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Higher Early-Onset CRC Mortality Seen in Racial, Ethnic Minorities
TOPLINE:
The largest racial and ethnic disparities in survival were linked to neighborhood socioeconomic status.
METHODOLOGY:
- US rates of EOCRC are increasing, with differences across racial and ethnic groups, but few studies have provided detailed risk estimates in the categories of Asian American and of Native Hawaiian or Other Pacific Islander, as well as the contribution of sociodemographic factors to these differences.
- A population-based cohort study analyzed California Cancer Registry data for 22,834 individuals aged 18-49 years diagnosed with EOCRC between January 2000 and December 2019.
- Researchers examined the association between mortality risk and racial and ethnic groups, including Asian American (15.5%, separated into seven subcategories), Hispanic (30.2%), Native Hawaiian or Other Pacific Islander (0.6%), non-Hispanic American Indian or Alaska Native (0.5%), non-Hispanic Black (7.3%), and non-Hispanic White (45.9%) individuals, with a median follow-up of 4.2 years.
- Statistical models measured baseline associations adjusting for clinical features and then tested for the contribution of socioeconomic factors together and separately, with adjustments for insurance status, neighborhood socioeconomic status, and more.
TAKEAWAY:
- Native Hawaiian or Other Pacific Islander individuals demonstrated the highest EOCRC mortality risk compared with non-Hispanic White individuals (socioeconomic status–adjusted HR [SES aHR], 1.34; 95% CI, 1.01-1.76).
- Non-Hispanic Black individuals showed a higher EOCRC mortality risk than non-Hispanic White individuals (SES aHR, 1.18; 95% CI, 1.07-1.29).
- Hispanic individuals’ higher EOCRC mortality (base aHR, 1.15; 95% CI, 1.08-1.22) disappeared after adjusting for neighborhood socioeconomic status (SES aHR, 0.98; 95% CI, 0.92-1.04).
- Southeast Asian individuals’ increased mortality risk (base aHR, 1.17; 95% CI, 1.03-1.34) was no longer significant after adjusting for insurance status (SES aHR, 1.10; 95% CI, 0.96-1.26).
IN PRACTICE:
“As clinicians and researchers, we should ask ourselves how to act on these findings,” wrote the authors of an invited commentary. “The effort cannot stop with data analysis alone, it must extend to actionable steps,” such as tailored efforts to deliver culturally competent care and patient navigation services to those with greatest need and at highest risk, they added.
SOURCE:
The study was led by Joshua Demb, PhD, University of California, San Diego. The study was published online on November 22 in JAMA Network Open (2024. doi: 10.1001/jamanetworkopen.2024.46820) with the invited commentary led by Clare E. Jacobson, MD, University of Michigan, Ann Arbor.
LIMITATIONS:
The study was limited by a relatively short follow-up time and small sample sizes in some racial and ethnic groups, potentially leading to imprecise aHR estimates. The generalizability of findings beyond California requires further investigation, and the ability to examine potential associations between neighborhood socioeconomic status and other factors was also constrained by small sample sizes.
DISCLOSURES:
The study received support from the National Cancer Institute at the National Institutes of Health. One study author reported receiving consulting fees from Guardant Health, InterVenn Biosciences, Geneoscopy, and Universal DX; research support from Freenome; and stock options from CellMax outside the submitted work. No other disclosures were reported by other authors of the study or the commentary.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
TOPLINE:
The largest racial and ethnic disparities in survival were linked to neighborhood socioeconomic status.
METHODOLOGY:
- US rates of EOCRC are increasing, with differences across racial and ethnic groups, but few studies have provided detailed risk estimates in the categories of Asian American and of Native Hawaiian or Other Pacific Islander, as well as the contribution of sociodemographic factors to these differences.
- A population-based cohort study analyzed California Cancer Registry data for 22,834 individuals aged 18-49 years diagnosed with EOCRC between January 2000 and December 2019.
- Researchers examined the association between mortality risk and racial and ethnic groups, including Asian American (15.5%, separated into seven subcategories), Hispanic (30.2%), Native Hawaiian or Other Pacific Islander (0.6%), non-Hispanic American Indian or Alaska Native (0.5%), non-Hispanic Black (7.3%), and non-Hispanic White (45.9%) individuals, with a median follow-up of 4.2 years.
- Statistical models measured baseline associations adjusting for clinical features and then tested for the contribution of socioeconomic factors together and separately, with adjustments for insurance status, neighborhood socioeconomic status, and more.
TAKEAWAY:
- Native Hawaiian or Other Pacific Islander individuals demonstrated the highest EOCRC mortality risk compared with non-Hispanic White individuals (socioeconomic status–adjusted HR [SES aHR], 1.34; 95% CI, 1.01-1.76).
- Non-Hispanic Black individuals showed a higher EOCRC mortality risk than non-Hispanic White individuals (SES aHR, 1.18; 95% CI, 1.07-1.29).
- Hispanic individuals’ higher EOCRC mortality (base aHR, 1.15; 95% CI, 1.08-1.22) disappeared after adjusting for neighborhood socioeconomic status (SES aHR, 0.98; 95% CI, 0.92-1.04).
- Southeast Asian individuals’ increased mortality risk (base aHR, 1.17; 95% CI, 1.03-1.34) was no longer significant after adjusting for insurance status (SES aHR, 1.10; 95% CI, 0.96-1.26).
IN PRACTICE:
“As clinicians and researchers, we should ask ourselves how to act on these findings,” wrote the authors of an invited commentary. “The effort cannot stop with data analysis alone, it must extend to actionable steps,” such as tailored efforts to deliver culturally competent care and patient navigation services to those with greatest need and at highest risk, they added.
SOURCE:
The study was led by Joshua Demb, PhD, University of California, San Diego. The study was published online on November 22 in JAMA Network Open (2024. doi: 10.1001/jamanetworkopen.2024.46820) with the invited commentary led by Clare E. Jacobson, MD, University of Michigan, Ann Arbor.
LIMITATIONS:
The study was limited by a relatively short follow-up time and small sample sizes in some racial and ethnic groups, potentially leading to imprecise aHR estimates. The generalizability of findings beyond California requires further investigation, and the ability to examine potential associations between neighborhood socioeconomic status and other factors was also constrained by small sample sizes.
DISCLOSURES:
The study received support from the National Cancer Institute at the National Institutes of Health. One study author reported receiving consulting fees from Guardant Health, InterVenn Biosciences, Geneoscopy, and Universal DX; research support from Freenome; and stock options from CellMax outside the submitted work. No other disclosures were reported by other authors of the study or the commentary.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
TOPLINE:
The largest racial and ethnic disparities in survival were linked to neighborhood socioeconomic status.
METHODOLOGY:
- US rates of EOCRC are increasing, with differences across racial and ethnic groups, but few studies have provided detailed risk estimates in the categories of Asian American and of Native Hawaiian or Other Pacific Islander, as well as the contribution of sociodemographic factors to these differences.
- A population-based cohort study analyzed California Cancer Registry data for 22,834 individuals aged 18-49 years diagnosed with EOCRC between January 2000 and December 2019.
- Researchers examined the association between mortality risk and racial and ethnic groups, including Asian American (15.5%, separated into seven subcategories), Hispanic (30.2%), Native Hawaiian or Other Pacific Islander (0.6%), non-Hispanic American Indian or Alaska Native (0.5%), non-Hispanic Black (7.3%), and non-Hispanic White (45.9%) individuals, with a median follow-up of 4.2 years.
- Statistical models measured baseline associations adjusting for clinical features and then tested for the contribution of socioeconomic factors together and separately, with adjustments for insurance status, neighborhood socioeconomic status, and more.
TAKEAWAY:
- Native Hawaiian or Other Pacific Islander individuals demonstrated the highest EOCRC mortality risk compared with non-Hispanic White individuals (socioeconomic status–adjusted HR [SES aHR], 1.34; 95% CI, 1.01-1.76).
- Non-Hispanic Black individuals showed a higher EOCRC mortality risk than non-Hispanic White individuals (SES aHR, 1.18; 95% CI, 1.07-1.29).
- Hispanic individuals’ higher EOCRC mortality (base aHR, 1.15; 95% CI, 1.08-1.22) disappeared after adjusting for neighborhood socioeconomic status (SES aHR, 0.98; 95% CI, 0.92-1.04).
- Southeast Asian individuals’ increased mortality risk (base aHR, 1.17; 95% CI, 1.03-1.34) was no longer significant after adjusting for insurance status (SES aHR, 1.10; 95% CI, 0.96-1.26).
IN PRACTICE:
“As clinicians and researchers, we should ask ourselves how to act on these findings,” wrote the authors of an invited commentary. “The effort cannot stop with data analysis alone, it must extend to actionable steps,” such as tailored efforts to deliver culturally competent care and patient navigation services to those with greatest need and at highest risk, they added.
SOURCE:
The study was led by Joshua Demb, PhD, University of California, San Diego. The study was published online on November 22 in JAMA Network Open (2024. doi: 10.1001/jamanetworkopen.2024.46820) with the invited commentary led by Clare E. Jacobson, MD, University of Michigan, Ann Arbor.
LIMITATIONS:
The study was limited by a relatively short follow-up time and small sample sizes in some racial and ethnic groups, potentially leading to imprecise aHR estimates. The generalizability of findings beyond California requires further investigation, and the ability to examine potential associations between neighborhood socioeconomic status and other factors was also constrained by small sample sizes.
DISCLOSURES:
The study received support from the National Cancer Institute at the National Institutes of Health. One study author reported receiving consulting fees from Guardant Health, InterVenn Biosciences, Geneoscopy, and Universal DX; research support from Freenome; and stock options from CellMax outside the submitted work. No other disclosures were reported by other authors of the study or the commentary.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
NCCN Expands Cancer Genetic Risk Assessment Guidelines
Additional cancer types were included in the title and content for both guidelines. Prostate cancer was added to Genetic/Familial High-Risk Assessment: Breast, Ovarian, Pancreatic, and Prostate, and endometrial and gastric cancer were added to Genetic/Familial High-Risk Assessment: Colorectal, Endometrial, and Gastric.
For these cancers, the expanded guidelines include information on when genetic testing is recommended and what type of testing may be best. These guidelines also detail the hereditary conditions and genetic mutations associated with elevated cancer risk and include appropriate “next steps” for individuals who have them, which may involve increased screening or prevention surgeries.
“These updates include the spectrum of genes associated with genetic syndromes, the range of risk associated with each pathogenic variant, the improvements in screening and prevention strategies, the role of genetic data to inform cancer treatment, and the expansion of the role of genetic counseling as this field moves forward,” Mary B. Daly, MD, PhD, with Fox Chase Cancer Center, Philadelphia, Pennsylvania, said in a news release. Daly chaired the panel that updated the breast, ovarian, pancreatic, and prostate cancer guidelines.
Oncologists should, for instance, ask patients about their family and personal history of cancer and known germline variants at time of initial diagnosis. With prostate cancer, if patients meet criteria for germline testing, multigene testing should include a host of variants, including BRCA1, BRCA2, ATM, PALB2, CHEK2, HOXB13, MLH1, MSH2, MSH6, and PMS2.
The updated guidelines on genetic risk assessment of colorectal, endometrial, and gastric cancer include new recommendations to consider for hereditary cancer screening in patients with newly diagnosed endometrial cancer, for evaluating and managing CDH1-associated gastric cancer risk, and for managing gastric cancer risk in patients with APC pathogenic variants.
For CDH1-associated gastric cancer, for instance, the guidelines recommend carriers be referred to institutions with expertise in managing risks for cancer associated with CDH1, “given the still limited understanding and rarity of this syndrome.”
“These expanded guidelines reflect the recommendations from leading experts on genetic testing based on the latest scientific research across the cancer spectrum, consolidated into two convenient resources,” said NCCN CEO Crystal S. Denlinger, MD, with Fox Chase Cancer Center, in a news release.
“This information is critical for guiding shared decision-making between health care providers and their patients, enhancing screening practices as appropriate, and potentially choosing options for prevention and targeted treatment choices. Genetic testing guidelines enable us to better care for people with cancer and their family members,” Denlinger added.
A version of this article first appeared on Medscape.com.
Additional cancer types were included in the title and content for both guidelines. Prostate cancer was added to Genetic/Familial High-Risk Assessment: Breast, Ovarian, Pancreatic, and Prostate, and endometrial and gastric cancer were added to Genetic/Familial High-Risk Assessment: Colorectal, Endometrial, and Gastric.
For these cancers, the expanded guidelines include information on when genetic testing is recommended and what type of testing may be best. These guidelines also detail the hereditary conditions and genetic mutations associated with elevated cancer risk and include appropriate “next steps” for individuals who have them, which may involve increased screening or prevention surgeries.
“These updates include the spectrum of genes associated with genetic syndromes, the range of risk associated with each pathogenic variant, the improvements in screening and prevention strategies, the role of genetic data to inform cancer treatment, and the expansion of the role of genetic counseling as this field moves forward,” Mary B. Daly, MD, PhD, with Fox Chase Cancer Center, Philadelphia, Pennsylvania, said in a news release. Daly chaired the panel that updated the breast, ovarian, pancreatic, and prostate cancer guidelines.
Oncologists should, for instance, ask patients about their family and personal history of cancer and known germline variants at time of initial diagnosis. With prostate cancer, if patients meet criteria for germline testing, multigene testing should include a host of variants, including BRCA1, BRCA2, ATM, PALB2, CHEK2, HOXB13, MLH1, MSH2, MSH6, and PMS2.
The updated guidelines on genetic risk assessment of colorectal, endometrial, and gastric cancer include new recommendations to consider for hereditary cancer screening in patients with newly diagnosed endometrial cancer, for evaluating and managing CDH1-associated gastric cancer risk, and for managing gastric cancer risk in patients with APC pathogenic variants.
For CDH1-associated gastric cancer, for instance, the guidelines recommend carriers be referred to institutions with expertise in managing risks for cancer associated with CDH1, “given the still limited understanding and rarity of this syndrome.”
“These expanded guidelines reflect the recommendations from leading experts on genetic testing based on the latest scientific research across the cancer spectrum, consolidated into two convenient resources,” said NCCN CEO Crystal S. Denlinger, MD, with Fox Chase Cancer Center, in a news release.
“This information is critical for guiding shared decision-making between health care providers and their patients, enhancing screening practices as appropriate, and potentially choosing options for prevention and targeted treatment choices. Genetic testing guidelines enable us to better care for people with cancer and their family members,” Denlinger added.
A version of this article first appeared on Medscape.com.
Additional cancer types were included in the title and content for both guidelines. Prostate cancer was added to Genetic/Familial High-Risk Assessment: Breast, Ovarian, Pancreatic, and Prostate, and endometrial and gastric cancer were added to Genetic/Familial High-Risk Assessment: Colorectal, Endometrial, and Gastric.
For these cancers, the expanded guidelines include information on when genetic testing is recommended and what type of testing may be best. These guidelines also detail the hereditary conditions and genetic mutations associated with elevated cancer risk and include appropriate “next steps” for individuals who have them, which may involve increased screening or prevention surgeries.
“These updates include the spectrum of genes associated with genetic syndromes, the range of risk associated with each pathogenic variant, the improvements in screening and prevention strategies, the role of genetic data to inform cancer treatment, and the expansion of the role of genetic counseling as this field moves forward,” Mary B. Daly, MD, PhD, with Fox Chase Cancer Center, Philadelphia, Pennsylvania, said in a news release. Daly chaired the panel that updated the breast, ovarian, pancreatic, and prostate cancer guidelines.
Oncologists should, for instance, ask patients about their family and personal history of cancer and known germline variants at time of initial diagnosis. With prostate cancer, if patients meet criteria for germline testing, multigene testing should include a host of variants, including BRCA1, BRCA2, ATM, PALB2, CHEK2, HOXB13, MLH1, MSH2, MSH6, and PMS2.
The updated guidelines on genetic risk assessment of colorectal, endometrial, and gastric cancer include new recommendations to consider for hereditary cancer screening in patients with newly diagnosed endometrial cancer, for evaluating and managing CDH1-associated gastric cancer risk, and for managing gastric cancer risk in patients with APC pathogenic variants.
For CDH1-associated gastric cancer, for instance, the guidelines recommend carriers be referred to institutions with expertise in managing risks for cancer associated with CDH1, “given the still limited understanding and rarity of this syndrome.”
“These expanded guidelines reflect the recommendations from leading experts on genetic testing based on the latest scientific research across the cancer spectrum, consolidated into two convenient resources,” said NCCN CEO Crystal S. Denlinger, MD, with Fox Chase Cancer Center, in a news release.
“This information is critical for guiding shared decision-making between health care providers and their patients, enhancing screening practices as appropriate, and potentially choosing options for prevention and targeted treatment choices. Genetic testing guidelines enable us to better care for people with cancer and their family members,” Denlinger added.
A version of this article first appeared on Medscape.com.
Recognizing Burnout: Why Physicians Often Miss the Signs in Themselves
Summary and Key Highlights
Summary: This section explores why physicians often struggle to recognize burnout within themselves, partly due to stigma and a tendency to focus on productivity over well-being. Dr. Tyra Fainstad shares personal experiences of burnout symptoms, emphasizing the importance of awareness and self-reflection. Recognizing and addressing burnout early can help physicians find healthier coping strategies, avoid productivity traps, and seek support.
Key Takeaways:
- Many physicians struggle to identify burnout due to stigma and self-blame.
- Awareness of burnout symptoms is essential for early intervention and healthy coping.
- Seeking support can prevent burnout from worsening and improve quality of life.
Our Editors Also Recommend:
Medscape Physician Burnout & Depression Report 2024: ‘We Have Much Work to Do’
Medscape Hospitalist Burnout & Depression Report 2024: Seeking Progress, Balance
Medscape Physician Lifestyle & Happiness Report 2024: The Ongoing Struggle for Balance
A Transformative Rx for Burnout, Grief, and Illness: Dance
Next Medscape Masters Event:
Stay at the forefront of obesity care. Register for exclusive insights and the latest treatment innovations.
Lotte Dyrbye, has disclosed the following relevant financial relationships: Co-inventor of the Well-being Index and its derivatives, which Mayo Clinic has licensed. Dyrbye receives royalties.
A version of this article first appeared on Medscape.com.
Summary and Key Highlights
Summary: This section explores why physicians often struggle to recognize burnout within themselves, partly due to stigma and a tendency to focus on productivity over well-being. Dr. Tyra Fainstad shares personal experiences of burnout symptoms, emphasizing the importance of awareness and self-reflection. Recognizing and addressing burnout early can help physicians find healthier coping strategies, avoid productivity traps, and seek support.
Key Takeaways:
- Many physicians struggle to identify burnout due to stigma and self-blame.
- Awareness of burnout symptoms is essential for early intervention and healthy coping.
- Seeking support can prevent burnout from worsening and improve quality of life.
Our Editors Also Recommend:
Medscape Physician Burnout & Depression Report 2024: ‘We Have Much Work to Do’
Medscape Hospitalist Burnout & Depression Report 2024: Seeking Progress, Balance
Medscape Physician Lifestyle & Happiness Report 2024: The Ongoing Struggle for Balance
A Transformative Rx for Burnout, Grief, and Illness: Dance
Next Medscape Masters Event:
Stay at the forefront of obesity care. Register for exclusive insights and the latest treatment innovations.
Lotte Dyrbye, has disclosed the following relevant financial relationships: Co-inventor of the Well-being Index and its derivatives, which Mayo Clinic has licensed. Dyrbye receives royalties.
A version of this article first appeared on Medscape.com.
Summary and Key Highlights
Summary: This section explores why physicians often struggle to recognize burnout within themselves, partly due to stigma and a tendency to focus on productivity over well-being. Dr. Tyra Fainstad shares personal experiences of burnout symptoms, emphasizing the importance of awareness and self-reflection. Recognizing and addressing burnout early can help physicians find healthier coping strategies, avoid productivity traps, and seek support.
Key Takeaways:
- Many physicians struggle to identify burnout due to stigma and self-blame.
- Awareness of burnout symptoms is essential for early intervention and healthy coping.
- Seeking support can prevent burnout from worsening and improve quality of life.
Our Editors Also Recommend:
Medscape Physician Burnout & Depression Report 2024: ‘We Have Much Work to Do’
Medscape Hospitalist Burnout & Depression Report 2024: Seeking Progress, Balance
Medscape Physician Lifestyle & Happiness Report 2024: The Ongoing Struggle for Balance
A Transformative Rx for Burnout, Grief, and Illness: Dance
Next Medscape Masters Event:
Stay at the forefront of obesity care. Register for exclusive insights and the latest treatment innovations.
Lotte Dyrbye, has disclosed the following relevant financial relationships: Co-inventor of the Well-being Index and its derivatives, which Mayo Clinic has licensed. Dyrbye receives royalties.
A version of this article first appeared on Medscape.com.
Breaking the Cycle: Why Self-Compassion Is Essential for Today’s Physicians
Summary and Key Highlights
Summary: Dr Tyra Fainstad explores the ingrained culture in medicine that encourages self-criticism, with many physicians feeling that they must be hard on themselves to succeed. Dr Fainstad challenges this belief, advocating for self-compassion as a healthier alternative. The evolving medical field now includes physicians who prioritize well-being without sacrificing quality of care, underscoring the importance of self-kindness for sustainable practice.
Key Takeaways:
- Many physicians believe that self-criticism is necessary for success, a mindset rooted in medical culture.
- Practicing self-compassion can improve long-term resilience and prevent burnout.
- The changing landscape of healthcare supports a more balanced approach to physician well-being.
Our Editors Also Recommend:
Medscape Physician Burnout & Depression Report 2024: ‘We Have Much Work to Do’
Medscape Hospitalist Burnout & Depression Report 2024: Seeking Progress, Balance
Medscape Physician Lifestyle & Happiness Report 2024: The Ongoing Struggle for Balance
A Transformative Rx for Burnout, Grief, and Illness: Dance
Next Medscape Masters Event:
Stay at the forefront of obesity care. Register for exclusive insights and the latest treatment innovations.
Lotte Dyrbye, has disclosed the following relevant financial relationships: Co-inventor of the Well-being Index and its derivatives, which Mayo Clinic has licensed. Dyrbye receives royalties.
A version of this article first appeared on Medscape.com.
Summary and Key Highlights
Summary: Dr Tyra Fainstad explores the ingrained culture in medicine that encourages self-criticism, with many physicians feeling that they must be hard on themselves to succeed. Dr Fainstad challenges this belief, advocating for self-compassion as a healthier alternative. The evolving medical field now includes physicians who prioritize well-being without sacrificing quality of care, underscoring the importance of self-kindness for sustainable practice.
Key Takeaways:
- Many physicians believe that self-criticism is necessary for success, a mindset rooted in medical culture.
- Practicing self-compassion can improve long-term resilience and prevent burnout.
- The changing landscape of healthcare supports a more balanced approach to physician well-being.
Our Editors Also Recommend:
Medscape Physician Burnout & Depression Report 2024: ‘We Have Much Work to Do’
Medscape Hospitalist Burnout & Depression Report 2024: Seeking Progress, Balance
Medscape Physician Lifestyle & Happiness Report 2024: The Ongoing Struggle for Balance
A Transformative Rx for Burnout, Grief, and Illness: Dance
Next Medscape Masters Event:
Stay at the forefront of obesity care. Register for exclusive insights and the latest treatment innovations.
Lotte Dyrbye, has disclosed the following relevant financial relationships: Co-inventor of the Well-being Index and its derivatives, which Mayo Clinic has licensed. Dyrbye receives royalties.
A version of this article first appeared on Medscape.com.
Summary and Key Highlights
Summary: Dr Tyra Fainstad explores the ingrained culture in medicine that encourages self-criticism, with many physicians feeling that they must be hard on themselves to succeed. Dr Fainstad challenges this belief, advocating for self-compassion as a healthier alternative. The evolving medical field now includes physicians who prioritize well-being without sacrificing quality of care, underscoring the importance of self-kindness for sustainable practice.
Key Takeaways:
- Many physicians believe that self-criticism is necessary for success, a mindset rooted in medical culture.
- Practicing self-compassion can improve long-term resilience and prevent burnout.
- The changing landscape of healthcare supports a more balanced approach to physician well-being.
Our Editors Also Recommend:
Medscape Physician Burnout & Depression Report 2024: ‘We Have Much Work to Do’
Medscape Hospitalist Burnout & Depression Report 2024: Seeking Progress, Balance
Medscape Physician Lifestyle & Happiness Report 2024: The Ongoing Struggle for Balance
A Transformative Rx for Burnout, Grief, and Illness: Dance
Next Medscape Masters Event:
Stay at the forefront of obesity care. Register for exclusive insights and the latest treatment innovations.
Lotte Dyrbye, has disclosed the following relevant financial relationships: Co-inventor of the Well-being Index and its derivatives, which Mayo Clinic has licensed. Dyrbye receives royalties.
A version of this article first appeared on Medscape.com.
Finding Fulfillment Beyond Metrics: A Physician’s Path to Lasting Well-Being
Summary and Key Highlights
Summary: Dr Tyra Fainstad shares her personal experience with burnout and the journey to recovery through coaching and self-compassion. She describes the pressures of seeking validation through external achievements, which ultimately led to a crisis in self-worth after medical training. Through coaching, she learned to cultivate a sense of internal fulfillment, reconnecting with her passion for medicine and achieving a healthier balance.
Key Takeaways:
- Relying solely on external validation can deepen burnout and affect well-being.
- Coaching empowers physicians to develop self-compassion and sustainable coping strategies.
- Shifting from external to internal validation strengthens long-term fulfillment and job satisfaction.
Our Editors Also Recommend:
Medscape Physician Burnout & Depression Report 2024: ‘We Have Much Work to Do’
Medscape Hospitalist Burnout & Depression Report 2024: Seeking Progress, Balance
Medscape Physician Lifestyle & Happiness Report 2024: The Ongoing Struggle for Balance
A Transformative Rx for Burnout, Grief, and Illness: Dance
Next Medscape Masters Event:
Stay at the forefront of obesity care. Register for exclusive insights and the latest treatment innovations.
A version of this article first appeared on Medscape.com.
Summary and Key Highlights
Summary: Dr Tyra Fainstad shares her personal experience with burnout and the journey to recovery through coaching and self-compassion. She describes the pressures of seeking validation through external achievements, which ultimately led to a crisis in self-worth after medical training. Through coaching, she learned to cultivate a sense of internal fulfillment, reconnecting with her passion for medicine and achieving a healthier balance.
Key Takeaways:
- Relying solely on external validation can deepen burnout and affect well-being.
- Coaching empowers physicians to develop self-compassion and sustainable coping strategies.
- Shifting from external to internal validation strengthens long-term fulfillment and job satisfaction.
Our Editors Also Recommend:
Medscape Physician Burnout & Depression Report 2024: ‘We Have Much Work to Do’
Medscape Hospitalist Burnout & Depression Report 2024: Seeking Progress, Balance
Medscape Physician Lifestyle & Happiness Report 2024: The Ongoing Struggle for Balance
A Transformative Rx for Burnout, Grief, and Illness: Dance
Next Medscape Masters Event:
Stay at the forefront of obesity care. Register for exclusive insights and the latest treatment innovations.
A version of this article first appeared on Medscape.com.
Summary and Key Highlights
Summary: Dr Tyra Fainstad shares her personal experience with burnout and the journey to recovery through coaching and self-compassion. She describes the pressures of seeking validation through external achievements, which ultimately led to a crisis in self-worth after medical training. Through coaching, she learned to cultivate a sense of internal fulfillment, reconnecting with her passion for medicine and achieving a healthier balance.
Key Takeaways:
- Relying solely on external validation can deepen burnout and affect well-being.
- Coaching empowers physicians to develop self-compassion and sustainable coping strategies.
- Shifting from external to internal validation strengthens long-term fulfillment and job satisfaction.
Our Editors Also Recommend:
Medscape Physician Burnout & Depression Report 2024: ‘We Have Much Work to Do’
Medscape Hospitalist Burnout & Depression Report 2024: Seeking Progress, Balance
Medscape Physician Lifestyle & Happiness Report 2024: The Ongoing Struggle for Balance
A Transformative Rx for Burnout, Grief, and Illness: Dance
Next Medscape Masters Event:
Stay at the forefront of obesity care. Register for exclusive insights and the latest treatment innovations.
A version of this article first appeared on Medscape.com.
Negotiating for a Successful Career in Private Practice Gastroenterology
In this video, Aja McCutchen, MD, of Atlanta Gastroenterology Associates in Georgia, discusses why she chose to enter private practice gastroenterology, and identifies some key considerations on the road to a successful career.
Dr. McCutchen is vice chair of the AGA Research Foundation. She has no financial conflicts relative to the topics in this video.
In this video, Aja McCutchen, MD, of Atlanta Gastroenterology Associates in Georgia, discusses why she chose to enter private practice gastroenterology, and identifies some key considerations on the road to a successful career.
Dr. McCutchen is vice chair of the AGA Research Foundation. She has no financial conflicts relative to the topics in this video.
In this video, Aja McCutchen, MD, of Atlanta Gastroenterology Associates in Georgia, discusses why she chose to enter private practice gastroenterology, and identifies some key considerations on the road to a successful career.
Dr. McCutchen is vice chair of the AGA Research Foundation. She has no financial conflicts relative to the topics in this video.
Navigating the Physician Mortgage Loan
Navigating the path to homeownership can be particularly challenging for physicians, who often face a unique set of financial circumstances. With substantial student loan debt, limited savings, and a delayed peak earning potential, traditional mortgage options may seem out of reach.
Enter physician mortgage loans—specialized financing designed specifically for medical professionals. These loans offer tailored solutions that address the common barriers faced by doctors, making it easier for them to achieve their homeownership goals. In this article, we’ll
What Is a Physician Mortgage Loan?
A physician mortgage loan, also known as a ‘doctor loan,’ is a specialized mortgage product designed for a specific group of qualifying medical professionals. These loans are particularly attractive to new doctors who may have substantial student loan debt, limited savings, and an income that is expected to increase significantly over time. As unique portfolio loans, physician mortgage products can vary considerably between lending institutions. However, a common feature is that they typically require little to no down payment and do not require private mortgage insurance (PMI).
Beyond the common features, loan options and qualifying parameters can vary significantly from one institution to another. Therefore, it’s important to start gathering information as early as possible, giving you ample time to evaluate which institution and loan option best meet your needs.
How Do I Know if I Am Eligible for a Physician Mortgage Loan?
Physician loans are typically offered to MDs, DOs, DDSs, DMDs, and ODs, though some institutions expand this list to include DPMs, PAs, CRNAs, NPs, PharmDs, and DVMs. Additionally, most of these loan products are available to residents, fellows, and attending or practicing physicians.
How Do I Know What Physician Mortgage Loan Is Best for Me?
When selecting the optimal physician loan option for your home purchase, consider several important metrics:
- Duration of Stay: Consider how long you expect to live in the home. If you’re in a lengthy residency or fellowship program, or if you plan to move for a new job soon after, a 30-year fixed-rate loan might not be ideal. Instead, evaluate loan options that match your anticipated duration of stay. For example, a 5-year or 7-year ARM (adjustable rate mortgage) could offer a lower interest rate and reduced monthly payments for the initial fixed period, which aligns with your shorter-term stay. This can result in substantial savings if you do not plan to stay in the home for the full term of a traditional mortgage.
- Underwriting Guidelines: Each lender has different underwriting standards and qualifying criteria, so it’s essential to understand these differences. For instance, some lenders may have higher minimum credit score requirements or stricter debt-to-income (DTI) ratio limits. Others might require a larger down payment or have different rules regarding student loan payments and closing costs. Flexibility in these guidelines can impact your ability to qualify for a loan and the terms you receive. For example, some lenders may allow you to include student loan payments at a lower percentage of your income, which could improve your DTI ratio and help you secure a better loan offer.
- Closing Timing: The timing of your home closing relative to your job start date can be crucial, especially if you’re relocating. Some lenders permit closing up to 60-90 days before your job begins, while others offer up to 120 days. If you need to relocate your family before starting your new position, having the ability to close earlier can provide you with more flexibility in finding and moving into a home. This additional time can ease the transition and allow you to settle in before your new job starts.
Given the wide range of options and standards, it’s important to strategically identify which factors are most meaningful to you. Beyond interest rates, consider the overall cost of the loan, the flexibility of terms, and how well the loan aligns with your financial goals and career plans. For example, if you value lower monthly payments over a longer period or need to accommodate significant student loan debt, ensure that the loan program you choose aligns with these priorities.
What Attributes Should I Look for in My Loan Officer?
When interviewing multiple loan officers for your upcoming loan needs, it’s essential to use the right metrics—beyond just the interest rate—to determine the best fit for your situation. Some critical factors to consider include the loan officer’s experience working with physicians, that person’s availability and responsiveness, and the potential for building a long-term relationship.
As in most professions, experience is paramount—it’s something that cannot be taught or simply read in a training manual. Physicians, especially those in training or just stepping into an attending role, often have unique financial situations. This makes it crucial to work with a loan officer who has extensive experience serving physician clients. An experienced loan officer will better understand how to customize a loan solution that aligns with your specific needs, resulting in a much more tailored and meaningful mortgage. There is no one-size-fits-all mortgage. You are unique, and your loan officer should be crafting a mortgage solution that reflects your individuality and financial circumstances.
In my opinion, availability and responsiveness are among the most critical attributes your chosen loan officer should possess. Interestingly, this factor doesn’t directly influence the ‘cost’ of your loan but can significantly impact your experience. As a physician with a demanding schedule, it’s unrealistic to expect that all communication will take place strictly during business hours—this is true for any consumer. Pay close attention to how promptly loan officers respond during your initial interactions, and evaluate how thoroughly they explain loan terms, out-of-pocket costs, and the overall loan process. Your loan officer should be your trusted guide as you navigate through the complexities of the loan process, so setting yourself up for success starts with choosing someone who meets your expectations in this regard.
It’s crucial to build a good rapport with the loan officer you choose, as this likely won’t be the last mortgage or financial need you encounter in your lifetime. Establishing a personal connection with your loan officer fosters a level of trust that is invaluable. Whether you’re considering refinancing your current mortgage or exploring additional loan products for other financial needs, having a trusted advisor you can rely on as a financial resource is immensely beneficial as you progress in your career. A strong, long-standing relationship with a loan officer ensures you receive reliable and sound financial advice tailored to your unique needs.
Additional Things to Consider if You Are a First-Time Home Buyer
Interview multiple lenders and make those conversations about more than just interest rates. This approach will help you gauge their knowledge of physician mortgage loans while allowing you to assess who might be the best fit for you in terms of compatibility. Relying solely on an email blast to inquire about rates could easily lead you to a subpar lender and result in an unfavorable experience.
Don’t be afraid to ask a lot of questions! As a first-time home buyer, it’s natural to feel a bit overwhelmed by the process—it can seem daunting if you’ve never been through it before. That’s why it’s crucial to ask any questions that come to mind and to work with a lender who is willing to take the time to answer them while educating you throughout the home-buying journey. With a trusted guide and the right education, the process will feel far less overwhelming, leading to a smoother and more positive experience from start to finish.
In conclusion, choosing the right lender for a physician mortgage loan is a crucial step in securing your financial future and achieving homeownership. By thoroughly evaluating interest rates, down payment requirements, loan terms, and other key metrics, you can find a lender that offers competitive rates and favorable terms tailored to your unique needs. Consider factors such as customer service, closing costs, and the lender’s experience with physician loans to ensure a smooth and supportive mortgage process. By taking the time to compare options and select the best fit for your financial situation, you can confidently move forward in your home-buying journey and set the stage for a successful and fulfilling homeownership experience.
Mr. Kelley is vice president of mortgage lending and a physician mortgage specialist at Arvest Bank in Overland Park, Kansas.
Navigating the path to homeownership can be particularly challenging for physicians, who often face a unique set of financial circumstances. With substantial student loan debt, limited savings, and a delayed peak earning potential, traditional mortgage options may seem out of reach.
Enter physician mortgage loans—specialized financing designed specifically for medical professionals. These loans offer tailored solutions that address the common barriers faced by doctors, making it easier for them to achieve their homeownership goals. In this article, we’ll
What Is a Physician Mortgage Loan?
A physician mortgage loan, also known as a ‘doctor loan,’ is a specialized mortgage product designed for a specific group of qualifying medical professionals. These loans are particularly attractive to new doctors who may have substantial student loan debt, limited savings, and an income that is expected to increase significantly over time. As unique portfolio loans, physician mortgage products can vary considerably between lending institutions. However, a common feature is that they typically require little to no down payment and do not require private mortgage insurance (PMI).
Beyond the common features, loan options and qualifying parameters can vary significantly from one institution to another. Therefore, it’s important to start gathering information as early as possible, giving you ample time to evaluate which institution and loan option best meet your needs.
How Do I Know if I Am Eligible for a Physician Mortgage Loan?
Physician loans are typically offered to MDs, DOs, DDSs, DMDs, and ODs, though some institutions expand this list to include DPMs, PAs, CRNAs, NPs, PharmDs, and DVMs. Additionally, most of these loan products are available to residents, fellows, and attending or practicing physicians.
How Do I Know What Physician Mortgage Loan Is Best for Me?
When selecting the optimal physician loan option for your home purchase, consider several important metrics:
- Duration of Stay: Consider how long you expect to live in the home. If you’re in a lengthy residency or fellowship program, or if you plan to move for a new job soon after, a 30-year fixed-rate loan might not be ideal. Instead, evaluate loan options that match your anticipated duration of stay. For example, a 5-year or 7-year ARM (adjustable rate mortgage) could offer a lower interest rate and reduced monthly payments for the initial fixed period, which aligns with your shorter-term stay. This can result in substantial savings if you do not plan to stay in the home for the full term of a traditional mortgage.
- Underwriting Guidelines: Each lender has different underwriting standards and qualifying criteria, so it’s essential to understand these differences. For instance, some lenders may have higher minimum credit score requirements or stricter debt-to-income (DTI) ratio limits. Others might require a larger down payment or have different rules regarding student loan payments and closing costs. Flexibility in these guidelines can impact your ability to qualify for a loan and the terms you receive. For example, some lenders may allow you to include student loan payments at a lower percentage of your income, which could improve your DTI ratio and help you secure a better loan offer.
- Closing Timing: The timing of your home closing relative to your job start date can be crucial, especially if you’re relocating. Some lenders permit closing up to 60-90 days before your job begins, while others offer up to 120 days. If you need to relocate your family before starting your new position, having the ability to close earlier can provide you with more flexibility in finding and moving into a home. This additional time can ease the transition and allow you to settle in before your new job starts.
Given the wide range of options and standards, it’s important to strategically identify which factors are most meaningful to you. Beyond interest rates, consider the overall cost of the loan, the flexibility of terms, and how well the loan aligns with your financial goals and career plans. For example, if you value lower monthly payments over a longer period or need to accommodate significant student loan debt, ensure that the loan program you choose aligns with these priorities.
What Attributes Should I Look for in My Loan Officer?
When interviewing multiple loan officers for your upcoming loan needs, it’s essential to use the right metrics—beyond just the interest rate—to determine the best fit for your situation. Some critical factors to consider include the loan officer’s experience working with physicians, that person’s availability and responsiveness, and the potential for building a long-term relationship.
As in most professions, experience is paramount—it’s something that cannot be taught or simply read in a training manual. Physicians, especially those in training or just stepping into an attending role, often have unique financial situations. This makes it crucial to work with a loan officer who has extensive experience serving physician clients. An experienced loan officer will better understand how to customize a loan solution that aligns with your specific needs, resulting in a much more tailored and meaningful mortgage. There is no one-size-fits-all mortgage. You are unique, and your loan officer should be crafting a mortgage solution that reflects your individuality and financial circumstances.
In my opinion, availability and responsiveness are among the most critical attributes your chosen loan officer should possess. Interestingly, this factor doesn’t directly influence the ‘cost’ of your loan but can significantly impact your experience. As a physician with a demanding schedule, it’s unrealistic to expect that all communication will take place strictly during business hours—this is true for any consumer. Pay close attention to how promptly loan officers respond during your initial interactions, and evaluate how thoroughly they explain loan terms, out-of-pocket costs, and the overall loan process. Your loan officer should be your trusted guide as you navigate through the complexities of the loan process, so setting yourself up for success starts with choosing someone who meets your expectations in this regard.
It’s crucial to build a good rapport with the loan officer you choose, as this likely won’t be the last mortgage or financial need you encounter in your lifetime. Establishing a personal connection with your loan officer fosters a level of trust that is invaluable. Whether you’re considering refinancing your current mortgage or exploring additional loan products for other financial needs, having a trusted advisor you can rely on as a financial resource is immensely beneficial as you progress in your career. A strong, long-standing relationship with a loan officer ensures you receive reliable and sound financial advice tailored to your unique needs.
Additional Things to Consider if You Are a First-Time Home Buyer
Interview multiple lenders and make those conversations about more than just interest rates. This approach will help you gauge their knowledge of physician mortgage loans while allowing you to assess who might be the best fit for you in terms of compatibility. Relying solely on an email blast to inquire about rates could easily lead you to a subpar lender and result in an unfavorable experience.
Don’t be afraid to ask a lot of questions! As a first-time home buyer, it’s natural to feel a bit overwhelmed by the process—it can seem daunting if you’ve never been through it before. That’s why it’s crucial to ask any questions that come to mind and to work with a lender who is willing to take the time to answer them while educating you throughout the home-buying journey. With a trusted guide and the right education, the process will feel far less overwhelming, leading to a smoother and more positive experience from start to finish.
In conclusion, choosing the right lender for a physician mortgage loan is a crucial step in securing your financial future and achieving homeownership. By thoroughly evaluating interest rates, down payment requirements, loan terms, and other key metrics, you can find a lender that offers competitive rates and favorable terms tailored to your unique needs. Consider factors such as customer service, closing costs, and the lender’s experience with physician loans to ensure a smooth and supportive mortgage process. By taking the time to compare options and select the best fit for your financial situation, you can confidently move forward in your home-buying journey and set the stage for a successful and fulfilling homeownership experience.
Mr. Kelley is vice president of mortgage lending and a physician mortgage specialist at Arvest Bank in Overland Park, Kansas.
Navigating the path to homeownership can be particularly challenging for physicians, who often face a unique set of financial circumstances. With substantial student loan debt, limited savings, and a delayed peak earning potential, traditional mortgage options may seem out of reach.
Enter physician mortgage loans—specialized financing designed specifically for medical professionals. These loans offer tailored solutions that address the common barriers faced by doctors, making it easier for them to achieve their homeownership goals. In this article, we’ll
What Is a Physician Mortgage Loan?
A physician mortgage loan, also known as a ‘doctor loan,’ is a specialized mortgage product designed for a specific group of qualifying medical professionals. These loans are particularly attractive to new doctors who may have substantial student loan debt, limited savings, and an income that is expected to increase significantly over time. As unique portfolio loans, physician mortgage products can vary considerably between lending institutions. However, a common feature is that they typically require little to no down payment and do not require private mortgage insurance (PMI).
Beyond the common features, loan options and qualifying parameters can vary significantly from one institution to another. Therefore, it’s important to start gathering information as early as possible, giving you ample time to evaluate which institution and loan option best meet your needs.
How Do I Know if I Am Eligible for a Physician Mortgage Loan?
Physician loans are typically offered to MDs, DOs, DDSs, DMDs, and ODs, though some institutions expand this list to include DPMs, PAs, CRNAs, NPs, PharmDs, and DVMs. Additionally, most of these loan products are available to residents, fellows, and attending or practicing physicians.
How Do I Know What Physician Mortgage Loan Is Best for Me?
When selecting the optimal physician loan option for your home purchase, consider several important metrics:
- Duration of Stay: Consider how long you expect to live in the home. If you’re in a lengthy residency or fellowship program, or if you plan to move for a new job soon after, a 30-year fixed-rate loan might not be ideal. Instead, evaluate loan options that match your anticipated duration of stay. For example, a 5-year or 7-year ARM (adjustable rate mortgage) could offer a lower interest rate and reduced monthly payments for the initial fixed period, which aligns with your shorter-term stay. This can result in substantial savings if you do not plan to stay in the home for the full term of a traditional mortgage.
- Underwriting Guidelines: Each lender has different underwriting standards and qualifying criteria, so it’s essential to understand these differences. For instance, some lenders may have higher minimum credit score requirements or stricter debt-to-income (DTI) ratio limits. Others might require a larger down payment or have different rules regarding student loan payments and closing costs. Flexibility in these guidelines can impact your ability to qualify for a loan and the terms you receive. For example, some lenders may allow you to include student loan payments at a lower percentage of your income, which could improve your DTI ratio and help you secure a better loan offer.
- Closing Timing: The timing of your home closing relative to your job start date can be crucial, especially if you’re relocating. Some lenders permit closing up to 60-90 days before your job begins, while others offer up to 120 days. If you need to relocate your family before starting your new position, having the ability to close earlier can provide you with more flexibility in finding and moving into a home. This additional time can ease the transition and allow you to settle in before your new job starts.
Given the wide range of options and standards, it’s important to strategically identify which factors are most meaningful to you. Beyond interest rates, consider the overall cost of the loan, the flexibility of terms, and how well the loan aligns with your financial goals and career plans. For example, if you value lower monthly payments over a longer period or need to accommodate significant student loan debt, ensure that the loan program you choose aligns with these priorities.
What Attributes Should I Look for in My Loan Officer?
When interviewing multiple loan officers for your upcoming loan needs, it’s essential to use the right metrics—beyond just the interest rate—to determine the best fit for your situation. Some critical factors to consider include the loan officer’s experience working with physicians, that person’s availability and responsiveness, and the potential for building a long-term relationship.
As in most professions, experience is paramount—it’s something that cannot be taught or simply read in a training manual. Physicians, especially those in training or just stepping into an attending role, often have unique financial situations. This makes it crucial to work with a loan officer who has extensive experience serving physician clients. An experienced loan officer will better understand how to customize a loan solution that aligns with your specific needs, resulting in a much more tailored and meaningful mortgage. There is no one-size-fits-all mortgage. You are unique, and your loan officer should be crafting a mortgage solution that reflects your individuality and financial circumstances.
In my opinion, availability and responsiveness are among the most critical attributes your chosen loan officer should possess. Interestingly, this factor doesn’t directly influence the ‘cost’ of your loan but can significantly impact your experience. As a physician with a demanding schedule, it’s unrealistic to expect that all communication will take place strictly during business hours—this is true for any consumer. Pay close attention to how promptly loan officers respond during your initial interactions, and evaluate how thoroughly they explain loan terms, out-of-pocket costs, and the overall loan process. Your loan officer should be your trusted guide as you navigate through the complexities of the loan process, so setting yourself up for success starts with choosing someone who meets your expectations in this regard.
It’s crucial to build a good rapport with the loan officer you choose, as this likely won’t be the last mortgage or financial need you encounter in your lifetime. Establishing a personal connection with your loan officer fosters a level of trust that is invaluable. Whether you’re considering refinancing your current mortgage or exploring additional loan products for other financial needs, having a trusted advisor you can rely on as a financial resource is immensely beneficial as you progress in your career. A strong, long-standing relationship with a loan officer ensures you receive reliable and sound financial advice tailored to your unique needs.
Additional Things to Consider if You Are a First-Time Home Buyer
Interview multiple lenders and make those conversations about more than just interest rates. This approach will help you gauge their knowledge of physician mortgage loans while allowing you to assess who might be the best fit for you in terms of compatibility. Relying solely on an email blast to inquire about rates could easily lead you to a subpar lender and result in an unfavorable experience.
Don’t be afraid to ask a lot of questions! As a first-time home buyer, it’s natural to feel a bit overwhelmed by the process—it can seem daunting if you’ve never been through it before. That’s why it’s crucial to ask any questions that come to mind and to work with a lender who is willing to take the time to answer them while educating you throughout the home-buying journey. With a trusted guide and the right education, the process will feel far less overwhelming, leading to a smoother and more positive experience from start to finish.
In conclusion, choosing the right lender for a physician mortgage loan is a crucial step in securing your financial future and achieving homeownership. By thoroughly evaluating interest rates, down payment requirements, loan terms, and other key metrics, you can find a lender that offers competitive rates and favorable terms tailored to your unique needs. Consider factors such as customer service, closing costs, and the lender’s experience with physician loans to ensure a smooth and supportive mortgage process. By taking the time to compare options and select the best fit for your financial situation, you can confidently move forward in your home-buying journey and set the stage for a successful and fulfilling homeownership experience.
Mr. Kelley is vice president of mortgage lending and a physician mortgage specialist at Arvest Bank in Overland Park, Kansas.
Lessons Learned: What Docs Wish Med Students Knew
Despite 4 years of med school and 3-7 years in residency, when you enter the workforce as a doctor, you still have much to learn. There is only so much your professors and attending physicians can pack in. Going forward, you’ll continue to learn on the job and via continuing education.
Some of that lifelong learning will involve soft skills — how to compassionately work with your patients and their families, for instance. Other lessons will get down to the business of medicine — the paperwork, the work/life balance, and the moral dilemmas you never saw coming. And still others will involve learning how to take care of yourself in the middle of seemingly endless hours on the job.
“We all have things we wish we had known upon starting our careers,” said Daniel Opris, MD, a primary care physician at Ohio-based Executive Medical Centers.
We tapped several veteran physicians and an educator to learn what they wish med students knew as they enter the workforce. We’ve compiled them here to give you a head start on the lessons ahead.
You Won’t Know Everything, and That’s Okay
When you go through your medical training, it can feel overwhelming to absorb all the knowledge your professors and attendings impart. The bottom line, said Shoshana Ungerleider, MD, an internal medicine specialist, is that you shouldn’t worry about it.
David Lenihan, PhD, CEO at Ponce Health Sciences University, agrees. “What we’ve lost in recent years, is the ability to apply your skill set and say, ‘let me take a day and get back to you,’” he said. “Doctors love it when you do that because it shows you can pitch in and work as part of a team.”
Medicine is a collaborative field, said Ungerleider, and learning from others, whether peers, nurses, or specialists, is “not a weakness.” She recommends embracing uncertainty and getting comfortable with the unknown.
You’ll Take Your Work Home With You
Doctors enter the field because they care about their patients and want to help. Successful outcomes are never guaranteed, however, no matter how much you try. The result? Some days you’ll bring home those upsetting and haunting cases, said Lenihan.
“We often believe that we should leave our work at the office, but sometimes you need to bring it home and think it through,” he said. “It can’t overwhelm you, but you should digest what happened.”
When you do, said Lenihan, you’ll come out the other end more empathetic and that helps the healthcare system in the long run. “The more you reflect on your day, the better you’ll get at reading the room and treating your patients.”
Drew Remignanti, MD, a retired emergency medicine physician from New Hampshire, agrees, but puts a different spin on bringing work home.
“We revisit the patient care decisions we made, second-guess ourselves, and worry about our patients’ welfare and outcomes,” he said. “I think it can only lead to better outcomes down the road, however, if you learn from that bad decision, preventing you from committing a similar mistake.”
Burnout Is Real — Make Self-Care a Priority
As a retired physician who spent 40 years practicing medicine, Remignanti experienced the evolution of healthcare as it has become what he calls a “consumer-provider” model. “Productivity didn’t use to be part of the equation, but now it’s the focus,” he said.
The result is burnout, a very real threat to incoming physicians. Remignanti holds that if you are aware of the risk, you can resist it. Part of avoiding burnout is self-care, according to Ungerleider. “The sooner you prioritize your mental, emotional, and physical well-being, the better,” she said. “Balancing work and life may feel impossible at times but taking care of yourself is essential to being a better physician in the long run.”
That means carving out time for exercise, hobbies, and connections outside of the medical field. It also means making sleep and nutrition a priority, even when that feels hard to accomplish. “If you don’t take care of yourself, you can’t take care of others,” added Opris. “It’s so common to lose yourself in your career, but you need to hold onto your physical, emotional, and spiritual self.”
Avoid Relying Too Heavily on Tech
Technology is invading every aspect of our lives — often for the greater good — but in medicine, it’s important to always return to your core knowledge above all else. Case in point, said Opris, the UpToDate app. While it can be a useful tool, it’s important not to become too reliant on it. “UpToDate is expert opinion-based guidance, and it’s a fantastic resource,” he said. “But you need to use your references and knowledge in every case.”
It’s key to remember that every patient is different, and their case may not line up perfectly with the guidance presented in UpToDate or other technology source. Piggybacking on that, Ungerleider added that it’s important to remember medicine is about people, not just conditions.
“It’s easy to focus on mastering the science, but the real art of medicine comes from seeing the whole person in front of you,” she said. “Your patients are more than their diagnoses — they come with complex emotions, life stories, and needs.” Being compassionate, listening carefully, and building trust should match up to your clinical skills.
Partner With Your Patients, Even When It’s Difficult
Perhaps the most difficult lesson of all is remembering that your patients may not always agree with your recommendations and choose to ignore them. After all your years spent learning, there may be times when it feels your education is going to waste.
“Remember that the landscape today is so varied, and that bleeds into medicine,” said Opris. “We go into cases with our own biases, and it’s important to take a step back to reset, every time.”
Opris reminds himself of Sir William Osler’s famous essay, “Aequanimitas,” in which he tells graduating medical students to practice with “coolness and presence of mind under all circumstances.”
Remignanti offers this advice: “Physicians need to be able to partner with their patients and jointly decide which courses of action are most effective,” he said. “Cling to the idea that you are forming a partnership with your patients — what can we together determine is the best course?”
At the same time, the path the patient chooses may not be what’s best for them — potentially even leading to a poor outcome.
“You may not always understand their choices,” said Opris. “But they do have a choice. Think of yourself almost like a consultant.”
A version of this article first appeared on Medscape.com.
Despite 4 years of med school and 3-7 years in residency, when you enter the workforce as a doctor, you still have much to learn. There is only so much your professors and attending physicians can pack in. Going forward, you’ll continue to learn on the job and via continuing education.
Some of that lifelong learning will involve soft skills — how to compassionately work with your patients and their families, for instance. Other lessons will get down to the business of medicine — the paperwork, the work/life balance, and the moral dilemmas you never saw coming. And still others will involve learning how to take care of yourself in the middle of seemingly endless hours on the job.
“We all have things we wish we had known upon starting our careers,” said Daniel Opris, MD, a primary care physician at Ohio-based Executive Medical Centers.
We tapped several veteran physicians and an educator to learn what they wish med students knew as they enter the workforce. We’ve compiled them here to give you a head start on the lessons ahead.
You Won’t Know Everything, and That’s Okay
When you go through your medical training, it can feel overwhelming to absorb all the knowledge your professors and attendings impart. The bottom line, said Shoshana Ungerleider, MD, an internal medicine specialist, is that you shouldn’t worry about it.
David Lenihan, PhD, CEO at Ponce Health Sciences University, agrees. “What we’ve lost in recent years, is the ability to apply your skill set and say, ‘let me take a day and get back to you,’” he said. “Doctors love it when you do that because it shows you can pitch in and work as part of a team.”
Medicine is a collaborative field, said Ungerleider, and learning from others, whether peers, nurses, or specialists, is “not a weakness.” She recommends embracing uncertainty and getting comfortable with the unknown.
You’ll Take Your Work Home With You
Doctors enter the field because they care about their patients and want to help. Successful outcomes are never guaranteed, however, no matter how much you try. The result? Some days you’ll bring home those upsetting and haunting cases, said Lenihan.
“We often believe that we should leave our work at the office, but sometimes you need to bring it home and think it through,” he said. “It can’t overwhelm you, but you should digest what happened.”
When you do, said Lenihan, you’ll come out the other end more empathetic and that helps the healthcare system in the long run. “The more you reflect on your day, the better you’ll get at reading the room and treating your patients.”
Drew Remignanti, MD, a retired emergency medicine physician from New Hampshire, agrees, but puts a different spin on bringing work home.
“We revisit the patient care decisions we made, second-guess ourselves, and worry about our patients’ welfare and outcomes,” he said. “I think it can only lead to better outcomes down the road, however, if you learn from that bad decision, preventing you from committing a similar mistake.”
Burnout Is Real — Make Self-Care a Priority
As a retired physician who spent 40 years practicing medicine, Remignanti experienced the evolution of healthcare as it has become what he calls a “consumer-provider” model. “Productivity didn’t use to be part of the equation, but now it’s the focus,” he said.
The result is burnout, a very real threat to incoming physicians. Remignanti holds that if you are aware of the risk, you can resist it. Part of avoiding burnout is self-care, according to Ungerleider. “The sooner you prioritize your mental, emotional, and physical well-being, the better,” she said. “Balancing work and life may feel impossible at times but taking care of yourself is essential to being a better physician in the long run.”
That means carving out time for exercise, hobbies, and connections outside of the medical field. It also means making sleep and nutrition a priority, even when that feels hard to accomplish. “If you don’t take care of yourself, you can’t take care of others,” added Opris. “It’s so common to lose yourself in your career, but you need to hold onto your physical, emotional, and spiritual self.”
Avoid Relying Too Heavily on Tech
Technology is invading every aspect of our lives — often for the greater good — but in medicine, it’s important to always return to your core knowledge above all else. Case in point, said Opris, the UpToDate app. While it can be a useful tool, it’s important not to become too reliant on it. “UpToDate is expert opinion-based guidance, and it’s a fantastic resource,” he said. “But you need to use your references and knowledge in every case.”
It’s key to remember that every patient is different, and their case may not line up perfectly with the guidance presented in UpToDate or other technology source. Piggybacking on that, Ungerleider added that it’s important to remember medicine is about people, not just conditions.
“It’s easy to focus on mastering the science, but the real art of medicine comes from seeing the whole person in front of you,” she said. “Your patients are more than their diagnoses — they come with complex emotions, life stories, and needs.” Being compassionate, listening carefully, and building trust should match up to your clinical skills.
Partner With Your Patients, Even When It’s Difficult
Perhaps the most difficult lesson of all is remembering that your patients may not always agree with your recommendations and choose to ignore them. After all your years spent learning, there may be times when it feels your education is going to waste.
“Remember that the landscape today is so varied, and that bleeds into medicine,” said Opris. “We go into cases with our own biases, and it’s important to take a step back to reset, every time.”
Opris reminds himself of Sir William Osler’s famous essay, “Aequanimitas,” in which he tells graduating medical students to practice with “coolness and presence of mind under all circumstances.”
Remignanti offers this advice: “Physicians need to be able to partner with their patients and jointly decide which courses of action are most effective,” he said. “Cling to the idea that you are forming a partnership with your patients — what can we together determine is the best course?”
At the same time, the path the patient chooses may not be what’s best for them — potentially even leading to a poor outcome.
“You may not always understand their choices,” said Opris. “But they do have a choice. Think of yourself almost like a consultant.”
A version of this article first appeared on Medscape.com.
Despite 4 years of med school and 3-7 years in residency, when you enter the workforce as a doctor, you still have much to learn. There is only so much your professors and attending physicians can pack in. Going forward, you’ll continue to learn on the job and via continuing education.
Some of that lifelong learning will involve soft skills — how to compassionately work with your patients and their families, for instance. Other lessons will get down to the business of medicine — the paperwork, the work/life balance, and the moral dilemmas you never saw coming. And still others will involve learning how to take care of yourself in the middle of seemingly endless hours on the job.
“We all have things we wish we had known upon starting our careers,” said Daniel Opris, MD, a primary care physician at Ohio-based Executive Medical Centers.
We tapped several veteran physicians and an educator to learn what they wish med students knew as they enter the workforce. We’ve compiled them here to give you a head start on the lessons ahead.
You Won’t Know Everything, and That’s Okay
When you go through your medical training, it can feel overwhelming to absorb all the knowledge your professors and attendings impart. The bottom line, said Shoshana Ungerleider, MD, an internal medicine specialist, is that you shouldn’t worry about it.
David Lenihan, PhD, CEO at Ponce Health Sciences University, agrees. “What we’ve lost in recent years, is the ability to apply your skill set and say, ‘let me take a day and get back to you,’” he said. “Doctors love it when you do that because it shows you can pitch in and work as part of a team.”
Medicine is a collaborative field, said Ungerleider, and learning from others, whether peers, nurses, or specialists, is “not a weakness.” She recommends embracing uncertainty and getting comfortable with the unknown.
You’ll Take Your Work Home With You
Doctors enter the field because they care about their patients and want to help. Successful outcomes are never guaranteed, however, no matter how much you try. The result? Some days you’ll bring home those upsetting and haunting cases, said Lenihan.
“We often believe that we should leave our work at the office, but sometimes you need to bring it home and think it through,” he said. “It can’t overwhelm you, but you should digest what happened.”
When you do, said Lenihan, you’ll come out the other end more empathetic and that helps the healthcare system in the long run. “The more you reflect on your day, the better you’ll get at reading the room and treating your patients.”
Drew Remignanti, MD, a retired emergency medicine physician from New Hampshire, agrees, but puts a different spin on bringing work home.
“We revisit the patient care decisions we made, second-guess ourselves, and worry about our patients’ welfare and outcomes,” he said. “I think it can only lead to better outcomes down the road, however, if you learn from that bad decision, preventing you from committing a similar mistake.”
Burnout Is Real — Make Self-Care a Priority
As a retired physician who spent 40 years practicing medicine, Remignanti experienced the evolution of healthcare as it has become what he calls a “consumer-provider” model. “Productivity didn’t use to be part of the equation, but now it’s the focus,” he said.
The result is burnout, a very real threat to incoming physicians. Remignanti holds that if you are aware of the risk, you can resist it. Part of avoiding burnout is self-care, according to Ungerleider. “The sooner you prioritize your mental, emotional, and physical well-being, the better,” she said. “Balancing work and life may feel impossible at times but taking care of yourself is essential to being a better physician in the long run.”
That means carving out time for exercise, hobbies, and connections outside of the medical field. It also means making sleep and nutrition a priority, even when that feels hard to accomplish. “If you don’t take care of yourself, you can’t take care of others,” added Opris. “It’s so common to lose yourself in your career, but you need to hold onto your physical, emotional, and spiritual self.”
Avoid Relying Too Heavily on Tech
Technology is invading every aspect of our lives — often for the greater good — but in medicine, it’s important to always return to your core knowledge above all else. Case in point, said Opris, the UpToDate app. While it can be a useful tool, it’s important not to become too reliant on it. “UpToDate is expert opinion-based guidance, and it’s a fantastic resource,” he said. “But you need to use your references and knowledge in every case.”
It’s key to remember that every patient is different, and their case may not line up perfectly with the guidance presented in UpToDate or other technology source. Piggybacking on that, Ungerleider added that it’s important to remember medicine is about people, not just conditions.
“It’s easy to focus on mastering the science, but the real art of medicine comes from seeing the whole person in front of you,” she said. “Your patients are more than their diagnoses — they come with complex emotions, life stories, and needs.” Being compassionate, listening carefully, and building trust should match up to your clinical skills.
Partner With Your Patients, Even When It’s Difficult
Perhaps the most difficult lesson of all is remembering that your patients may not always agree with your recommendations and choose to ignore them. After all your years spent learning, there may be times when it feels your education is going to waste.
“Remember that the landscape today is so varied, and that bleeds into medicine,” said Opris. “We go into cases with our own biases, and it’s important to take a step back to reset, every time.”
Opris reminds himself of Sir William Osler’s famous essay, “Aequanimitas,” in which he tells graduating medical students to practice with “coolness and presence of mind under all circumstances.”
Remignanti offers this advice: “Physicians need to be able to partner with their patients and jointly decide which courses of action are most effective,” he said. “Cling to the idea that you are forming a partnership with your patients — what can we together determine is the best course?”
At the same time, the path the patient chooses may not be what’s best for them — potentially even leading to a poor outcome.
“You may not always understand their choices,” said Opris. “But they do have a choice. Think of yourself almost like a consultant.”
A version of this article first appeared on Medscape.com.
How Do Novel CRC Blood Tests Fare Against Established Tests?
TOPLINE:
METHODOLOGY:
- Researchers estimated the clinical and economic impacts of emerging blood- and stool-based CRC screening tests with established alternatives in average-risk adults aged 45 years and older.
- The established screening tools were colonoscopy, a fecal immunochemical test (FIT), and a multitarget stool DNA test (MT-sDNA, Exact Sciences Cologuard).
- The four emerging screening methods were two cf-bDNA tests (Guardant Shield and Freenome); an enhanced, a next-generation multitarget stool test (ngMT-sDNA), and a novel FIT-RNA test (Geneoscopy ColoSense).
TAKEAWAY:
- Assuming 100% participation in all screening steps, colonoscopy and FIT yielded reductions of more than 70% in CRC incidence and 75% in mortality vs no screening.
- The MT-sDNA test reduced CRC incidence by 68% and mortality by 73%, with similar rates for the ngMT-sDNA and FIT-RNA tests vs no screening. The cf-bDNA tests yielded CRC incidence and mortality reductions of only 42% and 56%.
- Colonoscopy and FIT were more effective and less costly than the cf-bDNA and MT-sDNA tests, and the MT-sDNA test was more effective and less costly than the cf-bDNA test.
- Population benefits from blood tests were seen only in those who declined colonoscopy and stool tests. Substituting a blood test for those already using colonoscopy or stool tests led to worse population-level outcomes.
IN PRACTICE:
“First-generation novel cf-bDNA tests have the potential to decrease meaningfully the incidence and mortality of CRC compared with no screening but substantially less profoundly than screening colonoscopy or stool tests. Net population benefit or harm can follow incorporation of first-generation cf-bDNA CRC screening tests into practice, depending on the balance between bringing unscreened persons into screening (addition) vs shifting persons away from the more effective strategies of colonoscopy or stool testing (substitution),” the authors concluded.
SOURCE:
The study, with first author Uri Ladabaum, MD, MS, Stanford University School of Medicine, California, was published online in Annals of Internal Medicine.
LIMITATIONS:
Limitations included test-specific participation patterns being unknown over time.
DISCLOSURES:
Disclosure forms for the authors are available with the article online. Funding was provided by the Gorrindo Family Fund.
A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Researchers estimated the clinical and economic impacts of emerging blood- and stool-based CRC screening tests with established alternatives in average-risk adults aged 45 years and older.
- The established screening tools were colonoscopy, a fecal immunochemical test (FIT), and a multitarget stool DNA test (MT-sDNA, Exact Sciences Cologuard).
- The four emerging screening methods were two cf-bDNA tests (Guardant Shield and Freenome); an enhanced, a next-generation multitarget stool test (ngMT-sDNA), and a novel FIT-RNA test (Geneoscopy ColoSense).
TAKEAWAY:
- Assuming 100% participation in all screening steps, colonoscopy and FIT yielded reductions of more than 70% in CRC incidence and 75% in mortality vs no screening.
- The MT-sDNA test reduced CRC incidence by 68% and mortality by 73%, with similar rates for the ngMT-sDNA and FIT-RNA tests vs no screening. The cf-bDNA tests yielded CRC incidence and mortality reductions of only 42% and 56%.
- Colonoscopy and FIT were more effective and less costly than the cf-bDNA and MT-sDNA tests, and the MT-sDNA test was more effective and less costly than the cf-bDNA test.
- Population benefits from blood tests were seen only in those who declined colonoscopy and stool tests. Substituting a blood test for those already using colonoscopy or stool tests led to worse population-level outcomes.
IN PRACTICE:
“First-generation novel cf-bDNA tests have the potential to decrease meaningfully the incidence and mortality of CRC compared with no screening but substantially less profoundly than screening colonoscopy or stool tests. Net population benefit or harm can follow incorporation of first-generation cf-bDNA CRC screening tests into practice, depending on the balance between bringing unscreened persons into screening (addition) vs shifting persons away from the more effective strategies of colonoscopy or stool testing (substitution),” the authors concluded.
SOURCE:
The study, with first author Uri Ladabaum, MD, MS, Stanford University School of Medicine, California, was published online in Annals of Internal Medicine.
LIMITATIONS:
Limitations included test-specific participation patterns being unknown over time.
DISCLOSURES:
Disclosure forms for the authors are available with the article online. Funding was provided by the Gorrindo Family Fund.
A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Researchers estimated the clinical and economic impacts of emerging blood- and stool-based CRC screening tests with established alternatives in average-risk adults aged 45 years and older.
- The established screening tools were colonoscopy, a fecal immunochemical test (FIT), and a multitarget stool DNA test (MT-sDNA, Exact Sciences Cologuard).
- The four emerging screening methods were two cf-bDNA tests (Guardant Shield and Freenome); an enhanced, a next-generation multitarget stool test (ngMT-sDNA), and a novel FIT-RNA test (Geneoscopy ColoSense).
TAKEAWAY:
- Assuming 100% participation in all screening steps, colonoscopy and FIT yielded reductions of more than 70% in CRC incidence and 75% in mortality vs no screening.
- The MT-sDNA test reduced CRC incidence by 68% and mortality by 73%, with similar rates for the ngMT-sDNA and FIT-RNA tests vs no screening. The cf-bDNA tests yielded CRC incidence and mortality reductions of only 42% and 56%.
- Colonoscopy and FIT were more effective and less costly than the cf-bDNA and MT-sDNA tests, and the MT-sDNA test was more effective and less costly than the cf-bDNA test.
- Population benefits from blood tests were seen only in those who declined colonoscopy and stool tests. Substituting a blood test for those already using colonoscopy or stool tests led to worse population-level outcomes.
IN PRACTICE:
“First-generation novel cf-bDNA tests have the potential to decrease meaningfully the incidence and mortality of CRC compared with no screening but substantially less profoundly than screening colonoscopy or stool tests. Net population benefit or harm can follow incorporation of first-generation cf-bDNA CRC screening tests into practice, depending on the balance between bringing unscreened persons into screening (addition) vs shifting persons away from the more effective strategies of colonoscopy or stool testing (substitution),” the authors concluded.
SOURCE:
The study, with first author Uri Ladabaum, MD, MS, Stanford University School of Medicine, California, was published online in Annals of Internal Medicine.
LIMITATIONS:
Limitations included test-specific participation patterns being unknown over time.
DISCLOSURES:
Disclosure forms for the authors are available with the article online. Funding was provided by the Gorrindo Family Fund.
A version of this article appeared on Medscape.com.
Thrombocytosis and Cancer Risk: Management in Primary Care
This transcript has been edited for clarity.
In this podcast, I’m going to talk about unexplained high platelet counts, or thrombocytosis, and the risk for cancer in primary care. Let’s start with a typical case we all might see in primary care.
Louisa is 47 years old and is the chief financial officer for a tech startup company. She presents to us in primary care feeling tired all the time — a very common presentation in primary care — with associated reduced appetite. Past medical history includes irritable bowel syndrome, and she’s an ex-smoker.
Systemic inquiry is unremarkable. Specifically, there is no history of weight loss. Louisa has not been prescribed any medication and uses over-the-counter remedies for her irritable bowel syndrome. Examination is also unremarkable. Blood tests were checked, which were all reassuring, except for a platelet count of 612 × 109 cells/L (usual normal range, about 150-450).
What do we do next? Do we refer for an urgent chest x-ray to exclude lung cancer? Do we check a quantitative immunohistochemical fecal occult blood test (qFIT) to identify any occult bleeding in her stool? Do we refer for a routine upper gastrointestinal endoscopy or pelvic ultrasound scan to exclude any upper gastrointestinal or endometrial malignancy?
Do we simply repeat the bloods? If so, do we repeat them routinely or urgently, and indeed, which ones should we recheck?
Louisa has an unexplained thrombocytosis. How do we manage this in primary care? Thrombocytosis is generally defined as a raised platelet count over 450. Importantly, thrombocytosis is a common incidental finding in around 2% of those over 40 years of age attending primary care. Reassuringly, 80%-90% of thrombocytosis is reactive, secondary to acute blood loss, infection, or inflammation, and the majority of cases resolve within 3 months.
Why the concern with Louisa then? Although most cases are reactive, clinical guidance (for example, NICE suspected cancer guidance in the UK and Scottish suspected cancer guidance in Scotland) reminds us that unexplained thrombocytosis is a risk marker for some solid-tumor malignancies.
Previous studies have demonstrated that unexplained thrombocytosis is associated with a 1-year cancer incidence of 11.6% in males and 6.2% in females, well exceeding the standard 3% threshold warranting investigation for underlying malignancy. However, thrombocytosis should not be used as a stand-alone diagnostic or screening test for cancer, or indeed to rule out cancer.
Instead, unexplained thrombocytosis should prompt us to think cancer. The Scottish suspected cancer referral guidelines include thrombocytosis in the investigation criteria for what they call the LEGO-C cancers — L for lung, E for endometrial, G for gastric, O for oesophageal, and C for colorectal, which is a useful reminder for us all.
What further history, examination, and investigations might we consider in primary care if we identify an unexplained high platelet count? As always, we should use our clinical judgment and trust our clinical acumen.
We should consider all the possible underlying causes, including infection, inflammation, and blood loss, including menstrual blood loss in women; myeloproliferative disorders such as polycythemia rubra vera, chronic myeloid leukemia, and essential thrombocythemia; and, of course, underlying malignancy. If a likely underlying reversible cause is present (for example, a recent lower respiratory tract infection), simply repeating the full blood count in 4-6 weeks is quite appropriate to see if the thrombocytosis has resolved.
Remember, 80%-90% of cases are reactive thrombocytosis, and most cases resolve within 3 months. If thrombocytosis is unexplained or not resolving, consider checking ferritin levels to exclude iron deficiency. Consider checking C-reactive protein (CRP) levels to exclude any inflammation, and also consider checking a blood film to exclude any hematologic disorders, in addition, of course, to more detailed history-taking and examination to elicit any red flags.
We can also consider a JAK2 gene mutation test, if it is available to you locally, or a hematology referral if we suspect a myeloproliferative disorder. JAK2 is a genetic mutation that may be present in people with essential thrombocythemia and can indicate a diagnosis of polycythemia rubra vera.
Subsequent to this, and again using our clinical judgment, we then need to exclude the LEGO-C cancers. Consider urgent chest x-ray to exclude lung cancer or pelvic ultrasound in women to exclude endometrial cancer. Also, we should consider an upper gastrointestinal endoscopy, particularly in those individuals who have associated upper gastrointestinal symptoms and/or weight loss.
Finally, consider a qFIT to identify any occult bleeding in the stool, again if it’s available to you, or certainly if not, urgent lower gastrointestinal investigations to exclude colorectal cancer.
Alongside these possible investigations, as always, we should safety-net appropriately within agreed timeframes and check for resolution of the thrombocytosis according to the condition being suspected. Remember, most cases resolve within 3 months.
Returning to Louisa, what did I do? After seeing a platelet count of 600, I subsequently telephoned her and reexplored her history, which yielded nil else of note. Specifically, there was no history of unexplained weight loss, no history of upper or lower gastrointestinal symptoms, and certainly nothing significantly different from her usual irritable bowel syndrome symptoms. There were also no respiratory or genitourinary symptoms of note.
I did arrange for Louisa to undergo a chest x-ray over the next few days, though, as she was an ex-smoker. This was subsequently reported as normal. I appreciate chest x-rays have poor sensitivity for detecting lung cancer, as highlighted in a number of recent papers, but it was mutually agreed with Louisa that we would simply repeat her blood test in around 6 weeks. As well as repeating the full blood count, I arranged to check her ferritin, CRP, and a blood film, and then I was planning to reassess her clinically in person.
These bloods and my subsequent clinical review were reassuring. In fact, her platelet count had normalized after that 6 weeks had elapsed. Her thrombocytosis had resolved.
I didn’t arrange any further follow-up for her, but I did give her the usual safety netting advice to re-present to me or one of my colleagues if she does develop any worrying symptoms or signs.
I appreciate these scenarios are not always this straightforward, but I wanted to outline what investigations and referrals we may need to consider in primary care if we encounter an unexplained high platelet count.
There are a couple of quality-improvement activities for us all to consider in primary care. Consider as a team how we would respond to an incidental finding of thrombocytosis on a full blood count. Also consider what are our safety-netting options for those found to have raised platelet counts but no other symptoms or risk factors for underlying malignancy.
Finally, I’ve produced a Medscape UK primary care hack or clinical aide-memoire on managing unexplained thrombocytosis and associated cancer risk in primary care for all healthcare professionals working in primary care. This can be found online. I hope you find this resource helpful.
Dr. Kevin Fernando, General practitioner partner with specialist interests in cardiovascular, renal, and metabolic medicine, North Berwick Group Practice in Scotland, has disclosed relevant financial relationships with Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Dexcom, Lilly, Menarini, Novartis, Novo Nordisk, Roche Diagnostics, Embecta, Roche Diabetes Care, Sanofi Menarini, and Daiichi Sankyo.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
In this podcast, I’m going to talk about unexplained high platelet counts, or thrombocytosis, and the risk for cancer in primary care. Let’s start with a typical case we all might see in primary care.
Louisa is 47 years old and is the chief financial officer for a tech startup company. She presents to us in primary care feeling tired all the time — a very common presentation in primary care — with associated reduced appetite. Past medical history includes irritable bowel syndrome, and she’s an ex-smoker.
Systemic inquiry is unremarkable. Specifically, there is no history of weight loss. Louisa has not been prescribed any medication and uses over-the-counter remedies for her irritable bowel syndrome. Examination is also unremarkable. Blood tests were checked, which were all reassuring, except for a platelet count of 612 × 109 cells/L (usual normal range, about 150-450).
What do we do next? Do we refer for an urgent chest x-ray to exclude lung cancer? Do we check a quantitative immunohistochemical fecal occult blood test (qFIT) to identify any occult bleeding in her stool? Do we refer for a routine upper gastrointestinal endoscopy or pelvic ultrasound scan to exclude any upper gastrointestinal or endometrial malignancy?
Do we simply repeat the bloods? If so, do we repeat them routinely or urgently, and indeed, which ones should we recheck?
Louisa has an unexplained thrombocytosis. How do we manage this in primary care? Thrombocytosis is generally defined as a raised platelet count over 450. Importantly, thrombocytosis is a common incidental finding in around 2% of those over 40 years of age attending primary care. Reassuringly, 80%-90% of thrombocytosis is reactive, secondary to acute blood loss, infection, or inflammation, and the majority of cases resolve within 3 months.
Why the concern with Louisa then? Although most cases are reactive, clinical guidance (for example, NICE suspected cancer guidance in the UK and Scottish suspected cancer guidance in Scotland) reminds us that unexplained thrombocytosis is a risk marker for some solid-tumor malignancies.
Previous studies have demonstrated that unexplained thrombocytosis is associated with a 1-year cancer incidence of 11.6% in males and 6.2% in females, well exceeding the standard 3% threshold warranting investigation for underlying malignancy. However, thrombocytosis should not be used as a stand-alone diagnostic or screening test for cancer, or indeed to rule out cancer.
Instead, unexplained thrombocytosis should prompt us to think cancer. The Scottish suspected cancer referral guidelines include thrombocytosis in the investigation criteria for what they call the LEGO-C cancers — L for lung, E for endometrial, G for gastric, O for oesophageal, and C for colorectal, which is a useful reminder for us all.
What further history, examination, and investigations might we consider in primary care if we identify an unexplained high platelet count? As always, we should use our clinical judgment and trust our clinical acumen.
We should consider all the possible underlying causes, including infection, inflammation, and blood loss, including menstrual blood loss in women; myeloproliferative disorders such as polycythemia rubra vera, chronic myeloid leukemia, and essential thrombocythemia; and, of course, underlying malignancy. If a likely underlying reversible cause is present (for example, a recent lower respiratory tract infection), simply repeating the full blood count in 4-6 weeks is quite appropriate to see if the thrombocytosis has resolved.
Remember, 80%-90% of cases are reactive thrombocytosis, and most cases resolve within 3 months. If thrombocytosis is unexplained or not resolving, consider checking ferritin levels to exclude iron deficiency. Consider checking C-reactive protein (CRP) levels to exclude any inflammation, and also consider checking a blood film to exclude any hematologic disorders, in addition, of course, to more detailed history-taking and examination to elicit any red flags.
We can also consider a JAK2 gene mutation test, if it is available to you locally, or a hematology referral if we suspect a myeloproliferative disorder. JAK2 is a genetic mutation that may be present in people with essential thrombocythemia and can indicate a diagnosis of polycythemia rubra vera.
Subsequent to this, and again using our clinical judgment, we then need to exclude the LEGO-C cancers. Consider urgent chest x-ray to exclude lung cancer or pelvic ultrasound in women to exclude endometrial cancer. Also, we should consider an upper gastrointestinal endoscopy, particularly in those individuals who have associated upper gastrointestinal symptoms and/or weight loss.
Finally, consider a qFIT to identify any occult bleeding in the stool, again if it’s available to you, or certainly if not, urgent lower gastrointestinal investigations to exclude colorectal cancer.
Alongside these possible investigations, as always, we should safety-net appropriately within agreed timeframes and check for resolution of the thrombocytosis according to the condition being suspected. Remember, most cases resolve within 3 months.
Returning to Louisa, what did I do? After seeing a platelet count of 600, I subsequently telephoned her and reexplored her history, which yielded nil else of note. Specifically, there was no history of unexplained weight loss, no history of upper or lower gastrointestinal symptoms, and certainly nothing significantly different from her usual irritable bowel syndrome symptoms. There were also no respiratory or genitourinary symptoms of note.
I did arrange for Louisa to undergo a chest x-ray over the next few days, though, as she was an ex-smoker. This was subsequently reported as normal. I appreciate chest x-rays have poor sensitivity for detecting lung cancer, as highlighted in a number of recent papers, but it was mutually agreed with Louisa that we would simply repeat her blood test in around 6 weeks. As well as repeating the full blood count, I arranged to check her ferritin, CRP, and a blood film, and then I was planning to reassess her clinically in person.
These bloods and my subsequent clinical review were reassuring. In fact, her platelet count had normalized after that 6 weeks had elapsed. Her thrombocytosis had resolved.
I didn’t arrange any further follow-up for her, but I did give her the usual safety netting advice to re-present to me or one of my colleagues if she does develop any worrying symptoms or signs.
I appreciate these scenarios are not always this straightforward, but I wanted to outline what investigations and referrals we may need to consider in primary care if we encounter an unexplained high platelet count.
There are a couple of quality-improvement activities for us all to consider in primary care. Consider as a team how we would respond to an incidental finding of thrombocytosis on a full blood count. Also consider what are our safety-netting options for those found to have raised platelet counts but no other symptoms or risk factors for underlying malignancy.
Finally, I’ve produced a Medscape UK primary care hack or clinical aide-memoire on managing unexplained thrombocytosis and associated cancer risk in primary care for all healthcare professionals working in primary care. This can be found online. I hope you find this resource helpful.
Dr. Kevin Fernando, General practitioner partner with specialist interests in cardiovascular, renal, and metabolic medicine, North Berwick Group Practice in Scotland, has disclosed relevant financial relationships with Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Dexcom, Lilly, Menarini, Novartis, Novo Nordisk, Roche Diagnostics, Embecta, Roche Diabetes Care, Sanofi Menarini, and Daiichi Sankyo.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
In this podcast, I’m going to talk about unexplained high platelet counts, or thrombocytosis, and the risk for cancer in primary care. Let’s start with a typical case we all might see in primary care.
Louisa is 47 years old and is the chief financial officer for a tech startup company. She presents to us in primary care feeling tired all the time — a very common presentation in primary care — with associated reduced appetite. Past medical history includes irritable bowel syndrome, and she’s an ex-smoker.
Systemic inquiry is unremarkable. Specifically, there is no history of weight loss. Louisa has not been prescribed any medication and uses over-the-counter remedies for her irritable bowel syndrome. Examination is also unremarkable. Blood tests were checked, which were all reassuring, except for a platelet count of 612 × 109 cells/L (usual normal range, about 150-450).
What do we do next? Do we refer for an urgent chest x-ray to exclude lung cancer? Do we check a quantitative immunohistochemical fecal occult blood test (qFIT) to identify any occult bleeding in her stool? Do we refer for a routine upper gastrointestinal endoscopy or pelvic ultrasound scan to exclude any upper gastrointestinal or endometrial malignancy?
Do we simply repeat the bloods? If so, do we repeat them routinely or urgently, and indeed, which ones should we recheck?
Louisa has an unexplained thrombocytosis. How do we manage this in primary care? Thrombocytosis is generally defined as a raised platelet count over 450. Importantly, thrombocytosis is a common incidental finding in around 2% of those over 40 years of age attending primary care. Reassuringly, 80%-90% of thrombocytosis is reactive, secondary to acute blood loss, infection, or inflammation, and the majority of cases resolve within 3 months.
Why the concern with Louisa then? Although most cases are reactive, clinical guidance (for example, NICE suspected cancer guidance in the UK and Scottish suspected cancer guidance in Scotland) reminds us that unexplained thrombocytosis is a risk marker for some solid-tumor malignancies.
Previous studies have demonstrated that unexplained thrombocytosis is associated with a 1-year cancer incidence of 11.6% in males and 6.2% in females, well exceeding the standard 3% threshold warranting investigation for underlying malignancy. However, thrombocytosis should not be used as a stand-alone diagnostic or screening test for cancer, or indeed to rule out cancer.
Instead, unexplained thrombocytosis should prompt us to think cancer. The Scottish suspected cancer referral guidelines include thrombocytosis in the investigation criteria for what they call the LEGO-C cancers — L for lung, E for endometrial, G for gastric, O for oesophageal, and C for colorectal, which is a useful reminder for us all.
What further history, examination, and investigations might we consider in primary care if we identify an unexplained high platelet count? As always, we should use our clinical judgment and trust our clinical acumen.
We should consider all the possible underlying causes, including infection, inflammation, and blood loss, including menstrual blood loss in women; myeloproliferative disorders such as polycythemia rubra vera, chronic myeloid leukemia, and essential thrombocythemia; and, of course, underlying malignancy. If a likely underlying reversible cause is present (for example, a recent lower respiratory tract infection), simply repeating the full blood count in 4-6 weeks is quite appropriate to see if the thrombocytosis has resolved.
Remember, 80%-90% of cases are reactive thrombocytosis, and most cases resolve within 3 months. If thrombocytosis is unexplained or not resolving, consider checking ferritin levels to exclude iron deficiency. Consider checking C-reactive protein (CRP) levels to exclude any inflammation, and also consider checking a blood film to exclude any hematologic disorders, in addition, of course, to more detailed history-taking and examination to elicit any red flags.
We can also consider a JAK2 gene mutation test, if it is available to you locally, or a hematology referral if we suspect a myeloproliferative disorder. JAK2 is a genetic mutation that may be present in people with essential thrombocythemia and can indicate a diagnosis of polycythemia rubra vera.
Subsequent to this, and again using our clinical judgment, we then need to exclude the LEGO-C cancers. Consider urgent chest x-ray to exclude lung cancer or pelvic ultrasound in women to exclude endometrial cancer. Also, we should consider an upper gastrointestinal endoscopy, particularly in those individuals who have associated upper gastrointestinal symptoms and/or weight loss.
Finally, consider a qFIT to identify any occult bleeding in the stool, again if it’s available to you, or certainly if not, urgent lower gastrointestinal investigations to exclude colorectal cancer.
Alongside these possible investigations, as always, we should safety-net appropriately within agreed timeframes and check for resolution of the thrombocytosis according to the condition being suspected. Remember, most cases resolve within 3 months.
Returning to Louisa, what did I do? After seeing a platelet count of 600, I subsequently telephoned her and reexplored her history, which yielded nil else of note. Specifically, there was no history of unexplained weight loss, no history of upper or lower gastrointestinal symptoms, and certainly nothing significantly different from her usual irritable bowel syndrome symptoms. There were also no respiratory or genitourinary symptoms of note.
I did arrange for Louisa to undergo a chest x-ray over the next few days, though, as she was an ex-smoker. This was subsequently reported as normal. I appreciate chest x-rays have poor sensitivity for detecting lung cancer, as highlighted in a number of recent papers, but it was mutually agreed with Louisa that we would simply repeat her blood test in around 6 weeks. As well as repeating the full blood count, I arranged to check her ferritin, CRP, and a blood film, and then I was planning to reassess her clinically in person.
These bloods and my subsequent clinical review were reassuring. In fact, her platelet count had normalized after that 6 weeks had elapsed. Her thrombocytosis had resolved.
I didn’t arrange any further follow-up for her, but I did give her the usual safety netting advice to re-present to me or one of my colleagues if she does develop any worrying symptoms or signs.
I appreciate these scenarios are not always this straightforward, but I wanted to outline what investigations and referrals we may need to consider in primary care if we encounter an unexplained high platelet count.
There are a couple of quality-improvement activities for us all to consider in primary care. Consider as a team how we would respond to an incidental finding of thrombocytosis on a full blood count. Also consider what are our safety-netting options for those found to have raised platelet counts but no other symptoms or risk factors for underlying malignancy.
Finally, I’ve produced a Medscape UK primary care hack or clinical aide-memoire on managing unexplained thrombocytosis and associated cancer risk in primary care for all healthcare professionals working in primary care. This can be found online. I hope you find this resource helpful.
Dr. Kevin Fernando, General practitioner partner with specialist interests in cardiovascular, renal, and metabolic medicine, North Berwick Group Practice in Scotland, has disclosed relevant financial relationships with Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Dexcom, Lilly, Menarini, Novartis, Novo Nordisk, Roche Diagnostics, Embecta, Roche Diabetes Care, Sanofi Menarini, and Daiichi Sankyo.
A version of this article first appeared on Medscape.com.