test, implement, and improve new safety practices and provides a phased roadmap from idea to results. Measurement collects data to drive improvement and show impact. Metrics track progress and allow benchmarking. Person-centeredness puts patients first in safety efforts through participation, education, and transparency.
The Veterans Health Administration piloted a comprehensive high reliability hospital (HRH) model. Over 3 years, the Veterans Health Administration focused on leadership, culture, and process improvement at a hospital. After initiating the model, the pilot hospital improved its safety culture, reported more minor safety issues, and reduced deaths and complications better than other hospitals. The high-reliability approach successfully instilled principles and improved culture and outcomes. The HRH model is set to be expanded to 18 more US Department of Veterans Affairs (VA) sites for further evaluation across diverse settings.5
Trustworthy AI Framework
AI systems are growing more powerful and widespread, including in health care. Unfortunately, irresponsible AI can introduce new harm. ChatGPT and other large language models, for example, sometimes are known to provide erroneous information in a compelling way. Clinicians and patients who use such programs can act on such information, which would lead to unforeseen negative consequences. Several frameworks on ethical AI have come from governmental groups.6-9 In 2023, the VA National AI Institute suggested a Trustworthy AI Framework based on core principles tailored for federal health care. The framework has 6 key principles: purposeful, effective and safe, secure and private, fair and equitable, transparent and explainable, and accountable and monitored (Table 2).10
First, AI must clearly help veterans while minimizing risks. To ensure purpose, the VA will assess patient and clinician needs and design AI that targets meaningful problems to avoid scope creep or feature bloat. For example, adding new features to the AI software after release can clutter and complicate the interface, making it difficult to use. Rigorous testing will confirm that AI meets intent prior to deployment. Second, AI is designed and checked for effectiveness, safety, and reliability. The VA pledges to monitor AI’s impact to ensure it performs as expected without unintended consequences. Algorithms will be stress tested across representative datasets and approval processes will screen for safety issues. Third, AI models are secured from vulnerabilities and misuse. Technical controls will prevent unauthorized access or changes to AI systems. Audits will check for appropriate internal usage per policies. Continual patches and upgrades will maintain security. Fourth, the VA manages AI for fairness, avoiding bias. They will proactively assess datasets and algorithms for potential biases based on protected attributes like race, gender, or age. Biased outputs will be addressed through techniques such as data augmentation, reweighting, and algorithm tweaks. Fifth, transparency explains AI’s role in care. Documentation will detail an AI system’s data sources, methodology, testing, limitations, and integration with clinical workflows. Clinicians and patients will receive education on interpreting AI outputs. Finally, the VA pledges to closely monitor AI systems to sustain trust. The VA will establish oversight processes to quickly identify any declines in reliability or unfair impacts on subgroups. AI models will be retrained as needed based on incoming data patterns.
Each Trustworthy AI Framework principle connects to others in existing frameworks. The purpose principle aligns with human-centric AI focused on benefits. Effectiveness and safety link to technical robustness and risk management principles. Security maps to privacy protection principles. Fairness connects to principles of avoiding bias and discrimination. Transparency corresponds with accountable and explainable AI. Monitoring and accountability tie back to governance principles. Overall, the VA framework aims to guide ethical AI based on context. It offers a model for managing risks and building trust in health care AI.
Combining VA principles with high-reliability safety principles can ensure that AI benefits veterans. The leadership and culture aspects will drive commitment to trustworthy AI practices. Leaders will communicate the importance of responsible AI through words and actions. Culture surveys can assess baseline awareness of AI ethics issues to target education. AI security and fairness will be emphasized as safety critical. The process aspect will institute policies and procedures to uphold AI principles through the project lifecycle. For example, structured testing processes will validate safety. Measurement will collect data on principles like transparency and fairness. Dashboards can track metrics like explainability and biases. A patient-centered approach will incorporate veteran perspectives on AI through participatory design and advisory councils. They can give input on AI explainability and potential biases based on their diverse backgrounds.
Conclusions
Joint principles will lead to successful AI that improves care while proactively managing risks. Involve leaders to stress the necessity of eliminating biases. Build security into the AI development process. Co-design AI transparency features with end users. Closely monitor the impact of AI across safety, fairness, and other principles. Adhering to both Trustworthy AI and high reliability organizations principles will earn veterans’ confidence. Health care organizations like the VA can integrate ethical AI safely via established frameworks. With responsible design and implementation, AI’s potential to enhance care quality, safety, and access can be realized.
Acknowledgments
We would like to acknowledge Joshua Mueller, Theo Tiffney, John Zachary, and Gil Alterovitz for their excellent work creating the VA Trustworthy Principles. This material is the result of work supported by resources and the use of facilities at the James A. Haley Veterans’ Hospital.
1. Sahni NR, Carrus B. Artificial intelligence in U.S. health care delivery. N Engl J Med. 2023;389(4):348-358. doi:10.1056/NEJMra2204673
2. Borkowski AA, Jakey CE, Mastorides SM, et al. Applications of ChatGPT and large language models in medicine and health care: benefits and pitfalls. Fed Pract. 2023;40(6):170-173. doi:10.12788/fp.0386
3. Moyal-Smith R, Margo J, Maloney FL, et al. The patient safety adoption framework: a practical framework to bridge the know-do gap. J Patient Saf. 2023;19(4):243-248. doi:10.1097/PTS.0000000000001118
4. Isaacks DB, Anderson TM, Moore SC, Patterson W, Govindan S. High reliability organization principles improve VA workplace burnout: the Truman THRIVE2 model. Am J Med Qual. 2021;36(6):422-428. doi:10.1097/01.JMQ.0000735516.35323.97
5. Sculli GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes. J Patient Saf. 2022;18(1):64-70. doi:10.1097/PTS.0000000000000788
6. National Institute of Standards and Technology. AI risk management framework. Accessed January 2, 2024. https://www.nist.gov/itl/ai-risk-management-framework
7. Executive Office of the President, Office of Science and Technology Policy. Blueprint for an AI Bill of Rights. Accessed January 11, 2024. https://www.whitehouse.gov/ostp/ai-bill-of-rights
8. Executive Office of the President. Executive Order 13960: promoting the use of trustworthy artificial intelligence in the federal government. Fed Regist. 2020;89(236):78939-78943.
9. Biden JR. Executive Order on the safe, secure, and trustworthy development and use of artificial intelligence. Published October 30, 2023. Accessed January 11, 2024. https://www.whitehouse.gov/briefing-room/presidential-actions/2023/10/30/executive-order-on-the-safe-secure-and-trustworthy-development-and-use-of-artificial-intelligence/
10. US Department of Veterans Affairs. Trustworthy AI. Accessed January 11, 2024. https://department.va.gov/ai/trustworthy/
1. Sahni NR, Carrus B. Artificial intelligence in U.S. health care delivery. N Engl J Med. 2023;389(4):348-358. doi:10.1056/NEJMra2204673
2. Borkowski AA, Jakey CE, Mastorides SM, et al. Applications of ChatGPT and large language models in medicine and health care: benefits and pitfalls. Fed Pract. 2023;40(6):170-173. doi:10.12788/fp.0386
3. Moyal-Smith R, Margo J, Maloney FL, et al. The patient safety adoption framework: a practical framework to bridge the know-do gap. J Patient Saf. 2023;19(4):243-248. doi:10.1097/PTS.0000000000001118
4. Isaacks DB, Anderson TM, Moore SC, Patterson W, Govindan S. High reliability organization principles improve VA workplace burnout: the Truman THRIVE2 model. Am J Med Qual. 2021;36(6):422-428. doi:10.1097/01.JMQ.0000735516.35323.97
5. Sculli GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes. J Patient Saf. 2022;18(1):64-70. doi:10.1097/PTS.0000000000000788
6. National Institute of Standards and Technology. AI risk management framework. Accessed January 2, 2024. https://www.nist.gov/itl/ai-risk-management-framework
7. Executive Office of the President, Office of Science and Technology Policy. Blueprint for an AI Bill of Rights. Accessed January 11, 2024. https://www.whitehouse.gov/ostp/ai-bill-of-rights
8. Executive Office of the President. Executive Order 13960: promoting the use of trustworthy artificial intelligence in the federal government. Fed Regist. 2020;89(236):78939-78943.
9. Biden JR. Executive Order on the safe, secure, and trustworthy development and use of artificial intelligence. Published October 30, 2023. Accessed January 11, 2024. https://www.whitehouse.gov/briefing-room/presidential-actions/2023/10/30/executive-order-on-the-safe-secure-and-trustworthy-development-and-use-of-artificial-intelligence/
10. US Department of Veterans Affairs. Trustworthy AI. Accessed January 11, 2024. https://department.va.gov/ai/trustworthy/
Moving the Field FORWARD
As an organization, AGA has invested heavily in programs and initiatives to support the professional development of its members across career stages. This includes programs such as the AGA-AASLD Academic Skills Workshop (in which I was fortunate to participate in 2016), Women’s Leadership and Executive Leadership Conferences (with the Midwest Women in GI Regional Workshop taking place later this month), and the AGA Research Foundation Awards Program, which distributes over $2 million in funding annually to support promising early career and senior investigators.
AGA’s Fostering Opportunities Resulting in Workforce and Research Diversity (FORWARD) Program, which was first funded by the National Institutes of Health in 2018 and is focused on improving the diversity of the GI research workforce, is another shining example. Led by Dr. Byron Cryer and Dr. Sandra Quezada, the program recently welcomed its 3rd cohort of participants, including 14 mentees and 28 senior and near-peer mentors.
We are pleased to frequently highlight these programs in the pages of GI & Hepatology News, and hope you enjoy learning more about each of these initiatives in future issues.
In this month’s issue of GIHN, we highlight AGA’s newest Clinical Practice Guideline focused on management of pouchitis. We also report on the results of a recent RCT published in the New England Journal of Medicine demonstrating the efficacy of thalidomide as a treatment for recurrent bleeding due to small-intestinal angiodysplasia and summarize other key journal content impacting your clinical practice. In our February Member Spotlight, we feature Dr. Rajeev Jain of Texas Digestive Disease Consultants, a former AGA Governing Board member, and learn about his advocacy work to improve patient care and reduce physician burnout through insurance coverage and MOC reform. We hope you enjoy this, and all the exciting content included in our February issue!
Megan A. Adams, MD, JD, MSc
Editor-in-Chief
As an organization, AGA has invested heavily in programs and initiatives to support the professional development of its members across career stages. This includes programs such as the AGA-AASLD Academic Skills Workshop (in which I was fortunate to participate in 2016), Women’s Leadership and Executive Leadership Conferences (with the Midwest Women in GI Regional Workshop taking place later this month), and the AGA Research Foundation Awards Program, which distributes over $2 million in funding annually to support promising early career and senior investigators.
AGA’s Fostering Opportunities Resulting in Workforce and Research Diversity (FORWARD) Program, which was first funded by the National Institutes of Health in 2018 and is focused on improving the diversity of the GI research workforce, is another shining example. Led by Dr. Byron Cryer and Dr. Sandra Quezada, the program recently welcomed its 3rd cohort of participants, including 14 mentees and 28 senior and near-peer mentors.
We are pleased to frequently highlight these programs in the pages of GI & Hepatology News, and hope you enjoy learning more about each of these initiatives in future issues.
In this month’s issue of GIHN, we highlight AGA’s newest Clinical Practice Guideline focused on management of pouchitis. We also report on the results of a recent RCT published in the New England Journal of Medicine demonstrating the efficacy of thalidomide as a treatment for recurrent bleeding due to small-intestinal angiodysplasia and summarize other key journal content impacting your clinical practice. In our February Member Spotlight, we feature Dr. Rajeev Jain of Texas Digestive Disease Consultants, a former AGA Governing Board member, and learn about his advocacy work to improve patient care and reduce physician burnout through insurance coverage and MOC reform. We hope you enjoy this, and all the exciting content included in our February issue!
Megan A. Adams, MD, JD, MSc
Editor-in-Chief
As an organization, AGA has invested heavily in programs and initiatives to support the professional development of its members across career stages. This includes programs such as the AGA-AASLD Academic Skills Workshop (in which I was fortunate to participate in 2016), Women’s Leadership and Executive Leadership Conferences (with the Midwest Women in GI Regional Workshop taking place later this month), and the AGA Research Foundation Awards Program, which distributes over $2 million in funding annually to support promising early career and senior investigators.
AGA’s Fostering Opportunities Resulting in Workforce and Research Diversity (FORWARD) Program, which was first funded by the National Institutes of Health in 2018 and is focused on improving the diversity of the GI research workforce, is another shining example. Led by Dr. Byron Cryer and Dr. Sandra Quezada, the program recently welcomed its 3rd cohort of participants, including 14 mentees and 28 senior and near-peer mentors.
We are pleased to frequently highlight these programs in the pages of GI & Hepatology News, and hope you enjoy learning more about each of these initiatives in future issues.
In this month’s issue of GIHN, we highlight AGA’s newest Clinical Practice Guideline focused on management of pouchitis. We also report on the results of a recent RCT published in the New England Journal of Medicine demonstrating the efficacy of thalidomide as a treatment for recurrent bleeding due to small-intestinal angiodysplasia and summarize other key journal content impacting your clinical practice. In our February Member Spotlight, we feature Dr. Rajeev Jain of Texas Digestive Disease Consultants, a former AGA Governing Board member, and learn about his advocacy work to improve patient care and reduce physician burnout through insurance coverage and MOC reform. We hope you enjoy this, and all the exciting content included in our February issue!
Megan A. Adams, MD, JD, MSc
Editor-in-Chief
Psychogenic Purpura
To the Editor:
A 14-year-old Black adolescent girl presented with episodic, painful, edematous plaques that occurred symmetrically on the arms and legs of 5 years’ duration. The plaques evolved into hyperpigmented patches within 24 to 48 hours before eventually resolving. Fatigue, headache, arthralgias of the arms and legs, chest pain, abdominal pain, nausea, and vomiting variably accompanied these episodes.
Prior to visiting our clinic, the patient had been seen by numerous specialists. A review of her medical records revealed an initial diagnosis of Henoch-Schönlein purpura (HSP), then urticarial vasculitis. She had been treated with antihistamines, topical and systemic steroids, hydroxychloroquine, mycophenolate mofetil, dapsone, azathioprine, and gabapentin. All treatments were ineffectual. She underwent extensive diagnostic testing and imaging, which were normal or noncontributory, including type I allergy testing; multiple exhaustive batteries of hematologic testing; and computed tomography/magnetic resonance imaging/magnetic resonance angiography of the brain, chest, abdomen, and pelvic region. Biopsies from symptomatic segments of the gastrointestinal tract were normal.
Chronic treatment with systemic steroids over 9 months resulted in gastritis and an episode of hematemesis requiring emergent hospitalization. A lengthy multidisciplinary evaluation was conducted at the patient’s local community hospital; the team concluded that she had an urticarial-type rash with accompanying symptoms that did not have an autoimmune, rheumatologic, or inflammatory basis.
The patient’s medical history was remarkable for recent-onset panic attacks. Her family medical history was noncontributory. Physical examination revealed multiple violaceous hyperpigmented patches diffusely located on the proximal upper arms (Figure 1). There were no additional findings on physical examination.
Punch biopsies were performed on lesional areas of the arm. Histopathology indicated a mild superficial perivascular dermal mixed infiltrate and extravasated erythrocytes (Figure 2). Direct immunofluorescence (DIF) testing was negative for vasculitis. Immunohistochemical stains for CD117 and tryptase demonstrated a slight increase in the number of dermal mast cells; however, the increase was not sufficient to diagnose cutaneous mastocytosis, which was in the differential. We proposed a diagnosis of psychogenic purpura (PP)(also known as Gardner-Diamond syndrome). She was treated with gabapentin, a selective serotonin reuptake inhibitor, and cognitive therapy. Unfortunately, after starting therapy the patient was lost to follow-up.
Psychogenic purpura is a rare vasculopathy of unknown etiology that may be a special form of factitious disorder.1,2 In one study, PP occurred predominantly in females aged 15 to 66 years, with a median onset age of 33 years.3 A prodrome of localized itching, burning, and/or pain precedes the development of edematous plaques. The plaques evolve into painful ecchymoses within 1 to 2 days and resolve in 10 days or fewer without treatment. Lesions most commonly occur on the extremities but may occur anywhere on the body. The most common associated finding is an underlying depressive disorder. Episodes may be accompanied by headache, dizziness, fatigue, fever, arthralgia, nausea, vomiting, abdominal pain, menstrual irregularities, myalgia, and urologic conditions.
In 1955, Gardner and Diamond4 described the first cases of PP in 4 female patients at Peter Bent Brigham Hospital in Boston, Massachusetts. The investigators were able to replicate the painful ecchymoses with intradermal injection of the patient’s own erythrocytes into the skin. They proposed that the underlying pathogenesis involved autosensitization to erythrocyte stroma.4 Since then, others have suggested that the pathogenesis may include autosensitization to erythrocyte phosphatidylserine, tonus dysregulation of venous capillaries, abnormal endothelial fibrin synthesis, and capillary wall instability.5-7
Histopathology typically reveals superficial and deep perivascular inflammation with extravasated erythrocytes. Direct immunofluorescence is negative for vasculitis.8 Diagnostics and laboratory findings for underlying systemic illness are negative or noncontributory. Cutaneous injection of 1 mL of the patient’s own washed erythrocytes may result in the formation of the characteristic painful plaques within 24 hours; however, this test is limited by lack of standardization and low sensitivity.3
Psychogenic purpura may share clinical features with cutaneous small vessel vasculitis, such as HSP or urticarial vasculitis. Some of the findings that our patient was experiencing, including purpura, arthralgia, and abdominal pain, are associated with HSP. However, HSP typically is self-limiting and classically features palpable purpura distributed across the lower extremities and buttocks. Histopathology demonstrates the classic findings of leukocytoclastic vasculitis; DIF typically is positive for perivascular IgA and C3 deposition. Increased serum IgA may be present.9 Urticarial vasculitis appears as erythematous indurated wheals that favor a proximal extremity and truncal distribution. They characteristically last longer than 24 hours, are frequently associated with nonprodromal pain or burning, and resolve with hyperpigmentation. Arthralgia and gastrointestinal, renal, pulmonary, cardiac, and neurologic symptoms may be present, especially in patients with low complement levels.10 Skin biopsy demonstrates leukocytoclasia that must be accompanied by vessel wall necrosis. Fibrinoid deposition, erythrocyte extravasation, or perivascular inflammation may be present. In 70% of cases revealing perivascular immunoglobulin, C3, and fibrinogen deposition, DIF is positive. Serum C1q autoantibody may be associated with the hypocomplementemic form.10
The classic histopathologic findings in leukocytoclastic vasculitis include transmural neutrophilic infiltration of the walls of small vessels, fibrinoid necrosis of vessel walls, leukocytoclasia, extravasated erythrocytes, and signs of endothelial cell damage.9 A prior punch biopsy in this patient demonstrated rare neutrophilic nuclear debris within the vessel walls without fibrin deposition. Although the presence of nuclear debris and extravasated erythrocytes could be compatible with a manifestation of urticarial vasculitis, the lack of direct evidence of vessel wall necrosis combined with subsequent biopsies unequivocally ruled out cutaneous small vessel vasculitis in our patient.
Psychogenic purpura has been reported to occur frequently in the background of psycho-emotional distress. In 1989, Ratnoff11 noted that many of the patients he was treating at the University Hospitals of Cleveland, Ohio, had a depressive syndrome. A review of patients treated at the Mayo Clinic in Rochester, Minnesota, illustrated concomitant psychiatric illnesses in 41 of 76 (54%) patients treated for PP, most commonly depressive, personality, and anxiety disorders.3
There is no consensus on therapy for PP. Treatment is based on providing symptomatic relief and relieving underlying psychiatric distress. Block et al12 found the use of selective serotonin reuptake inhibitors, tricyclic antidepressants, and psychotherapy to be successful in improving symptoms and reducing lesions at follow-up visits.
- Piette WW. Purpura: mechanisms and differential diagnosis. In: Bolognia JL, Schaffer JV, Cerroni L. Dermatology. 4th ed. Elsevier; 2018:376-389.
- Harth W, Taube KM, Gieler U. Factitious disorders in dermatology. J Dtsch Dermatol Ges. 2010;8:361-372.
- Sridharan M, Ali U, Hook CC, et al. The Mayo Clinic experience with psychogenic purpura (Gardner-Diamond syndrome). Am J Med Sci. 2019;357:411‐420.
- Gardner FH, Diamond LK. Autoerythrocyte sensitization; a form of purpura producing painful bruising following autosensitization to red blood cells in certain women. Blood. 1955;10:675-690.
- Groch GS, Finch SC, Rogoway W, et al. Studies in the pathogenesis of autoerythrocyte sensitization syndrome. Blood. 1966;28:19-33.
- Strunecká A, Krpejsová L, Palecek J, et al. Transbilayer redistribution of phosphatidylserine in erythrocytes of a patient with autoerythrocyte sensitization syndrome (psychogenic purpura). Folia Haematol Int Mag Klin Morphol Blutforsch. 1990;117:829-841.
- Merlen JF. Ecchymotic patches of the fingers and Gardner-Diamond vascular purpura. Phlebologie. 1987;40:473-487.
- Ivanov OL, Lvov AN, Michenko AV, et al. Autoerythrocyte sensitization syndrome (Gardner-Diamond syndrome): review of the literature. J Eur Acad Dermatol Venereol. 2009;23:499-504.
- Wetter DA, Dutz JP, Shinkai K, et al. Cutaneous vasculitis. In: Bolognia JL, Schaffer JV, Cerroni L. Dermatology. 4th ed. Elsevier; 2018:409-439.
- Hamad A, Jithpratuck W, Krishnaswamy G. Urticarial vasculitis and associated disorders. Ann Allergy Asthma Immunol. 2017;118:394-398.
- Ratnoff OD. Psychogenic purpura (autoerythrocyte sensitization): an unsolved dilemma. Am J Med. 1989;87:16N-21N.
- Block ME, Sitenga JL, Lehrer M, et al. Gardner‐Diamond syndrome: a systematic review of treatment options for a rare psychodermatological disorder. Int J Dermatol. 2019;58:782-787.
To the Editor:
A 14-year-old Black adolescent girl presented with episodic, painful, edematous plaques that occurred symmetrically on the arms and legs of 5 years’ duration. The plaques evolved into hyperpigmented patches within 24 to 48 hours before eventually resolving. Fatigue, headache, arthralgias of the arms and legs, chest pain, abdominal pain, nausea, and vomiting variably accompanied these episodes.
Prior to visiting our clinic, the patient had been seen by numerous specialists. A review of her medical records revealed an initial diagnosis of Henoch-Schönlein purpura (HSP), then urticarial vasculitis. She had been treated with antihistamines, topical and systemic steroids, hydroxychloroquine, mycophenolate mofetil, dapsone, azathioprine, and gabapentin. All treatments were ineffectual. She underwent extensive diagnostic testing and imaging, which were normal or noncontributory, including type I allergy testing; multiple exhaustive batteries of hematologic testing; and computed tomography/magnetic resonance imaging/magnetic resonance angiography of the brain, chest, abdomen, and pelvic region. Biopsies from symptomatic segments of the gastrointestinal tract were normal.
Chronic treatment with systemic steroids over 9 months resulted in gastritis and an episode of hematemesis requiring emergent hospitalization. A lengthy multidisciplinary evaluation was conducted at the patient’s local community hospital; the team concluded that she had an urticarial-type rash with accompanying symptoms that did not have an autoimmune, rheumatologic, or inflammatory basis.
The patient’s medical history was remarkable for recent-onset panic attacks. Her family medical history was noncontributory. Physical examination revealed multiple violaceous hyperpigmented patches diffusely located on the proximal upper arms (Figure 1). There were no additional findings on physical examination.
Punch biopsies were performed on lesional areas of the arm. Histopathology indicated a mild superficial perivascular dermal mixed infiltrate and extravasated erythrocytes (Figure 2). Direct immunofluorescence (DIF) testing was negative for vasculitis. Immunohistochemical stains for CD117 and tryptase demonstrated a slight increase in the number of dermal mast cells; however, the increase was not sufficient to diagnose cutaneous mastocytosis, which was in the differential. We proposed a diagnosis of psychogenic purpura (PP)(also known as Gardner-Diamond syndrome). She was treated with gabapentin, a selective serotonin reuptake inhibitor, and cognitive therapy. Unfortunately, after starting therapy the patient was lost to follow-up.
Psychogenic purpura is a rare vasculopathy of unknown etiology that may be a special form of factitious disorder.1,2 In one study, PP occurred predominantly in females aged 15 to 66 years, with a median onset age of 33 years.3 A prodrome of localized itching, burning, and/or pain precedes the development of edematous plaques. The plaques evolve into painful ecchymoses within 1 to 2 days and resolve in 10 days or fewer without treatment. Lesions most commonly occur on the extremities but may occur anywhere on the body. The most common associated finding is an underlying depressive disorder. Episodes may be accompanied by headache, dizziness, fatigue, fever, arthralgia, nausea, vomiting, abdominal pain, menstrual irregularities, myalgia, and urologic conditions.
In 1955, Gardner and Diamond4 described the first cases of PP in 4 female patients at Peter Bent Brigham Hospital in Boston, Massachusetts. The investigators were able to replicate the painful ecchymoses with intradermal injection of the patient’s own erythrocytes into the skin. They proposed that the underlying pathogenesis involved autosensitization to erythrocyte stroma.4 Since then, others have suggested that the pathogenesis may include autosensitization to erythrocyte phosphatidylserine, tonus dysregulation of venous capillaries, abnormal endothelial fibrin synthesis, and capillary wall instability.5-7
Histopathology typically reveals superficial and deep perivascular inflammation with extravasated erythrocytes. Direct immunofluorescence is negative for vasculitis.8 Diagnostics and laboratory findings for underlying systemic illness are negative or noncontributory. Cutaneous injection of 1 mL of the patient’s own washed erythrocytes may result in the formation of the characteristic painful plaques within 24 hours; however, this test is limited by lack of standardization and low sensitivity.3
Psychogenic purpura may share clinical features with cutaneous small vessel vasculitis, such as HSP or urticarial vasculitis. Some of the findings that our patient was experiencing, including purpura, arthralgia, and abdominal pain, are associated with HSP. However, HSP typically is self-limiting and classically features palpable purpura distributed across the lower extremities and buttocks. Histopathology demonstrates the classic findings of leukocytoclastic vasculitis; DIF typically is positive for perivascular IgA and C3 deposition. Increased serum IgA may be present.9 Urticarial vasculitis appears as erythematous indurated wheals that favor a proximal extremity and truncal distribution. They characteristically last longer than 24 hours, are frequently associated with nonprodromal pain or burning, and resolve with hyperpigmentation. Arthralgia and gastrointestinal, renal, pulmonary, cardiac, and neurologic symptoms may be present, especially in patients with low complement levels.10 Skin biopsy demonstrates leukocytoclasia that must be accompanied by vessel wall necrosis. Fibrinoid deposition, erythrocyte extravasation, or perivascular inflammation may be present. In 70% of cases revealing perivascular immunoglobulin, C3, and fibrinogen deposition, DIF is positive. Serum C1q autoantibody may be associated with the hypocomplementemic form.10
The classic histopathologic findings in leukocytoclastic vasculitis include transmural neutrophilic infiltration of the walls of small vessels, fibrinoid necrosis of vessel walls, leukocytoclasia, extravasated erythrocytes, and signs of endothelial cell damage.9 A prior punch biopsy in this patient demonstrated rare neutrophilic nuclear debris within the vessel walls without fibrin deposition. Although the presence of nuclear debris and extravasated erythrocytes could be compatible with a manifestation of urticarial vasculitis, the lack of direct evidence of vessel wall necrosis combined with subsequent biopsies unequivocally ruled out cutaneous small vessel vasculitis in our patient.
Psychogenic purpura has been reported to occur frequently in the background of psycho-emotional distress. In 1989, Ratnoff11 noted that many of the patients he was treating at the University Hospitals of Cleveland, Ohio, had a depressive syndrome. A review of patients treated at the Mayo Clinic in Rochester, Minnesota, illustrated concomitant psychiatric illnesses in 41 of 76 (54%) patients treated for PP, most commonly depressive, personality, and anxiety disorders.3
There is no consensus on therapy for PP. Treatment is based on providing symptomatic relief and relieving underlying psychiatric distress. Block et al12 found the use of selective serotonin reuptake inhibitors, tricyclic antidepressants, and psychotherapy to be successful in improving symptoms and reducing lesions at follow-up visits.
To the Editor:
A 14-year-old Black adolescent girl presented with episodic, painful, edematous plaques that occurred symmetrically on the arms and legs of 5 years’ duration. The plaques evolved into hyperpigmented patches within 24 to 48 hours before eventually resolving. Fatigue, headache, arthralgias of the arms and legs, chest pain, abdominal pain, nausea, and vomiting variably accompanied these episodes.
Prior to visiting our clinic, the patient had been seen by numerous specialists. A review of her medical records revealed an initial diagnosis of Henoch-Schönlein purpura (HSP), then urticarial vasculitis. She had been treated with antihistamines, topical and systemic steroids, hydroxychloroquine, mycophenolate mofetil, dapsone, azathioprine, and gabapentin. All treatments were ineffectual. She underwent extensive diagnostic testing and imaging, which were normal or noncontributory, including type I allergy testing; multiple exhaustive batteries of hematologic testing; and computed tomography/magnetic resonance imaging/magnetic resonance angiography of the brain, chest, abdomen, and pelvic region. Biopsies from symptomatic segments of the gastrointestinal tract were normal.
Chronic treatment with systemic steroids over 9 months resulted in gastritis and an episode of hematemesis requiring emergent hospitalization. A lengthy multidisciplinary evaluation was conducted at the patient’s local community hospital; the team concluded that she had an urticarial-type rash with accompanying symptoms that did not have an autoimmune, rheumatologic, or inflammatory basis.
The patient’s medical history was remarkable for recent-onset panic attacks. Her family medical history was noncontributory. Physical examination revealed multiple violaceous hyperpigmented patches diffusely located on the proximal upper arms (Figure 1). There were no additional findings on physical examination.
Punch biopsies were performed on lesional areas of the arm. Histopathology indicated a mild superficial perivascular dermal mixed infiltrate and extravasated erythrocytes (Figure 2). Direct immunofluorescence (DIF) testing was negative for vasculitis. Immunohistochemical stains for CD117 and tryptase demonstrated a slight increase in the number of dermal mast cells; however, the increase was not sufficient to diagnose cutaneous mastocytosis, which was in the differential. We proposed a diagnosis of psychogenic purpura (PP)(also known as Gardner-Diamond syndrome). She was treated with gabapentin, a selective serotonin reuptake inhibitor, and cognitive therapy. Unfortunately, after starting therapy the patient was lost to follow-up.
Psychogenic purpura is a rare vasculopathy of unknown etiology that may be a special form of factitious disorder.1,2 In one study, PP occurred predominantly in females aged 15 to 66 years, with a median onset age of 33 years.3 A prodrome of localized itching, burning, and/or pain precedes the development of edematous plaques. The plaques evolve into painful ecchymoses within 1 to 2 days and resolve in 10 days or fewer without treatment. Lesions most commonly occur on the extremities but may occur anywhere on the body. The most common associated finding is an underlying depressive disorder. Episodes may be accompanied by headache, dizziness, fatigue, fever, arthralgia, nausea, vomiting, abdominal pain, menstrual irregularities, myalgia, and urologic conditions.
In 1955, Gardner and Diamond4 described the first cases of PP in 4 female patients at Peter Bent Brigham Hospital in Boston, Massachusetts. The investigators were able to replicate the painful ecchymoses with intradermal injection of the patient’s own erythrocytes into the skin. They proposed that the underlying pathogenesis involved autosensitization to erythrocyte stroma.4 Since then, others have suggested that the pathogenesis may include autosensitization to erythrocyte phosphatidylserine, tonus dysregulation of venous capillaries, abnormal endothelial fibrin synthesis, and capillary wall instability.5-7
Histopathology typically reveals superficial and deep perivascular inflammation with extravasated erythrocytes. Direct immunofluorescence is negative for vasculitis.8 Diagnostics and laboratory findings for underlying systemic illness are negative or noncontributory. Cutaneous injection of 1 mL of the patient’s own washed erythrocytes may result in the formation of the characteristic painful plaques within 24 hours; however, this test is limited by lack of standardization and low sensitivity.3
Psychogenic purpura may share clinical features with cutaneous small vessel vasculitis, such as HSP or urticarial vasculitis. Some of the findings that our patient was experiencing, including purpura, arthralgia, and abdominal pain, are associated with HSP. However, HSP typically is self-limiting and classically features palpable purpura distributed across the lower extremities and buttocks. Histopathology demonstrates the classic findings of leukocytoclastic vasculitis; DIF typically is positive for perivascular IgA and C3 deposition. Increased serum IgA may be present.9 Urticarial vasculitis appears as erythematous indurated wheals that favor a proximal extremity and truncal distribution. They characteristically last longer than 24 hours, are frequently associated with nonprodromal pain or burning, and resolve with hyperpigmentation. Arthralgia and gastrointestinal, renal, pulmonary, cardiac, and neurologic symptoms may be present, especially in patients with low complement levels.10 Skin biopsy demonstrates leukocytoclasia that must be accompanied by vessel wall necrosis. Fibrinoid deposition, erythrocyte extravasation, or perivascular inflammation may be present. In 70% of cases revealing perivascular immunoglobulin, C3, and fibrinogen deposition, DIF is positive. Serum C1q autoantibody may be associated with the hypocomplementemic form.10
The classic histopathologic findings in leukocytoclastic vasculitis include transmural neutrophilic infiltration of the walls of small vessels, fibrinoid necrosis of vessel walls, leukocytoclasia, extravasated erythrocytes, and signs of endothelial cell damage.9 A prior punch biopsy in this patient demonstrated rare neutrophilic nuclear debris within the vessel walls without fibrin deposition. Although the presence of nuclear debris and extravasated erythrocytes could be compatible with a manifestation of urticarial vasculitis, the lack of direct evidence of vessel wall necrosis combined with subsequent biopsies unequivocally ruled out cutaneous small vessel vasculitis in our patient.
Psychogenic purpura has been reported to occur frequently in the background of psycho-emotional distress. In 1989, Ratnoff11 noted that many of the patients he was treating at the University Hospitals of Cleveland, Ohio, had a depressive syndrome. A review of patients treated at the Mayo Clinic in Rochester, Minnesota, illustrated concomitant psychiatric illnesses in 41 of 76 (54%) patients treated for PP, most commonly depressive, personality, and anxiety disorders.3
There is no consensus on therapy for PP. Treatment is based on providing symptomatic relief and relieving underlying psychiatric distress. Block et al12 found the use of selective serotonin reuptake inhibitors, tricyclic antidepressants, and psychotherapy to be successful in improving symptoms and reducing lesions at follow-up visits.
- Piette WW. Purpura: mechanisms and differential diagnosis. In: Bolognia JL, Schaffer JV, Cerroni L. Dermatology. 4th ed. Elsevier; 2018:376-389.
- Harth W, Taube KM, Gieler U. Factitious disorders in dermatology. J Dtsch Dermatol Ges. 2010;8:361-372.
- Sridharan M, Ali U, Hook CC, et al. The Mayo Clinic experience with psychogenic purpura (Gardner-Diamond syndrome). Am J Med Sci. 2019;357:411‐420.
- Gardner FH, Diamond LK. Autoerythrocyte sensitization; a form of purpura producing painful bruising following autosensitization to red blood cells in certain women. Blood. 1955;10:675-690.
- Groch GS, Finch SC, Rogoway W, et al. Studies in the pathogenesis of autoerythrocyte sensitization syndrome. Blood. 1966;28:19-33.
- Strunecká A, Krpejsová L, Palecek J, et al. Transbilayer redistribution of phosphatidylserine in erythrocytes of a patient with autoerythrocyte sensitization syndrome (psychogenic purpura). Folia Haematol Int Mag Klin Morphol Blutforsch. 1990;117:829-841.
- Merlen JF. Ecchymotic patches of the fingers and Gardner-Diamond vascular purpura. Phlebologie. 1987;40:473-487.
- Ivanov OL, Lvov AN, Michenko AV, et al. Autoerythrocyte sensitization syndrome (Gardner-Diamond syndrome): review of the literature. J Eur Acad Dermatol Venereol. 2009;23:499-504.
- Wetter DA, Dutz JP, Shinkai K, et al. Cutaneous vasculitis. In: Bolognia JL, Schaffer JV, Cerroni L. Dermatology. 4th ed. Elsevier; 2018:409-439.
- Hamad A, Jithpratuck W, Krishnaswamy G. Urticarial vasculitis and associated disorders. Ann Allergy Asthma Immunol. 2017;118:394-398.
- Ratnoff OD. Psychogenic purpura (autoerythrocyte sensitization): an unsolved dilemma. Am J Med. 1989;87:16N-21N.
- Block ME, Sitenga JL, Lehrer M, et al. Gardner‐Diamond syndrome: a systematic review of treatment options for a rare psychodermatological disorder. Int J Dermatol. 2019;58:782-787.
- Piette WW. Purpura: mechanisms and differential diagnosis. In: Bolognia JL, Schaffer JV, Cerroni L. Dermatology. 4th ed. Elsevier; 2018:376-389.
- Harth W, Taube KM, Gieler U. Factitious disorders in dermatology. J Dtsch Dermatol Ges. 2010;8:361-372.
- Sridharan M, Ali U, Hook CC, et al. The Mayo Clinic experience with psychogenic purpura (Gardner-Diamond syndrome). Am J Med Sci. 2019;357:411‐420.
- Gardner FH, Diamond LK. Autoerythrocyte sensitization; a form of purpura producing painful bruising following autosensitization to red blood cells in certain women. Blood. 1955;10:675-690.
- Groch GS, Finch SC, Rogoway W, et al. Studies in the pathogenesis of autoerythrocyte sensitization syndrome. Blood. 1966;28:19-33.
- Strunecká A, Krpejsová L, Palecek J, et al. Transbilayer redistribution of phosphatidylserine in erythrocytes of a patient with autoerythrocyte sensitization syndrome (psychogenic purpura). Folia Haematol Int Mag Klin Morphol Blutforsch. 1990;117:829-841.
- Merlen JF. Ecchymotic patches of the fingers and Gardner-Diamond vascular purpura. Phlebologie. 1987;40:473-487.
- Ivanov OL, Lvov AN, Michenko AV, et al. Autoerythrocyte sensitization syndrome (Gardner-Diamond syndrome): review of the literature. J Eur Acad Dermatol Venereol. 2009;23:499-504.
- Wetter DA, Dutz JP, Shinkai K, et al. Cutaneous vasculitis. In: Bolognia JL, Schaffer JV, Cerroni L. Dermatology. 4th ed. Elsevier; 2018:409-439.
- Hamad A, Jithpratuck W, Krishnaswamy G. Urticarial vasculitis and associated disorders. Ann Allergy Asthma Immunol. 2017;118:394-398.
- Ratnoff OD. Psychogenic purpura (autoerythrocyte sensitization): an unsolved dilemma. Am J Med. 1989;87:16N-21N.
- Block ME, Sitenga JL, Lehrer M, et al. Gardner‐Diamond syndrome: a systematic review of treatment options for a rare psychodermatological disorder. Int J Dermatol. 2019;58:782-787.
PRACTICE POINTS
- Psychogenic purpura is a rare vasculopathy characterized by painful recurrent episodes of purpura. It is a diagnosis of exclusion that may manifest with signs similar to cutaneous small vessel vasculitis.
- Awareness of this condition could help prevent unnecessary diagnostics, medications, and adverse events.
Surveillance for 21 Possible Effects of Endocrine Disruptors
Santé Publique France (SPF), the French national public health agency, has released the findings of the PEPS’PE study, which was launched in 2021. The study aims to prioritize, following extensive consultation, the health effects to be monitored for their potential link to endocrine disruptors (EDs). Out of 59 health effects suspected to be associated with exposure to EDs, 21 have been considered a priority for surveillance. Based on these results and others, SPF will expand the scope of the Agency’s surveillance by incorporating new pathologies.
As part of its environmental health program and the National Strategy on EDs, To incorporate new scientific knowledge, the PEPS’PE project aims to prioritize health effects related to EDs and identify health events to integrate into the agency’s current surveillance. The 59 health effects suspected to be associated with exposure to EDs were to be evaluated based on two criteria: The weight of evidence and the epidemiological and societal impact of the health effect. A diverse panel of international experts and French stakeholders in the field of EDs classified 21 health effects as a priority for surveillance.
Among these effects, six reproductive health effects are already monitored in the surveillance program: Cryptorchidism, hypospadias, early puberty, testicular cancer, alteration of sperm quality, and endometriosis. In addition, infertility and decreased fertility (which are not currently monitored for their link to EDs) have been included.
Metabolic effects (including overweight and obesity, cardiovascular diseases, type 2 diabetes, and metabolic syndrome), child neurodevelopmental disorders (including behavioral disorders, intellectual deficits, and attention-deficit disorders), cancers (including breast cancer, prostate cancer, lymphomas, and leukemias in children), and asthma have also been highlighted.
Furthermore, 22 effects were considered low priorities or deemed nonpriorities when, for example, they presented weak or moderate evidence with varying levels of interest in implementing surveillance. Finally, 16 health effects could not be prioritized because of a lack of scientific experts on these topics and a failure to achieve consensus (eg, bone disorders, adrenal disorders, and skin and eye disorders). Consensus was sought during this consultation using a Delphi method.
“These results indicate the need to expand the scope of the Agency’s surveillance beyond reproductive health, incorporating new pathologies when surveillance data are available,” SPF declared in a press release.
“With the initial decision elements obtained through this study, Santé Publique France will analyze the feasibility of implementing surveillance for effects classified as priorities.”
This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.
Santé Publique France (SPF), the French national public health agency, has released the findings of the PEPS’PE study, which was launched in 2021. The study aims to prioritize, following extensive consultation, the health effects to be monitored for their potential link to endocrine disruptors (EDs). Out of 59 health effects suspected to be associated with exposure to EDs, 21 have been considered a priority for surveillance. Based on these results and others, SPF will expand the scope of the Agency’s surveillance by incorporating new pathologies.
As part of its environmental health program and the National Strategy on EDs, To incorporate new scientific knowledge, the PEPS’PE project aims to prioritize health effects related to EDs and identify health events to integrate into the agency’s current surveillance. The 59 health effects suspected to be associated with exposure to EDs were to be evaluated based on two criteria: The weight of evidence and the epidemiological and societal impact of the health effect. A diverse panel of international experts and French stakeholders in the field of EDs classified 21 health effects as a priority for surveillance.
Among these effects, six reproductive health effects are already monitored in the surveillance program: Cryptorchidism, hypospadias, early puberty, testicular cancer, alteration of sperm quality, and endometriosis. In addition, infertility and decreased fertility (which are not currently monitored for their link to EDs) have been included.
Metabolic effects (including overweight and obesity, cardiovascular diseases, type 2 diabetes, and metabolic syndrome), child neurodevelopmental disorders (including behavioral disorders, intellectual deficits, and attention-deficit disorders), cancers (including breast cancer, prostate cancer, lymphomas, and leukemias in children), and asthma have also been highlighted.
Furthermore, 22 effects were considered low priorities or deemed nonpriorities when, for example, they presented weak or moderate evidence with varying levels of interest in implementing surveillance. Finally, 16 health effects could not be prioritized because of a lack of scientific experts on these topics and a failure to achieve consensus (eg, bone disorders, adrenal disorders, and skin and eye disorders). Consensus was sought during this consultation using a Delphi method.
“These results indicate the need to expand the scope of the Agency’s surveillance beyond reproductive health, incorporating new pathologies when surveillance data are available,” SPF declared in a press release.
“With the initial decision elements obtained through this study, Santé Publique France will analyze the feasibility of implementing surveillance for effects classified as priorities.”
This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.
Santé Publique France (SPF), the French national public health agency, has released the findings of the PEPS’PE study, which was launched in 2021. The study aims to prioritize, following extensive consultation, the health effects to be monitored for their potential link to endocrine disruptors (EDs). Out of 59 health effects suspected to be associated with exposure to EDs, 21 have been considered a priority for surveillance. Based on these results and others, SPF will expand the scope of the Agency’s surveillance by incorporating new pathologies.
As part of its environmental health program and the National Strategy on EDs, To incorporate new scientific knowledge, the PEPS’PE project aims to prioritize health effects related to EDs and identify health events to integrate into the agency’s current surveillance. The 59 health effects suspected to be associated with exposure to EDs were to be evaluated based on two criteria: The weight of evidence and the epidemiological and societal impact of the health effect. A diverse panel of international experts and French stakeholders in the field of EDs classified 21 health effects as a priority for surveillance.
Among these effects, six reproductive health effects are already monitored in the surveillance program: Cryptorchidism, hypospadias, early puberty, testicular cancer, alteration of sperm quality, and endometriosis. In addition, infertility and decreased fertility (which are not currently monitored for their link to EDs) have been included.
Metabolic effects (including overweight and obesity, cardiovascular diseases, type 2 diabetes, and metabolic syndrome), child neurodevelopmental disorders (including behavioral disorders, intellectual deficits, and attention-deficit disorders), cancers (including breast cancer, prostate cancer, lymphomas, and leukemias in children), and asthma have also been highlighted.
Furthermore, 22 effects were considered low priorities or deemed nonpriorities when, for example, they presented weak or moderate evidence with varying levels of interest in implementing surveillance. Finally, 16 health effects could not be prioritized because of a lack of scientific experts on these topics and a failure to achieve consensus (eg, bone disorders, adrenal disorders, and skin and eye disorders). Consensus was sought during this consultation using a Delphi method.
“These results indicate the need to expand the scope of the Agency’s surveillance beyond reproductive health, incorporating new pathologies when surveillance data are available,” SPF declared in a press release.
“With the initial decision elements obtained through this study, Santé Publique France will analyze the feasibility of implementing surveillance for effects classified as priorities.”
This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.
The Potential for Artificial Intelligence Tools in Residency Recruitment
According to Electronic Residency Application Service (ERAS) statistics, there were more than 1400 dermatology applicants in 2022, with an average of almost 560 applications received per program.1,2 With the goal to expand the diversity of board-certified dermatologists, there is increasing emphasis on the holistic review of applications, forgoing filtering by discrete metrics such as AOA (American Osteopathic Association) membership and US Medical Licensing Examination (USMLE) scores.3 According to the Association of American Medical Colleges, holistic review focuses on an individual applicant’s experience and unique attributes in addition to their academic achievements.4 Recent strategies to enhance the residency recruitment process have included the introduction of standardized letters of recommendation, preference signaling, and supplemental applications.5,6
Because it has become increasingly important to include applicant factors and achievements that extend beyond academics, the number of data points that are required for holistic review has expanded. If each application required 20 minutes to review, this would result in 166 total hours for complete holistic review of 500 applications. Tools that can facilitate holistic review of candidates and select applicants whose interests and career goals align with individual residency programs have the potential to optimize review. Artificial intelligence (AI) may aid in this process. This column highlights some of the published research on novel AI strategies that have the potential to impact dermatology residency recruitment.
Machine Learning to Screen Applicants
Artificial intelligence involves a machine-based system that can make decisions, predictions, and recommendations when provided a given set of human-defined objectives.7 Autonomous systems, machine learning (ML), and generative AI are examples of AI models.8 Machine learning has been explored to shorten and streamline the application review process and decrease bias. Because ML is a model in which the computer learns patterns based on large amounts of input data,9 it is possible that models could be developed and used in future cycles. Some studies found that applicants were discovered who traditionally would not have made it to the next stage of consideration based primarily on academic metrics.10,11 Burk-Rafel et al10 developed and validated an ML-based decision support tool for residency program directors to use for interview invitation decisions. The tool utilized 61 variables from ERAS data from more than 8000 applications in 3 prior application cycles at a single internal medicine residency program. An interview invitation was designated as the target outcome. Ultimately, the model would output a probability score for an interview invitation. The authors were able to tune the model to a 91% sensitivity and 85% specificity; for a pool of 2000 applicants and an invite rate of 15%, 1475 applicants would be screened out with a negative predictive value of 98% with maintenance of performance, even with removal of USMLE Step 1 examination scores. Their ML model was prospectively validated during an ongoing resident selection cycle, and when compared with human review, the AI model found an additional 20 applicants to invite for interviews. They concluded that this tool could potentially augment the human review process and reveal applicants who may have otherwise been overlooked.10
Rees and Ryder11 utilized another ML screening approach with the target outcome of ranked and matriculated compared with ranked applicants based on ERAS data using 72 unique variables for more than 5000 applicants. Their model was able to identify ranked candidates from the overall applicant pool with high accuracy; identification of ranked applicants that matriculated at the program was more modest but better than random probability.11Both the Burk-Rafel et al10 and Rees and Ryder11 models excluded some unstructured data components of the residency application, such as personal statements, medical student performance evaluation letters, transcripts, and letters of reference, that some may consider strongly in the holistic review process. Drum et al12 explored the value of extraction of this type of data. They created a program to extract “snippets” of text that pertained to values of successful residents for their internal medicine–pediatrics residency program that they previously validated via a modified Delphi method, which then were annotated by expert reviewers. Natural language processing was used to train an ML algorithm (MLA) to classify snippets into 11 value categories. Four values had more than 66% agreement with human annotation: academic strength; leadership; communication; and justice, equity, diversity, and inclusion. Although this MLA has not reached high enough levels of agreement for all the predetermined success values, the authors hope to generate a model that could produce a quantitative score to use as an initial screening tool to select applicants for interview.12 This type of analysis also could be incorporated into other MLAs for further refinement of the mentoring and application process.
Knapke et al13 evaluated the use of a natural language modeling platform to look for semantic patterns in medical school applications that could predict which students would be more likely to pursue family medicine residency, thus beginning the recruitment process even before residency application. This strategy could be particularly valuable for specialties for which there may be greater need in the workforce.
AI for Administrative Purposes
Artificial intelligence also has been used for nonapplication aspects of the residency recruitment process, such as interview scheduling. In the absence of coordinated interview release dates (as was implemented in dermatology starting in the 2020-2021 application cycle), a deluge of responses to schedule an interview comes flooding in as soon as invitations for interviewees are sent out, which can produce anxiety both for applicants and residency program staff as the schedule is sorted out and can create delays at both ends. Stephens et al14 utilized a computerized scheduling program for pediatric surgery fellowship applicants. It was used in 2016 to schedule 26 interviews, and it was found to reduce the average time to schedule an interview from 14.4 hours to 1.7 hours. It also reduced the number of email exchanges needed to finalize scheduling.14
Another aspect of residency recruitment that is amenable to AI is information gathering. Many would-be applicants turn to the internet and social media to learn about residency programs—their unique qualities, assets, and potential alignment of career goals.15 This exchange often is unidirectional, as the applicant clicks through the website searching for information. Yi et al16 explored the use of a chatbot, which mimics human conversation and exchange, on their institution’s pain fellowship website. Fellowship applicants could create specific prompts, such as “Show me faculty that trained at <applicant’s home program>,” and the chatbot would reply with the answer. The researchers sent a survey to all 258 applicants to the pain fellowship program that was completed by 48 applicants. Of these respondents, more than 70% (35/48) utilized the chatbot, and 84% (40/48) stated that they had found the information that was requested. The respondents overall found the chatbot to be a useful and positive experience.16
Specific Tools to Consider
There are some tools that are publicly available for programs and applicants to use that rely on AI.
In collaboration with ERAS and the Association of American Medical Colleges, Cortex powered by Thalamus (SJ MedConnect Inc)(https://thalamusgme.com/cortex-application-screening/) offers technology-assisted holistic review of residency and fellowship applications by utilizing natural language processing and optical character recognition to aggregate data from ERAS.
Tools also are being leveraged by applicants to help them find residency programs that fit their criteria, prepare for interviews, and complete portions of the application. Match A Resident (https://www.matcharesident.com/) is a resource for the international medical graduate community. As part of the service, the “Learn More with MARai” feature uses AI to generate information on residency programs to increase applicants’ confidence going into the interview process.17 Big Interview Medical (https://www.biginterviewmedical.com/ai-feedback), a paid interview preparation system developed by interview experts, utilizes AI to provide feedback to residents practicing for the interview process by measuring the amount of natural eye contact, language used, and pace of speech. A “Power Word” score is provided that incorporates aspects such as using filler words (“umm,” “uhh”). A Pace of Speech Tool provides rate of speaking feedback presuming that there is an ideal pace to decrease the impression that the applicant is nervous. Johnstone et al18 used ChatGPT (https://chat.openai.com/auth/login) to generate 2 personal statements for anesthesia residency applicants. Based on survey responses from 31 program directors, 22 rated the statements as good or excellent.18
Ethnical Concerns and Limitations of AI
The potential use of AI tools by residency applicants inevitably brings forth consideration of biases, ethics, and current limitations. These tools are highly dependent on the quality and quantity of data used for training and validation. Information considered valuable in the holistic review of applications includes unstructured data such as personal statements and letters of recommendation, and incorporating this information can be challenging in ML models, in contrast to discrete structured data such as grades, test scores, and awards. In addition, MLAs depend on large quantities of data to optimize performance.19 Depending on the size of the applicant pool and the amount of data available, this can present a limitation for smaller programs in developing ML tools for residency recruitment. Studies evaluating the use of AI in the residency application process often are from single institutions, and therefore generalizability is uncertain. The risk for latent bias—whereby a historical or pre-existing stereotype gets perpetuated through the system—must be considered, with the development of tools to detect and address this if found. Choosing which data to use to train the model can be tricky as well as choosing the outcome of interest. For these interventions to become more resilient, programs need to self-examine what defines their criteria for a successful match to their program to incorporate this data into their ML studies. The previously described models in this overview focused on outcomes such as whether an applicant was invited to interview, whether the applicant was ranked, and whether the applicant matriculated to their program.10,11 For supervised ML models that rely on outcomes to develop a prediction, continued research as to what outcomes represent resident success (eg, passing board certification examinations, correlation with clinical performance) would be important. There also is the possibility of applicants restructuring their applications to align with goals of an AI-assisted search and using AI to generate part or all of their application. The use of ChatGPT and other AI tools in the preparation of personal statements and curriculum vitae may provide benefits such as improved efficiency and grammar support.20 However, as use becomes more widespread, there is the potential increased similarity of personal statements and likely varied opinions on the use of such tools as writing aids.21,22 Continued efforts to develop guidance on generative AI use cases is ongoing; an example is the launch of VALID AI (https://validai.health/), a collaboration among health systems, health plans, and AI research organizations and nonprofits.23
Final Thoughts
Artificial intelligence tools may be a promising resource for residency and fellowship programs seeking to find meaningful ways to select applicants who are good matches for their training environment. Prioritizing the holistic review of applications has been promoted as a method to evaluate the applicant beyond their test scores and grades. The use of MLAs may streamline this review process, aid in scheduling interviews, and help discover trends in successful matriculants.
- Association of American Medical Colleges. ERAS® Statistics. Accessed January 16, 2024. https://www.aamc.org/data-reports/data/eras-statistics-data
- National Resident Matching Program, Data Release and ResearchCommittee: Results of the 2022 NRMP Program Director Survey. Accessed January 18, 2024. https://www.nrmp.org/wp-content/uploads/2022/09/PD-Survey-Report-2022_FINALrev.pdf
- Isaq NA, Bowers S, Chen ST. Taking a “step” toward diversity in dermatology: de-emphasizing USMLE Step 1 scores in residency applications. Int J Womens Dermatol. 2020;6:209-210. doi:10.1016/j.ijwd.2020.02.008
- Association of American Medical Colleges. Holistic review in medical school admissions. Accessed January 16, 2024. https://students-residents.aamc.org/choosing-medical-career/holistic-review-medical-school-admissions
- Association of American Medical Colleges. The MyERAS® application and program signaling for 2023-24. Accessed January 16, 2024. https://students-residents.aamc.org/applying-residencies-eras/myeras-application-and-program-signaling-2023-24
- Tavarez MM, Baghdassarian A, Bailey J, et al. A call to action for standardizing letters of recommendation. J Grad Med Educ. 2022;14:642-646. doi:10.4300/JGME-D-22-00131.1
- US Department of State. Artificial intelligence (AI). Accessed January 16, 2024. https://www.state.gov/artificial-intelligence/
- Stanford University Human-Centered Artificial Intelligence. Artificial intelligence definitions. Accessed January 16, 2024.https://hai.stanford.edu/sites/default/files/2023-03/AI-Key-Terms-Glossary-Definition.pdf
- Rajkomar A, Dean J, Kohane I. Machine learning in medicine. N Engl J Med. 2019;380:1347-1358. doi:10.1056/NEJMra1814259
- Burk-Rafel J, Reinstein I, Feng J, et al. Development and validation of a machine learning-based decision support tool for residency applicant screening and review. Acad Med. 2021;96(11S):S54-S61. doi:10.1097/ACM.0000000000004317
- Rees CA, Ryder HF. Machine learning for the prediction of ranked applicants and matriculants to an internal medicine residency program. Teach Learn Med. 2023;35:277-286. doi:10.1080/10401334.2022.2059664
- Drum B, Shi J, Peterson B, et al. Using natural language processing and machine learning to identify internal medicine-pediatrics residency values in applications. Acad Med. 2023;98:1278-1282. doi:10.1097/ACM.0000000000005352
- Knapke JM, Mount HR, McCabe E, et al. Early identification of family physicians using qualitative admissions data. Fam Med. 2023;55:245-252. doi:10.22454/FamMed.2023.596964
- Stephens CQ, Hamilton NA, Thompson AE, et al. Use of computerized interview scheduling program for pediatric surgery match applicants. J Pediatr Surg. 2017;52:1056-1059. doi:10.1016/j.jpedsurg.2017.03.033
- Nickles MA, Kulkarni V, Varghese JA, et al. Dermatology residency programs’ websites in the virtual era: a cross-sectional analysis. J Am Acad Dermatol. 2022;86:447-448. doi:10.1016/j.jaad.2021.09.064
- Yi PK, Ray ND, Segall N. A novel use of an artificially intelligent Chatbot and a live, synchronous virtual question-and answer session for fellowship recruitment. BMC Med Educ. 2023;23:152. doi:10.1186/s12909-022-03872-z
- Introducing “Learn More with MARai”—the key to understanding your target residency programs. Match A Resident website. Published September 23, 2023. Accessed January 16, 2024. https://blog.matcharesident.com/ai-powered-residency-insights/
- Johnstone RE, Neely G, Sizemore DC. Artificial intelligence softwarecan generate residency application personal statements that program directors find acceptable and difficult to distinguish from applicant compositions. J Clin Anesth. 2023;89:111185. doi:10.1016/j.jclinane.2023.111185
- Khalid N, Qayyum A, Bilal M, et al. Privacy-preserving artificial intelligence in healthcare: techniques and applications. Comput Biol Med. 2023;158:106848. doi:10.1016/j.compbiomed.2023.106848
- Birt J. How to optimize your resume for AI scanners (with tips). Indeed website. Updated December 30, 2022. Accessed January 16, 2024. https://www.indeed.com/career-advice/resumes-cover-letters/resume-ai
- Patel V, Deleonibus A, Wells MW, et al. Distinguishing authentic voices in the age of ChatGPT: comparing AI-generated and applicant-written personal statements for plastic surgery residency application. Ann Plast Surg. 2023;91:324-325. doi:10.1097/SAP.0000000000003653
- Woodfin MW. The personal statement in the age of artificial intelligence. Acad Med. 2023;98:869. doi:10.1097/ACM.0000000000005266
- Diaz N. UC Davis Health to lead new gen AI collaborative. Beckers Healthcare website. Published October 10, 2023. AccessedJanuary 16, 2024. https://www.beckershospitalreview.com/digital-health/uc-davis-health-to-lead-new-gen-ai-collaborative.html
According to Electronic Residency Application Service (ERAS) statistics, there were more than 1400 dermatology applicants in 2022, with an average of almost 560 applications received per program.1,2 With the goal to expand the diversity of board-certified dermatologists, there is increasing emphasis on the holistic review of applications, forgoing filtering by discrete metrics such as AOA (American Osteopathic Association) membership and US Medical Licensing Examination (USMLE) scores.3 According to the Association of American Medical Colleges, holistic review focuses on an individual applicant’s experience and unique attributes in addition to their academic achievements.4 Recent strategies to enhance the residency recruitment process have included the introduction of standardized letters of recommendation, preference signaling, and supplemental applications.5,6
Because it has become increasingly important to include applicant factors and achievements that extend beyond academics, the number of data points that are required for holistic review has expanded. If each application required 20 minutes to review, this would result in 166 total hours for complete holistic review of 500 applications. Tools that can facilitate holistic review of candidates and select applicants whose interests and career goals align with individual residency programs have the potential to optimize review. Artificial intelligence (AI) may aid in this process. This column highlights some of the published research on novel AI strategies that have the potential to impact dermatology residency recruitment.
Machine Learning to Screen Applicants
Artificial intelligence involves a machine-based system that can make decisions, predictions, and recommendations when provided a given set of human-defined objectives.7 Autonomous systems, machine learning (ML), and generative AI are examples of AI models.8 Machine learning has been explored to shorten and streamline the application review process and decrease bias. Because ML is a model in which the computer learns patterns based on large amounts of input data,9 it is possible that models could be developed and used in future cycles. Some studies found that applicants were discovered who traditionally would not have made it to the next stage of consideration based primarily on academic metrics.10,11 Burk-Rafel et al10 developed and validated an ML-based decision support tool for residency program directors to use for interview invitation decisions. The tool utilized 61 variables from ERAS data from more than 8000 applications in 3 prior application cycles at a single internal medicine residency program. An interview invitation was designated as the target outcome. Ultimately, the model would output a probability score for an interview invitation. The authors were able to tune the model to a 91% sensitivity and 85% specificity; for a pool of 2000 applicants and an invite rate of 15%, 1475 applicants would be screened out with a negative predictive value of 98% with maintenance of performance, even with removal of USMLE Step 1 examination scores. Their ML model was prospectively validated during an ongoing resident selection cycle, and when compared with human review, the AI model found an additional 20 applicants to invite for interviews. They concluded that this tool could potentially augment the human review process and reveal applicants who may have otherwise been overlooked.10
Rees and Ryder11 utilized another ML screening approach with the target outcome of ranked and matriculated compared with ranked applicants based on ERAS data using 72 unique variables for more than 5000 applicants. Their model was able to identify ranked candidates from the overall applicant pool with high accuracy; identification of ranked applicants that matriculated at the program was more modest but better than random probability.11Both the Burk-Rafel et al10 and Rees and Ryder11 models excluded some unstructured data components of the residency application, such as personal statements, medical student performance evaluation letters, transcripts, and letters of reference, that some may consider strongly in the holistic review process. Drum et al12 explored the value of extraction of this type of data. They created a program to extract “snippets” of text that pertained to values of successful residents for their internal medicine–pediatrics residency program that they previously validated via a modified Delphi method, which then were annotated by expert reviewers. Natural language processing was used to train an ML algorithm (MLA) to classify snippets into 11 value categories. Four values had more than 66% agreement with human annotation: academic strength; leadership; communication; and justice, equity, diversity, and inclusion. Although this MLA has not reached high enough levels of agreement for all the predetermined success values, the authors hope to generate a model that could produce a quantitative score to use as an initial screening tool to select applicants for interview.12 This type of analysis also could be incorporated into other MLAs for further refinement of the mentoring and application process.
Knapke et al13 evaluated the use of a natural language modeling platform to look for semantic patterns in medical school applications that could predict which students would be more likely to pursue family medicine residency, thus beginning the recruitment process even before residency application. This strategy could be particularly valuable for specialties for which there may be greater need in the workforce.
AI for Administrative Purposes
Artificial intelligence also has been used for nonapplication aspects of the residency recruitment process, such as interview scheduling. In the absence of coordinated interview release dates (as was implemented in dermatology starting in the 2020-2021 application cycle), a deluge of responses to schedule an interview comes flooding in as soon as invitations for interviewees are sent out, which can produce anxiety both for applicants and residency program staff as the schedule is sorted out and can create delays at both ends. Stephens et al14 utilized a computerized scheduling program for pediatric surgery fellowship applicants. It was used in 2016 to schedule 26 interviews, and it was found to reduce the average time to schedule an interview from 14.4 hours to 1.7 hours. It also reduced the number of email exchanges needed to finalize scheduling.14
Another aspect of residency recruitment that is amenable to AI is information gathering. Many would-be applicants turn to the internet and social media to learn about residency programs—their unique qualities, assets, and potential alignment of career goals.15 This exchange often is unidirectional, as the applicant clicks through the website searching for information. Yi et al16 explored the use of a chatbot, which mimics human conversation and exchange, on their institution’s pain fellowship website. Fellowship applicants could create specific prompts, such as “Show me faculty that trained at <applicant’s home program>,” and the chatbot would reply with the answer. The researchers sent a survey to all 258 applicants to the pain fellowship program that was completed by 48 applicants. Of these respondents, more than 70% (35/48) utilized the chatbot, and 84% (40/48) stated that they had found the information that was requested. The respondents overall found the chatbot to be a useful and positive experience.16
Specific Tools to Consider
There are some tools that are publicly available for programs and applicants to use that rely on AI.
In collaboration with ERAS and the Association of American Medical Colleges, Cortex powered by Thalamus (SJ MedConnect Inc)(https://thalamusgme.com/cortex-application-screening/) offers technology-assisted holistic review of residency and fellowship applications by utilizing natural language processing and optical character recognition to aggregate data from ERAS.
Tools also are being leveraged by applicants to help them find residency programs that fit their criteria, prepare for interviews, and complete portions of the application. Match A Resident (https://www.matcharesident.com/) is a resource for the international medical graduate community. As part of the service, the “Learn More with MARai” feature uses AI to generate information on residency programs to increase applicants’ confidence going into the interview process.17 Big Interview Medical (https://www.biginterviewmedical.com/ai-feedback), a paid interview preparation system developed by interview experts, utilizes AI to provide feedback to residents practicing for the interview process by measuring the amount of natural eye contact, language used, and pace of speech. A “Power Word” score is provided that incorporates aspects such as using filler words (“umm,” “uhh”). A Pace of Speech Tool provides rate of speaking feedback presuming that there is an ideal pace to decrease the impression that the applicant is nervous. Johnstone et al18 used ChatGPT (https://chat.openai.com/auth/login) to generate 2 personal statements for anesthesia residency applicants. Based on survey responses from 31 program directors, 22 rated the statements as good or excellent.18
Ethnical Concerns and Limitations of AI
The potential use of AI tools by residency applicants inevitably brings forth consideration of biases, ethics, and current limitations. These tools are highly dependent on the quality and quantity of data used for training and validation. Information considered valuable in the holistic review of applications includes unstructured data such as personal statements and letters of recommendation, and incorporating this information can be challenging in ML models, in contrast to discrete structured data such as grades, test scores, and awards. In addition, MLAs depend on large quantities of data to optimize performance.19 Depending on the size of the applicant pool and the amount of data available, this can present a limitation for smaller programs in developing ML tools for residency recruitment. Studies evaluating the use of AI in the residency application process often are from single institutions, and therefore generalizability is uncertain. The risk for latent bias—whereby a historical or pre-existing stereotype gets perpetuated through the system—must be considered, with the development of tools to detect and address this if found. Choosing which data to use to train the model can be tricky as well as choosing the outcome of interest. For these interventions to become more resilient, programs need to self-examine what defines their criteria for a successful match to their program to incorporate this data into their ML studies. The previously described models in this overview focused on outcomes such as whether an applicant was invited to interview, whether the applicant was ranked, and whether the applicant matriculated to their program.10,11 For supervised ML models that rely on outcomes to develop a prediction, continued research as to what outcomes represent resident success (eg, passing board certification examinations, correlation with clinical performance) would be important. There also is the possibility of applicants restructuring their applications to align with goals of an AI-assisted search and using AI to generate part or all of their application. The use of ChatGPT and other AI tools in the preparation of personal statements and curriculum vitae may provide benefits such as improved efficiency and grammar support.20 However, as use becomes more widespread, there is the potential increased similarity of personal statements and likely varied opinions on the use of such tools as writing aids.21,22 Continued efforts to develop guidance on generative AI use cases is ongoing; an example is the launch of VALID AI (https://validai.health/), a collaboration among health systems, health plans, and AI research organizations and nonprofits.23
Final Thoughts
Artificial intelligence tools may be a promising resource for residency and fellowship programs seeking to find meaningful ways to select applicants who are good matches for their training environment. Prioritizing the holistic review of applications has been promoted as a method to evaluate the applicant beyond their test scores and grades. The use of MLAs may streamline this review process, aid in scheduling interviews, and help discover trends in successful matriculants.
According to Electronic Residency Application Service (ERAS) statistics, there were more than 1400 dermatology applicants in 2022, with an average of almost 560 applications received per program.1,2 With the goal to expand the diversity of board-certified dermatologists, there is increasing emphasis on the holistic review of applications, forgoing filtering by discrete metrics such as AOA (American Osteopathic Association) membership and US Medical Licensing Examination (USMLE) scores.3 According to the Association of American Medical Colleges, holistic review focuses on an individual applicant’s experience and unique attributes in addition to their academic achievements.4 Recent strategies to enhance the residency recruitment process have included the introduction of standardized letters of recommendation, preference signaling, and supplemental applications.5,6
Because it has become increasingly important to include applicant factors and achievements that extend beyond academics, the number of data points that are required for holistic review has expanded. If each application required 20 minutes to review, this would result in 166 total hours for complete holistic review of 500 applications. Tools that can facilitate holistic review of candidates and select applicants whose interests and career goals align with individual residency programs have the potential to optimize review. Artificial intelligence (AI) may aid in this process. This column highlights some of the published research on novel AI strategies that have the potential to impact dermatology residency recruitment.
Machine Learning to Screen Applicants
Artificial intelligence involves a machine-based system that can make decisions, predictions, and recommendations when provided a given set of human-defined objectives.7 Autonomous systems, machine learning (ML), and generative AI are examples of AI models.8 Machine learning has been explored to shorten and streamline the application review process and decrease bias. Because ML is a model in which the computer learns patterns based on large amounts of input data,9 it is possible that models could be developed and used in future cycles. Some studies found that applicants were discovered who traditionally would not have made it to the next stage of consideration based primarily on academic metrics.10,11 Burk-Rafel et al10 developed and validated an ML-based decision support tool for residency program directors to use for interview invitation decisions. The tool utilized 61 variables from ERAS data from more than 8000 applications in 3 prior application cycles at a single internal medicine residency program. An interview invitation was designated as the target outcome. Ultimately, the model would output a probability score for an interview invitation. The authors were able to tune the model to a 91% sensitivity and 85% specificity; for a pool of 2000 applicants and an invite rate of 15%, 1475 applicants would be screened out with a negative predictive value of 98% with maintenance of performance, even with removal of USMLE Step 1 examination scores. Their ML model was prospectively validated during an ongoing resident selection cycle, and when compared with human review, the AI model found an additional 20 applicants to invite for interviews. They concluded that this tool could potentially augment the human review process and reveal applicants who may have otherwise been overlooked.10
Rees and Ryder11 utilized another ML screening approach with the target outcome of ranked and matriculated compared with ranked applicants based on ERAS data using 72 unique variables for more than 5000 applicants. Their model was able to identify ranked candidates from the overall applicant pool with high accuracy; identification of ranked applicants that matriculated at the program was more modest but better than random probability.11Both the Burk-Rafel et al10 and Rees and Ryder11 models excluded some unstructured data components of the residency application, such as personal statements, medical student performance evaluation letters, transcripts, and letters of reference, that some may consider strongly in the holistic review process. Drum et al12 explored the value of extraction of this type of data. They created a program to extract “snippets” of text that pertained to values of successful residents for their internal medicine–pediatrics residency program that they previously validated via a modified Delphi method, which then were annotated by expert reviewers. Natural language processing was used to train an ML algorithm (MLA) to classify snippets into 11 value categories. Four values had more than 66% agreement with human annotation: academic strength; leadership; communication; and justice, equity, diversity, and inclusion. Although this MLA has not reached high enough levels of agreement for all the predetermined success values, the authors hope to generate a model that could produce a quantitative score to use as an initial screening tool to select applicants for interview.12 This type of analysis also could be incorporated into other MLAs for further refinement of the mentoring and application process.
Knapke et al13 evaluated the use of a natural language modeling platform to look for semantic patterns in medical school applications that could predict which students would be more likely to pursue family medicine residency, thus beginning the recruitment process even before residency application. This strategy could be particularly valuable for specialties for which there may be greater need in the workforce.
AI for Administrative Purposes
Artificial intelligence also has been used for nonapplication aspects of the residency recruitment process, such as interview scheduling. In the absence of coordinated interview release dates (as was implemented in dermatology starting in the 2020-2021 application cycle), a deluge of responses to schedule an interview comes flooding in as soon as invitations for interviewees are sent out, which can produce anxiety both for applicants and residency program staff as the schedule is sorted out and can create delays at both ends. Stephens et al14 utilized a computerized scheduling program for pediatric surgery fellowship applicants. It was used in 2016 to schedule 26 interviews, and it was found to reduce the average time to schedule an interview from 14.4 hours to 1.7 hours. It also reduced the number of email exchanges needed to finalize scheduling.14
Another aspect of residency recruitment that is amenable to AI is information gathering. Many would-be applicants turn to the internet and social media to learn about residency programs—their unique qualities, assets, and potential alignment of career goals.15 This exchange often is unidirectional, as the applicant clicks through the website searching for information. Yi et al16 explored the use of a chatbot, which mimics human conversation and exchange, on their institution’s pain fellowship website. Fellowship applicants could create specific prompts, such as “Show me faculty that trained at <applicant’s home program>,” and the chatbot would reply with the answer. The researchers sent a survey to all 258 applicants to the pain fellowship program that was completed by 48 applicants. Of these respondents, more than 70% (35/48) utilized the chatbot, and 84% (40/48) stated that they had found the information that was requested. The respondents overall found the chatbot to be a useful and positive experience.16
Specific Tools to Consider
There are some tools that are publicly available for programs and applicants to use that rely on AI.
In collaboration with ERAS and the Association of American Medical Colleges, Cortex powered by Thalamus (SJ MedConnect Inc)(https://thalamusgme.com/cortex-application-screening/) offers technology-assisted holistic review of residency and fellowship applications by utilizing natural language processing and optical character recognition to aggregate data from ERAS.
Tools also are being leveraged by applicants to help them find residency programs that fit their criteria, prepare for interviews, and complete portions of the application. Match A Resident (https://www.matcharesident.com/) is a resource for the international medical graduate community. As part of the service, the “Learn More with MARai” feature uses AI to generate information on residency programs to increase applicants’ confidence going into the interview process.17 Big Interview Medical (https://www.biginterviewmedical.com/ai-feedback), a paid interview preparation system developed by interview experts, utilizes AI to provide feedback to residents practicing for the interview process by measuring the amount of natural eye contact, language used, and pace of speech. A “Power Word” score is provided that incorporates aspects such as using filler words (“umm,” “uhh”). A Pace of Speech Tool provides rate of speaking feedback presuming that there is an ideal pace to decrease the impression that the applicant is nervous. Johnstone et al18 used ChatGPT (https://chat.openai.com/auth/login) to generate 2 personal statements for anesthesia residency applicants. Based on survey responses from 31 program directors, 22 rated the statements as good or excellent.18
Ethnical Concerns and Limitations of AI
The potential use of AI tools by residency applicants inevitably brings forth consideration of biases, ethics, and current limitations. These tools are highly dependent on the quality and quantity of data used for training and validation. Information considered valuable in the holistic review of applications includes unstructured data such as personal statements and letters of recommendation, and incorporating this information can be challenging in ML models, in contrast to discrete structured data such as grades, test scores, and awards. In addition, MLAs depend on large quantities of data to optimize performance.19 Depending on the size of the applicant pool and the amount of data available, this can present a limitation for smaller programs in developing ML tools for residency recruitment. Studies evaluating the use of AI in the residency application process often are from single institutions, and therefore generalizability is uncertain. The risk for latent bias—whereby a historical or pre-existing stereotype gets perpetuated through the system—must be considered, with the development of tools to detect and address this if found. Choosing which data to use to train the model can be tricky as well as choosing the outcome of interest. For these interventions to become more resilient, programs need to self-examine what defines their criteria for a successful match to their program to incorporate this data into their ML studies. The previously described models in this overview focused on outcomes such as whether an applicant was invited to interview, whether the applicant was ranked, and whether the applicant matriculated to their program.10,11 For supervised ML models that rely on outcomes to develop a prediction, continued research as to what outcomes represent resident success (eg, passing board certification examinations, correlation with clinical performance) would be important. There also is the possibility of applicants restructuring their applications to align with goals of an AI-assisted search and using AI to generate part or all of their application. The use of ChatGPT and other AI tools in the preparation of personal statements and curriculum vitae may provide benefits such as improved efficiency and grammar support.20 However, as use becomes more widespread, there is the potential increased similarity of personal statements and likely varied opinions on the use of such tools as writing aids.21,22 Continued efforts to develop guidance on generative AI use cases is ongoing; an example is the launch of VALID AI (https://validai.health/), a collaboration among health systems, health plans, and AI research organizations and nonprofits.23
Final Thoughts
Artificial intelligence tools may be a promising resource for residency and fellowship programs seeking to find meaningful ways to select applicants who are good matches for their training environment. Prioritizing the holistic review of applications has been promoted as a method to evaluate the applicant beyond their test scores and grades. The use of MLAs may streamline this review process, aid in scheduling interviews, and help discover trends in successful matriculants.
- Association of American Medical Colleges. ERAS® Statistics. Accessed January 16, 2024. https://www.aamc.org/data-reports/data/eras-statistics-data
- National Resident Matching Program, Data Release and ResearchCommittee: Results of the 2022 NRMP Program Director Survey. Accessed January 18, 2024. https://www.nrmp.org/wp-content/uploads/2022/09/PD-Survey-Report-2022_FINALrev.pdf
- Isaq NA, Bowers S, Chen ST. Taking a “step” toward diversity in dermatology: de-emphasizing USMLE Step 1 scores in residency applications. Int J Womens Dermatol. 2020;6:209-210. doi:10.1016/j.ijwd.2020.02.008
- Association of American Medical Colleges. Holistic review in medical school admissions. Accessed January 16, 2024. https://students-residents.aamc.org/choosing-medical-career/holistic-review-medical-school-admissions
- Association of American Medical Colleges. The MyERAS® application and program signaling for 2023-24. Accessed January 16, 2024. https://students-residents.aamc.org/applying-residencies-eras/myeras-application-and-program-signaling-2023-24
- Tavarez MM, Baghdassarian A, Bailey J, et al. A call to action for standardizing letters of recommendation. J Grad Med Educ. 2022;14:642-646. doi:10.4300/JGME-D-22-00131.1
- US Department of State. Artificial intelligence (AI). Accessed January 16, 2024. https://www.state.gov/artificial-intelligence/
- Stanford University Human-Centered Artificial Intelligence. Artificial intelligence definitions. Accessed January 16, 2024.https://hai.stanford.edu/sites/default/files/2023-03/AI-Key-Terms-Glossary-Definition.pdf
- Rajkomar A, Dean J, Kohane I. Machine learning in medicine. N Engl J Med. 2019;380:1347-1358. doi:10.1056/NEJMra1814259
- Burk-Rafel J, Reinstein I, Feng J, et al. Development and validation of a machine learning-based decision support tool for residency applicant screening and review. Acad Med. 2021;96(11S):S54-S61. doi:10.1097/ACM.0000000000004317
- Rees CA, Ryder HF. Machine learning for the prediction of ranked applicants and matriculants to an internal medicine residency program. Teach Learn Med. 2023;35:277-286. doi:10.1080/10401334.2022.2059664
- Drum B, Shi J, Peterson B, et al. Using natural language processing and machine learning to identify internal medicine-pediatrics residency values in applications. Acad Med. 2023;98:1278-1282. doi:10.1097/ACM.0000000000005352
- Knapke JM, Mount HR, McCabe E, et al. Early identification of family physicians using qualitative admissions data. Fam Med. 2023;55:245-252. doi:10.22454/FamMed.2023.596964
- Stephens CQ, Hamilton NA, Thompson AE, et al. Use of computerized interview scheduling program for pediatric surgery match applicants. J Pediatr Surg. 2017;52:1056-1059. doi:10.1016/j.jpedsurg.2017.03.033
- Nickles MA, Kulkarni V, Varghese JA, et al. Dermatology residency programs’ websites in the virtual era: a cross-sectional analysis. J Am Acad Dermatol. 2022;86:447-448. doi:10.1016/j.jaad.2021.09.064
- Yi PK, Ray ND, Segall N. A novel use of an artificially intelligent Chatbot and a live, synchronous virtual question-and answer session for fellowship recruitment. BMC Med Educ. 2023;23:152. doi:10.1186/s12909-022-03872-z
- Introducing “Learn More with MARai”—the key to understanding your target residency programs. Match A Resident website. Published September 23, 2023. Accessed January 16, 2024. https://blog.matcharesident.com/ai-powered-residency-insights/
- Johnstone RE, Neely G, Sizemore DC. Artificial intelligence softwarecan generate residency application personal statements that program directors find acceptable and difficult to distinguish from applicant compositions. J Clin Anesth. 2023;89:111185. doi:10.1016/j.jclinane.2023.111185
- Khalid N, Qayyum A, Bilal M, et al. Privacy-preserving artificial intelligence in healthcare: techniques and applications. Comput Biol Med. 2023;158:106848. doi:10.1016/j.compbiomed.2023.106848
- Birt J. How to optimize your resume for AI scanners (with tips). Indeed website. Updated December 30, 2022. Accessed January 16, 2024. https://www.indeed.com/career-advice/resumes-cover-letters/resume-ai
- Patel V, Deleonibus A, Wells MW, et al. Distinguishing authentic voices in the age of ChatGPT: comparing AI-generated and applicant-written personal statements for plastic surgery residency application. Ann Plast Surg. 2023;91:324-325. doi:10.1097/SAP.0000000000003653
- Woodfin MW. The personal statement in the age of artificial intelligence. Acad Med. 2023;98:869. doi:10.1097/ACM.0000000000005266
- Diaz N. UC Davis Health to lead new gen AI collaborative. Beckers Healthcare website. Published October 10, 2023. AccessedJanuary 16, 2024. https://www.beckershospitalreview.com/digital-health/uc-davis-health-to-lead-new-gen-ai-collaborative.html
- Association of American Medical Colleges. ERAS® Statistics. Accessed January 16, 2024. https://www.aamc.org/data-reports/data/eras-statistics-data
- National Resident Matching Program, Data Release and ResearchCommittee: Results of the 2022 NRMP Program Director Survey. Accessed January 18, 2024. https://www.nrmp.org/wp-content/uploads/2022/09/PD-Survey-Report-2022_FINALrev.pdf
- Isaq NA, Bowers S, Chen ST. Taking a “step” toward diversity in dermatology: de-emphasizing USMLE Step 1 scores in residency applications. Int J Womens Dermatol. 2020;6:209-210. doi:10.1016/j.ijwd.2020.02.008
- Association of American Medical Colleges. Holistic review in medical school admissions. Accessed January 16, 2024. https://students-residents.aamc.org/choosing-medical-career/holistic-review-medical-school-admissions
- Association of American Medical Colleges. The MyERAS® application and program signaling for 2023-24. Accessed January 16, 2024. https://students-residents.aamc.org/applying-residencies-eras/myeras-application-and-program-signaling-2023-24
- Tavarez MM, Baghdassarian A, Bailey J, et al. A call to action for standardizing letters of recommendation. J Grad Med Educ. 2022;14:642-646. doi:10.4300/JGME-D-22-00131.1
- US Department of State. Artificial intelligence (AI). Accessed January 16, 2024. https://www.state.gov/artificial-intelligence/
- Stanford University Human-Centered Artificial Intelligence. Artificial intelligence definitions. Accessed January 16, 2024.https://hai.stanford.edu/sites/default/files/2023-03/AI-Key-Terms-Glossary-Definition.pdf
- Rajkomar A, Dean J, Kohane I. Machine learning in medicine. N Engl J Med. 2019;380:1347-1358. doi:10.1056/NEJMra1814259
- Burk-Rafel J, Reinstein I, Feng J, et al. Development and validation of a machine learning-based decision support tool for residency applicant screening and review. Acad Med. 2021;96(11S):S54-S61. doi:10.1097/ACM.0000000000004317
- Rees CA, Ryder HF. Machine learning for the prediction of ranked applicants and matriculants to an internal medicine residency program. Teach Learn Med. 2023;35:277-286. doi:10.1080/10401334.2022.2059664
- Drum B, Shi J, Peterson B, et al. Using natural language processing and machine learning to identify internal medicine-pediatrics residency values in applications. Acad Med. 2023;98:1278-1282. doi:10.1097/ACM.0000000000005352
- Knapke JM, Mount HR, McCabe E, et al. Early identification of family physicians using qualitative admissions data. Fam Med. 2023;55:245-252. doi:10.22454/FamMed.2023.596964
- Stephens CQ, Hamilton NA, Thompson AE, et al. Use of computerized interview scheduling program for pediatric surgery match applicants. J Pediatr Surg. 2017;52:1056-1059. doi:10.1016/j.jpedsurg.2017.03.033
- Nickles MA, Kulkarni V, Varghese JA, et al. Dermatology residency programs’ websites in the virtual era: a cross-sectional analysis. J Am Acad Dermatol. 2022;86:447-448. doi:10.1016/j.jaad.2021.09.064
- Yi PK, Ray ND, Segall N. A novel use of an artificially intelligent Chatbot and a live, synchronous virtual question-and answer session for fellowship recruitment. BMC Med Educ. 2023;23:152. doi:10.1186/s12909-022-03872-z
- Introducing “Learn More with MARai”—the key to understanding your target residency programs. Match A Resident website. Published September 23, 2023. Accessed January 16, 2024. https://blog.matcharesident.com/ai-powered-residency-insights/
- Johnstone RE, Neely G, Sizemore DC. Artificial intelligence softwarecan generate residency application personal statements that program directors find acceptable and difficult to distinguish from applicant compositions. J Clin Anesth. 2023;89:111185. doi:10.1016/j.jclinane.2023.111185
- Khalid N, Qayyum A, Bilal M, et al. Privacy-preserving artificial intelligence in healthcare: techniques and applications. Comput Biol Med. 2023;158:106848. doi:10.1016/j.compbiomed.2023.106848
- Birt J. How to optimize your resume for AI scanners (with tips). Indeed website. Updated December 30, 2022. Accessed January 16, 2024. https://www.indeed.com/career-advice/resumes-cover-letters/resume-ai
- Patel V, Deleonibus A, Wells MW, et al. Distinguishing authentic voices in the age of ChatGPT: comparing AI-generated and applicant-written personal statements for plastic surgery residency application. Ann Plast Surg. 2023;91:324-325. doi:10.1097/SAP.0000000000003653
- Woodfin MW. The personal statement in the age of artificial intelligence. Acad Med. 2023;98:869. doi:10.1097/ACM.0000000000005266
- Diaz N. UC Davis Health to lead new gen AI collaborative. Beckers Healthcare website. Published October 10, 2023. AccessedJanuary 16, 2024. https://www.beckershospitalreview.com/digital-health/uc-davis-health-to-lead-new-gen-ai-collaborative.html
Practice Points
- Artificial intelligence solutions may increase the efficiency of the holistic review process and enhance the opportunity to find applicants who may have been overlooked by a traditional review process.
- Artificial intelligence support also may be utilized by applicants to aid in discovering training programs that fit their interests, practice interview strategies, and refine their written application.
Ob.Gyns. Face ‘Occupational Crisis’ Navigating Abortion Ban
A 14-year-old girl arrived at a South Carolina clinic just one day after the state’s anti-abortion law would have allowed her to terminate a pregnancy in instances of rape or incest.
Angela Dempsey-Fanning, MD, MPH, an ob.gyn. in Charleston, had to inform the teenager, a victim of incest, that she could not legally provide abortion care, so the girl and her mother decided to seek treatment in a different state.
“I couldn’t shake the sense that so many principles of medical ethics were being violated in denying care to her,” said Dr. Dempsey-Fanning, president of the Society of Family Planning, a nonprofit that advocates for abortion access. “When I interact with patients in these situations ... I carry the emotional and mental burden for weeks.”
South Carolina is one of 16 states to put in place severe abortion restrictions in the wake of the US Supreme Court ruling in June 2022 on the Dobbs v. Jackson Women’s Health Organization case that overturned Roe v. Wade.
according to a study recently published in the JAMA Network Open.
Public discourse on the Dobbs v. Jackson ruling has mostly centered on the impact to patients, according to Mara Buchbinder, PhD, professor and vice chair in the Department of Social Medicine at University of North Carolina Chapel Hill School of Medicine, and a coauthor of the study.
“We were interested in what the impacts would be for the obstetric workforce as well,” she said.
In 2022 and 2023, Dr. Buchbinder and her colleagues interviewed 54 ob.gyns. practicing in 13 states where abortion had become illegal with limited exceptions, including Texas, West Virginia, and South Dakota.
Clinicians who participated in the study described instances in which the state restrictions on abortion forced them to delay what they deemed to be medically necessary care until a patient faced severe complications or even death. More than 90% reported moral distress concerning situations where legal constraints prevented them or their colleagues from following clinical standards.
“You have somebody hemorrhaging with an intrauterine pregnancy with a heartbeat ... I [didn’t yet] have legal coverage for that, but there’s only so many times you can transfuse somebody and they’re begging for their life before you say, ‘This is unconscionable,’ ” one clinician reported to researchers.
Another clinician said, “Is a 5% risk of death enough? Does it take 20%? Does it take 50%? What is enough legally?”
The US Department of Health and Human Services has announced a new team to ensure hospitals in all states comply with the Emergency Medical Treatment and Labor Act, which, according to the Biden administration, includes emergency abortions. Still, some hospitals may not have clear policies that define pregnancy-related emergencies, making it challenging for clinicians to feel protected in clinically complex situations.
The study also highlighted aiding and abetting clauses, which prevent ob.gyns. from providing referrals for abortions or discussing the option with patients. Participants described the limitations as undermining their medical expertise.
“Some of the harm that is done to these ob.gyns. is not only from the laws themselves, but from their own institutions,” Dr. Buchbinder said. “Hospitals have to decide, ‘what does this law mean and how are we going to put it to practice here?’ ”
Angela Hawkins, MD, a hospitalist practicing in Oklahoma, encountered a patient who was experiencing an obvious miscarriage. But because the situation could not yet be established as life-threatening, Dr. Hawkins felt that she could not intervene.
“There are things I know are straightforward and I would’ve handled them completely differently in the past,” Dr. Hawkins said, adding that she needed to seek reassurance from her hospital employer that she would not face legal ramifications if she provided care.
“It’s frustrating to know that this is medicine and I can’t practice it without calling legal and ethics in the middle of the night,” said Dr. Hawkins, chair of the Oklahoma section of the American College of Obstetrics and Gynecology.
Still, more than half of Oklahoma’s 77 counties are considered maternity care deserts, meaning they have little to no obstetric services available for pregnant patients. Dr. Hawkins recently completed her own survey of practicing ob.gyns. in the state. In soon-to-be published research, almost 60% of the 63 respondents reported thinking about leaving or were planning to leave the state to practice in areas that are less restrictive.
“That’s very concerning to the ob.gyns. that are left,” she said. “I feel like, if everyone leaves, who is left to take care of the patients?”
The study in JAMA Network Open also highlighted that 11% of participants had moved their practices to less restrictive states with stronger abortion protections.
In addition to losing existing clinicians, the laws have made it difficult for medical centers to recruit new ones, according to Kavita Shah Arora, MD, MBE, MS, director for Division of General Obstetrics, Gynecology, and Midwifery at the University of North Carolina at Chapel Hill, and a coauthor of the study. North Carolina enacted a new law in July 2023 that reduced the time allowed for an abortion from 20 weeks to 12 weeks under most circumstances.
“Our department faces new challenges in recruitment and retention being in a restrictive state that we haven’t had to deal with before,” Dr. Arora said. “It’s impacting how medical students choose which residency programs to apply to.”
Ob.gyns. may not be the only clinicians who feel the effect of laws restricting abortion, according to Deborah Nucatola, MD, chief medical officer of Planned Parenthood Great Northwest, Hawai’i, Alaska, Indiana, Kentucky.
Patients who live in areas with limited access to obstetrics services often present to urgent care facilities or emergency departments for medical care that are staffed with family, internal medicine, and emergency physicians, Dr. Nucatola said.
“I don’t want anyone by any means to think this is isolated to one specialty,” said Dr. Nucatola, who was not involved with the study. “It’s going to affect everyone who cares for these patients; you lose the ability to use your medical knowledge and then have to navigate this legal restriction that doesn’t correlate with anything that happens in medicine.”
Dr. Dempsey-Fanning’s 14-year-old patient did eventually receive abortion care outside of South Carolina. Dr. Dempsey-Fanning said that she and her colleagues have spent hours coordinating for patients to receive care in a different state. Then, patients and their families must come up with the money for travel and any missed work to get to another clinician working where abortion is legal.
Despite this, she said, “You are left still feeling as though you abandoned this patient in many practical ways.
“I know I weigh the decision about my future practice almost daily, wondering how long I can stay and keep fighting for patients in an environment ripe with fear, worry, and an overriding sense of injustice,” said Dr. Dempsey-Fanning.
The study authors and experts quoted in the story report no relevant disclosures.
A version of this article appeared on Medscape.com.
A 14-year-old girl arrived at a South Carolina clinic just one day after the state’s anti-abortion law would have allowed her to terminate a pregnancy in instances of rape or incest.
Angela Dempsey-Fanning, MD, MPH, an ob.gyn. in Charleston, had to inform the teenager, a victim of incest, that she could not legally provide abortion care, so the girl and her mother decided to seek treatment in a different state.
“I couldn’t shake the sense that so many principles of medical ethics were being violated in denying care to her,” said Dr. Dempsey-Fanning, president of the Society of Family Planning, a nonprofit that advocates for abortion access. “When I interact with patients in these situations ... I carry the emotional and mental burden for weeks.”
South Carolina is one of 16 states to put in place severe abortion restrictions in the wake of the US Supreme Court ruling in June 2022 on the Dobbs v. Jackson Women’s Health Organization case that overturned Roe v. Wade.
according to a study recently published in the JAMA Network Open.
Public discourse on the Dobbs v. Jackson ruling has mostly centered on the impact to patients, according to Mara Buchbinder, PhD, professor and vice chair in the Department of Social Medicine at University of North Carolina Chapel Hill School of Medicine, and a coauthor of the study.
“We were interested in what the impacts would be for the obstetric workforce as well,” she said.
In 2022 and 2023, Dr. Buchbinder and her colleagues interviewed 54 ob.gyns. practicing in 13 states where abortion had become illegal with limited exceptions, including Texas, West Virginia, and South Dakota.
Clinicians who participated in the study described instances in which the state restrictions on abortion forced them to delay what they deemed to be medically necessary care until a patient faced severe complications or even death. More than 90% reported moral distress concerning situations where legal constraints prevented them or their colleagues from following clinical standards.
“You have somebody hemorrhaging with an intrauterine pregnancy with a heartbeat ... I [didn’t yet] have legal coverage for that, but there’s only so many times you can transfuse somebody and they’re begging for their life before you say, ‘This is unconscionable,’ ” one clinician reported to researchers.
Another clinician said, “Is a 5% risk of death enough? Does it take 20%? Does it take 50%? What is enough legally?”
The US Department of Health and Human Services has announced a new team to ensure hospitals in all states comply with the Emergency Medical Treatment and Labor Act, which, according to the Biden administration, includes emergency abortions. Still, some hospitals may not have clear policies that define pregnancy-related emergencies, making it challenging for clinicians to feel protected in clinically complex situations.
The study also highlighted aiding and abetting clauses, which prevent ob.gyns. from providing referrals for abortions or discussing the option with patients. Participants described the limitations as undermining their medical expertise.
“Some of the harm that is done to these ob.gyns. is not only from the laws themselves, but from their own institutions,” Dr. Buchbinder said. “Hospitals have to decide, ‘what does this law mean and how are we going to put it to practice here?’ ”
Angela Hawkins, MD, a hospitalist practicing in Oklahoma, encountered a patient who was experiencing an obvious miscarriage. But because the situation could not yet be established as life-threatening, Dr. Hawkins felt that she could not intervene.
“There are things I know are straightforward and I would’ve handled them completely differently in the past,” Dr. Hawkins said, adding that she needed to seek reassurance from her hospital employer that she would not face legal ramifications if she provided care.
“It’s frustrating to know that this is medicine and I can’t practice it without calling legal and ethics in the middle of the night,” said Dr. Hawkins, chair of the Oklahoma section of the American College of Obstetrics and Gynecology.
Still, more than half of Oklahoma’s 77 counties are considered maternity care deserts, meaning they have little to no obstetric services available for pregnant patients. Dr. Hawkins recently completed her own survey of practicing ob.gyns. in the state. In soon-to-be published research, almost 60% of the 63 respondents reported thinking about leaving or were planning to leave the state to practice in areas that are less restrictive.
“That’s very concerning to the ob.gyns. that are left,” she said. “I feel like, if everyone leaves, who is left to take care of the patients?”
The study in JAMA Network Open also highlighted that 11% of participants had moved their practices to less restrictive states with stronger abortion protections.
In addition to losing existing clinicians, the laws have made it difficult for medical centers to recruit new ones, according to Kavita Shah Arora, MD, MBE, MS, director for Division of General Obstetrics, Gynecology, and Midwifery at the University of North Carolina at Chapel Hill, and a coauthor of the study. North Carolina enacted a new law in July 2023 that reduced the time allowed for an abortion from 20 weeks to 12 weeks under most circumstances.
“Our department faces new challenges in recruitment and retention being in a restrictive state that we haven’t had to deal with before,” Dr. Arora said. “It’s impacting how medical students choose which residency programs to apply to.”
Ob.gyns. may not be the only clinicians who feel the effect of laws restricting abortion, according to Deborah Nucatola, MD, chief medical officer of Planned Parenthood Great Northwest, Hawai’i, Alaska, Indiana, Kentucky.
Patients who live in areas with limited access to obstetrics services often present to urgent care facilities or emergency departments for medical care that are staffed with family, internal medicine, and emergency physicians, Dr. Nucatola said.
“I don’t want anyone by any means to think this is isolated to one specialty,” said Dr. Nucatola, who was not involved with the study. “It’s going to affect everyone who cares for these patients; you lose the ability to use your medical knowledge and then have to navigate this legal restriction that doesn’t correlate with anything that happens in medicine.”
Dr. Dempsey-Fanning’s 14-year-old patient did eventually receive abortion care outside of South Carolina. Dr. Dempsey-Fanning said that she and her colleagues have spent hours coordinating for patients to receive care in a different state. Then, patients and their families must come up with the money for travel and any missed work to get to another clinician working where abortion is legal.
Despite this, she said, “You are left still feeling as though you abandoned this patient in many practical ways.
“I know I weigh the decision about my future practice almost daily, wondering how long I can stay and keep fighting for patients in an environment ripe with fear, worry, and an overriding sense of injustice,” said Dr. Dempsey-Fanning.
The study authors and experts quoted in the story report no relevant disclosures.
A version of this article appeared on Medscape.com.
A 14-year-old girl arrived at a South Carolina clinic just one day after the state’s anti-abortion law would have allowed her to terminate a pregnancy in instances of rape or incest.
Angela Dempsey-Fanning, MD, MPH, an ob.gyn. in Charleston, had to inform the teenager, a victim of incest, that she could not legally provide abortion care, so the girl and her mother decided to seek treatment in a different state.
“I couldn’t shake the sense that so many principles of medical ethics were being violated in denying care to her,” said Dr. Dempsey-Fanning, president of the Society of Family Planning, a nonprofit that advocates for abortion access. “When I interact with patients in these situations ... I carry the emotional and mental burden for weeks.”
South Carolina is one of 16 states to put in place severe abortion restrictions in the wake of the US Supreme Court ruling in June 2022 on the Dobbs v. Jackson Women’s Health Organization case that overturned Roe v. Wade.
according to a study recently published in the JAMA Network Open.
Public discourse on the Dobbs v. Jackson ruling has mostly centered on the impact to patients, according to Mara Buchbinder, PhD, professor and vice chair in the Department of Social Medicine at University of North Carolina Chapel Hill School of Medicine, and a coauthor of the study.
“We were interested in what the impacts would be for the obstetric workforce as well,” she said.
In 2022 and 2023, Dr. Buchbinder and her colleagues interviewed 54 ob.gyns. practicing in 13 states where abortion had become illegal with limited exceptions, including Texas, West Virginia, and South Dakota.
Clinicians who participated in the study described instances in which the state restrictions on abortion forced them to delay what they deemed to be medically necessary care until a patient faced severe complications or even death. More than 90% reported moral distress concerning situations where legal constraints prevented them or their colleagues from following clinical standards.
“You have somebody hemorrhaging with an intrauterine pregnancy with a heartbeat ... I [didn’t yet] have legal coverage for that, but there’s only so many times you can transfuse somebody and they’re begging for their life before you say, ‘This is unconscionable,’ ” one clinician reported to researchers.
Another clinician said, “Is a 5% risk of death enough? Does it take 20%? Does it take 50%? What is enough legally?”
The US Department of Health and Human Services has announced a new team to ensure hospitals in all states comply with the Emergency Medical Treatment and Labor Act, which, according to the Biden administration, includes emergency abortions. Still, some hospitals may not have clear policies that define pregnancy-related emergencies, making it challenging for clinicians to feel protected in clinically complex situations.
The study also highlighted aiding and abetting clauses, which prevent ob.gyns. from providing referrals for abortions or discussing the option with patients. Participants described the limitations as undermining their medical expertise.
“Some of the harm that is done to these ob.gyns. is not only from the laws themselves, but from their own institutions,” Dr. Buchbinder said. “Hospitals have to decide, ‘what does this law mean and how are we going to put it to practice here?’ ”
Angela Hawkins, MD, a hospitalist practicing in Oklahoma, encountered a patient who was experiencing an obvious miscarriage. But because the situation could not yet be established as life-threatening, Dr. Hawkins felt that she could not intervene.
“There are things I know are straightforward and I would’ve handled them completely differently in the past,” Dr. Hawkins said, adding that she needed to seek reassurance from her hospital employer that she would not face legal ramifications if she provided care.
“It’s frustrating to know that this is medicine and I can’t practice it without calling legal and ethics in the middle of the night,” said Dr. Hawkins, chair of the Oklahoma section of the American College of Obstetrics and Gynecology.
Still, more than half of Oklahoma’s 77 counties are considered maternity care deserts, meaning they have little to no obstetric services available for pregnant patients. Dr. Hawkins recently completed her own survey of practicing ob.gyns. in the state. In soon-to-be published research, almost 60% of the 63 respondents reported thinking about leaving or were planning to leave the state to practice in areas that are less restrictive.
“That’s very concerning to the ob.gyns. that are left,” she said. “I feel like, if everyone leaves, who is left to take care of the patients?”
The study in JAMA Network Open also highlighted that 11% of participants had moved their practices to less restrictive states with stronger abortion protections.
In addition to losing existing clinicians, the laws have made it difficult for medical centers to recruit new ones, according to Kavita Shah Arora, MD, MBE, MS, director for Division of General Obstetrics, Gynecology, and Midwifery at the University of North Carolina at Chapel Hill, and a coauthor of the study. North Carolina enacted a new law in July 2023 that reduced the time allowed for an abortion from 20 weeks to 12 weeks under most circumstances.
“Our department faces new challenges in recruitment and retention being in a restrictive state that we haven’t had to deal with before,” Dr. Arora said. “It’s impacting how medical students choose which residency programs to apply to.”
Ob.gyns. may not be the only clinicians who feel the effect of laws restricting abortion, according to Deborah Nucatola, MD, chief medical officer of Planned Parenthood Great Northwest, Hawai’i, Alaska, Indiana, Kentucky.
Patients who live in areas with limited access to obstetrics services often present to urgent care facilities or emergency departments for medical care that are staffed with family, internal medicine, and emergency physicians, Dr. Nucatola said.
“I don’t want anyone by any means to think this is isolated to one specialty,” said Dr. Nucatola, who was not involved with the study. “It’s going to affect everyone who cares for these patients; you lose the ability to use your medical knowledge and then have to navigate this legal restriction that doesn’t correlate with anything that happens in medicine.”
Dr. Dempsey-Fanning’s 14-year-old patient did eventually receive abortion care outside of South Carolina. Dr. Dempsey-Fanning said that she and her colleagues have spent hours coordinating for patients to receive care in a different state. Then, patients and their families must come up with the money for travel and any missed work to get to another clinician working where abortion is legal.
Despite this, she said, “You are left still feeling as though you abandoned this patient in many practical ways.
“I know I weigh the decision about my future practice almost daily, wondering how long I can stay and keep fighting for patients in an environment ripe with fear, worry, and an overriding sense of injustice,” said Dr. Dempsey-Fanning.
The study authors and experts quoted in the story report no relevant disclosures.
A version of this article appeared on Medscape.com.
Medical Aid in Dying Should Be Legal, Says Ethicist
This transcript has been edited for clarity.
Hi. I’m Art Caplan. I’m at the Division of Medical Ethics at the NYU Grossman School of Medicine.
Right now, there are 10 states and the District of Columbia that have had some version of medical assistance in dying approved and on the books. That basically means that about 20% of Americans have access where they live to a physician who can prescribe a lethal dose of medication to them if they’re terminally ill and can ingest the medication themselves. That leaves many Americans not covered by this kind of access to this kind of service.
Many of you watching this may live in states where it is legal, like Oregon, Washington, New Jersey, Colorado, and Hawaii. I know many doctors say, “I’m not going to do that.” It’s not something that anyone is compelling a doctor to do. For some Americans, access is not just about where they live but whether there is a doctor willing to participate with them in bringing about their accelerated death, knowing that they’re inevitably going to die.
There’s not much we can do about that. It’s up to the conscience of each physician as to what they’re comfortable with. Certainly, there are other things that can be done to extend the possibility of having this available.
One thing that’s taking place is that, after lawsuits were filed, Vermont and Oregon have given up on their residency requirement, so you don’t have to be there 6 months or a year in order to use this opportunity. It’s legal now to move to the state or visit the state, and as soon as you get there, sign up for this kind of end-of-life intervention.
New Jersey is also being sued. I’ll predict that every state that has a residency requirement, when sued in court, is going to lose because we’ve long recognized the right of Americans to seek out healthcare in the United States, wherever they want to go.
If some states have made this a legitimate medical procedure, courts are going to say you can’t restrict it only to state residents. If someone wants to use a service, they’re entitled to show up from another state or another place and use it. I’m not sure about foreign nationals, but I’m very sure that Americans can go state to state in search of legitimate medical procedures.
The other bills that are out there, however, are basically saying they want to emulate Oregon, Washington, and the other states and say that the terminally ill, with severe restrictions, are going to be able to get this service without going anywhere.
The restrictions include a diagnosis of terminal illness and that you have to be deemed mentally competent. You can’t use this if you have Alzheimer’s or severe depression. You have to make a request twice with a week or two in between to make sure that your request is authentic. And obviously, everyone is on board to make sure that you’re not being coerced or pushed somehow into requesting a somewhat earlier death than you would have experienced without having the availability of the pills.
You also have to take the pills yourself or be able to pull a switch so that you could use a feeding tube–type administration. If you can’t do that, say due to ALS, you’re not eligible to use medical aid in dying. It’s a pretty restricted intervention.
Many people who get pills after going through these restrictions in the states that permit it don’t use it. As many as one third say they like having it there as a safety valve or a parachute, but once they know they could end their life sooner, then they’re going to stick it out.
Should states make this legal? New York, Massachusetts, Florida, and many other states have bills that are moving through. I’m going to say yes. We’ve had Oregon and Washington since the late 1990s with medical aid in dying on the books. There doesn’t seem to be any evidence of pushing people to use this, of bias against the disabled, or bigotry against particular ethnic or racial groups being used to encourage people to end their life sooner.
I think it is an option that Americans want. I think it’s an option that makes some sense. I’m well aware that we also have to make sure that people know about hospice. In some of these states, medical aid in dying is offered as a part of hospice — not all, but a few. Not everybody wants hospice once they realize that they’re dying and that it is coming relatively soon. They may want to leave with family present, with a ceremony, or with a quality of life that they desire.
Past experience says let’s continue to expand availability in each state. Let’s also realize that we have to keep the restrictions in place on how it’s used because they have protected us against abuse. Let’s understand that every doctor has an option to do this or not do this. It’s a matter of conscience and a matter of comfort.
I think legalization is the direction we’re going to be going in. Getting rid of the residency requirements that have been around, as I think courts are going to overturn them, also gives a push to the idea that once the service is in this many states, it’s something that should be available if there are doctors willing to do it.
I’m Art Caplan at the Division of Medical Ethics at NYU Grossman School of Medicine. New York, NY. Thank you for watching.
Arthur L. Caplan, PhD, has disclosed the following relevant financial relationships:
- Served as a director, officer, partner, employee, advisor, consultant, or trustee for: Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position)
- Serves as a contributing author and adviser for: Medscape
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
Hi. I’m Art Caplan. I’m at the Division of Medical Ethics at the NYU Grossman School of Medicine.
Right now, there are 10 states and the District of Columbia that have had some version of medical assistance in dying approved and on the books. That basically means that about 20% of Americans have access where they live to a physician who can prescribe a lethal dose of medication to them if they’re terminally ill and can ingest the medication themselves. That leaves many Americans not covered by this kind of access to this kind of service.
Many of you watching this may live in states where it is legal, like Oregon, Washington, New Jersey, Colorado, and Hawaii. I know many doctors say, “I’m not going to do that.” It’s not something that anyone is compelling a doctor to do. For some Americans, access is not just about where they live but whether there is a doctor willing to participate with them in bringing about their accelerated death, knowing that they’re inevitably going to die.
There’s not much we can do about that. It’s up to the conscience of each physician as to what they’re comfortable with. Certainly, there are other things that can be done to extend the possibility of having this available.
One thing that’s taking place is that, after lawsuits were filed, Vermont and Oregon have given up on their residency requirement, so you don’t have to be there 6 months or a year in order to use this opportunity. It’s legal now to move to the state or visit the state, and as soon as you get there, sign up for this kind of end-of-life intervention.
New Jersey is also being sued. I’ll predict that every state that has a residency requirement, when sued in court, is going to lose because we’ve long recognized the right of Americans to seek out healthcare in the United States, wherever they want to go.
If some states have made this a legitimate medical procedure, courts are going to say you can’t restrict it only to state residents. If someone wants to use a service, they’re entitled to show up from another state or another place and use it. I’m not sure about foreign nationals, but I’m very sure that Americans can go state to state in search of legitimate medical procedures.
The other bills that are out there, however, are basically saying they want to emulate Oregon, Washington, and the other states and say that the terminally ill, with severe restrictions, are going to be able to get this service without going anywhere.
The restrictions include a diagnosis of terminal illness and that you have to be deemed mentally competent. You can’t use this if you have Alzheimer’s or severe depression. You have to make a request twice with a week or two in between to make sure that your request is authentic. And obviously, everyone is on board to make sure that you’re not being coerced or pushed somehow into requesting a somewhat earlier death than you would have experienced without having the availability of the pills.
You also have to take the pills yourself or be able to pull a switch so that you could use a feeding tube–type administration. If you can’t do that, say due to ALS, you’re not eligible to use medical aid in dying. It’s a pretty restricted intervention.
Many people who get pills after going through these restrictions in the states that permit it don’t use it. As many as one third say they like having it there as a safety valve or a parachute, but once they know they could end their life sooner, then they’re going to stick it out.
Should states make this legal? New York, Massachusetts, Florida, and many other states have bills that are moving through. I’m going to say yes. We’ve had Oregon and Washington since the late 1990s with medical aid in dying on the books. There doesn’t seem to be any evidence of pushing people to use this, of bias against the disabled, or bigotry against particular ethnic or racial groups being used to encourage people to end their life sooner.
I think it is an option that Americans want. I think it’s an option that makes some sense. I’m well aware that we also have to make sure that people know about hospice. In some of these states, medical aid in dying is offered as a part of hospice — not all, but a few. Not everybody wants hospice once they realize that they’re dying and that it is coming relatively soon. They may want to leave with family present, with a ceremony, or with a quality of life that they desire.
Past experience says let’s continue to expand availability in each state. Let’s also realize that we have to keep the restrictions in place on how it’s used because they have protected us against abuse. Let’s understand that every doctor has an option to do this or not do this. It’s a matter of conscience and a matter of comfort.
I think legalization is the direction we’re going to be going in. Getting rid of the residency requirements that have been around, as I think courts are going to overturn them, also gives a push to the idea that once the service is in this many states, it’s something that should be available if there are doctors willing to do it.
I’m Art Caplan at the Division of Medical Ethics at NYU Grossman School of Medicine. New York, NY. Thank you for watching.
Arthur L. Caplan, PhD, has disclosed the following relevant financial relationships:
- Served as a director, officer, partner, employee, advisor, consultant, or trustee for: Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position)
- Serves as a contributing author and adviser for: Medscape
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
Hi. I’m Art Caplan. I’m at the Division of Medical Ethics at the NYU Grossman School of Medicine.
Right now, there are 10 states and the District of Columbia that have had some version of medical assistance in dying approved and on the books. That basically means that about 20% of Americans have access where they live to a physician who can prescribe a lethal dose of medication to them if they’re terminally ill and can ingest the medication themselves. That leaves many Americans not covered by this kind of access to this kind of service.
Many of you watching this may live in states where it is legal, like Oregon, Washington, New Jersey, Colorado, and Hawaii. I know many doctors say, “I’m not going to do that.” It’s not something that anyone is compelling a doctor to do. For some Americans, access is not just about where they live but whether there is a doctor willing to participate with them in bringing about their accelerated death, knowing that they’re inevitably going to die.
There’s not much we can do about that. It’s up to the conscience of each physician as to what they’re comfortable with. Certainly, there are other things that can be done to extend the possibility of having this available.
One thing that’s taking place is that, after lawsuits were filed, Vermont and Oregon have given up on their residency requirement, so you don’t have to be there 6 months or a year in order to use this opportunity. It’s legal now to move to the state or visit the state, and as soon as you get there, sign up for this kind of end-of-life intervention.
New Jersey is also being sued. I’ll predict that every state that has a residency requirement, when sued in court, is going to lose because we’ve long recognized the right of Americans to seek out healthcare in the United States, wherever they want to go.
If some states have made this a legitimate medical procedure, courts are going to say you can’t restrict it only to state residents. If someone wants to use a service, they’re entitled to show up from another state or another place and use it. I’m not sure about foreign nationals, but I’m very sure that Americans can go state to state in search of legitimate medical procedures.
The other bills that are out there, however, are basically saying they want to emulate Oregon, Washington, and the other states and say that the terminally ill, with severe restrictions, are going to be able to get this service without going anywhere.
The restrictions include a diagnosis of terminal illness and that you have to be deemed mentally competent. You can’t use this if you have Alzheimer’s or severe depression. You have to make a request twice with a week or two in between to make sure that your request is authentic. And obviously, everyone is on board to make sure that you’re not being coerced or pushed somehow into requesting a somewhat earlier death than you would have experienced without having the availability of the pills.
You also have to take the pills yourself or be able to pull a switch so that you could use a feeding tube–type administration. If you can’t do that, say due to ALS, you’re not eligible to use medical aid in dying. It’s a pretty restricted intervention.
Many people who get pills after going through these restrictions in the states that permit it don’t use it. As many as one third say they like having it there as a safety valve or a parachute, but once they know they could end their life sooner, then they’re going to stick it out.
Should states make this legal? New York, Massachusetts, Florida, and many other states have bills that are moving through. I’m going to say yes. We’ve had Oregon and Washington since the late 1990s with medical aid in dying on the books. There doesn’t seem to be any evidence of pushing people to use this, of bias against the disabled, or bigotry against particular ethnic or racial groups being used to encourage people to end their life sooner.
I think it is an option that Americans want. I think it’s an option that makes some sense. I’m well aware that we also have to make sure that people know about hospice. In some of these states, medical aid in dying is offered as a part of hospice — not all, but a few. Not everybody wants hospice once they realize that they’re dying and that it is coming relatively soon. They may want to leave with family present, with a ceremony, or with a quality of life that they desire.
Past experience says let’s continue to expand availability in each state. Let’s also realize that we have to keep the restrictions in place on how it’s used because they have protected us against abuse. Let’s understand that every doctor has an option to do this or not do this. It’s a matter of conscience and a matter of comfort.
I think legalization is the direction we’re going to be going in. Getting rid of the residency requirements that have been around, as I think courts are going to overturn them, also gives a push to the idea that once the service is in this many states, it’s something that should be available if there are doctors willing to do it.
I’m Art Caplan at the Division of Medical Ethics at NYU Grossman School of Medicine. New York, NY. Thank you for watching.
Arthur L. Caplan, PhD, has disclosed the following relevant financial relationships:
- Served as a director, officer, partner, employee, advisor, consultant, or trustee for: Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position)
- Serves as a contributing author and adviser for: Medscape
A version of this article appeared on Medscape.com.
The Emerging Physician-Scientist Crisis in America
Recent reporting has shown that That’s a problem, because physician-scientists are uniquely equipped to make scientific discoveries in the laboratory and translate them to the clinic. Indeed, many of the discoveries that have transformed medicine for the better were made by physician-scientists. For example, Jonas Salk developed the polio vaccine, Timothy Ley sequenced the first cancer genome, and Anthony Fauci coordinated public health responses to both the HIV/AIDS and COVID-19 pandemics. Indicative of their sheer impact, at least a third and as many as half of all Nobel Prizes and Lasker Awards in physiology/medicine have gone to physician-scientists.
So why is the supply of physician-scientists shrinking so precipitously at a time when medical discoveries are being made at a record-high rate? Immunotherapy and proton therapy are transforming cancer care; RNA technology led to COVID vaccines; CRISPR is facilitating gene editing and treatment of diseases like sickle cell anemia. Yet, as exciting as medical science has become, only 1.5% of American doctors work as physician-scientists, more than a threefold drop compared with 30 years ago when the figure was a more robust 4.7%. What’s going on?
Residency training programs at prestigious academic medical centers have standard infolded research years; for example, neurosurgery residents at academic medical centers will often get 2 years of protected research time. And the National Institutes of Health has training grants dedicated to physician-scientists, such as the K08 award program. Several foundations are also dedicated to supporting early-career physician-scientists. Yet, the number of physicians deciding to become physician-scientists remains low, and, more troubling, the attrition rate of those who do decide to go this route is quite high.
The underlying issue is multifold. First, funding rates from the federal government for grants have become competitive to the point of being unrealistic. For example, the current funding rate for the flagship R01 program from the National Cancer Institute is only 12%. Promotions are typically tied to these grant awards, which means physician-scientists who are unable to acquire substantial grant funding are unable to pay for their research or win promotion — and often exit the physician-scientist track altogether.
Compounding this issue is a lack of mentorship for early-career physician-scientists. With the rise of “careerism” in medicine, senior-level physician-scientists may have less incentive to mentor those who are earlier in their careers. Rather, there seems to be greater reward to “managing up” — that is, spending time to please hospital administrators and departmental leadership. Being involved in countless committees appears to carry more value in advancing an established investigator’s career than does mentorship.
Finally, physician-scientists typically earn less than their clinician colleagues, despite juggling both scientific and clinical responsibilities. While many are comfortable with this arrangement when embarking on this track, the disparity may become untenable after a while, especially as departmental leadership will often turn to physician-scientists to fill clinical coverage gaps when faculty leave the department, or as the medical center expands to satellite centers outside the primary hospital. Indeed, physician-scientists get pulled in several directions, which can lead to burnout and attrition, with many who are highly equipped for this track ultimately hanging up their cleats and seeking more clinical or private industry–oriented opportunities.
Every academic medical center operates differently. Some clearly have done a better job than others promoting and fostering physician-scientists. What we find in the centers that manage to retain physician-scientists is leadership plays a major role: If a medical center values the importance of physician-scientists, they will do things to foster the success of those people, such as assembling mentorship committees, establishing clear criteria for promotion and career advancement, protecting research time while maintaining some level of pay equity, advocating for team science approaches, and supporting investigators in cases of gaps in federal funding. Different countries also have different models for physician-scientist training, with Germany, for example, allowing medical residents to have 3 years of protected time to engage in research after their second year of residency.
The stakes here are high. If we can’t address the physician-scientist recruitment and retention crisis in America now, we risk falling behind other countries in our ability to innovate and deliver world-class care.
Dr Chaudhuri is a tenure-track physician-scientist at Washington University in St. Louis, a Paul and Daisy Soros Fellow, and a Public Voices Fellow of The OpEd Project.
Aadel Chaudhuri, MD, PhD, has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Recent reporting has shown that That’s a problem, because physician-scientists are uniquely equipped to make scientific discoveries in the laboratory and translate them to the clinic. Indeed, many of the discoveries that have transformed medicine for the better were made by physician-scientists. For example, Jonas Salk developed the polio vaccine, Timothy Ley sequenced the first cancer genome, and Anthony Fauci coordinated public health responses to both the HIV/AIDS and COVID-19 pandemics. Indicative of their sheer impact, at least a third and as many as half of all Nobel Prizes and Lasker Awards in physiology/medicine have gone to physician-scientists.
So why is the supply of physician-scientists shrinking so precipitously at a time when medical discoveries are being made at a record-high rate? Immunotherapy and proton therapy are transforming cancer care; RNA technology led to COVID vaccines; CRISPR is facilitating gene editing and treatment of diseases like sickle cell anemia. Yet, as exciting as medical science has become, only 1.5% of American doctors work as physician-scientists, more than a threefold drop compared with 30 years ago when the figure was a more robust 4.7%. What’s going on?
Residency training programs at prestigious academic medical centers have standard infolded research years; for example, neurosurgery residents at academic medical centers will often get 2 years of protected research time. And the National Institutes of Health has training grants dedicated to physician-scientists, such as the K08 award program. Several foundations are also dedicated to supporting early-career physician-scientists. Yet, the number of physicians deciding to become physician-scientists remains low, and, more troubling, the attrition rate of those who do decide to go this route is quite high.
The underlying issue is multifold. First, funding rates from the federal government for grants have become competitive to the point of being unrealistic. For example, the current funding rate for the flagship R01 program from the National Cancer Institute is only 12%. Promotions are typically tied to these grant awards, which means physician-scientists who are unable to acquire substantial grant funding are unable to pay for their research or win promotion — and often exit the physician-scientist track altogether.
Compounding this issue is a lack of mentorship for early-career physician-scientists. With the rise of “careerism” in medicine, senior-level physician-scientists may have less incentive to mentor those who are earlier in their careers. Rather, there seems to be greater reward to “managing up” — that is, spending time to please hospital administrators and departmental leadership. Being involved in countless committees appears to carry more value in advancing an established investigator’s career than does mentorship.
Finally, physician-scientists typically earn less than their clinician colleagues, despite juggling both scientific and clinical responsibilities. While many are comfortable with this arrangement when embarking on this track, the disparity may become untenable after a while, especially as departmental leadership will often turn to physician-scientists to fill clinical coverage gaps when faculty leave the department, or as the medical center expands to satellite centers outside the primary hospital. Indeed, physician-scientists get pulled in several directions, which can lead to burnout and attrition, with many who are highly equipped for this track ultimately hanging up their cleats and seeking more clinical or private industry–oriented opportunities.
Every academic medical center operates differently. Some clearly have done a better job than others promoting and fostering physician-scientists. What we find in the centers that manage to retain physician-scientists is leadership plays a major role: If a medical center values the importance of physician-scientists, they will do things to foster the success of those people, such as assembling mentorship committees, establishing clear criteria for promotion and career advancement, protecting research time while maintaining some level of pay equity, advocating for team science approaches, and supporting investigators in cases of gaps in federal funding. Different countries also have different models for physician-scientist training, with Germany, for example, allowing medical residents to have 3 years of protected time to engage in research after their second year of residency.
The stakes here are high. If we can’t address the physician-scientist recruitment and retention crisis in America now, we risk falling behind other countries in our ability to innovate and deliver world-class care.
Dr Chaudhuri is a tenure-track physician-scientist at Washington University in St. Louis, a Paul and Daisy Soros Fellow, and a Public Voices Fellow of The OpEd Project.
Aadel Chaudhuri, MD, PhD, has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Recent reporting has shown that That’s a problem, because physician-scientists are uniquely equipped to make scientific discoveries in the laboratory and translate them to the clinic. Indeed, many of the discoveries that have transformed medicine for the better were made by physician-scientists. For example, Jonas Salk developed the polio vaccine, Timothy Ley sequenced the first cancer genome, and Anthony Fauci coordinated public health responses to both the HIV/AIDS and COVID-19 pandemics. Indicative of their sheer impact, at least a third and as many as half of all Nobel Prizes and Lasker Awards in physiology/medicine have gone to physician-scientists.
So why is the supply of physician-scientists shrinking so precipitously at a time when medical discoveries are being made at a record-high rate? Immunotherapy and proton therapy are transforming cancer care; RNA technology led to COVID vaccines; CRISPR is facilitating gene editing and treatment of diseases like sickle cell anemia. Yet, as exciting as medical science has become, only 1.5% of American doctors work as physician-scientists, more than a threefold drop compared with 30 years ago when the figure was a more robust 4.7%. What’s going on?
Residency training programs at prestigious academic medical centers have standard infolded research years; for example, neurosurgery residents at academic medical centers will often get 2 years of protected research time. And the National Institutes of Health has training grants dedicated to physician-scientists, such as the K08 award program. Several foundations are also dedicated to supporting early-career physician-scientists. Yet, the number of physicians deciding to become physician-scientists remains low, and, more troubling, the attrition rate of those who do decide to go this route is quite high.
The underlying issue is multifold. First, funding rates from the federal government for grants have become competitive to the point of being unrealistic. For example, the current funding rate for the flagship R01 program from the National Cancer Institute is only 12%. Promotions are typically tied to these grant awards, which means physician-scientists who are unable to acquire substantial grant funding are unable to pay for their research or win promotion — and often exit the physician-scientist track altogether.
Compounding this issue is a lack of mentorship for early-career physician-scientists. With the rise of “careerism” in medicine, senior-level physician-scientists may have less incentive to mentor those who are earlier in their careers. Rather, there seems to be greater reward to “managing up” — that is, spending time to please hospital administrators and departmental leadership. Being involved in countless committees appears to carry more value in advancing an established investigator’s career than does mentorship.
Finally, physician-scientists typically earn less than their clinician colleagues, despite juggling both scientific and clinical responsibilities. While many are comfortable with this arrangement when embarking on this track, the disparity may become untenable after a while, especially as departmental leadership will often turn to physician-scientists to fill clinical coverage gaps when faculty leave the department, or as the medical center expands to satellite centers outside the primary hospital. Indeed, physician-scientists get pulled in several directions, which can lead to burnout and attrition, with many who are highly equipped for this track ultimately hanging up their cleats and seeking more clinical or private industry–oriented opportunities.
Every academic medical center operates differently. Some clearly have done a better job than others promoting and fostering physician-scientists. What we find in the centers that manage to retain physician-scientists is leadership plays a major role: If a medical center values the importance of physician-scientists, they will do things to foster the success of those people, such as assembling mentorship committees, establishing clear criteria for promotion and career advancement, protecting research time while maintaining some level of pay equity, advocating for team science approaches, and supporting investigators in cases of gaps in federal funding. Different countries also have different models for physician-scientist training, with Germany, for example, allowing medical residents to have 3 years of protected time to engage in research after their second year of residency.
The stakes here are high. If we can’t address the physician-scientist recruitment and retention crisis in America now, we risk falling behind other countries in our ability to innovate and deliver world-class care.
Dr Chaudhuri is a tenure-track physician-scientist at Washington University in St. Louis, a Paul and Daisy Soros Fellow, and a Public Voices Fellow of The OpEd Project.
Aadel Chaudhuri, MD, PhD, has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.